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BACKGROUND: Little is known about disparities in oncoplastic breast surgery delivery. METHODS: The Massachusetts All-Payer Claims Database was queried for patients who received lumpectomy for a diagnosis of breast cancer. Oncoplastic surgery was defined as adjacent tissue transfer, complex trunk repair, reduction mammoplasty, mastopexy, flap-based reconstruction, prosthesis insertion, or unspecified breast reconstruction after lumpectomy. RESULTS: We identified 18 748 patients who underwent lumpectomy between 2016 and 2020. Among those, 3140 patients underwent immediate oncoplastic surgery and 436 patients underwent delayed oncoplastic surgery. Eighty-one percent of patients who underwent oncoplastic surgery did so in the same county as they underwent a lumpectomy. However, the relative frequency of oncoplastic surgery varied significantly among counties. In multivariable regression, public insurance status (odds ratio: 0.87, 95% confidence interval: 0.80-0.95, p = 0.002) was associated with lower odds of undergoing oncoplastic surgery, even after adjusting for macromastia, other comorbidities, and county of lumpectomy. Average payments for lumpectomy with oncoplastic surgery were more than twice as high from private insurers ($840 vs. $1942, p < 0.001). CONCLUSION: Disparities in the receipt of oncoplastic surgery were related to differences in local practice patterns and the type of insurance patients held. Expanding services across counties and considering billing reform may help reduce these disparities.
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Neoplasias da Mama , Disparidades em Assistência à Saúde , Mamoplastia , Mastectomia Segmentar , Humanos , Feminino , Neoplasias da Mama/cirurgia , Neoplasias da Mama/economia , Pessoa de Meia-Idade , Mastectomia Segmentar/estatística & dados numéricos , Mastectomia Segmentar/economia , Mamoplastia/economia , Mamoplastia/estatística & dados numéricos , Mamoplastia/métodos , Disparidades em Assistência à Saúde/estatística & dados numéricos , Massachusetts , Estados Unidos , Idoso , Adulto , Seguro Saúde , Padrões de Prática Médica/estatística & dados numéricos , Padrões de Prática Médica/economia , Seguimentos , PrognósticoRESUMO
BACKGROUND: Little is known about practice patterns and payments for immediate lymphatic reconstruction (ILR). This study aims to evaluate trends in ILR delivery and billing practices. METHODS: We queried the Massachusetts All-Payer Claims Database between 2016 and 2020 for patients who underwent lumpectomy or mastectomy with axillary lymph node dissection for oncologic indications. We further identified patients who underwent lymphovenous bypass on the same date as tumor resection. We used ZIP code data to analyze the geographic distribution of ILR procedures and calculated physician payments for these procedures, adjusting for inflation. We used multivariable logistic regression to identify variables, which predicted receipt of ILR. RESULTS: In total, 2862 patients underwent axillary lymph node dissection over the study period. Of these, 53 patients underwent ILR. Patients who underwent ILR were younger (55.1 vs 59.3 years, P = 0.023). There were no significant differences in obesity, diabetes, or smoking history between the two groups. A greater percentage of patients who underwent ILR had radiation (83% vs 67%, P = 0.027). In multivariable regression, patients residing in a county neighboring Boston had 3.32-fold higher odds of undergoing ILR (95% confidence interval: 1.76-6.25; P < 0.001), while obesity, radiation therapy, and taxane-based chemotherapy were not significant predictors. Payments for ILR varied widely. CONCLUSIONS: In Massachusetts, patients were more likely to undergo ILR if they resided near Boston. Thus, many patients with the highest known risk for breast cancer-related lymphedema may face barriers accessing ILR. Greater awareness about referring high-risk patients to plastic surgeons is needed.
