Publications by authors named "Samuel O Poore"

85 Publications

Informed Consent Practices in Global Surgery among Plastic Surgery Organizations.

Plast Reconstr Surg 2022 Aug 8. Epub 2022 Aug 8.

Division of Plastic Surgery, University of Wisconsin School of Medicine and Public Health.

Background: Global surgery organizations often serve vulnerable and complex patient populations, but there is limited knowledge on the protocols used to obtain informed consent for procedures and content sharing.

Methods: The Plastic Surgery Foundation Volunteers in Plastic Surgery (VIPS) database was queried for organizations actively involved in global surgery. Seventy-nine organizations received email invitations to participate in a survey study regarding their protocols for obtaining consent for procedures and sharing multimedia content.

Results: A total of 17 (22% yield) organizations completed the survey. All were active for at least 10 years and 88% (15/17) organized at least two mission trips annually. Eighty-eight percent (15/17) reported obtaining written consent for surgical procedures. Less than half (46%, 8/17) of used a written consent form that was created jointly with the local hospital. For sharing content related to global surgery experiences, 75% (12/16) obtained some form of written consent while 6% (1/16) did not routinely obtain any consent. Organizations shared content most commonly through their websites and Facebook. All organizations reported using interpreters to obtain informed consent at least some of the time. 62% (10/16) reported that they relied primarily on volunteers or community members to provide informal interpretation assistance, rather than formally trained professional interpreters.

Conclusion: Practices related to obtaining informed consent vary widely among global surgery organizations. The development of standardized protocols and guidelines will ensure that global health organizations, in collaboration with their local partners, properly obtain informed consent for procedures and sharing publicly viewable content.
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http://dx.doi.org/10.1097/PRS.0000000000009561DOI Listing
August 2022

The Impact of Abdominal Liposuction on Abdominally Based Autologous Breast Reconstruction: A Systematic Review.

Arch Plast Surg 2022 May 27;49(3):324-331. Epub 2022 May 27.

Division of Plastic Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin.

Prior abdominal liposuction can be viewed as a relative or absolute contraindication to abdominally based autologous breast reconstruction given concerns for damaged perforators and scarring complicating intraoperative dissection. This systematic review aims to explore the outcomes of abdominally based breast reconstruction in patients with a history of abdominal liposuction. A Preferred Reporting Items for Systematic Reviews and Meta-Analyses-guided literature search was conducted using PubMed, Scopus, and Web of Science from the earliest available date through June 2020. Deep inferior epigastric perforator, muscle-sparing transverse rectus abdominis musculocutaneous (TRAM), superficial inferior epigastric artery, and pedicled TRAM flaps were included for evaluation. Complications included total or partial flap loss, fat necrosis, seroma, delayed wound healing, and donor site complications. After inclusion criteria were applied, 336 nonduplicate articles were screened, yielding 11 for final review, representing 55 flaps in 43 patients. There was no instance of total flap loss, eight (14.5%) flaps developed partial loss or fat necrosis, three (5.4%) flaps had delayed wound healing, and two (4.6%) patients had donor site complications. Most authors (8/11) utilized some type of preoperative imaging. Doppler ultrasonography was the most used modality, and these patients had the lowest rate of partial flap loss or flap fat necrosis (8%), followed by those without any preoperative imaging (10%). In conclusion, this review supports that patients undergoing abdominally based autologous breast reconstruction with a history of abdominal liposuction are not at an increased risk of flap or donor site complications. Although preoperative imaging was common, it did not reliably decrease complications. Further prospective studies are needed to address the role of imaging in improving outcomes.
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http://dx.doi.org/10.1055/s-0042-1748646DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9142226PMC
May 2022

Electrical Stimulation of Acute Fractures: A Narrative Review of Stimulation Protocols and Device Specifications.

Front Bioeng Biotechnol 2022 2;10:879187. Epub 2022 Jun 2.

Division of Plastic Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States.

Orthopedic fractures have a significant impact on patients in the form of economic loss and functional impairment. Beyond the standard methods of reduction and fixation, one adjunct that has been explored since the late 1970s is electrical stimulation. Despite robust evidence for efficacy in the preclinical arena, human trials have mixed results, and this technology is not widely accepted. The purpose of this review is to examine the body of literature supporting electrical stimulation for the purpose of fracture healing in humans with an emphasis on device specifications and stimulation protocols and delineate a minimum reporting checklist for future studies of this type. We have isolated 12 studies that pertain to the administration of electrical stimulation for the purpose of augmenting fracture healing in humans. Of these, one was a direct current electrical stimulation study. Six studies utilized pulsed electromagnetic field therapy and five used capacitive coupling. When examining these studies, the device specifications were heterogenous and often incomplete in what they reported, which rendered studies unrepeatable. The stimulation protocols also varied greatly study to study. To demonstrate efficacy of electrical stimulation for fractures, the authors recommend isolating a fracture type that is prone to nonunion to maximize the electrical stimulation effect, a homogenous study population so as to not dilute the effect of electrical stimulation, and increasing scientific rigor in the form of pre-registration, blinding, and sham controls. Finally, we introduce the critical components of minimum device specification reporting for repeatability of studies of this type.
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http://dx.doi.org/10.3389/fbioe.2022.879187DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9201474PMC
June 2022

Diversity Drives Innovation: The Impact of Female Driven Publications.

Aesthet Surg J 2022 May 29. Epub 2022 May 29.

University of Wisconsin School of Medicine and Public Health Division of Plastic Surgery, Madison, WI, USA.

Background: Gender disparities are pervasive in academic plastic surgery. Previous research demonstrates articles authored by women receive fewer citations than those written by men, suggesting the presence of implicit gender bias.

