Parental-leave policies and perceptions of pregnancy during surgical residency training in North America: a scoping review.

BACKGROUND: The number of surgical residents experiencing childbearing during residency training is increasing, and there is an absence of clarity with respect to parental-leave, lactation and return-to-work policies in support of residents. The aim of this review was to examine parental-leave policies during residency training in surgery and the perceptions of these policies by residents, program directors and coresidents, as described in the literature. METHODS: We performed a scoping review of the literature based on the following themes: maternity or parental-leave policies; antepartum work-restriction policies and obstetric complications; accommodations for training absences; support for, and perceptions of, maternity or parental leave during residency training; and challenges upon return to work, namely resident performance and breastfeeding. RESULTS: Parental-leave policies during surgical residency training have historically lacked clarity and enforcement. Although recommendations for parental leave are now in place, this may have historically contributed to a lack of perceived support for surgical residents and may result in variable leave permitted to residents. Unclear policies may also contribute to career dissatisfaction among resident parents, which may deter qualified individuals from selecting surgical subspecialties. CONCLUSION: A call for a cultural shift is required to inform policies that would better support residents across all surgical specialties to pursue success in their dual roles as parents and surgeons. With increased awareness, progress in policy and guideline development is under way.

Simulating the IMA Recipient Site for DIEP Flap Surgery: A New Model for Dynamic Microsurgery Simulation with Real-Time Respiration and a Pilot Study.

BACKGROUND: Breast reconstruction (BR) using autologous free flaps has been shown to have numerous psychosocial and quality-of-life benefits. Unfortunately, the microsurgical learning curve is quite steep due to some unique operative challenges. Currently, there is no realistic simulation model that captures real-life respiratory excursion and the depth of internal mammary vessels within the compact recipient site. The purpose of this study was to delineate intraoperative measurements of depth and motion, describe the resulting simulation model, and conduct a pilot study evaluating the simulator as an educational resource. METHODS: This is a single-center, ethics-approved study. For the intraoperative measurements, all consecutive patients undergoing free flap BR using internal mammary vessels as recipients were recruited. Patient and intraoperative factors as well as intraoperative measurements were recorded. A dynamic model was developed based on intraoperative parameters. For the pilot study, plastic and reconstructive surgery trainees were recruited to complete a hand-sewn internal mammary artery (IMA) anastomosis using the new simulator and completed objective questionnaires pre- and postsimulation. Subjective feedback was recorded and themes determined. RESULTS: Fifteen operative sites were analyzed. Flap pocket was found to be between 4 and 5 cm in depth with vertical excursion of 3.7 ± 1.0mm and a respiratory rate of 9 to 14 breaths/minute. Previous radiation, rib space, body mass index (BMI), blood pressure, heart rate, tidal volume, and respiratory rate showed no correlation to vessel depth/excursion. Laterality, rib space, BMI, radiation, vitals, and tidal volume had no correlation with vessel movement. Twenty-two trainees were included in the pilot. An increase in confidence and mixed results for anxiety was reported. CONCLUSION: This study reports a novel microsurgical simulation model that provides a realistic deep inferior epigastric perforator free flap BR IMA anastomosis experience. It replicates movement of vessels in situ with real-time respiratory excursion and similar physical structures of the internal mammary system. This model shows promising results for increased use in microsurgical education.

Practice Patterns in Primary Breast Augmentation: A 16-Year Review of Continuous Certification Tracer Data from the American Board of Plastic Surgery.

BACKGROUND: As part of the continuous certification process, the American Board of Plastic Surgery collects case data for specific tracer procedures in aesthetic surgery to assess practice improvement by the diplomates. These case-based data provide valuable information on national trends in clinical practice. The current study was performed to analyze practice patterns in aesthetic primary breast augmentation. METHODS: Breast augmentation tracer data were reviewed from 2005 to 2021 and grouped into an early cohort (EC), from 2005 through 2014, and a recent cohort (RC), from 2015 through 2021. Fisher exact tests and two-sample t tests compared demographic characteristics of the patients, surgical techniques, and complication rates. RESULTS: Patients in the RC were slightly older (34 versus 35 years; P < 0.001), more likely to have ptosis greater than 22 cm (20% versus 23%; P < 0.0001), less likely to smoke (12% versus 8%; P < 0.0001), and less likely to undergo a preoperative mammogram (29% versus 24%; P < 0.0001). From a technical standpoint, inframammary incisions have become more common (68% versus 80%; P < 0.0001), whereas periareolar incision use has decreased (24% versus 14%; P < 0.0001). Submuscular plane placement has increased (22% versus 56%; P < 0.0001), while subglandular placement has decreased (19% versus 7%; P < 0.0001). Silicone implants are most popular (58% versus 82%; P < 0.0001). Textured implant use increased from 2011 (2%) to 2016 (16%), followed by a sharp decline to 0% by 2021. Trends follow U.S. Food and Drug Administration approvals and warnings. CONCLUSIONS: This study highlights evolving trends in aesthetic breast augmentation over the past 16 years. The most common technique remains a smooth silicone prosthesis placed in the subpectoral plane through an inframammary incision.

