Influence of Triple-Negative versus Luminal A Breast Cancer Subtype on Choice of Autologous versus Implant-Based Delayed-Immediate Breast Reconstruction.

BACKGROUND: Triple-negative (TN) and luminal A breast cancer molecular subtypes have divergent clinical and prognostic characteristics for breast cancer patients. Our study aims to compare the reconstructive choice of these two groups from the time they receive a tissue expander (TE) to the time they complete autologous or implant-based breast reconstruction. METHODS: A total of 255 patients who underwent delayed-immediate breast reconstruction with TE placement from 2013 to 2017 diagnosed with either TN (n = 73) or luminal A (n = 182) invasive breast cancer subtype seen by two surgeons at a single institution were identified. Preference of autologous and implant-based reconstruction was analyzed, along with TE complications, race, age, body mass index (BMI), smoking, adjuvant therapy, and comorbidities. RESULTS: There was a significant difference in the choice of implant- or autologous-based reconstruction among these two groups (p < 0.05). A greater proportion of luminal A patients underwent implant-based reconstruction (63.47%) and a greater proportion of TN patients underwent autologous-based reconstruction (53.13%). With regard to TE outcomes, there was no significant difference between the two groups with regard to duration of TE placement by reconstructive type or TE surgical complications. Significantly, more TN patients underwent radiation therapy (p < 0.01) and neoadjuvant chemotherapy (p < 0.0001) than luminal A patients. BMI, comorbidities, radiation therapy, and overall TE complications were identified as predictive factors of patients electing for autologous reconstruction over implants. CONCLUSION: TN breast cancer patients mostly chose autologous-based reconstruction, while luminal A patients chose implant-based reconstruction. Both patient groups carried their TEs for similar duration with similar complication profile. Radiation therapy is likely a major factor in the decision for the type of delayed-immediate reconstruction among this population.

Increased Opioid Consumption following DIEP Flap Breast Reconstruction: Effect of Depression and Anxiety.

BACKGROUND: Enhanced Recovery After Surgery (ERAS) protocols have decreased postoperative opioid consumption and hospital length of stay in deep inferior epigastric perforator (DIEP) flap breast reconstruction. We aim to evaluate whether there needs to be further adjustments to best improve outcomes specifically in patients with a preexisting psychiatric condition. METHODS: A retrospective review was performed of all patients that underwent DIEP flap breast reconstruction between October 2018 and September 2020. This includes all patients with the most recent ERAS protocol implementation of intraoperative transverse abdominal plane blocks with liposomal bupivacaine. We looked at patients with a psychiatric diagnosis at the time of surgery. Specifically, forms of depression and anxiety were the psychiatric diagnoses for these patients. We divided these patients into three groups: those with no diagnoses, those with a single diagnosis, and those with both diagnoses. Primary outcomes observed were postoperative opioid consumption and length of stay. A one-way analysis of variance determined whether there was a difference between the three groups and a Tukey post hoc analysis made pairwise comparisons. A p-value of < 0.05 was significant. RESULTS: A total of 176 patients were analyzed in this study: 59 (33.5%) of our study population had a diagnosis of either depression, anxiety, or both. Postoperative opioid consumption was higher in patients with a psychiatric diagnosis compared with those without (123.8 to 91.5; p < 0.0005). A multiple regression model consisting of operating time, hospital length of stay, whether the patient has a psychiatric diagnosis, and history of chemotherapy statistically significantly predicted opioid consumption (p < 0.0005). CONCLUSION: With similar hospital length of stay postoperatively, it is notable that patients with a psychiatric diagnosis had significantly higher amounts of postoperative opioid consumption. This study highlights the need to further improve multidisciplinary integrated care for patients with psychiatric comorbidities to improve pain management postoperatively.

Intraoperative Microvascular Complications in Autologous Breast Reconstruction: The Effects of Resident Training on Microsurgical Outcomes.

