Development of "Explore Plastic Surgery": An Educational Program for Medical Students Without Home Residency Programs.

BACKGROUND: Medical students who attend institutions without plastic surgery residency programs are at a disadvantage in the plastic surgery match. We developed an educational program for medical students without home programs called Explore Plastic Surgery to provide an overview of the steps toward a career in plastic surgery. The purpose of this study was to assess the impact, utility, and success of the novel program. METHODS: Pre- and postevent surveys were distributed to participants. Survey data were analyzed including participant demographics, perceptions of barriers unique to those without home programs, and the overall event utility. RESULTS: Two hundred seventeen students registered for the program. Ninety-five participants completed the pre-event survey (44%), and of those, 57 participants completed the post-event survey (60%). There was an increase in understanding of the steps toward a career in plastic surgery ( P < 0.001), confidence in overcoming barriers ( P = 0.005), and level of comfort in reaching out to faculty for opportunities ( P = 0.01). There was a decrease in the perceived negative impact that attending medical schools without a home program will have on their abilities to pursue careers in plastic surgery ( P = 0.006). CONCLUSIONS: After the event, participants demonstrated an increase in their confidence in overcoming barriers and a decrease in their perceptions that attending an institution without a home program would negatively impact their ability to pursue plastic surgery. Initiatives focused on early exposure and recruitment of medical students may be important to promote accessibility and diversity within plastic surgery.

The role of tumor phenotype in the surgical treatment of early-stage breast cancer.

BACKGROUND: We investigated whether tumor phenotype influences surgical decision-making, and how that may impact overall survival (OS) for early-stage breast cancer. METHODS: Women aged 18-69 with cT0-2/cN0/cM0 breast cancer in the National Cancer Database (2010-2017) were included. A generalized logistic model was used to identify factors associated with surgery type. A Kaplan-Meier curve was used to visualize unadjusted OS, and the log-rank test was used to test for differences in OS between surgery types. RESULTS: Of 597,149 patients, 58% underwent lumpectomy with radiation (BCT), 25% unilateral mastectomy (UM), and 17% bilateral mastectomy (BM). After adjustment, HER2+ and triple-negative (TN) tumors were less likely to undergo UM than BCT, versus hormone receptor-positive tumors (OR = 0.881, 95% CI = 0.860-0.903; OR = 0.485, 95% CI = 0.470-0.501). UM and BM had worse 5-year OS versus BCT (UM: 0.926, vs BM: 0.952, vs BCT: 0.960). CONCLUSIONS: BCT is increasingly used to treat HER2+ and TN tumors. More extensive surgery is not associated with better survival outcomes, regardless of tumor phenotype.

The Patient Narrative for Breast Implant Illness: A 10-Year Review of the U.S. Food and Drug Administration's MAUDE Database.

BACKGROUND: There is growing recognition of a condition known as breast implant illness. Very little information exists about the diagnosis and natural history of breast implant illness. To better understand the patient experience, we surveyed the U.S. Food and Drug Administration's Manufacturer and User Facility Device Experience (MAUDE) database for narratives describing symptoms of breast implant illness. METHODS: The MAUDE database was queried for all reports that included breast implant illness within the patient narrative between 2010 and 2020. A review of narratives was used to identify and summarize 36 symptoms over nine symptom classes. Event year and reporting year were summarized. Hierarchical clustering analysis using centroid components was conducted on all reported breast implant illness symptoms, and a dendrogram was created to visualize clustering. RESULTS: During the study period from 2010 to 2020, there were 751 captured adverse event reports in the MAUDE database that referenced breast implant illness, with the first report submission in 2014. Of those reports, 60.6 percent were for silicone implants and 39.4 percent were for saline implants. The three most commonly reported symptom categories were neurologic [ n = 544 (72.4 percent)], followed by musculoskeletal [ n = 418 (55.7 percent)], and dermatologic [ n = 273 (36.4 percent)]. The top 10 symptoms, irrespective of category, include fatigue/weakness, numbness/tingling, brain fog, depression/anxiety, arthralgia, myalgia, headache, hair loss, gastrointestinal issues, and weight change. A hierarchical clustering analysis demonstrated that symptoms reported by patients clustered into two major groups. CONCLUSION: This study demonstrates the utility of public-facing databases, such as the Manufacturer and User Facility Device Experience database, in understanding the patient experience as it relates to breast implant illness.

