1
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Talwar AA, Copeland-Halperin LR, Walsh LR, Christopher AN, Cunning J, Broach RB, Baratta MD, Copeland M, Shankaran V, Butler PD. Outcomes of Extended Pedicle Technique vs Free Nipple Graft Reduction Mammoplasty for Patients With Gigantomastia. Aesthet Surg J 2023; 43:NP91-NP99. [PMID: 36161307 DOI: 10.1093/asj/sjac258] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Revised: 09/15/2022] [Accepted: 09/15/2022] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Optimal reduction mammoplasty techniques to treat patients with gigantomastia have been debated and can involve extended pedicles (EP) or free nipple grafts (FNG). OBJECTIVES The authors compared clinical, patient-reported, and aesthetic outcomes associated with reduction mammoplasty employing EP vs FNG. METHODS A multi-institutional, retrospective study of adult patients with gigantomastia who underwent reduction mammoplasty at 2 tertiary care centers from 2017 to 2020 was performed. Gigantomastia was defined as reduction weight >1500 g per breast or sternal notch-to-nipple distance ≥40 cm. Surgeons at 1 institution employed the EP technique, whereas those at the other utilized FNG. Baseline characteristics, preoperative and postoperative BREAST-Q, and clinical outcomes were collected. Aesthetic outcomes were assessed in 1:1 propensity score-matched cases across techniques. Preoperative and postoperative photographs were provided to reviewers across the academic plastic surgery continuum (students to faculty) and non-medical individuals to evaluate aesthetic outcomes. RESULTS Fifty-two patients met the inclusion criteria (21 FNG, 31 EP). FNG patients had a higher incidence of postoperative cellulitis (23% vs 0%, P < 0.05) but no other differences in surgical or medical complications. Baseline BREAST-Q scores did not differ between groups. Postoperative BREAST-Q scores revealed greater satisfaction with the EP technique (P < 0.01). The aesthetic assessment of outcomes in 14 matched pairs of patients found significantly better aesthetic outcomes in all domains with the EP procedure (P < 0.05), independent of institution or surgical experience. CONCLUSIONS This multi-institutional study suggests that, compared with FNG, the EP technique for reduction mammoplasty provides superior clinical, patient-reported, and aesthetic outcomes for patients with gigantomastia. LEVEL OF EVIDENCE: 4
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Affiliation(s)
- Ankoor A Talwar
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Libby R Copeland-Halperin
- Division of Plastic Surgery, Department of Surgery, The Brigham and Women's Hospital, Boston, MA, USA
| | - Landis R Walsh
- Division of Plastic Surgery, Department of Surgery, Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, NY, USA
| | - Adrienne N Christopher
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Jessica Cunning
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Robyn B Broach
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Michael D Baratta
- Division of Plastic Surgery, Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Michelle Copeland
- Division of Plastic Surgery, Department of Surgery, Mount Sinai Health System, New York, NY, USA
| | - Vidya Shankaran
- Division of Plastic Surgery, Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Paris D Butler
- Division of Plastic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
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2
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Christopher AN, Nembhard IM, Wu L, Yee S, Sebastian A, Charan N, Betchen S. Association of women leaders in the C-suite with hospital performance. BMJ Lead 2022; 6:271-277. [PMID: 36794614 DOI: 10.1136/leader-2021-000543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 11/28/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND Women comprise 50% of the healthcare workforce, but only about 25% of senior leadership positions in the USA. No studies to our knowledge have investigated the performance of hospitals led by women versus those led by men to evaluate the potential explanation that the inequity reflects appropriate selection due to skill or performance differences. METHODS We conducted a descriptive analysis of the gender composition of hospital senior leadership (C-suite) teams and cross-sectional, regression-based analyses of the relationship between gender composition, hospital characteristics (eg, location, size, ownership), and financial, clinical, safety, patient experience and innovation performance metrics using 2018 data for US adult medical/surgical hospitals with >200 beds. C-suite positions examined included chief executive officer (CEO), chief financial officer (CFO) and chief operating officer (COO). Gender was obtained from hospital web pages and LinkedIn. Hospital characteristics and performance were obtained from American Hospital Directory, American Hospital Association Annual Hospital Survey, Healthcare Cost Report Information System and Hospital Consumer Assessment of Healthcare Providers and Systems surveys. RESULTS Of the 526 hospitals studied, 22% had a woman CEO, 26% a woman CFO and 36% a woman COO. While 55% had at least one woman in the C-suite, only 15.6% had more than one. Of the 1362 individuals who held one of the three C-suite positions, 378 were women (27%). Hospital performance on 27 of 28 measures (p>0.05) was similar between women and men-led hospitals. Hospitals with a woman CEO performed significantly better than men-led hospitals on one financial metric, days in accounts receivable (p=0.04). CONCLUSION Hospitals with women in the C-suite have comparable performance to those without, yet inequity in the gender distribution of leaders remains. Barriers to women's advancement should be recognised and efforts made to rectify this inequity, rather than underusing an equally skilled pool of potential women leaders.
