A Single Institution Multi-disciplinary Approach to Power-assisted Liposuction for the Management of Lymphedema.

OBJECTIVE: To implement and evaluate outcomes from a comprehensive, multi-disciplinary debulking program in the United States. SUMMARY OF BACKGROUND DATA: Interest in and access to surgical treatment for chronic lymphedema (LE) in the United States have increased in recent years, yet there remains little attention on liposuction, or debulking, as an effective treatment option. In some other countries, debulking is a common procedure for the surgical treatment of LE, is covered by insurance, and has demonstrated excellent, reproducible outcomes. In this study we describe our experience implementing a debulking technique from Sweden in the United States. METHODS: Patients who presented with chronic LE followed a systematic multi-disciplinary work-up. For debulking with power assisted liposuction, the surgical protocol was modeled after that developed by Håkan Brorson. A retrospective review of consecutive patients who underwent debulking at our institution was conducted. RESULTS: Between December 2017 and January 2020, 39 patients underwent 41 debulking procedures with power assisted liposuction, including 23 upper and 18 lower extremities. Mean patient age was 58 years and 85% of patients had LE secondary to cancer, the majority of which (64%) was breast cancer. Patients experienced excess volume reductions of 116% and 115% in the upper and lower extremities, respectively, at 1 year postoperatively. Overall quality of life (LYMQOL) improved by a mean of 33%. Finally, patients reported a decreased incidence of cellulitis and decreased reliance on conservative therapy modalities postoperatively. CONCLUSIONS: Debulking with power assisted liposuction is an effective treatment for patients with chronic extremity LE. The operation addresses patient goals and improves quality of life, and additionally reduces extremity volumes, infection rates and reliance on outpatient therapy. A comprehensive, multi-disciplinary debulking program can be successfully implemented in the United States healthcare system.

Chaperone Use During Plastic Surgery Physical Examinations: Nationwide Provider Practices and Impact of Level of Training.

BACKGROUND: Medical chaperones often play an important role during physical examinations, providing patient comfort and serving as medicolegal witness. The purpose of this study was to evaluate and compare practices regarding chaperone use by plastic surgery attendings and trainees. METHODS: A voluntary survey was distributed to members of the American Council of Academic Plastic Surgeons. The survey included a standardized set of questions regarding physician demographics, nature of practice training, and current practices pertaining to chaperone use. Data were analyzed in a descriptive fashion. Ordinal logistic regression models were used to identify predictors of chaperone use. RESULTS: We received 167 responses, of which 107 (64.1%) were attendings and 60 (35.9%) were trainees. In total, 78.3% of the respondents were male and 21.7% were female. Routine use of chaperones was reported at 58.6%. Compared with plastic surgery trainees, attending surgeons were 12.8 times more likely to use a chaperone during sensitive examinations (P < 0.001). In addition, male respondents were 6.43 times more likely than their female counterparts to involve a chaperone during sensitive examinations (P < 0.001). Forty-eight percent of the trainees acknowledged receiving education regarding chaperone use, and this cohort was 7 times more likely to use a chaperone when compared with trainees who had not received chaperone instruction (P < 0.001). CONCLUSIONS: This study highlights the wide variability of chaperone use among plastic surgery attendings and trainees. Integration and standardization of chaperone education within plastic surgery training may be an effective technique to promote this practice and lead to improved patient-provider clinical experiences.

Is Immediate Lymphatic Reconstruction Cost-effective?

