The Keystone Perforator Island Flap: Review of Utility and Versatile Clinical Applications.

Background: The keystone perforator island flap (KPIF) was described almost a decade ago. However, this flap has only recently been recognized for its advantages in various clinical applications in plastic surgery. A better understanding of the versatility of KPIFs can help promote the widespread adoption of this technique for complex wounds in various anatomical regions. Methods: A retrospective chart review was conducted of patients undergoing KPIFs from December 2018 to March 2022 at the authors' home institution. The indications, surgical approaches, patient characteristics, and outcomes were extracted for review and analysis. Results: A total of 12 patients (ages 13-86 years) underwent reconstruction with KPIFs for oncologic and nononcologic defects. By anatomic region, three cases involved the upper back, six involved the lumbosacral region, one involved the perineum, and two involved the midfoot. Half of the patients (n = 6) had failed previous attempts at wound closure. The mean defect size was 13.8 × 10.0 cm for the upper back lesions, 13.7 × 4.8 for the lumbosacral defects, and 3.5 × 2.0 for the metatarsal wounds. Median follow-up time for all patients was 7.5 months (IQR: 4-10.5). On follow-up, there was 100% flap survival. Conclusion: KPIFs are a simple, safe, and suitable option for reconstructive closure of defects in many anatomical areas, including wounds complicated by previous failed closure attempts, with low complication risk profile.

External Validation of the Breast Cancer Surgery Risk Calculator (BCSRc): A Predictive Model for Postoperative Complications.

BACKGROUND: The breast cancer surgical risk calculator (BCSRc) is a prognostic tool that determines a breast cancer patient's unique risk of acute complications following each possible surgical intervention. When used in the preoperative setting, it can help to stratify patients with an increased complication risk and enhance the patient-physician informed decision-making process. The objective of this study was to externally validate the four models used in the BCSRc on a large cohort of patients who underwent breast cancer surgery. METHODS: The BCSRc was developed by using a retrospective cohort from the National Surgical Quality Improvement Program database from 2005 to 2018. Four models were built by using logistic regression methods to predict the following composite outcomes: overall, infectious, hematologic, and internal organ complications. This study obtained a new cohort of patients from the National Surgical Quality Improvement Program by utilizing participant user files from 2019 to 2020. The area under the curve, brier score, and Hosmer-Lemeshow goodness of fit test measured model performance, accuracy, and calibration, respectively. RESULTS: A total of 192,095 patients met inclusion criteria in the development of the BCSRc, and the validation cohort included 60,144 women. The area under the curve during external validation for each model was approximately 0.70. Accuracy, or Brier scores, were all between 0.04 and 0.003. Model calibration using the Hosmer-Lemeshow statistic found all p-values > 0.05. All of these model coefficients will be updated on the web-based BCSRc platform: www.breastcalc.org . CONCLUSIONS: The BCSRc continues to show excellent external-validation measures. Collectively, this prognostic tool can enhance the decision-making process, help stratify patients with an increased complication risk, and improve expectant management.

Poor accessibility to consumer pricing exists for elective hernia repair surgery.

BACKGROUND: Hospital price transparency is federally mandated to improve consumer accessibility. We aimed to evaluate how hospitals were complying with these regulations for elective hernia repairs. METHODS: Searches were performed for different hospital systems in attempt to find a price for the procedure using author's own health insurance. Data collected included time to reach the cost estimate tool, time to obtain price estimates, and price ranges. With prices for inguinal and ventral hernia repairs varying across the state's medical centers. RESULTS: Fourteen medical centers across the country were included, all had a cost estimate calculator. The average success rate of obtaining a cost for inguinal hernia was 48%. Comparatively, the average success rate of obtaining a cost for ventral hernia was 12%. Of the successful searches for price, significant variation exists amongst the accessed hernia procedure cost. CONCLUSION: Despite federal mandates for hospital price transparency, online cost-estimate calculators are underperforming, thus exposing a need for more accessible cost-estimates for patients undergoing elective hernia repair.

Closed Incision Negative Pressure Therapy in Oncoplastic Breast Surgery: A Comparison of Outcomes.

