Interpectoral nerve blocks may lower postoperative narcotic use after mastectomy.

BACKGROUND: Pain management following mastectomy is a significant challenge often requiring opioids. Nonopioid pain management utilizing nerve blocks has been shown in other fields to reduce postoperative opioid use and may be effective for postoperative pain in mastectomy patients. The primary purpose of this study was to compare postoperative opioid use, measured in morphine milligram equivalents (MME), between mastectomy patients who underwent interpectoral nerve block (IPNB) and a historical control group. Secondary outcomes included length of stay (LOS) and postoperative pain scores. METHODS: This is a single-center, retrospective cohort study. The charts of women who underwent mastectomy for cancer without immediate reconstruction from 10/2017-12/2019 were reviewed. Wilcoxon rank sum test was used for unadjusted analysis and multiple linear regression for adjusted analysis. RESULTS: There were 105 patients included in this study, of which 37 (35%) underwent IPNB. In unadjusted analysis, median MME use was significantly lower in patients that received IPNB compared to the control group (IPNB = 5, controls = 17, p = 0.03). Patients that received IPNB had an observed reduction in LOS and postoperative pain, though these results failed to reach statistical significance. There were no IPNB-related complications. CONCLUSIONS: IPNB may be an effective strategy to decrease postoperative opioid use in mastectomy patients. Larger, prospective studies are needed to further investigate the effectiveness of IPNB.

Comparison of mastectomy and breast reconstruction outcomes using low thermal dissection versus traditional electrocautery: a blinded randomized trial.

INTRODUCTION: PlasmaBlade® is a thermal dissection device that may allow for improved perfusion of the mastectomy flap by limiting thermal injury. In this study we aim to compare the mastectomy flap perfusion using PlasmaBlade® versus traditional electrocautery. METHODS: Patients undergoing bilateral mastectomy with immediate breast reconstruction were recruited. The right and left breasts of each patient were randomized to dissection with PlasmaBlade® or standard electrocautery. Randomization was performed using random sequences on the day of surgery and was blinded to the plastic surgeon. Mastectomy flap perfusion was assessed following completion of the mastectomy using intra-operative fluoroscopy and plastic surgeon review. Surgical site drainage and pain score were measured. Sign tests were employed to assess differences in perfusion and Wilcoxon paired test for the secondary outcomes. RESULTS: Twenty patients were enrolled in the study with median age of 40.5 years and median BMI of 26 kg/m2. In 18 patients (90%), perfusion was assessed to be better on the side of the PlasmaBlade® dissection. Median daily drainage over a 7-day period was 51 cc (IQR 35-61) on the PlasmaBlade® side and 44 cc (IQR 31-61) on the control side. Median pain score on the PlasmaBlade® side was 4.0 (IQR 2.3-5.9) and 4.4 (IQR 2.9-6) on the control side. No skin necrosis was noted in either groups. CONCLUSION: Use of PlasmaBlade® appears to be a safe and reliable technique to perform mastectomy and breast reconstruction with equivalent outcomes to traditional electrocautery. Although, mastectomy skin flap perfusion was rated better intra-operatively for the PlasmaBlade® group, both cohorts had comparable outcomes. ClinicalTrials.gov Identifier: NCT03711916 Level of Evidence: I (Randomized trial).

Establishing a Culture of Patient Safety, Quality, and Service in Plastic Surgery: Integrating the Fractal Model.

PROBLEM: There are obstacles to effective nationwide implementation of a culture of patient safety. Plastic surgery faces unique challenges in this area because quality measures are not as well-established as in other fields. Plastic surgery may also require emphasis on patient-reported outcomes as a quality-of-life specialty with distinct concomitant analytical methods. APPROACH: We devised a dynamic framework, based on our 3-year experience using a Comprehensive Unit-Based Safety Program-a formal quality improvement committee structure, literature review, and work from The Johns Hopkins Armstrong Institute for Patient Safety and Quality. This framework is specific and exportable to the field of plastic surgery. Monthly patient safety, quality, and service committee meetings encourage multilevel participation in a bottom-up fashion, while connecting with other departments and entities in Johns Hopkins Medicine. Our model focuses our work in the following four domains: (1) safety, (2) external measures, (3) patient experience, and (4) value. Our framework identifies and communicates clear goals, creates necessary infrastructure, identifies opportunities and needs, uses robust performance to develop and implement interventions, and includes analytics to track improvement plans and results. OUTCOMES: We have gradually implemented this quality improvement structure into the Johns Hopkins Department of Plastic and Reconstructive Surgery successfully since 2012. Outcomes have improved in externally reported measures of patient safety, quality, and service. We have demonstrated exemplary National Surgical Quality Improvement Program performance for morbidity, return to operating room, and readmission rates. Patient satisfaction surveys show improvement related to the high-level patient experience.

