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Zibitt M, Shauly O, Ash M, Menon A, Gould DJ, Faulkner H, Losken A. Defining the Ideal Reduction Mammoplasty: A Crowdsourcing Study. Aesthet Surg J 2024:sjae092. [PMID: 38669196 DOI: 10.1093/asj/sjae092] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 04/11/2024] [Accepted: 04/12/2024] [Indexed: 04/28/2024] Open
Abstract
BACKGROUND Reduction mammoplasty relieves macromastia symptoms while improving breast aesthetics, though the ideal breast aesthetically has been shown to differ culturally in previous crowdsourcing studies. Better understanding these differences can aid in setting postoperative expectations. OBJECTIVES The aim of this study was to characterize the ideal reduction mammoplasty according to demographics such as gender, ethnicity, socioeconomic status, and education. METHODS A crowdsourcing platform was used to collect 10,169 de-identified responses. Users completed one of three surveys, either a preoperative, postoperative, or preoperative and postoperative paired survey. The preoperative and postoperative surveys addressed 10 breast measurements including upper breast slope, projection proportion, nipple position, breast width, and breast fullness. The paired pre- and postoperative survey assessed nipple areolar complex (NAC), chest fit, symmetry improvement, and scarring. RESULTS Preoperative images were rated more aesthetic than postoperative images. This was consistent across all demographics evaluated. Female, African American, Asian, participants aged 55+, and participants with no high school degree or a graduate degree found the most improvement in breast symmetry (p = 0.001, p = 0.002, p = 0.027, p < 0.001, p = 0.01). Male and Hispanic participants were most likely to see no change in symmetry (p = 0.008, p = 0.04), and South Asian participants found breasts less symmetric postoperative (p < 0.001). There were significant demographic differences in aesthetic ratings of NAC, scarring, and breast fit. CONCLUSIONS Perceived breast aesthetics after reduction mammoplasty vary significantly across demographics including gender, ethnicity, age, socioeconomic status, and educational achievement. Surgeons should consider demographics when planning each patient's reduction mammoplasty.
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Affiliation(s)
- Meira Zibitt
- Medical student, Medical College of Georgia, Augusta, GA, USA
| | - Orr Shauly
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Emory University, Atlanta, GA, USA
| | - Makenna Ash
- Medical students, Emory University School of Medicine, Atlanta, GA, USA
| | - Ambika Menon
- Medical students, Emory University School of Medicine, Atlanta, GA, USA
| | - Daniel J Gould
- Plastic surgeon in private practice, Beverly Hills, CA, USA
| | - Heather Faulkner
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Emory University, Atlanta, GA, USA
| | - Albert Losken
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Emory University, Atlanta, GA, USA
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Ash M, Zibitt M, Shauly O, Menon A, Losken A, Gould D. The Innovative and Evolving Landscape of Topical Exosome and Peptide Therapies: A Systematic Review of the Available Literature. Aesthet Surg J Open Forum 2024; 6:ojae017. [PMID: 38633728 PMCID: PMC11023079 DOI: 10.1093/asjof/ojae017] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2024] Open
Abstract
Topical antiaging therapies provide noninvasive delivery of active therapeutics. Exosomes, or extracellular nanovesicles, and peptides, small strings of amino acids, have shown promise as topical therapies in early trials, but neither is FDA approved. This review aims to elucidate the current and future landscape of topical exosomes and peptides as therapeutics for skin rejuvenation. A literature search was conducted using the keywords "peptides" OR "exosomes" AND "skin" OR "rejuvenation." Primary endpoints included mechanisms of action in humans or live animals as well as clinical data supporting the use of exosomes or peptides topically for skin rejuvenation or wound healing. Secondary endpoints were safety, side effects, and efficacy. The articles were collected, organized, and sorted using the Covidence software (Melbourne, Australia) for systematic review. Nine articles evaluating topical application of exosomes and 9 of peptides met inclusion criteria. Topical exosomes were found to increase collagen deposition, accelerate wound healing, and improve overall cosmesis. Several clinical trials are currently underway. Topical peptides were found to improve appearance of fine lines and wrinkles, elasticity and viscoelasticity, skin texture, skin thickness, and the potential for accelerated wound healing. Peptides are quite common in "cosmeceutical" products, and several patents have been filed for topical peptide products aimed at increasing skin rejuvenation. This could indicate a movement toward pursuing FDA approval. The future of topical exosome and peptide products for the purpose of skin rejuvenation appears promising. Preliminary data from the studies reviewed here indicates that these products have the potential to be safe and effective. Level of Evidence 3
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Affiliation(s)
| | | | - Orr Shauly
- Corresponding Author: Dr Orr Shauly, 100 Woodruff Circle, Atlanta, GA 30322, USA. E-mail: ; Instagram: @orrshaulymd
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3
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Williams S, Menon A, Shauly O, Van Natta B, Gould D, Losken A. Reviewing Outcomes and Complications with the Use of Mesh in Breast Reduction Surgery. Aesthetic Plast Surg 2024:10.1007/s00266-024-03896-4. [PMID: 38448602 DOI: 10.1007/s00266-024-03896-4] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 01/30/2024] [Indexed: 03/08/2024]
Abstract
INTRODUCTION Reduction mammoplasty is a common reconstructive and esthetic procedure with variable long-term outcomes regarding breast shape, projection, and nipple-areolar complex. One common complaint is recurrent breast ptosis, which may be mitigated by sufficient support of the inferior pole. This review will look at the effects of mesh in mitigating postoperative ptosis following reduction mammoplasty. METHODS A comprehensive review of the literature was performed using the PubMed database. Manuscripts that provided data with respect to the effects of mesh on cosmetic outcomes, patient-reported outcomes, complications, and surveillance were utilized. RESULTS Six studies with a total of 634 patients were included in this review. There is limited evidence to support a cosmetic benefit with the use of mesh in reduction mammoplasty patients. While subjective satisfaction was demonstrated in one paper, few others had objective measurements of the impact of mesh. Complications included infection, skin necrosis, and loss of nipple sensation. Mammography was found to not be affected by mesh placement. DISCUSSION The use of mesh during reduction mammoplasty is a relatively modern innovation that does not appear to have a significantly different risk profile than that of traditional reduction procedures. There is limited cosmetic value based on currently available data. More objective future analysis is necessary in order to justify the use of mesh in reduction mammoplasty for its claimed cosmetic benefits. 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 Table of Contents or online Instructions to Authors www.springer.com/00266.
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Affiliation(s)
| | | | - Orr Shauly
- Emory Division of Plastic and Reconstructive Surgery, 3200 Downwood Circle Northwest, Atlanta, GA, 30327, USA.
| | | | | | - Albert Losken
- Emory Division of Plastic and Reconstructive Surgery, 3200 Downwood Circle Northwest, Atlanta, GA, 30327, USA
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Turgeon MK, Willcox LM, Styblo TM, Losken A. Impact of Oncoplastic Surgery on Oncologic Outcomes in Patients with Breast Cancer. Plast Reconstr Surg Glob Open 2024; 12:e5561. [PMID: 38292812 PMCID: PMC10827286 DOI: 10.1097/gox.0000000000005561] [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] [Received: 07/07/2023] [Accepted: 11/27/2023] [Indexed: 02/01/2024]
Abstract
Background For patients with breast cancer, oncoplastic surgery (OPS) serves as a valuable technique that allows for immediate reconstruction at the time of resection. While the aim of OPS is to improve breast cosmesis, it is critical to ensure OPS does not negatively impact appropriate cancer treatment. Methods Based on current literature, this study provides a broad overview on the potential oncologic advantages of OPS for patients diagnosed with breast cancer. Results OPS has been shown to be a safe and reliable approach with oncologic advantages. More specifically, OPS broadens the indications for breast conservation therapy (BCT); allows for a more generous margin of resection, thus decreasing rates of re-excision; and provides the opportunity to sample additional breast tissue, which may detect occult disease. Reduction mammaplasty may also decrease the risk for developing breast cancer. Importantly, in the era of multimodality therapy, long-term oncologic outcomes and postoperative surveillance algorithms appear to be similar when comparing patients who undergo OPS and BCT. Conclusions For patients with breast cancer, oncoplastic surgery has emerged as a valuable technique to improve breast cosmesis while achieving optimal oncologic outcomes. As the landscape of breast oncology continues to evolve, it is critical for a multidisciplinary team to be involved to guide management and reconstructive strategies.