Vasorelaxation effect and mechanism of action of vascular endothelial growth factor-165 in isolated perfused human skin flaps.

BACKGROUND: Experimental evidence is accumulating to indicate that local acute vascular endothelial growth factor-165 (VEGF(165)) therapy is effective in attenuation of skin ischemia and increase in skin viability in rat skin flap surgery and the mechanism involves vasodilation induced by VEGF(165). So far, the vasodilator effect and mechanism of action of VEGF(165) have not been studied in human skin. The objective of this project is to test the hypothesis that VEGF(165) is also a potent vasodilator in human skin vasculature. MATERIALS AND METHODS: We used an established isolated perfused human skin flap model and pharmacologic probes to demonstrate that VEGF(165) is a potent vasodilator in human skin vasculature and the mechanism involves activation of receptors and postreceptor signaling pathway, which in turn stimulates local synthesis/release of endothelial vasodilators. RESULTS: We observed that VEGF(165) induced a concentration-dependent vasorelaxation in human skin flaps preconstricted with norephinephrine (8 × 10(-7)M; n = 7) or endothelin-1 (3 × 10(-9)M; n = 6). The vasorelaxation potency of VEGF(165) (pD(2) = 12.02 ± 0.25; n = 7) was higher (P < 0.05) than that of acetylcholine (pD(2) = 6.76 ± 0.06; n = 5) in human skin flaps preconstricted with 8 x 10(-7)M of norepinephrine. Using pharmacologic probes, we also detected that the vasorelaxation effect of VEGF(165) in the isolated perfused human skin flaps (n = 4) was triggered by activation of VEGF receptor-2. Furthermore, the postreceptor signaling pathway involved activation of Src family tyrosine kinase, phospholipase C, protein kinase C, an increase in inositol 1,4,5-triphosphate activity, a release of the intracellular Ca(2+) store, and finally synthesis/release of the endothelial nitric oxide (eNO) and prostacyclin and eNO predominantly mediated the vasodilator effect of VEGF(165) in the effector mechanism. CONCLUSION: These findings support our hypothesis that VEGF(165) is a potent vasodilator in human skin vasculature and also provide important insights into the clinical study of local acute VEGF(165) therapy for prevention/treatment of skin ischemia in skin flap surgery.

Surgeon Gender-Related Differences in Operative Coding in Plastic Surgery.

BACKGROUND: Numerous studies in the medical and surgical literature have discussed the income gap between male and female physicians, but none has adequately accounted for the disparity. METHODS: This study was performed to determine whether gender-related billing and coding differences may be related to the income gap. A 10 percent minimum difference was set a priori as statistically significant. A cohort of 1036 candidates' 9-month case lists for the American Board of Plastic Surgery over a 5-year span (2014 to 2018) was evaluated for relationships between surgeon gender and work relative value units, coding information, major and minor cases performed, and work setting. Data were deidentified by the American Board of Plastic Surgery before evaluation. The authors hypothesized that work relative value units, average codes per case, major cases, and minor cases would be at least 10 percent higher for male than for female physicians. RESULTS: Significant differences were found between male and female surgeons in work relative value units billed, work relative value units billed per case, and the numbers of major cases performed. The average total work relative value units for male surgeons was 19.34 percent higher than for female surgeons [3253.2 (95 percent CI, 3090.5 to 3425.8) versus 2624.1 (95 percent CI, 2435.2 to 2829.6)]. Male surgeons performed 14.28 percent more major cases than female surgeons [77.6 percent (95 percent CI, 72.7 to 82.7 percent) versus 90.5 percent (95 percent CI, 86.3 to 94.9 percent); p = 0.0002]. CONCLUSIONS: The authors' findings support the hypothesis that billing and coding practices can, in part, account for income differences between male and female plastic surgeons. Potential explanations include practices focusing on larger and more complex operative cases and differences in coding practices.

