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.

Human Factors Approach to Assess Physician Workload in Elective Plastic Surgery Breast Procedures.

Background: Human factors research involves the study of work system interactions, physician workload, cognitive effort, and performance. This pilot study incorporated a human factor approach and other surgery-based metrics to assess cognitive workload among plastic surgeons during elective plastic surgery breast procedures. Methods: In this prospective study of plastic surgery breast procedures over a 3-month period, surgeon and patient demographics and procedural details were collected. The lead surgeon assessed each procedure using a validated workload questionnaire (National Aeronautics and Space Administration Task Load Index [NASA-TLX]) that included 6 subscales (ie, mental, physical, temporal demand, performance, effort, and frustration), a question on distraction, and their expectation of procedural difficulty. Results: Fifty-seven cases were included in this study. Surgical duration had a positive correlation with increased mental demand (P < .001), physical demand (P < .001), and degree of distractions (P < .001). Free flap reconstruction, breast reduction, and transgender mastectomy had the highest average mental, physical demands, and perceived effort. Bilateral cases had significantly higher workload than unilateral ones (P = .002). NASA-TLX scores between immediate and delayed reconstructions were comparable, but delayed cases had higher degree of distractions (P = .04). There was a strong correlation between degree of distractions and increased mental workload (R = 0.68; P < .001), increased physical demand (P = 0.61; P < .001), and increased temporal demand (R = 0.78; P < .001). More difficult procedures were associated with greater procedural duration than those rated as difficult as expected or less difficult than expected (P = .02). Conclusions: These preliminary data demonstrated multiple factors that may influence and govern perceived physician workload and may provide insight for targeted quality improvement to plan procedures safely and effectively.

Patient Experience and Clinical Outcomes after Same-day Outpatient Mastectomy and Immediate Breast Reconstruction Protocol during the Global Pandemic.

The coronavirus disease 2019 (COVID-19) pandemic provoked rapid changes in clinical practice to accommodate mandated restrictions within healthcare delivery. This study reviewed patient-reported experiences and clinical outcomes after implementation of a same-day discharge protocol after mastectomy with immediate alloplastic breast reconstruction compared with our historical overnight stay protocol. Methods: This is a retrospective single-institution study of consecutive patients who underwent mastectomy and immediate alloplastic reconstruction between July 2019 and November 2020. A postoperative survey was completed by patients to evaluate satisfaction with perioperative communications, recovery, and their overall experience. Results: A total of 302 patients (100% women) underwent mastectomy and immediate alloplastic reconstruction (174 pre-COVID-19, 128 during COVID-19). During COVID-19, 71% of patients were scheduled for a same-day discharge, among which 89% were successfully discharged the same day. Compared with pre-COVID-19, there were no differences in type of surgery, operative times, pain scores, 30-day readmission, or unplanned visits (all P > 0.05) during the COVID-19 pandemic. Compared with pre-COVID-19, patients during the pandemic reported comparable satisfaction with their care experience and postoperative recovery (56% survey response rate). Patient satisfaction was also similar between those discharged the same day (n = 81) versus the next day (n = 47) during COVID-19. Conclusions: Same-day discharge is feasible, safe, and can provide similar patient-reported satisfaction and outcomes compared with traditional overnight stay. These data highlight the ability to deliver adaptable, high-quality breast cancer care, within the constraints of a global pandemic.

Outcomes of Standardized Protocols in Supercharged Pedicled Jejunal Esophageal Reconstruction.

