Dynamic insights into infection risk over time in two-stage implant-based breast reconstruction: a retrospective cohort study.

BACKGROUND: Infections following postmastectomy implant-based breast reconstruction (IBR) can compromise surgical outcomes and lead to significant morbidity. This study aimed to discern the timing of infections in two-stage IBR and associated risk factors. METHOD: A review of electronic health records was conducted on 1,096 breasts in 1,058 patients undergoing two-stage IBR at ** National University Hospital (2015-2020). Infections following the first-stage tissue expander (TE) insertion and second-stage TE exchange were analyzed separately, considering associated risk factors. RESULTS: Over a median follow-up of 53.5 months, infections occurred in 2.9% (32/1096) after the first stage and 4.1% (44/1070) after the second stage. Infections following the first-stage procedure exhibited a bimodal distribution across time, while those after the second-stage procedure showed a unimodal pattern. When analyzing risk factors for infection after the first-stage procedure, axillary lymph node dissection (ALND) was associated with early (≤7 weeks) infection, while both ALND and obesity were independent predictors of late (>7 weeks) infection. For infections following the second-stage procedure, obesity, postmastectomy radiotherapy, a history of expander infection, ALND, and the use of textured implants were identified as independent risk factors. Postmastectomy radiotherapy was related to non-salvaged outcomes after infection following both stages. CONCLUSION: Infections following first and second-stage IBR exhibit distinct timelines reflecting different pathophysiology. Understanding these timelines and associated risk factors will inform patient selection for IBR and aid in tailored postoperative surveillance planning. These findings contribute to refining patient suitability for IBR and optimizing personalized postoperative care strategies.

Radiation-Induced Morphea of the Breast Treated With Wide Local Excision and Abdominal Free Flap Breast Reconstruction.

Radiation-induced morphea (RIM) associated with breast cancer treatment is a rare and underdiagnosed skin complication of radiotherapy that can lead to severe and painful contractures, resulting in disfigurement, failure of reconstruction, and poor quality of life in patients. The condition may present on a spectrum of local or more generalized forms involving skin over the breast and anterior chest wall. This diagnosis must be differentiated from post-radiation fibrosis, infection, cancer recurrence, inflammatory breast cancer, and other inflammatory conditions as the clinical course and treatment approaches differ. Various noninvasive and topical agents have been used; however, many cases are refractory to treatment. Surgery has been less commonly described in the management of generalized RIM. This report describes a case of RIM in a patient with breast cancer who experienced simultaneous resolution of symptoms as well as successful breast reconstruction using autologous free-tissue transfer.

Safety and Sustainability: Optimizing Outcomes and Changing Paradigms in Global Health Endeavors.

Background: The need to address inequities in global surgical care has garnered increased attention since 2015, after the Lancet Commission on Global Surgery underscored the importance of ensuring safe, accessible, affordable, and timely surgical and anesthetic care. The vast unmet global plastic surgery needs make plastic surgery care essential in reducing the global burden of disease. In the past, many nonprofit organizations undertook humanitarian activities within low- and middle-income countries that were primarily service-provision oriented. The Lancet Commission on Global Surgery report prompted a shift in focus from direct patient care models to sustainable global surgical models. The realization that 33% of deaths worldwide were due to unmet surgical needs led to a global shift of strategy toward the development of local systems, surgical capacity, and a focus on patient safety and quality of care within international global surgery partnerships. Methods: In this report, the authors explore some of the primary components of sustainable international global surgical partnerships discussed in a recent panel at the American Society of Plastic Surgeons Plastic Surgery The Meeting 2022, titled "Safety and Sustainability Overseas: Optimizing Outcomes and Changing Paradigms in Global Health Endeavors." A literature review elaborating the topics discussed was performed. Results: This report focuses on cultural competence and humility, international collaboration, and the use of technology and innovation, all of which are needed to promote sustainability and patient safety, within global surgery efforts. Conclusions: The adoption of these components into international surgical collaborations will lead to greatly enhancing the development and sustainability of mutually beneficial relationships.

Paradigm Shifts in Alloplastic Breast Reconstruction: A Nationwide Analysis of Direct-To-Implant Trends.

