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BACKGROUND: The timing of free flap reconstruction after lower extremity trauma has been a controversial debate since Marko Godina's original 72 hour recommendation. Recent advances in microsurgery warrant an evaluation of the optimal time to reconstruction. METHODS: The Nationwide Readmission Database (2014-2019) was used to identify patients undergoing free flap reconstruction after lower extremity trauma. Risk-adjusted statistical methods were used to identify optimal time where risk of infectious and microsurgical complications increase and to quantify the risk associated with time delays. RESULTS: One-thousand and thirty patients undergoing reconstruction were identified. The mean time to flap coverage was 24.3 days. Thirty-three percent were performed within 72 hours, 24% from 72 hours-10 days, 18% from 10-30 days, and 24% after 30 days. Flaps performed after 10 days were associated with increased risk of surgical site infection, osteomyelitis, and other wound complications, compared to those performed within 72 hours. There was no increased risk in the period of 72 hours to 10 days. Revision amputation and microsurgical complications were not increased after 10 days. The predicted optimal cutoff was 9.5 days for microsurgical complications and 14.5 days for infectious complications. CONCLUSIONS: Advances in microsurgery may be responsible for extending the time in which definitive soft tissue coverage is required for wounds resulting from lower extremity trauma. Although it appears the original 72-hour time window can be safely extended, efforts should be made to refer patients to specialty limb salvage centers in a timely fashion.
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Background: A previous study by the authors noted a decline in independent plastic surgery residency programs and rising applicant participation. This study provides updates on match trends and influential predictors, and gathers program leaders' views on the future of the independent track. Methods: Match data (2019-2022) were obtained from the San Francisco match after American Council of Educators in Plastic Surgery approval. Variables influencing match success were analyzed, and program leaders were surveyed about desirable applicant traits and program trajectories. Results: From 2019 to 2022, 243 of 428 applicants matched. Programs and positions declined by 10% and 9.5%, respectively. Applicants rose to 42.3%, but match rates fell from 82% to 56%. Osteopathic graduates doubled, whereas international graduates increased to 53.8%. Successful matches were associated with US allopathic medical school graduates, university-affiliated general surgery residencies, eight or more interviews, United States Medical Licensing Examination scores greater than 230, and high post graduate year (PGY)1-3 American Board of Surgery In-service Training Examination scores (PGY1-64.7%, PGY2-61.2%, PGY3-60.7%; P < 0.05). Of surveyed programs, 55.6% aimed to continue running the independent track in the next year. Conversely, 7.4% planned to discontinue in the next year, 22.2% within 2-5 years, 7.4% within the next decade, and 7.4% were unsure. Conclusions: Although support for the independent plastic surgery track remains, program participation diminishes as applicant interest increases, intensifying match challenges. Increasing number of interviews improves match potential. Program leaders display varied commitments, with looming plans for some programs to discontinue offering this track. Applicant evaluation pivots on strong recommendations, research, and test scores.
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INTRODUCTION: The prevalence of obesity has risen worldwide, posing a problem to surgeons as obesity is a well-known risk factor for surgical outcomes. While prior studies have suggested performing reduction mammaplasty (RM) in patients with obesity, the variance in outcomes and quality of life (QoL) for obesity classes are ill-defined. We investigated whether obesity classes should be considered for RM by examining the surgical outcomes and QoL across different weight classes, aiming to pinpoint when outcomes become less favorable. METHODS: Patients undergoing RM by nine surgeons from 2016 to 2022 were included. Body mass index (BMI) cohorts were formed according to the Center for Disease Control and Prevention (CDC) guidelines: Healthy (18.5-24.9 kg/m 2 ), overweight (25-29.9 kg/m 2 ), obesity class I (30-34.9 kg/m 2 ), II (35-39.9 kg/m 2 ), and III (>40 kg/m 2 ). QoL was assessed by comparing preoperative and postoperative BREAST-Q scores within cohorts. A comparison analysis was performed between weight classes. RESULTS: A total of 461 RM patients were identified (healthy: 83, overweight: 178, I: 142, II: 39, III: 19). Percentage of Black patients, procedure length, weight of tissue removed, and inferior pedicle technique all significantly increased as BMI increased ( P < 0.001). Higher BMI cohorts, especially class III, had significantly higher rates of surgical site infections (healthy: 0%, overweight: 1.1%, I: 1.4%, II: 0%, III: 15.8%, P < 0.01), fat necrosis (healthy: 1.2%, overweight: 5.1%, I: 7%, II: 0%, III: 22.2%, P = 0.01), dehiscence (healthy: 3.6%, overweight: 2.8%, I: 2.1%, II: 5.1%, III: 31.6%, P < 0.01), delayed healing (health: 4.8%, overweight: 11.2%, I: 16.9%, II: 28.2%, III: 42.1%, P < 0.01), minor T-point breakdown (healthy: 10.8%, overweight: 15.7%, I: 23.9%, II: 23.1%, III: 52.6%, P = 0.01), and surgical site occurrence requiring procedural intervention (healthy: 6.0%, overweight: 5.6%, I: 6.3%, II: 15.4%, III: 21.1%, P < 0.05). When compared to the other weight classes independently, class III was associated with unfavorable outcomes ( P < 0.05). Significant improvement in average postoperative QoL scores in satisfaction with breast, psychosocial well-being, sexual well-being, and physical well-being were seen in all cohorts except class III ( P < 0.05). CONCLUSIONS: Severe obesity class III patients undergoing RM have a higher yet still acceptable risk profile and should be counseled on the risks despite its improved quality of life.
