One-Stage Deep Inferior Epigastric Perforator Flap Salvage of Infected Tissue Expanders.

BACKGROUND: Tissue expander-based breast reconstruction is associated with high rates of infectious complications, often leading to tissue expander explants and delays in receipt of definitive breast reconstruction and adjuvant therapy. In this study, we describe a single-stage technique where deep inferior epigastric artery perforator (DIEP) flaps are used to salvage actively infected tissue expanders among patients originally planning for free flap reconstruction. METHODS: In this technique, patients with tissue expander infections without systemic illness are maintained on oral antibiotics until the day of their DIEP flap surgery, at which time tissue expander explant is performed in conjunction with aggressive attempt at total capsulectomy and immediate DIEP flap reconstruction. Patients are maintained on 1-2 weeks of oral antibiotics tailored to culture data. Patients undergoing this immediate salvage protocol were retrospectively reviewed, and complications and length of stay were assessed. RESULTS: In a retrospective series, a total of six consecutive patients with culture-proven tissue expander infections underwent tissue expander removal and DIEP flap reconstruction in a single stage and were maintained on 7-14 days of oral antibiotics postoperatively. Within this cohort, no surgical site infections, microvascular complications, partial flap losses, reoperations, or returns to the operating room were noted within a 90-day period. CONCLUSIONS: Among a select cohort of patients, actively infected tissue expanders may be salvaged with free flap breast reconstruction in a single surgery with a low incidence of postoperative complications. Prospective studies are needed to evaluate the influence of this treatment strategy on costs, number of surgeries, and dissatisfaction after staged breast reconstruction complicated by tissue expander infections.

Assessing the Benefits and Downsides of Physician Review Websites to Plastic Surgeons: A Cost-Benefit Analysis.

BACKGROUND: Patients often evaluate the reputations of plastic surgeons based on their performances on physician review websites. This article aims to compare rating methodologies and conduct a cost-benefit analysis of physician review websites to further understand how plastic surgeons and their patients can utilize review websites to inform their practice and care. METHODS: A review of online literature, blogs, and 17 of the most common physician review websites was conducted to identify information on review website methodology, cost, and benefits most pertinent to plastic surgeons and their patients. RESULTS: Physician review websites utilize various combinations of physician-related and unrelated criteria to evaluate plastic surgeons. Across 17 reviewed platforms, most (71%) utilize star ratings to rate physicians, 18% require an appointment to conduct a review, and 35% feature search engine optimization. Many websites (53%) allow physicians to pay for benefits or extension packages, with benefits offered including advertising, search engine optimization, competitor blocking, social media marketing, consultant services, and data analytics. Competitor blocking was provided by the most number of websites who offered additional services for pay (78%). CONCLUSIONS: Appointments are not required to post physician reviews on many review websites, and many websites allow physicians to purchase packages to enhance their search engine optimization or consumer reach. Accordingly, plastic surgeons' reputations on review websites may be influenced by factors extraneous to actual patient care. Patients and physicians should be cognizant that physician review websites may not be reflective of factors related to quality of patient care.

A Multi-institutional Analysis of a Textbook Outcome Among Patients Undergoing Microvascular Breast Reconstruction.

BACKGROUND: Individual outcomes may not accurately reflect the quality of perioperative care. Textbook outcomes (TOs) are composite metrics that provide a comprehensive evaluation of hospital performance and surgical quality. This study aimed to investigate the prevalence and predictors of TOs in a multi-institutional cohort of patients who underwent breast reconstruction with deep inferior epigastric artery perforator flaps. METHODS: For autologous reconstruction, a TO was previously defined as a procedure without intraoperative complications, reoperation, infection requiring intravenous antibiotics, readmission, mortality, systemic complications, operative duration ≤12 hours for bilateral and ≤10 hours for unilateral/stacked reconstruction, and length of stay (LOS) ≤5 days. We investigated associations between patient-level factors and achieving a TO using multivariable regression analysis. RESULTS: Of 1000 patients, most (73.2%) met a TO. The most common reasons for deviation from a TO were reoperation (9.6%), prolonged operative time (9.5%), and prolonged LOS (9.2%). On univariate analysis, tobacco use, obesity, widowed/divorced marital status, and contralateral prophylactic mastectomy or bilateral reconstruction were associated with a lower likelihood of TOs (P < 0.05). After adjustment, bilateral prophylactic mastectomy (odds ratio [OR], 5.71; P = 0.029) and hormonal therapy (OR, 1.53; P = 0.050) were associated with a higher likelihood of TOs; higher body mass index (OR, 0.91; P = <0.001) was associated with a lower likelihood. CONCLUSION: Approximately 30% of patients did not achieve a TO, and the likelihood of achieving a TO was influenced by patient and procedural factors. Future studies should investigate how this metric may be used to evaluate patient and hospital-level performance to improve the quality of care in reconstructive surgery.

