A Multi-institutional Analysis of a Textbook Outcome Among Patients Undergoing Microvascular Breast Reconstruction.

BACKGROUND: Individual outcomes may not accurately reflect the quality of perioperative care. Textbook outcomes (TOs) are composite metrics that provide a comprehensive evaluation of hospital performance and surgical quality. This study aimed to investigate the prevalence and predictors of TOs in a multi-institutional cohort of patients who underwent breast reconstruction with deep inferior epigastric artery perforator flaps. METHODS: For autologous reconstruction, a TO was previously defined as a procedure without intraoperative complications, reoperation, infection requiring intravenous antibiotics, readmission, mortality, systemic complications, operative duration ≤12 hours for bilateral and ≤10 hours for unilateral/stacked reconstruction, and length of stay (LOS) ≤5 days. We investigated associations between patient-level factors and achieving a TO using multivariable regression analysis. RESULTS: Of 1000 patients, most (73.2%) met a TO. The most common reasons for deviation from a TO were reoperation (9.6%), prolonged operative time (9.5%), and prolonged LOS (9.2%). On univariate analysis, tobacco use, obesity, widowed/divorced marital status, and contralateral prophylactic mastectomy or bilateral reconstruction were associated with a lower likelihood of TOs (P < 0.05). After adjustment, bilateral prophylactic mastectomy (odds ratio [OR], 5.71; P = 0.029) and hormonal therapy (OR, 1.53; P = 0.050) were associated with a higher likelihood of TOs; higher body mass index (OR, 0.91; P = <0.001) was associated with a lower likelihood. CONCLUSION: Approximately 30% of patients did not achieve a TO, and the likelihood of achieving a TO was influenced by patient and procedural factors. Future studies should investigate how this metric may be used to evaluate patient and hospital-level performance to improve the quality of care in reconstructive surgery.

Assessment of Microsurgery Simulation Course Access in Plastic Surgery Training Programs.

BACKGROUND: Microsurgery requires complex skill development with a steep learning curve for plastic surgery trainees. Flap dissection courses and simulation exercises are useful to acquire these skills. This study aims to assess plastic surgery training programs' access to and interest in microsurgical courses. METHODS: A survey was distributed to plastic surgery residency and microsurgery fellowship program directors (PDs). The survey collected program demographics and attendance of trainees at structured microsurgical skills or flap dissection courses. We assessed if PDs thought trainees would benefit from instructional courses. RESULTS: There were 44 residency PD responses (44/105, 41.9%, 36 integrated, 8 independent), and 16 fellowship PD responses (16/42, 38.1%). For residency PDs, 54.5% (24/44) sent residents to flap courses, and 95% (19/20) of remaining PDs felt residents would benefit from attending. In addition, 59.1% of programs (26/44) sent residents to microsurgical skills courses, and 83.3% (15/18) of remaining PDs felt residents would benefit from attending. When examining fellowship PDs, 31.2% of programs (5/16) sent fellows to flap dissection courses and 10/11 of remaining PDs felt fellows would benefit from attending a course (90.1%). Half of programs (8/16) sent fellows to microsurgical skills courses, and 7/8 remaining PDs felt fellows would benefit from attending (87.5%). CONCLUSION: Only half of the plastic surgery trainees have access to microsurgical skills and flap dissection courses. The majority of residency and fellowship PDs feel that training courses are valuable. Expanding access to these courses could provide a significant benefit to microsurgical education in plastic surgery training.

Textbook outcomes in DIEP flap breast reconstruction: a Delphi study to establish consensus.

