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BACKGROUND: Adherence to screening guidelines among transgender and non-binary (TGNB) populations is not well studied. This study examines breast cancer screening patterns among TGNB patients at an urban academic medical center. METHODS: Demographic information, risk factors, and screening mammography were collected. Mammography rates were calculated in populations of interest according to national guidelines, and mammogram person-years were also calculated. Univariate and multivariate logistic regression was performed. RESULTS: Overall, 253 patients were analyzed: 193 transgender women and non-binary people designated male at birth (TGNB DMAB) and 60 transgender men and non-binary people designated female at birth (TGNB DFAB). The median (interquartile range) age was 53.2 years (42.3-62.6). Most patients had no family history of breast cancer (n = 163, 64.4%) and were on hormone therapy (n = 191, 75.5%). Most patients where White (n = 164, 64.8%), employed (n = 113, 44.7%), and had public insurance (n = 128, 50.6%). TGNB DFAB breast screening rates were low, ranging from 2.0 to 50.0%, as were TGNB DMAB screening rates, ranging from 7.1 to 47.6%. The screening rates among the TGNB DFAB and TGNB DMAB groups did not significantly differ from one another. Among TGNB DFAB patients, univariate analyses showed no significant predictors for mammography. Among TGNB DMAB patients, not being on hormone therapy resulted in fewer odds of undergoing mammography. There were no significant findings on multivariate analyses. CONCLUSION: Mammography rates in the TGNB population are lower than institutional and national rates for cisgender patients, which are 77.3% and 66.7-78.4%, respectively. Stage of transition, organs present, hormone therapy, and risk factors should be considered to guide screening.
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Neoplasias da Mama , Pessoas Transgênero , Neoplasias da Mama/diagnóstico por imagem , Detecção Precoce de Câncer , Feminino , Humanos , Recém-Nascido , Masculino , Mamografia , Programas de Rastreamento , Pessoa de Meia-IdadeRESUMO
Injured peripheral nerves typically exhibit unsatisfactory and incomplete functional outcomes, and there are no clinically approved therapies for improving regeneration. Post-operative electrical stimulation (ES) increases axon regrowth, but practical challenges from the cost of extended operating room time to the risks and pitfalls associated with transcutaneous wire placement have prevented broad clinical adoption. This study presents a possible solution in the form of advanced bioresorbable materials for thin, flexible, wireless implant that provides precisely controlled ES of the injured nerve for a brief time in the immediate post-operative period. Afterward, rapid, complete and safe modes of bioresorption naturally and quickly eliminate all of the constituent materials in their entirety, without the need for surgical extraction. The unusually high rate of bioresorption follows from the use of a unique, bilayer enclosure that combines two distinct formulations of a biocompatible form of polyanhydride as an encapsulating structure, to accelerate the resorption of active components and confine fragments until complete resorption. Results from mouse models of tibial nerve transection with re-anastomosis indicate that this system offers levels of performance and efficacy that match those of conventional wired stimulators, but without the need to extend the operative period or to extract the device hardware.
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ABSTRACT: Mastectomy for chest masculinization is a commonly performed gender-affirming surgery in minor patients, a vulnerable population with unique developmental and psychosocial needs. We aimed to use principles of medical ethics (eg, autonomy, beneficence, nonmaleficence, and justice) as a framework to analyze preoperative clinical decision making by pediatric plastic surgeons who work with transmasculine and nonbinary adolescents designated female at birth presenting for chest masculinization. Two patients were selected for inclusion in this case series based on the senior author's (J.F.C.) clinical experience. A retrospective chart review was conducted to extract relevant psychosocial and clinical information from clinic notes and supplemental documentation (eg, letters from outside providers) available in the electronic medical record. In case A, a 17-year-old patient presented to a plastic surgery clinic with mixed parental support and restrictive insurance requirements. In case B, a 16-year-old patient presented to the emergency room after an attempt to remove his own breasts. The cases highlight the role of the plastic surgeon in advocating for adolescent autonomy and justice by facilitating shared family decision making and navigating barriers to care. In addition, we recommend multidisciplinary care, including trusted, transcompetent mental health professionals, to ensure beneficence and nonmaleficence by providing timely care when appropriate.
