Association of Medicaid Expansion with Post-mastectomy Reconstruction Rates.

BACKGROUND: The Affordable Care Act sought to improve access to health care for low-income individuals. This study aimed to assess whether expansion of Medicaid coverage increased rates of post-mastectomy reconstruction (PMR) for patients who had Medicaid or no insurance. METHODS: A retrospective analysis performed through the National Cancer Database examined women who underwent PMR and were uninsured or had Medicaid, private insurance, or Medicare, and whose race/ethnicity, age, and state expansion status were known. Trends in the use of PMR after passage of Medicaid expansion in 2014 were evaluated. RESULTS: In all states and at all time periods, patients with private insurance were about twice as likely to undergo PMR as patients who had Medicaid or no insurance. In 2016, only 28.7 % of patients with Medicaid or no insurance in nonexpansion states underwent PMR (p < 0.001) compared with 38.5 % of patients in expansion states (p < 0.001). Patients in expansion states also have higher levels of education, higher income, and greater likelihood of living in metropolitan areas. Additionally, patients in all states saw an increase in early-stage disease, with a concomitant reduction in late disease, but this change was greater in expansion states than in non-expansion states. CONCLUSIONS: Expansion states have larger proportions of patients undergoing PMR than non-expansion states. This difference stems from significant differences in income, education, comorbidities, race, and location. Large metropolitan areas have the largest number of patients undergoing PMR, whereas rural areas have the least.

Predictors for Prolonged Drain Use Following Autologous Breast Reconstruction.

BACKGROUND: Surgical drains are routinely used following autologous reconstruction, but are often cited as the leading cause of peri-operative discomfort. This study defined routine drain use duration and assessed the risk factors for prolonged breast and abdominal drain use during microvascular breast reconstruction, measures which have never previously been defined. METHODS: Patients who underwent an abdominal microvascular free flap were included. Demographics, comorbidities, and operation-related characteristics were retrospectively collected in a prospectively maintained database. Statistical analysis utilized chi-square independent t-test, and linear regression analyses. RESULTS: One hundred forty-nine patients comprising 233 breast flaps were included. Average breast and abdominal drain duration were 12.9 ± 3.9 and 17.7 ± 8.2 days, respectively. Prolonged breast and abdominal drain duration were defined as drain use beyond the 75th percentile at 14 and 19 days, respectively. Multivariable regression revealed hypertension was associated with an increased breast drain duration by 1.4 days (p = 0.024), axillary dissection with 1.7 days (p = 0.026), African-American race with 3.1 days (p < 0.001), Hispanic race with 1.6 days (p = 0.029), return to the OR with 3.2 days (p = 0.004), and each point increase in BMI with 0.1 days (p = 0.028). For abdominal drains, each point increase in BMI was associated with an increased abdominal drain duration by 0.3 days (p = 0.011), infection with 14.4 days (p < 0.001), and return to the OR with 5.7 days (p = 0.007). CONCLUSION: Elevated BMI, hypertension, and axillary dissection increase risk for prolonged breast drain requirement in autologous reconstruction. African-American and Hispanic populations experience prolonged breast drain requirement after controlling for other factors, warranting further study.

Assessing Interobserver Variability of Cosmetic Outcome Assessment in Breast Cancer Patients Undergoing Breast-Conservation Surgery.