PURPOSE: Composite measures, like textbook outcomes, may be superior to individual metrics when assessing hospital performance and quality of care. This study utilized a Delphi process to define a textbook outcome in DIEP flap breast reconstruction. METHODS: A two-round Delphi survey defined: (1) A textbook outcome, (2) Exclusion criteria for a study population, and (3) Respondent opinion regarding textbook outcomes. An a priori threshold of ≥ 70% agreement among respondents established consensus among the tested statements. RESULTS: Out of 85 invitees, 48 responded in the first round and 41 in the second. A textbook outcome was defined as one that meets the following within 90 days: (1) No intraoperative complications, (2) Operative duration ≤ 12 h for bilateral and ≤ 10 h for unilateral/stacked reconstruction, (3) No post-surgical complications requiring re-operation, (4) No surgical site infection requiring IV antibiotics, (5) No readmission, (6) No mortality, (7) No systemic complications, and (8) Length of stay < 5 days. Exclusion criteria for medical and surgical characteristics (e.g., BMI > 40, HgbA1c > 7) and case-volume cut-offs for providers (≥ 21) and institutions (≥ 44) were defined. Most agreed that textbook outcomes should be defined for complex plastic surgery procedures (75%) and utilized to gauge hospital performance for microsurgical breast reconstruction (77%). CONCLUSION: This Delphi study identified (1) Key elements of a textbook outcome for DIEP flap breast reconstruction, (2) Exclusion criteria for future studies, and (3) Characterized surgeon opinions regarding the utility of textbook outcomes in serving as quality metric for breast reconstruction care.

Complications, Costs, and Healthcare Resource Utilization After Staged, Delayed, and Immediate Free-Flap Breast Reconstruction: A Longitudinal, Claims-Based Analysis.

BACKGROUND: There is a lack of consensus detailing the optimal approach to free-flap breast reconstruction when considering immediate, delayed, or staged techniques. This study compared costs, complications, and healthcare resource utilization (HCRU) across staged, delayed, and immediate free-flap breast reconstruction. PATIENTS AND METHODS: Retrospective study using MarketScan databases to identify women who underwent mastectomies and free-flap reconstructions between 2014 and 2018. Complications, costs, and HCRU [readmission, reoperation, emergency department (ED) visits] occurring 90 days after mastectomy and 90 days after free flap were compared across immediate, delayed, and staged reconstruction. RESULTS: Of 3310 women identified, 69.8% underwent immediate, 11.7% underwent delayed, and 18.5% underwent staged free-flap reconstruction. Staged reconstruction was associated with the highest rate (57.8% staged, 42.3% delayed, 32.0% immediate; p < 0.001) and adjusted relative risk [67% higher than immediate (95% CI: 49-87%; p < 0.001)] of surgical complications. Staged displayed the highest HCRU (staged 47.9%, delayed, 38.4%, immediate 25.2%; p < 0.001), with 16.5%, 30.7%, and 26.5% of staged patients experiencing readmission, reoperation, or ED visit, respectively. The adjusted probability of HCRU was 206% higher (95% CI: 156-266%; p < 0.001) for staged compared with immediate. Staged had the highest mean total cost (staged $106,443, delayed $80,667, immediate $76,756; p < 0.001) with regression demonstrating the adjusted mean cost for staged is 31% higher (95% CI: 23-39%; p < 0.001) when compared with immediate. CONCLUSIONS: Staged free-flap reconstruction is associated with increased complications, costs, and HCRU, while immediate demonstrated the lowest. The potential esthetic benefits of a staged approach should be balanced with the increased risk for adverse events after surgery.

Air or Saline? A Propensity Score-Matched Analysis on the Effect of Tissue Expander Fill on Complications in Immediate Breast Reconstruction.

BACKGROUND: Tissue expander fill medium and volume have implications for the pressure exerted on mastectomy skin flaps. This study evaluated the influence of initial fill medium (air vs. saline) on complications in immediate breast reconstruction within a propensity score-matched cohort. PATIENTS AND METHODS: Patients undergoing immediate tissue expander-based breast reconstruction with initial intraoperative fill with air were propensity score matched 1:2 to those with saline initial fill based on patient and tissue expander characteristics. Incidence of overall and ischemic complications were compared by fill medium (air vs. saline). RESULTS: A total of 584 patients were included, including 130 (22.2%) with initial fill with air, 377 (64.6%) with initial fill with saline, and 77 (13.2%) with 0 cc of initial fill. After multivariate adjustment, higher intraoperative fill volume was associated with increased risk of mastectomy skin flap necrosis [regression coefficient (RC) 15.7; p = 0.049]. Propensity score matching was then conducted among 360 patients (Air: 120 patients vs. Saline: 240 patients). After propensity score matching, there were no significant differences in the incidences of mastectomy skin flap necrosis, extrusion, reoperation, or readmission between the air and saline cohorts (all p > 0.05). However, initial fill with air was associated with lower incidence of infection requiring oral antibiotics (p = 0.003), seroma (p = 0.004), and nipple necrosis (p = 0.03). CONCLUSIONS: Within a propensity score-matched cohort, initial fill with air was associated with a lower incidence of complications, including ischemic complications after nipple-sparing mastectomy. Initial fill with air and lower fill volumes may be strategies to reducing risk of ischemic complications among high-risk patients.

