The Essential Local Muscle Flaps for Lower Extremity Reconstruction.

BACKGROUND: Lower extremity reconstruction is often a challenging prospect with major implications on a patient's quality of life. For complex defects of the lower extremity, special consideration must be given to ensure suitable and durable coverage. In the following article, we present the essential local muscle flaps for lower extremity reconstruction and discuss guiding principles for the reconstructive surgeon to consider. METHODS: A thorough literature review was performed using PubMed to identify commonly used local muscle flaps for lower extremity reconstruction. Common considerations for each identified flap were noted. RESULTS: The essential local muscle flaps for lower extremity reconstruction were identified and classified based on anatomical region of the defect to be reconstructed. General considerations and postoperative management were discussed to aid in operative decision making. CONCLUSION: While many factors must be taken into account when performing lower extremity reconstruction, there are numerous reliable local muscle flaps which can be used to successfully provide durable coverage for a variety of soft tissue defects of the lower extremity.

Breast cancer tumor histopathology, stage at presentation, and treatment in the extremes of age.

BACKGROUND: Given presumed differences in disease severity between young (≤ 45 years) and elderly (≥ 75 years) women with breast cancer, we sought to compare tumor histopathology, stage at presentation, patterns of care, and survival at the extremes of age. METHODS: Adults with stages 0-IV breast cancer in the National Cancer Database (2004-2015) were categorized by age (18-45 years, 46-74 years, ≥ 75 years) and compared. Kaplan-Meier curves were used to visualize unadjusted overall survival (OS). A Cox proportional-hazards model was used to estimate the effect of age group, including adjustment for tumor subtype [hormone receptor [HR]+/HER2-, HER2+, triple-negative (TN)]. RESULTS: Of the 1,201,252 patients identified, 13% were ≤ 45 years and 17.5% were ≥ 75 years. Women ≤ 45 years were more likely to have higher pT/N stages and grade 3 disease compared to older patients; however, rates of de novo cM1 disease were comparable (3.7% vs 3.5%). HER2+ and TN tumors were more common in those ≤ 45 years (HER2+ : 18.6% vs 9.2%; TN: 14.9% vs 8.2%), while HR+/HER2- tumors were more likely in women ≥ 75 years (69.3% vs 51.3%) (all p < 0.001). Younger patients were more likely to undergo mastectomy vs lumpectomy (56% vs 34%), and receive chemotherapy (65.8% vs 10.2%) and radiation (56.2% vs 39.5%). After adjustment, OS was worse in older patients (older HR 2.94, CI 2.86-3.03). CONCLUSIONS: High-risk tumor subtypes and comprehensive multimodal treatment remain significantly more common among younger women (≤ 45 years) with breast cancer, yet, elderly women are similarly diagnosed with incurable de novo metastatic disease. Tailored screening and treatment strategies are critical to prevent age-related disparities in breast cancer care.

Vascularized Composite Allotransplantation: A Functional Hind Limb Model in Mice.

BACKGROUND: Vascularized composite allograft has emerged as a reconstructive option for patients who have suffered severe tissue loss. Animal models are critical for understanding the unique mechanisms of rejection in vascularized composite allograft. We present a functional mouse model of orthotopic hind limb transplantation using end-to-side anastomoses of the donor aorta and inferior vena cava to the respective recipient vessels. To the best of our knowledge, this approach has not been reported in the scientific literature. MATERIALS AND METHODS: A single surgeon performed all transplants (J.W.). A total of 13 syngeneic and 10 fully mismatched allogeneic transplants were performed without immunosuppression. Skin samples from the grafts were collected at the time of euthanasia. RESULTS: Five syngeneic mice survived for more than 90 d after transplant. All allografts displayed clinical and histologic signs of acute rejection such as a rash at the time of graft excision. The overall technical success rate of all transplants in this study was 74% (17 of 23). CONCLUSIONS: We demonstrate the feasibility of end-to-side anastomoses of the donor aorta and inferior vena cava with functional recovery of the transplant in a mouse model of orthotopic hind limb transplantation.

Quantifying Surgical Complications for Reduction Mammaplasty in Adolescents.

