Patient Safety and Quality Improvement Initiatives in Cleft Lip and Palate Surgery: A Systematic Review.

BACKGROUND: Cleft lip and/or palate repair techniques require continued reevaluation of best practice through high-quality evidence. The objective of this systematic review was to highlight the existing evidence for patient safety and quality improvement (QI) initiatives in cleft lip and palate surgery. METHODS: A systematic review of published literature evaluating patient safety and QI in patients with cleft lip and/or palate was conducted from database inception to June 9, 2022, using Preferred Reporting Items for Systematic Reviews guidelines. Quality appraisal of included studies was conducted using Methodological Index for Non-Randomized Studies, Cochrane, or a Measurement Tool to Assess Systematic Reviews (AMSTAR) 2 instruments, according to study type. RESULTS: Sixty-one studies met inclusion criteria, with most published between 2010 and 2020 (63.9%). Randomized controlled trials represented the most common study design (37.7%). Half of all included studies were related to the topic of pain and analgesia, with many supporting the use of infraorbital nerve block using 0.25% bupivacaine. The second most common intervention examined was use of perioperative antibiotics in reducing fistula and infection (11.5%). Other studies examined optimal age and closure material for cleft lip repair, early recovery after surgery protocols, interventions to reduce blood loss, and safety of outpatient surgery. CONCLUSIONS: Patient safety and QI studies in cleft surgery were of moderate quality overall and covered a wide range of interventions. To further enhance PS in cleft repair, more high-quality research in the areas of perioperative pharmaceutical usage, appropriate wound closure materials, and optimal surgical timing are needed.

Measuring the Unilateral Cleft Lip Nasal Deformity: Lateral Deviation of Subnasale Is a Clinical and Morphologic Index of Unrepaired Severity.

OBJECTIVE: Objective measurement of pre-operative severity is important to optimize evidence-based practices given that the wide spectrum of presentation likely influences outcomes. The purpose of this study was to determine the correlation of objective measures of form with a subjective standard of cleft severity. DESIGN: 3D images were ranked according to severity of nasal deformity by 7 cleft surgeons so that the mean rank could be used as the severity standard. PATIENTS: 45 patients with unilateral cleft lip and 5 normal control subjects. INTERVENTIONS: Each image was assessed using traditional anthropometric analysis, 3D landmark displacements, and shape-based analysis to produce 81 indices for each subject. MAIN OUTCOME: The correlation of objective measurements with the clinical severity standard. RESULTS: Lateral deviation of subnasale from midline was the best predictor of severity (0.86). Other strongly-correlated anthropometric measurements included columellar angle, nostril width ratio, and lateral lip height ratio (0.72, 0.80, 0.79). Almost all shape-based measurements had tight correlation with the severity standard, however, dorsum deviation and point difference nasolabial symmetry were the most predictive (0.84, 0.82). CONCLUSIONS: Quantitative measures of severity transcend cleft type and can be used to grade clinical severity. Lateral deviation of subnasale was the best measure of severity and may be used as a surrogate of uncoupled premaxillary growth; it should be recorded as an index of pre-operative severity with every cleft lip repair. The correlation of other measures evaluated clarify treatment priorities and could potentially be used to grade outcomes.

Systematic Review of Patient Safety and Quality Improvement Initiatives in Breast Reconstruction.

BACKGROUND: Improving patient care and safety requires high-quality evidence. The objective of this study was to systematically review the existing evidence for patient safety (PS) and quality improvement initiatives in breast reconstruction. METHODS: A systematic review of the published plastic surgery literature was undertaken using a computerized search and following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Publication descriptors, methodological details, and results were extracted. Articles were assessed for methodological quality and clinical heterogeneity. Descriptive statistics were completed, and a meta-analysis was considered. RESULTS: Forty-six studies were included. Most studies were retrospective (52.2%) and from the third level of evidence (60.9%). Overall, the scientific quality was moderate, with randomized controlled trials generally being higher quality. Studies investigating approaches to reduce seroma (28.3% of included articles) suggested a potential benefit of quilting sutures. Studies focusing on infection (26.1%) demonstrated potential benefits to prophylactic antibiotics and drain use under 21 days. Enhanced recovery after surgery protocols (10.9%) overall did not compromise PS and was beneficial in reducing opioid use and length of stay. Interventions to increase flap survival (10.9%) demonstrated a potential benefit of nitroglycerin on mastectomy skin flaps. CONCLUSIONS: Overall, studies were of moderate quality and investigated several worthwhile interventions. More validated, standardized outcome measures are required, and studies focusing on interventions to reduce thromboembolic events and bleeding risk could further improve PS.