Long-term Surgical and Patient-Reported Outcomes Comparing Skin-Preserving, Staged Versus Delayed Microvascular Breast Reconstruction.

BACKGROUND: Skin-preserving, staged, microvascular, breast reconstruction often is preferred in patients requiring postmastectomy radiotherapy (PMRT) but may lead to complications. We compared the long-term surgical and patient-reported outcomes between skin-preserving and delayed microvascular breast reconstruction with and without PMRT. METHODS: We conducted a retrospective, cohort study of consecutive patients who underwent mastectomy and microvascular breast reconstruction between January 2016 and April 2022. The primary outcome was any flap-related complication. The secondary outcomes were patient-reported outcomes and tissue-expander complications. RESULTS: We identified 1002 reconstructions (672 delayed; 330 skin-preserving) in 812 patients. Mean follow-up was 24.2 ± 19.3 months. PMRT was required in 564 reconstructions (56.3%). In the non-PMRT group, skin-preserving reconstruction was independently associated with shorter hospital stay (ß - 0.32, p = 0.045) and lower odds of 30-days readmission (odds ratio [OR] 0.44, p = 0.042), seroma (OR 0.42, p = 0.036), and hematoma (OR 0.24, p = 0.011) compared with delayed reconstruction. In the PMRT group, skin-preserving reconstruction was independently associated with shorter hospital stay (ß - 1.15, p < 0.001) and operative time (ß - 97.0, p < 0.001) and lower odds of 30-days readmission (OR 0.29, p = 0.005) and infection (OR 0.33, p = 0.023) compared with delayed reconstruction. Skin-preserving reconstruction had a 10.6% tissue expander loss rate and did not differ from delayed reconstruction in terms of patient-reported satisfaction with breast, psychosocial well-being, or sexual well-being. CONCLUSIONS: Skin-preserving, staged, microvascular, breast reconstruction is safe regardless of the need for PMRT, with an acceptable tissue expander loss rate, and is associated with improved flap outcomes and similar patient-reported quality of life to that of delayed reconstruction.

The evolution of facial reanimation techniques.

This review article provides an updated discussion on evidence-based practices related to the evaluation and management of facial paralysis. Ultimately, the goals of facial reanimation include obtaining facial symmetry at rest, providing corneal protection, restoring smile symmetry and facial movement for functional and aesthetic purposes. The treatment of facial nerve injury is highly individualized, especially given the wide heterogeneity regarding the degree of initial neuronal insult and eventual functional outcome. Recent advancements in facial reanimation techniques have better equipped clinicians to approach challenging patient scenarios with reliable, effective strategies. We discuss how technology such as machine learning software has revolutionized pre- and post-intervention assessments and provide an overview of current controversies including timing of intervention, choice of donor nerve, and management of nonflaccid facial palsy with synkinesis. We highlight novel considerations to mainstay conservative management strategies and examine innovations in modern surgical techniques with a focus on gracilis free muscle transfer. Innervation sources, procedural staging, coaptation patterns, and multi-vector and multi-muscle paddle design are modifications that have significantly evolved over the past decade.

Trends in Patient-Reported Outcomes Reporting in Breast Reconstruction: A Scoping Literature Review.

