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ABSTRACT: Breast ptosis presents challenges for implant-based reconstruction due to the large skin envelope. Skin-reducing mastectomy reduces the envelope but must consider many other factors including complications. Limited data exist on incision impact on outcomes. We compare oblique-elliptical and Wise-pattern incisions on complications and patient-reported quality of life in immediate implant-based reconstruction.A retrospective review of patients who underwent immediate implant-based skin-reducing mastectomy at a single institution from 2015 to 2021 was done and was divided into two cohorts: wise and oblique incisions. Demographics, complications, and patient-reported outcomes (BREAST-Q) were compared. Descriptive, t test, and chi-square test analyses, followed by adjusted linear and logistic regression models, were performed to compare complication rates and BREAST-Q scores.Eighty-nine patient breasts were analyzed, 39 (43.8%) in the oblique (OI) and 50 (56.2%) in the wise (WI) cohort. No differences in demographics or preoperative comorbidities between groups were found. The oblique incision patients had significantly more mean total complications (OI 1.46 vs WI 0.88; P = 0.048), as well as increased incidence of explantation (OI 15 vs WI 3; P = 0.003) and cellulitis (OI 14 vs WI 3; P = 0.020) compared to wise group. Linear regression analysis revealed that incision choice was a significant predictor of complication rate (ß = -1.06, 95% CI [-1.63--0.50], P = <0.001). Logistic regression analysis showed that incision was a significant predictor of specific complications such as explantation (odds ratio = 0.10, 95% CI [0.02-0.52], P = 0.006) and cellulitis (odds ratio = 0.16, 95% CI [0.03-0.73], P = 0.018), with decreased risk of choosing wise incision. There was no difference in BREAST-Q results.Ptotic patients with oblique incision are associated with higher rates of postoperative complications compared to wise incisions.These findings suggest that incision choice is an important factor in postoperative complication development and emphasizes the need for further investigation and discussion with patients during preoperative planning.
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Implante Mamário , Complicações Pós-Operatórias , Humanos , Feminino , Estudos Retrospectivos , Pessoa de Meia-Idade , Implante Mamário/métodos , Adulto , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Medidas de Resultados Relatados pelo Paciente , Neoplasias da Mama/cirurgia , Mastectomia/métodos , Qualidade de Vida , Implantes de MamaRESUMO
BACKGROUND: Plastic surgery training has undergone tremendous change and transitioned through many models over the years, including independent, combined, and integrated. This study evaluates how these changes and others have affected plastic surgery applicants' demographics and academic qualifications over the last 30 years. METHODS: Data on applicant demographics and academic qualifications were extracted from multiple sources including the National Resident Matching Program, the American Association of Medical Colleges, and cross-sectional surveys of plastic surgery applicants for the years 1992, 2005, 2011, and 2022. Data were compared using pairwise χ2 goodness of fit tests. RESULTS: The sex distribution of plastic surgery applicants changed significantly over the last 30 years: whereas men predominated in 1992 (86% male vs 14% female), by 2011, the distribution was nearly equal (54% male vs 46% female in both 2011 and 2022, P < 0.001).The racial makeup of applicants also changed over time (P < 0.05). White applicants decreased from 73% in 1992 to 55% in 2011, and 53% in 2022. While there was an increase in Asian (7% to > 17% to > 20%) and other (13% to > 14% to > 21%) applicants over time, whereas the proportion of Black applicants remained stagnant (5% to > 6% to > 8%).Applicants with prior general surgery experience declined precipitously over the years: 96% in 1992, 64% in 2005, 37% in 2011, and 26% in 2022 (P < 0.001). When compared with 1992, Alpha Omega Alpha status increased significantly in 2011 (36% vs 12%, P < 0.05) but did not change considerably in 2005 (22%) and 2022 (23%). Research experience increased dramatically over the years, with the proportion of applicants with at least one publication going from 43% in 1992, to 75% in 2005, to 89% in 2011, and to 99% in 2022 (P < 0.001). Applicant interest in academic plastic surgery did not change considerably over the years at roughly ranging from 30% to 50% of applicants (P = ns). CONCLUSIONS: There has been a shift in the demographics and academic qualifications of plastic surgery applicants over the last 3 decades. Understanding this evolution is critical for reviewing and evaluating the makeup of our specialty, and enacting changes to increase representation where necessary.