BACKGROUND: This study evaluated clinical and patient-reported outcomes (PROs) of long-segment supercharged pedicled jejunal (SPJ) interposition after implementation of a dedicated multidisciplinary pathway and technical refinements. METHODS: This study was a 6-year review of consecutive patients who underwent complex esophageal reconstruction with SPJ interposition. Clinical data were abstracted, and PRO data were collected prospectively by using the Upper Digestive Disease mobile application (UDD App). This standardized questionnaire comprised domains for mental and physical health, pain, dysphagia, reflux, hypoglycemia dumping, and gastrointestinal dumping symptoms. Operative refinements were comprehensively established by 2018. RESULTS: A total of 19 patients were included in the study, 15 of whom had a history of esophageal malignant disease and neoadjuvant chemoradiation. Most patients (18; 95%) underwent delayed reconstruction after diversion. There was no 90-day mortality or flap loss. Most patients (18; 95%) achieved an enteral diet. Seven patients (37%) experienced early complications (<90 days) requiring procedural intervention. The incidence of any medical or surgical complication was similar in the earlier (2015-2017) and late (2018-2020) cohorts, but aspiration events, surgical site infections, anastomotic leak rates, and median hospital stay (reduced from 15 days [IQR, 10-21 days] to 9 days [IQR, 9-13 days]) improved in the contemporary cohort. PRO data were collected in 14 of 15 (93%) living patients. Severe symptoms in at least 1 domain were reported by most patients (11; 79%) and improved over time. CONCLUSIONS: Dedicated care pathways allow standardization of complex procedures, and targeted modifications may optimize recovery and patient outcomes. This cohort of patients may report severe symptoms that require ongoing monitoring and intervention.

Breast reconstruction after mastectomy in patients with obesity: a narrative review.

Background and Objective: Breast reconstruction in patients with obesity presents numerous challenges, both in terms of surgical technique and post-operative complication management. As breast reconstruction techniques continue to evolve, the armamentarium of reconstructive options for patients with obesity has vastly expanded. Options now include immediate or delayed, implant-based, autologous, or hybrid reconstruction. Determining the optimal breast reconstruction in this complex population requires nuanced and experienced decision-making. Methods: A literature search was conducted to identify studies assessing breast reconstruction considerations in patients with obesity. The search was performed on PubMed and was limited to English language studies published between 1990 and 2023. Primary studies, case reports, chart reviews, and qualitative studies were included. Additional articles were identified for inclusion based on a review of references, as well as a web-based search, to identify additional studies that were not captured with the primary search strategy. Key Content and Findings: This narrative review article summarizes the current literature available to guide surgeons in breast reconstruction in patients with obesity. Conclusions: The advancements in oncologic surgery and breast reconstruction techniques have expanded available surgical options, including immediate or delayed implant-based, autologous, or hybrid breast reconstruction. Each approach has its unique advantages, disadvantages, and surgical considerations. Despite the challenges, patients with obesity can achieve favorable aesthetic outcomes through careful assessment of comorbidities and expectation management.

Supercharged Jejunal Interposition.

Complex esophageal reconstruction represents a high risk and challenging procedure. A dedicated pathway with multispecialty teams can facilitate a systematic checklist approach to perioperative management and evaluation of long-term outcomes. Refinements in the operative technique for supercharged pedicled jejunum (SPJ) for long segment interposition in esophageal reconstruction are reviewed in this article. Medical and surgical complications among this complex niche group of patients are significant and require care in specialist centers with a focused team. Patient-reported outcomes (PROs) in long-segment SPJ interposition are recognized to provide additional monitoring of surgical outcomes and may help guide interventions for subsequent symptom control.

Microsurgical skills training course and impact on trainee confidence and workload.