We aim to discern the impact of closed incision negative pressure therapy (ciNPT) on wound healing in the oncoplastic breast surgery population. Methods: A retrospective analysis was conducted on patients who underwent oncoplastic breast surgery with and without ciNPT in a single health system over 6 years. Oncoplastic breast surgery was defined as breast conservation surgery involving partial mastectomy with immediate volume displacement or replacement techniques. Primary outcomes were rates of clinically significant complications requiring either medical or operative intervention, including seroma, hematoma, fat necrosis, wound dehiscence, and infection. Secondary outcomes were rates of minor complications. Results: ciNPT was used in 75 patients; standard postsurgical dressing was used in 142 patients. Mean age (P = 0.73) and Charlson Comorbidity Index (P = 0.11) were similar between the groups. The ciNPT cohort had higher baseline BMIs (28.23 ± 4.94 versus 30.55 ± 6.53; P = 0.004), ASA levels (2.35 ± 0.59 versus 2.62 ± 0.52; P = 0.002), and preoperative macromastia symptoms (18.3% versus 45.9%; P ≤ 0.001). The ciNPT cohort had statistically significant lower rates of clinically relevant complications (16.9% versus 5.3%; P = 0.016), the number of complications (14.1% versus 5.3% with one complication, 2.8% versus 0% with >2; P = 0.044), and wound dehiscence (5.6% versus 0%; P = 0.036). Conclusions: The use of ciNPT reduces the overall rate of clinically relevant postoperative complications, including wound dehiscence. The ciNPT cohort had higher rates of macromastia symptoms, BMI, and ASA, all of which put them at increased risk for complications. Therefore, ciNPT should be considered in the oncoplastic population, especially in those patients with increased risk for postoperative complications.

The adoption of oncoplastic surgery: Is there a learning curve?

INTRODUCTION: Oncoplastic surgery (OPS) is a form of breast conservation surgery involving partial mastectomy followed by volume displacement or replacement surgery. As the field of OPS is growing, we sought to determine if there was a learning curve to this surgery. METHODS: A retrospective chart review was conducted of all patients who underwent OPS over a 6-year period with a single surgeon formally trained in both Plastic Surgery and Breast Oncology. Cumulative summation analysis (CUSUM) was performed on mean operative time to generate the learning curve and learning curve phases. Outcomes were compared between phases to determine significance. RESULTS: Mean operative time decreased significantly across the 6-year period, generating three distinct learning curve phases: Learner phase (cases 1-23), Competence phase (24-73), and Mastery phase (74 and greater). The overall positive margin rate was 10.9% and there was no significant difference in rates between phases (p = 0.49). Overall complication rates, reoperation rates, and locoregional recurrence remained the same across all phases (p = 0.16; p = 0.65; p = 0.41). The rate of partial nipple loss decreased between phases (p = 0.02). CONCLUSION: As with many complex operations, there does appear to be a learning curve with OPS, as the operative time and the rates of partial nipple loss decreased over time.

Single Versus Dual Surgeon Approaches to Oncoplastic Surgery: A Comparison of Outcomes.

INTRODUCTION: Oncoplastic surgery (OPS) is traditionally performed using a dual surgeon (DS) approach that involves both a breast surgeon and a plastic surgeon. It is also performed using a single surgeon (SS) approach with a surgeon trained in both breast surgical oncology and plastic surgery. We sought to determine if outcomes differed between SS versus DS OPS approaches. METHODS: A retrospective chart review was conducted of all OPS performed in a single health system over a 6-y period by either an SS or a DS approach. Primary outcomes were rates of positive margins and the overall complication rate; secondary outcomes were loco-regional recurrence, disease-free survival, and overall survival. RESULTS: A total of 217 patients were identified; 117 were SS cases and 100 were DS cases. Baseline preoperative patient characteristics were similar between the two groups as there was no difference in mean Charlson Comorbidity Index scores (P = 0.07). There was no difference in tumor stage (P = 0.09) or nodal status (P = 0.31). Rates of positive margins were not significantly different (10.9% (SS) versus 9% (DS); P = 0.81), nor were rates of complications (11.1% (SS) versus 15% (DS); P = 0.42). Rates of locoregional recurrence were also not significantly different (1.7% (SS) versus 0% (DS); P = 0.5). Disease-free survival and overall survival were not significantly different at 1-y, 3-y, and 5-y time points (P = 0.20 and P = 0.23, respectively) although follow-up time was not sufficient for definitive analysis regarding survival. CONCLUSIONS: Both SS and DS approaches to OPS have similar outcomes with regards to positive margin rates and surgical complication rates and are comparably safe.