Comparing Operative Performance between Independent and Integrated Plastic Surgery Residents.

BACKGROUND: Anecdotally, faculty report that independent residents' operative skills differ from those of their integrated peers. This study compared operative competency between integrated (postgraduate years 4 to 6) and independent plastic surgery residents. METHODS: The authors compared independent (postgraduate years 1 to 3) and integrated (postgraduate years 4 to 6) plastic surgery residents at their institution using operative performance data from the Operative Entrustability Assessment, a validated five-point assessment tool that provides residents with real-time feedback about their operative performance, documenting performance at the point of care. Independent postgraduate year 1, 2, and 3 residents were categorized as postgraduate year 4, 5, and 6 residents, respectively, for comparison. The authors analyzed attending physician (evaluator) Operative Entrustability Assessment scores over time using the independent t test. RESULTS: From July 1, 2013, to June 30, 2018, Operative Entrustability Assessments were completed at one training program for residents in postgraduate years 4 to 6: 1886 (47.4 percent) by independent [n = 12 (37.5 percent)] and 2094 (52.6 percent) by integrated [n = 20 (62.5 percent)] residents. Evaluator scores were lower for independent track residents throughout the first two quarters of postgraduate year 4 (quarter 1 delta, -0.49 point, p < 0.001; quarter 2 delta, -0.36 point, p < 0.001). However, this difference was no longer statistically significant during the third and fourth quarters of postgraduate year 4 (p = 0.192 and p = 0.228, respectively). No difference was detectable at postgraduate year 5 (p = 0.095) or postgraduate year 6 (p = 0.877). CONCLUSIONS: Operative Entrustability Assessment data demonstrate that differences between independent and integrated plastic surgery residents regarding operative skills (0.49 of 5 points) and amount of time needed for independent residents to catch up (6 months) is minimal and resolves during the third quarter of independent postgraduate year 1. Programs can design curricula to facilitate independent residents' plastic surgery skill acquisition during their first two quarters.

Determinants of receiving immediate breast reconstruction: An analysis of patient characteristics at a tertiary care center in the US.

BACKGROUND: Breast reconstruction is an option for women undergoing mastectomy for breast cancer. Previous studies have reported underutilization of reconstructive surgery. This study aims to examine the role demographic, clinical and socio-economic factors may have on patients' decisions to undergo breast reconstruction. METHODS: We analyzed data from our institutional database. Using multivariable and multinomial logistic regression, we compared breast cancer patients who had undergone mastectomy-only to those who had immediate breast reconstruction (overall and by type of reconstruction). RESULTS: We analyzed data on 1459 women who underwent mastectomy during the period 2003-2015. Of these, 475 (32.6%) underwent mastectomy-only and 984 (67.4%) also underwent immediate breast reconstruction. After adjusting for potential confounders, older age (OR = 0.18, 95%CI:0.08-0.40), Asian race (OR = 0.29, 95%CI:0.19-0.45), bilateral mastectomy (OR = 0.71, 95%CI:0.56-0.90), and higher stage of disease (OR = 0.44, 95%CI:0.26-0.74) were independent risk factors for not receiving immediate breast reconstruction. Furthermore, patients with Medicare or Medicaid insurance were less likely than patients with private insurance to receive an autologous reconstruction. There was no evidence for changes over time in the way socio-demographic and clinical factors were related to receiving immediate breast reconstruction after mastectomy. CONCLUSIONS: Clinical characteristics, sociodemographic factors like age, race and insurance coverage affect the decision for reconstructive surgery following mastectomy.

