Lymphovenous Coupler-Assisted Bypass for Immediate Lymphatic Reconstruction.

BACKGROUND: Breast cancer-related lymphedema is the most common cause of lymphedema in the United States and occurs in up to 50% of individuals receiving axillary lymph node dissection (ALND). Lymphovenous bypass (LVB) at the time of ALND may prevent lymphedema, but long-term results and anastomotic patency are unclear. This study evaluates the feasibility and outcomes of performing immediate lymphatic reconstruction via coupler-assisted bypass (CAB). METHODS: This is a retrospective review of all patients undergoing prophylactic LVB following ALND at two tertiary care centers between 2018 and 2022. Patients were divided into cohorts based on whether they received the "standard" end-to-end (E-E) suturing or CAB technique. The primary outcome of interest was development of lymphedema. Quantitative and qualitative assessments for lymphedema were performed preoperatively and at 3, 6, 12, and 24 months postoperatively. RESULTS: Overall, 63 LVBs were performed, of which 24 lymphatics underwent immediate reconstruction via "CAB" and 39 lymphatics via "standard" end-to-end suture. Patient characteristics, including body mass index, and treatment characteristics, including radiation therapy, did not significantly differ between groups. CAB was associated with a greater mean number of lymphatics bypassed per vein (standard 1.7 vs. CAB 2.6, p = 0.0001) and bypass to larger veins (standard 1.2 vs. CAB 2.2 mm, p < 0.0001). At a median follow-up of 14.7 months, 9.1% (1/11) of individuals receiving CAB developed lymphedema. These rates were similar to those seen following standard bypass at 4.8% (1/21), although within a significantly shorter follow-up duration (standard 7.8 vs. CAB 14.7 months, p = 0.0170). CONCLUSION: The CAB technique is a viable, effective technical alternative to the standard LVB technique. This comparative study of techniques in prophylactic LVB suggests that CABs maintain long-term patency, possibly due to the ease of anastomosing several lymphatics to single large caliber veins while reducing the technical demands of the procedure.

Free Flap Reconstruction of Traumatic Pediatric Foot and Ankle Defects: An Analysis of Clinical and Functional Outcomes.

BACKGROUND: Traumatic lower extremity injuries involving the foot and ankle can have devastating consequences and represent a complex reconstructive challenge. To date, there are limited reports on microsurgical reconstruction for foot and ankle defects in children. This study aims to evaluate clinical and functional outcomes of free flaps for pediatric foot and ankle injuries. METHODS: This is a retrospective review of patients undergoing free flaps for traumatic foot and ankle defects at a pediatric trauma center between 2000 and 2015. Patients with less than 5-year follow-up were excluded. Demographics, clinical characteristics, and postoperative outcomes were evaluated. RESULTS: Thirty patients undergoing 30 flaps were analyzed. The mean age was 11.9 years (range: 2 to 17 years). Muscle flaps (n = 21, 70%) were more common than fasciocutaneous flaps (n = 9, 30%). Limb salvage with functional ambulation was achieved in 96.7% of patients (n = 29). The complication rate was 33.3% (n = 10), with wound breakdown (n = 6, 20.0%) as most common feature. There were no significant differences in limb salvage, total or partial flap loss, fracture union, and donor-site complications based on flap type. Fasciocutaneous flaps were more likely to require revision procedures for contour compared with muscle flaps (55.6 vs. 9.5%, p = 0.013). Mean follow-up was 8.5 years. CONCLUSION: Microsurgical reconstruction of pediatric foot and ankle defects results in high rates of limb salvage. A defect- and patient-centered approach to reconstruction, emphasizing durable coverage and contour, is critical to facilitating ambulation and ensuring favorable long-term functional outcomes.

Salvage of Implant-Based Breast Reconstruction in Nipple-Sparing Mastectomies With Autologous Flaps.