A Cost-Utility Analysis of the Use of Closed-Incision Negative Pressure System in Vascular Surgery Groin Incisions.

OBJECTIVE: Closed-incision negative pressure therapy (CINPT) with the Prevena system has been used and clinically evaluated in high-risk groin incisions to reduce the risk of postoperative complications. We performed a cost-effectiveness analysis evaluating CINPT in femoral-popliteal bypass with prosthetic graft. METHODS: A literature review looking at prospective randomized trials determined the probabilities and outcomes for femoral-popliteal bypass with and without CINPT. Reported utility scores were used to estimate the quality adjusted life years (QALYs) associated with a successful procedure and postoperative complications. Medicare current procedure terminology and diagnosis-related group codes were used to assess the costs for a successful surgery and associated complications. A decision analysis tree was constructed with rollback analysis to highlight the more cost-effective strategy. An incremental cost-effectiveness ratio (ICER) analysis was performed with a willingness to pay at $50,000. Deterministic and probabilistic sensitivity analyses were performed to validate the robustness of the results, and to accommodate for the uncertainty in the literature. RESULTS: Femoral-popliteal bypass with CINPT is less costly ($40,138 vs $41,774) and more effective (6.14 vs 6.13) compared to without CINPT. This resulted in a negative ICER of -234,764.03, which favored CINPT, indicating a dominant strategy. In one-way sensitivity analysis, surgery without CINPT was more cost-effective if the probability of successful surgery falls below 84.9% or if the cost of CINPT exceeds $3139. Monte Carlo analysis showed a confidence of 99.07% that CINPT is more cost-effective. CONCLUSIONS: Despite the added device cost of CINPT, it is cost-effective in vascular surgical operations using groin incisions.

Examining a decade of racial disparity in partial mastectomy and oncoplastic surgery.

BACKGROUND AND OBJECTIVES: Understanding racial disparity is crucial to addressing health equity and access to care. Our study aims to examine racial differences in breast conserving surgery (BCS) utilization rates and determine how these rates have changed over time. METHODS: This retrospective cohort analysis utilized the NSQIP database to identify women diagnosed with breast cancer who underwent BCS procedures between 2008 and 2019. Racial utilization trends were analyzed using a Cochran-Armitage test and Index of Disparity analysis. RESULTS: In the 12-year period, 202 492 women underwent a breast cancer surgery, of which 47% underwent BCS. Within the BCS subgroup, oncoplastic surgery utilization increased from 3% to 10%, leading to a declining proportion of partial mastectomies: 97% to 90.0% (both p < 0.01). The racial index of disparity for overall BCS patients decreased from 7% to 6%, remained unchanged (1%) for partial mastectomies, and significantly decreased in oncoplastics (23%-7.6%). CONCLUSION: BCS represents a mainstay option for early-staged breast cancer interventions, this study demonstrate promising progress in decreasing the index of disparity among races and persistent racial inequalities.

Management of Gynecomastia and Male Benign Diseases.

Gynecomastia is a common benign breast disease involving abnormally increased mammary gland tissue that can affect men of all ages. It is usually due to a hormonal imbalance without a definitive underlying cause (idiopathic), or secondary to medications/drugs, systemic disorders, or malignancy. Gynecomastia is often self-limiting, and its management is watchful waiting. Other male benign breast diseases, such as cysts, lipomas, seromas, infections, and pseudoangiomatous stromal hyperplasia, should be worked up in a similar manner and often require surgical drainage or excision.

Rare Presentation of Breast Implant Infection and Breast Implant Illness Caused by Penicillium Species.