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Internato e Residência , Procedimentos de Cirurgia Plástica , Cirurgia Plástica , Humanos , Masculino , Feminino , Estados Unidos , Cirurgia Plástica/educação , Estudos Transversais , Educação de Pós-Graduação em MedicinaRESUMO
BACKGROUND: There has been increasing emphasis on patient-reported satisfaction as a measure of surgical outcomes. While previous research has investigated factors influencing patient satisfaction following breast reconstruction, there are few studies on how patient satisfaction is impacted by revision procedures. The purpose of this study was to investigate whether elective revisions following breast reconstruction are significantly associated with changes in patient-reported outcomes and quality of life. METHODS: A retrospective review was conducted of patients who underwent immediate autologous or alloplastic breast reconstruction at a single institution from 2015 to 2021. Patients were included if they had completed BREAST-Q preoperatively, post-initial reconstruction, and post-revision procedures. Patients were excluded if they received adjuvant radiation or if they had previously undergone breast reconstruction procedures. The primary outcome measures were BREAST-Q domains. Demographic, clinical, and surgical variables were also analyzed. RESULTS: Of the 123 patients included for analysis, 61 underwent autologous breast reconstruction and 62 underwent alloplastic reconstruction. Mean age was 49.31 ± 11.58 years and body mass index (BMI) was 29.55 ± 5.63 kg/m2. Forty-eight patients underwent no revision procedures and 75 patients underwent at least one revision. Between these two groups, there were no differences in age, BMI, complication rates, socioeconomic status, or preoperative BREAST-Q scores. Patients reported significantly higher satisfaction with outcome after their first revision compared with after initial reconstruction alone (p = 0.04). Autologous reconstruction patients who had at least one revision had significantly higher satisfaction with outcome (p = 0.02) and satisfaction with surgeon (p = 0.05) in the 2-year follow-up period compared with patients who had no revisions. CONCLUSION: Revision procedures following autologous breast reconstruction are associated with higher patient satisfaction with outcome. Further research should explore specific factors influencing patient decision-making regarding whether to undergo revisions.
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BACKGROUND: Microsurgical reconstruction for bilateral mastectomy defects after unilateral radiation often results in asymmetry, despite both flap tissues never being radiated. METHODS: Photos of 16 patients who received prior radiation to one breast and underwent bilateral abdominal free flap reconstruction were taken postoperatively. Layperson and expert assessment were attained via online crowdsourcing and a panel of attending surgeons and senior residents. Stratification by interflap weight differences was done for subanalysis. RESULTS: A total of 399 laypersons responded, with the majority (57.3%) reporting that the radiated breast appeared smaller than the nonradiated breast. When the photos were stratified by interflap weight differences, the photos with the radiated side flap weight over 3% more than nonradiated side were significantly more likely to be perceived by laypersons as the same size (odds ratio [OR] = 2.7; p < 0.001) and of similar aesthetic (OR = 1.9; p < 0.001) when compared with photos with same-sized flaps. Of the expert responses (n = 16), the radiated side was perceived as smaller 72.3% of the time and the nonradiated side appeared more aesthetic 52.7% of the time. Contrary to layperson responses, the experts tend to report the radiated side as smaller despite varying flap weight. Interestingly, expert raters were significantly more likely to rate the flaps of equal aesthetics when the radiated side has a flap larger by 3% or more (OR = 3.6; p < 0.001). CONCLUSION: Higher aesthetic scores were noted when larger flaps were inset to the radiated envelope by both laypersons and experts, suggesting potential technical refinement in reconstructive outcomes.
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Neoplasias da Mama , Retalhos de Tecido Biológico , Mamoplastia , Humanos , Feminino , Mastectomia/métodos , Mamoplastia/métodos , Estudos Retrospectivos , Percepção VisualRESUMO
BACKGROUND: Microsurgical breast reconstruction after mastectomy is now the standard of care for breast cancer patients. However, the costs and resources involved in free flap reconstruction can vary across different medical settings. To enhance patient outcomes in a cost-effective manner, we investigated the effect of intravenous magnesium sulfate (IV Mg) on postoperative opioid usage in this context. METHODS: A retrospective chart review was performed on all consecutive patients who underwent abdominal-based free flap breast reconstruction in a single institute following an enhanced recovery after surgery (ERAS) protocol. Patients who received IV Mg were compared with those who did not receive supplementation. Serum magnesium levels at different time points, narcotic consumption in units of oral morphine milligram equivalents (MMEs), and other postoperative recovery parameters were compared. RESULTS: Eighty-two patients were included. Those who received IV Mg on postoperative day 0 (n = 67) showed significantly lower serum magnesium levels before repletion (1.5 vs. 1.7 mg/dL, p = 0.004) and significantly higher levels on postoperative day 1 after repletion (2.2 vs. 1.7 mg/dL, p = 0.0002) compared to patients who received no magnesium repletion (n = 13). While both groups required a similar amount of narcotics on postoperative day 0 (20.2 vs. 13.2 MMEs, p = 0.2), those who received IV Mg needed significantly fewer narcotics for pain control on postoperative day 1 (12.2 MMEs for IV Mg vs. 19.8 MMEs for No Mg, p = 0.03). Recovery parameters, including maximal pain scores, postoperative mobilization, and length of hospital stay, did not significantly differ between the two groups. CONCLUSION: This is the first study to describe the potential analgesic benefits of routine postoperative magnesium repletion in abdominal-based free flap reconstruction. Further research is necessary to fully understand the role of perioperative magnesium supplementation as part of an ERAS protocol.
