Effectiveness of Liposomal Bupivacaine Transversus Abdominis Plane Block in DIEP Flap Breast Reconstruction: Randomized Controlled Trial.

BACKGROUND: Transversus Abdominis Plane (TAP) blocks improve pain control and reduce narcotic medication requirements in various surgical procedures. Liposomal bupivacaine may provide more sustained analgesia. This study compares pain related outcomes between standard bupivacaine and liposomal bupivacaine TAP blocks after autologous breast reconstruction. METHODS: Prospective single-center, single-blinded, randomized controlled trial between March 2021 and December 2022. DIEP flap breast reconstruction patients in a standardized Enhanced Recovery After Surgery (ERAS) pathway were randomized to receive intraoperative TAPs with either bupivacaine / epinephrine (control) or liposomal bupivacaine / bupivacaine / epinephrine (experimental). Primary outcome was postoperative narcotic medication requirements, with secondary outcomes of pain scores, length of stay (LOS), and narcotic medication refills. RESULTS: 117 patients met inclusion criteria (59 control, 58 experimental). Patient demographics, comorbidities, breast pathologic variables, surgery laterality and immediate versus delayed reconstruction status were equivalent between groups. Control group had significantly higher average pain scores postoperatively (4.3 vs. 3.6, p=0.004). However, there were no significant differences in mean narcotic use (66.9 MME vs 60.2 MME, p=0.47). Both LOS and postoperative narcotic prescription refills were equivalent between groups (2.1 vs 2.2 days, p = 0.55, 22% vs 17.2%, p=0.52). CONCLUSION: Addition of liposomal bupivacaine to standard bupivacaine TAP block mixture in a standardized ERAS protocol did not demonstrate a significant reduction in postoperative narcotic requirements after DIEP flap breast reconstruction compared to standard bupivacaine alone. Patient-reported pain scores, however, were lower among liposomal bupivacaine patients after the initial 24 hours postoperatively and consistent with a longer duration of analgesia.

The LIMB-Q: Reliability and Validity of a Novel Patient-Reported Outcome Measure for Lower Extremity Trauma Patients.

BACKGROUND: The LIMB-Q is a novel patient-reported outcome measure for lower extremity trauma patients. The aim of this study was to perform a psychometric validation of the LIMB-Q based on the Rasch Measurement Theory. METHODS: An international, multi-site convenience sample of patients with lower extremity traumatic injuries distal to the mid-femur were recruited via clinical sites (United States, Netherlands) and online platforms (English; Trauma Survivors Network, Prolific). A cross-sectional survey of the LIMB-Q was conducted with test-rest (TRT) measured 1-2 weeks after initial completion in a sub-group of patients. RESULTS: The LIMB-Q was field-tested in 713 patients. The mean age was 41 years (standard deviation (SD) 17, range 18-85), mean time from injury was 7 years (SD 9, range 0-58), and there were variable injury and treatment characteristics (39% fracture surgery only, 38% flap or graft, 13% amputation, 10% amputation and flap/graft). Out of 382 items tested, 164 were retained across 16 scales. Reliability was demonstrated with person separation index values 0.80 and greater in 14 scales (0.78-0.79 in remaining 2 scales), Cronbach alpha values 0.83 and greater, and intraclass correlation coefficient values 0.70 and greater. Each scale was unidimensional, measurement invariance was confirmed across clinical and demographic factors, TRT showed adequate reliability, and construct validity was demonstrated. CONCLUSIONS: The LIMB-Q is a patient reported outcome measure with 16 independently functioning scales (6-15 items per scale) developed and validated specifically for lower extremity trauma patients with fractures, reconstruction, and/or amputation.

Efficacy of Prophylactic Postoperative Antibiotics in Tissue Expander-Based Breast Reconstruction: A Propensity Score-Matched Analysis.