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Neoplasias da Mama , Adolescente , Beneficência , Criança , Feminino , Humanos , Recém-Nascido , Mastectomia , Menores de Idade , Autonomia Pessoal , Estudos RetrospectivosRESUMO
PURPOSE: Targeted muscle reinnervation (TMR) is a technique for the management of peripheral nerves in amputation. Phantom limb pain (PLP) and residual limb pain (RLP) trouble many patients after amputation, and TMR has been shown to reduce this pain when performed after the initial amputation. We hypothesize that TMR at the time of amputation may improve pain for patients after major upper-extremity amputation. METHODS: We conducted a retrospective review of patients who underwent major upper-extremity amputation with TMR performed at the time of the index amputation (early TMR). Phantom limb pain and RLP intensity and associated symptoms were assessed using the numeric rating scale (NRS), the Patient-Reported Outcome Measurement Information System (PROMIS) Pain Intensity Short-Form 3a, the Pain Behavior Short-Form 7a, and the Pain Interference Short-Form 8a. The TMR cohort was compared with benchmarked data from a sample of upper-extremity amputees. RESULTS: Sixteen patients underwent early TMR and were compared with 55 benchmark patients. More than half of early TMR patients were without PLP (62%) compared with 24% of controls. Furthermore, half of all patients were free of RLP compared with 36% of controls. The median PROMIS PLP intensity score for the general sample was 47 versus 38 in the early TMR sample. Patients who underwent early TMR reported reduced pain behaviors and interference specific to PLP (50 vs 53 and 41 vs 50, respectively). The PROMIS RLP intensity score was lower in patients with early TMR (36 vs 47). CONCLUSIONS: This study demonstrates that early TMR is a promising strategy for treating pain and improving the quality of life in the upper-extremity amputee. Early TMR may preclude the need for additional surgery and represents an important technique for peripheral nerve surgery. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.
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Membro Fantasma , Qualidade de Vida , Amputação Cirúrgica , Humanos , Músculo Esquelético , Estudos RetrospectivosRESUMO
BACKGROUND: Female sexual function is a complex model of biological and nonbiological factors. The impact of self-perceived vulvar appearance on female sexual function is not well understood. OBJECTIVES: The aim of this study was to determine the influence of vulvar appearance on sexual function in adult women. The primary aim was to assess the relation between self-perceived vulvar appearance and sexual function. The secondary aim was to assess the influence of prior genital procedures on vulvar appearance and sexual function. METHODS: An observational study of adult women was conducted utilizing Amazon Mechanical Turk, an online crowdsourcing platform. The survey instrument included demographic information, subjective vulvar appearance measures, and the Female Sexual Function Index (FSFI) questionnaire. RESULTS: Out of 398 respondents, 148 (37.2%) reported concern about their vulvar appearance and 134 (33.7%) reported a history of genital cosmetic procedures. Women who were uncomfortable with their vulvar appearance had lower FSFI scores than those comfortable with their vulvar appearance, 24.6 vs 27.0 (P = 0.01), respectively. Among women uncomfortable with their vulvar appearance, 70.9% of subjects met the criteria for sexual dysfunction. Women who were uncomfortable with their vulvar appearance were significantly more at risk of sexual dysfunction (adjusted odds ratio: 2.43; 95% CI: 1.46-4.10; P < 0.001). Women with a history of cosmetic genital procedures were significantly more at risk of sexual dysfunction (adjusted odds ratio: 2.46; 95% CI: 1.43-4.23). CONCLUSIONS: Women who are uncomfortable with their vulvar appearance had higher rates of sexual dysfunction. Women seeking cosmetic genital procedures should be screened for sexual dysfunction to facilitate realistic expectations and optimal care.
