Facial Dermal Filler Injection and Vaccination: A 12-Year Review of Adverse Event Reporting and Literature Review.

BACKGROUND: Following authorization of 2 COVID-19 vaccines in December 2020, media attention increased towards postvaccine adverse events (AEs) in patients with facial dermal filler injections. OBJECTIVES: The purpose of this study was to characterize vaccine-related facial dermal filler AEs by scrutinizing the FDA's Manufacturer and User Facility Device Experience (MAUDE) database. METHODS: The MAUDE database was queried from January 1, 2011 to January 28, 2023 for facial dermal filler medical device reports (MDRs) discussing vaccination-related AEs. A PubMed (National Institutes of Health, Bethesda, MD) literature review on dermal filler AEs was then conducted. Data were analyzed with descriptive statistics. RESULTS: Of 10,637 MDRs identified, 33 were included. There were 25 MDRs (75.8%) related to COVID-19 vaccination. Hyaluronic acid-based fillers were described in 31 MDRs (93.9%). AEs were mostly reported within days postinjection (n = 7, 21.2%), but ranged from immediately (n = 2, 6.1%) to months (n = 6, 18.2%) postinjection. Most AEs were reported postvaccine (n = 17, 51.5%) vs postfiller (n = 14, 42.4%). In 26 reports (78.8%), AEs occurred at the site of filler injection. Most MDRs described inflammation/swelling (n = 21, 28.0%). The literature review returned 302 articles, of which 14 were included. Only 1 article (7.1%) was published in a plastic surgery journal. CONCLUSIONS: Although the pandemic brought attention to COVID-19 vaccine-related facial dermal filler AEs, this study shows a low incidence compared with the millions of vaccine and filler injections administered. Reactions with non-COVID-19 vaccines were also documented. Increased awareness may help providers counsel patients undergoing vaccination and dermal filler implantation.

Perioperative systemic nonsteroidal anti-inflammatory drugs (NSAIDs) in women undergoing breast surgery.