INTRODUCTION: Patient-reported outcomes (PROs) provide essential information in reconstructive surgery, where interventions center on patients' functional and aesthetic goals. Although multiple patient-reported outcome measures (PROMs) have been validated for breast reconstruction since 2009, no studies have assessed recent frequency and consistency in use. This study aims to characterize recent trends in inclusion of PROs in recent breast reconstruction literature. METHODS: Articles published between 2015 and 2021 pertaining to autologous and/or prosthetic breast reconstruction in Annals of Plastic Surgery and Journal of Plastic and Reconstructive Surgery were considered in a scoping review. Original breast reconstruction articles were reviewed for use of PROMs and characteristics of administration in accordance with PRISMA-Scr guidelines. Previously defined scoping review criteria were considered, including PROM used, timeline of collection, and topics addressed, with trends in frequency and consistency of usage assessed over the designated period. RESULTS: Of the 877 articles reviewed and 232 articles included, 24.6% reported using any PROM. The majority used BREAST-Q (n = 42, 73.7%), with the remainder being institutional surveys or previously validated questionnaires. Patient-reported outcomes were most often collected retrospectively (n = 20, 64.9%) and postoperatively (n = 33, 57.9%). The average time point of postoperative survey administration was 16.03 months (SD, 19.185 months). χ2 Analysis revealed no significant association between the numbers of articles, including PROMs and the year (P = 0.1047). CONCLUSIONS: This study demonstrates that only one-fourth of breast reconstruction articles report the use of PROMs with no interval increase over recent years. Patient-reported outcome measures were predominantly used retrospectively and postoperatively with notable variation in timing of administration. The findings highlight the need for improved frequency and consistency of PROM collection and reporting, as well as for further exploration into barriers and facilitators of PROM use.

Defining Our Terms: Are Postoperative Complications Adequately Defined in the Rhinoplasty Literature?

BACKGROUND: Rhinoplasty is one of the most common aesthetic surgical procedures, and yet its postoperative complication profile remains somewhat ill-defined and underreported. The purpose of this study was to examine the quality of complication reporting in the rhinoplasty literature and provide a framework for future complication classification. METHODS: Studies were identified from a previously published 2019 systematic review conducted at Duke University Medical Center. Each included study was again reviewed to determine the reported complications and definitions. Reported complications were analyzed to determine occurrence rate, definition presence/absence, definition location, subjectivity/objectivity, and presence of severity grading system. RESULTS: A total of 30 studies were included. Overall, 63% (n = 19) of studies failed to provide a single definition for any reported complications. The remaining 11 studies (37%) provided at least one definition for their reported complications. Grading/severity scales were included by 8 studies. A specific complication was identified as a "primary outcome" in 15 cases. Definitions were included for 11 (73%) of these 15 complications. Complications denoted as "primary outcomes" were significantly more likely to have an included definition (p <0.01). CONCLUSIONS: Postoperative complications following rhinoplasty are inadequately defined in the available literature, with over sixty percent of studies failing to define a single-reported complication. When complication definitions are included, they are often subjective in nature and rarely include a grading or severity scale. In the absence of standardized rhinoplasty complication definitions, comparing complication rates across studies is exceedingly difficult, and the ability to conduct high-quality meta-analyses is limited. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Consequences and Predictors of Prolonged Tissue Expander Duration in Breast Reconstruction.

BACKGROUND: Tissue expanders (TEs) are temporary devices used in breast reconstruction, which are generally removed within 1 year. There is a paucity of data regarding the potential consequences when TEs have longer indwelling times. Thus, we aim to determine whether prolonged TE implantation length is associated with TE-related complications. METHODS: This is a single-center retrospective review of patients who underwent TE placement for breast reconstruction from 2015 to 2021. Complications were compared between patients who had a TE for >1 year and <1 year. Univariate and multivariate regressions were used to evaluate predictors of TE complications. RESULTS: A total of 582 patients underwent TE placement and 12.2% had the expander for >1 year. Adjuvant chemoradiation, body mass index (BMI), overall stage, and diabetes predicted the duration of TE placement (p ≤ 0.006). Rate of return to the operating room was higher in patients who had TEs in place >1 year (22.5 vs 6.1%, p < 0.001). On multivariate regression, prolonged TE duration predicted an infection requiring antibiotics, readmission, and reoperation (p < 0.001). Reasons for longer indwelling times included need for additional chemoradiation (79.4%), TE infections (12.7%), and requesting a break from surgery (6.3%). CONCLUSION: Indwelling TEs for >1 year are associated with higher rates of infection, readmission, and reoperation even when controlling for adjuvant chemoradiation. Patients with diabetes, a higher BMI, advanced cancer stage, and those requiring adjuvant chemoradiation should be advised they may require a TE for a longer time interval prior to final reconstruction.

Dissatisfaction After Post-Mastectomy Breast Reconstruction: A Mixed-Methods Study.