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Retalhos de Tecido Biológico , Sulfato de Magnésio , Mamoplastia , Dor Pós-Operatória , Humanos , Sulfato de Magnésio/administração & dosagem , Sulfato de Magnésio/uso terapêutico , Feminino , Mamoplastia/métodos , Estudos Retrospectivos , Dor Pós-Operatória/prevenção & controle , Dor Pós-Operatória/tratamento farmacológico , Pessoa de Meia-Idade , Neoplasias da Mama/cirurgia , Mastectomia , Analgésicos Opioides/uso terapêutico , Analgésicos Opioides/administração & dosagem , Recuperação Pós-Cirúrgica Melhorada , Adulto , Magnésio/administração & dosagem , Resultado do TratamentoRESUMO
BACKGROUND: The iPhone (Apple Inc, Cupertino, California) contains a high-fidelity 3D-scanner and is widely distributed in the United States. Presently, 3D analysis of the breast necessitates ownership of cost-prohibitive cameras and software packages such as the Vectra system. OBJECTIVES: We compared the accuracy of 3D photos of the breast obtained with the iPhone X 3D scanner against the Canfield Vectra H2 (Canfield Scientific Inc. Parsippany, NJ) in an effort to expand access to 3D technology in plastic surgery. METHODS: Twenty breasts (n=20) were 3D-photographed with iPhone X and the Vectra H2 and compared with color map analysis and by measuring distances across the model between key anatomical landmarks. These distances included sternal notch to nipple (SN-N), mid-chest to nipple (M-N), nipple to mid-inframammary fold (N-IMF), and inframammary fold width (IMF). Statistical tests included the Bland-Altman Plot analysis. RESULTS: When comparing absolute differences in distances between key anatomical landmarks, the average discrepancy in measurements between iPhone and Vectra image pairs were the following: SN-N: 0.94mm, M-N: 0.70mm, N-IMF 0.81mm, and IMF 0.96mm. Colormap analysis demonstrated an average error of 1.53mm, mean of 0.53mm, and standard deviation of ±1.81mm. Bland-Altman Plot revealed a mean difference of 0.13mm and an agreement interval between -1.90 and 2.17mm. CONCLUSIONS: The iPhone is capable of capturing 3D-photographs with a high level of fidelity when compared to Vectra. 3D-scans obtained with the iPhone may be useful for planning nipple position, measuring the breast footprint, choosing implants, and performing other functions using 3D technology that are typically performed using the more expensive systems.
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BACKGROUND: Racial disparities in American healthcare contribute to worse outcomes among minority patients. Minority patients undergoing breast reconstruction are more likely to report dissatisfaction with their reconstruction process as compared with White patients, yet there is limited research exploring contributory factors. This study investigates which process-of-care, clinical, and surgical variables are most strongly correlated with Black and Hispanic patients' reported satisfaction. METHODS: A retrospective review of all patients who underwent postmastectomy breast reconstruction at a single academic center from 2015 to 2021 was performed. Patients were included for analysis if they identified as Black or Hispanic and completed preoperative, less than 1-year postoperative, and 1- to 3-year postoperative BREAST-Q surveys. At both postoperative time points, the association between satisfaction with outcome and surgeon and selected independent variables was determined using regression analysis. RESULTS: One hundred eighteen Black and Hispanic patients were included for analysis, with average age 49.59 ± 9.51 years and body mass index 30.11 ± 5.00 kg/m 2 . In the multivariate model for predicting satisfaction with outcome, only satisfaction with preoperative information ( P < 0.001) was a statistically significant predictor during early and late postoperative evaluations. For predicting satisfaction with surgeon, satisfaction with information ( P < 0.001) remained a significant predictor in the early and late postoperative evaluations, with lower body mass index as an additionally significant predictor during the late postoperative period. CONCLUSIONS: Patient satisfaction with preoperative information received is the single most significant factor associated with Black and Hispanic patient satisfaction with outcome and plastic surgeon. This finding encourages further research on effective and culturally inclusive information delivery so as to both improve patient satisfaction and reduce healthcare disparities.
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Neoplasias da Mama , Mamoplastia , Educação de Pacientes como Assunto , Satisfação do Paciente , Relações Médico-Paciente , Cirurgiões , Adulto , Feminino , Humanos , Pessoa de Meia-Idade , Neoplasias da Mama/reabilitação , Neoplasias da Mama/cirurgia , Hispânico ou Latino , Mamoplastia/psicologia , Mastectomia , Satisfação do Paciente/etnologia , Estudos Retrospectivos , Estados Unidos , Resultado do Tratamento , Educação de Pacientes como Assunto/métodosRESUMO
BACKGROUND: Implant-based reconstruction remains the most common form of postmastectomy breast reconstruction. With ever-evolving device characteristics, including the advent of high-profile, cohesive, fifth-generation implants, the incidence of anterior-posterior flipping of implants is presenting a new challenge. Patient and device characteristics associated with this phenomenon have yet to be fully elucidated. METHODS: Patients who underwent nipple- or skin-sparing mastectomy with subsequent 2-stage or direct-to-implant reconstruction with smooth implants between 2015 and 2021 were retrospectively identified and stratified by incidence of implant flipping. Patient, procedural, and device characteristics were evaluated. RESULTS: Within 165 patients (255 reconstructed breasts), 14 cases of implant flipping were identified (flip rate 5.5%). All flips occurred in patients with cohesive implants (odds ratio [OR], 87.0; P = 0.002). On univariate analysis, extra full implant profile (OR, 11.2; P < 0.001) and use of a smooth tissue expander for 2-stage reconstruction (OR, 4.1; P = 0.03) were associated with flipping. Implants that flipped were larger than those that did not (652.5 ± 117.8 vs 540.1 ± 171.0 mL, P = 0.0004). Prepectoral implant placement (OR, 2.7; P = 0.08) and direct-to-implant method (OR, 3.17; P = 0.07) trended toward association, but this effect was not significant. Patient BMI, weight fluctuation during the reconstructive course, mastectomy weight, AlloDerm use, and history of seroma or periprosthetic infection were not associated with flipping. CONCLUSION: Patients who receive a highly cohesive, high profile, larger implant are at increased risk for implant flipping. In addition, patients who receive a smooth tissue expander are more likely to experience flipping of their subsequent implant, compared with those who had textured tissue expanders. These characteristics warrant consideration during device selection to minimize discomfort, aesthetic deformity, and the need for reoperation.