BACKGROUND: Direct-to-implant breast reconstruction is an attractive choice for appropriately-selected patients, as a single-stage procedure can enhance global metrics of care. In an era of high-value healthcare, therefore, it is important to investigate utilization of such procedures. This study investigated direct-to-implant trends over the past decade on a nationwide basis. METHODS: This was a retrospective investigation of direct-to-implant reconstruction between 2010-2018 in the United States, using the National Inpatient Sample (NIS) database. All study analyses were undertaken using Stata v15.0. RESULTS: The weighted sample included 287,093 women who underwent implant-based reconstruction between 2010-2018, of whom 43,064 (15%) underwent direct-to-implant reconstruction. Across the study period, the proportion of direct-to-implant procedures significantly increased (p=0.03), relative to staged and delayed implant-based procedures. While direct-to-implant patients were younger, more likely to be white and privately-insured, the proportion of non-white, publicly-insured patients undergoing direct-to-implant reconstruction significantly increased by 2018 (p<0.05). Furthermore, direct-to-implant utilization amongst Medicaid patients increased at 2.2 times the rate in Medicaid expansion states compared to non-expansion states. Direct-to-implant patients had significantly higher APR-DRG risk scores in 2018 than in 2010 (p=0.02), indicating expanding clinical indications for this procedure. Direct-to-implant reconstruction had significantly lower inpatient charges than staged procedures (p=0.03), when considering expander placement and expander-implant exchange. CONCLUSION: Overall, utilization of direct-to-implant breast reconstruction has significantly increased over the past decade, facilitated by expanding clinical indications and improved insurance coverage. However, certain disparities continue to exist. Further work should investigate drivers of disparities to allow continued expansion of direct-to-implant reconstruction as clinically appropriate.

A Systematic Review and Meta-Analysis Comparing the Clinical Outcomes of Profunda Artery Perforator Versus Gracilis Thigh Flap as a Second Choice for Autologous Breast Reconstruction.

PURPOSE: Autologous breast reconstruction remains a versatile option to produce a natural appearing breast after mastectomy. The deep inferior epigastric perforator remains the most commonly used flap choice, but when this donor site is unsuitable or unavailable, the transverse upper gracilis (TUG) or profunda artery perforator (PAP) flaps are popular secondary alternatives. We conduct a meta-analysis to better understand patient outcomes and adverse events in secondary flap selection in breast reconstruction. METHODS: A systematic search was conducted on MEDLINE and Embase for all articles published on TUG and/or PAP flaps for oncological breast reconstruction in postmastectomy patients. A proportional meta-analysis was conducted to statistically compare outcomes between PAP and TUG flaps. RESULTS: The TUG and PAP flaps were noted to have similar reported rates of success and incidences of hematoma, flap loss, and flap healing (P > 0.05). The TUG flap was noted to have significantly more vascular complications (venous thrombosis, venous congestion, and arterial thrombosis) than the PAP flap (5.0% vs 0.6%, P < 0.01) and significantly greater rates of unplanned reoperations in the acute postoperative period (4.4% vs 1.8%, P = 0.04). Infection, seroma, fat necrosis, donor healing complications, and rates of additional procedures all exhibited high degree of heterogeneity precluding mathematical synthesis of outcomes across studies. CONCLUSIONS: Compared with TUG flaps, PAP flaps have fewer vascular complications and fewer unplanned reoperations in the acute postoperative period. There is need for greater homogeneity in reported outcomes between studies to enable for synthesis of other variables important in determining flap success.

Characterizing Clinical Trials in Plastic and Reconstructive Surgery: A Systematic Review of ClinicalTrials.gov From 2007 to 2020.

