Are Large Intraoperative Fill Volumes Associated With Increased Complications After Tissue Expander Placement?

Background: With the increased adoption of skin-sparing mastectomies, immediate 2-stage breast reconstruction is a common option for breast cancer patients. During the first stage of the procedure with tissue expander placement, higher intraoperative percent fill has been identified as a risk factor for complications. However, the postoperative outcomes of higher intraoperative fill volumes are not well established. The authors sought to evaluate if a higher initial intraoperative tissue expander fill volume is associated with higher complication rates in patients undergoing immediate breast reconstruction with tissue expander placement. Methods: A retrospective review of patients who underwent immediate breast reconstruction with a tissue expander placement from 2016 to 2018 was conducted. Patient demographics and perioperative data were recorded. Large intraoperative fill was defined as saline fill volume greater than 350 mL. The primary outcome evaluated was skin and nipple necrosis. Secondary outcomes were major infections, minor infections, seroma, and hematoma. Results: A total of 147 breasts in 86 patients were included. Mean intraoperative fill volume was 246.4 ± 106.6 mL. Thirty-five tissue expanders were filled with greater than 350 mL of saline intraoperatively. Patients with large intraoperative fill volume were older (mean age, 52.6 vs 47.9 years; P = .04), had a higher mean body mass index (BMI; 33.2 vs 25.9 kg/m2; P < .0001), and had larger preoperative breast anthropometrics (P < .0001). During a mean follow-up period of 20.1 months (range, 3-55 months), 9 breasts were noted to have skin/nipple necrosis. After multivariate analysis, large tissue expander fill volume was not a significant predictor of skin or nipple necrosis (P = .62). Hypertension and anticoagulant use were associated with increased skin and nipple necrosis (P = .04 and P = .03, respectively). Large fill volume was not associated with statistically significant increases in rates of other complications like major infections, minor infections, seroma, or hematoma. Conclusions: Larger fill volumes are often required and benefit patients with higher BMI or bra sizes. This also reduces the number of postoperative fills required. In this patient population, larger intraoperative tissue expander saline fill volume (greater than 350 mL) was not associated with increased postoperative complications. After careful patient selection and perfusion evaluation, larger fill volumes may be considered a safe option to improve the aesthetic outcomes in patients with high BMI.

Is Irradiated Homologous Costal Cartilage Reliable? A Meta-Analysis of Complication Rates in Rhinoplasty.

Background: Irradiated homologous costal cartilage (IHCC) may be a convenient, cost-effective and efficient alternative source of graft material in rhinoplasty; however, a systematic review and meta-analysis on this topic have not been previously performed. Objectives: We sought to summarize and pool data on complications associated with the use of IHCC grafting in rhinoplasty. Methods: A systematic review and meta-analysis was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria. We conducted PubMed, Cochrane, Embase, Web of Science database searches, and screened articles using specific inclusion and exclusion criteria. Pooled complication rates were analyzed using a random-effects model. Results: Of the 13 studies that met criteria for systematic review, 11 studies involving 1017 patients, with 1956 IHCC grafts used, were included in the meta-analysis. Mean follow-up across all studies was 47 months. Overall, the pooled complication rates were 1.14% (95% CI: 0.3%-2.0%) for resorption, 0.5% (95% CI: 0.1%-0.9%) for warping, 1.2% (95% CI: 0.3%-2.1%) for infection, 1.0% (95% CI: 0.1%-2.0%) for mobility, and 0.8% (95% CI: 0.1%-1.6%) for graft removal or replacement. No allergic reactions or systemic disease associated with IHCC use were reported in any of the studies. Conclusions: The overall complications associated with IHCC use in rhinoplasty were very low. Costal cartilage allografts are an area of renewed interest that may represent an alternative to autologous costal cartilage grafting in rhinoplasty due to their low complication rates, convenience, cost-effectiveness, and elimination of donor-site complications.