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Disfunções Sexuais Fisiológicas , Adulto , Feminino , Humanos , Comportamento Sexual , Disfunções Sexuais Fisiológicas/diagnóstico , Disfunções Sexuais Fisiológicas/epidemiologia , Disfunções Sexuais Fisiológicas/etiologia , Inquéritos e QuestionáriosRESUMO
BACKGROUND: Targeted muscle reinnervation is an emerging surgical technique to treat neuroma pain whereby sensory and mixed motor nerves are transferred to nearby redundant motor nerve branches. In a recent randomized controlled trial, targeted muscle reinnervation was recently shown to reduce postamputation pain relative to conventional neuroma excision and muscle burying. QUESTIONS/PURPOSES: (1) Does targeted muscle reinnervation improve residual limb pain and phantom limb pain in the period before surgery to 1 year after surgery? (2) Does targeted muscle reinnervation improve Patient-reported Outcome Measurement System (PROMIS) pain intensity and pain interference scores at 1 year after surgery? (3) After 1 year, does targeted muscle reinnervation improve functional outcome scores (Orthotics Prosthetics User Survey [OPUS] with Rasch conversion and Neuro-Quality of Life [Neuro-QOL])? METHODS: Data on patients who were ineligible for randomization or declined to be randomized and underwent targeted muscle reinnervation for pain were gathered for the present analysis. Data were collected prospectively from 2013 to 2017. Forty-three patients were enrolled in the study, 10 of whom lacked 1-year follow-up, leaving 33 patients for analysis. The primary outcomes measured were the difference in residual limb and phantom limb pain before and 1 year after surgery, assessed by an 11-point numerical rating scale (NRS). Secondary outcomes were change in PROMIS pain measures and change in limb function, assessed by the OPUS Rasch for upper limbs and Neuro-QOL for lower limbs before and 1 year after surgery. RESULTS: By 1 year after targeted muscle reinnervation, NRS scores for residual limb pain from 6.4 ± 2.6 to 3.6 ± 2.2 (mean difference -2.7 [95% CI -4.2 to -1.3]; p < 0.001) and phantom limb pain decreased from 6.0 ± 3.1 to 3.6 ± 2.9 (mean difference -2.4 [95% CI -3.8 to -0.9]; p < 0.001). PROMIS pain intensity and pain interference scores improved with respect to residual limb and phantom limb pain (residual limb pain intensity: 53.4 ± 9.7 to 44.4 ± 7.9, mean difference -9.0 [95% CI -14.0 to -4.0]; residual limb pain interference: 60.4 ± 9.3 to 51.7 ± 8.2, mean difference -8.7 [95% CI -13.1 to -4.4]; phantom limb pain intensity: 49.3 ± 10.4 to 43.2 ± 9.3, mean difference -6.1 [95% CI -11.3 to -0.9]; phantom limb pain interference: 57.7 ± 10.4 to 50.8 ± 9.8, mean difference -6.9 [95% CI -12.1 to -1.7]; p ≤ 0.012 for all comparisons). On functional assessment, OPUS Rasch scores improved from 53.7 ± 3.4 to 56.4 ± 3.7 (mean difference +2.7 [95% CI 2.3 to 3.2]; p < 0.001) and Neuro-QOL scores improved from 32.9 ± 1.5 to 35.2 ± 1.6 (mean difference +2.3 [95% CI 1.8 to 2.9]; p < 0.001). CONCLUSIONS: Targeted muscle reinnervation demonstrates improvement in residual limb and phantom limb pain parameters in major limb amputees. It should be considered as a first-line surgical treatment option for chronic amputation-related pain in patients with major limb amputations. Additional investigation into the effect on function and quality of life should be performed. LEVEL OF EVIDENCE: Level IV, therapeutic study.
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Dor Crônica/cirurgia , Músculo Esquelético/inervação , Transferência de Nervo/métodos , Neuroma/cirurgia , Membro Fantasma/cirurgia , Adulto , Amputação Cirúrgica/efeitos adversos , Dor Crônica/etiologia , Dor Crônica/fisiopatologia , Feminino , Humanos , Extremidade Inferior/inervação , Extremidade Inferior/fisiopatologia , Extremidade Inferior/cirurgia , Masculino , Pessoa de Meia-Idade , Músculo Esquelético/cirurgia , Neuroma/etiologia , Neuroma/fisiopatologia , Medidas de Resultados Relatados pelo Paciente , Membro Fantasma/etiologia , Membro Fantasma/fisiopatologia , Estudos Prospectivos , Resultado do Tratamento , Extremidade Superior/inervação , Extremidade Superior/fisiopatologia , Extremidade Superior/cirurgiaRESUMO
BACKGROUND: Complex regional pain syndrome (CRPS) is a chronic, posttraumatic condition defined by severe pain and sensorimotor dysfunction. In cases of severe CRPS, patients request amputation, which may cause phantom limb pain (PLP) and residual limb pain (RLP). Targeted muscle reinnervation (TMR) reduces the risk of PLP and RLP. This report describes the use of TMR at the time of amputation in a series of patients with CRPS. PATIENTS AND METHODS: Four patients (ages 38-71 years) underwent TMR at the time of amputation for CRPS between April 2018 and January 2019. Three patients had a history of trauma and surgery to the affected limb. All patients attempted pharmacologic and interventional treatments for 1-7 years before requesting amputation. Three patients underwent below-knee amputations (BKA) and one had an above-knee amputation (AKA). Target muscles included the soleus, gastrocnemius, and flexor hallucis longus (BKA), and semitendinosus, biceps femoris, and vastus medialis (AKA). Postoperative phantom and residual limb pain symptoms were collected via a telephone survey adapted from the Patient-Reported Outcomes Measurement Information System (PROMIS). RESULTS: There were no complications related to the TMR procedure. Average follow-up time was 12.75 months. Patients reported varied outcomes: two had RLP and PLP, one had RLP only, and one had PLP only. All patients reported successful prosthetic use. CONCLUSION: TMR may be performed at the time of amputation for CRPS. Further study is necessary to determine the effect of TMR on pain, pain medication use, prosthesis use, and other domains of function.