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Implante Mamário , Implantes de Mama , Neoplasias da Mama , Mamoplastia , Humanos , Feminino , Mastectomia/métodos , Neoplasias da Mama/complicações , Implantes de Mama/efeitos adversos , Implante Mamário/métodos , Estudos Retrospectivos , Mamoplastia/métodos , Dispositivos para Expansão de Tecidos/efeitos adversos , Mamilos/cirurgia , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/cirurgiaRESUMO
BACKGROUND: Autologous fat grafting (AFG) is often used to reconstruct defects after breast conservation therapy (BCT). However, concerns exist about the possibility of AFG-related recurrence or metastasis. This study aims to evaluate the literature to evaluate oncologic outcomes in patients undergoing AFG at the time of BCT. METHODS: A systematic review of articles related to AFG based reconstruction at the time of BCT from 1970 to 2021 was performed via PubMed. Patients were grouped based on the presence or lack of AFG usage at the time of BCT, and oncologic outcomes and complications were compared. RESULTS: Of the 146 articles identified, 15 were included. Nine hundred patients underwent BCT alone and 1063 patients underwent BCT with AFG patients. Similar average follow-up time was observed between the groups, 58.7 months (BCT only) and 55.2 months (BCT with AFG). On pooled analysis, no difference was identified in local recurrence 4.8% (43 patients) of the BCT group and 3% (32 patients) in the AFG group (P = 0.8), metastasis 4.8% (43 patients) of the BCT group and 6.9% (73 patients) in the AFG group (P = 0.3), or fat necrosis (P = 0.44). Meta-analysis additionally did not identify any statistically significant odds ratios between the BCT only group and BCT with AFG group when evaluated for total recurrence, local recurrence, metastasis or fat necrosis. CONCLUSIONS: The results show no significant difference in cancer recurrence or metastasis in the BCT only group versus BCT and AFG, showing that fat grafting has safe outcomes.
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Neoplasias da Mama , Necrose Gordurosa , Mamoplastia , Humanos , Feminino , Mastectomia Segmentar/métodos , Mamoplastia/métodos , Necrose Gordurosa/etiologia , Necrose Gordurosa/cirurgia , Tecido Adiposo/transplante , Recidiva Local de Neoplasia/patologia , Transplante Autólogo/métodos , Neoplasias da Mama/cirurgiaRESUMO
BACKGROUND: While the number of female plastic surgeons has continued to increase over time, plastic surgery has historically been a male-dominated profession with only 15% of practicing plastic surgeons being female. Microsurgery, as a subspecialty, has been long perceived as an even more male-centric career path. The objective of this study was to determine the representation of females in the subspecialty field of microsurgery and the impact of microsurgical fellowship training. METHODS: A review of all microsurgery fellowship programs participating in the microsurgery fellowship match from 2010 to 2019 were analyzed. Fellows were identified through fellowship Web site pages or direct contact with fellowship program coordinators and directors. The current type of practice and performance of microsurgery were also identified through a Web search and direct contact with fellowship program coordinators and directors. RESULTS: A total of 21 programs and 317 fellows over a 10-year period were analyzed. Over this 10-year period, there was a total of 100 (31.5%) female microsurgery fellows and 217 (68.5%) male microsurgery fellows. There was a small, statistically insignificant increase in the yearly percentage of female microsurgery fellows over this 10-year period with an average yearly increase of 2.7% (p = 0.60; 95% confidence interval: -6.9 to 13.2%). There were significantly fewer females who continued to practice microsurgery compared to males (75 [75.0%] vs. 186 [85.7%], p = 0.02). There was no significant difference in the current practice types (academic, private, and nonacademic hospital) between females and males (p = 0.29). CONCLUSION: Women are underrepresented in the field of microsurgery to a similar extent as they are underrepresented in overall plastic surgery. While there is a small insignificant increase in the number of female microsurgery fellows every year, a significantly smaller proportion of females continue to practice microsurgery compared to males.