Renseignements généraux: Le cartilage costal homologue irradié peut être une source de matériel de greffe de rechange pratique, rentable et efficace dans les cas de rhinoplastie; or, une revue systématique et une méta-analyse sur le sujet n'avaient jamais été réalisées. Objectifs: Nous avons cherché à résumer et à regrouper les données sur les complications associées à la greffe recourant à un cartilage costal homologue irradié dans les cas de rhinoplastie. Méthodologie: Une revue systématique et une méta-analyse ont été réalisées à l'aide des critères PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses, Éléments de rapport préférés pour effectuer des examens systématiques et des méta-analyses). Nous avons effectué des recherches dans les bases de données PubMed, Cochrane, Embase et Web of Science, puis évalué des articles en utilisant des critères d'inclusion et d'exclusion spécifiques. Les taux de complications regroupés ont été analysés au moyen d'un modèle à effets aléatoires. Résultats: Parmi les 13 études qui répondaient aux critères de revue systématique, 11 études avaient été menées auprès de 1 017 patients et 1 956 greffes effectuées à l'aide d'un cartilage costal homologue irradié ont été incluses dans la méta-analyse. Dans l'ensemble des études, le suivi moyen était de 47 mois. Globalement, les taux de complications regroupés ont été de 1,14% (IC à 95%: 0,3%-2,0%) pour la résorption, de 0,5% (IC à 95%: 0,1%-0,9%) pour la déviation, de 1,2% (IC à 95%: 0,3%-2,1%) pour les infections, de 1,0% (IC à 95%: 0,1%-2,0%) pour la mobilité et de 0,8% (IC à 95%: 0,1%-1,6%) pour le retrait ou le remplacement du greffon. Aucune réaction allergique ou maladie systémique associée à l'utilisation du cartilage costal homologue irradié n'a été signalée dans quelque étude que ce soit. Conclusions: Dans l'ensemble, les complications associées à l'utilisation du cartilage costal homologue irradié dans les cas de rhinoplastie étaient très faibles. Les allogreffes de cartilage costal représentent un domaine d'intérêt renouvelé, qui pourrait constituer une solution de rechange à la greffe de cartilage costal autologue dans les cas de rhinoplastie, et ce, en raison de leurs faibles taux de complications, de leur caractère pratique, de leur rentabilité et de l'élimination des complications liées aux régions de prélèvement des greffons chez les donneurs.

DermACELL Acellular Dermal Matrix in Oncologic Breast Reconstruction: A Cohort Study and Systematic Review.

Acellular dermal matrices (ADMs) are commonly used in tissue expander and direct-to-implant reconstruction following mastectomy. Few studies have reported outcomes of DermACELL use or compared DermACELL with AlloDerm ADM. This study sought to compare outcomes of DermACELL and AlloDerm in oncologic breast reconstruction and to review the literature reporting outcomes of patients undergoing reconstruction using DermACELL. Methods: We conducted a retrospective cohort study to compare outcomes between DermACELL and AlloDerm ADM, and a systematic review of the literature with a meta-analysis to evaluate clinical outcomes with DermACELL. Results: Seventy-four patients (128 breasts) undergoing immediate reconstruction were evaluated retrospectively. Chi-square analysis revealed no significant difference in postoperative outcomes between the two groups. Our systematic review of the literature yielded 12 total studies reporting DermACELL use for breast reconstruction encompassing 518 patients and 608 total breasts. A pooled analysis of the published data did not reveal a significant change in the rate of explantation when either chemotherapy or radiation was used. Meta-analysis did not show a significant difference in the rate of any of the complications evaluated. Conclusion: DermACELL is safe to use with a relatively consistent complication profile as compared with AlloDerm.

The Batwing Mastopexy in Immediate Implant-Based Breast Reconstruction: An Aesthetic Enhancement for Patients with Cancer.

BACKGROUND: Historically, many patients with breast ptosis have been excluded from nipple-sparing mastectomies. By performing mastopexy at the time of immediate reconstruction, more patients with breast ptosis can be considered for nipple-sparing mastectomies. The authors review their experience of simultaneous batwing mastopexy performed at the time of immediate implant-based reconstruction. METHODS: Using retrospective chart review, the authors identified patients who underwent immediate implant-based breast reconstruction from 2015 through 2020 at a single institution. The patients were divided into two cohorts-batwing mastopexy and standard reconstruction (no mastopexy)-and compared. RESULTS: A total of 324 breast operations in 188 patients were included (80 concurrent batwing and 244 standard implant-based reconstructions). Patient characteristics were similar between the groups, except that patients in the batwing group had greater ptosis and more patients in the standard group underwent adjuvant chemotherapy. Mean follow-up was 15.9 months (range, 3.19 to 55.20 months). Complication rates were comparable in the batwing and standard groups, with no statistically significant differences in rates of hematoma (1.3 versus 3.3 percent; = 0.34), seroma (5.0 versus 8.2 percent; p = 0.34), major infection (8.8 versus 9.0 percent; p = 0.94), skin or nipple necrosis (6.3 versus 11.5 percent; p = 0.18), or explantation (11.3 versus 14.8 percent; p = 0.43). The rate of minor infections was higher in the group with concurrent batwing mastopexy (10.0 versus 3.7 percent; p = 0.03). CONCLUSIONS: The authors demonstrate that simultaneous batwing mastopexy can be performed safely at the time of immediate breast reconstruction. This technique provides comparable complication rates, improves aesthetic outcomes in patients with significant ptosis or macromastia, and allows nipple-sparing mastectomy to be an option for those who would otherwise be excluded. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Racial disparities in short-term outcomes after breast reduction surgery-A National Surgical Quality Improvement Project Analysis with 23,268 patients using Propensity Score Matching.