Patient-Related Risk Factors for Worsened Abdominal Well-Being after Autologous Breast Reconstruction.

BACKGROUND: Patient-reported lower satisfaction with the abdomen preoperatively is a strong predictor of undergoing DIEP flap surgery. The authors evaluated physical well-being of the abdomen before and after flap-based breast reconstruction to determine potential predictors for decreased postoperative abdominal well-being. METHODS: The authors retrospectively analyzed an institutional breast reconstruction registry, selecting patients who underwent abdominally based autologous flap breast reconstruction from 2010 to 2015. The authors' primary outcome was the Physical Well-being of the Abdomen domain from the BREAST-Q, measured preoperatively and at 6- and 12-month follow-up visits after final reconstruction. The authors classified two patient groups: those who experienced a clinically important worsening of Physical Well-being of the Abdomen score and those who did not. The authors used the chi-square test, t test, and Wilcoxon rank sum test, and multivariable logistic regression to identify potential predictors. RESULTS: Of 142 women identified, 74 (52 percent) experienced clinically important worsening of physical well-being of the abdomen, whereas 68 (48 percent) did not. The first group experienced a 25-point (95 percent CI, 22 to 28) decrease and the latter an 8-point (95 percent CI, 5 to 10) decrease in score compared to baseline. Multivariable analysis showed an association between higher baseline score and race, with higher odds of decreased score at the 12-month follow-up. A higher baseline RAND-36 general health score, bilateral reconstruction, and a lower body mass index demonstrated a trend for clinically important worsening of physical well-being of the abdomen. CONCLUSIONS: More than half of flap-based breast reconstruction patients experienced clinically important worsening of abdominal well-being after final breast reconstruction. Clinicians may use these findings to identify patients at higher risk of worsened postoperative abdominal well-being. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Survival and Disease Recurrence Rates among Breast Cancer Patients following Mastectomy with or without Breast Reconstruction.

BACKGROUND: Concerns have been expressed about the oncologic safety of breast reconstruction following mastectomy for breast cancer. This study aimed to evaluate the association of breast reconstruction with breast cancer recurrence, and 5-year survival among breast cancer patients. METHODS: The authors analyzed data from The Johns Hopkins Hospital comprehensive cancer registry, comparing mastectomy-only to postmastectomy breast reconstruction in breast cancer patients to evaluate differences in breast cancer recurrence and 5-year survival. Kaplan-Meier curves were used to compare unadjusted estimates of survival or disease recurrence. Data were modeled through Cox proportional hazards regression, using as outcomes time to death from any cause or time to cancer recurrence. RESULTS: The authors analyzed data on 1517 women who underwent mastectomy for breast cancer at The Johns Hopkins hospital between 2003 and 2015. Of these, 504 (33.2 percent) underwent mastectomy only and 1013 (66.8 percent) underwent mastectomy plus immediate breast reconstruction. Women were followed up for a median of 5.1 years after diagnosis. There were 132 deaths and 100 breast cancer recurrences. A comparison of Kaplan-Meier survival estimates demonstrated a survival benefit among patients undergoing mastectomy plus reconstruction. After adjusting for various clinical and socioeconomic variables, there was still an overall survival benefit associated with breast reconstruction which, however, was not statistically significant (hazard ratio, 0.78; 95 percent CI, 0.53 to 1.13). Patients who underwent reconstruction had a similar rate of recurrence compared to mastectomy-only patients (hazard ratio, 1.08; 95 percent CI, 0.69 to 1.69). CONCLUSION: This study suggests that breast reconstruction does not have a negative impact on either overall survival or breast cancer recurrence rates. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

A large-volume academic center retrospective audit of the temporal evolution of immediate breast reconstruction protocols and the effect on breast prosthetic infection.