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BACKGROUND: Accurate flap weight estimation is crucial for preoperative planning in microsurgical breast reconstruction; however, current flap weight estimation methods are time consuming. It was our objective to develop a parsimonious and accurate formula for the estimation of abdominal-based free flap weight. METHODS: Patients who underwent hemi-abdominal-based free tissue transfer for breast reconstruction at a single institution were retrospectively reviewed. Subcutaneous tissue thicknesses were measured on axial computed tomography angiograms at several predetermined points. Multivariable linear regression was used to generate the parsimonious flap weight estimation model. Split-sample validation was used to for internal validation. RESULTS: A total of 132 patients (196 flaps) were analyzed, with a mean body mass index of 31.2 ± 4.0 kg/m2 (range: 22.6-40.7). The mean intraoperative flap weight was 990 ± 344 g (range: 368-2,808). The full predictive model (R 2 = 0.68) estimated flap weight using the Eq. 91.3x + 36.4y + 6.2z - 1030.0, where x is subcutaneous tissue thickness (cm) 5 cm lateral to midline at the level of the anterior superior iliac spine (ASIS), y is distance (cm) between the skin overlying each ASIS, and z is patient weight (kg). Two-thirds split-sample validation was performed using 131 flaps to build a model and the remaining 65 flaps for validation. Upon validation, we observed a median percent error of 10.2% (interquartile range [IQR]: 4.5-18.5) and a median absolute error of 108.6 g (IQR: 45.9-170.7). CONCLUSION: We developed and internally validated a simple and accurate formula for the preoperative estimation of hemi-abdominal-based free flap weight for breast reconstruction.
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Retalhos de Tecido Biológico , Mamoplastia , Retalho Perfurante , Angiografia/métodos , Humanos , Mamoplastia/métodos , Estudos Retrospectivos , Tomografia Computadorizada por Raios X/métodosRESUMO
BACKGROUND: The internal mammary artery (IMA) has supplanted the thoracodorsal artery as the primary recipient vessel in autologous breast reconstruction. Additionally, the IMA continues to be the preferred bypass graft choice in patients undergoing coronary artery bypass grafting (CABG). However, practice patterns in breast reconstruction have evolved considerably since the adoption of the IMA for this application. The authors sought to evaluate the safety of IMA harvest for breast reconstruction in our current practice, given the possibility that patients may require CABG in the future. METHODS: The authors reviewed the prospective database of free flaps for breast reconstruction performed at their center from 2009 to 2017. Patients were divided into three groups (2009-2011, 2011-2013, 2014-2017) and compared on the basis of demographics, medical comorbidities, and laterality of reconstruction. Patients were further risk stratified for 10-year risk of cardiovascular events using the American College of Cardiology's atheroscletoric and cardiovascular disease (ASCVD) risk calculator. RESULTS: There was a marked increase in the number of patients who underwent microsurgical breast reconstruction at our institution over the past three years (2009-2011, n = 55; 2012-2014, n = 50; 2015-2017, n = 145). The distribution of unilateral versus bilateral flaps changed meaningfully; however, they did not change statistically significantly over the study period (2009-2011 = 32.7%, 2012-2014 = 28.0%, 2015-2017 = 49.0%, p = 0.12). The rise in bilateral reconstructions over the study period is commensurate with the observed significant rise in contralateral prophylactic mastectomies (2009-2011 = 25.5%, 2012-2014 = 20.0%, 2015-2017 = 42.1%, p = 0.022). The mean 10-year risk of major cardiovascular events in the entire sample was 6.3 ± 7.1% (median 4.0%). The maximum individual risk score exceeded 25% in all three groups. CONCLUSION: Given overall trends in breast reconstruction and the sometimes-elevated cardiac risk profiles of our patients, the authors recommend risk stratification of all patients using the proposed Breast Reconstruction Internal Mammary Assessment (BRIMA) scoring system and consideration of left internal mammary artery preservation in select cases.
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Neoplasias da Mama , Mamoplastia , Artéria Torácica Interna , Mama , Neoplasias da Mama/epidemiologia , Neoplasias da Mama/cirurgia , Ponte de Artéria Coronária , Feminino , Humanos , Artéria Torácica Interna/cirurgia , Estudos RetrospectivosRESUMO
BACKGROUND: Given the relatively small size of thigh-based flaps and the possible necessity for a multiflap reconstruction, it is imperative to arrive at an accurate estimation of flap weight during preoperative planning. It was our objective to develop a novel technique for the preoperative estimation of profunda artery perforator (PAP) flap weight. METHODS: All patients that underwent transverse PAP flap breast reconstruction at two institutions were retrospectively reviewed. Subcutaneous tissue thicknesses were measured on axial computed tomography angiography scans at several predetermined points. The distance from the inferior gluteal crease to the PAP was also recorded. Linear regression was used to estimate flap weight. RESULTS: A total of 18 patients (32 flaps) were analyzed. The median intraoperative flap weight was 299 g (interquartile range [IQR]: 235-408). The parsimonious model (R 2 = 0.80) estimated flap weight using the Eq. 77.9x + 33.8y + 43.4z - 254.3, where x is subcutaneous tissue thickness (cm) at the lateral border of long head of the biceps femoris at a level 4.5 cm caudal to the inferior gluteal fold, y is distance (cm) from the inferior gluteal fold to the dominant PAP, and z has a value of 1 if the patient was scanned in the supine position or 0 if prone. The aforementioned formula yielded a median estimated flap weight of 305 g (IQR: 234-402) and a median percent error of 10.5% (IQR: 6.1-16.2). CONCLUSION: The authors demonstrate a simple and accurate formula for the preoperative estimation of transverse PAP flap weight for breast reconstruction.
