Social Determinants of Health and Patient-reported Outcomes Following Autologous Breast Reconstruction, Using Insurance as a Proxy.

BACKGROUND: Insurance type can serve as a surrogate marker for social determinants of health and can influence many aspects of the breast reconstruction experience. We aimed to examine the impact of insurance coverage on patients reported outcomes with the BREAST-Q (patient reported outcome measure for breast reconstruction patients, in patients receiving) in patients receiving deep inferior epigastric artery perforator (DIEP) flap breast reconstruction. METHODS: We retrospectively examined patients who received DIEP flaps at our institution from 2010 to 2019. Patients were divided into categories by insurance: commercial, Medicaid, or Medicare. Demographic factors, surgical factors, and complication data were recorded. Descriptive statistics, Fisher's exact, Kruskal-Wallis rank sum tests, and generalized estimating equations were performed to identify associations between insurance status and five domains of the BREAST-Q Reconstructive module. RESULTS: A total of 1,285 patients were included, of which 1,011 (78.7%) had commercial, 89 (6.9%) had Medicaid, and 185 (14.4%) had Medicare insurances. Total flap loss rates were significantly higher in the Medicare and Medicaid patients as compared to commercial patients; however, commercial patients had a higher rate of wound dehiscence as compared to Medicare patients. With all other factors controlled for, patients with Medicare had lower Physical Well-being of the Chest (PWBC) than patients with commercial insurance (ß = - 3.1, 95% confidence interval (CI): -5.0, -1.2, p = 0.002). There were no significant associations between insurance classification and other domains of the BREAST-Q. CONCLUSION: Patients with government-issued insurance had lower success rates of autologous breast reconstruction. Further, patients with Medicare had lower PWBC than patients with commercial insurance regardless of other factors, while other BREAST-Q metrics did not differ. Further investigation as to the causes of such variation is warranted in larger, more diverse cohorts.

Early Complications in Prepectoral Tissue Expander-Based Breast Reconstruction.

BACKGROUND: Prepectoral implant placement for postmastectomy breast reconstruction has increased in recent years. Benefits of prepectoral reconstruction may include lack of animation deformities and reduced postoperative pain, but its complication profile is currently unclear. This study aimed to examine the complication profile of prepectoral tissue expanders (TEs) to determine factors associated with TE loss. METHODS: A retrospective review was performed to identify all patients who underwent immediate prepectoral TE reconstruction from January 2018 to June 2021. The decision to use the prepectoral technique was based on mastectomy skin quality and patient comorbidities. Patient demographics, comorbidities, and operative details were evaluated. Outcomes of interest included TE loss, seroma, hematoma, infection/cellulitis, mastectomy skin flap necrosis requiring revision, and TE exposure. Logistic regression analysis was performed to identify factors associated with TE loss. RESULTS: The study identified 1225 TEs. The most frequent complications were seroma (8.7%, n = 106), infection/cellulitis (8.2%, n = 101), and TE loss (4.2%, n = 51). Factors associated with TE loss in the univariate analysis included ethnicity, history of smoking, body mass index, mastectomy weight, and neoadjuvant chemotherapy. In the multivariate regression analysis, only mastectomy weight had a positive association with TE loss (odds ratio, 1.001; p = 0.016). CONCLUSION: Prepectoral two-stage breast reconstruction can be performed safely with an acceptable early complication profile. The study data suggest that increasing mastectomy weight is the most significant factor associated with TE loss. Further research examining the quality of the soft tissue envelope and assessing patient-reported outcomes would prove beneficial.

National Trends in Acellular Dermal Matrix Utilization in Immediate Breast Reconstruction.

