Quality of Surgical Outcomes Reporting in Plastic Surgery: A 15-Year Analysis of Complication Data

Incidence of postoperative complications is underestimated if outcome data are recorded by interns and first year residents in a low volume hospital setting

The aim of this study is to evaluate the accuracy of outcome reporting after elective visceral surgery in a low volume district hospital. Outcome measurement as well as transparent reporting of surgical complications becomes more and more important. In the future, financial and personal resources may be distributed due to reported quality and thus, it is in the main interest of healthcare providers that outcome data are accurately collected. Between 10/2020 and 09/2021 postoperative complications during the hospitalisation were recorded using the Clavien-Dindo classification (CDC) and comprehensive complication index by residents of a surgical department in a district hospital. After one year of prospective data collection, data were retrospectively analyzed and re-evaluated for accuracy by senior consultant surgeons. In 575 patients undergoing elective general or visceral surgery interns and residents reported an overall rate of patients with complications of 7.3% (n = 42) during the hospitalization phase, whereas a rate of 18.3% (n = 105) was revealed after retrospective analysis by senior consultant surgeons. Thus, residents failed to report patients with postoperative complications in 60% of cases (63/105). In the 42 cases, in which complications were initially reported, the grading of complications was correct only in 33.3% of cases (n = 14). Complication grades that were most missed were CDC grade I and II. Quality of outcome measurement in a district hospital is poor if done by unexperienced residents and significantly underestimates the true complication rate. Outcome measurement must be done or supervised by experienced surgeons to ensure correct and reliable outcome data.

Factors necessary for entrustment decision-making in surgical operating rooms: A modified Delphi study

Objective

Resident autonomy in an operation theatre has been directly linked with patient safety in healthcare. The objective of this study was to identify the factors necessary for making resident-entrustment decisions from the perspective of a supervisor/consultant viewpoint. The second objective was to develop a checklist for assessing resident readiness for independent work.

Materials and methods

This study employed a mixed-method Delphi approach. In the first stage, a comprehensive literature review and a qualitative exploratory study produced a list of factors related to residents. The second phase involved content validation by a panel of experts, followed by a two-round Delphi study with 20 expert panelists.

Results

A total of 49 resident-related factors for entrustment were identified, which were reduced to 46 after content validation. During Delphi Round I, 17 factors were fully accepted, 7 were rejected and 22 items were partially accepted. Out of the 39 items sent to Delphi Round II, 23 items were accepted and 16 were rejected. A final 23-item checklist was formed based on the following factors; 6 Cognitive (knowledgeable, risk manager, safe doctor, general manager, field of interest, communicator), 5 Psychomotor (past performer, competent, ability to pick critical findings, ability to act situationally, decision maker) and 12 affective (responsible, leader, honest, empathetic, ethical, receptive, humble, emotionally intelligent, motivated, accountable, team player, disciplined) factors.

Conclusion

The study resulted in the formation of a checklist based on the factors necessary for entrustment decision-making in surgical operating rooms. Some of the novel contextual factors were 'general manager', 'field of interest', 'ability to pick critical findings', 'accountable', 'risk manager', and 'past performer'. This framework offers a guideline for supervisors and residents to evaluate progress throughout the residency program. The developed tool demonstrates good content validity and is suitable for entrustment assessment following construct validation.

Effect of prolonged antibiotic prophylaxis on the occurrence of surgical site wound infection after instant breast reconstruction: A meta-analysis

The purpose of the meta-analysis was to evaluate and compare the effects of prolonged antibiotic prophylaxis on the occurrence of surgical site wound infection after instant breast reconstruction. The results of this meta-analysis were analysed, and the odds ratio (OR) and mean difference with 95% confidence intervals (CIs) were calculated using dichotomous or contentious random- or fixed-effect models. For the current meta-analysis, 18 examinations spanning from 2009 to 2023 were included, encompassing 19 301 females with instant breast reconstruction. Systemic antibiotic prophylaxis had a significantly lower surgical site wound infection rate (OR, 0.85; 95% CI, 0.75-0.98, p = 0.02) compared with the standard of care after instant breast reconstruction in females. Topical antibiotic prophylaxis had a significantly lower surgical site wound infection rate (OR, 0.26; 95% CI, 0.13-0.52, p < 0.001) compared with the standard of care after instant breast reconstruction in females. The examined data revealed that systemic and topical antibiotic prophylaxis had a significantly lower surgical site wound infection rate compared with the standard of care after instant breast reconstruction in females. However, given that several examinations had a small sample size, consideration should be given to their values.