A Systematic Review of Feeding Interventions for Infants with Cleft Palate.

OBJECTIVE: Various devices and techniques have been proposed to reduce feeding difficulties experienced by infants with cleft palate. The aim of this review is to identify and assess the scope and quality of evidence for these interventions. METHODS: A systematic review of published literature evaluating feeding interventions for infants with cleft palate (with or without cleft lip) from database inception to 2021 was conducted using Preferred Reporting Items for Systematic Reviews guidelines. Quality appraisal of included studies was conducted using a methodological index for nonrandomized studies, Cochrane, or a measurement tool to assess systematic reviews 2 instruments, according to study type. RESULTS: Fourteen studies met inclusion criteria, with the majority (71%) of studies consisting of second-level evidence. Included interventions were specialty bottles (21%), alternative feeding delivery systems (14%), obturators (14%), and educational programs (14%). Specialty bottles and palatal obturators did not appear to offer any substantial growth advantages compared to traditional bottles or no intervention, respectively. Designated education programs for the mothers of infants with clefts had a positive impact on infant growth. CONCLUSIONS: Overall evidence evaluating feeding interventions for infants with cleft palate was moderate to low. While it does not appear that specialized feeding delivery systems or palatal obturators significantly improve growth in infants with clefts compared to children without cleft conditions, education programs do appear to be beneficial.

Comparison of two Specialized Cleft Palate Feeders.

OBJECTIVE: To evaluate feeding efficiency and weight gain in infants with cleft palate fed using 1 of the 2 specialty feeders. DESIGN: Retrospective cohort study. SETTING: Cleft palate clinic in a tertiary pediatric hospital. PARTICIPANTS: Infants with cleft palate (with or without cleft lip) fed using the Medela SpecialNeeds® Feeder (n = 39) or the Dr. Brown's® Specialty Feeding System (n = 16) and who had documented feeding and growth data available from the time of initial assessment in the first month of life and at subsequent follow-up between 2 and 4 months. PRIMARY OUTCOME MEASURE: Feeding velocity (mL/min). SECONDARY OUTCOMES MEASURES: Calorie velocity (kcal/min), weight gain, and complications associated with poor feeding. RESULTS: No statistically significant differences in feeding or calorie velocities were identified between infants with cleft palate fed with the Medela SpecialNeeds® feeder and those fed with the Dr. Brown's® feeder. Mean weight z-scores by month did not differ significantly between the 2 bottle groups at the time of initial assessment (P = .84) and follow-up (P = .20). Mean weight z-scores by month for the infants included in this study fell below the 50th percentile. The proportion of infants who developed otitis media, reflux requiring treatment, or who required hospital admission for nasogastric (NG) feeds did not differ significantly between the 2 groups. CONCLUSIONS: Despite being adequately powered for the primary outcome, no significant differences were identified between infants fed with the Medela or the Dr. Brown's feeders in terms of feeding velocity, calorie velocity, weight gain, or complications.

A case of migraine treatment in a patient with a clinical diagnosis of CHARGE syndrome using onabotulinum toxin A.

CHARGE syndrome is a genetic disorder that affects multiple organ and sensory systems. Cranial nerve involvement is one of the key clinical diagnostic criteria. We present the case of an 8-year-old girl with CHARGE syndrome, associated right-sided facial palsy, and chronic severe migraines, that were intractable to medical treatment. At age 6, onabotulinum toxin A was used to weaken the contralateral non-paralyzed side of her face to address her stigmatizing asymmetry. Onabotulinum toxin A chemodenervation was performed on the left lower lip depressors to relax the muscles and improve left lower lip position. Coincidentally, it was noted that with these treatments, migraine symptoms resolved. As the chemodenervation subsided over the next 3-4 months, the severe migraines returned. Continued treatment with onabotulinum toxin A injections every 3 months has resulted in ongoing improvements in facial symmetry and migraine control. Onabotulinum toxin A is a well-known treatment of chronic migraine. Injections are usually directed to the occipitalis, frontalis, and corrugator muscles. The literature has no reports of injections to the lower lip depressors as a useful therapy for migraine, making the results from this case unique.