Symptom Duration and Diabetic Control Influence Success of Steroid Injection in Trigger Finger.

BACKGROUND: Trigger finger is one of the most common hand abnormalities, with a prevalence of 2 percent of the general population. Conservative treatment with corticosteroid injections at the A1 pulley has been shown to be a cost-effective first-line treatment. However, additional patient factors have not fully been described regarding steroid injection efficacy. The authors hypothesize that patients presenting with longer chronicity of symptoms before treatment and elevated blood glucose would have reduced success rates of steroid injection therapy. METHODS: A retrospective chart review of 297 patients at a single institution was performed between 2013 and 2019. Patients were included if they presented with the diagnosis of trigger finger and were treated with initial corticosteroid injection at the A1 pulley. RESULTS: Steroid injection therapy alone was successful in 65 percent of patients. Patients received on average of 1.61 steroid injections. Patients who failed treatment received an average of 1.85 injections compared to 1.49 for those who had successful corticosteroid injection therapy ( p = 0.001). Presence of ipsilateral hand disease was associated with significant increase in failure of steroid injections (43.4 percent versus 30.8 percent; p = 0.032). Diabetic patients with hemoglobin A1c levels greater than 6.5 percent had a significantly higher rate of failing steroid injection therapy (71.9 percent versus 38.1 percent; p < 0.001). Patients who presented with greater than 2.5 months of symptoms had a higher failure rate of corticosteroid therapy (40.4 percent versus 29.5 percent; p = 0.048). CONCLUSION: Patients with a coexisting diagnosis of diabetes and a hemoglobin A1c level greater than 6.5 percent, ipsilateral concomitant hand disease, or presence of symptoms for greater than 2.5 months should be counseled regarding higher risk of failure of local corticosteroid injection. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Contextualizing Breast Implant Removal Patterns with Google Trends: Big Data Applications in Surgical Demand.

The demand for breast implant removal (BIR) has increased substantially in recent years. This study leveraged large datasets available through Google Trends to understand how changes in public perception could be influencing surgical demand, both geographically and temporally. METHODS: Using Google Trends, we extracted relative search volume for BIR-related search terms in the United States from 2006 to 2019. A network of related search terms was established using pairwise correlative analysis. Terms were assessed for correlation with national BIR case volume based on annual reports provided by the American Society of Plastic Surgeons. A surgical demand index for BIR was created on a state-by-state basis. RESULTS: A network of internally correlated BIR search terms was found. Search volumes for such terms, including "explant" [ρ = 0.912], "breast implant removal" [ρ = 0.596], "breast implant illness" [ρ = 0.820], "BII" [ρ = 0.600], and "ALCL" [ρ = 0.895] (P < 0.05), were found to be positively correlated with national BIR case volume, whereas "breast augmentation" [ρ = -0.596] (P < 0.05) was negatively correlated. Our 2019 BIR surgical demand index revealed that Nevada, Arizona, and Louisiana were the states with the highest BIR demand per capita. CONCLUSIONS: Google Trends is a powerful tool for tracking public interest and subsequently, online health information seeking behavior. There are clear networks of related Google search terms that are correlated with actual BIR surgical volume. Understanding the online health queries patients have can help physicians better understand the factors driving patient decision-making.

Assessing the Influence of Failed Implant Reconstruction on Patient Satisfaction and Decision Regret after Salvage Free-Flap Breast Reconstruction.

BACKGROUND: Free-flap breast reconstruction after failed implant reconstruction is associated with improved patient outcomes. How the level of satisfaction achieved compares between patients with and without previously failed implant reconstruction remains unknown. The aim of this study was to assess the influence of prior failed implant-based reconstruction on long-term patient-reported outcomes after free-flap breast reconstruction. METHODS: All patients undergoing free-flap breast reconstruction between 2015 and 2019 were identified. Patient satisfaction using the BREAST-Q and decisional regret using the Decision Regret Scale were compared between patients with and without a history of implant breast reconstruction. RESULTS: Overall, 207 patients were contacted and 131 completed the BREAST-Q and Decision Regret Scale. A total of 23 patients had a history of failed implant-based reconstruction requiring free-flap-flap salvage, most commonly due to infection (39.1%), chronic pain (34.8%), capsular contracture (26%), and implant malposition (26.1%). Following definitive free-flap reconstruction, patients with prior failed implant reconstruction had significantly lower BREAST-Q scores for satisfaction with breast (61.2 ± 16.7 vs. 70.4 ± 18.7; p = 0.04) and sexual well-being (38.5 ± 18.2 vs. 52.8 ± 24.7; p = 0.01) and reported higher decision regret (19.1 ± 18.6 vs. 9.6 ± 15.6, respectively). There were no significant differences for psychosocial well-being (p = 0.67), physical well-being (chest; p = 0.27), and physical well-being (abdomen; p = 0.91). CONCLUSION: A history of failed implant-based reconstruction is associated with reduced satisfaction and increased decision regret with the final reconstructive outcome. This data underscores the importance of appropriate patient selection at the initial consultation, and informed preoperative counseling regarding long-term outcomes in patients presenting for free-flap reconstruction after a failed implant-based reconstruction.