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Neoplasias da Mama , Excisão de Linfonodo , Humanos , Pessoa de Meia-Idade , Feminino , Massachusetts , Neoplasias da Mama/cirurgia , Neoplasias da Mama/economia , Excisão de Linfonodo/economia , Mastectomia/economia , Estudos Retrospectivos , Disparidades em Assistência à Saúde/economia , Disparidades em Assistência à Saúde/estatística & dados numéricos , Idoso , Adulto , Axila/cirurgia , Mastectomia Segmentar/economia , Padrões de Prática Médica/economia , Padrões de Prática Médica/estatística & dados numéricosRESUMO
INTRODUCTION: Single-use medical devices used in surgery can create environmental waste and increased costs. Reprocessed medical devices may reduce cost and environmental impact. This study investigated the reprocessing capabilities of newly FDA-approved devices in surgery. METHODS: Devices were identified using the publicly-available FDA Releasable 510(k) Database from 2018 to 2023 using the instrument product codes for laparoscope, general, and plastic surgery (GCJ); and electrosurgical (GEI) devices. GCJ and GEI devices were categorized based on usage, and the number of devices (total, single, and reprocessed) were extracted. Costs were obtained from public websites. RESULTS: There were 658,510(k) applications for surgical devices, representing 3.8 % (658/16723) of total applications. Reprocessing capabilities existed for 29 % of GCJ devices and 14 % of GEI devices. Among GCJ devices, 5 (56 %) laparoscopy and 16 (38 %) camera devices had reprocessing capabilities. For GEI devices, 7 (50 %) laparoscopic and 5 (50 %) cable devices had reprocessing capabilities. Only one (6 %) tissue ablation device had reprocessing capabilities. The average cost of GCJ and GEI single-use devices ($11314; $8554, respectively) was less than reprocessed counterparts ($17206; $16134, respectively). CONCLUSION: Reprocessing capabilities for newly approved surgical devices are variable and overall limited. To enhance adoption of reprocessing in surgical practice, future efforts will likely be needed to expand the reprocessing potential of new surgical devices.
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BACKGROUND: Private insurers have considered consolidating the billing codes presently available for microvascular breast reconstruction. There is a need to understand how these different codes are currently distributed and used to help inform how coding consolidation may impact patients and providers. METHODS: Using the Massachusetts All-Payer Claims Database between 2016 and 2020, patients who underwent microsurgical breast reconstruction following mastectomy for cancer-related indications were identified. Multivariable logistic regression was used to test whether an S2068 claim was associated with insurance type and median household income by patient ZIP code. The ratio of S2068 to CPT19364 claims for privately insured patients was calculated for providers practicing in each county. Total payments for professional fees were compared between billing codes. RESULTS: There were 272 claims for S2068 and 209 claims for CPT19364. An S2068 claim was associated with age < 45 years (OR: 1.89, 95% CI: 1.11-3.20, p = 0.019), more affluent ZIP codes (OR: 1.11, 95% CI: 1.03-1.19, p = 0.004), and private insurance (OR: 16.13, 95% CI: 7.81-33.33, p < 0.001). Median total payments from private insurers were 101% higher for S2068 than for CPT19364. In all but two counties (Worcester and Hampshire), the S-code was used more frequently than CPT19364 for their privately insured patients. CONCLUSION: Coding practices for microsurgical breast reconstruction lacked uniformity in Massachusetts, and payments differed greatly between S2068 and CPT19364. Patients from more affluent towns were more likely to have S-code claims. Coding consolidation could impact access, as the majority of providers in Massachusetts might need to adapt their practices if the S-code were discontinued.
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BACKGROUND: Prophylactic lymphatic bypass or LYMPHA (LYmphatic Microsurgical Preventive Healing Approach) is increasingly offered to prevent lymphedema following breast cancer treatment, which develops in up to 47% of patients. Previous studies focused on intraoperative and postoperative lymphedema risk factors, which are often unknown preoperatively when the decision to perform LYMPHA is made. This study aims to identify preoperative lymphedema risk factors in the high-risk inflammatory breast cancer (IBC) population. METHODS: Retrospective review of our institution's IBC program database was conducted. The primary outcome was self-reported lymphedema development. Multivariable logistic regression analysis was performed to identify preoperative lymphedema risk factors, while controlling for number of lymph nodes removed during axillary lymph node dissection (ALND), number of positive lymph nodes, residual disease on pathology, and need for adjuvant chemotherapy. RESULTS: Of 356 patients with IBC, 134 (mean age: 51 years, range: 22-89 years) had complete data. All 134 patients underwent surgery and radiation. Forty-seven percent of all 356 patients (167/356) developed lymphedema. Obesity (body mass index > 30) (odds ratio [OR]: 2.7, confidence interval [CI]: 1.2-6.4, p = 0.02) and non-white race (OR: 4.5, CI: 1.2-23, p = 0.04) were preoperative lymphedema risk factors. CONCLUSION: Patients with IBC are high risk for developing lymphedema due to the need for ALND, radiation, and neoadjuvant chemotherapy. This study also identified non-white race and obesity as risk factors. Larger prospective studies should evaluate potential racial disparities in lymphedema development. Due to the high prevalence of lymphedema, LYMPHA should be considered for all patients with IBC.