Consecutive Microsurgical Cases Performed by Single Surgeon at a Canadian Tertiary Care Center: A Retrospective Review

Background: The practice of a microsurgeon evolves over time with experience, changes in clinical interest, and practice setting. Previous reports suggest that complication rates may be influenced by years of practice. The aim of this study was to analyze consecutive microsurgical cases performed by a single surgeon during the first half of their career in a broad microsurgical practice at a Canadian academic tertiary care center. Methods: A retrospective chart review of all free tissue transfers between 2007 and 2020 completed by a single academic plastic surgeon was performed. The primary outcomes were the odds of postoperative complications and free flap failure. The secondary outcomes included the annual number and type of free flap cases over time. Results: The surgeon performed 795 free flaps on 537 patients. There were a total of 131 postoperative complications. There was no statistically significant association between the years in practice and odds of a complication. Overall, there were 26 flap failures, yielding a 96.7% success rate. There was no association between flap failure and years in practice. The most common type of reconstruction was breast, followed by lower extremity and head and neck. There was a significant change in the type of reconstruction cases over time (P < 0.005). Conclusion: The type and volume of free flap reconstruction conducted by the surgeon has changed over time. In this single surgeon career, surgical experience did not have a significant impact on free flap complications. At our center, free tissue transfer remains a valuable tool for reconstruction in both low and high-risk patients.

Preservation versus dissection of the intercostobrachial nerve for breast cancer surgeries: a systematic review and meta-analysis

Introduction

This meta-analysis aimed to compare the efficacy of preservation of the intercostobrachial nerve (ICBN) versus its dissection for patients who underwent breast surgery.

Methods

The authors searched Web of Science, PubMed, Cochrane CENTRAL, and Scopus from inception until March 2023. Records were screened for eligible studies, and all relevant outcomes were pooled as an odds ratio (OR) with the corresponding 95% CI in the meta-analysis models using RevMan version 5.4.

Results

These results from 11 studies (1021 patients) favored preservation of the ICBN over its dissection in terms of anaesthesia and hypaesthesia [OR 0.50, (95% CI, 0.31-0.82); P = 0.006] and [OR 0.33, (95% CI, 0.16-0.68); P = 0.003], respectively. Whereas the overall effect favored ICBN dissection over preservation in the case of hyperaesthesia [OR 4.34, (95% CI, 1.43-13.15); P = 0.01]. Conversely, no significant variance was detected between the two groups in terms of pain [OR 0.68, (95% CI, 0.28-1.61) P = 0.38], paraesthesia [OR 0.88, (95% CI, 0.49-1.60); P = 0.68], and analgesia [OR 1.46, (95% CI, 0.05-45.69); P = 0.83].

Conclusion

This meta-analysis revealed that the preservation of the ICBN has a significant effect on the disturbance of sensory parameters of hypaesthesia and anaesthesia when compared to its dissection. Further studies with larger sample sizes are recommended to precisely compare both techniques on a wider range of parameters.

Systematic review of cost-effectiveness in breast reconstruction: deep inferior epigastric perforator flap vs. implant-based breast reconstruction

BACKGROUND

There are several techniques for reconstructing breasts after mastectomy, but little scientific evidence for which technique is superior. The aim of this systematic review was to compare the cost-effectiveness of implant-based and autologous reconstruction and to evaluate the overall certainty of evidence, as well as the quality of reporting of the included studies.