BACKGROUND: Complications of tissue expanders (TEs) in breast reconstruction are challenging. We sought to identify TE infection risks and acellular dermal matrix (ADM) and infection control protocol impacts on infection in a longitudinal study. METHODS: We retrospectively analyzed TE/implant reconstructions in 2004 (no ADM), 2009 (TE and ADM), 2013 (TE, ADM, and infection control protocol), and 2015 (TE, ADM, and infection control protocol). We assessed demographic, disease, and operative factors and analyzed rates of seroma, hematoma, skin necrosis, and infection. Statistical analysis, including simple and multivariable logistic regression, was performed using Stata v13.1. RESULTS: 478 TEs were placed in 324 women, with a 30% overall patient complication rate (23% of breasts). A total of 14% of TEs became infected. Although unadjusted analysis showed no ADM and infection association (p = 0.269), multivariable logistic regression showed a significant association with more infections (OR: 3.21; 95% CI: 1.13-9.313; p = 0.029). The infection control protocol decreased infections by 28% (16% in 2009 vs 11% in 2013); however, this did not achieve statistical significance (unadjusted p = 0.192, adjusted p = 0.156). Seroma (p < 0.001), older age (p = 0.040), larger mastectomy volume (p = 0.001), smoking (p = 0.037), BMI (p < 0.001), vascular disorders (p = 0.007), and hypertension (p < 0.001) significantly increased infections. CONCLUSIONS: Identifiable risks exist in TE/implant breast reconstruction. ADM infection risk may mitigate some potential benefits. Anti-infection protocols may reduce infections, and further investigation may reveal the most effective prophylactic strategies. Absence of major changes in complications over time supports validity of studies examining large numbers of despite evolution of techniques.

Delayed Breast Reconstruction on Patients With Upper Extremity Lymphedema: A Systematic Review of the Literature and Pooled Analysis.

BACKGROUND: Breast cancer-related lymphedema (BCRL) is a debilitating condition with morbidity, hindered quality of life, and increased health-related costs. Experimental studies support the use of musculocutaneous flaps for managing animal models with lymphedema. Although vascularized lymph node transfer (VLNT) and lymphovenous anastomosis are used to surgically treat patients with lymphedema, it is not known whether musculocutaneous or adipocutaneous flaps (eg, delayed autologous breast reconstruction) are effective for treating refractory upper extremity BCRL. We conducted a systematic review and pooled analysis to assess the impact of delayed breast reconstruction on developed BCRL. METHODS: Following PRISMA guidelines, we systematically searched PubMed, Scopus, EMBASE, and Google Scholar databases for relevant studies published through November 11, 2016. We screened 934 unique articles. Of these, we conducted full-text and reference screening on 37 articles. We then performed a pooled and sensitivity analysis using random effects. RESULTS: Eight studies met our inclusion criteria. One study was a case report; 7 studies were case series with sample sizes ranging from 3 to 38 patients. According to our pooled analysis 58% of patients reported improvement after breast reconstruction with or without VLNT. Sensitivity analysis revealed that 84% (95% confidence interval, 0.74-0.95) of patients who underwent breast reconstruction and VLNT reported improvement, whereas only 22% (95% confidence interval, 0.12-0.32) of those who had breast reconstruction alone reported improvement. CONCLUSIONS: Our review summarizes the current evidence regarding the effect of delayed breast reconstruction on established lymphedema. The VLNT component of the autologous breast reconstruction procedures may be the largest contributing factor leading to lymphedema improvement.

Understanding Surgical Resident and Fellow Perspectives on Their Operative Performance Feedback Needs: A Qualitative Study.

OBJECTIVE: Operative performance feedback is essential for surgical training. We aimed to understand surgical trainees' views on their operative performance feedback needs and to characterize feedback to elucidate factors affecting its value from the resident perspective. DESIGN: Using a qualitative research approach, 2 research fellows conducted semistructured, one-on-one interviews with surgical trainees. We analyzed recurring themes generated during interviews related to feedback characteristics, as well as the extent to which performance rating tools can help meet trainees' operative feedback needs. SETTING: Departments or divisions of general or plastic surgery at 9 US academic institutions. PARTICIPANTS: Surgical residents and clinical fellows in general or plastic surgery. RESULTS: We conducted 30 interviews with 9 junior residents, 14 senior residents, and 7 clinical fellows. Eighteen (60%) participants were in plastic and 12 (40%) were in general surgery. Twenty-four participants (80%) reported feedback as very or extremely important during surgical training. All trainees stated that verbal, face-to-face feedback is the most valuable, especially if occurring during (92%) or immediately after (65%) cases. Of those trainees using performance rating tools (74%), most (57%) expressed positive views about them but wanted the tools to complement and not replace verbal feedback in surgical education. Trainees value feedback more if received within 1 week or the case. CONCLUSIONS: Verbal, face-to-face feedback is very or extremely important to surgical trainees. Residents and fellows prefer to receive feedback during or immediately after a case and continue to value feedback if received within 1 week of the event. Performance rating tools can be useful for providing formative feedback and documentation but should not replace verbal, face-to-face feedback. Considering trainee views on feedback may help reduce perceived gaps in feedback demand-versus-supply in surgical training, which may be essential to overcoming current challenges in surgical education.