An Assessment of Patient Satisfaction and Decisional Regret in Patients Undergoing Staged Free-Flap Breast Reconstruction.

BACKGROUND: In the setting of radiation therapy or significant medical comorbidities, free-flap breast reconstruction may be intentionally delayed or staged with tissue expander placement ("delayed-immediate" approach). The effect of a staged approach on patient satisfaction and decisional regret remains unclear. METHODS: All patients undergoing free-flap breast reconstruction (n = 334) between 2014 and 2019 were identified. Complication rates, patient satisfaction using the BREAST-Q, and decisional regret using the Decision Regret Scale were compared between patients undergoing immediate, delayed, and staged approaches. RESULTS: Overall, 100 patients completed the BREAST-Q and Decision Regret Scale. BREAST-Q scores for psychosocial well-being (P = 0.19), sexual well-being (P = 0.26), satisfaction with breast (P = 0.28), physical well-being (chest, P = 0.49), and physical well-being (abdomen, P = 0.42) did not significantly vary between patients undergoing delayed, staged, or immediate reconstruction. Overall, patients experienced low regret after reconstruction (mean score, 11.5 ± 17.1), and there was no significant difference in regret scores by reconstruction timing (P = 0.09). Compared with normative BREAST-Q data, unlike immediate and delayed approaches, staged reconstruction was associated with lower sexual well-being (P = 0.006). Furthermore, a significantly higher infection rate was seen among staged patients (immediate 0%, delayed 5%, staged 20%, P = 0.01). CONCLUSIONS: Staged free-flap breast reconstruction confers similar long-term satisfaction and decisional regret as immediate and delayed reconstruction but may be associated with worsened sexual well-being, when compared with normative data, and an increased risk of surgical site infection. When counseling patients regarding the timing of reconstruction, it is important to weigh these risks in the context of equivalent long-term satisfaction and decisional regret between immediate, delayed, and staged approaches.

Survival Outcomes Among Patients with Metastatic Breast Cancer: Review of 47,000 Patients.

BACKGROUND: Although metastatic breast cancer (MBC) remains incurable, advances in therapies have improved survival. Using a contemporary dataset of de novo MBC patients, we explore how overall (OS) and cancer-specific survival (CSS) changed over time. METHODS: All patients with de novo MBC from 1988 to 2016 were selected from Surveillance, Epidemiology, and End Results (SEER) 18. Unadjusted OS and CSS were estimated by Kaplan-Meier method and stratified by disease characteristics. Cox proportional hazards models determined factors associated with survival. RESULTS: 47,034 patients were included, with median OS of 25 months and CSS of 27 months. Survival steadily improved over time (1988: 1-year OS 62%, CSS 65%; 2015: 1-year OS 72%, CSS 74%). Patients with triple-negative breast cancer (TNBC) had the worst prognosis and were most likely to die from MBC [versus human epidermal growth factor receptor 2 (HER2)+ and hormone receptor (HR)+/HER2-]. Those with ≥ 4 sites of metastatic disease were also more likely to die from MBC with nearly identical OS and CSS (5-year OS 9%, CSS 9%), when compared with those with 1 site (5-year OS 31%, CSS 35%). After adjustment, improved CSS was associated with bone-only disease [hazard ratio (HR) 0.88, 95% confidence interval (CI) 0.83-0.94], while TNBC (versus HER2+: HR 3.12, 95% CI 2.89-3.36) and > 3 sites of metastatic disease (versus 1 site: HR 3.24, 95% CI 2.68-3.91) were associated with worse CSS (all p < 0.001). CONCLUSIONS: Accurate prognostic estimates are essential for patient care. As treatments for patients with MBC have expanded, OS and CSS have improved, and more patients, particularly with limited distant disease or favorable tumor subtypes, are also dying from non-MBC causes.