BACKGROUND: Breast surgery encompasses oncologic, reconstructive, and cosmetic procedures. With the recent focus on the over-prescribing of opioids in the literature, it is important to assess the effectiveness and safety of non-opioid pain medication regimens including nonsteroidal anti-inflammatory drugs (NSAIDs) or NSAID pain medications. Clinicians have differing opinions on the safety of perioperative (relating to, occurring in, or being the period around the time of a surgical operation) NSAIDs for breast surgery given the unclear risk/benefit ratio. NSAIDs have been shown to decrease inflammation, pain, and fever, while potentially increasing the risks of bleeding complications. OBJECTIVES: To assess the effects of perioperative NSAID use versus non-NSAID analgesics (other pain medications) in women undergoing any form of breast surgery. SEARCH METHODS: The Cochrane Breast Information Specialist searched the Cochrane Breast Cancer Group (CBCG) Specialized Register, CENTRAL (the Cochrane Library), MEDLINE, Embase, The WHO International Clinical Trials Registry Platform (ICTRP) and Clinicaltrials.gov registries to 21 September 2020. Full articles were retrieved for potentially eligible trials. SELECTION CRITERIA: We considered all randomized controlled trials (RCTs) looking at perioperative NSAID use in women undergoing breast surgery. DATA COLLECTION AND ANALYSIS: Two review authors independently screened studies, extracted data and assessed risk of bias, and certainty of the evidence using the GRADE approach. The main outcomes were incidence of breast hematoma within 90 days (requiring reoperation, interventional drainage, or no treatment) of breast surgery and pain intensity 24 hours following surgery, incidence rate or severity of postoperative nausea, vomiting or both, bleeding from any location within 90 days, need for blood transfusion, other side effects of NSAID use, opioid use within 24 hours of surgery, length of hospital stay, breast cancer recurrence, and non-prescribed NSAID use. Data were presented as risk ratios (RRs) for dichotomous outcomes and standardized mean differences (SMDs) for continuous outcomes. MAIN RESULTS: We included 12 RCTs with a total of 1596 participants. Seven studies compared NSAIDs (ketorolac, diclofenac, flurbiprofen, parecoxib and celecoxib) to placebo. Four studies compared NSAIDs (ketorolac, flurbiprofen, ibuprofen, and celecoxib) to other analgesics (morphine, hydrocodone, hydromorphone, fentanyl). One study compared NSAIDs (diclofenac) to no intervention. NSAIDs compared to placebo Most outcomes are judged to have low-certainty evidence unless stated otherwise. There may be little to no difference in the incidence of breast hematomas within 90 days of breast surgery (RR 0.33, 95% confidence interval (CI) 0.05 to 2.02; 2 studies, 230 participants; I2 = 0%). NSAIDs may reduce pain intensity 24 (± 12) hours following surgery compared to placebo (SMD -0.26, 95% CI -0.49 to -0.03; 3 studies, 310 participants; I2 = 73%). There may be little to no difference in the incidence rates or severities of postoperative nausea, vomiting, or both (RR 1.15, 95% CI 0.58 to 2.27; 4 studies, 939 participants; I2 = 81%), bleeding from any location within 90 days (RR 1.05, 95% CI 0.89 to 1.24; 2 studies, 251 participants; I2 = 8%), or need for blood transfusion compared to placebo groups, but we are very uncertain (RR 4.62, 95% CI 0.23 to 91.34; 1 study, 48 participants; very low-certainty evidence). There may be no difference in other side effects (RR 1.12, 95% CI 0.44 to 2.86; 2 studies, 251 participants; I2 = 0%). NSAIDs may reduce opioid use within 24 hours of surgery compared to placebo (SMD -0.45, 95% CI -0.85 to -0.05; 4 studies, 304 participants; I2 = 63%). NSAIDs compared to other analgesics There is little to no difference in the incidence of breast hematomas within 90 days of breast surgery, but we are very uncertain (RR 0.33, 95% CI 0.01 to 7.99; 1 study, 100 participants; very low-certainty evidence). NSAIDs may reduce pain intensity 24 (± 12) hours following surgery (SMD -0.68, 95% CI -0.97 to -0.39; 3 studies, 200 participants; I2 = 89%; low-certainty evidence) and probably reduce the incidence rates or severities of postoperative nausea, vomiting, or both compared to other analgesics (RR 0.18, 95% CI 0.06 to 0.57; 3 studies, 128 participants; I2 = 0%; moderate-certainty evidence). There is little to no difference in the development of bleeding from any location within 90 days of breast surgery or in other side effects, but we are very uncertain (bleeding: RR 0.33, 95% CI 0.01 to 7.99; 1 study, 100 participants; other side effects: RR 0.11, 95% CI 0.01 to 1.80; 1 study, 48 participants; very low-certainty evidence). NSAIDs may reduce opioid use within 24 hours of surgery compared to other analgesics (SMD -6.87, 95% CI -10.93 to -2.81; 3 studies, 178 participants; I2 = 96%; low-certainty evidence). NSAIDs compared to no intervention There is little to no difference in pain intensity 24 (± 12) hours following surgery compared to no intervention, but we are very uncertain (SMD -0.54, 95% CI -1.09 to 0.00; 1 study, 60 participants; very low-certainty evidence). AUTHORS' CONCLUSIONS: Low-certainty evidence suggests that NSAIDs may reduce postoperative pain, nausea and vomiting, and postoperative opioid use. However, there was very little evidence to indicate whether NSAIDs affect the rate of breast hematoma or bleeding from any location within 90 days of breast surgery, the need for blood transfusion and incidence of other side effects compared to placebo or other analgesics. High-quality large-scale RCTs are required before definitive conclusions can be made.

Breast Implant-Associated Anaplastic Large Cell Lymphoma Online Education Tools: A Multimetric Analysis.

PURPOSE: In light of highly publicized media coverage on breast implant recalls and Food and Drug Administration hearings on breast implant safety, online searches of these topics have surged. It is thus critical to determine whether such searches are providing meaningful information for those who use them. Patient/laywomen-directed online education materials on breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) must not only be comprehensible but also accurate, actionable, and culturally concordant, especially as more diverse populations turn to the internet for breast implant-related information. This study assessed the overall suitability of BIA-ALCL patient-directed educational text and video-based materials online. METHODS: This was a cross-sectional, multimetric investigation of online text- and video-based patient-directed educational materials for BIA-ALCL using multiple validated measures. Two reviewers assessed each resource. Kruskal-Wallis and Fisher exact analyses were used as appropriate to compare text- and video-based online resources. RESULTS: In total, 30 websites and 15 videos were evaluated, more than half (56%) of which were from academic/physician or governmental/nonprofit sources. Overall, website and video content, as well as quality, varied by source. Academic/physician or governmental/nonprofit sources tended to be more comprehensive and have higher-quality information than commercial/media outlet sources. Median actionability of websites was 38%, well below the threshold of 70% used in the literature to identify actionable resources. The median suitability score for BIA-ALCL websites was 57%, which is considered "adequate" based on published thresholds. The mean overall Cultural Sensitivity Assessment Tool score for websites was 2.4; Cultural Sensitivity Assessment Tool scores higher than 2.5 are generally regarded as culturally sensitive. In general, videos were more understandable than websites. Substantial interrater reliability across the validated tools used in this study was noted using Pearson correlation coefficients. CONCLUSIONS: Online resources varied in content and quality by source. As BIA-ALCL becomes an increasingly salient topic among both providers and patients, it is important to empower women with accurate information about this implant-associated cancer. Of available resources, providers should refer patients or those seeking more information to websites from governmental/academic organizations (".gov" or ".org" domains) and videos from academic/physician or governmental sources, given that among high-quality resources, these were most clear/comprehensible. Overall, there is a need for improved online content on this topic.