The reliability of operative rating tool evaluations: How late is too late to provide operative performance feedback?

BACKGROUND: Operative rating tools can enhance performance assessment in surgical training. However, assessments completed late may have questionable reliability. We evaluated the reliability of assessments according to evaluation time-to-completion. METHODS: We stratified assessments from MileMarker's™ Operative Entrustability Assessment by evaluation time-to-completion, using concordance correlation coefficient (CCC) between self-assessment and evaluator scores as a measure of reliability. RESULTS: Overall, self-assessment and evaluator scores were strongly correlated (CCC = 0.72; p < 0.001) though self-assessments were slightly higher (p = 0.048). Reliability remained stable for evaluations completed within 0 days (CCC = 0.77; p < 0.001), 1-3 days (CCC = 0.73; p < 0.001), and 4-13 days after surgery (CCC = 0.69; p < 0.001), but dropped for evaluations completed within 14-38 days (CCC = 0.60; p < 0.001) and over 38 days (CCC = 0.54; p < 0.001) after surgery. There was strong evidence for an interaction between time-to-completion and reliability (p < 0.001). CONCLUSIONS: Our data support the reliability of assessments completed until 2 weeks after surgery. This finding may help refine the interpretation of evaluation scores as surgical specialties move toward competency-based accreditation.

The Effect of Radiation on Quality of Life throughout the Breast Reconstruction Process: A Prospective, Longitudinal Pilot Study of 200 Patients with Long-Term Follow-Up.

BACKGROUND: Despite well-established correlation of postmastectomy radiotherapy and surgical complications in breast reconstruction, its impact on patient reported outcomes is less clear. We sought to determine the effect of postmastectomy radiotherapy on patient reported outcomes throughout the breast reconstruction process. METHODS: Patients undergoing prosthetic and autologous breast reconstruction from November 2010 to June 2013 were prospectively followed with BREAST-Q surveys (preoperatively, after expander placement, and 6 and 12 months after final reconstruction). Paired t test, Wilcoxon rank sum test, and multiple linear regression were used to determine the effect of radiation on patient reported outcomes. RESULTS: Two hundred patients were included in the study, of which 51 (25.5 percent) received postmastectomy radiotherapy. Prosthetic reconstruction was performed in 75 patients (37.5 percent), autologous reconstruction was performed in 118 (59 percent), and pure fat grafting was performed in seven (3.5 percent). At one-year follow-up, the nonirradiated group reported higher BREAST-Q scores when compared with the irradiated group, in Satisfaction with Breasts (p = 0.003), Psychosocial Well-being (p = 0.003), Sexual Well-being (p < 0.001), Physical Well-being of Chest (p = 0.024), and Satisfaction with Outcome (p = 0.03). When accounting for baseline values, Satisfaction with Breasts and Physical Well-being of Chest significantly worsened in irradiated patients undergoing prosthetic reconstruction, an effect not seen with autologous reconstructions. All irradiated patients significantly worsened in Psychosocial Well-being and Sexual Well-being scores. CONCLUSIONS: Postmastectomy radiotherapy is associated with worse patient reported outcomes following breast reconstruction. Autologous reconstruction can mitigate patient dissatisfaction in some domains. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Breast reconstruction and risk of arm lymphedema development: A meta-analysis.

