Beyond Mastectomy: The Incidence of Subsequent Aesthetic Procedures after Mastectomy with and without Breast Reconstruction.

Background: Mastectomy poses significant challenges to a woman's body image and psychological well-being, and breast reconstruction plays a pivotal role in postoperative quality of life. Following breast reconstruction, many patients choose to have subsequent aesthetic procedures. Data on the prevalence of such subsequent aesthetic interventions are lacking in the literature. The aim of this study was to analyze trends in aesthetic procedures in patients following mastectomy with and without breast reconstruction. Methods: The PearlDiver database was queried within its capabilities for patients who underwent mastectomy with and without breast reconstruction, and a variety of aesthetic procedures after mastectomy. Aesthetic procedure rates were compared between cohorts. Results: We identified 365,525 mastectomy patients: 282,815 without reconstruction and 82,710 with reconstruction. In total, 609 patients with reconstruction and 329 without underwent subsequent aesthetic procedures. The rate of aesthetic procedures was higher in the reconstruction group (0.7%) compared with the nonreconstruction group (0.1%; P < 0.001). Conclusions: Patients who chose to have breast reconstruction after mastectomy underwent significantly more subsequent aesthetic procedures compared with those who chose mastectomy alone. Our findings provide insights on the prevalence of aesthetic procedures in postmastectomy patients, highlighting the potentially longitudinal nature of the reconstructive and aesthetic journey beyond the index oncologic procedure. Further research is needed to address motivations for such procedures as well as patient-reported outcomes and satisfaction.

Predicting Reduction Mammaplasty Total Resection Weight With Machine Learning.

BACKGROUND: Machine learning (ML) is a form of artificial intelligence that has been used to create better predictive models in medicine. Using ML algorithms, we sought to create a predictive model for breast resection weight based on anthropometric measurements. METHODS: We analyzed 237 patients (474 individual breasts) who underwent reduction mammoplasty at our institution. Anthropometric variables included body surface area (BSA), body mass index, sternal notch-to-nipple (SN-N), and nipple-to-inframammary fold values. Four different ML algorithms (linear regression, ridge regression, support vector regression, and random forest regression) either including or excluding the Schnur Scale prediction for the same data were trained and tested on their ability to recognize the relationship between the anthropometric variables and total resection weights. Resection weight prediction accuracy for each model and the Schnur scale alone were evaluated based on using mean absolute error (MAE). RESULTS: In our cohort, mean age was 40.36 years. Most patients (71.61%) were African American. Mean BSA was 2.0 m2, mean body mass index was 33.045 kg/m2, mean SN-N was 35.0 cm, and mean nipple-to-inframammary fold was 16.0 cm. Mean SN-N was found to have the greatest variable importance. All 4 models made resection weight predictions with MAE lower than that of the Schnur Scale alone in both the training and testing datasets. Overall, the random forest regression model without Schnur scale weight had the lowest MAE at 186.20. CONCLUSION: Our ML resection weight prediction model represents an accurate and promising alternative to the Schnur Scale in the setting of reduction mammaplasty consultations.

Trends of medicare reimbursement for breast cancer and reconstructive surgery.

This study evaluated trends in Medicare reimbursement for commonly performed breast oncologic and reconstructive procedures. Average national relative value units (RVUs) for physician-based work, facilities, and malpractice were collected along with the corresponding conversion factors for each year. From 2010 to 2021, there was an overall average decrease of 15% in Medicare reimbursement for both breast oncology (-11%) and reconstructive procedures (-16%). Based on these findings, breast and reconstructive surgeons should advocate for reimbursement that better reflects the costs of their practice.

Enormous myxoid/round cell liposarcoma: A case report.

Myxoid/round cell liposarcomas (MRCLPS) are a rare soft tissue sarcoma. We report the largest sarcoma in our institutional history. We discuss the patient's surgical management and treatment of the tumor and challenges given its dimensions. Several complications arose following primary resection that were managed by a multidisciplinary team. Although MRCLPS can vary in size, large MRCLPS must be treated cautiously given the potential for complications. Additionally, multidisciplinary treatment of MRCLPS is essential in diagnosing and treating these complex cases.

Immediate Lymphatic Reconstruction with Vascularized Omentum Lymph Node Transplant: Reducing the Risk of Both Painful Contracture and Lymphedema.