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Neoplasias da Mama , Neoplasias Inflamatórias Mamárias , Linfedema , Humanos , Pessoa de Meia-Idade , Feminino , Neoplasias da Mama/cirurgia , Neoplasias da Mama/patologia , Neoplasias Inflamatórias Mamárias/complicações , Neoplasias Inflamatórias Mamárias/cirurgia , Estudos Prospectivos , Linfedema/etiologia , Linfedema/cirurgia , Excisão de Linfonodo/efeitos adversos , Fatores de Risco , Obesidade/complicações , Axila/cirurgia , Biópsia de Linfonodo Sentinela/efeitos adversosRESUMO
BACKGROUND: Sensation after autologous breast reconstruction is an increasingly important outcome. Several studies demonstrated improved sensation with flap neurotization but utilized heterogenous measures and follow-up intervals. This review evaluates sensory outcomes after neurotization using uniform, objective outcome measurements. METHODS: PubMed/Medline and Embase databases were queried for articles published between January 1990 and January 2022. Inclusion criteria included studies with free flap tissue transfer breast reconstruction patients and use of Semmes-Weinstein Monofilaments (SWM) to quantify return of sensation after either neurotization or no neurotization. Reviews, case reports, and studies utilizing implants or pedicled flaps were excluded. RESULTS: Overall, 513 articles were screened. Eleven articles met inclusion criteria for a total of 474 patients. There were 254 non-neurotized patients included as controls (Group A) and 220 neurotized patients (Group B). Mean follow-up time was similar in both groups (22.06 months vs. 22.78 months, p > 0.05). There was no significant difference in age (Group A = 49.97 years vs. Group B = 42.47 years) or BMI (Group A = 25.48 vs. Group B = 25.97) between groups. More patients in group B received radiation therapy (Group B = 32.72% vs. Group A = 20.86%, p > 0.05). Patients that received neurotization had lower mean pressure thresholds (Group A = 38.85 gm/mm2 vs. Group B = 6.69 gm/mm2 , p = 0.053) than comorbidity-matched controls. CONCLUSION: Neurotization has been shown to be a safe and feasible option for enhancing return of sensation after breast reconstruction. Future studies with standardized, long-term follow-up will further elucidate the pattern of breast sensation return and the impact of neurotization.
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Retalhos de Tecido Biológico , Mamoplastia , Transferência de Nervo , Humanos , Pessoa de Meia-Idade , Mamoplastia/efeitos adversos , Sensação/fisiologia , Mama/cirurgia , Retalhos de Tecido Biológico/cirurgiaRESUMO
BACKGROUND: The purpose of this study was to determine the optimal timing of delayed microvascular breast reconstruction after completion of postmastectomy radiation therapy (PMRT). The authors evaluated whether the timing of reconstruction after PMRT completion affects the development of major postoperative complications. We hypothesize that delayed microvascular breast reconstruction can be safely performed within 12 months of PMRT completion. METHODS: A retrospective chart review of microvascular, autologous breast reconstructions at Brigham and Women's Hospital from 2007 to 2019 was performed. Logistic regression analysis and marginal estimation methods were used to estimate the probability of any major complication (flap compromise requiring operative intervention, hematoma formation requiring evacuation, infection requiring readmission, and flap necrosis requiring operative debridement) occurring in 2-month intervals after PMRT. Patients were classified as having undergone reconstruction 0 to 12 months after PMRT (group 1), 12 to 18 months after PMRT (group 2), or 18 to 50 months after PMRT (group 3). RESULTS: A total of 303 patients were identified. All patients received postmastectomy radiation (n = 143 group 1, n = 57 group 2, n = 103 group 3). Mean follow-up time was 71.4 ± 38 months. Patients in group 1 were significantly younger and more likely to have undergone neoadjuvant chemotherapy (p < 0.05). Major complications occurred in 10% of patients. There was no significant difference in the development of major complications between the three groups (p = 0.57). Although not statistically significant, the probability of any major complication peaked 2 to 6 months after PMRT completion. CONCLUSION: There was no significant difference in major complications among patients who underwent delayed, microvascular breast reconstruction within versus beyond 1 year of PMRT completion. These findings suggest that delayed microvascular breast reconstruction can be safely performed beginning 6 months after PMRT completion.