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Affiliation(s)
- Adrienne N Christopher
- Department of General Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA.,Division of Plastic Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ingrid M Nembhard
- The Wharton School, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Liza Wu
- Division of Plastic Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA.,The Wharton School, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Stephanie Yee
- The Wharton School, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Division of Hematology/Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Albertina Sebastian
- Division of Neurosurgery, Department of Surgery, Maimonides Medical Center, Brooklyn, New York, USA
| | - Nidhi Charan
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Simone Betchen
- The Wharton School, University of Pennsylvania, Philadelphia, Pennsylvania, USA .,Division of Neurosurgery, Department of Surgery, Maimonides Medical Center, Brooklyn, New York, USA
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3
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Morris MP, Christopher AN, Patel V, Onyekaba G, Broach RB, Fischer JP. Negative Pressure Wound Therapy After Abdominal Body Contouring: A Comparative Matched Analysis of Outcomes and Cost. Plast Surg (Oakv) 2022; 30:360-367. [PMID: 36212102 PMCID: PMC9537721 DOI: 10.1177/22925503211019627] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 04/16/2021] [Indexed: 11/03/2023] Open
Abstract
Background: Studies that have previously validated the use of incisional negative pressure wound therapy (iNPWT) after body contouring procedures (BCP) have provided limited data regarding associated health care utilization and cost. We matched 2 cohorts of patients after BCP with and without iNPWT and compared utilization of health care resources and post-operative clinical outcomes. Methods: Adult patients who underwent abdominoplasty and/or panniculectomy between 2015 and 2020 by a single surgeon were identified. Patients were propensity score matched by body mass index (BMI), gender, smoking history, diabetes mellitus, hypertension, and incision type. Primary outcomes included time to final drain removal, outpatient visits, homecare visits, emergency department visits, and cost. Secondary outcomes included surgical site occurrences (SSO), surgical site infections, reoperations, and revisions. Results: One hundred sixty-six patients were eligible, and 40 were matched (20 with iNPWT and 20 without iNPWT) with a median age of 47 years and BMI of 32 kg/m2. There were no differences in demographics or intraoperative details (all P > .05). No significant differences were found between the cohorts in terms of health care utilization measures or clinical outcomes (all P > .05). Direct cost was significantly greater in the iNPWT cohort (P = .0498). Inpatient length of stay and procedure time were independently associated with increased cost on multivariate analysis (all P < .0001). Conclusion: Consensus guidelines recommend the use of iNPWT in high-risk patients, including abdominal BCP. Our results show that iNPWT is associated with equivalent health care utilization and clinical outcomes, with increased cost. Additional randomized controlled trials are needed to further elucidate the cost utility of this technique in this patient population.
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Affiliation(s)
- Martin P. Morris
- Division of Plastic Surgery, Department of Surgery, University of
Pennsylvania. Philadelphia, PA, USA
| | - Adrienne N. Christopher
- Division of Plastic Surgery, Department of Surgery, University of
Pennsylvania. Philadelphia, PA, USA
- Department of Surgery, Thomas Jefferson University, Philadelphia,
PA, USA
| | - Viren Patel
- Division of Plastic Surgery, Department of Surgery, University of
Pennsylvania. Philadelphia, PA, USA
| | - Ginikanwa Onyekaba
- Division of Plastic Surgery, Department of Surgery, University of
Pennsylvania. Philadelphia, PA, USA
| | - Robyn B. Broach
- Division of Plastic Surgery, Department of Surgery, University of
Pennsylvania. Philadelphia, PA, USA
| | - John P. Fischer
- Division of Plastic Surgery, Department of Surgery, University of
Pennsylvania. Philadelphia, PA, USA
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4
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Naga HI, Mellia JA, Basta MN, Morris MP, Christopher AN, Campbell FM, Sommers K, Levinson H, Nelson JA, Fischer JP. Breast Implant-Associated Anaplastic Large-Cell Lymphoma: Updated Systematic Review and Analysis of Treatment Strategies. Plast Reconstr Surg 2022; 150:762-769. [PMID: 35862104 PMCID: PMC9551598 DOI: 10.1097/prs.0000000000009538] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Although guidelines have been published on treatment of breast implant-associated anaplastic large-cell lymphoma (BIA-ALCL), there has been no comprehensive analysis of BIA-ALCL treatment variation based on the available literature. The authors sought to assess current treatment strategies of BIA-ALCL relative to current guidelines. METHODS Database searches were conducted in June of 2020. Included articles were case reports and case series with patient-level data. Collected variables included clinicopathologic features, implant characteristics, diagnostic tests, ALCL characteristics, treatment, and details of follow-up and outcome. Treatment data from before and after 2017 were compared with National Cancer Center Network guidelines. RESULTS A total of 89 publications were included and 178 cases of BIA-ALCL were identified. Most patients presented with seroma ( n = 114, 70.4 percent), followed by a mass ( n = 14, 8.6 percent), or both ( n = 23, 14.2 percent). Treatment included en bloc capsulectomy of the affected implant in 122 out of 126 cases with treatment details provided (96.8 percent). Radiation therapy was given in 38 cases (30.2 percent) and chemotherapy was given in 71 cases (56.3 percent). Practitioners used less chemotherapy for local disease after treatment guideline publication in 2017 ( p < 0.001), whereas treatment for advanced disease remained unchanged ( p = 0.3). There were 10 recurrences and eight fatalities attributable to BIA-ALCL, which were associated with advanced presentation (29 versus 2.1 percent; OR, 19.4; 95 percent CI, 3.9 to 96.3; p < 0.001). CONCLUSIONS BIA-ALCL remains a morbid but treatable condition. Current guidelines focus treatment for local disease and reduce nonsurgical interventions with radiation or chemotherapy. Patients presenting with advanced BIA-ALCL experience higher rates of recurrence and mortality.
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Affiliation(s)
- Hani I. Naga
- Division of Plastic Surgery, Duke University, Durham, NC
- Division of Plastic Surgery, University of Pennsylvania, Philadelphia, PA
| | - Joseph A. Mellia
- Division of Plastic Surgery, University of Pennsylvania, Philadelphia, PA
| | - Marten N. Basta
- Division of Plastic Surgery, University of Pennsylvania, Philadelphia, PA
| | - Martin P. Morris
- Division of Plastic Surgery, University of Pennsylvania, Philadelphia, PA
| | | | - Frank M. Campbell
- Biomedical Library, Perelman School of Medicine, University of Pennsylvania, PA
| | | | - Howard Levinson
- Division of Plastic Surgery, University of Pennsylvania, Philadelphia, PA
- Plastic Surgery Foundation, Arlington Heights, IL
| | - Jonas A. Nelson
- Plastic and Reconstructive Surgical Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - John P. Fischer
- Division of Plastic Surgery, University of Pennsylvania, Philadelphia, PA
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5
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Christopher AN, Sanchez J, Fischer JP. A Biomechanical Analysis of Prophylactic Mesh Reinforced Porcine Laparotomy Incisions. J Surg Res 2022; 278:196-205. [PMID: 35617785 PMCID: PMC9580392 DOI: 10.1016/j.jss.2022.04.058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 03/10/2022] [Accepted: 04/08/2022] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Research indicates that prophylactic mesh may help prevent incisional hernia after laparotomy, but best practice patterns in these situations are still evolving. Here, we compare the failure loads (FLs) and biomechanical stiffness (BMS) of 35 porcine abdominal wall laparotomy incisions reinforced with meshes of various widths and fixation distances using biomechanical testing. METHODS In each specimen, a 10-cm incision was made and closed using continuous 1-0 Maxon suture. Specimens were randomized to mesh width (none, 2.5 cm, 3 cm, 4 cm, 6 cm, 8 cm) and tack separation (1.5 cm, 2 cm apart) and the meshes secured in an onlay fashion. Cyclic loads oscillating from 15 N to 140 N were applied to simulate abdominal wall stress, and the specimens subsequently loaded to failure. FLs (N) and BMS (N/mm) were comparatively analyzed. RESULTS All specimens failed via suture pull-through. FLs and BMS were lowest in specimens with suture-only (421.43 N; 11.69 N/mm). FLs and BMS were significantly higher in 4-cm mesh specimens (567.51 N) than those with suture, 2.5-cm, and 3.0-cm mesh (all P < 0.05). FLs in specimens with a greater number of tacks were consistently higher in meshes of similar sizes, although these did not reach significance. CONCLUSIONS A 4-cm mesh reenforcement was superior to suture-only and smaller meshes at preserving strength in laparotomy closure in a porcine model but larger meshes (6 cm, 8 cm) did not provide an additional benefit. Meshes with more fixation points may be advantageous, but additional data are needed to make definitive conclusions.
