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1.
Ann Surg Oncol ; 2021 Feb 24.
Artículo en Inglés | MEDLINE | ID: mdl-33629252

RESUMEN

BACKGROUND: Although ketorolac is an effective adjunct for managing pain in the perioperative period, it is associated with a risk of postoperative bleeding. This study retrospectively investigated the association between ketorolac use and both reoperation and postoperative opioid use among mastectomy patients. METHODS: The study identified all women undergoing mastectomy (unilaterally or bilaterally) at our ambulatory surgery cancer center from January 2016 to June 2019. The primary outcome was reoperation for bleeding on postoperative day 0 or 1, and the secondary outcome was postoperative opioid use. The association between ketorolac and outcomes was assessed using multivariable regression models. The covariates were age, body mass index, breast reconstruction, bilateral surgery, peripheral nerve block, and preoperative antiplatelet and/or anticoagulation medication. RESULTS: A cohort of 3469 women were identified. Ketorolac was given to 1549 (45%) of the women, with 922 women (60%) receiving 30 mg and 627 women (40%) receiving 15 mg. The overall reoperation rate for bleeding was 3.1% (1.8% without ketorolac vs 4.8% with ketorolac). In the multivariable analysis, ketorolac was associated with a higher risk of reoperation [odds ratio (OR) 2.43; 95% confidence interval (CI) 1.60-3.70; P < 0.0001]. Ketorolac also was associated with a lower proportion of patients receiving any postoperative narcotic within 24 h (15 mg: OR 0.73; 95% CI 0.57-0.94; P = 0.014 vs 30 mg: OR 0.52; 95% CI 0.42-0.66; P < 0.0001). CONCLUSIONS: Ketorolac use decreased postoperative opioid use, but this benefit was outweighed by the increased risk of bleeding requiring reoperation. This finding led to a change in practice at the authors' center, with ketorolac no longer administered in the perioperative care of the mastectomy patient.

2.
Artículo en Inglés | MEDLINE | ID: mdl-33151192

RESUMEN

Oral cancer treatment involving the maxilla and/or mandible often results in esthetic and functional deficits that can diminish the patient's quality of life. As a result, expeditious reconstruction of the defect and dental rehabilitation is desirable. Dental rehabilitation shortly after reconstruction with an osteocutaneous free flap and resection prosthesis is a persistent challenge for patients with oncologic defects where immediate dental rehabilitation is not a possibility. Additionally, conventional prosthesis fabrication techniques are impractical or impossible due to postoperative anatomical changes and limitations in clinical armamentarium. To address these limitations, a technique and a novel implant-supported prosthetic workflow for the oncologic patient were developed to provide interim dental rehabilitation for such clinical situations. This article describes the prosthesis fabrication technique, reports short-term outcomes, and evaluates patient-reported quality-of-life outcomes using the FACE-Q Head and Neck Cancer Module.


Asunto(s)
Implantes Dentales , Colgajos Tisulares Libres , Reconstrucción Mandibular , Implantación Dental Endoósea , Prótesis Dental de Soporte Implantado , Peroné/cirugía , Humanos , Calidad de Vida
3.
Plast Reconstr Surg ; 146(5): 964-975, 2020 11.
Artículo en Inglés | MEDLINE | ID: mdl-33141527

