Assessment of Microsurgery Simulation Course Access in Plastic Surgery Training Programs.

BACKGROUND: Microsurgery requires complex skill development with a steep learning curve for plastic surgery trainees. Flap dissection courses and simulation exercises are useful to acquire these skills. This study aims to assess plastic surgery training programs' access to and interest in microsurgical courses. METHODS: A survey was distributed to plastic surgery residency and microsurgery fellowship program directors (PDs). The survey collected program demographics and attendance of trainees at structured microsurgical skills or flap dissection courses. We assessed if PDs thought trainees would benefit from instructional courses. RESULTS: There were 44 residency PD responses (44/105, 41.9%, 36 integrated, 8 independent), and 16 fellowship PD responses (16/42, 38.1%). For residency PDs, 54.5% (24/44) sent residents to flap courses, and 95% (19/20) of remaining PDs felt residents would benefit from attending. In addition, 59.1% of programs (26/44) sent residents to microsurgical skills courses, and 83.3% (15/18) of remaining PDs felt residents would benefit from attending. When examining fellowship PDs, 31.2% of programs (5/16) sent fellows to flap dissection courses and 10/11 of remaining PDs felt fellows would benefit from attending a course (90.1%). Half of programs (8/16) sent fellows to microsurgical skills courses, and 7/8 remaining PDs felt fellows would benefit from attending (87.5%). CONCLUSION: Only half of the plastic surgery trainees have access to microsurgical skills and flap dissection courses. The majority of residency and fellowship PDs feel that training courses are valuable. Expanding access to these courses could provide a significant benefit to microsurgical education in plastic surgery training.

Autologous Breast Reconstruction Success Rates in Hypercoagulable Patients.

BACKGROUND: Hypercoagulable disorders may adversely affect microsurgical outcomes, including increased flap failure and complication rates. Outcomes specific to autologous breast reconstruction are not well described. METHODS: A retrospective review was performed of autologous breast reconstructions between 2009 and 2020. Patients with either a thrombophilic disorder (TD) diagnosis or a previous thrombotic event (TE) were identified. The analysis compared perioperative complications and flap success rates. RESULTS: In this series, 23 patients with a TD underwent 39 flaps, and 78 patients who had experienced a TE underwent 126 flaps, compared with 815 control patients, who underwent 1300 flaps. In logistic regression models, a TD diagnosis was an independent predictor of early total flap loss [OR, 8.42 (95% CI, 1.59 to 44.47); P = 0.01], late partial flap loss [OR, 3.9 (95% CI, 1.0 to 15.22); P = 0.05], and delayed healing [OR, 2.26 (95% CI, 1.02 to 5.04); P = 0.04]. TE history trended toward an association only with late partial flap loss ( P = 0.057). Flap salvage rates (25%) and flap success rates (92.3%) were statistically lower in patients with a TD but normal in patients who had experienced a TE. CONCLUSIONS: Microsurgical breast reconstruction is a reasonable option for patients with hypercoagulation disorders. No increased risk of flap complications was associated with a previous TE; however, TDs carried increased risk. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

An Updated Systematic Review and Meta-Analysis of Tissue Oximetry Versus Conventional Methods for Postoperative Monitoring of Autologous Breast Reconstruction.

BACKGROUND: Tissue oximetry monitoring has shown superior outcomes to conventional monitoring methods for autologous breast reconstruction in retrospective studies with consecutive cohorts. A recent study used consecutive cohorts with tissue oximetry as the earlier cohort and found that tissue oximetry was nonsuperior. We hypothesize that improvement in microsurgical outcomes with institutional experience confounds the superiority of tissue oximetry demonstrated in prior studies. This study aimed to perform a systematic review and meta-analysis of the outcomes of tissue oximetry monitoring compared with conventional monitoring. METHODS: Relevant studies were found using PubMed, Embase, and Web of Science searches for keywords such as near-infrared spectroscopy or tissue oximetry and microsurgery. Studies included compared tissue oximetry and conventional monitoring in autologous breast reconstruction patients. Studies were excluded if they did not contain a comparison group. Random-effective models were used to analyze early returns to the operating room, the total number of partial or complete flap loss, and late fat necrosis. RESULTS: Six hundred sixty-nine studies were identified; 3 retrospective cohort studies met the inclusion criteria. A total of 1644 flaps were in the tissue oximetry cohort, and 1387 flaps were in the control cohort. One study contained tissue oximetry as the former cohort; 2 had tissue oximetry as the latter. Neither technique was superior for any measured outcomes. The estimated mean differences between tissue oximetry and conventional monitoring method were early returns, -0.06 (95% confidence interval [CI], -0.52 to 0.410; P = 0.82); partial flap loss, -0.04 (95% CI, -0.86 to 0.79; P = 0.93); complete flap loss, -1.29 (95% CI, -3.45 to 0.87; P = 0.24); and late fat necrosis -0.02 (95% CI, -0.42 to, 0.39; P = 0.94). CONCLUSIONS: In a systematic review and meta-analysis of mixed timeline retrospective cohort studies, tissue oximetry does not provide superior patient outcomes and shifts our current understanding of postoperative breast reconstruction monitoring. Prospective studies and randomized trials comparing monitoring methods need to be included in the existing literature.