BACKGROUND: Implant-based reconstruction is the most common method of immediate breast reconstruction in the United States, with acellular dermal matrices (ADMs) playing a significant role in implant support and coverage. This study evaluated recent national trends in ADM use in immediate breast reconstruction and assessed patient characteristics and 30-day complication rates. METHODS: The authors queried the American College of Surgeons National Surgical Quality Improvement Program database for all patients undergoing immediate breast reconstruction from 2015 to 2020. Primary outcomes were major surgical and medical complications, as well as ADM use per year. Subset analysis was performed to compare patients undergoing immediate breast reconstruction with ADM in 2015 versus 2020. RESULTS: In 39,800 immediate breast reconstructions, ADMs were used in 55.5% of cases ( n = 22,087). ADM usage increased annually from 2015 through 2020. Direct-to-implant reconstruction was significantly associated with ADM use ( P < 0.001). Compared with the no-ADM cohort, there was a significantly increased rate of return to the operating room for any reason ( P < 0.001). When comparing the 2015 and 2020 ADM cohorts, the 2020 ADM cohort had a significantly higher rate of superficial infections. Obesity, smoking history, and insulin-dependent diabetes were independent risk factors for superficial wounds in patients receiving ADM. CONCLUSIONS: ADM use in immediate breast reconstruction increased significantly from 2015 to 2020, likely reflecting national trends in increasing direct-to-implant and prepectoral breast reconstruction. Obesity, smoking history, and insulin-dependent diabetes were independent risk factors for superficial wound infections in the ADM cohort. Patients with ADM had a slight increased incidence of return to the operating room. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Early Complications in Prepectoral Breast Reconstructions with and without Acellular Dermal Matrix: A Preliminary Analysis of Outcomes.

BACKGROUND: Prepectoral tissue expander (TE) placement for two-stage postmastectomy reconstruction is usually performed in conjunction with insertion of acellular dermal matrix (ADM). However, the effects of ADM use on TE loss or other early complications remain unknown. Therefore, the aim of this study was to compare early postoperative complications in patients who underwent prepectoral breast implant reconstruction with or without ADM use. METHODS: The authors performed a retrospective cohort study of all patients at their institution who underwent prepectoral breast reconstruction from January of 2018 to June of 2021. The primary outcome was TE loss within 90 days of surgery; secondary outcomes included other complications such as infection, TE exposure, mastectomy skin flap necrosis requiring revision, and seroma. RESULTS: Data on 714 patients with 1225 TEs (1060 with ADM and 165 without) were analyzed. Baseline demographics did not differ by ADM use, although mastectomy breast tissue weight was higher in patients without ADM (750.3 g versus 540.8 g; P < 0.001). Rates of TE loss were similar in reconstructions with (3.8%) ADM and without (6.7%; P = 0.09). We also did not find differences in the rates of secondary outcomes between cohorts. CONCLUSIONS: ADM use had no statistically significant effect on early complication rates among patients undergoing breast reconstruction with prepectoral TEs. Still, this study was underpowered, and data trended toward statistical significance; thus, larger studies are required in the future. Additional research and randomized studies should focus on larger cohorts and examine long-term complications such as capsular contracture and implant malposition. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

The evolution of pediatric soft-tissue free flap reconstruction of the lower extremity after oncologic resection: A 30 year experience.

INTRODUCTION: Limb salvage has become the standard of care for lower extremity tumors because of improvements in adjuvant treatments and reconstructive techniques. While there is literature assessing pediatric lower extremity free flap reconstruction in the setting of trauma, there is a paucity of literature that analyzes oncologic free flap reconstruction in this patient population. We report our long-term experience and evolution of care for lower extremity oncologic free flap reconstruction in pediatric patients. METHODS: This is a retrospective case series of all patients ≤18 years of age who underwent oncologic soft-tissue microvascular reconstruction of the lower extremity, from 1992 to 2021. Data were collected for patient demographics, oncologic treatment, operative details, and post-operative outcomes. Functional outcomes were assessed by weight bearing status, ambulation, and participation in activities-of-daily-living (ADLs), and musculoskeletal tumor society (MSTS) scores. RESULTS: Over the 30-year study period, inclusion criteria were met by 19 patients (11 males, 8 females) with a mean age of 13.8 years and a mean follow-up of 5.3 years. At last follow-up, 13 patients (68.5%) were alive. The most common pathology was osteogenic sarcoma (13 patients, 68.5%). Sites of reconstruction were the hip (n = 1), thigh (n = 5), knee (n = 4), leg (n = 7), and the foot (n = 2). The most commonly used flaps were latissimus dorsi (n = 8), gracilis (n = 4), and anterolateral thigh ± vastus (n = 4). Postoperative complications occurred in nine patients (43%). Overall flap success rate was 95%. At latest follow-up, ambulation without assistive device was obtained in 11 patients (58%), full weight bearing was achieved by 13 patients (68.5%), and ADLs could be performed independently by 13 patients (68.5%). Mean MSTS score was 23.1/30. CONCLUSION: Microvascular reconstruction for oncological lower extremity defects in the pediatric population has high limb salvage rates and good functional outcomes.

