RESUMO
BACKGROUND: Patients with advanced cancer staging have a greater risk of developing venous thromboembolism than noncancer patients. The impact of breast cancer stage and treatment on outcomes after autologous free-flap breast reconstruction (ABR) is not well-established. The objective of this retrospective study is to determine the impact of breast cancer characteristics, such as cancer stage, hormone receptor status, and neoadjuvant treatments, on vascular complications of ABR. METHODS: A retrospective review was conducted examining patients who underwent ABR from 2009 to 2018. Breast cancer stage, cancer types, hormone receptor status, and treatments were collected in addition to demographic data. Intraoperative vascular concerns, postoperative vascular concerns, and flap loss were analyzed. Univariate analysis and fixed-effects models were used to associate breast cancer characteristics with outcomes. RESULTS: Neoadjuvant hormone therapy was associated with increased risk for intraoperative vascular concern (odds ratio, 1.059 [ P = 0.0441]). Neoadjuvant trastuzumab was associated with decreased risk of postoperative vascular concern (odds ratio, 0.941 [ P = 0.018]). Breast cancer stage, somatic genetic mutation, receptor types, neoadjuvant chemotherapy, and neoadjuvant radiation had no effect on any vascular complications of ABR. CONCLUSION: Autologous free-flap breast reconstruction is a reliable reconstructive option for patients with all stages and types of breast cancer. There is potentially increased risk of intraoperative microvascular compromise in patients who have neoadjuvant hormone therapy. Trastuzumab is potentially protective against postoperative microvascular compromise. Patients should feel confident that, despite higher stage cancer, they can pursue their desired reconstructive option without fear of vascular compromise.
Assuntos
Neoplasias da Mama , Doenças Cardiovasculares , Mamoplastia , Humanos , Feminino , Neoplasias da Mama/tratamento farmacológico , Mastectomia/efeitos adversos , Mamoplastia/efeitos adversos , Estudos Retrospectivos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/cirurgia , Trastuzumab/uso terapêutico , Hormônios/uso terapêutico , Resultado do TratamentoRESUMO
BACKGROUND: Optimal reduction mammoplasty techniques to treat patients with gigantomastia have been debated and can involve extended pedicles (EP) or free nipple grafts (FNG). OBJECTIVES: The authors compared clinical, patient-reported, and aesthetic outcomes associated with reduction mammoplasty employing EP vs FNG. METHODS: A multi-institutional, retrospective study of adult patients with gigantomastia who underwent reduction mammoplasty at 2 tertiary care centers from 2017 to 2020 was performed. Gigantomastia was defined as reduction weight >1500 g per breast or sternal notch-to-nipple distance ≥40 cm. Surgeons at 1 institution employed the EP technique, whereas those at the other utilized FNG. Baseline characteristics, preoperative and postoperative BREAST-Q, and clinical outcomes were collected. Aesthetic outcomes were assessed in 1:1 propensity score-matched cases across techniques. Preoperative and postoperative photographs were provided to reviewers across the academic plastic surgery continuum (students to faculty) and non-medical individuals to evaluate aesthetic outcomes. RESULTS: Fifty-two patients met the inclusion criteria (21 FNG, 31 EP). FNG patients had a higher incidence of postoperative cellulitis (23% vs 0%, P < 0.05) but no other differences in surgical or medical complications. Baseline BREAST-Q scores did not differ between groups. Postoperative BREAST-Q scores revealed greater satisfaction with the EP technique (P < 0.01). The aesthetic assessment of outcomes in 14 matched pairs of patients found significantly better aesthetic outcomes in all domains with the EP procedure (P < 0.05), independent of institution or surgical experience. CONCLUSIONS: This multi-institutional study suggests that, compared with FNG, the EP technique for reduction mammoplasty provides superior clinical, patient-reported, and aesthetic outcomes for patients with gigantomastia.
Assuntos
Mamoplastia , Mamilos , Adulto , Humanos , Mamilos/cirurgia , Estudos Retrospectivos , Resultado do Tratamento , Retalhos Cirúrgicos/transplante , Mama/cirurgia , Mamoplastia/efeitos adversos , Mamoplastia/métodos , Hipertrofia/cirurgia , Hipertrofia/etiologiaRESUMO
INTRODUCTION: Research indicates that prophylactic mesh may help prevent incisional hernia after laparotomy, but best practice patterns in these situations are still evolving. Here, we compare the failure loads (FLs) and biomechanical stiffness (BMS) of 35 porcine abdominal wall laparotomy incisions reinforced with meshes of various widths and fixation distances using biomechanical testing. METHODS: In each specimen, a 10-cm incision was made and closed using continuous 1-0 Maxon suture. Specimens were randomized to mesh width (none, 2.5 cm, 3 cm, 4 cm, 6 cm, 8 cm) and tack separation (1.5 cm, 2 cm apart) and the meshes secured in an onlay fashion. Cyclic loads oscillating from 15 N to 140 N were applied to simulate abdominal wall stress, and the specimens subsequently loaded to failure. FLs (N) and BMS (N/mm) were comparatively analyzed. RESULTS: All specimens failed via suture pull-through. FLs and BMS were lowest in specimens with suture-only (421.43 N; 11.69 N/mm). FLs and BMS were significantly higher in 4-cm mesh specimens (567.51 N) than those with suture, 2.5-cm, and 3.0-cm mesh (all P < 0.05). FLs in specimens with a greater number of tacks were consistently higher in meshes of similar sizes, although these did not reach significance. CONCLUSIONS: A 4-cm mesh reenforcement was superior to suture-only and smaller meshes at preserving strength in laparotomy closure in a porcine model but larger meshes (6 cm, 8 cm) did not provide an additional benefit. Meshes with more fixation points may be advantageous, but additional data are needed to make definitive conclusions.
