Evaluating Diversity Promotion on Integrated Plastic Surgery Residency Program Websites and Instagram Accounts.

BACKGROUND: Medical students applying to residency, including those from underrepresented groups, strongly value cultural fit and program diversity. Program websites and social media are thus an influential information source for prospective applicants and recruitment tool for residencies. We evaluated whether and how integrated plastic surgery residency program websites and social media display commitments to diversity online. METHODS: We evaluated program websites for 8 predetermined diversity elements, (1) nondiscrimination and (2) diversity statements, (3) community resources, (4) faculty and (5) resident biographies, (6) faculty and (7) resident photographs, and (8) resident resources, and assessed Instagram accounts for diversity-related images, captions, and hashtags. Our analysis used Mann-Whitney U , chi-squared, and t tests; significance level was P < 0.05. RESULTS: We reviewed 82 program websites with a mean of 3.4 ± 1.4 diversity elements. Resident (n = 76, 92.7%) and faculty photographs (n = 65, 79.3%) and resident biographies (n = 43, 52.4%) were the most common. Seventy programs (85.4%) had Instagram accounts, the majority of which (n = 41, 58.6%) shared content related to diversity in race, ethnicity, gender, and/or sexual orientation. Programs located in smaller cities were more likely to have ≥4 website diversity elements ( P = 0.014) and mention diversity on Instagram ( P = 0.0037). Programs with women chairs/chiefs were more likely to mention diversity on Instagram ( P = 0.007). CONCLUSIONS: In the age of virtual recruitment, program websites and social media should provide sufficient information, described in our diversity element checklist, to help prospective applicants determine fit from a diversity perspective. Residents, who often contribute to program social media, and women chairs/chiefs may be critical to driving diversity promotion.

Evaluating Language Characteristics and Related Gender Bias in Letters of Recommendation for Hand Surgery Fellowship.

PURPOSE: Letters of recommendation (LORs) function as an indicator of competence and future potential for a trainee. Our purpose was to evaluate gender bias in hand surgery fellowship applicant LORs. METHODS: This was a retrospective study of all LORs submitted to a hand surgery fellowship program between 2015 and 2020. Demographic data about applicants and letter writers were collected. Linguistic analysis was performed using a text analysis software, and results were evaluated with nonparametric tests, multiple linear regression models, and a mixed effects regression model. RESULTS: Letters of recommendation were analyzed; 720 letters for 188 (23.4%) female applicants and 2,337 letters for 616 (76.6%) male applicants. Compared with LORs written for men, those written for women had more references to categories of anxiety (eg, worried and fearful) and affiliation (eg, ally and friend). Letters for women had more "clout." In subgroup analysis, letters for female plastic surgery applicants had more words signaling power, whereas recommendations for female applicants from orthopedic residencies had more words related to anxiety, achievement, work, and leisure. CONCLUSIONS: Letters of recommendation written for female residents applying to hand fellowship had more references to anxiety but were written with higher clout and more words of affiliation. Subgroup analysis looking at orthopedic and plastic surgery applicants separately found a mixed picture. Overall, these LORs written for applicants to hand fellowship had no notable specific patterns of gender bias in our analyses. CLINICAL RELEVANCE: Because programs look to train the next generation of hand surgeons, alerting letter readers to trends in implicit bias may help in the selection of qualified applicants. Bringing topics of implicit bias forward may help writers think more critically about word choice and topics.

Identifying Public Perceptions, Attitudes, and Concerns about Breast Implants and Their Complications: A National Survey.

