An Evaluation of Early Complications after Prepectoral Tissue Expander Placement in First-Stage Breast Reconstruction with and without Acellular Dermal Matrix.

PURPOSE: Prepectoral breast reconstruction has become popularized with the concurrent use of acellular dermal matrix (ADM). We sought to compare three-month postoperative complication rates and explantation rates for first stage, tissue expander based prepectoral breast reconstruction with and without the use of ADM. METHODS: A single institution retrospective chart review was performed to identify consecutive patients undergoing prepectoral tissue-expander based breast reconstruction from August 2020 to January 2022. Chi-squared tests were used to compare demographic categorical variables and multiple variable regression models were used to identify variables associated with three-month postoperative outcomes. RESULTS: We enrolled 124 consecutive patients. Fifty-five patients (98 breasts) were included in the no-ADM cohort and 69 patients (98 breasts) were included in the ADM cohort. There were no statistically significant differences between ADM and no-ADM cohort in regard to 90-day postoperative outcomes. On multivariable analysis, there were no independent associations between seroma, hematoma, wound dehiscence, mastectomy skin flap necrosis, infection, unplanned return to the OR, or explanation in the ADM or no ADM groups after controlling for age, BMI, history of diabetes, tobacco use, neoadjuvant chemotherapy, and postoperative radiotherapy. CONCLUSION: Our results reveal no significant differences in odds of postoperative complications, unplanned return to the OR, or explantation between ADM and no-ADM cohorts. More studies are needed to evaluate the safety of prepectoral, tissue expander placement without ADM.

Scheduled Postoperative Ketorolac Does Not Decrease Opiate Use following Free Flap Breast Reconstruction.

BACKGROUND: In the setting of the opioid crisis, managing postoperative pain without the exclusive use of opiates has become a topic of interest. Many hospitals have begun implementing enhanced recovery after surgery protocols to decrease postoperative complications, hospital costs, and opiate utilization. Ketorolac has been added to many of these protocols, but few studies have examined its effects independently. METHODS: A retrospective chart review was performed on all patients that received autologous breast reconstruction from October 2020 to June 2022 at an academic institution. We identified patients who did and did not receive postoperative ketorolac. Use of ketorolac was based upon surgeon preference. The two groups were compared in basic demographics, reconstruction characteristics, length of stay, complications, reoperations, and morphine milligram equivalents (MMEs). RESULTS: One-hundred ten patients were included for the analysis, with 55 receiving scheduled postoperative ketorolac and 55 who did not receive ketorolac. There were seven incidences of postoperative complications in each group (12.7%, p = 1.00). The total mean postoperative MMEs were 344.7 for the nonketorolac group and 336.5 for the ketorolac group (p = 0.81). No variable was found to be independently associated with postoperative opiate use. Ketorolac was not found to contribute significantly to any postoperative complication. CONCLUSION: In this study, the use of ketorolac did not significantly reduce opiate use in a cohort of 110 patients. Surgeons should consider whether the use of ketorolac alone is the best option to reduce postoperative opiate use following free flap breast reconstruction.

Landmark Plastic Surgeon Advocacy within the Federal Government: Four Case Studies.

BACKGROUND: Throughout history, plastic surgeons have advocated for the protection of the specialty and for better care for their patients. Whether through efforts to support and move legislation through Congress or through preventative advocacy in the form of lobbying against legislation, plastic surgeons have often used their expertise in the political sphere to shape patient care. We hope to inspire current and future plastic surgeons to be politically active and to devise ways in which their expertise can be used within the legislative system to better care for their patients. METHODS: This article highlights four historical examples of plastic surgeon-led advocacy within the federal government: the U.S. Flammable Fabrics Act; the American Society of Plastic and Reconstructive Surgeons and the Federal Trade Commission, 1979; the Women's Health and Cancer Rights Act; and the Breast Cancer Patient Education Act. RESULTS: We hope that plastic surgeons will-like Dr. Crikelair, Dr. Wider, and the members of American Society of Plastic Surgeons/American Society of Plastic and Reconstructive Surgeons-continue to play an active role in the shaping of the legislative system for our profession and, ultimately, our patients. CONCLUSIONS: To ensure the best care for their patients, plastic surgeons must continue to maintain their relationship with public health and legal professionals and legislators. Through relationships with patients and a firm understanding of their stories, plastic surgeons can have great impacts in all local, state, and national political spheres.

