The Impact of Obesity on Success of Immediate Lymphatic Reconstruction for Prevention of Breast Cancer-Related Lymphedema.

BACKGROUND: Breast cancer-related lymphedema (BRCL) is a potential sequela of high-risk breast cancer treatment. Preventive treatment with immediate lymphatic reconstruction (ILR) at the time of axillary lymph node dissection (ALND) has emerged as the standard of care; however, there is relatively little known about factors that may contribute to procedural failure. METHODS: A retrospectively maintained, institutional review board-approved study followed patients who underwent ILR at the time of ALND at our tertiary care center between May 2018 and May 2023. Patients who presented for at least one follow-up visit in our multidisciplinary lymphedema clinic met the criteria for inclusion. Patients who developed lymphedema despite ILR and potential contributing factors were further explored. RESULTS: 349 patients underwent ILR at our institution between May 2018 and May 2023. 341 of these patients have presented for follow-up in our multidisciplinary lymphedema clinic. 32 (9.4%) patients developed lymphedema despite ILR. This cohort was significantly more likely to be obese (56% vs 35%, P = 0.04). Multivariate logistic regression demonstrates increased odds of procedural failure in patients with a body mass index (BMI) ≥30 kg/m2 (odds ratio 2.6 [1.2-5.5], P = 0.01). CONCLUSION: These data comment upon our institutions outcomes following ILR. Patients who develop lymphedema despite ILR tend to have a higher BMI, with a significantly increased risk in patients with a BMI of 30 or greater. Consideration of these data is critical for preprocedural counseling and may support a BMI cutoff when considering candidacy for ILR going forward, as well as when optimizing failures for secondary lymphedema procedures.

Breastfeeding Ability After Breast Reductions: What does the Literature Tell us in 2023?

INTRODUCTION: Reduction mammaplasties are routinely performed on women of child-bearing age, yet there still exists some uncertainty regarding a patient's ability to breastfeed following the procedure. This is due to inconsistent definitions of "successful" breastfeeding, a variety of pedicles implemented, and inadequate follow-up in the published literature. Our aim was to summarize the current data and provide clear recommendations for counseling patients on expected breastfeeding outcomes following reduction mammaplasty. METHODS: A systematic review and meta-analysis in accordance with the PRISMA guidelines was conducted. We included papers that reported proportion of breastfeeding ability following reduction mammaplasty. RESULTS: We identified 33 papers that met our inclusion criteria. We found that women who undergo reduction mammaplasty are at a 3.5 times increased odds of not being able to breastfeed compared to controls. Overall, reduction mammaplasty patients have a breastfeeding success rate of 62%. The breastfeeding success rate for patients with inferior pedicles was 64%, superior pedicles was 59%, and lateral pedicles was 55%. No conclusions could be drawn regarding medial, central, vertical, and horizontal pedicles on breastfeeding ability. CONCLUSION: Current data suggest that women undergoing reduction mammaplasty have an increased odds of unsuccessful breastfeeding when compared to similar women who have not undergone the procedure. Based on the current literature, pedicle type does play a role in rate of breastfeeding success, although there is a need for further research on the aforementioned pedicles. Physicians should be aware of the likelihood of successful breastfeeding following reduction mammaplasty so that patients can be more thoroughly counseled prior to a decision for surgery. LEVEL OF EVIDENCE I: 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 .

Immediate Lymphatic Reconstruction in 77 Consecutive Breast Cancer Patients: 2-year Follow-up.

