A retrospective case series of Mohs micrographic surgery and interdisciplinary management of female genital skin cancers: Local recurrence rates and patient-reported outcomes.

BACKGROUND: Conventional excision of female genital skin cancers has high rates of local recurrence and morbidity. Few publications describe local recurrence rates (LRRs) and patient-reported outcomes (PROs) after Mohs micrographic surgery (MMS) for female genital skin cancers. OBJECTIVE: To evaluate LRRs, PROs, and interdisciplinary care after MMS for female genital skin cancers. METHODS: A retrospective case series was conducted of female genital skin cancers treated with MMS between 2006 and 2021 at an academic center. The primary outcome was local recurrence. Secondary outcomes were PROs and details of interdisciplinary care. RESULTS: Sixty skin cancers in 57 patients were treated with MMS. Common diagnoses included squamous cell cancer (n = 26), basal cell cancer (n = 12), and extramammary Paget disease (n = 11). Three local recurrences were detected with a mean follow-up of 61.1 months (median: 48.8 months). Thirty-one patients completed the PROs survey. Most patients were satisfied with MMS (71.0%, 22/31) and reported no urinary incontinence (93.5%, 29/31). Eight patients were sexually active at follow-up and 75.0% (6/8) experienced no sexual dysfunction. Most cases involved interdisciplinary collaboration 71.7% (43/60). LIMITATIONS: Limitations include the retrospective single-center design, heterogeneous cohort, and lack of preoperative function data. CONCLUSIONS: Incorporating MMS into interdisciplinary teams may help achieve low LRRs and satisfactory function after genital skin cancer surgery.

Direct-to-Implant Versus 2-Stage Breast Reconstruction: Which Technique Is Better? An Analysis of 104 Patients at a Single Institution.

BACKGROUND: Two-stage (TS) implant-based reconstruction is the most commonly performed method of reconstruction after mastectomy. A growing number of surgeons are offering patients direct-to-implant (DTI) reconstruction, which has the potential to minimize the number of surgeries needed and time to complete reconstruction, as well as improve health care utilization. However, there are conflicting data regarding the outcomes and complications of DTI, and studies comparing the 2 methods exclusively are lacking. METHODS: Patients undergoing implant-based reconstruction after mastectomy within a large interstate health system between 2015 and 2019 were retrospectively identified and grouped by reconstruction technique (TS and DTI). The primary outcomes were a composite of complications (surgical site occurrences), health care utilization (reoperations, unplanned emergency department visits, and readmissions), and time to reconstruction completion. Risk-adjusted logistic and generalized linear models were used to compare outcomes between TS and DTI. RESULTS: Of 104 patients, 42 underwent DTI (40.4%) and 62 underwent TS (59.6%) reconstruction. Most demographic characteristics, and oncologic and surgical details were comparable between groups ( P > 0.05). However, patients undergoing TS reconstruction were more likely to be publicly insured, have a smoking history, and undergo skin-sparing instead of nipple-sparing mastectomy. The composite outcome of complications, reoperations, and health care utilization was higher for DTI reconstruction within univariate (81.0% vs 59.7%, P = 0.03) and risk-adjusted analyses (odds ratio, 3.78 [95% confidence interval [CI], 1.09-13.9]; P < 0.04). Individual outcome assessment showed increased mastectomy flap necrosis (16.7% vs 1.6%, P < 0.01) and reoperations due to a complication (33.3% vs 16.1%; P = 0.04) in the DTI cohort. Although DTI patients completed their aesthetic revisions sooner than TS patients (median, 256 days vs 479 [ P < 0.01]; predicted mean difference for TS [reference DTI], 298 days [95% CI, 71-525 days]; P < 0.01), the time to complete reconstruction (first to last surgery) did not differ between groups (median days, DTI vs TS, 173 vs 146 [ P = 0.25]; predicted mean difference [reference, DTI], -98 days [95% CI, -222 to 25.14 days]; P = 0.11). CONCLUSIONS: In this cohort of patients, DTI reconstruction was associated with higher complications, reoperations, and health care utilization with no difference in time to complete reconstruction compared with TS reconstruction. Further studies are warranted to investigate patient-reported outcomes and cost analysis between TS and DTI reconstruction.