Physician Scientists Of Yesterday, Today And Tomorrow - Published 44(3) September 2021.

In this issue, Ryan Kirkpatrick and Gordon Boyd speculated on the reasons for the dwindling number of physician scientists in Canada. To help stimulate discussion on this important issue, Clinical and Investigative Medicine invited two distinguished scientists to present their views on this issue.

A Toolbox of Surgical Techniques for Palatal Fistula Repair.

OBJECTIVE: To provide an inventory of oronasal fistula repair techniques alongside expert commentary on which techniques are appropriate for each fistula type. DESIGN: A 4-stage approach was used to develop a consensus on surgical techniques available for fistula repair: (1) in-person discussion of oronasal fistula cases among cleft surgeons, (2) development of a schema for fistula management using transcripts of the in-person case discussion, (3) evaluation of the preliminary schema via a web-based survey of additional cleft surgeons, and (4) revision of the management schema using survey responses. PARTICIPANTS: Six cleft surgeons participated in the in-person case discussion. Eleven additional surgeons participated in the web-based survey. Participants had diverse training experiences, having completed residency and fellowship at 20 different hospitals. RESULTS: A schema for fistula management was developed, organized by fistula location. The schema catalogues all viable approaches for each location. For fistulae involving the soft palate, the schema stresses the importance of evaluating for velopharyngeal insufficiency (VPI) and incorporating VPI management into fistula repair. For fistulae involving the hard palate, the schema separately enumerates the techniques available for nasal lining repair and for oral lining repair in each region. The schema also catalogues the diversity of approaches to lingual- and labioalveolar fistula, including variation in timing, orthodontic preparation, and simultaneous alveolar bone grafting. CONCLUSIONS: This study employed consensus methods to create a comprehensive inventory of available fistula repair techniques and to identify preferential techniques among a diverse group of surgeons.

The Selective Angiotensin II Type 2 Receptor Agonist Compound 21 Reduces Abdominal Adhesions in Mice.

BACKGROUND: Abdominal adhesions (AAs) are post-traumatic fibrous bands that connect visceral and/or peritoneal surfaces, leading to possible long-term complications. The effect of a novel antifibrotic selective angiotensin II type 2 receptor agonist, compound 21 (C21) on AA formation was assessed in a murine model. METHODS: Female BALB/c mice were laparotomized and the cecum and overlying parietal peritoneum abraded. C21 (10 µg/kg) or saline (vehicle) were administered orally or intraperitoneally daily. Mice were sacrificed 8 days after surgery, adhesions graded, and peritoneal fluid collected for transforming growth factor (TGF)-ß levels. Laparotomy incisions were excised for immunohistochemistry. In vitro, scratch assays were performed using primary parietal peritoneal fibroblasts and visceral mesothelial cells treated with C21 (10 µM), angiotensin II (1 µM), or both. Western blot analysis of primary cell lysates was performed for total and phosphorylated SMAD 2/3. RESULTS: Oral and intraperitoneal C21 reduced AA formation and TGF-ß levels in peritoneal fluid. Surgical incisions demonstrated decreased α-smooth muscle actin expression in C21-treated animals, but no difference in vascularity, macrophage infiltration, collagen I/III distribution and density, and dermal thickness. Migration and expression of phosphorylated SMAD 2/3 was reduced in parietal peritoneal fibroblasts and visceral mesothelial cells treated with C21. CONCLUSIONS: Local and systemic C21 administration reduced or completely prevented AA formation. These findings may be attributed to decreased intraperitoneal TGF-ß in vivo and decreased migration of peritoneal fibroblasts and visceral mesothelial cells. Importantly, C21 did not have histologically quantifiable effects on laparotomy wounds, suggesting C21 could reduce AA formation without compromising laparotomy healing.

Patient survival following renal transplantation in Indigenous populations: A systematic review.