Objectives: We aim to describe current citation trends in plastic surgery literature and assess gender bias. We expected women to be cited less frequently than their male peers.

Methods: Articles published between 2017 and 2019 were collected from eight representative plastic surgery journals stratified by impact factor. Names of primary and senior authors of the fifty most cited articles per year per journal were collected and author gender was determined via online database and internet search. Median number of citations by primary and senior author gender were compared via Kruskal-Wallis test.

Results: Among 1167 articles, women wrote 27.3% as primary author and 18% as senior author. Women-authored articles were cited as often as those authored by men (p>0.05) across all journal tiers. Articles with a female primary and male senior author had significantly more citations than articles with a male primary author (p=0.038).

Conclusions: No implicit gender bias was identified in citations trends, a finding unique to plastic surgery. Women primary authors are cited more often than male primary authors despite women comprising a small fraction of authorship overall. Additionally, variegated authorship pairings outperformed homogenous ones. Therefore, increasing gender diversity within plastic surgery academia remains critical.
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http://dx.doi.org/10.1093/asj/sjac137DOI Listing
May 2022

Local Environment Induces Differential Gene Expression in Regenerating Nerves.

J Surg Res 2022 Oct 23;278:418-432. Epub 2022 May 23.

Division of Plastic Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin. Electronic address:

Introduction: Approximately 80% of amputations are complicated by neuromas. Methods for neuroma management include nerve translocation into bone and implantation into skeletal muscle grafts, which have also facilitated the development of regenerative neural interfaces to enable fixation of prosthetics with motor and sensory feedback. However, molecular-level differences between nerves in these environments have not been investigated. This study aimed to elucidate the physiology of regenerating nerves in different settings by assessing gene expression.

Materials And Methods: New Zealand white rabbits underwent transfemoral amputation with sciatic nerve transposition into the femur or tacked to skeletal muscle. At 5 wk, ribonucleic acid (RNA) sequencing of samples of distal nerve terminating in bone or muscle and nerve of the contralateral limb (control) identified differentially expressed genes (DEGs) and biochemical pathways (α = 0.05).

Results: Three samples of nerve housed in bone, four of nerve tacked to muscle, and seven naïve controls were analyzed. Relative to controls, nerve housed in bone had little within-group variation and 13,028 DEGs, and nerve tacked to muscle had dramatic within-group variation and 12,811 DEGs. These samples upregulated the following pathways: lysosome, phagosome, antigen processing/presentation, and cell adhesion molecule. Relative to nerve housed in bone, nerve tacked to muscle had 12,526 DEGs, demonstrating upregulation of pathways of B-cell receptor signaling, focal adhesion, natural killer-cell mediated cytotoxicity, leukocyte transendothelial migration, and extracellular matrix-receptor interactions.

Conclusions: Nerve housed in bone has a more predictable molecular profile than does nerve tacked to muscle. Thus, the intramedullary canal may provide a more reliable setting for neuroma prevention and neural interfacing.
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http://dx.doi.org/10.1016/j.jss.2022.04.017DOI Listing
October 2022

Surgical and demographic predictors of free flap salvage after takeback: A systematic review.

Microsurgery 2022 May 25. Epub 2022 May 25.

Division of Plastic Surgery, Department of Surgery, University of Wisconsin-Madison, School of Medicine and Public Health, Madison, Wisconsin, USA.

Background: Microsurgical free tissue transfer (FTT) is a widely employed surgical modality utilized for reconstruction of a broad range of defects, including head and neck, extremity, and breast. Flap survival is reported to be 90%-95%. When FTT fails, salvage procedures aim at establishing reperfusion while limiting ischemia time-with salvage rates between 22% and 67%. There are limited data-driven predictors of successful salvage present in the literature. This systematic review aims to identify predictors of flap salvage.

Methods: A systematic literature review was conducted per PRISMA guidelines. Articles included in the final analysis were limited to those investigating FTT salvage procedures and included factors impacting outcomes. Cohort and case series (>5 flaps) studies up until March 2021 were included. Chi-square tests and linear regression modeling was completed for analysis.

Results: The patient-specific factors significantly associated with salvage included the absence of hypercoagulability (p < .00001) and no previous salvage attempts (p < .00001). Case-specific factors significantly associated with salvage included trunk/breast flaps (p < .00001), fasciocutaneous/osteocutaneous flaps (p = .006), venous compromise (p < .00001), and shorter time from index procedure to salvage attempt (R = .746). Radiation in the head and neck population was significantly associated with flap salvage failure.

Conclusions: Given the complexity and challenges surrounding free flap salvage procedures, the goal of this manuscript was to present data helping guide surgical decision-making. Based on our findings, patients without documented hypercoagulability, no previous salvage attempts, fasciocutaneous/osteocutaneous flaps, trunk/breast flaps, and a shorter time interval post-index operation are the best candidates for a salvage attempt.
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http://dx.doi.org/10.1002/micr.30921DOI Listing
May 2022

Women in Leadership and Their Influence on the Gender Diversity of Academic Plastic Surgery Programs.

Plast Reconstr Surg 2022 07 24;150(1):237e. Epub 2022 May 24.

Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Wisconsin-Madison, Madison. Wis.

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http://dx.doi.org/10.1097/PRS.0000000000009219DOI Listing
July 2022

The Effect of Tension on Gene Expression in Primary Nerve Repair via the Epineural Suture Technique.

J Surg Res 2022 Sep 30;277:211-223. Epub 2022 Apr 30.

Division of Plastic Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin. Electronic address:

Introduction: The precise mechanism through which excessive tension confers poor outcomes in nerve gap repair is yet to be elucidated. Furthermore, the effect of tension on gene expression in regenerating nerves has not been characterized. This study investigated differential gene expression in transected nerves repaired under high and minimal tension.