METHODS

Studies investigating the cost-effectiveness of breast reconstruction with a deep inferior epigastric perforator (DIEP) flap compared to implant-based reconstruction, meeting criteria defined in a PICO (population, intervention, comparison, and outcome), were included. Medline, PubMed, Embase, Cochrane library, CinahL, EconLit, and NHS EED databases were searched. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to assess the certainty of evidence, and the Consolidated Health Economic Evaluation Reporting Standard (CHEERS) 2022 was used to evaluate the quality of reporting.

RESULTS AND CONCLUSIONS

A total of 256 abstracts were retrieved from the search, and after scrutiny, seven studies were included. The findings of this present systematic review should be interpreted with caution as the overall certainty of evidence is low (GRADE ƟƟОО). The included studies suggest that DIEP-flaps are cost-effective compared with implant-based breast reconstruction when the applied cost-effectiveness thresholds of $50,000 to $100,000 per quality-adjusted life years are used. It is noteworthy that no high level evidence exists regarding cost-effeciency, to support recommendations and decision in breast reconstruction. Methodological issues that can be improved in future studies are presented.

Why is there a lack of evidence regarding errors and complications in periodontal and implant therapy?

The occurrence of errors, complications, and adverse effects may occur as a consequence of single or multiple events related to the clinician and/or patient. Apparently, the amount of dental literature on these undesirable outcomes has not been as prolific as that obtained for conventional primary periodontal outcome measures. This review explores the potential reasons for the lack of studies reporting on errors and complications in periodontal and implant therapy, as well as other noteworthy methodological aspects, to enlighten their impact on the selection of the best (or most appropriate) "gold standard" periodontal/implant-related treatment options, and on the overall decision-making process. The following points were addressed: (a) the importance of reporting errors and complications in clinical research; (b) the adequate reporting of errors and complications in periodontology and dental implantology; and (c) efficacy trials vs effectiveness studies and their impact on the assessment and report of periodontal and implant treatment-related risks and complications.

Aesthetic training concept during plastic surgery residency - Opportunity or risk?

Background

Aesthetic surgery training renders to be challenging to acquire sufficient hands-on experience during residency. To resolve this problem, the "Munich Model" was established in our clinic: Senior residents perform aesthetic surgeries, supervised by an experienced plastic surgeon while patients benefit from reduced surgery costs. With this model, we hypothesize no significant differences in the postoperative outcome between procedures performed by residents and plastic surgeons.

Methods

Between August 2012 and December 2017, 481 aesthetic surgeries were included in this retrospective single-center study, of which 283 were performed by residents and 198 by plastic surgeons. Procedures included mastopexy, abdominoplasty, extremity lift, breast reduction, breast augmentation, facial surgery, aesthetic liposuction and lipedema liposuction. Postoperative outcomes were compared regarding surgery time, time of drain removal, inpatient length of stay, duration of wound healing, perioperative blood loss and occurrence of major (surgical revision needed) and minor complications (no surgery needed).

Results

We found no significant differences in aesthetic surgical procedures between residents and board-certified plastic surgeons in the outcome measures of surgery duration, time of drain removal, inpatient length of stay, perioperative blood loss and complication rate, including major and minor complications. Only the inpatient stay was prolonged in aesthetic liposuctions performed by residents.

Conclusion

This study demonstrates comparatively that supervised aesthetic surgeries at a university hospital utilizing the "Munich Model" widely meet the specialist surgeons' standards.

Trends in Patient-Reported Outcomes Reporting in Breast Reconstruction: A Scoping Literature Review

INTRODUCTION

Patient-reported outcomes (PROs) provide essential information in reconstructive surgery, where interventions center on patients' functional and aesthetic goals. Although multiple patient-reported outcome measures (PROMs) have been validated for breast reconstruction since 2009, no studies have assessed recent frequency and consistency in use. This study aims to characterize recent trends in inclusion of PROs in recent breast reconstruction literature.