BACKGROUND: Clinical trials form the backbone of evidence-based medicine. ClinicalTrials.gov is the world's largest clinical trial registry, and the state of clinical trials in plastic and reconstructive surgery (PRS) within that database has not been comprehensively studied. To that end, we explored the distribution of therapeutic areas that are under investigation, impact of funding on study design and data reporting, and trends in research patterns of all PRS interventional clinical trials registered with ClinicalTrials.gov. METHODS: Using the ClinicalTrials.gov database, we identified and extracted all clinical trials relevant to PRS that were submitted between 2007 and 2020. Studies were classified based on anatomic locations, therapeutic categories, and specialty topics. Cox proportional hazard was used to calculate adjusted hazard ratios (HRs) for early discontinuation and results reporting. RESULTS: A total of 3224 trials that included 372,095 participants were identified. The PRS trials grew at an annual rate of 7.9%. The therapeutic classes most represented were wound healing (41.3%) and cosmetics (18.1%). Funding for PRS clinical trials is largely provided through academic institutions (72.7%), while industry and US government constituted a minority. Industry-funded studies were more likely to be discontinued early than those funded by academics (HR, 1.89) or government (HR, 1.92) and to be nonblinded and nonrandomized. Academic-funded studies were the least likely to report results data within 3 years of trial completion (odds ratio, 0.87). CONCLUSIONS: A gulf exists in the representation of different PRS specialties among clinical trials. We highlight the role of funding source in trial design and data reporting to identify a potential source of financial waste and to stress the need for continued appropriate oversight.

Prioritizing Native Breast Skin Preservation or Scar Symmetry in Autologous Breast Reconstruction? Using Crowdsourcing to Assess Preference.

Background: Recent literature on autologous breast reconstruction suggests that such factors as scar symmetry and skin paddle size impact patient preferences more than preservation of native breast skin. Since patient satisfaction with plastic surgery procedures can be largely influenced by beauty standards set by the general public, this study used a novel crowdsourcing method to evaluate laypeople's aesthetic preferences for different bilateral autologous breast reconstructions to determine the relative importance of scar and skin paddle symmetry and preservation of native skin. Methods: Using Amazon's Mechanical Turk crowdsourcing marketplace, participants ranked images of reconstructions based on overall aesthetic appearance. Images were digitally modified to reflect 4 types of reconstruction: immediate (IR), delayed symmetric (DS), delayed asymmetric (DA), or mixed (MR). Results: DS was ranked most favorably (1.74), followed by IR (1.95), DA (2.93), and MR (3.34). Friedman rank sum and pairwise tests showed statistical significance for comparisons of all 4 reconstruction types. Likert ratings were higher for IR than for DA reconstructions for skin quality (P = .002), scar visibility (P < .001), scar position (P < .001), and breast symmetry, shape, and position (P < .001). Ratings increased for all aesthetic factors following nipple-areolar-complex reconstruction (P < .001). Conclusions: More symmetric breast scars were rated aesthetically higher than nonsymmetric scarring, and our participants preferred maintenance of scar symmetry over preservation of native breast skin. These findings are consistent with previous studies that surveyed non-crowdsourced participants, which demonstrates the potential for crowdsourcing to be used to better understand the general public's preferences in plastic surgery.

Outcomes of Biosynthetic and Synthetic Mesh in Ventral Hernia Repair.

The introduction of mesh for reinforcement of ventral hernia repair (VHR) led to a significant reduction in hernia recurrence rates. However, it remains controversial whether synthetic or biologic mesh leads to superior outcomes. Recently, hybrid mesh consisting of reinforced biosynthetic ovine rumen (RBOR) has been developed and aims to combine the advantages of biologic and synthetic mesh; however, outcomes after VHR with RBOR have not yet been compared with the standard of care. Methods: We performed a retrospective analysis on 109 patients, who underwent VHR with RBOR (n = 50) or synthetic polypropylene mesh (n = 59). Demographic characteristics, comorbidities, postoperative complications, and recurrence rates were analyzed and compared between the groups. Multivariate logistic regression models were fit to assess associations of mesh type with overall complications and surgical site occurrence (SSO). Results: Patients who underwent VHR with RBOR were older (mean age 63.7 versus 58.8 years, P = 0.02) and had a higher rate of renal disease (28.0 versus 10.2%, P = 0.01) compared with patients with synthetic mesh. Despite an unfavorable risk profile, patients with RBOR had lower rates of SSO (16.0 versus 30.5%, P = 0.12) and similar hernia recurrence rates (4.0 versus 6.78%, P = 0.68) compared with patients with synthetic mesh. The use of synthetic mesh was significantly associated with higher odds for overall complications (3.78, P < 0.05) and SSO (3.87, P < 0.05). Conclusion: Compared with synthetic polypropylene mesh, the use of RBOR for VHR mitigates SSO while maintaining low hernia recurrence rates at 30-month follow-up.