Analysis of Readmissions and Reoperations in Pediatric Microvascular Reconstruction.

BACKGROUND: Free tissue transfer is utilized as a reconstructive option for various anatomic defects. While it has long been performed in adults, reconstructive surgeons have used free tissue transfer to a lesser degree in children. As such, there are few analyses of factors associated with complications in free tissue transfer within this population. The aim of this study is to assess factors associated with readmission and reoperation in pediatric free flap patients utilizing the pediatric National Surgical Quality Improvement Program database. METHODS: Pediatric patients who underwent microvascular reconstruction between 2015 and 2020 were included. Patients were identified by five microvascular reconstruction Current Procedural Terminology codes and were then stratified by flap site (head and neck, extremities, trunk) and defect etiology (congenital, trauma, infection, neoplasm). Multivariate logistic regression was performed to identify factors associated with readmissions and reoperations. RESULTS: The study cohort consisted of 258 patients. The average age was 10.0 ± 4.7 years and the majority of patients were male (n = 149, 57.8%), were of white race (n = 164, 63.6%), and had a normal body mass index. Twenty-two patients (8.5%) experienced an unplanned readmission within 30 days of the initial operation, most commonly for wound disruption (31.8% of readmissions). The overall rate of unplanned reoperation within 30 days was 11.6% (n = 30) for all patients, with an average of 8.9 ± 7.5 days to reoperation. On multivariate regression analysis, each hour increase in operative time was associated with an increased odds of reoperation (odds ratio [OR]: 1.27; 95% confidence interval [CI]: 1.12, 1.45) and readmission (OR: 1.16; 95% CI: 1.02, 1.34). CONCLUSION: In pediatric patients undergoing free tissue transfer, higher readmission and reoperation risk was associated with longer operative duration. Overall, free tissue transfer is safe in the pediatric population with relatively low rates of readmission and reoperation.

The BREASTrial Stage III: Acellular Dermal Matrix Breast Reconstruction Outcomes from 3 Months to 2 Years Postoperatively.

BACKGROUND: The Breast Reconstruction Evaluation of Acellular Dermal Matrix as a Sling Trial (BREASTrial) is a blinded, randomized trial comparing the outcomes of tissue expander breast reconstruction using AlloDerm or DermaMatrix. In this final stage of the trial, outcomes 3 months to 2 years after definitive reconstruction are reported along with patient satisfaction data. METHODS: A randomized trial was conducted to compare complication rates between groups of patients who underwent reconstruction with AlloDerm and DermaMatrix. Regression models were used to analyze the impact of matrix type, age, chemotherapy, radiation therapy, and reconstructive type on complication rates. Premastectomy and postmastectomy questionnaires were used to assess patient satisfaction and were also analyzed using regression models. RESULTS: Of the 128 patients (199 breasts) who were randomized in the trial, 108 patients (167 breasts) were available for analysis in stage III. There was no difference in the overall complication rates between the AlloDerm and DermaMatrix groups (6% versus 13.2%; P = 0.3) or the severity of those complications ( P = 0.7). Obesity was a positive predictor for complications, regardless of reconstruction group ( P = 0.02). Patient satisfaction was positive overall and did not grossly vary between AlloDerm and DermaMatrix groups. CONCLUSIONS: Findings from the BREASTrial conclude that AlloDerm and DermaMatrix exhibit similar histologic and clinical outcomes. Patient satisfaction is also similar between matrices. Obesity is a predictor of complications, and acellular dermal matrices should be used with caution in these patients. As the largest head-to-head trial comparing two acellular dermal matrices, the BREASTrial contributes to the fund of knowledge regarding acellular dermal matrix supplementation in breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Multidisciplinary Presurgical Education: Clinical Impact on Children With Orofacial Clefts Undergoing Maxillary Distraction via Rigid External Distraction.

