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BACKGROUND: Frailty is associated with higher risk of complications following breast reconstruction, but its impact on long-term surgical and patient-reported outcomes has not been investigated. We examined the association of the five-item modified frailty index (MFI) score with long-term surgical and patient-reported outcomes in autologous breast reconstruction. PATIENTS AND METHODS: We conducted a retrospective cohort study of consecutive patients who underwent mastectomy and autologous breast reconstruction between January 2016 and April 2022. Primary outcome was any flap-related complication. Secondary outcomes were patient-reported outcomes and predictors of complications in the frail cohort. RESULTS: We identified 1640 reconstructions (mean follow-up 24.2 ± 19.2 months). In patients with MFI ≥ 2, the odds of surgical [odds ratio (OR) 2.13, p = 0.023] and medical (OR 17.02, p < 0.001) complications were higher than in nonfrail patients. We found no significant difference in satisfaction with the breast (p = 0.287), psychosocial well-being (p = 0.119), or sexual well-being (p = 0.314) according to MFI score. Chronic obstructive pulmonary disease was an independent predictor of infection (OR 3.70, p = 0.002). Tobacco use (OR 7.13, p = 0.002) and contralateral prophylactic mastectomy (OR 2.36, p = 0.014) were independent predictors of wound dehiscence. Dependent functional status (OR 2.36, p = 0.007) and immediate reconstruction (compared with delayed reconstruction; OR 3.16, p = 0.026) were independent predictors of skin flap necrosis. Dependent functional status was also independently associated with higher odds of reoperation (OR 2.64, p = 0.011). CONCLUSION: Frailty is associated with higher risk of complications in breast reconstruction, but there is no significant difference in long-term patient-reported outcomes. MFI should be considered in breast reconstruction to improve outcomes in high-risk frail patients.
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Neoplasias da Mama , Fragilidade , Mamoplastia , Humanos , Idoso , Feminino , Mastectomia/efeitos adversos , Estudos Retrospectivos , Fragilidade/complicações , Neoplasias da Mama/cirurgia , Idoso Fragilizado , Mamoplastia/efeitos adversos , Mamoplastia/psicologia , Complicações Pós-Operatórias/etiologia , Resultado do Tratamento , Medidas de Resultados Relatados pelo PacienteRESUMO
BACKGROUND: Abdominal wall reconstruction (AWR) is a treatment option for structural defects of the abdominal wall. The most frequently cited publications related to AWR have not been quantitatively or qualitatively assessed. This bibliometric analysis characterizes and assesses the most frequently cited AWR publications, to identify trends, gaps, and guide future efforts for the international research community. METHODS: The 100 most cited publications in AWR were identified on Web of Science, across all available journal years (from May 1964 to December 2023). Study details, including the citation count, main content focus, and outcome measures, were extracted and tabulated from each publication. Oxford Centre for Evidence-Based Medicine levels of evidence (LOE) of each study were also assessed. RESULTS: The 100 most cited publications in AWR were cited by a total of 9674 publications. Citations per publication ranged from 43 to 414 (mean 96.7 ± 52.48). Most publications were LOE 3 (n = 60), representative of the large number of retrospective cohort studies. The number of publications for LOE 5, 4, 3, 2, and 1 was 21, 2, 60, 2, and 12, respectively. The main content focus was surgical technique in 44 publications followed by outcomes in 38 publications. Patient-reported outcome measures were used in 3 publications, and no publications reported validated esthetic outcome measures. CONCLUSIONS: Overall, 3 was the LOE for most frequently cited AWR publications, with more publications below LOE 3 than above LOE 3. Validated outcome measures and patient-reported outcome measures were infrequently incorporated in the studies evaluated.
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OBJECTIVE: To determine if global budget revenue (GBR) models incent the centralization of complex surgical care. SUMMARY BACKGROUND: In 2014, Maryland initiated a statewide GBR model. While prior research has shown improvements in cost and outcomes for surgical care post-GBR implementation, the mechanism remains unclear. METHODS: Utilizing state inpatient databases, we compared the proportion of adults undergoing elective complex surgeries (gastrectomy, pneumonectomy/lobectomy, proctectomies, and hip/knee revision) at high-concentration hospitals (HCHs) in Maryland and control states. Annual concentration, per procedure, was defined as hospital volume divided by state volume. HCHs were defined as hospitals with a concentration at least at the 75 th percentile in 2010. We estimated the difference-in-differences (DiD) of the probability of patients undergoing surgery at HCHs before and after GBR implementation. FINDINGS: Our sample included 122,882 surgeries. Following GBR implementation, all procedures were increasingly performed at HCHs in Maryland. States satisfied the parallel trends assumption for the centralization of gastrectomy and pneumonectomy/lobectomy. Post-GBR, patients were more likely to undergo gastrectomy (DiD: 5.5 p.p., 95% CI [2.2, 8.8]) and pneumonectomy/lobectomy (DiD: 12.4 p.p., 95% CI [10.0, 14.8]) at an HCH in Maryland compared with control states. For our hip/knee revision analyses, we assumed persistent counterfactuals and noted a positive DiD post-GBR implementation (DiD: 4.8 p.p., 95% CI [1.3, 8.2]). No conclusion could be drawn for proctectomy due to different pre-GBR trends. CONCLUSIONS: GBR implementation is associated with increased centralization for certain complex surgeries. Future research is needed to explore the impact of centralization on patient experience and access.