Immediate Breast Reconstruction for Inflammatory Breast Cancer: Trends in Use and Clinical Outcomes 2004-2016.

INTRODUCTION: National guidelines specify against immediate breast reconstruction (IBR) among inflammatory breast cancer (IBC) patients. However, limited data exist regarding this practice. We report practice patterns and oncologic outcomes among nonmetastatic IBC patients receiving trimodality therapy, with or without IBR. METHODS: Using the National Cancer Database, we identified nonmetastatic IBC patients treated with trimodality therapy from 2004 to 2016. Primary outcome was overall survival (OS), assessed on unadjusted analysis using Kaplan-Meier estimates and on adjusted analysis using multivariable Cox proportional hazards and inverse probability weighting (IPW) models. OS analysis was also conducted with propensity score matched (PSM) cohorts. Secondary outcomes included IBR utilization rates, time to postmastectomy radiotherapy (PMRT), and surgical outcomes. RESULTS: 6589 women were included, including 5954 (90.4%) non-reconstructed and 635 (9.6%) IBR. Among IBR recipients, 250 (39.4%) underwent autologous reconstruction, 171 (26.9%) underwent implant-based reconstruction, and 214 (33.7%) unspecified. IBR utilization increased from 6.3% to 10.1% from 2004 to 2016 at a 4% average annual growth rate (P < 0.001). Median follow-up was 43 and 45 months for IBR and non-reconstructed patients, respectively (P = 0.29). On Cox multivariable analysis, IBR was associated with improved OS (HR 0.63, 95% CI 0.44-0.90, P = 0.01), but this association was not significant on IPW analysis (P = 0.06). In PSM cohorts, this association remained significant (HR 0.60, 95% CI 0.40-0.92, P = 0.02). Margin status, time to PMRT, 30-day readmission, and 30-/90-day mortality did not differ between groups (all P > 0.05). CONCLUSION: Although not endorsed by national guidelines, IBR is increasing among IBC patients; however, more granular data are needed to determine oncologic safety.

An Update on Social Media in Academic Plastic Surgery Training Programs: The Rising Trend of Likes, Shares, and Retweets.

BACKGROUND: Increasing in popularity, social media provides powerful marketing and networking tools for private practice plastic surgeons. The authors sought to examine social media utilization by academic plastic surgery training programs. METHODS: Facebook, Instagram, and Twitter were queried for plastic surgery training program, program director, and chief/chair accounts. Training program posts were categorized as educational, operative, social, informational, self-promotional, visiting lecturer, research-related, and other. Factors influencing total number of followers were analyzed including number of accounts followed, frequency, total number, and types of posts as well as duration of account. Other variables included geographic location, 2018 to 2019 Doximity residency ranking, and US News and World Report rankings of affiliated hospital systems and medical schools. Social media accounts were analyzed using Kruskal-Wallis, Wilcoxon rank sum, and regression analysis. RESULTS: Facebook is the most popular social media platform among chiefs/chairs (34, 35.7%), followed by Instagram (20, 21.1%) and Twitter (19, 20.0%). Facebook is used more by program directors (31, 32.6%) followed by Instagram (22, 23.1%) and Twitter (15, 15.7%). The majority of Facebook and Twitter leadership accounts are for personal use (62%-67%), whereas Twitter is used primarily for professional purposes (60%-84%). Training program social media use is rising, with Instagram and Twitter presence growing at exponential rates (R = 0.97 and 0.97, respectively). Of 95 training programs evaluated, 54 (56.8%) have Instagram accounts, 29 (30.5%) have Facebook accounts, and 27 (28.4%) have Twitter accounts. Most training programs using social media have 2 or more accounts (37, 67.3%). West coast programs have more Instagram followers than other geographic regions, significantly more than Southern programs (P = 0.05). Program accounts with more followers are affiliated with top-ranked hospitals (P = 0.0042) or top-ranked Doximity training programs (P = 0.02). CONCLUSIONS: Similar to its adoption by private practice plastic surgery, social media use in academic plastic surgery is growing exponentially. Now, over half of residency programs have Instagram accounts. Program leaders are using Facebook and Instagram primarily for personal use and Twitter for professional use. Programs affiliated with a top-ranked hospital or ranked highly by Doximity have more followers on social media.