BACKGROUND: Conflicting evidence exists regarding the utility of prophylactic postoperative antibiotics in tissue expander (TE)-based breast reconstruction. This study evaluated the risk of surgical-site infection between patients receiving 24 hours of perioperative antibiotics alone versus prolonged postoperative antibiotics within a propensity score-matched cohort. METHODS: Patients undergoing TE-based breast reconstruction receiving 24 hours of perioperative antibiotics alone were propensity score-matched 1:3 to patients receiving postoperative antibiotics based on demographics, comorbidities, and treatment factors. Incidence of surgical-site infection was compared based on duration of antibiotic prophylaxis. RESULTS: Of a total of 431 patients undergoing TE-based breast reconstruction, postoperative antibiotics were prescribed in 77.2%. Within this cohort, 348 were included for propensity matching (no antibiotics, 87 patients; antibiotics, 261 patients). After propensity score matching, there was no significant difference in incidence of infection requiring intravenous (no antibiotics, 6.9%; antibiotics, 4.6%; P = 0.35) or oral antibiotics (no antibiotics, 11.5%; antibiotics, 16.1%; P = 0.16). In addition, rates of unplanned reoperation ( P = 0.88) and 30-day readmission ( P = 0.19) were similar. After multivariate adjustment, prescription of postoperative antibiotics was not associated with a reduction in surgical-site infection (OR, 0.5; 95% CI, -0.3 to 1.3; P = 0.23). CONCLUSIONS: Within a propensity score-matched cohort accounting for patient comorbidities and receipt of adjuvant therapies, prescription of postoperative antibiotics after TE-based breast reconstruction conferred no improvement in rates of TE infection, reoperation, or unplanned health care use. These data underscore the need for multicenter randomized trials on the utility of antibiotic prophylaxis in TE-based breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Patient Preferences for Postmastectomy Breast Reconstruction.

Importance: Up to 40% of women experience dissatisfaction after breast reconstruction due to unexpected outcomes that are poorly aligned with personal preferences. Identifying what attributes patients value when considering surgery could improve shared decision-making. Adaptive choice-based conjoint (ACBC) analysis can elicit individual-level treatment preferences. Objectives: To identify which attributes of breast reconstruction are most important to women considering surgery and to describe how these attributes differ by those who prefer flap vs implant reconstruction. Design, Setting, and Participants: This web-based, cross-sectional study was conducted from March 1, 2022, to January 31, 2023, at Duke University and between June 1 and December 31, 2022, through the Love Research Army with ACBC analysis. Participants were 105 women at Duke University with a new diagnosis of or genetic predisposition to breast cancer who were considering mastectomy with reconstruction and 301 women with a history of breast cancer or a genetic predisposition as identified through the Love Research Army registry. Main Outcomes and Measures: Relative importance scores, part-worth utility values, and maximum acceptable risks were estimated. Results: Overall, 406 women (105 from Duke University [mean (SD) age, 46.3 (10.5) years] and 301 from the Love Research Army registry [mean (SD) age, 59.2 (11.9) years]) participated. The attribute considered most important was the risk of abdominal morbidity (mean [SD] relative importance [RI], 28% [11%]), followed by chance of major complications (RI, 25% [10%]), number of additional operations (RI, 23% [12%]), appearance of the breasts (RI, 13% [12%]), and recovery time (RI, 11% [7%]). Most participants (344 [85%]) preferred implant-based reconstruction; these participants cared most about abdominal morbidity (mean [SD] RI, 30% [11%]), followed by the risk of complications (mean [SD], RI, 26% [11%]) and additional operations (mean [SD] RI, 21% [12%]). In contrast, participants who preferred flap reconstruction cared most about additional operations (mean [SD] RI, 31% [15%]), appearance of the breasts (mean [SD] RI, 27% [16%]), and risk of complications (mean [SD] RI, 18% [6%]). Factors independently associated with choosing flap reconstruction included being married (odds ratio [OR], 2.30 [95% CI, 1.04-5.08]; P = .04) and higher educational level (college education; OR, 2.43 [95% CI, 1.01-5.86]; P = .048), while having an income level of greater than $75 000 was associated with a decreased likelihood of choosing the flap profile (OR, 0.45 [95% CI, 0.21-0.97]; P = .01). Respondents who preferred flap appearance were willing to accept a mean (SD) increase of 14.9% (2.2%) chance of abdominal morbidity (n = 113) or 6.4% (4.8%) chance of complications (n = 115). Conclusions and Relevance: This study provides information on how women value different aspects of their care when making decisions for breast reconstruction. Future studies should assess how decision aids that elicit individual-level preferences can help tailor patient-physician discussions to focus preoperative counseling on factors that matter most to each patient and ultimately improve patient-centered care.