The Influence of Patient and Surgeon Characteristics on Press Ganey Provider Ratings in Plastic Surgery.

BACKGROUND: Although patient satisfaction ratings are increasingly used as hospital and provider performance metrics, these ratings may be affected by factors extraneous to surgeon performance. OBJECTIVES: The aim of this study was to assess whether outpatient Press Ganey ratings for plastic surgery providers were tied more to provider or patient characteristics. METHODS: All Consumer Assessment of Healthcare Providers and Systems Clinician & Group Survey (CG-CAHPS) responses for plastic surgery providers from 2017 to 2023 from a single institution were analyzed. Ordered logistic regression models were used to identify characteristics associated with provider ratings. RESULTS: In total, 6442 surveys from 4594 patients representing 29 plastic surgery providers were analyzed. Across the patient cohort, 23.2% (N = 1492) rated plastic surgery providers lower than a 10/10. After adjustment, provider characteristics including provider gender, patient-provider gender concordance, and years in practice were not associated with overall provider ratings (all P > .05). In contrast, patient characteristics were associated with provider ratings. Older patient age (odds ratio [OR], 1.02; P < .001) was associated with higher ratings. Finally, self-reported overall health and mental health were associated with lower provider ratings (both P < .05); specifically, mental health categories lower than "Excellent" were associated with significantly lower provider ratings (overall mental health "Very Good': OR, 0.57; "Good": OR, 0.53; "Fair": OR, 0.59; "Poor": OR, 0.55; all P < .05). CONCLUSIONS: Press Ganey ratings for plastic surgeons are influenced by patient characteristics, including age and mental health. Because satisfaction ratings are increasingly used as performance metrics in plastic surgery, adjusted rating models may be needed to more accurately reflect surgeon performance.

Complications, Costs, and Healthcare Resource Utilization After Staged, Delayed, and Immediate Free-Flap Breast Reconstruction: A Longitudinal, Claims-Based Analysis.

BACKGROUND: There is a lack of consensus detailing the optimal approach to free-flap breast reconstruction when considering immediate, delayed, or staged techniques. This study compared costs, complications, and healthcare resource utilization (HCRU) across staged, delayed, and immediate free-flap breast reconstruction. PATIENTS AND METHODS: Retrospective study using MarketScan databases to identify women who underwent mastectomies and free-flap reconstructions between 2014 and 2018. Complications, costs, and HCRU [readmission, reoperation, emergency department (ED) visits] occurring 90 days after mastectomy and 90 days after free flap were compared across immediate, delayed, and staged reconstruction. RESULTS: Of 3310 women identified, 69.8% underwent immediate, 11.7% underwent delayed, and 18.5% underwent staged free-flap reconstruction. Staged reconstruction was associated with the highest rate (57.8% staged, 42.3% delayed, 32.0% immediate; p < 0.001) and adjusted relative risk [67% higher than immediate (95% CI: 49-87%; p < 0.001)] of surgical complications. Staged displayed the highest HCRU (staged 47.9%, delayed, 38.4%, immediate 25.2%; p < 0.001), with 16.5%, 30.7%, and 26.5% of staged patients experiencing readmission, reoperation, or ED visit, respectively. The adjusted probability of HCRU was 206% higher (95% CI: 156-266%; p < 0.001) for staged compared with immediate. Staged had the highest mean total cost (staged $106,443, delayed $80,667, immediate $76,756; p < 0.001) with regression demonstrating the adjusted mean cost for staged is 31% higher (95% CI: 23-39%; p < 0.001) when compared with immediate. CONCLUSIONS: Staged free-flap reconstruction is associated with increased complications, costs, and HCRU, while immediate demonstrated the lowest. The potential esthetic benefits of a staged approach should be balanced with the increased risk for adverse events after surgery.