BACKGROUND: Academic medical centers with large volumes of autologous breast reconstruction afford residents hand-on educational experience in microsurgical techniques. We present our experience with autologous reconstruction (deep inferior epigastric perforators, profunda artery perforator, lumbar artery perforator, bipedicled, and stacked) where a supervised trainee completed the microvascular anastomosis. METHODS: Retrospective chart review was performed on 413 flaps (190 patients) with microvascular anastomoses performed by postgraduate year (PGY)-4, PGY-5, PGY-6, PGY-7 (microsurgery fellow), or attending physician (AP). Comorbidities, intra-operative complications, revisions, operative time, ischemia time, return to operating room (OR), and flap losses were compared between training levels. RESULTS: Age and all comorbidities were equivalent between groups. Total operative time was highest for the AP group. Flap ischemia time, return to OR, and intraoperative complication were equivalent between groups. Percentage of flaps requiring at least one revision of the original anastomosis was significantly higher in PGY-4 and AP than in microsurgical fellows: PGY-4 (16%), PGY-5 (12%), PGY-6 (7%), PGY-7 (2.1%), and AP (16%), p = 0.041. Rates of flap loss were equivalent between groups, with overall flap loss between all groups 2/413 (<1%). CONCLUSION: With regard to flap loss and microsurgical vessel compromise, lower PGYs did not significantly worsen surgical outcomes for patients. AP had the longest total operative time, likely due to flap selection bias. PGY-4 and AP groups had higher rates of revision of original anastomosis compared with PGY-7, though ultimately these differences did not impact overall operative time, complication rate, or flap losses. Hands-on supervised microsurgical education appears to be both safe for patients, and also an effective way of building technical proficiency in plastic surgery residents.

Composite Tissue Preservation.

Composite tissue (CT) preservation is important to outcomes after replant or transplant. Since the first limb replant, the mainstay of preservation has been static cold storage with the amputated part being placed in moistened gauze over ice. Historically, the gold-standard in solid organ preservation has been static cold storage with specialized solution, but this has recently evolved in the last few decades to develop technologies such as machine perfusion and even persufflation. This review explores the impact of cooling and oxygenation on CT, summarizes the work done in the area of CT preservation, discusses lessons learned from our experience in solid organ preservation, and proposes future directions.

Congenital Inverted Conchal Bowl Deformity: Proposed Technique.

Congenital inverted conchal bowl is a rare deformity with unknown etiology. Its occurrence poses both functional and aesthetic difficulties for patients. We report 2 cases of congenital inverted conchal bowl deformity in an 8-year-old male and 17-year-old female. Both patients were first evaluated in a delayed fashion with concern for difficulty hearing, poor hygiene, and aesthetic concerns. Patient presentation, surgical management, and 6-month follow-up results are presented. Both patients had improved functional and aesthetic outcome after surgical correction.

The evolution of vasectomy reversal.

In the USA, about 500,000 vasectomies are performed each year, with up to 6% of men requesting reversal. The technique of vasectomy reversal has evolved from macrosurgical to the implementation of both microscopic and robotic technologies. The very earliest attempts at vasectomy reversal, the vasoepididymostomy and vasovasostomy, have remained central in the treatment of male infertility and will continue to be so for years to come. As seen throughout its history, urological microsurgery has consistently implemented advanced techniques and state-of-the art technology in its craft, and its continued refinement will allow for even more favorable outcomes in the lives of patients seeking restoration of fertility following vasectomy. Here, we review the evolution of vasectomy reversal and its current techniques.

How to Start a Microsurgery Practice: Success and Sustainability in Academic Practice.

Starting an academic microsurgery practice is a daunting task for plastic surgery graduates. Despite this, academic practice provides many advantages as a starting point for a career. Microsurgical faculty can make use of several unique benefits within an academic center. These include vast resources of clinical and basic science departments, communications and public affairs divisions, and quality improvement teams. Building a multi-disciplinary microsurgery practice with specific focus will jumpstart research questions and outcome data. Using residents and students to their full potential is both rewarding and efficient as a microsurgeon. Finally, peer faculty in an academic environment provide a stimulating resource for growth and assistance when needed. This special topic provides insight into starting a microsurgery practice for any resident considering a career in academics.

BREAST-Q and Donor Site Comparison in Bilateral Stacked Autologous Breast Reconstruction.