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Índice de Massa Corporal , Mamoplastia , Obesidade , Qualidade de Vida , Humanos , Mamoplastia/métodos , Feminino , Adulto , Pessoa de Meia-Idade , Obesidade/cirurgia , Obesidade/complicações , Estudos Retrospectivos , Resultado do Tratamento , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologiaRESUMO
BACKGROUND: The use of post-mastectomy radiation therapy (PMRT) in the setting of immediate two-stage breast reconstruction is becoming increasingly widespread. However, the timeframe of tissue expander exchange for permanent implant placement following PMRT is not well-defined, and it remains unclear what time interval optimizes surgical outcomes and patient satisfaction. METHODS: A systematic review conducted in accordance with PRISMA 2020 was completed. PubMed, Embase, Scopus, and Cochrane databases were searched under keywords pertaining to concepts of tissue expander breast reconstruction and PMRT. Inclusion criteria encompassed primary articles on tissue expander breast reconstruction with adjuvant radiation therapy reporting timing of exchange to permanent implant following radiation and surgical outcomes. RESULTS: Of the initial 1,259 publications, 15 studies met our inclusion criteria, and 11 studies had granular enough data to use for pooled analysis. Implant exchange less than 6 months after PMRT was found to be associated with increased incidence of wound dehiscence (17.12% vs 3.64%, p<0.001) and hematoma (25% vs 2.59%, p<0.001) compared to exchange after 6 months. There was no significant difference in incidence of SSI, seroma, capsular contracture, and reconstructive failure. CONCLUSIONS: Expander to implant exchange at less than 6 months is associated with a higher incidence of wound dehiscence and hematoma formation but does not increase the risk of reconstruction failure. The limited research on ideal timing prompts further investigation to optimize surgical outcomes for the increasing patient population undergoing PMRT and immediate two-staged breast reconstruction.
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LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Understand the types of abdominally based flaps, their anatomy, and their drawbacks. 2. Understand important aspects of the history and physical examination of patients wishing to undergo these procedures. 3. Understand the benefits of preoperative planning and its role in avoiding complication. 4. Understand the operative steps of the procedures and tips to increase efficiency. 5. Understand the postoperative care of these patients and the role of enhanced recovery pathways. SUMMARY: In this article, the authors review the history, current state, and future directions related to abdominally based microsurgical breast reconstruction. This article covers preoperative, intraoperative, and postoperative considerations intended to improve patient outcomes and prevent complications. Evidence-based findings are reported when available to comprehensively review important aspects of these procedures.
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Mamoplastia , Microcirurgia , Retalhos Cirúrgicos , Humanos , Mamoplastia/métodos , Microcirurgia/métodos , Feminino , Retalhos Cirúrgicos/transplante , Retalhos Cirúrgicos/irrigação sanguínea , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/prevenção & controle , Neoplasias da Mama/cirurgia , Cuidados Pós-Operatórios/métodosRESUMO
BACKGROUND: Autologous breast reconstruction (ABR) after mastectomy is increasing due to benefits over implant-based reconstruction. However, free flap reconstruction is not universally offered to patients of advanced age due to perceived increased perioperative risk. METHODS: Patients undergoing free flap breast reconstruction at our institution from 2005 to 2018 were included. Risk-adjusted logistic regression models were fit while controlling for demographic and comorbid characteristics to determine the association of age with the probability of venous thromboembolism (VTE), delayed healing, skin necrosis, surgical site infection (SSI), seroma, hematoma, hernia, and flap loss. Linear predictions from risk-adjusted logistic regression models were used to create spline curves and determine the risk of outcomes associated with age. RESULTS: A cohort of 2,598 patients underwent free flap breast reconstruction in the period examined. The median age was 51 with approximately 9% of patients being 65 or older. Increased age was associated with a greater risk of delayed healing, skin necrosis, and hematoma after surgery. There was no increased risk of medical complications such as VTE or complications such as flap loss, seroma, or SSI. CONCLUSION: A set age cutoff for patients undergoing free flap breast reconstruction does not appear warranted. There is no difference in major surgical complications such as flap loss with increasing age. However, older age does predispose patients to specific wound complications such as hematoma, skin necrosis, and delayed wound healing, which should guide preoperative counseling. Further, medical complications do not increase with advanced age. Overall, however, the safety of ABR in older patients appears uncompromised.