Air or Saline? A Propensity Score-Matched Analysis on the Effect of Tissue Expander Fill on Complications in Immediate Breast Reconstruction.

BACKGROUND: Tissue expander fill medium and volume have implications for the pressure exerted on mastectomy skin flaps. This study evaluated the influence of initial fill medium (air vs. saline) on complications in immediate breast reconstruction within a propensity score-matched cohort. PATIENTS AND METHODS: Patients undergoing immediate tissue expander-based breast reconstruction with initial intraoperative fill with air were propensity score matched 1:2 to those with saline initial fill based on patient and tissue expander characteristics. Incidence of overall and ischemic complications were compared by fill medium (air vs. saline). RESULTS: A total of 584 patients were included, including 130 (22.2%) with initial fill with air, 377 (64.6%) with initial fill with saline, and 77 (13.2%) with 0 cc of initial fill. After multivariate adjustment, higher intraoperative fill volume was associated with increased risk of mastectomy skin flap necrosis [regression coefficient (RC) 15.7; p = 0.049]. Propensity score matching was then conducted among 360 patients (Air: 120 patients vs. Saline: 240 patients). After propensity score matching, there were no significant differences in the incidences of mastectomy skin flap necrosis, extrusion, reoperation, or readmission between the air and saline cohorts (all p > 0.05). However, initial fill with air was associated with lower incidence of infection requiring oral antibiotics (p = 0.003), seroma (p = 0.004), and nipple necrosis (p = 0.03). CONCLUSIONS: Within a propensity score-matched cohort, initial fill with air was associated with a lower incidence of complications, including ischemic complications after nipple-sparing mastectomy. Initial fill with air and lower fill volumes may be strategies to reducing risk of ischemic complications among high-risk patients.

Mapping Patient Encounters in Breast Cancer Care: An Analysis of 8800 Clinical Encounters Among Patients Undergoing Mastectomy.

BACKGROUND: Transitions toward value-based systems require a comprehensive definition of the complexity and duration of provider effort required for a given diagnosis. This study modeled the numbers of clinical encounters involved in various treatment pathways among breast cancer patients undergoing mastectomy. METHODS: Clinical encounters with medical oncologists, radiation oncologists, breast surgeons, or plastic surgeons ≤4 years after diagnosis among all patients undergoing mastectomy from 2017 to 2018 were reviewed. Relative encounter volumes were modeled each 90-day period after diagnosis. RESULTS: A total of 8807 breast cancer-related encounters from 221 patients were analyzed, with mean (SD) encounter volume 39.9 (27.2) encounters per patient. Most encounters occurred in the first year after diagnosis (70.0%), with years 2, 3, and 4 representing 15.8%, 9.1%, and 3.5% of encounters, respectively. Overall stage was associated with encounter volume, with higher encounter volume with increasing stage (stages 0: 27.4 vs I: 28.5 vs II: 48.4 vs III: 61.1 vs IV: 80.8 mean encounters). Body mass index (odds ratio [OR], 0.22), adjuvant radiation (OR, 6.8), and receipt of breast reconstruction (OR, 3.5) were also associated with higher encounter volume (all P 's < 0.01). Duration of encounter volume varied by treatment phases, with medical oncology and plastic surgery sustaining high clinical encounter volume 3 years after diagnosis. CONCLUSIONS: Encounter utilization in breast cancer care persists 3 years after index diagnosis and is influenced by overall stage and treatment characteristics, including receipt of breast reconstruction. These results may inform the design of episode durations within value-based models and institutional resource allocation for breast cancer care.

