Same day discharge following mastectomy and immediate tissue expander reconstruction: The effect of patient expectations.

BACKGROUND AND PURPOSE: Within, we compare the short-term outcomes of patients receiving same day mastectomy and tissue expander reconstruction for those discharged on postoperative day one versus those discharged immediately following surgery to explore the safety, efficacy, and potential impact on hospital processes. METHODS: This was a retrospective review of patients undergoing mastectomy with immediate TE reconstruction from March 2019 to March 2021. Patients were stratified into two cohorts; observation overnight (OBS), and discharge on same day of surgery (DC). RESULTS: In total, 153 patients underwent 256 mastectomies with immediate TE reconstruction. All patients were female and the mean age was 48 years old. The DC cohort contained 71 patients (125 mastectomies) and there were 82 patients (131 mastectomies) within the OBS cohort. On average the DC cohort had a lower BMI than the OBS group (mean ± SD; DC 26.8 kg/m2 ± 5.3 kg/m2, OBS 28.7 kg/m2 ± 6.1 kg/m2, p = 0.05), the DC cohort had higher rates of adjuvant chemotherapy (DC 40.1%, OBS 23.2%, p = 0.02), and were more likely to undergo bilateral TE reconstruction (DC 76%, OBS 60%, p = 0.03) than the OBS group. No differences were observed between cohorts in complication rates regarding primary or secondary outcomes. CONCLUSION: These findings indicate that it is safe and effective within the immediate 7-day post-operative period to immediately discharge patients undergoing mastectomy with immediate TE reconstruction. Additionally, alteration of patient management practices can have a profound impact on the operational flow within hospitals.

A Novel Framework for Optimizing Efficiency and Education in Microsurgical Breast Reconstruction.

Deep inferior epigastric perforator (DIEP) flaps are becoming the most frequent choice for autologous breast reconstruction. There are many benefits to DIEP flaps, but the procedures can be lengthy and have a steep learning curve. The balance of efficiency and education can be difficult to achieve. A framework was implemented to focus on both efficiency and education at each stage of the DIEP flap procedure. The author's methods to improve efficiency include a two-team approach with assigned roles for faculty and residents. The roles are consistent across the institution. Methods to enhance education include practice in a laboratory-based microsurgical training course and assigning goals for the rotation. Trainees include independent and integrated plastic surgery residents without microsurgical fellows. Bilateral DIEPs are performed with two attendings, and unilateral DIEPs, with one attending. A retrospective review identified patients undergoing DIEP flap reconstruction from 2017 to 2020. Outcome measures include operative time and complications, which are comparable to previously published data. Focusing on education allows residents to learn each stage of the case. The authors present a framework for training residents in DIEP flap reconstruction to optimize efficiency and education.

Revisiting Bipedicled Flaps for Lower Extremity Distal Third Defects.

BACKGROUND: Lower extremity reconstruction of the distal third of the leg is challenging. Free tissue transfer is the criterion standard. The COVID-19 pandemic encouraged seeking alternatives for resource consuming procedures. Bipedicled flaps are flaps with a dual-source subdermal perfusion. The purpose of this study was to assess outcomes of patients who had bipedicled flaps primary or auxiliary local flap for distal third leg/foot reconstruction. METHODS: A retrospective review of patients undergoing lower extremity reconstruction (2020-2021) was performed. Inclusion criteria were patients older than 18 years with lower extremity wounds secondary to traumatic injury for which bipedicled flaps were used in the reconstruction. Exclusion criteria included lower extremity wounds secondary to peripheral vascular disease or diabetes. RESULTS: Fourteen patients were included in the study. All patients had distal third of the leg/foot wounds, and 12 patients (87.5%) had concurrent leg fractures. In 8 patients (57.1%), the bipedicled flap was used to decrease the wound size and facilitate another concurrent flap: hemisoleus (21.4%), anterior tibialis muscle turnover (14.3%), medial plantar artery (14.3%), and posterior tibial artery perforator (14.3%). Mean wound size for bipedicle flaps used alone was 42.0 ± 18.3 cm2, whereas wounds that required a bipedicled flap with an additional flap were 69.9 ± 80.8 cm2 (P = 0.187). Two patients had partial flap necrosis (14.3%) but healed their defect. One patient had nonunion (7.1%). Limb salvage rate was 100%. CONCLUSIONS: Bipedicled flaps can be used as an alternative to free flaps in distal third leg/foot defects in select patients. If distal extremity wounds cannot be covered with a bipedicled flap alone, the flap can be used an accessory flap to facilitate reconstruction with other local flaps.