BACKGROUND: Implant-based breast reconstruction (IBR) after nipple-sparing mastectomies (NSM) can have complications that require explantation of a tissue expander or permanent prosthesis. When complications occur, preservation of the nipple-areola complex (NAC) remains critical to ensure aesthetic breast reconstruction. To date, there are minimal data on outcomes for patients experiencing unplanned explantations in IBR after NSM. OBJECTIVES: To evaluate final reconstructive outcomes for NSM patients who undergo IBR and have an unplanned explanation and to separately analyze the outcome of the NAC aesthetic subunit. METHODS: We analyzed a prospectively maintained database of NSM patients undergoing IBR reconstruction at a single institution to identify patients who had complications resulting in unplanned explanation. Demographics, covariates, and reconstructive outcomes, including salvage with IBR or autologous flaps, were assessed. Final outcomes of the NAC were also evaluated. RESULTS: A total of 213 patients underwent 382 NSM with IBR with either direct-to-implant (DTI) or tissue expander/implant (TE/I) reconstructions. The complication rate was 15.2% (N = 58) and 33 (8.6%) unplanned explantations occurred: 23 (69.8%) of whom ultimately completed reconstruction with either IBR (30.4%) or autologous flaps (69.6%). NACs were preserved in 62.5% of breasts with unplanned explantations. Only 8 NACs were lost in the entire cohort (2.1%). CONCLUSIONS: Following unplanned explantations in IBR after NSM, salvage can be performed with either IBR or autologous flaps. However, the majority of salvage procedures in IBR after NSM will be with autologous flaps that bring in healthy soft tissue to restore location specific defects caused by complications. The NAC can ultimately be preserved as an aesthetic subunit in most patients despite the occurrence of initial complications.

Complications and thromboembolic events associated with tamoxifen therapy in patients with breast cancer undergoing microvascular breast reconstruction: a systematic review and meta-analysis.

PURPOSE: Tamoxifen therapy is integral in the treatment of patients with hormone receptor-positive breast cancer. However, there is an association between tamoxifen and thromboembolic events. Flap and systemic thromboembolic events have devastating consequences in microvascular breast reconstruction. Currently, there are conflicting data on the association between tamoxifen therapy and thromboembolic complications for patients undergoing microvascular breast reconstruction. The objective of this study is to determine if perioperative tamoxifen therapy modifies the risk of complications and thromboembolic events for patients with breast cancer undergoing microvascular breast reconstruction. METHODS: A comprehensive literature search was performed across six databases from January 2003 to February 2016. Pooled estimates and relative risk (RR) were calculated using a random-effects model, confounding was examined with meta-regression, and risk of bias was evaluated. Primary outcomes were thrombotic flap complications and total flap loss. Study quality was assessed using Downs and Black criteria. RESULTS: Of 95 studies reviewed, 4 studies comprising 1700 patients and 2245 procedures were included for analysis. Compared to non-recipients, patients on tamoxifen were at increased risk of developing thrombotic flap complications (pooled RR 1.5; 95% CI 1.14-1.98) and total flap loss (pooled RR 3.35; 95% CI 0.95-11.91). There was no significant heterogeneity present in either outcome and no evidence of publication bias. CONCLUSIONS: Perioperative tamoxifen therapy may increase the risk of thrombotic flap complications and flap loss for patients with breast cancer undergoing microvascular reconstruction. These findings further the ability of providers to make evidence-based recommendations in the perioperative management of patients with breast cancer.

Paravertebral Blocks Reduce Narcotic Use Without Affecting Perfusion in Patients Undergoing Autologous Breast Reconstruction.