BACKGROUND: Inequities in health care predispose Indigenous populations to poor health outcomes. The objective of this study was to examine patient survival and other post-transplant outcomes of kidney transplantation among Indigenous patients compared with non-Indigenous populations. METHODS: A systematic review of MEDLINE, EMBASE, and Google Scholar was undertaken from inception to September 30, 2019, using a computerized search. Publication descriptors and methodological and statistical details were extracted. Articles were assessed using the methodological index for non-randomized studies (MINORS) scale. RESULTS: Twelve studies were included. All studies were retrospective and published between 2004 and 2018. Mean Indigenous patient age was 40 (range: 8-76), while non-Indigenous was 41 (range: 6-74). Mean sample size for Indigenous populations was 398 (range: 24-1459), while for non-Indigenous patients was 1102 (range: 53-7555). Eight studies examined indigenous populations in Australia, two in Canada, one in the United States, and one in New Zealand. All studies were considered of high methodological quality and clinically homogenous. Results indicated that patient survival, graft survival, and delayed graft function were significantly reduced among Indigenous populations compared with non-Indigenous populations. CONCLUSIONS: Post-transplant outcomes among various Indigenous populations are significantly worse compared with non-Indigenous populations. The reasons for poor outcomes are likely multifactorial. Improved standardized reporting of transplant outcomes of Indigenous patients is necessary to better inform healthcare services and improve clinical outcomes.

Prevention of Autologous Costal Cartilage Graft Warping in Secondary Rhinoplasty.

BACKGROUND: Autogenous costal cartilage grafts (ACCG) are frequently used in secondary rhinoplasty; however, these grafts tend to warp. The objective of this study is to systematically evaluate current interventions to prevent warping of ACCGs and to assess long-term outcomes with their use. METHODS: A systematic review was undertaken using a computerized search. Eligible articles assessed adult patients undergoing secondary rhinoplasty with ACCGs. Interventions to reduce warping were examined. Publication descriptors were extracted, heterogeneity was examined, and methodological quality of articles was assessed. RESULTS: Eighteen studies were included. Most studies were published after 2010 (83.3%), assessed a single intervention (83.3%), and were of levels of evidence III and IV. Mean patient age was 30 (range 5-95 years) and studies included a mean of 64 cases (range 9-357). Nine of the 15 non-comparative studies were considered of high methodological quality, while all 3 comparative studies were considered high quality. Secondary rhinoplasties which did not describe a method to address warping showed increased rates of warping compared to counter balancing techniques, chimeric grafts, titanium microplating, Kirschner wire and suture usage, irradiation, and various carving techniques. Rates of warping remained low with no major complications with the use of a variety of approaches. CONCLUSIONS: ACCG warping during secondary rhinoplasty can be alleviated with a variety of techniques with no clear difference in outcomes between approaches. Plastic surgeons may consider adopting one of the various techniques described in order to reduce warping, maximize aesthetic outcomes and patient satisfaction.

Shared decision-making in older children and parents considering elective adenotonsillectomy.

OBJECTIVES: Shared decision-making describes a collaborative process in which healthcare providers and patients/families make treatment decisions using the best available evidence, while taking into account the patient's values and preferences. The objectives of this study were to assess the level of decisional conflict and shared decision-making experienced by older children and their parents when considering elective adentonsillectomies. DESIGN: A prospective cohort study. SETTING: Paediatric otolaryngology clinic in a teaching hospital. PARTICIPANTS: Participants included 53 children older than 9 years and their parents who underwent consultation for tonsillectomy with or without adenoidectomy. MAIN OUTCOMES MEASURES: Children and parents completed the Decisional Conflict Scale (DCS) and Shared Decision-Making Questionnaire-Patient Version (SDM-Q-9). Surgeons completed the Shared Decision-Making Questionnaire-Physician Version (SDM-Q-Doc). RESULTS: Overall, 10 (19%) parents and 18 (34%) children reported clinically significant decisional conflict. Parents who opted not to proceed with surgery had significantly higher DCS scores than those who decided to proceed with surgery. Both parents and children SDM-Q-9 and total DCS scores were significantly negatively correlated. Physician SDM-Q-Doc and parent total DCS scores were negatively correlated, while parent and physician SDM scores were positively correlated. CONCLUSIONS: Many older children and parents reported significant decisional conflict when considering elective paediatric otolaryngology surgery. Decisional conflict levels for both children and parents decreased with greater perceived levels of shared decision-making. Older children did not appear to discern the same levels of shared decision-making as parents and surgeons. Future research should assess methods to implement shared decision-making into clinical practice for clinicians, parents and children when appropriate.

Comparison of Distraction Osteogenesis and Single-Stage Remodeling for Correction of Unilateral Coronal Craniosynostosis.