Canadian Expert Opinion on Breast Reconstruction Access: Strategies to Optimize Care during COVID-19.

BACKGROUND: Breast reconstructive services are medically necessary, time-sensitive procedures with meaningful health-related quality of life benefits for breast cancer survivors. The COVID-19 global pandemic has resulted in unprecedented restrictions in surgical access, including access to breast reconstructive services. A national approach is needed to guide the strategic use of resources during times of fluctuating restrictions on surgical access due to COVID-19 demands on hospital capacity. METHODS: A national team of experts were convened for critical review of healthcare needs and development of recommendations and strategies for patients seeking breast reconstruction during the pandemic. Following critical review of literature, expert discussion by teleconference meetings, and evidenced-based consensus, best practice recommendations were developed to guide national provision of breast reconstructive services. RESULTS: Recommendations include strategic use of multidisciplinary teams for patient selection and triage with centralized coordinated use of alternate treatment plans during times of resource restrictions. With shared decision-making, patient-centered shifting and consolidation of resources facilitate efficient allocation. Targeted application of perioperative management strategies and surgical treatment plans maximize the provision of breast reconstructive services. CONCLUSIONS: A unified national approach to strategically reorganize healthcare delivery is feasible to uphold standards of patient-centered care for patients interested in breast reconstruction.

The Impact of the COVID-19 Pandemic on Breast Reconstruction: A Canadian Perspective.

BACKGROUND: The COVID-19 pandemic has led to unprecedented challenges and restrictions in surgical access across Canada, including for breast reconstructive services which are an integral component of comprehensive breast cancer care. We sought to determine how breast reconstructive services are being restricted, and what strategies may be employed to optimize the provision of breast reconstruction through a pan-Canadian evaluation from the providers' perspective. METHODS: This was a cross-sectional survey of Canadian plastic and reconstructive surgeons who perform breast reconstruction. The 33-item web-based questionnaire was developed by a pan-Canadian working group of breast reconstruction experts and disseminated via email to members of the Canadian Society of Plastic Surgery. The questionnaire queried respondents on the impact of the COVID-19 pandemic and associated restrictions on surgeons' breast reconstruction practice patterns and opinions on strategies for resource utilization. RESULTS: Responses were received from 49 surgeons, who reported practicing in 8 of 10 Canadian provinces. Restrictions on the provision of breast reconstructive procedures were most limited during the First Wave of the COVID-19 pandemic, where all respondents reported at least some reduction in capacity and more than a quarter reporting complete cessation. Average reported reduction in capacity ranged from 31% to 78% across all 3 waves. Autologous, delayed, and prophylactic reconstructions were most commonly restricted. CONCLUSION: This study provides a pan-Canadian impact assessment on breast reconstructive services during the COVID-19 pandemic from the providers' perspective. To uphold the standards of patient-centred care, a unified approach to strategically reorganize health care delivery now and in the future is needed.

HISTORIQUE: La pandémie de COVID-19 a donné lieu à des défis et des restrictions sans précédent en matière d'accès aux interventions chirurgicales au Canada, y compris les services de reconstruction mammaire qui font partie intégrante des soins complets du cancer du sein. Les chercheurs ont voulu déterminer le mode de restriction des services de reconstruction mammaire et les stratégies possibles pour en optimiser la prestation grâce à une évaluation pancanadienne du point de vue des chirurgiens. MÉTHODOLOGIE: La présente étude transversale a été effectuée auprès de chirurgiens plasticiens et reconstructeurs canadiens qui font de la reconstruction mammaire. Un groupe de travail pancanadien d'experts de la reconstruction mammaire a préparé le questionnaire en ligne en 33 points, lequel a été transmis par courriel aux membres de la Société canadienne de chirurgiens-plasticiens. Le questionnaire portait sur les répercussions de la pandémie de COVID-19 et les restrictions connexes sur les modes de pratique de reconstruction mammaire des chirurgiens, de même que sur leurs avis et stratégies à l'égard de l'utilisation des ressources. RÉSULTATS: Un total de 49 chirurgiens, qui ont déclaré exercer dans huit des dix provinces canadiennes, ont répondu au sondage. Les restrictions imposées aux interventions de reconstruction mammaire ont été plus limitées pendant la première vague de la pandémie COVID-19, puisque tous les répondants ont rendu compte d'au moins une certaine restriction de la capacité et que plus du quart ont fait état de leur arrêt complet. La diminution moyenne de la capacité a varié de 31 % à 78 % dans l'ensemble des trois vagues. Ce sont les reconstructions autologues, tardives et prophylactiques qui ont surtout été touchées. CONCLUSION: La présente étude fournit une évaluation pancanadienne des incidences de la pandémie de COVID-19 sur les services de reconstruction mammaire du point de vue des chirurgiens. Pour maintenir les normes des soins axés sur les patients, il faudra procéder à une réorganisation stratégique unifiée de la prestation des soins, tant maintenant qu'à l'avenir.