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Affiliation(s)
| | | | - Toncred M. Styblo
- Winship Cancer Institute, Division of Surgical Oncology, Department of Surgery, Emory University, Atlanta, Ga
| | - Albert Losken
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Emory University, Atlanta, Ga
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Menon A, Shauly O, Marxen T, Losken A, Faulkner HR. A Clinical Guide to the Treatment of Cellulite and Comprehensive Review of the Etiology, Pathophysiology, and Utility of Intervention. Aesthetic Plast Surg 2023:10.1007/s00266-023-03762-9. [PMID: 38057600 DOI: 10.1007/s00266-023-03762-9] [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: 08/05/2023] [Accepted: 11/14/2023] [Indexed: 12/08/2023]
Abstract
INTRODUCTION Cellulite is a common esthetic concern affecting most women. Despite its prevalence, there is no consensus on the optimal treatment approach for cellulite, partly due to the complex and multifactorial nature of its pathophysiology. Understanding the underlying biological processes along with available treatment options is important to be able to effectively counsel patients on effective management of this condition. This review aims to focus on high-quality evidence behind pathophysiology of cellulite, severity and grading, and its available treatment options. METHODS A comprehensive review of the literature was performed using PubMed and Embase databases. Manuscripts that provided objective data with respect to pathophysiology, grading scales, and applications of treatment options were utilized. RESULTS Using the existing CSS classification, an evidence-based algorithm is proposed for treatment of cellulite. Mild cellulite is best served with lifestyle modifications such as healthy diet, hydration, and exercise. Use of topicals in mild cellulite patients as adjuncts to lifestyle modifications have the highest efficacy, although there are inconsistent data on topical treatments. Moderate cellulite is best targeted with noninvasive treatment options including laser therapy, radiofrequency, and ultrasound. Radiofrequency demonstrates the strongest efficacy in the current peer-reviewed literature. Severe cellulite is recommended to be treated with minimally invasive approaches such as subcision and injectables. CONCLUSION Cellulite is a challenging cosmetic problem to treat, and thus multimodal treatment options should be considered in an attempt to achieve optimal outcomes and patient satisfaction. As the pathophysiology of cellulite is further elucidated, more targeted treatments may be developed in the future. LEVEL OF EVIDENCE V 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)
- Ambika Menon
- Emory University School of Medicine, Atlanta, Georgia
| | - Orr Shauly
- Division of Plastic and Reconstructive Surgery, Emory University School of Medicine, Atlanta, Georgia.
| | - Troy Marxen
- Division of Plastic and Reconstructive Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Albert Losken
- Division of Plastic and Reconstructive Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Heather R Faulkner
- Division of Plastic and Reconstructive Surgery, Emory University School of Medicine, Atlanta, Georgia
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Brown OH, Danko D, Muret-Wagstaff SL, Emefiele J, Argüello-Angarita M, Baker NF, Losken A, Carlson G, Cheng A, Walsh M, Muralidharan VJ, Thompson PW. Close the GAPS: A Standardized Perioperative Protocol Reduces Breast Reconstruction Implant Infections. Plast Reconstr Surg 2023; 152:1175-1184. [PMID: 37010468 DOI: 10.1097/prs.0000000000010491] [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: 04/04/2023]
Abstract
BACKGROUND Implant-based breast reconstruction (IBBR) is a complex process with significant practice variability. Infections after IBBR are associated with higher rates of readmission, reoperation, and reconstructive failure. To reduce process variability and postoperative infections, the authors implemented an evidence-based, standardized protocol for IBBR. METHODS The protocol was applied to all patients undergoing IBBR at a single institution from December of 2019 to February of 2021. Intraoperative protocol adherence was recorded, and infection events were considered minor (managed with outpatient antibiotics) or major (managed with readmission or reoperation). A historic control group was retrospectively analyzed for comparison. RESULTS Sixty-nine patients (120 breasts) in the protocol group were compared with 159 patients (269 breasts) in the retrospective group. No differences were found in demographic characteristics, comorbidities, or type of reconstruction (expander versus implant). Intraoperative protocol adherence was 80.5% (SD, 13.9%). Overall infection rate was significantly lower in the protocol group versus controls (8.7% versus 17.0%; P < 0.05). When dichotomized, protocol patients had a lower rate of both minor (2.9% versus 5.7%; P = 0.99) and major (5.8% versus 11.3%; P = 0.09) infections, although this was not statistically significant. Rate of reconstructive failure secondary to infection was significantly lower in the protocol group (4.4% versus 8.8%; P < 0.05). Among protocol patients, those without infection had higher protocol adherence (81.5% versus 72.2%; P < 0.06), which neared statistical significance. CONCLUSION A standardized perioperative protocol for IBBR reduces process variability and significantly decreases rate of overall infections and reconstructive failure secondary to infection. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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Affiliation(s)
- Owen H Brown
- From the Division of Plastic and Reconstructive Surgery
| | | | | | | | | | | | - Albert Losken
- From the Division of Plastic and Reconstructive Surgery
| | - Grant Carlson
- From the Division of Plastic and Reconstructive Surgery
| | - Angela Cheng
- From the Division of Plastic and Reconstructive Surgery
| | - Mark Walsh
- From the Division of Plastic and Reconstructive Surgery
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Ghanouni A, Thompson P, Losken A. Outcomes of the Goldilocks Technique in High-Risk Breast Reconstruction Patients. Plast Reconstr Surg 2023; 152:35S-40S. [PMID: 36862960 DOI: 10.1097/prs.0000000000010354] [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: 03/04/2023]
Abstract
BACKGROUND The Goldilocks technique seeks to provide a safe alternative for patients who are otherwise at risk of adverse complications during reconstruction. The technique involves deepithelializing and locally contouring mastectomy skin flaps to create a breast mound. The purpose of this study was to analyze outcomes in this cohort of patients. METHODS A review was performed on a prospective database of all patients who underwent postmastectomy Goldilocks reconstruction between June of 2017 and January of 2021 at a tertiary care center. Data queried included patient demographics, comorbidities, complications, outcomes, and subsequent secondary reconstructive surgery. RESULTS This series included 58 patients (83 breasts) who underwent Goldilocks reconstruction. Mean age at reconstruction was 56 years (range, 34 to 78 years), and 82% (48 patients) were obese (average body mass index, 36.8). When analyzed by individual breast, the overall complication rate was 18%. Most complications ( n = 9), such as infection, skin necrosis, and seroma, were treated in the office. Six breasts experienced major complications (ie, hematoma and skin necrosis) requiring additional surgery. At the time of follow-up, 35% ( n = 29) of breasts had a secondary reconstruction, consisting of 17 implants (59%), two expanders (7%), three fat grafts (10%), and seven autologous reconstructions (24%). The complication rate for secondary reconstruction was 14%. CONCLUSIONS The Goldilocks breast reconstruction technique is safe and effective for high-risk breast reconstruction patients. Although early postoperative complications are limited, patients should be counseled on the likelihood of a subsequent secondary reconstruction procedure to achieve their desired aesthetic outcome. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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Affiliation(s)
- Arian Ghanouni
- From the Department of Plastic and Reconstructive Surgery, Emory University School of Medicine
| | - Peter Thompson
- From the Department of Plastic and Reconstructive Surgery, Emory University School of Medicine
| | - Albert Losken
- From the Department of Plastic and Reconstructive Surgery, Emory University School of Medicine
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Jonczyk MM, Karamchandani M, Zaccardelli A, Bahadur A, Fisher CS, Czerniecki B, Margenthaler JA, Persing S, Homsy C, Nardello S, O'Brien J, Losken A, Chatterjee A. External Validation of the Breast Cancer Surgery Risk Calculator (BCSRc): A Predictive Model for Postoperative Complications. Ann Surg Oncol 2023; 30:6245-6253. [PMID: 37458950 DOI: 10.1245/s10434-023-13904-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 06/28/2023] [Indexed: 09/12/2023]
Abstract
BACKGROUND The breast cancer surgical risk calculator (BCSRc) is a prognostic tool that determines a breast cancer patient's unique risk of acute complications following each possible surgical intervention. When used in the preoperative setting, it can help to stratify patients with an increased complication risk and enhance the patient-physician informed decision-making process. The objective of this study was to externally validate the four models used in the BCSRc on a large cohort of patients who underwent breast cancer surgery. METHODS The BCSRc was developed by using a retrospective cohort from the National Surgical Quality Improvement Program database from 2005 to 2018. Four models were built by using logistic regression methods to predict the following composite outcomes: overall, infectious, hematologic, and internal organ complications. This study obtained a new cohort of patients from the National Surgical Quality Improvement Program by utilizing participant user files from 2019 to 2020. The area under the curve, brier score, and Hosmer-Lemeshow goodness of fit test measured model performance, accuracy, and calibration, respectively. RESULTS A total of 192,095 patients met inclusion criteria in the development of the BCSRc, and the validation cohort included 60,144 women. The area under the curve during external validation for each model was approximately 0.70. Accuracy, or Brier scores, were all between 0.04 and 0.003. Model calibration using the Hosmer-Lemeshow statistic found all p-values > 0.05. All of these model coefficients will be updated on the web-based BCSRc platform: www.breastcalc.org . CONCLUSIONS The BCSRc continues to show excellent external-validation measures. Collectively, this prognostic tool can enhance the decision-making process, help stratify patients with an increased complication risk, and improve expectant management.
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Affiliation(s)
- Michael M Jonczyk
- Department of Surgery, Lahey Hospital & Medical Center, Burlington, MA, USA.
| | | | | | | | - Carla Suzanne Fisher
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | | | - Julie A Margenthaler
- Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Sarah Persing
- Department of General Surgery, Tufts Medical Center, Boston, MA, USA
| | - Christopher Homsy
- Department of General Surgery, Tufts Medical Center, Boston, MA, USA
| | | | - Julie O'Brien
- Department of Surgery, Lahey Hospital & Medical Center, Burlington, MA, USA
| | - Albert Losken
- Division of Plastic and Reconstructive Surgery, Emory University School of Medicine, Atlanta, GA, USA
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Jonczyk MM, Karamchandani M, Zaccardelli A, Bahadur A, Fisher CS, Czerniecki B, Margenthaler JA, Persing S, Homsy C, Nardello S, O'Brien J, Losken A, Chatterjee A. ASO Visual Abstract: External Validation of the Breast Cancer Surgery Risk Calculator (BCSRc): A Predictive Model for Postoperative Complications. Ann Surg Oncol 2023; 30:6254-6255. [PMID: 37523117 DOI: 10.1245/s10434-023-14044-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/01/2023]
Affiliation(s)
- Michael M Jonczyk
- Department of Surgery, Lahey Hospital and Medical Center, Burlington, MA, USA.