Consequences and Predictors of Prolonged Tissue Expander Duration in Breast Reconstruction.

BACKGROUND: Tissue expanders (TEs) are temporary devices used in breast reconstruction, which are generally removed within 1 year. There is a paucity of data regarding the potential consequences when TEs have longer indwelling times. Thus, we aim to determine whether prolonged TE implantation length is associated with TE-related complications. METHODS: This is a single-center retrospective review of patients who underwent TE placement for breast reconstruction from 2015 to 2021. Complications were compared between patients who had a TE for >1 year and <1 year. Univariate and multivariate regressions were used to evaluate predictors of TE complications. RESULTS: A total of 582 patients underwent TE placement and 12.2% had the expander for >1 year. Adjuvant chemoradiation, body mass index (BMI), overall stage, and diabetes predicted the duration of TE placement (p ≤ 0.006). Rate of return to the operating room was higher in patients who had TEs in place >1 year (22.5 vs 6.1%, p < 0.001). On multivariate regression, prolonged TE duration predicted an infection requiring antibiotics, readmission, and reoperation (p < 0.001). Reasons for longer indwelling times included need for additional chemoradiation (79.4%), TE infections (12.7%), and requesting a break from surgery (6.3%). CONCLUSION: Indwelling TEs for >1 year are associated with higher rates of infection, readmission, and reoperation even when controlling for adjuvant chemoradiation. Patients with diabetes, a higher BMI, advanced cancer stage, and those requiring adjuvant chemoradiation should be advised they may require a TE for a longer time interval prior to final reconstruction.

Evaluating Disparities in Pathways to Breast Reconstruction.

BACKGROUND: Rates of postmastectomy breast reconstruction have been shown to vary by racial, ethnic, and socioeconomic factors. In this study, we evaluated disparities across pathways toward breast reconstruction. METHODS: All women who underwent mastectomy for breast cancer at a single institution from 2017 to 2018 were reviewed. Rates of discussions about reconstruction with breast surgeons, plastic surgery referrals, plastic surgery consultations, and ultimate decisions to pursue reconstruction were compared by race/ethnicity. RESULTS: A total of 218 patients were included, with the racial/ethnic demographic of 56% white, 28% Black, 1% American Indian/Native Alaskan, 4% Asian, and 4% Hispanic/Latina. The overall incidence of postmastectomy breast reconstruction was 48%, which varied by race (white: 58% vs. Black: 34%; p < 0.001). Plastic surgery was discussed by the breast surgeon with 68% of patients, and referrals were made in 62% of patients. While older age (p < 0.001) and nonprivate insurance (p < 0.05) were associated with lower rates of plastic surgery discussion and referral, it did not vary by race/ethnicity. The need for an interpreter was associated with lower rates of discussion (p < 0.05). After multivariate adjustment, a lower reconstruction rate was associated with the Black race (odds ratio [OR] = 0.33; p = 0.014) and body mass index (BMI) ≥ 35 (OR = 0.14; p < 0.001). Elevated BMI did not disproportionately lower breast reconstruction rates in Black versus white women (p = 0.27). CONCLUSION: Despite statistically equivalent rates of plastic surgery discussions and referrals, black women had lower breast reconstruction rates versus white women. Lower rates of breast reconstruction in Black women likely represent an amalgamation of barriers to care; further exploration within our community is warranted to better understand the racial disparity observed.

The Influence of Age on Complications After Correction of Congenital Breast Deformities: A National Analysis of the Pediatric and Adult NSQIP Data Sets.