Assuntos
Parede Abdominal , Hérnia Ventral , Hérnia Incisional , Animais , Parede Abdominal/cirurgia , Hérnia Ventral/prevenção & controle , Hérnia Ventral/cirurgia , Hérnia Incisional/cirurgia , Laparotomia/efeitos adversos , Telas Cirúrgicas , Suturas , SuínosRESUMO
BACKGROUND: Obese individuals are thought to be higher risk for complications after excisional abdominal body contouring (EAC) due to co-morbidities and significant tissue resection. OBJECTIVES: We comparatively analyzed EAC patients with Body Mass Index (BMI) ≥35 kg/m2 and BMI <35 kg/m2 to highlight key differences in clinical and patient-reported-outcomes (PROs). METHODS: Patients ≥18 years-old undergoing EAC by a single surgeon from 01/2018-01/2020 were identified and separated into cohorts based on BMI (<35 and ≥35 kg/m2). Patients were excluded if they had a cosmetic abdominoplasty without history of bariatric surgery or massive weight loss, or if they had <1000 gs of tissue resected. Clinical outcomes and PROs using the BODY-Q were comparatively analyzed. RESULTS: 70 total patients with median BMIs of 30[26-32] and 41[37-45] kg/m2 in each cohort, were identified. Patients with BMI ≥35 kg/m2 were more likely to have higher ASA (P<0.01) and use of incisional negative pressure wound devices (P = 0.042). Alternatively, they were less likely to have had concurrent liposuction (P = 0.05). There were no differences in development of an SSO, SSI or SSOpi (P>0.05) between cohorts. Multivariate logistic regression showed that BMI ≥35 kg/m2, iNPWD and liposuction were not associated with the development of complications. PROs demonstrated improvement in multiple domains despite BMI. CONCLUSION: There was no association with BMI ≥35 kg/m2 and the development of complications within our cohort. We encourage preoperative weight loss when possible, however these procedures can be performed safely with acceptable outcomes even in individuals who are obese and/or require extensive tissue removal.
Assuntos
Abdominoplastia , Cirurgia Bariátrica , Contorno Corporal , Obesidade Mórbida , Abdominoplastia/efeitos adversos , Adolescente , Cirurgia Bariátrica/efeitos adversos , Cirurgia Bariátrica/métodos , Contorno Corporal/efeitos adversos , Contorno Corporal/métodos , Índice de Massa Corporal , Humanos , Obesidade Mórbida/complicações , Obesidade Mórbida/cirurgia , Medidas de Resultados Relatados pelo Paciente , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/cirurgia , Estudos Retrospectivos , Resultado do TratamentoRESUMO
INTRODUCTION: Although there are many patient-reported outcome measures used for ventral hernia (VH), disease-specific instruments, such as the Hernia-related Quality-of-Life (QoL) Survey (HerQLes) and Abdominal Hernia-Q (AHQ), have shown greater accuracy in capturing all VH-related QoL. We present a novel calibration that allows providers to convert scores between the AHQ and HerQLes, enabling better unification of QoL data. METHODS: Patients with VH were prospectively identified and simultaneously administered both the AHQ and HerQLes pre- and post-operatively. To ensure the validity of the calibration, responses were excluded if patients answered instruments on different dates or if the responses were discordant on corresponding questions within each instrument. The calibration was estimated using a linear mixed effects model, including linear and quadratic scores, timing of survey relative to surgery and their interactions as fixed effects, and patients as random effects to account for multiple surveys from the same patient. RESULTS: In total, 109 patients were included, responding to 300 pairs of surveys (112 preoperative and 188 postoperative), of which 17 (5.6%) were excluded because of discordant responses. Conversion of the HerQLes to AHQ was most accurate when including whether the survey was completed pre- or post-operatively, with a mean squared error of 0.0091. Similarly, converting the AHQ to HerQLes was most accurate when factoring in the timing of survey administration, with a mean squared error of 0.016. CONCLUSIONS: We present a novel and accurate method to convert scores between the AHQ and HerQLes. Being able to unify QoL data from different PROMs supports efforts to more broadly integrate PROMs in surgery and to understand patient-defined measures of success.