BACKGROUND: Inter-rater reliability between breast surgical oncologists and reconstructive surgeons using cosmesis scales, and the correlation between their observations and patients' own subjective assessments, is poorly understood. METHODS: Patients undergoing BCS in a prospective trial rated their cosmetic outcome on a Likert scale (poor/fair/good/excellent) at the postoperative and 1-year time points; photographs were also taken. Three breast surgical oncologists (not involved in these cases) and two reconstructive surgeons were asked to independently rate cosmesis using the Harvard/NSABP/RTOG scale. RESULTS: Overall, 55 and 17 patients had photographs and Likert self-evaluations at the postoperative and 1-year time points, respectively. There was poor agreement between surgeon and patient ratings postoperatively [kappas - 0.042 (p = 0.659), 0.069 (p = 0.226), and 0.076 (p = 0.090) for the breast surgical oncologists; and 0.018 (p = 0.689) and 0.112 (p = 0.145) for the reconstructive surgeons], and poor interobserver agreement between surgeons of the same specialty (kappa - 0.087, 95% confidence interval [CI] - 0.091 to - 0.082, p = 0.223 for breast surgical oncologists; and kappa - 0.150, 95% CI - 0.157 to - 0.144, p = 0.150, for reconstructive surgeons). At 1 year, the interobserver agreement between breast surgical oncologists was better (kappa 0.507, 95% CI 0.501-0.512, p < 0.001); however, there was still poor correlation between the reconstructive surgeons (kappa - 0.040, 95% CI - 0.049 to - 0.031, p = 0.772). Agreement between surgeon and patient ratings remained poor at this time point [kappas - 0.115 (p = 0.477), 0.177 (p = 0.245), and 0.101 (p = 0.475) for breast surgical oncologists; and 0.335 (p = 0.037) and -0.118 (p = 0.221) for reconstructive surgeons]. CONCLUSION: Despite gradation scales for measuring cosmesis after BCS, high levels of agreement between surgeons is lacking and these do not always reflect patients' subjective assessments.

Surgical Outcomes of Mastectomy with Immediate Autologous Reconstruction Followed by Radiation.

INTRODUCTION: Timing of autologous reconstruction relative to postmastectomy radiation therapy (PMRT) is debated. Benefits of immediate reconstruction must be weighed against a possibly heightened risk of complications from flap irradiation. We reviewed flap outcomes after single operation plus PMRT in a large institutional cohort. METHODS: Medical records were reviewed for women who underwent simultaneous mastectomy-autologous reconstruction with PMRT from 2007 to 2016. Primary endpoints were rates and types of radiation-related flap complications and reoperations, whose predictors were assessed by multivariable analysis. A p value < 0.10 was deemed significant to avoid type II error. Non-parametric logistic regression generated a model of PMRT timing associated with probabilities of complications and reoperations. RESULTS: One-hundred and thirty women underwent 208 mastectomy reconstruction operations, with a median follow up of 35.1 months (interquartile range 23.6-56.5). Forty-seven (36.2%) women experienced radiation-related complications, commonly fat necrosis (44.1%) and chest wall asymmetry (28.8%). Complications were higher among women who received PMRT < 3 months after surgery (46.8% for < 3 months vs. 29.3% for ≥ 3 months; p = 0.06), most of whom received neoadjuvant chemotherapy, and among women treated with internal mammary nodal (IMN) radiation (65.2% vs. 26.4%; p < 0.01); IMN radiation remained strongly associated in multivariable analysis (odds ratio [OR] 5.24; p < 0.01). Thirty-two (24.6%) women underwent 70 reoperations, commonly fat grafting (51.9%) and fat necrosis excision (17.1%). Reoperations were higher among women who received PMRT < 3 months after surgery (48.9 for < 3 months vs. 36.6 for ≥ 3 months; p = 0.19), which was significantly associated in multivariable analysis (OR 0.42; p = 0.08 for ≥ 3 months). The probabilities of complications and reoperations were lowest when PMRT was administered ≥ 3 months after surgery. CONCLUSIONS: Among a large institutional cohort, immediate autologous reconstruction was associated with similar rates of adverse flap outcomes as historically reported alternatively sequenced protocols. IMN radiation increased risk, while PMRT ≥ 3 months after surgery decreased risk. Additional studies are needed to elaborate the impact of IMN radiation and early PMRT in immediate versus delayed autologous reconstruction.

Risk Factors for Lymphedema After Breast Conservation Therapy and Oncoplastic Reduction.