Smooth versus textured tissue expanders in breast reconstruction - A retrospective review of post-operative surgical site infections.

BACKGROUND: Textured tissue expanders (TTEs) were introduced to limit migration and reduce capsular contracture, which were inherent to smooth tissue expanders (STEs). Previous reports suggest that textured devices have increased rates of bacterial contamination and biofilm formation in comparison with smooth devices. Recently, the relative increased association of anaplastic large cell lymphoma (ALCL) with textured versus smooth devices has led to increased adoption of smooth devices. The aim of our study is to evaluate the post-operative surgical site infection (SSI) rates of STEs versus TTEs. METHODS: A retrospective case series was conducted at a single academic teaching hospital from April 2016 to December 2019. The primary outcome variable was the development of a post-operative SSI. RESULTS: One hundred seventy-seven breasts underwent reconstruction with TTEs and 109 breasts underwent reconstruction with STE. In total, 54 SSIs were recorded (n = 34 TTE; n = 20 STE), with the majority of infections occurring within the first 30 post-operative days (TTE 65%, STE 70%). There was no statistically significant difference in overall post-operative infection rates between TTE and STE groups when broken down into the following time points: <30 day, 30-60 days, and >90 days (p = 0.924). There was no statistically significant difference between infection type (superficial vs. deep, p = 0.932), infection management (medical, surgical, or both, p = 0.409) or salvage results (p = 0.078) seen in STE versus TTE cohort. On multivariate analysis, seroma history was associated with SSI development (OR 3.18, p = 0.041). CONCLUSION: There was no significant difference in the rate of post-operative SSI following breast reconstruction with STE relative to TTE.

Air versus Saline: The Effect of Tissue Expander Fill on Outcomes of Prepectoral Breast Reconstruction.

BACKGROUND: Traditionally, saline is used for intraoperative/postoperative expansion in two-stage alloplastic breast reconstruction. Recently, intraoperative expansion with air has been proposed, to reduce pressure on the mastectomy skin flap in the immediate postoperative setting. The authors examined whether the intraoperative tissue expansion medium (i.e., air versus saline) affected postmastectomy complications in two-stage prepectoral reconstruction. METHODS: This was a retrospective cohort study of 87 patients (144 breasts) undergoing prepectoral breast reconstruction at the authors' institution. Patient data were abstracted from medical records. Stepwise, multivariable-adjusted logistic regression using robust variances was used to identify predictors of postmastectomy complications. Statistical and power analyses were completed. RESULTS: Of the 87 study patients, 29 (33.3 percent) received intraoperative saline fill and 58 (66.7 percent) received air fill. Demographic/clinical data were well-matched between cohorts. Median follow-up was 165 days, and average patient age was 46.7 years. Initial tissue expander fill volumes were similar between study cohorts ( p = 0.2). The crude association between air versus saline fill on overall complication rates suggested that air-filled tissue expanders may be protective (OR = 0.4; p = 0.03), and the suggested protective effect was maintained with borderline significance even after potential confounders (i.e., American Society of Anesthesiologists class III or higher, body mass index, diabetes, mastectomy specimen weight, smoking status) were added to the model (OR = 0.4; p = 0.05). In addition, fewer complications requiring salvage reoperation were observed with air-filled tissue expanders (adjusted OR = 0.3; p = 0.02). CONCLUSIONS: The medium used for immediate intraoperative tissue expansion impacted postmastectomy outcomes in patients undergoing two-stage prepectoral breast reconstruction. The results demonstrated that air-filled tissue expanders were associated with fewer postoperative complications/salvage reoperations relative to saline-filled tissue expanders. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

The Price of Publishing: An Investigation of the Open Access Landscape in Plastic Surgery.