A Comparison of Patient-Reported Outcomes in Bipedicled Total Abdominal versus Unipedicled Hemiabdominal Free Flaps for Unilateral Breast Reconstruction.

BACKGROUND: While bipedicled free flaps enable increased soft tissue volume and potential for contralateral symmetry in unilateral breast reconstruction, the influence of bipedicled flap reconstruction on patient-reported outcomes remains unclear. METHODS: Patients undergoing unilateral free flap breast reconstruction at a single institution from 2014 to 2019 were retrospectively reviewed and sent the BREAST-Q and Decision Regret Scale. Complication rates and the BREAST-Q and Decisional Regret Scale scores (0-100) were compared between patients receiving bipedicled total abdominal and unipedicled hemiabdominal free flaps. RESULTS: Sixty-five patients undergoing unilateral breast reconstruction completed the BREAST-Q and Decision Regret Scale with median (interquartile range [IQR]) follow-up time of 32 [22-55] months. Compared with bipedicled flaps, patients receiving unipedicled hemiabdominal flaps had higher mean body mass index (BMI; p = 0.009) and higher incidence of fat grafting (p = 0.03) and contralateral reduction mammaplasties (p = 0.03). There was no difference in incidence of major or minor complications, abdominal hernias or bulges, or total operative time between bipedicled and unipedicled flaps (p > 0.05). Overall, BREAST-Q scores for satisfaction with breast, sexual wellbeing, psychosocial wellbeing, physical wellbeing (chest), and physical wellbeing (abdomen) and the Decision Regret Scale scores did not significantly vary between bipedicled and unipedicled reconstructions (all p > 0.05). However, among large-breasted patients (≥C cup), mean (standard deviation [SD]) sexual wellbeing was significantly higher after bipedicled total abdominal free flap reconstruction ([60.2 (23.3) vs. 46.2 (22.0)]; p = 0.04), though this difference did not reach significance after multivariate adjustment. CONCLUSION: Unilateral breast reconstruction with bipedicled total abdominal free flaps results in similar complication risk, patient satisfaction, and decisional regret without the need for as many contralateral reduction procedures.

Systematic Review of Tissue Expansion: Utilization in Non-breast Applications.

BACKGROUND: Tissue expansion is a versatile reconstructive technique providing well-vascularized local tissue. The current literature focuses largely on tissue expansion for breast reconstruction and in the context of burn and pediatric skin/soft tissue replacement; however, less traditional applications are also prevalent. The aim of this study was to systematically review the utilization of tissue expansion in such less well-characterized circumstances. METHODS: The authors conducted a systematic review of all publications describing non-breast applications of tissue expansion. Variables regarding expander specifications, expansion process, and complications were collected and further analyzed. RESULTS: A total of 565 publications were identified. Of these, 166 publications described tissue expansion for "less traditional" indications, which fell into 5 categories: ear reconstruction, cranioplasty, abdominal wall reconstruction, orthopedic procedures, and genital (penile/scrotal and vaginal/vulva) reconstruction. While lower extremity expansion is known to have high complication rates, tissue expander failure, infection, and exposure rates were in fact highest for penile/scrotal (failure: 18.5%; infection: 15.5%; exposure: 12.5%) and vaginal/vulva (failure: 20.6%; infection: 10.3%; exposure: 6.9%) reconstruction. CONCLUSIONS: Tissue expansion enables index operations by providing additional skin before definitive reconstruction. Tissue expanders are a valuable option along the reconstructive ladder because they obviate the need for free tissue transfer. Although tissue expansion comes with inherent risk, aggregate outcome failures of the final reconstruction are similar to published rates of complications without pre-expansion. Thus, although tissue expansion requires a staged approach, it remains a valuable option in facilitating a variety of reconstructive procedures.

Volumetric Symmetry after Unilateral Autologous Breast Reconstruction: A Reasonable Goal.