Evaluation of Prepectoral Breast Tissue Expander Reconstruction Intraoperative Fill: Air or Saline?

SUMMARY: Staged implant-based breast reconstruction with immediate tissue expanders (TEs) is the most common method of breast reconstruction after mastectomy. TEs traditionally are filled with saline for expansion. Some surgeons have advocated initial intraoperative fill of the TE with air to avoid excess pressure on ischemic mastectomy skin flaps. The purpose of the study was to compare intraoperative air versus saline tissue fills. All patients who underwent prepectoral TE reconstruction after mastectomy from 2017 to 2019 were reviewed. The primary predictive variable was whether saline or air was used for initial tissue expansion. Outcome variables included mastectomy skin necrosis, nipple necrosis, infection, number of expansions, hematoma, and explantation. A total of 53 patients (88 TEs) were included in the study: 28 patients (44 TEs) who underwent initial intraoperative fill with air and 25 patients (44 TEs) who underwent an initial saline fill were assessed. There were no significant differences in complication rates between initial TE fill with saline versus air, including nipple necrosis, wound dehiscence, cellulitis, abscess, or TE removal ( P = 1.0). The number of postoperative TE fills in the initial air fill group was 3.2 compared to 2.7 in the initial saline fill group ( P = 0.27). Prepectoral TE initial fill with air has similar postoperative outcomes compared to initial saline fill. The authors found no benefit to initially filling prepectoral TEs with air intraoperatively. Given the additional effort of exchanging air for saline during the first postoperative fill, there was no clinical advantage of filling prepectoral TEs with air. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Outcomes after Anterior Interosseous Nerve to Ulnar Motor Nerve Transfer.

Background Ulnar nerve lesions proximal to the elbow can result in loss of intrinsic muscle function of the hand. The anterior interosseous nerve (AIN) to deep motor branch of the ulnar nerve (DBUN) transfer has been demonstrated to provide intrinsic muscle reinnervation, thereby preventing clawing and improving pinch and grip strength. The purpose of this study was to evaluate the efficacy of the AIN to DBUN transfer in restoring intrinsic muscle function for patients with traumatic ulnar nerve lesions. Methods We performed a prospective, multi-institutional study of outcomes following AIN to DBUN transfer for high ulnar nerve injuries. Twelve patients were identified, nine of which were enrolled in the study. The mean time from injury to surgery was 15 weeks. Results At final follow-up (mean postoperative follow-up 18 months + 15.5), clawing was observed in all nine patients with metacarpophalangeal joint hyperextension of the ring finger averaging 8.9 degrees (+ 10.8) and small finger averaging 14.6 degrees (+ 12.5). Grip strength of the affected hand was 27% of the unaffected extremity. Pinch strength of the affected hand was 29% of the unaffected extremity. None of our patients experienced claw prevention after either end-to-end ( n = 4) or end-to-side ( n = 5) AIN to DBUN transfer. Conclusion We conclude that, in traumatic high ulnar nerve injuries, the AIN to DBUN transfer does not provide adequate intrinsic muscle reinnervation to prevent clawing and normalize grip and pinch strength.

Supraclavicular Approach to the Brachial Plexus.