BACKGROUND: Autologous breast reconstruction offers excellent long term outcomes after mastectomy. However, maintaining adequate postoperative analgesia remains challenging. Use of paravertebral blocks (PVBs) reduces postoperative narcotic use and length of stay, and enhanced recovery protocols with mixed analgesia methods are gaining popularity, but few studies have explored the intraoperative effects of these interventions. METHODS: Patients who underwent abdominally based autologous breast reconstruction between 2010 and 2016 were compiled into a retrospective database. We used electronic medical records to determine demographics, as well as perioperative and intraoperative vital signs and narcotic, anxiolytic, crystalloid, colloid, blood product, and vasopressor requirements, and postoperative complications. Results were compared between patients who had a PVB and those who did not and those who had a PVB alone and those who followed our enhanced recovery protocol using standard statistical methods and adjusting for preoperative values. RESULTS: A total of 170 patients were included in the study. Sixty-six had a PVB, and 104 did not. Of the 66 who had a PVB, 19 followed our enhanced recovery protocol. Patients who did not have a PVB required 171.6 mg of total narcotic medication in the perioperative period, those with a PVB alone required 146.9 mg, and those who followed the ERAS protocol 95.2 mg (p = 0.01). There was no difference in intraoperative mean arterial pressure, time with mean arterial pressure <80% of baseline, vasopressor use, or fluid requirement. There was no difference in complication rate. CONCLUSIONS: PVBs and an enhanced recovery protocol reduce the use of narcotic medications in autologous breast reconstruction without impacting intraoperative hemodynamics. Breast reconstruction after mastectomy restores body image and improves health-related quality of life, satisfaction with appearance and physical, psychosocial, and sexual well-being (Donovan et al. in J Clin Oncol 7(7):959-968, 1989; Eltahir et al. in Plast Reconstr Surg 132(2):201e-209e, 2013; Jagsi et al. in Ann Surg 261(6):1198-1206, 2015). For patients pursuing breast reconstruction, there are two major options: prosthetic (tissue expander/implant) or autologous reconstruction. However, while providing exceptional long-term outcomes, postoperative pain and length of hospital stay remains a major challenge preventing more widespread adoption of autologous breast reconstruction (Albornoz et al. in Plast Reconstr Surg 131(1):15-23, 2013; Gurunluoglu et al. in Ann Plast Surg 70(1):103-110, 2013; Kulkarni et al. in Plast Reconstr Surg 132(3):534-541, 2013; Sbitany et al. in Plast Reconstr Surg 124(6):1781-1789, 2009). Acute postoperative pain contributes to prolonged hospital stays, increased narcotic use, and associated risks of the aforementioned.

Nonsurgical Facial Rejuvenation: Outcomes and Safety of Neuromodulator and Soft-Tissue Filler Procedures Performed in a Resident Cosmetic Clinic.

BACKGROUND: The ability to perform nonsurgical facial rejuvenation procedures is a core competency requirement for plastic surgery residents. However, limited data exist on training models to achieve competency in nonsurgical facial rejuvenation and on outcomes of these procedures performed by residents. The purpose here is to evaluate patient-reported outcomes and safety of nonsurgical facial rejuvenation procedures performed by plastic surgery residents. METHODS: We prospectively enrolled 50 patients undergoing neuromodulator and/or soft-tissue filler injections in a resident cosmetic clinic between April and August 2016. Patients completed FACE-Q modules pre-procedure, and at 1 week and 1 month post-procedure. Paired t-tests were used to calculate statistical significance of changes between pre- and post-procedure scores. Effect sizes were calculated to assess clinical improvement from pre- to post-procedure. The magnitude of change was interpreted using Cohen's arbitrary criteria (small 0.20, moderate 0.50, large 0.80). RESULTS: Forty-five patients completed the study. Patients experienced significant improvements (p < 0.001) in all FACE-Q domains, including aging appearance appraisal (improved from 49.7 ± 29.4 to 70.1 ± 21.6, effect size 0.79), psychological well-being (44.0 ± 14.6-78.6 ± 20.7, effect size 1.93), social functioning (48.6 ± 16.6-75.5 ± 21.7, effect size 1.20), and satisfaction with facial appearance (50.1 ± 13.7-66.2 ± 19.7, effect size 0.95). At 1 month, overall satisfaction with outcome and decision were 75.8 ± 20.7 and 81.1 ± 20.4, respectively. No patients experienced complications. CONCLUSIONS: Nonsurgical facial rejuvenation procedures performed by residents can improve patients' quality of life and provide high satisfaction without compromising safety. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors http://www.springer.com/00266 .