| | | | | | | | - Carla Suzanne Fisher
- Department of Surgery, Indiana University School of Medicine Indianapolis, Indianapolis, IN, USA
| | | | - Julie A Margenthaler
- Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Sarah Persing
- Department of General Surgery, Tufts Medical Center, Boston, MA, USA
| | - Christopher Homsy
- Department of General Surgery, Tufts Medical Center, Boston, MA, USA
| | | | - Julie O'Brien
- Department of Surgery, Lahey Hospital and Medical Center, Burlington, MA, USA
| | - Albert Losken
- Division of Plastic and Reconstructive Surgery, Emory University School of Medicine, Atlanta, GA, USA
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10
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Krupp J, Menon A, Shauly O, Losken A. Reflecting upon the Long-term Impact of COVID-19 on Cosmetic Plastic Surgery and Education. Plast Reconstr Surg Glob Open 2023; 11:e5359. [PMID: 37850209 PMCID: PMC10578663 DOI: 10.1097/gox.0000000000005359] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 09/11/2023] [Indexed: 10/19/2023]
Abstract
As we enter a new year, this article serves as an opportunity to ponder on the impact of a worldwide pandemic on physicians and the field of plastic surgery, which began 4 years ago in January 2020. When looking at the data in the general-surgery and reconstructive literature, the surgical treatment of patients with COVID-19 appears safest 8 weeks after infection. It was also found that the so-called Zoom-boom crush of cosmetic surgery cases following pandemic lockdown appeared to be largely due to a backlog of cases. Cosmetic surgery, particularly facial cosmetic surgery, continues to increase in popularity year over year. However, the effects on plastic surgery training remain unclear. Even so, those affected by the pandemic seem more driven than ever to find job stability and security.
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Affiliation(s)
- James Krupp
- From the Division of Plastic and Reconstructive Surgery, Emory University, Atlanta, Ga
| | - Ambika Menon
- School of Medicine, Emory University, Atlanta, Ga
| | - Orr Shauly
- From the Division of Plastic and Reconstructive Surgery, Emory University, Atlanta, Ga
| | - Albert Losken
- From the Division of Plastic and Reconstructive Surgery, Emory University, Atlanta, Ga
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11
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Shauly O, Olson B, Marxen T, Menon A, Losken A, Patel KM. Direct-to-implant versus autologous tissue transfer: A meta-analysis of patient-reported outcomes after immediate breast reconstruction. J Plast Reconstr Aesthet Surg 2023; 84:93-106. [PMID: 37329749 DOI: 10.1016/j.bjps.2023.05.029] [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: 12/05/2022] [Revised: 05/12/2023] [Accepted: 05/15/2023] [Indexed: 06/19/2023]
Abstract
BACKGROUND The effect of immediate implant and autologous breast reconstruction on complication rates has been studied extensively; however, the patient-reported outcomes for these procedures during immediate, one-stage reconstruction has yet to be comprehensively investigated. OBJECTIVE This study compared the patient-reported outcomes for immediate implant reconstruction with those associated with immediate autologous reconstruction to determine the advantages and disadvantages for each modality from the patient's perspective. METHODS A literature search of PubMed between 2010 and 2021 was performed, and 21 studies containing patient-reported outcomes were selected for the analysis. A meta-analysis of patient-reported outcome scores was performed separately for immediate breast reconstruction using autologous tissue transfer and synthetic implants. RESULTS Nineteen manuscripts were included, representing data on a total of 1342 patients across all studies. The pooled mean of patients' satisfaction with their breasts was 70.7 (95% CI, 69.4-72.0) after immediate autologous reconstruction and 68.5 (95% CI, 67.1-69.9) after immediate implant reconstruction, showing a statistically significant difference in outcomes (p < 0.05). The pooled mean of patients' sexual well-being was 59.3 (95% CI, 57.8-60.8) after immediate autologous reconstruction and 62.8 (95% CI, 60.7-64.8) after immediate implant reconstruction (p < 0.01). The pooled mean of patients' satisfaction with their outcome was 78.8 (95% CI, 76.2-81.3) after immediate autologous reconstruction and 82.3 (95% CI, 80.4-84.1) after immediate implant reconstruction (p < 0.05). The results of each meta-analysis were summarized on forest plots depicting the distribution of patient-reported outcome scores from each study. CONCLUSIONS Immediate reconstruction with implants may have a similar or greater capacity to achieve patient satisfaction and improve patients' QoL compared to those associated with immediate reconstruction with autologous tissue transfer when both procedures are available.
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Affiliation(s)
- Orr Shauly
- Emory University School of Medicine, Division of Plastic and Reconstructive Surgery, GA, United States
| | - Blade Olson
- University of Southern California, Keck School of Medicine, Division of Plastic and Reconstructive Surgery, CA, United States
| | - Troy Marxen
- Emory University School of Medicine, Division of Plastic and Reconstructive Surgery, GA, United States.
| | - Ambika Menon
- Emory University School of Medicine, Division of Plastic and Reconstructive Surgery, GA, United States
| | - Albert Losken
- Emory University School of Medicine, Division of Plastic and Reconstructive Surgery, GA, United States
| | - Ketan M Patel
- University of Southern California, Keck School of Medicine, Division of Plastic and Reconstructive Surgery, CA, United States
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Faulkner HR, Merceron T, Wang J, Losken A. Safe Reproducible Breast Reduction. Plast Reconstr Surg Glob Open 2023; 11:e5245. [PMID: 38152713 PMCID: PMC10752459 DOI: 10.1097/gox.0000000000005245] [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] [Received: 10/20/2022] [Accepted: 07/14/2023] [Indexed: 12/29/2023]
Abstract
Breast reduction is a common operation performed by plastic surgeons. Patients can have significant improvement in physical symptoms in addition to increased self-esteem, body image, and quality of life as a result. The authors describe common techniques for breast reduction and provide representative photographs and videos of these techniques. An evidence-based review is provided for patient selection criteria, common surgical techniques, and methods to avoid and treat complications. Information is also provided on patient education about breast reduction. In most cases, breast reduction is safe to perform in the outpatient setting. The Wise pattern and vertical pattern are among the most common techniques for skin incisions, and the inferior and superomedial pedicles are two of the most common pedicles used in breast reduction. Enhanced Recovery After Surgery protocols are helpful to effectively control pain and reduce narcotic use postoperatively. Patient satisfaction after breast reduction surgery is typically high. Multiple techniques are available to successfully perform breast reduction. The plastic surgeon needs to select patients carefully and determine the appropriate technique to use. Patient education about the operation, recovery, expected result, and risks is an important component of achieving an optimal result.
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Affiliation(s)
| | - Tyler Merceron
- From the Emory University Division of Plastic Surgery, Atlanta, Ga
| | | | - Albert Losken
- From the Emory University Division of Plastic Surgery, Atlanta, Ga
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13
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Kebede SN, Martin MS, Baker NF, Saad OA, Losken A. Beyond Physical Well-being: Exploring Demographic Variances in Psychosocial Well-being before Breast Reconstruction. Plast Reconstr Surg Glob Open 2023; 11:e5124. [PMID: 37465281 PMCID: PMC10351932 DOI: 10.1097/gox.0000000000005124] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 06/01/2023] [Indexed: 07/20/2023]
Abstract
A patient's preoperative satisfaction with their breasts and baseline psychosocial, sexual, and physical well-being are important considerations when planning breast reconstruction. We sought to elucidate variances in preoperative responses among patients undergoing postmastectomy breast reconstruction. Methods Preoperative BREAST-Q responses and demographic data, including race, generation, median household incomeinstitutional review board and body mass index (BMI) were collected from breast cancer patients scheduled for mastectomy. Associations between demographic group and survey response were analyzed by chi-square or independent t-tests. Results In total, 646 of 826 patients identified had complete data and were included in the final analysis. Patients in BMI group 1 (16-24.9) were more likely to report feeling "very satisfied" with how they looked unclothed compared with patients in other BMI groups (P = 0.031). Conversely, patients in groups 3 and 4 (35+), reported lower satisfaction (P = 0.037) and felt less attractive without clothes (P = 0.034). Asian women were less likely to feel attractive (P = 0.007), and Black patients were less likely to feel of equal worth to other women (P < 0.001). Finally, patients were less likely to report confidence in social settings if they were Black (P < 0.001), Asian (P < 0.001), from the millennial generation (P = 0.017), or living in zip codes with median household income less than $55,000 (P = 0.042). Conclusions Breast cancer patients' feelings toward their natural breasts vary widely between demographic groups. Understanding baseline psychosocial factors in this population is key to informing preoperative discussions and interpreting postoperative satisfaction.