Surgical Management of Textured Breast Implants: Assessing Risk and Analyzing Patient-Reported Outcomes.

BACKGROUND: Textured implants have been linked to breast implant-associated anaplastic large-cell lymphoma. Patients who undergo explantation have options for reconstruction, but data on safety and patient-reported outcomes (PROs) is limited. The purpose of this study was to classify complications and PROs in patients opting for surgical management of textured implants. METHODS: Complication rates and BREAST-Q scores were compared between (i) asymptomatic patients who underwent conversion from textured to smooth implants (n=224), (ii) symptomatic patients who underwent conversion from textured to smooth implants (n=83), (iii) patients who underwent explantation without replacement (n=44), and (iv) patients who underwent replacement with autologous reconstruction (n=33). Linear regression examined PROs controlling for clinical and surgical variables. RESULTS: Overall complication rates in 384 patients (637 implants) differed across groups (p=0.034) with the highest rate (25%) in patients who underwent explantation without replacement. These patients were specifically more impacted by minor complications, notably seroma. Capsulectomy extent did not significantly impact complications. Asymptomatic and symptomatic smooth implant patients had improvements in satisfaction with breasts (<0.05). Autologous reconstruction patients had significant improvements in satisfaction with breasts sustained after 3 months postoperative (p<0.01) and sexual well-being sustained after 6-months postoperative (p<0.05). Patients who underwent removal without replacement had lower physical well-being of the chest scores at ≥1 year than the other groups. CONCLUSIONS: Replacement of textured implants with smooth implants or flaps is safe and is associated with improved satisfaction with breasts and quality of life. The degree of capsulectomy does not appear to impact the incidence of perioperative complications.

Decreasing length of stay in breast reconstruction patients: A national analysis of 2019-2020.

BACKGROUND: The effects of COVID-19 on breast reconstruction included shifts toward alloplastic reconstruction methods to preserve hospital resources and minimize COVID exposures. We examined the effects of COVID-19 on breast reconstruction hospital length of stay (LOS) and subsequent early postoperative complication rates. METHODS: Using the National Surgical Quality Improvement Program, we examined female patients who underwent mastectomy with immediate breast reconstruction from 2019 to 2020. We compared postoperative complications across 2019-2020 for alloplastic and autologous reconstruction patients. We further performed subanalysis of 2020 patients based on LOS. RESULTS: Both alloplastic and autologous reconstruction patients had shorter inpatient stays. Regarding the alloplastic 2019 versus 2020 cohorts, complication rates did not differ (p > 0.05 in all cases). Alloplastic patients in 2020 with longer LOS had more unplanned reoperations (p < 0.001). Regarding autologous patients in 2019 versus 2020, the only complication increasing from 2019 to 2020 was deep surgical site infection (SSI) (2.0% vs. 3.6%, p = 0.024). Autologous patients in 2020 with longer LOS had more unplanned reoperations (p = 0.007). CONCLUSIONS: In 2020, hospital LOS decreased for all breast reconstruction patients with no complication differences in alloplastic patients and a slight increase in SSIs in autologous patients. Shorter LOS may lead to improved satisfaction and lower healthcare costs with low complication risk, and future research should examine the potential relationship between LOS and these outcomes.

Regulation of RNA methylation by therapy treatment, promotes tumor survival.

Our data previously revealed that chemosurviving cancer cells translate specific genes. Here, we find that the m6A-RNA-methyltransferase, METTL3, increases transiently in chemotherapy-treated breast cancer and leukemic cells in vitro and in vivo. Consistently, m6A increases on RNA from chemo-treated cells, and is needed for chemosurvival. This is regulated by eIF2α phosphorylation and mTOR inhibition upon therapy treatment. METTL3 mRNA purification reveals that eIF3 promotes METTL3 translation that is reduced by mutating a 5'UTR m6A-motif or depleting METTL3. METTL3 increase is transient after therapy treatment, as metabolic enzymes that control methylation and thus m6A levels on METTL3 RNA, are altered over time after therapy. Increased METTL3 reduces proliferation and anti-viral immune response genes, and enhances invasion genes, which promote tumor survival. Consistently, overriding phospho-eIF2α prevents METTL3 elevation, and reduces chemosurvival and immune-cell migration. These data reveal that therapy-induced stress signals transiently upregulate METTL3 translation, to alter gene expression for tumor survival.