BACKGROUND: Timing of surgical intervention is controversial among patients seeking correction of congenital breast deformities. OBJECTIVES: This study aimed to assess the influence of age on 30-day complications and unplanned healthcare utilization after reconstruction of congenital breast deformities. METHODS: Female patients undergoing breast reconstruction for congenital breast deformities and Poland syndrome were identified on the basis of International Classification of Diseases (ICD) codes in the 2012 to 2021 pediatric and adult National Surgical Quality Improvement Project (NSQIP) data sets. Complications based on age at correction were compared, and multivariate logistic regression was used to identify predictors of overall and wound healing complications. RESULTS: Among 528 patients meeting inclusion criteria, mean (SD) age at surgical correction was 30.2 (13.3) years. Patients most commonly underwent implant placement (50.5%), mastopexy (26.3%), or tissue expander placement (11.6%). Across the cohort, overall incidence of postoperative complications was 4.4%, most commonly superficial surgical site infection (1.0%), reoperation (1.1%), or readmission (1.0%). After multivariate adjustment, increasing age at time of correction was associated with higher incidence of wound complications [odds ratio (OR) 1.001; 95% confidence interval (CI) 1.0003-1.002; P = .009], in addition to BMI (OR 1.002; 95% CI 1.0007-1.004; P = .006) and tobacco use (OR 1.06; 95% CI 1.02-1.11; P = .003). CONCLUSIONS: Breast reconstruction for congenital breast deformities may be safely undertaken at a young age with a low associated risk of postoperative complications. Large, multi-institutional studies are needed to assess the influence of surgical timing on psychosocial outcomes in this population.

A Novel Staging System for De Novo Metastatic Breast Cancer Refines Prognostic Estimates.

OBJECTIVE: We aim to identify prognostic groups within a de novo metastatic cohort, incorporating both anatomic and biologic factors. BACKGROUND: Staging for breast cancer now includes anatomic and biologic factors, although the guidelines for stage IV disease do not account for how these factors may influence outcomes. METHODS: Adults with de novo metastatic breast cancer were selected from the National Cancer DataBase (2010-2013). Recursive partitioning analysis was used to group patients with similar overall survival (OS) based on clinical T/N stage, tumor grade, ER, PR, HER2, number of metastatic sites, and presence of bone-only metastases. Categories were created by amalgamating homogeneous groups based on 3-year OS rates (stage IVA: >50%, stage IVB: 30%-50%, stage IVC: <30%). RESULTS: 16,187 patients were identified; median follow-up was 32 months. 65.2% had 1 site of distant metastasis, and 42.9% had bone-only metastases. Recursive partitioning analysis identified the number of metastatic sites (1 vs >1) as the first stratification point, and ER status as the second stratification point for both resulting groups. Additional divisions were made based on HER2 status, PR status, cT stage, tumor grade, and presence of bone-only metastases. After bootstrapping, significant differences in 3-year OS were noted between the 3 groups [stage IVB vs IVA: HR 1.58 (95% confidence interval 1.50-1.67), stage IVC vs IVA: HR 3.54 (95% confidence interval 3.33-3.77)]. CONCLUSIONS: Both anatomic and biologic factors yielded reliable and reproducible prognostic estimates among patients with metastatic disease. These findings support formal stratification of de novo stage IV breast cancer into 3 distinct prognosis groups.

Dissatisfaction After Post-Mastectomy Breast Reconstruction: A Mixed-Methods Study.

BACKGROUND: Breast reconstruction is associated with improved patient well-being after mastectomy; however, factors that contribute to post-surgical dissatisfaction remain poorly characterized. METHODS: Adult women who underwent post-mastectomy implant-based or autologous breast reconstruction between 2015 and 2019 were recruited to participate in semi-structured interviews regarding their lived experiences with reconstructive care. Participants completed the BREAST-Q, and tabulated scores were used to dichotomize patient-reported outcomes as satisfied or dissatisfied (high or low) for each BREAST-Q domain. A convergent mixed-methods analysis was used to evaluate interviews for content related to satisfaction or dissatisfaction with breast reconstruction. RESULTS: Overall, we interviewed 21 women and identified 17 subcodes that corresponded with the five BREAST-Q domains. Sources of dissatisfaction were found to be related to the following domains: (a) low breast satisfaction due to asymmetry, cup size, and lack of sensation and physical feeling (n = 8, 38%); (b) poor sexual well-being due to shape, look and feel (n = 7, 78% [of 9 who discussed sexual well-being]); (c) reduced physical well-being of the chest due to persistent pain and weakness (n = 11, 52%); (d) reduced abdominal well-being due to changes in abdominal strength, numbness, and posture (n = 6, 38% [of 16 who underwent abdominally based reconstruction]); and (e) low psychosocial well-being impacted by an unexpected appearance that negatively influenced self-confidence and self-identity (n = 13, 62%). CONCLUSION: Patients may be unprepared for the physical, sexual, and psychosocial outcomes of breast reconstruction. Targeted strategies to improve preoperative education and shared decision making are needed to mitigate unexpectedness associated with breast reconstruction and related outcomes.