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Affiliation(s)
- Sara N. Kebede
- From the Emory University Division of Plastic and Reconstructive Surgery, Atlanta, Ga
| | | | - Nusaiba F. Baker
- University of San Francisco Division of Plastic and Reconstructive Surgery, San Francisco, Calif
| | - Omar A. Saad
- From the Emory University Division of Plastic and Reconstructive Surgery, Atlanta, Ga
| | - Albert Losken
- From the Emory University Division of Plastic and Reconstructive Surgery, Atlanta, Ga
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Danko D, Ash ME, Brown OH, Losken A, Thompson PW. Implant-Based Breast Reconstruction in the Elderly: Complications and Patient-Reported Outcomes in Women Older Than 70 Years. Ann Plast Surg 2023; 91:55-61. [PMID: 37450861 DOI: 10.1097/sap.0000000000003615] [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: 07/18/2023]
Abstract
BACKGROUND Advanced age is considered by many to be a relative contraindication to breast reconstruction. However, despite increased medical comorbidities and a perception that elderly patients are less concerned with body image, more women older than 70 years are choosing to undergo breast reconstruction. There is a paucity of data to guide reconstructive decision-making and counseling in this population. OBJECTIVES The aim of this study was to evaluate patient satisfaction, complication rates, and long-term outcomes in women older than 70 years undergoing implant-based breast reconstruction. METHODS A total of 400 patients were identified at the authors' institution and divided into 2 groups: ≥70 and <70 years old. Medical comorbidities, surgical outcomes, and patient-reported outcomes as defined by the BREAST-Q were compared using the χ2 tests for categorical variables and t tests for continuous variables. RESULTS The cohort of patients older than 70 years was made up of 25 women, with a mean age of 73 years, and the cohort of patients younger than 70 years was made up of 375 women, with a mean age of 50 years. There was no significant difference in body mass index (P = 0.373), smoking status (P = 0.360), or history of prior ipsilateral radiation (P = 0.508) between the 2 cohorts; however, the elderly cohort was significantly more likely to have diabetes (P = 0.026). Although elderly patients were less likely to undergo bilateral mastectomy (P < 0.001), there was no significant difference in the type of mastectomy, pathological diagnosis, or method of reconstruction. There was no significant difference in complication rates when looking at minor infection (P = 0.553) or major infection (P = 0.553). The 2 groups were equally likely to undergo secondary procedures (P = 0.192). Overall satisfaction rates were high in all BREAST-Q categories in the elderly group and not significantly different when compared with the group of patients younger than 70 years. Matched-pair analysis showed a significant difference with the group of patients older than 70 years having higher levels physical well-being (P < 0.001). CONCLUSIONS Immediate breast reconstruction can be performed safely and with similar high satisfaction rates in the elderly population as their younger counterparts. Age alone should not be used as a reason for excluding women from these life-changing operations.
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Affiliation(s)
| | | | - Owen H Brown
- Department of Plastic and Reconstructive Surgery, Emory University, Atlanta, GA
| | - Albert Losken
- Department of Plastic and Reconstructive Surgery, Emory University, Atlanta, GA
| | - Peter W Thompson
- Department of Plastic and Reconstructive Surgery, Emory University, Atlanta, GA
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15
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Marxen T, Su S, Brown C, Faulkner HR, Losken A. Preoperative Glucose Predicts Postoperative Complications After Complex Abdominal Wall Reconstruction. Ann Plast Surg 2023; 91:124-128. [PMID: 37450870 DOI: 10.1097/sap.0000000000003618] [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: 07/18/2023]
Abstract
BACKGROUND Despite advances in surgical methods, complication rates after complex abdominal wall reconstruction (CAWR) remain high. Identification of preoperative risk factors can assist surgeons with risk stratification and patient counseling. The deleterious effects of hyperglycemia on wound healing are well established. With the increasing prevalence of diabetes (diabetes mellitus) and prediabetes, a greater proportion of patients are likely to have increased blood glucose levels that may contribute to poor surgical outcomes. The primary aim of this study was to determine whether preoperative hyperglycemia predicted surgical outcome. The secondary aim was to establish glucose thresholds to assist with surgical risk stratification. METHODS All patients who underwent CAWR by the senior author at a single institution from 2002 to 2021 were retrospectively reviewed. Patients were stratified into 4 groups based on preoperative blood glucose: <100 mg/dL (n = 184), 100-140 mg/dL (n = 207), 140-180 mg/dL (n = 41), and >180 mg/dL (n = 16). Patient demographics, risk factors, surgical techniques, complications, and outcomes were recorded and compared. RESULTS The study cohort comprised of 478 patients. Mean age was 53.9 ± 12.3 years. Mean body mass index was 32.1 ± 7.8 kg/m2. Higher age (P = 0.0085), higher body mass index (P = 0.0005), the presence of diabetes (P < 0.0001), and hypertension (P = 0.0004) were significantly associated with higher glucose. Overall complication rates ranged from 26% (glucose <100 mg/dL) to 94% (glucose >180 mg/dL), whereas recurrence rates ranged from 10% (glucose <100 mg/dL) to 37% (glucose 140-180 mg/dL). Multivariate logistic regression analysis revealed preoperative glucose to have a significant, independent effect on overall complication rate (P < 0.0001), major complication rate (P < 0.0001), and recurrence rate (P < 0.0031). CONCLUSIONS Preoperative hyperglycemia is an important predictor of postoperative complications and recurrence after CAWR. Point-of-care glucose levels are routinely gathered before surgery and may help to establish thresholds for which elective CAWR might be deferred. Strategies to lower preoperative glucose should be part of an optimization protocol for improving outcomes.
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Affiliation(s)
- Troy Marxen
- From the Emory University School of Medicine
| | - Shannon Su
- From the Emory University School of Medicine
| | - Ciara Brown
- Division of Plastic and Reconstructive Surgery, Emory University School of Medicine, Atlanta, GA
| | - Heather R Faulkner
- Division of Plastic and Reconstructive Surgery, Emory University School of Medicine, Atlanta, GA
| | - Albert Losken
- Division of Plastic and Reconstructive Surgery, Emory University School of Medicine, Atlanta, GA
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Jones HE, Cruz C, Stewart C, Losken A. Decision Regret in Plastic Surgery: A Summary. Plast Reconstr Surg Glob Open 2023; 11:e5098. [PMID: 37383479 PMCID: PMC10299769 DOI: 10.1097/gox.0000000000005098] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 05/10/2023] [Indexed: 06/30/2023]
Abstract
Patient decision regret can occur following elective healthcare decisions. The current era is focused on patient-reported outcomes, and decision regret is another metric by which surgeons can and should measure postoperative results. Patients who experience decision regret after elective procedures can often blame themselves, the surgeon, or the clinical practice, and this can lead to downstream psychological and economic consequences for all parties involved. Methods A literature search was conducted on PubMed using the following search terms: (aesthetic surgery) AND (decision regret), (rhinoplasty) AND (decision regret), (face-lift) AND (decision regret), (abdominoplasty) AND (decision regret), (breast augmentation) AND (decision regret), (breast reconstruction) AND (decision regret), (FACE-Q) AND (rhinoplasty), (BREAST-Q) AND (breast augmentation). The following article types were included in the search: randomized controlled trials, meta-analysis, and systematic reviews. Results After review of the literature, preoperative education, decisional tools, and postoperative complications were found to be the most important factors affecting decision regret after surgery. Conclusions A better understanding of the factors associated with decision regret can help surgeons provide more effective preoperative counseling and prevent postoperative decision regret. Plastic surgeons can use these tools within a context of shared decision-making and ultimately increase patient satisfaction. Decision regret for plastic surgical procedures was mainly in the context of breast reconstruction. The differences in medical necessity create unique psychological challenges, emphasizing the need for more studies and a better understanding of the topic for other elective and cosmetic surgery procedures.
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Affiliation(s)
| | - Claudia Cruz
- Department of Surgery, Florida State University College of Medicine, Tallahassee, Fla
| | | | - Albert Losken
- Department of Surgery, Florida State University College of Medicine, Tallahassee, Fla
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Losken A. Annals of Plastic Surgery: Introduction to the SESPRS Supplement. Ann Plast Surg 2023; 90:S325. [PMID: 37332206 DOI: 10.1097/sap.0000000000003631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/20/2023]
Affiliation(s)
- Albert Losken
- From the Emory Division of Plastic and Reconstructive Surgery, Atlanta, GA
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18
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Om A, Marxen T, Kebede S, Losken A. The Usage of Intravenous Tranexamic Acid in Reduction Mammaplasty Safely Reduces Hematoma Rates. Ann Plast Surg 2023; 90:S371-S374. [PMID: 36729851 PMCID: PMC10578999 DOI: 10.1097/sap.0000000000003296] [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] [Indexed: 02/03/2023]
Abstract
BACKGROUND Bleeding complications are not uncommon after breast reduction surgery, and recently, tranexamic acid (TXA) as an antifibrinolytic agent has been used in various surgical specialties as a way to minimizes such adverse outcomes. We elected to evaluate the effectiveness of intravenous (IV) intraoperative TXA in reduction mammoplasty patients. METHODS This is a retrospective chart review of clinical charts of all patients who received reduction mammoplasty by a single surgeon at Emory University Hospital or its affiliated Aesthetic Center from January 1, 2020, to March 1, 2022. Seventy-four consecutive breast reduction patients received 1-g IV TXA intraoperatively compared with 117 consecutive controls. The outcome of interest included 30-day postoperative bleeding complications. RESULTS There was no significant difference in age ( P = 0.92), body mass index ( P = 0.98), percentage of smokers ( P = 0.56), operating time ( P = 0.87), estimated blood loss ( P = 0.90), or weight removed ( P = 0.98) between patients in each arm. There were 19 bleeding events (16.2%) in the non-TXA arm compared with 1 bleeding event (1.4%) in the TXA arm ( P = 0.0143). Of the 19, 6 (5.1%) were major events, and 13 were minor events (11.1%); the only bleeding event in the TXA arm was minor. Number needed to treat all bleeding events with use of TXA was 7, and the number needed to treat minor hematomas was 11. There was no significant difference in the rate of seroma, wound healing complications, infection, or nipple necrosis between the 2 arms ( P > 0.05). CONCLUSIONS The use of IV TXA is a safe and effective way to reduce hematoma rates in patients receiving reduction mammoplasty.
