Decreased Use of Anti-Inflammatory Medications in Autoimmune Connective Tissue Disease Patients Following Breast Implant Removal: A National Analysis.

Background: Recent case studies demonstrate resolution of rheumatologic symptoms following implant explantation, raising concern around breast implant illness and associated inflammatory symptomatology. In patients with connective tissue disorders (CTD) and breast implants, we quantified the number of anti-inflammatory medications as a proxy for inflammation and disease burden before and after implant removal. Methods: Using the Clinformatics Data Mart Database, adult female patients from 2003 to 2021 were queried. Current Procedural Terminology codes were used to identify patients who underwent implant-based reconstruction and subsequent implant removal. International Classification of Diseases, Ninth (ICD-9) and Tenth Revision (ICD-10) codes identified patients with CTD. Filled prescriptions of anti-inflammatory drugs were quantified for each patient during the preoperative, perioperative, and postoperative windows surrounding breast implant removal. Results: Of 1015 patients meeting criteria (mean age 56 ± 12 years), 821 (81%) filled prescriptions during the preoperative window, 753 (74%) filled during the perioperative window, and 735 (73%) filled during the postoperative window. Patients filled significantly fewer postoperative prescriptions than preoperative prescriptions (P < .001).Statistically significant predictors of the number of anti-inflammatory prescriptions filled in the postoperative window included additional anti-inflammatory prescriptions filled in the preoperative (P < .001) and perioperative (P < .001) windows. Experiencing a complication was not associated with the number of prescriptions filled in the postoperative window (P = .935). Conclusions: We found a significant decrease in filled anti-inflammatory prescriptions in patients with known CTD following implant removal, suggesting that breast implant removal may help diminish inflammatory symptomology in predisposed patients.

A New Start with HAART: Evaluating Breast Reconstruction in the Era of Highly Active Antiretroviral Therapy.

Background: As HIV-positive individuals utilizing highly active antiretroviral therapy live longer, the burden of breast cancer increases in the population. Breast reconstruction is an integral aspect of surgical treatment for many patients after a breast cancer diagnosis, prompting this examination of the characteristics and outcomes of breast reconstruction in this growing patient population. Methods: Using Merative MarketScan Research Databases, a large multipayer database, HIV-positive adult patients who underwent autologous or implant-based breast reconstruction between 2007 and 2021 were identified using International Classification of Disease codes and Common Procedural Terminology codes. In both HIV-positive and -negative cohorts, patient demographics, procedure-related complications, and postoperative revisions were recorded. Shapiro-Wilk, chi-square, Wilcoxon-Mann-Whitney, and multivariable logistic regression tests were used for statistical analysis. Results: Of 173,421 patients who underwent breast reconstruction, 1816 had an HIV diagnosis. HIV-positive patients were younger (P < 0.001), underwent surgery more recently (P < 0.001), more often underwent immediate breast reconstruction (P < 0.001), and had higher comorbidity levels (P < 0.001). There was a regional variation in which the patient cohorts underwent breast reconstruction. There was no significant difference in overall complication rates between patient groups, but HIV-negative patients more often underwent revision procedures (P = 0.009). Conclusions: When compared to their HIV-negative counterparts, breast reconstruction can be considered safe and efficacious in patients living with HIV. HIV-positive patients are a growing demographic who seek breast reconstruction, and surgeons must continue to further understand the unique implications of breast reconstruction in this population.

Associations between prior COVID-19 infection and venous thromboembolism following common plastic surgery operations.

INTRODUCTION: SARS-CoV-2 (COVID-19) infection has been described as a cause of systemic hypercoagulability and a risk factor for the development of venous thromboembolism (VTE). Whereas some multispecialty studies have proposed a link between COVID-19 and postoperative thrombosis, other single-specialty studies have found no such association. We utilized a large national database to determine whether prior COVID-19 infection was associated with the incidence of VTE following common plastic surgery operations. METHODS: The Merative™ MarketScan® Research Databases were used to identify female patients who underwent index abdominal panniculectomy, breast reduction, autologous breast reconstruction, or implant-based breast reconstruction procedures between 2020 and 2021. International Classification of Disease, tenth edition (ICD-10) codes were used to identify patients diagnosed with COVID-19 preoperatively and those who experienced a VTE in the 90 days postoperatively. Propensity score matching and multivariable logistic regression were used to determine any independent association between COVID-19 and postoperative VTE. RESULTS: Twenty-four thousand two hundred and twenty-eight patients met inclusion criteria. Mean age at time of surgery was 44 years. Six percent carried a preoperative COVID-19 diagnosis, and postoperative VTE occurred in 1.3%. In a propensity-score-matched analysis of 2754 patients, COVID-19 did not significantly correlate with incidence of postoperative VTE (P = 0.463). Compared with a matched prepandemic cohort (14,151 patients), the incidence of VTE did not increase following any of the four studied procedures during the COVID-19 pandemic. CONCLUSION: This analysis of a national insurance claims database provides evidence against a link between resolved COVID-19 infection and VTE within 90 days of four common plastic surgery operations.