RESUMEN

BACKGROUND: Despite the rise in rates of contralateral prophylactic mastectomy, few studies have used patient-reported outcomes to assess satisfaction between unilateral and bilateral breast reconstruction with autologous tissue. The purpose of this study was to investigate patient satisfaction and quality of life following autologous reconstruction to determine whether differences exist between unilateral and bilateral reconstructions to better guide clinical decision-making. METHODS: The current study examined prospectively collected BREAST-Q results following abdominal free flap breast reconstruction procedures performed at a tertiary academic medical center from 2009 to 2017. The reconstruction module of the BREAST-Q was used to assess outcomes between laterality groups (unilateral versus bilateral) at 1 year, 2 years, 3 years, and more than 3 years. RESULTS: Overall, 405 patients who underwent autologous breast reconstruction completed the BREAST-Q. Cross-sectional analysis at 1 year, 2 years, and 3 years revealed similar satisfaction scores between groups; however, bilateral reconstruction patients demonstrated higher satisfaction scores at more than 3 years (p = 0.04). Bilateral reconstruction patients reported lower scores of abdominal well-being at 1 year, 2 years, and more than 3 years (p = 0.01, p = 0.03, and p = 0.01, respectively). CONCLUSIONS: These results suggest that satisfaction with breasts does not differ with the laterality of the autologous reconstruction up to 3 years postoperatively but may diverge thereafter. Bilateral reconstruction patients, however, have lower satisfaction with the abdominal donor site. These data can be used in preoperative counseling, informed consent, and expectations management in patients considering contralateral prophylactic mastectomy.

4.
Plast Reconstr Surg ; 146(6): 768e-776e, 2020 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-33234971

RESUMEN

BACKGROUND: Despite reports demonstrating feasibility of immediate dental implant placement in mandibular reconstruction with free fibula flaps for benign disease, this practice is not routinely used in the oncologic setting. The authors aim to demonstrate the safety of immediate dental implant placement for oncologic mandible reconstruction. METHODS: In 2017, the authors' center began immediate dental implant placement in free fibula flaps for oncologic patients undergoing mandibulectomy reconstruction. Immediate dental implant placement patients were compared to a historical cohort also reconstructed with computer-aided design and manufacturing technology beginning in 2011 (n = 34) as a noninferiority study design. Primary outcomes of interest included 90-day complications, time to radiotherapy, and time to and number of patients achieving dental restoration. RESULTS: Sixty-one patients underwent free fibula flaps following mandibulectomy using computer-aided design and manufacturing. Seventy-two dental implants were placed in the immediate dental implant placement cohort (n = 27). No differences were noted in major or minor 90-day complications between groups (p > 0.05). Radiotherapy was required in 55 percent in the immediate dental implant placement cohort versus 62 percent in the historical cohort, with no significant difference in time to radiotherapy (67.6 days versus 62.2 days, respectively). One dental implant was removed for nonosseointegration noted during vestibuloplasty. Fourteen (51.8 percent) immediate dental implant patients had complete dental restoration at 90 days compared with none in the historical cohort (p < 0.05). CONCLUSIONS: Immediate dental implant placement is a safe procedure with an unchanged short-term complication profile and no delay in radiotherapy initiation. Patients undergoing immediate dental implant placement are more likely to complete full dental rehabilitation. Long-term and health-related quality-of-life outcomes remain to be determined. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

5.
Ann Surg ; 2020 Jul 16.
Artículo en Inglés | MEDLINE | ID: mdl-32694446

RESUMEN

OBJECTIVE: This study sought to estimate the incidence and incidence rate of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) at a high-volume single institution, which enables vigorous long-term follow-up and implant tracking for more accurate estimates. SUMMARY BACKGROUND DATA: The reported incidence of BIA-ALCL is highly variable, ranging from 1 in 355 to 1 in 30,000 patients, demonstrating a need for more accurate estimates. METHODS: All patients who underwent implant-based breast reconstruction from 1991 to 2017 were retrospectively identified. The incidence and incidence rate of BIA-ALCL were estimated per patient and per implant. A time-to-event analysis was performed using the Kaplan-Meier estimator and life table. RESULTS: During the 26-year study period, 9373 patients underwent reconstruction with 16,065 implants, of which 9589 (59.7%) were textured. Eleven patients were diagnosed with BIA-ALCL, all of whom had a history of textured implants. The overall incidence of BIA-ALCL was 1.79 per 1000 patients (1 in 559) with textured implants and 1.15 per 1000 textured implants (1 in 871), with a median time to diagnosis of 10.3 years (range, 6.4-15.5 yrs). Time-to-event analysis demonstrated a BIA-ALCL cumulative incidence of 0 at up to 6 years, increasing to 4.4 per 1000 patients at 10 to 12 years and 9.4 per 1000 patients at 14 to 16 years, although a sensitivity analysis showed loss to follow-up may have skewed these estimates. CONCLUSIONS: BIA-ALCL incidence and incidence rates may be higher than previous epidemiological estimates, with incidence increasing over time, particularly in patients exposed to textured implants for longer than 10 years.