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Mamoplastia , Retalho Perfurante , Artérias , Angiografia por Tomografia Computadorizada , Humanos , Estudos RetrospectivosRESUMO
BACKGROUND: Delayed immediate (DI) autologous breast reconstruction consists of immediate postmastectomy tissue expander placement, radiation therapy, and subsequent autologous reconstruction. The decision between timing of reconstructive methods is challenging and remains to be elucidated. We aim to compare patient reported outcomes and quality of life between delayed and DI reconstruction. METHODS: A retrospective review of all patients, who underwent autologous breast reconstruction at Montefiore Medical Center from January 2009 to December 2016, was conducted. Patients who underwent postmastectomy radiotherapy were divided into two cohorts: delayed and DI autologous breast reconstruction. Patients were mailed a BREAST-Q survey and their responses, demographic information, complications, and need for revisionary procedures were analyzed. RESULTS: A total of 79 patients met inclusion criteria: 34.2% (n = 27) in the delayed and 65.8% (n = 52) in the DI group. 77.2% (n = 61) of patients were a minority population. Patients in each cohort had similar baseline characteristics; however, the DI cohort was more likely to have bilateral reconstruction (46.2% [n = 24] vs. 7.4% [n = 2]; p = 0.0005) and to have major mastectomy flap necrosis (22.4% [n = 17] vs. 0.0% [n = 0]; p = 0.002). Premature tissue expander removal occurred in 17.3% (n = 9) of patients in the DI group. BREAST-Q response rates were 44.4% (n = 12) in the delayed group and 57.7% (n = 30) in the DI group. Responses showed similar satisfaction with their breasts, well-being, and overall outcome. CONCLUSION: Delayed and DI autologous breast reconstruction yield similar patient-reported satisfaction; however, patients undergoing DI reconstruction have higher rates of major mastectomy necrosis. Furthermore, patients in the DI group risk premature tissue expander removal.
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Mamoplastia/métodos , Grupos Minoritários/estatística & dados numéricos , Satisfação do Paciente , Qualidade de Vida , Neoplasias da Mama/radioterapia , Neoplasias da Mama/cirurgia , Terapia Combinada , Estudos Transversais , Feminino , Retalhos de Tecido Biológico , Humanos , Mastectomia , Microcirurgia , Pessoa de Meia-Idade , Complicações Pós-Operatórias , Estudos Retrospectivos , Inquéritos e Questionários , Dispositivos para Expansão de TecidosRESUMO
BACKGROUND: The pectoralis major muscle flap is a versatile reconstructive option for deep sternal wound infections (DSWI). The timing and surgical technique of bilateral pectoralis major muscle advancement flaps versus unilateral pectoralis major muscle turnover and unilateral pectoralis major muscle advancement flap on patient outcomes remain to be elucidated. The purpose of this investigation was to compare timing, immediate versus delayed reconstruction, and the surgical technique in patients with deep sternal wounds infections on patient outcomes. METHODS: A retrospective review of patients who underwent sternal reconstruction with pectoralis major muscle was conducted. Patients diagnosed with DSWI after undergoing cardiac surgery were included for analysis. Patients were divided by flap timing and flap type for analyses. Bivariate tests were performed to compare patient clinical characteristics. Outcomes of interest were rates of postoperative complications, same admission mortality, reoperation, readmission, operating room time, and length of stay. RESULTS: A total of 88 patients were included for analyses (n = 57 bilateral advancement, n = 31 unilateral advancement with unilateral turnover; n = 62 immediate, and n = 26 delayed). Baseline characteristics did not differ between groups of flap type or timing. When postoperative complication rates were compared, the rate of tissue necrosis was significantly greater in patients with unilateral advancement with unilateral turnover flaps (n = 6 [19.4%]) compared with bilateral advancement flaps (n = 2 [3.5%]; p = 0.021). Mortality during admission did not differ with respect to flap type but differed significantly with respect to flap timing (immediate n = 7 [11.3%], delayed n = 9 [34.6%]; p = 0.015). Length of stay differed significantly by both type and timing (type: bilateral advancement = 26.9 ± 22.6 days, unilateral turnover = 38.0 ± 26.7 days, p = 0.042; timing: immediate = 26.8 ± 22.1 days, delayed = 40.2 ± 27.8, p = 0.019). CONCLUSION: Patients who underwent pectoralis major muscle advancement flaps had lower incidence of tissue necrosis. Furthermore, the timing of immediate sternal reconstruction was associated with a decreased hospital length of stay.