A Regional Analysis of Hospital Readmissions Following Total Hip and Knee Arthroplasty and the Impact of Medicaid Expansion.

The Hospital Readmissions Reduction Program (HRRP) works to temper nationally rising readmission rates. Total knee arthroplasty (TKA) and total hip arthroplasty (THA) have a 30-day readmission cost burden of $889,300 and $689,400, respectively. No research has compared TKA and THA readmission rates by region and Medicaid expansion status. This study compares THA and TKA readmission rates in the United States by region, Medicaid status, and performance. One-way ANOVAs were conducted to determine the regions with the highest and lowest mean excess readmission ratios (ERRs). An independent t-test compared Medicaid versus non-Medicaid expansion states. Southern hospitals have the highest mean ERR, followed by northeastern, midwestern, and then western hospitals. Although Medicaid expansion states have significantly lower ERRs compared to non-expansion states, Medicaid status alone does not account for regional differences in ERRs after THA and TKA. Regional factors likely confound Medicaid status's effect on readmission rates. (Journal of Surgical Orthopaedic Advances 32(1):005-008, 2023).

A Characterization of Pediatric Craniofacial Injuries from Children's Toys.

INTRODUCTION: Playing with toys contributes significantly to the cognitive, physical, and social development of children. Certain toys, unfortunately, carry the potential for serious craniofacial injury. There is a gap in the literature regarding the comprehensive assessment of toy-related craniofacial injuries. By studying mechanisms of injury and ensuing trauma, our goal is to encourage innovative design and educate caregivers, health care workers, and the Consumer Product Safety Commission on risk mitigation and prevention. METHODS AND MATERIALS: The National Electronic Injury Surveillance System Database was queried to analyze toy-related craniofacial injuries that occurred in children (ages 0-10) between 2011 and 2020. RESULTS: Approximately 881,000 injuries occurred over a 10-year span. Children ages 1 to 5 sustained most injuries, peaking at age 2 (16.3%). Males were injured 1.95 times more frequently than females. Injured sites included the face (43.7%), head (29.7%), mouth (13.5%), ears (6.9%), and eyes (6.2%). The top diagnoses were lacerations (40.4%), foreign bodies (16.2%), internal injuries (15.8%), and contusions (15.8%). The most common causes were scooters (13%), balls (6.9%), toy vehicles excluding riding toys (6.3%), building sets (4.4%), and tricycles (3%). DISCUSSION: This study identifies toys that most frequently cause craniofacial injuries in children. These results provide new information about types of play that should be supervised, and this data helps anticipate injury profiles seen in emergency settings. Future research should study why the products identified are strongly associated with injuries, so safety features can be optimized and designs appropriately altered.

Three-Dimensional Surface Analysis for Preoperative Prediction of Breast Volume: A Validation Study.

BACKGROUND: Few studies have examined whether preoperative three-dimensional surface imaging can accurately predict breast volume. Reliably predicting breast volume preoperatively can assist with breast reconstruction planning, patient education, and perioperative risk stratification. METHODS: The authors conducted a review of patients who underwent mastectomy from 2020 to 2021 and included all patients who had preoperative VECTRA XT three-dimensional imaging. VECTRA Analysis Module (VAM) and VECTRA Body Sculptor (VBS) were used for volumetric analysis using standard anatomical breast borders. Breast weights were obtained intraoperatively. Predictive accuracy was defined as VAM estimates ±10% of mastectomy specimen weight or ±100 g of mastectomy weight. RESULTS: The study included 179 patients (266 breasts). There was no significant difference ( P = 0.22) between mean mastectomy weight of 620.8 ± 360.3 g and mean VAM estimate of 609.5 ± 361.9 g. Mean VBS estimate was 498.9 ± 337.6 g, which differed from mean mastectomy weight ( P < 0.001). When defining predictive accuracy as ±100 g, 58.7% of VAM and 44.4% of VBS estimates were accurate. Body mass index, body surface area, and ptosis grade significantly affected VAM and VBS breast volume predictions. CONCLUSIONS: VAM is more accurate at predicting mastectomy weight than VBS, likely because of VAM's analysis of surface topography rather than discrete surface landmarks. Discrepancies between VECTRA estimates and mastectomy weight were likely attributable to differences between surgical mastectomy borders and breast borders used in volumetric analysis. Surgeons should consider the physical characteristics of patients when using three-dimensional imaging. CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, I.