Assuntos
Hérnia Ventral , Herniorrafia , Calibragem , Hérnia Ventral/cirurgia , Herniorrafia/métodos , Humanos , Medidas de Resultados Relatados pelo Paciente , Qualidade de VidaRESUMO
INTRODUCTION: Liposomal bupivacaine (LB) has emerged as a superior form of local anesthetic across numerous surgical subspecialties. The purpose of this study is to evaluate the ex-vivo antimicrobial effects of LB in comparison with traditional local anesthetics. METHODS: A standardized inoculum of bacteria commonly associated with surgical site infection was inoculated into a suspension of 1% lidocaine, 0.25% bupivacaine, Exparel (proprietary liposomally packaged 1.3% bupivacaine), and normal saline as a growth control. RESULTS: In all five bacteria tested, the medium inoculated with traditional local anesthetics reduced growth to a greater degree than LB-inoculated plates. Both conventional local anesthetics reduced the growth of all bacteria when compared with the control with the exception of methicillin-susceptible Staphylococcus aureus growth in bupivacaine. LB-inoculated plates had equivalent growth to the control in all plates with the exception of Escherichia coli plates which demonstrated superior growth. CONCLUSIONS: The results of this simple ex-vivo model suggest that the liposomal packaging of bupivacaine may decrease this local anesthetic's innate antibacterial properties.
Assuntos
Anestésicos Locais , Bupivacaína , Anestesia Local , Anestésicos Locais/farmacologia , Bupivacaína/farmacologia , Escherichia coli , Humanos , Lidocaína/farmacologia , Dor Pós-Operatória , Staphylococcus aureusRESUMO
BACKGROUND: Although occupational exposure to radiation has been previously studied in the hand surgery literature, there is a paucity of studies looking at radiation exposure to the patient during fluoroscopy-guided hand surgery. We aimed to describe the level of radiation experienced by patients undergoing common hand and wrist fracture fixation and to identify risk factors for increased radiation exposure. METHODS: We performed a retrospective review of patients at a single institution who underwent fracture fixation of the hand, wrist, or forearm requiring mini c-arm fluoroscopic guidance from 2016 to 2020. Data points collected included patient demographics, procedural details, and indicators of radiation exposure including dose-area product (DAP), total intraoperative images, and total fluoroscopy time. Effective dose (ED) was calculated using DAP, field size, and a previously established conversion factor. RESULTS: The final sample included 361 patients with an average age of 46 years. Procedures included fixation of forearm fractures (3.3%), distal radius fractures (35.7%), metacarpal fractures (30.8%), and phalangeal fractures (30.2%). The median number of intraoperative images acquired was 36, median total fluoroscopy time was 43 seconds, median DAP was 4.8 cGycm2, and median ED was 0.13 µSv. Distal (metacarpal and phalangeal) fractures required more intraoperative images and longer total fluoroscopy time (49 images, 61 seconds) compared with proximal (forearm and distal radius) fractures (39 images, 47 seconds) (images, P = 0.004; exposure time, P = 0.004). However, distal fractures had a lower average ED compared with proximal fractures (0.15 vs 0.19 µSv, P = 0.020). When compared with open procedures, percutaneous procedures had higher DAPs (8.8 vs 4.9 cGycm2, P < 0.001), higher ED (0.22 vs 0.15 µSv, P < 0.001), more intraoperative images (65 vs 36 images, P < 0.001), and longer total fluoroscopy time (81.9 vs 44.4 seconds, P < 0.001). CONCLUSIONS: Patient-level radiation exposure during fluoroscopy-guided hand and wrist procedures is low relative to other common imaging modalities, such as dental radiographs, chest x-rays, and computed tomography scans, and is comparable with less than a few hours of natural background radiation exposure, highlighting the overall safety of this important technology. Further study should be performed to establish reference ranges, which could lead to improved patient counseling and evidence-based guidelines on patient shielding.