Patients undergoing extensive lymph node dissection and radiation are at high risk for not only lymphedema but also painful contracture. In a standard lymphadenectomy, immediate lymphatic reconstruction using a lymphovenous bypass is effective in reconstructing the lymphatic defect. However, a more aggressive nodal clearance leaves the patient with a large cavity and skeletonized neurovascular structures, often resulting in severe contracture, pain, cosmetic deformity, and venous stricture. Adjuvant radiotherapy to the nodal bed can lead to severe and permanent disability despite physical therapy. Typically, these patients are referred to us after the fact, where surgery will rarely restore the patient to normal function. In an effort to avoid lymphedema and contracture, we have been reconstructing both the lymphatic and soft tissue defect during lymphadenectomy, using vascularized omentum lymphatic transplant (VOLT). A total of 13 patients underwent immediate reconstruction with VOLT at the time of axillary (n = 8; 61.5%) or groin (n = 5; 38.5%) dissection. No postoperative complications were observed. The mean follow-up time was 15.1 ±â€…12.5 months. Only one lower extremity patient developed mild lymphedema (11% volume differential), with excellent scores in validated patient-reported outcomes. All patients maintained full range of motion with no pain. None of the 13 patients required a compression garment. Immediate lymphatic reconstruction with VOLT is a promising procedure for minimizing the risk of lymphedema and contracture in the highest risk patients undergoing particularly extensive lymph node dissection and radiotherapy.

Demystifying vascularized lymph node transfers and lymphatico-venous anastomoses.

Lymphedema continues to be a widely prevalent condition with no definitive cure. It affects a wide range of patients across different ages and backgrounds. The significant burden of this chronic and debilitating condition necessitates more research and comprehensive healthcare coverage for affected patients. In developed countries, cancer survivors are disproportionality affected by this condition. Risk factors including lymph node dissections and radiation render many cancer patients more susceptible to the development of lymphedema. Part of the challenge with lymphedema care, is that it exits on a broad spectrum with significant variability of symptoms. Advances and broader availability of various imaging modalities continue to foster progress in lymphedema surgery. The conservative management of lymphedema remains the primary initial management option. However, lymphedema surgeries can provide significant hope and may pave the way for significant improvements in the quality-of-life for many patients afflicted by this progressive and enfeebling condition. Reductive and physiologic procedures are becoming an important part of the armamentarium of the modern plastic and reconstructive surgeon. Recent advances in physiologic lymphedema surgeries are accelerating their transition from experimental surgeries to broadly adopted and widely accepted procedures that can lead to major successes in the fight against this condition. Prophylactic lymphedema surgery also presents a promising choice for many patients and can help prevent lymphedema development in high-risk patients.

Trends of Medicare Reimbursement Rates for Lower Extremity Procedures.

BACKGROUND: Data collected across many surgical specialties suggest that Medicare reimbursement for physicians consistently lags inflation. Studies are needed that describe reimbursement rates for lower extremity procedures. Our goal is to analyze the trends in Medicare reimbursement rates from 2010 to 2021 for both lower extremity amputation and salvage surgeries. METHODS: The Physician Fee Schedule Look-Up Tool of the Centers for Medicare and Medicaid Services was assessed and Current Procedural Terminology codes for common lower extremity procedures were collected. Average reimbursement rates from 2010 to 2021 were analyzed and adjusted for inflation. The rates of work-, facility-, and malpractice-related relative value units (RVUs) were also collected. RESULTS: We found an overall increase in Medicare reimbursement of 4.73% over the study period for lower extremity surgery. However, after adjusting for inflation, the average reimbursement decreased by 13.19%. The adjusted relative difference was calculated to be (-)18.31 and (-)11.34% for lower extremity amputation and salvage procedures, respectively. We also found that physician work-related RVUs decreased by 0.27%, while facility-related and malpractice-related RVUs increased. CONCLUSION: Reimbursement for lower extremity amputation and salvage procedures has steadily declined from 2010 to 2021 after adjusting for inflation, with amputation procedures being devaluated at a greater rate than lower extremity salvage procedures. With the recent marked inflation, knowledge of these trends is crucial for surgeons, hospitals, and health care policymakers to ensure appropriate physician reimbursement. LEVEL OF EVIDENCE: IV (cross-sectional study).

United States insurance coverage of immediate lymphatic reconstruction.