Air versus Saline in Initial Prepectoral Tissue Expansion: A Comparison of Complications and Perioperative Patient-Reported Outcomes.

BACKGROUND: One option to optimize prepectoral tissue expander fill volume while minimizing stress on mastectomy skin flaps is to use air as an initial fill medium, with subsequent exchange to saline during postoperative expansion. The authors compared complications and early patient-reported outcomes (PROs) based on fill type in prepectoral breast reconstruction patients. METHODS: Prepectoral breast reconstruction patients who underwent intraoperative tissue expansion with air or saline from 2018 to 2020 were reviewed to assess fill-type utilization. The primary endpoint was expander loss; secondary endpoints included seroma, hematoma, infection/cellulitis, full-thickness mastectomy skin flap necrosis requiring revision, expander exposure, and capsular contracture. PROs were assessed with the BREAST-Q Physical Well-Being of the Chest scale 2 weeks postoperatively. Propensity-matching was performed as a secondary analysis. RESULTS: Of 560 patients (928 expanders) included in the analysis, 372 had devices initially filled with air (623 expanders), and 188 with saline (305 expanders). No differences were observed for overall rates of expander loss (4.7% versus 3.0%, P = 0.290) or overall complications (22.5% versus 17.7%, P = 0.103). No difference in BREAST-Q scores was observed ( P = 0.142). Utilization of air-filled expanders decreased substantially over the last study year. After propensity matching, no differences in loss, other complications, or PROs were observed across cohorts. CONCLUSIONS: Tissue expanders initially filled with air seem to have no significant advantage over saline-filled expanders in maintaining mastectomy skin flap viability or PROs, including after propensity matching. These findings can help guide choice of initial tissue expander fill type. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Increasing rates of general anesthesia use in lumpectomy procedures: A 15-year trends analysis.

BACKGROUND: Anesthesia methods in oncologic breast surgery have evolved with less invasive practices. The aims of this study were primarily to examine trends in anesthesia type used during lumpectomy. METHODS: We analyzed lumpectomy procedures from 2005 to 2019 using the NSQIP database. Upon defining the nadir in general anesthesia (GA) and peak in monitored anesthesia care (MAC) use as 2007, we compared patient characteristics and complications in the 2007 versus 2019 GA and MAC cohorts. Multivariable logistic regression was used to examine associations with receipt of GA. RESULTS: Of 253 545 lumpectomy patients, 191 773 (75.6%) received GA and 61 772 (24.4%) received MAC. From 2005 to 2019, GA rates increased from 66.7% to 82.5%, while MAC rates decreased from 33.3% to 17.5%. More GA patients were obese and American Society of Anesthesiologists class 3. Over time, age and body mass index (BMI) increased in both GA and MAC cohorts. Odds of receiving GA increased over time, and predictors included concurrent axillary lymph node dissection (p < 0.0001) or sentinel lymph node biopsy (p < 0.0001). CONCLUSIONS: We demonstrate increasing use of GA over time for lumpectomy, which may be related to aging lumpectomy patient population with higher BMIs. We also find a strong association between use of GA and concurrent lymph node procedures.

An updated systematic review of esthetic grading tools in postmastectomy breast reconstruction.

BACKGROUND AND OBJECTIVES: We ascertained whether a validated esthetic grading tool for breast reconstruction had been developed and widely adopted since the last published systematic review on the topic from 2015. METHODS: We performed a systematic review identifying all studies using a grading tool to assess breast reconstruction, using search terms associated with all types of breast surgery and outcomes research. Articles were assessed for patient number, validated scale use, assessor type and training, assessor blinding, assessment method, scoring system type, type and timing of reconstruction, and usage of corroborating scales. RESULTS: Of 2809 articles screened, 148 met the criteria. Only 3 used a validated tool, the Esthetic Items Scale. Most used study-only tools (n = 111) or unvalidated tools (n = 28). The most used unvalidated tool was the Garbay/Lowery 5-subscale rubric. Unanchored Likert scales were the most common subjective tool; two-dimensional images were the most used medium. Surgeons, patients, and nurses were the most common assessors. Twenty percent of studies used corroborating scales. CONCLUSIONS: In the absence of a validated esthetic grading tool for breast reconstruction, researchers continue to rely on unvalidated scales. The only validated scale available is used infrequently and only validated among physicians. A validated, reliable, simple grading tool with clinical and scholastic relevance is needed.

