Reconstructing Failure: Assessing Surgical and Patient Reported Outcomes Following Loss of Initial Breast Reconstruction.

BACKGROUND: Breast reconstruction failure, defined as the removal of a prosthetic device or flap without immediate replacement, can be traumatic for patients. We aim to describe the progression of patients who experience tissue expander (TE), implant, or autologous breast reconstructive failure and assess the patient reported outcomes (PROs) among patients who undergo additional reconstruction. METHOD: Patients undergoing TE, implant, or autologous breast reconstruction between 2017 and 2022 were included, and patients with reconstructive failures were identified. Outcomes of interests included (1) receipt of additional reconstruction and (2) BREAST-Q scores 1-year after reconstructive failure. We also performed a propensity-matched analysis between patients who undergo secondary reconstruction and patients who had an uncomplicated reconstruction. RESULTS: 4,258 TE, 4,420 implant, and 1,545 autologous breast reconstruction patients were included. Of patients who experienced reconstructive failures, 49.5% of TE, 4.8% of implant, and 53.8% of autologous patients underwent secondary reconstruction. Age, psychiatric diagnosis, chemotherapy, radiation, and mastectomy type were associated with increased likelihood of secondary reconstruction. Between patients with and without additional reconstruction, higher Psychosocial Well-being trended towards the former cohort (61 [Interquartile Range: 56, 80] vs 50 [46, 65], p=0.085). Propensity-matched analysis demonstrated comparable PROs at 1-year after definite reconstruction. CONCLUSION: Less than half of reconstructive failure patients undergo an additional reconstruction. Patients with secondary reconstruction may have improved Psychosocial Well-being than those who do not and comparable PROs to those who had uncomplicated initial reconstruction. Surgeons should counsel patients with reconstructive failures that although traumatizing, secondary reconstruction may be beneficial.

Synergistic Dual-Cure Reactions for the Fabrication of Thermosets by Chemical Heating.

Large composite structures, such as those used in wind energy applications, rely on the bulk polymerization of thermosets on an impressively large scale. To accomplish this, traditional thermoset polymerizations require both elevated temperatures (>100 °C) and extended cure durations (>5 h) for complete conversion, necessitating the use of oversize ovens or heated molds. In turn, these requirements lead to energy-intensive polymerizations, incurring high manufacturing costs and process emissions. In this study, we develop thermoset polymerizations that can be initiated at room temperature through a transformative "chemical heating" concept, in which the exothermic energy of a secondary reaction is used to facilitate the heating of a primary thermoset polymerization. By leveraging a redox-initiated methacrylate free radical polymerization as a source of exothermic chemical energy, we can achieve peak reaction temperatures >140 °C to initiate the polymerization of epoxy-anhydride thermosets without external heating. Furthermore, by employing Trojan horse methacrylate monomers to induce mixing between methacrylate and epoxy-anhydride domains, we achieve the synthesis of homogeneous hybrid polymeric materials with competitive thermomechanical properties and tunability. Herein, we establish a proof-of-concept for our innovative chemical heating method and advocate for its industrial integration for more energy-efficient and streamlined manufacturing of wind blades and large composite parts more broadly.

Morel-Lavallée lesion diagnosed with point-of-care ultrasound.

The Morel-Lavallée lesion is an internal degloving injury seen after a traumatic force. These lesions are frequently missed on initial presentation, leading to a delay in diagnosis and increased morbidity. We present a case of a 52-year-old male who suffered an injury to his right thigh and was ultimately diagnosed with a Morel-Lavallée lesion after the third emergency department visit. Point-of-care ultrasound (POCUS) assisted with making the diagnosis and expediting proper care.

Predicting Postoperative Satisfaction with Breasts: How Important is the Preoperative BREAST-Q Score?

BACKGROUND: The role that preoperative Satisfaction with Breast plays in a patient's postoperative course after postmastectomy breast reconstruction (PMBR) is not understood. The aim of this study is to understand the impact of the preoperative score on postoperative outcome as an independent variable. METHODS: We examined patients who underwent PMBR between 2017 and 2021 and who completed the BREAST-Q Satisfaction with Breasts at 1 year postoperatively. Two multiple linear regression models (Model 1 with the preoperative Satisfaction with Breasts score and Model 2 without the preoperative score), likelihood ratio tests, simple t-statistics, and sample patient dataset to predict the 1 year score were performed. Multiple imputation was used to account for missing preoperative scores. RESULTS: Overall, 2324 patients were included. Model 1 showed that the preoperative score is significantly associated with the postoperative score (ß = 0.09, 95% confidence interval 0.04-0.14; p < 0.001). Comparing Model 1 and Model 2 demonstrated that including preoperative Satisfaction with Breasts in a regression significantly improves model fit (test statistic = 10.04; p = 0.0021). Using the absolute value of the t-statistics as a measure of variable importance in linear regression, the importance of the preoperative score was quantified as 3.39-more important than neoadjuvant radiation, mastectomy weight, body mass index, bilateral prophylactic mastectomy, and race, but less than adjuvant radiation, reconstruction type, and psychiatric diagnoses. CONCLUSION: Preoperative Satisfaction with Breasts scores are an important independent predictor of postoperative satisfaction after PMBR. Just as vital sign and work-up are carefully documented before surgery, preoperative scores should be collected to pre-emptively gauge patients' satisfaction and optimize postoperative outcomes.

