Novel computational biology modeling system can accurately forecast response to neoadjuvant therapy in early breast cancer.

BACKGROUND: Generalizable population-based studies are unable to account for individual tumor heterogeneity that contributes to variability in a patient's response to physician-chosen therapy. Although molecular characterization of tumors has advanced precision medicine, in early-stage and locally advanced breast cancer patients, predicting a patient's response to neoadjuvant therapy (NAT) remains a gap in current clinical practice. Here, we perform a study in an independent cohort of early-stage and locally advanced breast cancer patients to forecast tumor response to NAT and assess the stability of a previously validated biophysical simulation platform. METHODS: A single-blinded study was performed using a retrospective database from a single institution (9/2014-12/2020). Patients included: ≥ 18 years with breast cancer who completed NAT, with pre-treatment dynamic contrast enhanced magnetic resonance imaging. Demographics, chemotherapy, baseline (pre-treatment) MRI and pathologic data were input into the TumorScope Predict (TS) biophysical simulation platform to generate predictions. Primary outcomes included predictions of pathological complete response (pCR) versus residual disease (RD) and final volume for each tumor. For validation, post-NAT predicted pCR and tumor volumes were compared to actual pathological assessment and MRI-assessed volumes. Predicted pCR was pre-defined as residual tumor volume ≤ 0.01 cm3 (≥ 99.9% reduction). RESULTS: The cohort consisted of eighty patients; 36 Caucasian and 40 African American. Most tumors were high-grade (54.4% grade 3) invasive ductal carcinomas (90.0%). Receptor subtypes included hormone receptor positive (HR+)/human epidermal growth factor receptor 2 positive (HER2+, 30%), HR+/HER2- (35%), HR-/HER2+ (12.5%) and triple negative breast cancer (TNBC, 22.5%). Simulated tumor volume was significantly correlated with post-treatment radiographic MRI calculated volumes (r = 0.53, p = 1.3 × 10-7, mean absolute error of 6.57%). TS prediction of pCR compared favorably to pathological assessment (pCR: TS n = 28; Path n = 27; RD: TS n = 52; Path n = 53), for an overall accuracy of 91.2% (95% CI: 82.8% - 96.4%; Clopper-Pearson interval). Five-year risk of recurrence demonstrated similar prognostic performance between TS predictions (Hazard ratio (HR): - 1.99; 95% CI [- 3.96, - 0.02]; p = 0.043) and clinically assessed pCR (HR: - 1.76; 95% CI [- 3.75, 0.23]; p = 0.054). CONCLUSION: We demonstrated TS ability to simulate and model tumor in vivo conditions in silico and forecast volume response to NAT across breast tumor subtypes.

Evaluating Autologous Lipofilling for Parry-Romberg Syndrome-Associated Defects: A Systematic Literature Review and Case Report.

BACKGROUND: Parry-Romberg syndrome (PRS) is a rare craniofacial disease that causes progressive hemifacial atrophy of the soft tissue before spontaneously entering remission. Autologous fat grafting may provide a less invasive alternative, producing aesthetically pleasing results while avoiding the need for traditional microsurgical free flap coverage. METHODS: A systematic review of the literature was conducted. Inclusion and exclusion criteria were applied. The case report highlights the technique using two-dimensional and three-dimensional photography. RESULTS: Our review yielded 31 articles in addition to our case describing 147 cases of lipofilling to correct PRS soft-tissue defects. Patients underwent an average of 2.2 procedures, receiving on average 95 mL of grafted fat. Disease severity was classified into mild (41%), moderate (42%), and severe (17%) in the identified patients. Increasing disease severity correlated with an increasing number of procedures and fat-grafting volumes to achieve adequate aesthetic outcomes (mean, 1.5 and 38 mL; 2.3 and 81 mL; 3.7 and 129 mL, respectively). Reported benefits over flap-based reconstructions included reductions in cost (40%), operative time (50%), donor-site morbidity (52%), and rate of complications (33%). Aesthetic benefits cited included improved skin quality (65%), more natural contours (1%), and more natural facial expressions (10%). CONCLUSION: Fat grafting for correction of PRS-associated soft-tissue defects is receiving heightened acceptance for its ability to restore natural facial contours. While additional fat-grafting procedures may be required with increased disease severity, autologous fat grafting may be a beneficial option as a sole modality to correct PRS-associated soft-tissue atrophy.