METHODS

Articles published between 2015 and 2021 pertaining to autologous and/or prosthetic breast reconstruction in Annals of Plastic Surgery and Journal of Plastic and Reconstructive Surgery were considered in a scoping review. Original breast reconstruction articles were reviewed for use of PROMs and characteristics of administration in accordance with PRISMA-Scr guidelines. Previously defined scoping review criteria were considered, including PROM used, timeline of collection, and topics addressed, with trends in frequency and consistency of usage assessed over the designated period.

RESULTS

Of the 877 articles reviewed and 232 articles included, 24.6% reported using any PROM. The majority used BREAST-Q (n = 42, 73.7%), with the remainder being institutional surveys or previously validated questionnaires. Patient-reported outcomes were most often collected retrospectively (n = 20, 64.9%) and postoperatively (n = 33, 57.9%). The average time point of postoperative survey administration was 16.03 months (SD, 19.185 months). χ2 Analysis revealed no significant association between the numbers of articles, including PROMs and the year (P = 0.1047).

CONCLUSIONS

This study demonstrates that only one-fourth of breast reconstruction articles report the use of PROMs with no interval increase over recent years. Patient-reported outcome measures were predominantly used retrospectively and postoperatively with notable variation in timing of administration. The findings highlight the need for improved frequency and consistency of PROM collection and reporting, as well as for further exploration into barriers and facilitators of PROM use.

Outcome measures reported following feminizing genital gender affirmation surgery for transgender women and gender diverse individuals: A systematic review

Background

Feminizing genital gender affirmation surgery (fgGAS) may be an essential adjunct in the care of some transgender women and gender diverse individuals with gender incongruence. However, the comparison of different techniques of fgGAS may be confounded by variable outcome reporting and the use of inconsistent outcomes in the literature. This systematic review provides the most in-depth examination of fgGAS studies to date, and summarizes all reported outcomes, definitions, and the times when outcomes were assessed following these surgical interventions. Aims/Methods: This work intends to quantify the levels of outcome variability and definition heterogeneity in this expanding field and provides guidance on outcome reporting for future study authors. Candidate studies for this systematic review were sourced via an electronic, multi-database literature search. All primary, clinical research studies of fgGAS were included with no date limits. Paired collaborators screened each study for inclusion and performed data extraction to document the outcomes, definitions, and times of outcome assessment following fgGAS.

Results

After screening 1225 studies, 93 studies proceeded to data extraction, representing 7681 patients. 2621 separate individual outcomes were reported, 857 (32.7%) were defined, and the time of outcome assessment was given for 1856 outcomes (70.8%) but relied on nonspecific ranges of follow-up dates. "Attainment of orgasm", "Neovaginal stenosis", and "Neovaginal depth/length" were among the most commonly reported outcomes. Profound heterogeneity existed in the definitions used for these and for all outcomes reported in general.

Discussion

The results demonstrate a need for clear outcomes, agreed definitions, and times of outcome assessment following fgGAS in transgender women and gender diverse individuals. The adoption of a consistent set of outcomes and definitions reported by all future studies of fgGAS (a Core Outcome Set) will aid in improving treatment comparisons in this patient group. This review is the first step in that process.

Defining Mastectomy Skin Flap Necrosis: A Systematic Review of the Literature and a Call for Standardization

BACKGROUND

Mastectomy skin flap necrosis following breast reconstruction may lead to wound dehiscence, infection, implant exposure, and reconstructive failure. The absence of a standardized definition for it has led to variation in estimated incidence, from as low as 2 percent to greater than 40 percent. The authors systematically reviewed the literature on mastectomy skin flap necrosis to characterize existing definitions and provide a framework for future classification.

METHODS

A systematic review of the PubMed and Cochrane databases identified studies reporting a discrete definition of mastectomy skin flap necrosis and corresponding outcomes in breast reconstruction. Provided definitions were extracted, categorized, and comparatively analyzed.