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BACKGROUND: Microsurgery requires a high level of skill achieved only through repeated practice. With duty-hour restrictions and supervision requirements, trainees require more opportunities for practice outside the operating room. Studies show simulation training improves knowledge and skills. While numerous microvascular simulation models exist, virtually all lack the combination of human tissue and pulsatile flow. METHODS: The authors utilized a novel simulation platform incorporating cryopreserved human vein and a pulsatile flow circuit for microsurgery training at two academic centers. Subjects performed a standardized simulated microvascular anastomosis and repeated this task at subsequent training sessions. Each session was evaluated using pre- and postsimulation surveys, standardized assessment forms, and the time required to complete each anastomosis. Outcomes of interest include change in self-reported confidence scores, skill assessment scores, and time to complete the task. RESULTS: In total, 36 simulation sessions were recorded including 21 first attempts and 15 second attempts. Pre- and postsimulation survey data across multiple attempts demonstrated a statistically significant increase in self-reported confidence scores. Time to complete the simulation and skill assessment scores improved with multiple attempts; however, these findings were not statistically significant. Subjects unanimously reported on postsimulation surveys that the simulation was beneficial in improving their skills and confidence. CONCLUSION: The combination of human tissue and pulsatile flow results in a simulation experience that approaches the level of realism achieved with live animal models. This allows plastic surgery residents to improve microsurgical skills and increase confidence without the need for expensive animal laboratories or any undue risk to patients.
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Internato e Residência , Treinamento por Simulação , Animais , Humanos , Educação de Pós-Graduação em Medicina/métodos , Simulação por Computador , Inquéritos e Questionários , Competência ClínicaRESUMO
BACKGROUND: Implant-based breast reconstruction is the most common reconstructive approach after mastectomy. Prepectoral implants offer advantages over submuscular implants, such as less animation deformity, pain, weakness, and postradiation capsular contracture. However, clinical outcomes after prepectoral reconstruction are debated. The authors performed a matched-cohort analysis of outcomes after prepectoral and submuscular reconstruction at a large academic medical center. METHODS: Patients treated with implant-based breast reconstruction after mastectomy from January of 2018 through October of 2021 were retrospectively reviewed. Patients were propensity score exact matched to control demographic, preoperative, intraoperative, and postoperative differences. Outcomes assessed included surgical-site occurrences, capsular contracture, and explantation of either expander or implant. Subanalysis was done on infections and secondary reconstructions. RESULTS: A total of 634 breasts were included (prepectoral, 197; submuscular, 437). A total of 292 breasts were matched (146 prepectoral:146 submuscular) and analyzed for clinical outcomes. Prepectoral reconstructions were associated with greater rates of SSI (prepectoral, 15.8%; submuscular, 3.4%; P < 0.001), seroma (prepectoral, 26.0%; submuscular, 10.3%; P < 0.001), and explantation (prepectoral, 23.3%; submuscular, 4.8%; P < 0.001). Subanalysis of infections revealed that prepectoral implants have shorter time to infection, deeper infections, and more Gram-negative infections, and are more often treated surgically (all P < 0.05). There have been no failures of secondary reconstructions after explantation in the entire population at a mean follow-up of 20.1 months. CONCLUSIONS: Prepectoral implant-based breast reconstruction is associated with higher rates of infection, seroma, and explantation compared with submuscular reconstructions. Infections of prepectoral implants may need different antibiotic management to avoid explantation. Secondary reconstruction after explantation can result in long-term success. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.