Background: Patients undergoing bilateral autologous breast reconstruction may benefit from increased flap volume using bilateral stacked deep inferior epigastric perforator (DIEP) and profunda artery perforator (PAP) flaps. Our aim was to characterize the donor site morbidity and patient-reported outcomes in four-flap breast reconstruction. Methods: Retrospective review was performed for all patients undergoing four-flap breast reconstruction by two surgeons between January 2010 and September 2021. Outcome measures including the BREAST-Q reconstructive module, the lower extremity functional scale (LEFS), inpatient surgical site pain scores by numeric pain rating scale (NPRS), and a postoperative subjective survey comparing donor sites were obtained. Four-flap BREAST-Q scores were compared with bilateral DIEP and bilateral PAP patients. Results: A total of 79 patients undergoing four-flap breast reconstruction were identified. Four-flap BREAST-Q scores (n = 56) were similar to bilateral DIEP and bilateral PAP reconstruction patients. Long-term survey outcomes from the LEFS demonstrated improved score trend after 6 months. Mean instances of donor site pain location recorded at the abdomen were significantly higher than the thigh during the postoperative admission. Subjective survey data revealed more long-term donor site pain at the PAP site, a patient preference for the DIEP donor site, and easier postoperative care for the DIEP donor site. Conclusions: This is the largest consecutive series of four-flap breast reconstruction outcomes reported to date. BREAST-Q scores in four-flap patients demonstrate overall patient satisfaction that is similar to both bilateral DIEP and bilateral PAP reconstruction patients. The DIEP donor site appears to be preferred by patients over the PAP donor site.

Treatment of Nonreplantable Total Thumb Amputation at the CMC Level Using Index Finger Pollicization.

BACKGROUND: Pollicization of the index finger is a rarely performed reconstructive option for patients with total thumb amputations with nonsalvageable carpometacarpal (CMC) joint and thenar muscles. Successful pollicization can provide basic grasp and pinch to help patients carry out activities of daily living. We present a retrospective review of 4 patients who underwent index finger pollicization for traumatic total thumb amputations. METHODS: A retrospective review of 4 cases of pollicization using an injured index finger for traumatic thumb amputation was performed. Patients available for follow-up were contacted for functional assessment. Outcomes including range of motion (ROM), grip strength, key pinch, 2-point discrimination, and Disabilities of the Arm, Shoulder, and Hand score were obtained. Functional thenar muscle and the CMC joint were absent in all cases. Injury mechanism was firework in 2 patients and crush in 2 patients. RESULTS: The time from injury to pollicization ranged from 8 days to 17 months. Follow-up time ranged from 10 weeks to 3 years. Three patients regularly used the pollicized thumb in activities of daily living such as writing. Tip pinch and lateral pinch along with grip strength were weak in all cases; the best recorded pinch strength was 24% and grip strength was 25% compared with the contralateral hand. The ROM of the pollicized thumb was limited. CONCLUSIONS: Index finger pollicization following total thumb amputation can be a viable last-resort option for patients. The pollicized digit acts as a sensate post and avoids further morbidity from the traumatized extremity.

Smile Train: Making the Grade in Global Cleft Care.

The global medical and psychological burden of cleft lip and palate is large, especially in low- and middle-income countries. For decades, medical missions have sought to alleviate this burden; however, there are significant barriers to providing sustainable, high-quality cleft care using the mission model. Smile Train, an international children's charity founded in 1999, has developed a scalable model which provides support to local partner hospitals and surgeons around the world. Smile Train partners with hospitals to support cleft care treatment across the developing world. Partner hospitals are held to strict safety and quality standards. Local or regional providers are primarily used to train medical personnel. A quality assurance process developed by the Smile Train's Medical Advisory Board is used to assess cleft surgery cases and suggest additional review and training as needed. Surgical candidates are systematically evaluated and must meet specific medical criteria to ensure safety. Experienced anesthetists adhere to Smile Train's safety and quality protocols including anesthesia guidelines. Smile Train and its partners have provided more than 1.2 million safe, high-quality cleft surgical treatments since 1999. Smile Train has sponsored more than 3,000 hands-on training opportunities, 30,000 opportunities to participate in cleft conferences, and 40,000 virtual cleft training opportunities. Through rigorous self-governance and its sustainable, scalable model, this organization has elevated the standard of cleft care in the developing world.

A Sustainable and Scalable Approach to the Provision of Cleft Care: A Focus on Safety and Quality.

BACKGROUND: A global health model based on partnering with local hospitals and surgical teams, providing education and training for local providers, and mandating adherence to safety and quality standards to ensure safe surgery and anesthesia care can build local surgical capacity and strengthen existing health care systems in low- and middle-income countries. Smile Train uses this sustainable partnership model to provide responsible humanitarian aid while maintaining a bidirectional exchange with its international partners. METHODS: A voluntary online survey is administered annually to Smile Train's global partners. One portion of this survey focuses on how Smile Train can best support providers' adherence to the Smile Train Safety and Quality Protocol and Anesthesia Guidelines for cleft care. RESULTS: In 2014 and 2015, 1132 health care providers responded to Smile Train's annual partner survey (77 percent response rate). When asked how Smile Train could best support partners to continually meet the safety and quality standards, most partners reported that they could benefit from additional financial support (59.6 percent) and medical professional education and training opportunities (59.2 percent). CONCLUSIONS: The results from the partner survey yield important insights into the programmatic needs of Smile Train partners. Smile Train uses this information to efficiently allocate and distribute resources and to strategically plan and implement training opportunities where needed. The partner survey helps to ensure that Smile Train patients around the world consistently receive safe and high-quality cleft surgery and anesthesia care.