Assessing Outcomes and Safety of Inpatient Versus Outpatient Tissue Expander Immediate Breast Reconstruction.

BACKGROUND: With the rising cost of healthcare delivery and bundled payments for episodes of care, there has been impetus to minimize hospitalization and increase utilization of outpatient surgery mechanisms. Given the increase in outpatient mastectomy and immediate tissue expander (TE)-based reconstruction and the paucity of data on its comparative safety to inpatient procedures, we sought to understand the risk for early postoperative complications in an outpatient model compared with more traditional inpatient status using the National Surgical Quality Improvement Program database. METHODS: NSQIP data files from 2005 to 2012 were queried to identify patients undergoing immediate TE-based breast reconstruction after mastectomy. Patients were stratified by whether they received outpatient or inpatient care and then propensity score matched based on preoperative baseline characteristics to produce matched cohorts. Multivariate regression analysis was used to determine whether outpatient versus inpatient status conferred differing risk for 30-days complications. RESULTS: Of the 2014 patients who met criteria, 1:1 propensity matching yielded 634 patients in each of the matched cohorts. Overall complications (5.2 vs. 5.4 %), overall surgical complications (4.3 vs. 3.9 %), overall medical complications (1.3 vs. 2.1 %), and return to the operating room (6.6 vs. 7.3 %) were similar between outpatient and inpatients cohorts (p > .2), respectively. There was a small, but significant increased risk of organ/space SSI in outpatients (1.9 vs. 0.5 %, p = .02) and trend for increased risk for pulmonary embolus (PE) and urinary tract infection (UTI) in inpatients (0.3 vs. 0 %, p = .16; 0.3 vs. 0 %, p = .16). CONCLUSIONS: Our studies suggest that outpatient TE confers similar safety profiles to inpatient TE with regards to 30-day postoperative overall complications, medical and surgical morbidity, and return to the operating room. A slightly increased risk for surgical site infection must be balanced against potential risk for known inpatient-related complications such as UTI and PE.

Assessing safety and outcomes in outpatient versus inpatient thyroidectomy using the NSQIP: a propensity score matched analysis of 16,370 patients.

BACKGROUND: With increasing economic healthcare constraints and an evolving understanding of patient selection criteria and patient safety, outpatient thyroidectomy is now more frequently employed. However, robust statistical analyses evaluating outcomes and safety after outpatient thyroidectomy with matched comparisons to inpatient cohorts are lacking. METHODS: The 2011-2012 NSQIP datasets were queried to identify all patients undergoing thyroidectomy. Inpatient and outpatient procedures cohorts were matched 1:1 using propensity score analysis to assess outcomes. Outcomes of interest included surgical and medical complications, reoperation, mortality, and readmission. Univariate and multivariate analyses were utilized to identify predictors of these events. Relative risk ratios were calculated for adverse events between inpatient and outpatient cohorts. RESULTS: In total, 21,508 patients were identified to have undergone a thyroidectomy in 2011-2012. Inpatients and outpatients were matched 1:1 with respect to preoperative and operative characteristics, leaving 8,185 patients in each treatment arm. After matching, overall 30-day morbidity was rare with only 250 patients (1.53 %) experiencing any perioperative morbidity. 476 patients (2.91 %) were readmitted within 30-days of the operation. Both pre- and post-matching, inpatient thyroidectomy was associated with increased risks of readmission, reoperation, and any complication. CONCLUSIONS: Based on this comprehensive population-based study, outpatient thyroidectomy appears to be at least as safe as inpatient thyroidectomy. However, there are still differences in outcomes between inpatient and outpatient cohorts, despite statistical matching of preoperative and intraoperative variables. Future research needs to be spent identifying these as-of-yet unknown risk factors to resolve this discrepancy.