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Implante Mamário , Implantes de Mama , Neoplasias da Mama , Contratura , Mamoplastia , Humanos , Feminino , Mastectomia/efeitos adversos , Implante Mamário/efeitos adversos , Estudos Retrospectivos , Neoplasias da Mama/cirurgia , Neoplasias da Mama/etiologia , Seroma/etiologia , Mamoplastia/efeitos adversos , Implantes de Mama/efeitos adversos , Contratura/etiologiaRESUMO
BACKGROUND: Patients with advanced cancer staging have a greater risk of developing venous thromboembolism than noncancer patients. The impact of breast cancer stage and treatment on outcomes after autologous free-flap breast reconstruction (ABR) is not well-established. The objective of this retrospective study is to determine the impact of breast cancer characteristics, such as cancer stage, hormone receptor status, and neoadjuvant treatments, on vascular complications of ABR. METHODS: A retrospective review was conducted examining patients who underwent ABR from 2009 to 2018. Breast cancer stage, cancer types, hormone receptor status, and treatments were collected in addition to demographic data. Intraoperative vascular concerns, postoperative vascular concerns, and flap loss were analyzed. Univariate analysis and fixed-effects models were used to associate breast cancer characteristics with outcomes. RESULTS: Neoadjuvant hormone therapy was associated with increased risk for intraoperative vascular concern (odds ratio, 1.059 [ P = 0.0441]). Neoadjuvant trastuzumab was associated with decreased risk of postoperative vascular concern (odds ratio, 0.941 [ P = 0.018]). Breast cancer stage, somatic genetic mutation, receptor types, neoadjuvant chemotherapy, and neoadjuvant radiation had no effect on any vascular complications of ABR. CONCLUSION: Autologous free-flap breast reconstruction is a reliable reconstructive option for patients with all stages and types of breast cancer. There is potentially increased risk of intraoperative microvascular compromise in patients who have neoadjuvant hormone therapy. Trastuzumab is potentially protective against postoperative microvascular compromise. Patients should feel confident that, despite higher stage cancer, they can pursue their desired reconstructive option without fear of vascular compromise.
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Neoplasias da Mama , Doenças Cardiovasculares , Mamoplastia , Humanos , Feminino , Neoplasias da Mama/tratamento farmacológico , Mastectomia/efeitos adversos , Mamoplastia/efeitos adversos , Estudos Retrospectivos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/cirurgia , Trastuzumab/uso terapêutico , Hormônios/uso terapêutico , Resultado do TratamentoRESUMO
BACKGROUND: The COVID-19 pandemic resulted in sweeping shutdowns of surgical operations to increase hospital capacity and conserve resources. Our institution, following national and state guidelines, suspended nonessential surgeries from March 16 to May 4, 2020. This study examines the financial impact of this decision on our institution's health system by comparing 2 waves of COVID-19 cases. METHODS: The total revenue was obtained for surgical cases occurring during the first wave of the pandemic between March 1, 2020 and July 31, 2020 and the second wave between October 1, 2020 and February 29, 2021 for all surgical departments. During the same time intervals, in the prepandemic year 2019, total revenue was also obtained for comparison. Net revenue and work relative value units per month were compared to each respective month for all surgical divisions within the department of surgery. RESULTS: Comparing the 5-month first wave period in 2020 to prepandemic 2019 for all surgical departments, there was a net revenue loss of $99,674,376, which reflected 42% of the health system's revenue loss during this period. The department of surgery contributed to a net revenue loss of $58,368,951, which was 24.9% of the health system's revenue loss. Within the department of surgery, there was a significant difference between the net revenue loss per month per division of the first and second wave: first wave median -$636,952 [interquartile range: -1,432,627; 26,111] and second wave median -$274,626 [-781,124; 396,570] (P = .04). A similar difference was detected when comparing percent change in work relative value units between the 2 waves (wave 1: median -13.2% [interquartile range: -41.3%, -1.8%], wave 2: median -7.8% [interquartile range: -13.0%, 1.8%], P = .003). CONCLUSION: Stopping elective surgeries significantly decreased revenue for a health system. Losses for the health system totaled $234,839,990 during the first wave, with lost surgical revenue comprising 42% of that amount. With elective surgeries continuing during the second wave of COVID-19 cases, the health system losses were substantially lower. The contribution surgery has to a hospital's cash flow is essential in maintaining financial solvency. It is important for hospital systems to develop innovative and alternative solutions to increase capacity, offer comprehensive care to medical and surgical patients, and prevent shutdowns of surgical activity through a pandemic to maintain financial security.