BACKGROUND: Reduction mammaplasty is a safe, effective procedure to alleviate symptoms of adolescent macromastia. However, there remain limited data on surgical complications associated with reduction mammaplasty in adolescents, which may not be concordant with those cited for adults seeking reduction mammaplasty. METHODS: A retrospective review was conducted of all consecutively performed reduction mammaplasty cases for symptomatic macromastia in patients aged 20 years and younger over a 7-year period from 2014 to 2021. RESULTS: One hundred sixty total breasts were analyzed in 80 patients. Mean age was 18.3 ± 1.4 years, with an age range from 15 to 20 years. Mean body mass index was 27.17 ± 5.49 kg/m 2 . Mean reduction weight was 584.79 ± 261.19 g. A medial pedicle was used in 91%, and an inferior pedicle was used in 9%. For skin incision, a Wise pattern was used in 60%, and a short-scar was used in 40%. There was a 16.3% rate of any surgical complication, which included wound healing by secondary intention treated with local wound care. There were no significant risk factors for a surgical complication in reduction mammaplasty, and no differences in surgical complications related to skin incision type, pedicle use, or breast reduction weight. Performance of a receiver operating characteristic curve for age at surgery and complication demonstrated that there was no age cutoff where the risk of surgical complication was appreciably increased or decreased. CONCLUSIONS: Age was not identified as a risk factor for surgical complications in adolescent reduction mammaplasty. Overall, complication rates were very low and minor in nature for adolescent reduction mammaplasty, with no significant risk factors identified. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Design and evaluation of an interprofessional education workshop series for preclinical and prelicensure health professional students.

BACKGROUND: There are a variety of designs and implementation strategies reported for interprofessional education (IPE); however, most of these descriptions lack robust evaluations of interprofessional (IP) outcomes. INTERPROFESSIONAL EDUCATION ACTIVITY: An IPE Workshop Series was implemented for preclinical and prelicensure students in eight health professions, consisting of four sessions: health professionals' roles and responsibilities (1A); introduction to patient safety (1B); IP diabetes management (2A); and IP pain management in the opioid epidemic (2B). For Workshops 2A and 2B, student perceptions of IPE were measured using the validated Students Perceptions of Interprofessional Clinical Education Revised Version 2 and IP team care plans were assessed with a rubric. Five hundred twenty-seven students attended all four workshops and completed all surveys. Student perceptions of IPE and collaboration were significantly increased after completing the IPE Workshop Series. Most teams met or exceeded expectations on the diabetes team care plans for collaboration, addressing patient concerns, and gaps in care; however, most teams needed improvement on addressing additional workup and management. The pain management team care plans were below expectations for most teams. DISCUSSION: Student perceptions of IP collaboration increased and were maintained longitudinally indicating a positive impact on this IPE outcome; however, performance on team care plans did not meet faculty expectations suggesting areas for improvement in the design and evaluation for this outcome. IMPLICATIONS: These findings reinforce the importance of evaluation to ensure IPE curricula are achieving IP outcomes, notably, utilizing validated instruments and incorporating faculty assessments that are appropriately leveled for learners.

The Influence of Fat Grafting on Breast Imaging after Postmastectomy Reconstruction: A Matched Cohort Analysis.

BACKGROUND: Fat grafting to the reconstructed breast may result in the development of benign lesions on physical examination, prompting further investigation with imaging and biopsy. The aim of this study was to assess the influence of fat grafting on the incidence of imaging and biopsies after postmastectomy reconstruction. METHODS: Patients who underwent autologous or implant-based reconstruction following mastectomy from 2010 to 2018 were identified. Those receiving fat grafting as part of their reconstructive course were propensity matched 1:1 to those that did not with body mass index, reconstruction timing, and reconstruction type as covariates in a multivariable logistic regression model. RESULTS: A total of 186 patients were identified, yielding 93 propensity-matched pairs. Fat-grafted patients had higher incidences of palpable masses (38.0 percent versus 18.3 percent; p = 0.003) and postreconstruction imaging (47.3 percent versus 29.0 percent; p = 0.01), but no significant difference in the number of biopsies performed (11.8 percent versus 7.5 percent; p = 0.32). Imaging was predominately interpreted as normal (Breast Imaging-Reporting and Data System 1, 27.9 percent) or benign (Breast Imaging-Reporting and Data System 2, 48.8 percent), with fat necrosis being the most common finding [n = 20 (45.5 percent)]. No demographic, oncologic, reconstructive, or fat grafting-specific variables were predictive of receiving postreconstruction imaging on multivariate analysis. Fat grafting was not associated with decreased 5-year overall survival or locoregional recurrence-free survival. CONCLUSIONS: Fat grafting to the reconstructed breast is associated with increased incidences of palpable masses and subsequent postreconstruction imaging with benign radiographic findings. Although the procedure is oncologically safe, both patients and providers should be aware that concerning physical examination findings can be benign sequelae of fat grafting and may lead to increased imaging after breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Assessing the Utility of Post-Mastectomy Imaging after Breast Reconstruction.