BACKGROUND: Evidence of widespread disparities in healthcare for racial and ethnic minorities is well documented. This study aims to evaluate differences in surgical outcomes after breast reduction surgery (BRS) according to patients' ethnicities. METHODS: The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database (2005-2018) was utilized to analyze two propensity score matched patient cohorts-White and non-White-that underwent BRS. Preoperative variables assessed included demographic data and comorbidities such as diabetes mellitus, hypertension, and obesity. Postoperative outcomes assessed were medical complications, minor and major surgical complications, as well as mortality. RESULTS: In total, 23268 patients underwent BRS and met the inclusion criteria. After propensity score matching, the two cohorts were matched with respect to these preoperative variables, and 7187 patients were included in each cohort of White and non-White patients (total 14374). After matching, overall 30-day major complications were not significantly different between White and non-White cohort (2.25% vs 2.14%, p=0.65). After accounting for differences in confounding variables at the patient and socioeconomic level, racial and ethnic minorities who underwent breast reduction were found to experience fewer minor surgical complications. The analysis of temporal trends identified an overall rise in the number of patients seeking BRS, with a higher increase noted in the non-White population. CONCLUSION: Overall, our findings are reassuring exemptions to prevalent racial and ethnic health inequalities and can serve as a positive example for adequate and fair provision of surgical care.

Compliance With Surgical Oncology Specialty Care at a Safety Net Facility.

BACKGROUND: Social determinants of health challenge in at-risk patients seen in safety net facilities. STUDY DESIGN: We performed a retrospective review of surgical oncology specialty clinic referrals at a safety net institution evaluating referral compliance and times to first appointment and initiation of definitive treatment. Main outcomes measured included completion of initial visit, initiation of definitive treatment, time from referral to first appointment, and time from first appointment to initiation of definitive treatment. RESULTS: Of 189 new referrals, English was not spoken by 52.4% and 69.4% were Hispanic. Patients presented without insurance in 39.2% of cases. Electronic patient portal was accessed by 31.6% of patients. Of all new referrals, 55.0% arrived for initial consultation and 53.4% initiated definitive treatment. Malignant diagnosis (P < .0001) and lack of insurance (P = .01) were associated with completing initial consultation. Initiation of definitive treatment was associated with not speaking English (P = .03), malignant diagnosis (P < .0001), and lack of insurance (P = .03). Times to first appointment and initiation of definitive treatment were not significantly affected by race/ethnicity, language, insurance, treatment recommended, or electronic patient portal access. CONCLUSION: Access to surgical oncology care for at-risk patients at a safety net facility is not adversely affected by lack of insurance, primary spoken language, or race/ethnicity. However, a significant proportion of all patients fail to complete the initial consultation and definitive treatment. Lessons learned from safety net facilities may help to inform disparities in health care found elsewhere.

Financial Decisions and Reopening a Practice During the COVID-19 Pandemic: A Survey of California Plastic Surgeons.