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COVID-19 , Humanos , COVID-19/epidemiologia , Pandemias/prevenção & controle , Procedimentos Cirúrgicos Eletivos , HospitaisRESUMO
OBJECTIVE: To investigate key morphometric features identifiable on routine preoperative computed tomography (CT) imaging indicative of incisional hernia (IH) formation following abdominal surgery. BACKGROUND: IH is a pervasive surgical disease that impacts all surgical disciplines operating in the abdominopelvic region and affecting 13% of patients undergoing abdominal surgery. Despite the significant costs and disability associated with IH, there is an incomplete understanding of the pathophysiology of hernia. METHODS: A cohort of patients (n=21,501) that underwent colorectal surgery was identified, and clinical data and demographics were extracted, with a primary outcome of IH. Two datasets of case-control matched pairs were created for feature measurement, classification, and testing. Morphometric linear and volumetric measurements were extracted as features from anonymized preoperative abdominopelvic CT scans. Multivariate Pearson testing was performed to assess correlations among features. Each feature's ability to discriminate between classes was evaluated using 2-sided paired t testing. A support vector machine was implemented to determine the predictive accuracy of the features individually and in combination. RESULTS: Two hundred and twelve patients were analyzed (106 matched pairs). Of 117 features measured, 21 features were capable of discriminating between IH and non-IH patients. These features are categorized into three key pathophysiologic domains: 1) structural widening of the rectus complex, 2) increased visceral volume, 3) atrophy of abdominopelvic skeletal muscle. Individual prediction accuracy ranged from 0.69 to 0.78 for the top 3 features among 117. CONCLUSIONS: Three morphometric domains identifiable on routine preoperative CT imaging were associated with hernia: widening of the rectus complex, increased visceral volume, and body wall skeletal muscle atrophy. This work highlights an innovative pathophysiologic mechanism for IH formation hallmarked by increased intra-abdominal pressure and compromise of the rectus complex and abdominopelvic skeletal musculature.
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Hérnia Incisional , Atrofia , Estudos de Casos e Controles , Humanos , Hérnia Incisional/diagnóstico por imagem , Hérnia Incisional/etiologia , Hérnia Incisional/cirurgia , Estudos Retrospectivos , Tomografia Computadorizada por Raios X/métodosRESUMO
BACKGROUND: Women undergoing immediate breast reconstruction without radiation therapy have reconstruction methods available with uncertain long-term costs associated with complications requiring surgery and revisions. We evaluated cost-effectiveness of nine methods of immediate breast reconstruction for women with localized breast cancer. METHODS: Markov modeling was performed over 10-years for unilateral/bilateral breast reconstructions from healthcare/societal perspectives. PubMed, Embase, Cochrane, Scopus, and CINAHL were searched to derive data from 13,744 patients in 79 prospective studies. Complications requiring surgery (mastectomy necrosis, total/partial flap necrosis, seroma, hematoma, infection, wound dehiscence, abdominal hernia, implant removal/explantation) and revisions (fat necrosis, capsular contracture, asymmetry, scars/redundant tissue, implant rupture/removal, fat grafting) were evaluated over yearly cycles. Reconstructions included: direct-to-implant (DTI), tissue expander-to-implant (TEI), latissimus dorsi flap-to-implant (LDI), latissimus dorsi (LD), pedicled transverse rectus abdominis myocutaneous (TRAM), free TRAM, deep inferior epigastric perforator/superficial inferior epigastric artery (DIEP/SIEA), thigh-based, or gluteal based flaps. Outcomes were incremental cost-effectiveness ratios (ICER) and net monetary benefits (NMB). Willingness-to-pay thresholds were $50,000 and $100,000. RESULTS: From a healthcare perspective for unilateral reconstruction, compared to LD, the ICER for DTI was -$42,109.35/quality-adjusted life-years (QALY), LDI was -$25,300.83/QALY, TEI was -$22,036.02/QALY, DIEP/SIEA was $8307.65/QALY, free TRAM was $8677.26/QALY, pedicled TRAM was $13,021.44/QALY, gluteal-based was $17,698.99/QALY, and thigh-based was $23,447.82/QALY. NMB of DIEP/SIEA was $404,523.47, free TRAM was $403,821.40, gluteal-based was $392,478.64, thigh-based was $387,691.70, pedicled TRAM was $376,901.83, LD was $370,646.93, DTI was $339,668.77, LDI was $334,350.30, and TEI was $329,265.84. CONCLUSIONS: All nine methods of immediate breast reconstruction were considered cost-effective from healthcare/societal perspectives. LD provided the lowest costs, while DIEP/SIEA provided the greatest effectiveness and NMB.