BACKGROUND: Aesthetic and reconstructive implant-based breast operations are among the most common plastic surgery procedures. This study assessed the baseline knowledge of common breast implant-associated complications, and their influence on consideration of breast implants among adult laywomen within the United States. METHODS: Five hundred women were recruited through Amazon's Mechanical Turk. Respondents self-reported demographics and experience with breast implants. Questions were asked addressing respondents' understanding of complications and concerns regarding breast implants. RESULTS: Of the authors' cohort (average age, 37.8 ± 11.7 years), 12.0% had received breast implants, 72.8% knew someone with implants, and nearly 50% would consider receiving implants in the future. As many as 82.2% reported at least one concern influencing their consideration of implants: safety (75.2%), cost (70.0%), unnatural shape (43.3%), and feel (45.2%). Respondents not considering implants were significantly concerned by foreign body implantation ( P < 0.001). Almost 75% believed that implants last longer than 10 years. Following education about risks of capsular contracture and implant rupture, one-third of respondents considering implants and half of those unsure were "less likely" to receive implants. The majority were unchanged in their likelihood after learning about infection (74.4%) and implant migration (69.2%). Respondents with a history of implants were significantly less likely to believe there is strong evidence supporting the aforementioned complications ( P < 0.001). CONCLUSIONS: The rising awareness surrounding breast implant safety has the potential to significantly impact perceptions and receptivity. This study identifies public perceptions of common breast implant-associated complications and primary long-term concerns, highlighting the importance of education on postoperative complications in informed consent and surgical decision-making.

Prepectoral breast reconstruction is safe in the setting of post-mastectomy radiation therapy.

BACKGROUND: Many breast reconstruction patients undergo post-mastectomy radiation therapy (PMRT), which is well known to increase the risk of complications. There is limited data on outcomes and safety of prepectoral breast reconstruction in this setting. The purpose of this study was to compare the outcomes of prepectoral versus subpectoral two-stage breast reconstruction in patients undergoing PMRT. METHODS: We conducted a retrospective cohort study of two-stage breast reconstructions performed at our institution during a 22-month period. Patients who received PMRT were identified, and two cohorts were created: those who underwent prepectoral versus subpectoral reconstruction. We collected data including patient characteristics, operative variables, and clinical outcomes. Bivariate analyses and multivariable logistic regressions were conducted. RESULTS: We captured 313 patients (492 breasts) that had undergone two-stage reconstruction. A total of 69 breasts received PMRT; 28 were reconstructed prepectorally, and 41 breasts subpectorally. The two cohorts were well matched. We detected no differences in clinical outcomes between the two groups after a median follow-up time of 24 months. There, however, were differences in perioperative variables. Prepectoral reconstruction was associated with a shorter operative time, shorter length of hospital stay, higher cost, and shorter time to final reconstruction. Multivariable logistic regression demonstrated that prepectoral reconstruction is not an independent predictor of adverse events. CONCLUSIONS: Although radiation is a known risk factor for many complications following breast reconstruction, prepectoral device placement is safe in this high-risk population. Although the rate of capsular contracture is reported to be higher in the general prepectoral population, this was not found in our radiated prepectoral population.

Infections after mastectomy and tissue expander placement: A multivariate regression analysis.

BACKGROUND: While breast surgery is considered a clean case, tissue expander-based breast reconstruction (TE-BR) has infection rates quoted up to 31%, decidedly higher than the typical 1% to 2% rate of surgical site infections. Through multivariate regression, we sought to analyze risk factors that contribute to infections following TE placement. METHODS: A retrospective study reviewed all patients undergoing mastectomy with immediate or delayed TE placement over a 22-month period. Infections were defined as clinically documented cellulitis or infection, return to the operating room (RTOR) for suspected infection, or positive operative or seroma cultures. RESULTS: A total of 311 patients underwent mastectomy and TE placement to 490 breasts. 13.5% of breasts developed an infection prior to second stage reconstruction. Multivariate logistic regression indicated that patients who developed infections were older (52.8 vs. 47.6 years, OR 1.04, p = 0.02), had higher rates of full-thickness necrosis (24.6% vs. 3.6%, OR 6.64, p<0.01), had higher rates of seromas requiring drainage (33.3% vs. 11.5%, OR 2.79, p<0.01), and had longer periods of drain therapy (24.9 vs. 21.0 days, OR 1.04, p = 0.04). Logistic regression established that longer discharge antibiotic length was not protective against the development of infection. CONCLUSION: Patients were more likely to develop an infection as the length of surgical drain retention increased, patient age increased, or if they developed seromas and full-thickness necrosis. Longer post-operative antibiotics were not protective against the development of infection in this sample. Prospective studies are needed to assess how antibiotic lengths can affect the morbidity of patients undergoing TE-BR.

