Postoperative Antibiotics Confer No Protective Association After Fat Grafting for Breast Reconstruction.

INTRODUCTION: Autologous fat grafting after breast reconstruction is a commonly used technique to address asymmetry and irregularities in breast contour. While many studies have attempted to optimize patient outcomes after fat grafting, a key postoperative protocol that lacks consensus is the optimal use of perioperative and postoperative antibiotics. Reports suggest that complication rates for fat grafting are low relative to rates after reconstruction and have been shown to not be correlated to antibiotic protocol. Studies have additionally demonstrated that the use of prolonged prophylactic antibiotics do not lower the complication rates, stressing the need for a more conservative, standardized antibiotic protocol. This study aims to identify the optimal use of perioperative and postoperative antibiotics that optimizes patient outcomes. METHODS: Patients in the Optum Clinformatics Data Mart who underwent all billable forms of breast reconstruction followed by fat grafting were identified via Current Procedural Terminology codes. Patients meeting inclusion criteria had an index reconstructive procedure at least 90 days before fat grafting. Data concerning these patient's demographics, comorbidities, breast reconstructions, perioperative and postoperative antibiotics, and outcomes were collected via querying relevant reports of Current Procedural Terminology ; International Classification of Diseases, Ninth Revision ; International Classification of Diseases, Tenth Revision ; National Drug Code Directory, and Healthcare Common Procedure Coding System codes. Antibiotics were classified by type and temporal delivery: perioperatively or postoperatively. If a patient received postoperative antibiotics, the duration of antibiotic exposure was recorded. Outcomes analysis was limited to the 90-day postoperative period. Multivariable logistic regression was performed to ascertain the effects of age, coexisting conditions, reconstruction type (autologous or implant-based), perioperative antibiotic class, postoperative antibiotic class, and postoperative antibiotic duration on the likelihood of any common postoperative complication occurring. All statistical assumptions made by logistic regression were met successfully. Odds ratios and corresponding 95% confidence intervals were calculated. RESULTS: From more than 86 million longitudinal patient records between March 2004 and June 2019, our study population included 7456 unique records of reconstruction-fat grafting pairs, with 4661 of those pairs receiving some form of prophylactic antibiotics. Age, prior radiation, and perioperative antibiotic administration were consistent independent predictors of increased all-cause complication likelihood. However, administration of perioperative antibiotics approached a statistically significant protective association against infection likelihood. No postoperative antibiotics of any duration or class conferred a protective association against infections or all-cause complications. CONCLUSIONS: This study provides national, claims-level support for antibiotic stewardship during and after fat grafting procedures. Postoperative antibiotics did not confer a protective benefit association against infection or all-cause complication likelihood, while administering perioperative antibiotics conferred a statistically significant increase in the likelihood that a patient experienced postoperative complication. However, perioperative antibiotics approach a significant protective association against postoperative infection likelihood, in line with current guidelines for infection prevention. These findings may encourage the adoption of more conservative postoperative prescription practices for clinicians who perform breast reconstruction, followed by fat grafting, reducing the nonindicated use of antibiotics.

Analyzing the Visibility of Gender-Affirming Surgery Education on US Plastic Surgery Residency Program Web Sites.

BACKGROUND: As the demand for gender affirmation grows, teaching gender-affirming surgery (GAS) in plastic and reconstructive surgery (PRS) programs has become increasingly important. Residency applicants interested in GAS often use program web sites to explore potential training opportunities. Our study aimed to quantify the GAS training opportunities promoted on residency program web sites and determine the characteristics of programs likely to promote GAS training. METHODS: An assessment of 88 integrated PRS residency programs' web sites was conducted between 2021 and 2022. Plastic and reconstructive surgery residency and institutional webpages were queried for geographical location, training opportunities in GAS through residency or fellowship, and the number of faculty performing GAS. Descriptive statistics and multivariable regressions were used to describe and identify factors associated with increased GAS residency training opportunities. RESULTS: Twenty-six percent of PRS residencies mentioned training opportunities for GAS on their web sites. Gender-affirming surgery fellowships were offered at 7% of institutions, and an additional 7% were available via adjunct academic programs. Programs with faculty practicing GAS were 54% more likely to mention GAS on their residency page (odds ratio, 1.54; 95% confidence interval, 1.14-2.21; P = 0.009). CONCLUSIONS: Few PRS residency programs mention GAS on their web sites. As GAS becomes a more robust component of plastic surgery, appropriate information about the extent of GAS training should be available for applicants. Determining how local, state, and federal policies impact programs' abilities to highlight GAS should be investigated in future studies.