Modern Innovations in Breast Surgery: Robotic Breast Surgery and Robotic Breast Reconstruction.

Robotic surgery has a history of applications in multiple surgical areas and has been applied in plastic surgery over the past decade. Robotic surgery allows for minimal access incisions and decreased donor site morbidity in breast extirpative surgery, breast reconstruction, and lymphedema surgery. Although a learning curve exists for the use of this technology, it can be safely applied with careful preoperative planning. Robotic nipple-sparing mastectomy may be combined with either robotic alloplastic or robotic autologous reconstruction in the appropriate patient.

Autologous Breast Reconstruction after Massive Weight Loss: Understanding Risks in a Growing Population.

BACKGROUND: Massive weight loss (MWL) may have suboptimal effects on tissues used for autologous reconstruction. With the rising rates of obesity and bariatric surgery, more patients who have experienced MWL will be presenting for breast reconstruction. The authors hypothesize that autologous breast reconstruction in patients with a history of MWL will have more complications and require more revisions compared with reconstruction in patients without a history of MWL. METHODS: A retrospective review was performed on patients who underwent autologous breast reconstruction by five microsurgeons at an academic institution from 2009 through 2020. Patients with a history of bariatric surgery or greater than 50-pound weight loss were identified and compared with patients who had not experienced MWL. Analysis compared demographics, operative details, complications, revision rates, and BREAST-Q scores. RESULTS: Of 916 patients who underwent 1465 flaps, 39 patients with MWL (4.3%) underwent 68 flaps (4.6%), and 877 patients without MWL underwent 1397 flaps. MWL patients were more likely to require blood transfusions postoperatively ( P = 0.005); experienced more surgical-site infections ( P = 0.02), wound-healing complications of flap ( P = 0.007) and donor sites ( P = 0.03), and late partial flap losses ( P = 0.03); and required more revisional surgery for flap ( P = 0.009) and donor sites ( P = 0.01). BREAST-Q scores were not statistically different for satisfaction with breasts or surgeon but were lower in MWL patients for psychosocial ( P = 0.01) and sexual well-being ( P = 0.04). CONCLUSIONS: Reconstructive surgeons should expect increased postoperative complications when performing autologous breast reconstruction in patients who have experienced MWL. These patients should be counseled on the possibility of an increased risk of postoperative complications and need for revisional surgery. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Preoperative Examination Is Not Associated with Postoperative Function following Radial Forearm Free Flap Harvest.

BACKGROUND: There is debate on the utility of a preoperative Allen test or ultrasound before radial forearm free flap (RFFF) harvest. This study sought to evaluate correlations between preoperative testing and donor-site morbidity. METHODS: A survey of plastic surgery and otolaryngology RFFF patients was conducted at a Midwestern academic center. The modified Cold Intolerance Symptom Severity (modCISS) and Quick Disabilities of the Arm, Shoulder, and Hand (QDASH) instruments were administered. A retrospective chart review was performed to assess perioperative factors. RESULTS: Of 212 RFFFs completed over 7 years, 144 patients were contacted, and 71 patients completed the survey (33% response rate). Preoperative Allen test was negative in 92% of patients (65 of 71). There was no statistical association between Allen test and duplex ultrasound findings ( P = 0.19). Cold intolerance screening was positive on 20% of donor arms (14 of 71), with an average positive modCISS score of 39.0 ± 14.7. Disability was reported on the QDASH by 76% of patients (54 of 71), with an average score of 21.0 ± 22.3. There was no statistical correlation between preoperative Allen test or ultrasound classification and modCISS or QDASH score. There was a borderline positive correlation between modCISS and QDASH scores that did not reach statistical significance ( r = 0.22, P = 0.067). Operative characteristics also did not predict modCISS or QDASH scores. CONCLUSIONS: Following RFFF harvest, donor extremity cold intolerance is reported in 20% of patients, and extremity-related disability is reported in the majority of patients. Preoperative ultrasound and physical examination findings are not predictive of morbidity.