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

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

Pain Management in Breast Surgery: Recommendations of a Multidisciplinary Expert Panel-The American Society of Breast Surgeons.

Opioid overdose accounted for more than 47,000 deaths in the United States in 2018. The risk of new persistent opioid use following breast cancer surgery is significant, with up to 10% of patients continuing to fill opioid prescriptions one year after surgery. Over prescription of opioids is far too common. A recent study suggested that up to 80% of patients receiving a prescription for opioids post-operatively do not need them (either do not fill the prescription or do not use the medication). In order to address this important issue, The American Society of Breast Surgeons empaneled an inter-disciplinary committee to develop a consensus statement on pain control for patients undergoing breast surgery. Representatives were nominated by the American College of Surgeons, the Society of Surgical Oncology, The American Society of Plastic Surgeons, and The American Society of Anesthesiologists. A broad literature review followed by a more focused review was performed by the inter-disciplinary panel which was comprised of 14 experts in the fields of breast surgery, anesthesiology, plastic surgery, rehabilitation medicine, and addiction medicine. Through a process of multiple revisions, a consensus was developed, resulting in the outline for decreased opioid use in patients undergoing breast surgery presented in this manuscript. The final document was reviewed and approved by the Board of Directors of the American Society of Breast Surgeons.

Pure fat grafting for breast reconstruction: An alternative autologous breast reconstruction.

Plastic surgeons offer various options for breast reconstruction based on patient preference, underlying disease, and comorbidities. An alternative form of breast reconstruction exists, which includes tissue expansion with tissue expander and subsequent fat grafting without the use of implant or flap. We retrospectively reviewed the breast cancer patients who underwent breast reconstruction at our institution to identify those with pure fat grafting. Demographic information, complications, operative details, and BREAST-Q scores were abstracted. From 2010-2015, 10 patients were identified. Patients with unilateral or bilateral mastectomy followed by pure fat grafting had a median of 3.5 or 4 sessions and a total median fat grafting volume of 380 or 974.5 cc, respectively. Patients were followed for 12 months, and no complications or breast cancer recurrences were noted. Finally, BREAST-Q scores at the 12-month follow-up were comparable to the preoperative values.

Postoperative Free Flap Breast Protocol Optimizing Resources and Patient Safety.

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

Establishing Institution-Specific Normative Data for the BREAST-Q Reconstruction Module: A Prospective Study.

BACKGROUND: Breast satisfaction in general female populations is relatively unknown and prior research populations do not reflect our community. OBJECTIVES: We sought to assess breast satisfaction in a cohort of female participants utilizing the BREAST-Q and determine the impact of participant-related factors. METHODS: Females with no history of breast cancer or breast surgery attending gynecology appointments completed preoperative BREAST-Q reconstruction modules and demographic forms in this prospective, single-center, patient-reported outcomes study. We also assessed participant-related factors capable of influencing BREAST-Q scores. RESULTS: Three hundred females were included. Increasing body mass index had significant associations with lower Satisfaction with Breasts and Psychosocial Well-being scores. Increasing age was associated with significantly lower Sexual Well-being scores. African Americans had significantly higher scores for Satisfaction with Breasts, Psychosocial Well-being, and Sexual Well-being compared with Caucasians. Bra cup sizes A and C were associated with significantly higher Psychosocial Well-being scores than other sizes. Bra cup sizes A, B, and C were associated with significantly higher Sexual Well-being and Physical Well-being: Chest scores than larger sizes. Bra cup sizes B and C were associated with significantly higher Physical Well-being: Abdomen scores than size DD. Bra cup size A was associated with significantly higher Satisfaction with Breasts scores than sizes DD and >DD. Bra cup size C was associated with significantly higher Satisfaction with Breasts scores than larger sizes. CONCLUSIONS: Body mass index, age, race, and bra cup sizes significantly impact BREAST-Q scores in our population. Determining normative BREAST-Q scores in female populations could represent important baselines for breast outcomes research.Level of Evidence: 2.