OBJECTIVE: Treatment of severe maxillary hypoplasia is commonly addressed via distraction osteogenesis with a rigid external device (RED). While effective, this method can be socially stigmatizing in an already vulnerable patient population. To prepare children and their caregivers for life with a RED and decrease peri-operative anxiety, we instituted a multidisciplinary pre-surgical education session (MPES). This educational team involves our cleft care coordinator, child life specialist, orthodontist and plastic surgeon 2 weeks prior to surgery. We reviewed the impact of this intervention by examining clinical outcomes before and after its implementation. DESIGN: From February 2017 to February 2020, a retrospective chart review was performed to include patients with orofacial clefts and maxillary hypoplasia who underwent maxillary distraction osteogenesis with RED at our center before (28 patients) and after (29 patients) the implementation of MPES. RESULTS: MPES was associated with a significantly shorter length of stay compared to controls who did not receive MPES (3.6 vs 3.1 days, p < 0.03) and significantly decreased usage of inpatient narcotic pain medication compared to controls (16.8 morphine equivalents vs 31.8 morphine equivalents, p < 0.02). Our intervention also demonstrated a trend towards decrease in minor complications but did not achieve statistical significance p = 0.32). CONCLUSIONS: Multidisciplinary presurgical education is a beneficial adjunct in the care of patients with orofacial clefts and maxillary hypoplasia undergoing maxillary advancement with a RED.

An Evaluation of Racial Disparities in Online Marketing of Academic Plastic Surgery Practices.

BACKGROUND: Racial disparities in plastic surgery limit health care accessibility and quality. The aim of this study is to determine if racial disparities exist within patient-targeted advertising materials on academic plastic surgery practice (APSP) Web sites and if disparities are more pronounced in specific categories within plastic surgery. METHODS: Throughout May 2021, 3 independent reviewers analyzed the Web sites for APSPs and identified all photos, videos, and graphics with visible skin. For each image, the Fitzpatrick skin tone scale was used to classify the skin tone as "White" (I-III) or "non-White" (IV-VI). The images were further categorized based on the type of procedure depicted. Comparisons were made to publish US census data using χ 2 tests and linear mixed effects models. RESULTS: In total, 4615 images were analyzed from 100 APSP Web sites. Seven hundred eighty (16.9%) portrayed non-White skin tone, which was significantly less than expected based on US census data (23.7% non-White race) ( P < 0.001). Online representation had the starkest disparity in hand surgery (8.65% non-White) and adult craniofacial (9.74% non-White). The only categories that showed no significant difference between representation and demographics included implant-based breast reconstruction ( P = 0.32) and pediatric craniofacial ( P = 0.93). Overall, the marketing materials demonstrated significantly lower representation of non-White skin compared with the census demographics by an absolute difference of -4.71% ( P < 0.001). CONCLUSIONS: Non-White patients are significantly underrepresented in advertising materials published by APSPs, indicating systemic racial biases. Patient-targeted advertising can be improved to promote equality in representation for patients seeking plastic and reconstructive surgery.

A Nationwide Analysis Evaluating the Safety of Using Acellular Dermal Matrix with Tissue Expander-Based Breast Reconstruction.

Background In March 2021, the United States Food and Drug Administration (FDA) safety communication cautioned against the use of acellular dermal matrix (ADM) products in breast reconstruction and reiterated that the FDA does not approve ADM use in breast surgery. This study aims to assess the safety of ADM use in breast reconstruction. Methods Women who underwent ADM and non-ADM assisted tissue expander (TE)-based breast reconstruction were identified using the National Surgical Quality Improvement Program database (2012-2019). Trends of ADM use over time, and 30-day outcomes of surgical site infection (SSI), dehiscence, and unplanned reoperation were assessed. Results Of the 49,049 TE-based breast reconstructive cases, 42.4% were ADM assisted and 57.6% non-ADM assisted. From 2012 to 2019, the use of ADM increased from 26.1 to 55.6% (relative risk [RR] =1.10; p < 0.01). Higher rates of SSI (3.9 vs. 3.4%; p = 0.003) and reoperation (7.4 vs. 6.0%; p < 0.001) were seen in the ADM cohort. There was no significant difference seen in dehiscence rates (0.7 vs. 0.7%; p = 0.73). The most common reoperation within 30 days for the ADM group (17.6%) was removal of TE without insertion of implant (current procedural terminology: 11,971). ADM-assisted breast reconstruction was associated with increased relative risk of SSI by 10% (RR = 1.10, confidence interval [CI]: 1.01-1.21; p = 0.03) and reoperation by 15% (RR = 1.15, CI: 1.08-1.23; p < 0.001). Conclusions ADM-assisted breast reconstruction more than doubled from 2012 to 2019. There are statistically higher complication rates of SSI (0.5%) and reoperation (1.4%) with ADM use in TE-based breast reconstruction, suggesting that reconstruction without ADM is safe when comparing immediate postoperative outcomes.