BACKGROUND: Open access publishing in plastic surgery has rapidly gained traction in the past decade. This study investigated the digital landscape of plastic surgery open access publishing. METHODS: This was a cross-sectional bibliometric investigation of plastic surgery-focused journals. Three publication models were investigated: subscription-only journals, hybrid journals offering both paywalled and open access publishing, and open access-only journals. RESULTS: Eighty-two journals were investigated. In 2010, open access journals comprised 18 percent of all plastic surgery journals online, subscription journals comprised 79 percent, and hybrid journals comprised 3 percent. Conversely, in 2020, open access journals comprised 55 percent of all journals, hybrid journals comprised 45 percent, and there were no subscription-only journals. Multivariable linear regression adjusting for article type/content demonstrated that open access articles from hybrid journals [beta coefficient, 1.3; F(4, 18) = 790; p = 0.05] and high-quality open access journals [beta coefficient, 0.9; F(4, 19) = 738; p = 0.04] were significantly positively associated with number of full-text views. Although impact factor and article processing charges were positively correlated [Pearson correlation coefficient: r(25) = 0.39, p = 0.04] for open access publishing, some high-quality open access journals were found to offer fee waivers/free publishing. Lastly, level of evidence offered by articles from open access versus hybrid journals differed. CONCLUSIONS: Overall, this study highlighted important distinctions between trustworthy and predatory journals offering open access publishing in plastic surgery. Open access publishing in trustworthy sources offers greater visibility and is not necessarily cost-prohibitive, but some open access journals can be limited in scope (i.e., less coverage of subspecialty topics) and quality of content. Study findings were used to generate recommendations for navigating open access publishing in plastic surgery.

Combining Breast and Ovarian Operations Increases Complications.

BACKGROUND: Breast cancer resulting from a genetic mutations, such as BRCA1 or BRCA2, is seen in 5 to 10 percent of patients. More widespread genetic testing has increased the number of affected women undergoing prophylactic mastectomy and oophorectomy. Recent studies have yielded mixed results regarding complication rates after combined breast and ovarian operations. The authors compared surgical outcomes of breast operations performed in combination with salpingo-oophorectomies or as separate procedures. METHODS: The authors retrospectively analyzed surgical complications and length of hospital stay in 145 female patients, from which 87 had undergone combined breast surgery and salpingo-oophorectomy, and 58 had undergone these procedures separately. Multivariate logistic regression models were used to calculate odds ratios and 95 percent confidence intervals. RESULTS: Patients undergoing combined breast and ovarian operations experienced higher rates of overall complications (46.5 percent versus 19 percent; p < 0.001), infections (22.2 percent versus 8.6 percent; p < 0.05), and delayed wound healing (13.2 percent versus 0 percent; p < 0.05) related to the breast surgery, when compared with patients undergoing separate procedures. Multivariate logistic regression analysis confirmed a significant association between combined surgery and overall postoperative complications (OR, 5.87; 95 percent CI, 2.03 to 16.91; p = 0.02). Patients undergoing tissue expander-based breast reconstruction combined with ovarian surgery had significantly longer hospital stays compared to patients undergoing separate procedures (3.5 days versus 1.8 days; p < 0.001). CONCLUSIONS: The authors' data indicate that combining breast and ovarian operations is associated with a higher risk of postoperative complications related to the breast procedure and increases the duration of hospital stay in patients with tissue expander-based reconstructions. The authors' study provides valuable information for preoperative counseling of patients considering both breast and ovarian surgery. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Reinforced Biologic Mesh Reduces Postoperative Complications Compared to Biologic Mesh after Ventral Hernia Repair.

BACKGROUND: The use of biologic mesh to reinforce the abdominal wall in ventral hernia repair has been proposed as a viable alternative to synthetic mesh, particularly for high-risk patients and in contaminated settings. However, a comparison of clinical outcomes between the currently available biologic mesh types has yet to be performed. METHODS: We performed a retrospective analysis of 141 patients who had undergone ventral hernia repair with biologic mesh, including noncross-linked porcine ADM (NC-PADM) (n = 51), cross-linked porcine ADM (C-PADM) (n = 17), reinforced biologic ovine rumen (RBOR) (n = 36), and bovine ADM (BADM) (n = 37) at the Stanford University Medical Center between 2002 and 2020. Postoperative donor site complications and rates of hernia recurrence were compared between patients with different biologic mesh types. RESULTS: Abdominal complications occurred in 47.1% of patients with NC-PADM, 52.9% of patients with C-PADM, 16.7% of patients with RBOR, and 43.2% of patients with BADM (P = 0.015). Relative risk for overall complications was higher in patients who had received NC-PADM (RR = 2.64, P = 0.0182), C-PADM (RR = 3.19, P = 0.0127), and BADM (RR = 2.11, P = 0.0773) compared with those who had received RBOR. Furthermore, relative risk for hernia recurrence was also higher in all other mesh types compared with RBOR. CONCLUSION: Our data indicate that RBOR decreases abdominal complications and recurrence rates after ventral hernia repair compared with NC-PADM, C-PADM, and BADM.

