The evaluation of the delayed swollen breast in patients with a history of breast implants.

Breast implants, whether placed for reconstructive or cosmetic purposes, are rarely lifetime devices. Rupture, resulting from compromised implant shell integrity, and capsular contracture caused by constriction of the specialized scar tissue that normally forms around breast implants, have long been recognized, and remain the leading causes of implant failure. It is apparent, however, that women with breast implants may also experience delayed breast swelling due to a range of etiologic factors. While a majority of delayed seromas associated with breast implants have a benign etiology, this presentation cannot be ignored without an adequate workup as malignancies such as breast implant associated anaplastic large cell lymphoma (BIA-ALCL), breast implant associated diffuse large B-cell lymphoma (BIA-DLBCL), and breast implant associated squamous cell carcinoma (BIA-SCC) can have a similar clinical presentation. Since these malignancies occur with sufficient frequency, and with sometimes lethal consequences, their existence must be recognized, and an appropriate diagnostic approach implemented. A multidisciplinary team that involves a plastic surgeon, radiologist, pathologist, and, as required, surgical and medical oncologists can expedite judicious care. Herein we review and further characterize conditions that can lead to delayed swelling around breast implants.

Immediate Postmastectomy Implant-Based Breast Reconstruction: An Outpatient Procedure?

BACKGROUND: Coronavirus disease of 2019 (COVID-19) poses unique challenges for breast reconstruction. At the authors' institution, COVID-19 postoperative protocols mandated patients undergoing immediate prosthetic breast reconstruction transition from 23-hour postoperative observation to same-day discharge. The authors sought to compare complications and hospital costs between these groups. METHODS: A retrospective study of consecutive patients who underwent immediate prosthetic breast reconstruction from March of 2019 to April of 2021 at an academic hospital was performed. Before mid-March of 2020, patients were admitted postoperatively for observation; after mid-March of 2020, patients were discharged the same day. Postoperative complications at 48 hours, 30 days, and 90 days and hospital costs were compared. RESULTS: There were 238 patients included (119 outpatient and 119 observation). Across all time points, total complications, major complications, categorical complications (wound healing, seroma, hematoma, infection, implant exposure), and reconstructive failures were low and not statistically different between groups. There were no differences in 30-day hospital readmission/reoperation rates (7.6% outpatient versus 9.2% observation; P = 0.640). No patient or surgical factors predicted major complication or hematoma by 48 hours or infection by 90 days. At 90 days, radiation history ( P = 0.002) and smoking ( P < 0.001) were significant predictors of major complications. Average patient care costs outside of surgery-specific costs were significantly lower for outpatients ($1509 versus $4045; P < 0.001). CONCLUSIONS: Complications after immediate prosthetic breast reconstruction are low. Outpatient surgery is safe, harboring no increased risk of complications. Furthermore, outpatient care is more cost-effective. Therefore, surgeons should consider outpatient management of these patients to minimize COVID-19 exposure and reduce resource consumption, all while maintaining excellent surgical care. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Lidocaine Nerve Block Diminishes the Effects of Therapeutic Electrical Stimulation to Enhance Nerve Regeneration in Rats.

BACKGROUND: Although electrical stimulation (ES) can improve nerve regeneration, the impact of nerve block, such as lidocaine (Lido), on the therapeutic benefits of ES remains unclear. We used a rat tibial nerve transection-and-repair model to explore how either preoperative (PreOp) or postoperative (PostOp) nerve block affects ES-related improvement in regeneration. METHODS: Lewis rats were used in 1 of 2 studies. The first evaluated the effects of extraneural Lido on both healthy and injured nerves. In the second study, rats were randomized to 5 experimental groups: No ES (negative control), PreOp Lido, ES + PreOp Lido, PostOp + ES, and ES (positive control). All groups underwent tibial nerve transection and repair. In both studies, nerves were harvested for histological analysis of regeneration distal to the injury site. RESULTS: Application of extraneural Lido did not damage healthy or injured nerve based on qualitative histological observations. In the context of nerve transection and repair, the ES group exhibited improved axon regeneration at 21 days measured by the total number of myelinated fibers compared with No ES. Fiber density and percentage of neural tissue in the ES group were greater than those in both No ES and PreOp Lido + ES groups. ES + PostOp Lido was not different from No ES or ES group. CONCLUSIONS: Extraneural application of Lido did not damage nerves. Electrical stimulation augmented nerve regeneration, but Lido diminished the ES-related improvement in nerve regeneration. Clinical studies on the effects of ES to nerve regeneration may need to consider nerve block as a variable affecting ES outcome.

An Education Intervention to Raise Awareness Reduces Self-reported Opioid Overprescribing by Plastic Surgery Residents.