Evaluating Disparities in Pathways to Breast Reconstruction.

BACKGROUND: Rates of postmastectomy breast reconstruction have been shown to vary by racial, ethnic, and socioeconomic factors. In this study, we evaluated disparities across pathways toward breast reconstruction. METHODS: All women who underwent mastectomy for breast cancer at a single institution from 2017 to 2018 were reviewed. Rates of discussions about reconstruction with breast surgeons, plastic surgery referrals, plastic surgery consultations, and ultimate decisions to pursue reconstruction were compared by race/ethnicity. RESULTS: A total of 218 patients were included, with the racial/ethnic demographic of 56% white, 28% Black, 1% American Indian/Native Alaskan, 4% Asian, and 4% Hispanic/Latina. The overall incidence of postmastectomy breast reconstruction was 48%, which varied by race (white: 58% vs. Black: 34%; p < 0.001). Plastic surgery was discussed by the breast surgeon with 68% of patients, and referrals were made in 62% of patients. While older age (p < 0.001) and nonprivate insurance (p < 0.05) were associated with lower rates of plastic surgery discussion and referral, it did not vary by race/ethnicity. The need for an interpreter was associated with lower rates of discussion (p < 0.05). After multivariate adjustment, a lower reconstruction rate was associated with the Black race (odds ratio [OR] = 0.33; p = 0.014) and body mass index (BMI) ≥ 35 (OR = 0.14; p < 0.001). Elevated BMI did not disproportionately lower breast reconstruction rates in Black versus white women (p = 0.27). CONCLUSION: Despite statistically equivalent rates of plastic surgery discussions and referrals, black women had lower breast reconstruction rates versus white women. Lower rates of breast reconstruction in Black women likely represent an amalgamation of barriers to care; further exploration within our community is warranted to better understand the racial disparity observed.

Mapping Patient Encounters in Breast Cancer Care: An Analysis of 8800 Clinical Encounters Among Patients Undergoing Mastectomy.

BACKGROUND: Transitions toward value-based systems require a comprehensive definition of the complexity and duration of provider effort required for a given diagnosis. This study modeled the numbers of clinical encounters involved in various treatment pathways among breast cancer patients undergoing mastectomy. METHODS: Clinical encounters with medical oncologists, radiation oncologists, breast surgeons, or plastic surgeons ≤4 years after diagnosis among all patients undergoing mastectomy from 2017 to 2018 were reviewed. Relative encounter volumes were modeled each 90-day period after diagnosis. RESULTS: A total of 8807 breast cancer-related encounters from 221 patients were analyzed, with mean (SD) encounter volume 39.9 (27.2) encounters per patient. Most encounters occurred in the first year after diagnosis (70.0%), with years 2, 3, and 4 representing 15.8%, 9.1%, and 3.5% of encounters, respectively. Overall stage was associated with encounter volume, with higher encounter volume with increasing stage (stages 0: 27.4 vs I: 28.5 vs II: 48.4 vs III: 61.1 vs IV: 80.8 mean encounters). Body mass index (odds ratio [OR], 0.22), adjuvant radiation (OR, 6.8), and receipt of breast reconstruction (OR, 3.5) were also associated with higher encounter volume (all P 's < 0.01). Duration of encounter volume varied by treatment phases, with medical oncology and plastic surgery sustaining high clinical encounter volume 3 years after diagnosis. CONCLUSIONS: Encounter utilization in breast cancer care persists 3 years after index diagnosis and is influenced by overall stage and treatment characteristics, including receipt of breast reconstruction. These results may inform the design of episode durations within value-based models and institutional resource allocation for breast cancer care.

Complications, Costs, and Healthcare Resource Utilization After Staged, Delayed, and Immediate Free-Flap Breast Reconstruction: A Longitudinal, Claims-Based Analysis.