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Hospitais , Pacientes Internados , Adulto , Humanos , MarylandRESUMO
OBJECTIVE: To develop, validate, and evaluate ML algorithms for predicting MSFN. BACKGROUND: MSFN is a devastating complication that causes significant distress to patients and physicians by prolonging recovery time, compromising surgical outcomes, and delaying adjuvant therapy. METHODS: We conducted comprehensive review of all consecutive patients who underwent mastectomy and immediate implant-based reconstruction from January 2018 to December 2019. Nine supervised ML algorithms were developed to predict MSFN. Patient data were partitioned into training (80%) and testing (20%) sets. RESULTS: We identified 694 mastectomies with immediate implant-based reconstruction in 481 patients. The patients had a mean age of 50 ± 11.5 years, years, a mean body mass index of 26.7 ± 4.8 kg/m 2 , and a median follow-up time of 16.1 (range, 11.9-23.2) months. MSFN developed in 6% (n = 40) of patients. The random forest model demonstrated the best discriminatory performance (area under curve, 0.70), achieved a mean accuracy of 89% (95% confidence interval, 83-94), and identified 10 predictors of MSFN. Decision curve analysis demonstrated that ML models have a superior net benefit regardless of the probability threshold. Higher body mass index, older age, hypertension, subpectoral device placement, nipple-sparing mastectomy, axillary nodal dissection, and no acellular dermal matrix use were all independently associated with a higher risk of MSFN. CONCLUSIONS: ML algorithms trained on readily available perioperative clinical data can accurately predict the occurrence of MSFN and aid in individualized patient counseling, preoperative optimization, and surgical planning to reduce the risk of this devastating complication.
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Neoplasias da Mama , Mamoplastia , Humanos , Adulto , Pessoa de Meia-Idade , Feminino , Mastectomia/efeitos adversos , Mamoplastia/efeitos adversos , Neoplasias da Mama/cirurgia , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Medição de Risco , Necrose , Estudos RetrospectivosRESUMO
BACKGROUND: Outcomes studies for abdominal wall reconstruction (AWR) in the setting of previous oncologic extirpation are lacking. We sought to evaluate long-term outcomes of AWR using acellular dermal matrix (ADM) after extirpative resection, compare them to primary herniorrhaphy, and report the rates and predictors of postoperative complications. METHODS: We conducted a retrospective cohort study of patients who underwent AWR after oncologic resection from March 2005 to June 2019 at a tertiary cancer center. The primary outcome was hernia recurrence (HR). Secondary outcomes included surgical site occurrences (SSOs), surgical site infection (SSIs), length of hospital stay (LOS), reoperation, and 30-day readmission. RESULTS: Of 720 consecutive patients who underwent AWR during the study period, 194 (26.9%) underwent AWR following resection of abdominal wall tumors. In adjusted analyses, patients who had AWR after extirpative resection were more likely to have longer LOS (ß, 2.57; 95%CI, 1.27 to 3.86, p < 0.001) than those with primary herniorrhaphy, but the risk of HR, SSO, SSI, 30-day readmission, and reoperation did not differ significantly. In the extirpative cohort, obesity (Hazard ratio, 6.48; p = 0.003), and bridged repair (Hazard ratio, 3.50; p = 0.004) were predictors of HR. Radiotherapy (OR, 2.23; p = 0.017) and diabetes mellites (OR, 3.70; p = 0.005) were predictors of SSOs. Defect width (OR, 2.30; p < 0.001) and mesh length (OR, 3.32; p = 0.046) were predictors of SSIs. Concomitant intra-abdominal surgery for active disease was not associated with worse outcomes. CONCLUSIONS: AWR with ADM following extirpative resection demonstrated outcomes comparable with primary herniorrhaphy. Preoperative risk assessment and optimization are imperative for improving outcomes.