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Neoplasias da Mama , Mamoplastia , Humanos , Feminino , Neoplasias da Mama/complicações , Mastectomia , Resultado do Tratamento , Estudos Retrospectivos , Seguimentos , Radioterapia Adjuvante/efeitos adversos , Mamoplastia/métodos , Complicações Pós-Operatórias/etiologiaRESUMO
PURPOSE: The identification of patient-specific risk factors, which predict morbidity following abdominally based microvascular breast reconstruction is difficult. Sarcopenia is a proxy for patient frailty and is an independent predictor of complications in a myriad of surgical disciplines. We predict that sarcopenic patients will be at higher risk for surgical complications following abdominally based microvascular breast reconstruction. METHODS: A retrospective study of all patients who underwent delayed abdominally based autologous breast reconstruction following postmastectomy radiation therapy from 2007 to 2013 at a single institution was conducted. Univariate and multiple logistic regression models were used to assess the effect of sarcopenia on postoperative outcomes. RESULTS: Two hundred and eight patients met the inclusion criteria, of which 30 met criteria for sarcopenia (14.1%). There were no significant differences in demographics between groups. There were no significant differences in minor (36.7% vs 44.4%; P = .43) or major (16.7% vs 25.3%; P = .36) complications between groups as well as hospital length of stay. Multivariable logistic regression demonstrated that a staged reconstruction with the use of a tissue expander was the only consistent variable, which predicted major complications (OR, 2.24; 95% CI, 1.18-4.64; P = .015). CONCLUSIONS: Sarcopenia does not predispose to minor or major surgical complications in patients who undergo abdominally based microsurgical breast reconstruction.
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Abdome/cirurgia , Neoplasias da Mama/cirurgia , Retalhos de Tecido Biológico/efeitos adversos , Mamoplastia/efeitos adversos , Mastectomia/efeitos adversos , Complicações Pós-Operatórias/diagnóstico , Sarcopenia/fisiopatologia , Neoplasias da Mama/patologia , Feminino , Seguimentos , Retalhos de Tecido Biológico/transplante , Humanos , Pessoa de Meia-Idade , Assistência Perioperatória , Complicações Pós-Operatórias/etiologia , Prognóstico , Estudos Prospectivos , Estudos Retrospectivos , Transplante AutólogoRESUMO
PURPOSE: To determine the innervation pattern to the thumb carpometacarpal (CMC) joint and assess the safety and efficacy of selective joint denervation for the treatment of pain and impairment associated with thumb CMC arthritis. METHODS: Cadaveric dissections were performed in 10 fresh upper extremities to better define the innervation patterns to the CMC joint and guide the surgical approach for CMC joint denervation. Histologic confirmation of candidate nerves was performed with hematoxylin and eosin staining. Results from a series of 12 patients with symptomatic thumb CMC arthritis who underwent selective denervation were retrospectively evaluated to determine the safety and efficacy of this treatment approach. Differences in preoperative and postoperative measurements of grip and key-pinch strength as well as subjective reporting of symptoms were compared. RESULTS: Nerve branches to the thumb CMC joint were found to arise from the lateral antebrachial cutaneous nerve (10 of 10 specimens), the palmar cutaneous branch of the median nerve (7 of 10 specimens), and the radial sensory nerve (4 of 10 specimens). With an average follow-up time of 15 months, 11 of 12 patients (92%) reported complete or near-complete relief of pain. Average improvements in grip and lateral key-pinch strength were 4.1 ± 3.0 kg (18% ± 12% from baseline) and 1.7 ± 0.5 kg (37% ± 11% from baseline), respectively. One patient experienced the onset of new pain consistent with a neuroma that resolved with steroid injection. All patients were released to light activity at 1 week after surgery, and all activity restrictions were lifted by 6 weeks after surgery. CONCLUSIONS: Selective denervation of the CMC joint is an effective approach to treat pain and alleviate impairment associated with CMC arthritis. The procedure is well tolerated, with faster recovery as compared with trapeziectomy. Branches arising from the lateral antebrachial cutaneous nerve, palmar cutaneous branch of the median nerve, and radial sensory nerve can be identified and resected with a single-incision Wagner approach. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic V.