A Paradigm Shift: Outcomes of Early Autologous Breast Reconstruction after Radiation Therapy.

BACKGROUND: Radiation creates significant challenges for breast reconstruction. There is no consensus regarding optimal timing for autologous reconstruction following radiation. This study explores clearly defined, shorter time intervals between completion of radiation and reconstruction than previously reported. METHODS: A retrospective review was performed on patients who underwent autologous reconstruction by five microsurgeons at an academic institution from 2009 to 2020. Cohorts were selected by time elapsed between radiation and autologous reconstruction including <3 months, 3 to 6 months, 6 to 9 months, 9 to 12 months, 12 to 24 months, and >24 months. Analysis compared baseline characteristics, operative details, complications, revision rates, and BREAST-Q scores. Analysis of variance was used for continuous variables and chi-square for discrete variables. RESULTS: In total, 462 radiated patients underwent 717 flaps. There were 69 patients at <3 months (14.9%), 97 at 3 to 6 months (21%), 64 at 6 to 9 months (13.9%), 36 at 9 to 12 months (7.8%), 73 at 12 to 24 months (15.8%), and 123 at >24 months (26.6%). Age, time from mastectomy, and failure of primary reconstruction were higher at >24 months (p < 0.001). There was no difference between cohorts in intraoperative complications in radiated or nonradiated breasts. There was no difference in acute and late postoperative complications between cohorts. Wound-healing complications in radiated sides were lowest at <3 months and 3 to 6 months (5/69 [7.3%] and 11/97 [11.3%], respectively) compared with other groups (18.8-22.2%) but did not reach significance (p = 0.11). More fat graft revisions occurred at <3 months (p = 0.003). CONCLUSION: Reconstruction can be safely performed within 3 months after radiation without increases in intraoperative, acute, or late reconstructive complications.

Comparing tissue oximetry to doppler monitoring in 1367 consecutive breast free flaps.

BACKGROUND: Retrospective studies evaluating tissue oximetry in a more recent cohort have shown superiority in flap outcomes. This study compares the use of tissue oximetry in a historical cohort to clinical observation and handheld doppler in a more recent cohort. We hypothesize that there is no benefit to using tissue oximetry. METHODS: A retrospective review was performed on patients who underwent abdominal-based autologous breast reconstruction by five microsurgeons at an academic institution from 2009 to 2020. Method of postoperative flap monitoring was determined then operative details and complications were analyzed. RESULTS: 1367 flaps were reviewed; 740 flaps in 460 patients were monitored with clinical observation and tissue oximetry, and 627 flaps in 391 patients were monitored with clinical observation and handheld doppler. There were no statistical differences in ischemic (p = .59) or congestive complications (p = .41), flap salvage rates when exploring for venous or arterial compromise (p = .52), or early flap loss (p = .56). Although not significant, acute flap-related return to the operating room was lower in the doppler group (4.6%) compared to the oximetry group (6.1%; p = .22). Flaps monitored with tissue oximetry had a statistical increase in length of stay (4.8 ± 1.4 days vs. 3.8 ± 1.6 days; p ≤ .001). The rates of late partial flap loss and fat necrosis were significantly higher in the oximetry group (2.6%, 19/740 vs. 0.3%, 2/740; p = .04) and (18.2%, 135/740 vs. 13.6%, 85/627; p = .02), respectively. CONCLUSIONS: There is no statistical benefit to the use of tissue oximetry compared to handheld doppler in flap monitoring with regards to flap outcomes.

Characterizing Outcomes of Medial and Lateral Perforators in Deep Inferior Epigastric Perforator Flaps.