BACKGROUND: Breast cancer-related lymphedema (BCRL) is a cyclical, progressive disease that begins at the time of axillary dissection and worsens in the setting of adjuvant oncologic therapies. The paradigm of lymphedema management in these patients is shifting from therapeutic surgeries and decongestive therapy to preventative surgery with immediate lymphatic reconstruction (ILR). METHODS: After institutional review board approval, a prospective database was maintained of all patients undergoing ILR. Patients were excluded if they had preoperative lymphedema or expired during the study period. All ILR were performed by the senior author. A control group was established with standardized physician delivered phone surveys of patients who had axillary dissection for breast cancer (same oncologic surgeon cohort) prior to the implementation of ILR at the same institution. The study and control groups were matched based on history of adjuvant radiation and body mass index. RESULTS: A cohort of patients between 2016 and 2019 with 2 years of follow-up after undergoing ILR (77 patients) were matched with those who did not undergo lymphatic reconstruction (94 patients). The incidence of lymphedema in the study group undergoing ILR was 10% (N = 8). In comparison, the incidence in the cohort who did not undergo lymphatic reconstruction was 38% (N = 36; p < 0.01). Patients with ILR had 92% lower odds of developing lymphedema (p < 0.01). CONCLUSION: ILR can significantly reduce the risk of developing BRCL in high-risk patients at 2 years of follow-up. Patients receiving adjuvant radiation therapy are more likely to develop BCRL after ILR compared with those who do not. Ongoing studies include investigation aimed at identifying patients most at risk for the development of BRCL to help target intervention as well as elucidate factors that contribute to the success of ILR.

Syringe Suction Yields Greater Adipocyte Viability for Fat Grafting: Fact or Fiction?

ABSTRACT: Autologous fat grafting is a technique that can be used for cosmetic and reconstructive indications such as oncologic defects, aging, trauma, and congenital malformations. However, there is no standardized technique, and one of the main challenges is the unpredictable rate of fat resorption. When using fat grafting, it is crucial to understand the different factors that contribute to adipocyte viability. A literature search, using PubMed, was conducted in 2022 with variations of the terms "autologous fat grafting," "fat harvesting," "fat processing," and "fat injection." Articles in the English language that presented original data about different factors that may affect adipocyte viability for fat grafting were included in this review. Syringe suction harvests (lower pressures), compared with other methods with higher pressures, were found to have increased adipocyte counts and viability, but this did not translate clinically during in vivo studies. The studies have shown that, despite our efforts in optimizing fat harvest, processing, and injection, no statistical or clinical differences have been found. Additional studies are still needed to determine a universal protocol for optimal fat graft survival.

Reliable Location of Upper Extremity Lymphatic Channels for Use in Immediate Lymphatic Reconstruction.

BACKGROUND: Breast cancer-related lymphedema (BCRL) is a limiting sequelae of breast cancer treatment that may negatively impact 30% to 50% of high-risk breast cancer survivors. Risk factors for development of BCRL include axillary lymph node dissection (ALND), and recently, axillary reverse lymphatic mapping and immediate lymphovenous reconstruction (ILR) at time of ALND have been implemented to prevent BCRL. Reliable anatomy of neighboring venules has been commented on in the literature; however, little information exists about anatomical location of local lymphatic channels amenable for bypass. METHODS: After institutional review board approval, patients who underwent ALND with axillary reverse lymphatic mapping and ILR at a tertiary cancer center from November 2021 to August 2022 were applicable for this study. The location and number of lymphatic channels used for ILR were identified and measured intraoperatively with the arm abducted to 90 degrees and soft tissue under no tension. Four measurements were taken to localize each lymphatic and were based on relationship with reliable anatomic landmarks including 4th rib, anterior axillary line, and lower border of the pectoralis major muscle. Demographics, oncologic treatments, intraoperative factors, and outcomes were prospectively maintained. RESULTS: Twenty-seven patients met inclusion for this study by August 2022 with a total of 86 lymphatic channels identified. Patients were on average 50 ± 12 years old with a body mass index of 30 ± 6 and had an average of 1 vein and 3 identifiable lymphatic channels amenable to bypass. Seventy percent of lymphatic channels were found in a cluster of 2 or more channels. The average horizontal location was 4.5 ± 1.4 cm lateral to the 4th rib. The average vertical location was 1.3 ± 0.9 cm from the superior border of the 4th rib. CONCLUSIONS: These data comment upon intraoperatively identified and consistent location of upper extremity lymphatic channels used for ILR. These lymphatic channels are often found in clusters with 2 or more lymphatic channels at the same location. Such insight may aid in easier intraoperative identification of amenable vessels for the unexperienced surgeon, decrease in intraoperative time, and higher success of ILR.

