Effect of Smartphone App Postoperative Home Monitoring After Oncologic Surgery on Quality of Recovery: A Randomized Clinical Trial.

Importance: There has been an increase in health care-focused smartphone apps, including those for encouraging healthy behaviors and managing chronic conditions, but app-assisted postsurgical care has yet to be fully explored. Objective: To compare quality of recovery and patient satisfaction between conventional in-person follow-up and smartphone app-assisted follow-up for patients following Enhanced Recovery After Surgery Society (ERAS) protocols. Design, Setting, and Participants: This randomized clinical trial, conducted from June 2019 to April 2021, included women older than 18 years undergoing oncologic breast reconstruction or major gynecologic oncology surgery following ERAS protocols with the care of 2 surgeons at an academic tertiary care center. Interventions: Patients were randomized 1:1 to receive smartphone app-assisted follow-up or conventional in-person follow-up. The smartphone group used a surgeon-monitored app to record Quality of Recovery 15 (QoR15) scores, European Organisation for Research and Treatment of Cancer-selected adverse events, drain outputs, and surgical site photographs over 6 weeks. Patient satisfaction scores were assessed using validated Patient Satisfaction Questionnaire III (PSQ-III) subscales at 2 and 6 weeks postoperatively. The conventional follow-up group also completed the QoR15 and PSQ-III questionnaires at these intervals. Main Outcomes and Measures: The primary outcomes were quality of recovery and patient satisfaction, as measured by the QoR15 and PSQ-III, respectively. Secondary outcomes were costs of follow-up; the number of contacts with the medical system, complications, and surgeons' contacts with patients; and surgeons' perceptions of app-assisted care. Results: Of 72 patients included in the trial, 36 underwent breast reconstruction (mean [SD] age, 45.30 [9.13] years) and 36 underwent gynecologic oncology surgery (mean [SD] age, 54.90 [11.18] years). Three patients dropped out (2 who underwent breast reconstruction [1 in the app group, 1 in the control group], 1 who underwent gynecologic oncology surgery [control group]). The app group had significantly higher mean (SD) QoR15 scores than the control group (2 weeks: 127.58 [22.03] vs 117.68 [17.52], P = .02; 6 weeks: 136.64 [17.53] vs 129.76 [16.42], P = .03). Patients were equally satisfied between groups in all subsets of the PSQ-III at these intervals. The mean (SD) number of complications was similar in both groups, and a similar number of surgeon contacts per patient occurred (1.6 [1.2] vs 2.1 [2.0], P = .16). Surgeons appreciated early identification of complications with the app. Conclusions and Relevance: In this randomized clinical trial, postoperative follow-up for patients undergoing breast reconstruction and gynecologic oncology surgery using smartphone app-assisted monitoring led to improved quality of recovery and equal satisfaction with care compared with conventional in-person follow-up. Trial Registration: ClinicalTrials.gov Identifier: NCT03456167.

Breast Reconstruction Decision Aids Decrease Decisional Conflict and Improve Decisional Satisfaction: A Randomized Controlled Trial.

BACKGROUND: Decision aids are useful adjuncts to clinical consultations for women considering breast reconstruction. This study compared the impact of two online decision aids, the Breast RECONstruction Decision Aid (BRECONDA) and the Alberta Health Services (AHS) decision aid, on decisional conflict, decisional satisfaction, and decisional regret. METHODS: This randomized controlled trial included 60 women considering whether or not to undergo breast reconstruction. Two online decision aids, the AHS and the BRECONDA, were compared using randomized two-arm equal allocation. Participants responded to questionnaires at baseline, after the first and second consultations, and at 6 weeks and 6 months after deciding to, or not to, undergo reconstruction. Change in decisional conflict scores was compared between the BRECONDA and the AHS decision aid. Secondary outcomes included decisional regret and decisional satisfaction. RESULTS: Both groups were similar in demographic, clinical, and behavioral characteristics. Women spent more time consulting the BRECONDA in comparison to women using the AHS decision aid (56.7 ± 53.8 minutes versus 28.4 ± 27.2 minutes; P < 0.05). Decisional conflict decreased (P < 0.05), and decisional satisfaction improved over time in both groups (P < 0.05). However, there were no differences based on the type of decision aid used (P > 0.05). Both decision aids had a similar reduction in decisional regret (P > 0.05). CONCLUSIONS: Decision aids decrease decisional conflict and improve decisional satisfaction among women considering breast reconstruction. Physicians should therefore offer patients access to decision aids as an adjunct to breast reconstruction consultations to help patients make an informed decision. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, I.

Exploring breast surgeons' reasons for women not undergoing immediate breast reconstruction.