What is breast implant illness? What is the proposed pathophysiology behind breast implant illness? What are the most common etiologies of fungal breast implant infections? What risks should patients undergoing breast augmentation be informed of?

The Thoracodorsal Artery Perforator Flap: A Powerful Tool in Breast Reconstruction.

BACKGROUND: Perforator flap use in breast cancer reconstruction has evolved significantly in the last decade. The authors reviewed their experience and evaluated thoracodorsal artery perforator (TDAP) flap outcomes in breast reconstruction. METHODS: A retrospective chart review was conducted of all women undergoing breast reconstruction between 2012 and 2018. Included were patients who underwent a mastectomy (unilateral or bilateral) with immediate reconstruction or requiring a revision reconstruction with a TDAP flap. Reconstruction for nonmalignant causes were excluded. Patient demographics, risk factors, indications, operative details, and complications were reviewed. Major (partial or total flap necrosis, hematoma, and wound breakdown requiring operative management) and minor (cellulitis, seroma, and minor wound breakdown managed with local wound care) complications were recorded. RESULTS: A total of 138 charts were reviewed for the years 2012 and 2018, and 126 patients met inclusion criteria. Mean patient age was 52.1 years. Mean patient body mass index was 29.1 kg/m 2 . A total of 174 TDAP flaps were performed. The success rate was 98.3 percent. There were three flap losses (all partial). Operable fat necrosis rate was 3 percent. Donor-site morbidity was low at a rate of 1.2 percent. There was no difference in complications between patients who had a history of radiation therapy and those who did not (16.7 and 18.6 percent, respectively; p = 0.829). CONCLUSIONS: This study is the largest series in the literature that highlights the utility of the TDAP flap in breast reconstruction. This flap is a powerful tool that should be considered in patients for whom other reconstructive options have been exhausted or unavailable. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Comparing oncoplastic breast reduction with immediate symmetry surgery to standard breast reduction surgery: Are postoperative complications worse?

INTRODUCTION: Oncoplastic breast reduction mammoplasty (ORM) is an excellent treatment option for women with breast cancer and macromastia undergoing breast conservation therapy. Here, we aim to better understand the risks associated with ORM compared to standard reduction mammoplasty (SRM). METHODS: A retrospective chart review was performed of patients undergoing ORM or SRM from 2015 to 2021. Primary outcomes included the occurrence of major or minor postoperative complications in the two groups and delays to adjuvant therapy (>90 days) among the women undergoing ORM. RESULTS: Women in the ORM group (n = 198) were significantly older (p < 0.001) with a higher prevalence of smoking (p < 0.001), diabetes mellitus (p < 0.01), and a Charlson comorbidity index ≥ 3 (p < 0.001) compared to women undergoing SRM (n = 177). After controlling for potential confounders, there were no significant between-group differences in the odds of developing postoperative complications (odds ratio = 0.80, 95% confidence interval: 0.36-1.69). Only 3% (n = 4) of the 150 women undergoing adjuvant radiation or chemotherapy experienced delays related to postoperative complications. CONCLUSION: ORM has a similar safety profile as SRM, despite the older age and higher number of comorbidities often seen in patients undergoing ORM, and is a safe option for achieving contralateral symmetry at the time of partial mastectomy without delays to adjuvant therapy.

Breast Implant Illness: Treatment Using Total Capsulectomy and Implant Removal.

Background: Breast implant illness (BII) is extramammary systemic symptoms that are caused by breast implants. The emergence of this controversial topic has spurred patients with breast implants who are experiencing these symptoms to seek implant removal, hoping to feel better. This article presents novel outcomes and suggestions for plastic surgeons in managing BII using total capsulectomy and breast implant removal. Methods: In this retrospective cohort study conducted between 2016 and 2020, medical records of all patients undergoing breast implant removal were reviewed. Inclusion criteria consisted of all patients with history of breast implant placement presenting with mastodynia and capsular contracture on physical examination. Patients with history of implant-based reconstruction following mastectomy and patients who underwent implant exchange were excluded. All patients underwent bilateral implant removal and total capsulectomies. Results: A total of 200 patients who fulfilled the inclusion criteria were identified. Average age was 45.5 (range: 29-73) years and average body mass index was 26.28 (range: 19-36.8), with an average follow-up time of 5 months postoperatively. Of patients with a presentation of BII, 96% reported improved or complete resolution of their systemic symptoms after implant removal and total capsulectomy. A positive microbial culture was found in 68.5% of patients, and all culture-positive patients reported improvement post-treatment. The most common organisms found were Propionibacterium acnes (49.6%). There were no associations between implant characteristics and rate of positive microbiology findings. Conclusions: Our study shows that implant removal with capsulectomy drastically improves BII symptoms. Further large prospective cohort studies are needed to better understand this entity.