Professional Burnout in United States Plastic Surgery Residents: Is It a Legitimate Concern?

BACKGROUND: Physician burnout is intimately associated with institutional losses, substance abuse, depression, suicidal ideation, medical errors, and lower patient satisfaction scores. OBJECTIVES: By directly sampling all US plastic and reconstructive surgery residents, this study examined burnout, medical errors, and program-related factors. METHODS: Cross-sectional study of data collected from current US plastic and reconstructive surgery residents at Accreditation Council for Graduate Medical Education-accredited programs during the 2018 to 2019 academic year. Previously validated survey instruments included the Stanford Professional Fulfillment and Maslach Burnout Indices. Additional data included demographics, relationship status, program-specific factors, and admission of medical errors. RESULTS: A total of 146 subjects responded. Residents from each postgraduate year (PGY) in the first 6 years were well represented. Overall burnout rate was 57.5%, and on average, all residents experienced work exhaustion and interpersonal disengagement. No relation was found between burnout and age, gender, race, relationship status, or PGY. Burnout was significantly associated with respondents who feel they matched into the wrong program, would not recommend their program to students, do not feel involved in program decisions, reported increasing hours worked in the week prior, feel that they take too much call, reported making a major medical error that could have harmed a patient, or reported making a lab error. CONCLUSIONS: This study directly examined burnout, self-reported medical errors, and program suitability in US plastic and reconstructive residents based on validated scales and suggests that burnout and some medical errors may be related to program-specific, modifiable factors, not limited to, but including, involvement in program-related decisions and call structure.

The Role of a Resident Aesthetic Clinic in Addressing the Trainee Autonomy Gap.

BACKGROUND: Our institution supports a chief resident aesthetic clinic with the goal of fostering autonomy and preparedness for independent practice in a safe environment. OBJECTIVES: The aim of this study was to compare safety profiles and costs for common aesthetic procedures performed in our resident versus attending clinics. METHODS: A retrospective review was conducted of all subjects presenting for aesthetic face, breast, and/or abdominal contouring surgery at our institution from 2008 to 2017. Two cohorts were identified: subjects undergoing surgery through the chief resident versus attending clinics. Aesthetic procedures queried included: (1) blepharoplasty, rhinoplasty, or rhytidectomy; (2) augmentation mammaplasty, reduction mammaplasty, or mastopexy; (3) abdominoplasty; and (4) combination. Demographics, perioperative characteristics, costs, and postoperative complications were analyzed. RESULTS: In total, 262 and 238 subjects underwent aesthetic procedures in the resident and attending clinics, respectively. Subjects presenting to the residents were younger (P < 0.001), lower income (P < 0.001), and had fewer comorbidities (P < 0.001). Length of procedure differed between resident and attending cohorts at 181 and 152 minutes, respectively (P < 0.001), although hospital costs were not significantly increased. Total costs were higher in the attending cohort independent of aesthetic procedure (P < 0.001). Hospital readmissions (P < 0.05) and cosmetic revisions (P < 0.002) were more likely to occur in the attending physician cohort. Postoperative complications (P < 0.50) and reoperative rates (P < 0.39) were not significantly different. CONCLUSIONS: The resident aesthetic clinic provides a mechanism for increased autonomy and decision-making, while maintaining patient safety in commonly performed cosmetic procedures.

A Systematic Meta-analysis of Prosthetic-Based Breast Reconstruction in Irradiated Fields With or Without Autologous Muscle Flap Coverage.