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Síndromes da Dor Regional Complexa , Membro Fantasma , Adulto , Idoso , Amputação Cirúrgica , Síndromes da Dor Regional Complexa/etiologia , Síndromes da Dor Regional Complexa/cirurgia , Humanos , Extremidade Inferior/cirurgia , Pessoa de Meia-Idade , Medição da DorRESUMO
OBJECTIVE: To compare targeted muscle reinnervation (TMR) to "standard treatment" of neuroma excision and burying into muscle for postamputation pain. SUMMARY BACKGROUND DATA: To date, no intervention is consistently effective for neuroma-related residual limb or phantom limb pain (PLP). TMR is a nerve transfer procedure developed for prosthesis control, incidentally found to improve postamputation pain. METHODS: A prospective, randomized clinical trial was conducted. 28 amputees with chronic pain were assigned to standard treatment or TMR. Primary outcome was change between pre- and postoperative numerical rating scale (NRS, 0-10) pain scores for residual limb pain and PLP at 1 year. Secondary outcomes included NRS for all patients at final follow-up, PROMIS pain scales, neuroma size, and patient function. RESULTS: In intention-to-treat analysis, changes in PLP scores at 1 year were 3.2 versus -0.2 (difference 3.4, adjusted confidence interval (aCI) -0.1 to 6.9, adjusted P = 0.06) for TMR and standard treatment, respectively. Changes in residual limb pain scores were 2.9 versus 0.9 (difference 1.9, aCI -0.5 to 4.4, P = 0.15). In longitudinal mixed model analysis, difference in change scores for PLP was significantly greater in the TMR group compared with standard treatment [mean (aCI) = 3.5 (0.6, 6.3), P = 0.03]. Reduction in residual limb pain was favorable for TMR (P = 0.10). At longest follow-up, including 3 crossover patients, results favored TMR over standard treatment. CONCLUSIONS: In this first surgical RCT for the treatment of postamputation pain in major limb amputees, TMR improved PLP and trended toward improved residual limb pain compared with conventional neurectomy. TRIAL REGISTRATION: NCT02205385 at ClinicalTrials.gov.
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Amputação Cirúrgica/reabilitação , Amputados/reabilitação , Músculo Esquelético/inervação , Transferência de Nervo/métodos , Neuroma/cirurgia , Dor Pós-Operatória/cirurgia , Membro Fantasma/cirurgia , Adulto , Feminino , Seguimentos , Humanos , Masculino , Medição da Dor , Dor Pós-Operatória/diagnóstico , Estudos Prospectivos , Procedimentos de Cirurgia Plástica/métodos , Método Simples-CegoRESUMO
BACKGROUND: We describe a multidisciplinary approach for comprehensive care of amputees with concurrent targeted muscle reinnervation (TMR) at the time of amputation. METHODS: Our TMR cohort was compared to a cross-sectional sample of unselected oncologic amputees not treated at our institution (N = 58). Patient-Reported Outcomes Measurement Information System (NRS, PROMIS) were used to assess postamputation pain. RESULTS: Thirty-one patients underwent amputation with concurrent TMR during the study; 27 patients completed pain surveys; 15 had greater than 1 year follow-up (mean follow-up 14.7 months). Neuroma symptoms occurred significantly less frequently and with less intensity among the TMR cohort. Mean differences for PROMIS pain intensity, behavior, and interference for phantom limb pain (PLP) were 5.855 (95%CI 1.159-10.55; P = .015), 5.896 (95%CI 0.492-11.30; P = .033), and 7.435 (95%CI 1.797-13.07; P = .011) respectively, with lower scores for TMR cohort. For residual limb pain, PROMIS pain intensity, behavior, and interference mean differences were 5.477 (95%CI 0.528-10.42; P = .031), 6.195 (95%CI 0.705-11.69; P = .028), and 6.816 (95%CI 1.438-12.2; P = .014), respectively. Fifty-six percent took opioids before amputation compared to 22% at 1 year postoperatively. CONCLUSIONS: Multidisciplinary care of amputees including concurrent amputation and TMR, multimodal postoperative pain management, amputee-centered rehabilitation, and peer support demonstrates reduced incidence and severity of neuroma and PLP.