INTRODUCTION: Factors influencing breast reconstruction rates in Canada are complex and multi-factorial, ranging from patient-related to systemic considerations. For plastic surgeons, rates of immediate breast reconstruction (IBR) hinge on referral patterns from general surgeons performing breast cancer surgery and informed discussions with patients about their goals and risk tolerance. We seek to understand the reasons Alberta patients are not receiving IBR as reported by general surgeons. METHODS: The Synoptec™ database is a synoptic operative report designed by Cancer Surgery Alberta™ and utilized by 95% of Alberta breast cancer surgeons. Within this report are mandatory questions regarding if a patient is receiving IBR and, if not, why. A retrospective review of this database was performed for all patients undergoing surgical treatment of breast cancer over two years. All statistical comparisons were made using chi-squared test for categorical variables with a p-value of 0.05 considered significant. RESULTS: Of 6253 patients undergoing breast cancer surgery, 2649 underwent mastectomy and 615 mastectomy patients received IBR. The most commonly reported reasons patients did not undergo IBR were patient preference (55%), high likelihood of postoperative radiation therapy (20%), and high risk due to patient co-morbidities (12%). Resource limitations (2%) and a lack of an IBR discussion (3%) was rarely cited as reasons for no IBR. CONCLUSIONS: There are many reconstructive options following mastectomy in breast cancer survivors. This study provides a unique look into general surgeon reported reasons patients are not receiving IBR and demonstrates the need for further probing into the thought-process behind these reported reasons from both a surgeon and patient perspective.

Supporting Women's BIA-ALCL Decision-making: Role of the Individual Consult in Empowering the Patient-Physician Team.

BACKGROUND: Breast implant associated anaplastic large cell lymphoma (BIA-ALCL) is a T-cell non-Hodgkin's lymphoma and an uncommon risk of textured breast implants. Over the past decade, concern about BIA-ALCL has been increasing among both patients and surgeons. Patients are seeking a better understanding of their BIA-ALCL risk toward identifying a personalized care plan. This quality improvement project examines the value added by pairing group-based patient education seminars with one-on-one consults. METHODS: Individual consults were held following educational group seminars. Consult field notes underwent qualitative thematic analysis. Themes were cross referenced against a quantitative chart review of patient BIA-ALCL prophylaxis decisions over time. RESULTS: Four key themes were identified: weighing, perceiving, guiding, and supporting. Weighing considers the risk-benefit assessments patients make when weighing their BIA-ALCL risk. Perceiving describes the underlying psychosocial factors that frame patient perceptions of BIA-ALCL risk. Guiding presents the levels of guidance that patients require when making BIA-ALCL prophylaxis decisions. Supporting explores the therapeutic value of the individual consult. Ultimately, 41% of post-seminar consult attendees sought explantation, compared with 4% among patients who did not participate in this program (P < 0.001). CONCLUSIONS: Key lessons include the following: (1) patients weigh BIA-ALCL risk against perceived surgical risks and the value of their reconstruction; (2) patients can benefit from a personalized balance of autonomy and surgeon guidance when selecting a BIA-ALCL prevention plan; (3) surgeons should seek to understand the psychosocial factors that may underlie patient perceptions of BIA-ALCL risk; and (4) individual consults can be therapeutic and help strengthen the patient-surgeon relationship.

Assessing exposure to dermoscopy in plastic surgery training programs.

BACKGROUND: Dermoscopy is a noninvasive tool that improves the diagnostic accuracy of melanoma and other cutaneous malignancies; yet, it is not widely used by plastic surgeons, who commonly manage skin lesions. Thus, the purpose of this study was to explore current practice patterns and knowledge of dermoscopy among plastic surgeons and postgraduate plastic surgery trainees. Additionally, interest to establish a formal dermoscopy curriculum as part of plastic surgery residency training was evaluated. METHODS: An online electronic questionnaire was developed and distributed through email to practicing plastic surgeons and plastic surgery trainees at two Canadian universities. RESULTS: Of the 59 potential participants, 27 (46%) responded. While the majority of participants were familiar with dermoscopy (n = 26; 96%), only one respondent reported using dermoscopy in clinical practice. However, all respondents reported exposure to melanoma clinically (n = 26; one participant did not provide a response). A lack of training, along with lack of access to dermatoscopes, were the most frequently cited reasons for not using dermoscopy. Knowledge scores with regard to dermoscopic features were also low; coupled with a noted propensity toward diagnostic or excisional biopsy, whichcould raise the benign to malignant ratio. Overall, 89% (n = 24) of respondents expressed interest in dermoscopy training in plastic surgery postgraduate training. CONCLUSIONS: Few responding plastic surgeons or plastic surgery residents currently use dermoscopy in training or practice but are interested in formal dermoscopy training in residency.

Evaluation of Intra-Lesional Interleukin 2 for the Treatment of In-Transit Melanoma Disease: L'évaluation de l'interleukine-2 intralésionnelle pour traiter les mélanomes en transit.

