Comparison of Human, Porcine, and Bovine Acellular Dermal Matrix in Prepectoral Breast Reconstruction: A Scoping Review.

OBJECTIVE: The aim of the study is to determine rates of overall complications and failure of prepectoral breast reconstruction between various types of acellular dermal matrices (ADMs). BACKGROUND: Implant-based breast reconstruction is the most common reconstructive technique after mastectomy in the United States. Traditionally, the reconstruction has been performed in the subpectoral plane; however, there has been an emerging interest in prepectoral reconstruction using ADM. Human (hADM), porcine (pADM), and bovine (bADM) ADMs are available for use, but little is known about the benefits and complication profiles of each for prepectoral breast reconstruction. METHODS: Studies examining complications after the use of ADM for prepectoral breast reconstruction were identified using MEDLINE, Embase, the Cochrane Library, LILACS, and the Web of Science from January 2010 to August 2021. Titles and abstracts of 1838 studies were screened, followed by full-text screening of 355 articles. Thirty-three studies were found to meet inclusion criteria. RESULTS: From the 33 studies, 6046 prepectoral reconstructions were examined. Implant loss was comparable across the different types of ADM (pADM, 4.0%; hADM, 4.0%; bADM, 3.7%). Bovine ADM had the highest rate of capsular contracture (6.1%), infection (9.0%), skin flap necrosis (8.3%), dehiscence (5.4%), and hematoma (6.1%) when compared with both hADM and pADM. Human ADM had the highest rate of postoperative seroma (5.3%), followed by pADM (4.6%) and bADM (4.5%). CONCLUSIONS: Among the prepectoral breast reconstruction studies using hADM, pADM, or bADM included in our analysis, complication profiles were similar. Bovine ADM had the highest proportion of breast complications in the following categories: capsular contracture, infection rate, skin flap necrosis, dehiscence, and hematoma. Implant loss was comparable across the cohorts. Overall, prepectoral breast reconstruction using ADM leads to relatively low complication rates with the highest rates within the bADM cohort.

Elective surgery resource utilization.

PURPOSE: Cessation of elective surgery during COVID-19 was partly driven by concern for consumption of hospital resources required by critically ill patients. We aim to determine the extent of resource utilization by elective outpatient surgery to assist in ensuring future resource conservation decisions are data driven. METHODS: The study utilized a retrospective cohort gathered from the American College of Surgeons National Surgical Quality Improvement Program database. Participants were adult patients who underwent elective or non-elective surgery between 2017 and 2018. Outcomes included patient characteristics and post-operative outcomes for elective and non-elective surgeries. Post-operative outcomes were used as a surrogate for the consumption of hospital resources. RESULTS: A total of 1,558,938 (79.8%) elective and 393,339 (20.2%) non-elective surgeries were identified. Elective surgery patients were more likely to be outpatient status, have an ASA class < 3, and exhibited lower rates of prolonged ventilation, 30-day reoperation, and 30-day readmissions, and averaged 5 days less of inpatient stay. Elective outpatient surgery (vs. elective inpatient surgery) averaged shorter operative times and exhibited lower rates of readmissions (2.1% vs. 5.5%; p < 0.001), reoperations (1.1% vs. 2.8%; p < 0.001), prolonged ventilation (0.0% vs. 0.3%; p < 0.001), and 30-day mortality (0.1% vs. 0.5%; p < 0.001) and accounted for 30.2% of the overall relative value units ($339,815,038). CONCLUSION: We evaluated utilization of hospital resources by patients undergoing elective outpatient surgery by identifying surgeries performed in 2017-2018 then stratifying them by outpatient status. Elective outpatient surgeries consumed negligible amounts of hospital resources and should not be considered a threat to resources in the setting of high demand by critically ill COVID-19 patients.

National Trends in Length of Stay for Microvascular Breast Reconstruction: An Evaluation of 10,465 Cases Using the American College of Surgeons National Surgical Quality Improvement Program Database.