Lower Extremity Reconstruction with Free Gracilis Flaps.

Background There have been significant advancements in lower extremity reconstruction over the last several decades, and the plastic surgeon's armamentarium has grown to include free muscle and fasciocutaneous flaps along with local perforator and propeller flaps. While we have found a use for a variety of techniques for lower extremity reconstruction, the free gracilis has been our workhorse flap due to the ease of harvest, reliability, and low donor site morbidity. Methods This is a retrospective review of a single surgeon's series of free gracilis flaps utilized for lower extremity reconstruction. Demographic information, comorbidities, outcomes, and secondary procedures were analyzed. Results We identified 24 free gracilis flaps. The duration from injury to free flap coverage was ≤ 7 days in 6 patients, 8-30 days in 11 patients, 31-90 days in 4 patients, and > 90 days in 3 patients. There were 22 (92%) successful flaps and an overall limb salvage rate of 92%. There was one partial flap loss. Two flaps underwent incision and drainage in the operating room for infection. Two patients developed donor site hematomas. Four patients underwent secondary procedures for contouring. Our subset of pediatric patients had 100% flap survival and no secondary procedures at a mean 30-month follow-up. Conclusion This study demonstrates the utility of the free gracilis flap in reconstruction of small- to medium-sized defects of the lower extremity. This flap has a high success rate and a low donor site morbidity. Atrophy of the denervated muscle over time allows for good shoe fit, often obviating the need for secondary contouring procedures.

Patient-Reported Outcomes of Aesthetics and Satisfaction in Immediate Breast Reconstruction After Nipple-Sparing Mastectomy With Implants and Fat Grafting.

Background: Direct-to-implant (DTI) and tissue expander/implant (TE/I) reconstructions are the most common implant-based reconstructions after nipple-sparing mastectomy (NSM). However, there are little data beyond complication rates comparing these options. Fat grafting has emerged as an adjunct in NSM reconstructions to improve aesthetic results; however, its impact on patient perceptions of aesthetic outcomes remain unknown. To improve patient-centered care, aesthetic outcomes must be considered from the patients' perspective. Objectives: To evaluate patient-reported outcomes of aesthetic satisfaction and quality of life in patients undergoing immediate DTI vs TE/I reconstruction after NSM and to assess the role of fat grafting on these outcomes. Methods: This is a prospective cohort study comparing NSM patients undergoing DTI or TE/I reconstruction. Patient-reported outcomes were evaluated using the BREAST-Q. Continuous and categorical variables were analyzed using t test and Fisher's exact test, respectively. Results: Fifty-nine patients underwent 113 reconstructions with either DTI (n = 41) or TE/I (n = 18). Mean follow up was 12.1 months. DTI and TE/I patients had comparable satisfaction with outcome, though TE/I patients had significantly larger final implant sizes. TE/I who underwent fat grafting also had significantly higher satisfaction with outcome and psychosocial wellbeing. Conclusions: Patient-reported outcomes are comparable between DTI and TE/I reconstructions after NSM. In order for TE/I patients to achieve a similar level of satisfaction, they may require a larger final implant and additional operations compared to DTI patients. Additionally, fat grafting improves overall satisfaction. TE/I patients may have different aesthetic expectations than DTI patients, emphasizing patient-centered discussions are essential to optimizing outcomes after NSM. Level of Evidence: 3.

Preoperative Paravertebral Block Improves Postoperative Pain Control and Reduces Hospital Length of Stay in Patients Undergoing Autologous Breast Reconstruction after Mastectomy for Breast Cancer.

