Optimizing the Timeliness of Surgical Therapy in Patients with Breast Cancer Undergoing Immediate Breast Reconstruction.

BACKGROUND: In breast cancer, coordination of surgical therapy with immediate breast reconstruction (IBR) has been found to significantly delay surgical therapy, which in turn can have an adverse effect on patient survival. The objective of this study was to investigate factors that impact the timeliness of surgical therapy in this setting, which may help to optimize the care of patients with breast cancer. PATIENTS AND METHODS: Patients with breast cancer undergoing surgical therapy for breast cancer and immediate reconstruction were reviewed. Patients were divided into two groups: those who underwent surgery ≤ 30 days (group A) and > 30 days (group B) after diagnosis. Multivariate statistical analysis of demographic, disease, surgical, and process of care factors was performed. RESULTS: A total of 348 cases met inclusion criteria, of which 255 (73.2%) were in group A and 93 (26.7%) were in group B. No significant differences were identified in clinical stage, oncologic procedure, or type of reconstruction. On multivariate analysis, an increased likelihood of undergoing surgery ≤ 30 days of diagnosis was observed, with shorter time intervals between surgical oncologist and plastic surgeon consultations [odds ratio (OR) 1.3; 95% confidence interval (CI) 1.1-1.6, p = 0.011]. The number of operating days in common between the surgical oncologist and plastic surgeon nor having the same clinic day impacted timeliness. CONCLUSIONS: Patients may undergo both breast conservation surgery and mastectomy with all major types of immediate reconstruction in a timely manner. Early initiation of plastic surgery referrals and surgeon flexibility to work outside the parameters of institutional schedules may help facilitate the timeliness of surgery.

Surgical Residents' Perceptions of the Impact of Productivity-Based Faculty Compensation at an Academic Medical Center.

BACKGROUND: Academic medical centers have increasingly adopted productivity-based compensation models for faculty. The potential exists for conflict between financial incentives and the quality of surgical resident education. This study aims to examine surgical residents' perceptions regarding the impact of productivity-based compensation on education. METHODS: Following implementation of a productivity-based compensation plan, a survey of surgical residents (general surgery, plastic surgery, otolaryngology, urology, orthopedic surgery, and neurosurgery) was conducted to examine perceptions of its impact on didactics, patient care, surgical technique, teaching in the operating room, and financial considerations. Survey data were prospectively collected and analyzed. A retrospective analysis of relative value units (RVUs) was also performed. RESULTS: Following implementation of the productivity-based compensation plan, annual work RVUs increased by 8.9% in surgery as a whole, with increases observed within all surgical subspecialties. A total of 100 surveys were sent and 35 were completed (35% response rate and at least 30% within each surgical subspecialty). Forty-nine percent of participants perceived an increased focus on clinical productivity by faculty. Thirty-seven percent reported learning more about RVUs and Current Procedural Terminology coding. Most residents reported that the compensation plan did not have an impact on their education with respect to didactics (77%), patient care (94%), surgical technique (97%), and teaching in the operating room (83%). CONCLUSIONS: Increased clinical productivity in the setting of an RVU-based compensation plan was not perceived by most surgical residents to have impacted their education. In some cases, this model may enhance education in relation to RVUs, Current Procedural Terminology coding, and the financial aspects of surgery.

Reconstruction of a radical total vulvectomy defect with a single split anterolateral thigh perforator flap: A case report and review of the literature.

Reconstruction following total vulvectomy is a reconstructive challenge. Previously described techniques typically require bilateral flaps and the associated donor site morbidity. We present a case of reconstruction after radical total vulvectomy using a single split anterolateral thigh (ALT) perforator flap with a design that optimizes perfusion while allowing for primary donor site closure. A 68-year-old female with a history of vulvar squamous cell carcinoma who had previously undergone vulvectomy and radiation therapy presented with local recurrence. The patient required a radical total vulvectomy, resulting in a 12 × 10 cm vulvar defect. A 2-perforator ALT flap (25 × 7 cm) was harvested, split transversely, and then inset in a circumferential manner around the vulva. This approach contrasts with previous reports, which split the ALT flap longitudinally or centrally, and can compromise perfusion and/or preclude primary donor site closure. The patient healed without complication with 6 months of follow-up. The described approach allows for total vulvectomy reconstruction using a single ALT flap with a perforator configuration that maximizes perfusion while obviating the need for donor site grafting.