The Zoom Effect: A Google Trends Analysis.

BACKGROUND: Increased video-chatting, stimulated by the COVID-19 pandemic, has been correlated with increased appearance concerns. Initial lockdown restrictions correlated with a decrease in aesthetic/cosmetic plastic surgery case volumes. OBJECTIVES: The authors aimed to delineate public interest in aesthetic procedures surrounding the COVID-19 pandemic via Google Trends. They hypothesized that because of the pandemic, public interest in plastic surgery procedures increased, especially localized above the shoulder. METHODS: Trends in the United States for given search terms and volumes were gathered via Google Trends between January 2015 and March 2021. The search volumes were normalized, and a bivariate regression analysis of panel data was then applied to the aggregate trendlines to determine if a statistically significant change in search volume occurred following the stay-at-home orders. RESULTS: The following search terms had statistically significant (P < 0.000) increases in search volumes after February 2020: blepharoplasty, Botox, brachioplasty, breast implant removal, breast reduction, brow lift, buccal fat removal, hair transplantation, lip augmentation, mentoplasty, otoplasty, platysmaplasty, rhinoplasty, and thighplasty. Chi-squared analysis demonstrated a statistically significant association (chi-squared = 4.812, P = 0.028) between increases in search volume and above-the-shoulder procedures. CONCLUSIONS: Public interest in above-the-shoulder surgical procedures statistically significantly increased following February 2020 compared with below-the-shoulder procedures. Continued examination of specific procedure trends and determining correlations with more accurate procedural datasets will provide increased insight into consumers' mindsets and to what extent video conferencing plays a role in the public's interest in pursuing aesthetic surgery.

National trends in revision procedures in post-mastectomy breast reconstruction: Autologous vs implant-based approaches.

BACKGROUND: Breast reconstruction involves collaborative decision-making between patients and surgeons, but the need for multiple revisions after the initial reconstructive surgery process can burden patients and the healthcare system. This study explored how the type of breast reconstruction (autologous [ABR], immediate implant-based reconstruction [IBR], or two-stage IBR) impacts postreconstruction revision rates. METHOD: Using MarketScan Databases, a retrospective database study (2007-2021) was conducted, identifying revision procedures through Current Procedural Terminology codes. Statistical analysis with linear models, adjusted for patient characteristics and surgical factors, used a significance threshold of p < 0.05. RESULTS: Among 58,264 patients, 6.2% of ABR patients, 3.8% of immediate IBR patients, and 3.6% of two-stage IBR patients underwent future revisions. IBR had a 51% lower incidence rate of revision operations than ABR (incidence rate ratio = 0.49, p < 0.001). Within IBR, there was no significant difference in the number of operations between immediate IBR (0.06 ± 0.32) and two-stage IBR (0.05 ± 0.32, p = 0.95). Immediate IBR demonstrated 12% (OR = 0.88, p = 0.0022) and 70% (OR = 0.30, p < 0.001) lower odds of requiring breast revision and fat grafting compared to ABR, respectively. Two-stage reconstruction had 66 % lower odds of requiring only fat grafting than ABR (OR = 0.34, p < 0.001). CONCLUSION: ABR necessitated a higher number of total revision procedures after completion of the initial reconstruction. These findings will better equip providers and patients to counsel patients in understanding their reconstructive journey, planning their reconstructions and timing, and provide more accurate estimates of the number of procedures that will be required to reach their aesthetic goals and final outcome.

Impact of post-operative infection on revision procedures in breast reconstruction: A marketscan database analysis.