BACKGROUND: Postoperative pain is a major challenge for patients undergoing breast reconstruction after surgical treatment of breast cancer, resulting in prolonged hospitalizations and additional resource utilization. Evidence on the efficacy of techniques to minimize postoperative pain in autologous breast reconstruction is lacking. We sought to determine whether preoperative paravertebral block (PVB), a regional anesthetic technique, affects postoperative pain control and hospital length of stay (LOS) in patients undergoing autologous breast reconstruction. METHODS: Consecutive patients undergoing postmastectomy autologous breast reconstruction between 2012 and 2015 were identified from a prospectively collected database to compare those who received PVB to those who did not. Primary outcomes included self-reported pain score, time to oral-only narcotic usage (TTON), and LOS. Sample differences were compared using Wilcoxon rank-sum and Chi square tests for continuous and categorical variables. Kaplan-Meier analysis was used to evaluate TTON and LOS, with Mantel-Cox test used to compare groups. RESULTS: Of 78 patients, 39 received PVB and 39 did not. Study groups did not differ regarding age, body mass index, American Society of Anesthesiologists class, mastectomy type, flap type, or cancer stage (p > 0.05). Patients in the PVB group reported significantly lower postoperative pain at 2 (p < 0.01) and 24 h (p < 0.01) and shorter median TTON (66 vs. 76 h, p < 0.01). Importantly, median LOS was reduced for patients receiving a PVB in both hours (95 vs. 116, p < 0.01) and hospital nights (4 vs. 5, p = 0.05). CONCLUSIONS: Preoperative PVB is associated with improved postoperative pain control and shorter hospitalizations for patients with breast cancer undergoing postmastectomy autologous reconstruction.

Resident Cosmetic Clinic: Practice Patterns, Safety, and Outcomes at an Academic Plastic Surgery Institution.

BACKGROUND: Comprehensive aesthetic surgery education is an integral part of plastic surgery residency training. Recently, the ACGME increased minimum requirements for aesthetic procedures in residency. To expand aesthetic education and prepare residents for independent practice, our institution has supported a resident cosmetic clinic for over 25 years. OBJECTIVES: To evaluate the safety of procedures performed through a resident clinic by comparing outcomes to benchmarked national aesthetic surgery outcomes and to provide a model for resident clinics in academic plastic surgery institutions. METHODS: We identified a consecutive cohort of patients who underwent procedures through our resident cosmetic clinic between 2010 and 2015. Major complications, as defined by CosmetAssure database, were recorded and compared to published aesthetic surgery complication rates from the CosmetAssure database for outcomes benchmarking. Fisher's exact test was used to compare sample proportions. RESULTS: Two hundred and seventy-one new patients were evaluated and 112 patients (41.3%) booked surgery for 175 different aesthetic procedures. There were 55 breast, 19 head and neck, and 101 trunk or extremity aesthetic procedures performed. The median number of preoperative and postoperative visits was 2 and 4 respectively with a mean follow-up time of 35 weeks. There were 3 major complications (2 hematomas and 1 infection requiring IV antibiotics) with an overall complication rate of 1.7% compared to 2.0% for patients in the CosmetAssure database (P = .45). CONCLUSIONS: Surgical outcomes for procedures performed through a resident cosmetic clinic are comparable to national outcomes for aesthetic surgery procedures, suggesting this experience can enhance comprehensive aesthetic surgery education without compromising patient safety or quality of care. LEVEL OF EVIDENCE: 4 Risk.

Identifying risk factors using a skin cancer screening program.