Mohs moat: peripheral cutaneous margin clearance in a collaborative approach for aggressive and deeply invasive basal cell carcinoma.

Although Mohs micrographic surgery is the standard of care for large, aggressive or recurrent non-melanoma skin cancers of the head and neck, tumours that involve deep underlying structures (including bone, parotid gland and named nerves) are impractical for extirpation under local anaesthesia. Such cases are often referred to a head and neck surgeon, who typically relies on intraoperative frozen section analysis of the peripheral cutaneous margin. Here we describe the use of the Mohs moat technique as part of a collaborative approach for the treatment of aggressive and deeply invasive basal cell carcinoma that allows an analysis of the complete peripheral cutaneous margin and results in decreased operating room and general anaesthesia time.

Single-stage nipple-areolar complex reconstruction technique, outcomes, and patient satisfaction.

INTRODUCTION: Nipple-areolar reconstruction (NAR) is the final phase of breast reconstruction and is associated with increased patient satisfaction. Nipple-areolar reconstruction is typically performed in 2 separate stages, which include nipple reconstruction and tattooing of the nipple-areolar complex (NAC). Previous studies have demonstrated that increased duration of the reconstruction is associated with decreased patient satisfaction. Because a 2-stage reconstruction prolongs the reconstructive process, we introduce a simple and novel method of single-stage NAR (SS NAR), which combines the use of local flaps for nipple reconstruction and medical tattooing of the NAC in 1 session and delivers predictable outcomes with high patient satisfaction. METHODS: A retrospective chart review of patients who underwent SS NAR at our institution during the period from September 2010 to May 2012 was performed. Patient demographics, complications, outcomes, and overall patient satisfaction were assessed. A modified questionnaire (Likert scale) was used to assess patient satisfaction of nipple size, color, shape, and projection. RESULTS: Twenty-nine SS NARs were performed in 18 patients: 7 unilateral and 11 bilateral. Mean age was 45 years (range, 34-60 years). No major complications were identified. Mean length of follow-up was 10 months (range, 2-22 months). A 17% complication rate was observed: 14% (4/29) had irregular dye uptake of the areola, and 3% (1/29) had dehiscence from silicone guard pressure on the incision. Two patients underwent revisions: one patient underwent additional tattooing, and the other required flap readvancement and implant downsizing secondary to the wound dehiscence. We obtained a 70% survey response rate with 100% of responders who reported that they were "very satisfied" with NAC in each dimension. CONCLUSIONS: Our study demonstrates that SS NAR is a safe procedure with reproducible, excellent clinical results and very low complication rates or need for revisions. This method is cost-effective, convenient for the patient, and shortens patient recovery time with high patient satisfaction.

Bilateral implant breast reconstruction: outcomes, predictors, and matched cohort analysis in 730 2-stage breast reconstructions over 10 years.

BACKGROUND: Rates of bilateral implant breast reconstruction (BI/BR) are rising despite the lack of precise information. Previous studies have examined unilateral reconstruction, making it difficult to counsel patients regarding the risk of BI/BR. The purpose of this study was to identify the incidence of complications and predictors of unfavorable aesthetic outcomes in the largest study to date of exclusive 2-stage BI/BR. Furthermore, a novel matched cohort analysis was conducted in patients who underwent contralateral prophylactic mastectomy and therapeutic mastectomy, whereby each patient acts as her own perfect internal control. METHODS: A retrospective chart review of consecutive patients who underwent BI/BR from 1997 to 2007 was performed to obtain patient demographics, treatment, and outcomes. Univariate and multivariate logistic regression analyses were performed to determine risk factors leading to the development of unfavorable aesthetic outcomes. χ test and Fisher exact analysis were used for matched-pairs analysis. RESULTS: Seven hundred thirty 2-stage BI/BRs were performed in 365 patients; perioperative complication rates were low at 9.3%. Long-term outcomes/unfavorable aesthetics were rippling (12.7%), capsular contracture (8.4%), and malposition (7.8%). After regression analysis, age [odds ratio (OR), 1.05], radiation (OR, 4.27), and length of follow-up (OR, 1.48) were significantly associated with capsular contracture. Radiation (OR, 0.26) and body mass index (OR, 0.95) were inversely associated with rippling. In the matched cohort, complication rates were similar between sides with malposition and rippling as significantly different aesthetic outcomes (P < 0.05). Adjusted individual complication rates in the bilateral cohort of 18.4% were comparable with previous mixed and majority unilateral cohorts in the literature. CONCLUSIONS: Bilateral implant breast reconstruction has become increasingly prevalent for patients with breast cancer. Overall complications are low; BI/BR does not appear to incur additive risk. Matched cohort analysis confirmed low complication rates with only malposition and rippling as significant differences between sides.