Sleep Quality Among Burn Survivors and the Importance of Intervention: A Systematic Review and Meta-Analysis.

Burn survivors undergo a plethora of physiologic disturbances that can greatly affect the quality of life (QOL) and healing processes. This review aimed to systematically examine sleep quality among individuals with burns and to explore the effectiveness of interventions using a meta-analytic approach. A systematic review of the literature was conducted by searching for articles using various databases. Titles and abstracts were screened and full texts of retained articles were assessed based on eligibility criteria. Methodological quality was ascertained in all articles using various scales. Overall, 5323 articles were screened according to titles and abstracts and 25 articles were retained following full-text screening. Of the 25 articles, 17 were assessed qualitatively, while 8 were included in the meta-analysis. Based on the qualitative analysis, sleep was found to be negatively affected in patients with burn injuries. The subsample of eight articles included in the meta-analysis showed an overall weighted mean effect size (Hedges's g) of 1.04 (SE = 0.4, 95% CI, z = 3.0; P < 0.01), indicating a large, positive effect of the intervention on sleep quality for patients with burn injuries. This review was able to demonstrate the detrimental effects of burn injury on sleep quality. Several interventions have been examined throughout the literature and have shown to be beneficial for sleep quality. However, there is great heterogeneity between existing interventions. The results from this review suggest that further research is needed before recommendations can be made as to which intervention is most effective at improving sleep in patients suffering from burn injuries.

Surgical Lymphedema Treatment: A Meta-Analysis and Recommendations.

Background: Lymphedema is a common complication of lymph node surgery; however, evidence on diagnosing, monitoring, and treating the condition is sparse. This meta-analysis evaluates the outcomes of common surgical treatments of lymphedema and provides suggestions for future research directions. Methods: A review of PubMed and Embase was performed according to Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines. All English-language studies published through June 1, 2020, were included. We excluded nonsurgical interventions, literature reviews, letters, commentaries, nonhuman or cadaver studies, and studies with inadequate sample size (N < 20). Results: A total of 583 cases from 15 studies in patients with lymphedema met our inclusion criteria for our 1-arm meta-analysis: 387 upper extremity treatments and 196 lower extremity treatments. The volume reduction rates of lymphedema for upper extremity and lower extremity treatments were 38.0% [95% confidence interval (CI), 25.9%-50.2%] and 49.5% (95% CI, 32.6%-66.3%), respectively. The most common postoperative complications were cellulitis, reported in 4.5% of patients (95% CI, 0.9%-10.6%), and seromas, reported in 4.6% (95% CI, 0%-17.8%) of patients. Average quality of life measures across all studies improved by 52.2% (95% CI, 25.1%-79.2%) for patients who underwent upper extremity treatment. Conclusions: Surgical management of lymphedema shows great promise. Our data suggest that adopting a standardized system of limb measurement and disease staging can increase effectiveness of treatment outcomes.

Immediate Lymphatic Reconstruction for Prevention of Secondary Lymphedema: A Meta-Analysis.