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Affiliation(s)
- Adrienne N Christopher
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | | | - John P Fischer
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania.
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6
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Rios-Diaz AJ, Morris MP, Christopher AN, Patel V, Broach RB, Heniford BT, Hsu JY, Fischer JP. National epidemiologic trends (2008-2018) in the United States for the incidence and expenditures associated with incisional hernia in relation to abdominal surgery. Hernia 2022; 26:1355-1368. [PMID: 36006563 DOI: 10.1007/s10029-022-02644-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 06/04/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE It is unknown whether the trend of rising incisional hernia (IH) repair (IHR) incidence and costs until 2011 currently persists. We aimed to evaluate how the IHR procedure incidence, cost and patient risk-profile have changed over the last decade relative to all abdominal surgeries (AS). METHODS Repeated cross-sectional analysis of 38,512,737 patients undergoing inpatient 4AS including IHR within the 2008-2018 National Inpatient Sample. Yearly incidence (procedures/1,000,000 people [PMP]), hospital costs, surgical and patient characteristics were compared between IHR and AS using generalized linear and multinomial regression. RESULTS Between 2008-2018, 3.1% of AS were IHR (1,200,568/38,512,737). There was a steeper decrease in the incidence of AS (356.5 PMP/year) compared to IHR procedures (12.0 PMP/year) which resulted in the IHR burden relative to AS (2008-2018: 12,576.3 to 9,113.4 PMP; trend difference P < 0.01). National costs averaged $47.9 and 1.7 billion/year for AS and IHR, respectively. From 2008-2018, procedure costs increased significantly for AS (68.2%) and IHR (74.6%; trends P < 0.01). Open IHR downtrended (42.2%), whereas laparoscopic (511.1%) and robotic (19,301%) uptrended significantly (trends P < 0.01). For both AS and IHR, the proportion of older (65-85y), Black and Hispanic, publicly-insured, and low-income patients, with higher comorbidity burden, undergoing elective procedures at small- and medium-sized hospitals uptrended significantly (all P < 0.01). CONCLUSION IH persists as a healthcare burden as demonstrated by the increased proportion of IHR relative to all AS, disproportionate presence of high-risk patients that undergo these procedures, and increased costs. Targeted efforts for IH prevention have the potential of decreasing $17 M/year in costs for every 1% reduction.
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Affiliation(s)
- A J Rios-Diaz
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, 51 North 39th Street, Wright Saunders Building, Philadelphia, PA, 19104, USA
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - M P Morris
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, 51 North 39th Street, Wright Saunders Building, Philadelphia, PA, 19104, USA
| | - A N Christopher
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, 51 North 39th Street, Wright Saunders Building, Philadelphia, PA, 19104, USA
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - V Patel
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, 51 North 39th Street, Wright Saunders Building, Philadelphia, PA, 19104, USA
| | - R B Broach
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, 51 North 39th Street, Wright Saunders Building, Philadelphia, PA, 19104, USA
| | - B T Heniford
- Division of Gastrointestinal and Minimally Invasive Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - J Y Hsu
- Center for Clinical Epidemiology and Biostatistics (CCEB), University of Pennsylvania, Philadelphia, PA, USA
| | - J P Fischer
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, 51 North 39th Street, Wright Saunders Building, Philadelphia, PA, 19104, USA.
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7
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Sorice-Virk S, Patel V, Christopher AN, Morris MP, Broach RB, Rothman JD, Serletti JM. Patient Perceptions of Cancer and Reconstructive Care During the COVID-19 Pandemic. Plast Surg (Oakv) 2022. [PMCID: PMC9240721 DOI: 10.1177/22925503221101938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background: The Coronavirus-2019 (COVID-19) pandemic profoundly
impacted care for breast cancer patients. Oncologic and reconstructive surgeries
were delayed as hospitals attempted to preserve personal protective equipment
and bed capacity. Little is known about how this unprecedented time has affected
breast cancer patients’ mental health and perceptions regarding their care.
Methods: A survey was sent to surgical oncology and plastic
surgery patients who received breast cancer care between March and May 2020,
during which our institution suspended elective surgery. The survey questions
included patient demographics, as well as questions focused on worries related
to COVID-19, individualized cancer and reconstructive care, and patient
satisfaction with telemedicine. Descriptive statistics were used to assess
patient responses. Results: 56 breast cancer patients completed the
survey, which reflected a 25% response rate. A majority of patients expressed
moderate concern about contracting COVID-19, accessing high-quality cancer care
(78%), and receiving timely surgical care (68%). Only 43% of patients reported
delays in their surgical cancer and reconstructive care, when in actuality 57%
of patients experienced surgical delays. Overall, patients were satisfied with
telemedicine and did not feel it negatively impacted their care (69%).
Conclusions: The COVID-19 pandemic has led to disruptions of
routine oncologic and reconstructive care for breast cancer patients. Patients
were concerned about receiving high-quality cancer and reconstructive care, and
the results of this study uncovered gaps in patient–physician communication. The
implementation of telemedicine was received positively. These data can be used
to improve future health system practices as the medical community faces new
potential shutdowns of surgical services.