Concurrent Ventral Hernia Repair Is Effective in Patients Undergoing Abdominally Based Microsurgical Breast Reconstruction.

BACKGROUND: The abdomen remains the most preferable donor site for autologous breast reconstruction. Many patients in this population will have had prior abdominal surgery, which is the chief risk factor for having a ventral hernia. While prior studies have examined the impact of prior abdominal surgery on breast reconstruction, limited data exist on the management of patients with a preexisting ventral hernia. The objective of this study was to investigate outcomes of performing ventral hernia repair concurrent with abdominally based microsurgical breast reconstruction. METHODS: A 5-year retrospective review of patients undergoing abdominally based microsurgical breast reconstruction was performed. The experimental group consisted of patients with a preexisting ventral hernia that was repaired at the time of breast reconstruction, and was compared with a historical cohort of patients without preexisting hernias. RESULTS: There were a total of 18 and 225 patients in the experimental and control groups, respectively. There was a higher incidence of prior abdominal surgery in the experimental group (p = 0.0008), but no other differences. Mean follow-up was 20.5 ± 5.2 months. There were no instances of recurrent hernia or flap loss in the experimental group. No significant differences were observed between the experimental and control groups in the incidence of donor-site complications (27.8 vs. 20.9%, respectively; p = 0.55), recipient site complications (27.8 vs. 24.0%, respectively; p = 0.78), operative time (623 ± 114 vs. 598 ± 100 minutes, respectively; p = 0.80), or length of stay (3.4 ± 0.5 vs. 3.1 ± 0.4 days, respectively; p = 0.98). CONCLUSION: Concurrent ventral hernia repair at the time of abdominally based microsurgical breast reconstruction appears to be safe and effective. Larger studies are needed to further define this relationship.

Waist-to-hip ratio is a better predictor than body mass index for morbidity in abdominally based breast reconstruction.

BACKGROUND: Body mass index is a universally recognized measure of obesity. However, it does not take body fat distribution (BFD) into account, which has been established as a significant risk factor in both medicine and surgery. The objective of this study was to compare previously developed anthropometric measures of BFD with body mass index in predicting morbidity with abdominally based microsurgical breast reconstruction. METHODS: A review of patients who underwent abdominally based breast reconstruction was performed. Multivariate logistic regression was performed to determine the relationship between complications (recipient, donor, total) with body mass index, waist circumference, waist-to-hip ratio, waist-to-height ratio, conicity index, and abdominal volume index. RESULTS: A total of 325 patients who underwent 442 flaps were analyzed. Waist circumference (OR, 1.16; 95% CI 1.07-1.76), waist-to-hip ratio (OR, 1.94; 95% CI 1.25-3.35), and waist-to-height ratio (OR, 1.19; 95% CI 1.01-1.70) were significant risk factors for recipient site complications. Body mass index (OR, 1.14; 95% CI 1.01-1.56), and waist-to-hip ratio (OR, 2.01; 95% CI 1.30-3.95) were significant risk factors for donor site complications. Waist-to-hip ratio (OR, 1.87; 95% CI 1.22-4.00) was the only measure found to be a significant risk factor for experiencing any complication. A waist-to-hip ratio >0.84 was associated with increased risk. CONCLUSIONS: Waist-to-hip ratio is a significant risk factor for recipient and donor site morbidity in abdominally based breast reconstruction. It is a readily calculable and clinically significant measure distinct from body mass index that should be considered for use in clinical care and research.

The Impact of Physician Assistants on a Breast Reconstruction Practice: Outcomes and Cost Analysis.