With growing concerns about the overuse of contralateral prophylactic mastectomy, optimizing unilateral mastectomy reconstruction outcomes becomes a priority. However, there remains a paucity of objective data that describe volumetric symmetry between a natural and autologous-reconstructed breast. METHODS: We evaluated patients who underwent unilateral mastectomy reconstruction with free-flap abdominal tissue transfer from 04/2006 to 01/2015, and had at least 2 postoperative magnetic resonance images (MRIs; n = 28). Using these MRI data, volumetric measurements of the reconstructed and natural breast were performed at the first postoperative MRI (after all revisions were complete) and the most recent MRI. Relationships were analyzed using Spearman correlation coefficients. A symmetry score (SS) was calculated such that values closer to 1.0 reflected volumetric symmetry. RESULTS: The mean age (years) and BMI of the patients was 44.8 and 26.8, respectively. The mean interval time between the MRIs was 3.03 years (range 0.43-6.6). After surgical revisions were complete, volumetric symmetry between reconstructed and nonreconstructed breasts was typically achieved (mean SS 0.92). This symmetry was also retained at the end of follow-up (mean SS 0.96), despite a mean change in BMI of 3.9% (range 1.1-7.7). Additionally, the mean number of flap revisions was 0.75 (range 0-2), and 39% of patients had a procedure performed on the natural breast. CONCLUSION: In patients undergoing unilateral abdominal-based breast reconstruction, volumetric symmetry is attainable; however, it can require flap revisions and procedures to natural breast. Interestingly, this study does show that initial symmetry is retained postoperatively, regardless of changes in BMI.

Long-Term Functional Outcomes after Hematopoietic Stem Cell Transplant for Early Infantile Krabbe Disease.

Allogeneic hematopoietic stem cell transplantation (HSCT) can retard the progression of early infantile Krabbe disease (EIKD). Superior outcomes are achieved if HSCT is performed before the onset of symptoms; however, little information is available about the long-term outcomes in surviving patients. We now describe functional outcomes in presymptomatic infants who underwent HSCT for EIKD at ≤ 2 months of age. Records of the 19 patients who underwent HSCT for EIKD at ≤ 2 months of age from 1996 to 2010 were reviewed. Long-term functional outcomes were compared between those transplanted at < 30 days and ≥ 30 days of life. Median age at transplant was 27 days (range, 19 to 61). Median follow-up of the cohort was 12.6 years. Overall survival at 5 and 10 years post-transplant was 84.2% (95% confidence interval, 58.7% to 94.6%) and 78.6% (95% confidence interval, 52.5% to 91.4%), respectively. More favorable outcomes were seen in patients who underwent HSCT at < 30 days of age, particularly in domains of mobility (P = .01), communication (P = .02), and feeding (P = .008). Improved functional outcomes were observed when HSCT was performed in the first month of life, defining a critical period for intervention. These results support the implementation of newborn screening to enable rapid diagnosis and early treatment of infants with EIKD.

Late Effects after Umbilical Cord Blood Transplantation in Very Young Children after Busulfan-Based, Myeloablative Conditioning.

Infants and young children who undergo allogeneic cord blood transplantation (CBT) are at increased risk for late effects because of exposure of developing organs to chemotherapy and radiation therapy typically used in transplant conditioning regimens. Busulfan (Bu)-based myeloablative regimens were developed to eliminate radiation exposure in these young children with the hope that late effects would be minimized. We now describe the late effects in 102 consecutive patients surviving a minimum of 5 years (median follow-up, 12.9 years) post-CBT. Patients were conditioned with high-dose chemotherapy using Bu-containing regimens. No patient received total body irradiation. The median age at transplant was 1 year (range, .1 to 2). Diagnoses included inherited metabolic diseases (59.8%), leukemia (17.6%), congenital immune deficiency (20.2%), bone marrow failure/myelodysplastic syndrome (3.9%), and hemoglobinopathy (2%). Among patients surviving 5 years, the overall survival rate at 10 years post-CBT was 93% (95% CI, 84.9 to 96.8). Virtually all patients (98%) experienced at least 1 significant late effect. Most (83.3%) experienced 2 or more late effects, and more than half of the patients (64.7%) experienced 3 or more late effects. The most commonly observed late effects included dental problems (92.2%), short stature (55.9%), cognitive deficits (53.6%), pulmonary dysfunction (18.6%), and abnormal pubertal development (27.9%). This is the first report of late effects of Bu-based conditioning in a cohort of very young patients at the time of transplant. These results will inform clinical care guidelines for long-term follow-up and add to the growing information regarding outcomes of hematopoietic stem cell transplantation.