The brachial plexus consists of an intricate array of nerves originating from the C5-T1 ventral rami of the spinal cord. Their course is complex and can be substantially distorted after injury. Thus, dissection of the brachial plexus can be difficult. Here, we present a practical approach to the supraclavicular dissection of the brachial plexus, with emphasis on relevant anatomy and surgical landmarks. Methods: This anatomical review was prepared using intraoperative surgical imaging. In addition, illustrations are used to display the images in schematic form. We present a stepwise surgical approach to the supraclavicular dissection of the brachial plexus. We highlight the differences between pre- and postganglionic nerve root injuries, and also relevant anatomical variants of the brachial plexus. Results: Eleven steps are recommended to facilitate the supraclavicular approach to the brachial plexus. Conclusion: The supraclavicular dissection of the brachial plexus is reliable with consistent landmarks and can be carried out in a stepwise fashion.

Comparison of Breast Reconstruction Outcomes Using Oxychlorosene versus Triple Antibiotic Solution for Pocket Irrigation.

Background: Breast pocket irrigation with antiseptic solutions is performed to reduce contamination with breast implants. The optimal antiseptic irrigation solution and the efficacy of individual practices are unclear. Oxychlorosene sodium is frequently used at our institution. Oxychlorosene is bactericidal with a mechanism of action of oxidation and hypochlorination. The purpose of our study was to compare the outcomes of oxychlorosene sodium irrigation with triple antibiotic solution (TAS) in implant-based breast reconstruction. Methods: All patients who underwent implant-based reconstruction after mastectomy were reviewed. The primary predictive variable was type of solution used for pocket irrigation (TAS or oxychlorosene). Outcome variables included surgical site infection, device removal, and wound complications. Results: Between 2013 and 2018, 331 implant-based breast reconstructions were performed. Of these, 62% (n = 206) received oxychlorosene for surgical pocket irrigation (group I), and 38% (n = 125) received TAS (group II). Group I had an 11.7% (n = 24) 90-day surgical site infection rate, with 4.9% (n = 10) requiring oral antibiotics, 2.4% (n = 5) requiring intravenous antibiotics without device removal, and 4.4% (n = 9) requiring prosthetic removal. Group II had an 11.2% (n = 14) 90-day infection rate, with 5.6% (n = 7) requiring oral antibiotics, 2.4% (n = 3) requiring intravenous antibiotics without device removal, and 3.2% (n = 4) requiring removal (P = 0.90). When comparing the cost of oxychlorosene irrigation with TAS irrigation, oxychlorosene was less expensive. Conclusions: Oxychlorosene and TAS have similar surgical site infection rates in prosthetic breast reconstruction. Ease of preparation and cost make oxychlorosene a more favorable option for antibiotic irrigation in reconstructive breast surgery with prosthetic devices.

Optimizing tissue expander breast reconstruction in nicotine users: An algorithmic approach.

INTRODUCTION: Smoking is a risk factor for post-operative complications following breast reconstruction. Abruptly refraining from all nicotine products may be difficult for patients with a new cancer diagnosis. The goal of this study is to assess complications following a distinct approach to tissue expander reconstruction in nicotine users. METHODS: Patients who underwent tissue expander reconstruction after mastectomy were retrospectively reviewed. The approach to optimize outcomes in smokers was to delay reconstruction at least 7 days after the mastectomy and place the expander submuscularly (Group I). The other patients underwent standard immediate reconstruction on the day of mastectomy and were divided into Group II (active smokers) and Group III (non-smokers). Group III was considered the control group. RESULTS: There was a total of 195 patients (323 breast reconstructions): Group I (10 patients, 19 expanders); Group II (11 patients, 19 expanders) and Group III (174 patients, 285 expanders). In Group I, n = 1/19 breasts had wound dehiscence requiring surgical management, compared to n = 18/285 in Group III (p = 1.0). Group II exhibited more wound dehiscence (n = 6/19) compared to Group III (p = 0.002). There was no significant difference when comparing wound dehiscence in prepectoral expander placement (7.0%) versus submuscular placement (4.8%) in Group III (p = 0.60). CONCLUSION: Nicotine users who are offered tissue expander breast reconstruction 1) at least 7 days after the mastectomy (to allow for vascular delay and demarcation) and 2) in the submuscular plane can normalize their risk of skin necrosis to that of non-smokers who have standard (prepectoral or submuscular) reconstruction on the day of mastectomy.

Long-Term Outcomes After Treatment for Type B Ulnar Polydactyly.