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Parede Abdominal , Hérnia Ventral , Humanos , Parede Abdominal/cirurgia , Hérnia Ventral/cirurgia , Estudos Retrospectivos , Resultado do Tratamento , Recidiva Local de Neoplasia/cirurgia , Recidiva Local de Neoplasia/complicações , Herniorrafia/efeitos adversos , Infecção da Ferida Cirúrgica/etiologia , Infecção da Ferida Cirúrgica/cirurgia , Telas Cirúrgicas/efeitos adversos , RecidivaRESUMO
BACKGROUND: While many studies evaluated outcomes of abdominal wall reconstruction with biologic mesh, long-term data is lacking. In this study, we sought to analyze the outcomes of complex AWR with biologic mesh in a robust cohort of patients with a mean follow up of 8 years. METHODS: We conducted a longitudinal study of AWR patients from 2005 to 2019. Hernia recurrence was the primary outcome, and surgical site occurrence was the secondary outcome. Predictive/protective factors were identified using a Cox proportional hazards regression models. RESULTS: We identified 109 consecutive patients who met the inclusion criteria. Patient's mean (± SD) age was 57.5 ± 11.8 years, mean body mass index was 30.7 ± 7.2 kg/m2, and mean follow-up time was 96.2 ± 15.9 months. Fifty-six percent had clean defects, 34% had clean-contaminated defects, and 10% had contaminated/infected defects. Patients had a mean defect size of 261 ± 199.6 cm2 and mean mesh size of 391.3 ± 160.2 cm2. Nineteen patients (17.4%) developed HR at the final follow-up date. Obesity was independently associated with a four-fold higher risk of HR (hazard ratio, 3.98; 95%CI, 1.34 to 14.60, p = 0.02). SSOs were identified in 24.8% of patients. A prior hernia repair was associated with a three-fold higher risk of SSOs (Odds ratio, 3.13; 95%CI, 1.10 to 8.94, p = 0.03). No patient developed mesh infection. CONCLUSION: These longitudinal data demonstrate that complex AWR with biologic mesh provides long-term durable outcomes with acceptable HR and SSO rates despite high contamination levels, patients complexity, and large defect size.
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Parede Abdominal , Produtos Biológicos , Hérnia Ventral , Humanos , Pessoa de Meia-Idade , Idoso , Parede Abdominal/cirurgia , Hérnia Ventral/cirurgia , Seguimentos , Estudos Longitudinais , Telas Cirúrgicas , Resultado do Tratamento , Estudos Retrospectivos , Modelos Logísticos , Herniorrafia , RecidivaRESUMO
BACKGROUND: Following implant-based breast reconstruction (IBR) infection and explantation, autologous reconstruction is a common option for patients who desire further reconstruction. However, few data exist about the outcomes of secondary autologous reconstruction (i.e., free flap breast reconstruction) in this population. We hypothesized that autologous reconstruction following infected device explantation is safe and has comparable surgical outcomes to delayed-immediate reconstruction. METHODS: We conducted a retrospective analysis of patients who underwent IBR explantation due to infection from 2006 through 2019, followed by secondary autologous reconstruction. The control cohort comprised patients who underwent planned primary delayed-immediate reconstruction (tissue expander followed by autologous flap) in 2018. RESULTS: We identified 38 secondary autologous reconstructions after failed primary IBR and 52 primary delayed-immediate reconstructions. Between secondary autologous and delayed-immediate reconstructions, there were no significant differences in overall complications (29 and 37%, respectively, p = 0.45), any breast-related complications (18 and 21%, respectively, p = 0.75), or any major breast-related complications (13 and10%, respectively, p = 0.74). Two flap losses were identified in the secondary autologous reconstruction group while no flap losses were reported in the delayed-immediate reconstruction group (p = 0.18). CONCLUSION: Autologous reconstruction is a reasonable and safe option for patients who require explantation of an infected prosthetic device. Failure of primary IBR did not confer significantly higher risk of complications after secondary autologous flap reconstruction compared with primary delayed-immediate reconstruction. This information can help plastic surgeons with shared decision-making and counseling for patients who desire reconstruction after infected device removal.