Classification of breast tissue expander infections: Back to the basics.

BACKGROUND: Infections following tissue expander (TE) placement are frequent complications in breast reconstruction. While breast surgery is a clean case, implant-based breast reconstruction has rates of infection up to 31%, decidedly higher than the typical 1% to 2% rate of surgical site infections (SSI). Few authors use the Center for Disease Control's (CDC) SSI definition for TE infections. We highlight how adoption of a consistent definition of TE infection may change how infections are researched, categorized, and ultimately managed. METHODS: Two researchers with definitional discrepancies of infection performed an independent analysis of all postmastectomy patients receiving TEs (n = 175) in 2017. RESULTS: Researcher One, using a clinical definition, delineated an infection rate of 19.4%. Antibiotics alone successfully treated 50% of cases. Researcher Two found an infection rate of 13.7% using CDC criteria. These infections were further delineated by a SSI rate of 6.3% and a TE infection rate post port access of 7.4%. Only 45.5% SSI's and 15.4% of TE infections were salvaged with antibiotics alone. CONCLUSIONS: Rigorous adoption of CDC criteria for infection characterization in published research will help standardize the definition of infection and allow surgeons to create evidence-based infection prevention regimens.

The notion of the ideal breast and its variability: Reviewing the difficulty of perceiving beauty through defined margins.

The pursuit of the perfect breast has existed for centuries. Today, women seek reconstructive or cosmetic procedures to approach their current ideals. We conducted a literature search for studies relevant to physical markers of esthetically pleasing breasts and tools to help surgeons achieve these results. Various studies created parameters to define the ideal breast, such as specific proportions, while others suggest that attitudes will fluctuate based on culture and experience. Clinicians should be aware of potential parameters that define the ideal breast and that preference can be influenced by demographics.

Reconstruction options and outcomes for breast sarcoma patients.

Breast sarcomas constitute a rare and heterogeneous group of tumors. Given their aggressive nature and the potential for extensive resections, rates of reconstruction have been low. We retrospectively reviewed subjects derived from our institutional registry presented between 2003 and 2015. Thirty-four patients with primary breast sarcoma were identified. The average age was 51.9 years and the average follow-up was 58 months. The most common histological type was malignant phyllodes (61.8%). Two patients suffered cancer recurrence. Twelve patients (35.3%) underwent reconstruction. Four underwent implant-based reconstruction, seven had autologous-based reconstruction, and one had combined reconstruction. Major complications were one flap loss and one implant removal. Our relatively high rates of breast reconstruction suggest a newly increased willingness to offer reconstruction to this rarer patient population.

Delayed Breast Reconstruction on Patients With Upper Extremity Lymphedema: A Systematic Review of the Literature and Pooled Analysis.

BACKGROUND: Breast cancer-related lymphedema (BCRL) is a debilitating condition with morbidity, hindered quality of life, and increased health-related costs. Experimental studies support the use of musculocutaneous flaps for managing animal models with lymphedema. Although vascularized lymph node transfer (VLNT) and lymphovenous anastomosis are used to surgically treat patients with lymphedema, it is not known whether musculocutaneous or adipocutaneous flaps (eg, delayed autologous breast reconstruction) are effective for treating refractory upper extremity BCRL. We conducted a systematic review and pooled analysis to assess the impact of delayed breast reconstruction on developed BCRL. METHODS: Following PRISMA guidelines, we systematically searched PubMed, Scopus, EMBASE, and Google Scholar databases for relevant studies published through November 11, 2016. We screened 934 unique articles. Of these, we conducted full-text and reference screening on 37 articles. We then performed a pooled and sensitivity analysis using random effects. RESULTS: Eight studies met our inclusion criteria. One study was a case report; 7 studies were case series with sample sizes ranging from 3 to 38 patients. According to our pooled analysis 58% of patients reported improvement after breast reconstruction with or without VLNT. Sensitivity analysis revealed that 84% (95% confidence interval, 0.74-0.95) of patients who underwent breast reconstruction and VLNT reported improvement, whereas only 22% (95% confidence interval, 0.12-0.32) of those who had breast reconstruction alone reported improvement. CONCLUSIONS: Our review summarizes the current evidence regarding the effect of delayed breast reconstruction on established lymphedema. The VLNT component of the autologous breast reconstruction procedures may be the largest contributing factor leading to lymphedema improvement.