BACKGROUND: Physician assistants (PAs) are commonly employed in plastic surgery. However, limited data exist on their impact, which may guide decisions regarding how best to integrate them into practice. METHODS: A review of the practices of 2 breast reconstructive surgeons was performed. A comparison was made between a 1-year period before to a 1-year period after the addition of a PA into practice. The practice model was a one-to-one pairing of a plastic surgeon and a PA. RESULTS: A total of 4141 clinic encounters and 1356 surgical cases were reviewed. After the addition of PAs, there was a significant increase in relative value units (1057 vs 1323 per month per surgeon, P < 0.001). Operative times were similar with and without PAs (P = 0.45). However, clinic encounter times for surgeons were shorter for all visit types when patients were first seen by a PA before the surgeon: global follow-up (P = 0.03), other follow-up (P = 0.002), consultation (P = 0.76), and preoperative (P = 0.02), translating to 9 additional patients seen per day. Charges (P = 0.001) and payments (P = 0.007) also increased, which offset the cost of using a PA. However, the financial contribution from PA involvement as first assistant in surgery was limited (5.2%). The peak effect of PAs was observed between the third and fourth quarters. CONCLUSIONS: In breast reconstruction, PAs primarily enhance the efficiency of plastic surgeons, particularly in the clinic, with downstream clinical and financial gains of an indirect nature for surgeons.

Pre-programmed robotic osteotomies for fibula free flap mandible reconstruction: A preclinical investigation.

Bony free flap reconstruction of the facial skeleton remains a challenging area of reconstructive surgery. Despite technological advances that have aided planning and execution of these procedures, surgical inaccuracy is not insignificant. One source of error that has not been wholly addressed is that attributable to a human operator. In this study, we investigate the feasibility and accuracy of performing osteotomies robotically in pre-programmed fashion for fibula free flap mandible reconstruction as a method to reduce inaccuracies related to human error. A mandibular defect and corresponding free fibula flap reconstruction requiring six osteotomies were designed on a CAD platform. A methodology was developed to translate this virtual surgical plan data to a robot (KUKA, Augsburgs, Germany), which then executed osteotomies on three-dimensional (3D) printed fibula flaps with the aid of dynamic stereotactic navigation. Using high-resolution computed tomography, the osteotomized segments were compared to the virtually planned segments in order to measure linear and angular accuracy. A total of 18 robotic osteotomies were performed on three 3D printed fibulas. Compared to the virtual preoperative plan, the average linear variation of the osteotomized segments was 1.3 ± 0.4 mm, and the average angular variation was 4.2 ± 1.7°. This preclinical study demonstrates the feasibility of pre-programmed robotic osteotomies for free fibula flap mandible reconstruction. Preliminarily, this method exhibits high degrees of linear and angular accuracy, and may be of utility in the development of techniques to further improve surgical accuracy.

Processes of Care in Breast Reconstruction and the Long-Term Impact of a Comprehensive Breast Center.

BACKGROUND: Increased emphasis has been placed on process outcomes for breast cancer care, but limited data exists on these measures for breast reconstruction. These processes are likely to be impacted by increased centralization of care into comprehensive breast centers (CBC). Our study objectives were to define measures for processes of care in breast reconstruction and to determine the effect of a CBC on these measures. METHODS: A 5-year review was performed of patients who underwent mastectomy with or without reconstruction for a newly diagnosed breast cancer between 2010 and 2014, which spans from 1 year before to 4 years after introduction of our CBC. RESULTS: A total of 4179 patients were reviewed. The referral rate for immediate reconstruction increased from 40.0 to 70.8 % (p < .001), and the immediate reconstruction rate increased from 36.7 to 65.0 % (p < .001), both plateauing in the fourth study year. The interval between surgical oncology and plastic surgery consultation decreased (from 9.2 to 2.5 days; p < .001), and stabilized in the second study year. The interval between plastic surgery consultation and surgery decreased throughout the entire study period (from 37.6 to 20.8 days; p < .001), resulting in continued improvements in the interval between surgical oncology consultation and surgery (from 46.8 to 23.3 days, p < .001). CONCLUSIONS: In breast reconstruction, a CBC results in improvements in process outcomes, some of which are realized in the short-term and others in the long-term. The timeliness of treatment of patients who undergo immediate postmastectomy reconstruction can be similar to targets set for patients who undergo mastectomy alone.

Surgical management of soft tissue sarcomas: extremity sarcomas.

