Comparisons of Impact of Vein Grafting with Different Indications on Outcomes of Reconstruction with Free Flaps.

BACKGROUND: Prior studies have shown an increased risk of complications and flap loss with the use of vein grafts in microsurgery. We hypothesize that indication for use of a vein graft can affect flap complications and loss rates. METHODS: We performed a retrospective review of all patients at our institution from 2010 to 2020 who underwent free flap reconstruction and required use of a vein graft. Indications for vein grafting included: salvage of flap during primary operation after microvascular compromise, augmentation of flow during primary operation, lengthening of the flap pedicle during the primary operation, and salvage of the flap during a secondary salvage operation after microvascular compromise. RESULTS: A total of 79 patients met the study inclusion criteria. There were significant differences among the vein graft indication groups and the following: area of reconstruction (p = 0.002), vein graft length (p = 0.018), vessels grafted (p = 0.001), vein graft donor site (p = 0.011), and total flap loss (p = 0.047). Of the four indications for vein grafting, salvage of the flap during secondary salvage operation after microvascular compromise had the highest rate of total flap loss (26.7%). There were no significant associations between other flap complications and vein graft indications. CONCLUSION: Vein graft use in the primary reconstructive setting is efficacious, with low risk of thrombosis. Use in secondary procedures, however, is associated with higher rates of total flap loss, likely due to the thrombotic process, which was initiated prior to the use of the graft resulting in the salvage procedure and not secondary to the graft itself.

Textured versus Smooth Tissue Expanders: A Comparison of Complications in 3526 Breast Reconstructions.

BACKGROUND: Increased understanding of breast implant-associated anaplastic large-cell lymphoma has led to a shift away from textured breast devices. A few small studies have compared the complication rates of textured and smooth tissue expanders (TEs). The aim of this study was to compare complication profiles in patients undergoing two-stage postmastectomy breast reconstruction with either textured or smooth TEs. METHODS: The authors performed a retrospective review of female patients who underwent immediate breast reconstruction with textured or smooth TEs from 2018 to 2020 at their institution. Rates of seroma, infection/cellulitis, malposition/rotation, exposure, and TE loss were analyzed in the overall cohort and subgroups undergoing prepectoral and subpectoral TE placement. A propensity score-matched analysis was used to decrease the effects of confounders comparing textured and smooth TEs. RESULTS: The authors analyzed 3526 TEs (1456 textured and 2070 smooth). More frequent use of acellular dermal matrix, SPY angiography, and prepectoral TE placement was noted in the smooth TE cohort ( P < 0.001). Univariate analysis suggested higher rates of infection/cellulitis, malposition/rotation, and exposure in smooth TEs (all P < 0.01). Rates of TE loss did not differ. After propensity matching, no differences were noted in infection or TE loss. Prepectoral smooth expanders had increased rates of malposition/rotation. CONCLUSIONS: TE surface type did not affect rates of TE loss, although increased rates of expander malposition were noted in the smooth prepectoral cohort. Further research is needed to examine breast implant-associated anaplastic large-cell lymphoma risk with temporary textured TE exposure to improve decision-making. CLINICAL QUESTION/LEVEL OF EVIDENCW: Therapeutic, III.

Clinical, functional, and patient-reported outcomes of radial forearm versus anterolateral thigh free tissue transfer for reconstruction of glossectomy defects.

BACKGROUND: There is a lack of literature of health-related quality of life endpoints for radial forearm (RF) versus anterolateral thigh (ALT) free flap reconstruction for glossectomy defects. Our goal was to perform a comprehensive evaluation of clinical, functional, and quality of life outcomes after glossectomy reconstruction using a RF or ALT flap. METHODS: A retrospective review was performed on patients who underwent glossectomy and immediate reconstruction with RF or ALT flaps between 2016 and 2021. Outcomes of interest included readmission and reoperation rates, functional assessments, tracheostomy and gastrostomy tube status, and FACE-Q Head and Neck Cancer scores. RESULTS: Seventy-eight patients consisting of 54 RF and 24 ALT free flaps were included. ALT patients had a larger median flap size (72 vs. 48 cm2 , p = 0.021) and underwent mandibulotomy (50% vs. 7.4%, p < 0.0001) and base of tongue resection (58.3% vs. 24.1%, p = 0.005) at higher rates. No significant differences were found with respect to other outcomes. CONCLUSION: The RF and ALT flaps are suitable for glossectomy reconstruction, with minimal differences seen in postoperative outcomes. Our study suggests that ALT can be used in patients with base of tongue and larger defect sizes, while providing similar functional and clinical outcomes to RF reconstruction.