Recognizing the Vulnerable: Perspectives, Attitudes, and Interests of Women With Uterine Factor Infertility Towards Uterus Allotransplantation.

BACKGROUND: Uterine allotransplantation (UTx) is a novel therapy to allow women with uterine factor infertility (UFI) to bear their own children. To date, over 60 UTx have been performed, resulting in 15 live births. Our study investigates the attitudes, perspectives, and interests of women with UFI towards UTx. METHODS: Anonymous questionnaires were distributed electronically to women diagnosed with UFI at Johns Hopkins Hospital between the years 2003 and 2018. RESULTS: Thirty-one women with UFI were identified, resulting in 10 completed surveys. The average age was 31.7 ± 6.31 years, and the average age of diagnosis was 20 years (range 14-31); all 10 surveyed women had congenital UFI. Of note, 80% of women agreed that UTx should be an option for women with UFI, and 90% would consider receiving a UTx. The majority of the nine (90%) women who had previously heard of UTx learned about it from the news (5, 50%). When asked to rank the risks related to UTx in order of personal importance, only two women ranked themselves most important; the other woman ranked fetus and donor as more important. All women had health insurance (70% had private insurance), and 90% believed that UTx should be covered by health insurance. CONCLUSIONS: We surveyed women with UFI and found that the majority are willing to have UTx, despite the associated risks of the procedure. Taking into consideration the responses for ranking the importance of risks of the procedure, women with UFI should be considered a vulnerable population, requiring special considerations for UTx informed consents.

A New Decade for Diversity: Trends in Representation of Women at the Northeastern Society of Plastic Surgeons.

BACKGROUND: In 2018, the Northeastern Society of Plastic Surgeons first Women in Plastic Surgery was established, reflecting the national trend to address the gender gap between men and women in surgery. Conferences, such as the annual NESPS, are important opportunities to increase visibility of female role models and resources to address deterrents to surgical careers. We thus sought to examine the participation and visibility of women in the NESPS over the last decade. METHODS: Abstracts and programs from the NESPS regional conferences between 2013 and 2019 were accessed via the publicly available past meetings archives, and registration lists were provided by the NESPS. Registrants, panelists, speakers, moderators, and first author and senior author listed for each poster presentation, podium presentation was listed, sex was determined (male or female), and sex were aggregated by category of participation. Significance was set at a P value of less than 0.05. RESULTS: Registration of women for the NESPS annual conferences was constant for 5 years (2013-2017), followed by an increase in female registrants from 27.1% in 2017 to 42.3% in 2019. Female representation among poster and podium presentations also increased from 2017 to 2019 (7.7%-23.3% poster presentations and 11.1%-23.4% podium presentations). Invited positions (speakers, panelists, and moderators) had a peak of 32.2% in 2017, but otherwise, there is no clear evidence of improved representation of women. CONCLUSIONS: We found an increase in the proportion of female registrants at the annual NESPS conferences from 2013 to 2019. However, visibility of female participants fluctuated over the same period; addressing this represents one opportunity for closing the gender gap at the NESPS. As the percentage of female trainees continues to rise, we look to female faculty to continue to participate in educational events, such as the NESPS meeting, and to be present as role models for the growing new generation of female plastic surgeons.

Quantifying the Effect of Topical Nitroglycerin on Random Pattern Flap Perfusion in a Rodent Model: An Application of the ViOptix Intra.Ox for Dynamic Flap Perfusion Assessment and Salvage.