Mini: We conducted a cost-utility analysis to evaluate the cost and quality of life of patients undergoing axillary lymph node dissection (ALND) and ALND with regional lymph node radiation (RLNR), with and without lymphatic microsurgical preventive healing approach (LYMPHA), in a node-positive breast cancer population. We found that the addition of LYMPHA to both ALND or ALND with RLNR is more cost-effective. Objective: This manuscript is the first to employ rigorous methodological criteria to critically appraise a surgical preventative technique for breast cancer-related lymphedema from a cost-utility standpoint. Summary of Background Data: Breast cancer-related lymphedema is a well-documented complication of breast cancer survivors in the US. In this study, we conduct a cost-utility analysis to evaluate the cost-effectiveness of the LYMPHA. Methods: Lymphedema rates after each of the following surgical options: (1) ALND, (2) ALND + LYMPHA, (3) ALND + RLNR, (4) ALND + RLNR + LYMPHA were extracted from a recently published meta-analysis. Procedural costs were calculated using Medicare reimbursement rates. Average utility scores were obtained for each health state using a visual analog scale, then converted to quality-adjusted life years (QALYs). A decision tree was generated and incremental cost-utility ratios (ICUR) were calculated. Multiple sensitivity analyses were performed to evaluate our findings. Results: ALND with LYMPHA was more cost-effective with an ICUR of $1587.73/QALY. In the decision tree rollback analysis, a clinical effectiveness gain of 1.35 QALY justified an increased incremental cost of $2140. Similarly, the addition of LYMPHA to ALND with RLNR was more cost-effective with an ICUR of $699.84/QALY. In the decision tree rollback analysis, a clinical effectiveness gain of 2.98 QALY justified a higher incremental cost of $2085.00. Conclusions: Our study supports that the addition of LYMPHA to both ALND or ALND with RLNR is the more cost-effective treatment option.

The Postpartum Hemorrhage Patient Safety Bundle Implementation at a Single Institution: Successes, Failures, and Lessons Learned.

OBJECTIVE: In 2015, a multidisciplinary consensus bundle of recommendations for the anticipation and management of postpartum hemorrhage was published. Our goal was to evaluate the successes and failures of our institutional bundle implementation process. STUDY DESIGN: An interdisciplinary committee was created to facilitate bundle implementation. All components of the bundle were addressed with cross-disciplinary teaching between stakeholders on the obstetrics units. Tools were built in the electronic medical record to facilitate bundle components of risk stratification, quantitative blood loss calculation, and stage-based hemorrhage management. Bundle components were individually evaluated for acceptability and sustainability. Overall rates of hemorrhage and transfusion from the periods 1 year before and after bundle implementation were also evaluated. RESULTS: Readiness bundle components were successfully implemented, although simulation drills demonstrated limited sustainability. Recognition components were mixed: risk stratification was successfully and sustainably implemented while quantitative blood loss met resistance and was ultimately discontinued as it did not clinically perform superiorly to estimated blood loss. Among response and reporting elements, patient level support and team debriefing were noted as particular deficiencies in our program. CONCLUSION: The postpartum hemorrhage patient safety bundle provided concrete individual elements, which overall improved the success of a stratified program implementation. Multiple deficiencies in acceptability and sustainability were uncovered during our process, particularly concerns about quantitative blood loss implementation and team communication skills. KEY POINTS: · Supply readiness and protocol development were "quick wins.". · Culture change elements included recognition, response, and communication.. · Dedicated champions and electronic medical record tools improved sustainability.. · Poor acceptability and lack of improved outcomes led to element failure..

Breast Cancer-Related Lymphedema: Magnetic Resonance Imaging Evidence of Sparing Centered Along the Cephalic Vein.

BACKGROUND: A distinct pattern of edema distribution is seen in breast cancer-related lymphedema. The area of edema sparing has not been characterized in relation to anatomy. Specifically, alternate lymphatic pathways are known to travel adjacent to the cephalic vein. Our study aims to define the location of edema sparing in the arm relative to the cephalic vein. METHODS: A retrospective review of patients who underwent magnetic resonance imaging (MRI) between March 2017 and September 2018 was performed. Variables including patient demographics, arm volumes, and MRI data were extracted. MRIs were reviewed to define the amount of sparing, or angle of sparing, and the deviation between the center of sparing and the cephalic vein, or angle of deviation. RESULTS: A total of 34 consecutive patients were included in the analysis. Five patients demonstrated circumferential edema (no sparing) and 29 patients demonstrated areas of edema sparing. Advanced age (69.7 vs. 57.6 years) and greater excess arm volume (40.4 vs. 20.8%) correlated with having circumferential edema without sparing (p = 0.003). In 29 patients with areas of edema sparing, the upper arm demonstrated the greatest angle of sparing (183.2 degrees) and the narrowest in the forearm (99.9 degrees; p = 0.0032). The mean angle of deviation to the cephalic vein measured 3.2, -0.1, and -5.2 degrees at the upper arm, elbow, and forearm, respectively. CONCLUSION: Our study found that the area of edema sparing, when present, is centered around the cephalic vein. This may be explained by the presence of the Mascagni-Sappey (M-S) pathway as it is located alongside the cephalic vein. Our findings represent a key springboard for additional research to better elucidate any trends between the presence of the M-S pathway, areas of sparing, and severity of lymphedema.