BACKGROUND: Intra-lesional interleukin 2 (IL-2) therapy trials for the treatment of in-transit melanoma using different treatment protocols have been published reporting varied results. This study assesses the results of IL-2 therapy in our institution and to evaluate the reproducibility of our response rates when using the same treatment protocol as another Canadian centre. METHODS: A retrospective review was undertaken of patients with in-transit melanoma who were treated with intralesional IL-2 in a single institution from 2010 to 2016. Responses were evaluated using RECIST criteria. Demographic data, tumour characteristics, follow-up data, in-transit-free interval, and survival data were collected and analysed. RESULTS: Forty-nine patients were identified. Overall tumour response rate was 72%, including complete response in 23 patients (47%) and partial response in 12 patients (24%). Stable disease was observed in 4% of patients and progressive disease in 25%. The main side effects were minor discomfort with injections and auto-limited flu-like symptoms. The presence of tumour-infiltrating lymphocytes may be a predictor of better response. CONCLUSION: This study confirms prior experience with intra-lesional IL-2, demonstrating it to be an effective, safe, and well-tolerated therapy for in-transit melanoma. Tumour-infiltrating lymphocytes as a predictor of better response warrant further study.

HISTORIQUE: Les publications sur l'utilisation d'interleukine-2 (IL-2) intralésionnelle pour traiter les mélanomes en transit faisant appel à divers protocoles thérapeutiques ont rendu compte de résultats variables. Dans la présente étude, les chercheurs évaluent les résultats du traitement à l'IL-2 au sein de leur établissement et la reproductibilité de leur taux de réponse lorsqu'ils utilisent le même protocole thérapeutique qu'un autre centre canadien. MÉTHODOLOGIE: Les chercheurs ont effectué une analyse rétrospective des patients atteints d'un mélanome en transit qui ont reçu de l'IL-2 intralésionnelle dans un même établissement entre 2010 et 2016. Ils ont évalué les réponses selon les critères d'évaluation RECIST et ont colligé et analysé les données démographiques, les caractéristiques des tumeurs, les données de suivi, l'intervalle libre en transit et les données de survie. RÉSULTATS: Les chercheurs ont dénombré 49 patients. Le taux de réponse global des tumeurs s'élevait à 72 %, y compris une réponse complète chez 23 patients (47 %) et une réponse partielle chez 12 patients (24 %). Ils ont observé une maladie stable chez 4 % des patients et une maladie évolutive chez 25 % d'entre eux. Les principaux effets secondaires étaient des malaises mineurs à l'injection et des symptômes pseudogrippaux autolimités. L'infiltration lymphocytaire des tumeurs pourrait être un élément prédicteur d'une meilleure réponse. CONCLUSION: La présente étude confirme l'expérience antérieure de l'IL-2 intralésionnelle et démontre qu'il s'agit d'un traitement efficace, sécuritaire et bien toléré contre le mélanome en transit. D'autres études devront être réalisées pour établir si l'infiltration lymphocytaire des tumeurs est un bon élément prédicteur.

COVID-19 and the Impact on Surgical Fellows: Uniquely Vulnerable Learners.

Introduction The COVID 19 pandemic has affected education at all levels. Surgical fellows have faced unique challenges. PROBLEMS: The authors address aspects of Canadian surgical fellowships that have been impacted by the pandemic. These include case volumes, training objectives, funding models, burden of stress and research productivity. SOLUTIONS: Solutions are proposed including varying the mix of cases to meet objectives, pursuing alternative finance structures and leveraging technology for both research and advancing surgical technique. CONCLUSION: These solutions are offered to help mitigate the effects of future pandemics for both current and future surgical fellows.

Delivering Breast Reconstruction Information to Patients-Part 2: Women Report on Preferred Information Content.

PURPOSE: To determine the type of information women want to be provided in order to make an informed decision as to whether, when, and using what technique to proceed with breast reconstruction. METHOD: Using purposeful sampling, 19 patients who had recently undergone various breast reconstruction procedures were recruited to each participate in a 30- to 45-minute semi-structured interview. Participants shared their insights and beliefs regarding the type of breast reconstruction information they most valued prior to undergoing breast reconstruction surgery. Participants were also queried as to perceived information gaps. In some cases, the participants' partners or support persons were also interviewed. Grounded theory and thematic analysis assisted in interview transcript analysis. RESULTS: Eight topics were identified relating to women's informational needs around breast reconstruction. Examples include how to weigh the pros and cons of various breast reconstruction options to decide between flap or implant reconstruction, whether there are safety concerns with immediate breast reconstruction or nipple-sparing reconstruction, and expectations and advice on how to manage possibly unexpected intimacy issues after breast reconstruction. CONCLUSIONS: Using mixed methods research methodology, 19 women reported on preoperative informational gaps relating to their recent breast reconstruction experiences. Patients report that adequate breast reconstruction information prior to breast reconstruction surgery helps them to manage their expectations, prepare for surgery and recovery, and improve postoperative satisfaction.