BACKGROUND: Near-infrared spectroscopy can detect changes in tissue oxygenation postoperatively that predict flap necrosis. The authors hypothesized that this technology can be applied along with topical nitroglycerin to measure an improvement in tissue oxygenation that correlates with tissue salvage. METHODS: Dorsal, random pattern flaps measuring 10 × 3 cm were raised using Sprague-Dawley rats. Tissue oxygenation was measured after flap elevation in 10 locations using the ViOptix Intra.Ox. Animals were divided into three groups that received 30 mg of topical nitroglycerin daily, twice-daily, or not at all. Oxygenation measurements were repeated on postoperative day 1 and animals were euthanized on day 7 and evaluated for tissue necrosis. RESULTS: Tissue necrosis was greatest in controls (51.3 mm) compared to daily (28.8 mm) and twice-daily nitroglycerin (18.8 mm; p = 0.035). Three flap perfusion zones were identified: healthy (proximal, 50 mm), necrotic (distal, 20 mm), and watershed. Immediate postoperative tissue oxygenation was highest in healthy tissue (57.2 percent) and decreased to 33.0 and 19.3 percent in the watershed and necrotic zones, respectively (p < 0.001). One day after treatment with nitroglycerin, oxygenation in the healthy zone did not increase significantly (mean difference, -1.5 percent). The watershed (17.8 percent; p < 0.001) and necrotic zones (16.3 percent; p <0.001) did exhibit significant improvements that were greater than those measured in control tissues (7.9 percent; both p < 0.001). CONCLUSIONS: Serial perfusion assessment using the ViOptix Intra.Ox measured a significant improvement in flap oxygenation after treatment with topical nitroglycerin. Within the watershed area of the flap, this increase in tissue oxygenation was associated with the salvage of ischemic tissue.

Revision Breast Reconstruction with Prepectoral Pocket Conversion of Submuscular Breast Implants.

BACKGROUND: Prepectoral reconstruction using prosthetic devices has demonstrated a notable increase in popularity and confers a number of advantages over subpectoral placement, including minimal animation, no pain secondary to muscle spasm, and less device displacement or malposition. As such, more women with implants in the dual-plane position are seeking a remedy for animation deformities, chronic pain caused by muscle spasm, and implant malposition. The purpose of this study was to review outcomes following the conversion from subpectoral to prepectoral implant placement. METHODS: This was a retrospective review of 63 patients who underwent breast implant conversion from the subpectoral plane to the prepectoral plane from 2009 to 2019. RESULTS: A total of 73 implant pocket conversions from subpectoral to prepectoral were performed on 41 women who met inclusion criteria for this study. The mean time interval from the initial subpectoral operation to the prepectoral conversion was 1608.4 days. The reasons cited for prepectoral conversion was animation deformity (87.8 percent), significant levels of pain related to the implant (34.1 percent), capsular contracture (26.8 percent), or asymmetries and implant displacements (9.8 percent); 7.8 percent of individuals continued to experience their presenting symptom after plane conversion. Rippling and wrinkling were noted in 19.5 percent of individuals and edge visibility was documented in 4.9 percent. Complication rates were low, and no patients experienced necrosis of the mastectomy flap or nipple-areola complex. CONCLUSIONS: The use of prepectoral conversion for revision implant-based breast reconstruction successfully resolves animation deformity. This technique can be reliably and safely performed in a variety of patient demographics. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

The Intra.Ox Near-Infrared Spectrometer Measures Variations in Flap Oxygenation That Correlate to Flap Necrosis in a Preclinical Rodent Model.

BACKGROUND: Mastectomy flap necrosis affects 7 to 40 percent of patients undergoing immediate breast reconstruction, with many cases resulting in infection and/or explantation. The Intra.Ox near-infrared spectrometer is a novel device that assesses tissue perfusion by measuring the interactions of light with oxygenated and deoxygenated hemoglobin. This handheld device facilitates serial flap perfusion assessment and may objectively identify at-risk tissues and guide evidence-based treatment algorithms. In this preliminary study, we hypothesized that the Intra.Ox spectrometer detects differences in tissue oxygenation that correlate to tissue necrosis. METHODS: Dorsal, random-pattern flaps measuring 10 × 3 cm were raised in eight male Sprague-Dawley rats. Intraoperative tissue oxygen saturation was measured using Intra.Ox in 10 standardized locations. On postoperative day 7, the skin flaps were evaluated for full-thickness necrosis. Data were analyzed using the chi-square test and one-way analysis of variance. A receiver operating characteristic curve assessed the accuracy of intraoperative tissue oxygenation in predicting the risk of flap necrosis. RESULTS: Tissue oxygen saturation exhibited a strong negative correlation to distance from the flap pedicle (r = -0.798). Oxygen saturation in tissue that developed necrosis averaged 32 percent, compared to 59 percent in tissues that did not (p < 0.001). The area under the receiver operating characteristic curve was 0.969. Post hoc oxygen saturation cutoffs with 100 percent specificity and sensitivity in predicting necrosis were identified at 46 percent and 54 percent, respectively. CONCLUSIONS: Intra.Ox detects significant differences in tissue oxygenation saturation that are associated with the risk for flap necrosis. This technology can be used to identify at-risk tissues and represents an avenue for research aimed at preventing flap necrosis.