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Affiliation(s)
- Sarah Sorice-Virk
- Department of Surgery, University of Florida Health Division of Plastic Surgery, Gainesville, FL, USA
| | - Viren Patel
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Adrienne N. Christopher
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Martin P. Morris
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Robyn B. Broach
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Jami D. Rothman
- Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Joseph M. Serletti
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
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8
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Callahan ZM, Roberts AL, Christopher AN, Gadomski SP, Kuchta KM, Costanzo CM, Phillips BR, Isenberg GA, Goldstein SD. The Effect of the Commonly Used Local Anesthetic on Bacterial Growth. J Surg Res 2022; 274:16-22. [DOI: 10.1016/j.jss.2021.12.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 10/23/2021] [Accepted: 12/15/2021] [Indexed: 10/19/2022]
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9
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Xu W, Christopher AN, Hu S, Steinberg DR, Bozentka DJ, Lin IC. Investigating Patient-Level Radiation Exposure in Hand and Wrist Fracture Surgery. Ann Plast Surg 2022; 88:S309-S313. [PMID: 35513337 DOI: 10.1097/sap.0000000000003204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Although occupational exposure to radiation has been previously studied in the hand surgery literature, there is a paucity of studies looking at radiation exposure to the patient during fluoroscopy-guided hand surgery. We aimed to describe the level of radiation experienced by patients undergoing common hand and wrist fracture fixation and to identify risk factors for increased radiation exposure. METHODS We performed a retrospective review of patients at a single institution who underwent fracture fixation of the hand, wrist, or forearm requiring mini c-arm fluoroscopic guidance from 2016 to 2020. Data points collected included patient demographics, procedural details, and indicators of radiation exposure including dose-area product (DAP), total intraoperative images, and total fluoroscopy time. Effective dose (ED) was calculated using DAP, field size, and a previously established conversion factor. RESULTS The final sample included 361 patients with an average age of 46 years. Procedures included fixation of forearm fractures (3.3%), distal radius fractures (35.7%), metacarpal fractures (30.8%), and phalangeal fractures (30.2%). The median number of intraoperative images acquired was 36, median total fluoroscopy time was 43 seconds, median DAP was 4.8 cGycm2, and median ED was 0.13 μSv. Distal (metacarpal and phalangeal) fractures required more intraoperative images and longer total fluoroscopy time (49 images, 61 seconds) compared with proximal (forearm and distal radius) fractures (39 images, 47 seconds) (images, P = 0.004; exposure time, P = 0.004). However, distal fractures had a lower average ED compared with proximal fractures (0.15 vs 0.19 μSv, P = 0.020). When compared with open procedures, percutaneous procedures had higher DAPs (8.8 vs 4.9 cGycm2, P < 0.001), higher ED (0.22 vs 0.15 μSv, P < 0.001), more intraoperative images (65 vs 36 images, P < 0.001), and longer total fluoroscopy time (81.9 vs 44.4 seconds, P < 0.001). CONCLUSIONS Patient-level radiation exposure during fluoroscopy-guided hand and wrist procedures is low relative to other common imaging modalities, such as dental radiographs, chest x-rays, and computed tomography scans, and is comparable with less than a few hours of natural background radiation exposure, highlighting the overall safety of this important technology. Further study should be performed to establish reference ranges, which could lead to improved patient counseling and evidence-based guidelines on patient shielding.
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Affiliation(s)
- Wen Xu
- From the Division of Plastic Surgery, Department of Surgery, University of Pennsylvania
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10
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Christopher AN, Patel V, Mellia JA, Morris MP, Diatta F, Murphy AI, Fischer JP. Leadership Roles, Academic Appointments, and Scholarly Activity—Does a Fellowship after Plastic Surgery Training Make a Difference? Arch Plast Surg 2022; 49:207-214. [PMID: 35832666 PMCID: PMC9045523 DOI: 10.1055/s-0042-1744418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background
Fellowship training is becoming more popular in plastic surgery, with over half of residents pursuing advanced training. Here, we investigate how clinical and research fellowship training impacts career trajectory and scholastic achievement in academic plastic surgery.
Methods
Plastic surgery faculty members, from programs recognized by the American Council of Academic Plastic Surgeons, were identified using institutional Web sites. Data extracted included faculty demographics, training history, academic positions, and research productivity. Continuous and categorical variables were compared using
t
-tests and chi-square, respectively.
Results
In total, 949 faculty members were included, with 657 (69%) having completed fellowship training. Integrated program residents were more likely to complete a fellowship when compared with independent residents (
p
< 0.0001). Fellowship trained faculty were more likely to have graduated from a higher ranked residency program, in terms of both overall and research reputation (
p
= 0.005 and
p
= 0.016, respectively). When controlling for years in practice, there was no difference found in number of publications, Hirsch index (h-index), or National Institutes of Health funding between faculty between the two cohorts (
p
> 0.05). In a subanalysis comparing hand, craniofacial, microsurgery, and research fellowships, those who completed a research fellowship had higher h-indices and were more likely to reach full professor status (
p
< 0.001 and
p
= 0.001, respectively). Fellowship training had no effect on being promoted to Chief/Chair of departments (
p
= 0.16).
Conclusion
Fellowship training is common among academic plastic surgeons. In this study, both clinical and research fellowships were associated with various aspects of academic success. However, fellowship training alone did not affect attainment of leadership positions.