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Cotos de Amputação/inervação , Amputação Cirúrgica/métodos , Amputação Cirúrgica/reabilitação , Músculo Esquelético/inervação , Neoplasias/cirurgia , Transferência de Nervo/métodos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Neoplasias Ósseas/reabilitação , Neoplasias Ósseas/cirurgia , Estudos de Coortes , Continuidade da Assistência ao Paciente , Estudos Transversais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Neoplasias/reabilitação , Osteossarcoma/reabilitação , Osteossarcoma/cirurgia , Equipe de Assistência ao Paciente , Membro Fantasma/prevenção & controle , Sarcoma/reabilitação , Sarcoma/cirurgia , Adulto JovemRESUMO
BACKGROUND: Vascularized lymph node transfer (VLNT) is a well-established method for the surgical management of refractory extremity lymphedema. Generally, donor lymph nodes are harvested from the axilla, groin, or supraclavicular area. However, these sites offer their own disadvantages and introduce risk for inducing lymphedema at the surgical donor site. In our experience, the jejunal mesentery can be an excellent source of lymph nodes without the risk of donor site lymphedema. Long term complications are unknown for this procedure; we report our experience, complication rates, and lessons learned. METHODS: A retrospective review was performed for all patients at our institution undergoing surgical treatment of lymphedema using jejunal mesenteric VLNT from February 2015 to February 2018. Demographic data, length of follow up, and surgical complications were reviewed. RESULTS: Twenty-nine patients have undergone jejunal VLNT at our institution during the three-year study period, with a total of 30 transfers. Five patients had a concurrent omental lymph node transfer. Average length of follow up was 17.6 months (range 1.0-36.8 months). There was one flap loss in this time frame (3.3%). Four patients developed hernias post-operatively (13.8%), and three had nonoperative small bowel obstructions (10.3%). One patient had a postoperative wound infection at the abdominal incision (3.4%). CONCLUSIONS: Jejunal VLNT can be an effective option for surgical treatment of lymphedema, without the risk of postoperative donor site lymphedema. Patients and surgeons should be aware of the risks of hernia and small bowel obstruction with this method compared to other lymph node sources.
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Retalhos de Tecido Biológico/transplante , Linfonodos/irrigação sanguínea , Linfonodos/transplante , Linfedema/cirurgia , Microcirurgia/métodos , Complicações Pós-Operatórias/etiologia , Coleta de Tecidos e Órgãos/métodos , Idoso , Idoso de 80 Anos ou mais , Feminino , Seguimentos , Humanos , Jejuno/cirurgia , Masculino , Mesentério/cirurgia , Pessoa de Meia-Idade , Estudos RetrospectivosRESUMO
BACKGROUND: Abdominal wall morbidity following microvascular breast reconstruction continues to be an area of interest due to both functional and aesthetic concerns. Donor-site closure technique has been shown to affect bulge and hernia rates and ranges from primary closure to various uses of mesh. Few studies to date have compared types of mesh. The present study compares BARD polypropylene to bioabsorbable GORE Bio-A (polyglycolic acid/trimethylene carbonate) mesh used as a fascial underlay with primary fascial closure. METHODS: A retrospective review of all consecutive deep inferior epigastric artery-based microvascular breast reconstructions, including perforator and muscle-sparing flaps, performed between September 2014 and February 2017 was performed. All patients underwent primary fascial closure with mesh underlay. Risk factors for the formation of an abdominal bulge or hernia were identified by multivariate logistic regression. RESULTS: Eighty-seven patients, with 123 abdominal donor sites, were included. Heavy-weight polypropylene mesh was used for 58 donor sites, while polyglycolic acid/trimethylene carbonate mesh was used in 65 donor sites. The overall incidence of bulge or hernia was 11.4%. The bioabsorbable cohort experienced significantly more bulges/hernias than the polypropylene mesh cohort (20% vs. 1.7% by donor site). Time to diagnosis of bulge was longer for the bioabsorbable group (219 ± 107 vs. 69 days). Flap type and perforator row were not associated with bulge/hernia. The polyglycolic acid/trimethylene carbonate mesh was associated with a 13.3-fold risk of bulge/hernia (p = 0.016). CONCLUSION: Polyglycolic acid/trimethylene carbonate mesh is not appropriate for anterior rectus fascia reinforcement following abdominal tissue transfer.
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Parede Abdominal/irrigação sanguínea , Implantes Absorvíveis , Sobrevivência de Enxerto/fisiologia , Mamoplastia/métodos , Polipropilenos , Retalhos Cirúrgicos/irrigação sanguínea , Telas Cirúrgicas , Artérias Epigástricas/cirurgia , Estética , Feminino , Humanos , Pessoa de Meia-Idade , Satisfação do Paciente , Estudos Retrospectivos , Resultado do TratamentoRESUMO
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.