BACKGROUND: On March 11, 2020, the World Health Organization declared COVID-19 as a global pandemic. As a response, the United States shut down public gatherings and businesses in an effort to quarantine. This included the stopping of elective operations, which greatly affected plastic surgeons and their practices during the initial shutdown. OBJECTIVES: We aim to study the early impact of COVID-19 on the financial implications and practice patterns of plastic surgeons in the state of California during the initial shutdown of elective surgery and provide guidelines for effective management during future crises. METHODS: A 20-question survey was sent using Qualtrics XM software to 851 surgeon members of the California Society of Plastic Surgeons. The survey was open from May 13, 2020, to May 29, 2020. Standard statistical analysis was completed to compare private practice and nonprivate practice plastic surgeons. RESULTS: We had a total of 140 respondents to our survey for a 16.5% response rate. The majority (77.1%) of the respondents were in a private practice setting. Private practice plastic surgeons reported a higher financial impact with a 79% reduction in financial income compared with nonprivate practice plastic surgeons at a 37% reduction (P < 0.0001). Additionally, private practice plastic surgeons demonstrated a higher reduction in case volume and were more likely to lay off or furlough staff, close their practice, and apply for loans (P < 0.001). CONCLUSIONS: Our survey study showed that private practice plastic surgeons in the state of California faced the most financial hardship during the early shutdown of the COVID-19 pandemic. It serves as a valuable snapshot in our economic history and depicts the heavy financial impact of the stopping of elective surgery. Since the reopening of practices, new guidelines have been implemented to maintain safe elective surgery while the pandemic continues. Further follow-up studies on both the state and national level need to be completed to see the continued financial effects on private and nonprivate plastic surgery practices since the reopening and resumption of elective surgery.

Combined (endo-)vascular intervention and microsurgical lower extremity free flap reconstruction-A propensity score matching analysis in 5386 ACS-NSQIP patients.

BACKGROUND: Compromised lower limb perfusion due to vascular changes such as peripheral artery disease impedes wound healing and may lead to large-scale tissue defects and lower limb amputation. In such patients with defects and compromised or lacking recipient vessels, combined vascular reconstruction with free flap transfer is an option for lower extremity salvage. METHODS: By using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database (2005-2018), we analyzed two patient cohorts undergoing (A) free flap lower limb reconstruction (LXTR) only and (B) combined (endo-)vascular reconstruction (vascLXTR). The preoperative variables assessed included demographic data and comorbidities, including smoking, diabetes mellitus, preoperative steroid use, and American Society of Anesthesiology (ASA) Physical Status Classification. Using a neighbor matching algorithm, we performed a 1:1 propensity score matching of 615 LXTR patients and 615 vascLXTR patients. Bivariate analysis for postoperative surgical and medical complications was performed for outcomes in the propensity-matched cohort. RESULTS: We identified 5386 patients who underwent microsurgical free flap reconstruction of the lower extremity. A total of 632 patients underwent a combined (endo-)vascular intervention and lower extremity free flap reconstruction. Diabetes and smoking were more prevalent in this group, with 206 patients having diabetes (32.6%) and 311 being smokers (49.2%). More patients returned to the operating room in the cohort that underwent a combined vascular intervention (24.4% versus 9.9%; p<0.0001). The 30-day mortality for patients undergoing a combined vascular procedure was 3.5%, compared with 1.3% with free tissue transfer only (p<0.0001). CONCLUSION: Despite the risks associated, the combined intervention decreases the very high mortality associated with limb amputation in severely sick patient populations. Careful preoperative assessment of modifiable risk factors may reduce complication rates while allowing limb salvage.

Impact of Robotic Surgery on Residency Training for Herniorrhaphy and Cholecystectomy.

Robotic surgery has increased for common general surgery procedures. This study evaluates how robotic use affects the case distributions of herniorrhaphy and cholecystectomy for general surgery residents according to postgraduate year (PGY). We reviewed Accreditation Council for Graduate Medical Education (ACGME) biliary or hernia cases logged by surgical residents in the academic year 2017-2018. Operative reports were reviewed to compare approaches (robotic, laparoscopic, and open) by resident role and PGY level. Open cholecystectomies were excluded. Overall, 470 hernia and 657 cholecystectomy cases were logged. Hernia repairs were performed robotically in 15.9%, laparoscopically in 9.5%, and open in 74.7%. Cholecystectomies were performed robotically in 16.4% and laparoscopically in 83.6%. Residents were teaching assistants in 1.8% of hernia repairs and 1.5% of cholecystectomies. Distribution of cases by technique and PGY level was significantly different for both procedures, with chief residents performing the majority of robotic cholecystectomies (52.6%, P < .0001) and hernia repairs (59.7%, P < .0001). Migration of robotic cases to senior resident level and low percentage of teaching assistant roles held by residents suggest exposure to common operations may be delayed during general surgery residency training. Introduction of new technology in surgical training should be carefully reviewed and may benefit from a structured curriculum.