Methods: Male Lewis rats underwent right sciatic nerve transection with either minimal-tension or high-tension repair. Fourteen weeks postoperatively, segments of the right sciatic nerves were harvested along with equal-length segments from the contralateral, healthy nerve to serve as internal controls (naïve nerve). Differentially expressed genes (DEGs) and differentially regulated biochemical pathways between the samples were identified.

Results: Seventeen animals were studied. The gene expression profiles of naïve nerve and minimal-tension repair demonstrated minimal within-group variation, whereas that of high-tension repair demonstrated heterogeneity. Relative to naïve nerve, high-tension repair samples had 4276 DEGs (1941 upregulated and 2335 downregulated) and minimal-tension repair samples had 3305 DEGs (1479 upregulated and 1826 downregulated). High-tension repair samples had 360 DEGs relative to minimal-tension repair samples (68 upregulated and 292 downregulated). Upregulated biological pathways in all repaired nerves included steroid biosynthesis, extracellular matrix-receptor interaction, and ferroptosis. Finally, upregulated pathways in high-tension repair samples relative to minimal-tension repair samples included tumor necrosis factor signaling, interleukin-17 signaling, cytokine-cytokine receptor interaction, and mitogen-activated protein kinase signaling.

Conclusions: The improved outcomes achieved with minimal-tension nerve repair may take root in a favorable gene expression profile. Future elucidation of biochemical pathways in nerve regeneration may identify potential therapeutic targets to optimize primary nerve repair outcomes.
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http://dx.doi.org/10.1016/j.jss.2022.03.029DOI Listing
September 2022

To Decline or Accept: A Guide for Determining the Legitimacy of Academic Conference Invitations.

Ann Plast Surg 2022 07 20;89(1):8-16. Epub 2022 Apr 20.

From the Division of Plastic Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI.

Importance: After the rise of predatory journals characterized by false claims of legitimacy and a pay-to-publish model, similar "predatory conferences" have become increasingly common. The email inbox of an academic physician can be filled with daily announcements encouraging conference attendance, abstract submission, and often panel or keynote speaker invitations. It therefore becomes important for the plastic surgeon to be able to discern whether these invitations are from "predatory" conferences or legitimate career advancement opportunities, especially early in practice.

Objective: To aid the invited physician in determining the legitimacy of a conference, we aimed to characterize objective features of conferences for which email invitations have been received and use this information to build a decision-making guide.

Design: We analyzed all conference invitations received by the email of one academic plastic surgeon in a 4-month period. These conferences were organized into 3 groups based on affiliation with known professional societies. The following information was collected if available: affiliation with a professional society, type of invitation, conference location, conference format (in-person, virtual, or hybrid), conference title, conference fees, conference organizer, associated journals or publishers, abstract journal submission, grammar, headshots, time to abstract review, and acceptance.

Results: There were 56 unique conference invitations. These were categorized into 15 affiliated conferences, 28 unaffiliated conferences, and 17 conferences of undetermined affiliation. Unaffiliated conferences were more likely to solicit speaker invitations ( P < 0.001), claim to be "international" ( P = 0.001), send emails with grammatical errors ( P < 0.001), use unprofessional headshots on the conference Web site ( P < 0.001), and have reduced virtual conference fees ( P = 0.0032) as compared with conferences affiliated with known professional societies. When comparing the attendance and presenter fees of in-person venues, there was no significant difference between affiliated and unaffiliated conferences ( P = 0.973, P = 0.604). Affiliated conferences were more likely to take place in the United States ( P = 0.014).

Conclusions And Relevance: We present a method to quickly assess the legitimacy of an academic meeting by way of a few important questions. Based on our findings, emails soliciting conference speakers, claims of international presence, grammatical errors, unprofessional headshots, and reduced virtual conference fees are all characteristics that should raise red flags.
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http://dx.doi.org/10.1097/SAP.0000000000003180DOI Listing
July 2022

Clinical Basis for Creating an Osseointegrated Neural Interface.

Front Neurosci 2022 12;16:828593. Epub 2022 Apr 12.

Division of Plastic Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States.

As technology continues to improve within the neuroprosthetic landscape, there has been a paradigm shift in the approach to amputation and surgical implementation of haptic neural prosthesis for limb restoration. The Osseointegrated Neural Interface (ONI) is a proposed solution involving the transposition of terminal nerves into the medullary canal of long bones. This design combines concepts of neuroma formation and prevention with osseointegration to provide a stable environment for conduction of neural signals for sophisticated prosthetic control. While this concept has previously been explored in animal models, it has yet to be explored in humans. This anatomic study used three upper limb and three lower limb cadavers to assess the clinical feasibility of creating an ONI in humans. Anatomical measurement of the major peripheral nerves- circumference, length, and depth- were performed as they are critical for electrode design and rerouting of the nerves into the long bones. CT imaging was used for morphologic bone evaluation and virtual implantation of two osseointegrated implants were performed to assess the amount of residual medullary space available for housing the neural interfacing hardware. Use of a small stem osseointegrated implant was found to reduce bone removal and provide more intramedullary space than a traditional implant; however, the higher the amputation site, the less medullary space was available regardless of implant type. Thus the stability of the endoprosthesis must be maximized while still maintaining enough residual space for the interface components. The results from this study provide an anatomic basis required for establishing a clinically applicable ONI in humans. They may serve as a guide for surgical implementation of an osseointegrated endoprosthesis with intramedullary electrodes for prosthetic control.
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http://dx.doi.org/10.3389/fnins.2022.828593DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9039253PMC
April 2022

Electronic Bone Growth Stimulators for Augmentation of Osteogenesis in and Models: A Narrative Review of Electrical Stimulation Mechanisms and Device Specifications.