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Neoplasias da Mama , Mamoplastia , Retalho Miocutâneo , Neoplasias da Mama/complicações , Neoplasias da Mama/cirurgia , Análise Custo-Benefício , Técnicas de Apoio para a Decisão , Feminino , Humanos , Mamoplastia/métodos , Mastectomia/métodos , Retalho Miocutâneo/transplante , Necrose/etiologia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/cirurgia , Estudos Prospectivos , Reto do Abdome/transplanteRESUMO
ABSTRACT: It is unknown if craniofacial trauma services are inequitably distributed throughout the US. The authors aimed to describe the geographical distribution of craniofacial trauma, surgeons, and training positions nationwide. State-level data were obtained on craniofacial trauma admissions, surgeons, training positions, population, and income for 2016 to 2017. Normalized densities (per million population [PMP]) were ascertained. State/ regional-level densities were compared between highest/lowest. Risk-adjusted generalized linear models were used to determine independent associations. There were 790,415 craniofacial trauma admissions (x?â=â2330.6 PMP), 28,004 surgeons (x?â=â83.5 PMP), and 746 training positions (x?â=â1.9 PMP) nationwide. There was significant state-level variation in the density PMP of trauma (median 1999.5 versus 2983.5, P â < â0.01), surgeon (70.8 versus 98.8, P â<â0.01), training positions (0 versus 3.4, P â<â0.01) between lowest/highest quartiles. Surgeon distribution was positively associated with income and training positions density ( P â<â0.01). Subanalysis revealed that there was an increase of 6.7 plastic and reconstructive surgeons/PMP for every increase of 1000 trauma admissions/PMP ( P â<â0.01). There is an uneven state-level distribution of facial trauma surgeons across the US associated with income. Plastic surgeon distribution corresponded closer to craniofacial trauma care need than that of ENT and OMF surgeons. Further work to close the gap between workforce availability and clinical need is necessary.
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Traumatismos Faciais , Acessibilidade aos Serviços de Saúde , Cirurgiões , Estudos Transversais , Traumatismos Faciais/epidemiologia , Traumatismos Faciais/cirurgia , Acessibilidade aos Serviços de Saúde/estatística & dados numéricos , Humanos , Renda , Cirurgiões/provisão & distribuição , Centros de Traumatologia/provisão & distribuição , Recursos HumanosRESUMO
BACKGROUND: Postmastectomy radiation therapy (PMRT) is an important component in the treatment of locally advanced breast cancer. Optimal timing of therapy in relation to autologous breast reconstruction (ABR) remains clinically debated. Herein, we comparatively analyze short- and long-term outcomes between immediate ABR (I-ABR) and delayed-immediate ABR (DI-ABR) in the setting of PMRT. METHODS: Adult patients undergoing ABR with PMRT were separated into cohorts based on reconstructive timeline: I-ABR or DI-ABR. The groups were propensity matched 1:1 by age, body mass index, and comorbidities. Surgical site events and long-term clinical outcomes (readmissions, reoperations, and revision procedures) were collected. Univariate analyses were completed using Pearson's chi-squared tests and Fisher's exact tests, and statistical significance was set at p < 0.05. RESULTS: One hundred and thirty-two flaps (66 in each cohort) were identified for inclusion. Patients with I-ABR were more likely to experience fat necrosis (p = 0.034) and skin necrosis (p < 0.001), require additional office visits (p < 0.001) and outpatient surgeries (p = 0.015) to manage complications, and undergo revision surgery after reconstruction (p < 0.001). DI-ABR patients, however, had a 42.4% incidence of complications following tissue expander placement prior to reconstruction, with 16.7% of patients requiring reoperation during this time. Only one patient (I-ABR) experienced flap loss due to a vascular complication. CONCLUSION: The complications encountered in both of these groups were not prohibitive to offering either treatment. Patients should be made aware of the specific and unique risks of these reconstruction timelines and involved throughout the entire decision-making process. Plastic surgeons should continue to strive to elucidate innovative approaches that facilitate enhanced quality of life without compromising oncologic therapy.