BACKGROUND: Lymphedema is a known complication after the surgical management of breast cancer, yet the incidence is poorly defined after breast conserving therapy and oncoplastic reduction. The primary aim of this study was to define lymphedema incidence in this population. Furthermore, we sought to correlate demographic factors, surgical approach, and complementary treatment modalities with incidence. METHODS: Data were collected retrospectively on patients who underwent breast conserving therapy at our institution from 2012 to 2015 with greater than 1 year of follow-up. Patients were excluded if they underwent breast surgery before treatment, completion mastectomy, delayed breast reconstruction, or delayed breast reduction. RESULTS: Five hundred and eighty-four patients met study criteria with a 11% lymphedema rate. Patients developing lymphedema had higher preoperative body mass index (P = 0.02), larger breast mass resection volume (P < 0.01), higher rate of axillary dissection (P < 0.01), increased rate of adjuvant whole-breast radiation (P = 0.03), supraclavicular radiation (P < 0.01), axillary radiation (P < 0.01), and neoadjuvant medical therapy (P < 0.01). Multivariate analysis showed breast specimen mass, axillary radiation, and neoadjuvant medical therapy, which were associated with lymphedema (P < 0.05). There was no difference in lymphedema incidence between partial mastectomy and oncoplastic reduction cohorts with independent multivariate analyses for each showing axillary radiation and neoadjuvant medical therapy were significantly associated with lymphedema (P < 0.05), although breast specimen mass was not. CONCLUSIONS: Elevated preoperative body mass index, radiation, axillary dissection, and neoadjuvant medical therapy are associated with an increased risk of lymphedema after breast conserving surgery. Oncoplastic reconstruction is not a risk factor for lymphedema.

Comparing complications in irradiated and non-irradiated free-flaps in patients with bilateral immediate breast reconstruction and unilateral post-mastectomy radiotherapy.

BACKGROUND: Numerous studies have evaluated the effect of post-mastectomy radiotherapy (PMRT) on autologous breast reconstruction, but the variability of PMRT regimens and inadequate controls have made results difficult to interpret. Therefore, in this study, irradiated free-flaps are compared to non-irradiated internal controls in patients who underwent immediate bilateral reconstruction followed by unilateral PMRT to better delineate the effect of PMRT. The role of regional nodal irradiation (RNI) is also specifically assessed. METHODS: Appropriate patients were identified through retrospective review. Complications such as fat necrosis, fibrosis, infection, delayed healing, and flap loss, as well as revision surgeries, among the irradiated free-flaps were compared to those on the contralateral non-irradiated side. Additional analyses were performed to evaluate the effect of patient demographics and treatment characteristics, such as RNI, on complications involving the irradiated free-flaps. RESULTS: Seventy-three women were included. There was no significant difference between complication rates for the irradiated and non-irradiated free-flaps (39.7% vs. 38.4%, p = .78), although irradiated free-flaps were more likely to have fibrosis (17.0% vs. 0.0%; p < .0001) and multiple complications (9.6% vs. 0.0%; p = .02). Both groups underwent a similar number of revision surgeries (42.5% vs. 41.1%; p = .29). Looking at the irradiated free-flaps, internal mammary node (IMN) irradiation was the only factor predictive of complications (IRR 3.80, CI 1.32-10.97; p = .01). CONCLUSIONS: PMRT may contribute to free-flap fibrosis, but does not appear to affect the overall risk of complications or revision surgeries. However, additional counseling is warranted if IMN irradiation is likely, as it is potentially associated with increased complications.

Abdominal subcutaneous fat thickness as a substitute for BMI in predicting complications in abdominally-based autologous breast reconstruction.

INTRODUCTION: Patient selection for autologous tissue transfer for postmastectomy breast reconstruction often utilizes body mass index (BMI) to risk stratify patients, though it only estimates fat content and does not address fat distribution. This study aims to identify a measurement of abdominal subcutaneous fat thickness (ASFT) from preoperative computed tomography (CT) angiography imaging to better predict complications. METHODS: A retrospective review of patients who underwent an abdominal microvascular free flap breast reconstruction was performed. The average of the bilateral distances from the lateral border of the rectus abdominus to the most proximal point of the dermis at the L4-L5 space was measured on preoperative imaging to estimate ASFT. This measurement was compared to BMI in regards to correlation with any complication, major or minor complications, and donor or recipient site complications. Statistical analysis utilized point-biserial correlations and multivariable logistic regression analyses. RESULTS: Three hundred and nine cases comprising a total of 496 breast reconstructions were identified. BMI did not correlate with any of the grouped complications, while ASFT correlated with occurrence of any complication (p = .003), minor complications (p = .001), and recipient site complications (p = .001). Further analysis revealed ASFT is specifically correlated with fat necrosis (p = .005). In independent multivariable regression models, both BMI (p = .011) and ASFT (p = .001) were significant predictors of fat necrosis. The ASFT model had a BIC of 335.42 compared to the BMI model with a value of 340.89, with smaller numbers representing more predictive models. CONCLUSION: Estimation of ASFT is easily performed and is a significantly better predictor of flap fat necrosis than BMI.