The Plane of Mesh Placement Does Not Impact Abdominal Donor Site Complications in Microsurgical Breast Reconstruction.

BACKGROUND: Reinforcement of the abdominal wall with synthetic mesh in autologous breast reconstruction using abdominal free tissue transfer decreases the risk of bulging and herniation. However, the impact of the plane of mesh placement on donor site complications has not yet been investigated. METHODS: We performed a retrospective analysis of 312 patients who had undergone autologous breast reconstruction with muscle-sparing transverse rectus abdominis myocutaneous (MS-TRAM) flaps or deep inferior epigastric perforator (DIEP) flaps as well as polypropylene mesh implantation at the donor site. Donor site complications were compared among patients with different flap types and different mesh positions including overlay (n = 90), inlay and overlay (I-O; n = 134), and sublay (n = 88). RESULTS: Abdominal hernias occurred in 2.86% of patients who had undergone MS-TRAM reconstructions and in 2.63% of patients who had undergone DIEP reconstructions. When comparing patients with different mesh positions, donor site complications occurred in 14.4% of patients with overlay mesh, 13.4% of patients with I-O mesh, and 10.2% of patients with sublay mesh (P = 0.68). Abdominal hernias occurred in 4.44% of patients with overlay mesh, 2.24% of patients with I-O mesh, and 2.27% of patients with sublay mesh (P = 0.69). Multivariable logistic regression analysis did not identify a significant association between mesh position and hernia rates as well as wound complications. CONCLUSIONS: Our data indicate that the plane of synthetic mesh placement in relation to the rectus abdominis muscle does not impact the rate of postoperative donor site complications in patients undergoing breast reconstruction with MS-TRAM or DIEP flaps.

Examining the Effects of Postmastectomy Radiation Therapy in Prepectoral Versus Subpectoral Autologous Breast Reconstruction.

BACKGROUND: Postmastectomy radiation therapy (PMRT) is known to increase the risk of multiple adverse outcomes after breast reconstruction. In the context of delayed-immediate autologous breast reconstruction, PMRT is typically conducted after placement of subpectoral (SP) tissue expanders. With the re-emergence of prepectoral (PP) reconstruction, there are little data assessing the outcomes of PP reconstruction in breasts receiving PMRT. We compared postoperative outcomes of PMRT patients undergoing delayed-immediate, autologous breast reconstruction with placement of tissue expanders in either the PP or SP plane. METHODS: A retrospective chart review was conducted on all consecutive patients who underwent delayed-immediate autologous breast reconstruction and received PMRT at either the Stanford University or the Johns Hopkins University Hospitals between January 2009 and December 2018. Demographics, comorbidities, perioperative information, and oncologic data were collected for all patients. Complications were collected and analyzed after stage 1 surgery, between 30 days of stage 1 and up to stage 2 surgery, and after stage 2 surgery. Multivariable regressions were used to determine predictors of 1 or more complications. RESULTS: A total of 71 patients (73 breasts) were included. Prepectoral reconstruction comprised of 52.2% of the cohort, and the remaining 47.8% were SP reconstructions. Demographics and comorbidities were similar between groups, except for premastectomy radiation, which was more prevalent in the PP cohort (P = 0.010). Complications were similar between cohorts after stage 1 surgery (P = 0.420), between stages 1 and 2 (P = 0.100), and after stage 2 (P = 0.570). There were higher rates of skin necrosis in the SP cohort between stages 1 and 2 (PP: 2.6%, SP: 20%, P = 0.004). Multivariable analysis revealed body mass index to be the only predictor of complication (P = 0.041). The mean number of revisionary surgeries was higher in the SP cohort (PP: 0.8 vs SP: 1.9, P = 0.002). The mean follow-up was 385.5 days and similar between groups (P = 0.870). CONCLUSIONS: Rates of overall complication were similar between PP and SP expander placement. However, in SP reconstructions, skin necrosis was significantly higher between stages 1 and 2. The patients in the SP cohort also underwent a greater number of revisionary surgeries, although overall rates of pursuing any revisionary surgery were similar between groups.