Pectoral placement of tissue expanders affects inpatient opioid use.

Prepectoral breast reconstruction promises to minimize breast animation deformity and decrease pain associated with subpectoral dissection and tissue expansion. This latter benefit is particularly timely given the ongoing opioid epidemic; however, this theoretical benefit remains to be demonstrated clinically. As such, this study aimed to compare inpatient opioid use and prescription practices following prepectoral and subpectoral expander-based breast reconstruction. A retrospective review was performed of patients undergoing immediate tissue expander placement between January 2017 and April 2018. Medical records were reviewed for surgical details, 24-hour inpatient PRN opioid usage (oral morphine equivalents [OME]), and discharge prescriptions. Comparisons were made using chi-squared and student's t tests where appropriate. Two hundred and thirty-one patients were identified, (mean age 48.8 years), 222 of which met inclusion criteria. 89 underwent subpectoral and 133 prepectoral tissue expander placements. All but two subpectoral patients and two prepectoral patients were opioid-naïve. The rate of bilateral procedures did not differ between cohorts (P = .194). Overall, 94% of patients were discharged within 24 hours, and length of stay did not differ between cohorts (P = .0753). Two subpectoral and two prepectoral patients required prolonged admission due to postoperative pain. All patients were ordered standing acetaminophen, celecoxib, and gabapentin, and subpectoral patients cyclobenzaprine. Narcotic pain medication was offered on an "as needed" (PRN) basis. Opioid usage within the first 24-hours was halved in the prepectoral cohort (22.2 vs 44.5 OME, P = .0003), which was not associated with bi/unilaterality of procedure or the presence of any psychiatric conditions. The amount of opioids prescribed on discharge was not significantly different between cohorts (308.42 OME prepectoral vs 336.99 subpectoral, P = .3197). Prepectoral expander placement appears to be associated with decreased inpatient opioid use postoperatively. This may represent an opportunity to improve patient satisfaction and safety by decreasing outpatient opioid prescriptions.

Perspectives of 281 patients with Mayer-Rokitansky-Küster-Hauser Syndrome on uterine transplantation.

OBJECTIVES: To investigate the personal, ethical, and financial perspectives of individuals with Mayer-Rokitansky-Küster-Hauser syndrome (MRKH), a congenital uterine factor infertility condition, regarding uterine transplantation (UTx). DESIGN: Cross-sectional, quantitative survey. SETTING: A 60-item anonymous electronic questionnaire was disseminated via social media sites. PATIENTS: International members of the Beautiful You MRKH Foundation. INTERVENTIONS: None. MAIN OUTCOME MEASURES: The survey contained UTx educational materials followed by questions assessing participants' baseline knowledge, global perceptions, financial concerns, and ethical considerations regarding UTx. RESULTS: We received 281 responses, with a mean participant age of 28.2 ± 9.8 years. After reviewing the education material, most participants considered receiving a UTx (73%), believed that it should be an option for all women with uterine factor infertility (86%), and believed that it should be covered by health insurance (78%). Respondents perceived the benefits of the procedure to outweigh the risks (67%) and considered it to be an ethical procedure (82%). Almost one-half (49%) were willing to spend more than $10,000 out of pocket to receive the procedure. When asked to rank the risk of UTx to self, donor, and fetus in order of personal importance, 21% ranked their own safety last. CONCLUSION: There is a profound desire in the MRKH community for UTx to become more widely available and affordable. MRKH patients may represent a vulnerable population requiring special considerations for informed consent and rigorous evaluation for UTx. Providers caring for MRKH patients should be prepared to provide education about UTx and to thoughtfully engage with news and media outlets to communicate evidence-supported information.