Breast implant-associated EBV-positive diffuse large B-cell lymphoma: Two case reports and literature review.

Lymphomas associated with breast implants are mostly of the T-cell type. They are predominantly anaplastic lymphoma kinase-negative anaplastic large cell lymphoma (ALK-negative ALCL) characterized by CD30 positivity universally. Whilst the majority of primary breast lymphomas occurring in the absence of breast implants are of B-cell origin, there are few cases of implant-associated B-cell lymphomas reported to date in the literature, a subset of which are diffuse large B-cell lymphoma (DLBCL). Given the rarity of this entity, we describe two cases of breast implant-associated DLBCL. Both patients developed Epstein-Barr Virus (EBV)-positive large cell lymphoma of B-cell origin confined to the implant capsule with no evidence of systemic lymphoma. Considering the association with EBV, the activated B-cell phenotype and the presumed chronic inflammatory environment associated with the implant capsule, these might represent forms of DLBCL associated with chronic inflammation (DLBCL-CI) or fibrin-associated DLBCL (FA-DLBCL). Treatment included implant removal with total capsulectomy, and for one of the cases adjuvant systemic chemotherapy. Recognizing this rare type of breast implant-associated B-cell lymphoma could improve our understanding of this entity and hence develop appropriate management strategies.

State of Gender Diversity and Equity Policies within Plastic and Reconstructive Surgery in Canada.

BACKGROUND: Given the growing number of women in plastic and reconstructive surgery (PRS), it is imperative to evaluate the extent of gender diversity and equity policies among Canadian PRS programs to support female trainees and staff surgeons. METHODS: A modified version of the United Nations Women's Empowerment Principles (WEPs) Gender Gap Analysis tool was delivered to Canadian PRS Division Chairs (n = 11) and Residency Program Directors (n = 11). The survey assessed gender discrimination and equity policies, paid parental leave policies, and support for work/life balance. RESULTS: Six Program Directors (55% response rate) and ten Division Chairs (91% response rate) completed the survey. Fifty percent of respondents reported having a formal gender non-discrimination and equal opportunity policy in their program or division. Eighty-three percent of PRS residency programs offered paid maternity/paternity/caregiver leave; however, only 29% offered financial or non-financial support to its staff surgeons. Only 33% of programs had approaches to support residents as parents and/or caregivers upon return to work. Work/life balance was supported for most trainees (67%) but only few faculty members (14%). CONCLUSIONS: The majority of Canadian PRS programs have approaches rather than formal policies to ensure gender non-discrimination and equal opportunity among residents and faculty. Although residency programs support wellness, few have approaches for trainees as parents and/or caregivers upon return to work. At the faculty level, approaches and policies lack support for maternity/paternity/caregiver leave or work/life balance. This information can be used to develop policy for support of plastic surgery trainees and faculty.

Na+/H+ exchange inhibitor cariporide attenuates skeletal muscle infarction when administered before ischemia or reperfusion.

