The Impact of Timing of Delayed Autologous Breast Reconstruction following Postmastectomy Radiation Therapy on Postoperative Morbidity.

BACKGROUND: The ideal time to perform reconstruction after the completion of postmastectomy radiation therapy (PMRT) in patients with locally advanced breast cancer is currently unknown. We evaluate the association between the timing of delayed autologous breast reconstruction following PMRT and postoperative complications. METHODS: Patients who underwent mastectomy, PMRT, and then delayed autologous breast reconstruction from 2009 to 2016 were identified from the Truven Health MarketScan Research Databases. Timing of reconstruction following PMRT was grouped 0-3, 3-6, 6-12, 12-24, and after 24 months. Multivariable models were used to assess associations between timing of reconstruction following PMRT and key measures of morbidity. RESULTS: A total of 1,039 patients met inclusion criteria. The rate of any complications for the analytic cohort was 39.4%, including 13.3% of patients who experienced wound complications and 11.3% of patients requiring additional flaps. Unadjusted rates of complications increased from 23.4% between 0 and 3 months to 49.4% between 3 and 6 months and decreased thereafter. Need for additional flaps was highest within 3 to 6 months (14.0%). Multivariate analysis revealed higher rates of any complications when reconstruction was performed between 3 and 6 months (odds ratio [OR]: 3.04, p < 0.001), 6 and 12 months (OR: 2.66, p < 0.001), or 12 and 24 months (OR: 2.13, p = 0.001) after PMRT. No difference in complications were noted in reconstructions performed after 24 months compared with those performed before 3 months (p > 0.05). However, rates of wound complications were least likely in reconstructions after 24 months (OR: 0.34, p = 0.035). CONCLUSION: These findings suggest plastic surgeons may consider performing autologous breast reconstruction early for select patients, before 3 months following PMRT without increasing postoperative morbidity.

Epidemiology of Upper Extremity Firearm Injuries among Major Trauma Hospitals in the United States.

BACKGROUND: As many as 34 percent of nonfatal firearm injuries involve the upper extremity. Although not lethal, these injuries cause substantial morbidity. The authors conducted an epidemiologic study characterizing upper extremity firearm-related injuries presenting to U.S. trauma centers over a 10-year period. METHODS: The authors used the National Trauma Databank from 2007 to 2017 to identify isolated upper extremity firearm-related injuries. Descriptive statistics were performed to characterize patient demographic data, firearm type, extremity injury patterns, treatments received, hospital length of stay, and regional variation. RESULTS: The authors identified 48,254 upper extremity firearm-related injuries. The patients were largely male patients (85 percent), and over half were between the ages of 20 and 39 years. Handguns (34 percent) were the most frequently used firearm. Shoulder and upper arm were the most frequently injured areas (54 percent); however, 18 percent of patients injured two or more areas. Patients were most often treated at university hospitals (59 percent) with Level I or II trauma designation. Seventy percent were admitted and/or taken directly to the operating room. The mean hospital length of stay was 3 days. Payer mix among these patients was variable: Medicaid, 20 percent; private insurance, 20 percent; and self-pay, 29 percent. CONCLUSIONS: Upper-extremity firearm injuries are resource intensive, with three-quarters of patients requiring operative intervention and/or hospitalization. Level I and II trauma centers were the site of care for the majority of patients. Targeted gun policy reform and prevention measures directed toward at-risk groups have the potential to limit the unnecessary morbidity and costs associated with these injuries.