Tissue Expander-Based Breast Reconstruction in the Prepectoral Versus Subpectoral Plane: An Analysis of Short-Term Outcomes.

BACKGROUND: Breast reconstruction is becoming an increasingly important and accessible component of breast cancer care. We hypothesize that prepectoral patients benefit from lower short-term complications and shorter periods to second-stage reconstruction compared with individuals receiving reconstruction in the subpectoral plane. METHODS: An institutional review board-approved retrospective review of all adult postmastectomy patients receiving tissue expanders (TEs) was completed for a 21-month period (n = 286). RESULTS: A total of 286 patients underwent mastectomy followed by TE placement, with 59.1% receiving prepectoral TEs and 40.9% receiving subpectoral TEs. Participants receiving prepectoral TEs required fewer clinic visits before definitive reconstruction (6.4 vs 8.8, P <0.01) and underwent definitive reconstruction 71.6 days earlier than individuals with subpectoral TE placement (170.8 vs 242.4 days, P < 0.01). Anesthesia time was significantly less for prepectoral TE placement, whether bilateral (68.0 less minutes, P < 0.01) or unilateral (20.7 minutes less, P < 0.01). Operating room charges were higher in the prepectoral subgroup ($31,276.8 vs $22,231.8, P < 0.01). Partial necrosis rates were higher in the prepectoral group (21.7% vs 10.9%, P < 0.01). CONCLUSIONS: Patients undergoing breast reconstruction using prepectoral TE-based reconstruction benefit from less anesthesia time, fewer postoprative clinic visits, and shorter time to definitive reconstruction, at the compromise of higher operating room charges.

Prepectoral 2-stage Breast Reconstruction with Carbon Dioxide Tissue Expansion.

Roughly 80% of patients undergoing mastectomy in the United States opt for reconstruction with implants. The introduction of acellular dermal matrices has allowed for placement of breast prostheses in the prepectoral plane, while a new carbon dioxide tissue expander (TE) (AeroForm) allows for needle-free, patient-controlled expansion. These 2 novel technologies have ushered in a new patient-centered era of breast reconstruction, with the possibility of reducing patient morbidity for the first time in decades. We hypothesize that AeroForm expanders placed in the prepectoral plane reduce time to second-stage reconstruction, reduce the number of clinic visits, and have lower complications than traditional saline TEs. METHODS: This is a retrospective review of all patients undergoing breast mastectomy and TE placement in the prepectoral plane over a 21-month period (169 patients, 267 breasts), comparing AeroForm expanders to TEs. RESULTS: The AeroForm group (n = 57) had a shorter period to second-stage reconstruction than the TE group (n = 210) (135.4 versus 181.7 days; P = 0.01) and required fewer clinic visits (5.1 versus 6.9; P < 0.01). Partial thickness (25.6% versus 12.3%, P = 0.03) and full thickness (8.7% versus 0.0%, P = 0.02) necrosis were more common in the saline cohort. The rates of infection, hematoma, and seroma requiring drainage were not statistically significant between the 2 groups. CONCLUSIONS: Two-staged breast reconstruction with the use of AeroForm expanders in the prepectoral space marks progress in improving care for breast cancer patients by demonstrating a reduction in some adverse events, the number of clinic visits, and the time to second-stage reconstruction.

Public Perceptions on Breast Implant-Associated Anaplastic Large Cell Lymphoma.

BACKGROUND: Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) has entered the spotlight, as several high-profile media outlets have begun to relay the evolving science to the public. This study aimed to gauge the baseline knowledge and concern regarding BIA-ALCL among adult laywomen within the United States. METHODS: Mechanical Turk was used to survey 500 American women on self-reported demographics, prior experience with breast implants, and 11 questions regarding their knowledge and concern regarding BIA-ALCL. Responses were reviewed for quality control before study inclusion. RESULTS: Overall, 12 percent of respondents had received breast implants and 73 percent knew someone with implants; 13.6 percent of respondents (including 51.7 percent of respondents with implants) had previously heard of BIA-ALCL. After providing information about its risk, 58.4 percent of respondents were still willing to receive a reconstructive implant and 45.8 percent a cosmetic implant; 35.8 percent reported they would be less likely to receive an implant. Of the respondents with breast implants, 66.7 percent reported some degree of concern regarding BIA-ALCL and 35.0 percent are strongly considering removing their implants. Those who had heard of BIA-ALCL consumed information from several sources, predominantly health professionals or media/health care blogs. Different sources of information were not associated with a respondent's degree of concern. CONCLUSIONS: Only a minority of American women have heard of BIA-ALCL and understand its association with breast implants. As plastic surgeons who perform breast reconstruction, we can promote the spread of information through the popular media and health care blogs to address this growing concern, particularly among women with existing breast implants.