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Implantes de Mama , Neoplasias da Mama , Retalhos de Tecido Biológico , Mamoplastia , Humanos , Feminino , Implantes de Mama/efeitos adversos , Remoção de Dispositivo/efeitos adversos , Estudos Retrospectivos , Retalhos de Tecido Biológico/cirurgia , Mamoplastia/efeitos adversos , Complicações Pós-Operatórias/cirurgia , Complicações Pós-Operatórias/etiologia , Neoplasias da Mama/cirurgia , Neoplasias da Mama/complicaçõesRESUMO
BACKGROUND: The impact of obesity on outcomes of prepectoral vs subpectoral implant-based reconstruction (IBR) is not well-established. OBJECTIVES: The goal of this study was to assess the surgical and patient-reported outcomes of prepectoral vs subpectoral IBR. The authors hypothesized that obese patients would have similar outcomes regardless of device plane. METHODS: We conducted a retrospective review of obese patients who underwent 2-stage IBR from January 2017 to December 2019. The primary endpoint was the occurrence of any breast-related complication; the secondary endpoint was device explantation. RESULTS: The authors identified a total of 284 reconstructions (184 prepectoral, 100 subpectoral) in 209 patients. Subpectoral reconstruction demonstrated higher rates of overall complications (50% vs 37%, P = .047) and device explantation (25% vs 12.5%, P = .008) than prepectoral reconstruction. In multivariable regression, subpectoral reconstruction was associated with higher risk of infection (hazard ratio [HR], 1.65; P = .022) and device explantation (HR, 1.97; P = .034). Subgroup analyses demonstrated significantly higher rates of complications and explantation in the subpectoral group in those with a body mass index (BMI) ≥ 35 and BMI ≥40. The authors found no significant differences in mean scores for satisfaction with the breast (41.57 ± 13.19 vs 45.50 ± 11.91, P = .469), psychosocial well-being (39.43 ± 11.23 vs 39.30 ± 12.49, P = .915), and sexual well-being (17.17 ± 7.83 vs 17.0 ± 9.03, P = .931) between subpectoral and prepectoral reconstruction. CONCLUSIONS: Prepectoral reconstruction was associated with significantly decreased overall complications, infections, and device explantation in obese patients compared with subpectoral reconstruction. Prepectoral reconstruction provides superior outcomes to subpectoral reconstruction with comparable patient-reported outcomes.
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Implante Mamário , Implantes de Mama , Neoplasias da Mama , Mamoplastia , Humanos , Feminino , Implante Mamário/efeitos adversos , Implantes de Mama/efeitos adversos , Reoperação , Obesidade/complicações , Estudos Retrospectivos , Neoplasias da Mama/cirurgia , Neoplasias da Mama/etiologiaRESUMO
BACKGROUND: Mastectomy skin flap necrosis (MSFN) is a common complication following mastectomy that causes significant distress to patients and physicians and also compromises oncologic, surgical, and quality-of-life outcomes. OBJECTIVES: We sought to investigate the long-term outcomes of MSFN following implant-based reconstruction (IBR) and determine the rates and predictors of post-MSFN complications. METHODS: This was a 20-year analysis of consecutive adult (>18 years) patients who developed MSFN following mastectomy and IBR from January 2001 to January 2021. Multivariable analyses were performed to identify factors associated with post-MSFN complications. RESULTS: We identified 148 reconstructions, with a mean follow-up time of 86.6 ± 52.9 months. The mean time from reconstruction to MSFN was 13.3 ± 10.4 days, and most cases (n = 84, 56.8%) were full-thickness injuries. Most cases (63.5%) were severe, 14.9% were moderate, and 21.6% were mild. Forty-six percent (n = 68) developed a breast-related complication, with infection being the most common (24%). An independent predictor of overall complications was longer time from reconstruction to MSFN (odds ratio [OR], 1.66; P = .040). Aging was an independent predictor of overall complications (OR, 1.86; P = .038); infection (OR, 1.72; P = .005); and dehiscence (OR, 6.18; P = .037). Independent predictors of dehiscence were longer interval from reconstruction to MSFN (OR, 3.23; P = .018) and larger expander/implant size (OR, 1.49; P = .024). Independent predictors of explantation were larger expander/implant size (OR, 1.20; P = .006) and nipple-sparing mastectomy (OR, 5.61; P = .005). CONCLUSIONS: MSFN is associated with high risk of complications following IBR. Awareness of the timing and severity of MSFN and the predictors of post-MSFN complications is crucial for guiding evidence-based decision-making and improving outcomes.
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BACKGROUND: Ventral hernia repair (VHR) is one of the most commonly performed procedures in the United States, but studies assessing the long-term outcomes of VHR using biologic mesh are scarce. OBJECTIVE: We sought to determine the rates of hernia recurrence (HR) and surgical site occurrences (SSOs) in a large cohort of patients who underwent AWR with biologic mesh. METHODS: We conducted a retrospective cohort study of patients who underwent AWR using either porcine ADM (PADM) or bovine ADM (BADM) from 2005 to 2019. We analyzed the full cohort and a subset of our population with minimum long-term follow-up (LTF) of 5 years. The primary outcome measure was HR. Secondary outcomes were SSOs. RESULTS: We identified a total of 725 AWRs (49.5% PADM, 50.5% BADM). Mean age was 69 ± 11.5 years and mean body mass index was 31 ± 7 kg/m 2 . Forty-two percent of the defects were clean at the time of AWR, 44% were clean-contaminated, and 14% were contaminated/infected. Mean defect size was 180 ± 174 cm 2 , mean mesh size was 414 ± 203 cm 2 . Hernia recurred in 93 patients (13%), with cumulative HR rates of 4.9%, 13.5%, 17.3%, and 18.8% at 1, 3, 5, and 7 years, respectively. There were no differences in HR ( P = 0.83) and SSO ( P = 0.87) between the 2 mesh types. SSOs were identified in 27% of patients. In our LTF group (n = 162), the HR rate was 16%. Obesity, bridged repair, and concurrent stoma presence/creation were independent predictors of HR; component separation was protective against HR. CONCLUSIONS: Despite its use in complex AWR, ADM provides durable long-term outcomes with relatively low recurrence rates.