BACKGROUND: Perforators are typically found in rows in the deep inferior epigastric perforator (DIEP) flap. As methods to assess flap perfusion continue to improve, surgeons may be more likely to select perforators traditionally avoided. The purpose of this article is to describe clinical outcomes based on row and number of perforators to reevaluate flap and abdominal donor site morbidity. METHODS: A retrospective analysis was performed on patients who underwent breast reconstruction with DIEP flaps by four microsurgeons from 2013 to 2020. The row and number of perforators were determined from operative reports. Chi-square and t-test or nonparametric Fisher's exact test and Wilcoxon two-sample test were used for discrete and continuous variable, respectively, as applicable. Logistic regression was used for multivariable analyses. RESULTS: Of 628 flaps, 305 were medial row (58.7%), 159 were lateral row (30.6%), and 55 had both rows (10.6%). Partial flap loss was higher in both rows (p = 0.003). Fat necrosis was higher with medial (p = 0.03) and both rows (p = 0.01) when compared with lateral using multivariable analysis. Hernia or bulge was higher in lateral row flaps (lateral: 8/157, 5.1%; medial, 5/299, 1.7%; both, 0/55; p = 0.05); however, mesh was more commonly used in both row flaps (p = 0.05). There was no difference in fat necrosis or abdominal morbidity between single and multiple perforators. CONCLUSION: There was no difference in fat necrosis based on the number or row of perforators. The lateral row provides adequate perfusion but may be associated with an elevated risk of hernia or bulge. Patients may benefit from mesh, especially when both rows are dissected.

Quantifying Complications: An Analysis of Operative Time and Intraoperative Factors in Microsurgical Breast Reconstruction.

BACKGROUND: Analysis of operative flow has been shown to improve efficiency in breast microsurgery. Both complex decision-making skills and technical mastery are required to overcome intraoperative challenges encountered during microsurgical reconstruction. Effects of intraoperative complications on operative time have not yet been reported. METHODS: A retrospective chart review of microsurgical breast reconstructions by three surgeons between 2013-2020 analyzed operative variables and duration. Intraoperative complications were determined from the operative report. Correlations between continuous variables were determined using Spearman correlation coefficients. Nonparametric testing was used when comparing operative duration between groups. RESULTS: Operative duration was analyzed for 547 autologous breast reconstruction cases; 210 reconstructions were unilateral and 337 were bilateral. Average operative duration was 471.2 SD 132.2 minutes overall (360.1 SD 100.5 minutes for unilateral cases and 530.5 SD 110.5 minutes for bilateral cases). Operative duration decreased with surgeon experience (r = -0.17, p< .001).Regarding intraoperative complications, difficult donor dissection was correlated with an average operative duration increase of 91.7 minutes (n = 43, 7.9%, p< .001), pedicle injury with an additional 67.7 minutes (n = 19, 3.5%, p = .02) and difficult recipient vessel dissection with an increase of 63.0 minutes (n = 35, 6.4%, p = .003). Complications with anastomosis also showed a statistically significant increase in operative duration, with arterial complications resulting in an increase of 104.3 minutes (n = 41, 7.5%, p< .001) and venous complications resulting in an increase in 78.8 minutes (n = 32, 5.8%, p< .001). Intraoperative thrombus resulted in an increase of 125.5 minutes (n = 20, 3.7%, p< .001), and requiring alternative venous outflow added an average of 193.7 minutes (n = 8, 1.5%, p< .001). CONCLUSION: Intraoperative complications in autologous breast reconstruction significantly increase operative time. The greatest increase in operative time is seen with intraoperative thrombosis or requiring alternative venous outflow. As these complications are rarely encountered in breast microsurgery, opportunities for simulation and case-based practice exist to improve efficiency.

Closed-Incision Negative Pressure Therapy Prevents Major Abdominal Donor-Site Complications in Autologous Breast Reconstruction.

BACKGROUND: Outcomes in autologous breast reconstruction continue to improve with refinements in microsurgical techniques; however, donor-site morbidity remains a concern. Closed-incision negative pressure therapy (ciNPT) has been shown to reduce wound complications. Limited evaluation in abdominal donor sites has shown promising results. We hypothesize that ciNPT will reduce abdominal donor-site complications. METHODS: A retrospective chart review was performed of patients who underwent abdominally based autologous free tissue transfer for breast reconstruction by 4 microsurgeons at an academic institution from 2015 to 2020. The application of a commercial ciNPT for donor-site management was at the discretion of the operating surgeon. Demographics, operative details, and management of donor-site complications were analyzed. RESULTS: Four hundred thirty-three patients underwent autologous breast reconstruction; 212 abdominal donor sites were managed with ciNPT and 219 with standard dressings. Demographics were statistically similar between groups. Abdominal wound healing complications were noted in 30.2% of ciNPT patients (64/212) and 22.8% of control patients (50/219, P = 0.08); however, overall wound complications were attributed to obesity on multivariable analysis. Closed-incision negative pressure therapy significantly decreased complications requiring reoperation (ciNPT 6.2%, 4/64; control 26.5%, 13/51; P = 0.004). There were no significant differences in surgical site infection rates (P = 0.73) and rates of abdominal scar revisions (ciNPT 11.8%, 25/212; control 9.1%, 20/219; P = 0.37). CONCLUSIONS: Use of ciNPT in abdominal donor-site management significantly decreases the incidence of delayed wound healing requiring surgical intervention, with one major wound healing complication prevented for every 6 donor sites managed with ciNPT.