BACKGROUND: Few guidelines exist regarding surveillance and diagnostic imaging after breast reconstruction. This study investigated the influence of breast reconstruction on the frequency of post-mastectomy imaging, the relative utility of imaging, and its effect on overall and locoregional recurrence-free survival. STUDY DESIGN: A retrospective review identified breast cancer patients (n = 1,216) who underwent mastectomy with or without reconstruction. Logistic regression identified surgical and oncologic predictors of post-reconstruction imaging. Kaplan-Meier method determined the impact of post-reconstruction imaging on overall and locoregional recurrence-free survival. RESULTS: Overall, 662 (54.4%) patients underwent mastectomy only and 554 (45.6%) underwent breast reconstruction. Patients undergoing reconstruction were more likely to receive imaging compared with patients undergoing mastectomy only (n = 205, 37.0% vs n = 168, 25.4%; p < 0.0001); however, this difference was not statistically significant after adjusting for age and follow-up time (p = 0.16). Most radiographic studies were Breast Imaging Reporting and Data System (BI-RADS) 1 (n = 58, 30%) or 2 (n = 95, 49%) and were ordered by nonsurgical providers (n = 128, 63%). Post-reconstruction imaging did not influence overall or locoregional recurrence-free survival. The 5-year survival probabilities for breast reconstruction patients who underwent imaging for a palpable mass, surveillance, or who did not undergo imaging were 100%, 95% (95% CI 89% to 100%), and 96% (95% CI 94% to 99%), respectively. Post-reconstruction imaging was not a significant predictor of overall survival (hazard ratio [HR] 0.95; 95% CI 0.61 to 1.46; p = 0.30). CONCLUSIONS: The limited utility of routine post-reconstruction imaging should be reinforced when evaluating breast reconstruction patients. Multidisciplinary collaboration should be emphasized when attempting to distinguish benign postoperative findings from a malignant process to reduce unnecessary imaging and biopsy after breast reconstruction.

Slow-release delivery enhances the pharmacological properties of oral 5-hydroxytryptophan: mouse proof-of-concept.

5-hydroxytryptophan (5-HTP) has shown therapeutic promise in a range of human CNS disorders. But native 5-HTP immediate release (IR) is poorly druggable, as rapid absorption causes rapid onset of adverse events, and rapid elimination causes fluctuating exposure. Recently, we reported that 5-HTP delivered as slow-release (SR) in mice augmented the brain pro-serotonergic effect of selective serotonin reuptake inhibitors (SSRIs), without the usual adverse events associated with 5-HTP IR. However, our previous study entailed translational limitations, in terms of route, dose, and duration. Here we modeled oral 5-HTP SR in mice by administering 5-HTP via the food. We modeled oral SSRI treatment via fluoxetine in the water, in a regimen recapitulating clinical pharmacokinetics and pharmacodynamics. 5-HTP SR produced plasma 5-HTP levels well within the range enhancing brain 5-HT function in humans. 5-HTP SR robustly increased brain 5-HT synthesis and levels. When administered with an SSRI, 5-HTP SR enhanced 5-HT-sensitive behaviors and neurotrophic mRNA expression. 5-HTP SR's pro-serotonergic effects were stronger in mice with endogenous brain 5-HT deficiency. In a comprehensive screen, 5-HTP SR was devoid of overt toxicological effects. The present preclinical data, appreciated in the context of published 5-HTP clinical data, suggest that 5-HTP SR could represent a new therapeutic approach to the plethora of CNS disorders potentially treatable with a pro-serotonergic drug. 5-HTP SR might in particular be therapeutically relevant when brain 5-HT deficiency is pathogenic and as an adjunctive augmentation therapy to SSRI therapy.