Impact of socioeconomic status on psychological functioning in survivorship following breast cancer and reconstruction.

Socioeconomic status (SES) remains an important population health risk factor and impacts a patient's experience of care during breast cancer. This study explored the relationship between SES and quality of life and satisfaction in survivorship following breast cancer and reconstruction. All patients underwent breast reconstruction at a single academic center from 2013 to 2017. Patients completed the five quality of life and satisfaction domains of the BREAST-Q, a validated patient-reported outcome measure. Estimated home value using a web-based real estate website was used to approximate a patient's socioeconomic status. Correlations were evaluated using Pearson's correlation methods, where appropriate, as well as analysis of covariance. Data were stratified for comparison utilizing t tests and linear regression models. Significance was defined as P ≤ .05. Four hundred patients underwent 711 breast reconstructions during the study time period. Satisfaction with the breast (P = .038) and psychosocial well-being (P = .012) had significant positive correlations with increasing socioeconomic status. When stratifying patients' socioeconomic status into thirds, the upper third had significantly higher psychosocial well-being (P = .001), satisfaction with breasts (P = .010), and physical well-being of the chest (P = .001) than the lower third. Significance persisted even after controlling for cancer stage, treatment, complications, and baseline comorbidities. Higher socioeconomic status is associated with greater satisfaction with breast reconstruction and psychosocial well-being following breast cancer treatment. Providing added social, psychological, and emotional support networks may be beneficial long after the initial cancer treatment and reconstruction are complete. Patients of lower socioeconomic status may benefit from additional resources.

Breast reconstruction patterns and outcomes in academic and community practices within a single institution.

Breast reconstruction is a common procedure that is performed in both community and academic settings. At Yale-New Haven Hospital (YNHH), both academic (AP) and community-based (CP) plastic surgeons perform breast reconstructions. We aim to compare practice patterns in breast reconstruction between two practice environments within a single institution. A retrospective chart review of all breast reconstructions at YNHH between 2013 and 2018 was performed. Data collected included demographics, preoperative history, and postoperative outcomes. Results were further subdivided by practice setting. A total of 1045 patients (1683 breasts) underwent breast reconstruction during the study period. About 52.8% were performed by AP while 47.2% were performed by CP. CP had higher rates of autologous reconstruction (P < .001) and nipple-sparing mastectomy (P < .0001). Age and BMI were similar between the cohorts. However, patients cared for by AP had 2.6% increased prevalence of diabetes (P = .064), 5.5% greater prevalence of psychiatric diagnoses (P = .004), and 7.1% higher open abdominal surgery rates (P < .001). Outcomes were similar between the groups except for higher infection rates (P = .027) and explant rates (P = .003) in the CP cohort. When evaluating insurance status, the AP cohort had 30.5% fewer patients with commercial insurance, 16.7% more patients with Medicaid and 6.1% more patients with Medicare (P < .001). Within our institution, academic and community-based plastic surgeons perform breast reconstruction with overall similar complication rates. Patients treated by AP have a higher rate of preoperative medical and psychiatric comorbidities. Patients treated by CP have higher rates of infection and implant explant. AP plastic surgeons care for a significantly higher rate of Medicare and Medicaid patients with proportionally fewer patients with commercial insurance.

Patients with psychiatric illness report worse patient-reported outcomes and receive lower rates of autologous breast reconstruction.