INTRODUCTION: Immediate Lymphatic Reconstruction (ILR) is a prophylactic microsurgical lymphovenous bypass technique developed to prevent breast cancer related lymphedema (BCRL). We investigated current coverage policies for ILR among the top insurance providers in the United States and compared it to our institutional experience with obtaining coverage for ILR. METHODS: The study analyzed the publicly available ILR coverage statements for American insurers with the largest market share and enrollment per state to assess coverage status. Institutional ILR coverage was retrospectively analyzed using deidentified claims data and categorizing denials based on payer reason codes. RESULTS: Of the 63 insurance companies queried, 42.9% did not have any publicly available policies regarding ILR coverage. Of the companies with a public policy, 75.0% deny coverage for ILR. In our institutional experience, $170,071.80 was charged for ILR and $166 118.99 (97.7%) was denied by insurance. CONCLUSIONS: Over half of America's major insurance providers currently deny coverage for ILR, which is consistent with our institutional experience. Randomized trials to evaluate the efficacy of ILR are underway and focus should be shifted towards sharing high level evidence to increase insurance coverage for BCRL prevention.

Clinical Outcomes Following Resection of Distal Lower Extremity Soft Tissue Sarcomas.

OBJECTIVE: Resection of soft tissue sarcoma (STS) in the distal lower extremity can result in large soft tissue defects that create difficult wounds to manage and significant risks for complications. Often, the anticipated or resultant tissue defect or loss of functional anatomy is an indication for amputation over limb salvage. Soft tissue reconstruction managed by plastic and reconstructive surgery (PRS) may help offer limb salvage as a therapeutic option with acceptable oncologic outcomes and wound complication rates. METHODS: This was a review of 52 patients who underwent resection of STS at the level of the knee or distal between 2010 and 2020. Plastic and reconstructive surgery soft tissue management was utilized in 40.4% (n = 21) of cases, most of whom would have otherwise been considered candidates for amputation. RESULTS: The overall rate of limb salvage was 76.9%. The overall rate of wound complications was 19.2%. The overall rate of negative margins of resection was 92.3%. The 1-, 5-, and 10-year overall survival probabilities were 92%, 85%, and 85%, respectively. Of the 40 limb salvage procedures, two required subsequent amputation, one for multiply recurrent disease and one for necrosis. The wound complication rate was 14.3% in the PRS management group and 22.6% in cases of wound closure managed by the primary surgeon. There were zero instances of total wound or flap loss in PRS- managed closures. When comparing patients with wound complications to those without, there was no difference in age (59.5 ± 21 vs. 51 ± 18 years, p = 0.42), body mass index (31.1 ± 4.8 vs. 26.1 ± 7.1 kg/m2 , p = 0.19), or tumor size (6.8 ± 5.0 vs. 6.4 ± 4.7 cm, p = 0.82). At final follow-up, 67% (n = 35) of patients were alive and disease-free. CONCLUSIONS: Wound complications are not uncommon after resection of distal lower extremity STS. Our experience has been successful in achieving limb salvage in these challenging cases. Without PRS soft tissue management, however, many patients may alternatively be candidates for amputation.

A Cohort Analysis of Early Outcomes After AlloDerm, FlexHD, and SurgiMend Use in Two-Stage Prepectoral Breast Reconstruction.

BACKGROUND: Acellular dermal matrix (ADM) is frequently utilized in prepectoral breast reconstruction, but few studies have examined the role of ADM type in complication risk. OBJECTIVES: This study was performed to determine the impact of ADM type on early complication rates in 2-stage alloplastic prepectoral breast reconstruction. METHODS: We performed a cohort examination of all patients who underwent mastectomy with immediate 2-stage alloplastic prepectoral breast reconstruction with ADM support at Memorial Sloan Kettering Cancer Center from 2018 to 2021. ADM types utilized included AlloDerm (LifeCell Corporation, Branchburg, NJ), FlexHD (MTF Biologics, Edison, NJ), and SurgiMend (Integra LifeSciences Corporation, Princeton, NJ). Complication rates based on the number of tissue expanders (TEs) were determined for each ADM type. Performance of multivariate logistic regression determined the impact of ADM type on complication risk after accounting for confounders. RESULTS: Overall, 726 patients (1054 TEs: 194 AlloDerm, 93 FlexHD, 767 SurgiMend) were included. The 3 cohorts differed in terms of mastectomy type (nipple-sparing: 23.5% of AlloDerm, 33.3% of FlexHD, 19.1% of SurgiMend, P = .038); ADM perforation (perforated: 94.8% of AlloDerm, 98.2% of FlexHD, 100% of SurgiMend, P < .001); and ADM size (AlloDerm: 153.2 cm2 [37.6], SurgiMend: 198.7 cm2 [10.4], FlexHD: 223.7 cm2 [37.9], P < .001). On univariate examination, no differences existed between ADM types for seroma, infection, exposure, malposition, or TE loss. Additionally, after adjustment for confounders with multivariate regression, no ADM type had higher odds of TE loss. CONCLUSIONS: In this large cohort of prepectoral reconstruction patients, ADM type did not significantly affect the risk of complications. Additional prospective studies are warranted to better evaluate ADM choice for prepectoral breast reconstruction.