BACKGROUND: Breast reconstruction is associated with improved patient well-being after mastectomy; however, factors that contribute to post-surgical dissatisfaction remain poorly characterized. METHODS: Adult women who underwent post-mastectomy implant-based or autologous breast reconstruction between 2015 and 2019 were recruited to participate in semi-structured interviews regarding their lived experiences with reconstructive care. Participants completed the BREAST-Q, and tabulated scores were used to dichotomize patient-reported outcomes as satisfied or dissatisfied (high or low) for each BREAST-Q domain. A convergent mixed-methods analysis was used to evaluate interviews for content related to satisfaction or dissatisfaction with breast reconstruction. RESULTS: Overall, we interviewed 21 women and identified 17 subcodes that corresponded with the five BREAST-Q domains. Sources of dissatisfaction were found to be related to the following domains: (a) low breast satisfaction due to asymmetry, cup size, and lack of sensation and physical feeling (n = 8, 38%); (b) poor sexual well-being due to shape, look and feel (n = 7, 78% [of 9 who discussed sexual well-being]); (c) reduced physical well-being of the chest due to persistent pain and weakness (n = 11, 52%); (d) reduced abdominal well-being due to changes in abdominal strength, numbness, and posture (n = 6, 38% [of 16 who underwent abdominally based reconstruction]); and (e) low psychosocial well-being impacted by an unexpected appearance that negatively influenced self-confidence and self-identity (n = 13, 62%). CONCLUSION: Patients may be unprepared for the physical, sexual, and psychosocial outcomes of breast reconstruction. Targeted strategies to improve preoperative education and shared decision making are needed to mitigate unexpectedness associated with breast reconstruction and related outcomes.

Improvement in insulin sensitivity and prevention of high fat diet-induced liver pathology using a CXCR2 antagonist.

BACKGROUND: Liver pathology (LP) characteristic of non-alcoholic fatty acid disease (NAFLD)/non-alcoholic steatohepatitis (NASH) is a prevalent co-morbidity of type 2 diabetes (T2D). Accumulating evidence indicates that neutrophils driving insulin resistance (IR), including hepatic IR, precipitate T2D-associated NAFLD/NASH. We hypothesized that targeting neutrophil accumulation into insulin-sensitive tissues in mice using a CXCR2 antagonist under T2D-precipitating high fat diet (HFD) could improve insulin sensitivity and prevent the progression towards liver pathology reminiscent of NAFLD/NASH. METHODS: Mice were age-matched and on standard rodent chow prior to 1:1 randomization into control and HFD formulated with the CXCR2 antagonist AZD5069 or with biologically inactive substitute. They were monitored for metabolic changes including insulin sensitivity using the hyperinsulinemic-euglycemic clamp and hepatic histopathologic evaluation in H&E-stained sections as well as via immunofluorescence microscopy of liver sections for leukocyte markers, collagen 1A1 formation, α-smooth muscle actin (SMA), and galectin-3 expression, for 16 weeks. Statistical tests used to determine significant differences among study groups and outcomes include Student's t-test, one-way ANOVA, repeated measures two-way ANOVA, and Fisher's exact test, depending on the analytical question. RESULTS: Compared to mice on HFD, mice in the AZD5069-formulated HFD exhibited improved insulin sensitivity, a modest reduction in weight gain, and a significant improvement in LP and markers related to NAFLD/NASH. Mice in the AZD5069-formulated HFD also exhibited reduced neutrophil accumulation into the liver at the end of the 16 week study period. CONCLUSIONS: These results show, for the first time, the effectiveness of a selective CXCR2 antagonist to improve insulin sensitivity, concomitantly preventing the progression towards LP characteristic of NAFLD/NASH. This represents a novel approach to target IR and developing LP under T2D-susceptible conditions using a single agent. Furthermore, our data extend the growing evidence in support of neutrophils as a leukocyte population that imprints and maintains a chronic inflammatory state in the progression of dysregulated metabolism in liver-specific co-morbid conditions.

Neutrophils and their role in the aetiopathogenesis of type 1 and type 2 diabetes.