BACKGROUND: Esthetic complications, such as capsular contracture and soft-tissue contour defects, hinder the desired outcomes of breast reconstruction. As subclinical infection is a prevailing theory behind capsular contracture, we investigated the effects of post-operative infections on these issues and revision procedures. METHODS: We conducted a retrospective database study (2007-2021) on breast reconstruction patients from the MarketScan® Databases. Esthetic complications were defined by their associated revision procedures and queried via CPT codes. Severe capsular contracture (Grade 3-4) was defined as requiring capsulotomy or capsulectomy with implant removal or replacement. Moderate and severe soft-tissue defects were determined by the need for fat grafting or breast revision, respectively. Generalized linear models were used, adjusting for comorbidities and surgical factors (p < 0.05). RESULTS: We analyzed the data on 62,510 eligible patients. Post-operative infections increased the odds of capsulotomy (OR 1.59, p < 0.001) and capsulectomy (OR 2.30, p < 0.001). They also raised the odds of breast revision for severe soft-tissue defects (OR 1.21, p < 0.001). There was no significant association between infections and fat grafting for moderate defects. Patients who had post-operative infections were also more likely to experience another infection after fat grafting (OR 3.39, p = 0.0018). In two-stage reconstruction, infection after tissue expander placement was associated with greater odds of infection after implant placement. CONCLUSION: Post-operative infections increase the likelihood of developing severe soft-tissue defects and capsular contracture requiring surgical revision. Our data reinforce the role of infections in the pathophysiology of capsular contracture. Additionally, infections elevate the risk of subsequent infections after fat grafting for moderate defects, further increasing patient morbidity.

How Postoperative Infection Affects Reoperations after Implant-based Breast Reconstruction: A National Claims Analysis of Abandonment of Reconstruction.

Infection after implant-based breast reconstruction adversely affects surgical outcomes and increases healthcare utilization. This study aimed to quantify how postimplant breast reconstruction infections impact unplanned reoperations, hospital length of stay, and discontinuation of initially desired breast reconstruction. Methods: We conducted a retrospective cohort study using Optum's de-identifed Clinformatics Data Mart Database to analyze women undergoing implant breast reconstruction from 2003 to 2019. Unplanned reoperations were identified via Current Procedural Terminology (CPT) codes. Outcomes were analyzed via multivariate linear regression with Poisson distribution to determine statistical significance at P < 0.00625 (Bonferroni correction). Results: In our national claims-based dataset, post-IBR infection rate was 8.53%. Subsequently, 31.2% patients had an implant removed, 6.9% had an implant replaced, 3.6% underwent autologous salvage, and 20.7% discontinued further reconstruction. Patients with a postoperative infection were significantly associated with increased incidence rate of total reoperations (IRR, 3.11; 95% CI, 2.92-3.31; P < 0.001) and total hospital length of stay (IRR, 1.55; 95% CI, 1.48-1.63; P < 0.001). Postoperative infections were associated with significantly increased odds of abandoning reconstruction (OR, 2.92; 95% CI, 0.081-0.11; P < 0.001). Conclusions: Unplanned reoperations impact patients and healthcare systems. This national, claims-level study shows that post-IBR infection was associated with a 3.11× and 1.55× increase in the incidence rate of unplanned reoperations and length of stay. Post-IBR infection was associated with 2.92× increased odds of abandoning further reconstruction after implant removal.

Racial Disparities in Postoperative Breast Reconstruction Outcomes: A National Analysis.