INTRODUCTION: Our objective was to measure the impact of a basic microsurgery training course on trainees' confidence and workload in performing microsurgery. METHODS: A prospective study of participants in an accredited 5-day microsurgery course over a 3-month period. The confidence and workload of the participants were assessed after the first and final day. The workload was assessed using the validated NASA Task Load Index composed of 6 subscales scored on a 20-point visual analog scale (VAS). Confidence was assessed over 5 dimensions on a 5-point VAS for anastomosis performance, vessels preparation, knot tying, training effectiveness, and future practice of microsurgery. RESULTS: A total of 31 participants completed the study with 55% reporting some previous microsurgery experience. All confidence dimensions improved significantly after completing the course, regardless of prior experience (p<0.01). Those with prior experience started and finished the course at higher confidence levels in anastomosis performance and vessel preparation than the non-experienced group (p<0.05). Overall workload showed a downward trend (improvement) at the end of the course, but no significant changes in the experienced and non-experienced groups (p>0.05). Most participants scored above the 50% "sustainability threshold" for mental demand, both before (71%) and after the course (73%), however, perceived physical demand significantly reduced, p = 0.01. CONCLUSION: The microsurgery course teaches fundamental skills and principles; therefore, it has merit in those who will utilize these skills in their future practice. Although there is increased confidence in skill acquisition, the impact on perceived workload during a short 5-day basic microsurgery course did not significantly change.

Diversity Matters: A 21-Year Review of Trends in Resident Recruitment into Surgical Specialties.

Background: Diversity within the healthcare workforce is essential to improve quality of care, although evaluation of diversity within surgical training remains limited. This study analyzed diversity in recruitment of residents into surgical subspecialties at a large academic medical institution and national trends. Methods: A 21-year cross-sectional study of medical school graduates accepted into all surgical subspecialty training programs was performed. The institutional cohort was divided into two groups (1997-2006, 2007-2017). Subspecialty acceptance rates were determined between 2011 and 2018. Data on candidate demographics including gender, race, ethnicity, citizenship, and origin of medical education at a single institution and nationally were extracted. Results: Two thousand found hundred seventy-two residents were included in this study. From 1997 to 2018, female acceptances increased from 21.1% to 29.7% (p < 0.01), non-White increased from 27.9% to 31.8% (p = 0.01), and international medical graduates decreased from 28.8% to 25.5% (p = 0.02). There was no significant change in accepted Hispanic and Non-US candidates. Female subspecialty rates for subspecialties increased nationally and was comparable to our cohort, except in general surgery. Hispanic subspecialty acceptance rates were less than 10% and Black/African American acceptance rates remained less than 5% across subspecialties nationally and at our institution. Conclusion: Diversity in surgical training has modestly progressed over the last two decades, but the degree of positive change has not been universal and highlights the critical need for improvement and action. Continued institution driven and collaborative strategies are essential to promote diversity in recruitment across all surgical specialties that has implications on our future workforce and surgical leadership.

A Cadaveric Anatomical and Histological Study of Recipient Intercostal Nerve Selection for Sensory Reinnervation in Autologous Breast Reconstruction.

BACKGROUND: Autologous breast reconstruction (ABR) has grown in popularity due to improved aesthetic and long-term patient reported outcomes, but data regarding sensory reinnervation of autologous flaps remain limited. Traditionally, the lateral cutaneous branch of the fourth intercostal nerve has been used for flap neurotization, but the use of the anterior cutaneous branch of the intercostal nerves (ACB) offer a more optimal location to the microsurgical field when using internal mammary vessels for the microanastomosis. This study aimed to evaluate the optimum ACB recipient site level for sensory nerve coaptation in ABR. METHODS: Twelve hemi-chests were dissected from six fresh cadaveric females. Costal cartilages were removed and the anterior cutaneous intercostal nerve (ACB) and the lateral (subcutaneous) division of the anterior cutaneous branch (LACB) of the intercostal nerve were exposed. Anatomical measurements were recorded, and nerve samples were evaluated histologically with carbonic anhydrase staining to differentiate sensory fascicles. Assessment of fascicular diameter, axonal counts, and fascicular area were compared. RESULTS: A total of 75 nerve specimens were assessed. The ACB was identified at all levels (100%) and the subcutaneous LACB was noted consistently in the second to fourth rib space (96% cadavers), with a median length of 43, 37.5, and 37 mm, respectively. Across all rib spaces, the fascicular and axonal counts were comparable between the LACB and ACB. Nerves in the second intercostal space had a significantly larger mean fascicular area mean (112,816 ± 157,120 µm2) compared with that in the fourth (mean 26,474 ± 38,626 µm2), p = 0.03. Axonal count of sensory fascicles was the highest in the second intercostal nerves (p < 0.05). CONCLUSION: This study provides anatomical and histological basis to determine the optimum recipient site choice for sensory coaptation in microsurgical breast reconstruction. This would aid in operative decision-making regarding the ideal recipient anterior cutaneous intercostal nerve branches for recipient site coaptation in ABR.