Administration of Na(+)/H(+) exchange isoform-1 (NHE-1) inhibitors before ischemia has been shown to attenuate myocardial infarction in several animal models of ischemia-reperfusion injury. However, controversy still exists as to the efficacy of NHE-1 inhibitors in protection of myocardial infarction when administered at the onset of reperfusion. Furthermore, the efficacy of NHE-1 inhibition in protection of skeletal muscle from infarction (necrosis) has not been studied. This information has potential clinical applications in prevention or salvage of skeletal muscle from ischemia-reperfusion injury in elective and trauma reconstructive surgery. The objective of this research project is to test our hypothesis that the NHE-1 inhibitor cariporide is effective in protection of skeletal muscle from infarction when administered at the onset of sustained ischemia or reperfusion and to study the mechanism of action of cariporide. In our studies, we observed that intravenous administration of cariporide 10 min before ischemia (1 or 3 mg/kg) or reperfusion (3 mg/kg) significantly reduced infarction in pig latissimus dorsi muscle flaps compared with the control, when these muscle flaps were subjected to 4 h of ischemia and 48 h of reperfusion (P < 0.05; n = 5 pigs/group). Both preischemic and postischemic cariporide treatment (3 mg/kg) induced a significant decrease in muscle myeloperoxidase activity and mitochondrial-free Ca(2+) content and a significant increase in muscle ATP content within 2 h of reperfusion (P < 0.05; n = 4 pigs/group). Preischemic and postischemic cariporide treatment (3 mg/kg) also significantly inhibited muscle NHE-1 protein expression within 2 h of reperfusion after 4 h of ischemia, compared with the control (P < 0.05; n = 3 pigs/group). These observations support our hypothesis that cariporide attenuates skeletal muscle infarction when administered at the onset of ischemia or reperfusion, and the mechanism involves attenuation of neutrophil accumulation and mitochondrial-free Ca(2+) overload and preservation of ATP synthesis in the early stage of reperfusion.

Breast Reconstruction Following Breast Implant-Associated Anaplastic Large Cell Lymphoma.

BACKGROUND: Standard of care treatment of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) involves surgical resection with implant removal and complete capsulectomy. We report a case series of BIA-ALCL reconstruction with proposals for timing and technique selection. METHODS: We retrospectively reviewed and prospectively enrolled all BIA-ALCL patients at 2 tertiary care centers and 1 private plastic surgery practice from 1998 to 2017. Demographics, treatment, reconstruction, pathology staging, patient satisfaction, and oncologic outcomes were reviewed. RESULTS: We treated 66 consecutive BIA-ALCL patients and 18 (27%) received reconstruction. Seven patients (39%) received immediate reconstruction, and 11 (61%) received delayed reconstruction. Disease stage at presentation was IA (T1N0M0 disease confined to effusion or a layer on luminal side of capsule with no lymph node involvement and no distant spread) in 56%, IB in 17%, IC (T3N0M0 cell aggregates or sheets infiltrating the capsule, no lymph node involvement and no distant spread) in 6%, IIA (T4N0M0 lymphoma infiltrating beyond the capsule, no lymph node involvement and no distant spread) in 11%, and III in 11%. Types of reconstruction included smooth implants (72%), immediate mastopexy (11%), autologous flaps (11%), and fat grafting (6%). Outcomes included no surgical complications, but 1 patient progressed to widespread bone metastasis (6%); ultimately, all patients achieved complete remission. Ninety-four percent were satisfied/highly satisfied with reconstructions, whereas 6% were highly unsatisfied with immediate smooth implants. CONCLUSIONS: Breast reconstruction following BIA-ALCL management can be performed with acceptable complications if complete surgical ablation is possible. Immediate reconstruction is reserved for disease confined to capsule on preoperative positive emission tomography/computed tomography scan. Genetic predisposition and bilateral cases suggest that BIA-ALCL patients should not receive textured implants. Autologous options are preferable for implant adverse BIA-ALCL patients. Patients with extensive disease at presentation should be considered for 6- to 12-month delayed reconstruction with interval positive emission tomography/computed tomography evaluation.

Which venous system to choose for anastomosis in head and neck reconstructions?

It has been postulated that venous thrombosis in free flap surgery necessitates the use of 2 venous anastomoses into different venous systems. We retrospectively analyzed a single surgeon's 10-year experience (August 1993 to August 2003) in primary free flap reconstruction for malignant tumors of the head and neck. Of 492 primary reconstructions that did not need a vein graft, vein loop, or cephalic turnover procedure, 251 used the internal jugular venous system as venous outflow, 140 used the subclavian system as outflow, and 101 used both. Two hundred thirty-eight of 251 (95%) of flaps utilizing the internal jugular venous system for outflow were successful compared with 129 of 140 (92%) of flaps utilizing the subclavian system. Where both venous systems were used the success rate was 101 of 101 (100%) (P < 0.05). Where possible, a second venous anastomosis should be performed utilizing both venous drainage systems.