BACKGROUND: Type B ulnar polydactyly is a common congenital hand difference and can be treated with either ligation or surgical excision. There is a paucity of literature, however, evaluating long-term patient reported outcomes of these treatments. The purpose of this study was to compare the long-term outcomes after ligation and excision for the management of type B ulnar polydactyly. METHODS: We created a database of patients who underwent treatment for type B ulnar polydactyly at a single pediatric health system from 2005 to 2014. We administered the Patient Reported Outcomes Measurement Information System (PROMIS) Pediatric Upper Extremity survey to patients through telephone and assessed for their satisfaction. RESULTS: We successfully collected outcomes from 69 of 173 eligible patients treated in infancy (40% response rate). The mean follow-up was 11.1±2.5 years, and the average age of the participant at the time of the survey was 11.7±2.6 years of age. Twenty-four patients were treated with in-office ligation and 45 underwent formal surgical excision. Ten patients who were initially treated with ligation required future treatment with surgery because of symptomatic neuroma stump or persistent polydactyly (42%). Patients who were treated with surgical excision rated significantly higher satisfaction with their treatment than those who underwent ligation (P=0.003). Patients in both cohorts rated similar satisfaction with the esthetic appearance of their hand (P=0.07). There was no significant difference in PROMIS-rated hand function between the ligation and surgical cohort (P=0.765) and treated adolescents PROMIS scores were not statistically different than age-matched controls without polydactyly. CONCLUSION: While ligation and surgical excision result in similar function and esthetics, patient satisfaction is higher after surgery. Furthermore, a significant number of patients fail ligation and ultimately undergo surgery for symptomatic neuroma or persistent polydactyly. Counseling parents of patients with type B ulnar polydactyly should include these considerations to assist them in selecting the best treatment for their child. LEVEL OF EVIDENCE: Level III.

Do Patient Expectations of Discharge Affect Length of Stay after Deep Inferior Epigastric Perforator Flap for Breast Reconstruction?

BACKGROUND: Deep inferior epigastric artery perforator (DIEP) flap is a common method of breast reconstruction. Enhanced recovery after surgery (ERAS) postoperative protocols have been used to optimize patient outcomes and facilitate shorter hospital stays. The effect of patient expectations on length of stay (LOS) after DIEP has not been evaluated. The purpose of this study was to investigate whether patient expectations affect LOS. METHODS: A retrospective chart review was performed for patients undergoing DIEP flaps for breast reconstruction from 2017 to 2020. All patients were managed with the same ERAS protocol. Patients were divided in Group I (early expectations) and Group II (standard expectations). Group I patients had expectations set for discharge postoperative day (POD) 2 for unilateral DIEP and POD 3 for bilateral DIEP. Group II patients were given expectations for POD 3 to 4 for unilateral DIEP and POD 4 to 5 for bilateral. The primary outcome variable was LOS. RESULTS: The study included 215 DIEP flaps (45 unilateral and 85 bilateral). The average age was 49.8 years old, and the average body mass index (BMI) was 31.4. Group I (early expectations) included 56 patients (24 unilateral DIEPs, 32 bilateral). Group II (standard expectations) had 74 patients (21 unilateral, 53 bilateral). LOS for unilateral DIEP was 2.9 days for Group I compared with 3.7 days for Group II (p = 0.004). Group I bilateral DIEP patients had LOS of 3.5 days compared with 3.9 days for Group II (p = 0.02). Immediate timing of DIEP (Group I 42.9 vs. Group II 52.7%) and BMI (Group I 32.1 vs. Group II 30.8) were similar (p = 0.25). CONCLUSION: Our study found significantly shorter hospital stay after DIEP flap for patients who expected an earlier discharge date despite similar patient characteristics and uniform ERAS protocol. Patient expectations should be considered during patient counseling and as a confounding variable when analyzing ERAS protocols.

CT-Guided Percutaneous Needle Biopsy of Retroperitoneal and Pelvic Lymphadenopathy: Assessment of Technique, Diagnostic Yield, and Clinical Value.