Efficacy of Immediate Lymphatic Reconstruction in Prevention of Breast Cancer-Related Lymphedema.

INTRODUCTION: Breast cancer-related lymphedema (BCRL) is a chronic condition that can negatively affect the quality of life of breast cancer survivors. Immediate lymphatic reconstruction (ILR) at the time of axillary lymph node dissection is emerging as a technique for the prevention of BCRL. This study compared the incidence of BRCL in patients who received ILR and those who were not amenable to ILR. METHODS: Patients were identified through a prospectively maintained database between 2016 and 2021. Some patients were deemed nonamenable to ILR due to a lack of visualized lymphatics or anatomic variability (eg, spatial relationships or size discrepancies). Descriptive statistics, independent t test, and Pearson χ 2 test were used. Multivariable logistic regression models were created to assess the association between lymphedema and ILR. A loose age-matched subsample was created for subanalysis. RESULTS: Two hundred eighty-one patients were included in this study (252 patients who underwent ILR and 29 patients who did not). The patients had a mean age of 53 ± 12 years and body mass index of 28.6 ± 6.8 kg/m 2 . The incidence of developing lymphedema in patients with ILR was 4.8% compared with 24.1% in patients who underwent attempted ILR without lymphatic reconstruction ( P = 0.001). Patients who did not undergo ILR had significantly higher odds of developing lymphedema compared with those who had ILR (odds ratio, 10.7 [3.2-36.3], P < 0.001; matched OR, 14.2 [2.6-77.9], P < 0.001). CONCLUSIONS: Our study showed that ILR was associated with lower rates of BCRL. Further studies are needed to determine which factors place patients at highest risk of developing BCRL.

Complications of Medical Tourism in Aesthetic Surgery: A Systematic Review.

INTRODUCTION: As medical cost continues to rise, so has the use of medical tourism by patients as a more cost-effective alternative. While the upfront cost savings attract many unsuspecting patients from their country of origin, there are significant patient safety issues surrounding short- and long-term follow-up, as well as the management and cost of complications. METHODS: A systematic review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses on complications that presented after cosmetic surgeries performed abroad. The literature search was performed on October 18, 2022, using the databases of PubMed, Google Scholar, and Embase. RESULTS: From the 44 studies that were included, 589 patients were identified who presented with complications after having a cosmetic procedure abroad. Infection was the most prevalent complication in this study followed by wound dehiscence, seroma/hematoma, and tissue necrosis. Ninety-eight percent of the infectious organisms were bacterial, and 81% of them were from the Mycobacterium genus. CONCLUSIONS: Cosmetic tourism is a global phenomenon. This systematic review highlights the nature of complications following cosmetic tourism, the surgeries that resulted in complications, the countries that the primary procedures took place in, and the countries of origin of the patients. To aid in reducing morbidity and mortality from cosmetic tourism, regulatory bodies should educate and empower the public to aid them in making educated medical conditions when seeking care.

Complication Profile of Total Submuscular Versus Prepectoral Tissue Expander Placement: A Retrospective Cohort Study.

BACKGROUND: We sought to compare the safety profile of prepectoral breast reconstruction with total submuscular tissue expander reconstruction, previously our standard. Primary outcomes of interest in this retrospective cohort study were incidence of infection, hematoma, seroma, mastectomy flap necrosis, and reconstruction loss. METHODS: Total submuscular and prepectoral with acellular dermal matrix reconstructions consecutively performed by a single surgeon (P.D.S.) between January 1, 2016, and December 31, 2019, were compared. Demographic and clinical characteristics, as well as complications and complication types, were extracted for all patients. A t test was used to assess differences in continuous variables. Multivariate logistics regression was used to assess the association between type of reconstruction and complication rate. The statistical significance was set at 0.05 for all comparisons. RESULTS: A total of 133 patients (234 breasts) were included. There was a significantly greater incidence of infection (16.5% vs 5.5%, P < 0.01) in the prepectoral/acellular dermal matrix cohort. However, reconstructive loss was low in both cohorts (2.5% and 3.0%, P = 0.83). Adjusted odds ratio for complications in the prepectoral cohort was 2.26, but this was not statistically significant (adjusted P = 0.24). CONCLUSIONS: Prepectoral breast reconstruction shares an overall complication profile that is not greater than that of total submuscular reconstruction. It is associated with a greater risk of infection; however, the ability to salvage the reconstruction with early, aggressive intervention results in low rates of reconstructive loss, comparable with those of total submuscular reconstruction.