Multiple and complex aetiological processes underlie diabetes mellitus, which invariably result in the development of hyperglycaemia. Although there are two prevalent distinct forms of the disease, that is, type 1 and type 2 diabetes, accumulating evidence indicates that these syndromes share more aetiopathological mechanisms than originally thought. This compels a rethinking of the approaches to prevent and treat the different manifestations of what eventually becomes a hyperglycaemic state. This review aims to address the involvement of neutrophils, the most abundant type of granulocytes involved in the initiation of the acute phase of inflammation, in the aetiopathogenesis of diabetes mellitus, with a focus on type 1 and type 2 diabetes. We review the evidence that neutrophils are the first leucocytes to react to and accumulate inside target tissues of diabetes, such as the pancreas and insulin-sensitive tissues. We then review available data on the role of neutrophils and their functional alteration, with a focus on NETosis, in the progression towards clinical disease. Finally, we review potential approaches as secondary and adjunctive treatments to limit neutrophil-mediated damage in the prevention of the progression of subclinical disease to clinical hyperglycaemia.

Leadership and Advanced Degrees: Evaluating the Association Between Dual Degrees and Leadership Roles in Academic Plastic Surgery.

BACKGROUND: There are increasingly prevalent formal educational programs for physicians who seek to be better trained to advance their fields. Although higher education and advanced degrees are not necessarily linked to leadership, we hypothesize that leaders in plastic surgery commonly have dual degrees. We sought to evaluate the prevalence of and association between additional advanced degrees in academic plastic surgery and plastic surgery leadership. METHODS: Plastic surgery faculty from 96 academic training programs and all executive committee and board of directors' members from national, regional, and local plastic surgery societies were evaluated. Surgeons' institutional online profile pages, personal web pages, societal websites, and LinkedIn profiles were all evaluated for current/past leadership roles, as well as for advanced degree. Odds ratios (ORs) were used to determine if the presence of extra degrees increased their likelihood of leadership roles. RESULTS: A total of 1036 plastic surgeons were evaluated. Sixteen percent of academic faculty have a dual degree. Furthermore, 25.5% of plastic surgeons holding formal academic leadership roles have a dual degree (OR, 2.15; P = 0.043), as do 34.4% of those serving on the executive committee or board of directors in national plastic surgery societies (OR, 2.23; P = 0.026) and 29.2% of those serving in local/regional societal leadership roles (OR, 1.96; P = 0.043). Among all dual degrees, Masters in Business Administration has the highest association with leadership roles (OR, 3.45; P = 0.002). CONCLUSIONS: Academic plastic surgeons with dual degrees are approximately twice as likely to hold a formal academic or societal leadership role. Additional studies are needed to determine if causative relationships exist.

Assessing the Influence of Failed Implant Reconstruction on Patient Satisfaction and Decision Regret after Salvage Free-Flap Breast Reconstruction.

BACKGROUND: Free-flap breast reconstruction after failed implant reconstruction is associated with improved patient outcomes. How the level of satisfaction achieved compares between patients with and without previously failed implant reconstruction remains unknown. The aim of this study was to assess the influence of prior failed implant-based reconstruction on long-term patient-reported outcomes after free-flap breast reconstruction. METHODS: All patients undergoing free-flap breast reconstruction between 2015 and 2019 were identified. Patient satisfaction using the BREAST-Q and decisional regret using the Decision Regret Scale were compared between patients with and without a history of implant breast reconstruction. RESULTS: Overall, 207 patients were contacted and 131 completed the BREAST-Q and Decision Regret Scale. A total of 23 patients had a history of failed implant-based reconstruction requiring free-flap-flap salvage, most commonly due to infection (39.1%), chronic pain (34.8%), capsular contracture (26%), and implant malposition (26.1%). Following definitive free-flap reconstruction, patients with prior failed implant reconstruction had significantly lower BREAST-Q scores for satisfaction with breast (61.2 ± 16.7 vs. 70.4 ± 18.7; p = 0.04) and sexual well-being (38.5 ± 18.2 vs. 52.8 ± 24.7; p = 0.01) and reported higher decision regret (19.1 ± 18.6 vs. 9.6 ± 15.6, respectively). There were no significant differences for psychosocial well-being (p = 0.67), physical well-being (chest; p = 0.27), and physical well-being (abdomen; p = 0.91). CONCLUSION: A history of failed implant-based reconstruction is associated with reduced satisfaction and increased decision regret with the final reconstructive outcome. This data underscores the importance of appropriate patient selection at the initial consultation, and informed preoperative counseling regarding long-term outcomes in patients presenting for free-flap reconstruction after a failed implant-based reconstruction.