Self-assessment and Modulation of Traction During Shoulder Dystocia Simulation Training.

OBJECTIVE: The aim of the study is to determine diagnostic traction for shoulder dystocia and to assess whether applied traction is modifiable with force training. METHODS: We tethered a force-measuring fetal mannequin (PROMPT, Limbs & Things) within a simulated pelvis such that it would not deliver. We asked participants to apply traction to diagnose shoulder dystocia then stop. Blinded from participants' view, we recorded the peak traction. We then asked them to apply what they perceived to be 20 lb (89 N) traction. Each participant estimated the traction s/he applied. The actual force applied was then revealed to the participants and another blinded sequence was performed. We then allowed participants to view actual force measurements in real time while they practiced getting to their diagnostic traction and to 20 lb (89 N); this was followed by another blinded sequence of traction applications and estimations. Median diagnostic traction and injury threshold values (20 lb [89 N]), and mean ratio of estimated to actual force applied were compared pretraining and posttraining, using Wilcoxon signed rank sum test and t test. Rates of clinical shoulder dystocia and associated brachial plexus injury before and after the study period were compared using chi-square. Significance was set at P < 0.05. RESULTS: One hundred participants demonstrated a range of diagnostic traction. For 23 participants, traction exceeded injury thresholds, but the average was lowered with training. Before training, participants underestimated their own applied traction by an average of 30%. CONCLUSIONS: Subjective diagnosis of shoulder dystocia during simulation training varies widely and exceeds possible injury threshold for 22% of participants. Accuracy of self-assessment applied delivery traction improves significantly with force training as does clinical diagnosis of shoulder dystocia and decrease in brachial plexus injury incidence.

Imaging in Autologous Breast Reconstruction.

The evolution of imaging actively shapes clinical management in the field. Ultrasonography (US), computed tomography angiography (CTA), and magnetic resonance angiography (MRA) stand out as the most extensively researched imaging modalities for ABR. Ongoing advancements include "real-time" angiography and three-dimensional (3D) surface imaging, and future prospects incorporate augmented or virtual reality (AR/VR) and artificial intelligence (AI). These technologies may further enhance perioperative efficiency, reduce donor-site morbidity, and improve surgical outcomes in ABR.

Osseous Maxillary Reconstruction with Immediate Dental Implant Placement: An Optimized Workflow for the Oncologic Patient.

INTRODUCTION: Maxillary reconstruction is a complex undertaking characterized by a 3-dimensional surgical site with deficiencies in multiple tissue types. Prior to virtual surgical planning(VSP), bony reconstruction was inaccurate and inefficient, thus reconstructions defaulted to soft tissue flaps or obturators. The current study describes an efficient and accurate approach to bony maxillary reconstruction with immediate dental implant placement(IDIP). METHODS: A reconstructive workflow was developed for osseous reconstruction to improve functional and aesthetic outcomes. Critical aspects include VSP, 3-D printed plates and IDIP. Review of a prospectively maintained database identified patients who underwent osseous maxillary reconstruction with a fibula flap and immediate dental implants from 2017-2022, with a focus on oncologic characteristics and reconstructive outcomes. RESULTS: During the study, 20 patients underwent maxillary reconstruction with VSP and IDIP. One dental implant out of 55 failed to osseointegrate and no flaps were lost. Three patients suffered partial loss of the fibula skin island; one required palatal closure with a radial forearm flap, and two were managed with outpatient debridement. Fifteen patients achieved either an interim or final retained dental prosthesis. All prostheses achieved acceptable aesthetic results without the instability associated with non-bone borne devices(e.g.dentures/obturators). No patients experienced delays in oncologic treatment. CONCLUSIONS: VSP technology has enabled surgeons to replace like with like to achieve better outcomes with acceptable morbidity for maxillary defects. IDIP provides all patients an opportunity for a fixed prosthesis even though not all complete the process. This maxillary reconstruction workflow can be safely accomplished in oncologic patients with promising and effective early results.

Breast Conserving Therapy Preserves Sexual Well-Being More Than Postmastectomy Breast Reconstruction: Trends, Factors, and Interventions.