BACKGROUND: The popularity of implant-based breast reconstruction, along with the well-established benefits of radiation therapy, unfortunately can lead to device placement into irradiated fields. Here, we compare prosthetic reconstructions with latissimus dorsi (LD) or subpectoral implants alone via systematic meta-analysis. METHODS: A literature search identified articles involving prosthetic-based breast reconstruction in the setting of prior irradiation with or without an LD flap. The primary outcomes of interest, including device loss, capsular contracture, reoperation, and infection, were analyzed via head-to-head meta-analysis. RESULTS: Thirty-one studies and 1275 reconstructions were included. Average age was 48.9 years and average follow-up was 42.8 months. The head-to-head odds ratio for implant loss with implant-only versus LD-assisted reconstruction was 4.33 (P = 0.0003, I = 7%), favoring LD-assisted reconstruction. Implant loss in pooled analysis was 5.0% for LD-assisted reconstruction and 15.0% for implant-only (P < 0.001). CONCLUSIONS: In previously irradiated fields, prostheses placed with an LD flap demonstrated a clinically significant reduction in device loss, infection, and reoperation.

Bilateral Free Flap Breast Reconstruction After Unilateral Radiation: Comparing Intraoperative Vascular Complications and Postoperative Outcomes in Radiated Versus Nonradiated Breasts.

BACKGROUND: Radiation induces vessel damage and impairs tissue healing. To date, only 1 study has examined radiation's impact in autologous breast reconstruction on intraoperative vascular complications and postoperative outcomes. In this follow-up paper, we examine a larger cohort with an improved study design to better control for patient characteristics. METHODS: A database of 1780 patients who underwent autologous breast free flap reconstruction at the University of Pennsylvania's Health System between 2003 and 2014 was searched for patients who underwent bilateral breast reconstruction after unilateral radiation, returning 199 patients for review. These were then analyzed for intraoperative vascular complications as well as postoperative complications. McNemar tests were performed on all variables, comparing between radiated and nonradiated fields. RESULTS: Fields with prior radiation were significantly more likely to have any type of intraoperative vascular complication and need for arterial anastomotic revision compared to fields without prior radiation (14% versus 7%, P = 0.03 and 8% versus 3%, P = 0.04, respectively). Although there was a trend for more frequent arterial thrombosis in radiated compared to nonradiated fields, this was nonsignificant (7% versus 3%, P = 0.08). There was no significant difference in venous thrombosis or need for venous anastomotic revision. Radiated fields were significantly more likely to have postoperative wound infections compared to nonradiated fields (4% versus 0.5%, P = 0.04). There was no difference in other postoperative complications, including postoperative thrombosis, flap loss, mastectomy flap necrosis, fat necrosis, hematoma, seroma, or delayed wound healing. CONCLUSIONS: Intraoperative vascular complications and postoperative wound infections are significantly more likely to occur in autologous breast free flap reconstruction with previous radiation therapy. It is important to plan for and counsel patients that fields with previous radiation are at higher risk for these complications.

The Patient's Perspective on the Effect of Autologous Breast Reconstruction on Lymphedema.

BACKGROUND: Lymphedema is a well-documented complication of the treatment for breast cancer. Although the onset of lymphedema is rare after delayed autologous breast reconstruction, no studies have surveyed a patient's perspective on the effects of reconstruction on lymphedema. METHODS: The design of this study was a retrospective review of delayed unilateral breast reconstruction performed by the senior authors between 2005 and 2009 combined with the use of a well-validated survey instrument that can be used to diagnose lymphedema. Patients were mailed a series of questions to determine if they had lymphedema. In addition, they were asked separate questions about reconstruction's effect on arm symptoms. RESULTS: During this period, 90 patients underwent delayed unilateral breast reconstruction with an autologous free flap. After 2 mailings, 68.8% (n = 62) of patients returned the survey and were included in data analysis. Of the 62 respondents, 11.3% (n = 7) had been diagnosed and documented as having lymphedema in the medical record. This is in stark contrast to the survey that reported 48.3% (n = 30) with lymphedema (P < 0.01), which is more consistent with previous reports of lymphedema after mastectomy. Overall, 29.0% (n = 18) reported mild lymphedema and 20.0% (n = 12) reported moderate/severe lymphedema. Of those diagnosed by survey, 51.7% thought there was no change, 27.6% were worse, and 20.7% were better after reconstruction. Although not necessarily indicative of a diagnosis of lymphedema, when asked questions about arm symptoms, 38.4% thought their symptoms were worse, 30.8% reported no change, and 30.8% stated they were better. Of those patients with lymphedema by survey, only 18.5% reported discussing this with their plastic surgeon. CONCLUSIONS: Overall, the prevalence of lymphedema was similar to published reports in the cancer literature, but much more common than reported in our plastic surgery clinic or recent plastic surgery literature. On the whole, delayed reconstruction seems to have no effect on lymphedema. Although more prospective study is necessary to answer this question conclusively, as part of a multidisciplinary team, plastic surgeons should be aware that lymphedema is common; patients may not volunteer their symptoms and may in fact benefit from specific questioning to aid in diagnosis and treatment.