Autoimmune Inflammation and Insulin Resistance: Hallmarks So Far and Yet So Close to Explain Diabetes Endotypes.

PURPOSE OF REVIEW: Diabetes mellitus can be categorized into two major variants, type 1 and type 2. A number of traits such as clinical phenotype, age at disease onset, genetic background, and underlying pathogenesis distinguish the two forms. RECENT FINDINGS: Recent evidence indicates that type 1 diabetes can be accompanied by insulin resistance and type 2 diabetes exhibits self-reactivity. These two previously unknown conditions can influence the progression and outcome of the disease. Unlike most conventional considerations, diabetes appears to consist of a spectrum of intermediate phenotypes that includes monogenic and polygenic loci linked to inflammatory processes including autoimmunity, beta cell impairment, and insulin resistance. Here we discuss why a shift of the classical bi-modal view of diabetes (autoimmune vs. non-autoimmune) is necessary in favor of a model of an immunological continuum of endotypes lying between the two extreme "insulin-resistant" and "autoimmune beta cell targeting," shaped by environmental and genetic factors which contribute to determine specific immune-conditioned outcomes.

A Comparison of Patient-Reported Outcomes in Bipedicled Total Abdominal versus Unipedicled Hemiabdominal Free Flaps for Unilateral Breast Reconstruction.

BACKGROUND: While bipedicled free flaps enable increased soft tissue volume and potential for contralateral symmetry in unilateral breast reconstruction, the influence of bipedicled flap reconstruction on patient-reported outcomes remains unclear. METHODS: Patients undergoing unilateral free flap breast reconstruction at a single institution from 2014 to 2019 were retrospectively reviewed and sent the BREAST-Q and Decision Regret Scale. Complication rates and the BREAST-Q and Decisional Regret Scale scores (0-100) were compared between patients receiving bipedicled total abdominal and unipedicled hemiabdominal free flaps. RESULTS: Sixty-five patients undergoing unilateral breast reconstruction completed the BREAST-Q and Decision Regret Scale with median (interquartile range [IQR]) follow-up time of 32 [22-55] months. Compared with bipedicled flaps, patients receiving unipedicled hemiabdominal flaps had higher mean body mass index (BMI; p = 0.009) and higher incidence of fat grafting (p = 0.03) and contralateral reduction mammaplasties (p = 0.03). There was no difference in incidence of major or minor complications, abdominal hernias or bulges, or total operative time between bipedicled and unipedicled flaps (p > 0.05). Overall, BREAST-Q scores for satisfaction with breast, sexual wellbeing, psychosocial wellbeing, physical wellbeing (chest), and physical wellbeing (abdomen) and the Decision Regret Scale scores did not significantly vary between bipedicled and unipedicled reconstructions (all p > 0.05). However, among large-breasted patients (≥C cup), mean (standard deviation [SD]) sexual wellbeing was significantly higher after bipedicled total abdominal free flap reconstruction ([60.2 (23.3) vs. 46.2 (22.0)]; p = 0.04), though this difference did not reach significance after multivariate adjustment. CONCLUSION: Unilateral breast reconstruction with bipedicled total abdominal free flaps results in similar complication risk, patient satisfaction, and decisional regret without the need for as many contralateral reduction procedures.

Microsurgery Fellowship Website and Social Media Presence: Are Programs Optimizing Recruitment Strategy?