Beyond the Tip of the Blade: An Investigation of Upper Extremity Machete Injuries in Honduras.

BACKGROUND: Machete injuries constitute a major cause of morbidity in Honduras. In this study, we aimed to determine the incidence, initial management, surgical treatment, and follow-up patterns for machete injuries at the national public hospital in Honduras. Microsurgery in Honduras is currently in transition with limitations at multiple levels. This study aims to provide critical information to better prepare visiting surgeons and establishes a blueprint to improve microsurgical reconstruction. METHODS: A retrospective chart review was performed to identify patients with machete injuries to the upper extremity (UE) who presented to the Hospital Escuela Universitario (HEU) for treatment from 2015 to 2017. Additional microsurgical data was obtained by personal communication with members of the plastic surgery department at the HEU. RESULTS: Complete data was retrieved for 100 patients who presented to the HEU with a UE machete wound. The cohort was male dominated (93%), employed as farmers (47%), and had a mean age of 32.1 years. Violence was the most common mechanism of injury (p < 0.001). The majority of UE machete injuries involved tendon (70%), nerve (28%), and an open fracture (55%). Of the 76% of patients who were scheduled for a follow-up visit, only 25% attended. Within the last calendar year, one replantation, 10 revascularizations at the wrist and forearm level, three microvascular free tissue transfers, and 175 nerve repairs were performed. CONCLUSION: Management of UE machete injuries in Honduras is challenging and requires early recognition of possible injuries to multiple anatomical systems. The majority of injuries required operative intervention. Only a small percentage of patients presented for follow up. A program to streamline care starting at injury recognition up to final follow-up is currently unavailable and needs to be developed to optimize microsurgical care.

MRI staging of upper extremity secondary lymphedema: correlation with clinical measurements.

OBJECTIVES: Staging of upper extremity lymphedema is needed to guide surgical management, but is not standardized due to lack of accessible, quantitative, or precise measures. Here, we established an MRI-based staging system for lymphedema and validate it against existing clinical measures. METHODS: Bilateral upper extremity MRI and lymphoscintigraphy were performed on 45 patients with unilateral secondary lymphedema, due to surgical intervention, who were referred to our multidisciplinary lymphedema clinic between March 2017 and October 2018. MRI short-tau inversion recovery (STIR) images were retrospectively reviewed. A grading system was established based on the cross-sectional circumferential extent of subcutaneous fluid infiltration at three locations, labeled MRI stage 0-3, and was compared to L-Dex®, ICG lymphography, volume, lymphedema quality of life (LYMQOL), International Society of Lymphology (ISL) stage, and lymphoscintigraphy. Linear weighted Cohen's kappa was calculated to compare MRI staging by two readers. RESULTS: STIR images on MRI revealed a predictable pattern of fluid infiltration centered on the elbow and extending along the posterior aspect of the upper arm and the ulnar side of the forearm. Patients with higher MRI stage were more likely to be in ISL stage 2 (p = 0.002) or to demonstrate dermal backflow on lymphoscintigraphy (p = 0.0002). No correlation was found between MRI stages and LYMQOL. Higher MRI stage correlated with abnormal ICG lymphography pattern (rs = 0.63, p < 0.0001), larger % difference in limb volume (rs = 0.68, p < 0.0001), and higher L-Dex® ratio (rs = 0.84, p < 0.0001). Cohen's kappa was 0.92 (95% CI, 0.85-1.00). CONCLUSION: An MRI staging system for upper extremity lymphedema offers an improved non-invasive precision marker for lymphedema for therapeutic planning. KEY POINTS: • Diagnosis and staging of patients with secondary upper extremity lymphedema may be performed with non-contrast MRI, which is non-invasive and more readily accessible compared to lymphoscintigraphy and evaluation by lymphedema specialists. • MRI-based staging of secondary upper extremity lymphedema is highly reproducible and could be used for long-term follow-up of patients. • In patients with borderline clinical measurements, MRI can be used to identify patients with early-stage lymphedema.

A Multimetric Health Literacy Analysis of Autologous Versus Implant-Based Breast Reconstruction.