Plastic surgery residency websites: a critical analysis of accessibility and content.

BACKGROUND: Medical students applying for plastic surgery residency utilize the Internet to manage their residency applications. Applicants often apply to many programs and rely on advice from colleagues, mentors, and information gathered from plastic surgery residency websites (PSRWs). The purpose of the present study was to evaluate integrated and combined PSRWs with respect to accessibility, resident recruitment, and education. METHODS: Websites from all 63 integrated and combined plastic surgery residencies available to graduating medical students during the 2013 academic year were available for study inclusion. Databases from national bodies for plastic surgery education were analyzed for accessibility of information. PSRWs were evaluated for comprehensiveness in the domains of resident education and recruitment. Residency programs were compared according to program characteristics using the Student t test and ANOVA with Tukey method. RESULTS: Of the 63 residencies available to graduating medical students, only 57 had combined or integrated program information on their PSRWs (90.5%). In the domain of resident recruitment, evaluators found an average of 5.5 of 15 content items (36.7%). As a whole, 26.3% of PSRWs had academic conference schedules, 17.5% had call schedules, and only 8.8% had operative case listings. For resident education, PSRWs provided an average of 4.6 of 15 content items (30.7%). Only 31.6% of PSRWs had interview schedules, 24.6% had graduate fellowship information, and 5.3% had information on board exam performance. Upon comparison, programs in the Midwest had more online recruitment content than programs in the West (47.1% vs. 24.2%, P < 0.01). Additionally, programs with a larger class of incoming residents (2 vs. 1) had greater online recruitment content (40.0% vs. 26.7%, P < 0.05). Larger programs with 3 integrated spots had more online education content than smaller programs with only 1 integrated spot (40.0% vs. 19.4%, P < 0.01). CONCLUSION: PSRWs are often not readily accessible and do not provide basic information that allow residency applicants to use this recruitment tool effectively. The paucity of online content suggests PSRWs are underutilized as an educational and recruitment tool. These findings have implications for applicants and plastic surgery residency programs, and there may be future opportunity to utilize this tool more effectively.

Lower extremity free flap outcomes using an anastomotic venous coupler device.

INTRODUCTION: Venous anastomosis is one of the most challenging technical aspects of microsurgery. Recently, it has been expedited by the use of an anastomotic coupler device in multiple reconstructive venues. However, there are few studies in the literature evaluating the use of the coupler in lower extremity reconstruction. We present one of the largest series to date examining the use of the venous coupler in microsurgical reconstruction of the lower extremity. METHODS: A retrospective chart review was completed including all lower extremity soft tissue reconstruction over a 26-month period performed by the senior authors. The Synovis venous coupler was used in all coupled venous anastomoses (Synovis Micro Companies Alliance Inc, Birmingham, Alabama). Patients under 18 years of age were excluded. RESULTS: Forty-nine free flaps were performed in 48 patients. All arterial anastomoses were hand sewn. The anastomotic venous coupler was used in 48 of 49 flaps (97.9%) with 1 hand-sewn case due to attending preference during early experience. There were no intraoperative vascular complications. Successful free flap reconstruction occurred in 47 of 49 flaps (95.9%). Of the flap losses, one was due to delayed venous thrombosis, the other attributed to delayed arterial thrombosis. Venous thrombosis rate was 2.1% when the coupler was used (1 failure in 48 flaps). CONCLUSIONS: The use of the venous coupler device in lower extremity reconstruction can be performed with a high degree of success. The potential of the venous coupler for reduced operative time, more efficient anastomoses with decreased ischemia, and reduced thrombotic rates represents potential benefits of this important tool.

Reexamining free flap breast reconstruction in the community and university setting: is there a difference?