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Affiliation(s)
- Adrienne N. Christopher
- Division of Plastic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Viren Patel
- Division of Plastic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joseph A. Mellia
- Division of Plastic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
- Renaissance School of Medicine, Stony Brook University, Stony Brook, New York
| | - Martin P. Morris
- Division of Plastic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Fortunay Diatta
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Alexander I. Murphy
- Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | - John P. Fischer
- Division of Plastic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
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11
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McAuliffe PB, Hsu JY, Broach RB, Borovskiy Y, Christopher AN, Morris MP, Fischer JP. Systematic variable reduction for simplification of incisional hernia risk prediction instruments. Am J Surg 2022; 224:576-583. [DOI: 10.1016/j.amjsurg.2022.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 02/14/2022] [Accepted: 03/01/2022] [Indexed: 11/29/2022]
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12
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Christopher AN, Othman S, Morris MP, Broach RB, Percec I. Clinical and Patient-Reported Outcomes of 19 Patients Undergoing Clitoral and Labial Reconstruction After Female Genital Mutilation/Cutting. Aesthetic Plast Surg 2022; 46:468-477. [PMID: 34729638 DOI: 10.1007/s00266-021-02648-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 10/24/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND Female genital mutilation/cutting (FGM/C) is the intentional alteration, removal, or injury of female genitalia for non-medical reasons. Approximately 200 million females have been victims of FGM/C, and genital reconstructive procedures are increasing in demand. OBJECTIVES The objectives of this study were to assess clinical and patient-reported outcomes after FGM/C reconstruction to help guide treatment practices. METHODS Adult patients undergoing anatomic reconstruction after FGM/C were retrospectively identified. Outcomes included clitoral, labial, and donor site surgical site occurrences (SSO) and the need for revision operations. Patient-reported outcomes were assessed using an adapted version of the Female Sexual Function Index (FSFI), a validated outcomes instrument that assesses sexual function through 6 domains, with each domain having a maximum score of 6. RESULTS Nineteen patients were identified in our review. Patients presented for reconstruction due to dyspareunia, inability to orgasm, chronic infections, to normalize appearance, and/or to "feel normal." There were no SSOs and two revision operations for adhesions. 74% of patients completed the FSFI postoperatively. Despite most patients seeking repair for inability to orgasm and/or dyspareunia, the median scores for these domains were 4.6 and 5.2. Patients' desire to engage in sexual activity scored lowest (3.9), and patients reported concerns over the appearance of their genitalia (50%) that affected self-confidence (85.7%). CONCLUSION FGM/C reconstruction is safe and contributes to improvements in physical sexual health. Psychological trauma may contribute to lessened sexual desire and self-confidence even after reconstruction. Multidisciplinary treatment is important to address the long-term psychological effects of this practice. LEVEL OF EVIDENCE IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
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Morris MP, Toyoda Y, Christopher AN, Broach RB, Percec I. A Systematic Review of Aesthetic Surgery Training Within Plastic Surgery Training Programs in the USA: An In-Depth Analysis and Practical Reference. Aesthetic Plast Surg 2022; 46:513-523. [PMID: 34467421 DOI: 10.1007/s00266-021-02557-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 08/22/2021] [Indexed: 01/10/2023]
Abstract
BACKGROUND The importance of aesthetic surgery exposure for plastic and reconstructive trainees has been recently validated by the expansion of case requirements for aesthetic procedures from 50 to 150, as well as resident-driven desire for increased cosmetic exposure throughout training. We aim to systematically review the literature at a national level to report on overall trends in aesthetic surgery training within PRS residencies. METHODS A literature search of PubMed, Embase, and Scopus identified all English articles published in the USA between 2000 and 2020, using a combination of "aesthetic surgery", "cosmetic surgery", "plastic surgery", "residency and internship", "education", and "training." RESULTS Our initial search resulted in 415 articles. After review of inclusion and exclusion criteria, in addition to cross-referencing, 41 studies remained, including 15 studies discussing resident and/or program director surveys, eight studies discussing teaching methods, sixteen studies discussing dedicated resident clinics, four studies discussing cosmetic/aesthetic fellowships, three studies discussing cosmetic practice patterns, and eleven studies discussing patient outcomes. CONCLUSION Current literature demonstrates that there are gaps in aesthetic surgery training for PRS residents in the USA, including facial and neck surgeries and non-surgical interventions. Resident clinics have clear benefits for resident education, without sacrificing patient outcomes. Residency programs should consider the development of a resident cosmetic clinic and/or dedicated cosmetic center to increase surgical exposure and increase trainee comfort in providing this subset of procedures. Published literature is limited in consistency of methods of evaluation, and further in-depth analysis of case volume and diversity at training programs within the USA and internationally is indicated. LEVEL OF EVIDENCE III This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
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Affiliation(s)
- Martin P Morris
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, 3400 Civic Center Boulevard, South Pavilion, 14th Floor, Philadelphia, PA, 19104, USA
| | - Yoshiko Toyoda
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, 3400 Civic Center Boulevard, South Pavilion, 14th Floor, Philadelphia, PA, 19104, USA
| | - Adrienne N Christopher
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, 3400 Civic Center Boulevard, South Pavilion, 14th Floor, Philadelphia, PA, 19104, USA
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Robyn B Broach
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, 3400 Civic Center Boulevard, South Pavilion, 14th Floor, Philadelphia, PA, 19104, USA
| | - Ivona Percec
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, 3400 Civic Center Boulevard, South Pavilion, 14th Floor, Philadelphia, PA, 19104, USA.
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Christopher AN, Morris MP, Broach RB, Serletti JM. A Comparative Analysis of Immediate and Delayed-immediate Breast Reconstruction after Postmastectomy Radiation Therapy. J Reconstr Microsurg 2021; 38:499-505. [PMID: 34921369 DOI: 10.1055/s-0041-1740123] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Postmastectomy radiation therapy (PMRT) is an important component in the treatment of locally advanced breast cancer. Optimal timing of therapy in relation to autologous breast reconstruction (ABR) remains clinically debated. Herein, we comparatively analyze short- and long-term outcomes between immediate ABR (I-ABR) and delayed-immediate ABR (DI-ABR) in the setting of PMRT. METHODS Adult patients undergoing ABR with PMRT were separated into cohorts based on reconstructive timeline: I-ABR or DI-ABR. The groups were propensity matched 1:1 by age, body mass index, and comorbidities. Surgical site events and long-term clinical outcomes (readmissions, reoperations, and revision procedures) were collected. Univariate analyses were completed using Pearson's chi-squared tests and Fisher's exact tests, and statistical significance was set at p < 0.05. RESULTS One hundred and thirty-two flaps (66 in each cohort) were identified for inclusion. Patients with I-ABR were more likely to experience fat necrosis (p = 0.034) and skin necrosis (p < 0.001), require additional office visits (p < 0.001) and outpatient surgeries (p = 0.015) to manage complications, and undergo revision surgery after reconstruction (p < 0.001). DI-ABR patients, however, had a 42.4% incidence of complications following tissue expander placement prior to reconstruction, with 16.7% of patients requiring reoperation during this time. Only one patient (I-ABR) experienced flap loss due to a vascular complication. CONCLUSION The complications encountered in both of these groups were not prohibitive to offering either treatment. Patients should be made aware of the specific and unique risks of these reconstruction timelines and involved throughout the entire decision-making process. Plastic surgeons should continue to strive to elucidate innovative approaches that facilitate enhanced quality of life without compromising oncologic therapy.