RESULTS

Fifty-nine studies met inclusion criteria, with a combined total of 14,368 patients and 18,920 breasts. Thirty-four studies (57.6 percent) reported mastectomy skin flap necrosis solely as a function of total breasts, and 11 (18.6 percent) reported mastectomy skin flap necrosis solely as a function of total patients. Only 14 studies (23.7 percent) provided two separate rates. The overall rate of mastectomy skin flap necrosis was 10.4 percent (range, 2.3 to 41.2 percent) and 15.3 percent (range, 4.7 to 39.0 percent), when reported per breast or per patient, respectively. Studies were categorized by mastectomy skin flap necrosis definition, including intervention (n = 33), depth (n = 20), area (n = 4), and timing (n = 2). Mastectomy skin flap necrosis rates were highest in studies defining necrosis by depth (15.1 percent), followed by intervention (9.6 percent), timing (6.4 percent), and area (6.3 percent). Necrosis rates among studies defining mastectomy skin flap necrosis by intervention, depth, and area were found to be statistically different (p < 0.001).

CONCLUSIONS

Reported mastectomy skin flap necrosis definitions and outcomes vary significantly in the existing literature. For accurate characterization and quantification, a clear, simplified, consensus definition must be adopted.

New Classification for the Reporting of Complications in Retinal Detachment Surgical Trials

IMPORTANCE

Quantifying severity of complications in rhegmatogenous retinal detachment (RRD) surgical trials is needed. A consensus classification system will help surgeons to more effectively compare harms of different surgical techniques.

OBJECTIVE

To develop a new consensus-based classification to quantify severity of complications of RRD surgery.

DESIGN, SETTING, AND PARTICIPANTS

A comprehensive list of complications was developed followed by a Delphi consensus survey of international vitreoretinal surgeons. The survey was conducted in 17 countries in mainland Europe, the United Kingdom, the United States, Asia, South Africa, and Australia. Seventy vitreoretinal surgeons were invited to take part in the Delphi survey; 45 agreed to participate. Participants were selected through boards/members lists of retinal societies. Data were analyzed between April 2019 and August 2019.

MAIN OUTCOMES AND MEASURES

Consensus-derived classification of complications of RRD surgery, according to their severity.

RESULTS

Forty-three of 45 vitreoretinal surgeons who agreed to participate in the Delphi survey completed round 1 (96%); all but 1 (98%) completed round 2. Consensus was reached for 96% of the 84 complications assessed. Examples of complications classified as least severe (graded 1) included subconjunctival hemorrhage and chemosis while those classified as most severe included endophthalmitis and sympathetic ophthalmia (graded 9) and phthisis (graded 10).

CONCLUSIONS AND RELEVANCE

We propose a new classification for quantifying severity of surgical complications based on an international consensus of vitreoretinal surgeons to quantify harm and improve the reporting of complications of RRD surgery.

A Comparison of Surgical Complications in Patients Undergoing Delayed versus Staged Tissue-Expander and Free-Flap Breast Reconstruction

BACKGROUND

Patients undergoing mastectomy may not be candidates for immediate free-flap breast reconstruction because of medical comorbidities or postmastectomy radiation therapy. In this setting, flap reconstruction may be intentionally delayed or staged with tissue expander placement ("delayed-immediate" reconstruction). The optimal reconstructive choice and incidence of complications for these approaches remain unclear.

METHODS

The authors retrospectively identified patients who underwent delayed [n = 140 (72 percent)] or staged [n = 54 (28 percent)] abdominal free-flap breast reconstruction between 2010 and 2018 and compared the incidence of postoperative complications.

RESULTS

Patients undergoing staged reconstruction had a higher overall incidence of perioperative complications, including surgical-site infection (40.7 percent versus 6.5 percent; p < 0.001), wound healing complications (29.6 percent versus 12.3 percent; p = 0.004), hematoma (11.1 percent versus 0.7 percent; p < 0.001), and return to the operating room (27.8 percent versus 4.4 percent; p < 0.0001). These complications occurred predominately during the expansion stage, resulting in an 18.5 percent (n = 10) rate of tissue expander failure. Mean time from mastectomy to flap reconstruction was 476.8 days (delayed, 536.4 days; staged, 322.4 days; p < 0.001). At the time of flap reconstruction, there was no significant difference in the incidence of complications between the staged cohort versus the delayed cohort, including microsurgical complications (1.9 percent versus 4.3 percent; p = 0.415), total flap loss (0 percent versus 2.1 percent; p = 0.278), or fat necrosis (5.6 percent versus 5.0 percent; p = 0.875).