Ulnar forearm free flaps in head and neck reconstruction: systematic review of the literature and a case report.

OBJECTIVE: Under the assumption that the ulnar artery is the predominant blood supply to the hand, radial forearm free flaps (RFFF) generally have been preferred over ulnar forearm free flaps (UFFF) in head and neck reconstruction. The objective of this study is to create the first and only systematic review of the literature regarding UFFF in head and neck reconstruction, assessing the usage, morbidity, complications, and rationale of its use. METHODS: A systematic review of the literature was conducted using PubMed, including Mesh terms and manual searches. Articles not in English were excluded. RESULTS: Seventeen articles of the 80 articles identified by our search criteria met inclusion criteria; a total of 682 cases of UFFF were identified, including our patient case. Fifty-five percent of the cases involved use of the Allen's test. Mean flap size was 6.1 × 10.5 cm. Of the 432 cases reporting flap survival, 14 (3.2%) flap losses were reported, 13 total (3.0%), and one partial (0.2%). The UFFF was preferred to the RFFF due to decreased hirsutism (61%), better cosmetic outcomes (91%), and better post-operative hand function with reduced donor site morbidity (73%). For the case report, an UFFF was used successfully for lid reconstruction and resurfacing in a 72-year-old man who presented with late ectropion and exposure keratopathy following maxillary resection for leiomyosarcoma. CONCLUSIONS: This is the first and only systematic review of the literature to date of UFFF in head and neck reconstruction. Our review demonstrates that the UFFF rarely results in flap loss, donor site morbidity, or hand ischemia, instead providing enhanced outcomes. With its many surgeon-perceived advantages and minimal morbidity, the UFFF may become a preferred forearm flap for head and neck reconstruction.

Next generation immuno-oncology tumor profiling using a rapid, non-invasive, computational biophysics biomarker in early-stage breast cancer.

Background: Immuno-oncology (IO) therapies targeting the PD-1/PD-L1 axis, such as immune checkpoint inhibitor (ICI) antibodies, have emerged as promising treatments for early-stage breast cancer (ESBC). Despite immunotherapy's clinical significance, the number of benefiting patients remains small, and the therapy can prompt severe immune-related events. Current pathologic and transcriptomic predictions of IO response are limited in terms of accuracy and rely on single-site biopsies, which cannot fully account for tumor heterogeneity. In addition, transcriptomic analyses are costly and time-consuming. We therefore constructed a computational biomarker coupling biophysical simulations and artificial intelligence-based tissue segmentation of dynamic contrast-enhanced magnetic resonance imaging (DCE-MRIs), enabling IO response prediction across the entire tumor. Methods: By analyzing both single-cell and whole-tissue RNA-seq data from non-IO-treated ESBC patients, we associated gene expression levels of the PD-1/PD-L1 axis with local tumor biology. PD-L1 expression was then linked to biophysical features derived from DCE-MRIs to generate spatially- and temporally-resolved atlases (virtual tumors) of tumor biology, as well as the TumorIO biomarker of IO response. We quantified TumorIO within patient virtual tumors (n = 63) using integrative modeling to train and develop a corresponding TumorIO Score. Results: We validated the TumorIO biomarker and TumorIO Score in a small, independent cohort of IO-treated patients (n = 17) and correctly predicted pathologic complete response (pCR) in 15/17 individuals (88.2% accuracy), comprising 10/12 in triple negative breast cancer (TNBC) and 5/5 in HR+/HER2- tumors. We applied the TumorIO Score in a virtual clinical trial (n = 292) simulating ICI administration in an IO-naïve cohort that underwent standard chemotherapy. Using this approach, we predicted pCR rates of 67.1% for TNBC and 17.9% for HR+/HER2- tumors with addition of IO therapy; comparing favorably to empiric pCR rates derived from published trials utilizing ICI in both cancer subtypes. Conclusion: The TumorIO biomarker and TumorIO Score represent a next generation approach using integrative biophysical analysis to assess cancer responsiveness to immunotherapy. This computational biomarker performs as well as PD-L1 transcript levels in identifying a patient's likelihood of pCR following anti-PD-1 IO therapy. The TumorIO biomarker allows for rapid IO profiling of tumors and may confer high clinical decision impact to further enable personalized oncologic care.