BACKGROUND: This study aimed to compare free flap breast reconstruction outcomes in community and university settings to determine whether the latter is necessary for successful performance of this complex procedure. METHODS: Free tissue transfer procedures for breast reconstruction from 1 university and 1 community hospital performed between 2005 and 2011 were included. Procedures were performed by the same 2 surgeons at both institutions. Demographics and outcome measures were evaluated. RESULTS: Of the 1293 free tissue breast reconstructions performed, 99 (7.7%) were performed in a community hospital and 1194 (92.3%) were performed in a university center. No differences were noted in demographics, comorbidities, or type of free flap reconstruction. However, a number of perioperative characteristics differed. In the community setting, operative time was less (7.3 vs 8.3 hours, P < 0.0001), estimated blood loss was higher (330 vs 248 mL, P < 0.0001), and blood transfusions were more prevalent (24.6% vs 8.3%, P < 0.0001). Furthermore, no significant differences were noted in overall postoperative complications, although a higher rate of abdominal wound infections was noted in the community setting (7.2% vs 2.6%, P = 0.03). The mean number of hospital days was similar between the community and the university (should include value P = 0.44). CONCLUSIONS: Although slight differences were noted in a number of perioperative variables and wound complications, we conclude that the key to a successful free tissue transfer reconstruction is in the expertise of the surgeon and not the setting in which it is performed. Despite its complexity, free flap breast reconstruction can be safely and successfully performed in the community setting.

The impact of obesity on abdominal wall function after free autologous breast reconstruction.

BACKGROUND: The functional impact of obesity on abdominal wall strength after abdominally based autologous reconstruction is unknown. The purpose of this study was to determine if obesity alters the postoperative abdominal wall strength profile after autologous reconstruction. METHODS: We prospectively examined abdominal wall strength and function following autologous breast reconstruction between 2005 and 2010. Enrolled patients completed functional testing [upper abdominal strength (UA), lower abdominal strength (LA), and functional independence measure (FIM)] and psychometric testing utilizing the short form 36 (SF36). Data were obtained at preoperative, early (<90d), and late (90-365d) follow-up visits. Obese patients were compared with non-obese patients in both unilateral and bilateral reconstructions. RESULTS: Overall, 167 patients were enrolled, with obesity noted in 34% of patients. Obese Unilateral reconstruction patients had lower preoperative UA strength (4.7 vs.4.2, P=0.05) and FIM (6.7 vs. 6.9, P=0.008) scores compared with non-obese patients. These scores significantly worsened in all patients from preoperative to early follow-up, yet scores did not differ at late follow-up between obesity cohorts. Obese bilateral reconstruction patients had similar preoperative functional scores; however, UA strength scores at early (2.5 vs. 3.2, P=0.008) and late (3.6 vs. 4.3, P=0.005) follow-up were significantly lower compared with non-obese patients. No differences in subjective health were noted in follow-up for unilateral or bilateral reconstructions. CONCLUSION: Obesity significantly impacts the abdominal function profile of autologous breast reconstruction patients; however, subjective physical and mental health differences are less notable. This is especially true for obese patients who undergo bilateral reconstructions. In these patients, a careful balance between optimizing flap perfusion, limiting donor site morbidity, and enabling functional recovery should be considered.

Prepectoral versus Submuscular Implant-Based Breast Reconstruction: A Matched-Pair Comparison of Outcomes.