BACKGROUND: Up to 85% of breast cancer patients report sexual health concerns, but their concerns are not adequately addressed by providers. Sexual dysfunction among breast cancer patients remains understudied. We aimed to investigate the impact of breast-conserving therapy (BCT) and postmastectomy breast reconstruction (PMBR) on the sexual health of breast cancer patients and frequency of sexual medicine consultation in postoperative care. METHODS: We conducted a retrospective analysis of patients who underwent BCT or PMBR and completed the Sexual Well-being of the BREAST-Q BCT and Reconstruction modules from January 2010 to October 2022. We compared Sexual Well-being scores between BCT and PMBR patients overtime up to 5-years postoperatively, delineated associated demographic and clinical factors with Sexual Well-being, and evaluated the frequency of sexual medicine consultations. RESULTS: Of 15,857 patients, 8,510 (53.7%) underwent BCT and 7,347 (46.3%) underwent PMBR. PMBR patients had significantly lower Sexual Well-being scores than BCT patients from preoperative to 5-year postoperative. Regression analyses showed that PMBR patients scored 7.6 points lower at 1-year than BCT patients. Separated marital status, higher body mass index, cardiovascular disease, hyperlipidemia, psychiatric diagnosis, and neoadjuvant chemotherapy were associated with significantly lower Sexual Well-being. 299 (3.5%) of BCT and 400 (5.4%) of PMBR patients received sexual medicine consultations. CONCLUSION: Sexual health concerns must be considered in breast cancer care, particularly among patients who undergo PMBR. Although many patients experience sexual dysfunction, most do not receive a sexual medicine consultation, suggesting an opportunity for providers to improve breast cancer patients' sexual health.

Impact of Mastectomy Flap Necrosis on Patient-Reported Quality-of-Life Measures After Nipple-Sparing Mastectomy: A Preliminary Analysis.

BACKGROUND: Mastectomy skin flap necrosis (SFN) is common following nipple-sparing mastectomy (NSM), but studies on its quality-of-life (QOL) impact are limited. We examined patient-reported QOL and satisfaction after NSM with/without SFN utilizing the BREAST-Q patient-reported outcome measure (PROM) survey. PATIENTS AND METHODS: Patients undergoing NSM between April 2018 and July 2021 at our institution were examined; the BREAST-Q PROM was administered preoperatively, and at 6 months and 1 year postoperatively. SFN extent/severity was documented at 2-3 weeks postoperatively; QOL and satisfaction domains were compared between patients with/without SFN. RESULTS: A total of 573 NSMs in 333 patients were included, and 135 breasts in 82 patients developed SFN (24% superficial, 56% partial thickness, 16% full thickness). Patients with SFN reported significantly lower scores in the satisfaction with breasts (p = 0.032) and psychosocial QOL domains (p = 0.009) at 6 months versus those without SFN, with scores returning to baseline at 1 year in both domains. In the "physical well-being-of-the-chest" domain, there was an overall decline in scores among all patients; however, there were no significant differences at any time point between patients with or without SFN. Sexual well-being scores declined for patients with SFN compared with those without at 6 months and also at 1 year, but this did not reach significance (p = 0.13, p = 0.2, respectively). CONCLUSIONS: Patients undergoing NSM who developed SFN reported significantly lower satisfaction and psychosocial well-being scores at 6 months, which returned to baseline by 1 year. Physical well-being of the chest significantly declines after NSM regardless of SFN. Future studies with larger sample sizes and longer follow-up are needed to determine SFN's impact on long-term QOL.

Breast-Conserving Therapy Versus Postmastectomy Breast Reconstruction: Propensity Score-Matched Analysis.

BACKGROUND: Although studies have compared patient-reported outcomes (PROs) after breast conserving-therapy (BCT) and postmastectomy breast reconstruction (PMBR), they often have been confounded by treatment or other factors that complicate a direct comparison. This study aimed to compare PROs after BCT and PMBR by using propensity score-matching analysis. METHODS: Patients who underwent BCT or PMBR between 2010 and 2022 and completed the BREAST-Q were identified. Each BCT patient was matched to a PMBR patient using nearest-neighbor 1:1 matching with replacement for each BREAST-Q time point. Outcomes included all prospectively collected BREAST-Q domains preoperatively, at 6 months, and at 1, 2, and 3 years postoperatively. A 4-point difference was considered clinically meaningful. RESULTS: For this study, 6215 patients (2501 BCT [40.2%] and 3714 PMBR [59.8%] patients) were eligible, and 2616 unique patients were matched. Preoperatively, 463 BCT and 463 PMBR patients were matched for analysis (6 months [443 matched pairs], 1 year [639 matched pairs], 2 years [421 matched pairs], 3 years [254 matched pairs]). At 6 months postoperatively, the BCT patients scored higher on all BREAST-Q domains than the PMBR patients (p < 0.05; differences > 4 points). At 1, 2, and 3 years, the patients who underwent BCT consistently had superior Satisfaction With Breasts, Psychosocial Well-Being, and Sexual Well-Being (p < 0.05), and the differences were clinically meaningful. CONCLUSION: In this statistically powered study, the BCT patients reported higher quality of life than the PMBR patients in early assessment and also through 3 years of follow-up evaluation. Given the equivalency in survival and recurrence outcomes between BCT and PMBR, patients eligible for either surgery should be counseled regarding the superiority of BCT in terms of PROs.