Breast Pocket Irrigation with Antibiotic Solution at Implant Insertion: A Systematic Review and Meta-Analysis.

BACKGROUND: Antibiotic irrigation is routinely used during implant insertion in augmentation mammoplasty procedures. However, the evidence for whether this reduces the incidence of infection or capsular contracture is unclear. METHODS AND MATERIALS: Five databases were used to search for all randomized control trials, retrospective cohort and prospective cohort studies containing original data related to the primary outcomes being investigated in this study. The primary outcomes were the effects of antibiotic breast pocket irrigation on clinical infection and capsular contracture. The literature search was designed to combine three concepts: implant or tissue expander-based breast surgery, antibiotic irrigation and clinical infection or capsular contracture. Studies found were screened using specific eligibility criteria. Risk ratios (RR) and 95% confidence interval (CI) were calculated using pooled acquired data from all included studies. RESULTS: The search identified 1256 citations. Three independent screeners identified seven studies that met the inclusion criteria with a pooled population of 4725. This included one prospective and six retrospective studies. A meta-analysis of pooled study data showed significant reductions in clinical infection (RR 0.52, 95% CI 0.33-0.81) and capsular contracture (RR 0.36, 95% CI 0.16-0.83) as a result of antibiotic irrigation. CONCLUSION: The meta-analyses support the use of antibiotic irrigation of the breast pocket. However, the results of this study are limited by the large proportion of retrospective studies, the small number of studies included, the lack of randomized controlled trials and the heterogeneity of the antibiotic and control regimes used. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Nipple-Sparing Mastectomy Improves Long-Term Nipple But Not Skin Sensation After Breast Reconstruction: Quantification of Long-Term Sensation in Nipple Sparing Versus Non-nipple Sparing Mastectomy.

BACKGROUND: Changes in breast sensation after reconstruction are expected. Return of breast sensation after reconstruction and whether nipple-sparing mastectomy offers a substantial benefit in terms of sensation has been inconsistently documented in the literature. We conducted the current study using the pressure-specified sensory device to quantify postoperative breast sensation in patients undergoing nipple-sparing versus non-nipple-sparing mastectomy. METHODS: Consecutive adult women who underwent nipple-sparing (NSM) and non-NSM (NNSM) and were at least 18 months postreconstruction were included. Breast measurements were taken in 4 quadrants (upper/lower lateral, upper/lower medial) and nipple. Averaged skin cutaneous thresholds [(UL+LL+UM+LM)/4] and nipple sensation between NSM and NNSM were compared as the primary outcome measure. A generalized estimating equations model was used; univariate and multivariate variable analyses were done when appropriate. RESULTS: Forty-four patients (74 breasts) were examined (53 NNSM vs 21 NSM). The groups were further subdivided into autologous versus implant-based reconstruction. Averaged cutaneous skin thresholds for quadrants were better for the NSM, 51.8(±24.5) g/mm versus NNSM, 56.5(±25.7) g/mm, although this difference was not statistically significant. However, NSM breasts measured higher nipple or nipple area sensitivity, 44.5(±30.8) g/mm versus NNSM, 83.8(±27.4) g/mm (P < 0.001). In a multivariate regression analysis, a predictor of decreased sensation was the number of revision surgeries, especially after third revision. CONCLUSIONS: Breast sensation is decreased after reconstruction in both NSM and NNSM, but nipple sensation or nipple area is better preserved in NSM breasts. Number of revision surgeries (>3) was a predictor of decreased sensation.

Long-term follow-up of changing practice patterns in breast reconstruction due to increased use of tissue expanders and perforator flaps.