Comparison of Human, Porcine, and Bovine Acellular Dermal Matrix in Prepectoral Breast Reconstruction: A Scoping Review.

OBJECTIVE: The aim of the study is to determine rates of overall complications and failure of prepectoral breast reconstruction between various types of acellular dermal matrices (ADMs). BACKGROUND: Implant-based breast reconstruction is the most common reconstructive technique after mastectomy in the United States. Traditionally, the reconstruction has been performed in the subpectoral plane; however, there has been an emerging interest in prepectoral reconstruction using ADM. Human (hADM), porcine (pADM), and bovine (bADM) ADMs are available for use, but little is known about the benefits and complication profiles of each for prepectoral breast reconstruction. METHODS: Studies examining complications after the use of ADM for prepectoral breast reconstruction were identified using MEDLINE, Embase, the Cochrane Library, LILACS, and the Web of Science from January 2010 to August 2021. Titles and abstracts of 1838 studies were screened, followed by full-text screening of 355 articles. Thirty-three studies were found to meet inclusion criteria. RESULTS: From the 33 studies, 6046 prepectoral reconstructions were examined. Implant loss was comparable across the different types of ADM (pADM, 4.0%; hADM, 4.0%; bADM, 3.7%). Bovine ADM had the highest rate of capsular contracture (6.1%), infection (9.0%), skin flap necrosis (8.3%), dehiscence (5.4%), and hematoma (6.1%) when compared with both hADM and pADM. Human ADM had the highest rate of postoperative seroma (5.3%), followed by pADM (4.6%) and bADM (4.5%). CONCLUSIONS: Among the prepectoral breast reconstruction studies using hADM, pADM, or bADM included in our analysis, complication profiles were similar. Bovine ADM had the highest proportion of breast complications in the following categories: capsular contracture, infection rate, skin flap necrosis, dehiscence, and hematoma. Implant loss was comparable across the cohorts. Overall, prepectoral breast reconstruction using ADM leads to relatively low complication rates with the highest rates within the bADM cohort.

Characterizing the volume of surgery and post-operative complications during the COVID-19 pandemic.

PURPOSE: The COVID-19 pandemic led to unprecedented changes in volume and quality of surgery. Utilizing the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database, the current study assesses the impact of COVID-19 on surgical volume during each quarter of 2020 in comparison to 2019. Quality of surgical care during 2020 was also investigated by assessing postoperative complications, readmissions, and reoperations during 2020 in comparison to the previous 5 years. MATERIALS AND METHODS: The NSQIP database was queried from 2015 to 2020. Descriptive statistics and a chi-squared test were utilized to compare demographic variables. A seasonal autoregressive integrated moving average time-series model was fit to assess the trend and seasonality of complications from 2015 to 2019 and was used to forecast the proportion of complications in the year 2020 and compared the forecast with the actual proportions graphically. RESULTS: There were fewer patients operated on in 2020 compared to 2019, with the most dramatic drop in Q2 with a nearly 27% decrease. Patients with ASA class 3 or greater were operated on at a greater proportion in every quarter of 2020. Q2 of 2020 represented the highest proportion of any operative complications since 2015 at ~13%. Q4 of 2020 demonstrated a return to 2020 Q1 complication proportions. CONCLUSION: Surgical volume was heavily affected in 2020, particularly in Q2. Patients during Q2 of 2020 were generally of a higher ASA class and had increased operative complications. Operative volume and overall surgical complication rate normalized over the next two quarters.

Smartphone Use for Patient Photography by Plastic Surgery Trainees.

Medical photography has become essential to patient care, trainee education, and research in highly visual specialties such as plastic surgery. As smartphone technology advances, plastic surgeons and trainees are using their personal smartphones to take medical photographs prompting ethical and legal concerns about patient consent and privacy. This study aims to determine the prevalence of personal smartphone use for patient photography among plastic surgery trainees, evaluate encryption practices, and establish understanding of current guidelines. Through a survey of 71 plastic surgery trainees throughout the United States, we show that 99% use their personal cell phone to take medical photographs while only 65% use HIPAA-compliant photo storage applications, and only 49% are aware of standard guidelines. This highlights that personal smartphone use among plastic surgery trainees is ubiquitous and there is a need for additional education and access to HIPAA-compliant photo storage applications.