PURPOSE: To assess the technical success rate, diagnostic yield, and clinical value of computed tomography (CT)-guided percutaneous needle biopsy (PNB) for retroperitoneal and pelvic lymphadenopathy. MATERIALS AND METHODS: This retrospective study included 344 patients evaluated for safety and technique and 334 patients evaluated for diagnostic yield and clinical analyses. PNBs were performed with fine-needle aspiration (FNA) in 315 patients and with core biopsy in 333 patients. Follow-up analyses, including repeat biopsy, open surgery, imaging, and clinical indicators, were conducted for 94 patients who had nonspecific malignant or benign results. Diagnostic yields were calculated based on biopsy and follow-up results. Factors associated with final diagnoses were compared and modeled by multivariate analysis. RESULTS: Technical success rate was 99.7%. Thirty-nine patients (11.3%) had minor complications. From biopsy results and follow-up analyses, final malignant diagnoses were determined for 281 patients (84.1%). Overall sensitivity, specificity, and accuracy rates of PNB were 91.5%, 100%, and 92.8%, respectively. For patients with a history of malignancy, the likelihood of nodal involvement was 84.6% and that of a new, different malignancy was 3.7%. Older age (odds ratio [OR], 1.03; 95% confidence interval [CI], 1.00-1.05), history of malignancy (OR, 3.44; 95% CI, 1.71-6.92), multiple lymph nodes (LNs; OR, 2.65; 95% CI, 1.38-5.09), and new or enlarging LNs (OR, 2.62; 95% CI, 1.25-5.48) were independent risk factors for malignancy diagnosis. CONCLUSIONS: CT-guided PNB is a safe, effective procedure that can achieve high diagnostic yields for patients with retroperitoneal and pelvic lymphadenopathy.

Vasodilation associated with supplement use: potential concern for military aviators.

Military aviators are exposed to high G environments while performing certain tactical aircraft maneuvers. G forces endured during such maneuvering have been shown to reduce mean arterial blood pressure (MAP) at eye level by 22 mmHg for every G endured, leaving the average aviator with a resting G tolerance of approximately 5 to 5.5 G before losing consciousness. Many sports performance supplements on the market today contain compounds that are boasted to increase vascularity and reduce muscle recovery time. Usage of such supplements has demonstrated a reduction of MAP by as much as 16 mmHg after 1 h of dosing and could potentially lower one's G tolerance by 14%. Military aviators should proceed on the side of caution due to the potential threats that exist with consuming such products until a formal study can be conducted to investigate this matter further.

Perspectives on performance assessment in medical simulation.

The work upon which this paper is based was supported by an award to Massachusetts General Hospital - CIMIT from the US Department of Defense. The opinions expressed herein are the sole responsibility of the author and do not represent the policy of the US Department of Defense.

The ABC's of stroke complications.

Stroke is the third leading cause of death in the United States, with more than 140,000 deaths per year. Complications related to stroke resulting in morbidity and mortality are very common and may result from cerebral and extracerebral causes. Cerebral causes include cerebral edema, hemorrhagic conversion of an ischemic infarct, and progression of penumbra to infarction. Extracerebral complications include deep vein thrombosis and pulmonary embolism, urinary tract infection, and aspiration. Many of these complications are largely preventable and often tracked as "quality metrics" in institutions with a stroke center designation. The focus of the article is primarily on common poststroke complications, such as aspiration, DVT, decubitus ulcers, seizures, and urinary catheter infections. Knowledge about potential poststroke complications is critical to earlier diagnosis, proper preventive strategies, and management.

The origins of Better Jobs Better Care.

Better Jobs Better Care was the nation's largest single initiative created to reduce the high vacancy and turnover rates of direct care workers and improve workforce quality through both policy and practice changes. In this article, we describe the important role and key characteristics of direct care workers, what motivated the unique partnership between a provider association and a direct care worker advocacy organization to create this initiative, and how the initiative was designed to respond to the key challenges through applied research and demonstration projects. We conclude by discussing how BJBC has influenced providers, policy makers, and direct care workers to think about these frontline caregivers, who are the crux of the long-term care workforce.