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.

A preliminary analysis of patient reported outcomes following posterolateral mandible reconstruction: The role of flap type.

BACKGROUND: The choice of tissue type for free flap reconstruction of posterolateral mandible resections is dependent on patient and defect characteristics. We compared clinical and patient-reported outcomes following reconstruction of these defects with a soft tissue or bony free flap. METHODS: A retrospective review was performed on patients who underwent posterolateral segmental mandibulectomy with immediate free flap reconstruction at MSKCC from 2006 to 2021. Outcomes of interest were patient-reported outcome measures (PROMs) assessed by FACE-Q surveys and complications at the flap recipient site. RESULTS: Ninety patients received a bony flap and 24 patients received a soft tissue flap. Patients reconstructed with soft tissue flaps had greater rates of composite soft tissue defects (p < 0.0001), condyle resection (p = 0.001), and peripheral vascular disease (p = 0.035). Complication rates were similar between the cohorts (p > 0.05). Bony flaps scored higher on multiple FACE-Q scales: Facial Appearance (p = 0.023) Eating/Drinking (p = 0.029), Smiling (p = 0.012), Speaking (p < 0.001), Swallowing (p = 0.012), Smiling Distress (p = 0.037), and Speaking Distress (p = 0.001). CONCLUSION: Reconstruction of posterolateral mandibular defects has a similar complication profile when utilizing a bony or soft tissue free flap. Bony flaps may perform better with respect to PROMs. Reconstructive surgeons should consider using bony flap reconstruction to achieve higher patient satisfaction and quality of life.

Missing Data in Patient-Reported Outcomes Research: Utilizing Multiple Imputation to Address an Unavoidable Problem.

BACKGROUND: Patient-reported outcomes (PROs) have become a focus in postoperative surgical care. Unfortunately, studies using PROs can be subject to missing data, which may lead to biases or inaccurate conclusions. Multiple imputation (MI) is a statistical method for addressing missing data in clinical research. The aim of this study was to explore MI as a way to address missing data in PRO research. METHODS: A working example of MI using real-world data was performed using the BREAST-Q PRO measure in postmastectomy reconstruction. A retrospective review of immediate tissue expander breast reconstruction patients in 2019 was conducted to compare BREAST-Q physical well-being of the chest scores between prepectoral and subpectoral cohorts at 2 weeks postoperatively. The observed dataset and three hypothetical missingness situations were created to assess how increasing missingness affects MI results. RESULTS: Overall, 916 patients were included in the analysis. When excluding patients with missing information and solely performing analysis on the completed cases, prepectoral patients had significantly higher physical well-being of the chest scores at 2 weeks postoperatively; however, this trend was reversed with increasing missingness scenarios, where subpectoral patients had higher scores. In comparison, all MI results showed that prepectoral patients had higher scores on average compared with subpectoral patients regardless of missingness scenario. CONCLUSIONS: MI demonstrated consistent results with increasing missingness scenarios, whereas performing analysis in higher missingness scenarios without MI led to varying results. This working example emphasizes the need for missing data methodology to be considered in PRO research.

Long-Term Patient-Reported Outcomes Comparing Oncoplastic Breast Surgery and Conventional Breast-Conserving Surgery: A Propensity Score-Matched Analysis.