Front Bioeng Biotechnol 2022 14;10:793945. Epub 2022 Feb 14.

Division of Plastic Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States.

Since the piezoelectric quality of bone was discovered in 1957, scientists have applied exogenous electrical stimulation for the purpose of healing. Despite the efforts made over the past 60 years, electronic bone growth stimulators are not in common clinical use. Reasons for this include high cost and lack of faith in the efficacy of bone growth stimulators on behalf of clinicians. The purpose of this narrative review is to examine the preclinical body of literature supporting electrical stimulation and its effect on bone properties and elucidate gaps in clinical translation with an emphasis on device specifications and mechanisms of action. When examining these studies, trends become apparent. and small animal studies are successful in inducing osteogenesis with all electrical stimulation modalities: direct current, pulsed electromagnetic field, and capacitive coupling. However, large animal studies are largely unsuccessful with the non-invasive modalities. This may be due to issues of scale and thickness of tissue planes with varying levels of resistivity, not present in small animal models. Additionally, it is difficult to draw conclusions from studies due to the varying units of stimulation strength and stimulation protocols and incomplete device specification reporting. To better understand the disconnect between the large and small animal model, the authors recommend increasing scientific rigor for these studies and reporting a novel minimum set of parameters depending on the stimulation modality.
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http://dx.doi.org/10.3389/fbioe.2022.793945DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8882968PMC
February 2022

Osseointegration of Extremity Prostheses: A Primer for the Plastic Surgeon.

Plast Reconstr Surg 2022 01;149(1):150e-151e

Division of Plastic Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wis.

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http://dx.doi.org/10.1097/PRS.0000000000008644DOI Listing
January 2022

Plastic surgery and specialty creep: an analysis of publication trends.

Arch Plast Surg 2021 Nov 15;48(6):651-659. Epub 2021 Nov 15.

Division of Plastic Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.

Background: Many surgical specialties have had pioneering influences from plastic surgeons. However, many of these areas of practice have evolved to include surgeons from diverse training backgrounds. This raises the question as to whether the prominence of other specialties in clinical practice translates to greater research productivity in these areas. The objective of this paper is to investigate the publication volumes of plastic surgeons in selected areas of practice compared to surgeons from other disciplines.

Methods: PubMed was used to examine publication trends in areas associated with plastic surgery. Searches for the following topics were performed: head and neck reconstruction, hand surgery, breast reconstruction, ventral hernia repair, abdominal component separation, brachial plexus injury, craniofacial surgery, and aesthetic surgery. Affiliation tags were used to examine contributions from nine specialties. Web of Science was used to identify the top cited articles for the last 10 years in each area.

Results: Articles by non-plastic surgeons comprise the majority of the literature for all areas of practice studied except for breast reconstruction and aesthetic surgery. Despite this, plastic surgeons contributed the greatest number of top cited articles over the last 10 years for five of the areas of practice.

Conclusions: While plastic surgeons do not contribute the greatest proportion of articles published each year in several of the selected areas of practice, they do publish a larger number of articles that are the most cited. Plastic surgeons remain the dominant academic force in terms of volume and citations for both breast and aesthetic surgery.
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http://dx.doi.org/10.5999/aps.2021.00745DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8627949PMC
November 2021

Navigating the Gray of Academic Publication: Avoiding Predatory Publishers and Creating Your "Whitelist".

Ann Plast Surg 2021 12;87(6):e171-e179

From the Division of Plastic Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI.

Abstract: Academic publishing has undergone a transition from print-based, subscription access journals targeted toward physicians and scientists to the widely accessible, open access (OA) format made possible by the Internet. The objectives of OA broadly include audience expansion and improved public access to publicly funded research, reduction of limitations on content reuse and alteration, and prompt turnaround from submission to publication. Despite well-intended founding principles, unexpected disadvantages of the OA model have arisen including the emergence of predatory journals, which exploit the author-pays publishing model with the deceptive promise of reputable publishing platforms. Predatory journals can be difficult to discern from the legitimate yet unsophisticated novice journal, which represents a destructive influence on the credibility of surgeons and scientists within many specialties. As an author, when the highly reputable, "whitelisted" journals in our field are not available or interested in the scope of our work, how can we ensure authenticity of those journals that exist in the gray area between legitimate and illegitimate? Given these questions, the goal of this article is to demystify the history and selected issues that surround academic publication including content access, licensing, indexing, and journal metrics. With this background, we then evaluate highly visible OA journals in plastic and reconstructive surgery and build a basic framework, which authors can use to evaluate a journal for legitimacy and visibility.
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http://dx.doi.org/10.1097/SAP.0000000000002902DOI Listing
December 2021

Breast Implants: Common Questions and Answers.

Am Fam Physician 2021 Nov;104(5):500-508

University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.

Breast implants are used for a wide range of cosmetic and reconstructive purposes. In addition to breast augmentation, implants can be used for postmastectomy breast reconstruction, correction of congenital breast anomalies, breast or chest wall deformities, and male-to-female top surgery. Breast implants may confer significant benefits to patients, but several factors are important to consider preoperatively, including the impact on mammography, future lactation, and potential long-term implant complications (e.g., infection, capsular contracture, rupture, and the need for revision, replacement, or removal). A fundamental understanding of implant monitoring is also paramount to implant use. Patients with silicone breast implants should undergo routine screening for implant rupture with magnetic resonance imaging or ultrasonography completed five to six years postoperatively and then every two to three years thereafter. With the exception of complications, there are no formal recommendations regarding the timing of breast implant removal or exchange. Women with unilateral breast swelling should be evaluated with ultrasonography for an effusion that might indicate breast implant-associated anaplastic large cell lymphoma. There are no specific breast cancer screening recommendations for patients with breast implants, but special mammographic views are indicated to enhance accuracy. Although these discussions are a routine component of consultation and postoperative follow-up for plastic surgeons performing these procedures, family physicians should have a working knowledge of implant indications, characteristics, and complications to better counsel their patients, to ensure appropriate screening, and to coordinate care after surgery.
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November 2021

The Need to Work Arm in Arm: Calling for Collaboration in Delivering Neuroprosthetic Limb Replacements.