BACKGROUND: Lymphedema remains a significant complication following breast cancer surgery when there is axillary lymph node intervention. Previous systematic reviews have identified risk factors for breast cancer-related lymphedema, including increased BMI, number of lymph nodes dissected and radiotherapy. However, they have not examined the effect of breast reconstruction on lymphedema occurrence. In this systematic review and meta-analysis, we sought to evaluate the association between breast reconstruction (BR) and lymphedema. METHODS: We searched PubMed (1966-2016), Embase (1966-2016), Scopus (2004-2016) and Google Scholar (2004-2016) for studies involving breast reconstruction and upper-extremity lymphedema or breast cancer-related lymphedema. Our primary outcome was lymphedema occurrence. We performed a meta-analysis using random effects due to heterogeneity of the studies. RESULTS: Our search strategy identified 934 articles. After screening, 19 studies were included in our meta-analysis evaluating outcomes based on number of patients (7501) or number of breasts surgically treated (2063). Breast reconstruction was significantly associated with lower odds of lymphedema (p < 0.001) compared to mastectomy only or breast-conserving surgery. Lymphedema rates were not statistically significantly different between patients undergoing implant-based or autologous BR. CONCLUSIONS: Breast reconstruction is associated with lower rates of lymphedema compared to mastectomy only or breast conserving surgery patients. Although the study does not prove causation, we hypothesize that this association is likely due to multiple factors, including a self-selecting population and mechanisms through which BR may contribute to primary or secondary prevention of lymphedema. Further prospective studies are needed to clarify this beneficial relationship between breast reconstruction and reduced lymphedema risk.

The Ethics of Hand Transplantation: A Systematic Review.

PURPOSE: We conducted a systematic review to document ethical concerns regarding human upper extremity (UE) allotransplantation and how these concerns have changed over time. METHODS: We performed a systematic review of 5 databases to find manuscripts addressing ethical concerns related to UE allotransplantation. Inclusion criteria were papers that were on the topic of UE allotransplantation, and related ethical concerns, written in English. We extracted and categorized ethical themes under the 4 principles of bioethics: Autonomy, Beneficence, Nonmaleficence, and Justice. We assessed theme frequency by publication year using Joinpoint regression, analyzing temporal trends, and estimating annual percent change. RESULTS: We identified 474 citations; 49 articles were included in the final analysis. Publication years were 1998 to 2015 (mean, 3 publications/y; range, 0-7 publications/y). Nonmaleficence was most often addressed (46 of 49 papers; 94%) followed by autonomy (36 of 49; 74%), beneficence (35 of 49; 71%), and justice (31 of 49; 63%). Of the 14 most common themes, only "Need for More Research/Data" (nonmaleficence) demonstrated a significant increase from 1998 to 2002. CONCLUSIONS: Upper extremity transplantation is an appealing reconstructive option for patients and physicians. Its life-enhancing (vs life-saving) nature and requirement for long-term immunosuppression have generated much ethical debate. Availability of human data has influenced ethical concerns over time. Our results indicate that discussion of ethical issues in the literature increased following publication of UE transplants and outcomes as well as after meetings of national societies and policy decisions by regulatory agencies. CLINICAL RELEVANCE: Because UE transplantation is not a life-saving procedure, much ethical debate has accompanied its evolution. It is important for UE surgeons considering referring patients for evaluation to be aware of this discussion to fully educate patients and help them make informed treatment decisions.

The Effect of Resident Involvement on Postoperative Short-Term Surgical Outcomes in Immediate Breast Reconstruction: A National Surgical Quality Improvement Program Study of 24,005 Patients.