Free Vascularized Fibula Salvage of Failed CPH in Pediatric Sarcoma Patients.

Background: Due to extended life expectancy and recent improvements in surgical techniques, limb salvage has replaced amputation as the gold standard and is now performed in 90-95% of upper extremity malignancies. However, many of these salvage procedures are associated with significant postsurgical complications. In particular, the clavicula pro humero (CPH) procedure is associated with high rates of nonunion. We present our experience with upper extremity salvage using the free vascularized fibular flap (VFF) after failure or nonunion of the original CPH procedure in the pediatric population. Methods: Five patients under the age of 18 diagnosed with upper extremity sarcoma who underwent tumor resection with immediate CPH reconstruction complicated with nonunion, and subsequent revision with free VFF were included. Data on patient demographics, oncologic characteristics, surgical procedures, intraoperative details, postoperative complications, and time to graft union were recorded. Results: Five patients (average age = 8.4 years; range = 5-10 years at surgery date) underwent secondary limb salvage procedure with free VFF reconstruction following failed CPH reconstruction for proximal humeral osteosarcoma (n = 4) or Ewing sarcoma (n = 1). The mean follow-up was 3.7 years. Complications occurred in five patients (100%), with three patients requiring reoperation (60%). Four patients achieved graft union (average union time = 3.7 months) and successful limb reconstruction. Four patients were alive with no local recurrence of the disease. One patient did not achieve union and was lost to follow-up. Conclusion: Primary bone tumors in the pediatric population require wide surgical resection, and reconstruction often has high complication rates that can warrant further procedures. A free VFF is a viable option for upper extremity salvage after previously failed reconstructions because it provides vascularized tissue to a scarred tissue bed and allows for the replacement or augmentation of large bony defects.

Transverse Rectus Abdominis Muscle Flow-Through to Free Fibula Flap for Lumbar Spinal Reconstruction in a Pediatric Patient: A Case Report.

CASE: A 7-week-old girl presented with a recurrent primitive myxoid mesenchymal tumor of infancy requiring extensive resection of lower back musculature, L3-S2 vertebral bodies, and left L5 nerve root. Reconstruction consisted of transverse rectus abdominis muscle (TRAM) flow-through to free fibular flap to reconstruct the bony defect and fill the soft-tissue void. One-year postoperative imaging revealed a well-incorporated fibula graft. At the 30-month follow-up, the patient can bear weight on the autograft while sitting upright, allowing for efficient ambulation with a wheelchair. CONCLUSION: TRAM flow-through to free fibular flap is an efficacious reconstructive method for a multilevel vertebral spinal defect in a pediatric patient.

Severe Cherubism Treated with Curettage, Osteotomy, and Bony Repositioning: A Case Series of Three Patients.

Cherubism is a rare, autosomal dominant condition characterized by the replacement of medullary bone by fibro-osseous lesions, predominantly in the bilateral maxillae and/or mandibles. The clinical presentation of cherubism can vary widely, from clinically undetectable to severe facial disfigurement. Although there are no established management guidelines for this condition, conservative management with observation is typically favored in most cases due to the possibility of spontaneous regression following puberty. In this article, we present three cases of moderate to severe cherubism managed with early surgical intervention utilizing curettage and osteotomy followed by bony repositioning. We aimed to show the feasibility and safety of this minimally invasive surgical technique in the management of moderate to severe cases of cherubism to provide improvement in patient quality of life, aesthetics, and function while also possibly mitigating the need for later reconstructive surgery.

Implementation of Telehealth in a Pediatric Plastic Surgery Clinic: A Single Center's Response to COVID-19.

