An Expert Consensus Study for Informed Consent in Primary Breast Augmentation Surgery.

BACKGROUND: What constitutes adequate information for decision-making and informed consent is a practical question appropriately answered with deference to expertise. OBJECTIVES: The aims of this study were: (1) to establish consensus on a procedure-specific core information set of essential informed consent information by relevant medical experts for primary breast augmentation surgery; and (2) to define from the clinical perspective the data source and imminence elements of evidence-based risk communication. METHODS: The study followed a modified Delphi expert consensus model. Active members of The Aesthetic Society were identified as the relevant clinician experts and were recruited by email. Survey round 1 was informed by a scoping review of the relevant scientific and gray literature. Round 2 was informed by the initial survey round. Consensus was defined a priori as a 75% majority rating. RESULTS: Expert consensus of essential information was achieved for 16 risk items, 1 risk factor, and 8 expectations-including benefits and burdens-along with clarification of clinically appropriate options to present to all patients considering primary implant-based breast augmentation surgery. A basic, procedure-specific, structure for evidence-based risk data is also described. CONCLUSIONS: This paper reports results for the first phase of a larger pilot study aiming to develop a patient decision aid to replace traditional informed consent documents for the specified procedure. Implications for practice are encouraging in terms of reducing unwanted variation in disclosure practices and information overload.

Attitudes, Beliefs, and Practices of Aesthetic Plastic Surgeons Regarding Informed Consent.

BACKGROUND: Best practice for informed consent in aesthetic plastic surgery is a process of shared decision-making, yet evidence strongly suggests this is not commonly reflected in practice nor is it supported by traditional informed consent documents (ICD). Falsely held beliefs by clinicians about shared decision-making may contribute to its lack of adoption. OBJECTIVE: The authors sought to understand the baseline attitudes, beliefs, and practices of informed consent among board-certified plastic surgeons with a primarily aesthetics practice. METHODS: A 15-question online survey was emailed to active members of the American Society for Aesthetic Plastic Surgery. Items included demographics, Likert scales, free-text, acceptability, and 1 question seeking consensus on general information all patients must understand before any surgery. RESULTS: This survey yielded a 13% response rate with a 52% completion rate across 10 countries and 31 US states. A total of 69% were very or extremely confident that ICD contain evidence-based information, but 63% were not at all or not so confident in ICD effectiveness of prompting patients to teach-back essential information. A total of 50% believed surgical ICD should be reviewed annually. Eighty-six percent reported assistance with patient education during informed consent. Members of professional plastic surgery societies should be a source of evidence for content (free-text). A total of 64% were somewhat to very satisfied with the survey and 84% will probably to definitely participate in future related surveys. CONCLUSIONS: The findings echo concerns in the literature that ICD are focused on disclosure instead of patient understanding. There is notable concern regarding information overload and retention but less regarding the quality and completeness of information. Current culture suggests key clinician stakeholders are amenable to change.

Radiation and breast reconstruction: Algorithmic approach and evidence-based outcomes.

Postmastectomy radiation (PMRT) in the setting of immediate breast reconstruction has been associated with increased complications and poorer aesthetic outcomes for both autologous and implant reconstructions. Many centers have attempted to mitigate the deleterious effects associated with radiation by implementing an algorithmic approach to breast reconstruction. Although the literature regarding the optimal timing of radiotherapy and breast reconstruction remains controversial, reported outcomes following various algorithms have been encouraging and warrant further consideration. J. Surg. Oncol. 2016;113:906-912. © 2016 Wiley Periodicals, Inc.

Medical students impact laparoscopic surgery case time.

BACKGROUND: Medical students (MS) are increasingly assuming active roles in the operating room. Laparoscopic cases offer unique opportunities for MS participation. The aim of this study was to examine associations between the presence of MS in laparoscopic cases and operation time and postoperative complication rates. MATERIALS AND METHODS: Data from the American College of Surgeons National Surgical Quality Improvement Program were linked to operative records for nonemergent, inpatient, and laparoscopic general surgery cases at our institution from January, 2009-January, 2013. Cases were grouped into eight distinct procedure categories. Hospital records provided information on the presence of MS. Demographics, comorbidities, intraoperative variables, and postoperative complication rates were analyzed. RESULTS: Seven hundred laparoscopic cases were included. Controlling for wound class, procedure group, and surgeon, MS were associated with an additional 28 min of total operative time. The most significant increase occurred between the skin incision and skin closure. No significant association between the presence of MS and postoperative complications was observed. CONCLUSIONS: This is the first retrospective analysis to examine the effect of MS presence during laparoscopic procedures. Increase in the operation time associated with the presence of MS should be examined further, to optimize the educational experience without incurring increased cost due to increased operation time.