OBJECTIF: Déterminer le type d'information que les femmes veulent recevoir pour décider de manière éclairée si elles veulent subir une reconstruction mammaire, le moment de la subir et la technique à privilégier. MÉTHODOLOGIE: À l'aide de l'échantillonnage raisonné, 19 patientes qui avaient récemment subi des reconstructions mammaires différentes ont été recrutées pour participer à des entrevues semi-structurées individuelles de 30 à 45 minutes. Elles ont donné leur point de vue et leur avis quant au type d'information sur la reconstruction qu'elles trouvaient le plus important avant l'opération. Elles ont également été invitées à confier leurs perceptions à l'égard du manque d'information. Dans certains cas, les chercheurs ont également interviewé les conjoints ou les proches aidants des participantes. La théorie ancrée et l'analyse thématique ont contribué à l'analyse des entrevues après leur transcription. RÉSULTATS: Huit sujets ont émergé quant aux besoins d'information des femmes sur la reconstruction mammaire. Les exemples incluaient la manière de soupeser le pour et le contre pour choisir entre la reconstruction par lambeau ou par implant, les enjeux de sécurité d'une reconstruction mammaire immédiate ou d'une reconstruction avec épargne mammaire, de même que les attentes et les conseils sur la gestion du risque de problèmes d'intimité inattendus après la reconstruction mammaire. CONCLUSIONS: À l'aide d'une méthodologie de recherche mixte, 19 femmes ont confié les insuffisances d'information dont elles avaient eu l'expérience avant leur récente expérience de reconstruction mammaire. Elles ont déclaré que la transmission d'information appropriée sur la reconstruction mammaire avant l'intervention contribue à gérer les attentes, à se préparer à l'opération et à la convalescence et à accroître la satisfaction après l'opération.

Navigating Women's BIA-ALCL Information Needs: Group Seminars May Offer an Opportunity to Empower the Patient-Surgeon Team.

BACKGROUND: Breast Implant Associated Anaplastic Large Cell Lymphoma (BIA-ALCL) is a T-cell non-Hodgkin's lymphoma that has been linked to textured breast implants, and is an emerging concern within the plastic and reconstructive surgery community. Many surgeons are struggling with how best to inform their patients and manage BIA-ALCL care without overwhelming their standard clinical practice. METHODS: Five educational group seminars were held for 53 patients. A thematic analysis of the field notes taken at each seminar was conducted to identify recurring patient and surgeon behaviors. RESULTS: The thematic analysis identified 5 key themes: seeking, amplifying, framing, trusting, and empowering. Seeking describes the knowledge sought by patients and their varying engagement in their care. Amplifying underlines how the emotionally charged topic of BIA-ALCL impacted patient and surgeon behaviors. Framing presents surgeon efforts to help patients understand the risk level of BIA-ALCL. Trusting addresses the ways BIA-ALCL has impacted patient trust in the medical community and the mechanisms to rebuild this trust. Empowering outlines surgeon efforts to engage patients in shared decision-making. CONCLUSIONS: Herein is presented a possible framework for efficient BIA-ALCL patient education that can be adapted to different surgical practices. Lessons learned are: (1) patients want information on BIA-ALCL's clinical features and prophylactic implant removal; (2) BIA-ALCL discussions are emotionally charged and surgeons must remain cognizant of group dynamics and that the physician-patient power differential may impact patient decision-making; (3) patient trust has been strained but can be restored; and (4) patient responses to BIA-ALCL are variable and subjective; thus, surgeons should emphasize patient-centered care.

Intraoperative Near-infrared Spectroscopy Correlates with Skin Flap Necrosis: A Prospective Cohort Study.