Assuntos
Exposição Ocupacional , Exposição à Radiação , Fraturas do Rádio , Traumatismos do Punho , Fluoroscopia/efeitos adversos , Mãos/cirurgia , Humanos , Pessoa de Meia-Idade , Exposição Ocupacional/efeitos adversos , Doses de Radiação , Exposição à Radiação/prevenção & controle , Fraturas do Rádio/cirurgia , Punho/diagnóstico por imagem , Punho/cirurgia , Traumatismos do Punho/diagnóstico por imagem , Traumatismos do Punho/etiologia , Traumatismos do Punho/cirurgiaRESUMO
ABSTRACT: An increasing number of plastic and reconstructive surgery (PRS) units have transitioned from divisions to departments in recent years. This study aimed to identify quantifiable differences that may reflect challenges and benefits associated with each type of unit. We conducted a cross-sectional analysis of publicly-available data on characteristics of academic medical institutions housing PRS units, faculty size of surgical units within these institutions, and academic environments of PRS units themselves. Univariate analysis compared PRS divisions versus departments. Matched-paired testing compared PRS units versus other intra-institutional surgical departments. Compared to PRS divisions (nâ=â64), departments (nâ=â22) are at institutions with more surgical departments overall (Pâ=â0.0071), particularly departments that are traditionally divisions within the department of surgery (ie urology). Compared to PRS divisions, PRS departments have faculty size that more closely resembles other intra-institutional surgical departments, especially for full-time surgical faculty and faculty in areas of clinical overlap with other departments like hand surgery. Plastic and reconstructive surgery departments differ from PRS divisions by certain academic measures, including offering more clinical fellowships (Pâ=â0.005), running more basic science laboratories (Pâ=â0.033), supporting more nonclinical research faculty (Pâ=â0.0417), and training residents who produce more publications during residency (Pâ=â0.002). Institutions with PRS divisions may be less favorable environments for surgical divisions to become departments, but other recently-transitioned divisions could provide blueprints for PRS to follow suit. Bolstering full-time surgical faculty numbers and faculty in areas of clinical overlap could be useful for PRS divisions seeking departmental status. Transitioning to department may yield objective academic benefits for PRS units.
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Internato e Residência , Procedimentos de Cirurgia Plástica , Cirurgia Plástica , Estudos Transversais , Docentes de Medicina , Bolsas de Estudo , Humanos , Cirurgia Plástica/educação , Estados UnidosRESUMO
BACKGROUND: The importance of aesthetic surgery exposure for plastic and reconstructive trainees has been recently validated by the expansion of case requirements for aesthetic procedures from 50 to 150, as well as resident-driven desire for increased cosmetic exposure throughout training. We aim to systematically review the literature at a national level to report on overall trends in aesthetic surgery training within PRS residencies. METHODS: A literature search of PubMed, Embase, and Scopus identified all English articles published in the USA between 2000 and 2020, using a combination of "aesthetic surgery", "cosmetic surgery", "plastic surgery", "residency and internship", "education", and "training." RESULTS: Our initial search resulted in 415 articles. After review of inclusion and exclusion criteria, in addition to cross-referencing, 41 studies remained, including 15 studies discussing resident and/or program director surveys, eight studies discussing teaching methods, sixteen studies discussing dedicated resident clinics, four studies discussing cosmetic/aesthetic fellowships, three studies discussing cosmetic practice patterns, and eleven studies discussing patient outcomes. CONCLUSION: Current literature demonstrates that there are gaps in aesthetic surgery training for PRS residents in the USA, including facial and neck surgeries and non-surgical interventions. Resident clinics have clear benefits for resident education, without sacrificing patient outcomes. Residency programs should consider the development of a resident cosmetic clinic and/or dedicated cosmetic center to increase surgical exposure and increase trainee comfort in providing this subset of procedures. Published literature is limited in consistency of methods of evaluation, and further in-depth analysis of case volume and diversity at training programs within the USA and internationally is indicated. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
Assuntos
Internato e Residência , Procedimentos de Cirurgia Plástica , Cirurgia Plástica , Estética , Bolsas de Estudo , Humanos , Procedimentos de Cirurgia Plástica/educação , Cirurgia Plástica/educação , Estados UnidosRESUMO