Comparing Outcomes of Flap-Based Salvage Reconstructions in the Radiated Breast.

INTRODUCTION: Chest wall irradiation significantly decreases the strength and quality of breast tissue supporting prostheses, increasing the risk of skin breakdown and implant or tissue expander extrusion. Autologous tissue, including the latissimus dorsi (LD) or abdominal-based flaps, including the muscle-sparing transverse rectus abdominis myocutaneous or deep inferior epigastric perforator flaps, may be used to salvage reconstructions. However, data comparing outcomes of the two flap options remains limited. We compare postoperative outcomes from both flap types after autologous salvage reconstruction in irradiated breasts. METHODS: Charts were retrospectively reviewed from patients who underwent either chest wall radiation or postmastectomy radiation therapy followed by salvage autologous reconstruction with either a LD and an implant or an abdominal-based flap (muscle-sparing transverse rectus abdominis myocutaneous or deep inferior epigastric perforator flaps). Patients with a history of tissue expander or implant failure requiring autologous salvage as part of 2-staged or delayed-immediate breast reconstruction that were operated on between January 2005 and November 2015 were included. Basic demographics, comorbidities, and recipient site complications (infection, wound dehiscence, seroma, hematoma, fat necrosis, and flap failure) were collected. RESULTS: A total of 72 patients met the inclusion criteria which included 72 flaps; 35 LD and 37 abdominally based flaps. Demographics and comorbidities did not vary significantly between patient groups. Mean follow-up was 767.6 weeks, and all reconstructions were unilateral. Nineteen (26.4%) patients had at least one complication, most commonly minor infections (9.7%). Overall complication rates were not significantly different between flap groups (P = 0.083). Wound dehiscence was significantly higher in the abdominal group (P = 0.045), and fat necrosis also trended higher in this group (P = 0.085). Major infection trended higher in the latissimus group (P = 0.069). CONCLUSIONS: When comparing outcomes of salvage flap-based reconstruction in radiated breast tissue, overall complication rates were similar when comparing postoperative outcomes between the LD- and abdominal-based flaps. Wound dehiscence was significantly higher when salvage reconstruction used an abdominal flap. Understanding the complications after salvage procedures can help inform decision making and optimize patient care to improve outcomes after breast reconstruction in the radiated breast.

Revision Rates in Prepectoral Versus Subpectoral Delayed-Immediate Autologous Breast Reconstruction.

INTRODUCTION: Breast reconstruction in the prepectoral plane has recently fallen into favor. Minimizing the number of revisionary procedures after reconstruction is an important factor in improving patient care, but long-term studies on the effects of prepectoral reconstruction are limited. In this study, we compare the revision rates after delayed-immediate, autologous reconstruction between prepectoral and subpectoral reconstructions. METHODS: Postoperative charts for all patients undergoing subpectoral or prepectoral delayed-immediate autologous breast reconstruction were retrospectively reviewed at our single tertiary-care institution between 2009 and 2018. Patient demographics, comorbidities, and oncologic history were recorded. Charts after second stage reconstruction were reviewed for up to eighteen months to determine if revisions were necessary. Data collected included the total number of surgeries performed, the average number of procedures performed during each surgery, and the type of revision that was performed. Statistical tests included the chi squared test, unpaired t-test, and logistic regressions. RESULTS: Data from 89 patients with 125 breast reconstructions were collected. There was a 41.6% of these that were prepectoral reconstructions (P), and 58.4% were subpectoral reconstructions (S). For both groups, nipple sparing, followed by skin sparing mastectomies were most common. Mastectomy rates were not statistically different. Fewer breasts in the prepectoral cohort required any revisions (P, 21.2% vs S, 47.9%; P = 0.002). The subpectoral cohort had higher rates of soft tissue rearrangement (P, 7.7% vs S, 21.9%, P = 0.032), fat grafting (P, 9.6% vs S, 27.4%; P = 0.014), and nipple reconstruction (P: 5.8% vs 20.5%, P = 0.020). Mean follow-up time was not significantly different between patient groups (P, 290.5 days vs S, 375.0 days, P = 0.142). Subpectoral expander placement was found to be the only variable independently predictive of requiring 1 or more revision (P = 0.034). CONCLUSIONS: Breast reconstruction performed in the prepectoral plane is associated with lower overall rates of revisionary surgery. Rates of soft tissue rearrangement, fat grafting, and nipple reconstruction after autologous reconstruction trended higher in subpectoral reconstructions.