Wide surgical resection is the recommended treatment for extremity soft tissue sarcomas. Chemotherapy and/or radiotherapy may improve local control, but with marginal effect on overall survival. Advanced reconstructive techniques and multidisciplinary care, including plastic surgery, may allow a higher rate of limb salvage. This report focuses on surgical and reconstructive aspects in the multimodality care of extremity sarcomas.

Bone-supported arch bars are associated with comparable outcomes to Erich arch bars in the treatment of mandibular fractures with intermaxillary fixation.

PURPOSE: Titanium arch bars that are directly fixated to the maxilla and mandible with self-drilling locking screws combine features of Erich arch bars and bone-supported devices and present an alternative method of intermaxillary fixation (IMF) that possesses potential advantages over existing techniques. The objective of this study was to compare IMF using this device with Erich arch bars secured with circum-dental wires. MATERIALS AND METHODS: A retrospective cohort study was performed of patients who were surgically treated for mandibular fractures from 2012 through 2013. The primary predictor variable was fixation technique, which was IMF using Erich arch bars secured with circum-dental wires (group I) or titanium arch bars fixated with maxillary and mandibular screws (group II). The outcome variables were complication rates, time necessary for device application and removal, glove perforation rate, and cost. Statistical analysis was performed with InStat (GraphPad, Inc, La Jolla, CA) using the Fisher, χ(2), or Mann-Whitney test, as appropriate. RESULTS: Twenty-five consecutive cases in group I and in group II were reviewed. There were 43 male patients (86%) and 7 female patients (14%) with a mean age of 28.4 years. Mean follow-up was 2.0 months. Overall complication rates for groups I and II were similar (16.0% vs 12.0%, respectively; P = 1.00). In group II, there were 3 instances of delayed wound healing at the sites of gingivobuccal incisions attributed to the close proximity of the arch bar eyelets. The time necessary for device application was faster in group II than in group I (42 vs 62 minutes, respectively; P = .02). CONCLUSIONS: Bone-supported arch bars may be a comparable alternative to Erich arch bars secured with circum-dental wires for IMF. Careful planning of transoral incisions in relation to locking screw eyelets may help minimize wound complications.

Reconstruction after internal hemipelvectomy: outcomes and reconstructive algorithm.

Internal hemipelvectomy may be indicated in the treatment of select tumors of the pelvis and lower extremity, and has become our preferred approach due to favorable outcomes. After such extensive resections, which can involve long operative times and significant blood loss, there are often substantial bony and soft tissue deficits. However, it is unclear whether the benefits of reconstruction in these cases outweigh the risks involved. In the largest series to date of internal hemipelvectomy patients, we evaluate the effect of reconstruction on surgical complications, postoperative function, and survival. A retrospective review was performed of all patients who underwent internal hemipelvectomy between 1998 and 2011. Outcomes for patients who underwent reconstruction were compared to outcomes for those who did not. A total of 111 patients underwent internal hemipelvectomy, of which 51 (45.9%) received reconstruction and 60 (54.1%) did not. In cases of reconstruction, 30 (58.8%) involved placement of mesh for abdominal wall and pelvic floor reconstruction, 27 (52.9%) involved a soft tissue flap, and 15 (29.4%) involved a vascularized bone flap to restore pelvic ring continuity. Two concurrent reconstructive procedures were performed in 22 (43.1%) patients. The overall rate of early complications was 19.8%, which occurred in 15.7% of patients who received reconstruction compared to 23.3% in patients who did not (P = 0.35). Late recipient-site complications occurred significantly less often in patients who underwent reconstruction (7.8% vs 26.7%, respectively; P = 0.01). From a functional standpoint, Musculoskeletal Tumor Society scores were higher in patients who underwent reconstruction, although this was not statistically significant (62.8% vs 48.4%, respectively; P = 0.12). The 2 groups were similar with regard to operative time, blood loss, and hospital stay, as well as overall and disease-free survival rates. Overall, these results indicate that immediate reconstruction of internal hemipelvectomy defects significantly reduces the incidence of late recipient-site complications, without an adverse effect on perioperative course or overall function. An algorithm for reconstruction based on these outcomes is presented.