Patient-Reported Outcomes following Breast Conservation Therapy and Barriers to Referral for Partial Breast Reconstruction.

BACKGROUND: The purpose of this study was to evaluate the self-reported aesthetic outcome of breast conservation therapy in a generalized sample of patients, and to describe potential barriers to referral for partial breast reconstruction. METHODS: Consecutive breast conservation therapy patients completing radiotherapy over a 1-year period at a regional cancer center were identified. Eligible patients were contacted by means of mail/e-mail and invited to participate. Participants completed the BREAST-Q breast conservation therapy module along with a questionnaire examining feelings about breast reconstruction. Multiple regression analysis was performed using the satisfaction with breasts scale as the dependent variable. RESULTS: Surveys were completed by 185 of 592 eligible participants (response rate, 31.3 percent; mean age, 61 years) an average of 38 months after lumpectomy. The mean score for the BREAST-Q satisfaction with breasts scale was 59 of 100. Younger age (p = 0.038), lumpectomy reexcision (p = 0.018), and lumpectomy at a nonacademic center (p = 0.026) were significantly associated with lower satisfaction. Bra size, months from lumpectomy, and tumor quadrant/size were not significantly associated with satisfaction (p > 0.05). The most common statements regarding reconstruction were "I don't feel the need for it" (60.0 percent), "I don't like the thought of having breast implants" (22.7 percent), and "I don't want any more surgeon/doctor visits" (22.2 percent). Before lumpectomy, only 1.6 percent had a consultation for reconstruction, and only 22.7 percent were aware of this option. If offered, 33.1 percent of patients would have attended this consultation. CONCLUSION: There is an unmet demand for partial breast reconstruction, with an opportunity to advocate and increase awareness on behalf of patients undergoing breast conservation therapy.

Breast reconstruction with free flaps from the abdominal donor site: TRAM, DIEAP, and SIEA flaps.

Multiple types of free flap can be elevated from the lower abdominal region for use in breast reconstruction. These include the free transverse rectus abdominis myocutaneous flap, the deep inferior epigastric artery perforator flap, and the superficial inferior epigastric artery flap. This sequence of flaps represents an evolution in the protection of the donor site. However, the decision as to which flap may be most appropriate for an individual patient is complex. This article serves to review pertinent surgical anatomy, preoperative planning, intraoperative decision making in flap elevation, and reported outcomes.

Management of the BRCA mutation carrier or high-risk patient.

Women who are at high risk of breast cancer are eligible for several risk management strategies including intensified surveillance, chemoprevention, and prophylactic surgery. This article reviews and summarizes the risk factors associated with breast cancer, the different risk calculation models available, and risk management strategies.

A Qualitative Assessment of the Journey to Delayed Breast Reconstruction.

BACKGROUND: Canada has low immediate breast reconstruction (IBR) rates compared to the United States and Europe. Breast cancer survivors live with mastectomy defects sometimes for years, and this represents an area for improvement in cancer care. PURPOSE: This study qualitatively assessed (1) information provided about breast reconstruction at the time of cancer diagnosis among women seeking delayed breast reconstruction (DBR) and (2) referral practices for plastic surgery consultation for DBR. METHODS: Fifty-two consecutive patients seen in consultation for DBR at a single Canadian tertiary care centre completed questionnaires regarding their experience in seeking breast reconstruction. Seven semi-structured interviews were conducted to further explore themes identified through questionnaires. Questionnaire responses and interview transcripts were analyzed for recurring themes using standard qualitative techniques. RESULTS: A significant portion of women (43%) was interested in reconstruction prior to mastectomy, yet IBR was infrequently discussed (14%) or discouraged by their oncologic surgeons (33%). Common patient reasons for not pursuing IBR were referring physician objection and not having adequate knowledge. Women expressed wanting to discuss reconstruction at the time of cancer diagnosis. Half of the patients had attended another consultation, but the initial plastic surgeon either did not offer procedures for which these women were candidates or had prohibitively long surgical wait times. CONCLUSION: Lack of information about reconstructive options at the time of cancer diagnosis and perceived access barriers to plastic surgeons may contribute to underutilization of IBR in Canada. Access to breast reconstruction can be improved by reducing inefficiencies in plastic surgery referrals.