Preconditioning with Foam-mediated External Suction on Flap Microvasculature and Perfusion in a Rodent Model.

Foam-mediated external suction (FMES) has previously shown to improve tissue microcirculation. We hypothesized that preconditioning fasciocutaneous perforator flaps with FMES would augment perfusion and demonstrate greater capillary recruitment. METHODS: Gluteal perforator flaps were designed on sixteen 400 g rats. Continuous FMES at -125 mm Hg was applied on one side (intervention) to precondition tissue for 5 days, with the contralateral side as a paired control. In group A, we assessed changes following pretreatment, after surgery, and 7 days postprocedure, and in group B, we evaluated changes during preconditioning alone. In group A (N = 8), control and intervention flaps were assessed using laser-assisted indocyanine green fluorescence angiography. In group B, flap regions were assessed using 4-dimensional computed tomographic angiography. All flaps were analyzed for microvessel density using micro-computed tomography and histological assessment using hematoxylin and eosin and CD3 immunohistochemistry. RESULTS: Thirty-two flaps were included in this study (N = 16 intervention and matched controls). Four-dimensional computed tomographic angiography demonstrated 17% greater tissue perfusion in preconditioned flaps (mean, 78.7 HU; SD, 8.8) versus controls (mean, 67.3 HU; SD, 15.7; P < 0.01). Laser-assisted indocyanine green fluorescence angiography showed a 30% higher mean absolute intensity in preconditioned flaps versus controls (P < 0.01). Postsurgery mean absolute intensity in preconditioned flaps remained 21% higher than in controls (P = 0.03). Preconditioned flaps demonstrated a 2-fold increase in mean vessel volume of 9.1 mm3 (SD, 7) versus 4.5 mm3 (SD, 3) in controls (P = 0.04); there was a 33% higher mean area fraction of CD31 in preconditioned flaps, 3.9% (SD, 3) versus 2.9% (SD, 3) in controls (P = 0.03). CONCLUSION: FMES preconditioning has the potential to augment vascularity of tissue for flap harvest; however, further experimental studies are required to optimize strategies and evaluate long-term effects for clinical applications.

Autologous Breast Reconstruction in Low Body Mass Index Patients: Strategies for Maximizing Skin Envelope and Breast Volume.

Pure autologous breast reconstruction in thin patients creates challenges. This review highlights techniques to optimize the scarce donor tissue available, approaches to reconstruction, and microsurgical techniques. A systematic approach to maximize breast volume and the skin envelope in patients who underwent pure autologous breast reconstruction by a single senior surgeon is presented with a clinical case series. Included in the study were 125 patients (217) with autologous breast reconstructions. Although DIEP flaps were the commonest flap used overall (79%), within in the low body mass index (<22) group, there was a greater use of Latissimus (32%), and thigh-based flaps (>50%).

Recent Advances in Microsurgery: An Update in the Past 4 Years.

Microsurgery has broad applications in reconstructive surgery. As techniques, diagnostics, and advancing technology rapidly evolve, reconstructive microsurgeons can adapt to address new challenges and push the frontiers to achieve optimal functional and aesthetic reconstruction, and minimize donor site morbidity. This article briefly outlines some of the recent advances and innovations in microsurgery within the last 5 years in perforator flaps, breast, lymphedema surgery, extremity reconstruction, targeted muscle reinnervation, head and neck reconstruction, composite tissue allotransplantation, and robotic surgery.

