Optimizing Aesthetic Outcomes in Autologous Breast Reconstruction: 20 Pearls for Practice.

Autologous breast reconstruction with a deep inferior epigastric artery perforator (DIEP) flap is an excellent option for many patients proceeding with mastectomy for surgical management of their breast cancer. As microsurgical techniques and results improve and ensure consistent flap survival, optimizing aesthetic outcomes may become a primary focus. This article outlines 20 tips that can improve aesthetic results in DIEP flap breast reconstruction, based on our senior author's 8-year career in microsurgical breast reconstruction, with an emphasis on enhanced cosmesis. We highlight tips on preoperative planning, intraoperative, and revision stages of the reconstruction and provide a schematic for integrating the tips into a reader's microsurgical breast reconstruction practice.

Challenges in Autologous Breast Reconstruction: A Review of Recommendations.

Breast reconstruction is an integral part of breast cancer treatment and offers significant psychosocial benefits for patients undergoing mastectomy as a part of their treatment plan. Autologous breast reconstruction (ABR) utilizes a patient's own tissue to reconstruct the mastectomy defect, obviating the need for the implantation of a foreign object. As the field of plastic surgery progresses, ABR has become an excellent option for the recreation of a native breast mount. With that said, there are patient populations who present unique challenges when optimizing an aesthetic ABR result. We aim to discuss these challenging groups, including patients with both high and low body mass index (BMI), patients with a history of massive weight loss, patients who require post-mastectomy radiation therapy (PMRT), and patients electing for unilateral procedures where the surgeon attempts to match the reconstructed breast with the native breast. In our discussion, we review the literature recommendations for management as well as our experiences with our own patient cases. Ultimately, we believe this procedure can be performed in a wide variety of patient types and can be offered to those who may not be considered the "ideal" candidate.

Nose-Ocomial Pulmonary Edema: A Rare Complication of Oxymetazoline.

A 72-year-old female with epiphora presented for outpatient punctoplasty with probing and lacrimal stent placement. Oxymetazoline was administered intranasally and the case was completed in standard fashion. Postoperatively, the patient desaturated with a workup revealing elevated cardiac enzymes, pulmonary congestion, and sinus bradycardia. However, the final cardiac testing was noncontributory, suggesting flash pulmonary edema secondary to intranasal oxymetazoline. This case highlights a rare presentation of pulmonary compromise secondary to oxymetazoline, emphasizing the importance of intraoperative and postoperative vigilance in simple outpatient procedures.

Predicting Complications in Breast Reconstruction: Development and Prospective Validation of a Machine Learning Model.

IMPORTANCE: Necrosis of the nipple-areolar complex (NAC) is the Achilles heel of nipple-sparing mastectomy (NSM), and it can be difficult to assess which patients are at risk of this complication (Ann Surg Oncol 2014;21(1):100-106). OBJECTIVE: To develop and validate a model that accurately predicts NAC necrosis in a prospective cohort. DESIGN: Data were collected from a retrospectively reviewed cohort of patients who underwent NSM and immediate breast reconstruction between January 2015 and July 2019 at our institution, a high -volume, tertiary academic center. Preoperative clinical characteristics, operative variables, and postoperative complications were collected and linked to NAC outcomes. These results were utilized to train a random-forest classification model to predict necrosis. Our model was then validated in a prospective cohort of patients undergoing NSM with immediate breast reconstruction between June 2020 and June 2021. RESULTS: Model predictions of NAC necrosis in the prospective cohort achieved an accuracy of 97% (95% confidence interval [CI], 0.89-0.99; P = 0.009). This was consistent with the accuracy of predictions in the retrospective cohort (0.97; 95% CI, 0.95-0.99). A high degree of specificity (0.98; 95% CI, 0.90-1.0) and negative predictive value (0.98; 95% CI, 0.90-1.0) were also achieved prospectively. Implant weight was the most predictive of increased risk, with weights greater than 400 g most strongly associated with NAC ischemia. CONCLUSIONS AND RELEVANCE: Our machine learning model prospectively predicted cases of NAC necrosis with a high degree of accuracy. An important predictor was implant weight, a modifiable risk factor that could be adjusted to mitigate the risk of NAC necrosis and associated postoperative complications.