BACKGROUND: Female genital mutilation/cutting (FGM/C) is the intentional alteration, removal, or injury of female genitalia for non-medical reasons. Approximately 200 million females have been victims of FGM/C, and genital reconstructive procedures are increasing in demand. OBJECTIVES: The objectives of this study were to assess clinical and patient-reported outcomes after FGM/C reconstruction to help guide treatment practices. METHODS: Adult patients undergoing anatomic reconstruction after FGM/C were retrospectively identified. Outcomes included clitoral, labial, and donor site surgical site occurrences (SSO) and the need for revision operations. Patient-reported outcomes were assessed using an adapted version of the Female Sexual Function Index (FSFI), a validated outcomes instrument that assesses sexual function through 6 domains, with each domain having a maximum score of 6. RESULTS: Nineteen patients were identified in our review. Patients presented for reconstruction due to dyspareunia, inability to orgasm, chronic infections, to normalize appearance, and/or to "feel normal." There were no SSOs and two revision operations for adhesions. 74% of patients completed the FSFI postoperatively. Despite most patients seeking repair for inability to orgasm and/or dyspareunia, the median scores for these domains were 4.6 and 5.2. Patients' desire to engage in sexual activity scored lowest (3.9), and patients reported concerns over the appearance of their genitalia (50%) that affected self-confidence (85.7%). CONCLUSION: FGM/C reconstruction is safe and contributes to improvements in physical sexual health. Psychological trauma may contribute to lessened sexual desire and self-confidence even after reconstruction. Multidisciplinary treatment is important to address the long-term psychological effects of this practice. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
Assuntos
Circuncisão Feminina , Procedimentos de Cirurgia Plástica , Adulto , Circuncisão Feminina/efeitos adversos , Circuncisão Feminina/psicologia , Clitóris/cirurgia , Feminino , Humanos , Medidas de Resultados Relatados pelo Paciente , Procedimentos de Cirurgia Plástica/psicologia , Estudos RetrospectivosRESUMO
BACKGROUND: Postmastectomy radiation therapy (PMRT) is an important component in the treatment of locally advanced breast cancer. Optimal timing of therapy in relation to autologous breast reconstruction (ABR) remains clinically debated. Herein, we comparatively analyze short- and long-term outcomes between immediate ABR (I-ABR) and delayed-immediate ABR (DI-ABR) in the setting of PMRT. METHODS: Adult patients undergoing ABR with PMRT were separated into cohorts based on reconstructive timeline: I-ABR or DI-ABR. The groups were propensity matched 1:1 by age, body mass index, and comorbidities. Surgical site events and long-term clinical outcomes (readmissions, reoperations, and revision procedures) were collected. Univariate analyses were completed using Pearson's chi-squared tests and Fisher's exact tests, and statistical significance was set at p < 0.05. RESULTS: One hundred and thirty-two flaps (66 in each cohort) were identified for inclusion. Patients with I-ABR were more likely to experience fat necrosis (p = 0.034) and skin necrosis (p < 0.001), require additional office visits (p < 0.001) and outpatient surgeries (p = 0.015) to manage complications, and undergo revision surgery after reconstruction (p < 0.001). DI-ABR patients, however, had a 42.4% incidence of complications following tissue expander placement prior to reconstruction, with 16.7% of patients requiring reoperation during this time. Only one patient (I-ABR) experienced flap loss due to a vascular complication. CONCLUSION: The complications encountered in both of these groups were not prohibitive to offering either treatment. Patients should be made aware of the specific and unique risks of these reconstruction timelines and involved throughout the entire decision-making process. Plastic surgeons should continue to strive to elucidate innovative approaches that facilitate enhanced quality of life without compromising oncologic therapy.
Assuntos
Neoplasias da Mama , Mamoplastia , Adulto , Neoplasias da Mama/radioterapia , Neoplasias da Mama/cirurgia , Feminino , Humanos , Mamoplastia/métodos , Mastectomia/métodos , Complicações Pós-Operatórias/cirurgia , Qualidade de Vida , Radioterapia Adjuvante/efeitos adversos , Estudos Retrospectivos , Resultado do TratamentoRESUMO
BACKGROUND: While mesh re-enforcement and advanced surgical techniques are cornerstones of complex ventral hernia repair (CVHR), the risk of complications and recurrence is common. We aim to evaluate the efficacy, safety, and patient reported outcomes (PROs) of patients undergoing CVHR with onlay Poly-4-hydroxybutyrate (P4HB). METHODS: Adult (>18 y old) patients undergoing VHR with P4HB (Phasix) in the onlay plane by a single surgeon from 01/2015 to 05/2020 were reviewed. VHR was considered complex if patients had significant co-morbidities, large abdominal wall defects, a history of extensive abdominal surgery, and/or concurrent intra-abdominal pathology. A composite of postoperative outcomes including surgical site occurrences (SSO), surgical site infection (SSI), and surgical site occurrences requiring procedural intervention (SSOpi), as well as PROs as defined by the Abdominal Hernia-Q (AHQ), were analyzed. RESULTS: A total of 51 patients were included with average age and body mass index of 56.4 and 29.9 kg/m2. Median follow up was 20 mo with a hernia recurrence rate of 5.9% (n = 3). 21 patients had an SSO (41.2%), 8 had an SSI (15.7%), and 6 had an SSOpi (11.8%). There was an association with Ventral Hernia Working Group ≥ 2 and development of SSO. There was a significant improvement in overall PROs (P < 0.0001) with no difference in those patients with and without complications (P > 0.05). CONCLUSION: For hernia patients with large defects and complex intra-abdominal pathology, a safe and effective repair is difficult. The use of onlay P4HB was associated with acceptable postoperative outcomes and recurrence rate.