HISTORIQUE: Le taux de reconstructions mammaires immédiates (RMI) est faible au Canada par rapport aux États-Unis et à l'Europe. Les survivantes du cancer du sein vivent parfois avec une mastectomie pendant des années, ce qui représente un secteur à améliorer dans les soins du cancer. OBJECTIF: La présente étude était une analyse qualitative 1) de l'information transmise au sujet de la reconstruction mammaire au moment du diagnostic de cancer chez les femmes qui souhaitent une reconstruction mammaire tardive (RMT) et 2) des pratiques d'orientation vers une consultation en chirurgie plastique en vue d'une RMT. MÉTHODOLOGIE: Cinquante-deux patientes consécutives vues en consultation pour subir une RMT dans un seul centre canadien de soins tertiaries ont rempli des questionnaires sur leur expérience dans l'obtention d'une reconstruction mammaire. Les chercheurs ont organisé sept entrevues semi-structurées pour explorer les thèmes colligés grâce aux questionnaires. Ils ont utilisé des techniques qualitatives standards pour analyser les réponses aux questionnaires et les entrevues transcrites et relever des thèmes récurrents. RÉSULTATS: Avant la mastectomie, une forte proportion de femmes (43 %) souhaitait subir une reconstruction, mais leur chirurgien oncologue abordait rarement la RMI (14 %) ou la déconseillait (33 %). Les raisons fréquentes pour ne pas demander une RMI étaient l'objection du médecin traitant et le manque de connaissances suffisantes. Les femmes indiquaient vouloir parler de reconstruction au moment de leur diagnostic de cancer. La moitié des patientes avait participé à une autre consultation, mais le premier plasticien n'avait pas offert d'interventions auxquelles ces femmes étaient candidates ou présentait une trop longue liste d'attente avant l'opération. CONCLUSION: Le manque d'information sur les possibilités de reconstruction au moment du diagnostic de cancer et les obstacles perçus à l'accès aux plasticiens peuvent contribuer à une sous-utilisation de la RMI au Canada. Pour améliorer l'accès à la reconstruction mammaire, on peut réduire les inefficacités en matière de demande de consultation auprès des plasticiens.

Development of an in vitro model for study of the efficacy of ischemic preconditioning in human skeletal muscle against ischemia-reperfusion injury.

Ischemia-reperfusion (I/R) injury causes skeletal muscle infarction and ischemic preconditioning (IPC) augments ischemic tolerance in animal models. To date, this has not been demonstrated in human skeletal muscle. This study aimed to develop an in vitro model to investigate the efficacy of simulated IPC in human skeletal muscle. Human skeletal muscle strips were equilibrated in oxygenated Krebs-Henseleit-HEPES buffer (37 degrees C). Aerobic and reperfusion phases were simulated by normoxic incubation and reoxygenation, respectively. Ischemia was simulated by hypoxic incubation. Energy store, cell viability, and cellular injury were assessed using ATP, 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyl-2H-tetrazolium bromide (MTT), and lactate dehydrogenase (LDH) assays, respectively. Morphological integrity was assessed using electron microscopy. Studies were designed to test stability of the preparation (n = 5-11) under normoxic incubation over 24 h; the effect of 1, 2, 3, 4, or 6 h hypoxia followed by 2 h of reoxygenation; and the protective effect of hypoxic preconditioning (HPC; 5 min of hypoxia/5 min of reoxygenation) before 3 h of hypoxia/2 h of reoxygenation. Over 24 h of normoxic incubation, muscle strips remained physiologically intact as assessed by MTT, ATP, and LDH assays. After 3 h of hypoxia/2 h of reoxygenation, MTT reduction levels declined to 50.1 +/- 5.5% (P < 0.05). MTT reduction levels in HPC (82.3 +/- 10.8%) and normoxic control (81.3 +/- 10.2%) groups were similar and higher (P < 0.05) than the 3 h of hypoxia/2 h of reoxygenation group (45.2 +/- 5.8%). Ultrastructural morphology was preserved in normoxic and HPC groups but not in the hypoxia/reoxygenation group. This is the first study to characterize a stable in vitro model of human skeletal muscle and to demonstrate a protective effect of HPC in human skeletal muscle against hypoxia/reoxygenation-induced injury.