7.
Plast Reconstr Surg ; 146(3): 637-648, 2020 09.
Artículo en Inglés | MEDLINE | ID: mdl-32459736

RESUMEN

BACKGROUND: Maxillofacial reconstruction with vascularized bone restores facial contour and provides structural support and a foundation for dental rehabilitation. Routine implant placement in such cases, however, remains uncommon. This study aims to determine dental implant survival in patients undergoing vascularized maxillary or mandibular reconstruction through a systematic review of the literature. METHODS: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, the literature was queried for implant placement in reconstructed jaws using Medical Subject Headings terms on PubMed, Embase, and Cochrane platforms. Weighted implant survivals were calculated for the entire cohort and subcohorts stratified by radiotherapy. Meta-analyses were performed to estimate effect of radiation on implant osseointegration. RESULTS: Of 3965 publications identified, 42 were reviewed, including 1084 patients with 3636 dental implants. Weighted implant survival was 92.2 percent at a median follow-up of 36 months. Survival was 97.0 percent in 269 implants placed immediately in 60 patients versus 89.9 percent in 1897 delayed implants placed in 597 patients, with follow-up of 14 and 40 months, respectively. Dental implants without radiotherapy exposure had better survival than those exposed to radiation (95.3 versus 84.6 percent; p < 0.01) at a median follow-up of 36 months. Meta-analyses showed that radiation significantly increased the risk of implant failure (risk ratio, 4.74; p < 0.01) and suggested that implants placed before radiotherapy trended toward better survival (88.9 percent versus 83.4 percent, p = 0.07; risk ratio, 0.52; p = 0.14). CONCLUSIONS: Overall implant survival was 92.2 percent; however, radiotherapy adversely impacted outcomes. Implants placed before radiotherapy may demonstrate superior survival than implants placed after.


Asunto(s)
Trasplante Óseo/métodos , Implantación Dental Endoósea , Reconstrucción Mandibular/métodos , Oseointegración/fisiología , Colgajos Quirúrgicos/irrigación sanguínea , Humanos , Procedimientos Quirúrgicos Reconstructivos
8.
Ann Plast Surg ; 85(5): 516-521, 2020 11.
Artículo en Inglés | MEDLINE | ID: mdl-32032114

RESUMEN

INTRODUCTION: Traumatic intercalary defects of the tibia may be effectively managed with the free fibula flap. However, any alteration of limb alignment with residual bony angular deformity of the tibia must be also addressed. We describe the use of the free fibula flap in conjunction with external fixation to allow residual deformity correction and patient mobilization ambulation during healing of the free flap. METHODS: Retrospective medical record review was conducted of patients with segmental tibial defects greater than 7 cm who underwent reconstruction with fibula free flap and simple pin-bar external fixation, followed by conversion to 6-axis computer-assisted multiplanar circular ring external fixation to correct residual bony deformity. Outcomes analyses included free flap complications, return to the operating room, complications associated with the external fixation, bony union, correction of residual deformity, amputation rate, visual analog pain scales, and patient satisfaction. RESULTS: Eight patients (8 tibiae) underwent reconstruction. Mean tibial bone defect was 10.2 cm; all limbs had soft-tissue defects (mean size, 138 cm). Free fibula grafts were harvested as osteocutaneous or osteomyocutaneous flaps (average length, 12 cm). Complications included 1 delayed union and 3 (37.5%) patients readmitted for graft fracture. Ultimately, 100% of patients achieved graft union with satisfactory correction of residual limb deformity. Limb salvage rate was 100%. DISCUSSION: Management of segmental tibial bone loss utilizing initial simple external fixation and microsurgical reconstruction followed by application of computer-assisted circular external fixator may provide a reliable reconstructive protocol for posttraumatic tibial defects with residual bone malalignment.