Microvascular approach to scalp replantation and reconstruction: a thirty-six year experience.

BACKGROUND: Soft tissue defects of the scalp may result from multiple etiologies and can be challenging to reconstruct. We discuss our experience with scalp replantation and secondary microvascular reconstruction over 36 years, including techniques pioneered at our institution with twin-twin scalp allotransplant and innervated partial superior latissimus dorsi (LD) for scalp/frontalis loss. METHODS: A retrospective review of all patients presenting with scalp loss requiring microvascular reconstruction at a single center was performed from January 1971 to January 2007. Medical records were reviewed for age, gender, defect size/location, etiology, type of reconstruction, recipient vessels used, vein grafts, and complications. RESULTS: Thirty-three patients were identified; mean age was 33 years (range, 7-79). Mean scalp defect size was 442 cm(2) (range, 120-900 cm(2)). Thirty-six microvascular reconstructions were performed; of these, 10 scalp replants and 26 microvascular tissue transfers. Of these 26, 17 were LD based (partial superior LD with and without reinnervation, LD combined with serratus, LD combined with parascapular, LD combined with split rib, LD only) and 2 free scalp allotransplant among others. The superficial temporal artery and vein was used as recipient vessels in 70% of cases. Overall, microvascular success rate was 92%; complications occurred in 14 cases, nine major (tumor recurrence [n = 2], partial flap loss [n = 2], replant loss [n = 3, size <300 cm(2) ], hematoma [n = 2]) and five minor (donor site seroma /hematoma [n = 3], flap congestion [n = 1], superficial wound infection [n = 1]). CONCLUSIONS: Every attempt should be made at scalp replantation when the patient is stable and the parts salvageable. Larger avulsion defects had higher success rates after replantation than smaller defects (<300 cm(2) ), with the superficial temporal artery and vein most commonly used for recipient vessels (P = 0.0083). Microvascular tissue transfer remains a mainstay of treatment for scalp defects, with LD-based flaps, demonstrating excellent versatility for a range of defects.

Upregulation of neurodevelopmental genes during scarless healing.

Scarless fetal skin wound healing is a paradigm for ideal skin repair and is dependent on peripheral nerve function.To further explore neurogenic mechanisms influence on the scarless skin repair, fetal rats were wounded on gestational days 16 (E16; n = 24) and 18 (E18; n = 8) and wounds were harvested at 1 and 3 days after injury. Unwounded skin at identical gestational age was used for control comparison. The scarless E16 and scarring E18 wounds underwent macroarray gene expression analysis (1172 genes).During the scarless healing period, 53 (4.5%) genes had a statistically significant upregulation post-injury with at least a 2- to 3-fold change 1 day after wounding and 14 (1.2%) genes 3 days after wounding (P < 0.05). Many neurodevelopmental genes were increased during scarless repair on post-injury days 1 and 3. Neuropeptide Y Receptor type I, cJun related Transcription Factor (junD), Synaptophysin, SNAP 25, Neuronal calcium sensor 1 (NCS1), neural visine-like calcium binding protein 1 (NVP1), nerve growth factor-induced gene A (NGFI-A/EGR1), VGF8A protein, p27kip1, and members of the GABA and serotonin family each had 2- to 3-fold expression increases (P < 0.05).We speculate that fetal skin cells express neurotrophins during skin development that regulate peripheral neuron formation. During injury these factors promote the survival and regeneration of peripheral neurons; this interaction of neuropeptides, neuropeptide receptors, and neurotrophins may modulate the fetal scarless repair mechanisms in response to injury. Identification of these neurodevelopmental candidate genes provides insight for new investigation into mechanisms regulating scarless healing.