BACKGROUND: As the science of breast reconstruction evolves, significant changes in reconstruction strategies and outcomes are expected. The purpose of this study is to determine the changes in breast reconstruction trends and outcomes that occurred at a multidisciplinary academic institution during the last decade. METHODS: We compared 265 patients over two distinct 6-month intervals separated by 5 years (2002 vs. 2007) and performed long-term follow-up (4.75 ± 3.38 years 2002, 2.99 ± 2.25 years 2007). We studied patients seeking prophylactic mastectomy, patients with early breast cancer, and patients with locally advanced disease. We analyzed demographic data, breast cancer history and treatment, type and timing of reconstruction, and complications. RESULTS: Implant to flap reconstruction ratio was 48:49 in 2002 and 76:102 in 2007. Use of transverse rectus abdominis myocutaneous flap declined from 57 to 4%; conversely, deep inferior epigastric perforator flap increased from 27 to 91% (P < 0.001). Correspondingly, donor site chronic pain (4 vs. 0, P = 0.012) and postoperative abdominal wall bulge (9 vs. 3, P = 0.004) rates decreased. Timing of reconstruction showed increased staged cases in 2007 compared to 2002 (P = 0.045). Post-final reconstruction radiation therapy was reduced in 2007 (P = 0.016), with subsequent lower rates of implant rupture (P < 0.001). CONCLUSIONS: At our institution and over the last decade, increasing staged reconstructions have successfully reduced the rates of post-final reconstruction radiotherapy with optimized outcomes. Contrary to national trends, the rates of autologous flap reconstructions have increased with reduced donor site morbidity. This suggests that academic breast reconstruction trends are independent from national trends.

Risk of severe and refractory postoperative nausea and vomiting in patients undergoing diep flap breast reconstruction.

BACKGROUND: Postoperative nausea and vomiting (PONV) are commonly feared after general anesthesia and can impact results. The primary aim of our study was to examine incidence and severity of PONV by investigating complete response, or absence of PONV, to prophylaxis used in patients undergoing DIEP flaps. Our secondary aims were definition of the magnitude of risk, state of the art of interventions, clinical sequelae of PONV, and interaction between these variables, specifically for DIEP patients. METHODS: A retrospective chart review occurred for 29 patients undergoing DIEP flap breast reconstruction from September 2007 to February 2008. We assessed known patient and procedure-specific risks for PONV after DIEPs, prophylactic antiemetic regimens, incidence, and severity of PONV, postoperative antiemetic rescues, and effects of risks and treatments on symptoms. RESULTS: Three or more established risks existed in all patients, with up to seven risks per patient. Although 90% of patients received diverse prophylaxis, 76% of patients experienced PONV, and 66% experienced its severe form, emesis. Early PONV (73%) was frequent; symptoms were long lasting (average 20 hours for nausea and emesis); and multiple rescue medications were frequently required (55% for nausea, 58% for emesis). Length of surgery and nonsmoking statistically significantly impacted PONV. CONCLUSION: We identify previously undocumented high risks for PONV in DIEP patients. High frequency, severity, and refractoriness of PONV occur despite standard prophylaxis. Plastic surgeons and anesthesiologists should further investigate methods to optimize PONV prophylaxis and treatment in DIEP flap patients.

Quality of life before reconstructive breast surgery: A preoperative comparison of patients with immediate, delayed, and major revision reconstruction.

BACKGROUND: Women undergo breast reconstruction at different time-points in their cancer care; knowing patients' preoperative quality of life (QoL) is critical in the overall care of the patient with breast cancer. Our objective was to describe presurgical QoL among women undergoing immediate, delayed, or major revision breast reconstructive surgery at our institution. METHODS: From March 2008 to February 2009, we administered preoperative BREAST-Q questionnaires to women who presented to our institution for breast reconstruction. Univariate and multivariate analyses were performed to compare patient cohorts across multiple QoL domains including body image, physical well-being, psychosocial well-being, and sexual well-being. RESULTS: Of the 231 patients who presented for preoperative consultation, 176 returned the questionnaire (response rate 76%; 117 from the immediate, 21 from the delayed, and 32 from the major revision reconstruction groups, plus 6 mixed or unknown). The three groups differed significantly (P < 0.05) across four of the six domains: body image (satisfaction with breasts), psychosocial well-being, sexual well-being, and physical well-being of the chest and upper body. The immediate reconstruction group had higher (better) scores than the delayed reconstruction group, which had higher (better) scores than the major revision group. CONCLUSION: These data suggest that women presenting for breast reconstruction at different stages of reconstruction have different baseline QoL. Such data may help us better understand patient selection, education, and expectations, and may lead to improved patient-surgeon communication.