Psychiatric well-being impacts on general satisfaction and quality of life. This study explored how the presence of psychiatric diagnoses affects patient-reported outcomes in breast reconstruction and on selection of reconstructive modality. Patients who received breast reconstruction at a tertiary hospital between 2013 and 2018 and completed the BREAST-Q survey were included. BREAST-Q module scores were compared between patients who had a psychiatric diagnosis at presentation and the remaining cohort using t tests. General linear models (GLMs) were used to control for confounding factors. A chi-squared test was used to assess the effect on reconstructive modality, and binary logistic regression was used to control for confounding factors. Of the 471 patients included, 93 (19.7%) had at least one psychiatric diagnosis. Cohorts did not differ significantly by age, BMI, race, ASA classification, or insurance status. Patients with a psychiatric diagnosis experienced a decrease in BREAST-Q scores for the Psychosocial Wellbeing (B = 9.16, P = .001) and Sexual Wellbeing (B = 9.29, P = .025) modules. On binary logistic regression, patients with a psychiatric diagnosis were less likely to receive autologous reconstruction compared with implant reconstruction (OR = 0.489, P = .010). The presence of psychiatric diagnoses is an independent predictor of decreased BREAST-Q. Furthermore, there is a significant disparity in modality of reconstruction given to patients with psychiatric diagnoses. Further study is needed to evaluate interventions to improve satisfaction among at-risk populations and evaluate the reason for low autologous reconstruction in this population.

Optimizing Functional Outcomes in Mandibular Condyle Reconstruction With the Free Fibula Flap Using Computer-Aided Design and Manufacturing Technology.

PURPOSE: Mandibular defects involving the condyle represent a complex reconstructive challenge for restoring proper function of the temporomandibular joint (TMJ) because it requires precise bone graft alignment for full restoration of joint function. The use of computer-aided design and manufacturing (CAD/CAM) technology can aid in accurate reconstruction of mandibular condyle defects with a vascularized free fibula flap without the need for additional adjuncts. The purpose of this study was to analyze clinical and functional outcomes after reconstruction of mandibular condyle defects using only a free fibula graft with the help of virtual surgery techniques. MATERIALS AND METHODS: A retrospective review was performed to identify all patients who underwent mandibular reconstruction with only a free fibula flap without any TMJ adjuncts after a total condylectomy. Three-dimensional modeling software was used to plan and execute reconstruction for all patients. RESULTS: From 2009 through 2014, 14 patients underwent reconstruction of mandibular defects involving the condyle with the aid of virtual surgery technology. The average age was 38.7 years (range, 11 to 77 yr). The average follow-up period was 2.6 years (range, 0.8 to 4.2 yr). Flap survival was 100% (N = 14). All patients reported improved facial symmetry, adequate jaw opening, and normal dental occlusion. In addition, they achieved good functional outcomes, including normal intelligible speech and the tolerance of a regular diet with solid foods. Maximal interincisal opening range for all patients was 25 to 38 mm with no lateral deviation or subjective joint pain. No patient had progressive joint hypomobility or condylar migration. One patient had ankylosis, which required release. CONCLUSION: TMJ reconstruction poses considerable challenges in bone graft alignment for full restoration of joint function. The use of CAD/CAM technology can aid in accurate reconstruction of mandibular condyle defects with a vascularized free fibula flap through precise planning and intraoperative manipulation with optimal functional outcomes.

Optimizing venous outflow in reconstruction of Gustilo IIIB lower extremity traumas with soft tissue free flap coverage: Are two veins better than one?