The Influence of Body Mass Index on the Histopathology and Outcomes of Patients Diagnosed with Atypical Breast Lesions.

BACKGROUND: Multiple studies have demonstrated a link between obesity and breast cancer; however, the potential association between obesity and atypical high-risk breast lesions has not been well characterized. We sought to evaluate the characteristics and clinical outcomes of patients with breast atypia based on a woman's body mass index (BMI). METHODS: We retrospectively identified adult women diagnosed with atypical ductal hyperplasia (ADH), atypical lobular hyperplasia (ALH), and/or lobular carcinoma in situ (LCIS) at a single institution from 2008 to 2017. BMI groups were defined as a BMI 18.5 to < 30 or BMI ≥ 30 (obese). Adjusted logistic regression was used to estimate the association of BMI group with the odds of (1) upstage to cancer after atypia on needle biopsy, and (2) subsequent diagnosis of breast cancer. RESULTS: Breast atypia was identified in 503 patients (most advanced atypia: 74.8% ADH, 4.6% ALH, 20.7% LCIS), and 41% of these patients were classified as obese. After adjustment, BMI group was not associated with upstage to breast cancer at surgical excision following needle biopsy (p = 0.16) or development of a subsequent breast cancer (p = 0.08). For those upstaged to breast cancer at the time of surgical excision, or those who developed a subsequent malignancy, tumor subtype, grade and stage were not associated with BMI group (p > 0.05). CONCLUSION: In a large cohort of patients diagnosed with atypical breast histology, the risk of upstaging and/or subsequent progression to a breast malignancy was not associated with BMI. Factors other than obesity may influence breast cancer risk.

The Association Between Metabolic Derangement and Wound Complications in Elective Plastic Surgery.

INTRODUCTION: The incidence of metabolically unhealthy obesity is rising nationally. In this study, we compare wound and overall complications between metabolically unhealthy obese and healthy patients undergoing elective plastic surgery and model how operative time influences a complication risk. METHODS: Patients undergoing elective breast and body plastic surgery procedures in the 2009-2019 National Surgical Quality Improvement Program (NSQIP) dataset were identified. Complications were compared between metabolically unhealthy obese (body mass index [BMI] > 30 with diabetes and/or hypertension) versus metabolically healthy obese patients (BMI > 30 without diabetes or hypertension). Logistic regression was used to model the probability of wound complications across operative times stratified by metabolic status. RESULTS: Of 139,352 patients, 13.4% (n = 18,663) had metabolically unhealthy obesity and 23.8% (n = 33,135) had metabolically healthy obesity. Compared to metabolically healthy patients, metabolically unhealthy patients had higher incidence of wound complications (6.9% versus 5.6%; P < 0.001) and adverse events (12.4% versus 9.6%; P < 0.001), in addition to higher 30-d readmission, returns to the operating room, and length of stay (all P < 0.001). After adjustment, BMI (Odds ratio [OR] 7.86), hypertension (OR 1.15), and diabetes (OR 1.25) were independent risk factors for wound complications (all P < 0.001). Among metabolically unhealthy patients, the operative time was log-linear with a wound complication risk (OR 1.21; P < 0.001). CONCLUSIONS: Diabetes and hypertension are additive risk factors with obesity for wound complications in elective plastic surgery. Among patients with metabolically unhealthy obesity, a risk of wound complications increases logarithmically with operative time. This distinction with regard to metabolic state might explain the unclear impact of obesity on surgical outcomes within existing surgical literature.

A Personal Approach to Brachioplasty.