BACKGROUND: Secondary lymphedema remains one of the most notorious complications of axillary and pelvic lymph node surgery following mastectomy. There is a lack of high-level evidence found on the effectiveness of immediate lymphatic reconstruction (ILR) in preventing secondary lymphedema. This meta-analysis evaluates the outcomes of ILR for prevention of secondary lymphedema in patients undergoing different surgeries, and provides suggestions for lymphatic microsurgical preventive healing approach (LYMPHA). METHODS: A review of PubMed, Embase, and Web of Science was performed according to Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines. All English-language studies published from January 1, 2009 to June 1, 2020 were included. We excluded non-ILR interventions, literature reviews/letters/commentaries, and nonhuman or cadaver studies. A total of 789 patients that were enrolled in 13 studies were included in our one-arm meta-analysis. RESULTS: A total of 13 studies (n=789) met inclusion criteria: upper extremity ILR (n=665) and lower extremity ILR (n=124). The overall incidence of lymphedema for upper extremity ILR was 2.7% (95%CI: 1.1%-4.4%) and lower extremity ILR was 3.6% (95%CI: 0.3%-10.1%). For upper extremity ILR, the average follow-up time was 11.6 ± 7.8 months and the LE incidence appeared to be the highest approximately 1 to 2 years postoperation. CONCLUSIONS: Lymphedema is a common complication in cancer treatment. ILR, especially LYMPHA, may be an effective technique to facilitate lymphatic drainage at the time of the index procedure but future studies will be required to show its short-term efficacy and long-term outcomes.

Assessment of Financial Conflicts of Interest Related to the Use of Dermal Substitutes in Burn Management.

This study aims to systematically review the accuracy of the self-reporting of conflicts of interest (COIs) among studies related to the use of dermal substitute products in burn management and evaluate factors associated with increased discrepancies. To do so, a literature search was done to identify studies investigating the use of dermal substitutes in burn management published between 2015 and 2019. Industry payments were collected using the Centers for Medicare and Medicaid Services Open Payments database. Declared COIs were then compared with the listed payments. Studies and authors were considered to have a COI if they received payments totaling more than $100 for each company. A total of 51 studies (322 authors) were included for analysis. Forty studies and 104 authors received at least one payment from the industry. Of these studies, 38 (95%) studies and 91 (88%) authors were found to have a COI discrepancy. From 2015 to 2019, 1391 general payments (totaling $1,696,848) and 108 research payments (totaling $1,849,537) were made by 82 companies. When increasing the threshold on what would be considered an undisclosed payment, the proportion of authors with discrepancies gradually decreased, from 88% of authors with undisclosed payments more than $100 to 27% of authors with undisclosed payments more than $10,000. Author order, journal impact factor, and study type were not significantly associated with increased risk of discrepancy. We found that the majority of studies investigating the use of dermal substitute products for burn management did not accurately declare COI, highlighting the need for a uniform declaration process and greater transparency of industry sponsorship by authors when publishing peer-reviewed burn surgery research papers.

Patient Perspective on Post-Breast Reconstruction Exercise and Physical Therapy.

BACKGROUND: Breast reconstruction may result in significant functional compromise and pain. Postoperative exercise and physical therapy can mitigate these morbidities, but it is infrequently recommended by healthcare providers. This study asked how many breast reconstruction patients are instructed to perform postoperative at-home exercises or physical therapy, how many reported following through with these instructions, and what timeline they were given for these activities. METHODS: A 16-question multiple-choice anonymous online survey was distributed to a private breast cancer survivor Facebook group (Diep C. Foundation). RESULTS: A total of 150 breast reconstruction patients responded to our survey. The majority of respondents in our sample were not provided with specific instructions regarding postoperative at-home exercises (N = 70, 54.3%) or physical therapy (N = 77, 63.6%). Approximately 13 of 59 respondents (22%) who had been instructed to participate in postoperative at-home exercises were directed to begin at 2-3 weeks. Approximately 15 of 44 respondents (34.1%) who had been instructed to participate in physical therapy were directed to begin these at 4-5 weeks. CONCLUSIONS: To the best of our knowledge, this is the first study of how often postoperative at-home exercises and physical therapy are recommended to breast reconstruction patients. Despite robust evidence of these activities' benefits, most women are not instructed to participate in postoperative at-home exercises or physical therapy. This is likely to impede breast reconstruction patients' recovery and delay their return to activities of daily living. More studies are needed of how to actively engage breast reconstruction patients in postoperative at-home exercises and physical therapy.