BACKGROUND: Microsurgery fellowship applicants make decisions for future training based on information obtained from colleagues, mentors, and microsurgery fellowship program Websites (MFWs). In this study, we sought to evaluate the accessibility and quality of available information by microsurgery programs by analyzing the most commonly used web resources and social media outlets for applicants. METHODS: The San Francisco (SF) Match and American Society of Reconstructive Microsurgery Websites were queried in April 2020 for microsurgery fellowship programs (MFPs) participating in the SF Match. Twenty-two independent variables of information were assessed on MFWs based on previously published data. Social media presence was also assessed by querying Facebook, Instagram, and Twitter for official hospital, plastic surgery residency, and microsurgery fellowship accounts. RESULTS: All 24 MFWs participating in the SF Match had a webpage. Program description, faculty listing, operative volume, and eligibility requirements were listed for all programs (100%). The majority of MFWs listed affiliated hospitals (75%), provided a link to the fellowship application (66.7%), listed interview dates (66.7%), and highlighted research interests (50%). A minority of MFWs provided information on conference schedule (37.5%), current fellow listing (25%), previous fellow listing (16.67%), and positions held by previous fellows (8.33%). No MFWs (0%) presented information on selection process, or rotation schedule.All hospitals with an MFP had a Facebook page and nearly all had Instagram (83.3%) and Twitter accounts (95.8%). Plastic surgery residency programs at the same institution of an MFP had social media presence on Facebook (38.9%), Twitter (38.9%), and Instagram (66.7%). Only three MFPs had Facebook accounts (12.5%) and none had Instagram or Twitter accounts. CONCLUSION: As the field of microsurgery continues to grow, the need for effective recruitment and training of microsurgeons continues to be essential. Overall, we conclude that both the accessibility and quality of information available to applicants are limited, which is a missed opportunity for recruitment.

The Effect of Lavender Oil on Perioperative Pain, Anxiety, Depression, and Sleep after Microvascular Breast Reconstruction: A Prospective, Single-Blinded, Randomized, Controlled Trial.

BACKGROUND: Psychosocial distress, depression, or anxiety can occur in up to 50% of women after a breast cancer diagnosis and mastectomy. The purpose of this study was to assess the potential benefit of lavender oil as a perioperative adjunct to improve anxiety, depression, pain, and sleep in women undergoing microvascular breast reconstruction. METHODS: This was a prospective, single-blinded, randomized, controlled trial of 49 patients undergoing microvascular breast reconstruction. Patients were randomized to receive lavender oil or placebo (coconut oil) throughout their hospitalization. The effect of lavender oil on perioperative stress, anxiety, depression, sleep, and pain was measured using the hospital anxiety and depression scale, Richards-Campbell Sleep Questionnaire, and the visual analogue scale. RESULTS: Twenty-seven patients were assigned to the lavender group and 22 patients were assigned to the control group. No significant differences were seen in the perioperative setting between the groups with regard to anxiety (p = 0.82), depression (p = 0.21), sleep (p = 0.86), or pain (p = 0.30) scores. No adverse events (i.e., allergic reaction) were captured, and no significant differences in surgery-related complications were observed. When evaluating the entire cohort, postoperative anxiety scores were significantly lower than preoperative scores (p < 0.001), while depression scores were significantly higher postoperatively as compared with preoperatively (p = 0.005). CONCLUSION: In the setting of microvascular breast reconstruction, lavender oil and aromatherapy had no significant adverse events or complications; however, there were no measurable advantages pertaining to metrics of depression, anxiety, sleep, or pain as compared with the control group.

The effect of sarcopenia on perioperative complications in abdominally based free-flap breast reconstruction.

PURPOSE: The identification of patient-specific risk factors, which predict morbidity following abdominally based microvascular breast reconstruction is difficult. Sarcopenia is a proxy for patient frailty and is an independent predictor of complications in a myriad of surgical disciplines. We predict that sarcopenic patients will be at higher risk for surgical complications following abdominally based microvascular breast reconstruction. METHODS: A retrospective study of all patients who underwent delayed abdominally based autologous breast reconstruction following postmastectomy radiation therapy from 2007 to 2013 at a single institution was conducted. Univariate and multiple logistic regression models were used to assess the effect of sarcopenia on postoperative outcomes. RESULTS: Two hundred and eight patients met the inclusion criteria, of which 30 met criteria for sarcopenia (14.1%). There were no significant differences in demographics between groups. There were no significant differences in minor (36.7% vs 44.4%; P = .43) or major (16.7% vs 25.3%; P = .36) complications between groups as well as hospital length of stay. Multivariable logistic regression demonstrated that a staged reconstruction with the use of a tissue expander was the only consistent variable, which predicted major complications (OR, 2.24; 95% CI, 1.18-4.64; P = .015). CONCLUSIONS: Sarcopenia does not predispose to minor or major surgical complications in patients who undergo abdominally based microsurgical breast reconstruction.