Nursing Monitoring of Microsurgical Free Flaps: Identifying and Addressing Knowledge Gaps.

BACKGROUND: Microsurgical free flaps require careful monitoring to detect early signs of compromise. At many hospitals, nursing staff provides the majority of postoperative monitoring of free flap patients and it lies within their responsibility to alert physicians of a failing free flap. The aim of this study is to identify knowledge gaps in the monitoring of microvascular free tissue transfer in both novice and experienced nurses and to provide appropriate education to address these gaps. METHODS: This was a pre- and postintervention study. An initial pilot survey was administered to identify knowledge deficiencies. A nursing educational session on free flap physiology and monitoring was then designed to address these deficiencies. An 18-question multiple choice quiz was administered before and after the educational session. Pre- and post-test scores were compared based on nursing experience. At 6 months, the participating nurses completed a survey rating their confidence with free flap patient care as a result of the educational session. RESULTS: A total of 72 nurses completed the in-service training course and quiz. The average quiz score increased from 61.9 to 89.3% after the in-service (p < 0.001). There was no correlation between precurriculum test scores and nursing experience as referenced by total number of years in the profession (r s = -0.038, p = 0.754). The follow-up survey showed that prior to the course 38% of respondents reported little or no confidence caring for free flap patients, decreasing to 6% after the course (p < 0.05). CONCLUSION: Based on the results of this study, nursing knowledge of capillary refill, venous congestion, and basic microsurgical free flap physiology is inadequate. With implementation of a teaching in-service curriculum highlighting these key areas of deficiencies, nurses improved both their understanding and confidence levels, regardless of their level of experience.

The Double Donut: A Safe and Simple Option for Immediate Nipple Areolar Complex Reconstruction in Skin-Sparing Mastectomy Patients With Contraindications to Nipple-Sparing Mastectomy.

Background: Restoration of the nipple areolar complex (NAC) has been shown to improve quality of life (QoL) in post-mastectomy patients. Despite expansion of nipplesparing mastectomy inclusion criteria, many patients remain ineligible and are relegated to bilateral skin-sparing mastectomy. In this study, we evaluated immediate NAC reconstruction with the double donut areolar graft and split nipple composite graft reconstruction (DDSNS). Methods: A single-center prospective study was performed for patients undergoing immediate post-mastectomy reconstruction with the DDSNS technique. Demographics and post-reconstruction endpoints were collected, focusing on aesthetic and functional outcomes. Results: A total of 31 patients and 62 breasts underwent immediate reconstruction with the DDSNS technique. Four of 62 (6.4%) nipple composite grafts and 1 of 62 (1.6%) areolar grafts experienced partial graft loss. All incidents of initial loss healed to a satisfactory result. All patients were able to proceed with adjuvant therapy, if indicated, without delay. Conclusions: The DDSNS technique can be successfully applied to achieve cosmetically satisfactory results in the post-mastectomy patient. This technique has shown reliable outcomes with respect to graft success and patient satisfaction with their NAC reconstruction.

Mapping the zinc-transporting system in mammary cells: molecular analysis reveals a phenotype-dependent zinc-transporting network during lactation.

The mammary epithelial cell transitions from a non-secreting to a terminally differentiated, secreting cell during lactation. Zinc (Zn) is a key modulator of phenotypic transition as it regulates over 300 biological functions including transcription, translation, energy transformation, intracellular signaling, and apoptosis. In addition, Zn must be redirected from normal cellular functions into the secretory compartment, as many components of the secretory system are Zn-dependent and an extraordinary amount of Zn is secreted (1-3 mg Zn/day) into milk. Herein, we utilized a "systems biology" approach of genomic and proteomic profiling to explore mechanisms through which Zn is reallocated during phenotype transition in the lactating mammary gland from mice and cultured mammary cells. Nine Zn transporters play key roles in Zn redistribution within the network during lactation. Protein abundance of six Zip (Zip3, Zip5, Zip7, Zip8, Zip10, Zip11) and three ZnT (ZnT2, ZnT4, ZnT9) proteins was expanded >2-fold during lactation, which was not necessarily reflected by changes in mRNA expression. Our data suggest that Zip5, Zip8, and Zip10 may be key to Zn acquisition from maternal circulation, while multiple Zip proteins reuptake Zn from milk. Confocal microscopy of cultured mammary cells identified the Golgi apparatus (modulated in part by ZnT5, Zip7, and Zip11) and the late endosomal compartment (modulated in part by ZnT2 and Zip3) as key intracellular compartments through which Zn is reallocated during lactation. These results provide an important framework for understanding the "Zn-transporting network" through which mammary gland Zn pools are redistributed and secreted into milk.