BACKGROUND: With limitation of in-person clinical visits due to the COVID-19 pandemic, telehealth has emerged as an important platform to deliver healthcare. Satisfaction with telehealth has been examined previously in the adult plastic surgery population. However, studies examining its use and satisfaction in the pediatric plastic surgery population are limited. In this study, we explore patient/caregiver satisfaction with the rapid institution of telehealth in our pediatric plastic surgery clinic and factors affecting satisfaction scores. METHODS: From March 2020 to February 2021, families of pediatric patients seen via video telehealth in the pediatric plastic surgery clinic at our center were invited to participate in a posttelehealth session survey. Telehealth visits encompassed both preliminary consultations as well as follow-up visits. After appropriate consent was obtained, patients' families completed a posttelehealth survey conveying demographics and satisfaction with telehealth via a 5-point Likert scale. RESULTS: Seventy eight of 131 eligible families elected to participate. Visit types included the following: initial consultations (23.1%), preoperative visits (10.3%), postoperative visits (29.5%), and follow-up visits (37.1%). A total of 80.3% of the respondents were overall satisfied with their telehealth experience. A total of 85.3% of the respondents agreed that telehealth made it easier for them to see their doctor, and 96.7% of the respondents felt using telehealth saved them time in traveling to the clinic. A total of 89.5% of the respondents felt it important for the state of Utah to have a telehealth program available to pediatric patients. CONCLUSIONS: Video telehealth is a useful adjunct in the care of pediatric plastic surgery patients with high caregiver satisfaction.

Simultaneous Closure of the Cleft Alveolus and Hard Palate with Concomitant Bone Grafting.

Cleft repair has been in constant evolution since its inception. Conventional repair of the cleft hard palate involves closure of nasal and oral mucosa without bony reconstitution. In many instances, this approach is adequate, but, particularly in complete clefts, the lack of bony support can lead to collapse of the maxillary arch, dental crowding, and posterior cross-bite. To address these shortcomings, our institution performs a two-staged palatoplasty with concomitant bone grafting of the alveolus and hard palate in the second stage. A retrospective review of children who underwent a two-staged palatoplasty at our institution was performed. These patients' records and images were reviewed for complications and changes in maxillary morphology. Fourteen patients with complete clefts had a two-staged palatoplasty with bone grafting in the second stage. The mean age at surgery was 37.5 months, and the mean follow-up was 16 months. One patient had resorption of the alveolar bone graft requiring additional bone grafting. The remaining patients were without complications and had good consolidation of the bone graft on follow-up imaging. Our early results support that there is a low complication rate (7% regrafting) in those patients who underwent bone grafting at the time of cleft palate repair with early evidence of bony consolidation on imaging and clinical examination. Wide exposure during the repair allows complete grafting of the maxillary bony deficit, which is not possible with traditional alveolar cleft repair and may alleviate the shortcoming of soft-tissue closure only. Future study is necessary to determine long-term outcomes.

Elective surgery resource utilization.

PURPOSE: Cessation of elective surgery during COVID-19 was partly driven by concern for consumption of hospital resources required by critically ill patients. We aim to determine the extent of resource utilization by elective outpatient surgery to assist in ensuring future resource conservation decisions are data driven. METHODS: The study utilized a retrospective cohort gathered from the American College of Surgeons National Surgical Quality Improvement Program database. Participants were adult patients who underwent elective or non-elective surgery between 2017 and 2018. Outcomes included patient characteristics and post-operative outcomes for elective and non-elective surgeries. Post-operative outcomes were used as a surrogate for the consumption of hospital resources. RESULTS: A total of 1,558,938 (79.8%) elective and 393,339 (20.2%) non-elective surgeries were identified. Elective surgery patients were more likely to be outpatient status, have an ASA class < 3, and exhibited lower rates of prolonged ventilation, 30-day reoperation, and 30-day readmissions, and averaged 5 days less of inpatient stay. Elective outpatient surgery (vs. elective inpatient surgery) averaged shorter operative times and exhibited lower rates of readmissions (2.1% vs. 5.5%; p < 0.001), reoperations (1.1% vs. 2.8%; p < 0.001), prolonged ventilation (0.0% vs. 0.3%; p < 0.001), and 30-day mortality (0.1% vs. 0.5%; p < 0.001) and accounted for 30.2% of the overall relative value units ($339,815,038). CONCLUSION: We evaluated utilization of hospital resources by patients undergoing elective outpatient surgery by identifying surgeries performed in 2017-2018 then stratifying them by outpatient status. Elective outpatient surgeries consumed negligible amounts of hospital resources and should not be considered a threat to resources in the setting of high demand by critically ill COVID-19 patients.