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Affiliation(s)
- Anjali Om
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Emory University, Atlanta, GA
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Marxen T, Chan P, Baker N, Godette KD, Styblo TM, Carlson GW, Losken A. Time to Radiation after Oncoplastic Reduction versus After Lumpectomy. Plast Reconstr Surg Glob Open 2023; 11:e4970. [PMID: 37180986 PMCID: PMC10171717 DOI: 10.1097/gox.0000000000004970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 03/03/2023] [Indexed: 05/16/2023]
Abstract
Prior studies contrasting oncoplastic reduction (OCR) to traditional lumpectomy have validated oncoplastic reduction surgery with similar survival and oncological outcomes. The purpose of this study was to evaluate if there was a significant difference in the time to initiation of radiation therapy after OCR in comparison with the standard breast-conserving therapy (lumpectomy). Methods The patients included were from a database of breast cancer patients who all underwent postoperative adjuvant radiation after either OCR or lumpectomy at a single institution between 2003 and 2020. Patients who experienced delays in radiation for nonsurgical reasons were excluded. Comparisons were made between the groups in the time to radiation and complication rates. Results A total of 487 patients underwent breast-conserving therapy, with 220 having undergone OCR and 267 lumpectomy patients. There was no significant difference in days to radiation between patient cohorts (60.5 OCR, 56.2 lumpectomy, P = 0.059). There was a significant difference in the number of complications between OCR and lumpectomy patients (20.4% OCR, 2.2% lumpectomy, P < 0.001). However, of patients who had complications, there was no significant difference in the number of days to radiation (74.3 OCR, 69.3 lumpectomy, P = 0.732). Conclusions Compared with lumpectomy, OCR was not associated with an increased time to radiation but was associated with higher complications. Statistical analysis did not reveal surgical technique or complications to be independent, significant predictors of increased time to radiation. Surgeons should be aware that although complications may remain higher in OCR, this does not necessarily translate to delays in radiation.
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Affiliation(s)
- Troy Marxen
- From the Emory University School of Medicine, Atlanta, Ga
| | - Patricia Chan
- From the Emory University School of Medicine, Atlanta, Ga
| | - Nusaiba Baker
- From the Emory University School of Medicine, Atlanta, Ga
| | | | | | - Grant W Carlson
- Emory Division of Plastic and Reconstructive Surgery, Atlanta, Ga
| | - Albert Losken
- Emory Division of Plastic and Reconstructive Surgery, Atlanta, Ga
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Faulkner HR, Losken A. Modern Approaches to Oncoplastic Surgical Treatment. Clin Plast Surg 2023; 50:211-221. [PMID: 36813399 DOI: 10.1016/j.cps.2022.10.005] [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] [Indexed: 01/04/2023]
Abstract
Partial breast reconstruction using oncoplastic techniques is performed at the time of lumpectomy and includes volume replacement techniques such as flaps and volume displacement techniques such as reduction and mastopexy. These techniques are used to preserve breast shape, contour, size, symmetry, inframammary fold position, and position of the nipple-areolar complex. Newer techniques such as auto-augmentation flaps and perforator flaps continue to broaden options and newer radiation therapy protocols will hopefully reduce side effects. Options for the oncoplastic approach now include higher risk patients as there is a larger repository of data on the safety and efficacy of this technique.
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Affiliation(s)
- Heather R Faulkner
- Emory Division of Plastic and Reconstructive Surgery, 550 Peachtree Street Northeast, Suite 9000, Atlanta GA 30308, USA
| | - Albert Losken
- Emory Division of Plastic and Reconstructive Surgery, 550 Peachtree Street Northeast, Suite 9000, Atlanta GA 30308, USA.
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21
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Abstract
The purpose of this summary is to outline the available research on the psychological factors associated with aesthetic surgery. Aesthetic procedures such as abdominoplasty, breast augmentation, face lift, and rhinoplasty are shown to have unique preoperative and postoperative psychological factors. Depression and anxiety may occur after aesthetic procedures with an increased incidence in patients with certain depression prone personality traits. The pre-existing psychology of patients is also an important contributing factor to consider when evaluating surgical candidates. Pre-existing mood disorders such as depression and anxiety are shown with higher incidence in individuals pursuing aesthetic procedures and can predispose such individuals to worsening mood symptoms postoperatively. This article aims to equip surgeons with a better understanding of the common psychological factors seen in the field of aesthetic surgery, so patients can be better supported throughout all parts of the surgical process. Level of Evidence Therapeutic 5
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Affiliation(s)
- Hannah Elizabeth Jones
- Medical student, Emory University School of Medicine, Atlanta, GA, USA,Surgeons, Division of Plastic and Reconstructive Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | | | - Albert Losken
- Corresponding Author: Dr Albert Losken, 550 Peachtree Street NE, Suite 9000, Atlanta, GA 30308, USA. E-mail:
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22
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Marxen T, Shauly O, Losken A. The Safety of Same-day Discharge after Immediate Alloplastic Breast Reconstruction: A Systematic Review. Plastic and Reconstructive Surgery - Global Open 2022; 10:e4448. [PMID: 35924002 PMCID: PMC9298472 DOI: 10.1097/gox.0000000000004448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Accepted: 06/02/2022] [Indexed: 11/25/2022]
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Abstract
BACKGROUND Minority patients and those from low socioeconomic backgrounds are faced with barriers to care regarding breast reconstruction. With this study, we seek to elucidate variances in demographics to determine predictors of complications in implant-based breast reconstruction. METHODS Patients who underwent breast reconstruction with either direct to implant or immediate expander reconstruction by 1 surgeon were identified using the preoperative Breast-Q.Current income statistics available from the US Census Bureau by self-reported zip code were used to determine the median household income (MHI) to stratify differing socioeconomic backgrounds. Demographics were compared with body mass index, comorbidities, overall rate of postoperative complications, rate of implant infection, and type of reconstruction. RESULTS Two hundred ninety-five patients met inclusion criteria. Overall rate of complications and rate of breast implant infection was higher for MHI of less than $50,000 compared with greater than $50,000 (P = 0.043 overall complications 40.20% vs 28.8%) (P = 0.04 implant infection 14.4% vs 7.1%). African American patients had higher body mass index (P = <0.001), rates of HTN (P = <0.001), and diabetes (P = 0.001), and were more likely to have a lower income (P = <0.001). There was, however, no difference in overall complications (P = 0.26), implant infection rate (P = 0.994), or capsular contracture (0.367) based on race. There was no difference in rate of comorbidities between low and high socioeconomic areas. CONCLUSION This cohort demonstrates a higher rate of overall complications and infection in patients with a lower MHI and no difference based on race despite having higher risk factors for complications.Socioeconomic status is a multifaceted barrier to care that must be addressed in the perioperative period to decrease breast implant associated complications.
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Affiliation(s)
- Morgan S Martin
- From the Division of Plastic Surgery, Emory University, Atlanta, GA
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24
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Moriarty HK, Baker NF, Hart AM, Carlson GW, Losken A. Drain Removal Time in Pre-pectoral versus Dual Plane Prosthetic Breast Reconstruction following Nipple-sparing Mastectomy. Plast Reconstr Surg Glob Open 2022; 10:e4295. [PMID: 35620500 PMCID: PMC9126519 DOI: 10.1097/gox.0000000000004295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Accepted: 03/08/2022] [Indexed: 06/15/2023]
Abstract
Pre-pectoral prosthetic breast reconstruction following nipple-sparing mastectomy (NSM) has become a popular approach compared with the dual plane technique. Our objective was to determine if there was a difference in time to postoperative breast drain removal in direct-to-implant or tissue expander reconstruction following NSM when comparing pre-pectoral with dual plane technique. Methods A total of 200 patients (335 breasts) received NSM followed by implant or expander reconstruction at our institution between the years 2009 and 2020. Direct-to-implant reconstruction had 113 pre-pectoral versus 67 dual plane, and tissue expander reconstruction had six pre-pectoral versus 149 dual plane. Our analysis included age at mastectomy, body mass index, history of preoperative breast radiation, and smoking history. Case complications included seroma or hematoma, breast or axillary infection requiring antibiotics or operative washout, device replacement due to extrusion or infection, skin necrosis, and capsular contracture. Statistical analysis was completed with Pearson chi-square test, Fisher exact test, and the two-sample T-test using IBM SPSS Statistics 24.0 (IBM Corp., Armonk, N.Y.). Results The average time until breast drain removal in dual plane implant patients was significantly less than in pre-pectoral implant patients (9.42 versus 14.01 days). The average time until breast drain removal in dual plane expander patients was significantly less than in pre-pectoral expander patients (11.47 versus 20.30 days). Conclusion In both implant and expander reconstruction following NSM, patients receiving dual plane device placement had a shorter postoperative time until breast drain removal when compared with patients receiving pre-pectoral device placement.
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Affiliation(s)
- Hannah K. Moriarty
- From the Division of Plastic and Reconstructive Surgery, Emory University School of Medicine, Atlanta, Ga
| | - Nusaiba F. Baker
- From the Division of Plastic and Reconstructive Surgery, Emory University School of Medicine, Atlanta, Ga
| | - Alexandra M. Hart
- From the Division of Plastic and Reconstructive Surgery, Emory University School of Medicine, Atlanta, Ga
| | - Grant W. Carlson
- From the Division of Plastic and Reconstructive Surgery, Emory University School of Medicine, Atlanta, Ga
| | - Albert Losken
- From the Division of Plastic and Reconstructive Surgery, Emory University School of Medicine, Atlanta, Ga
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Abstract
PURPOSE The oncoplastic reduction approach is a popular option for women with breast cancer and macromastia. Although the benefits of this approach are numerous, data on the need for secondary surgeries are limited. We evaluated the need for all secondary surgeries after oncoplastic reduction in an attempt to understand the incidence and indications. METHODS All patients with breast cancer who underwent an oncoplastic breast reduction at the time of the tumor resection were queried from a prospectively maintained database from 1998 to 2020 (n = 547) at a single institution. Secondary surgical procedures were defined as any unplanned return to the operating room. Demographic and clinical variables were analyzed, and secondary surgeries were classified and evaluated. The timing and rates of secondary surgery were evaluated and compared with clinical variables. RESULTS There were 547 patients included in this series with a mean age of 55 years and body mass index of 33.5. Mean duration of follow-up was 3.8 years. One hundred and seventeen (21%) patients underwent 235 secondary surgeries, with an average of 1.4 operations until stable reconstruction was obtained. The reason for the secondary surgery was involved margins (7.5%), major complications (8.6%), aesthetic improvement (13.3%), and completion mastectomy (5.3%). Age 65 years and younger age was associated with any subsequent procedure (P = 0.023) and revision for cosmesis (P = 0.006). Patients with body mass index greater than 35 had increased secondary surgeries for operative complications (P = 0.026). CONCLUSIONS Secondary surgeries after oncoplastic breast reduction procedures are common. Management of margins and complications, such as hematoma and infection, are early indications, with aesthetic improvement, wound healing complications, fat necrosis, and recurrence being late reasons. The most common reason for reoperation is aesthetic improvement, especially in younger patients. Attention to surgical technique and patient selection will help minimize secondary surgeries for the nononcological reasons.