The immunologic response to severe acute respiratory syndrome coronavirus 2.

Background: The spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has precipitated the worst global pandemic in a century, which has caused millions of infections and deaths as well as massive economic repercussions. Objective: As with any pathogenic virus, it is crucial to understand its unique interactions with the human immune system so that pharmaceutical and prophylactic interventions can be deployed to effectively control the pandemic. Methods: A literature search by using PubMed was conducted in 2020 with variants of the terms "COVID-19," "SARS-CoV-2," and "immunological response." English language articles that presented original data about the immunologic response to coronavirus disease 2019 (COVID-19) were selected for review. This article reviewed the current understanding of the innate and adaptive immune responses to SARS-CoV-2 infection, including their relationship to current therapeutic and diagnostic strategies. Results: SARS-CoV-2 uses several unique molecular techniques to evade detection by the innate immune system early in the course of infection, and upregulation of these innate immune pathways may possibly accelerate the time to recovery and prevent severe disease. Although the majority of cases results in the patients' recovery, a significant proportion of infections result in deaths prompted by the host's inflammatory overreaction to the infection, a response that can be attenuated with corticosteroids and potentially other immune modulators. Conclusion: Current work by the scientific community to further understand how SARS-CoV-2 interacts with the human immune system will be invaluable to our response and preparedness for future coronavirus pandemics.

Preservation of the Implant in Nipple-Sparing Mastectomies: A Retrospective Cohort Study.

BACKGROUND: Mastectomies are an integral part of breast cancer treatment for many patients.1 Of those patients, a significant number have previously undergone breast augmentation before being diagnosed with breast cancer. Therefore, we developed the novel technique of performing nipple- and implant-sparing mastectomies (NISMs) for women with prior breast augmentations. This study will assess the plausibility of using NISMs versus nipple-sparing mastectomies (NSMs) in this subgroup of patients by comparing the complication rates. METHODS: Data were collected on age, tumor size, tumor grade, receptors, and the interval between mastectomy and implant exchange for both groups. Descriptive statistics were used to summarize patient characteristics. Independent samples t tests, χ2 tests, and Fisher exact tests were used to compare the NISM and NSM cohorts. Logistic regression was used to assess the association between complications and mastectomy type and was summarized as an odds ratio with a 95% confidence interval. RESULTS: Fifteen patients underwent an NISM and 35 patients underwent an NSM. The overall rate of complications was less in NISM cases than in NSM cases (20% vs 27%). However, this difference was not statistically significant (odds ratio, 0.54; 95% confidence interval, 0.18-1.64; P = 0.278). CONCLUSIONS: The overall complication rate was lower with NISMs compared with NSMs. Nipple- and implant-sparing mastectomy is a novel, viable, and safe option for patients with breast cancer and a history of submuscular breast augmentation.

The Learning Curve: Trends in the First 100 Immediate Lymphatic Reconstructions Performed at a Single Institution.

BACKGROUND: Cancer-related lymphedema will affect 10% to 50% of breast cancer survivors. Early data show that immediate lymphatic reconstruction may help prevent breast cancer lymphedema; however, the details have not been fully elucidated. The purpose of this study was to evaluate the cohort of our first 100 patients for trends in demographics, treatment, and technique. METHODS: At a tertiary care cancer center, high-risk breast cancer-related lymphedema patients underwent axillary reverse lymphatic mapping and immediate lymphatic reconstruction. After institutional review board approval, demographics, technique, and outcomes were recorded. The first 100 patients were analyzed to compare the differences between the first 50 versus the second 50 patient cohorts. RESULTS: Of the first 100 axillary reverse lymphatic mapping performed, there was a significant difference in neoadjuvant chemotherapy with 81% in the earlier cohort versus 98% in the later cohort (P = 0.01). An arborized technique was used more frequently in the second cohort (82% vs 54%, P = 0.01). The incidence of lymphedema was lower in the latter cohort (7 patients vs 1 patient, P = 0.03). The first cohort was 12.2 times more likely to develop lymphedema despite lymphatic reconstruction than the second cohort (P = 0.03). CONCLUSIONS: The data demonstrate multiple trends in the learning curve associated with immediate lymphatic reconstruction at a single institution including improvements in identifying and dissecting lymphatic structures, performing more anastomoses per patient, using the arborized technique more frequently, performing the operation with shorter operative times, and reducing the incidence of lymphedema.