Do Better Operative Reports Equal Better Surgery? A Comparative Evaluation of Compliance With Operative Standards for Cancer Surgery.

To improve the quality of cancer operations, the American College of Surgeons published Operative Standards for Cancer Surgery, which has been incorporated into Commission on Cancer (CoC) accreditation requirements. We sought to determine if compliance with operative standards was associated with technical surgical outcomes. Oncologic operative reports from 2017 at a CoC and non-CoC institution were examined for documentation of Operative Standards essential steps. Lymph node (LN) yield for lung and colon cases and re-excision rates for breast cases were recorded. Correct documentation was poor for colon, breast, and lung cases with numerous elements documented in <10% of operative reports at both centers. For lung cases, there was no significant difference in meeting ≥10 LN benchmark or average LN yield between the 2 institutions. For colon cases, average lymph node yield was lower in the non-CoC facility, but there was no significant difference in meeting ≥12 LN benchmark. For breast cases, re-excision rates were similar in both programs. Many essential steps in Operative Standards were poorly documented in operative reports, regardless of CoC status. Achieving benchmark technical surgical outcomes was not associated with documented compliance with these standards. Whether improved documentation leads to better surgical outcomes requires further investigation.

Long-Term Outcomes of Ventral Hernia Repair: An 11-Year Follow-Up.

BACKGROUND: Ventral hernia repair (VHR) is one of the most common general surgery procedures; however, few studies with long-term follow-up of VHR outcomes exist. METHODS: We performed a retrospective review of VHRs performed from 2000 to 2009 at a single institution. Our primary outcome was recurrence, and secondary outcomes were reoperations and complications including seroma, hematomas, abdominal wall abscess, wound infections, and mesh infections. RESULTS: Our sample population (n=420; mean age 46.3±11.7 years) included 230 females (54.8%), and cases included laparoscopic (n=31; 7.5%), laparoscopic converted to open (n=7; 1.7%), and open (n=373, 90%). As compared to suture repairs, mesh repair was associated with lower rates of complications (25.7% vs 29.5%, p=0.10) and recurrence (12.8% vs 15.2%, p=0.67). Laparoscopic repairs had lower rates of complications than open repairs (25% vs 26.8%; p=0.70) but similar rates of recurrence (13.8% and 13.6%; p=0.53). After logistic regression, obesity, chronic obstructive pulmonary disease, component separation technique, and prolonged operating time (>75th percentile) were associated with increased complications. CONCLUSION: Obesity is a modifiable risk factor and must be addressed in patients undergoing VHRs. Mesh repair does not increase the risk of adverse long-term outcomes and may be performed safely in patients undergoing VHR.

Has Breast Surgery Shattered the Glass Ceiling? Trends in Female Representation at The American Society of Breast Surgeons Annual Meeting 2009-2019.

BACKGROUND: Our study sought to evaluate gender representation and the impact of gender on the large volume of research presented at The American Society of Breast Surgeons (ASBrS) Annual Meeting, the largest breast surgery meeting in the United States. METHODS: Publicly available ASBrS meeting programs and proceedings from 2009 to 2019 were reviewed to ascertain proportions of female engagement in society positions, contributions to scientific sessions, and subsequent manuscript publications. Trend analyses for temporal changes in gender representation and univariate tests of associations between authorship gender and publication success were performed. RESULTS: Women comprised 44.8% of members of the board of directors, 41.7% of committee chairs, and 54.8% of committee members. There were significant annual increased proportions of female committee members (3.2% per year, p = 0.01) and chairs (6.0% per year, p = 0.03). Women represented > 50% of all speakership positions, except keynote (42.2%). For oral, quickshot, and poster scientific presentations, > 70% of first authors and > 60% of senior authors were women. The meeting-related publication rate with female senior authorship was higher than that with male senior authorship (41.0% vs. 36.3%, p = 0.04). CONCLUSIONS: Although female surgeons remain a minority at most conferences, women have represented the majority of participants in committees, speakership, and scientific presentations at the ASBrS Annual Meeting over the past 10 years. The glass ceiling in breast surgery has been shattered, but efforts to improve gender equity must continue, not only in breast surgery, but all surgical specialties.