BACKGROUND: Unilateral coronal craniosynostosis is a challenging condition in craniofacial surgery. Frontoorbital advancement by single-stage resorbable remodeling and distraction osteogenesis (DO) techniques have known intraoperative differences, but their comparative outcomes are less well characterized. METHODS: A systematic literature search of the MEDLINE, EMBASE, LILACS, and Web of Science databases was conducted. The search was performed using terms related to craniosynostosis and its operative management. The primary outcome of interest was the Whitaker classification. Secondary outcomes included cranial volume or cranial index change, and infection and reoperation rates. RESULTS: A total of 6978 eligible articles were identified of which 26 met inclusion criteria. A total of 292 patients were included in the studies, with 223 undergoing a single-stage remodeling procedure (76.4%) and 69 DO procedures (23.6%). There was a trend toward patients with DO having better Whitaker aesthetic outcomes. Only 2 studies reported volumetric changes. There was a substantial difference in planned and unplanned reoperation rates but not in infection rates. CONCLUSION: The results of this systematic review suggest that the techniques have similar outcomes and complications, although there was a trend toward better Whitaker outcomes with DO procedures. Inherent to the DO technique is the need for multiple operations to both insert and remove internal hardware which may affect the overall cost effectiveness.

What We Do: Povidone-Iodine Solution to Delineate the Cutaneous Roll.

BACKGROUND: Establishing continuity of the cutaneous roll is critical to cleft lip repair. Unfortunately, this landmark can be difficult to appreciate depending on the patient's skin tone, surgical lighting, or preexisting scar. SOLUTION: When applied to the lip, dilute povidone-iodine solution beads off the cutaneous roll and dry vermilion, clearly defining these structures. WHAT WE DO: We use dilute povidone-iodine solution not only to prep the lip but to delineate landmarks critical to cleft lip repair.

Assessing Attentional Bias in Secondary Cleft Lip Deformities: An Eye-Tracking Study.

OBJECTIVE: Using a well-established measure of attention, we aimed to objectively identify differences in severity between types of simulated secondary cleft lip deformities. DESIGN: Volunteer participants viewed a series of images of a child digitally modified to simulate different secondary unilateral cleft lip deformities (long lip, short lip, white roll/vermilion disjunction, and vermilion excess), a lip scar with no secondary deformity, or a normal lip. Eye movements were recorded using a table-mounted eye-tracking device. Dwell times for 7 facial regions (eyes, nose, mouth, left ear, right ear, scar, and entire face) were compared. PARTICIPANTS: Forty-six naive adults (25 male; mean age 25.5 years) were recruited from our local university community. MAIN OUTCOME: The primary outcome of the study was cumulative dwell time between facial regions (eyes, nose, mouth, left ear, right ear, scar, and entire face). RESULTS: Participants spent significantly more time focused on the upper lip regions in patients with simulated secondary deformities relative to those who did not ( P < .01). Severe short lip deformities resulted in longer fixation times than severe long lips ( P < .05). Participants spent less time focused on the eye region in the presence of a secondary lip deformity ( P < .05). When total facial fixation time was assessed, short lip deformities resulted in the greatest duration dwell time ( P < .001). CONCLUSIONS: This study presents objective data to support the concept that observers show varying degrees of attentional bias to the lip region depending on the type and severity of the simulated secondary cleft lip deformity.

The Effect of Written Information on Recall of Surgical Risks of Primary Cleft Palate Repair: A Randomized Controlled Study.

OBJECTIVE: To investigate parents' understanding of the risks of primary cleft palate surgery after counseling with and without the use of a written informational aid. DESIGN: Prospective, randomized, single-blind trial. SETTING: Academic tertiary care center. PARTICIPANTS: Parents of children undergoing primary cleft palate surgery. INTERVENTIONS: Parents were randomized to receive a standard informed consent discussion with or without provision of a written informational aid in the form of a pamphlet. MAIN OUTCOMES MEASURE: Parents' recall of 9 specific surgical risks 3 weeks after informed consent discussion. RESULTS: Forty parents enrolled in and completed the study (20 participants each in the control and intervention groups). There were no statistically significant differences between groups in terms of baseline demographics. The mean number of risks recalled were 3.7 (1.6) for the control group and 4.2 (1.9) for the intervention group (P = .37). The most commonly recalled risks were fistula formation and bleeding, while the least frequent were facial growth restriction and need for further surgery. No differences in risk recall were observed based on participant's gender, level of education, or income. CONCLUSION: Parents of children undergoing primary cleft palate surgery recall less than 50% of counseled risks. The use of a written aid in the form of a pamphlet did not significantly improve recall in this sample. These results demonstrate that surgeons should implement additional measures to improve comprehension of surgical risks.