BACKGROUND: Over the past decade, the demand for breast reconstruction has mirrored the rising incidence of breast cancer. Common postoncologic surgical options include autologous and implant-based reconstruction. Patient-directed health information for breast reconstruction can play a critical role in the decision-making process. This study comparatively evaluates the top online resources for autologous versus implant-based reconstruction using a multimetric health literacy analysis. METHODS: The top 10 websites for autologous and implant-based reconstruction were identified using a Google search. A total of 20 unique links were appraised by 2 independent raters for understandability and actionability using the Patient Education Materials Assessment Tool and cultural sensitivity using the Cultural Sensitivity Assessment Tool. A Cohen κ for interrater reliability was calculated. Mean reading grade level and word complexity were also determined. RESULTS: Websites for both autologous and implant-based modalities exceeded the recommended sixth- to eighth-grade reading level (12.4 and 12.1, respectively; P = 0.65). Mean understandability scores for each modality were low (60.5 and 62.5, P = 0.65). Autologous-based resources had a lower mean actionability score compared with implant-based materials (19.5 and 24, respectively; P = 0.04). Both reconstructive modalities met the threshold for acceptability for cultural sensitivity (2.79 and 2.58, P = 0.09). CONCLUSIONS: Our study revealed a chasm between the health literacy needs of the average adult and the quality of both implant-based and autologous breast reconstruction resources. Materials for both modalities were often too complex and failed to include tools to facilitate active decision making, particularly for autologous-based reconstruction. Strategies to improve materials should be patient centered and include simplification of reading grade level, incorporation of clear visual aids, and inclusion of procedural risks to promote patient comprehension, participation, and ultimately health outcomes.

A Multimetric Health Literacy Analysis of Online Information for Gluteal Augmentation With Fat Grafting.

BACKGROUND AND OBJECTIVES: According to the American Society of Plastic Surgeons the number of gluteal augmentations with fat grafting, colloquially known as the "Brazilian buttock lift" (BBL), doubled from 2014 to 2018. Recent studies have demonstrated that gluteal augmentation with fat grafting has a higher mortality rate when compared with other esthetic surgeries. We hypothesize that online patient-directed information for gluteal augmentation are overly complex, written at an elevated reading grade level, with incomplete or no information regarding associated surgical risks. OBJECTIVE: To perform an objective appraisal of the most popular online patient education materials for gluteal augmentation surgery and explore potential interventions for improving material quality. METHODS: An online Google search using the term "Brazilian butt lift" was performed and the top 10 websites providing relevant information were identified. Readability for each website was determined using Readability Studio. Understandability, actionability and cultural sensitivity was assessed with validated tools by 2 independent raters. RESULTS: The top 10 websites were written at a mean reading grade level of 13.0, appropriate for a high school graduate. No website was written at the American Medical Association and the National Institutes of Health recommended 6th to 8th grade reading level. Mean understandability and actionability scores of 51% and 18.9%, respectively, suggest significant room for improvement. The average cultural sensitivity assessment tool score was 2.30, below the recommended threshold for acceptability of 2.5. Ninety percent of all websites did not meet the threshold for cultural acceptability. CONCLUSIONS: Online patient education materials for gluteal augmentation with fat grafting were written at an inappropriately elevated reading grade level and were overly complex, did not promote reader action, and were not sensitive to the needs of the target demographic.

The All but Forgotten Mascagni-Sappey Pathway: Learning from Immediate Lymphatic Reconstruction.