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Ponte de Artéria Coronária , Músculos Peitorais/transplante , Procedimentos de Cirurgia Plástica/métodos , Esterno/cirurgia , Retalhos Cirúrgicos/transplante , Infecção da Ferida Cirúrgica/cirurgia , Idoso , Estudos Transversais , Feminino , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Readmissão do Paciente/estatística & dados numéricos , Complicações Pós-Operatórias/mortalidade , Reoperação/estatística & dados numéricos , Estudos Retrospectivos , Infecção da Ferida Cirúrgica/mortalidadeRESUMO
BACKGROUND: Breast cancer is the most commonly diagnosed malignancy in women. Mastectomy and breast-conserving surgery (BCS) have equivalent survival for early stage breast cancer. However, each surgery has different benefits and harms that women may value differently. Women of lower socioeconomic status (SES) diagnosed with early stage breast cancer are more likely to experience poorer doctor-patient communication, lower satisfaction with surgery and decision-making, and higher decision regret compared to women of higher SES. They often play a more passive role in decision-making and are less likely to undergo BCS. Our aim is to understand how best to support women of lower SES in making decisions about early stage breast cancer treatments and to reduce disparities in decision quality across socioeconomic strata. METHODS: We will conduct a three-arm, multi-site randomized controlled superiority trial with stratification by SES and clinician-level randomization. At four large cancer centers in the United States, 1100 patients (half higher SES and half lower SES) will be randomized to: (1) Option Grid, (2) Picture Option Grid, or (3) usual care. Interviews, field-notes, and observations will be used to explore strategies that promote the interventions' sustained use and dissemination. Community-Based Participatory Research will be used throughout. We will include women aged at least 18 years of age with a confirmed diagnosis of early stage breast cancer (I to IIIA) from both higher and lower SES, provided they speak English, Spanish, or Mandarin Chinese. Our primary outcome measure is the 16-item validated Decision Quality Instrument. We will use a regression framework, mediation analyses, and multiple informants analysis. Heterogeneity of treatment effects analyses for SES, age, ethnicity, race, literacy, language, and study site will be performed. DISCUSSION: Currently, women of lower SES are more likely to make treatment decisions based on incomplete or uninformed preferences, potentially leading to poorer decision quality, quality of life, and decision regret. This study hopes to identify solutions that effectively improve patient-centered care across socioeconomic strata and reduce disparities in decision and care quality. TRIAL REGISTRATION: NCT03136367 at ClinicalTrials.gov Protocol version: Manuscript based on study protocol version 2.2, 7 November 2017.
Assuntos
Neoplasias da Mama/cirurgia , Técnicas de Apoio para a Decisão , Disparidades em Assistência à Saúde , Relações Médico-Paciente , Classe Social , Adulto , Neoplasias da Mama/patologia , Protocolos Clínicos , Comunicação , Tomada de Decisões , Emoções , Feminino , Humanos , Estadiamento de Neoplasias , Satisfação do Paciente , Medição de RiscoRESUMO
BACKGROUND: Determinants of residency program reputation are multifactorial and include operative training, academic productivity, and geographic location. However, little is known about these relationships. This study aims to investigate the correlation between academic reputation of integrated plastic surgery programs and the research productivity of their respective full time faculty members. METHODS: Program rankings were identified from the 2016 Doximity standings and divided into 4 quartiles (Q1-Q4). Full-time faculty and program directors were identified through program websites. Publications by faculty members from 2000 to 2015 were identified through PubMed. Variables collected included affiliated institution, date of publication, authorship position, and journal. RESULTS: A total of 67 programs with 607 full-time faculty members were identified. Although not significantly different, program directors had a higher mean number of publications compared with faculty members for Q1, Q2, and Q4. Program departmental chairs had a significantly higher mean number of publications for Q1 and Q2. The Q1 faculty had a significantly higher mean number of publications as compared with Q2, Q3, and Q4. Although all quartiles had similar mean first author publications, Q1 and Q2 had more middle and last author publications. In addition, the higher-ranked programs were more likely to have faculty as middle authors of articles with more contributors. They were also more likely to publish in Plastic Reconstructive Surgery compared with other journals. CONCLUSIONS: Academic reputation of integrated plastic surgery residency programs is correlated with the scholarly activity of full-time faculty.
Assuntos
Pesquisa Biomédica , Mobilidade Ocupacional , Eficiência , Internato e Residência , Cirurgia Plástica/educação , Educação de Pós-Graduação em Medicina , Humanos , Editoração , Estados UnidosRESUMO
BACKGROUND: Venous thromboembolism (VTE) is a significant cause of postoperative morbidity and a focus of patient safety initiatives. Despite giving appropriate prophylaxis in accordance with the Caprini risk assessment model, we observed a high incidence of VTE in patients undergoing microsurgical breast reconstruction at our institution. To explore factors contributing to these events, we compared patients undergoing microsurgical breast reconstruction who sustained postoperative VTEs to those who did not. METHODS: A retrospective review of all patients who underwent microsurgical free flap breast reconstruction at Montefiore Medical Center from January 2009 to January 2016 was conducted. Patients were divided into two cohorts; those sustaining postoperative VTE and those who did not. Patients were compared based on demographics, comorbidities, operative time, estimated intraoperative blood loss, need for transfusion, volume of transfusion, and discharge on postoperative aspirin. RESULTS: A total of 133 patients underwent microsurgical breast reconstruction during the study period. Nine patients (6.8%) had postoperative VTE and there was one (0.8%) death. Patients having VTE were more likely to be Hispanic (33.3%, n = 3) in the VTE group versus 8.1% (n = 6) in the control group (p = 0.011), more likely to have an increased mean transfusion volume (455.5 ± 367.8 vs. 139.51 ± 221.7 mL, p = 0.03), and were more likely to be discharged without aspirin (77.8%, n = 7 and 58.1%, n = 72; p = 0.003). CONCLUSION: Patients sustaining postoperative VTE after microsurgical breast reconstruction are more likely to have an increased volume of blood transfusions and lack of discharge on postoperative aspirin.