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Gordura Abdominal/transplante , Índice de Massa Corporal , Rejeição de Enxerto/epidemiologia , Mamoplastia/métodos , Relação Cintura-Quadril , Adulto , Neoplasias da Mama/patologia , Neoplasias da Mama/cirurgia , Estudos de Coortes , Intervalos de Confiança , Feminino , Humanos , Incidência , Mamoplastia/efeitos adversos , Mastectomia/métodos , Pessoa de Meia-Idade , Análise Multivariada , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/fisiopatologia , Valor Preditivo dos Testes , Prognóstico , Estudos Retrospectivos , Medição de RiscoRESUMO
BACKGROUND: Increased surgical duration can impact patient outcomes and operative efficiency metrics. In particular, there are studies suggesting that increased surgical duration can increase the risk of venous thromboembolism (VTE). One of the longer duration plastic surgery procedures commonly performed is microsurgical breast reconstruction. With the widening indications for multiple and "stacked" free flaps to reconstruct breasts, we endeavored to assess (1) the relationship between duration of microsurgical breast reconstruction and VTE; and (2) determine if a threshold operative time exists that connotes VTE higher risk. METHODS: Patients from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) between 2005 and 2014 who underwent microsurgical breast reconstruction were identified by Current Procedural Terminology code. Three models of multivariate logistic regression were used to characterize the adjusted risk for VTE by operative duration, bilaterality, the length of stay, and patient demographics. RESULTS: A total of 4,782 patients who underwent microsurgical breast reconstruction were identified. Overall VTE incidence was 1.13%. The mean operative duration was 8:31 hours:minutes (standard deviation: 2:59). Operative duration was statistically associated with VTE in continuous, quintile, and dichotomized risk models. Beyond an operative duration of 11 hours, adjusted VTE risk increases fourfold corresponding to a number needed to harm of 45.8. CONCLUSIONS: Increasing surgical duration heightens the risk of VTE in microsurgical breast reconstruction. Increasing body mass index and age enhances this VTE risk. Moreover, limiting surgical duration to 11 hours or less can decrease VTE risk by fourfold vis-à-vis baseline. LEVEL OF EVIDENCE: Risk, II.
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Mamoplastia , Microcirurgia , Duração da Cirurgia , Tromboembolia Venosa/prevenção & controle , Adulto , Índice de Massa Corporal , Comorbidade , Feminino , Humanos , Tempo de Internação/estatística & dados numéricos , Modelos Logísticos , Mamoplastia/efeitos adversos , Pessoa de Meia-Idade , Fatores de Risco , Tromboembolia Venosa/etiologiaRESUMO
BACKGROUND: The "July Effect" refers to a theoretical increase in complications that may occur with the influx of inexperienced interns and residents at the beginning of each academic year in July. OBJECTIVES: We endeavored to determine if a July Effect occurs in plastic surgery. METHODS: Plastic surgery procedures were isolated from the National Surgical Quality Improvement Program registry. Cases involving residents were grouped as either having occurred within the first academic quarter (AQ1) or remaining year (AQ2-4). Groups were propensity matched using patient/operative factors and procedure type to account for baseline differences. Univariate and multivariate regression analyses assessed differences in overall complications, surgical and medical complications, individual complications, length of hospital stay, and operative time. A comparison group comprised of procedures without resident involvement was also analyzed. RESULTS: There were 5967 cases with resident involvement, 5156 of which successfully matched. Both univariate and multivariate regression analyses revealed no significant differences between AQ1 and AQ2-4 in terms of overall, surgical, medical and individual complications, or length of hospital stay. There was a statistically significant, albeit not clinically significant, increase in operative time by 10 minutes per procedure during AQ1 in comparison to AQ2-4 (P = 0.001). For procedures lacking resident participation, there were no differences between AQ1 and AQ2-4 in terms of these outcomes. CONCLUSIONS: A July Effect was not observed for plastic surgery procedures in our study, conceivably due to enhanced resident oversight and infrastructural safeguards. Patients electing to undergo plastic surgery early in the academic year can be reassured of their safety during this period.