Pressure injuries in COVID-19 patients: A tertiary center experience.

Pressure ulcers continue to severely impact patient outcomes and increase health care costs. We aimed to examine the incidence and risk factors related to pressure ulcers among COVID-19 patients. A retrospective was conducted between March 2020-April 2021. Baseline differences were examined using chi-square and Fischer's exact test. Logistic regression was employed to examine the association of the collected variables to development of new pressure ulcers. 4608 patients were included, of which eighty-three acquired new pressure ulcers. Risk factors were increased age, peripheral artery disease, abnormal albumin levels, but not prone position.

Efficacy and Safety of Microsurgical Pharyngolaryngeal and Pharyngoesophageal Reconstruction: A Systematic Review of the Literature.

Restoration of function and complication management after pharyngolaryngectomy remains a challenging task. The aim of our study was to compare the functional and clinical outcomes of pharyngolaryngeal and pharyngoesophageal reconstruction using free flaps, namely jejunal (FJF), anterolateral thigh, and radial forearm, and describe a reconstructive approach for these defects following tumor resection. Methods: We performed a systematic literature review on PubMed (Medline), Embase and Cochrane Library over the last two decades for articles reporting the surgical reconstructive modalities available after total or partial pharyngeal and/or laryngeal resection using a structured search strategy and strict inclusion and elimination criteria. Results: Our search identified a total of 677 articles, 112 full texts were fully reviewed for eligibility, and 39 met the inclusion criteria. The use of both FJF and fasciocutaneous flaps is safe. The FJF has optimal swallowing outcomes and a low incidence of major recipient-site complications. Nevertheless, free fasciocutaneous flaps exhibit comparable functional results, while they seem linked with fewer cases of perioperative mortality and flap failure. However, none of the currently available techniques can combine all potential benefits. Conclusions: Despite these procedures being mainly palliative in nature, the advent of microvascular techniques and utilization of fasciocutaneous free flaps has allowed optimal restoration of function combined with a reduced rate of perioperative and longterm complications. Both FJF and fasciocutaneous flaps can be viable treatment options, depending on the expertise of the surgeon and patient selection, to ensure the best outcomes.

Safety and Efficacy of Extended Postdischarge Venous Thromboembolism Prophylaxis in Microsurgical Breast Reconstruction.

Discharging patients on extended postoperative venous thromboembolism (VTE) prophylaxis is trending in microsurgical breast reconstruction (MBR). This study investigated contemporary bleeding and thromboembolic complications after MBR and reported postdischarge enoxaparin outcomes. Methods: The PearlDiver database was queried for MBR patients who did not receive postdischarge VTE prophylaxis (cohort 1) and MBR patients discharged with enoxaparin for at least 14 days (cohort 2), then queried for hematoma, deep venous thrombosis (DVT), and/or pulmonary embolism. Concurrently, a systematic review was undertaken to identify studies investigating VTE with postoperative chemoprophylaxis. Results: In total, 13,541 patients in cohort 1 and 786 patients in cohort 2 were identified. The incidence of hematoma, DVT, and pulmonary embolism were 3.51%, 1.01%, 0.55% in cohort 1, and 3.31%, 2.93%, and 1.78% in cohort 2, respectively. There was no significant difference in hematoma between these two cohorts (P = 0.767); however, a significantly lower rate of DVT (P < 0.001) and pulmonary embolism (P < 0.001) occurred in cohort 1. Ten studies met systematic review inclusion. Only three studies reported significantly lower VTE rates with postoperative chemoprophylaxis. Seven studies found no difference in bleeding risk. Conclusions: This is the first study utilizing a national database and a systematic review to investigate extended postoperative enoxaparin in MBR. Overall, rates of DVT/PE seem to be declining compared with previous literature. The results of this study suggest that there remains a lack of evidence supporting extended postoperative chemoprophylaxis, although the therapy appears safe in that it does not increase bleeding risk.

Forequarter Amputation: Reconstruction With Targeted Muscle Reinnervation to the Filet of Forearm Free Flap.

Forequarter amputation is a rarely indicated operation that has the potential for delayed wound healing, chronic pain, and dysfunction. Reconstruction in cases of skin and soft tissue loss may be particularly challenging. Here we present a 79-year-old female with recurrent, previously radiated left shoulder chondrosarcoma who underwent forequarter amputation with a 'spare parts' filet of forearm flap and targeted muscle reinnervation to the flap. The patient healed without complication and achieved reinnervation with minimal pain.