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Artrite/cirurgia , Articulações Carpometacarpais/inervação , Denervação , Polegar/inervação , Idoso , Artrite/fisiopatologia , Cadáver , Articulações Carpometacarpais/fisiopatologia , Articulações Carpometacarpais/cirurgia , Feminino , Seguimentos , Força da Mão/fisiologia , Humanos , Masculino , Pessoa de Meia-Idade , Dor/etiologia , Dor/cirurgia , Estudos Retrospectivos , Polegar/fisiopatologia , Polegar/cirurgiaRESUMO
PURPOSE: Little is known about the definitive course of the tendinous intersections from anterior to posterior through the rectus abdominis (RA) muscle. The implications of a full thickness intersection may have effects on the ability to neurotize the RA. We hypothesized that these tendinous inscriptions would be fully adherent to the anterior rectus sheath, but there would be an incomplete penetrance into the posterior surface, thereby allowing for muscle fibers and neurovascular structures to run the entire course of the RA muscle. METHODS: Fifty-five cadaveric, hemiabdominal walls were evaluated. Measurements were taken of RA muscle thickness, depth of penetrance of the tendinous intersections, and intersection thickness. RESULTS: Of the 32 cadavers, 2 had 4 paired tendinous intersections and the remaining 30 cadavers had 3 paired tendinous intersections. Rectus abdominis muscle belly tended to be thicker at midbelly, between intersections than at the level of the corresponding intersection. A total of 168 tendinous intersections were assessed. Thirty (18%) of these inscriptions proved to be full thickness extending from anterior rectus sheath to posterior rectus sheath without any intervening muscle or neurovascular structures. Twenty-three (42%) of the 55 hemiabdomens assessed had at least one full-thickness tendinous intersection. CONCLUSIONS: The majority of RA muscles have 3 paired tendinous intersections. Most intersections are incomplete and only encompass the anterior rectus sheath. However, there may be a higher percentage of full-thickness intersections than previously appreciated and the clinical relevance behind these remains unclear.
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Transferência de Nervo , Reto do Abdome/anatomia & histologia , Tendões/anatomia & histologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Reto do Abdome/inervação , Reto do Abdome/cirurgia , Tendões/inervação , Tendões/cirurgiaRESUMO
BACKGROUND: Chest wall reconstruction (CWR) with biologic matrices has gained popularity over the last decade; however, data on this topic remain sparse. The aim of this study is to review the different methods and materials used for CWR while reviewing and highlighting a novel approach using a biologic inlay and synthetic onlay technique for larger, complex high-risk defects. METHODS: A retrospective review was performed of all patients who underwent full thickness chest wall resection and reconstruction during a 10-year period. Patient characteristics, comorbidities, operative data, as well as postoperative wound complications and outcomes were reviewed. Different reconstructive methods and materials were reviewed and compared. RESULTS: From December 2003 to January 2014, a total of 81 patients underwent CWR. The indications for resection/reconstruction included oncologic in 49 patients (60.5%), desmoids tumors in 10 (12.3%), bronchopleural fistula in 3 (3.7%), infection in 7 (8.6%), and anatomic deformity in 7 (8.6%) patients. Synthetic and/or acellular dermal matrices (ADM) reconstruction was used in 59 patients (10 biologic, 22 synthetic, and 27 biologic ADM inlay/synthetic onlay combination). On average, 2.5, 3.5, and 3.6 ribs were resected in the biologic, synthetic, and combination group, respectively (P = 0.1). A greater number of patients in the combination group had a history of chemotherapy and/or radiation therapy (P = 0.03) than the synthetic or biologic alone groups. Risk analysis demonstrated an association between the number of ribs resected and postoperative chest wall complications. The incidence of chest wall/wound complications in the synthetic, combination, and biologic groups was 31.8%, 22.2%, and 10%, respectively (P = 0.47). CONCLUSIONS: In the largest single institution study comparing the use of different reconstructive materials, including ADM in CWR, the authors demonstrate that a biologic inlay/synthetic onlay may be used effectively for high-risk, large complex defects. Early outcomes with this technique are promising. The authors believe this combination highlights benefits from both materials because the ADM facilitates tissue ingrowth and revascularization, whereas the synthetic component provides structural durability. Additional studies with larger sample sizes are necessary to further explore the benefits of the combination technique to determine if outcomes are better than either material alone when used to reconstruct high-risk wounds after larger resections.