9.
Plast Reconstr Surg ; 145(2): 333-339, 2020 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-31985616

RESUMEN

BACKGROUND: Rates of autologous breast reconstruction are stagnant compared with prosthetic techniques. Insufficient physician payment for microsurgical autologous breast reconstruction is one possible explanation. The payment difference between governmental and commercial payers creates a natural experiment to evaluate its impact on method of reconstruction. This study assessed the influence of physician payment differences for microsurgical autologous breast reconstruction and implants by insurance type on the likelihood of undergoing microsurgical reconstruction. METHODS: The Massachusetts All-Payer Claims Database was queried for women undergoing immediate autologous or implant breast reconstruction from 2010 to 2014. Univariate analyses compared demographic and clinical characteristics between different reconstructive approaches. Logistic regression explored the relative impact of insurance type and physician payments on breast reconstruction modality. RESULTS: Of the women in this study, 82.7 percent had commercial and 17.3 percent had governmental insurance. Implants were performed in 80 percent of women, whereas 20 percent underwent microsurgical autologous reconstruction. Women with Medicaid versus commercial insurance were less likely to undergo microsurgical reconstruction (16.4 percent versus 20.3 percent; p = 0.063). Commercial insurance, older age, and obesity independently increased the odds of microsurgical reconstruction (p < 0.01). When comparing median physician payments, governmental payers reimbursed 78 percent and 63 percent less than commercial payers for microsurgical reconstruction ($1831 versus $8435) and implants ($1249 versus $3359, respectively). Stratified analysis demonstrated that as physician payment increased, the likelihood of undergoing microsurgical reconstruction increased, independent of insurance type (p < 0.001). CONCLUSIONS: Women with governmental insurance had lower odds of undergoing microsurgical autologous breast reconstruction compared with commercial payers. Regardless of payer, greater reimbursement for microsurgical reconstruction increased the likelihood of microsurgical reconstruction. Current microsurgical autologous breast reconstruction reimbursements may not be commensurate with physician effort when compared to prosthetic techniques. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.


Asunto(s)
Reembolso de Seguro de Salud/economía , Mamoplastia/economía , Microcirugia/economía , Adulto , Implantación de Mama/economía , Implantación de Mama/estadística & datos numéricos , Implantes de Mama/economía , Implantes de Mama/estadística & datos numéricos , Neoplasias de la Mama/economía , Neoplasias de la Mama/cirugía , Femenino , Colgajos Tisulares Libres/economía , Humanos , Mamoplastia/estadística & datos numéricos , Massachusetts , Mastectomía/economía , Mastectomía/métodos , Medicaid/economía , Medicaid/estadística & datos numéricos , Microcirugia/estadística & datos numéricos , Microvasos , Persona de Mediana Edad , Reoperación/economía , Reoperación/estadística & datos numéricos , Trasplante Autólogo/economía , Estados Unidos
10.
Clin Implant Dent Relat Res ; 22(1): 91-95, 2020 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-31777154

RESUMEN

OBJECTIVES: The current pilot study aims to report short-term experience as it relates to acute radiotherapy treatment outcomes comparing patients with immediate dental implants in fibula free flap reconstructions to a historical cohort of patients with fibula free flap reconstructions without dental implants. MATERIALS AND METHODS: A retrospective review of patients who underwent segmental mandibulectomy, reconstruction with fibula free flaps, and adjuvant radiotherapy with (n = 10) and without immediate dental implants (n = 10) at a tertiary cancer center from 2015 to 2018 was performed (IRB #17-271). Incidence of postoperative complications, time to initiation of radiation therapy, development of acute toxicity, and patient reported outcome data were recorded. The radiation plans were evaluated to identify the mean and maximum doses received by the mandible and oral cavity as well as the locations of radiation global hot spots. RESULTS: There was a similar number of postoperative complications in both cohorts, with three events in the case group and two events in the control group. Patients with dental implants reported less trismus than control patients. Evaluation of the radiation treatment plans revealed similar median radiation global hot spots in both groups. CONCLUSIONS: The current study suggests that the presence of dental implants does not increase the risk of complications following surgery or during radiation treatment. Implants do not alter radiation dosimetry but do appear to positively impact early patient quality of life. Although longer follow-up is needed, based on this preliminary experience, cancer patients should be offered this type of reconstruction without fear of impacting radiation timing or delivery.