BACKGROUND: Skin flap necrosis (SFN) is a morbid complication that is disfiguring, leads to acute and chronic wound issues, often requires further surgery, and can delay adjuvant chemotherapy. Although most surgeons rely on the clinical examination, near-infrared (NIR) spectroscopy can extrapolate tissue oxygenation and may serve as an important tool to assess flap perfusion intraoperatively. This cohort study was undertaken to evaluate the capacity of NIR spectroscopy to detect clinically relevant differences in tissue perfusion intraoperatively. METHODS: Patients undergoing oncologic resection of breast cancer, sarcomas, and cutaneous tumors requiring flap reconstruction (local, regional, or free) between January 2018 and January 2019 were analyzed in this study. Clinicians were blinded to device tissue oxygen saturation (StO2) measurements taken intraoperatively after closure and at follow-up appointments in the first 30 days. Measurements were categorized as (1) control areas not affected by the procedure, (2) areas at risk, and (3) areas of necrosis. These areas were retrospectively demarcated by 2 blinded assessors on follow-up images and transposed onto anatomically correlated intraoperative StO2 measurements. Mean StO2 values were compared using a single-sample t test and analysis of variance (ANOVA) to determine differences in oxygenation. RESULTS: Forty-two patients were enrolled, and 51 images were included in the analysis. Oncologic procedures were predominantly breast (22), postextirpative melanoma (13), and sarcoma (3) reconstructions. Flap reconstruction involved 30 regional skin flaps, 3 pedicled flaps, and 3 free flaps. Nine patients (20.9%) and 11 surgical sites developed SFN. Mean intraoperative StO2 measurements for control areas, areas at risk, and areas of SFN were 74.9%, 71.1%, and 58.3%, respectively. Relative to control areas, mean intraoperative StO2 measurements were lower by 17.5% (P = 0.01) in ultimate areas of SFN and in areas at risk by 5.8% (P = 0.003). Relative to areas at risk, mean StO2 measurements from areas of ultimate SFN were lower by 8.3% (P = 0.04). CONCLUSION: These preliminary data suggest that measuring skin flap tissue oxygenation intraoperatively, with NIR spectroscopy, can differentiate objective variations in perfusion that are associated with clinical outcomes.

Patient-Reported Satisfaction Following Radiation of Implant-Based Breast Reconstruction.

BACKGROUND: Little is known with regard to patient-reported outcomes (PROs) in the setting of implant-based reconstruction (IBR) with post-mastectomy radiation therapy (PMRT). METHODS: We identified patients who underwent immediate IBR from a prospectively compiled database. The Breast Reconstruction Satisfaction Questionnaire (BRECON-31) was scored and compared between patients with and without PMRT. RESULTS: Sixty-four women met the study criteria. Forty-eight did not receive PMRT and 16 did. Nine women had an unanticipated indication for PMRT. The PMRT group was similar to the control group with regard to baseline characteristics (ie, age, marital status, body mass index, tobacco use, and comorbidities). However, treatment and oncologic characteristics (eg, diagnosis, tumour characteristics, systemic therapy use) differed. Of all complications, only capsular contracture rates differed (1.2% vs 13%; P = .01). Of the 9 subscales, 7 showed no difference in satisfaction between the groups. Radiated women scored lower in the arm concerns and breast appearance subscales. Scores were similar whether the indication for PMRT had been anticipated or not. DISCUSSION: Women with immediate IBR scored similarly to their nonradiated counterparts across 7 of 9 domains of satisfaction. Arm concerns and breast appearance scores are lower with PMRT, likely secondarily to more extensive nodal procedures in higher stage patients and to the side effect profile of radiotherapy. Our findings are in line with the few available studies using other PRO tools to evaluate the impact of PMRT on patient satisfaction and studies objectively measuring the effect of PMRT on arm morbidity and cosmetic outcomes.

HISTORIQUE: On ne sait pas grand-chose de ce que les patientes pensent des résultats (PPR) de leur reconstruction par implant (RPI) lorsqu'elles subissent une radiothérapie après leur mastectomie (RTAM). MÉTHODOLOGIE: Les chercheurs ont recensé les patientes qui ont subi une RPI à partir d'une base de données compilée rétrospectivement. Ils ont calculé le score du questionnaire de satisfaction sur la reconstruction mammaire (BRECON-31) et l'ont comparé entre les patientes avec ou sans RTAM. RÉSULTATS: Soixante-quatre femmes respectaient les critères d'étude. Quarante-huit n'ont pas subi de RTAM et 16 en ont subi une. Neuf femmes ont reçu une indication non anticipée de RTAM. Le groupe ayant subi la RTAM était semblable au groupe témoin pour ce qui est des caractéristiques de base (âge, état matrimonial, indice de masse corporelle, tabagisme et comorbidités). Cependant, les caractéristiques thérapeutiques et oncologiques (diagnostics, caractéristiques de la tumeur, utilisation systémique de traitements) étaient différentes. De toutes les complications, seuls les taux de contracture capsulaire étaient différents (1,2 par rapport à 13 %, P = 0,001). Des neuf sous-échelles, sept ne révélaient pas de différence en matière de satisfaction entre les groupes. Les femmes ayant subi une radiothérapie obtenaient un score plus bas pour ce qui est des sous-échelles d'inquiétudes relatives au bras et à l'apparence des seins. Les scores étaient semblables, que l'indication de RTAM ait été anticipée ou non. EXPOSÉ: Les femmes qui avaient subi une RPI ont obtenu un score semblable à celui de leurs homologues qui n'en avaient pas subi dans sept des neuf domaines de satisfaction. Le score d'inquiétude relatif au bras et le score d'apparence du sein sont plus faibles en cas de RTAM, probablement à cause d'interventions nodales plus radicales chez des patientes à un stade plus avancé et du profil d'effets secondaires de la radiothérapie. Les constatations des chercheurs correspondent à celles des quelques études faisant appel à d'autres outils de PPR pour évaluer les répercussions de la RTAM sur la satisfaction des patientes et les études qui mesurent objectivement l'effet de la RTAM sur la morbidité du bras et les résultats esthétiques.