Inequity between male and female coverage in state infertility laws.

OBJECTIVE: To analyze state insurance laws mandating coverage for male factor infertility and identify possible inequities between male and female coverage in state insurance laws. DESIGN: We identified states with laws or codes related to infertility insurance coverage using the National Conference of States Legislatures' and the National Infertility Association's websites. We performed a primary, systematic analysis of the laws or codes to specifically identify coverage for male factor infertility services. SETTING: Not applicable. PATIENT(S): Not applicable. INTERVENTION(S): Not applicable. MAIN OUTCOME MEASURE(S): The presence or absence of language in state insurance laws mandating coverage for male factor infertility care. RESULT(S): There are 15 states with laws mandating insurance coverage for female factor infertility. Only eight of those states (California, Connecticut, Massachusetts, Montana, New Jersey, New York, Ohio, and West Virginia) have mandates for male factor infertility evaluation or treatment. Insurance coverage for male factor infertility is most specific in Massachusetts, New Jersey, and New York, yet significant differences exist in the male factor policies in all eight states. Three states (Massachusetts, New Jersey, and New York) exempt coverage for vasectomy reversal. CONCLUSION(S): Despite national recommendations that male and female partners begin infertility evaluations together, only 8 of 15 states with laws mandating infertility coverage include coverage for the male partner. Excluding men from infertility coverage places an undue burden on female partners and risks missing opportunities to diagnose serious male health conditions, correct reversible causes of infertility, and provide cost-effective treatments that can downgrade the intensity of intervention required to achieve a pregnancy.

Surgical Treatment of Pediatric Upper Limb Spasticity: The Wrist and Hand.

The wrist and hand are essential in the placement of the upper extremity in a functional position for grasp, pinch, and release activities. This depends on the delicate balance between the extrinsic and intrinsic muscles of the wrist and hand. Spasticity alters this equilibrium, limiting the interaction of the upper limb with the environment. Classically, pediatric patients with upper limb spasticity present with a flexed wrist, thumb-in-palm, and flexed finger posture. These contractures are typically secondary to spasticity of the extrinsic flexor muscles of the wrist and hand and intrinsic muscles of the thumb and digits. Tendon release, lengthening, or transfer procedures may help correct the resultant abnormal postures. A total wrist arthrodesis with or without proximal row carpectomy may help address the severely flexed wrist deformity. With proper diagnosis, a well-executed surgical plan, and a consistent hand rehabilitation regimen, successful surgical outcomes can be achieved.

Facial Skin Cancer Reconstruction.

Nonmelanoma skin cancers are the most common skin cancers in the United States and the most common malignancies afflicting the head and neck region. Reconstruction of resulting defects has significant aesthetic and functional implications, and plastic surgeons are frequently consulted for reconstruction. Reconstruction can be accomplished via a multitude of approaches spanning the reconstructive ladder, and the approach should be individualized based upon both patient-related and defect-related factors. Here the authors propose a simplified approach to facial reconstruction broken down by aesthetic region.

Update on Postsurgical Scar Management.

Postoperative scar appearance is often a significant concern among patients, with many seeking advice from their surgeons regarding scar minimization. Numerous products are available that claim to decrease postoperative scar formation and improve wound healing. These products attempt to create an ideal environment for wound healing by targeting the three phases of wound healing: inflammation, proliferation, and remodeling. With that said, preoperative interventions, such as lifestyle modifications and optimization of medical comorbidities, and intraoperative interventions, such as adherence to meticulous operative techniques, are equally important for ideal scarring. In this article, the authors review the available options in postoperative scar management, addressing the benefits of multimodal perioperative intervention. Although numerous treatments exist, no single modality has been proven superior over others. Therefore, each patient should receive a personalized treatment regimen to optimize scar management.

Noninvasive Facial Rejuvenation. Part 2: Physician-Directed-Neuromodulators and Fillers.