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Neoplasias da Mama , Mamoplastia , Adulto , Neoplasias da Mama/radioterapia , Neoplasias da Mama/cirurgia , Feminino , Humanos , Mamoplastia/métodos , Mastectomia/métodos , Complicações Pós-Operatórias/cirurgia , Qualidade de Vida , Radioterapia Adjuvante/efeitos adversos , Estudos Retrospectivos , Resultado do TratamentoRESUMO
INTRODUCTION: The 5-year incidence of locoregional recurrence (LRR) after mastectomy is 3-8 %. This study examines the incidence, modes of detection, and reconstructive options after loss of index reconstruction in the largest series of autologous free flap patients who subsequently developed LRR. METHODS: We identified patients undergoing muscle-sparing free transverse rectus abdominus muscle or deep inferior epigastric perforator flap reconstruction for breast cancer at our institution from 2005 to 2017 who subsequently developed LRR. The main outcomes were incidence of recurrence, primary mode of detection, surgical management, and patient and cancer-specific factors associated with surgical management and loss of index reconstruction. RESULTS: The incidence of LRR in this cohort was 3% (n=66 of 2240 flaps), and 71% (n=46) of recurrences were diagnosed on physical examination. 80% (n=53) of LRR required multidisciplinary management, whereas 56% (n=37) were managed surgically. Patients with postoperative radiation prior to recurrence, metastatic disease at diagnosis, nodal positivity, and chest wall involvement were less likely to be offered surgery (all p<0.05). Twelve patients lost their index reconstruction and five required subsequent advanced chest wall reconstruction. No differences were seen in terms of location of recurrence, detection of recurrence, or mortality between flap types (all p>0.05). CONCLUSION: Management of LRR is centered around early multidisciplinary involvement and often requires surgery. Removal of index reconstruction and/or advanced chest well reconstruction is indicated in select cases. Plastic surgeons should be aware of the indications and options that exist for management in these complex situations.
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Neoplasias da Mama , Retalhos de Tecido Biológico , Mamoplastia , Retalho Perfurante , Neoplasias da Mama/patologia , Neoplasias da Mama/cirurgia , Feminino , Seguimentos , Retalhos de Tecido Biológico/cirurgia , Humanos , Mamoplastia/métodos , Mastectomia , Recidiva Local de Neoplasia/patologia , Retalho Perfurante/cirurgia , Estudos RetrospectivosRESUMO
SUMMARY: The persistence of health care disparities along racial and ethnic lines highlights the complex and multifactorial nature of this national concern. The paucity of physicians ethnically underrepresented in medicine to treat an ever-growing heterogeneous population inherently contributes to these ongoing disparities. The authors proposed an approach to improve the representation of physicians underrepresented in medicine in their plastic surgery residency program. With a renewed commitment to ethnic diversity and inclusion, a multifaceted recruitment and retention approach was implemented at the University of Pennsylvania plastic and reconstructive surgery residency program from 2015 to 2020 (5 academic years). A retrospective review of the demographics of the program's residents was then assessed over the past 9 academic years for comparison (2011 to 2020). The representation of underrepresented-in-medicine residents within the plastic and reconstructive surgery residency program steadily increased with the implementation of this multifaceted approach, reaching an unprecedented high. Currently, 29 percent of all residents are underrepresented in medicine and 29 percent are female, some of whom are also underrepresented in medicine. Although the female representation is on par with the national average, the underrepresented-in-medicine representation is far greater than the national average. As a result of this multifaceted approach, the representation of African American and Latino plastic surgery residents at the University of Pennsylvania now far exceeds current national averages. Unfortunately, the representation of Native American and Alaskan Natives is still lacking, despite the program's broadened recruitment efforts. The success of this experience describes a successful strategy that institutions can implement to enhance underrepresented-in-medicine representation among its plastic surgery trainees.
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Etnicidade , Mão de Obra em Saúde , Internato e Residência , Grupos Minoritários , Seleção de Pessoal/métodos , Grupos Raciais , Cirurgia Plástica , Feminino , Humanos , Masculino , Pennsylvania , Estudos Retrospectivos , Cirurgia Plástica/educaçãoRESUMO
BACKGROUND: Linton A. Whitaker is a pioneer of craniofacial surgery. He served as chief of plastic surgery at the Children's Hospital of Philadelphia and University of Pennsylvania and director of the craniofacial training program. Herein, the authors reflect on his legacy by studying the accomplishments of his trainees. METHODS: Dr Whitaker's trainees who completed (a) craniofacial fellowship training while he was director of the program or (b) residency training while he was chief were identified. Curricula vitae were reviewed. Variables analyzed included geographic locations, practice types, academic leadership positions, scholarly work, and bibliometric data. RESULTS: Between 1980 and 2011, 34 surgeons completed craniofacial fellowship training under Dr Whitaker, and 11 completed plastic surgery training under his chairmanship and subsequent craniofacial fellowship. The majority had active craniofacial practices after training (83.3%) and practice in an academic setting (78.0%). Most settled in the northeast (31.1%) and south (31.1%) but across 24 states nationally. Overall, the mean ± SD number of publications was 76 ± 81 (range, 2-339); book chapters, 23 ± 29 (0-135); H-index, 18 ± 12 (1-45); and grants, 13 ± 16 (0-66). Of those who pursued academia, 53.1% were promoted to full professor, 46.9% had a program director role, 75.0% directed a craniofacial program, and 53.1% achieved the rank of chief/chair. CONCLUSIONS: Equally important to Dr Whitaker's clinical contributions in plastic and craniofacial surgery is the development and success of his trainees who will undoubtedly continue the legacy of training the next generation of craniofacial surgeon leaders.