Repair of Primary Cleft Palate and Oronasal Fistula With Acellular Dermal Matrix: A Systematic Review and Surgeon Survey.

OBJECTIVE: The current review and survey aim to assess the effectiveness of acellular dermal matrix (ADM) in the repair of cleft palate and oronasal fistula and to evaluate the current trends of ADM use in palate surgery. DESIGN: A systematic review of English articles was conducted using MEDLINE (1960 to July 1, 2016), the Cochrane Controlled Trials Register (1960 to July 1, 2016), and EMBASE (1991 to July 1, 2016). Additional studies were identified through a review of references cited in initially identified articles. Search terms included "cleft palate," "palatal," "oronasal fistula," "acellular dermal matrix," and "Alloderm®." An online survey was disseminated to members of the American Cleft Palate-Craniofacial Association to assess current trends in ADM use in palate surgery. STUDY SELECTION: All studies evaluating the outcome of primary palate repair or repair of oronasal fistula with the use of aceullar dermal matrix products were included in the review. RESULTS: Twelve studies met inclusion criteria for review. Studies were generally of low quality, as indicated by methodological index for non-randomized studies (MINORS) scores ranging from 7 to 14. The pooled estimate for fistula formation after primary palatoplasty following ADM use was 7.1%. The pooled estimate for recurrence of fistula after attempted repair using ADM was 11%. Thirty-six cleft surgeons responded to the online survey study. Of these, 45% used ADM in primary cleft palate repair, while 67% used ADM for repair of oronasal fistulae. CONCLUSION: Use of ADM products is commonplace in palate surgery. Despite this, there is a paucity of high-quality data demonstrating benefit. Further randomized controlled trials examining ADM in palate surgery are required to help develop structured guidelines and improve care.

Surgical Correction of Nonsyndromic Sagittal Craniosynostosis: Concepts and Controversies.

Sagittal craniosynostosis remains the most common type of isolated craniosynostosis, accounting for nearly half of all nonsyndromic cases. The clinical diagnosis is typically made on the basis of a scaphocephalic head shape and is confirmed by computed tomography or magnetic resonance imaging. The current review examines the major surgical options for correction of isolated sagittal craniosynostosis, including their complications and short- and long-term outcomes. Reconstructive techniques have benefited from advances in perioperative anesthesia monitoring and improved safety of blood transfusion. Although extensive calvarial remodeling is considered safe and may confer greater long-term skull shape correction and decreased neuropsychological sequelae, minimally invasive techniques, such as device-assisted expansion of the cranium continue to increase in popularity. This review underscores the need for additional prospective studies comparing different techniques to determine the optimal reconstructive approach for correction of sagittal craniosynostosis.

Women's Experiences With Flap Failure After Autologous Breast Reconstruction: A Qualitative Analysis.

Clinical experience suggests that flap failure after autologous breast reconstruction can be a devastating experience for women. Previous research has examined women's experiences with autologous breast reconstruction with and without complications, and patients' experiences with suboptimal outcomes from other medical procedures. The authors aimed to examine the psychosocial experience of flap failure from the patient's perspective. Seven women who had experienced unilateral flap failure after deep inferior epigastric perforator flap surgery in the past 12 years completed semistructured interviews about their breast cancer treatments, their experiences with flap failure, the impact of flap failure on their lives, and the coping strategies they used. Interpretive phenomenological analysis, a type of qualitative analysis that provides an in-depth account of participant's experiences and their meanings, was used to analyze the interview data. From these data, patient-derived recommendations were developed for surgeons caring for women who have experienced flap failure. Three main themes (6 subthemes) emerged: coming to terms with flap failure (coping with emotions, body dissatisfaction); making meaning of flap failure experience (questioning, relationship with surgeon); and care providers acknowledging the emotional experience of flap failure (experience of being treated "mechanically," suggestions for improvement). In conclusion, flap failure in breast reconstruction is an emotionally difficult experience for women. Although there are similarities to other populations of patients experiencing suboptimal outcomes from medical procedures, there are also unique aspects of the flap failure experience. A better understanding of women's experiences with flap failure will assist in providing more appropriate supports.