Contemporary Microsurgical Breast Reconstruction: Abdominally Based Flaps.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Understand the types of abdominally based flaps, their anatomy, and their drawbacks. 2. Understand important aspects of the history and physical examination of patients wishing to undergo these procedures. 3. Understand the benefits of preoperative planning and its role in avoiding complication. 4. Understand the operative steps of the procedures and tips to increase efficiency. 5. Understand the postoperative care of these patients and the role of enhanced recovery pathways. SUMMARY: In this article, the authors review the history, current state, and future directions related to abdominally based microsurgical breast reconstruction. This article covers preoperative, intraoperative, and postoperative considerations intended to improve patient outcomes and prevent complications. Evidence-based findings are reported when available to comprehensively review important aspects of these procedures.

Satisfaction with Breasts Following Autologous Reconstruction: Assessing Associated Factors and the Impact of Revisions.

BACKGROUND: Autologous breast reconstruction (ABR) may confer higher patient reported outcomes than implant breast reconstruction, but an in-depth examination of factors associated with satisfaction after ABR is lacking. We aimed to determine independent predictors of 1-year Satisfaction with Breasts after ABR and assess the importance of elective procedures on satisfaction. METHODS: A retrospective analysis of patients who underwent abdominal-based ABR between 2010 and 2021 and completed the BREAST-Q Satisfaction with Breasts module at 1-year was performed. Elective procedures comprised of breast revision and nipple areolar complex (NAC) reconstruction. RESULTS: 959 patients were included. Satisfaction with Breasts score improved from 53 (IQR: 44 to 64) preoperatively to 64 (53 to 78) at 1-year postoperatively (p<0.001). Factors significantly associated with decreased postoperative score included lower preoperative scores (ß=0.19 [95% CI: 0.08, 0.31], p=0.001), older age (ß=-0.17 [-0.34, -0.01], p=0.042), Asian race (versus White, ß=-6.7 [-12, -1.7], p=0.008), and a history of psychiatric diagnoses (ß=-3.4 [-6.2, -0.66], p=0.015). Patients who received radiation (ß=-5.6 [-9.0, -2.3], p=0.001) or had mastectomy skin flap/nipple necrosis (ß=-3.8 [-7.6, -0.06], p=0.046) also had significantly decreased scores. Satisfaction with Breasts significantly improved after breast revision procedures (54 [42 to 65] to 65 [54 to 78], p<0.001) and NAC reconstruction (58 [47 to 71] to 67 [57 to 82], p<0.001). CONCLUSION: Multiple independent patient and treatment level factors are associated with lower 1-year Satisfaction with Breasts following ABR. Elective procedures have the potential to improve satisfaction. Understanding these findings is imperative for optimizing clinical decision making and managing expectations.

Increased Time Interval of Postoperative Flap Monitoring After Autologous Breast Reconstruction.

BACKGROUND: Hourly flap checks are the most common means of flap monitoring during the first 24 hours following autologous breast reconstruction (ABR). This practice often requires intensive care unit (ICU) admission, which is a key driver of health care costs and decreased patient satisfaction. This study addresses these issues by demonstrating decreased cost and length of admission associated with a 4-hour interval between flap checks during the first 24 hours following ABR. METHODS: This is a retrospective review of ABR surgeries performed by multiple surgeons from 2017 to 2020. Two cohorts were identified, one that underwent flap checks every hour in the ICU (Q1 cohort) and the other that underwent flap checks every 4 hours on the hospital floor (Q4 cohort). Our primary outcome measures were length of stay (LOS), flap takebacks, flap loss, and encounter cost. RESULTS: Rates of flap takeback and loss did not differ between cohorts (P = 0.18, P = 0.21). The Q4 cohort's average LOS was shorter than the Q1 cohort (P = 0.002). The Q4 cohort's average cost was also $25,554.80 less than the Q1 cohort (P < 0.001). This association persisted after controlling for LOS, operating room takeback, timing and laterality of reconstruction, and flap configuration (hazard ratio = 0.65, P = 0.0007). CONCLUSION: This study demonstrates the benefits of lengthened flap check intervals during the first 24 hours following ABR. These intervals decrease the cost of ABR while also maintaining safety, making ABR a more accessible option for breast reconstruction patients.