Lymphadenectomy After Melanoma-A National Analysis of Recurrence Rates and Risk of Lymphedema.

INTRODUCTION: Treatment for melanoma after a positive sentinel lymph node biopsy includes nodal observation or lymphadenectomy. Important considerations for management, however, involve balancing the risk of recurrence and the risk of lymphedema after lymphadenectomy. METHODS: From the Merative MarketScan Research Databases, adult patients were queried from 2007 to 2021. International Classification of Disease, Ninth (ICD-9) and Tenth (ICD-10) Editions, diagnosis codes and Current Procedural Terminology codes were used to identify patients with melanoma diagnoses who underwent an index melanoma excision with a positive sentinel lymph node biopsy (SLNB). Main outcomes were completion lymph node dissection (CLND) utilization after a positive SLNB, developing lymphedema with or without CLND, and nodal basin recurrence 3 months or more after index excision. Subanalyses stratified by index excision year (2007-2017 and 2018-2021) and propensity score matched were additionally conducted. Demographics and comorbidities (measured by Elixhauser index) were recorded. RESULTS: A total of 153,085,453 patients were identified. Of those, 359,298 had a diagnosis of melanoma, and 202,456 patients underwent an excision procedure. The study cohort comprised 3717 patients with a melanoma diagnosis who underwent an excision procedure and had a positive SLNB. The mean age of the study cohort was 49 years, 57% were male, 41% were geographically located in the South, and 24% had an Elixhauser index of 4+. Among the 350 patients who did not undergo CLND, 10% experienced recurrence and 22% developed lymphedema. A total of 3367 patients underwent CLND, of which 8% experienced recurrence and 20% developed lymphedema. Completion lymph node dissection did not significantly affect risk of recurrence [odds ratio (OR), 1.370, P = 0.090] or lymphedema (OR, 1.114, P = 0.438). After stratification and propensity score matching, odds of experiencing lymphedema (OR, 1.604, P = 0.058) and recurrence (OR, 1.825, P = 0.058) after CLND were not significantly affected. Rates of CLND had significantly decreased (P < 0.001) overtime, without change in recurrence rate (P = 0.063). CONCLUSIONS: Electing for nodal observation does not increase the risk of recurrence or reduce risk of lymphedema. Just as CLND does not confer survival benefit, its decreased utilization has not increased recurrence rate.

A national analysis of burn injuries among homeless persons presenting to emergency departments.

INTRODUCTION: Burn injuries among the homeless are increasing as record numbers of people are unsheltered and resort to unsafe heating practices. This study characterizes burns in homeless encounters presenting to US emergency departments (EDs). METHODS: Burn encounters in the 2019 Nationwide Emergency Department Sample (NEDS) were queried. ICD-10 and CPT codes identified homelessness, injury regions, depths, total body surface area (TBSA %), and treatment plans. Demographics, comorbidities, and charges were analyzed. Discharge weights generated national estimates. Statistical analysis included univariate testing and multivariate modeling. RESULTS: Of 316,344 weighted ED visits meeting criteria, 1919 (0.6%) were homeless. Homeless encounters were older (mean age 44.83 vs. 32.39 years), male-predominant (71% vs. 52%), and had more comorbidities, and were more often White or Black race (p < 0.001). They more commonly presented to EDs in the West and were covered by Medicaid (51% vs. 33%) (p < 0.001). 12% and 5% of homeless burn injuries were related to self-harm and assault, respectively (p < 0.001). Homeless encounters experienced more third-degree burns (13% vs. 4%; p < 0.001), though TBSA % deciles were not significantly different (34% vs. 33% had TBSA % of ten or lower; p = 0.516). Homeless encounters were more often admitted (49% vs. 7%; p < 0.001), and homelessness increased odds of admission (OR 4.779; p < 0.001). Odds of transfer were significantly lower (OR 0.405; p = 0.021). CONCLUSION: Homeless burn ED encounters were more likely due to assault and self-inflicted injuries, and more severe. ED practitioners should be aware of these patients' unique presentation and triage to burn centers accordingly.

Updated Trends and Outcomes in Autologous Breast Reconstruction in the United States, 2016-2019.