INTRODUCTION: Oncoplastic breast surgery (OBS) combines plastic surgery techniques with conventional breast-conserving surgery (BCS) and expands BCS eligibility. Limited data are available on patient-reported outcomes (PROs) after OBS. Here we compare long-term PROs after OBS and BCS utilizing the BREAST-Q. PATIENTS AND METHODS: Women undergoing OBS or BCS between 2006 and 2019 who completed ≥ 1 long-term BREAST-Q survey 3-5 years postoperatively were identified. Baseline characteristics were compared between women who underwent OBS/BCS. Women who underwent OBS were paired with those who underwent BCS using 1:2 propensity matching [by age, body mass index (BMI), race, T stage, and multifocality]. BREAST-Q scores were compared preoperatively and 3-5 years postoperatively. RESULTS: A total of 297 patients were included for analysis (99 OBS/198 BCS). Women who underwent OBS were younger (p < 0.001) and had higher BMI (p = 0.005) and multifocal disease incidence (p = 0.004). There was no difference between groups in nodal stage, re-excision rates, axillary surgery, chemotherapy, endocrine therapy, or radiotherapy. After propensity matching preoperatively, women who underwent OBS reported lower psychosocial well-being (63 versus 100, p = 0.039) but similar breast satisfaction and sexual well-being compared with women who underwent BCS; however, only three patients who underwent BCS had preoperative BREAST-Q scores available for review. In long-term follow-up, women who underwent OBS reported lower psychosocial scores (74 versus 93, p = 0.011) 4 years postoperatively, but not at 5 years (76 versus 77, p = 0.83). There was no difference in long-term breast satisfaction or sexual well-being. CONCLUSIONS: Women who undergo OBS present with a larger disease burden and may represent a group of non-traditional BCS candidates; they reported similar long-term breast satisfaction and sexual well-being compared with women who undergo BCS. While women who underwent OBS reported lower psychosocial well-being scores preoperatively and during a portion of the follow-up period, this difference was no longer seen at 5 years postoperatively.

A Cohort Analysis of Early Outcomes After AlloDerm, FlexHD, and SurgiMend Use in Two-Stage Prepectoral Breast Reconstruction.

BACKGROUND: Acellular dermal matrix (ADM) is frequently utilized in prepectoral breast reconstruction, but few studies have examined the role of ADM type in complication risk. OBJECTIVES: This study was performed to determine the impact of ADM type on early complication rates in 2-stage alloplastic prepectoral breast reconstruction. METHODS: We performed a cohort examination of all patients who underwent mastectomy with immediate 2-stage alloplastic prepectoral breast reconstruction with ADM support at Memorial Sloan Kettering Cancer Center from 2018 to 2021. ADM types utilized included AlloDerm (LifeCell Corporation, Branchburg, NJ), FlexHD (MTF Biologics, Edison, NJ), and SurgiMend (Integra LifeSciences Corporation, Princeton, NJ). Complication rates based on the number of tissue expanders (TEs) were determined for each ADM type. Performance of multivariate logistic regression determined the impact of ADM type on complication risk after accounting for confounders. RESULTS: Overall, 726 patients (1054 TEs: 194 AlloDerm, 93 FlexHD, 767 SurgiMend) were included. The 3 cohorts differed in terms of mastectomy type (nipple-sparing: 23.5% of AlloDerm, 33.3% of FlexHD, 19.1% of SurgiMend, P = .038); ADM perforation (perforated: 94.8% of AlloDerm, 98.2% of FlexHD, 100% of SurgiMend, P < .001); and ADM size (AlloDerm: 153.2 cm2 [37.6], SurgiMend: 198.7 cm2 [10.4], FlexHD: 223.7 cm2 [37.9], P < .001). On univariate examination, no differences existed between ADM types for seroma, infection, exposure, malposition, or TE loss. Additionally, after adjustment for confounders with multivariate regression, no ADM type had higher odds of TE loss. CONCLUSIONS: In this large cohort of prepectoral reconstruction patients, ADM type did not significantly affect the risk of complications. Additional prospective studies are warranted to better evaluate ADM choice for prepectoral breast reconstruction.

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.

The Preferred Design of the Profunda Artery Perforator Flap for Autologous Breast Reconstruction: Transverse or Diagonal?

Background: Since its introduction for autologous breast reconstruction in 2010, the profunda artery perforator (PAP) flap has emerged as a preferred choice when an abdominal flap is suboptimal. The traditional transverse design (tPAP) was popularized, given the inconspicuous donor scar. A diagonal design (dPAP) has since evolved to address some of the shortcomings of the tPAP. The authors aimed to compare outcomes of tPAP/dPAP flaps harvested for breast reconstruction by a single surgeon. Methods: A retrospective review was conducted from 2017 to 2022 of patients undergoing tPAP versus dPAP-based breast reconstruction by a single surgeon at a tertiary cancer center. Patient variables and operative variables were assessed. Need for additional symmetrizing breast procedures were compared. Complications and BREAST-Q patient-reported outcome measures were analyzed. Results: Thirty-nine flaps were used to reconstruct 35 breasts in 24 patients. Average follow-up for the group was 1.8 years. The groups were similar with respect to demographics. The majority of dPAP flaps had two perforators, whereas most tPAP flaps had one perforator. The dPAP flaps had greater average weights, width, and overall surface area. There were no cases of partial/total flap loss. Complications and PROM results were similar between the two groups. Conclusions: The dPAP design allows for a larger skin paddle and greater tissue harvest and capture of cutaneous perforators, without increasing the risk of complications or compromising satisfaction. It should be considered as a viable option in patients unable to undergo abdominal-based reconstruction. Additional patients and multi-institutional efforts are necessary to better compare advantages of either design.