Autologous Breast Reconstruction after Massive Weight Loss: Understanding Risks in a Growing Population.

BACKGROUND: Massive weight loss (MWL) may have suboptimal effects on tissues used for autologous reconstruction. With the rising rates of obesity and bariatric surgery, more patients who have experienced MWL will be presenting for breast reconstruction. The authors hypothesize that autologous breast reconstruction in patients with a history of MWL will have more complications and require more revisions compared with reconstruction in patients without a history of MWL. METHODS: A retrospective review was performed on patients who underwent autologous breast reconstruction by five microsurgeons at an academic institution from 2009 through 2020. Patients with a history of bariatric surgery or greater than 50-pound weight loss were identified and compared with patients who had not experienced MWL. Analysis compared demographics, operative details, complications, revision rates, and BREAST-Q scores. RESULTS: Of 916 patients who underwent 1465 flaps, 39 patients with MWL (4.3%) underwent 68 flaps (4.6%), and 877 patients without MWL underwent 1397 flaps. MWL patients were more likely to require blood transfusions postoperatively ( P = 0.005); experienced more surgical-site infections ( P = 0.02), wound-healing complications of flap ( P = 0.007) and donor sites ( P = 0.03), and late partial flap losses ( P = 0.03); and required more revisional surgery for flap ( P = 0.009) and donor sites ( P = 0.01). BREAST-Q scores were not statistically different for satisfaction with breasts or surgeon but were lower in MWL patients for psychosocial ( P = 0.01) and sexual well-being ( P = 0.04). CONCLUSIONS: Reconstructive surgeons should expect increased postoperative complications when performing autologous breast reconstruction in patients who have experienced MWL. These patients should be counseled on the possibility of an increased risk of postoperative complications and need for revisional surgery. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Minimally Invasive Mandibular Microsurgery: A Systematic Review and Meta-analysis.

Microsurgical advances have led to minimally invasive approaches for mandibular reconstruction. Currently, no resource compares all minimally invasive microvascular mandibular reconstruction (MIMMR) treatment options. Methods: All known cases of MIMMR were identified following the Preferred Reporting Items for Systematic Reviews, Meta-Analyses guidelines, and our own surgical experience. Patient demographics, MIMMR type [submandibular (SM), modified facelift/retroauricular (MFL/RA), or intraoral (IO)], methodology, and clinical outcomes were analyzed with the Fisher exact and Kruskal-Wallis tests. Results: Forty-seven patients underwent MIMMR. Ameloblastoma was the most common pathology treated using all approaches, and MFL/RA was the only approach used to treat squamous cell carcinoma (P = 0.0103). Reconstruction was reported for large, bilateral defects only via the SM or IO approach (P = 0.0216). The iliac crest or fibula was used as a donor site. The facial artery was the most common recipient vessel using the IO and SM approaches, whereas the superior thyroid and external carotid vessels were the most common in the MFL/RA approach (P < 0.0001). Virtual planning was used in all cases performed via an IO approach, 80.0% of cases using an SM approach, and no MFL/RA cases (P < 0.0001). Good aesthetic and functional outcomes were reported for every patient, and there was no difference in complication rates (P = 0.2880). Conclusions: Minimally invasive approaches are safe and effective treatment options for patients requiring mandibular microsurgery, usually in the setting of benign pathology. The IO and SM approaches usually rely on the facial vessels, whereas the MFL/RA approach permits access to the superior thyroid and external carotid vessels and cervical lymphadenectomy.

Evaluating the Importance of Sub-Internships on the 2022 Integrated Plastic Surgery Match During Continued COVID-19 Regulations.