Front Neurorobot 2021 21;15:711028. Epub 2021 Jul 21.

Division of Plastic Surgery, Department of Surgery, University of Wisconsin-Madison, Madison, WI, United States.

Over the last few decades there has been a push to enhance the use of advanced prosthetics within the fields of biomedical engineering, neuroscience, and surgery. Through the development of peripheral neural interfaces and invasive electrodes, an individual's own nervous system can be used to control a prosthesis. With novel improvements in neural recording and signal decoding, this intimate communication has paved the way for bidirectional and intuitive control of prostheses. While various collaborations between engineers and surgeons have led to considerable success with motor control and pain management, it has been significantly more challenging to restore sensation. Many of the existing peripheral neural interfaces have demonstrated success in one of these modalities; however, none are currently able to fully restore limb function. Though this is in part due to the complexity of the human somatosensory system and stability of bioelectronics, the fragmentary and as-yet uncoordinated nature of the neuroprosthetic industry further complicates this advancement. In this review, we provide a comprehensive overview of the current field of neuroprosthetics and explore potential strategies to address its unique challenges. These include exploration of electrodes, surgical techniques, control methods, and prosthetic technology. Additionally, we propose a new approach to optimizing prosthetic limb function and facilitating clinical application by capitalizing on available resources. It is incumbent upon academia and industry to encourage collaboration and utilization of different peripheral neural interfaces in combination with each other to create versatile limbs that not only improve function but quality of life. Despite the rapidly evolving technology, if the field continues to work in divided "silos," we will delay achieving the critical, valuable outcome: creating a prosthetic limb that is right for the patient and positively affects their life.
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http://dx.doi.org/10.3389/fnbot.2021.711028DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8334559PMC
July 2021

The Contribution of the Lower Third of the Face to Perceived Age: Do Masks Make You Appear Younger?

Aesthet Surg J Open Forum 2021 Sep 6;3(3):ojab017. Epub 2021 May 6.

Department of Surgery, Division of Plastic Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.

Background: There is evidence that changes to the midface and lower third of the face in isolation contribute significantly to one's perception of the overall facial age. Since the spread of the coronavirus disease 2019 (COVID-19), mask wearing has become commonplace. To date, there have been no studies that explore how covering the lower third of the face impacts the perception of age.

Objectives: The authors hypothesized that covering the lower third of the face with a mask will make a person appear younger.

Methods: One hundred consecutive plastic surgery patients were photographed in a standardized fashion, both masked and unmasked. A questionnaire for factors known to contribute to facial aging was administered. These photographs were randomized to 6 judges who estimated the patients' age and also quantified facial rhytids with the validated Lemperle wrinkle assessment score of 6. Data were analyzed using PROC MIXED analysis.

Results: Masked patients on average appeared 6.17% younger (mean difference = 3.16 years, < 0.0001). Wrinkle assessment scores were 9.81% lower in the masked group (mean difference = 0.21, = 0.0003). All subgroups appeared younger in a mask except for patients aged 18 to 40 years chronological age ( = 0.0617) and patients BMI > 35 ( = 0.5084).

Conclusions: The mask group appeared younger and had lower overall and visible wrinkle assessment scores when compared with the unmasked group. This has implications for our understanding of the contributions of the lower third of the face to overall perceived facial age.
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http://dx.doi.org/10.1093/asjof/ojab017DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8241419PMC
September 2021

Dermatologic Complications Following Cosmetic and Reconstructive Plastic Surgery: A Systematic Review of the Literature.

Aesthetic Plast Surg 2021 12 6;45(6):3005-3018. Epub 2021 Jul 6.

Division of Plastic Surgery, Department of Surgery, G5-347 Clinical Sciences Center, University of Wisconsin School of Medicine and Public Health, 600 Highland Avenue, Madison, WI, 53711, USA.

Purpose: Plastic surgery procedures, including minimally invasive cosmetic procedures, continue to grow in popularity. Although dermatologic complications following plastic surgery procedures are rare, the authors have encountered several of these complications in their practice, including herpes simplex virus (HSV-1) and varicella zoster virus (VZV) infections, pyoderma gangrenosum (PG), contact dermatitis, and suture hypersensitivity. These cases prompted a systematic literature review of dermatologic complications following plastic surgery procedures.

Methods: The authors conducted a systematic review of PubMed, MEDLINE, EMBASE, Scopus, Web of Science, and the Cochrane Library to identify relevant articles published from 1975 to 2021. Articles were independently reviewed by the authors to determine whether studies met inclusion criteria.

Results: The majority of articles that met inclusion criteria represented level V evidence. The most robust evidence in the literature was for PG, for which there were 63 total studies. Pyoderma gangrenosum was most frequently reported following breast surgery (85.1%), while HSV-1 infections were frequently seen following minimally invasive procedures (84.6%). VZV reactivation was reported after a range of interventions, including pedicled flap surgeries and laser treatments. Other complications, such as suture hypersensitivity, were less frequently reported in the literature, usually as isolated case reports.

Conclusions: Dermatologic complications represent a rare but serious concern following plastic surgery procedures. While most dermatologic complications resolve with appropriate treatment, sequelae of these conditions can be devastating to the patient's overall outcome. Plastic surgeons performing procedures at a high risk of these complications should recognize the diagnostic criteria to facilitate appropriate treatment.