INTRODUCTION: Autologous breast reconstruction (ABR) has increased in recent decades, although concerns for access remain. As such, our goal is to trend national demographics and operative characteristics of ABR in the United States. METHODS: Using the National Inpatient Sample, 2016-2019, the International Classification of Disease , Tenth Edition codes identified adult female encounters undergoing ABR. Demographics and procedure-related characteristics were recorded. Discharge weights generated national estimates. Statistical analysis included univariate testing and multivariate regression modeling. RESULTS: A total of 52,910 weighted encounters met the criteria (mean age, 51.5 ± 10.0 years). Autologous breast reconstruction utilization increased (Δ = +5%), 2016-2019, primarily driven by a rise in deep inferior epigastric perforator (DIEP) reconstructions (Δ = +28%; incidence rate ratio [IRR], 1.070; P < 0.001), which were predominant throughout the study period (69%). More recent surgery year, bilateral reconstruction, higher income levels, commercial insurance, and care in the South US region increased the odds of DIEP-based ABR ( P ≤ 0.036). Transverse rectus abdominis myocutaneous flaps, bilateral reconstructions, higher comorbidity levels, and experiencing complications increased the length of stay ( P ≤ 0.038). Most ABRs (75%) were privately insured. The rates of immediate reconstructions increased over the study period (from 26% to 46%; IRR, 1.223; P < 0.001), as did the rates of bilateral reconstructions (from 54% to 57%; IRR, 1.026; P = 0.030). The rates of ABRs performed at teaching hospitals remained high (90% to 93%; P = 0.242). CONCLUSIONS: As of 2019, ABR has become more prevalent, with the DIEP flap constituting the most common modality. With the increasing ABR popularity, efforts should be made to ensure geographic and financial accessibility.

Risk Factors for Hardware Removal Following Bimaxillary Surgery: A National Database Analysis.

Orthognathic surgery typically relies on the rigid fixation of fracture fragments using metal hardware. Though hardware is usually intended to be implanted permanently, the removal of hardware (ROH) is sometimes indicated for a variety of reasons. The authors sought to identify risk factors for ROH following orthognathic surgery. The authors conducted a retrospective analysis of the Merative MarketScan Research Databases, 2007-2021 using Current Procedural Terminology (CPT) and International Classification of Disease (ICD-9 and ICD-10) codes to identify patients who underwent an index Le Fort 1 osteotomy and bilateral sagittal split osteotomy operation on the same day. Statistical analysis involved χ2, Shapiro-Wilk, Wilcoxon-Mann-Whitney, Poisson regression, and multivariable logistic regression tests. 4698 patients met the inclusion criteria. The mean age at surgery was 25 years, and 57% were female. ROH occurred in 5.9% of patients. The mean time to hardware removal was 190.5±172.4 days. In a multivariate logistic regression, increased odds of ROH were associated with older patient age [OR: 1.02 (1.01-1.03), P=0.046], sleep apnea [OR: 1.62 (1.13-2.32), P=0.018], and craniofacial syndrome and/or cleft diagnoses [OR: 1.88 (1.14-2.55), P<0.001]. In the same model, postoperative oral antibiotic prophylaxis was not associated with ROH (P=0.494). The incidence of all-cause complications [IRR: 1.03 (1.01-1.05), P<0.001] rose over the study period, while the incidence of ROH did not change significantly (P=0.281). Patients at elevated risk should be counseled on the increased possibility of a second operation for ROH before having orthognathic surgery to ensure expectations and health care utilization decisions align with the evidence.

Racial Disparities in Postoperative Breast Reconstruction Outcomes: A National Analysis.

BACKGROUND: Studies have shown that Black patients are more likely to experience complications following breast reconstruction compared to other racial groups. Most of these studies have been conducted on patient populations focusing on either autologous or implant-based reconstruction without possible predictive indicators for complication disparities for all types of reconstruction procedures. The aim of this study is to elucidate disparities among patient demographics by identifying predictors of complications and postoperative outcomes among different racial/ethnic patients undergoing breast reconstruction utilizing multi-state, multi-institution, and national level data. METHODS: Patients in the Optum Clinformatics Data Mart that underwent all billable forms of breast reconstruction were identified via CPT codes. Demographics, medical history, and postoperative outcome data were collected by querying relevant reports of CPT, ICD-9, and ICD-10 codes. Outcomes analysis was limited to the 90-day global postoperative period. A multivariable logistic-regression analysis was performed to ascertain the effects of age, patient reported ethnicity, coexisting conditions, and reconstruction type on the likelihood of any common postoperative complication occurring. Linearity of the continuous variables with respect to the logit of the dependent variable was confirmed. Odds ratios and corresponding 95% confidence intervals were calculated. RESULTS: From over 86 million longitudinal patient records, our study population included 104,714 encounters for 57,468 patients who had undergone breast reconstruction between January 2003 and June 2019. Black race (relative to White), autologous reconstruction, hypertension, type II diabetes mellitus, and tobacco use were independent predictors of increased likelihood of complication. Specifically, the odds ratios for complication occurrence for Black, Hispanic, and Asian ethnicity (relative to White) were 1.09, 1.03, and 0.77, respectively. Black patients had an overall breast reconstruction complication rate of 20.4%, while the corresponding rate for White, Hispanic, and Asian patients were 17.0%, 17.9%, and 13.2%, respectively. CONCLUSION: Our analysis of a national-level database shows that Black patients undergoing implant-based or autologous reconstruction have increased risk of complications, likely due to multifactorial components that play a role in the care of this patient population. While higher rates of comorbidities have been cited as a possible cause, providers must consider racial influences involving cultural context, historical mistrust in medicine, and physician/health institution factors that may drive this disparity of outcomes among our patients.