BACKGROUND: Upper extremity lymphedema occurs in 25 to 40% of patients after axillary lymph node dissection (ALND). Immediate lymphatic reconstruction (ILR) or the lymphatic micro- surgical preventative healing approach has demonstrated a significant decrease in postoperative rates of lymphedema (LE) from 4 to 12%. Our objective was to map the Mascagni -Sappey pathway, the lateral upper arm draining lymphatics, in patients undergoing ILR to better characterize the drainage pattern of this lymphosome to the axilla. METHODS: A retrospective review of our institutional lymphatic database was conducted and consecutive breast cancer patients undergoing ILR were identified from November 2017 through June 2018. Patient demographics, clinical characteristics, and intraoperative records were retrieved and analyzed. RESULTS: Twenty-nine consecutive breast cancer patients who underwent ILR after ALND were identified. Patients had a mean age of 54.6years and body mass index (BMI) of 26.6 kg/m2. Fluorescein isothiocyanate (FITC) was injected at the medial upper arm and isosulfan blue was injected at the cephalic vein, or lateral upper arm, prior to ALND. After ALND, an average 2.5 divided lymphatics were identified, and a mean 1.2 lymphatics were bypassed. In all patients, divided FITC lymphatics were identified. However, in only three patients (10%), divided blue lymphatics were identified after ALND. CONCLUSION: In this study, variable drainage of the lateral upper arm to the axillary bed was noted. This study is the first to provide a description of intraoperative findings, demonstrating variable drainage patterns of upper extremity lymphatics to the axilla. Moreover, we noted that the lateral- and medial-upper arm lymphosomes have mutually exclusive pathways draining to the axilla. Further study of lymphatic anatomy variability may elucidate the pathophysiology of lymphedema development and influence approaches to immediate lymphatic reconstruction.

Closed-Incision Negative-Pressure Therapy Efficacy in Abdominal Wall Reconstruction in High-Risk Patients: A Meta-analysis.

BACKGROUND: Obesity is a known risk factor for surgical complications. Closed-incision negative-pressure therapy (ciNPT) has been used anecdotally in high-risk patients to prevent wound complications and infection. This meta-analysis aims to evaluate the efficacy of ciNPT in reducing the incidence of wound complications and infection in abdominal wall reconstruction. METHODS: A literature search using the PubMed/MEDLINE databases (2006-2016) was conducted to identify publications comparing ciNPT to standard incisional care for abdominal wall reconstruction. Outcomes of interest included surgical site infection, wound dehiscence, seroma, hematoma, reoperation, and readmission. Overall rates and associations were pooled. A fixed and random effects model was used upon meta-analysis. Publication bias was assessed using funnel plots. RESULTS: A total of 11 studies met inclusion criteria. There were 1723 patients included, 681 in the ciNPT group, and 1042 in the standard incisional care group. The majority of patients were obese, diabetic, and had a recent history of smoking. On meta-analysis, the risk of surgical site infection decreased by 51% (relative risk: 0.51, 95% confidence interval [0.41-0.63]). The risk of wound dehiscence decreased by 51% (relative risk: 0.51, 95% confidence interval [0.34-0.76]). There was no significant decreased risk observed with ciNPT use for the outcomes of seroma, hematoma, reoperation, and readmission. CONCLUSIONS: The use of ciNPT reduced the incidence of infection and wound dehiscence in patients with varying risk factors undergoing abdominal wall reconstruction. Future prospective randomized clinical trials are still needed to determine the efficacy of ciNPT in plastic surgery.

A Comparative Multimetric Assessment of English and Spanish Carpal Tunnel Syndrome Materials.

BACKGROUND: Spanish-speaking Hispanics living in the United States utilize the internet as a primary means to obtain health information. Accurate, accessible information is important for English speakers; however, it could have even greater utility for Spanish speakers who have lower health literacy levels. The aim of this study was to evaluate and compare online English and Spanish carpal tunnel surgery materials provided by using a multimetric approach. MATERIALS AND METHODS: A web search using the English term "carpal tunnel surgery" was performed. The first 10 institutional/organizational websites that provided carpal tunnel surgery information in English and Spanish were included. All relevant online materials were evaluated using the Patient Education and Materials Assessment Tool (PEMAT), Cultural Sensitivity Assessment Tool (CSAT), and Simplified Measure of Gobbledygook, Spanish (SOL) to assess understandability and actionability, cultural sensitivity, and readability, respectively. RESULTS: There were no statistically significant differences in understandability or actionability scores between Spanish and English materials. Average cultural sensitivity scores for Spanish materials were significantly lower than English materials (P = 0.015). The average reading grade level of online English materials was greater than that for Spanish materials (P = 0.011). Both mean values were above the recommended sixth-grade reading level. CONCLUSIONS: Online patient-directed information regarding carpal tunnel surgery exceeded the recommended reading grade level for both English and Spanish-speaking populations. Most Spanish materials were often direct translations and were not contoured to the elevated literacy needs of this demographic. Institutions must caution their authors to tailor their web material in a way that is sensitive to their target population to optimize understanding.

Cultural Insensitivity Pervasive in Spanish Online Cosmetic Surgery Resources: A Call to Action.