Pilot study of breast sensation after breast reconstruction: evaluating the effects of radiation therapy and perforator flap neurotization on sensory recovery.

BACKGROUND: Some sensation to the breast returns after breast reconstruction, but recovery is variable and unpredictable. We primarily sought to assess the impact of different types of breast reconstruction [deep inferior epigastric artery perforator (DIEP) flaps versus implants] and radiation therapy on the return of sensation. METHODS: Thirty-seven patients who had unilateral or bilateral breast reconstruction via a DIEP flap or implant-based reconstruction, with or without radiation therapy (minimum follow-up, 18 months; range, 18-61 months) were studied. Of the 74 breasts, 27 had DIEP flaps, 29 had implants, and 18 were nonreconstructed. Eleven breasts with implants and 10 with DIEP flaps had had prereconstruction radiation therapy. The primary outcome was mean patient-perceived static and moving cutaneous pressure threshold in nine areas. We used univariate and multivariate analyses to assess what independent factors affected the return of sensation (significance, P < 0.05). RESULTS: Implants provided better static (P = 0.071) and moving sensation (P = 0.041) than did DIEP flaps. However, among irradiated breasts, skin over DIEP flaps had significantly better sensation than did that over implants (static, P = 0.019; moving, P = 0.028). Implant reconstructions with irradiated skin had significantly worse static (P = 0.002) and moving sensation (P = 0.014) than did nonirradiated implant reconstructions. CONCLUSIONS: Without irradiation, skin overlying implants is associated with better sensation recovery than DIEP flap skin. However, with irradiation, DIEP flap skin had better sensation recovery than did skin over implants. Neurotization trended toward improvement in sensation in DIEP flaps.

Association of preoperative opioid use and postoperative complications following breast reconstruction.

BACKGROUND: Previous studies in orthopedics and general surgery have linked negative patient outcomes with preoperative opioid use. In this study, we investigated the association of preoperative opioid use on breast reconstruction outcomes and quality of life (QoL). METHODS: We reviewed our prospective registry of patients who underwent breast reconstruction for documented preoperative opioid use. Postoperative complications were recorded at 60 days after the first reconstructive surgery and 60 days after the final staged reconstruction. We used a logistic regression model to assess the association between opioid use and postoperative complications, controlling for smoking, age, laterality, BMI, comorbidities, radiation, and previous breast surgery; linear regression to analyze RAND36 scores to evaluate the impact of preoperative opioid use on postoperative QoL, controlling for the same factors; and Pearson chi-squared test to assess factors that may be associated with opioid use. RESULTS: Of the 354 patients eligible for inclusion, 29 (8.2%) were prescribed preoperative opioids. There were no differences in opioid use by race, BMI, comorbidities, previous breast surgery, or laterality. Preoperative opioids were associated with increased odds of postoperative complications within 60 days after the first reconstructive surgery (OR: 6.28; 95% CI: 1.69-23.4; p = 0.006) and within 60 days after the final staged reconstruction (OR: 8.38; 95% CI: 1.17-59.4; p = 0.03). Among patients using opioids preoperatively, the RAND36 physical and mental scores decreased but were not statistically significant. CONCLUSION: We found that preoperative opioid use is associated with increased odds of postoperative complications among patients who underwent breast reconstruction and may contribute to clinically significant declines in postoperative QoL.

Bilateral autologous breast reconstruction with deep inferior epigastric artery perforator flaps: Review of a single surgeon's early experience.

BACKGROUND: The purpose of this study is to describe the early experience of a single surgeon just out of training, including preoperative conditioning, surgical approach, and outcomes in bilateral deep inferior epigastric artery perforator (DIEP) flap breast reconstruction patients. METHODS: We retrospectively reviewed 54 consecutive patients who underwent 108 DIEP flap breast reconstructions performed by a single surgeon over an initial 2.5-year period. RESULTS: There was 100% overall flap survival. The unplanned reoperation rate was 7.6% (n = 4). Minor complications including nonoperative infection, minor wound dehiscence, and donor site seroma occurred in 26% of patients (n = 14). Significant late complications were abdominal wall bulge (n = 1) and fat necrosis < 10% of volume (n = 1). Tissue expander explantation due to infection occurred in 25% of attempted staged patients (two of eight); this did not seem to compromise their oncologic treatment or final reconstruction outcome. CONCLUSION: This study demonstrates the efficacy of the DIEP flap for bilateral autologous breast reconstruction in the immediate, staged, and delayed settings.