An interactive tool to forecast US hospital needs in the coronavirus 2019 pandemic.

OBJECTIVE: We developed an application (https://rush-covid19.herokuapp.com/) to aid US hospitals in planning their response to the ongoing Coronavirus Disease 2019 (COVID-19) pandemic. MATERIALS AND METHODS: Our application forecasts hospital visits, admits, discharges, and needs for hospital beds, ventilators, and personal protective equipment by coupling COVID-19 predictions to models of time lags, patient carry-over, and length-of-stay. Users can choose from 7 COVID-19 models, customize 23 parameters, examine trends in testing and hospitalization, and download forecast data. RESULTS: Our application accurately predicts the spread of COVID-19 across states and territories. Its hospital-level forecasts are in continuous use by our home institution and others. DISCUSSION: Our application is versatile, easy-to-use, and can help hospitals plan their response to the changing dynamics of COVID-19, while providing a platform for deeper study. CONCLUSION: Empowering healthcare responses to COVID-19 is as crucial as understanding the epidemiology of the disease. Our application will continue to evolve to meet this need.

Single stage, direct to implant pre-pectoral breast reconstruction.

BACKGROUND: Given the current trends in skin preservation during mastectomy, improved biofilm reduction algorithms, and advancements in tissue bioengineering and perfusion assessment, acellular dermal matrix (ADM)-reinforced single stage, direct to implant insertion in the pre-pectoral space has become a viable alternative to two-stage expander-based, sub-pectoral reconstruction. METHODS: The authors performed a retrospective review of their pre-pectoral cases evaluating outcomes for all single stage, direct to implant procedures. Outcomes reviewed included hematoma, seroma, infection, device loss or change, animation deformity and revisional procedures such as fat grafting. The anterior tenting surgical technique is also reviewed. RESULTS: The authors have carried out 305 direct to implant pre-pectoral breast reconstructions using an anterior tenting technique with low complication rates and superior clinical and functional outcomes. The benefits of this technique include less patient discomfort, no need for postoperative expansion, virtually no subjective negative impact on upper extremity function and elimination of animation deformity. Longer-term follow-up demonstrates maintenance of the integrity and quality of the reconstructions over time. CONCLUSIONS: The authors consider single stage, pre-pectoral direct to implant breast reconstruction to be a state-of-the-art breast reconstruction technique and have found it to be safe and reproducible. This technique is their primary choice for immediate implant-based reconstruction following mastectomy.

An Algorithmic Approach to Prepectoral Direct-to-Implant Breast Reconstruction: Version 2.0.

BACKGROUND: Prepectoral direct-to-implant breast reconstruction has historically been fraught with complications, including flap necrosis, implant extrusion, and capsular contracture, along with high rates of operative revisions. This may result from a number of factors, including the lack of an algorithmic approach, failure to predict postoperative migration of the implant, use of improper implants, and unsuitable patient selection. Over the past 5 years, the authors have gained significant experience in prepectoral breast reconstruction as they have transitioned their direct-to-implant technique. METHODS: Using video, technical aspects for achieving superior results are demonstrated, including suture technique, application of acellular dermal matrix, creation of the implant pocket, implant selection and placement, and postoperative dressings. Video is used to highlight technical aspects to yield consistent, predictable results using the anterior tenting technique. RESULTS: A systematic review of prepectoral direct-to-implant breast reconstruction was conducted to amalgamate the experience of the authors and others with regard to technique, material, and outcomes. CONCLUSIONS: Prepectoral direct-to-implant breast reconstruction represents a significant paradigm shift in postmastectomy breast reconstruction and warrants reconsideration. Prepectoral direct-to-implant breast reconstruction provides the potential benefits of a single-stage operation, elimination of dynamic deformity, enhanced aesthetic outcomes, and increased patient satisfaction. Although early evidence suggests an increased incidence of complications, our experience and that of others demonstrate favorable outcomes with version 2.0 of prepectoral direct-to-implant breast reconstruction. As the body of literature encompassing a modern approach to prepectoral direct-to-implant breast reconstruction grows, greater appreciation for operative technique, candidate selection, and implant choice may accelerate its adoption and mitigate past concerns.