The Making of Breasts: Navigating the Symbolism of Breasts in Women Facing Cancer.

In many cultures, the female breast is a potent symbol of beauty, motherhood, and vitality. When such breasts become diseased and a woman is faced with a mastectomy, multiple competing discourses converge to complicate the decision for or against breast reconstruction. This process can be fraught with tension and ambivalence. Women, along with surgeons working in the field of breast reconstruction, should be aware of the cultural history that shapes the understanding of breasts. When a woman considers her options, she is influenced by the personal and the evolving social and cultural discourse.

Dans bien des cultures, les seins féminins sont de puissants symboles de beauté, de maternité et de vitalité. Lorsqu'ils sont atteints par la maladie et que la femme subit une mastectomie, de multiples discours divergents compliquent la décision de subir ou non une reconstruction mammaire. Ce processus peut être teinté de tension et d'ambivalence. Les femmes, de même que les chirurgiens qui travaillent dans le domaine de la reconstruction mammaire, devraient connaître l'histoire culturelle qui façonne la compréhension des seins. Lorsqu'une femme évalue ses options, elle est influencée par son discours personnel et par l'évolution des discours sociaux et culturels.

Delivering Breast Reconstruction Information to Patients: Women Report on Preferred Information Delivery Styles and Options.

PURPOSE: To discover missed opportunities for providing information to women undergoing breast reconstruction in an effort to decrease regret and improve patient education, teaching modalities, and satisfaction. METHOD: Thirty- to 45-minute semi-structured interviews were conducted exploring patient experiences with information provision on breast reconstruction. Purposeful sampling was used to include women with a variety of reconstruction types at different time points along their recovery. Using grounded theory methodology, 2 independent reviewers analyzed the transcripts and generated thematic codes based on patient responses. BREAST-Q scores were also collected to compare satisfaction scores with qualitative responses. RESULTS: Patients were interested in a wide variety of topics related to breast reconstruction including the pros and cons of different options, nipple-sparing mastectomies, immediate breast reconstruction, oncological safety/monitoring and the impact of chemotherapy and radiotherapy, secondary procedures (balancing, nipple reconstruction), post-operative recovery, and long-term expectations. Patients valued accessing information from multiple sources, seeing numerous photographs, being guided to reliable information online, and having access to a frequently asked questions file or document. Information delivery via interaction with medical personnel and previously reconstructed patients was most appreciated. Compared with BREAST-Q scores for satisfaction with the plastic surgeon (mean: 95.7, range: 60-100), informational satisfaction scores were lower at 74.7 (50-100), confirming the informational gaps expressed by interviewees. CONCLUSIONS: Women having recently undergone breast reconstruction reported key deficiencies in information provided prior to surgery and identified preferred information delivery options. Addressing women's educational needs is important to achieve appropriate expectations and improve satisfaction.

OBJECTIF: Découvrir les occasions ratées de transmettre de l'information aux femmes qui subissent une reconstruction mammaire afin de réduire les regrets et d'améliorer l'éducation, les modalités d'enseignement et la satisfaction des patientes. MÉTHODOLOGIE: Les chercheurs ont effectué des entrevues semi-structurées de 30 à 45 minutes sur l'expérience des patientes à l'égard de la transmission d'information sur la reconstruction mammaire. Ils ont utilisé un échantillonnage par choix raisonné pour inclure des femmes qui avaient subi divers types de reconstruction à différents moments de leur convalescence. À l'aide de la méthodologie de la théorie à base empirique, deux analystes indépendants ont examiné les transcriptions et produit des codes thématiques en fonction des réponses des patientes. Les chercheurs ont également colligé les scores BREAST-Q pour comparer les scores de satisfaction aux réponses qualitatives. RÉSULTATS: Les patientes s'intéressaient à des sujets très variés liés à la reconstruction mammaire, y compris le pour et le contre des diverses possibilités, les mastectomies épargnant le mamelon, la reconstruction mammaire immédiate, la sécurité et la surveillance oncologique et les effets de la chimiothérapie et de la radiothérapie, les interventions secondaires (équilibrage, reconstruction du mamelon), la convalescence après l'intervention et les attentes à long terme. Les patientes aimaient avoir accès à de l'information provenant de multiples sources, voir de nombreuses photographies, être orientées vers de l'information fiable en ligne et avoir accès à une foire aux questions en ligne ou sur papier. Elles préféraient les interactions avec le personnel médical ou des patientes ayant déjà subi une reconstruction pour obtenir l'information. Par rapport au score BREAST-Q de satisfaction envers le plasticien (moyenne de 95,7, plage de 60 à 100), les scores de satisfaction informationnelle étaient plus faibles, à 74,7 (plage de 50 à 100), ce qui confirme les lacunes exprimées par les répondantes. CONCLUSION: Les femmes qui avaient récemment subi une reconstruction mammaire ont rendu compte de lacunes clés dans l'information qui leur avait été transmise avant leur opération et ont précisé les modes de transmission de l'information qu'elles privilégiaient. Il est important de se pencher sur les besoins d'information des femmes pour bien répondre à leurs attentes et accroître leur satisfaction.