Asunto(s)
Implantes Dentales , Colgajos Tisulares Libres , Neoplasias de Cabeza y Cuello , Neoplasias Mandibulares , Procedimientos Quirúrgicos Reconstructivos , Trasplante Óseo , Humanos , Mandíbula , Proyectos Piloto , Calidad de Vida , Estudios Retrospectivos , Resultado del Tratamiento
11.
Ann Surg Oncol ; 27(6): 1877-1888, 2020 Jun.
Artículo en Inglés | MEDLINE | ID: mdl-31811437

RESUMEN

BACKGROUND: Obesity is a significant public health concern and clear risk factor for complications following breast reconstruction. To date, few have assessed patient-reported outcomes (PROs) focused on this key determinant. OBJECTIVE: Our study aimed to investigate the impact of obesity (body mass index ≥ 30) on postoperative satisfaction and physical function utilizing the BREAST-Q in a cohort of autologous breast reconstruction patients. METHODS: An Institutional Review Board-approved prospective investigation was conducted to evaluate PROs in patients undergoing autologous breast reconstruction from 2009 to 2017 at a tertiary academic medical center. The BREAST-Q reconstruction module was used to assess outcomes between cohorts preoperatively and at 6 months, 1 year, 2 years, and 3 years after reconstruction. RESULTS: Overall, 404 patients underwent autologous breast reconstruction with abdominal free-tissue transfer (244 non-obese, 160 obese) and completed the BREAST-Q. Although obese patients demonstrated lower satisfaction with breasts preoperatively (p = 0.04), no significant differences were noted postoperatively (p = 0.58). However, physical well-being of the abdomen was lower in the obese cohort compared with their non-obese counterparts at long-term follow-up (3 years; p = 0.04). CONCLUSION: Obesity significantly impacts autologous breast reconstruction patients. Although obese patients are more likely to present with dissatisfaction with breasts preoperatively, they exhibit comparable PROs overall compared with their non-obese counterparts, despite increased complications.

12.
Plast Reconstr Surg ; 144(6): 1280-1290, 2019 12.
Artículo en Inglés | MEDLINE | ID: mdl-31764633

RESUMEN

BACKGROUND: Rates of breast reconstruction following mastectomy continue to increase. The objective of this study was to determine the frequency of elective revision surgery and the number of procedures required to achieve a stable breast reconstruction 2 years after mastectomy. METHODS: Women undergoing first-time breast reconstruction after mastectomy were enrolled and followed for 2 years, with completion of reconstruction occurring in 1996. Patients were classified based on the absence or presence of complications. Comparisons within cohorts were performed to determine factors associated with revisions and total procedures. Mixed-effects regression modeling identified factors associated with elective revisions and total operations. RESULTS: Overall, 1534 patients (76.9 percent) had no complications, among whom 40.2 percent underwent elective revisions. The average number of elective revisions differed by modality (p < 0.001), with abdominally based free autologous reconstruction patients undergoing the greatest number of elective revisions (mean, 0.7). The mean total number of procedures also differed (p < 0.001), with tissue expander/implant reconstruction patients undergoing the greatest total number of procedures (mean, 2.4). Complications occurred in 462 patients (23.1 percent), with 67.1 percent of these patients undergoing elective revisions, which was significantly higher than among patients without complications (p < 0.001). The mean number of procedures again differed by modality (p < 0.001) and followed similar trends, but with an increased mean number of revisions and procedures overall. Mixed-effects regression modeling demonstrated that patients experiencing complications had increased odds of undergoing elective revision procedures (OR, 3.2; p < 0.001). CONCLUSIONS: Breast reconstruction patients without complications undergo over two procedures on average to achieve satisfactory reconstruction, with 40 percent electing revisions. If a complication occurs, the number of procedures increases. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.