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Affiliation(s)
- Ciara A Brown
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Emory University
| | | | | | - Grant W Carlson
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Emory University
| | - Albert Losken
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Emory University
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Abstract
BACKGROUND TikTok is one of the most popular and fastest-growing social media apps in the world. Previous studies have analyzed the quality of patient education information on older video platforms, but the quality of plastic and cosmetic surgery videos on TikTok has not yet been determined. OBJECTIVES The aim of this study was to analyze the source and quality of certain cosmetic procedure videos on TikTok. METHODS The TikTok mobile application was queried for content related to 2 popular face procedures (rhinoplasty and blepharoplasty) and 2 body procedures (breast augmentation and abdominoplasty). Two independent reviewers analyzed video content according to the DISCERN scale, a validated, objective instrument that assesses the quality of information on a scale of 1 to 5. Quality scores were compared between videos produced by medical and nonmedical creators and between different content categories. RESULTS The included videos attracted 4.8 billion views and 76.2 million likes. Videos were created by medical doctors (56%) and laypersons (44%). The overall average DISCERN score out of 5 corresponded to very poor video quality for rhinoplasty (1.55), blepharoplasty (1.44), breast augmentation (1.25), and abdominoplasty (1.29). DISCERN scores were significantly higher among videos produced by doctors than by laypersons for all surgeries. Comedy videos consistently had the lowest average DISCERN scores, whereas educational videos had the highest. CONCLUSIONS It is increasingly important that medical professionals understand the possibility of patient misinformation in the age of social media. We encourage medical providers to be involved in creating quality information on TikTok and educate patients about misinformation to best support health literacy.
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Affiliation(s)
- Anjali Om
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Bobby Ijeoma
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Sara Kebede
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Albert Losken
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
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Abstract
OBJECTIVE The objective of this study was to evaluate long-term outcomes and weight loss after panniculectomy. METHODS A retrospective chart review study was performed on 225 consecutive patients who had undergone panniculectomy from 2002 and 2020. Demographic variables including smoking status, medical comorbidities, and prior history of weight loss/bariatric surgery were collected for 173 patients. Preoperative and postoperative body mass index (BMI) were calculated in addition to postoperative outcomes. RESULTS The study population was 85% female with a mean age of 57 years and an average follow-up of 3.9 years. Relevant comorbidities included obesity (88%), hypertension (65%), diabetes (37%), and smoking (8%), and the majority (53%) of patients had undergone prior bariatric surgery. The overall complication rate was 40%. Twenty percent of patients required reoperation or readmission, and 20% had minor complications addressed in an outpatient setting. Patients who had higher preoperative BMI experienced a significant long-term reduction in BMI. In addition, patients who did not undergo prior bariatric surgery tended to lose weight more often and by larger amounts than patients who had prior bariatric surgery (71.6% vs 57.6, P = 0.023). Complications were not uncommon and included infection (17%), delayed wound healing (16%), seroma (8%), and hematoma (3%). Patients who had prior bariatric surgery were at reduced risk of any complication (P = 0.012). Smoking increased the incidence of infection (38.5% of smokers vs 15.6% of nonsmokers, P = 0.039). Concomitant hernia repair increased the risk of overall complications (64.3% vs 35.9%, P = 0.003) and delayed wound healing (39.2% vs 11.7%, P < 0.001). In the subgroup of patients who did not lose weight, a panniculus weight greater than 5 kg was associated with an increased complication rate (61.5% vs 27%, P = 0.03). CONCLUSIONS Patients who underwent a panniculectomy tended to lose weight postoperatively, particularly those who had not undergone previous bariatric surgery. Complications were not uncommon, especially in patients with a smoking history. Prior bariatric surgery patients had a significant decrease in postoperative complications but tended to lose less weight after panniculectomy than those without prior bariatric surgery. Concomitant hernia repair put patients at an increased risk of complications.
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Affiliation(s)
- Christopher M Stewart
- From the Division of Plastic and Reconstructive Surgery, Emory University, Atlanta, GA
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Brown CA, Losken A. Commentary on: The "Hug Flap": Surgical Technique Refinement For Enhanced Aesthetic Breast Projection in Autologous Breast Reconstruction. Aesthet Surg J 2021; 41:NP1471-NP1472. [PMID: 33674878 DOI: 10.1093/asj/sjab009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Ciara A Brown
- Emory Division of Plastic and Reconstructive Surgery, Atlanta, GA, USA
| | - Albert Losken
- Emory Division of Plastic and Reconstructive Surgery, Atlanta, GA, USA
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Abstract
BACKGROUND Aesthetic and reconstructive implant-based breast surgeries are some of the most frequently performed procedures by plastic surgeons. As such, prevention of implant infection is of high importance. However, there remains no criterion-standard protocol for irrigation of the breast pocket. This review focuses on current irrigation practices in implant-based breast surgery. METHODS Four databases were used to search for all studies, including randomized controlled trials, retrospective cohort, and prospective cohort, containing original data related to the outcomes investigated in this study. Search terms included "breast," "irrigation," and "infection" in different combinations to isolate studies that focused on irrigation methods in both reconstructive and augmentation surgeries. Our selection criteria specifically concentrated on those studies that explicitly related irrigation procedures to rates of clinical infection and/or capsular contracture. Each was compiled into a table in chronological order to make comparisons between the differing irrigation methods. RESULTS Our search returned 239 full-text articles eligible for our review. Two independent screeners identified 9 studies that met the inclusion criteria. This included 1 prospective study and 8 retrospective studies. Two studies reported the use of chlorhexidine gluconate irrigation resulting in protection from clinical infection. Two studies investigated the role of triple antibiotic solution (TAS) either alone or combined with something else on risk of infection, and 3 reported TAS use on rates of capsular contracture. Two additional studies investigated the role of single antibiotic irrigation, concluding that some antibiotic regimen for irrigation may be sufficient in the breast pocket. Interestingly, one study noted the potential use of povidone-iodine (Betadine) as a method of irrigation. CONCLUSIONS These data suggest that chlorhexidine gluconate, Betadine, and TAS irrigation of the breast pocket can provide protection against infection and implant loss in both reconstruction and augmentation surgeries.
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Affiliation(s)
| | | | | | - Albert Losken
- Division of Plastic Surgery, Emory University, Atlanta, GA
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30
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Jonczyk MM, Fisher CS, Babbitt R, Paulus JK, Freund KM, Czerniecki B, Margenthaler JA, Losken A, Chatterjee A. Surgical Predictive Model for Breast Cancer Patients Assessing Acute Postoperative Complications: The Breast Cancer Surgery Risk Calculator. Ann Surg Oncol 2021; 28:5121-5131. [PMID: 33616770 DOI: 10.1245/s10434-021-09710-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 01/26/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Prognostic tools, such as risk calculators, improve the patient-physician informed decision-making process. These tools are limited for breast cancer patients when assessing surgical complication risk preoperatively. OBJECTIVE In this study, we aimed to assess predictors associated with acute postoperative complications for breast cancer patients and then develop a predictive model that calculates a complication probability using patient risk factors. METHODS We performed a retrospective cohort study using the National Surgical Quality Improvement Program (NSQIP) database from 2005 to 2017. Women diagnosed with ductal carcinoma in situ or invasive breast cancer who underwent either breast conservation or mastectomy procedures were included in this predictive modeling scheme. Four models were built using logistic regression methods to predict the following composite outcomes: overall, infectious, hematologic, and internal organ complications. Model performance, accuracy and calibration measures during internal/external validation included area under the curve, Brier score, and Hosmer-Lemeshow statistic, respectively. RESULTS A total of 163,613 women met the inclusion criteria. The area under the curve for each model was as follows: overall, 0.70; infectious, 0.67; hematologic, 0.84; and internal organ, 0.74. Brier scores were all between 0.04 and 0.003. Model calibration using the Hosmer-Lemeshow statistic found all p-values to be > 0.05. Using model coefficients, individualized risk can be calculated on the web-based Breast Cancer Surgery Risk Calculator (BCSRc) platform ( www.breastcalc.org ). CONCLUSION We developed an internally and externally validated risk calculator that estimates a breast cancer patient's unique risk of acute complications following each surgical intervention. Preoperative use of the BCSRc can potentially help stratify patients with an increased complication risk and improve expectations during the decision-making process.