PURPOSE: The dependent nature of the lower extremity predisposes to venous congestion, especially following significant trauma. The benefit of a second venous anastomosis, however, remains unclear in lower extremity trauma free flap reconstruction. This study investigated the effect of an additional venous anastomosis on flap outcomes in lower extremity trauma reconstruction. METHODS: Retrospective review between 1979 and 2016 identified 361 soft tissue flaps performed for Gustilo IIIB/C coverage meeting inclusion criteria. Muscle flaps were performed in 287 cases (79.9%) and fasciocutaneous flaps in 72 cases (20.1%). Single-vein anastomosis was performed in 76% of cases and dual-vein anastmoses in 24% of cases. Patient demographics, flap characteristics, and outcomes were examined. RESULTS: Fasciocutaneous flaps were more likely to have two veins performed (P < .001). Complications occurred in 143 flaps (39.8%): 45 take-backs (12.4%), 37 partial losses (10.3%), 31 complete losses (8.6%). Compared to single-vein flaps, two veins reduced major complications (P = .005), partial flap failures (P = .008), and any flap failure (P = .018). Multivariable regression analysis demonstrated two veins to be protective against complications (RR = 2.58, P = .009). Subset regression analysis by flap type demonstrated an even more significant reduction in complications among muscle flaps (RR = 3.92, P = .005). Additionally, a >1 mm vein size mismatch was predictive of total flap failure (RR = 3.02, P = .038). CONCLUSION: Lower extremity trauma free flaps with two venous anastomoses demonstrated a fourfold reduction in complication rates compared to single-vein flaps. Additionally, venous size mismatch >1 mm was an independent predictor of total flap failure, suggesting beneficial effects of both two-vein outflow and matched vessel diameter.

Reconstruction of Congenital Mandibular Hypoplasia With Microvascular Free Fibula Flaps in the Pediatric Population: A Paradigm Shift.

BACKGROUND: The microvascular free fibula flap has become the gold standard for reconstruction of complex mandibular defects since its description by Hidalgo in 1989. Prior studies have demonstrated its safety and efficacy in the pediatric population. However, this reconstructive method is often used only as a last resort for correction of congenital mandibular hypoplasia, after failure of bone grafting and distraction osteogenesis. The authors describe our experience using this technique, facilitated by virtual planning and prefabricated cutting jigs, for children with severe congenital mandibular hypoplasia. METHODS: All patients with mandibular reconstruction with a fibula flap in children with congenital mandibular hypoplasia between 2009 and 2014 by the senior authors were identified. Each patient underwent preoperative computed tomography scanning and virtual surgical planning to create custom cutting jigs for creation of the mandibular defect and fibular osteotomies. Preoperative, intraoperative, and postoperative medical records were examined in detail. RESULTS: Five patients age 10 to 18 with congenital mandibular hypoplasia and Pruzansky Grade III mandibles underwent microvascular free fibula flap for mandibular reconstruction during this period. Flap success rate was 100%. All patients underwent subsequent revision procedures to improve symmetry or for hardware removal. The 4 patients in our series who required dental implants were able to have them placed into their mandibular reconstruction. CONCLUSIONS: Preoperative virtual planning and prefabricated cutting jigs allow for precise complex fibula reconstruction of the mandible in the pediatric population. Additionally, virtual planning facilitates concomitant orthognathic procedures in patients with hemifacial microsomia. Our early success in this patient population leads us to suggest that while the free fibula can be safely and successfully used after multiple prior surgical interventions in the same anatomic region, it can also be a powerful tool for primary correction of congenital mandibular hypoplasia.

Dual venous outflow improves lower extremity trauma free flap reconstructions.

BACKGROUND: Venous outflow problems are the most common reasons for perioperative flap complications. The benefit of a second venous anastomosis, however, remains unclear in lower extremity trauma free flap reconstruction and warrants further investigation. MATERIALS AND METHODS: Retrospective review of our institutional flap registry from 1979 to 2014 identified 464 free flaps performed for lower leg trauma reconstruction. Patient demographics, flap characteristics, and outcomes were examined. RESULTS: A total of 219 flaps were randomly selected for preliminary analysis. Single-vein outflow was more common (72.6%) than dual-vein (27.4%); most of the recipients were in deep venous system (83.6%) versus superficial (11.9%) or both (4.6%). Two-vein anastomoses were more likely in fasciocutaneous flaps than muscle flaps (P = 0.001) and in smaller (<300 cm(2)) flaps (P = 0.002). Complications occurred in 98 flaps (44.7%); with 54 partial flap losses (24.7%), and 11 complete flap losses (5.0%). Multivariable regression analysis controlling for age, sex, flap type, presence of bone gap, flap size, vein size mismatch, and time since injury demonstrated dual-vein outflow to be protective against complications (relative risk [RR] = 0.269, P = 0.001), partial flap failure (RR = 0.351, P = 0.031), and any flap failure (RR = 0.31, P = 0.010). No significant difference in operative time was found (P = 0.664). CONCLUSIONS: Dual-vein outflow demonstrated 73% reduction in overall complications and 69% reduction in flap failure rate compared to single-vein flaps. These results suggest a protective effect of a dual-vein outflow system, and when considered together with our findings of unchanged operative time, provide evidence for preferential use of two venous anastomoses when possible for free flap reconstruction of lower extremity trauma.