Evolution of the Surgical Technique for "Breast in a Day" Direct-to-Implant Breast Reconstruction: Transitioning from Dual-Plane to Prepectoral Implant Placement.

BACKGROUND: Direct-to-implant breast reconstruction offers the intuitive advantages of shortening the reconstructive process and reducing costs. In the authors' practice, direct-to-implant breast reconstruction has evolved from dual-plane to prepectoral implant placement. The authors sought to understand postoperative complications and aesthetic outcomes and identify differences in the dual-plane and prepectoral direct-to-implant subcohorts. METHODS: A retrospective review of a prospectively maintained database was conducted from November of 2014 to March of 2018. Postoperative complication data, reoperation, and aesthetic outcomes were reviewed. Aesthetic outcomes were evaluated by a blinded panel of practitioners using standardized photographs. RESULTS: One hundred thirty-four direct-to-implant reconstructions were performed in 81 women: 42.5 percent were dual-plane (n = 57) and 57.5 percent were prepectoral (n = 77). Statistical analysis was limited to patients with at least 1 year of follow-up. Total complications were low overall (8 percent), although the incidence of prepectoral complications [n = 1 (2 percent)] was lower than the incidence of dual-plane complications [n = 7 (12 percent)], with the difference approaching statistical significance (p = 0.07). Panel evaluation for aesthetic outcomes favored prepectoral reconstruction. Pectoralis animation deformity was completely eliminated in the prepectoral cohort. CONCLUSIONS: The authors present the largest comparative direct-to-implant series using acellular dermal matrix to date. Transition to prepectoral direct-to-implant reconstruction has not resulted in increased complications, degradation of aesthetic results, or an increase in revision procedures. Prepectoral reconstruction is a viable reconstructive option with elimination of animation deformity and potential for enhanced aesthetic results. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Predictors of adverse events after neck dissection: An analysis of the 2006-2011 National Surgical Quality Improvement Program (NSQIP) Database.

While neck dissection is an important primary and adjunctive procedure in the treatment of head and neck cancer, there is a paucity of studies evaluating outcomes. A retrospective review of the National Surgical Quality Improvement Program (NSQIP) database was performed to identify factors associated with adverse events (AEs) in patients undergoing neck dissection. A total of 619 patients were identified, using CPT codes specific to neck dissection. Of the 619 patients undergoing neck dissection, 142 (22.9%) experienced an AE within 30 days of the surgical procedure. Risk factors on multivariate regression analysis associated with increased AEs included dyspnea (odds ratio [OR] 2.57; 95% confidence interval [CI] 1.06 to 6.22; p = 0.037), previous cardiac surgery (OR 3.38; 95% CI 1.08 to 10.52; p = 0.036), increasing anesthesia time (OR 1.005; 95% CI 1 to 1.009; p = 0.036), and increasing total work relative value units (OR 1.09; CI 1.04 to 1.13; p < 0.001). The current study is the largest, most robust analysis to identify specific risk factors associated with AEs after neck dissection. This information will assist with preoperative optimization, patient counseling, and appropriate risk stratification, and it can serve as benchmarking for institutions comparing surgical outcomes.

Virtual 3D planning and guidance of mandibular distraction osteogenesis.

We present a system for 3D planning and pre-operative rehearsal of mandibular distraction osteogenesis procedures. Two primary architectural components are described: a planning system that allows geometric bone manipulation to rapidly explore various modifications and configurations, and a visuohaptic simulator that allows both general-purpose training and preoperative, patient-specific procedure rehearsal. We provide relevant clinical background, then describe the underlying simulation algorithms and their application to craniofacial procedures.