Risk and Reward: Public Perception of Gluteal Fat Grafting Safety.

BACKGROUND: This study aims to understand how sociodemographic factors influence perceptions of "Brazilian Butt Lift" (BBL), the cosmetic procedure with the highest reported mortality rate, among adult women. We also investigate whether education about risks changes willingness to receive this procedure. METHODS: A Qualtrics© survey including education about BBL was administered on Amazon Mechanical Turk, with inclusion criteria of female sex. RESULTS: Survey data from 489 female participants were included. 78.1% of participants found the BBL mortality rate to be higher than expected. 70.1% of the original 177 willing or neutral participants became unwilling to undergo a BBL after education. Multivariate logistic regression indicated that individuals who were more willing to undergo BBL after education were individuals who have a diagnosis of body dysmorphic disorder (OR 60.5, p = 0.02) or have an acquaintance who received a BBL (OR 230.2, p < 0.01). CONCLUSIONS: Overall, survey participants were less willing to undergo BBL after learning its risks, indicating the critical role of patient education during informed consent. Additionally, individuals who are unhappy with their body shape, or who feel cultural or social pressure to attain a certain body shape, may accept higher levels of risk to improve their looks, suggesting patient motivation for the procedure may limit even the most effective informed consent process. In light of these findings, the surgical community may consider regulating the BBL procedure and improving safety using evidence-based risk reduction techniques. Ensuring that patients fully understand the risks associated with the BBL procedure is critical for both surgeon and patient. LEVEL OF EVIDENCE V: 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 .

Postoperative Free Flap Breast Protocol Optimizing Resources and Patient Safety.

BACKGROUND: As deep inferior epigastric artery perforator (DIEP) flaps have gained popularity in breast reconstruction, the postoperative care of these patients, including the appropriate hospital length-of-stay and the need for intensive care unit (ICU) admission, has become a topic of debate. At our institution, we have adopted a pathway that aims for discharge on postoperative day 3, utilizing continuous tissue oximetry without ICU admission. This study aims to evaluate outcomes with this pathway to assess its safety and feasibility in clinical practice. METHODS: A retrospective review was performed of patients undergoing DIEP flap breast reconstruction between January 2013 and August 2014. Data of interest included patient demographics and medical history as well as complication rates and date of hospital discharge. RESULTS: In total, 153 patients were identified undergoing 239 DIEP flaps. The mean age was 50 years (standard deviation [SD] = 10.2) and body mass index (BMI) 29.4 kg/m2 (SD = 5.2). Over the study period, the flap failure rate was 1.3% and reoperation rate 3.9%. Seventy-one percent of patients were discharged on postoperative day 3. Nine patients required hospitalization beyond 5 days. Theoretical cost savings from avoiding ICU admissions were $1,053 per patient. CONCLUSION: A pathway aiming for hospital discharge on postoperative day 3 without ICU admission following DIEP flap breast reconstruction can be feasibly implemented with an acceptable reoperation and flap failure rate.

Comparison of the ViOptix Intra.Ox Near Infrared Tissue Spectrometer and Indocyanine Green Angiography in a Porcine Bowel Model.