Impact of socioeconomic status on psychological functioning in survivorship following breast cancer and reconstruction.

Socioeconomic status (SES) remains an important population health risk factor and impacts a patient's experience of care during breast cancer. This study explored the relationship between SES and quality of life and satisfaction in survivorship following breast cancer and reconstruction. All patients underwent breast reconstruction at a single academic center from 2013 to 2017. Patients completed the five quality of life and satisfaction domains of the BREAST-Q, a validated patient-reported outcome measure. Estimated home value using a web-based real estate website was used to approximate a patient's socioeconomic status. Correlations were evaluated using Pearson's correlation methods, where appropriate, as well as analysis of covariance. Data were stratified for comparison utilizing t tests and linear regression models. Significance was defined as P ≤ .05. Four hundred patients underwent 711 breast reconstructions during the study time period. Satisfaction with the breast (P = .038) and psychosocial well-being (P = .012) had significant positive correlations with increasing socioeconomic status. When stratifying patients' socioeconomic status into thirds, the upper third had significantly higher psychosocial well-being (P = .001), satisfaction with breasts (P = .010), and physical well-being of the chest (P = .001) than the lower third. Significance persisted even after controlling for cancer stage, treatment, complications, and baseline comorbidities. Higher socioeconomic status is associated with greater satisfaction with breast reconstruction and psychosocial well-being following breast cancer treatment. Providing added social, psychological, and emotional support networks may be beneficial long after the initial cancer treatment and reconstruction are complete. Patients of lower socioeconomic status may benefit from additional resources.

The Not-So-Soft Spot: Pathophysiology of the Bulging Fontanelle in Association With Roseola.

Roseola infantum is a clinical syndrome characterized by high fever followed by the emergence of a rash. Case reports have documented an association between bulging fontanelles and roseola. We propose a novel mechanism for the development of intracranial hypertension caused by human herpesvirus 6-induced cytokine elevation leading to increased cerebrospinal fluid production.

Cryptogenic Intracranial Hemorrhagic Strokes Associated with Hypervitaminosis E and Acutely Elevated α-Tocopherol Levels.

OBJECTIVES: Up to 41% of intracerebral hemorrhages (ICH) are considered cryptogenic despite a thorough investigation to determine etiology. Certain over-the-counter supplements may increase proclivity to bleeding, and we hypothesize that specifically vitamin E may have an association with ICH and acutely elevated serum levels of α-tocopherol. Our aim is to report 3 cases of recently admitted patients with hypervitaminosis E and otherwise cryptogenic ICH. METHODS: At our institution between January and December 2018, 179 patients were admitted with ICH with 73 imputed to be "cryptogenic" (without clear etiology as per Structural vascular lesions, Medication, Amyloid angiopathy, Systemic disease, Hypertension, or Undetermined and Hypertension, Amyloid angiopathy, Tumor, Oral anticoagulants, vascular Malformation, Infrequent causes, and Cryptogenic criteria). Of these, we found 3 (4.1%) clearly admitted to consistent use of vitamin E supplementation for which α-tocopherol levels were checked. We describe the clinical presentation and course of these patients and their etiologic and diagnostic evaluations including neuroimaging and α-tocopherol laboratory data. RESULTS: All patients in this series were consistently consuming higher than recommended doses of vitamin E and developed acute ICH. The first 2 patients both had subcortical (thalamic) intraparenchymal hemorrhages while the third had an intraventricular hemorrhage. Serum α-tocopherol levels in patient A, B, and C were elevated at 30.8, 46.7, and 23.3 mg/L, respectively (normal range 5.7-19.9 mg/L) with a mean of 33.6 mg/L. No clear alternate etiologies to their ICH could be conclusively determined despite thorough workups. CONCLUSIONS: In patients with cryptogenic ICH, clinicians should consider hypervitaminosis E and check serum α-tocopherol level during admission. Reviewing the patient's pharmacologic history, including over-the-counter supplements such as vitamin E, may help identify its association, and its avoidance in the future may mitigate risk. With its known vitamin K antagonism, hypo-prothrombinemic effect, cytochrome p-450 interaction, and antiplatelet activity, vitamin E may not be as benign as presumed. Its consumption in nonrecommended doses may increase ICH risk, which may be underestimated and under-reported.