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Internato e Residência , Cirurgiões , Cirurgia Plástica , Criança , Bolsas de Estudo , Humanos , Masculino , Philadelphia , Cirurgia Plástica/educaçãoRESUMO
BACKGROUND: As the number of postmastectomy patients who receive abdominally based autologous breast reconstruction (ABABR) increases, the frequency of unique paramedian incisional hernias (IHs) at the donor site is increasing as well. We assessed incidence, repair techniques, and outcomes to determine the optimal treatment for this morbid condition. METHODS: A total of 1600 consecutive patients who underwent ABABR at the University of Pennsylvania between January 1, 2009, and August 31, 2016, were retrospectively identified. Preoperative and operative information was collected for these patients. Incisional hernia incidence was determined by flap type and donor site closure technique. Repair techniques and postoperative outcomes for all patients receiving IH repair (IHR) after ABABR at our institution were also determined. Univariate and multivariate analyses were conducted. RESULTS: The incidence of IH after ABABR in our health system was 3.6% (n = 61). Fifteen additional patients were referred from outside hospitals for a total of 76 patients who received IHR. At the time of IHR, mesh was used in 79% (n = 60) of cases (13 biologic and 47 synthetic), with synthetics having significantly lower recurrent IH incidence (10.6% vs 38.5%, P = 0.017) when compared with biologics. Mesh position did not have any statistically significant effect on outcomes; however, sublay mesh position had zero adverse outcomes. CONCLUSIONS: Mesh should be used in all cases when possible. Although retrorectus repair with mesh is optimal, this plane is often nonexistent or too scarred in after ABABR. Thus, intraperitoneal underlay mesh with primary fascial closure or primary closure with onlay mesh placement should then be considered.
Assuntos
Neoplasias da Mama , Hérnia Ventral , Hérnia Incisional , Mamoplastia , Feminino , Seguimentos , Hérnia Ventral/cirurgia , Herniorrafia , Humanos , Incidência , Hérnia Incisional/epidemiologia , Hérnia Incisional/etiologia , Hérnia Incisional/cirurgia , Mastectomia , Recidiva Local de Neoplasia , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/cirurgia , Recidiva , Estudos Retrospectivos , Telas CirúrgicasRESUMO
BACKGROUND: Aesthetic surgery is a critical component of academic plastic surgery. As institutions are placing increased focus on aesthetic surgery, there is an opportunity to identify factors that facilitate the creation and maintenance of successful aesthetic plastic surgery programs. OBJECTIVES: The aim of this study was to conduct a national survey to evaluate the current state of academic aesthetic surgery and to identify factors that contribute to success. METHODS: A REDCap 122-question survey was developed and validated by members of the Academic Aesthetic Surgery Roundtable (AASR). The national survey was distributed to department chairs and division chiefs with active ACGME-approved plastic surgery programs (n = 92). Responses underwent Pearson's chi-squared, Wilcoxon rank-sum, and postselection inference analyses. AASR members convened to interpret data and identify best practices. RESULTS: Responses were received from 64 of 92 queries (69.6%). The multivariate analysis concluded traits associated with successful academic aesthetic surgery practices included the presence of aesthetic surgery-focused, full-time faculty whose overall practice includes >50% aesthetic surgery (P = 0.040) and nonphysician aesthetic practitioners who provide injection services (P = 0.025). In the univariate analysis, factors associated with strong aesthetic surgery training programs included resident participation in faculty aesthetic clinics (P = 0.034), aesthetic research (P = 0.006), and discounted resident aesthetic clinics (P < 0.001). CONCLUSIONS: The growth of academic aesthetic surgery practices represents a significant opportunity for advancement of resident training, departmental financial success, and diversification of faculty practices. By identifying and sharing best practices and strategies, academic aesthetic surgery practices can be further enhanced.