BACKGROUND: The association between resident involvement and surgical morbidity in immediate breast reconstruction is not fully elucidated, and prior studies have had conflicting results. The authors studied whether resident involvement in immediate breast reconstruction is associated with the most important short-term outcomes: increased 30-day surgical morbidity, readmission and reoperation rates, operative time, and length of stay. METHODS: Patients undergoing immediate breast reconstruction were identified in the 2005 to 2012 American College of Surgeons National Surgical Quality Improvement Program Participant Use Data Files. The authors used simple and multivariable regression to assess surgical complications and secondary outcomes, stratifying by training level and reconstruction type. RESULTS: A total of 24,191 patients underwent immediate breast reconstruction; 17,840 had resident involvement. Thirty-day surgical morbidity was observed in 5.25 percent (95 percent CI, 4.92 to 5.58 percent) of cases with resident involvement and 5.12 percent (95 percent CI, 4.59 to 5.58 percent) of cases without, with no evidence of association between resident involvement and 30-day morbidity (adjusted OR, 0.97; 95 percent CI, 0.85 to 1.11; p = 0.652). Resident involvement was not associated with an increase in complications in implant-based or mixed types of reconstruction, and was associated with lower odds of complications in autologous reconstructions (OR, 0.70; 95 percent CI, 0.53 to 0.91; p = 0.008). It was associated with longer operative times (an average of 24 additional minutes for implant-based and 54 additional minutes for autologous reconstructions; p < 0.001); this was balanced by a shorter length-of-stay for patients undergoing implant-based reconstruction (adjusted OR, 0.88; 95 percent CI, 0.79 to 0.96; p = 0.010). CONCLUSION: In immediate breast reconstruction patients, resident involvement was not associated with increased postoperative surgical morbidity or complications, although operative time was significantly increased with resident involvement across all levels of training. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Empirical validation of the Operative Entrustability Assessment using resident performance in autologous breast reconstruction and hand surgery.

BACKGROUND: In 2013, we developed the Operative Entrustability Assessment (OEA) to facilitate evaluation and documentation of resident operative skills. This web-based tool provides real-time, transparent feedback to residents on operative performance. This study evaluated the construct validity of the OEA, assessing its association with operative time. METHODS: We used simple and multiple linear regression to estimate associations between OEA scores and operative time in selected procedures performed. RESULTS: OEAs were completed for 93 autologous breast reconstructions and 185 hand procedures. Self-assessed OEA was associated with shorter operative time in breast (p = 0.008) and hand (p = 0.036) cases. Evaluator OEA was associated with shorter operative time in breast (p = 0.018), but not hand cases (p = 0.377). Post-graduate year was not associated. CONCLUSIONS: The OEA demonstrates construct validity: increasing scores are associated with shorter operative time and are better predictors of operative time than post-graduate year, making it an option for documenting competence prior to graduation.

Nipple-Sparing Mastectomy Improves Long-Term Nipple But Not Skin Sensation After Breast Reconstruction: Quantification of Long-Term Sensation in Nipple Sparing Versus Non-nipple Sparing Mastectomy.

BACKGROUND: Changes in breast sensation after reconstruction are expected. Return of breast sensation after reconstruction and whether nipple-sparing mastectomy offers a substantial benefit in terms of sensation has been inconsistently documented in the literature. We conducted the current study using the pressure-specified sensory device to quantify postoperative breast sensation in patients undergoing nipple-sparing versus non-nipple-sparing mastectomy. METHODS: Consecutive adult women who underwent nipple-sparing (NSM) and non-NSM (NNSM) and were at least 18 months postreconstruction were included. Breast measurements were taken in 4 quadrants (upper/lower lateral, upper/lower medial) and nipple. Averaged skin cutaneous thresholds [(UL+LL+UM+LM)/4] and nipple sensation between NSM and NNSM were compared as the primary outcome measure. A generalized estimating equations model was used; univariate and multivariate variable analyses were done when appropriate. RESULTS: Forty-four patients (74 breasts) were examined (53 NNSM vs 21 NSM). The groups were further subdivided into autologous versus implant-based reconstruction. Averaged cutaneous skin thresholds for quadrants were better for the NSM, 51.8(±24.5) g/mm versus NNSM, 56.5(±25.7) g/mm, although this difference was not statistically significant. However, NSM breasts measured higher nipple or nipple area sensitivity, 44.5(±30.8) g/mm versus NNSM, 83.8(±27.4) g/mm (P < 0.001). In a multivariate regression analysis, a predictor of decreased sensation was the number of revision surgeries, especially after third revision. CONCLUSIONS: Breast sensation is decreased after reconstruction in both NSM and NNSM, but nipple sensation or nipple area is better preserved in NSM breasts. Number of revision surgeries (>3) was a predictor of decreased sensation.