BACKGROUND: The incidence of melanoma and nonmelanoma skin cancer continues to increase. To detect lesions at an earlier phase in their progression, skin cancer screening programs have been advocated by some. However, the effectiveness of skin cancer screening and the ideal population that these screenings should target have yet to be firmly established. This study details the relationship of a group of well-known risk factors with presumptive diagnoses in a large series of individuals self-referred for free skin cancer screening. METHODS: Data obtained during 2007 to 2010 from a descriptive cross-sectional study skin cancer screening program are presented. Participant history was recorded using standardized medical history forms prior to skin examination. Screeners conducted a skin examination varying from whole-body to limited areas (per participant preference) and recorded diagnoses. Diagnoses were assigned to the nonmelanoma cancer (NMC) or suspicious pigmented lesion group for analysis. RESULTS: A presumptive diagnosis of NMC was associated with male sex, age ≥ 50 years, personal history of skin cancer, lower skin phototype, increased sunscreen use, and increased chronic sun exposure (all P values ≤ .0001). After controlling for skin phototype, increased sunscreen use was not associated with a presumptive diagnosis of NMC (P = .96). Presumptive diagnosis of a suspicious pigmented lesion was associated with a reported history of "changing mole" (P < .0001) and negatively associated with age ≥ 50 years (P < .0001) and a personal history of skin cancer (P = .0119). CONCLUSIONS: Several known risk factors for nonmelanoma skin cancer correlated with a presumptive diagnosis of NMC. The yield of presumptive atypical pigmented lesions was increased in participants aged < 50 years, supporting the notion that this population may benefit from screening.

Impact of High-Deductible Health Plans on Breast Reconstruction: Considerations for Financial Toxicity.

BACKGROUND: High-deductible health plans (HDHPs) are used within the United States to curb unnecessary health care spending; however, the resulting increased out-of-pocket (OOP) costs may be associated with financial toxicity. The aim was to assess the impact of HDHPs on use and seasonality of mastectomy and breast reconstruction procedures. The hypothesis is that the high OOP costs of HDHPs will lead to decreased overall service use and greater fourth-quarter use after the deductible has been met. METHODS: MarketScan was queried from 2014 to 2017 for episodes of mastectomy, breast reconstruction (immediate and delayed), breast revision, and reduction. Only patients continuously enrolled for the full calendar year after the index operation were included. HDHPs and low-deductible health plans (LDHPs) were compared based on OOP cost sharing. Outcomes included surgery use rates, seasonality of operations, and median/mean OOP costs. RESULTS: Annual mastectomy and breast reconstruction use rates varied little between LDHPs and HDHPs. Mastectomies, delayed breast reconstruction, and elective breast procedures (P < 0.001) all showed significant increases in fourth-quarter use, whereas immediate breast reconstruction did not. Regardless of timing and reconstruction method, HDHPs had significantly greater median OOP costs compared to LDHPs (all P < 0.001). CONCLUSIONS: Mastectomy and breast reconstruction rates did not differ between LDHPs and HDHPs, but seasonality for all breast procedures was measured with the exception of immediate breast reconstruction, suggesting that women are rational economic actors. Regardless of service timing and reconstruction modality, HDHP patients had greater OOP costs compared to LDHP patients, which serves as a good starting point for provider engagement in financial toxicity.

Quality of Life in Breast Reconstruction Patients after Irradiation to Tissue Expander: A Propensity-Matched Preliminary Analysis.

BACKGROUND: Tissue expanders (TEs) are routinely placed as a first step in breast reconstruction for women who require postmastectomy radiation therapy (PMRT). The final reconstruction can then be performed with implants or conversion to autologous tissues. The purpose of this study was to compare patient-reported outcomes and surgical complications in autologous (ABR) versus implant-based breast reconstruction (IBR) patients following TE-PMRT. METHODS: The authors performed a propensity score preliminary analysis (1:1 matching, no replacement) in patients undergoing ABR or IBR following TE-PMRT. Matched covariates included age, race/ethnicity, smoking status, body mass index, history of psychiatric diagnosis, and laterality of reconstruction. Outcomes of interest included complications and BREAST-Q scores for Satisfaction with Breasts, Physical Well-Being of the Chest, Sexual Well-Being, and Psychosocial Well-Being domains. RESULTS: Of 341 patients with TE-PMRT, a total of 106 patients were included in the matched analysis: 53 ABR patients and 53 IBR patients. ABR and IBR did not differ significantly in matched baseline, cancer, and surgical characteristics. ABR patients had higher scores for Satisfaction with Breasts (greater than the four-point minimal clinically important difference) at all postreconstruction time points compared with IBR patients ( P < 0.05). There were no significant postoperative differences in other BREAST-Q domains. The incidence of complications after definitive reconstruction did not differ significantly among cohorts. CONCLUSIONS: In this matched preliminary analysis, patients who underwent ABR following irradiation to a TE demonstrated superior satisfaction with breast scores compared with IBR patients. Higher powered matched studies are needed to improve shared decision-making for patients who require mastectomy and PMRT as part of their treatment. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

A prospective randomized clinical trial to assess antibiotic pocket irrigation on tissue expander breast reconstruction.