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Parede Abdominal , Derme Acelular , Produtos Biológicos , Hérnia Ventral , Parede Abdominal/cirurgia , Animais , Bovinos , Seguimentos , Hérnia Ventral/cirurgia , Herniorrafia/métodos , Recidiva Local de Neoplasia/cirurgia , Recidiva , Estudos Retrospectivos , Telas Cirúrgicas , Suínos , Resultado do TratamentoRESUMO
OBJECTIVE: We sought to evaluate patients at a single academic institution in a prospective manner to report patient presentation, clinical course, treatment, and outcomes in breast implant ALCL patients. BACKGROUND: Breast implant-associated anaplastic large cell lymphoma (breast implant ALCL) is an uncommon T cell lymphoma, which is associated with textured surface breast implants. The disease has received increasing attention over the last 20 years. Previous retrospective studies have begun to outline the clinical course of breast implant ALCL. METHODS: We prospectively followed women with cytologically proven breast implant ALCL from 2014 to 2019. Demographic, clinical, treatment, and outcome data were collected and descriptive statistics were performed on variables of interest. RESULTS: We identified 52 women with pathologically confirmed breast implant ALCL. Implants were placed for augmentation in 61.5% of women and reconstruction in 36.5% of women. All of the 41 patients with known implant information had implants with textured surface. The majority of patients presented with delayed seroma (69.2%) and without systemic symptoms (86.5%). Most patients with staging information presented with Stage IA disease. Patient outcomes were excellent with 2 disease recurrence (3.8%) and all patients ultimately achieved complete remission. CONCLUSIONS: Further evaluation of the prospective and growing database of patients with breast implant ALCL will further improve our understanding of the disease and its clinical course. Robust participation in the breast implant ALCL PROFILE registry will improve our knowledge of long-term outcomes after implant placement. Finally, increasing awareness for patients and providers will lead to earlier diagnosis and improved outcomes for patients.
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Implantes de Mama/efeitos adversos , Neoplasias da Mama/etiologia , Mamoplastia/efeitos adversos , Complicações Pós-Operatórias/etiologia , Adulto , Idoso , Biópsia , Neoplasias da Mama/diagnóstico , Feminino , Seguimentos , Humanos , Linfoma Anaplásico de Células Grandes/diagnóstico , Pessoa de Meia-Idade , Complicações Pós-Operatórias/diagnóstico , Estudos Prospectivos , Fatores de TempoRESUMO
PURPOSE: Telemedicine use during the COVID-19 pandemic among financially distressed patients with cancer, with respect to the determinants of adoption and patterns of utilization, has yet to be delineated. We sought to systematically characterize telemedicine utilization in financially distressed patients with cancer during the COVID-19 pandemic. METHODS: We conducted a cross-sectional analysis of nationwide survey data assessing telemedicine use in patients with cancer during the COVID-19 pandemic collected by Patient Advocate Foundation (PAF) in December 2020. Patients were characterized as financially distressed by self-reporting limited financial resources to manage out-of-pocket costs, psychological distress, and/or adaptive coping behaviors. Primary study outcome was telemedicine utilization during the pandemic. Secondary outcomes were telemedicine utilization volume and modality preferences. Multivariable and Poisson regression analyses were used to identify factors associated with telemedicine use. RESULTS: A convenience sample of 627 patients with cancer responded to the PAF survey. Telemedicine adoption during the pandemic was reported by 67% of patients, with most (63%) preferring video visits. Younger age (19-35 age compared to ≥ 75 age) (OR, 6.07; 95% CI, 1.47-25.1) and more comorbidities (≥ 3 comorbidities compared to cancer only) (OR, 1.79; 95% CI, 1.13-2.65) were factors associated with telemedicine adoption. Younger age (19-35 years) (incidence rate ratios [IRR], 1.78; 95% CI, 24-115%) and higher comorbidities (≥ 3) (IRR; 1.36; 95% CI, 20-55%) were factors associated with higher utilization volume. As area deprivation index increased by 10 units, the number of visits decreased by 3% (IRR 1.03, 95% CI, 1.03-1.05). CONCLUSIONS: The rapid adoption of telemedicine may exacerbate existing inequities, particularly among vulnerable financially distressed patients with cancer. Policy-level interventions are needed for the equitable and efficient provision of this service.