Level Of Evidence Iii: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors   www.springer.com/00266 .
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http://dx.doi.org/10.1007/s00266-021-02362-9DOI Listing
December 2021

Rates of Ipsilateral Local-regional Recurrence in High-risk Patients Undergoing Immediate Post-mastectomy Reconstruction (AFT-01).

Clin Breast Cancer 2021 10 27;21(5):433-439. Epub 2021 Mar 27.

Wisconsin Surgical Outcomes Research Program, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI; University of Wisconsin Carbone Cancer Center, University of Wisconsin School of Medicine and Public Health, Madison, WI; Division of Plastic Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI. Electronic address:

Background: Some surgeons remain hesitant to perform immediate breast reconstruction (IBR) in patients with higher risk cancers owing to concerns about cancer recurrence and/or detection. Our objective was to determine the rate of ipsilateral local-regional recurrence for stage II/III patients who underwent IBR.

Methods: The National Cancer Database special study mechanism was used to create a stratified sample of women diagnosed with stage II/III breast cancer from 1217 facilities. Demographic, tumor, and recurrence data for women who underwent mastectomy with or without IBR were abstracted, including location of recurrence and method of detection. Estimates of 5-year local-regional recurrence rates were calculated and factors associated with recurrence were identified with multivariable Cox regression.

Results: Some 13% (692/5318) of stage II/III patients underwent IBR after mastectomy. Patients undergoing IBR were younger (P < .001), with fewer comorbid conditions (P < .001), and with lower tumor burden in the breast (P = .001) and the lymph nodes (P = 0.01). The 5-year rate of ipsilateral local-regional recurrence was 3.6% with no significant difference between patients with or without IBR (3.0% vs. 3.7%, P = .4). Most recurrences were detected by the patient (45%) or on physician examination (24%). Reconstruction was not associated with recurrence on multivariable analysis (hazard ratio = 0.83, P = .52).

Conclusion: Women with stage II/III breast cancer selected for IBR had similar rates of ipsilateral local-regional recurrence compared with those undergoing mastectomy alone. Offering IBR after mastectomy in a patient-centered manner to select patients with stage II/III breast cancer is an acceptable consideration.
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http://dx.doi.org/10.1016/j.clbc.2021.03.009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8881795PMC
October 2021

Reply: Slowing the Spread and Minimizing the Impact of COVID-19: Lessons from the Past and Recommendations for the Plastic Surgeon.

Plast Reconstr Surg 2021 06;147(6):1078e-1079e

Division of Plastic Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wis.

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http://dx.doi.org/10.1097/PRS.0000000000007961DOI Listing
June 2021

Effect of Nimodipine and Botulinum Toxin A on Peripheral Nerve Regeneration in Rats: A Pilot Study.

J Surg Res 2021 08 7;264:208-221. Epub 2021 Apr 7.

University of Wisconsin School of Medicine and Public Health, Division of Plastic Surgery, Department of Surgery, Madison, Wisconsin. Electronic address:

Background: Peripheral nerve damage is a frequent problem, with an estimated 2.8%-5.0% of trauma admissions involving peripheral nerve injury. End-to-end, tension-free microsurgical repair (neurorrhaphy) is the current gold standard treatment for complete transection (neurotmesis). While neurorrhaphy reapproximates the nerve, it does not address the complex molecular regenerative process. Evidence suggests that botulinum toxin A (BTX) and nimodipine (NDP) may improve functional recovery, but mechanisms of action remain unknown.

Methods: This research investigates BTX and NDP for their novel capacity to improve neural regeneration in the setting of neurorrhaphy using a Lewis rat tibial nerve neurotmesis model. In a triple-masked, placebo-controlled, randomized study design, we compared functional (rotarod, horizontal ladder walk), electrophysiological (conduction velocity, duration), and stereological (axon count, density) outcomes of rats treated with: NDP+saline injection, BTX+NDP, Saline+placebo, and BTX+placebo. Additional controls included sham surgery +/- BTX.

Results: NDP+saline outperformed other treatment groups in the ladder walk. This group had the fewest deep slips (15.07% versus 30.77% in BTX+NDP, P = 0.122), and the most correct steps (70.53% versus 55.58% in BTX+NDP, P = 0.149) in functional testing. NDP+saline also had the fastest nerve conduction velocity (0.811m/s versus 0.598m/s in BTX+NDP, P = 0.126) among treatment groups. BTX+NDP had the highest axon count (10,012.36 versus 7,738.18 in NDP+Saline, P = 0.009).

Conclusion: This study is the first to test NDP with BTX in a multimodal assessment of nerve recovery following neurotmesis and neurorrhaphy. NDP outperformed BTX+NDP functionally. Future work will focus on nimodipine in an effort to improve nerve recovery in trauma patients.
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http://dx.doi.org/10.1016/j.jss.2021.02.016DOI Listing
August 2021

Evaluation of Racial Disparities in Postoperative Outcomes Following Breast Reconstruction at a Single Institution in Wisconsin.

WMJ 2021 Mar;120(S1):S42-S47

University of Wisconsin School of Medicine and Public Health, Division of Plastic Surgery, Madison, Wisconsin,

Introduction: Breast cancer is the most common cancer in women in Wisconsin. Evidence demonstrates that non-White racial minorities in the United States exhibit a higher mortality rate and more advanced or aggressive presentations of the disease than their White counterparts. Postmastectomy breast reconstruction remains essential to the treatment and recovery of these patients; however, racial disparities in the receipt of reconstruction are evident. This study evaluates the presence of racial disparities in postoperative outcomes of breast reconstruction at a single institution in Wisconsin.