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Affiliation(s)
- Adrienne N Christopher
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania.,Department of Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Martin P Morris
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Robyn B Broach
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joseph M Serletti
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
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Morris MP, Christopher AN, Patel V, Mellia JA, Liu T, Hsu JY, Broach RB, Ungar LH, Fischer JP. Feasibility of Natural Language Processing in Surgery: Sensitivity and Specificity Compared to Manual Extraction. J Am Coll Surg 2021. [DOI: 10.1016/j.jamcollsurg.2021.07.173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Rios-Diaz AJ, Morris MP, Christopher AN, Patel V, Broach RB, Hsu JY, Serletti JM, Fischer JP. Trends in Incisional Hernia Repair and Abdominal Surgery: A Nationwide Analysis of Hospitalization and Hospital Cost. J Am Coll Surg 2021. [DOI: 10.1016/j.jamcollsurg.2021.08.191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Christopher AN, Morris MP, Patel V, Broach RB, Fischer JP. Abdominal Body Contouring: Does Body Mass Index Affect Clinical and Patient Reported Outcomes? J Surg Res 2021; 270:348-358. [PMID: 34731733 DOI: 10.1016/j.jss.2021.09.035] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 08/01/2021] [Accepted: 09/09/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND Obese individuals are thought to be higher risk for complications after excisional abdominal body contouring (EAC) due to co-morbidities and significant tissue resection. OBJECTIVES We comparatively analyzed EAC patients with Body Mass Index (BMI) ≥35 kg/m2 and BMI <35 kg/m2 to highlight key differences in clinical and patient-reported-outcomes (PROs). METHODS Patients ≥18 years-old undergoing EAC by a single surgeon from 01/2018-01/2020 were identified and separated into cohorts based on BMI (<35 and ≥35 kg/m2). Patients were excluded if they had a cosmetic abdominoplasty without history of bariatric surgery or massive weight loss, or if they had <1000 gs of tissue resected. Clinical outcomes and PROs using the BODY-Q were comparatively analyzed. RESULTS 70 total patients with median BMIs of 30[26-32] and 41[37-45] kg/m2 in each cohort, were identified. Patients with BMI ≥35 kg/m2 were more likely to have higher ASA (P<0.01) and use of incisional negative pressure wound devices (P = 0.042). Alternatively, they were less likely to have had concurrent liposuction (P = 0.05). There were no differences in development of an SSO, SSI or SSOpi (P>0.05) between cohorts. Multivariate logistic regression showed that BMI ≥35 kg/m2, iNPWD and liposuction were not associated with the development of complications. PROs demonstrated improvement in multiple domains despite BMI. CONCLUSION There was no association with BMI ≥35 kg/m2 and the development of complications within our cohort. We encourage preoperative weight loss when possible, however these procedures can be performed safely with acceptable outcomes even in individuals who are obese and/or require extensive tissue removal.
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Affiliation(s)
- Adrienne N Christopher
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania. Philadelphia, PA; Department of Surgery. Thomas Jefferson University. Philadelphia, PA.
| | - Martin P Morris
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania. Philadelphia, PA
| | - Viren Patel
- Perelman School of Medicine, University of Pennsylvania. Philadelphia, PA
| | - Robyn B Broach
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania. Philadelphia, PA
| | - John P Fischer
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania. Philadelphia, PA.
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Christopher AN, Morris MP, Jia H, Patel V, Broach RB, Serletti JM, Fosnot J. Managing locoregional breast cancer recurrence after autologous free flap reconstruction: A retrospective review of 2,734 procedures. J Plast Reconstr Aesthet Surg 2021; 75:562-570. [PMID: 34789432 DOI: 10.1016/j.bjps.2021.09.078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 06/15/2021] [Accepted: 09/27/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION The 5-year incidence of locoregional recurrence (LRR) after mastectomy is 3-8 %. This study examines the incidence, modes of detection, and reconstructive options after loss of index reconstruction in the largest series of autologous free flap patients who subsequently developed LRR. METHODS We identified patients undergoing muscle-sparing free transverse rectus abdominus muscle or deep inferior epigastric perforator flap reconstruction for breast cancer at our institution from 2005 to 2017 who subsequently developed LRR. The main outcomes were incidence of recurrence, primary mode of detection, surgical management, and patient and cancer-specific factors associated with surgical management and loss of index reconstruction. RESULTS The incidence of LRR in this cohort was 3% (n=66 of 2240 flaps), and 71% (n=46) of recurrences were diagnosed on physical examination. 80% (n=53) of LRR required multidisciplinary management, whereas 56% (n=37) were managed surgically. Patients with postoperative radiation prior to recurrence, metastatic disease at diagnosis, nodal positivity, and chest wall involvement were less likely to be offered surgery (all p<0.05). Twelve patients lost their index reconstruction and five required subsequent advanced chest wall reconstruction. No differences were seen in terms of location of recurrence, detection of recurrence, or mortality between flap types (all p>0.05). CONCLUSION Management of LRR is centered around early multidisciplinary involvement and often requires surgery. Removal of index reconstruction and/or advanced chest well reconstruction is indicated in select cases. Plastic surgeons should be aware of the indications and options that exist for management in these complex situations.