BACKGROUND: Hispanics are the second largest demographic that underwent cosmetic surgery in 2017. The popularity of cosmetic surgeries among this group has increased significantly within the past decade and is projected to continue rising. Patient-directed websites that provide educational materials addressing these procedures should include information that is accurate, comprehensible, and sensitive to the demographic's diverse cultural and ethnic needs. Online health resources have been shown to vary significantly in their quality and reliability. This can be inimical for patients, as misinformation has been associated with poor health outcomes. The aim of this study is to evaluate online Spanish patient-directed materials for the top 5 cosmetic surgeries performed in 2017 using validated metrics. METHODS: The top 5 cosmetic surgeries performed in 2017 according to the American Society of Plastic Surgeons were identified, and a Google search was performed using the following terms: "breast augmentation," "liposuction," "rhinoplasty," "blepharoplasty," and "abdominoplasty." The top 10 websites providing relevant information in Spanish were identified for each procedure. Fifty unique web links were analyzed by 2 independent bilingual raters using the Cultural Sensitivity Assessment Tool, and mean reading grade level was determined. Interrater reliability was computed using a Cohen κ. RESULTS: Online information in Spanish was difficult to encounter, with an average of 130 websites evaluated to identify 10 websites for each surgery. The mean reading grade level of all evaluated pages was 10.19, appropriate for a high school sophomore. There were no statistically significant differences between cosmetic surgery procedures (P = 0.69). The mean cultural sensitivity score was 2.20 (2.08-2.38). No subgroup met the threshold score for acceptable cultural sensitivity of >2.5. CONCLUSION: This study demonstrates that US websites do not offer appropriate-level Spanish materials for patients seeking information on cosmetic surgeries. Websites providing information in Spanish were often inaccurate automatic translations and further compromised reader understanding. In our search, we frequently encountered organizational statements expressing a commitment to diversity. Increased awareness and development of more culturally appropriate materials is paramount to effectively communicate with patients and begin to close the gap in cultural disparities in health literacy.

The Impact of Taxane-based Chemotherapy on the Lymphatic System.

BACKGROUND: Breast cancer-related lymphedema affects 700,000 breast cancer survivors in the United States. Although taxane-based chemotherapy regimens are commonly used in the treatment of breast cancer, the impact of taxanes on the lymphatic system remains poorly understood. This study aims to examine the influence of taxane-based chemotherapy on lymphatic function in breast cancer patients. METHODS: A retrospective review of a prospectively-maintained database was performed. Consecutive patients with node positive breast cancer who underwent preoperative indocyanine green (ICG) lymphangiograms were identified. Information including patient demographics, baseline measurements, cancer characteristics, and treatment information were retrieved. Preoperative ICG lymphangiography videos were analyzed and lymphatic contractility was quantified for each subject. Multiple regions of interest were selected on each lymphatic channel and signal intensity was recorded for 3 minutes to generate contractility curves. Each lymphatic contraction was identified using a novel, systematic, and algorithmic approach. RESULTS: Twenty-nine consecutive patients with unilateral node-positive breast cancer were included for analysis. Average patient age was 54.5 (13) years and mean BMI was 26.8 kg/m (4). The mean lymphatic contractility of patients who received taxane-based neoadjuvant chemotherapy was 0.7 contractions/minute (c/m) (n = 19) compared to 1.1 c/m in those who received no neoadjuvant therapy (n = 10), (P = 0.11). In subgroup analysis, patients who reported taxane induced neuropathy demonstrated significantly lower lymphatic contractility values than those who were asymptomatic or did not receive any chemotherapy (P = 0.018). CONCLUSIONS: In this study, we used a novel method for quantifying and evaluating lymphatic contractility rates in routine ICG lymphangiograms. Diminished lymphatic contractility was noted in patients who received taxane-based neoadjuvant chemotherapy compared with those who did not. Taxane-based neoadjuvant chemotherapy may adversely affect the lymphatic system in the breast cancer population. A larger patient cohort with longer follow-up time is needed to validate this finding and evaluate any potential association with breast cancer-related lymphedema development.

Lymphedema Incidence After Axillary Lymph Node Dissection: Quantifying the Impact of Radiation and the Lymphatic Microsurgical Preventive Healing Approach.