Assuntos
Hérnia Ventral/cirurgia , Herniorrafia/efeitos adversos , Poliésteres , Telas Cirúrgicas/efeitos adversos , Infecção da Ferida Cirúrgica/epidemiologia , Adulto , Idoso , Feminino , Herniorrafia/instrumentação , Humanos , Masculino , Pessoa de Meia-Idade , Medidas de Resultados Relatados pelo Paciente , Recidiva , Estudos Retrospectivos , Infecção da Ferida Cirúrgica/etiologia , Infecção da Ferida Cirúrgica/cirurgia , Resultado do TratamentoRESUMO
INTRODUCTION: Consensus on the safety and efficacy of various types of mesh in reconstructing the abdomen has yet to be reached. Hybrid mesh products have been designed to address the need for a cost-effective mesh leveraging the tensile strength of a synthetic mesh while minimizing the prosthetic footprint within the abdominal wall through resorbable materials. In this study we evaluate early clinical outcomes and health related quality of life (HR-QOL) of a new Hybrid mesh, SynecorTM, for Ventral Hernia Repair (VHR). METHODS: Adult (>18 y old) patients undergoing VHR with SynecorTM mesh by a single surgeon between 2017-2019 with ≥1-y follow-up were identified. We analyzed a composite of postoperative outcomes as well as the incidence of hernia recurrence, readmissions, mortality, and HR-QOL. RESULTS: Thirty-five patients were included in our analysis with a median follow up of 2.1 y. The median age and BMI were 54.1 y and 33.2 kg/m2, respectively. The rate of surgical site occurrences was 37.1%, with only one patient (2.9%) requiring surgical intervention. No patients developed a hernia recurrence. Overall HR-QOL improved significantly (preoperative mean 2.5 [SD 0.7] versus postoperative 3.4 [0.4]; P< 0.01), particularly in regards to pain, functional status, self-esteem and body image (all P < 0.05). CONCLUSIONS: Abdominal reinforcement with SynecorTM mesh at the time of VHR results in promising early recurrence rates, an acceptable safety risk profile, and an improvement in overall HR-QOL.
Assuntos
Hérnia Ventral/cirurgia , Herniorrafia/instrumentação , Complicações Pós-Operatórias/epidemiologia , Telas Cirúrgicas , Adulto , Feminino , Herniorrafia/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Medidas de Resultados Relatados pelo Paciente , Pennsylvania/epidemiologia , Qualidade de Vida , Recidiva , Estudos RetrospectivosRESUMO
ABSTRACT: Chairs/chiefs of plastic surgery departments/divisions are responsible for directing activities at academic institutions and thus help determine the direction of academic plastic surgery. Other studies have characterized this group but have not shown which characteristics separate them from other surgeons in the field. To study this relationship, a cross-sectional analysis of plastic surgery faculty affiliated with United States residency training programs (nâ=â99) was initiated. Data were collected from public online websites. Univariate and multivariate logistic regression were used to identify factors independently associated with chairs/chief status. Sub-analyses were performed within Tiers stratified by residency program rank of chair/chief's current institution. Among 943 plastic surgeons, 98âchairs/chiefs were identified. In accordance with prior literature, most are male (89%) and fellowship-trained (62%), and they have a median H-index of 17. Compared to other surgeons, chair/chiefs have more years in practice (odds ratio [OR]: 1.026, confidence interval [CI]: 0.002-0.049, Pâ=â0.034), higher H-index (OR: 1.103, CI: 0.048-0.147, Pâ<â0.001), and more citations (OR: 1.000, CI: -0.000 to -0.001, Pâ=â0.006). Chair/chiefs were also more likely to be journal editorial board members (OR: 1.728, CI: -0.033 to 1.127, Pâ=â0.046) and national society/organization presidents (OR: 1.024, CI: 0.008-0.039, Pâ=â0.003). No notable differences were found between department chairs versus division chiefs or across Tiers. Overall, scholarly achievement and significant years of experience distinguish chairs/chiefs in American academic plastic surgery. Criteria for achieving this leadership role may not differ between departments and divisions. Further research is needed to evaluate whether these characteristics translate into more effective leadership.