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COVID-19 , Neoplasias , Telemedicina , Adulto , Estudos Transversais , Humanos , Neoplasias/terapia , Pandemias , Telemedicina/métodos , Adulto JovemRESUMO
BACKGROUND: As more plastic surgery clinicians pursue advanced degrees and strive to become stronger physician-scientists, an objective understanding of how such degrees influence careers becomes important. We hypothesized that having a master's degree is associated with higher scholarly activity, research funding, academic progression, and leadership appointments. METHODS: Accreditation Council for Graduate Medical Education-accredited integrated plastic surgery residency program Web sites were queried to create a data set of current academic plastic surgeons (APSs) and plastic surgery residents (PSRs). Scholarly metrics such as publications, citations, and H-indices were extracted from the Scopus database. National Institutes of Health and Plastic Surgery Foundation funding information was collected through their respective Web sites. RESULTS: Our cohort comprised 799 APSs and 922 PSRs, of whom 8% and 7.4%, respectively, had at least one master's degree. Academic plastic surgeons with master's of public health degrees had a significantly higher median number of publications and citations than APSs without a master's of public health. There was no association between any master's degree and academic rank or being a department chairman or program director. Academic plastic surgeons with master of science degrees were more likely to receive National Institutes of Health grants. Among PSRs, master's of science graduates had a higher median number of publications. Other master's degrees did not significantly influence scholarly productivity or funding. CONCLUSIONS: Certain master's degrees had an impact on scholarly productivity, with no significant effect on academic rank or leadership positions. The value of master's degrees in programs focusing on healthcare management, leadership skills, and business acumen likely extends beyond the scope of this study.
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Cirurgiões , Cirurgia Plástica , Estados Unidos , Humanos , National Institutes of Health (U.S.) , Eficiência , BibliometriaRESUMO
BACKGROUND: The role of physicians in dampening health care costs is a renewed focus of policy-makers. We examined provider- and practice-level factors affecting four domains of cost-consciousness among plastic surgeons performing breast reconstruction. METHODS: Secondary analysis was performed on the survey responses of 329 surgeons who routinely performed breast reconstruction. Using a 5-point Likert scale, we queried four domains of cost-consciousness: out-of-pocket cost awareness, cost discussions, cognizance of patients' financial burden, and attitudes regarding cost discussions. Multivariable linear regression was performed to identify provider- and practice-level factors affecting these domains according to composite scores. RESULTS: Overall cost-consciousness scores (CS) were moderate and ranged from 2.14 to 4.30. There were no significant differences across practice settings. Male gender (p = 0.048), Hispanic ethnicity (p = 0.021), and increasing clinical experience (p = 0.015) were associated with higher out-of-pocket cost awareness. Increasing surgeon experience was also associated with having cost discussions (p = 0.039). No provider- or practice-level factors were associated with cognizance of patients' financial burden. Salaried physicians displayed a more positive attitude toward out-of-pocket cost discussions (p = 0.049). On pairwise testing, the out-of-pocket cost awareness was significantly different between Hispanic surgeons and white surgeons (4.30 vs. 3.55), and between surgeons with more than 20 years' experience and with less than 5 years' experience (3.87 vs. 3.37). CONCLUSIONS: Surgeon gender, ethnicity, and experience and practice compensation type inform various domains of cost-consciousness in breast reconstruction. Structural and behavioral interventions could possibly increase physicians' cost-consciousness.
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Neoplasias da Mama , Mamoplastia , Cirurgiões , Neoplasias da Mama/epidemiologia , Neoplasias da Mama/cirurgia , Estado de Consciência , Humanos , Masculino , Padrões de Prática Médica , Inquéritos e Questionários , Estados Unidos/epidemiologiaRESUMO
BACKGROUND: Despite growing national attention, there is limited understanding of the patient- and treatment-level characteristics related to treatment cost-associated distress ("financial toxicity") in breast cancer patients. Our aim is to identify risk factors for financial toxicity amongst breast cancer patients undergoing surgical treatment. METHODS: This is a single-institution cross-sectional survey of adult female breast cancer patients who underwent lumpectomy or mastectomy between January 2018 and June 2019. Financial toxicity was measured via the 11-item comprehensive score for financial toxicity (COST) instrument. Responses were linked with data on patient demographics and clinical history abstracted from the corresponding medical record. Multivariate regression was used to identify patient- and treatment-level factors associated with worsening financial toxicity. Secondary outcome measures included self-reported coping strategies for high treatment costs. RESULTS: A total of 571 patients were included; overall, these individuals were mostly white (76.0%), in-state residents (72.3%), and married (73.0%). Following multivariate analysis, lower financial distress was associated with the use of supplemental insurance, increasing annual household income, and a higher credit score (score > 740). Conversely, work reduction or cessation, increased out-of-pocket spending, advanced tumor stage, and being employed at the time of diagnosis were associated with increased financial distress. Patients with higher reported financial distress were more likely to decrease their spending on food, clothing, and leisure activities. CONCLUSIONS: Financial toxicity was associated with baseline demographic, disease, and treatment characteristics in our cohort of insured patients. These characteristics may be critical opportunities for interventions related to financial navigation along the treatment continuum.