Evaluating the Importance of Sub-Internships on the 2022 Integrated Plastic Surgery Match During Continued COVID-19 Regulations.

OBJECTIVE: Following the 2021 integrated plastic surgery match, we found a significant increase in home match rates and decrease in match rate for students without a home plastic surgery program with the elimination of visiting sub-internships and the initiation of virtual interviewing. With the return of visiting sub-internships in the 2022 match cycle, we hypothesize that these rates will approach values more consistent with historical controls. DESIGN: Program match data was obtained from posts to residency program Instagram pages and posts associated with the hashtag #PRSMatch2022. Data on visiting sub-internship matches was obtained from a publicly available Google Sheet with applicant contributors. The Chi square test was used to assess for differences. SETTING: Medical schools and plastic surgery programs were categorized into west, midwest, south, and northeast regions. PARTICIPANTS: Matched applicants to integrated plastic surgery residency programs. RESULTS: In total, 192 of 194 (99%) of applicants matched to integrated plastic surgery residency positions were identified. The match rate for applicants without an affiliated plastic surgery program (31.3%) increased from 2021 (p = 0.03) and returned to a level consistent with historical controls (p = 0.38). Similarly, the home program match rate (15.1%) and match rate for applicants from Top 40 medical schools (34.2%) decreased from 2021, returning to pre-pandemic levels (p = 0.63, p = 0.12). Finally, regional match preferences remained generally consistent with historical controls, apart from a higher proportion of northeast applicants matching to programs in the northeast (72.5%, p = 0.04), and a lower proportion of west applicants matching to programs in the west (26.3%, p = 0.002). CONCLUSIONS: The 2022 integrated plastic surgery match cycle saw a reversal of many of the changes to match rates seen in the 2021 cycle. These changes may be due to the reintroduction of visiting sub-internships following updates in COVID-19 policies.

A Systematic Review of Breast Reconstruction Options After Mastectomy in Massive Weight Loss Patients.

ABSTRACT: Given global trends in obesity and bariatric surgeries, there are an increasing number of women presenting for breast reconstruction after massive weight loss. There is a paucity of literature about breast reconstruction after mastectomy in patients with a history of massive weight loss. A literature review revealed 10 articles that discussed outcomes of different reconstruction techniques in patients with massive weight loss. Autologous reconstruction techniques and implant-based reconstruction techniques were assessed to evaluate the advantages, disadvantages, and indications of each approach specific to this unique patient population. This article provides a summary of expected outcomes, including complication profiles. Ultimately, consideration should be given for breast reconstruction of mastectomy defects in patients with a history of massive weight loss, as satisfactory results are demonstrated to be possible. Both autologous reconstruction and implant-based reconstruction present feasible options, although reconstruction in this patient population may be associated with increased need for revisions and a higher complication rate compared with patients without a history of massive weight loss. For this reason, it is imperative to appropriately manage preoperative expectations in patients with a history of massive weight loss.

Effect of COVID-19 Restrictions on 2021 Integrated Plastic Surgery Match Outcomes.