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Affiliation(s)
- Michael M Jonczyk
- Department of Surgery, Tufts Medical Center, Boston, MA, USA. .,Clinical and Translational Science Graduate Program, Tufts University's Graduate School of Biomedical Sciences, Boston, MA, USA.
| | - Carla Suzanne Fisher
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Russell Babbitt
- Plastic Surgery of Southern New England, PC, Fall River, MA, USA
| | - Jessica K Paulus
- Department of Medicine and Institute for Clinical Research and Health Policy Studies (ICRHPS), Tufts Medical Center/Tufts University School of Medicine, Boston, MA, USA
| | - Karen M Freund
- Department of Medicine and Institute for Clinical Research and Health Policy Studies (ICRHPS), Tufts Medical Center/Tufts University School of Medicine, Boston, MA, USA
| | - Brian Czerniecki
- Department of Breast Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Julie A Margenthaler
- Department of Surgery, Washington University School of Medicine, St Louis, MO, USA
| | - Albert Losken
- Division of Plastic and Reconstructive Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Abhishek Chatterjee
- Clinical and Translational Science Graduate Program, Tufts University's Graduate School of Biomedical Sciences, Boston, MA, USA
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31
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Abstract
BACKGROUND The internet and social media are sources of information regarding breast reconstruction, which can educate and influence patients. OBJECTIVES This study aimed to evaluate internet and social media usage by breast reconstruction patients and its impact on patients. METHODS Eighty-six breast reconstruction patients over a 7-month period answered an anonymous survey, which queried demographics, reconstruction type, internet usage, social media usage, expectations, and impact on decisions. Fisher's exact test was performed to evaluate the use of social media. RESULTS Overall, 95% of patients used the internet for breast reconstruction information. The information was found to be easy to understand by 70% of patients, helpful by 76%, and trustworthy by 60%. The information influenced decisions regarding procedure by 23% of patients, regarding surgeon by 23%, and regarding hospital by 22%. Social media was used by 71% of the patients; 62% of patients found it easy to understand, 57% found it helpful, and 48% found it trustworthy. The information influenced decisions regarding procedure by 16% of patients, regarding surgeon by 11%, and regarding hospital by 10%. Twenty-six percent of women expected their final breast reconstruction to look better than their premastectomy breasts, 55% as good or similar, and 12% reported appearance to be unimportant. Women found social media information to be less helpful than internet information. There was no significant association between expectations and social media vs no social media usage. CONCLUSIONS Patients who undergo breast reconstruction use the internet and social media as sources of information. Although the information is generally trusted, it does not seem to heavily influence patient decision-making. Providers remain patients' main source of information, and need to direct patients to high-quality and accessible resources.
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Affiliation(s)
- Jonathan Nguyen
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, GA
| | - Peter Thompson
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, GA
| | - Albert Losken
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, GA
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Abstract
Aesthetic concern is one of the main driving forces behind the popularity of the oncoplastic approach to breast conservation therapy. Oncoplastic options at the time of lumpectomy include volume replacement techniques such as flaps and volume displacement techniques such as the oncoplastic reduction. These techniques can be employed to ensure preservation of breast shape and contour, size and symmetry, inframammary fold position, and position of the nipple-areola complex. The importance of aesthetic outcomes is not only to improve overall patient satisfaction but also to minimize the need for revisional surgeries for shape and symmetry. The purpose of this review is to discuss ways to optimize the aesthetic result and to review the evidence behind aesthetic outcomes.
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Affiliation(s)
- Albert Losken
- Division of Plastic and Reconstructive Surgery, Emory University School of Medicine, Atlanta, GA
| | - Ciara A Brown
- Division of Plastic and Reconstructive Surgery, Emory University School of Medicine, Atlanta, GA
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33
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Baker NF, Baecher KM, Hart AM, Styblo TM, Carlson GW, Losken A. The impact of axillary node surgery on outcomes following immediate breast reconstruction. Breast J 2020; 26:2170-2176. [DOI: 10.1111/tbj.14070] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 09/15/2020] [Accepted: 09/16/2020] [Indexed: 12/15/2022]
Affiliation(s)
- Nusaiba F. Baker
- Emory Division of Plastic and Reconstructive Surgery Atlanta GA USA
| | | | | | | | - Grant W. Carlson
- Emory Division of Plastic and Reconstructive Surgery Atlanta GA USA
| | - Albert Losken
- Emory Division of Plastic and Reconstructive Surgery Atlanta GA USA
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34
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Bloom JA, Asban A, Tian T, Sekigami Y, Losken A, Chatterjee A. A Cost-Utility Analysis Comparing Immediate Oncoplastic Surgery with Delayed Oncoplastic Surgery in Smoking Breast Cancer Patients. Ann Surg Oncol 2020; 28:2579-2588. [PMID: 33051741 DOI: 10.1245/s10434-020-09220-z] [Citation(s) in RCA: 8] [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: 07/13/2020] [Accepted: 09/18/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Oncoplastic reduction mammoplasty for smoking breast cancer patients committed to smoking cessation may be performed immediately (increasing smoking-related risk) or in a delayed fashion (increasing radiation-related risk). OBJECTIVE Our aim was to examine the cost utility of immediate versus delayed oncoplastic reconstruction when operating on a smoking patient with breast cancer and macromastia with a long-term commitment to smoking cessation. METHODS A literature review determined the probabilities and outcomes for the treatment of unilateral breast cancer with immediate or delayed oncoplastic surgery. Reported utility scores were used to estimate quality-adjusted life-years (QALYs) for varying health states. A decision analysis tree was constructed with rollback analysis to highlight the more cost-effective strategy, and an incremental cost-utility ratio (ICUR) was calculated. Sensitivity analyses were performed to validate the robustness of the results. RESULTS Immediate oncoplastic surgery is associated with a higher clinical effectiveness (QALY) of 33.3 compared with delayed oncoplastic surgery (33.26), with a higher increment of clinical effectiveness of 0.07 and relative cost reduction of $3458.11. This resulted in a negative ICUR of -50,194, which favored immediate reconstruction, indicating a dominant strategy. In one-way sensitivity analyses, delayed reconstruction was the more cost-effective strategy if the probability of successful immediate reconstruction falls below 29% or its cost exceeds $29,611. Monte-Carlo analysis showed a confidence of 99% that immediate oncoplastic surgery is more cost effective. CONCLUSIONS Despite the risk of postoperative complications associated with smoking, immediate oncoplastic surgery is more cost effective compared with delayed oncoplastic surgery in which reconstructive surgery would occur after radiation.
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Affiliation(s)
- Joshua A Bloom
- Department of Surgery, Tufts Medical Center, Boston, MA, USA. .,, Melrose, MA, USA.
| | - Ammar Asban
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Tina Tian
- Department of Surgery, Tufts Medical Center, Boston, MA, USA
| | - Yurie Sekigami
- Department of Surgery, Tufts Medical Center, Boston, MA, USA
| | - Albert Losken
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Atlanta, GA, USA
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35
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Bloom JA, Asban AA, Sekigami Y, Tian T, Losken A, Chatterjee A. A Cost-Utility Analysis Comparing Immediate Oncoplastic Surgery to Delayed Oncoplastic Surgery in Smoking Breast Cancer Patients. J Am Coll Surg 2020. [DOI: 10.1016/j.jamcollsurg.2020.07.007] [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: 11/25/2022]
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36
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Jonczyk MM, Suzanne Fisher C, Babbitt R, Paulus JK, Freund KM, Czerniecki BJ, Margenthaler JA, Losken A, Chatterjee A. Surgical Predictive Model for Breast Cancer Patients Assessing Acute Postoperative Complications: The Breast Cancer Surgery Risk Calculator (BCSRc). J Am Coll Surg 2020. [DOI: 10.1016/j.jamcollsurg.2020.07.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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37
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Hart A, Doyle K, Losken A, Carlson GW. Nipple malposition after bilateral nipple-sparing mastectomy with implant-based reconstruction: Objective postoperative analysis utilizing BCCT.core computer software. Breast J 2020; 26:1270-1275. [PMID: 31925847 DOI: 10.1111/tbj.13699] [Citation(s) in RCA: 2] [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: 09/26/2019] [Revised: 11/09/2019] [Accepted: 11/13/2019] [Indexed: 11/28/2022]
Abstract
Nipple-sparing mastectomies (NSMs) are accepted as safe oncologic procedures for select patient populations, but objective evaluation of aesthetic outcomes has not been clearly established. The purpose of this study was to utilize BCCT.core computer software to objectively evaluate NAC malposition following bilateral NSM with implant reconstruction and compare the analysis to an expert panel. Postoperative photographs of 43 patients who underwent bilateral NSM were analyzed with the BCCT.core and by an expert panel of plastic surgery residents and attendings. The panel was asked to only evaluate nipple asymmetry and position. The intraclass correlation coefficient (ICC) was used to determine interrater reliability (n = 12) and between expert panel ratings and BCCT.core ratings. Statistics were performed using SPSS statistical package version 24.0. The ICC for the expert panel interrater reliability was excellent (ICC = 0.941, 95% CI: 0.912-0.964). The analysis between BCCT.core individual parameters, specifically the breast retraction assessment (ie, BRA score = the difference in nipple position between the two breasts assessing breast symmetry) and expert panel, showed statistically significant positive correlation. The parameters provided by the BCCT.core software were correlated with both the mean expert panel rating and BCCT.core ratings. Therefore, it is plausible that BCCT.core parameters could be used to objectively quantify NAC malposition/asymmetry and guide treatment in patients undergoing bilateral NSM with implant reconstruction.