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Neoplasias da Mama , Adulto , Neoplasias da Mama/cirurgia , Efeitos Psicossociais da Doença , Estudos Transversais , Feminino , Gastos em Saúde , Humanos , Mastectomia , Projetos PilotoRESUMO
Autologous fat grafting (AFG) serves as an effective method to address volume defects, contour irregularities, and asymmetry in both aesthetic and reconstructive procedures. In recent years, there has been growing concern about the potential of cancer recurrence and interference with cancer surveillance in oncologic patients receiving AFG. The adipose tissue contains adipose-derived stem cells (ASCs), a specific type of mesenchymal stem cells, that facilitate secretion of numerous growth factors which in turn stimulate tissue regeneration and angiogenesis. As such, it has been theorized that ASCs may also have the potential to stimulate cancer cell proliferation and growth when used in oncologic patients. Multiple research studies have demonstrated the ability of ACSs to facilitate tumor proliferation in animal models. However, clinical research in oncologic patients has yielded contradictory findings. Although the literature pertaining to oncologic safety in head and neck, as well as sarcoma, cancer patients remains limited, studies demonstrate no increased risk of tumor recurrence in these patient populations receiving AFG. Similarly, both the efficacy and safety of AFG have been well established in breast cancer patients through numerous clinical studies. More recently, preclinical research in animal models has shown that AFG has the potential to facilitate tissue regeneration and improve joint contracture following irradiation. Ultimately, further research is needed to elucidate the safety of AFG in a variety of oncologic patients, as well as explore its use in tissue regeneration, particularly in the setting of radiotherapy. Level of Evidence: 4.
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Neoplasias da Mama , Mamoplastia , Tecido Adiposo , Neoplasias da Mama/cirurgia , Humanos , Recidiva Local de Neoplasia , Transplante AutólogoRESUMO
BACKGROUND: The use of autologous fat grafting (AFG) is becoming increasingly common as an adjunct to breast reconstruction. However, there is a paucity of data comparing the varying processing devices. OBJECTIVES: The goal of this study was to compare the outcomes of 2 commercially available AFG processing devices. METHODS: A retrospective review was conducted of patients who underwent AFG with dual-filter (Puregraft) or single-filter (Revolve) processing systems between 2016 and 2019. Propensity score matching was utilized to adjust for confounding. A total of 38 breasts from the Puregraft group were matched with 38 breasts from the Revolve group. RESULTS: Matching was successful in achieving a similar distribution of baseline characteristics between the 2 groups. The mean number of AFG sessions was comparable between the 2 groups (Pâ =â 0.37) with a similar median total volume (Puregraft, 159 mL vs Revolve, 130 mL; Pâ =â 0.23). Complication rates were similar between the 2 devices (Puregraft, 26%; Revolve, 18%; Pâ =â 0.47). Patients with at least 1 complication had higher overall AFG volume (median, 200 mL vs 130 mL; Pâ =â 0.03) and number of sessions (mean, 2.4 vs 1.8, Pâ =â 0.009) compared with those without any postoperative complication. CONCLUSIONS: Overall complication rates were comparable between 2 commonly used, commercially available AFG processing systems, and therefore the choice of which to use should be based on surgeon preference. Future studies are underway to decipher whether either system offers superior graft retention, cosmetic, or patient-reported outcomes.
Assuntos
Neoplasias da Mama , Mamoplastia , Tecido Adiposo , Feminino , Humanos , Mamoplastia/efeitos adversos , Pontuação de Propensão , Estudos Retrospectivos , Transplante AutólogoRESUMO
BACKGROUND: With the increased use of acellular dermal matrix (ADM) in breast reconstruction, the number of available materials has increased. There is a relative paucity of high-quality outcomes data for use of different ADMs. OBJECTIVES: The goal of this study was to compare the outcomes between a human (HADM) and a bovine ADM (BADM) in implant-based breast reconstruction. METHODS: A prospective, single-blinded, randomized controlled trial was conducted to evaluate differences in outcomes between HADM and BADM for patients undergoing immediate tissue expander breast reconstruction. Patients with prior radiation to the index breast were excluded. Patient and surgical characteristics were collected and analyzed. RESULTS: From April 2011 to June 2016, a total of 90 patients were randomized to a mesh group, with 68 patients (HADM, 36 patients/55 breasts; BADM, 32 patients/48 breasts) included in the final analysis. Baseline characteristics were similar between the 2 groups. No significant differences in overall complication rates were identified between HADM (n = 14, 25%) and BADM (n = 13, 27%) (P = 0.85). Similar trends were identified for major complications and complications requiring reoperation. Tissue expander loss was identified in 7% of HADM patients (n = 4) and 17% of BADM patients (n = 8) (P = 0.14). CONCLUSIONS: Similar complication and implant loss rates were found among patients undergoing immediate tissue expander breast reconstruction with HADM or BADM. Regardless of what material is used, careful patient selection and counseling, and cost consideration, help to improve outcomes and sustainability in immediate breast reconstruction.