Bacterial infection is the most common complication following staged post-mastectomy breast reconstruction initiated with a tissue expander (TE). To limit bacterial infection, antibiotic irrigation of the surgical site is commonly performed despite little high-quality data to support this practice. We performed a prospective randomized control trial to compare the impact of saline irrigation alone to a triple antibiotic irrigation regimen (1 g cefazolin, 80 mg gentamicin, and 50,000 units of bacitracin in 500 mL of saline) for breast implant surgery. The microbiome in breasts with cancer (n = 16) was compared to those without (n = 16), as all patients (n = 16) had unilateral cancers but bilateral mastectomies (n = 32). Biologic and prosthetic specimens procured both at the time of mastectomy and during TE removal months later were analyzed for longitudinal comparison. Outcomes included clinical infection, bacterial abundance, and relative microbiome composition. No patient in either group suffered a reconstructive failure or developed an infection. Triple antibiotic irrigation administered at the time of immediate TE reconstruction did not reduce bacterial abundance or impact microbial diversity relative to saline irrigation at the time of planned exchange. Implanted prosthetic material adopted the microbial composition of the surrounding host tissue. In cancer-naïve breasts, relative to saline, antibiotic irrigation increased bacterial abundance on periprosthetic capsules (P = 0.03) and acellular dermal matrices (P = 0.04) and altered the microbiota on both. These data show that, relative to saline only, the use of triple antibiotic irrigation in TE breast reconstruction does impact the bacterial abundance and diversity of certain biomaterials from cancer-naïve breasts. IMPORTANCE The lifetime risk of breast cancer is ~13% in women and is treated with a mastectomy in ~50% of cases. The majority are reconstructed, usually starting with a tissue expander to help restore the volume for a subsequent permanent breast implant or the women's own tissues. The biopsychosocial benefits of breast reconstruction, though, can be tempered by a high complication rate of at least 7% but over 30% in some women. Bacterial infection is the most common complication, and can lead to treatment delays, patient physical and emotional distress and escalating health care cost. To limit this risk, plastic surgeons have tried a variety of strategies to limit bacterial infection including irrigating the pocket created after removing the breast implant with antibiotic solutions, but good-quality data are scarce. Herein, we study the value of antibiotics in pocket irrigation using a robust randomized clinical trial design and molecular microbiology approaches.

Acellular dermal matrix masking detection of recurrent breast carcinoma: a novel complication.

Acellular dermal matrix (ADM) use in prosthetic breast reconstruction has become increasingly popular. Several benefits have been reported with this technique including diminished donor-site morbidity and improved aesthetic outcomes. Recently, in an effort to ascertain the overall safety and efficacy of this approach, an emphasis has been placed on identifying potential postoperative complications. This report describes a unique complication experienced with ADM use in which ADM conceals the detection of recurrent breast carcinoma.

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Autonomic dysreflexia (AD) is an acute, life-threatening syndrome of uncontrolled sympathetic discharge that occurs in patients with spinal cord injury at T6 or higher. Despite a high incidence in tetraplegics, the condition is under-recognized, putting both the practitioner and patient at risk. This report presents a case of AD triggered by debridement of a pressure ulcer. To advance the understanding among wound care practitioners, the authors review the literature, describe the common clinical presentations and scenarios leading to AD, delineate a protocol to guide management, and conclude with a discussion of potential preventative measures. .