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Affiliation(s)
- Adrienne N Christopher
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania. Philadelphia, PA, USA; Department of Surgery. Thomas Jefferson University. Philadelphia, PA, USA
| | - Martin P Morris
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania. Philadelphia, PA, USA
| | - Hanna Jia
- Perelman School of Medicine, University of Pennsylvania. Philadelphia, PA, USA
| | - Viren Patel
- Perelman School of Medicine, University of Pennsylvania. Philadelphia, PA, USA
| | - Robyn B Broach
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania. Philadelphia, PA, USA
| | - Joseph M Serletti
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania. Philadelphia, PA, USA
| | - Joshua Fosnot
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania. Philadelphia, PA, USA
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19
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Christopher AN, Morris MP, Barrette LX, Patel V, Broach RB, Fischer JP. Longitudinal Clinical and Patient-Reported Outcomes After Transversus Abdominis Release for Complex Hernia Repair With a Review of the Literature. Am Surg 2021:31348211038580. [PMID: 34406098 DOI: 10.1177/00031348211038580] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
PURPOSE Posterior component separation with transversus abdominis release (TAR) enables medial myofascial flap advancement in complex abdominal wall reconstruction. Here, we add to a growing body of literature on TAR by assessing longitudinal clinical and patient-reported outcomes (PROs) after complex ventral hernia repair (VHR) with TAR. METHODS Adult patients undergoing VHR with TAR between 10/15/2015 and 1/15/2020 were retrospectively identified. Patients with parastomal hernias and <12 months of follow-up were excluded. Clinical outcomes and PROs were assessed. RESULTS Fifty-six patients were included with a median age and body mass index of 60 and 30.8 kg/m2, respectively. The average hernia defect was 384 cm2 [IQR 205-471], and all patients had retromuscular mesh placed. The most common complications were delayed healing (19.6%) and seroma (14.3%). There were no cases of mesh infection or explantation. Previous hernia repair and concurrent panniculectomy were risk factors for developing complications (P < .05). One patient (1.8%) recurred at a median follow-up of 25.2 months [IQR 18.2-42.4]. Significant improvement in disease-specific PROs was maintained throughout the follow-up period (before to after P < .05). CONCLUSION Transversus abdominis release is a safe and efficacious technique to achieve fascial closure and retromuscular mesh in the repair of complex hernia defects.
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Affiliation(s)
- Adrienne N Christopher
- Division of Plastic Surgery, Department of Surgery, 6572University of Pennsylvania, Philadelphia, PA, USA.,Department of Surgery. Thomas Jefferson University, Philadelphia, PA, USA
| | - Martin P Morris
- Division of Plastic Surgery, Department of Surgery, 6572University of Pennsylvania, Philadelphia, PA, USA
| | | | - Viren Patel
- Perelman School of Medicine, 6572University of Pennsylvania, Philadelphia, PA, USA
| | - Robyn B Broach
- Division of Plastic Surgery, Department of Surgery, 6572University of Pennsylvania, Philadelphia, PA, USA
| | - John P Fischer
- Division of Plastic Surgery, Department of Surgery, 6572University of Pennsylvania, Philadelphia, PA, USA
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Morris MP, Christopher AN, Patel V, Broach RB, Fischer JP, Butler PD. Assessing Disparities in Reduction Mammaplasty: There Is Room for Improvement. Aesthet Surg J 2021; 41:NP796-NP803. [PMID: 33735387 DOI: 10.1093/asj/sjab138] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Racial and socioeconomic disparities in access and quality of surgical care are well documented in many surgical subspecialties, including plastic surgery. OBJECTIVES The authors aimed to determine if demographic disparities exist in preoperative and postoperative satisfaction after breast reduction mammaplasty, utilizing patient-reported quality of life (QoL) scores. METHODS Patients who underwent breast reduction mammaplasty between 2015 and 2020 were identified. Patients who underwent complex concomitant procedures were excluded. Patient demographics and QoL, as measured by the BREAST-Q, were extracted. Wilcoxon Rank Sum and Kruskal-Wallis tests were employed to compare QoL scores across demographic subgroups. RESULTS A total of 115 patients met the inclusion criteria. QoL improved across all 4 BREAST-Q domains (all P < 0.001). Disparities were shown to exist in the following: median income vs postoperative satisfaction with information (P < 0.001), BMI vs preoperative physical well-being (P < 0.001), and ethnicity vs preoperative physical well-being (P = 0.003). A sub-group analysis of Caucasian patients compared with Black/African American patients revealed significant inequalities in BMI (P < 0.001), median income by zip code (P < 0.001), improvement in satisfaction with breasts (P = 0.039), satisfaction with information (P = 0.007), and satisfaction with office staff (P = 0.044). CONCLUSIONS Racial and socioeconomic inequalities exist in preoperative and postoperative satisfaction for patients undergoing breast reduction mammaplasty. Institutions should focus on developing tools for equitable and inclusive patient education and perioperative counseling. LEVEL OF EVIDENCE: 2
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Affiliation(s)
- Martin P Morris
- Department of Surgery, Division of Plastic Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Viren Patel
- Department of Surgery, Division of Plastic Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Robyn B Broach
- Department of Surgery, Division of Plastic Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - John P Fischer
- Department of Surgery, Division of Plastic Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Paris D Butler
- Department of Surgery, Division of Plastic Surgery, University of Pennsylvania, Philadelphia, PA, USA
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21
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Christopher AN, Patel V, Othman S, Jia H, Mellia JA, Broach RB, Fischer JP. Onlay Poly-4-Hydroxybutyrate (P4HB) Mesh for Complex Hernia: Early Clinical and Patient Reported Outcomes. J Surg Res 2021; 264:199-207. [PMID: 33838404 DOI: 10.1016/j.jss.2021.02.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 02/01/2021] [Accepted: 02/27/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND While mesh re-enforcement and advanced surgical techniques are cornerstones of complex ventral hernia repair (CVHR), the risk of complications and recurrence is common. We aim to evaluate the efficacy, safety, and patient reported outcomes (PROs) of patients undergoing CVHR with onlay Poly-4-hydroxybutyrate (P4HB). METHODS Adult (>18 y old) patients undergoing VHR with P4HB (Phasix) in the onlay plane by a single surgeon from 01/2015 to 05/2020 were reviewed. VHR was considered complex if patients had significant co-morbidities, large abdominal wall defects, a history of extensive abdominal surgery, and/or concurrent intra-abdominal pathology. A composite of postoperative outcomes including surgical site occurrences (SSO), surgical site infection (SSI), and surgical site occurrences requiring procedural intervention (SSOpi), as well as PROs as defined by the Abdominal Hernia-Q (AHQ), were analyzed. RESULTS A total of 51 patients were included with average age and body mass index of 56.4 and 29.9 kg/m2. Median follow up was 20 mo with a hernia recurrence rate of 5.9% (n = 3). 21 patients had an SSO (41.2%), 8 had an SSI (15.7%), and 6 had an SSOpi (11.8%). There was an association with Ventral Hernia Working Group ≥ 2 and development of SSO. There was a significant improvement in overall PROs (P < 0.0001) with no difference in those patients with and without complications (P > 0.05). CONCLUSION For hernia patients with large defects and complex intra-abdominal pathology, a safe and effective repair is difficult. The use of onlay P4HB was associated with acceptable postoperative outcomes and recurrence rate.
