The Role of Reconstruction on Desmoid Tumor Recurrence: A Systematic Review and Technical Considerations.

BACKGROUND: Desmoid tumors occur throughout the body, presenting as aggressive, locally invasive lesions that can impede quality of life. Many controversies remain regarding the optimal surgical treatment of desmoid. This article presents a systematic review and meta-analysis on surgical management, focusing on risk of recurrence and the utility of reconstruction within this unique patient population. METHODS: A systematic review was conducted to search for articles. The clinical course of patients diagnosed with desmoid tumors and treated by our institution's multidisciplinary team was retrospectively reviewed over a 13-year period. Meta-analysis study findings were compared with our cohort. RESULTS: From the systematic review, 10 studies with level of evidence III were found, which resulted in 981 patients. Twenty patients from our institution met the inclusion criteria for our study. In both our study cohort and the pooled results, recurrence was significantly higher in patients with positive microscopic margin after resection. In our study cohort, patients with recurrence had higher rates of positive margins compared with those without recurrence (83.3% vs 7.1%, P = 0.004), whereas the pooled study showed a difference of margin positivity of 50% vs 40% ( P = 0.01). No patients who underwent reconstruction in our study cohort had a recurrence during the study period. CONCLUSION: In both our cohort and pooled results, recurrence was significantly higher in patients with positive margins after initial resection. Reconstruction was not found to be a risk factor for recurrence. Reconstruction following desmoid tumor resection should be considered a viable option if a large and aggressive resection is required to obtain negative margins.

Static and Dynamic Stabilization of the Shoulder After Total Scapulectomy in an Electric Burn Patient.

ABSTRACT: An otherwise healthy 49-year-old man experienced a high-voltage electrical injury to the left shoulder resulting in total scapulectomy, partial calviculectomy, and a substantial soft tissue defect. The majority of the muscles around his shoulder were debrided because of necrosis, with only the pectoralis and latissimus dorsi muscles remaining attached to the humerus. Surprisingly, the patient's brachial plexus remained intact, and his left elbow, wrist, and hand function were preserved. A novel combination of 3 static and dynamic suspension techniques were used to stabilize his shoulder and prevent traction injury to the brachial plexus. Postoperative follow-up at 1 year demonstrated excellent stability of his reconstructed shoulder, which allowed him to ambulate independently and return to employment.

Psychological impact of the COVID-19 pandemic on breast cancer patients.

PURPOSE: The COVID-19 pandemic uniquely impacted patients with breast cancer as mastectomies were allowed to proceed, yet breast reconstruction surgeries were halted. The purpose of this study was to examine the effect of the COVID-19 pandemic on the rates of breast reconstruction and patients' well-being. METHODS: A chart review included all patients who underwent mastectomy from December 2019 to September 2021. Patients were contacted by a member of the research team and asked to participate in a COVID-19-specific survey and to complete the Hospital Anxiety and Depression Scale (HADS). Patients were then grouped into "surge" or "nonsurge" groups based on the date of mastectomy. RESULTS: Two hundred and fifty-nine patients were included in this study. During the study period, 42% (n = 111) of the patients underwent breast reconstruction. The "surge" group included 106 patients whereas the "nonsurge" group included 153 patients. Fewer patients began breast reconstruction during the surge period compared with the nonsurge period (34.0% vs. 49.0%, p = 0.017). Eighty-six patients participated in the COVID-19 survey. Forty-one percent (n = 35) of the patients felt that their care was disrupted because of COVID-19. Eighty-three patients completed the HADS survey. Overall, 16.8% and 15.7% of the respondents fell into the moderate to severe ranges for both anxiety and depression scales, respectively. CONCLUSIONS: Patients with breast cancer have faced increased difficulties with access to breast reconstruction throughout the COVID-19 pandemic. Our institution demonstrated decreased rates of breast reconstruction and an increase in anxiety and depression. The positive benefits of breast reconstruction cannot be overlooked when determining resource allocation in the future.

Tissue Expander-Based Breast Reconstruction at a Major Safety-Net Hospital: Managing the Outsized Risk of Infection.

Background: Immediate tissue expander (TE) breast reconstruction is reported to have the highest rate of postoperative infection among reconstructive modalities. The risk of infection is higher among patients treated at safety-net hospitals. Objectives: The goal of this study was to identify significant contributing factors to the elevated infection risk at our major safety-net institution. Methods: A retrospective chart review was conducted on all TE-based reconstruction patients with a diagnosis of postoperative infection between 2015 and 2019. Preoperative, perioperative, and postoperative risk factors for infection were determined and compared across patient and procedure demographics. Results: Two hundred forty-three patients, for a total of 412 breast reconstructions, were included in our study. Significant preoperative selection factors were identified to contribute to the elevated risk of infection, including the following: older age, higher BMI, and diabetes. Significant intraoperative and postoperative contributing factors included greater mastectomy weight, larger TE's and intraoperative fill volume, and longer drain duration. Doxycycline treatment for infected patients resulted in a significantly higher rate of resolution. Conclusions: Safety-net hospital population patients undergoing TE breast reconstruction are at higher risk for postoperative infection. Personal and procedural risk factors are identified. Balancing the benefits of immediate breast reconstruction with TEs with the elevated risk of postoperative infection remains challenging. Implementation of more stringent eligibility criteria may help mitigate the risk of infection.

Breaking Barriers to Breast Reconstruction among Socioeconomically Disadvantaged Patients at a Large Safety-net Hospital.

Socioeconomic disparities remain prevalent among those who undergo breast reconstruction. At our institution, patients must meet certain criteria to become eligible for breast reconstruction. The purpose of this study was to determine the impact of socioeconomic factors on breast reconstruction eligibility, enrollment, choice, and completion at our large safety-net institution. Methods: A retrospective chart review of patients who underwent partial or total mastectomy at a large safety-net hospital from 2016 to 2019 was completed. Surgical and demographic data were compared across varying socioeconomic factors. Results: A total of 645 patients were included in the study. More patients of a racial minority had government-based insurance than White patients (89% versus 81%; P = 0.01). Those with government-based insurance had higher average hemoglobin A1c values (6.26 versus 6.0; P = 0.03), proportion of American Society of Anesthesiologists scores greater than III (46% versus 40%; P = 0.01), and smokers (23% versus 9%; P = 0.02) than those with private insurance. Diabetic patients, patients with an American Society of Anesthesiologists greater than III, and active smokers were significantly less likely to receive a plastic surgery consult. Patients with government-based insurance underwent immediate tissue expander placement at mastectomy at rates lower than those with private insurance (57% versus 69%; P = 0.01). Conclusions: Barriers remain for socioeconomically disadvantaged patients to be eligible for, undergo, and complete breast reconstruction. Obesity, diabetes, smoking, and poor overall health were identified as the main barriers and were associated with racial minorities, government-based insurance, and lower incomes. Concerted effort through multidisciplinary teams is needed to maximize eligibility of socioeconomically disadvantaged breast cancer patients for reconstruction.