BACKGROUND: There is a lack of consensus detailing the optimal approach to free-flap breast reconstruction when considering immediate, delayed, or staged techniques. This study compared costs, complications, and healthcare resource utilization (HCRU) across staged, delayed, and immediate free-flap breast reconstruction. PATIENTS AND METHODS: Retrospective study using MarketScan databases to identify women who underwent mastectomies and free-flap reconstructions between 2014 and 2018. Complications, costs, and HCRU [readmission, reoperation, emergency department (ED) visits] occurring 90 days after mastectomy and 90 days after free flap were compared across immediate, delayed, and staged reconstruction. RESULTS: Of 3310 women identified, 69.8% underwent immediate, 11.7% underwent delayed, and 18.5% underwent staged free-flap reconstruction. Staged reconstruction was associated with the highest rate (57.8% staged, 42.3% delayed, 32.0% immediate; p < 0.001) and adjusted relative risk [67% higher than immediate (95% CI: 49-87%; p < 0.001)] of surgical complications. Staged displayed the highest HCRU (staged 47.9%, delayed, 38.4%, immediate 25.2%; p < 0.001), with 16.5%, 30.7%, and 26.5% of staged patients experiencing readmission, reoperation, or ED visit, respectively. The adjusted probability of HCRU was 206% higher (95% CI: 156-266%; p < 0.001) for staged compared with immediate. Staged had the highest mean total cost (staged $106,443, delayed $80,667, immediate $76,756; p < 0.001) with regression demonstrating the adjusted mean cost for staged is 31% higher (95% CI: 23-39%; p < 0.001) when compared with immediate. CONCLUSIONS: Staged free-flap reconstruction is associated with increased complications, costs, and HCRU, while immediate demonstrated the lowest. The potential esthetic benefits of a staged approach should be balanced with the increased risk for adverse events after surgery.

Defining the Value of Breast Reconstruction Surgeons: Quantifying Clinical Encounter and Operative Volume at an Academic Center.

Despite growing rates of postmastectomy breast reconstruction, the time contribution of breast reconstruction surgeons in comprehensive breast cancer care is often poorly accounted for by hospital and healthcare systems. This study models encounter volume and operative time utilization of breast reconstruction surgeons among patients undergoing postmastectomy breast reconstruction. Methods: All clinical encounters and operative time from a consecutive sample of breast cancer patients undergoing mastectomy and reconstruction were analyzed. Encounter volume and operative time utilization less than or equal to 4 years after diagnosis were modeled over time. Results: A total of 5057 breast cancer encounters were analyzed. Mean (SD) clinical encounter volume was 45.9 (28.5) encounters per patient, with encounter volume varying by specialty [plastic surgery: 16.5; medical oncology: 15.9; breast surgery: 7.2; radiation oncology: 6.3 mean encounters]. Receipt of adjuvant radiation, neoadjuvant chemotherapy, and major complications during reconstruction predicted higher encounter volume. Mean (SD) operative time utilization was 702 (317) minutes per patient [plastic surgery: 547 (305); breast surgery: 155 (71) minutes]. While both encounter volume and operative time for radiation oncologists and breast surgeons, respectively, were concentrated in the first year after diagnosis, medical oncologists and plastic surgeons sustained high clinical and operative time utilization 3 years after breast cancer diagnosis. Conclusions: Encounter volume and operative time utilization with breast reconstruction surgeons persist 3 years after a breast cancer diagnosis and are tied to treatment characteristics and incidence of reconstruction complications. Institutional- and system-level resource allocation must account for the complex and lengthy duration of care inherent to breast reconstruction care.

Community collaboration to improve access and outcomes in breast cancer reconstruction: protocol for a mixed-methods qualitative research study.

INTRODUCTION: Breast reconstruction plays an important role for many in restoring form and function of the breast after mastectomy. However, rates of breast reconstruction in the USA vary significantly by race, ethnicity and socioeconomic status. The lower rates of breast reconstruction in non-white women and in women of lower socioeconomic status may reflect a complex interplay between patient and physician factors and access to care. It remains unknown what community-specific barriers may be impacting receipt of breast reconstruction. METHODS AND ANALYSIS: This is a mixed-methods study combining qualitative patient interview data with quantitative practice patterns to develop an actionable plan to address disparities in breast reconstruction in the local community. The primary aims are to (1) capture barriers to breast reconstruction for patients in the local community, (2) quantitatively evaluate practice patterns at the host institution and (3) identify issues and prioritise interventions for change using community-based engagement. ETHICS AND DISSEMINATION: Ethics approval was obtained at the investigators' institution. Results from both the quantitative and qualitative portions of the study will be circulated via peer-review publication. These findings will also serve as pilot data for extramural funding to implement and evaluate these proposed solutions.