Risk Factors for Lymphedema after Thigh Sarcoma Resection and Reconstruction.

Secondary lymphedema can be a lifelong and debilitating consequence of lower extremity oncologic resection and reconstruction. The goal of this study was to identify risk factors for the development of lymphedema in patients treated for thigh sarcoma. METHODS: A retrospective review analyzed all patients who underwent thigh sarcoma resection and reconstruction by a plastic surgeon at the Mayo Clinic between 1997 and 2014. Patient demographics, tumor characteristics, surgical management, adjunctive therapies, and complications of patients who did and did not develop postoperative lymphedema were compared. RESULTS: A total of 148 patients were identified. Twelve percent of patients developed lymphedema postoperatively during an average follow-up of 26 months. Risk factors for the development of lymphedema included defect location in the medial thigh (P = 0.04), arterial resection (P = 0.001), arterial reconstruction (P = 0.027), and a history of cardiac disease (P = 0.03). Twenty-two percent of patients who developed lymphedema also experienced wound dehiscence compared with 4.6% of patients without lymphedema (P = 0.02). There were no differences in age, body mass index, smoking, history of deep venous thrombosis or venous stasis, wound dimensions, or type of reconstruction performed in patients with and without lymphedema. CONCLUSIONS: Lymphedema is common following major oncologic resection. Preexisting cardiac disease, tumor location in the medial thigh, and arterial resection and reconstruction were associated with a higher risk of postoperative lymphedema. Noninfectious wound dehiscence may be secondary to lymphedema or represent an early indicator of patients who will ultimately develop lymphedema.

Plastic Surgery Lockdown Learning during Coronavirus Disease 2019: Are Adaptations in Education Here to Stay?

The novel coronavirus disease 2019 has had a major impact on human life and livelihood. The unprecedented challenges have expanded beyond just social and work life, and have grown to impact resident education. In this article, we review the structure of plastic surgery education before the pandemic, the different online learning opportunities for self-directed learning. A summary of the range of platforms and approaches of online remote access delivery of conferences and education that emerged or expanded as a result of the crisis has been reported. This article highlighted the rapid initiatives and efforts of programs and national and international societies to support continuing medical education in conjunction with the guidelines to "shelter at home" and maintain social distancing, and possible future for expanding the reach of online academic initiatives, in addition to the role of developing virtual technologies. The coronavirus disease 2019 crisis has created an opportunity to analyze and advance online learning options to overcome the associated challenges and continue as a reliable platform even following the resolution of the social distancing requirements.

Does surgical procedure type impact postoperative pain and recovery in deep inferior epigastric artery perforator flap breast reconstruction?

BACKGROUND: The deep inferior epigastric artery perforator (DIEP) flap is the commonest flap used for breast reconstruction after mastectomy. It is performed as a unilateral (based on one [unipedicled] or two [bipedicled] vascular pedicles) or bilateral procedure following unilateral or bilateral mastectomies. No previous studies have comprehensively analyzed analgesia requirements and hospital stay of these three forms of surgical reconstruction. METHODS: A 7-year retrospective cohort study (2008-2015) of a single-surgeon's DIEP-patients was conducted. Patient-reported pain scores, patient-controlled morphine requirements and recovery times were compared using non-parametric statistics and multivariable regression. RESULTS: The study included 135 participants: unilateral unipedicled (n=84), unilateral bipedicled (n=24) and bilateral unipedicled (n=27). Univariate comparison of the three DIEP types showed a significant difference in 12-hour postoperative morphine requirements (P=0.020); bipedicled unilateral patients used significantly less morphine than unipedicled (unilateral) patients at 12 (P=0.005), 24 (P=0.020), and 48 (P=0.046) hours. Multivariable regression comparing these two groups revealed that both reconstruction type and smoking status were significant predictors for 12-hour postoperative morphine usage (P=0.038 and P=0.049, respectively), but only smoking, remained significant at 24 (P=0.010) and 48 (P=0.010) hours. Bilateral reconstruction patients' mean hospital stay was 2 days longer than either unilateral reconstruction (P<0.001). CONCLUSIONS: Although all three forms of DIEP flap breast reconstruction had similar postoperative pain measures, a novel finding of our study was that bipedicled DIEP flap harvest might be associated with lower early postoperative morphine requirements. Bilateral and bipedicled procedures in appropriate patients might therefore be undertaken without significantly increased pain/morbidity compared to unilateral unipedicled reconstructions.