OBJECTIVE: Due to the Coronavirus Disease 2019 Pandemic (COVID-19), guidelines regarding both elimination of visiting subinternships and substitution of virtual interviews for the 2021 match were adopted. We hypothesize that these changes will result in an increase in home institution match rates compared to previous years. DESIGN: Program match data was obtained using information posted to residency program Instagram pages and the hashtag #PRSMatch2021. Chi square was used to assess differences between groups. SETTING: Medical school regions were categorized as West, Midwest, South, and Northeast and compared to match program region. PARTICIPANTS: Matched candidates to integrated plastic surgery residencies RESULTS: A total of 181/187 (96.8%) integrated plastic surgery matched candidates were identified. Compared to historical controls, there was a statistically significant increase in the home match rate (24.3%, p = 0.004) and statistically significant decrease in match rate for students without a home plastic surgery program (21.0%, p = 0.004). Similar to prior years, applicants were more likely to match in their own region for all regions (p < 0.001); however, there was a statistical increase in students staying in the South region for residency compared to previous years (p = 0.007). CONCLUSIONS: The 2021 match cycle resulted in an increase in home program match rates, while decreasing match rates among students without a home plastic surgery program. COVID-19 polices may have resulted in disadvantages to students from diverse institutional backgrounds. Influences of virtual subinternships and virtual interviews should be further evaluated.

Evaluation of Liposomal Bupivacaine at Split-Thickness Skin Graft Donor Sites Through a Randomized, Controlled Trial.

Split-thickness skin grafts (STSG) are commonly required in reconstructive surgery but may cause significant pain. The goal of this investigator-initiated trial is to evaluate the effect of liposomal bupivacaine on donor site pain and opioid consumption. A parallel, randomized, controlled trial of adult acute burn patients with <20% TBSA burns was conducted to evaluate the efficacy of liposomal bupivacaine at STSG donor sites. The control group received standard subcutaneous infiltration of dilute lidocaine solution at the STSG donor site, and the experimental group received dilute liposomal bupivacaine infiltration in a similar fashion. Donor site pain scores and opioid consumption in morphine equivalents (MEE) were evaluated. A total of 25 patients were enrolled in each group. There were no statistical differences in demographic variables, and TBSA was 4.0% in both groups (P = .94). There were no statistical differences in pain scores at any time point postoperatively (mean control range 3.1/10-4.9/10, experimental range 3.3/10-4.3/10, P = .12-.96). There were no statistical differences in opioid consumption at 24, 48, or 72 h postoperatively between the groups (mean control MEE range 49.3-71.1, experimental MEE range 63.6-75.8, P = .34-.85). The average length of stay was 7.7 days in both groups (P = .88). No adverse events occurred in either group. There is no statistical benefit to the use of liposomal bupivacaine for infiltration at STSG donor sites compared to standard of care with respect to pain control, opioid use, or length of stay when evaluated in a randomized, controlled fashion.

Patient Satisfaction Increases with Nipple Reconstruction following Autologous Breast Reconstruction.

BACKGROUND: Nipple reconstruction has been linked to patient satisfaction; however, there is debate about the validity of these findings in autologous breast reconstruction patients. This study hypothesized that satisfaction would increase with nipple reconstruction following autologous breast reconstruction. METHODS: A comparison study was performed of autologous breast reconstruction patients. Patients completed a survey that included BREAST-Q and nipple satisfaction measures. A chart review identified reconstructive details. RESULTS: A total of 191 patients completed the survey (48 percent response rate), with an average age of 53.7 ± 10.0 years and follow-up time of 2.8 ± 1.5 years. Nipple-areola complex reconstruction was completed in 33 percent of patients (63 of 191). Nipple-areola complex tattoos were used most frequently [n = 37 (58 percent)], followed by local flaps [n = 10 (16 percent)], free nipple-areola complex grafts [n = 9 (14 percent)], and a combination of local flaps and tattoos [n = 7 (11 percent)]. In comparison to women who did not undergo nipple-areola complex reconstruction, women who underwent any type of nipple reconstruction had a statistically higher BREAST-Q score for Sexual Well-Being (60 ± 24 versus 50 ± 22; p = 0.01), Postoperative Satisfaction with Breasts (65 ± 11 versus 61 ± 12; p = 0.01), and Satisfaction with Surgeon (97 ± 6 versus 93 ± 16; p = 0.009). The average nipple satisfaction score was 74 ± 19. There were correlations between the nipple satisfaction score and BREAST-Q scores for Sexual Well-Being (r = 0.50; p < 0.001), Psychosocial Well-Being (r = 0.43; p < 0.001), and Postoperative Satisfaction with Breasts (r = 0.43; p < 0.001). CONCLUSION: Reconstruction of the nipple-areola complex is an important part of autologous breast reconstruction, resulting in increased sexual well-being and satisfaction with reconstructed breasts.

Variant Plantaris Anatomy During Tendon Harvest.