A Case for the Use of the 5-Item Modified Frailty Index in Preoperative Risk Assessment for Tissue Expander Placement in Breast Reconstruction.

BACKGROUND: Preoperative risk assessment is essential in determining which surgical candidates will have the most to gain from an operation. The 5-item modified frailty index (mFI-5) has been validated as an effective way to determine this risk. This study sought to evaluate the performance of the mFI-5 as a predictor of postoperative complications after tissue expander placement. METHODS: Patients who underwent placement of a tissue expander were identified using the 2012 to 2018 American College of Surgeons National Surgical Quality Improvement Project database. Univariate and multivariate regression analysis models were used to assess how mFI-5, the components of the mFI-5 (functional status, diabetes, chronic obstructive pulmonary disease, chronic heart failure, and hypertension), and other factors commonly used to risk stratify (age, body mass index [BMI], American Society of Anesthesiologists (ASA) classification, and history of smoking) were associated with complications. RESULTS: In 44,728 tissue expander placement cases, the overall complication rate was 10.5% (n = 4674). The mFI-5 score was significantly higher in the group that experienced complications (0.08 vs 0.06, P < 0.001). Compared with the mFI-5 individual components and other common variables used preoperatively to risk stratify patients, univariate analysis demonstrated that mFI-5 had the largest effect size (odds ratio [OR], 5.46; confidence interval [CI], 4.29-6.94; P < 0.001). After controlling for age, BMI, ASA classification, and history of smoking, the mFI-5 still remained the predictor of complications with the largest effect size (OR, 2.25; CI, 1.70-2.97; P < 0.001). In assessing specific complications, the mFI-5 is the independent predictor with the largest significant effect size for surgical dehiscence (OR, 12.76; CI, 5.58-28.18; P < 0.001), surgical site infection (OR, 6.68; CI, 4.53-9.78; P < 0.001), reoperation (OR, 5.23; CI, 3.90-6.99; P < 0.001), and readmission (OR, 4.59; CI, 3.25-6.45; P < 0.001) when compared with age, BMI, ASA class, and/or history of smoking alone. CONCLUSIONS: The mFI-5 can be used as an effective preoperative predictor of postoperative complications in patients undergoing tissue expander placement. Not only does it have the largest effect size compared with other historical perioperative risk factors, it is more predictive than each of its individual components.

Targeted Muscle Reinnervation in Children: A Case Report and Brief Overview of the Literature.

Absence of the proximal upper limb, whether congenital or acquired, has a profound impact on quality of life. Targeted muscle reinnervation (TMR) was originally developed to improve functional control over myoelectric prostheses; however, it has also been shown to decrease phantom limb pain and neuroma pain as well as prevent neuroma formation. In children, whose rates of prosthetic use are considerably lower than adults, the effects of amputation on limb function can be devastating. To date, there is very little literature regarding the use of TMR in children. In this case report, we review the current literature and present the case of a 9-year-old boy with a transhumeral amputation secondary to a traumatic injury who underwent acute TMR at the time of wound closure. At 22 months follow-up, the patient is doing well with minimal pain, no evidence of neuroma formation, and signs of muscle reinnervation.

A Case Report of Misdiagnosed Breast Implant-associated Anaplastic Large Cell Lymphoma with Lymphatic Extension.

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is a rare peripheral T-cell lymphoma associated with textured implants and usually presents as a late-onset periprosthetic seroma. We present a 70-year-old woman with a history of left breast invasive ductal carcinoma treated with mastectomy and textured implant-based reconstruction, and subsequent adjuvant chemotherapy due to lymphovascular extension. Eleven years following her reconstruction, the patient developed a periprosthetic seroma. Fine needle aspiration and partial capsulectomy were performed, but appropriate pathologic evaluation was not initially submitted. She then presented with lymphadenopathy, which was biopsied and revealed BIA-ALCL within an axillary lymph node. Despite implant explantation, complete capsulectomy, axillary lymph node dissection, and excision of groin lymphadenopathy, no evidence of primary ALCL was appreciated. This initially misdiagnosed case demonstrates the importance of following the National Comprehensive Cancer Network guidelines when a patient presents with late onset breast periprosthetic effusions.