Assuntos
Derme Acelular , Implante Mamário , Implantes de Mama , Neoplasias da Mama , Mamoplastia , Aloenxertos , Animais , Implante Mamário/efeitos adversos , Implantes de Mama/efeitos adversos , Neoplasias da Mama/cirurgia , Bovinos , Feminino , Xenoenxertos , Humanos , Mamoplastia/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Estudos Prospectivos , Telas Cirúrgicas/efeitos adversos , Dispositivos para Expansão de Tecidos/efeitos adversosRESUMO
BACKGROUND: Management of chest wall defects after oncologic resection is challenging due to multifactorial etiologies. Traditionally, skeletal stabilization in chest wall reconstruction (CWR) was performed with synthetic prosthetic mesh. The authors hypothesized that CWR for oncologic resection defects with acellular dermal matrix (ADM) is associated with a lower incidence of complications than synthetic mesh. METHODS: Consecutive patients who underwent CWR using synthetic mesh (SM) or ADM at a single center were reviewed. Only oncologic defects involving resection of at least one rib and reconstruction with both mesh and overlying soft tissue flaps were included in this study. Patients' demographics, treatment factors, and outcomes were prospectively documented. The primary outcome measure was surgical-site complications (SSCs). The secondary outcomes were specific wound-healing events, cardiopulmonary complications, reoperation, and mortality. RESULTS: This study investigated 146 patients [95 (65.1%) with SM; 51 (34.9%) with ADM] who underwent resection and CWR of oncologic defects. The mean follow-up period was 29.3 months (range 6-109 months). The mean age was 51.5 years, and the mean size of the defect area was 173.8 cm2. The SM-CWR patients had a greater number of ribs resected (2.7 vs. 2.0 ribs; p = 0.006) but a similar incidence of sternal resections (29.5% vs. 23.5%; p = 0.591) compared with the ADM-CWR patients. The SM-CWR patients experienced significantly more SSCs (32.6% vs. 15.7%; p = 0.027) than the ADM-CWR patients. The two groups had similar rates of specific wound-healing complications. No differences in mortality or reoperations were observed. CONCLUSIONS: The ADM-CWR patients experienced fewer SSCs than the SM-CWR patients. Surgeons should consider selectively using ADM for CWR, particularly in patients at higher risk for SSCs.
Assuntos
Derme Acelular , Parede Torácica , Humanos , Pessoa de Meia-Idade , Recidiva Local de Neoplasia , Procedimentos de Cirurgia Plástica , Estudos Retrospectivos , Telas Cirúrgicas , Parede Torácica/cirurgia , Resultado do TratamentoRESUMO
BACKGROUND AND OBJECTIVES: Sarcopenia is an objective measure of patient frailty and is a predictor of adverse surgical outcomes. We hypothesized that sarcopenia is associated with increased surgical site occurrence (SSO) and hernia occurrences in patients undergoing oncologic abdominal wall reconstruction. METHODS: Consecutive patients who underwent abdominal wall reconstruction (AWR) for an abdominal wall ablative defect at a single center from 2005 to 2015 were evaluated. The total psoas index (TPI) was used to define sarcopenia. The primary endpoint of the study was hernia occurrence; (SSO) was a secondary outcome measure. RESULTS: Eighty-six patients met the inclusion criteria. Multivariate analysis demonstrated that sarcopenia increased the risk of hernia more than threefold, trending toward significance (OR = 3.3; 95% CI: 0.69-15.4; P = .13). Multivariate logistic regression demonstrated that preoperative radiotherapy (OR = 4.8, 95% CI: 1.4-16; P = .01) and obesity (OR = 4.9, 95% CI: 1.5-16.3; P =.009) were independent predictors of developing an SSO. CONCLUSIONS: Sarcopenia, as defined by TPI, is correlated with hernia occurrence, but not SSO. These findings emphasize the importance of preoperative fitness and nutritional optimization and provide useful information for preoperative counseling and risk stratification.