BACKGROUND: This study aims to directly compare measurements of tissue oxygenation obtained using the Intra.Ox (Vioptix Inc., Fremont, CA) near infrared spectrometer with the perfusion assessment of the indocyanine green (ICG)-based SPY Elite imaging system (Stryker Co., Kalamazoo, MI) in a porcine bowel model. METHODS: Two live minipigs underwent laparotomy and isolation of a 30-cm segment of a large bowel. Standardized oximetry measurements were taken along the segment of bowel immediately before, after, and serially for 30 minutes following transection. A 0.5 mg/kg dose of ICG was then injected intravenously and the SPY Elite system was used to visualize and quantify tissue perfusion. Pearson's correlation coefficients were calculated using the outcomes. RESULTS: Transected and ligated bowel yielded mean Intra.Ox measurements of 61% oxygenation at the proximal base of the limb and 27.8% at the distal edges. Analysis of the relative ICG fluorescence using the SPY Elite's proprietary software yielded perfusion estimates of 64.8% proximally and 6.8% distally. Intra.Ox and SPY Elite measurements demonstrate a Pearson product-moment correlation of 0.929. Repeat measurements at 15-mm intervals along the tissue yielded decreasing Intra.Ox measurements along the length of the flap that correlate to SPY Elite measurements (r = 0.645). CONCLUSION: Both the Intra.Ox and the SPY detected clinically relevant changes in bowel oxygenation following transection and ligation. The use of intravenous ICG dye did not appear to affect measurements of tissue oxygenation obtained using the Intra.Ox.

Cost Utility of Breast Tissue Expansion using Carbon Dioxide versus Saline: An Analysis of Infection Risk.

BACKGROUND: The AeroForm System, a needle-free, patient-controlled carbon dioxide-filled tissue expander, represents a novel option for tissue expansion in 2-stage breast reconstruction. This technology has previously been found to decrease time to expansion, health-care utilization, and infection rates. The purpose of this study was to determine the economic impact of the reduced infection rate observed with the AeroForm tissue expander as compared with saline tissue expansion. METHODS: A decision model incorporating costs, quality-adjusted life years, and clinical outcomes of infection was designed to evaluate the cost-efficacy of AeroForm tissue expanders versus conventional saline expanders. All statistical calculations were performed in the R statistical computing environment. RESULTS: Pooled infection rates from the published literature following saline and AeroForm tissue expander placement were 5.83% and 2.62%, respectively. Cost-utility analysis resulted in a baseline expected savings of $253.29 and an expected gain of 0.00122 quality-adjusted life years with AeroForm tissue expanders. One-way sensitivity analysis revealed that AeroForm tissue expanders were dominant when the surgical site infection rate was greater than 4.56% with traditional saline expanders. CONCLUSIONS: Clinical benefits of an innovation are no longer sufficient to justify its acquisition costs. Novel technologies must also demonstrate favorable economic outcomes. This cost-utility analysis demonstrates that the use of AeroForm expanders is likely a cost-saving technology for 2-stage breast reconstruction.

Latissimus Denervation: A Review of Evidence.

BACKGROUND: Breast reconstruction is becoming an increasingly important and accessible component of breast cancer care. Among the many reconstructive options available, the latissimus dorsi flap has experienced a renewal in popularity because of its favorable properties and outcomes when used for breast reconstruction. However, a limitation unique to latissimus-based reconstruction is inappropriate breast animation postoperatively, due to persistent thoracodorsal innervation of the latissimus dorsi muscle after transfer to the mastectomy site. METHODS: A comprehensive literature search of PubMed and MEDLINE was conducted for studies investigating the role of thoracodorsal denervation in latissimus-based breast reconstruction. Data on surgical techniques, type of intervention, objective outcome measurements, and patient satisfaction-based outcomes were reported. Additional data included patient sample size, follow-up length, and treatment of thoracodorsal nerve (e.g., resection versus transection and length of transection) when applicable. RESULTS: Sixty-six search results were reviewed for inclusion and nine qualified after exclusion criteria for a total of 361 patients undergoing either unilateral or bilateral latissimus flap reconstruction. Successful thoracodorsal denervation rates were included in most studies and outcomes measurements were heterogeneous. Eight out of nine studies included patient-reported symptoms of breast animation postoperatively. Based on these findings, a systematic approach is presented. CONCLUSION: We present this review to elucidate successful practices, identify current gaps in knowledge, and offer a systematic approach to this clinical challenge.