The plantaris tendon is commonly used in upper extremity reconstruction as a tendon graft. Variations in plantaris anatomy are described as terminating proximally into the calcaneal tendon or gastrocnemius in certain cases, making the tendon an unusable length as a graft. A case of anomalous attachment of the gastrocnemius muscle to the plantaris tendon is described. After division of this attachment through a counterincision, complete harvest of the plantaris tendon was possible. Further exploration when resistance is encountered in standard plantaris tendon harvest is recommended to avoid unnecessary abandonment of a plantaris harvest.

A Comparative Analysis of Outcomes of Free Nipple Areolar Grafting in Autologous Breast Reconstruction.

BACKGROUND: Preserving the nipple areolar complex (NAC) increases satisfaction in breast reconstruction. This study aims to describe outcomes using free NAC grafts in microvascular breast reconstruction. METHODS: A case-control study evaluated prospective outcomes of microvascular breast reconstruction with free NAC grafts compared with matched controls with tattoo or local flap nipple reconstruction. Eligible patients for NAC grafting required correction of ptosis or nipple malposition. Postoperative photographs were rated for complications and aesthetics by the four study authors and two additional unbiased board-certified plastic surgeons. Satisfaction was measured with the BREAST-Q. RESULTS: Twenty patients who underwent 35 autologous breast reconstructions were analyzed. Nipple areolar reconstruction with grafts was completed with 13 NACs in 7 patients. The majority of free NAC grafts (11/13, 85%) were completed in immediate reconstruction, and 15% (2/13) were completed in delayed reconstruction. Partial graft hypopigmentation (mean 18.0%, standard deviation [SD] 7.5) was noted in all grafts. Less than half of grafts had areas of depigmentation (6/13, mean 6.1%, SD 7.5). Minor areas of partial loss occurred in 6/13 grafts (mean 2.9%, SD 4.6). Nipple projection was maintained in 54% of nipples (7/13). Depigmentation, hypopigmentation, graft loss, and projection were not statistically correlated with NAC aesthetic or overall aesthetic rating. However, NAC size (p = 0.003), position (p = 0.022), and symmetry (p = 0.028) were all correlated with aesthetic outcomes. Outcomes and satisfaction were similar to those seen with local flap reconstruction, although partial loss was less common in NAC grafts. CONCLUSION: Nipple reconstruction can successfully be performed in microvascular breast reconstruction using free grafts. Although partial graft hypopigmentation is common, smaller areas of graft loss or depigmentation are anticipated and do not affect aesthetic outcomes. The use of free NAC grafts may allow additional patients to use their own nipples as part of their microvascular reconstruction and avoid secondary NAC reconstruction procedures.

Predictors of Opioid Consumption in Immediate, Implant-Based Breast Reconstruction.

BACKGROUND: Current rates of opioid prescribing have deleterious consequences on both patient and societal levels. This study aims to evaluate responsible opioid prescribing and predictors of opioid consumption in immediate implant-based breast reconstruction. METHODS: Patients undergoing consultation for immediate, implant-based breast reconstruction were enrolled in a prospective, cohort survey study. A survey was administered at the preoperative and postoperative appointment to collect data on pain expectations and opioid use. A medical record review was performed. RESULTS: Of 100 enrolled patients, 97 (97.0 percent) underwent surgery and 85 (85.0 percent) completed the postoperative survey. Preoperatively, 27 patients (27.0 percent) had a history of a chronic pain syndrome, 34 (34.0 percent) had a history of a mental health comorbidity, and nine (9.0 percent) had a history of active preoperative opioid use. A total of 85 tissue expander (87.6 percent) and 12 direct-to-implant (12.4 percent) reconstructions were completed. Patients were prescribed an average of 36.0 5-mg oxycodone tablets postoperatively. Patients reported consuming an average of 20.6 tablets, or 57.0 percent of the average prescription amount. The majority of patients (75.3 percent) reported taking an opioid less than once per day at the time of survey completion, and 24 patients (28.2 percent) reported that they did not use any opioids postoperatively. Preoperative opioid use (p = 0.004), inpatient opioid consumption (p < 0.0001), and patient-reported anxiety related to pain control (p < 0.05) were predictors of opioid consumption. CONCLUSIONS: Patients undergoing mastectomy and implant-based breast reconstruction are prescribed nearly twice as many opioid tablets as consumed, and one in three patients report not using any opioids postoperatively. Clinical factors may help guide prescribing practices. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.