BACKGROUND: Studies have shown that Black patients are more likely to experience complications following breast reconstruction compared to other racial groups. Most of these studies have been conducted on patient populations focusing on either autologous or implant-based reconstruction without possible predictive indicators for complication disparities for all types of reconstruction procedures. The aim of this study is to elucidate disparities among patient demographics by identifying predictors of complications and postoperative outcomes among different racial/ethnic patients undergoing breast reconstruction utilizing multi-state, multi-institution, and national level data. METHODS: Patients in the Optum Clinformatics Data Mart that underwent all billable forms of breast reconstruction were identified via CPT codes. Demographics, medical history, and postoperative outcome data were collected by querying relevant reports of CPT, ICD-9, and ICD-10 codes. Outcomes analysis was limited to the 90-day global postoperative period. A multivariable logistic-regression analysis was performed to ascertain the effects of age, patient reported ethnicity, coexisting conditions, and reconstruction type on the likelihood of any common postoperative complication occurring. Linearity of the continuous variables with respect to the logit of the dependent variable was confirmed. Odds ratios and corresponding 95% confidence intervals were calculated. RESULTS: From over 86 million longitudinal patient records, our study population included 104,714 encounters for 57,468 patients who had undergone breast reconstruction between January 2003 and June 2019. Black race (relative to White), autologous reconstruction, hypertension, type II diabetes mellitus, and tobacco use were independent predictors of increased likelihood of complication. Specifically, the odds ratios for complication occurrence for Black, Hispanic, and Asian ethnicity (relative to White) were 1.09, 1.03, and 0.77, respectively. Black patients had an overall breast reconstruction complication rate of 20.4%, while the corresponding rate for White, Hispanic, and Asian patients were 17.0%, 17.9%, and 13.2%, respectively. CONCLUSION: Our analysis of a national-level database shows that Black patients undergoing implant-based or autologous reconstruction have increased risk of complications, likely due to multifactorial components that play a role in the care of this patient population. While higher rates of comorbidities have been cited as a possible cause, providers must consider racial influences involving cultural context, historical mistrust in medicine, and physician/health institution factors that may drive this disparity of outcomes among our patients.

Reporting and interpreting non-significant results in animal cognition research.

How statistically non-significant results are reported and interpreted following null hypothesis significance testing is often criticized. This issue is important for animal cognition research because studies in the field are often underpowered to detect theoretically meaningful effect sizes, i.e., often produce non-significant p-values even when the null hypothesis is incorrect. Thus, we manually extracted and classified how researchers report and interpret non-significant p-values and examined the p-value distribution of these non-significant results across published articles in animal cognition and related fields. We found a large amount of heterogeneity in how researchers report statistically non-significant p-values in the result sections of articles, and how they interpret them in the titles and abstracts. Reporting of the non-significant results as "No Effect" was common in the titles (84%), abstracts (64%), and results sections (41%) of papers, whereas reporting of the results as "Non-Significant" was less common in the titles (0%) and abstracts (26%), but was present in the results (52%). Discussions of effect sizes were rare (<5% of articles). A p-value distribution analysis was consistent with research being performed with low power of statistical tests to detect effect sizes of interest. These findings suggest that researchers in animal cognition should pay close attention to the evidence used to support claims of absence of effects in the literature, and-in their own work-report statistically non-significant results clearly and formally correct, as well as use more formal methods of assessing evidence against theoretical predictions.

Misaligned Versus Straight Placement of Anterior Cervical Plates: A Clinical and Radiologic Outcomes Study.

BACKGROUND: In anterior cervical diskectomy and fusion (ACDF), misaligned plates are concerning because of the risk of screw-and-plate failure; however, these plates also hypothetically have the potential for asymmetric micromotion on the facet and uncovertebral joint. The aim of this study was to determine whether misaligned plate placement during ACDF had clinical benefits compared with straight plate placement. METHODS: Postoperative AP radiographs of 128 consecutive patients who underwent ACDF with anterior cervical plate (ACP) fixation were reviewed, and plate alignment was assessed. Patients were separated into control group 1 (straight plates) or group 2 (misaligned plates). RESULTS: The mean age of patients was 51.5 ± 0.9 years, and women represented 51% of the total population. There was no significant difference between groups with regard to the preoperative visual analog scale (VAS) and Neck Disability Index (NDI) scores (P = 0.744 and P = 0.943, respectively). At 6 weeks postoperatively, the VAS scores for group 1 decreased from 7.6 ± 0.2 to 4.0 ± 0.2 compared with the scores in group 2, which decreased from 7.7 ± 0.2 to 2.1 ± 0.1, which demonstrated statistical significance (P = 0.019). At 2-year follow-up, no significant difference was demonstrated between the groups' VAS and NDI scores (P = 0.670 and P = 0.266). CONCLUSION: Misaligned plates have increased torsional strength and are associated with better clinical outcomes compared with those of straight plates in the early postoperative period. After fusion, no significant difference in clinical outcomes between the groups was noted, which may reduce the concerns regarding misaligned plates. LEVEL OF EVIDENCE: Retrospective comparative study.