OBJECTIVE: Following the 2021 integrated plastic surgery match, we found a significant increase in home match rates and decrease in match rate for students without a home plastic surgery program with the elimination of visiting sub-internships and the initiation of virtual interviewing. With the return of visiting sub-internships in the 2022 match cycle, we hypothesize that these rates will approach values more consistent with historical controls. DESIGN: Program match data was obtained from posts to residency program Instagram pages and posts associated with the hashtag #PRSMatch2022. Data on visiting sub-internship matches was obtained from a publicly available Google Sheet with applicant contributors. The Chi square test was used to assess for differences. SETTING: Medical schools and plastic surgery programs were categorized into west, midwest, south, and northeast regions. PARTICIPANTS: Matched applicants to integrated plastic surgery residency programs. RESULTS: In total, 192 of 194 (99%) of applicants matched to integrated plastic surgery residency positions were identified. The match rate for applicants without an affiliated plastic surgery program (31.3%) increased from 2021 (p = 0.03) and returned to a level consistent with historical controls (p = 0.38). Similarly, the home program match rate (15.1%) and match rate for applicants from Top 40 medical schools (34.2%) decreased from 2021, returning to pre-pandemic levels (p = 0.63, p = 0.12). Finally, regional match preferences remained generally consistent with historical controls, apart from a higher proportion of northeast applicants matching to programs in the northeast (72.5%, p = 0.04), and a lower proportion of west applicants matching to programs in the west (26.3%, p = 0.002). CONCLUSIONS: The 2022 integrated plastic surgery match cycle saw a reversal of many of the changes to match rates seen in the 2021 cycle. These changes may be due to the reintroduction of visiting sub-internships following updates in COVID-19 policies.

Evaluation of Liposomal Bupivacaine at Split-Thickness Skin Graft Donor Sites Through a Randomized, Controlled Trial.

Split-thickness skin grafts (STSG) are commonly required in reconstructive surgery but may cause significant pain. The goal of this investigator-initiated trial is to evaluate the effect of liposomal bupivacaine on donor site pain and opioid consumption. A parallel, randomized, controlled trial of adult acute burn patients with <20% TBSA burns was conducted to evaluate the efficacy of liposomal bupivacaine at STSG donor sites. The control group received standard subcutaneous infiltration of dilute lidocaine solution at the STSG donor site, and the experimental group received dilute liposomal bupivacaine infiltration in a similar fashion. Donor site pain scores and opioid consumption in morphine equivalents (MEE) were evaluated. A total of 25 patients were enrolled in each group. There were no statistical differences in demographic variables, and TBSA was 4.0% in both groups (P = .94). There were no statistical differences in pain scores at any time point postoperatively (mean control range 3.1/10-4.9/10, experimental range 3.3/10-4.3/10, P = .12-.96). There were no statistical differences in opioid consumption at 24, 48, or 72 h postoperatively between the groups (mean control MEE range 49.3-71.1, experimental MEE range 63.6-75.8, P = .34-.85). The average length of stay was 7.7 days in both groups (P = .88). No adverse events occurred in either group. There is no statistical benefit to the use of liposomal bupivacaine for infiltration at STSG donor sites compared to standard of care with respect to pain control, opioid use, or length of stay when evaluated in a randomized, controlled fashion.

Impact of a Streamlined Trauma-Focused Smartphone Application on Protocol Compliance and Delivery of Care.

BACKGROUND: In November 2015, an institution-specific mobile application (app) was created to provide rapid access to trauma protocols. The app was tested, and the results suggested that the app was difficult to use as it linked to web-based databases. In June 2018, the app was redesigned with protocol infographics and algorithms that are available offline, eliminating the need to scroll through web pages. We tested the redesigned app's ability to provide information quickly, in a user-friendly manner. METHODS: This was a prospective, experimental analysis of a streamlined, institution-specific trauma app. Participants included general surgery residents, advanced practice providers, and attending trauma surgeons. The primary outcomes of measure were time to complete an exam with trauma scenarios and the number of questions answered correctly. The primary exposure of interest was access to the app during the exam. RESULTS: There were 35 study participants: 17 with the 2018 version of the app to complete the quiz and 18 without app access. The group with access scored higher than those without access (70% versus 50%, P = 0.0005) as well as those with the old version of the app in the 2015 study (70% versus 55%, P = 0.0250). App access eliminated a significant difference in exam scores between residents and attendings that was present without the app. CONCLUSIONS: A mobile app with offline access to protocol infographics and algorithms gives providers access to recommended practices and may improve delivery of trauma care. The app is helpful to residents and helps bridge the knowledge gap between groups when the app is not available. LEVEL OF EVIDENCE: Level III.