Direct-to-implant Breast Reconstruction with Autoderm.

BACKGROUND: Traditional transverse mastectomies yield suboptimal results in women with higher body mass index, wide breast footprint, and ptotic breasts. An option for this patient population is a reduction-pattern style mastectomy, and recruiting an inferiorly based dermal flap using the lower mastectomy flap. This is analogous to a vascularized dermal matrix supporting the lower pole of the implant, termed "Autoderm" breast reconstruction. This allows for aesthetically appealing skin reduction mastectomies with the added safety of a vascularized dermal flap to facilitate an immediate direct-to-implant breast reconstruction. This study assesses patient satisfaction using the validated BRECON-31 questionnaire to enhance shared-decision making with women contemplating breast reconstruction. METHODS: A 2-year retrospective review of women who underwent Autoderm direct-to-implant breast reconstruction comparing patients who underwent unilateral and bilateral reconstruction in terms of characteristics, complications, and BRECON-31 scoring. RESULTS: Overall patient scores were high (81.6 of 100). In particular, women scored very high on self-image (85.0), arm concerns (86.4), intimacy (87.4), satisfaction (88.3), and expectations subscales (85.5). Women choosing bilateral reconstruction outperformed unilateral reconstruction in every subgroup, but only attained statistical significance in the "self-consciousness" subgroup. Compared with a historical cohort of a mix of implant reconstruction types, Autoderm patients showed improved satisfaction (88.3 versus 82.5; P = 0.07) and breast appearance (73.9 versus 66.8; P = 0.06), approaching significance. Safety was demonstrated by low major complications (4.7%) and low implant loss rates (2.3%). CONCLUSIONS: Autoderm breast reconstruction is a safe option in women with large, ptotic breasts, with patients reporting high satisfaction using a validated instrument.

Improved Recovery Experience Achieved for Women Undergoing Implant-Based Breast Reconstruction Using an Enhanced Recovery after Surgery Model.

BACKGROUND: Enhanced recovery after surgery was compared with traditional recovery after surgery for postmastectomy alloplastic breast reconstruction. METHODS: Length of stay, emergency room visits, and complications within 30 days of surgery were compared among three groups: traditional recovery after surgery, transition (some elements of enhanced recovery protocol, not transitioned to outpatient care), and enhanced recovery after surgery (day surgery, provided with standardized perioperative education and multimodal analgesia). Prospective data collection allowed quality-of-recovery assessment using a validated questionnaire for enhanced recovery/transition groups. Results were statistically analyzed (analysis of variance/chi-square). RESULTS: The traditional recovery, transition, and enhanced recovery cohorts comprised 29, 11, and 29 patients, respectively. No significant differences were present regarding age, smoking status, preoperative radiation, single stage direct-to-implant versus tissue expander, bilateral versus unilateral surgery, or immediate versus delayed reconstruction among groups. Average length of stay was 1.6 nights in both the traditional recovery and transition groups, compared with 0 nights in the enhanced recovery group (p < 0.001). Enhanced recovery patients had less severe pain (p = 0.02) and nausea (p = 0.01), and better enjoyed their food (p = 0.0002) and felt more rested (p = 0.02) than their transition counterparts. There were no differences in the number of emergency room visits among the three groups (p = 0.88). There was no difference in the rate of hematoma (p = 0.36), infection requiring intravenous antibiotics (p = 0.36), or infection requiring explantation (p = 0.36) among the three groups. CONCLUSION: An enhanced recovery protocol for alloplastic breast reconstruction treated patients safely, with improved patient satisfaction and same-day discharge and with no increase in complications. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Enhanced Recovery After Surgery (ERAS) Protocol Enables Safe Same-Day Discharge After Alloplastic Breast Reconstruction.