Assuntos
Cirurgiões , Cirurgia Plástica , Estudos Transversais , Docentes de Medicina , Bolsas de Estudo , Humanos , Liderança , Masculino , Estados UnidosRESUMO
INTRODUCTION: The Fleur-de-Lis panniculectomy (FdL) adds a vertical component to correct complex contour deformities after massive weight loss by addressing supra-umbilical horizontal skin excess which is not addressed with infra-umbilical transverse panniculectomy (TP). We aim to perform a head-to-head comparison of clinical outcomes and patient reported outcomes (PROs) between FdL and TP. METHODS: A retrospective review of patients ≥18 with a history of bariatric surgery undergoing FdL or TP by a single plastic surgeon between 07/01/2015 and 05/31/2020 was conducted. Surgical site occurrences (SSOs) including surgical site infection (SSI), delayed healing, cellulitis, seroma, hematoma, surgical site occurrences requiring procedural intervention (SSOpi), and a composite of other postoperative outcomes were assessed. In addition, patient satisfaction was analyzed using the Body-Q questionnaire across 12 domains. RESULTS: The analysis included 56 patients; 26 and 30 patients who were treated with FdL and TP, respectively. Cohorts were statistically similar in terms of age, gender, BMI, and co-morbid conditions. The overall complication rate was 50% (FdL n = 14 (53.9%), TP n = 14 (46.7%); p = 0.592). On multivariate analysis, pannus weight was associated with the development of SSO (p = 0.04). FdL incision, however, was not an independent risk factor for adverse outcomes. Absolute improvement in PROs was similar in both cohorts across multiple domains. CONCLUSION: FdL showed a comparable safety and efficacy profile to TP when performed in post-bariatric surgery patients, with equivalent improvement in PROs across multiple domains. Preoperative weight loss should be encouraged in this population as pannus weight is an independent risk factor for complications. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
Assuntos
Abdominoplastia , Cirurgia Bariátrica , Lipectomia , Abdominoplastia/efeitos adversos , Cirurgia Bariátrica/efeitos adversos , Humanos , Lipectomia/efeitos adversos , Estudos Retrospectivos , Resultado do Tratamento , Redução de PesoRESUMO
OBJECTIVE: Plastic surgery is one of the most competitive and innovative fields in medicine. The role of the academic plastic surgeon continues to grow beyond clinical care, and many surgeons have pursued advanced degrees (AD) to expand their professional skillset. We present an analysis of ADs of academic plastic surgery faculty in the USA, with consideration of timing of AD attainment. METHODS: All academic plastic surgery faculty members were identified from plastic surgery program websites, as recognized by the American Council of Academic Plastic Surgeons. ADs were defined as additional degrees beyond the primary medical degree. Outcomes included timing of AD attainment, residency rankings, institutional standings, and research productivity. RESULTS: 949 faculty members were identified, and 167 had ADs. The most common ADs were PhD (30%), MS/MSc (18%), and MBA/EMBA (17%). Timing of AD attainment was available for 146 faculty members (84.7%). Having an AD before residency was associated with matching into higher-tiered and integrated residency programs (both p < 0.05). For attending physicians, having an AD was associated with more journal editorial board positions, more publications, higher H-index, receiving NIH funding, and median number of NIH grants (adjusted for years in practice, all p<0.05). Institutional analysis revealed that employing more faculty with an AD was associated with having an integrated residency program, higher residency research ranking, and higher tier integrated residency (all p < 0.05). CONCLUSION: ADs are growing in popularity in academic plastic surgery and are temporally associated with specific advantages in terms of residency placement, research productivity, and institutional standing. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
Assuntos
Internato e Residência , Cirurgia Plástica , Livros , Eficiência , Docentes , Humanos , Cirurgia Plástica/educação , Estados UnidosRESUMO
BACKGROUND: Racial and socioeconomic disparities in access and quality of surgical care are well documented in many surgical subspecialties, including plastic surgery. OBJECTIVES: The authors aimed to determine if demographic disparities exist in preoperative and postoperative satisfaction after breast reduction mammaplasty, utilizing patient-reported quality of life (QoL) scores. METHODS: Patients who underwent breast reduction mammaplasty between 2015 and 2020 were identified. Patients who underwent complex concomitant procedures were excluded. Patient demographics and QoL, as measured by the BREAST-Q, were extracted. Wilcoxon Rank Sum and Kruskal-Wallis tests were employed to compare QoL scores across demographic subgroups. RESULTS: A total of 115 patients met the inclusion criteria. QoL improved across all 4 BREAST-Q domains (all Pâ <â 0.001). Disparities were shown to exist in the following: median income vs postoperative satisfaction with information (Pâ <â 0.001), BMI vs preoperative physical well-being (Pâ <â 0.001), and ethnicity vs preoperative physical well-being (Pâ =â 0.003). A sub-group analysis of Caucasian patients compared with Black/African American patients revealed significant inequalities in BMI (Pâ <â 0.001), median income by zip code (Pâ <â 0.001), improvement in satisfaction with breasts (Pâ =â 0.039), satisfaction with information (Pâ =â 0.007), and satisfaction with office staff (Pâ =â 0.044). CONCLUSIONS: Racial and socioeconomic inequalities exist in preoperative and postoperative satisfaction for patients undergoing breast reduction mammaplasty. Institutions should focus on developing tools for equitable and inclusive patient education and perioperative counseling.
Assuntos
Neoplasias da Mama , Mamoplastia , Mama/cirurgia , Feminino , Humanos , Satisfação do Paciente , Período Pós-Operatório , Qualidade de VidaRESUMO
PURPOSE: Posterior component separation with transversus abdominis release (TAR) enables medial myofascial flap advancement in complex abdominal wall reconstruction. Here, we add to a growing body of literature on TAR by assessing longitudinal clinical and patient-reported outcomes (PROs) after complex ventral hernia repair (VHR) with TAR. METHODS: Adult patients undergoing VHR with TAR between 10/15/2015 and 1/15/2020 were retrospectively identified. Patients with parastomal hernias and <12 months of follow-up were excluded. Clinical outcomes and PROs were assessed. RESULTS: Fifty-six patients were included with a median age and body mass index of 60 and 30.8 kg/m2, respectively. The average hernia defect was 384 cm2 [IQR 205-471], and all patients had retromuscular mesh placed. The most common complications were delayed healing (19.6%) and seroma (14.3%). There were no cases of mesh infection or explantation. Previous hernia repair and concurrent panniculectomy were risk factors for developing complications (P < .05). One patient (1.8%) recurred at a median follow-up of 25.2 months [IQR 18.2-42.4]. Significant improvement in disease-specific PROs was maintained throughout the follow-up period (before to after P < .05). CONCLUSION: Transversus abdominis release is a safe and efficacious technique to achieve fascial closure and retromuscular mesh in the repair of complex hernia defects.