Recalcitrant Hidradenitis Suppurativa: An Investigation of Demographics, Surgical Management, Bacterial Isolates, Pharmacologic Intervention, and Patient-reported Health Outcomes.

Hidradenitis suppurativa (HS) is characterized by chronic inflammation, recurrent abscesses, and scarring. Surgery is performed when medical management and antibiotic therapy fails. This study sought to evaluate the demographics, surgical procedures, bacteriology, pharmacologic intervention, and quality of life of patients with recalcitrant HS requiring surgical intervention. A retrospective chart review was performed of 76 recalcitrant HS patients at the University of Illinois Medical Center. Patient demographics, bacterial culture, and surgery data were reviewed. Quality of life was assessed using the 36-item short-form health survey. Patients were mostly female (73.7%) and African American (81.6%) with a mean duration of symptoms of 8.6 years before surgery. Patients underwent at least one surgical procedure, most often to the axillae (57.6%) and 73.7 per cent received antibiotics. The most common culture isolates were Corynebacterium species (14.0%), Staphylococcus epidermidis (13.1%), and Staphylococcus aureus (10.4%) with varying resistance patterns. Surveyed patients had depressed 36-item short-form health survey physical functioning and social functioning scores. Recalcitrant HS patients with progressive symptomology over approximately nine years before surgical intervention were more likely to be African American women with axillary HS. Quality of life was diminished. We recommend initial treatment of HS with clindamycin and trimethoprim-sulfamethoxazole in clindamycin refractory cases.

Trends in Breast Reconstruction by Ethnicity: An Institutional Review Centered on the Treatment of an Urban Population.

Previous studies have investigated reconstructive decisions after mastectomy and such studies document a preference among African American women for autologous tissue-based procedures and among Latin American women for implant-based reconstructions, however, there is a paucity of studies evaluating the current relationship between ethnicity and reconstructive preferences. This institutional review provides a unique, up-to-date evaluation of an understudied urban population composed of majority ethnic minority patients and explores reconstructive trends. Consecutive breast reconstruction patients were entered into a prospectively maintained database at the University of Illinois at Chicago and affiliate hospitals between July 2010 and October 2013. Demographics and oncologic characteristics including tumor stage, pathology, BRCA status, and adjuvant treatment were reviewed, and reconstructive trends were assessed by racial group with a focus on reconstructive procedure, mastectomy volume, and implant characteristics. Statistical analysis was performed using SAS (version 9.2). One-hundred and sixty breast reconstructions were performed in 105 women; of which 50 per cent were African American, 26 per cent Hispanic, 22 per cent Caucasian, and 2 per cent Asian. Age, tumor stage, prevalence of triple negative disease, chemotherapy, and radiation treatment was comparable between groups. Rates of obesity, hypertension, and diabetes mellitus were slightly higher in African American and Hispanic cohorts, with more African American patients having one or more of these comorbidities as compared with the Caucasian and Hispanic cohorts (P = 0.047). Despite comparable positive BRCA testing rates, significant differences were seen in the percentage of bilateral mastectomy; 68 per cent African American, 48 per cent Caucasian, and 30 per cent Hispanic (P = 0.004). Hispanics predominantly underwent flap-based reconstruction (56%), while African American (74%) and Caucasian (60%) patients had a preference toward tissue expander reconstruction (P = 0.04 across all groups). African American and Hispanic presented with increased mastectomy weights and thus required higher implant volumes as compared with Caucasians that approached significance (P = 0.06 and P = 0.06). Implant size utilization followed a unimodal distribution for Caucasians, peaking at 500 cc; while African American and Hispanic demonstrated a bimodal distribution, peaking once at 550 cc and again at the max implant volume of 800 cc. This study of a large proportion of minority patients in an urban geographic setting offers an evolving understanding of breast reconstruction patterns. The data demonstrated unique findings of increased rates of bilateral implant-based reconstruction in African American women and unilateral flap-based reconstructions in Hispanic patients. Reconstructive decision-making seems to be greatly influenced by cultural and geographically driven preferences.