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Músculo Esquelético/patologia , Músculo Esquelético/transplante , Procedimentos de Cirurgia Plástica/métodos , Parede Torácica/patologia , Parede Torácica/cirurgia , Materiais Biocompatíveis , Feminino , Humanos , Masculino , Estudos Retrospectivos , Telas Cirúrgicas , Infecção da Ferida Cirúrgica/prevenção & controle , Resultado do TratamentoRESUMO
BACKGROUND: Pyoderma gangrenosum (PG) is a rare cutaneous disorder that poses a diagnostic challenge in the postoperative period. A systematic literature review was performed to determine distinguishing characteristics of PG in the setting of breast surgery that can facilitate timely diagnosis and appropriate treatment. METHODS: PubMed, EMBASE, Scopus, and Web of Science databases were systematically searched for articles with cases of PG occurring after breast surgery. Forty-three relevant articles, including 49 case reports, were identified. RESULTS: PG manifested bilaterally in 30 of 34 cases (88%) in which bilateral surgery was performed. Abdominal wounds were present in 6 of 7 cases in which an abdominal donor site was used for breast reconstruction. Nipples were spared from wound involvement in 33 of 37 cases (89%) in which nipples were present after surgery. Presence of fever was noted in 27 cases (55%) and leukocytosis in 21 cases (43%). A total of 33 patients (67%) underwent wound debridement. Successful medical treatment most commonly involved steroids (41 cases, 84%) and cyclosporine (10 cases, 20%). CONCLUSIONS: Pertinent clinical features were identified that may aid in timely diagnosis and treatment of PG after breast surgery. Appearance of discrete wounds involving multiple surgical sites that surround but spare the nipples should raise suspicion for PG rather than infection or ischemia, even with concomitant fever and leukocytosis. Wound debridement should be minimized and skin grafting considered only after medical therapy is initiated. Cognizance of these features may enable prompt therapeutic intervention that minimizes morbidity and improves outcomes.
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Mamoplastia , Mastectomia , Complicações Pós-Operatórias/diagnóstico , Pioderma Gangrenoso/diagnóstico , Feminino , Humanos , Pioderma Gangrenoso/etiologiaRESUMO
BACKGROUND: Breast procedures are among the most common surgeries performed by Plastic Surgeons. The prevalence of persistent pain remains unknown. Our experience has been that persistent breast pain is often related to intercostal nerve trauma. The purpose of this article was to increase awareness of this problem while describing the diagnostic and management strategies for patients with post-operative breast pain. METHODS: A retrospective review of 10 patients with breast pain was stratified according to the index surgical procedures: implant-based reconstruction (7), breast reduction (1), breast augmentation (1), and mastopexy (1). Outcomes were assessed with a numerical analog score. Physical examination demonstrated painful trigger points along the pathway of one or more intercostal nerves. Prior to surgery, each patient improved ≥5 points after a diagnostic Xylocaine/Marcaine local anesthesia block of the suspected intercostal nerves. At surgery, one or more intercostal nerves were resected and implanted into adjacent muscles. RESULTS: At a mean of 16.5 months, there were six excellent, one good, and three poor self-reported results. Intercostal nerves resected included the intercostal-brachial (5 patients), 3rd (7 patients), 4th (8 patients), 5th (9 patients), 6th (7 patients), and 7th (1 patient). Multiple intercostal nerves were resected as follows: 3 nerves (4 patients), 4 nerves (1 patient), 5 nerves (3 patients), 6 nerves (1 patient), and 8 nerves (1 patient). CONCLUSIONS: Intercostal neuromas can be the source of breast pain following breast surgery. The same clinical and diagnostic approach used for upper and lower extremity neuroma pain can be used in patients with breast pain. © 2016 Wiley Periodicals, Inc. Microsurgery 36:535-538, 2016.
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Nervos Intercostais/lesões , Mamoplastia/efeitos adversos , Dor Pós-Operatória , Traumatismos dos Nervos Periféricos , Adulto , Feminino , Seguimentos , Humanos , Nervos Intercostais/cirurgia , Mamoplastia/métodos , Pessoa de Meia-Idade , Transferência de Nervo , Medição da Dor , Dor Pós-Operatória/diagnóstico , Dor Pós-Operatória/etiologia , Dor Pós-Operatória/cirurgia , Traumatismos dos Nervos Periféricos/diagnóstico , Traumatismos dos Nervos Periféricos/etiologia , Traumatismos dos Nervos Periféricos/cirurgia , Exame Físico , Estudos Retrospectivos , Resultado do TratamentoRESUMO
Background Close monitoring is crucial following successful flap surgery. Ideally, all patients undergoing microvascular reconstruction should be evaluated in a dedicated unit with specialized nurses; however, this is not always possible and there is often a varied skill mix of nursing staff. The purpose of this study was to identify deficiencies in microsurgical education among nursing staff in an effort to target future educational efforts. Methods A 22-question electronic survey was sent out to all nursing staff at three sampled hospitals that manage microsurgical patients. Statistical analysis was performed to identify factors that predicted aptitude, comfort, and deficiencies in the treatment of microsurgical patients. Results Of the 160 registered nurses sampled, 106 completed the survey completely (66%). A total of 59 nurses worked at a tertiary care academic institution (55%) and the remaining 47 nurses worked at one of two community hospitals (45%).Regardless of whether the provider self-identified as a critical care or floor nurse, nurses from an academic medical center were significantly more comfortable with their ability to care for microsurgical patients when compared with their community medical center counterparts (p < 0.05). Furthermore, regardless of whether the provider self-identified as a critical care or the hospital setting where they worked, nurses with greater than 5 years of experience were significantly more comfortable with their ability to care for microsurgical patients when compared with nurses who had less than 5 years of experience (p < 0.05).There was no correlation with comfort level and the ability to interpret various postoperative flap-monitoring technologies between intensive care unit nurses and floor nurses. Conclusions We have identified that nurses with less than 5 years of experience or nurses in a community setting may be less comfortable with the care of postoperative microsurgical patients, especially if newer flap monitoring technologies are employed.