Asunto(s)
Implantación de Mama/estadística & datos numéricos , Mastectomía/estadística & datos numéricos , Implantes de Mama/estadística & datos numéricos , Canadá , Procedimientos Quirúrgicos Electivos/estadística & datos numéricos , Femenino , Humanos , Persona de Mediana Edad , Estudios Prospectivos , Reoperación/estadística & datos numéricos , Colgajos Quirúrgicos/estadística & datos numéricos , Expansión de Tejido/estadística & datos numéricos , Dispositivos de Expansión Tisular/estadística & datos numéricos , Resultado del Tratamiento , Estados Unidos
13.
Plast Reconstr Surg Glob Open ; 7(10): e2475, 2019 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-31772898

RESUMEN

Reconstruction of segmental maxillary or mandibular defects with osteocutaneous free flaps can be reliably accomplished; however, buccal or lingual rotation of the fibula during rigid fixation can render immediate endosseous implant position unusable for functional dental rehabilitation. To address this issue, a custom inset guide is introduced which utilizes surface topography of the immediately placed dental implant abutments and the patient's dentition to orient the fibula segments during inset. Use of this technique facilitates successful endosseous implant position to optimize postoperative functional rehabilitation.

14.
Plast Reconstr Surg Glob Open ; 7(6): e2181, 2019 Jun.
Artículo en Inglés | MEDLINE | ID: mdl-31624664

RESUMEN

Objectives: The authors seek to highlight some of the ongoing challenges related to complex oncologic reconstruction and the current solutions to these problems. Summary: The standard of care in reconstruction following oncologic resection is continually evolving. Current frontiers in breast reconstruction include addressing animation deformity through prepectoral reconstruction, offering autologous reconstruction to patients with limited donor sites, and improving postoperative sensation with innervation of free tissue transfer. Facial nerve reconstruction and contour defects pose an ongoing challenge in patients undergoing parotidectomy requiring complex nerve transfers and autologous reconstruction. Lymphedema is not a monolithic disease, and as our understanding of the pathophysiology improves, our surgical algorithms continue to evolve.

15.
Plast Reconstr Surg Glob Open ; 7(6): e2299, 2019 Jun.
Artículo en Inglés | MEDLINE | ID: mdl-31624690

RESUMEN

Background: Alternatives to postoperative, narcotic pain management following implant-based, postmastectomy breast reconstruction (IBR) must be a focus for plastic surgeons and anesthesiologists, especially with the current opioid epidemic. Paravertebral blocks (PVBs) are a regional technique that has demonstrated efficacy in patients undergoing a variety of breast cancer-related surgeries. However, a specific understanding of PVB's efficacy in pain management in patients who undergo IBR is lacking. Methods: A systematic search of PubMed, EMBASE, and Cochrane Library electronic database was conducted to examine PVB administration in mastectomy patients undergoing IBR. Data were abstracted regarding: authors, publication year, study design, patient demographics, tumor laterality, tumor stage, type, and timing of reconstruction. The primary outcome was PVB efficacy, represented as patient-reported pain scores. Secondary outcomes of interest include narcotic consumption, postoperative nausea and vomiting, antiemetic use, and length of stay. Results: The search resulted in 1,516 unique articles. After title and abstract screening, 29 articles met the inclusion criteria for full-text review. Only 7 studies were included. Of those, 2 studies were randomized control trials and 5 were retrospective cohort studies. Heterogeneity of included studies precluded a meta-analysis. Overall, PVB patients had improved pain control, and less opioid consumption. Conclusion: PVBs are a regional anesthesia technique which may aid in pain management in the breast reconstructive setting. Evidence suggests that PVBs aid in controlling acute postoperative pain, reduce opioid consumption, and improve patient length of stay. However, some conflicting findings demonstrate a need for continued research in this area of pain control.