A proper knowledge of noninvasive facial rejuvenation is integral to the practice of a cosmetic surgeon. Noninvasive facial rejuvenation can be divided into patient- versus physician-directed modalities. Patient-directed facial rejuvenation combines the use of facial products such as sunscreen, moisturizers, retinoids, α-hydroxy acids, and various antioxidants to both maintain youthful skin as well as rejuvenate damaged skin. Physicians may recommend and often prescribe certain products, but patients are in control with this type of facial rejuvenation. On the other hand, physician-directed facial rejuvenation entails modalities that require direct physician involvement, such as neuromodulators, filler injections, laser resurfacing, microdermabrasion, and chemical peels. With the successful integration of each of these modalities, a complete facial regimen can be established and patient satisfaction can be maximized. This article is the second in a three-part series describing noninvasive facial rejuvenation. Here the authors discuss neuromodulators and fillers in detail, focusing on indications for use, techniques, and common side effects.

Augmented reality assisted surgery: a urologic training tool.

Augmented reality is widely used in aeronautics and is a developing concept within surgery. In this pilot study, we developed an application for use on Google Glass ® optical head-mounted display to train urology residents in how to place an inflatable penile prosthesis. We use the phrase Augmented Reality Assisted Surgery to describe this novel application of augmented reality in the setting of surgery. The application demonstrates the steps of the surgical procedure of inflatable penile prosthesis placement. It also contains software that allows for detection of interest points using a camera feed from the optical head-mounted display to enable faculty to interact with residents during placement of the penile prosthesis. Urology trainees and faculty who volunteered to take part in the study were given time to experience the technology in the operative or perioperative setting and asked to complete a feedback survey. From 30 total participants using a 10-point scale, educational usefulness was rated 8.6, ease of navigation was rated 7.6, likelihood to use was rated 7.4, and distraction in operating room was rated 4.9. When stratified between trainees and faculty, trainees found the technology more educationally useful, and less distracting. Overall, 81% of the participants want this technology in their residency program, and 93% see this technology in the operating room in the future. Further development of this technology is warranted before full release, and further studies are necessary to better characterize the effectiveness of Augmented Reality Assisted Surgery in urologic surgical training.

Treatment of Infected Facial Implants.

Alloplastic facial implants have a wide range of uses to achieve the appropriate facial contour. A variety of materials such as metals, polymers, ceramics and synthetic injectable fillers are available to the reconstructive and aesthetic surgeon. Besides choosing the right surgical technique and the adequate material, the surgeon must be prepared to treat complications. Infection is an uncommon but serious complication that can cause displeasing consequences for the patient. There are few references in literature regarding treatment and management of facial implant-related infections. This study aims to discuss the role of biofilm in predisposing alloplastic materials to infection, to provide a review of literature, to describe our own institutional experience, and to define a patient care pathway for facial implant-associated infection.

Side effects from oral opioids in older adults during the first week of treatment for acute musculoskeletal pain.

OBJECTIVES: The authors sought to describe the frequency of short-term side effects experienced by older adults initiating treatment with opioid-containing analgesics for acute musculoskeletal pain. METHODS: This was a cross-sectional study of individuals age 65 years or older initiating analgesic treatment following emergency department (ED) visits for acute musculoskeletal pain. Patients were called by phone 4 to 7 days after their ED visits to assess the intensity of six common opioid-related side effects using a 0 to 10 scale and to assess medication discontinuation due to side effects. Propensity score matching was used to compare side effects among patients initiating treatment with any opioid-containing analgesics to side effects among those initiating treatment with only nonopioids. RESULTS: Of 104 older patients initiating analgesic treatment following ED visits for musculoskeletal pain, 71 patients took opioid-containing analgesics, 15 took acetaminophen, and 18 took ibuprofen. Among the patients who took opioids, at least one side effect of moderate or severe intensity (score ≥ 4) was reported by 62%. Among patients with matching propensity scores, those taking opioids were more likely to have had moderate or severe side effects than those taking only nonopioids (62%, 95% confidence interval [CI] = 48% to 74% vs. 4%, 95% CI = 1% to 20%) and were also more likely to have discontinued treatment due to side effects (16%, 95% CI = 8% to 29% vs. 0%, 95% CI = 0% to 13%). The most common side effects due to opioids were tiredness, nausea, and constipation. CONCLUSIONS: Among older adults initiating treatment with opioid-containing analgesics for musculoskeletal pain, side effects were common and sometimes resulted in medication discontinuation.