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Competência Clínica/normas , Monitorização Fisiológica , Procedimentos de Cirurgia Plástica , Cuidados Pós-Operatórios/enfermagem , Trombose/prevenção & controle , Grau de Desobstrução Vascular/fisiologia , Centros Médicos Acadêmicos , Atitude do Pessoal de Saúde , Conhecimentos, Atitudes e Prática em Saúde , Humanos , Microcirurgia , Monitorização Fisiológica/métodos , Monitorização Fisiológica/enfermagem , Papel do Profissional de Enfermagem , Cuidados Pós-Operatórios/normasRESUMO
BACKGROUND: Asian facial aesthetic surgery should enhance, but not change, natural features. Augmentation rhinoplasty is a hallmark of Asian cosmetic surgery. In the authors' experience, I-shaped implants can elevate and efface the radix, leading to an unnatural appearance (elevated radix deformity). OBJECTIVES: The Chimeric technique was developed to control final radix position and preserve the nasal profile. We aim to demonstrate that the Chimeric technique promotes forward projection, not elevation, of the radix. METHODS: Between 2013 and 2015, 49 patients underwent rhinoplasty with I-shaped implants. Nineteen patients had Chimeric dorsal-glabellar implants, 30 did not. Standardized photographs were obtained at every visit. Novel and established photogrammetric parameters were used to describe radix position and position change. A retrospective chart review provided additional procedural details and outcomes data. RESULTS: Patients were followed for 10.8 months (range, 2-36 months). Nasal height increase (113% vs 107%) and bridge length increase (118% vs 105%) were significantly greater when the Chimeric technique was not performed (P < .0001). The nasofrontal angle increased 6° in both groups; there was no difference between groups. The vector of radix position change was 26.1° in the Chimeric group and 63.4° in the traditional group (P < .0001). CONCLUSIONS: The Chimeric technique preserves the nasal profile with a favorable (horizontal) radix transposition vector. There was not a significant difference in final radix position when Chimeric rhinoplasty was performed because that is controlled by implant thickness and position. The technique did not blunt the radix significantly. LEVEL OF EVIDENCE 4: Therapeutic.
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Povo Asiático , Estética , Deformidades Adquiridas Nasais/prevenção & controle , Nariz/cirurgia , Próteses e Implantes , Rinoplastia/instrumentação , Adolescente , Adulto , Pontos de Referência Anatômicos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Nariz/anatomia & histologia , Deformidades Adquiridas Nasais/etnologia , Fotografação , Desenho de Prótese , Estudos Retrospectivos , Rinoplastia/efeitos adversos , Taiwan , Fatores de Tempo , Resultado do Tratamento , Adulto JovemAssuntos
Mamoplastia , Sarcopenia , Mama/cirurgia , Humanos , Mamoplastia/efeitos adversos , Sarcopenia/etiologiaRESUMO
BACKGROUND: Large, composite abdominal wall defects represent complex problems requiring a multidisciplinary approach for reconstruction. Abdominal wall vascularized composite allotransplantation (AW-VCA) has been successfully performed in 21 patients, already receiving solid organ transplants, to provide immediate abdominal closure. The current study aims to establish a novel anatomic model for AW-VCA that retains motor and sensory function in an effort to preserve form and function while preventing complications. METHODS: Three fresh cadaver torsos were obtained. Dissection was started in the midaxillary line bilaterally through the skin and subcutaneous fascia until the external oblique was encountered. The thoracolumbar nerves were identified and measurements were obtained. A peritoneal dissection from the costal margin to pubic symphysis was performed and the vascular pedicle was identified for subsequent microsurgical anastomosis. RESULTS: The mean size of the abdominal wall graft harvested was 615 ± 120 cm(2). The mean time of abdominal wall procurement was â¼150 ± 12 minutes. The mean number of thoracolumbar nerves identified was 5 ± 1.4 on each side. The mean length of the skeletonized thoracolumbar nerves was 7.8 ± 1.7 cm. The cross-sectional diameter of all nerves as they entered the rectus abdominis was greater than 2 mm. CONCLUSIONS: Motor function and sensory recovery is expected in other forms of vascularized composite allotransplantation, such as the hand or face; however, this has never been tested in AW-VCA. This study demonstrates feasibility for the transplantation of large, composite abdominal wall constructs that potentially retains movement, strength, and sensation through neurotization of both sensory and motor nerves.