CONCLUSIONS

The aesthetic and psychosocial benefits of staged free-flap breast reconstruction should be balanced with the increased risk of perioperative complications as compared to a delayed approach. Complications related to definitive flap reconstruction do not appear to be affected by the approach taken at the time of mastectomy. .

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Reporting of Complications in Retinal Detachment Surgical Trials: A Systematic Review Using the CONSORT Extension for Harms

IMPORTANCE

Knowledge on the frequency and severity of complications in surgical trials for rhegmatogenous retinal detachment (RRD) is essential to determine whether surgical procedures are developed and compared adequately, taking into account not only efficacy but also harms.

OBJECTIVE

To review standards of reporting of complications in recent randomized clinical trials of RRD surgery.

EVIDENCE REVIEW

This systematic review included randomized clinical trials on RRD surgery published between January 2008 and January 2021 in Embase, MEDLINE, and Web of Science Core Collection databases. Titles, abstracts, and full-text articles retrieved were reviewed for eligibility by 2 independent authors. Eligible studies were evaluated against checklist items from the Consolidated Standards of Reporting Trials Extension for Harms criteria by 2 independent authors, and discrepancies were resolved by discussion with a third author.

FINDINGS

Fifty studies were included. The median number of checklist items fulfilled was 8 (range, 0-15), of a possible total of 18. Frequently reported items were discussions balanced with regard to efficacy and adverse events (42 studies [84%]) and inclusions of harm-associated timing of data collection (41 studies [82%]). The least frequently reported items were distinctions between expected and unexpected adverse events (1 study [2%]) and mentions of the use of a validated instrument to report adverse event severity (4 studies [8%]). Frequency of complications was commonly reported (29 studies [58%]) in contrast with complication severity (10 studies [20%]).

CONCLUSIONS AND RELEVANCE

This review suggests that severity of complications of RRD surgery has been infrequently quantified and reported in randomized clinical trials and potentially represents an important area of improvement in future RRD surgical trials.

Insurance Reimbursement in Plastic Surgery

SUMMARY

The ambiguity of medical finances, both to the patient and to the provider, has direct effects on the quality of care that is delivered to the patient. To encourage transparency in health care, physician reimbursement is a process that must be understood to ensure patient satisfaction, a physician's willingness to deliver care, and the success of health care facilities. Furthermore, physicians should be aware of the effects that legislative action, such as the Patient Protection and Affordable Care Act, has on their income. As a field that encompasses both cosmetic and reconstructive surgery, plastic surgeons must know this process intimately to ensure efficient services and appropriate reimbursement. In particular, plastic surgeons should be familiar with how the Affordable Care Act affects their income, practice, and the patient's access to care. As Medicare and Medicaid continue to increase health care access for many Americans, specialists such as plastic surgeons will need to reinforce the value of the specialty in the continuum of care. As the health care industry moves away from a fee-for-service system to one of value-based care, plastic surgeons need to be at the forefront of this transition to ensure that they are delivering quality care, and receiving appropriate reimbursement. The authors have provided data from the University of Michigan to demonstrate the reimbursement patterns seen in plastic surgery. This Special Topic article provides insight into the reimbursement process in the era of the Affordable Care Act and the various challenges that may be encountered within this field.

Early complications in delayed breast reconstruction: A prospective, randomized study comparing different reconstructive methods in radiated and non-radiated patients

BACKGROUND

There is little high-quality scientific evidence identifying the best and safest methods for delayed breast reconstruction, with most previous studies retrospective in nature. The primary aim was to compare early complication rates for two different breast-reconstructive methods in radiated and non-radiated patients, using a validated scale. The secondary aim was to identify predictors for complications.