Methods: An institutional review board-exempt retrospective study of postoperative outcomes was performed using a single institution's National Surgical Quality Improvement Program Registry to identify patients who underwent autologous or prosthesis-based breast reconstruction following mastectomy. Patient demographic, preoperative, operative, and postoperative variables were recorded. Postoperative outcomes in relation to self-reported race were evaluated using univariate analysis and propensity score matching.

Results: A total of 1,140 patients were included (1,092 White vs 48 non-White), with fewer non-White patients undergoing reconstruction. Patients of non-White race demonstrated a higher incidence of morbid obesity (4.4% White vs 12.5% non-White,  = 0.010) and bleeding disorders (0.3% White vs 4.2% non-White,  < 0.001). No association between self-reported race and postoperative complication was found.

Conclusion: This study did not reveal racial disparities in postoperative outcomes of breast reconstruction at a single institution in Wisconsin; however, non-White patients were less likely to undergo reconstruction. Further research into the underlying causes of unequal access to care, influence of insurance, effect of structural racism, and impact of physician- and patient-associated factors is warranted.
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March 2021

Improving the Selectivity of an Osseointegrated Neural Interface: Proof of Concept For Housing Sieve Electrode Arrays in the Medullary Canal of Long Bones.

Front Neurosci 2021 15;15:613844. Epub 2021 Mar 15.

Division of Plastic Surgery, Department of Surgery, University of Wisconsin - Madison, Madison, WI, United States.

Sieve electrodes stand poised to deliver the selectivity required for driving advanced prosthetics but are considered inherently invasive and lack the stability required for a chronic solution. This proof of concept experiment investigates the potential for the housing and engagement of a sieve electrode within the medullary canal as part of an osseointegrated neural interface (ONI) for greater selectivity toward improving prosthetic control. are that (A) the addition of a sieve interface to a cuff electrode housed within the medullary canal of the femur as part of an ONI would be capable of measuring efferent and afferent compound nerve action potentials (CNAPs) through a greater number of channels; (B) that signaling improves over time; and (C) that stimulation at this interface generates measurable cortical somatosensory evoked potentials through a greater number of channels. The modified ONI was tested in a rabbit ( = 1) amputation model over 12 weeks, comparing the sieve component to the cuff, and subsequently compared to historical data. Efferent CNAPs were successfully recorded from the sieve demonstrating physiological improvements in CNAPs between weeks 3 and 5, and somatosensory cortical responses recorded at 12 weeks postoperatively. This demonstrates that sieve electrodes can be housed and function within the medullary canal, demonstrated by improved nerve engagement and distinct cortical sensory feedback. This data presents the conceptual framework for housing more sophisticated sieve electrodes in bone as part of an ONI for improving selectivity with percutaneous connectivity toward improved prosthetic control.
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http://dx.doi.org/10.3389/fnins.2021.613844DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8006940PMC
March 2021

The Impact of Prior Abdominal Surgery on Complications of Abdominally Based Autologous Breast Reconstruction: A Systematic Review and Meta-Analysis.

J Reconstr Microsurg 2021 Sep 1;37(7):566-579. Epub 2021 Mar 1.

Department of Surgery, Division of Plastic Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin.

Background:  Approximately half of all patients presenting for autologous breast reconstruction have abdominal scars from prior surgery, the presence of which is considered by some a relative contraindication for abdominally based reconstruction. This meta-analysis examines the impact of prior abdominal surgery on the complication profile of breast reconstruction with abdominally based free tissue transfer.

Methods:  Literature search was conducted using PubMed, Scopus, and Web of Science. Included studies examined patients with a history of prior abdominal surgery who then underwent abdominally based free flap breast reconstruction. Prior liposuction patients and those with atypical flap designs were excluded. The Newcastle-Ottawa Scale was used to assess study quality. Flap complications included total and partial flap loss, fat necrosis, infection, and reoperation. Donor-site complications included delayed wound healing, infection, seroma, hematoma, and abdominal wall morbidity (hernia, bulge, laxity). Relative risk and 95% confidence intervals (CIs) between groups were calculated. Forest plots, statistic heterogeneity assessments, and publication bias funnel plots were produced. Publication bias was corrected with a trim-and-fill protocol. Overall effects were assessed by fixed-effects and random-effects models.

Results:  After inclusion and exclusion criteria were applied, 16 articles were included for final review. These included 14 cohort and 2 case-control studies, with 1,656 (46.3%) patients and 2,236 (48.5%) flaps having undergone prior surgery. Meta-analysis showed patients with prior abdominal surgery were significantly more likely to experience donor-site delayed wound healing with a risk ratio of 1.27 (random 95% CI [1.00; 1.61]; = 4) after adjustment for publication bias. No other complications were statistically different between groups.

Conclusion:  In patients with a history of prior abdominal surgery, abdominally based free tissue transfer is a safe and reliable option. Abdominal scars may slightly increase the risk of delayed donor-site wound healing, which can aid the surgeon in preoperative counseling.
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http://dx.doi.org/10.1055/s-0041-1723816DOI Listing
September 2021

Breast Cancer Extirpation, Reconstruction, and COVID-19: Paradigm Shifting Management during a Global Pandemic.

Plast Reconstr Surg Glob Open 2021 Jan 31;9(1):e3396. Epub 2020 Dec 31.

Division of Plastic Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wis.

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http://dx.doi.org/10.1097/GOX.0000000000003396DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7861651PMC
January 2021

Risks of Free Tissue Transfer in the Hypocoaguable Patient.

J Reconstr Microsurg 2020 Mar 6;36(3):e5. Epub 2021 Feb 6.

Division of Plastic Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin.

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http://dx.doi.org/10.1055/s-0041-1723818DOI Listing
March 2020

Beyond the Core Suture: A New Approach to Tendon Repair.

Plast Reconstr Surg Glob Open 2020 Dec 17;8(12):e3280. Epub 2020 Dec 17.

Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wis.