Optimizing Unilateral Deep Inferior Epigastric Perforator Flap Breast Reconstruction: A Quality Improvement Study.

ABSTRACT: Deep inferior epigastric perforator (DIEP) flap surgery commonly involves multiday hospitalization, although data suggest 95% of complications after unilateral DIEP flap breast reconstruction occur within the first 24 hours. The aim of this study was to decrease hospitalization time and optimize care of patients undergoing unilateral DIEP flap breast reconstruction. Our study followed Six Sigma's DMAIC (define, measure, analyze, improve, control) framework. First, we delineated the stakeholders involved in the process and defined workgroups based on temporal relation to the operation. We measured performance according to project SMART (specific, measurable, achievable, relevant, time bound) goals and subsequently conducted an analysis of inefficiencies. We then created new interventions for quality improvement. Control will entail ongoing monitoring to ensure progress is sustained after study completion. Our interventions lasted 6 months and included 70 patients. By actively striving to advance patients through postoperative milestones during their inpatient stay and creating an outpatient nursing roadmap including aspects of inpatient care, we decreased the median length of stay from 67.8 to 44.8 hours ( p < .001). After receiving nursing instruction, 77% of patients agreed that they felt ready to be discharged. Our study suggests that the DMAIC framework can decrease hospitalization time after DIEP surgery and spare resources for additional patients.

A characterization of home maintenance equipment-related hand and lower arm injuries.

Background: Thousands of Americans sustain injuries from various household appliances each year, though injury patterns have not been well characterized. We thus sought to determine the incidence, characteristics, and trends of household appliance-related hand injuries over the past decade. Methods: The National Electronic Injury Surveillance System database (NEISS) was queried from 2010 through 2019. Our analysis grouped patients into 10-year age groups. We defined types of appliances and injuries Chi-square tests were used to compare the most common injury mechanisms by age group. Results: Between 2010 and 2019, 30,336 total cases of home workshop equipment-related upper extremity injuries were recorded; 2,574 (8.48%) of these affected females, compared to 27,762 (91.52%) of the cases affecting males. Across all age groups, males were between 6 and 13 more times likely to be injured than females (p < 0.001). Between 2010 and 2019, we recorded a decline in total injuries from 168,795 to 147,584, with a Pearson correlation coefficient of -0.68 (p = 0.031). The appliances most likely to injure those in their 10s through 40s were mechanical tools such as screwdrivers. Meanwhile, those in their 50s through 70s were most likely to be injured by saws. Both amputations and avulsions were found to significantly increase with age (p = 0.038, p = 0.027, respectively). Most injuries result from manual tools and saws. Discussion: Males are significantly more likely to incur injuries than females from maintenance equipment, and risk of avulsions and amputations increase significantly with age. This aligns with previous research which also suggested that older saws were most likely to injure older individuals; namely, following new regulations on saws, older adults were more likely to be affected. This is especially worrisome in light of recent research showing that older adults with amputations are less likely to be offered replantations. Overall, these results can continue to guide and optimize community interventions on an epidemiological basis.

Effects of COVID-19 on mastectomy and breast reconstruction rates: A national surgical sample.