16.
Int J Prosthodont ; 32(5): 448-450, 2019.
Artículo en Inglés | MEDLINE | ID: mdl-31486818

RESUMEN

Leiomyosarcoma is a rare malignant condition occurring in the maxillofacial region in which the mandible may be affected. Management of this tumor in the mandible may include segmental mandibulectomy, osteocutaneous fibula free-flap reconstruction, endosseous implants, and postoperative radiotherapy. Posttreatment malocclusion can be managed with an overpartial mandibular resection prosthesis. The purpose of this report is to describe the expeditious oral rehabilitation of an oncologic patient with posttreatment malocclusion, demonstrating the utility of an overpartial mandibular resection prosthesis.


Asunto(s)
Colgajos Tisulares Libres , Leiomiosarcoma , Maloclusión , Neoplasias Mandibulares , Reconstrucción Mandibular , Procedimientos Quirúrgicos Reconstructivos , Trasplante Óseo , Humanos , Mandíbula , Prótesis e Implantes , Colgajos Quirúrgicos
18.
Ann Surg ; 270(3): 473-483, 2019 09.
Artículo en Inglés | MEDLINE | ID: mdl-31356276

RESUMEN

OBJECTIVE: To better understand the long-term patient-reported outcomes (PROs) in satisfaction and health-related quality of life (QOL) following post-mastectomy reconstruction (PMR) using the BREAST-Q, comparing PROs from patients undergoing implant-based breast reconstruction (IBR) or autologous breast reconstruction (ABR). SUMMARY OF BACKGROUND DATA: Multiple studies have demonstrated growth in mastectomy rates and concurrent increase in PMR utilization. However, most studies examining PMR PROs focus on short postoperative time periods-mainly within 2 years. METHODS: BREAST-Q scores from IBR or ABR patients at a tertiary center were prospectively collected from 2009 to 2017. Mean scores and standard deviations (SDs) were calculated for satisfaction with breast, satisfaction with outcome, psychosocial well-being, physical well-being of the chest, and sexual well-being. Satisfaction with breasts and physical well-being of the chest were compared using regression models at postoperative years 1, 3, 5, and 7. RESULTS: Overall, 3268 patients were included, with 336 undergoing ABR and 2932 undergoing IBR. Regression analysis demonstrated that ABR patients had greater postoperative satisfaction with breast scores at all timepoints compared with IBR patients. Postoperative radiation and mental illness adversely impacted satisfaction with breast scores. Furthermore, mental illness impacted physical wellbeing of the chest at all timepoints. IBR patients had satisfaction scores that remained stable over the study period. CONCLUSION: This study presents the largest prospective examination of PROs in PMR to date. Patients who opted for ABR had significantly higher satisfaction with their breast and QOL at each assessed time point, but IBR patients had stable long-term satisfaction and QOL postoperatively.


Asunto(s)
Implantes de Mama , Mamoplastia/métodos , Mastectomía/métodos , Medición de Resultados Informados por el Paciente , Satisfacción del Paciente/estadística & datos numéricos , Calidad de Vida , Adulto , Neoplasias de la Mama/cirugía , Bases de Datos Factuales , Femenino , Estudios de Seguimiento , Humanos , Mamoplastia/efectos adversos , Mastectomía/efectos adversos , Persona de Mediana Edad , Estudios Prospectivos , Medición de Riesgo , Encuestas y Cuestionarios , Centros de Atención Terciaria , Factores de Tiempo , Resultado del Tratamiento , Estados Unidos
19.
Plast Reconstr Surg Glob Open ; 7(1): e2100, 2019 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-30859051