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Internato e Residência/estatística & dados numéricos , Procedimentos de Cirurgia Plástica/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Melhoria de Qualidade , Cirurgia Plástica/educação , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Competência Clínica/estatística & dados numéricos , Feminino , Humanos , Internato e Residência/métodos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/prevenção & controle , Procedimentos de Cirurgia Plástica/educação , Procedimentos de Cirurgia Plástica/métodos , Procedimentos de Cirurgia Plástica/estatística & dados numéricos , Sistema de Registros/estatística & dados numéricos , Estudos Retrospectivos , Cirurgia Plástica/estatística & dados numéricos , Estados Unidos/epidemiologia , Adulto JovemRESUMO
Using an innovative, tissue-independent approach to decellularized tissue processing and biomaterial fabrication, the development of a series of "tissue papers" derived from native porcine tissues/organs (heart, kidney, liver, muscle), native bovine tissue/organ (ovary and uterus), and purified bovine Achilles tendon collagen as a control from decellularized extracellular matrix particle ink suspensions cast into molds is described. Each tissue paper type has distinct microstructural characteristics as well as physical and mechanical properties, is capable of absorbing up to 300% of its own weight in liquid, and remains mechanically robust (E = 1-18 MPa) when hydrated; permitting it to be cut, rolled, folded, and sutured, as needed. In vitro characterization with human mesenchymal stem cells reveals that all tissue paper types support cell adhesion, viability, and proliferation over four weeks. Ovarian tissue papers support mouse ovarian follicle adhesion, viability, and health in vitro, as well as support, and maintain the viability and hormonal function of nonhuman primate and human follicle-containing, live ovarian cortical tissues ex vivo for eight weeks postmortem. "Tissue papers" can be further augmented with additional synthetic and natural biomaterials, as well as integrated with recently developed, advanced 3D-printable biomaterials, providing a versatile platform for future multi-biomaterial construct manufacturing.
RESUMO
BACKGROUND: With the rising cost of healthcare delivery and bundled payments for episodes of care, there has been impetus to minimize hospitalization and increase utilization of outpatient surgery mechanisms. Given the increase in outpatient mastectomy and immediate tissue expander (TE)-based reconstruction and the paucity of data on its comparative safety to inpatient procedures, we sought to understand the risk for early postoperative complications in an outpatient model compared with more traditional inpatient status using the National Surgical Quality Improvement Program database. METHODS: NSQIP data files from 2005 to 2012 were queried to identify patients undergoing immediate TE-based breast reconstruction after mastectomy. Patients were stratified by whether they received outpatient or inpatient care and then propensity score matched based on preoperative baseline characteristics to produce matched cohorts. Multivariate regression analysis was used to determine whether outpatient versus inpatient status conferred differing risk for 30-days complications. RESULTS: Of the 2014 patients who met criteria, 1:1 propensity matching yielded 634 patients in each of the matched cohorts. Overall complications (5.2 vs. 5.4 %), overall surgical complications (4.3 vs. 3.9 %), overall medical complications (1.3 vs. 2.1 %), and return to the operating room (6.6 vs. 7.3 %) were similar between outpatient and inpatients cohorts (p > .2), respectively. There was a small, but significant increased risk of organ/space SSI in outpatients (1.9 vs. 0.5 %, p = .02) and trend for increased risk for pulmonary embolus (PE) and urinary tract infection (UTI) in inpatients (0.3 vs. 0 %, p = .16; 0.3 vs. 0 %, p = .16). CONCLUSIONS: Our studies suggest that outpatient TE confers similar safety profiles to inpatient TE with regards to 30-day postoperative overall complications, medical and surgical morbidity, and return to the operating room. A slightly increased risk for surgical site infection must be balanced against potential risk for known inpatient-related complications such as UTI and PE.
Assuntos
Assistência Ambulatorial/estatística & dados numéricos , Procedimentos Cirúrgicos Ambulatórios/efeitos adversos , Implante Mamário/efeitos adversos , Hospitalização/estatística & dados numéricos , Infecção da Ferida Cirúrgica/etiologia , Adulto , Assistência Ambulatorial/normas , Implantes de Mama/efeitos adversos , Feminino , Humanos , Pessoa de Meia-Idade , Pontuação de Propensão , Embolia Pulmonar/etiologia , Reoperação , Fatores de Tempo , Expansão de Tecido/efeitos adversos , Infecções Urinárias/etiologiaRESUMO
Oncologic resections near the shoulder create challenging reconstructive problems. In addition to severe contour defects and the risk for functional deficits resulting from contractures, there may be exposed bone and peripheral nerves rendering simple skin graft closures suboptimal long term. The lateral arm flap is a versatile septofasciocutaneous flap based on the posterior branch of the radial collateral artery in the lateral intermuscular septum of the upper arm. This paper details our experience with 3 patients who underwent wide local excision or radical resection of soft tissue tumors of the upper arm and closure with pedicled lateral arm fasciocutaneous flaps. Flap size ranged from 6 × 10 cm to 5 × 15 cm. Two flaps were transferred as 180-degree pivotal flaps; 1 flap was transferred as an advancement flap. There were no immediate postoperative complications or long-term functional deficits. The pedicled lateral arm flap is a safe and reliable option for soft tissue coverage of anterolateral shoulder defects. The vascular pedicle lies deep within the mid-upper arm and is rarely at risk during extensive tumor extirpation. The adjacent donor site allows for a single operative field without the need for repositioning and furthermore results in a skin paddle requirement that is one half the width of the original defect.