The Patient Narrative for Breast Implant Illness: A 10-Year Review of the U.S. Food and Drug Administration's MAUDE Database.

BACKGROUND: There is growing recognition of a condition known as breast implant illness. Very little information exists about the diagnosis and natural history of breast implant illness. To better understand the patient experience, we surveyed the U.S. Food and Drug Administration's Manufacturer and User Facility Device Experience (MAUDE) database for narratives describing symptoms of breast implant illness. METHODS: The MAUDE database was queried for all reports that included breast implant illness within the patient narrative between 2010 and 2020. A review of narratives was used to identify and summarize 36 symptoms over nine symptom classes. Event year and reporting year were summarized. Hierarchical clustering analysis using centroid components was conducted on all reported breast implant illness symptoms, and a dendrogram was created to visualize clustering. RESULTS: During the study period from 2010 to 2020, there were 751 captured adverse event reports in the MAUDE database that referenced breast implant illness, with the first report submission in 2014. Of those reports, 60.6 percent were for silicone implants and 39.4 percent were for saline implants. The three most commonly reported symptom categories were neurologic [ n = 544 (72.4 percent)], followed by musculoskeletal [ n = 418 (55.7 percent)], and dermatologic [ n = 273 (36.4 percent)]. The top 10 symptoms, irrespective of category, include fatigue/weakness, numbness/tingling, brain fog, depression/anxiety, arthralgia, myalgia, headache, hair loss, gastrointestinal issues, and weight change. A hierarchical clustering analysis demonstrated that symptoms reported by patients clustered into two major groups. CONCLUSION: This study demonstrates the utility of public-facing databases, such as the Manufacturer and User Facility Device Experience database, in understanding the patient experience as it relates to breast implant illness.

Resilience through practicing acceptance: A qualitative study of how patients cope with the psychosocial experiences following limb-threatening lower extremity trauma.

INTRODUCTION: Limb-threatening injuries can have a profound impact on patient lives. The impact on a patient's psychosocial well-being is widespread yet not well understood. This study aims to explore which psychosocial elements are central to patient experiences after limb-threatening lower extremity trauma. PATIENTS AND METHODS: This is a qualitative interview-based study to identify psychosocial experiences after limb-threatening lower extremity trauma in a patient-centered manner. Data were collected via semi-structured qualitative interviews and analyzed via an interpretive description approach. Interviews were performed until content saturation was reached. RESULTS: A total of 33 interviews were performed until reaching content saturation. Eleven participants underwent early amputation, 7 delayed amputation after an attempt at limb salvage, and 15 underwent limb salvage. A total of 533 unique psychosocial codes were identified, comprised of eight concepts: acceptance, body image, coping, distress, positive impact, emotional support, isolation, and intrapsychic. CONCLUSIONS: This study identified the concerns central to this patient population and developed a conceptual framework for how patients cope with these psychosocial experiences. These findings underscore the importance of developing resilience by actively practicing acceptance and reaching more positive mental health outcomes. Additionally, these findings highlight the importance of increasing access to early and routine psychological and social support for patients with severe lower extremity trauma.

Which Factors Are Important to Women When Choosing a Breast Reconstruction Surgeon?

BACKGROUND: Women undergoing breast reconstruction often research their health care provider options. The authors studied which factors may influence how a woman selects a plastic surgeon for breast reconstruction surgery. METHODS: An online survey was distributed by means of Amazon Mechanical Turk (MTurk; Amazon Web Services, Inc., Seattle, Wash.) to 1025 adult women. Participants were asked to imagine a scenario in which they had breast cancer, needed to undergo mastectomy, and were choosing a reconstructive surgeon. They were then asked to rank factors influencing this decision on a 1 to 7 Likert scale. Two-sample t tests were used to compare Likert scores between dichotomized categories based on participant characteristics. RESULTS: Women assigned the highest scores [mean (standard deviation)] to online reviews on Vitals or WebMD [6.1 (1.2)], years of experience [5.7 (1.4)], recommendations from another surgeon [5.7 (1.3)] or family/friend [4.9 (1.7)], and attending a top medical school [4.7 (1.7)]. Lowest ranked factors were online advertising and surgeon demographics, including having a sex concordant (female) surgeon. After amalgamation into attribute subsections, mean (standard deviation) rated relative importance of surgeon reputation [0.72 (0.13)] was higher than that of appearance [0.46 (0.19)] and demographics [0.31 (0.13)]. Patient demographics influenced relative importance of certain attributes; older, educated, and higher-income patients placed higher value on surgeon appearance (all p < 0.05). CONCLUSIONS: When selecting a breast reconstruction surgeon, women place the highest value on surgeons' online, educational, and personal reputations. Though most show no strong preferences for surgeon demographics or physical attributes, specific features may be important for some patients. Cognizance of these preferences may enable providers to more effectively understand patient expectations.