ABSTRACT: Brachioplasty has become one of the fastest-growing aesthetic surgery procedures, paralleling rising rates of weight loss surgery nationally. However, controversy persists regarding incision placement and utility of concurrent liposuction. In this article, the authors describe indications, patient selection, expected outcomes, and photographic standards for patients seeking brachioplasty after weight loss. Preoperative markings, scar placement, and operative steps of a posterior incision technique with or without concurrent liposuction if indicated are described. A personal experience with posterior incision brachioplasty along with current controversies, complications, and patient-reported outcomes after upper arm contouring are reviewed.

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

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

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

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

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

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

The Effect of Lavender Oil on Perioperative Pain, Anxiety, Depression, and Sleep after Microvascular Breast Reconstruction: A Prospective, Single-Blinded, Randomized, Controlled Trial.

BACKGROUND: Psychosocial distress, depression, or anxiety can occur in up to 50% of women after a breast cancer diagnosis and mastectomy. The purpose of this study was to assess the potential benefit of lavender oil as a perioperative adjunct to improve anxiety, depression, pain, and sleep in women undergoing microvascular breast reconstruction. METHODS: This was a prospective, single-blinded, randomized, controlled trial of 49 patients undergoing microvascular breast reconstruction. Patients were randomized to receive lavender oil or placebo (coconut oil) throughout their hospitalization. The effect of lavender oil on perioperative stress, anxiety, depression, sleep, and pain was measured using the hospital anxiety and depression scale, Richards-Campbell Sleep Questionnaire, and the visual analogue scale. RESULTS: Twenty-seven patients were assigned to the lavender group and 22 patients were assigned to the control group. No significant differences were seen in the perioperative setting between the groups with regard to anxiety (p = 0.82), depression (p = 0.21), sleep (p = 0.86), or pain (p = 0.30) scores. No adverse events (i.e., allergic reaction) were captured, and no significant differences in surgery-related complications were observed. When evaluating the entire cohort, postoperative anxiety scores were significantly lower than preoperative scores (p < 0.001), while depression scores were significantly higher postoperatively as compared with preoperatively (p = 0.005). CONCLUSION: In the setting of microvascular breast reconstruction, lavender oil and aromatherapy had no significant adverse events or complications; however, there were no measurable advantages pertaining to metrics of depression, anxiety, sleep, or pain as compared with the control group.

Do Histopathology and Clinical Outcomes of Breast Atypia Vary by Race/Ethnicity?

BACKGROUND: The clinical behavior of breast cancer varies by racial and ethnic makeup (REM), but the impact of REM on the clinical outcomes of breast atypia remains understudied. We examined the impact of REM on risk of underlying or subsequent carcinoma following a diagnosis of breast atypia. METHODS: In this retrospective, single-institution chart review, adult women diagnosed with breast atypia (atypical ductal hyperplasia, atypical lobular hyperplasia, or lobular carcinoma in situ) were stratified by REM. Regression modeling was used to estimate risk of underlying or subsequent carcinoma. RESULTS: We identified 539 patients with breast atypia, including 15 Hispanic (2.8%), 127 non-Hispanic black (23.6%), and 397 non-Hispanic white women (73.7%). Diagnoses included 75.1% atypical ductal hyperplasia (n = 405), 4.6% atypical lobular hyperplasia (n = 25), and 20.2% lobular carcinoma in situ (n = 109). Rates for each type of atypia did not vary by REM (P = 0.33). Of those with atypia on needle biopsy, the rate of underlying carcinoma at excision was 17.3%. After adjustment, REM was not associated with greater risk for carcinoma at excision (P = 0.41). Of those with atypia alone on surgical excision, the rate of a subsequent carcinoma diagnosis was 15.4% (median follow-up 49 mo). REM was not associated with a long-term risk for carcinoma (P = 0.37) or differences in time to subsequent carcinoma (log-rank P = 0.52). Chemoprevention uptake rates were low (10.6%), especially among Hispanic (0%) and non-Hispanic black (3.8%) patients (P = 0.01). CONCLUSIONS: Among patients with atypia, REM does not appear to influence type of histologic atypia, risk for carcinoma, or clinical outcome, despite differences in chemoprevention rates.