The Impact of Oncoplastic Reduction on Initiation of Adjuvant Radiation and Need for Reexcision: A Database Evaluation.

INTRODUCTION: Partial breast reconstruction with oncoplastic reduction can provide breast cancer patients with improved aesthetic outcomes after breast conservation therapy. This study evaluates the implications of simultaneous oncoplastic reduction with lumpectomy on complication rates, time to adjuvant radiation therapy, and rates of margin reexcision compared with lumpectomy alone. METHODS: The Clinformatics Data Mart Database is a national deidentified commercial claims data warehouse. From 2003 to 2020, adult female patients were queried to identify patients with a breast cancer diagnosis with International Classification of Disease codes. Among those, current procedural terminology codes were used to identify those who underwent lumpectomy alone versus lumpectomy with oncoplastic reduction. Patient demographics, complications, adjuvant oncologic therapies, and need for reexcision were recorded. Patients not continuously enrolled for at least 6 months before and after the index procedure were excluded. Multivariable regression and χ 2 tests were used for statistical analysis. RESULTS: Of 53,165 patients meeting criteria (mean age, 61.4 ± 11.6 years), 1552 (2.9%) underwent oncoplastic reduction. Diagnoses of most nonsurgical complications (seroma, wound dehiscence, postoperative infection, fat necrosis, tissue necrosis, and nonspecified complications of surgical care) were significantly higher in the oncoplastic reduction group, as were rates of some surgical complications (hematoma, seroma, and tissue debridement). However, undergoing oncoplastic reduction did not impact time to adjuvant radiation ( P = 0.194) and protected against positive margins requiring repeat lumpectomy or completion mastectomy ( P < 0.001). CONCLUSIONS: In patients undergoing breast conservation therapy, simultaneous oncoplastic reduction decreased occurrence of positive margins and did not impact time to adjuvant radiation therapy despite increased rates of surgical and nonsurgical complications.

Does Higher Intraoperative Fraction of Inspired Oxygen Improve Complication Rates Following Implant-Based Breast Reconstruction?

Background: The surgical literature debates about whether an average intraoperative fractional inspired level of oxygen (FiO2) greater than 80% confers lower postsurgical complication rates. Although some evidence demonstrates minimal or no difference in short-term mortality or surgical site infections, few studies suggest negative long-term outcomes. Objectives: To the best of our knowledge, this is the first study examining the relationship between intraoperative FiO2 levels and postoperative outcomes in the setting of immediate prepectoral implant-based breast reconstruction. Methods: The authors retrospectively reviewed the complication profiles of 309 patients who underwent prepectoral 2-stage breast reconstruction following mastectomy between 2018 and 2021 at a single institution. Two cohorts were created based on whether intraoperative FiO2 was greater than 80% or less than or equal to 80%. Complication rates between the cohorts were analyzed using Chi-squared test, Fisher's exact test, and multivariable logistic regressions. Variables examined included demographic information; smoking history; preexisting comorbidities; history of chemotherapy, radiation, or axillary lymph node dissection; and perioperative information. Results: Chi-squared and multivariable regression analysis demonstrated no significant difference between cohorts in complication rates other than reoperation. Reoperation rates were significantly increased in the FiO2 greater than 80% cohort (P = 0.018). Multivariable logistic regression also demonstrated that the use of acellular dermal matrix was significantly associated with increased postoperative complications (odds ratio 11.985; P = 0.034). Conclusions: Complication rates did not statistically differ in patients with varying intraoperative FiO2 levels outside of reoperation rates. In the setting of implant-based prepectoral breast reconstruction, hyperoxygenation likely does not lead to improved postsurgical outcomes.