The Association Between Metabolic Derangement and Wound Complications in Elective Plastic Surgery.

INTRODUCTION: The incidence of metabolically unhealthy obesity is rising nationally. In this study, we compare wound and overall complications between metabolically unhealthy obese and healthy patients undergoing elective plastic surgery and model how operative time influences a complication risk. METHODS: Patients undergoing elective breast and body plastic surgery procedures in the 2009-2019 National Surgical Quality Improvement Program (NSQIP) dataset were identified. Complications were compared between metabolically unhealthy obese (body mass index [BMI] > 30 with diabetes and/or hypertension) versus metabolically healthy obese patients (BMI > 30 without diabetes or hypertension). Logistic regression was used to model the probability of wound complications across operative times stratified by metabolic status. RESULTS: Of 139,352 patients, 13.4% (n = 18,663) had metabolically unhealthy obesity and 23.8% (n = 33,135) had metabolically healthy obesity. Compared to metabolically healthy patients, metabolically unhealthy patients had higher incidence of wound complications (6.9% versus 5.6%; P < 0.001) and adverse events (12.4% versus 9.6%; P < 0.001), in addition to higher 30-d readmission, returns to the operating room, and length of stay (all P < 0.001). After adjustment, BMI (Odds ratio [OR] 7.86), hypertension (OR 1.15), and diabetes (OR 1.25) were independent risk factors for wound complications (all P < 0.001). Among metabolically unhealthy patients, the operative time was log-linear with a wound complication risk (OR 1.21; P < 0.001). CONCLUSIONS: Diabetes and hypertension are additive risk factors with obesity for wound complications in elective plastic surgery. Among patients with metabolically unhealthy obesity, a risk of wound complications increases logarithmically with operative time. This distinction with regard to metabolic state might explain the unclear impact of obesity on surgical outcomes within existing surgical literature.

Racial and Ethnic Disparities in Surgical Outcomes after Postmastectomy Breast Reconstruction.

BACKGROUND: Women of color with breast cancer are less likely to undergo post-mastectomy reconstruction compared with White women, but it is unclear whether their perioperative outcomes are worse. The goal of this study was to investigate differences in preoperative comorbidities and postoperative complications by race/ethnicity among women with breast cancer undergoing postmastectomy reconstruction. STUDY DESIGN: Data were collected from the National Inpatient Sample database of the Healthcare Cost and Utilization Project from 2012 to 2016. Patient demographics, types of reconstruction, comorbid conditions, Charlson-Deyo Combined Comorbidity (CDCC) scores, length of stay (LOS), and perioperative complications were abstracted. Multivariate linear and logistic regression were performed to model LOS and likelihood of postoperative complications, respectively. RESULTS: Compared with White women (n = 19,730), Black women (n = 3,201) underwent autologous reconstruction more frequently (40.7% vs 28.3%), had more perioperative comorbidities (eg diabetes: 12.9% vs 5.8%), higher CDCC scores (% CDCC ≥ 4: 5.5% vs 2.7%), and longer LOS (median 3 vs 2 days, all p < 0.001). Being Black (vs White: +0.13 adjusted days, 95% CI 0.06 to 0.19) was also associated with longer LOS and an increased likelihood of surgical complications (vs White: odds ratio 1.24, 95% CI 1.09 to 1.42, both p < 0.01), but this association did not persist when outcomes were limited to microsurgical complications. CONCLUSION: Disparities in postmastectomy breast reconstruction between Black and White women extend beyond access to care and include perioperative factors and outcomes. These findings suggest an important opportunity to mitigate inequities in reconstruction through perioperative health optimization and improved access to and co-management with primary care.