Breast necrosis secondary to vasopressor extravasation: management using indocyanine green angiography and omental flap closure.

Extravasation is a rare but serious complication of vasopressor administration. A 60-year-old female who underwent ascending and hemiarch repair of the aorta along with aortic valve replacement developed extensive right breast and chest wall necrosis after vasopressor extravasation from an internal jugular vein central line. The patient underwent a total mastectomy due to deep tissue necrosis detected by laser-assisted indocyanine green dye angiography, and eventually required omental flap reconstruction to obtain adequate sternal coverage. This case represents a previously unreported complication of internal jugular central line extravasation of vasopressors with resultant breast and chest wall necrosis, and highlights the utility of the omentum in chest wall reconstruction.

Surgical Repair of an Avulsed Distal Flexor Carpi Radialis Tendon in a Boxer: A Case Report.

CASE: A 25-year-old professional boxer presented with a right distal flexor carpi radialis (FCR) tendon avulsion after sustaining an injury while boxing. The avulsion was identified and confirmed with magnetic resonance imaging, and the tendon was successfully reinserted into the trapezium. The patient returned to professional boxing 10 months later without complication. CONCLUSIONS: Distal FCR tendon avulsions are rare. Occasionally, this tendon can avulse after an application of excessive force. For some patients, unrepaired distal FCR tendon avulsions may prevent competitive performance. In this case, the tendon was reattached to the trapezium to aid wrist motion and stability, which are essential for professional boxing.

Schwannoma of the Palmar Cutaneous Branch of the Median Nerve.

Peripheral schwannomas are benign tumors originating from the Schwann cells of the peripheral nerve sheath. They make up a small percentage of the overall incidence of tumors of the hand, most commonly involving the ulnar nerve. The authors report a case of a 59-year-old patient with a slowly enlarging mass over his right wrist and no other symptoms. During surgery, a schwannoma involving the palmar cutaneous branch of the median nerve was found and successfully removed. This is a rare clinical entity, with few cases reported in the literature. In the current case, the lesion did not cause significant symptoms, and the authors demonstrated successful surgical enucleation of the lesion without complication. [Orthopedics. 2018; 41(4):e572-e573.].

Does the amount of time medical students spend in the operating room during the general surgery core clerkship affect their career decision?

BACKGROUND: The amount of time medical students (MS) spend in the operating room (OR) during their general surgery core clerkship has not been previously studied as a predictor for choosing a career in surgery. We hypothesize that MS choosing a career in surgery spend more time in the OR. METHODS: Operative records for surgery cases at our institution from 2009 to 2013 were linked to the schedules of MS from classes of 2010 to 2014. Total number of minutes, cases, and average number of minutes in the OR were calculated and compared with the match lists. Univariate analysis was conducted to assess for associations (P < .05). RESULTS: A total of 117 students and 1,524 procedures were included. Twenty-two MS chose a surgical career (19%). An average of 2,018.5 minutes per rotation was spent in the OR (81.2 min/d), but neither the amount of time nor the number of cases was associated with choosing a career in surgery. CONCLUSIONS: Quality of the educational experience trumps quantity regarding what most influences MS career decision.

Do medical students in the operating room affect patient care? An analysis of one institution's experience over the past five years.

BACKGROUND: Medical students are active learners in operating rooms during medical school. This observational study seeks to investigate the effect of medical students on operative time and complications. METHODS: Data from the American College of Surgeons National Surgical Quality Improvement Program was linked to operative records for nonemergent, inpatient general surgery cases at our institution from 1 January 2009 to 1 January 2013. Cases were grouped into 13 distinct procedure groups. Hospital records provided information on the presence of medical students. Demographics, comorbidities, intraoperative variables, and postoperative complications were analyzed. RESULTS: Overall, 2481 cases were included. Controlling for wound class, procedure group, and surgeon, medical students were associated with an additional 14 minutes of operative time. No association between medical students and postoperative complications was observed. CONCLUSIONS: The educational benefits gained by the presence of medical students do not appear to jeopardize the quality of patient care.