Pain and Anxiety Levels of Patients Undergoing Tissue Expansion After Mastectomies: A Case Series Study.

The tissue expansion process is done after mastectomies to increase the submuscular space in preparation for the placement of permanent breast implant. The process is often believed to be painful by patients who are often intimidated by the prospect of mechanically stretching out their skin and muscle. This study aims to quantify the pain experienced by patients and determine the different pain management techniques used. We used a case series approach, in which patients who were undergoing serial tissue expansion process were asked to rate their pain and anxiety on a scale from 1 to 10, using a questionnaire and the visual analog scale. Pain was rated during and after the expansion procedure, and patients were also surveyed to find the most commonly used and most effective pain management technique. Patients typically reported very little pain during and after the procedure, with an average of 0.4 to 2.5 pain experienced out of 10. The pain did not last, on average, longer than 1 day. Furthermore, the most widely used and most helpful pain medication was ibuprofen. During the tissue expansion procedure, the mean anxiety level was 0.64 (1.3). The findings show that tissue expansion process is a relatively low pain procedure and is not a contraindication for undergoing breast reconstruction. Ibuprofen, a mild treatment with few side effects, was efficacious in pain relief though most patients required no pain relief.

Impact of peer support on virologic failure in HIV-infected patients on antiretroviral therapy - a cluster randomized controlled trial in Vietnam.

BACKGROUND: The effect of peer support on virologic and immunologic treatment outcomes among HIVinfected patients receiving antiretroviral therapy (ART) was assessed in a cluster randomized controlled trial in Vietnam. METHODS: Seventy-one clusters (communes) were randomized in intervention or control, and a total of 640 patients initiating ART were enrolled. The intervention group received peer support with weekly home-visits. Both groups received first-line ART regimens according to the National Treatment Guidelines. Viral load (VL) (ExaVir™ Load) and CD4 counts were analyzed every 6 months. The primary endpoint was virologic failure (VL >1000 copies/ml). Patients were followed up for 24 months. Intention-to-treat analysis was used. Cluster longitudinal and survival analyses were used to study time to virologic failure and CD4 trends. RESULTS: Of 640 patients, 71% were males, mean age 32 years, 83% started with stavudine/lamivudine/nevirapine regimen. After a mean of 20.8 months, 78% completed the study, and the median CD4 increase was 286 cells/µl. Cumulative virologic failure risk was 7.2%. There was no significant difference between intervention and control groups in risk for and time to virologic failure and in CD4 trends. Risk factors for virologic failure were ART-non-naïve status [aHR 6.9;(95% CI 3.2-14.6); p < 0.01]; baseline VL ≥100,000 copies/ml [aHR 2.3;(95% CI 1.2-4.3); p < 0.05] and incomplete adherence (self-reported missing more than one dose during 24 months) [aHR 3.1;(95% CI 1.1-8.9); p < 0.05]. Risk factors associated with slower increase of CD4 counts were: baseline VL ≥100,000 copies/ml [adj.sq.Coeff (95% CI): -0.9 (-1.5;-0.3); p < 0.01] and baseline CD4 count <100 cells/µl [adj.sq.Coeff (95% CI): -5.7 (-6.3;-5.4); p < 0.01]. Having an HIV-infected family member was also significantly associated with gain in CD4 counts [adj.sq.Coeff (95% CI): 1.3 (0.8;1.9); p < 0.01]. CONCLUSION: There was a low virologic failure risk during the first 2 years of ART follow-up in a rural low-income setting in Vietnam. Peer support did not show any impact on virologic and immunologic outcomes after 2 years of follow up. TRIAL REGISTRATION: NCT01433601 .