Assuntos
Aspirina/uso terapêutico , Mamoplastia/efeitos adversos , Microcirurgia/efeitos adversos , Inibidores da Agregação Plaquetária/uso terapêutico , Complicações Pós-Operatórias/prevenção & controle , Tromboembolia Venosa/prevenção & controle , Adulto , Idoso , Índice de Massa Corporal , Comorbidade , Feminino , Humanos , Pessoa de Meia-Idade , Duração da Cirurgia , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Tromboembolia Venosa/tratamento farmacológico , Tromboembolia Venosa/etiologiaRESUMO
Background In patients with head and neck squamous cell carcinoma (HNSCC), disease recurrence remains a significant obstacle to long-term survival. If possible, surgical salvage with reconstruction remains the best treatment option for patients with recurrence. Currently, there is no literature discussing whether age should preclude microvascular reconstruction in these patients. We hypothesize that older age alone does not affect outcomes. Methods A retrospective chart review of patients with HNSCC at our institution between 2008 and 2015 was performed. Patients were included if they underwent simultaneous resection and flap reconstruction for recurrent HNSCC. Data collected included age, sex, primary site, type of reconstruction, previous treatments, postoperative complications (systemic and reconstructive), and overall survival. Results A total of 65 patients met inclusion criteria for the review: 42 (64.6%) patients ≤70 years and 23 (35.4%) patients > 70 years. Overall survival was not significantly different between the younger and older groups (p = 0.199). Five-year survival was 60.1% in the younger group and 46.8% in the older group. No significant difference was found in reconstructive complication rates (p = 0.179) or systemic complication rates (p = 0.241) between the two groups. Multivariate logistic regression analysis further showed no significant association between patients' age (≤70 years or > 70 years) and reconstructive complications (p = 0.396) or systemic complications (p = 0.119). Conclusion Age is not significantly associated with complications among patients undergoing resection and reconstruction for recurrent HNSCC. Microvascular reconstruction remains a feasible option in older patients with recurrent HNSCC. Advanced age alone should not preclude the surgical management of recurrent HNSCC.
Assuntos
Carcinoma de Células Escamosas/cirurgia , Neoplasias de Cabeça e Pescoço/cirurgia , Recidiva Local de Neoplasia/cirurgia , Procedimentos de Cirurgia Plástica/métodos , Complicações Pós-Operatórias/cirurgia , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Carcinoma de Células Escamosas/mortalidade , Carcinoma de Células Escamosas/fisiopatologia , Comorbidade , Feminino , Neoplasias de Cabeça e Pescoço/mortalidade , Neoplasias de Cabeça e Pescoço/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/mortalidade , Avaliação de Resultados em Cuidados de Saúde , Complicações Pós-Operatórias/mortalidade , Complicações Pós-Operatórias/fisiopatologia , Prognóstico , Procedimentos de Cirurgia Plástica/mortalidade , Estudos Retrospectivos , Carcinoma de Células Escamosas de Cabeça e Pescoço , Taxa de SobrevidaRESUMO
Background Higher body mass index (BMI) has been shown to increase postoperative complications in autologous breast reconstruction. However, the correlation with flap weight is unknown. Here, we explore the relationship of flap weights and complication rates in patients undergoing microvascular breast reconstruction. Methods Retrospective chart review identified all patients undergoing microvascular breast reconstruction with abdominally based flaps at a single institution between November 2007 and April 2013. Breasts with documented flap weight and 1-year follow-up were included. Patients undergoing stacked deep inferior epigastric perforator flaps were excluded. Breasts were divided into quartiles based on flap weight and examined by demographics, surgical characteristics, complications, and revisions. Results A total of 130 patients undergoing 225 flaps were identified. Patients had a mean age of 50.4 years, mean BMI of 27.1 kg/m2, and mean flap weight of 638.4 g (range: 70-1640 g). Flap weight and BMI were directly correlated. Flaps were divided into weight-based quartiles: first (70-396 g), second (397-615 g), third (616-870 g), and fourth (871-1640 g). There were no associations between flap weight and incidences of venous thrombosis, arterial thrombosis, hematoma, flap loss, fat necrosis, or donor site hernia. However, increased flap weight was associated with increased rate of donor site wound healing problems in both univariate and multivariate analysis. Conclusions Increased flap weight is not associated with added flap complications among patients undergoing microvascular breast reconstruction, however, patients with flaps of 667.5 g or more are more likely to have donor site healing problems. The success and evidence contrary to previous studies may be attributed to surgeon intraoperative flap choice.