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.

The Impact of Breast-Conserving Surgery Re-excision on Patient-Reported Outcomes Using the BREAST-Q.

BACKGROUND: Approximately 14% of women undergoing breast-conserving surgery (BCS) require re-excision to achieve negative margins following the Society of Surgical Oncology (SSO) and American Society for Radiation Oncology (ASTRO) margin guidelines, which may influence patient-reported outcomes (PROs). Few studies have assessed the impact of re-excision on PROs following BCS. PATIENTS AND METHODS: Women with stage 0-III breast cancer undergoing BCS who completed a BREAST-Q PRO measure from 2010 to 2016 were identified from a prospective database. Baseline characteristics were compared between women who underwent one BCS and those who underwent ≥ 1 re-excision surgery for positive margins (R-BCS). Linear mixed models were used to analyze associations between number of excisions and BREAST-Q scores over time. RESULTS: Of 2543 eligible women, 1979 (78%) had one BCS and 564 (22%) had R-BCS. Younger age, lower BMI, surgery pre-SSO Invasive Guidelines issuance, ductal carcinoma in situ (DCIS), multifocal disease, radiation therapy receipt, and endocrine therapy omission were more common in the R-BCS group. Breast satisfaction and sexual well-being were lower in the R-BCS group 2 years postoperatively. There were no differences in psychosocial well-being between groups over 5 years. On multivariable analysis, re-excision was associated with lower breast satisfaction and sexual well-being (p= 0.007 and p= 0.049, respectively), but there was no difference in psychosocial well-being (p= 0.250). CONCLUSIONS: Women with R-BCS had lower breast satisfaction and sexual well-being 2 years postoperatively, but this difference did not remain long term. Psychosocial well-being in women who underwent one BCS were largely comparable over time to the R-BCS group. These findings may help in counseling women who are concerned about satisfaction and quality-of-life outcomes with BCS if re-excision is necessary.

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.

The Impact of Lymphedema on Patient-Reported Outcomes After Breast Reconstruction: A Preliminary Propensity Score-Matched Analysis.

BACKGROUND: Studies on the impact of secondary lymphedema on patient-reported satisfaction and quality of life following postmastectomy breast reconstruction are limited by their heterogeneity. We aimed to reduce heterogeneity in study sample populations and compare BREAST-Q Reconstruction Module scores of patients with lymphedema matched to patients without lymphedema. METHODS: We identified patients who underwent postmastectomy breast reconstruction from 2009 to 2017 and performed a propensity score-matched analysis to compare patient-reported outcomes of patients who developed lymphedema with those who did not. Matched covariates included age, body mass index, race/ethnicity, smoking history, radiation or chemotherapy exposure, postoperative infection, and reconstruction modality and laterality. Outcomes of interest were pre- and postoperative BREAST-Q scores for Satisfaction with Breasts, Physical Well-being of the Chest, Sexual Well-Being, and Psychosocial Well-Being; the minimal clinically important difference (MCID) was four points. RESULTS: Matched cohorts included 322 patients per group. Preoperative BREAST-Q scores did not differ between lymphedema and non-lymphedema matched cohorts. Postoperative BREAST-Q scores were significantly lower in lymphedema patients: Physical Well-Being of the Chest (all time points), Satisfaction with Breast (at 1 and 2 years), Sexual Well-Being (at 2 years), and Psychosocial Well-Being (at 2 and 3 years). All significant differences in average scores were greater than the MCID. CONCLUSIONS: Patients with breast cancer-related lymphedema reported significantly lower Physical Well-Being of the Chest, Satisfaction with Breasts, Sexual Well-Being, and Psychosocial Well-Being at various time points. Our findings may prove useful for patient counseling and justify the need for further research on the prevention and treatment of this devastating disease.