Representation of Women on Plastic Surgery Journal Editorial Boards in the United States.

BACKGROUND: During the past decade, a growing number of women have pursued medical careers, including in plastic surgery. However, female physicians have tended to be underrepresented in a variety of leadership roles in their respective specialties. OBJECTIVES: The authors sought to evaluate the representation of female plastic surgeons on the editorial boards of high-impact plastic surgery journals. METHODS: The gender of editorial board members on 3 high-impact plastic surgery journals was evaluated from 2009 and 2018. The number of women on each editorial board was then compared with the number of board-certified female plastic surgeons (BCFPS) and board-certified female academic plastic surgeons (BCFAPS), a subgroup of BCFPS. RESULTS: There were 555 unique editorial board members from Plastic and Reconstructive Surgery, Aesthetic Surgery Journal, and Annals of Plastic Surgery from 2009 to 2018. During that period, 72 editors (13.0%) were women. At the beginning of the study, there were significantly fewer female editors than expected based on proportionate representation of BCFPS and BCFAPS to all board-certified plastic surgeons (P = 0.007 and 0.007, respectively). During the study, there was a 177% increase in women holding editorial board positions. At study end, women were adequately represented on all 3 editorial boards compared with their population data (BCFPS and BCFAPS). CONCLUSIONS: During the 10 years of this study (2009-2018), editorial boards have overcome the underrepresentation of women on, and female plastic surgeons are currently adequately represented on the top 3 high-impact journal editorial boards.

Development of a Classification Tree to Predict Implant-Based Reconstruction Failure with or without Postmastectomy Radiation Therapy for Breast Cancer.

PURPOSE: The aim of this study was to determine the complications, incidence, and predictors of implant-based reconstruction failure (RF) among patients treated with mastectomy for breast cancer. METHODS: We retrospectively reviewed 108 patients who underwent mastectomy, tissue expander, and implant-based breast reconstruction with or without radiation therapy (RT) at our institution (2000-2014). Descriptive statistics determined complication incidences, with major complications defined as any complications requiring surgical intervention or inpatient management. Chi square and Fisher's exact tests determined differences in RF incidences, defined as implant loss. Logistic regression analyses identified predictors of RF. RESULTS: Median follow-up was 42.5 months. Sixty patients (55.6%) experienced major complications. Overall, 27 patients (25%) experienced RF. Incidences of RF were significantly increased in patients who had any major complication (43.3% vs. 2.1%; p < 0.0001), especially infection (61.3% vs. 10.4%; p < 0.0001), delayed wound healing (83.3% vs. 21.7%; p = 0.004), and implant exposure (80.0% vs. 19.4%; p = 0.0002). Receiving RT, but not timing of RT, significantly predicted RF [odds ratio (OR) 4.00, 95% confidence interval (CI) 1.11-14.47; p = 0.03]. On multivariable analysis, infection (OR 7.69, 95% CI 2.12-27.89; p = 0.002) and delayed wound healing (OR 17.86, 95% CI 1.59-200.48; p = 0.02) independently predicted for RF. Our newly developed classification tree, which includes stepwise assessment of major infection, delayed wound healing, implant exposure, age ≥ 50 years, and total number of lymph nodes removed ≥ 10, accurately predicted 74% of RF events and 75% of non-RF events. CONCLUSIONS: Infection or delayed wound healing requiring surgical intervention or hospitalization and receipt of RT, but not radiation timing, were significant predictors of RF. Our classification tree demonstrated > 70% accuracy for stepwise prediction of RF.