MATERIALS AND METHODS

This study represents a clinical, randomized, prospective trial (ClinicalTrials.Gov identifier: NCT03963427), where the patients were divided into two study arms: non-radiated and radiated. In the non-radiated arm, patients were randomized to a one-stage lateral thoracodorsal flap with an implant or two-stage expander reconstruction. In the radiated arm, patients were randomized to a latissimus dorsi reconstruction combined with an implant or deep inferior epigastric artery perforator (DIEP) reconstruction. All adverse events were classified according to Clavien-Dindo and summarization of overall morbidity was performed by calculating the Comprehensive Complication Index score. The study was conducted from 2008 to 2020.

RESULTS

The complication frequencies were similar for the two surgical methods within each arm. In the non-radiated arm, risk factors for any complication were any comorbidities, and in the radiated arm, factors were a high body mass index and a contralateral operation.

CONCLUSIONS

The usage of the Clavien-Dindo scale in reconstructive surgery is feasible, but further validation is needed. In non-radiated patients, the frequencies of short-term complications were similar for lateral thoracodorsal flap and expander reconstruction, whereas in radiated patients, they were similar for DIEP and latissimus dorsi. The complication profile of the methods varied.

Extended Prophylactic Antibiotics for Mastectomy with Immediate Breast Reconstruction: A Meta-analysis

Supplemental Digital Content is available in the text.

Background:

The risk of surgical site infection (SSI) for breast surgery in patients without additional risk factors is low, below 5%. Evidence shows the risk of SSI is significantly elevated in patients undergoing immediate breast reconstruction (IBR). However, there is no consensus regarding the use of extended antibiotic prophylaxis. We aim to determine the effect of extended antibiotic prophylaxis on the incidence of SSI after IBR.

Methods:

PubMed and Scopus were searched by 2 independent reviewers. Data abstracted included types of study, basic characteristics, detailed antibiotic prophylaxis information, SSI event, and other secondary outcomes. We calculated the risk ratio (RR) and 95% confidence interval (CI) for each study and used a random-effects model to estimate the results. Study quality, bias, and heterogeneity were also analyzed.

Results:

A total of 11 studies (15,966 mastectomy procedures) were included. We found an overall 5.99% SSI rate in our population. Three studies comparing topical antibiotics with no topical antibiotics demonstrated statistical significance (RR = 0.26, 95% CI: 0.12–0.60, P = 0.001), whereas 8 studies comparing extended systemic antibiotics with standard of care found no statistical significance (RR = 0.80, 95% CI: 0.60–1.08, P = 0.13).

Conclusions:

In the setting of IBR following mastectomy, there is insufficient evidence for the use of extended prophylactic antibiotics to reduce SSI rates. Well-designed randomized controlled trials in patients undergoing IBR should be conducted to determine the appropriate regimen and/or duration of prophylactic antibiotics on SSI outcomes.

Self-assembling in situ gel based on lyotropic liquid crystals containing VEGF for tissue regeneration