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Parede Abdominal/inervação , Fáscia/transplante , Procedimentos de Cirurgia Plástica , Reto do Abdome/transplante , Alotransplante de Tecidos Compostos Vascularizados/métodos , Parede Abdominal/patologia , Cadáver , HumanosRESUMO
BACKGROUND: In the past decade, the practice of body contouring using cryolipolysis has increased tremendously. While numerous anecdotal reports extol the efficacy of this product, the majority of these studies are small, retrospective case-series that lack control groups. OBJECTIVE: The authors aim to systematically review available literature to better illustrate the efficacy and safety of this new procedure. METHODS: A systematic literature review performed using MEDLINE, Embase, PubMed, and Cochrane databases identified all published studies evaluating cryolipolysis for body contouring. RESULTS: A total of 34 articles up to February 2015 were identified. Nineteen articles matched the selection criteria and were included in the analysis. Sixteen were evaluated in the final analysis. A total of 1445 patients had reportable data for analysis of the safety profile. Twelve patients (0.82%) reported complications with the most common being diminished sensation lasting greater than 4 weeks. An aggregate total of 295 patients had objective data for evaluation of tissue reduction. The mean time from procedure to objective outcome evaluation was 3.83 months. The mean reduction of subcutaneous tissue was 19.55% with respect to a designated control site. CONCLUSIONS: Selective cryolipolysis appears, at short-term follow-up, to reliably decrease subcutaneous tissue deposits. Reported complications are uncommon and appear to resolve without intervention. Future studies should aim to optimize patient selection and treatment characteristics while obtaining long-term follow-up data.
Assuntos
Técnicas Cosméticas , Crioterapia/métodos , Lipectomia/métodos , Gordura Subcutânea , Adolescente , Adulto , Idoso , Crioterapia/efeitos adversos , Feminino , Humanos , Lipectomia/efeitos adversos , Masculino , Pessoa de Meia-Idade , Adulto JovemRESUMO
BACKGROUND: An abdominoperineal resection is an invasive procedure that leaves the patient with vast pelvic dead space. Traditionally, the vertical rectus abdominus myocutaneous flap is used to reconstruct these defects. Oftentimes, this flap cannot be used because of multiple ostomy placements or previous abdominal surgery. The anterolateral thigh flap can be used; however, the efficacy of this flap has been questioned. OBJECTIVE: We report a single surgeon's experience with perineal reconstruction in patients with cancer with the use of either the vertical rectus abdominus myocutaneous flap or the anterolateral thigh flap to demonstrate acceptable outcomes with either repair modality. DESIGN: From 2010 to 2012, 19 consecutive patients with perineal defects secondary to cancer underwent flap reconstruction. A retrospective chart review of prospectively entered data was conducted to determine the frequency of short-term and long-term complications. SETTINGS: This study was conducted at an academic, tertiary-care cancer center. PATIENTS: Patients in the study were patients with cancer who were receiving perineal reconstruction. INTERVENTIONS: Interventions were surgical and included either abdomen- or thigh-based reconstruction. MAIN OUTCOME MEASURES: The main outcome measures included infection, flap failure, length of stay, and time to radiotherapy. RESULTS: Of the 19 patients included in our study, 10 underwent anterolateral thigh flaps and 9 underwent vertical rectus abdominus myocutaneous flaps for reconstruction. There were no significant differences in demographics between groups (p > 0.05). Surgical outcomes and complications demonstrated no significant differences in the rate of infection, hematoma, bleeding, or necrosis. The mean length of stay after reconstruction was 9.7 ± 3.4 days (± SD) in the anterolateral thigh flap group and 13.4 ± 7.7 days in the vertical rectus abdominus myocutaneous flap group (p > 0.05). LIMITATIONS: The limitations of this study include a relatively small sample size and retrospective evaluation. CONCLUSION: This study suggests that the anterolateral thigh flap is an acceptable alternative to the vertical rectus abdominus myocutaneous flap for perineal reconstruction (see Video, Supplemental Digital Content 1, http://links.lww.com/DCR/A134).