BACKGROUND: Axillary surgery and radiotherapy are important aspects of breast cancer treatment associated with development of lymphedema. Studies demonstrate that Lymphatic Microsurgical Preventive Healing Approach (LYMPHA) may greatly reduce the incidence of lymphedema in high-risk groups. The objective of this study is to summarize the evidence relating lymphedema incidence to axillary lymph node dissection (ALND), regional lymph node radiation (RLNR) therapy, and LYMPHA. METHODS: We performed a literature search to identify studies involving breast cancer patients undergoing ALND with or without RLNR. Our primary outcome was the development of lymphedema. We analyzed the effect of LYMPHA on lymphedema incidence. We chose the DerSimonian and Laird random-effects meta-analytic model owing to the clinical, methodological, and statistical heterogeneity of studies. RESULTS: Our search strategy yielded 1476 articles. After screening, 19 studies were included. Data were extracted from 3035 patients, 711 of whom had lymphedema. The lymphedema rate was significantly higher when RLNR was administered with ALND compared with ALND alone (P < 0.001). The pooled cumulative incidence of lymphedema was 14.1% in patients undergoing ALND versus 2.1% in those undergoing LYMPHA and ALND (P = 0.029). The pooled cumulative incidence of lymphedema was 33.4% in those undergoing ALND and RLNR versus 10.3% in those undergoing ALND, RLNR, and LYMPHA (P = 0.004). CONCLUSION: Axillary lymph node dissection and RLNR are important interventions to obtain regional control for many patients but were found to constitute an increased risk of development of lymphedema. Our findings support that LYMPHA, a preventive surgical technique, may reduce the risk of breast cancer-related lymphedema in high-risk patients.

A Multimetric Evaluation of Online Spanish Health Resources for Lymphedema.

BACKGROUND: Breast cancer is a leading cause of death in US Hispanic females. This demographic is more likely to present with later-stage disease and require more extensive surgical treatment, including axillary lymph node dissection, which increases risk of lymphedema. The Spanish-speaking Hispanic population has a lower health literacy level and requires materials contoured to their unique needs. The aim of this study was to evaluate online Spanish lymphedema resources. METHODS: A web search using the Spanish term "linfedema" was performed, and the top 10 websites were identified. Each was analyzed using validated metrics to assess readability, understandability, actionability, and cultural sensitivity using the SOL (Simplified Measure of Gobbledygook, Spanish), Patient Education and Materials Assessment for Understandability and Actionability (Patient Education and Assessment Tool), and Cultural Sensitivity and Assessment Tool (CSAT), respectively. Online materials were assessed by 2 independent evaluators, and interrater reliability was determined. RESULTS: Online lymphedema material in Spanish had a mean reading grade level of 9.8 (SOL). Average understandability and actionability scores were low at 52% and 36%, respectively. The mean CSAT was 2.27, below the recommended value of 2.5. Cohen κ for interrater reliability was greater than 0.81 for the Patient Education and Assessment Tool and CSAT, suggesting excellent agreement between raters. CONCLUSIONS: Available online Spanish lymphedema resources are written at an elevated reading level and are inappropriate for a population with lower health literacy levels. As patients continue to use the internet as their primary source for health information, health care entities must improve the quality of provided Spanish resources in order to optimize patient comprehension.

The Impact of Resident Postgraduate Year Involvement in Body-Contouring and Breast Reduction Procedures: A Comprehensive Analysis of 9638 Patients.

Given the rising popularity in body-contouring procedures (BCPs) in the United States, it is important to assess the currently unknown association between resident involvement and postoperative complications. As such, the aim of this study was to evaluate the impact of resident involvement on outcomes in BCPs using a large national database. METHODS: A retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Program database was performed (2006-2012) to identify patients undergoing BCPs, using relevant Current Procedural Terminology codes. Outcome measures included postoperative complications, hospital length of stay, and operation time.Multivariate regression models were used to assess the impact of resident involvement and resident experience on outcomes. RESULTS: A total of 9638 cases were identified, of which 3311 involved resident participation.Resident involvement was associated with significantly higher rates of complications (7.8% vs 4.4%; P = 0.003) and longer operation times (180.7 vs 171.9 minutes; P = 0.005). For each year increase of resident postgraduate year, there was a significant decrease in odds of complications (odds ratio, 0.906; P = 0.013) and operative time (-2.7 minutes; P = 0.001). CONCLUSIONS: Resident involvement in BCPs was associated with an increased rate of overall complications in a large, national database. However, the clinical significance of these outcomes may be debated. Increased postgraduate year experience as a surgical resident was inversely associated with overall complications. Guided resident autonomy and earlier exposure to BCPs could lead to an optimization of clinical outcomes and resident education.