Novel Treatment of Pyoderma Gangrenosum With Porcine-Derived Extracellular Matrix Following Bilateral Latissimus Dorsi Breast Reconstruction: A Case Report.

Pyoderma gangrenosum (PG) is a rare disease characterized by ulcerative cutaneous lesions that can occur postoperatively and is often associated with autoimmune disorders. PG is diagnosed by excluding other conditions that can cause ulcerations, such as infections, which may also result in immunosuppressive treatment delays and suboptimal wound care. Operative debridement of wounds has traditionally been avoided in the acute setting secondary to pathergy. This article presents a case of extensive breast PG that was successfully treated with surgical debridement, porcine-derived extracellular matrix, and negative pressure wound therapy while on systemic immunosuppressive therapy.

Medical Tourism in Plastic Surgery: A Case Series of Complications.

Background: Medical tourism in plastic surgery has grown exponentially over the last decade. The rise in the number of cases is multifactorial but is mostly driven by reduced cost. While this may seem attractive to patients, it is not without risk. Even under the best circumstances, complications can arise, and patients may be put at increased risk of atypical infections due to different sterilization standards. Lack of customary follow-up and accessibility can lead to delays in diagnosing infections and cause patients to seek care locally. We present our experience in managing atypical infections resulting from cosmetic surgery tourism in a tertiary care system. Methods: We report a case series of 3 patients who underwent cosmetic procedures abroad who presented to our institutions with postoperative complications and infections. Results: Our cohort consist of 3 female patients ranging from 26 to 48 years of age who had cosmetic surgery abroad. All 3 presented with nontuberculous mycobacteria (NTM) infections. Conclusions: Cosmetic surgery tourism is luring patients with advertised all-inclusive surgery and vacation packages at reduced cost. This attracts vulnerable patients and puts them at risk of devastating long-term physical and financial sequalae. NTM infections should be considered early in this population, especially when they are not responding to other therapies. More widespread information about the consequences of traveling for medical procedures is needed to help inform and empower patients to make educated decisions when choosing where to seek care.

Is There a Difference in Abdominal Wall Muscle Strength, Endurance, and Motor Control Following Bilateral DIEP and TRAM Flaps for Breast Reconstruction?

Background: Abdominal donor site complications in bilateral pedicled transverse rectus abdominis muscle (TRAM) have been a concern when compared with bilateral deep inferior epigastric perforator (DIEP) flap breast reconstruction. This study aimed to assess the strength, endurance, and motor control in patients undergoing DIEP and TRAM flaps. Methods: A prospective, cohort study was performed at a single institution including patients who underwent pedicled TRAM and DIEP flap reconstruction after mastectomy from August 2017 to August 2018. Patients underwent pre- and postoperative testing involving rectus abdominis, prone plank, side bridge, and trunk flexor tests. Descriptive analyses and multivariate linear regressions were performed. Results: The final analysis included a total of 9 patients, 4 of whom underwent TRAM flap reconstruction while 5 underwent DIEP flap reconstruction. The tests were not statistically significant between the TRAM versus DIEP groups, including rectus abdominis mean time decrease (0.25 vs 0.60 sec, P = .51), prone plank time increase (1.38 vs 1.38 sec, P = .51), right side bridge time increase (7.54 sec vs 32.15 sec, P = 1.00), left side bridge time increase (2.14 vs 44.5 sec, P = .37), and trunk flexor time decrease (4.68 vs 1.68 sec, P = .44). Overall complications were similar between the 2 groups. Conclusions: No significant difference in abdominal donor site morbidity was found when comparing the 2 groups. This article provides a point of conversation with patients when discussing available reconstruction options.