Despite significant improvements in zone II flexor tendon repair over the last 2 decades, function-limiting complications persist. This article describes 2 novel repair techniques utilizing flexor digitorum superficialis (FDS) autografts to buttress the flexor digitorum profundus (FDP) repair site without the use of core sutures. The hypothesis being that the reclaimed FDS tendon autograft will redistribute tensile forces away from the FDP repair site, increasing overall strength and resistance to gapping in Zone II flexor tendon injuries compared with the current clinical techniques.

Methods: Two novel FDP repair methods utilizing portions of FDS have been described: (1) asymmetric repair (AR), and (2) circumferential repair. Ultimate tensile strength and cyclical testing were used to compare novel techniques to current clinical standard repairs: 2-strand (2-St), 4-strand (4-St), and 6-strand (6-St) methods. All repairs were performed in cadaveric sheep tendons (n = 10/group), by a single surgeon.

Results: AR and circumferential repair techniques demonstrated comparable ultimate tensile strength to 6-St repairs, with all 3 of these techniques able to tolerate significantly stronger loads than the 2-St and 4-St repairs ( 0.0001). Cyclical testing demonstrated that AR and circumferential repair were able to withstand a significantly higher total cumulative force ( 0.001 and = 0.0064, respectively) than the 6-St, while only AR tolerated a significantly greater force to 2-mm gap formation ( = 0.042) than the 6-St repair.

Conclusion: Incorporating FDS as an autologous graft for FDP repair provides at least a comparable ultimate tensile strength and a significantly greater cumulative force to failure and 2-mm gap formation than a traditional 6-St repair.
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http://dx.doi.org/10.1097/GOX.0000000000003280DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7787298PMC
December 2020

Augmentation of Chicken Thigh Model with Fluorescence Imaging Allows for Real-Time, High Fidelity Assessment in Supermicrosurgery Training.

J Reconstr Microsurg 2021 Jul 30;37(6):514-518. Epub 2020 Dec 30.

Division of Plastic Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin.

Background:  The skills required for supermicrosurgery are hard-earned and difficult to master. The University of Wisconsin "blue-blood" chicken thigh model incorporates perfusion of the thigh vessels with a blue liquid solution, allowing users to visualize flow across their anastomoses. This model has proven to be an excellent source of small vessels (down to 0.3 mm) but assessing the quality of anastomoses at this spatial scale has proven difficult. We evaluated whether fluorescent imaging with indocyanine green (ICG) in this realistic training model would enhance the assessment of supermicrosurgical anastomoses, and therefore improve real-time feedback to trainees.

Methods:  Anastomoses of vessels ranging from 0.35 to 0.55mm in diameter were performed followed by the capture of white light with and without fluorescence imaging overlay during infusion of "blue-blood" and ICG. Videos were randomized and shown to seven fellowship-trained microsurgeons at the University of Wisconsin-Madison who rated each anastomosis as "patent," "not patent," or "unsure." Surgeon accuracy, uncertainty, and inter-rater agreement were measured for each imaging modality.

Results:  Use of fluorescence significantly increased surgeon accuracy to 91% compared with 47% with white light alone ( = 0.015), decreased surgeon uncertainty to 4% compared with 41% with white light alone ( = 0.011), and improved inter-rater agreement from 53.1% with white light alone to 91.8% ( = 0.016).

Conclusion:  Augmentation of the University of Wisconsin "blue-blood" chicken thigh model with ICG fluorescence improves accuracy, decreases uncertainty, and improves inter-rater agreement when assessing supermicrosurgical anastomoses in a training setting. This improved, real-time feedback enhances this model's value as a supermicrosurgical training tool.
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http://dx.doi.org/10.1055/s-0040-1722184DOI Listing
July 2021

The Blue-Blood Porcine Chest Wall: A Novel Microsurgery Training Simulator for Internal Mammary Vessel Dissection and Anastomosis.

J Reconstr Microsurg 2021 May 21;37(4):353-356. Epub 2020 Sep 21.

Division of Plastic Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin.

Background:  Preparation of the internal mammary artery (IMA) is a critical step in autologous breast reconstruction. Intraoperatively, there is limited opportunity for residents to practice this skill. Porcine models provide highly realistic simulation for vascular surgery; however, use of live laboratory pigs is expensive, inconvenient, and offers limited opportunity for repetitive training. We aimed to develop an inexpensive and effective training model for IMA preparation. This article describes creation of a novel microsurgical model using cadaveric chest walls of Wisconsin Miniature Swine embedded in a modified mannequin thorax and augmented with a blue-blood perfusion system.

Methods:  Anatomic comparison: five porcine chest walls were dissected, and various anatomic measurements were made for anatomic comparison to existing human data in the literature. Model assembly: the chest wall is prepared by cannulating the proximal and distal ends of the internal mammary vessels with angiocatheters, which are then connected to the blue-blood perfusion system. The model is assembled in four layers including: (1) a mannequin thorax with a window removed to expose the first to fourth intercostal spaces, bilaterally, (2) a layer of foam simulating fat, (3) the perfused pig chest wall, and (4) a second mannequin shell placed posteriorly for support.

Results:  The porcine chest walls are similar to humans with regards to vessel size and location. This model can be assembled quickly, with a one-time approximate cost of $55.00, and allows for six training sessions per specimen. The model allows residents to practice the key steps of IMA preparation including dissection, elevation of perichondria, and vascular anastomosis while working at a depth that closely simulates the human thorax. Continuous blue-blood perfusion provides immediate feedback on anastomosis quality.

Conclusion:  Overall, this novel model can provide inexpensive and realistic simulation of internal mammary vessel preparation and anastomosis.
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http://dx.doi.org/10.1055/s-0040-1716859DOI Listing
May 2021
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