Robotic-Assisted DIEP Flap Harvest for Autologous Breast Reconstruction: A Comparative Feasibility Study on a Cadaveric Model.

BACKGROUND: The deep inferior epigastric perforator (DIEP) flap is the most common perforator flap for microsurgical breast reconstruction. Contrary to the conventional open approach, robotic-assisted DIEP flap harvest intends to preserve ARS integrity, thereby reducing the morbidity. We assessed the feasibility and compared performance outcomes of a robotic, cadaveric training model for DIEP flap harvest using two approaches: transabdominal preperitoneal (TAPP) and totally extraperitoneal (TEP). METHODS: A robotics system (da Vinci Xi) was applied in conjunction with a cadaveric training model. Ports were placed in the abdominal wall to triangulate each DIEP flap. Surgical time and technical characteristics were recorded. Values were analyzed and compared. RESULTS: Eight female cadavers (16 hemi-DIEP flaps) were dissected: 50% TAPP and 50% TEP approaches. Mean harvest time was 56 minutes (range: 48-74 minutes) and 65 minutes (range: 60-83 minutes) for TAPP versus TEP groups, respectively (p < 0.05). Mean pedicle dissection time was 36 minutes (range: 25-40 minutes) and 39 minutes (range: 30-42 minutes) for TAPP versus TEP groups, respectively (p > 0.05). Intra-abdominal contents were manipulated twice on average in the TAPP group versus 0 times in the TEP group (p < 0.05). One TAPP case had an injury to the bowel, and one TEP case was converted to conventional open due to pneumoperitoneum. CONCLUSION: Robotic-assisted DIEP flap harvest represents a technological enhancement for advanced regenerative plastic surgery. Our model demonstrated both TAPP and TEP are feasible, with TEP less invasive, preserving the posterior rectus sheath, and decreasing complication risks. However, there is a steeper and longer learning curve for TEP.

Complications after thigh sarcoma resection.

BACKGROUND AND OBJECTIVES: Standard treatment for extremity sarcoma is limb-sparing surgery often with radiation, but complications occur frequently. We sought to determine factors predictive of wound complications after thigh sarcoma resection and reconstruction while analyzing trends over time. METHODS: We reviewed all thigh defects requiring plastic surgeon reconstruction following sarcoma resection at our institution from 1997 to 2014. Patient demographics, comorbidities, operative characteristics, multi-modality therapies, and complications were analyzed. Wound complications were: infection, dehiscence, seroma, hematoma, or partial/total flap loss. RESULTS: There were 159 thigh reconstructions followed for 30 months on average. Eighty-seven percent of patients underwent radiation and 42% had chemotherapy. Almost half (49.1%) had a complication. The most common wound complication was surgical site infection (23.3%) followed by dehiscence (19.5%), and seroma (10.7%). Less common were partial (2.5%) or total flap loss (0.6%). Reoperation was required in 21 patients (13.2%). Tobacco use, older patient age, cardiac disease, and higher body mass index were independently associated with wound complications. Complications trended towards decreasing over time, but this was not statistically significant. CONCLUSIONS: Tobacco use, cardiac disease, and higher body mass index, but not the timing of reconstruction, appear to increase the risk of wound complications after thigh soft tissue sarcomas resection and plastic surgery reconstruction.