BACKGROUND: Decreasing length of stay benefits patients and hospital systems alike. This should be accomplished safely without negatively impacting patient outcomes. The authors hypothesize that in the United States, the average length of stay for patients undergoing microsurgical breast reconstruction has decreased since 2012 without a concurrent increase in complication and readmission rates. METHODS: The authors identified female patients who underwent microvascular breast reconstruction (CPT 19364) from the 2012 to 2018 National Surgical Quality Improvement Program database. Trends in complication and readmission rates and length of stay were examined over 7 years. Multivariable logistic regression models and Mann-Kendall trend tests were used to evaluate associations between length of stay and complication and readmission rates. RESULTS: A total of 10,465 cases were identified. The number of autologous microvascular breast reconstruction procedures performed increased annually between 2012 and 2018. Length of stay decreased significantly from 2012 to 2018 (from 4.47 days to 3.90 days) (p < 0.01). Minor and major complication rates remained constant, although major complications showed a decreasing trend (from 27 percent to 21 percent) (p = 0.07). Thirty-day readmission, surgical-site infection, and wound dehiscence rates remained consistent over the study period, whereas rates of blood transfusion or bleeding decreased (p = 0.02). CONCLUSIONS: Using a national sample from 2012 to 2018, the authors observed a significant decrease in length of stay for patients undergoing microvascular breast reconstruction without a concurrent increase in complication and readmission rates. Current efforts to reduce length of stay have been successful without increasing complication or readmission rates. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Hand and wrist injuries among collegiate athletes vary with athlete division.

BACKGROUND: The rates, severity and consequences of hand and wrist injuries sustained by National Collegiate Athletic Association athletes are not well characterized. This study describes the epidemiology of hand and wrist injuries among collegiate athletes competing in different divisions. METHODS: The National Collegiate Athletic Association Injury Surveillance Program (NCAA-ISP) was accessed from 2004 to 2015 for the following sports: baseball, basketball, football, ice hockey, lacrosse, soccer, wrestling, field hockey, gymnastics, softball and volleyball. The data were used to identify all hand and wrist injuries, the specific injury diagnosis, mean time loss of activity following injury, and need for surgery following injury. These were then stratified by gender. Descriptive statistics were performed to examine the association between sports, event type and division. Student's t test was used to calculate p-values for independent variables. Chi-Square test was used to calculate odds ratio. P < 0.05 was considered significant. RESULTS: 103,098 hand and wrist injuries were reported in in the studied NCAA sports from 2004 to 2015. Male athletes sustained 72,423 injuries (6.01/10,000 athlete exposure) and female athletes sustained 30,675 injuries (4.13/10,000 athlete exposure). Division I athletes sustained significantly more injuries compared to divisions II and III. Overall, 3.78% of hand and wrist injuries required surgical intervention. A significantly higher percentage of division I athletes (both male and female) underwent surgical intervention compared to divisions II and III. The mean time lost due to hand and wrist injury was 7.14 days for all athletes. Division I athletes missed the fewest days due to injury at 6.29 days though this was not significant. CONCLUSIONS: Hand and wrist injuries are common among collegiate athletes. Division I athletes sustain higher rates of injuries and higher surgical intervention rates, while tending to miss fewer days due to injury. Improved characterization of divisional differences in hand and wrist injuries can assist injury management and prevention.

A population-based study of breast implant illness.

BACKGROUND: Despite evidence supporting the safety of breast implants, some women associate their implants with adverse health effects and have called this syndrome "breast implant illness." We sought to characterize breast implant illness symptoms and to report how implant removal affects their symptoms. METHODS: An anonymous 20 question survey was administered to the Facebook group: "UTAH Breast Implant Illness" to characterize the symptoms these women attributed to their breast implants. Several questions allowed us to evaluate how implant removal affected women's symptoms. RESULTS: Of the 182 respondents, 97% report that implants negatively affect their health and 95% identify these symptoms with breast implant illness. Ninety-six percent of respondents had implants placed for cosmetic reasons and 51% had silicone implants. The most common symptoms associated with breast implant illness are brain fog (95%), fatigue (92%), joint pain (80%), and hair loss (74%). Sixty percent of respondents learned about breast implant illness from family/friends and/or social media platforms (56%), 40% of respondents had their implants removed, and 97% report relief of their symptoms post-removal (23% complete, 74% partial). Following explantation, there was a significant improvement in all but one reported symptom. An association was found between the number of symptoms reported prior to explantation and the number of symptoms resolving following explantation. CONCLUSIONS: Breast implant illness is a syndrome characterized by fatigue, decreased focus, hair loss, and joint pain after the placement of breast implants. Nearly all patients report improvement of symptoms after implant removal. Significant efforts should be made to better understand breast implant illness and its etiology.