The Impact of Intraoperative Microvascular Compromise on Outcomes in Microsurgical Breast Reconstruction.

BACKGROUND: In microsurgical breast reconstruction, the nature and fate of postoperative vascular compromise has been well studied, but limited data exist on intraoperative vascular compromise. METHODS: A review of all breast free flaps between 2007 and 2012 was performed. Details of intraoperative vascular compromise were recorded. Patients who experienced intraoperative microvascular compromise (Group I) were compared with patients who experienced only postoperative microvascular compromise (Group P) and all other patients (Group N). RESULTS: A total of 612 microsurgical breast reconstructions were reviewed. There were 73 (11.9%) flaps in Group I, 27 (4.4%) in Group P, and 512 (83.7%) in Group N. Compared with Group P, Group I more often involved arterial problems (p = 0.01), required supercharging for venous problems (p = 0.02), and was more likely to be salvaged (89.0 vs. 70.4%, p = 0.03). Group I had a similar overall complication rate compared with all other flaps (Group N + P) (31.5 vs. 27.1%, p = 0.49), but a higher flap loss rate (11.0 vs. 1.7%, p = 0.0003). The need to perform > 1 arterial revision was a risk factor for flap loss in Group I (p = 0.028). Total ischemia times > 175 minutes (p = 0.047) and reperfusion times > 80 minutes (p = 0.041) significantly increased the risk of flap loss to approximately 50%. CONCLUSION: Intraoperative vascular problems occur more frequently than postoperative vascular problems but are more frequently salvaged. They do not increase the likelihood of reoperation or total complications compared with all other flaps but do increase the risk of flap loss.

A Review of the Use of Acellular Dermal Matrices in Postmastectomy Immediate Breast Reconstruction.

Acellular dermal matrices (ADMs) are now commonly used in postmastectomy implant-based immediate breast reconstruction. In 2-stage reconstructions involving placement of a tissue expander followed by an implant, they can improve the aesthetic outcome and expedite the expansion process. The use of ADMs has also allowed for 1-stage immediate placement of an implant following mastectomy (direct-to-implant reconstruction). However, the use of ADMs is associated with an increased risk of certain types of complications. An understanding of the use of these materials is essential to the postoperative care of patients who undergo ADM-assisted breast reconstruction. In this article, the use of ADMs in postmastectomy immediate breast reconstruction is reviewed.

Alternatives to commonly used pelvic reconstruction procedures in gynecologic oncology.

OBJECTIVES: The objective of this review is to discuss alternatives to commonly used methods of soft tissue reconstruction in patients with gynecologic malignancies, and in particular alternatives to skin grafts, local skin flaps, and rectus abdominis/gracilis flaps. METHODS: A review of the literature was performed on soft tissue reconstruction in patients with gynecologic malignancies. RESULTS: Soft tissue reconstruction is often necessary to achieve successful wound healing, minimize complications, and to restore anatomic form and function. Commonly used methods such as skin grafts, local skin flaps, and rectus abdominis/gracilis flaps are effective, but many scenarios exist where they may be suboptimal or unavailable for use. Situations faced by the gynecologic oncologist where this may be the case include patients in whom prior treatments and/or tumor involvement have affected the vascular supply and tissues of commonly used options, those with disease recurrence who have previously undergone tumor extirpation and reconstruction, and patients undergoing radical surgery where commonly used options alone are inadequate. Under these circumstances, there are several alternative options, and an understanding of the full spectrum of reconstructive techniques is essential. CONCLUSIONS: Many clinical scenarios exist where commonly used options for soft tissue reconstruction are suboptimal or unavailable. Current evidence supports use of alternative methods of reconstruction in these situations. However, further larger scale and comparative studies are needed to refine surgical decision-making.

Current approaches to free flap monitoring.

Postoperative monitoring of free flaps remains an essential component of care in patients undergoing microsurgical reconstructive surgery. Early recognition of vascular problems and prompt surgical intervention improve the chances for flap salvage. Physical examination remains the cornerstone of free flap monitoring, but more recently, additional technologies have been developed for this purpose. In this article, current approaches to free flap monitoring are reviewed.