Nipple-Sparing Mastectomy and Immediate Reconstruction: A Propensity Score-Matched Analysis of Satisfaction and Quality of Life.

BACKGROUND: Although it is intuitive that nipple-sparing mastectomy in selected patients would result in excellent cosmetic outcomes and high patient satisfaction, studies of clinical outcomes and health-related quality of life are limited and show mixed results. This study aimed to use a propensity score-matching analysis to compare satisfaction and health-related quality-of-life outcomes in patients who underwent implant-based reconstruction following bilateral nipple-sparing mastectomy or skin-sparing mastectomy. METHODS: A propensity score-matching analysis (1:1 matching, no replacement) was performed comparing patients undergoing nipple-sparing or skin-sparing mastectomy with immediate bilateral implant-based breast reconstruction. Patients with a history of any radiation therapy were excluded. Matched covariates included age, body mass index, race, smoking history, neoadjuvant chemotherapy, bra size, and history of psychiatric diagnosis. Outcomes of interest included BREAST-Q scores and complications. RESULTS: The authors examined 1371 patients for matching and included 460 patients (nipple-sparing mastectomy, n = 230; skin-sparing mastectomy, n = 230) in the final analyses. The authors found no significant differences in baseline, cancer, and surgical characteristics between matched nipple-sparing and skin-sparing mastectomy patients, who also had similar profiles for surgical complications. Interestingly, the authors found that postoperative Satisfaction with Breasts scores and all other health-related quality-of-life domains were stable over a 3-year period and did not differ significantly between the two groups. CONCLUSIONS: Compared with skin-sparing mastectomy, bilateral nipple-sparing mastectomy did not improve patient-reported or clinical outcomes when combined with immediate implant-based reconstruction. The impact that nipple-sparing mastectomy may have on breast aesthetics and the ability of the BREAST-Q to gauge an aesthetic result following nipple-sparing mastectomy warrant further investigation. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Burden of Pressure Injuries: Findings From the Global Burden of Disease Study.

Background: Pressure injuries remain among the most common problems faced by plastic surgeons and comprise a large portion of wound clinic practice. However, little is known about the overall morbidity related to the disease. This research sought to identify the burden related to the diagnosis of pressure injuries. Methods: We used the Global Burden of Disease Study 2017 to extract information about incidence and disability-adjusted life years (DALYs) related to pressure injuries from 1990 to 2017. Descriptive statistics were used to identify changes in the outcomes of interest. Results: A relative though not statistically significantly decrease in the incidence and burden of pressure injuries was observed between 1990 and 2017. Rates of incidence in the US appear higher than other higher socio-demographic index countries. No clinically and statistically significant changes were observed based on age or sex. Conclusions: Pressure injury incidence and burden have remained relatively stable between 1990 and 2017 with no significant improvement noted. There is room for improvement on a national performance level, and further research is needed regarding inconsistencies in regional outcomes.

Prepectoral breast reconstruction is safe in the setting of post-mastectomy radiation therapy.

BACKGROUND: Many breast reconstruction patients undergo post-mastectomy radiation therapy (PMRT), which is well known to increase the risk of complications. There is limited data on outcomes and safety of prepectoral breast reconstruction in this setting. The purpose of this study was to compare the outcomes of prepectoral versus subpectoral two-stage breast reconstruction in patients undergoing PMRT. METHODS: We conducted a retrospective cohort study of two-stage breast reconstructions performed at our institution during a 22-month period. Patients who received PMRT were identified, and two cohorts were created: those who underwent prepectoral versus subpectoral reconstruction. We collected data including patient characteristics, operative variables, and clinical outcomes. Bivariate analyses and multivariable logistic regressions were conducted. RESULTS: We captured 313 patients (492 breasts) that had undergone two-stage reconstruction. A total of 69 breasts received PMRT; 28 were reconstructed prepectorally, and 41 breasts subpectorally. The two cohorts were well matched. We detected no differences in clinical outcomes between the two groups after a median follow-up time of 24 months. There, however, were differences in perioperative variables. Prepectoral reconstruction was associated with a shorter operative time, shorter length of hospital stay, higher cost, and shorter time to final reconstruction. Multivariable logistic regression demonstrated that prepectoral reconstruction is not an independent predictor of adverse events. CONCLUSIONS: Although radiation is a known risk factor for many complications following breast reconstruction, prepectoral device placement is safe in this high-risk population. Although the rate of capsular contracture is reported to be higher in the general prepectoral population, this was not found in our radiated prepectoral population.