Impact of Prior Tissue Expander/Implant on Postmastectomy Free Flap Breast Reconstruction.

BACKGROUND: Implant-based breast reconstructions can result in unsatisfactory results requiring surgical revision or salvage reconstructive surgery with autologous tissue. This study compares the outcomes and complications of salvage (tertiary) flap reconstruction after failed prosthesis placement to those of primary/secondary flap reconstruction. METHODS: All patients undergoing free flap breast reconstruction after failed prosthesis between July 1, 2005, and June 30, 2014, were identified. A matched number of patients who underwent a de novo free flap breast reconstruction were selected randomly for review. The indication for prosthesis removal, demographic and operative data, flap type and inset, and complication rates were evaluated. RESULTS: Eighty-nine women with a history of failed implant-based reconstruction required free flap reconstruction for salvage in 121 breasts. Capsular contracture was the most common indication for prosthesis removal (62.0 percent). Recipient vessel scarring was 5.23 times more likely to occur in the prior prosthesis group (p < 0.001). Alternate flap types other than deep inferior epigastric perforator and transverse rectus abdominis myocutaneous flaps were more frequently used in this cohort. Major complications requiring operative management were more common in the experimental group (17.4 percent versus 8.1 percent; p = 0.035). No difference was noted in flap loss rates, operative take back, or operative time. CONCLUSIONS: Salvage breast reconstruction with autologous tissue after failed prosthesis can be safely performed, with success rates similar to those of primary free flap breast reconstruction. However, these procedures may have increased complexity because of recipient vessel scarring, higher rates of prior radiation therapy, and major complications, which may warrant appropriate preoperative planning and patient counseling. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Reconstruction of skull base defects.

Skull base defects are classified into three regions based on the anatomic location and growth pattern of the tumors. The goals of reconstruction are based on the necessity of obtaining a watertight seal between the cranial contents and the aerodigestive tract, thereby avoiding any communication, which could result in ascending meningitis. Pedicled flap options have largely been replaced by free tissue transfers, with the exception of small Zone I defects that can still be safely reconstructed with local pedicle flaps. The rectus abdominis free muscle flap has become the workhorse of skull base reconstruction, resulting in a decrease in the complication rate following these procedures. Various other factors have significantly improved the prognosis of patients who require tumor ablation involving the skull base.

Breast reconstruction in older women: advantages of autogenous tissue.

As the population ages, the treatment of breast cancer among elderly women is becoming increasingly common. Decisions with regard to breast reconstruction require not only consideration of patient age and comorbidities but also a need to balance life expectancy with quality of life. Although it is often assumed that implant-based breast reconstruction is the least disruptive method, especially among patients who may be facing limited survival times, it was hypothesized that autogenous tissue breast reconstruction is a well-tolerated and perhaps preferable means of reconstruction for older women who choose to undergo reconstruction following mastectomy. No large series of autogenous tissue reconstructions in this age group has been presented. A retrospective study of 84 postmastectomy reconstructions (66 unilateral and 18 bilateral; 78.6 percent immediate) performed at the authors' institution for 81 women 65 years of age or older, between April of 1987 and December of 2000, was undertaken. Reconstructions were implant-based ( = 26), latissimus dorsi flap-based ( = 24), or transverse rectus abdominis myocutaneous (TRAM) flap-based ( = 34). Of the 34 TRAM flaps, 21 were free or supercharged. Breast complications were more frequent ( < 0.05) among recipients of implant-based reconstructions (76.9 percent) than among recipients of latissimus dorsi flap (41.7 percent) or TRAM flap (35.3 percent) reconstructions. In multivariate logistic regression analyses, comorbidities, smoking, radiotherapy, and body mass index had no effect. Medical complications without long-term sequelae were observed for two patients who underwent latissimus dorsi flap reconstructions and two patients who underwent free TRAM flap reconstructions; the difference in the rates of medical complications was not significant. At the mean follow-up time of 4.2 years, 92.8 percent of all study patients exhibited no evidence of disease. Notably, despite being free of disease, seven of the 26 patients (27 percent) who underwent implant-based reconstructions abandoned further reconstructive efforts after complications necessitated implant removal. It was concluded that age alone should not determine the type of breast reconstruction and that autogenous tissue breast reconstruction can be a safe successful alternative for women 65 years of age or older.