A 35-Year Evolution of Free Flap-Based Breast Reconstruction at a Large Urban Academic Center.

BACKGROUND: This study aims to characterize the evolution and trends in free flap breast reconstruction at our institution. METHODS: The authors reviewed and analyzed a registry of free flap breast reconstructions performed at a large urban academic center. RESULTS: Between 1979 and mid-2014, a total of 920 patients underwent breast reconstruction with 1,254 flaps. The mean age was 47.7 years (range, 16-79 years). Over the past 10 years, patients were older than all patients seen in the prior decade (average age 48.9 vs. 46.1 years, p = 0.002). Overall, 82% of flaps were performed at our university hospital, 17% at a major urban county hospital, and < 1% at other sites. A total of 99% patients received postmastectomy reconstruction for an existing cancer diagnosis or prophylaxis. There has been a significant increase in reconstructions, with 579 flaps performed over the past 5 years alone. There has been a fundamental shift in the predominant flap of choice over time. Perforator flaps have increased in popularity at our institution, with 74% of all reconstructions over this past 5 years being perforator based. Perforator flaps were more likely to be chosen over nonperforator flaps in older versus younger patients (p = 0.0008). There has been a steady increase in bilateral reconstructions since the first one was performed in 1987 (p = 0.002). CONCLUSIONS: Over the past 35 years, our institution has seen a significant evolution in free flap-based breast reconstruction. Besides a massive increase in flap numbers we have seen a significant trend toward bilateral reconstructions and perforator-based flaps.

Postoperative Expansion is not a Primary Cause of Infection in Immediate Breast Reconstruction with Tissue Expanders.

Perioperative infection is the most common and dreaded complication associated with tissue expander (TE) breast reconstruction. Historically, the expansion period was thought to be the time of greatest hazard to the implant. However, recent institutional observations suggest infectious complications occur prior to expansion. This investigation, therefore, was conducted to determine the timing of infectious complications associated with two-stage TE breast reconstructions. Following IRB approval, a retrospective review of all consecutive two-stage immediate TE breast reconstructions at a single institution from November 2007 to November 2011 was conducted. Reconstructions were then divided into two cohorts: those suffering infectious complications and those that did not. Infectious complications including minor cellulitis, major cellulitis, abscess drainage, and explantation were identified. Various operative and patient variables were evaluated in comparison. Eight hundred ninety immediate two-stage TE breast reconstructions met inclusion criteria. Patients suffering infection were older (55.4 years versus 49.3 years; p < 0.001), and more likely to have therapeutic mastectomy (94% versus 61%; p < 0.0001), the use of acellular dermal matrix (ADM; 72.5% versus 54.9%; p = 0.001), and greater initial TE fill (448.6 mL versus 404.7 mL; p = 0.0078). The average time to developing of infectious symptoms was 29.6 days (range 9-142 days), with 94.6% (n = 87) of infections prior to the start of expansion. Perioperative infections in immediate two-stage TE to implant breast reconstructions are significant and occur mostly prior to the start of expansion. Thus, challenging the conventional wisdom that instrumentation during expander filling as the primary cause of implant infections. Possible etiologic factors include greater age, therapeutic mastectomy versus prophylactic mastectomy, larger initial TE fill, and the use of ADM.

Th2 differentiation is necessary for soft tissue fibrosis and lymphatic dysfunction resulting from lymphedema.