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Affiliation(s)
- Adrienne N Christopher
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA; Department of Surgery, Thomas Jefferson University, Philadelphia, PA
| | - Viren Patel
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Sammy Othman
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Hanna Jia
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Joseph A Mellia
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Robyn B Broach
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - John P Fischer
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA.
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22
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Christopher AN, Fowler C, Patel V, Mellia JA, Morris MP, Broach RB, Fischer JP. Bilateral transversus abdominis release: Complex hernia repair without sacrificing quality of life. Am J Surg 2021; 223:250-256. [PMID: 33757660 DOI: 10.1016/j.amjsurg.2021.03.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 02/23/2021] [Accepted: 03/10/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Transversus Abdominis Release (TAR) during ventral hernia repair (VHR) allows for further lateral dissection by dividing the transversus abdominis muscles (TAM). The implications of division of the TAM on clinical and patient-reported outcomes has not be extensively studied. METHODS Adult patients undergoing retrorectus (RR) VHR with biosynthetic mesh with or without bilateral TAR were retrospectively identified. Post-operative and patient-reported outcomes (PROs) were collected. RESULTS Of 50 patients, 24 underwent TAR and 26 had RR repair alone. Median defect sizes were 449 cm2 and 208 cm2, respectively (p < 0.001). Rates of SSO and SSI were similar (p > 0.05). One TAR patient (4.2%) and four RR patients (15.4%) recurred (p = 0.26), with median follow up of 24 and 38 months. PROs improved significantly in both groups (p < 0.05). CONCLUSION Despite more complex abdominal wall reconstruction on larger defects, TAR has minimal major adverse events, low recurrence rates, and does not negatively affect PROs.
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Affiliation(s)
- Adrienne N Christopher
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA; Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Cody Fowler
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Viren Patel
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Joseph A Mellia
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Martin P Morris
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Robyn B Broach
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - John P Fischer
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA.
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Morris MP, Mellia JA, Christopher AN, Basta MN, Patel V, Qiu K, Broach RB, Fischer JP. Ventral hernia repair with synthetic mesh in a contaminated field: a systematic review and meta-analysis. Hernia 2021; 25:1035-1050. [PMID: 33464537 DOI: 10.1007/s10029-020-02358-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 12/07/2020] [Indexed: 11/30/2022]
Abstract
PURPOSE The use of mesh in ventral hernia repair becomes especially challenging when associated with a contaminated field. Permanent synthetic mesh use in this setting is currently debated and this discussion is yet to be resolved clinically or in the literature. We aim to systematically assess postoperative outcomes of non-absorbable synthetic mesh (NASM) used in ventral hernia repair in the setting of contamination. METHODS A literature search of PubMed, Embase, Scopus, Cinahl, and Cochrane Library identified all articles from 2000-2020 that examined the use of NASM for ventral hernia repair in a contaminated field. Postoperative outcomes were assessed by means of pooled analysis and meta-analysis. Qualitative analysis was completed for all included studies using a modified Newcastle-Ottawa scale. RESULTS Of 630 distinct publications and 104 requiring full review, this study included 17 articles published between 2007 and 2020. Meta-analysis demonstrated absorbable mesh was associated with more HR (OR 1.89, 1.15-3.12, p = 0.008), SSO (OR 1.43, 0.96-2.11, p = 0.087), SSI (OR 2.84, 1.85-4.35, p < 0.001), and unplanned reoperation (OR 1.99, 1.19-3.32, p = 0.009) compared to NASM. CONCLUSION The use of NASM for ventral hernia repair in a contaminated field may be a safe alternative to absorbable mesh, as evidenced by lower rates of postoperative complications. This review counters the current clinical paradigm, and additional prospective randomized controlled trials are warranted.
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Affiliation(s)
- M P Morris
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, Philadelphia, PA, USA
| | - J A Mellia
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, Philadelphia, PA, USA
| | - A N Christopher
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, Philadelphia, PA, USA.,Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - M N Basta
- Division of Plastic Surgery, Brown University, Providence, RI, USA
| | - V Patel
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, Philadelphia, PA, USA
| | - K Qiu
- University of Pennsylvania, Philadelphia, PA, USA
| | - R B Broach
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, Philadelphia, PA, USA
| | - J P Fischer
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, Philadelphia, PA, USA.
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Smith JL, Christopher AN, Evans NR. Novel Two-Stage Open Spine and Robotic Thoracic Approach to Resection of a Mediastinal Tumor. Ann Thorac Surg 2021; 111:e27-e29. [DOI: 10.1016/j.athoracsur.2020.05.043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 05/01/2020] [Indexed: 12/12/2022]
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Abstract
Background: Small bowel cancers, specifically duodenal cancer, occur at very low rates but require aggressive surgical resection when diagnosed. An even rarer finding is the presence of intestinal malrotation. Case Presentation: We present the unique case of a patient with both duodenal cancer and partial intestinal malrotation undergoing pancreaticoduodenectomy. We discuss the challenges faced and techniques used to successfully perform a surgical resection in this circumstance. Conclusion: Understanding of intestinal malrotation and review of the imaging is crucial in preparing for a resection of a duodenal tumor in a patient with this condition.
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Affiliation(s)
- William T. Li
- Department of Surgery, Jefferson Pancreas, Biliary, and Related Cancer Center, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Sonia Sethi
- Department of Surgery, Jefferson Pancreas, Biliary, and Related Cancer Center, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Adrienne N. Christopher
- Department of Surgery, Jefferson Pancreas, Biliary, and Related Cancer Center, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Deepika Koganti
- Department of Surgery, Jefferson Pancreas, Biliary, and Related Cancer Center, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Charles J. Yeo
- Department of Surgery, Jefferson Pancreas, Biliary, and Related Cancer Center, Thomas Jefferson University, Philadelphia, Pennsylvania
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