Combined pectoralis and rectus abdominis flaps are associated with improved outcomes in sternal reconstruction.

BACKGROUND: Mortality increases nearly 5-fold in the approximately 5% of patients who develop sternal wound complications after cardiothoracic surgery. Flap-based reconstruction can improve outcomes by providing well-vascularized soft tissue for potential space obliteration, antibiotic delivery, and wound coverage; however, reoperation and readmission rates remain high. This study used the high case volume at a tertiary referral center and a diverse range of reconstructive approaches to compare various types of flap reconstruction. Combined (pectoralis and rectus abdominis) flap reconstruction is hypothesized to decrease sternal wound complication-related adverse outcomes. METHODS: A retrospective cohort study of consecutive adult patients treated for cardiothoracic surgery sternal wound complications between 2008 and 2018 was performed. Patient demographics, comorbidities, wound characteristics, surgical parameters, and perioperative data were collected. Multivariable regression modeling with stepwise forward selection was used to characterize predictive factors for sternal wound-related readmissions and reoperations. RESULTS: In total, 215 patients were assessed for sternal wound reconstruction. Patient mortality at 1 year was 12.4%. Flap selection was significantly associated with sternal wound-related readmissions (P = .017) and reoperations (P = .014). Multivariate regression demonstrated rectus abdominis flap reconstruction independently predicted increased readmissions (odds ratio 3.4, P = .008) and reoperations (odds ratio 2.9, P = .038). Combined pectoralis and rectus abdominis flap reconstruction independently predicted decreased readmissions overall (odds ratio 0.4, P = .031) and in the deep sternal wound subgroup (odds ratio 0.1, P = .033). CONCLUSION: Although few factors can be modified in this complex highly comorbid population with a challenging and rare surgical problem, consideration of a more surgically aggressive multiflap reconstructive approach may be justified to improve outcomes.

Lower Extremity Reconstruction After Soft Tissue Sarcoma Resection.

Surgical resection with wide margins and perioperative radiation therapy is the standard treatment of extremity soft tissue sarcomas. This combination often results in complex wounds and functional compromise. Reconstructive surgery is integral to limb salvage after sarcoma resection. Advances in adjuvant therapy and reconstructive surgical techniques have made functional limb salvage, instead of amputation, possible for most patients. This article reviews key concepts in the multidisciplinary care of patients with extremity soft tissue sarcomas and details reconstructive surgical techniques, including locoregional and free tissue transfer, free functional muscle transfer, and vascularized bone transfer, to optimize functional limb restoration after sarcoma resection.

Challenges and Solutions for the Implementation of Shared Decision-making in Breast Reconstruction.

BACKGROUND: Patient-centered care is a hallmark of quality in healthcare. It is defined as care that is respectful of, and responsive to, individual patient preferences, needs, and values, while ensuring patients are informed and engaged in the treatment decision-making process. METHODS: We reviewed the literature and drew upon our own experiences to study the implementation of tools intended to facilitate shared decision-making in breast reconstruction. RESULTS: For women with breast cancer, decision-making about breast reconstruction is often a challenging and perplexing process. The variety of choices available regarding timing and type of reconstruction and the unique individual patient and clinical treatment variables to consider can further complicate decisions. Accordingly, strategies to facilitate the decision-making process and enable patients and clinicians to make high-quality decisions about breast reconstruction are an essential component of comprehensive breast cancer care. Shared decision making is one proposed model to support informed and preference-sensitive decision-making in line with the principles of patient-centered care. Despite an emerging level of interest in shared decision making, there remains a lack of clarity regarding what the process involves and how to effectively implement it into clinical practice. CONCLUSIONS: Thus, widespread adoption of shared decision making remains lacking in clinical practice for women considering postmastectomy breast reconstruction. To address these gaps, this article reviews the principles of shared decision making, explores ways shared decision making can be utilized for patients who are candidates for breast reconstruction, and provides a practical overview to facilitate implementation of shared decision making into clinical practice.