BACKGROUND: To compare enhanced recovery after surgery (ERAS) with traditional recovery after surgery (TRAS) for patients undergoing alloplastic breast reconstruction. METHODS: A retrospective chart review of 2 patient groups (ERAS and TRAS) undergoing alloplastic breast reconstruction was performed. Data were collected from 2012 to 2013 (TRAS) and from 2013 to 2016 (ERAS). The ERAS protocol included day surgery, multimodal analgesia, and preoperative anti-emetic. The TRAS pathway involved overnight admission, narcotic-based analgesia, and no preoperative anti-emetic. Demographics, operative variables, and complications were compared between groups. RESULTS: Seventy-eight ERAS patients and 78 TRAS patients were included. Length of stay was shorter for ERAS patients (0.38 nights ERAS and 1.45 nights TRAS; P < .001). The ERAS patients underwent significantly more bilateral surgery (80.8% ERAS and 55.1% TRAS; P < .001), immediate reconstruction (98.6% ERAS and 89.3% TRAS; P = .004), and had more implants versus expanders placed (66% [93/141] ERAS and 24.8% TRAS; P < .001). There were no differences in the number of post-operative emergency department visits (8% ERAS and 14% TRAS; P = .2) and readmissions (8% ERAS and 3.8% TRAS; P = .3) between the groups. There was no difference in the rate of hematoma (0.7% ERAS and 0% TRAS; P = .35), infection requiring explantation (1.4% ERAS and 0.8% TRAS; P = .65), infection requiring outpatient IV antibiotics (1.4% ERAS and 2.5% TRAS; P = .53), and infection requiring IV antibiotics and readmission (2.1% ERAS and 1.7% TRAS; P = .78) between the groups. There were no differences in the number of minor complications (22% ERAS and 23% TRAS; P = .82). CONCLUSION: The ERAS protocol for alloplastic breast reconstruction is safe, without increased readmission or complication rates compared to TRAS, and significantly decreased length of stay.

HISTORIQUE: Comparer la récupération rapide après la chirurgie (RRAC) à la récupération habituelle après la chirurgie (RHAC) chez les patientes qui subissent une récupération mammaire alloplastique. MÉTHODOLOGIE: Les chercheurs ont procédé à l'analyse rétrospective des dossiers de deux groupes de patientes (RRAC et RHAC) qui subissaient une reconstruction mammaire alloplastique. Ils ont recueilli les données de 2012 et 2013 (RHAC) et de 2013 à 2016 (RRAC). Le protocole RRAC incluait une chirurgie d'un jour, une analgésie multimodale et un anti-émétique préopératoire. La voie RHAC incluait l'admission d'une nuit, une analgésie narcotique et l'absence d'anti-émétique préopératoire. Les chercheurs ont comparé les données démographiques, les variables opératoires et les complications entre les groupes. RÉSULTATS: Au total, 78 patientes RRAC et 78 patientes RHAC ont participé à l'étude. Les patientes RRAC étaient hospitalisées moins longtemps (0,38 nuit RRAC, 1,45 nuit RHAC, p<0,001). Les patientes RRAC ont subi beaucoup plus de chirurgies bilatérales (80,8 % RRAC, 55,1 % RHAC, p<0,001) et de reconstructions immédiates (98,6 % RRAC, 89,3 % RHAC, p=0,004) et se sont fait installer plus d'implants que d'expanseurs (66 % RRAC [93 sur 141], 24,8 % RHAC, p<0,001). Les groupes ne présentaient pas de différence quant au nombre de rendez-vous postopératoires à l'urgence (8 % RRAC, 14 % RHAC, p=0,2) et de réhospitalisations (8 % RRAC, 3,8 % RHAC, p=0,3). Ils ne présentaient pas de différences quant au taux d'hématomes (0,7 % RRAC, 0 % RHAC, p=0,35) ni d'infection exigeant l'explantation (1,4 % RRAC, 0,8 % RHAC, p=0,65), la prise d'antibiotiques IV ambulatoires (1,4 % RRAC, 2,5 % RHAC, p=0,53) ou la prise d'antibiotiques IV et une réhospitalisation (2,1 % RRAC, 1,7 % RHAC, p=0,78). Le nombre de complications mineures ne différait pas davantage (22 % RRAC, 23 % RHAC, p=0,82). CONCLUSION: Le protocole RRAC de reconstruction mammaire alloplastique est sécuritaire, n'accroît pas le taux de réhospitalisations ou de complications par rapport à la RHAC et réduit le séjour hospitalier de manière significative.

Avoiding Skin Grafts: The Keystone Flap in Cutaneous Defects.

The Keystone Design Perforator Island Flap is a fasciocutaneous perforator flap resembling two end-to-end VY flaps. We used a modification of the original design to avoid extending the incision into an elliptical pattern, and maintained a trailing skin bridge whilst incising fascia in a tunneling fashion. Thirty patients underwent 32 flaps mainly on the lower leg to close defects that would traditionally require skin grafting. All flaps survived completely, with minor complications in four patients. All but five patients were allowed unrestricted ambulation after surgery. The modified design is straightforward to learn, has reliable perfusion, and provides a simpler recovery for patients. CLINICAL QUESTIONS/LEVEL OF EVIDENCE: Therapeutic, IV.