RESUMEN

Full dental rehabilitation following segmental mandibulectomy or maxillectomy for oncologic tumor ablation should be the goal for every patient. But despite advances in technology and reconstructive techniques, many patients do not achieve timely or complete oral rehabilitation. Recognizing this fault, we recently adopted an innovative workflow to increase the number of patients undergoing dental restoration, irrespective of tumor pathology or need for adjuvant radiotherapy. Preoperatively, every osseous jaw reconstruction undergoes virtual surgical planning to incorporate the placement of endosseous implants into the fibula osteocutaneous free flap. The dental implants are then placed intraoperatively at the time of tumor ablation and reconstruction. Four-to-six weeks following the initial surgery, the patient returns to the operating room for vestibuloplasty and exposure of the dental implants. Within 3 days of the vestibuloplasty, a temporary dental prosthesis is placed in the dental clinic, and the patient can then begin radiation therapy if needed. Following adjuvant radiation therapy, the temporary prosthesis can be replaced with a permanent one. At our institution, this innovative workflow has allowed for earlier aesthetic restoration of the jaw and greatly expanded the number of patients able to achieve oral rehabilitation. Herein, we describe this innovative workflow and provide technical pearls for successful execution.

20.
J Prosthet Dent ; 122(1): 82-87, 2019 Jul.
Artículo en Inglés | MEDLINE | ID: mdl-30782457

RESUMEN

STATEMENT OF PROBLEM: Treatment and timing considerations for patients seeking oral rehabilitation after marginal or segmental mandibulectomy (with osseous reconstruction) are not well understood. PURPOSE: The purpose of this retrospective review study was to report the type and timing of oral rehabilitation for mandibular defects without discontinuity and to describe additional treatment considerations for rehabilitation. MATERIAL AND METHODS: The records were reviewed of all patients who received a mandibular resection prosthesis after marginal mandibulectomy, marginal mandibulectomy with fasciocutaneous free-flap reconstruction, and segmental mandibulectomy with fibula free-flap reconstruction between 2000 and 2017 in the tertiary cancer care institution. Patients not treated by the Dental Service in the institution were excluded. The specific type of rehabilitation was noted, as was the time interval between primary surgery and prosthesis delivery. RESULTS: During the study period, 111 consecutive patients were treated by the Memorial Sloan Kettering Cancer Center Dental Service for mandibular rehabilitation. Forty-three patients underwent marginal mandibulectomy, 9 patients underwent marginal mandibulectomy with fasciocutaneous free-flap reconstruction, and 59 patients underwent segmental mandibulectomy with fibula free-flap reconstruction. Most patients in all 3 groups received mandibular resection prostheses without the use of endosseous implants. Only 4 (8%) patients who had undergone marginal mandibulectomy underwent endosseous implant placement, all of which followed marginal mandibulectomy in anterior mandibular segments without free-flap reconstruction. Patients who underwent marginal mandibulectomy with fasciocutaneous free-flap reconstruction were only restored with removable mandibular resection prostheses, and none had endosseous implants. In patients who underwent segmental mandibulectomy, 13 (22%) were rehabilitated with endosseous implants. The majority in this cohort (>50%) received radiation therapy as part of their treatment. The median time to oral rehabilitation was 8 months after marginal mandibulectomy, 14 months after marginal mandibulectomy with fasciocutaneous free-flap reconstruction, and 12 months after segmental mandibulectomy with fibula free-flap reconstruction. CONCLUSIONS: Timing for oral rehabilitation may differ depending on the treatment modality followed for mandibular tumors in the patient with oral cancer. However, most patients in this cohort underwent rehabilitation with removable mandibular resection prostheses regardless of the timing of care. Endosseous implants were used infrequently, but research is needed to better understand their potential role and indication in the patient with oral cancer.


Asunto(s)
Colgajos Tisulares Libres , Neoplasias Mandibulares , Reconstrucción Mandibular , Trasplante Óseo , Peroné , Humanos , Mandíbula , Osteotomía Mandibular , Prótesis e Implantes , Estudios Retrospectivos , Resultado del Tratamiento
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