Assuntos
Parede Abdominal , Hérnia Ventral , Hérnia Incisional , Adulto , Humanos , Músculos Abdominais/cirurgia , Hérnia Ventral/cirurgia , Estudos Retrospectivos , Herniorrafia/métodos , Hérnia Incisional/cirurgia , Hérnia Incisional/etiologia , Recidiva , Telas Cirúrgicas , Parede Abdominal/cirurgiaRESUMO
BACKGROUND: Women comprise 50% of the healthcare workforce, but only about 25% of senior leadership positions in the USA. No studies to our knowledge have investigated the performance of hospitals led by women versus those led by men to evaluate the potential explanation that the inequity reflects appropriate selection due to skill or performance differences. METHODS: We conducted a descriptive analysis of the gender composition of hospital senior leadership (C-suite) teams and cross-sectional, regression-based analyses of the relationship between gender composition, hospital characteristics (eg, location, size, ownership), and financial, clinical, safety, patient experience and innovation performance metrics using 2018 data for US adult medical/surgical hospitals with >200 beds. C-suite positions examined included chief executive officer (CEO), chief financial officer (CFO) and chief operating officer (COO). Gender was obtained from hospital web pages and LinkedIn. Hospital characteristics and performance were obtained from American Hospital Directory, American Hospital Association Annual Hospital Survey, Healthcare Cost Report Information System and Hospital Consumer Assessment of Healthcare Providers and Systems surveys. RESULTS: Of the 526 hospitals studied, 22% had a woman CEO, 26% a woman CFO and 36% a woman COO. While 55% had at least one woman in the C-suite, only 15.6% had more than one. Of the 1362 individuals who held one of the three C-suite positions, 378 were women (27%). Hospital performance on 27 of 28 measures (p>0.05) was similar between women and men-led hospitals. Hospitals with a woman CEO performed significantly better than men-led hospitals on one financial metric, days in accounts receivable (p=0.04). CONCLUSION: Hospitals with women in the C-suite have comparable performance to those without, yet inequity in the gender distribution of leaders remains. Barriers to women's advancement should be recognised and efforts made to rectify this inequity, rather than underusing an equally skilled pool of potential women leaders.
Assuntos
Pessoal de Saúde , Hospitais , Masculino , Adulto , Humanos , Feminino , Estados Unidos , Estudos Transversais , Inquéritos e Questionários , LiderançaRESUMO
BACKGROUND: With 400,000 hernias repaired annually, there is a need for development of efficient and effective repair techniques. Previously, the authors' group compared perioperative outcomes and hospital costs of patients undergoing ventral hernia repair with retromuscular mesh using suture fixation versus fibrin glue. This article reports on 3-year postoperative outcomes, including hernia recurrence, long-term clinical outcomes, and patient-reported quality of life. METHODS: Patients who underwent ventral hernia repair performed by a single surgeon between 2015 to 2017 were identified. Patients with retromuscular resorbable mesh placed were included and matched by propensity score. Primary outcomes included hernia recurrence, surgical-site infection, surgical-site occurrence, and surgical-site occurrence/surgical-site infection requiring procedural interventions. Secondary outcomes included quality of life as assessed by the Hernia-Related Quality of Life Survey. RESULTS: Sixty-three patients were eligible, and 46 patients were matched (23 suture fixation and 23 fibrin glue), with a median age of 62 years, a median body mass index of 29 kg/m2, and a median defect size of 300 cm2 (interquartile range, 180 to 378 cm2). Median follow-up was 36 months (interquartile range, 31 to 36 months). There was no difference in the incidence of hernia recurrence (13.0 percent for suture fixation and 8.7 percent for fibrin glue; p = 0.636) or other postoperative outcomes between techniques (all p > 0.05). Five patients required reoperation because of a complication (10.9 percent). Overall quality of life improved preoperatively to postoperatively at all time points (all p < 0.05), and no differences in quality-of-life improvement were seen between techniques (p > 0.05). CONCLUSION: Ventral hernia repair with atraumatic resorbable retromuscular mesh fixation using fibrin glue demonstrates equivalent postoperative clinical and quality-of-life outcomes when compared to mechanical suture fixation. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.