Assuntos
Carcinoma Basocelular/cirurgia , Fibroma/cirurgia , Melanoma/cirurgia , Procedimentos de Cirurgia Plástica/métodos , Ombro/cirurgia , Neoplasias de Tecidos Moles/cirurgia , Retalhos Cirúrgicos , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Neoplasias Cutâneas/cirurgia , Resultado do TratamentoRESUMO
BACKGROUND: Tissue-expander (TE) placement followed by implant exchange is currently the most popular method of breast reconstruction. There is a relative paucity of data demonstrating patient factors that predict complications specifically by stage of surgery. The present study attempts to determine what complications are most likely to occur at each stage and how the risk factors for complications vary by stage of reconstruction. METHODS: A retrospective chart review was performed on all 1275 patients who had TEs placed by the 2 senior authors between 2004 and 2013. Complication rates were determined at each stage of reconstruction, and these rates were further compared between patients who had pre-stage I radiation, post-stage I radiation, and no radiation exposure. Multivariate logistic regression was used to identify independent predictors of complications at each stage of reconstruction. RESULTS: A total of 1639 consecutive TEs were placed by the senior authors during the study period. The overall rate for experiencing a complication at any stage of surgery was 17%. Complications occurred at uniformly higher rates during stage I for all complications (92% stage I vs 7% stage II vs 1% stage III, P < 0.001). Predictors of stage I complications included increased body mass index [odds ratio (OR), 1.04; 95% confidence interval (CI), 1.01-1.07], current smoking status (OR, 3.0; 95% CI, 1.7-4.8), and higher intraoperative percent fill (OR, 3.3; 95% CI, 1.7-6.3). Post-stage I radiation was the only independent risk factor for a stage II complication (OR, 4.5; 95% CI, 1.4-15.2). CONCLUSIONS: Complications occur at higher rates after stage I than after stage II, and as expected, stage III complications are exceedingly rare. Risk factors for stage I complications are different from risk factors for stage II complications. Body mass index and smoking are associated with complications at stage I, but do not predict complications at stage II surgery. The stratification of risk factors by stage of surgery will help surgeons and patients better manage both risk and expectations.
Assuntos
Mamoplastia/métodos , Complicações Pós-Operatórias/etiologia , Expansão de Tecido/métodos , Adulto , Implante Mamário/métodos , Feminino , Seguimentos , Humanos , Modelos Logísticos , Mamoplastia/instrumentação , Mastectomia , Pessoa de Meia-Idade , Avaliação de Resultados em Cuidados de Saúde , Complicações Pós-Operatórias/epidemiologia , Estudos Retrospectivos , Fatores de Risco , Expansão de Tecido/instrumentação , Dispositivos para Expansão de TecidosRESUMO
BACKGROUND: Combined abdominal and breast surgery presents a convenient and relatively cost-effective approach for accomplishing both procedures. OBJECTIVES: This study is the largest to date assessing the safety of combined procedures, and it aims to develop a simple pretreatment risk stratification method for patients who desire a combined procedure. METHODS: All women undergoing abdominoplasty, panniculectomy, augmentation mammaplasty, and/or mastopexy in the TOPS database were identified. Demographics and outcomes for combined procedures were compared to individual procedures using χ(2) and Student's t-tests. Multiple logistic regression provided adjusted odds ratios for the effect of a combined procedure on 30-day complications. Among combined procedures, a logistic regression model determined point values for pretreatment risk factors including diabetes (1 point), age over 53 (1), obesity (2), and 3+ ASA status (3), creating a 7-point pretreatment risk stratification tool. RESULTS: A total of 58,756 cases met inclusion criteria. Complication rates among combined procedures (9.40%) were greater than those of aesthetic breast surgery (2.66%; P < .001) but did not significantly differ from abdominal procedures (9.75%; P = .530). Nearly 77% of combined cases were classified as low-risk (0 points total) with a 9.78% complication rates. Medium-risk patients (1 to 3 points) had a 16.63% complication rate, and high-risk (4 to 7 points) 38.46%. CONCLUSIONS: Combining abdominal and breast procedures is safe in the majority of patients and does not increase 30-day complications rates. The risk stratification tool can continue to ensure favorable outcomes for patients who may desire a combined surgery. LEVEL OF EVIDENCE: 4 Risk.