Lymphedema is a dreaded complication of cancer treatment. However, despite the fact that >5 million Americans are affected by this disorder, the development of effective treatments is limited by the fact that the pathology of lymphedema remains unknown. The purpose of these studies was to determine the role of inflammatory responses in lymphedema pathology. Using mouse models of lymphedema, as well as clinical lymphedema specimens, we show that lymphatic stasis results in a CD4 T-cell inflammation and T-helper 2 (Th2) differentiation. Using mice deficient in T cells or CD4 cells, we show that this inflammatory response is necessary for the pathological changes of lymphedema, including fibrosis, adipose deposition, and lymphatic dysfunction. Further, we show that inhibition of Th2 differentiation using interleukin-4 (IL-4) or IL-13 blockade prevents initiation and progression of lymphedema by decreasing tissue fibrosis and significantly improving lymphatic function, independent of lymphangiogenic growth factors. We show that CD4 inflammation is a critical regulator of tissue fibrosis and lymphatic dysfunction in lymphedema and that inhibition of Th2 differentiation markedly improves lymphatic function independent of lymphangiogenic cytokine expression. Notably, preventing and/or reversing the development of pathological tissue changes that occur in lymphedema may be a viable treatment strategy for this disorder.

Smooth versus Textured Tissue Expanders: Comparison of Outcomes and Complications in 536 Implants.

Background Increasing concerns regarding the safety of textured surface implants have resulted in surgeons transitioning from textured tissue expanders (TEs) to smooth TEs. Given this change has only recently occurred, this study evaluated outcomes between smooth and textured TEs. Methods Women who underwent two-stage breast reconstruction using TEs from 2013 to 2022 were included. TE-specific variables, perioperative information, pain scores, and complications were collected. Chi-squared, t -test, and linear regression analyses were performed. Results A total of 320 patients received a total of 384 textured and 152 smooth TEs. Note that 216 patients received bilateral reconstruction. TEs were removed in 9 cases. No significant differences existed between groups regarding comorbidities. Smooth TEs had a higher proportion of prepectoral placement ( p < 0.001). Smooth TEs had less fills (3 ± 1 vs. 4 ± 2, p < 0.001), shorter expansion periods (60 ± 44 vs. 90 ± 77 days, p < 0.001), smaller expander fill volumes (390 ± 168 vs. 478 ± 177 mL, p < 0.001), and shorter time to exchange (80 ± 43 vs. 104 ± 39 days, p < 0.001). Complication rates between textured and smooth TEs were comparable. Smooth TE had a greater proportion of TE replacements ( p = 0.030). On regression analysis, pain scores were more closely associated with age ( p = 0.018) and TE texture ( p = 0.046). Additional procedures at time of TE exchange ( p < 0.001) and textured TE ( p = 0.017) led to longer operative times. Conclusion As many surgeons have transitioned away from textured implants, our study shows that smooth TEs have similar outcomes to the textured alternatives.

HIF-1α coordinates lymphangiogenesis during wound healing and in response to inflammation.

This study aimed to investigate the mechanisms that coordinate lymphangiogenesis. Using mouse models of lymphatic regeneration and inflammatory lymphangiogenesis, we explored the hypothesis that hypoxia inducible factor-α (HIF-1α) is a central regulator of lymphangiogenesis. We show that HIF-1α inhibition by small molecule inhibitors (YC-1 and 2-methyoxyestradiol) results in delayed lymphatic repair, decreased local vascular endothelial growth factor-C (VEGF-C) expression, reduced numbers of VEGF-C(+) cells, and reductions in inflammatory lymphangiogenesis. Using transgenic HIF-1α/luciferase mice to image HIF-1α expression in real time in addition to Western blot analysis and pimonidazole staining for cellular hypoxia, we demonstrate that hypoxia stabilizes HIF-1α during initial stages of wound repair (1-2 wk); whereas inflammation secondary to gradients of lymphatic fluid stasis stabilizes HIF-1α thereafter (3-6 wk). In addition, we show that CD4(+) cell-mediated inflammation is necessary for this response and regulates HIF-1α expression by macrophages, as CD4-deficient or CD4-depleted mice demonstrate 2-fold reductions in HIF-1α expression as compared to wild-types. In summary, we show that HIF-1α is a critical coordinator of lymphangiogenesis by regulating the expression of lymphangiogenic cytokines as part of an early response mechanism to hypoxia, inflammation, and lymphatic fluid stasis.