BACKGROUND: The COVID-19 pandemic profoundly impacted breast cancer treatment in 2020. Guidelines initially halted elective procedures, subsequently encouraging less invasive surgeries and restricting breast reconstruction options. We examined the effects of COVID-19 on oncologic breast surgery and reconstruction rates during the first year of the pandemic. METHODS: Using the National Surgical Quality Improvement Program, we performed an observational examination of female surgical breast cancer patients from 2017 to 2020. We analyzed annual rates of lumpectomy, mastectomy (unilateral/contralateral prophylactic/bilateral prophylactic), and breast reconstruction (alloplastic/autologous) and compared 2019 and 2020 reconstruction cohorts to evaluate the effect of COVID-19. RESULTS: From 2017 to 2020, 175 949 patients underwent lumpectomy or mastectomy with or without reconstruction. From 2019 to 2020, patient volume declined by 10.7%, unilateral mastectomy rates increased (70.5% to 71.9%, p = 0.003), and contralateral prophylactic mastectomy rates decreased. While overall reconstruction rates were unchanged, tissue expander reconstruction increased (64.0% to 68.4%, p < 0.001) and direct-to-implant and autologous reconstruction decreased. Outpatient alloplastic reconstruction increased (65.7% to 73.8%, p < 0.0001), and length of hospital stay decreased for all reconstruction patients (p < 0.0001). CONCLUSIONS: In 2020, there was a nearly 11% decline in breast cancer surgeries, comparable mastectomy and reconstruction rates, increased use of outpatient alloplastic reconstruction, and significantly reduced in-hospital time across all reconstruction types.

Craniofacial Injuries From Personal Watercraft Accidents.

ABSTRACT: Personal watercraft (PWC) use is a popular leisure activity. Although injuries associated with PWCs have been examined broadly, there is a lack of investigation into craniofacial injuries within this setting. This paper reviews the literature discussing PWC incidents and PWC-related craniofacial injuries. A comprehensive literature search of the MEDLINE, EMBASE, Google Scholar, and National Library of Medicine databases was conducted for studies published through January 2021. Articles were selected if they contained information on PWC accidents and related craniofacial injuries. We also examined 3 patient cases of PWC-related craniofacial injuries. Overall, our review suggests that over the past 20 years, injuries and accidents have decreased significantly whereas fatalities have decreased to a lesser extent. Most PWC-related craniofacial injuries result from blunt trauma and a notable number of deaths and traumatic brain injuries occur in adolescents. Given the increasing number of PWC sales, PWC-related craniofacial injuries may be more prevalent, which prompts improved regulations and protective gears. Existing state laws on PWCs vary dramatically. As of now, there is no uniform policy that requires protective equipment use like helmets or instruction before PWC use. There also should be limitations on alcohol consumption as well as age of the riders. Overall, our review indicates that more research is needed to reduce the number of craniofacial injuries among PWC riders.

The 50 Most Cited Articles in Meniscal Injury Research.

BACKGROUND: Meniscal injuries are among the most common orthopaedic injuries, with a significant volume of published literature. PURPOSE: To perform a comprehensive bibliometric analysis that appropriately evaluates the 50 most cited articles in meniscal research. STUDY DESIGN: Cross-sectional study. METHODS: We performed a keyword search of the ISI Web of Knowledge database and then pared the results down to the 50 most cited articles using specific inclusion and exclusion criteria. Data extracted included title, first author, citation count, year of publication, topic, journal, article type, country of origin, and level of evidence. Correlation coefficients were calculated between publication date and citation density and between publication date and raw citation count. RESULTS: The 50 most cited articles were published from 1975 to 2013. The mean number of citations was 258.24 (range, 163-926; median, 225). The majority of articles were published in The American Journal of Sports Medicine (19%), the Journal of Bone and Joint Surgery (12%), and Arthritis & Rheumatology (14%). Most articles focused on either the anatomy and biomechanics of meniscal injury or on prevention and physical rehabilitation (12 papers each). CONCLUSION: The most popular fields of meniscal research involved anatomy/biomechanics and prevention/rehabilitation, and both are areas that will likely increase the probability of an article's being highly cited in the future. This study provided a quality selection of the most cited articles on meniscal injury and may provide a foundation for both beginner and senior clinician readers for further discussion and research.

Revisiting the Pericranial Flap for Scalp Reconstruction.

ABSTRACT: Soft tissue deficits of the scalp due to trauma, infection, or tumor resection present a unique challenge to the reconstructive surgeon whose goal is to achieve excellent cosmesis in a hair bearing area without compromising coverage. While extensive undermining for large rotation flaps or free tissue transfer can provide necessary coverage, the pericranial flap is an excellent alternative for less ideal surgical candidates who cannot tolerate more extensive interventions or for patients who require long-term cancer surveillance. Elevation of the pericranial flap limits the need for back cuts through the skin and uses blunt dissection to preserve overlying hair follicles. Here we present a review of the anatomy and historical use of the pericranial flap for scalp coverage and we present 4 cases to demonstrate its current utility.