BACKGROUND: Implant-based breast reconstruction is the most common reconstructive approach after mastectomy. Prepectoral implants offer advantages over submuscular implants, such as less animation deformity, pain, weakness, and postradiation capsular contracture. However, clinical outcomes after prepectoral reconstruction are debated. The authors performed a matched-cohort analysis of outcomes after prepectoral and submuscular reconstruction at a large academic medical center. METHODS: Patients treated with implant-based breast reconstruction after mastectomy from January of 2018 through October of 2021 were retrospectively reviewed. Patients were propensity score exact matched to control demographic, preoperative, intraoperative, and postoperative differences. Outcomes assessed included surgical-site occurrences, capsular contracture, and explantation of either expander or implant. Subanalysis was done on infections and secondary reconstructions. RESULTS: A total of 634 breasts were included (prepectoral, 197; submuscular, 437). A total of 292 breasts were matched (146 prepectoral:146 submuscular) and analyzed for clinical outcomes. Prepectoral reconstructions were associated with greater rates of SSI (prepectoral, 15.8%; submuscular, 3.4%; P < 0.001), seroma (prepectoral, 26.0%; submuscular, 10.3%; P < 0.001), and explantation (prepectoral, 23.3%; submuscular, 4.8%; P < 0.001). Subanalysis of infections revealed that prepectoral implants have shorter time to infection, deeper infections, and more Gram-negative infections, and are more often treated surgically (all P < 0.05). There have been no failures of secondary reconstructions after explantation in the entire population at a mean follow-up of 20.1 months. CONCLUSIONS: Prepectoral implant-based breast reconstruction is associated with higher rates of infection, seroma, and explantation compared with submuscular reconstructions. Infections of prepectoral implants may need different antibiotic management to avoid explantation. Secondary reconstruction after explantation can result in long-term success. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Breast Reconstruction Complications After Postmastectomy Proton Radiation Therapy for Breast Cancer.

Purpose: Our purpose was to report complications requiring surgical intervention among patients treated with postmastectomy proton radiation therapy (PMPRT) for breast cancer in the setting of breast reconstruction (BR). Methods and Materials: Patients enrolled on a prospective proton registry who underwent BR with immediate autologous flap, tissue expander (TE), or implant in place during PMPRT (50/50.4 Gy +/- chest wall boost) were eligible. Major reconstruction complication (MRC) was defined as a complication requiring surgical intervention. Absolute reconstruction failure was an MRC requiring surgical removal of BR. A routine revision (RR) was a plastic surgery refining cosmesis of the BR. Kaplan-Meier method was used to assess disease outcomes and MRC. Cox regression was used to assess predictors of MRC. Results: Seventy-three courses of PMPRT were delivered to 68 women with BR between 2013 and 2021. Median follow-up was 42.1 months. Median age was 47 years. Fifty-six (76.7%) courses used pencil beam scanning PMPRT. Of 73 BR, 29 were flaps (39.7%), 30 implants (41.1%), and 14 TE (19.2%) at time of irradiation. There were 20 (27.4%) RR. There were 9 (12.3%) MRC among 5 implants, 2 flaps, and 2 TE, occurring a median of 29 months from PMPRT start. Three-year freedom from MRC was 86.9%. Three (4.1%) of the MRC were absolute reconstruction failure. Complications leading to MRC included capsular contracture in 5, fat necrosis in 2, and infection in 2. On univariable analysis, BR type, boost, proton technique, age, and smoking status were not associated with MRC, whereas higher body mass index trended toward significance (hazard ratio, 1.07; 95% CI, 0.99-1.16; P = .10). Conclusions: Patients undergoing PMPRT to BR had a 12.3% incidence of major complications leading to surgical intervention, and total loss of BR was rare. MRC rates were similar among reconstruction types. Minor surgery for RR is common in our practice.

Chronic pain following abdominal free flap breast reconstruction: a prospective pilot analysis.

BACKGROUND: Chronic pain after breast reconstruction is an ill-defined process which can generate significant patient morbidity and disability. The purpose of this study was to examine chronic, persistent pain in a prospective study of free flap breast reconstruction patients, in an effort to identify possible points of intervention and counseling. METHODS: We performed a prospective study evaluating function, quality of life, and satisfaction in patients undergoing abdominally based autologous reconstruction between 2006 and 2010. Using the short form 36, we examined the presence of chronic body pain (>4 months) as well as overall mental and physical health. Patients with debilitating pain were compared to those without in a post hoc analysis. RESULTS: Overall, 399 women underwent reconstruction during the study period, with 149 enrolling and having long-term follow-up in this portion of the prospective study. Twenty-six (17%) of 149 patients experienced chronic body pain that was moderately debilitating after autologous reconstruction, making it one of the most common complications experienced in this cohort. No differences were noted in demographics, medical history, procedure type, history of axillary surgery, radiation treatment, surgical outcomes, or follow-up time between the cohorts. However, patients with chronic pain were found to have higher preoperative pain scores (P < 0.0001) and lower physical, mental, and overall health scores across time points. All scores significantly worsened with time in comparison to the cohort without pain, who, in contrast showed score improvement across all areas. Although pain issues trended toward being noted in postoperative visits more frequently in the chronic pain cohort (37% vs 19%, P = 0.051), only 1 (4.2%) patient was referred for pain service consultation. Additionally, satisfaction with reconstruction was significantly lower in patients who demonstrated chronic pain (P = 0.03). CONCLUSIONS: Factors contributing to chronic pain continue to be elusive and understudied. Our data demonstrate the importance of screening for chronic pain, as we determined that preoperative pain is linked to increased, moderately debilitating postoperative chronic pain. Persistent chronic pain, in turn, is associated with significant morbidity, disability, and dissatisfaction. Such patients with pain issues may benefit from additional preoperative counseling and early involvement of the pain service.