Reconstruction of Mohs Defects Located in the Head and Neck.

BACKGROUND: Defects following Mohs micrographic surgery (MMS) can range in size from small defects requiring linear closure to large defects needing flap coverage. Reconstruction is dependent on defect size and facial aesthetic unit involvement. The aim of this study was to review the types of facial reconstruction per aesthetic unit involvement and describe their outcomes. METHODS: All data were retrieved for patients ≥18 years who underwent multidisciplinary treatment including dermatological MMS and plastic surgical reconstruction at a single tertiary hospital center (2001-2017). Patient characteristics, tumor pathology, surgical specifics, reconstructive modalities, and surgical outcomes were analyzed. RESULTS: A total of 418 patients were included. Patients were predominantly White, non-Hispanic (97%) and female (58%) with a mean age of 60 ±â€Š13.9 years. Tumor pathology was predominantly basal cell carcinoma in 73% of all cases followed by squamous cell carcinoma in 14%. The nasal aesthetic unit was mostly affected (50%). Local advancement flaps and different types of grafts were used in 51% and 25% of reconstructions, respectively. Complications were observed in 3% and local cancer recurrence in 4% of the patients. Scar revision was needed in 6% of the patients. CONCLUSION: Reconstruction of facial defects after Mohs micrographic surgery can be challenging due to its technical complexity and aesthetic implications. There were differences in complications in reconstructions performed within the same day versus 1 week, with a majority of complications occurring within same-day Mohs reconstructions. A multidisciplinary structured approach, which incorporates patient-reported outcomes, may be needed to optimize surgical results.

Immediate lymphatic reconstruction.

Although surgical and medical treatment options are available for the treatment of chronic lymphedema, there is no cure. Recent advances in microsurgery have provided an opportunity to perform immediate lymphatic reconstruction after lymphadenectomy for disease prevention. In this review, we provide the historical background leading to a paradigm shift in performing this procedure. We will also discuss the current evidence for immediate lymphatic reconstruction, potential oncologic procedures amenable to this approach, and detail ongoing challenges.

Labiaplasty: Indications and Predictors of Postoperative Sequelae in 451 Consecutive Cases.

BACKGROUND: The increasing demand for labiaplasty is well recognized; however, the procedure remains contentious. OBJECTIVES: We aim to provide a large-scale, up-to-date analysis of labiaplasty outcomes and factors influencing postoperative sequelae (POS). METHODS: We analyzed a single-center, prospectively maintained database of females undergoing labiaplasty between 2002 and 2017. Demographic, procedural, and outcomes' data were retrieved. Binary logistic regressions were used to evaluate the odds of developing POS (revisional surgery and complications); presented as odds ratios (OR) with 95% confidence intervals (CI). RESULTS: Data for 451 consecutive patients were retrieved, ten of whom were <18 years of age. Overall, 86% were Caucasian, mean age was 32.6 years, and 11.8% were smokers. Concomitant labia majora reduction was performed in 7.3%, and clitoral hood reduction in 5.8%. There were 32 cases of POS (7.1%), while the complication rate was 3.8%. Comparing those with POS to those without, there were no differences in age (32.8 vs 29.9 years, P = 0.210), operative time (78.5 vs 80.6 minutes, P = 0.246), or comorbidities (P > 0.05 for all). On univariable analysis, increased odds of POS occurred with sexual dysfunction as an indication for surgery (OR 3.778, CI 1.682-8.483). On subgroup analysis of those ≥18 years, both smoking (2.576, CI 1.044-6.357) and sexual dysfunction as an indication (OR 4.022, CI 1.772-9.131) increased the odds of POS. On multivariable analysis of the subgroup, sexual dysfunction as an indication persisted in significance (OR 3.850, CI 1.683-8.807). CONCLUSIONS: Results compare favorably with previously reported complication and revisional surgery rates. Smoking and sexual dysfunction may increase the risk of complications.