Current tissue-regenerative biomaterials confront two critical issues: the uncontrollable delivery capacity of vascular endothelial growth factor (VEGF) for adequate vascularization and the poor mechanical properties of the system for tissue regeneration. To overcome these two issues, a self-assembling in situ gel based on lyotropic liquid crystals (LLC) was developed. VEGF-LLC was administrated as a precursor solution that would self-assemble into an in situ gel with well-defined internal inverse bicontinuous cubic phases when exposed to physiological fluid at a defect site. The inverse cubic phase with a 3D bicontinuous water channel enabled a 7-day sustained release of VEGF. The release profile of VEGF-LLC was controlled using octyl glucoside (OG) as a hydration-modulating agent, which could enlarge the water channel, yielding a 2-fold increase in water channel size and a 7-fold increase in VEGF release. For the mechanical properties, the elastic modulus was found to decrease from ∼100 kPa to ∼1.2 kPa, which might be more favorable for angiogenesis. Furthermore, the self-recovery ability of the VEGF-LLC gel was confirmed by quick recovery of the inner network in step-strain measurements. In vitro, VEGF-LLC considerably promoted the proliferation, migration, and tube formation of human umbilical vein endothelial cells (HUVECs) as compared to free VEGF (p < 0.05). Furthermore, angiogenesis was successfully induced in rats after subcutaneous injection of VEGF-LLC. The self-assembling LLC gel showed satisfactory degradability and mild inflammatory response with little impact on the surrounding tissue. The controllable release profile and unique mechanical properties of VEGF-LLC offer a new approach for tissue regeneration. STATEMENT OF SIGNIFICANCE: The potential clinical use of currently available biomaterials in tissue regeneration is limited by their uncontrollable drug delivery capacity and poor mechanical properties. Herein, a self-assembling in situ gel based on lyotropic liquid crystals (LLC) for induced angiogenesis was developed. The results showed that the addition of octyl glucoside (OG) could change the water channel size of LLC, which enabled the LLC system to release VEGF in a sustained manner and to possess a suitable modulus to favor angiogenesis simultaneously. Moreover, the self-recovery capability allowed the gel to match the deformation of surrounding tissues during body motion to maintain its properties and reduce discomfort. In vivo, angiogenesis was induced by VEGF-LLC 14 days after administering subcutaneous injection. These results highlight the potential of LLC as a promising sustained protein drug delivery system for vascular formation and tissue regeneration.

Outcomes Following Breast Reconstruction in Patients With Prior Mantle Radiation for Treatment of Hodgkin's Lymphoma

PURPOSE

External beam radiation in the mantle field has been a mainstay of therapy for Hodgkin's lymphoma for decades. The incidence of breast cancer in patients treated with mantle radiation is known to be elevated. Few studies have examined outcomes of breast reconstruction in this high-risk group. The current study presents the largest series of immediate breast reconstruction in this population and aims to evaluate reconstructive outcomes and examine differences between implant-based and autologous reconstructions.

METHODS

A retrospective review of records from a 10-year period at 2 institutions was undertaken. Patients treated with mantle radiation for Hodgkin's lymphoma who subsequently underwent mastectomy with immediate reconstruction were identified. Patient demographics, clinical characteristics, and outcomes including complications and operative revisions were gathered. Univariate and multivariate analyses were conducted to assess differences between implant-based and autologous reconstructions.

RESULTS

A total of 97 breast reconstructions were performed in 52 patients. Seventy-nine reconstructions were implant-based, and 18 were autologous. Patients with implant-based reconstructions were older than autologous reconstructions (47 ± 8.8 years vs 42 ± 6.5 years, P < 0.05). Both groups had long-term follow-up; however, the mean follow-up duration was shorter in the implant-based compared with the autologous group (5 years vs 8.3 years; P < 0.05). Otherwise, the groups were similar with respect to BMI, medical comorbidities, oncologic diagnosis, and therapy. The interval between mantle radiation and reconstruction was comparable for implant-based and autologous groups (23.4 ± 9 years vs 21.3 ± 6.1 years, P = 0.6). The overall complication rate of breast reconstruction was not statistically different between the implant-based and autologous groups (35% vs 16%, P = 0.16). Three implant-based reconstructions (3.7%) required explantation. There were no complete flap losses in the autologous group. An associated 6-fold higher rate of unplanned revisions was observed with the autologous reconstruction group compared with the implant-based reconstruction group (odds ratio, 6.09; 95% confidence interval, 1.14-32.48; P = 0.035).

CONCLUSIONS

In this study, long-term follow-up suggests immediate breast reconstruction in patients with prior mantle radiation can be achieved safely with an acceptable complication profile utilizing either implant-based or autologous techniques. Autologous breast reconstruction is linked with a higher rate of revisions compared with implant-based breast reconstruction in this study population.