An assessment of the risks and benefits of immediate autologous breast reconstruction in patients undergoing postmastectomy radiation therapy.

BACKGROUND: The utility of immediate autologous breast reconstruction in patients likely to undergo radiation therapy remains controversial. The purpose of this study was to perform a quantitative outcomes assessment of patients undergoing immediate free-flap breast reconstruction and postmastectomy radiation therapy (PMRT). METHODS: A retrospective chart review was performed of patients undergoing free-flap breast reconstruction by the senior authors (L.C.W. and J.M.S.) between 2005 and 2009. The treatment group included patients who underwent immediate free-flap breast reconstruction and received PMRT. The control group consisted of patients undergoing immediate breast reconstruction without PMRT. Variables assessed included postoperative complications and revision surgery. RESULTS: Four hundred seven women underwent immediate free-flap breast reconstruction for a total of 655 flaps. In the cohort that underwent unilateral reconstruction, there was a higher incidence of volume loss (28.26% vs 4.42%, P < 0.0001) and fat necrosis (19.57% vs 3.54%, P = 0.002) in the PMRT group. In the cohort that underwent bilateral reconstruction, there was a higher rate of volume loss for those in the PMRT group (19.75% vs 1.0%, P < 0.0001). However, for both patients who underwent unilateral reconstruction and those who underwent bilateral reconstruction, the PMRT group underwent similar rates of revision surgery. The cohort that underwent bilateral reconstruction experienced a higher incidence of volume loss in radiated perforator flaps (39%) vs muscle-sparing free transverse rectus abdominis myocutaneous flaps (12%; P = 0.013). CONCLUSIONS: Postmastectomy radiation therapy can result in volume loss and fat necrosis, yet there are no increases in other complications or revision procedures. The deleterious effects of PMRT do not preclude the decision for immediate autologous reconstruction.

Age and abdominal wall strength: assessing the aging abdominal wall after autologous breast reconstruction.

Autologous breast reconstruction is safe in advanced age, yet no study has examined its effects on the aging abdomen. We, therefore, studied 145 women who participated in a prospective study of abdominal strength following abdominal free flap breast reconstruction, comparing preoperative and late follow-up scores in patients ≥60 years old (11 unilateral, 13 bilateral) compared with patients <60 (58 unilateral, 63 bilateral). Simple in-office tests were utilized to test abdominal strength. No differences were noted in unilateral absolute scores at either time point, however, a decrease in upper abdominal strength was noted in the younger cohort over time (P = 0.01). Bilateral analyses revealed absolute score decreases in upper abdominal strength for both cohorts but no major differences between the two. We conclude that autologous breast reconstruction with abdominal tissue in older patients result in little to no difference in abdominal function as compared with younger patients.

Coumadin-induced skin necrosis of the breasts: case report.

A case report of coumadin-induced skin necrosis (CISN) is presented, followed by a topic review of CISN, which reviews presentation, pathophysiology, differential diagnosis, prevention, and management of this disorder. The prevalence of CISN is low (0.01%-0.1% of patients receiving coumadin). However, of those affected, over 50% required some form of surgical debridement or reconstruction. Although skin necrosis secondary to coumadin therapy is rare, it is essential for plastic surgeons to be aware of this clinical entity in order to make the correct diagnosis and provide appropriate treatment.