PURPOSE: The aim of this study was to understand how opioid prescribing practices of plastic surgery residents changed after instituting opioid prescribing education (OPE) interventions. METHODS: Plastic surgery residents at a single academic institution completed a survey (fall 2017) assessing opioid prescribing following 8 common procedures. The Division then completed 3 multidisciplinary OPE interventions over 2.5 years, which provided passive learning to raise awareness without top-down prescribing guidelines. Residents were resurveyed at 2 time points after the interventions (fall 2018 and spring 2020). The primary outcome measure was self-reported morphine milligram equivalents prescribed. RESULTS: Survey response rates were 84% to 100%. Preintervention opioid prescriptions were characterized by high variability and absolute doses for all procedures. We observed statistically significant decreases in prescribed doses for most procedures at 9 months post intervention and further decreases at 2.5 years. In the most recently surveyed cohort, only 3 of 16 residents (18.8%) had OPE before residency, whereas 12 of 16 residents (75.0%) participated in OPE during residency. Eighty-eight percent of respondents "always" (8/16, 50%) or "usually" (6/16, 38%) considered the opioid epidemic when prescribing opioids, suggesting an improved prescribing culture. Barriers to better prescribing included duplicate prescriptions/accessing state-run prescription drug monitoring programs (75.0%), remote prescribing (75%), providing refills (56%), and prescribing opioids for patients on chronic opioid therapy (56%). CONCLUSION: This prospective cohort study demonstrates that a simple multidisciplinary, didactic OPE intervention that aimed to increase residents' awareness has the potential to reduce self-reported opioid prescribing and sustain prescribing practices over many years. We identify persistent barriers facing our resident prescribers today, enabling more opioid educational interventions in the future.

Short-Duration, Pulsatile, Electrical Stimulation Therapy Accelerates Axon Regeneration and Recovery following Tibial Nerve Injury and Repair in Rats.

BACKGROUND: Repair of nerve injuries can fail to achieve adequate functional recovery. Electrical stimulation applied at the time of nerve repair can accelerate axon regeneration, which may improve the likelihood of recovery. However, widespread use of electrical stimulation may be limited by treatment protocols that increase operative time and complexity. This study evaluated whether a short-duration electrical stimulation protocol (10 minutes) was efficacious to enhance regeneration following nerve repair using rat models. METHODS: Lewis and Thy1-green fluorescent protein rats were randomized to three groups: 0 minutes of electrical stimulation (no electrical stimulation; control), 10 minutes of electrical stimulation, and 60 minutes of electrical stimulation. All groups underwent tibial nerve transection and repair. In the intervention groups, electrical stimulation was delivered after nerve repair. Outcomes were assessed using immunohistochemistry, histology, and serial walking track analysis. RESULTS: Two weeks after nerve repair, Thy1-green fluorescent protein rats demonstrated increased green fluorescent protein-positive axon outgrowth from the repair site with electrical stimulation compared to no electrical stimulation. Serial measurement of walking tracks after nerve repair revealed recovery was achieved more rapidly in both electrical stimulation groups as compared to no electrical stimulation. Histologic analysis of nerve distal to the repair at 8 weeks revealed robust axon regeneration in all groups. CONCLUSIONS: As little as 10 minutes of intraoperative electrical stimulation therapy increased early axon regeneration and facilitated functional recovery following nerve transection with repair. Also, as early axon outgrowth increased following electrical stimulation with nerve repair, these findings suggest electrical stimulation facilitated recovery because of earlier axon growth across the suture-repaired site into the distal nerve to reach end-organ targets. CLINICAL RELEVANCE STATEMENT: Brief (10-minute) electrical stimulation therapy can provide similar benefits to the 60-minute protocol in an acute sciatic nerve transection/repair rat model and merit further studies, as they represent a translational advantage.

The Effects of Intraoperative Electrical Stimulation on Regeneration and Recovery After Nerve Isograft Repair in a Rat Model.

Background: Therapeutic electrical stimulation (ES) applied to repaired nerve is a promising treatment option to improve regeneration. However, few studies address the impact of ES following nerve graft reconstruction. The purpose of this study was to determine if ES applied to a nerve repair using nerve isograft in a rodent model could improve nerve regeneration and functional recovery. Methods: Adult rats were randomized to 2 groups: "ES" and "Control." Rats received a tibial nerve transection that was repaired using a tibial nerve isograft (1.0 cm length), where ES was applied immediately after repair in the applicable group. Nerve was harvested 2 weeks postrepair for immunohistochemical analysis of axon growth and macrophage accumulation. Independently, rats were assessed using walking track and grid-walk analysis for up to 21 weeks. Results: At 2 weeks, more robust axon regeneration and greater macrophage accumulation was observed within the isografts for the ES compared to Control groups. Both walking track and grid-walk analysis revealed that return of functional recovery was accelerated by ES. The ES group demonstrated improved functional recovery over time, as well as improved recovery compared to the Control group at 21 weeks. Conclusions: ES improved early axon regeneration into a nerve isograft and was associated with increased macrophage and beneficial M2 macrophage accumulation within the isograft. ES ultimately improved functional recovery compared to isograft repair alone. This study supports the clinical potential of ES to improve the management of nerve injuries requiring a nerve graft repair.