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Affiliation(s)
- Alexandra Hart
- Division of Plastic Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Kathleen Doyle
- Division of Plastic Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Albert Losken
- Division of Plastic Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Grant W Carlson
- Division of Plastic Surgery, Emory University School of Medicine, Atlanta, Georgia
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38
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Abstract
Nipple sparing mastectomy has been popularized in the modern era of breast cancer treatment due to its touted advantages with regard to resultant body image and reconstructive outcome. Implant-based techniques remain the most prevalent means of breast reconstruction. Special considerations regarding patient selection and technique are reviewed for implant reconstruction in the setting of mastectomy with nipple preservation. Applications for prepectoral and direct-to-implant reconstruction are discussed and published outcomes are summarized.
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Affiliation(s)
- Carrie K Chu
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Matthew J Davis
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Amjed Abu-Ghname
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Sebastian J Winocour
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Albert Losken
- Division of Surgical Oncology, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia.,Division of Plastic and Reconstructive Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Grant W Carlson
- Division of Surgical Oncology, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia.,Division of Plastic and Reconstructive Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
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39
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Cohen SM, Sekigami Y, Schwartz T, Losken A, Margenthaler JA, Chatterjee A. Lipofilling after Breast Conserving Surgery: A Comprehensive Literature Review Investigating Its Oncologic Safety. J Am Coll Surg 2019. [DOI: 10.1016/j.jamcollsurg.2019.08.929] [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: 11/16/2022]
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40
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Cohen S, Sekigami Y, Schwartz T, Losken A, Margenthaler J, Chatterjee A. Lipofilling after breast conserving surgery: a comprehensive literature review investigating its oncologic safety. Gland Surg 2019; 8:569-580. [PMID: 31741888 DOI: 10.21037/gs.2019.09.09] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [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: 12/24/2022]
Abstract
Lipofilling has regenerative properties used to improve deformities after breast conserving surgery. Our hypothesis is that there is inadequate data to ensure that lipofilling does not increase locoregional cancer recurrence after breast conserving surgery. A PRISMA comprehensive literature review was conducted of articles published prior to October 2019 investigating recurrence in patients who underwent lipofilling after breast conserving surgery. All forms of breast conserving surgery, fat grafting, and injection intervals were included. Patients undergoing mastectomy were excluded. Requirements to define lipofilling as "safe" included (I) a defined interval between resection and lipofilling; (II) a minimum follow-up period of 6 years from tumor resection; (III) a minimum follow-up period of 3 years from lipofilling; (IV) presence of a control group; (V) controls matched for ER/PR/Her-2; (VI) a sub-group analysis focusing on ER/PR/Her-2; (VII) adequate powering. Nineteen studies met inclusion criteria. The range in time from breast conserving surgery to fat injection was 0-76 months. The average time to follow-up after lipofilling was 23 days-60 months. Two studies had a sufficient follow-up time from both primary resection and from lipofilling. Seventeen of the nineteen studies specified the interval between resection and lipofilling, but there is currently no consensus regarding how soon lipofilling can be performed following BCS. Eight studies performed a subgroup analysis in cases of recurrence and found recurrence after lipofilling was associated with number of positive axillary nodes, intraepithelial neoplasia, high grade histology, Luminal A subtype, age <50, Ki-67 expression, and lipofilling within 3 months of primary resection. Of the eleven studies that included a comparison group, one matched patient for Her-2 and there was a statistically significant difference in Her-2 positive cancers in the study arms of two articles. Several studies deemed lipofilling "safe," two showed association of lipofilling and local recurrence, and most studies concluded that further research was needed. Insufficient and contradictory data exists to demonstrate the safety of lipofilling after breast conserving surgery. A multicentered, well designed study is needed to verify the safety of this practice.
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Affiliation(s)
- Stephanie Cohen
- Division of Plastic Surgery, Division of Surgical Oncology, Department of Surgery, Tufts Medical Center, Boston, MA, USA
| | - Yurie Sekigami
- Division of Plastic Surgery, Division of Surgical Oncology, Department of Surgery, Tufts Medical Center, Boston, MA, USA
| | - Theresa Schwartz
- Division of Surgical Oncology, Department of Surgery, St. Louis University Hospital, St. Louis, MO, USA
| | - Albert Losken
- Division of Plastic Surgery, Department of Surgery, Emory University Hospital, Atlanta, GA, USA
| | - Julie Margenthaler
- Division of Endocrine and Oncologic Surgery, Department of Surgery, Barnes-Jewish Hospital, St. Louis, MO, USA
| | - Abhishek Chatterjee
- Division of Plastic Surgery, Division of Surgical Oncology, Department of Surgery, Tufts Medical Center, Boston, MA, USA
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41
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Merceron TK, Hart AM, Gruszynski MA, Pinell-White XA, Duggal C, Yoo J, Losken A. The Utility of Serum Albumin as a Marker for Risk Stratification in Patients Undergoing Complex Abdominal Wall Reconstruction. Am Surg 2019; 85:e173-e175. [PMID: 30947801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
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42
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Merceron TK, Hart AM, Gruszynski MA, Pinell-White XA, Duggal C, Yoo J, Losken A. The Utility of Serum Albumin as a Marker for Risk Stratification in Patients Undergoing Complex Abdominal Wall Reconstruction. Am Surg 2019. [DOI: 10.1177/000313481908500321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Tyler K. Merceron
- Division of Plastic Surgery Emory University School of Medicine Atlanta, Georgia
| | - Alexandra M. Hart
- Division of Plastic Surgery Emory University School of Medicine Atlanta, Georgia
| | - Mark A. Gruszynski
- Division of Plastic Surgery Emory University School of Medicine Atlanta, Georgia
| | | | - Claire Duggal
- Division of Plastic Surgery Emory University School of Medicine Atlanta, Georgia
| | - Jason Yoo
- Division of Plastic Surgery Emory University School of Medicine Atlanta, Georgia
| | - Albert Losken
- Division of Plastic Surgery Emory University School of Medicine Atlanta, Georgia
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43
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Merceron TK, Betarbet U, Hart A, Baker N, Carlson G, Losken A. Comparison of Complications Following Implant-Based Breast Reconstruction Using Triple Antibiotic Solution versus Low Concentration Chlorhexidine Gluconate Solution. ACTA ACUST UNITED AC 2019. [DOI: 10.4236/mps.2019.94010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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44
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Lovasik BP, Seidel RL, Novello M, Torres MA, Losken A, Rizzo M. Single incision for oncologic breast conserving surgery and sentinel node biopsy in early stage breast cancer: A minimally invasive approach. Breast J 2018; 25:41-46. [PMID: 30511408 DOI: 10.1111/tbj.13158] [Citation(s) in RCA: 4] [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: 08/11/2017] [Revised: 03/29/2018] [Accepted: 04/02/2018] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Breast conserving surgery (BCS) has a postoperative morbidity up to 30%. We report the feasibility of a single-incision approach for tumor excision and axillary sentinel node biopsy (SNB) sampling intended to minimize patient morbidity and complications. MATERIALS AND METHODS A tertiary surgical oncology single surgeon database was retrospectively reviewed for all patients undergoing BCS and SNB between January 2013 and December 2015. The single-incision approach used a single breast incision to resect the tumor and the Lymphazurin-tagged SNB. The multi-incision group used a breast incision and a separate axillary incision. RESULTS The single-incision approach was associated with shorter operative time (56 vs 64 minutes, P = 0.026). Sentinel node retrieval was achieved in 100% in both groups. The single-incision technique was used primarily in the upper outer quadrant (N = 41, 85.4%), but was also selectively applied in other quadrants (N = 5). There was no significant difference in complication rates between the two procedures (P = 0.425), and there were no instances of conversion from single-incision to standard BCS-SNB. CONCLUSIONS Minimally invasive breast conserving surgery is feasible for patients with early breast cancer located in the upper outer quadrants. This technique may reduce postoperative morbidity and improved cosmetic result.
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Affiliation(s)
| | - Rebecca L Seidel
- Department of Radiology and Imaging Sciences, Emory University, Atlanta, Georgia
| | | | - Mylin A Torres
- Department of Radiation Oncology, Emory University, Atlanta, Georgia.,Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Albert Losken
- Department of Surgery, Emory University, Atlanta, Georgia.,Division of Plastic and Reconstructive Surgery, Department of Surgery, Emory University, Atlanta, Georgia
| | - Monica Rizzo
- Department of Surgery, Emory University, Atlanta, Georgia.,Winship Cancer Institute, Emory University, Atlanta, Georgia.,Division of Surgical Oncology, Department of Surgery, Emory University, Atlanta, Georgia
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45
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Asban A, Homsy C, Chen L, Fisher C, Losken A, Chatterjee A. A cost-utility analysis comparing large volume displacement oncoplastic surgery to mastectomy with single stage implant reconstruction in the treatment of breast cancer. Breast 2018; 41:159-164. [PMID: 30099327 DOI: 10.1016/j.breast.2018.07.012] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [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: 03/31/2018] [Revised: 07/26/2018] [Accepted: 07/31/2018] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND For larger cancers in moderate to large breast sized women, breast surgical cancer treatment may include large volume displacement oncoplastic surgery (LVOS) or mastectomy with single stage implant reconstruction (SSIR). Often in the case of LVOS, reduction mammaplasty designs are used in the oncoplastic reconstructions with a contralateral symmetry operation. The goal of this study was to investigate the cost-utility between LVOS versus SSIR to determine which approach is cost-effective in the treatment of breast cancer. METHODS A review of the literature was performed to determine baseline values and ranges. An average national Medicare payment rates using DRG and CPT codes were used for cost assessment. After constructing a decision tree, an incremental cost-utility ratio (ICUR) was calculated comparing the difference for both surgical options in costs by the difference in clinical-effectiveness. To validate our results, we performed one-way sensitivity analyses in addition to a Monte-Carlo analysis. RESULTS An ICUR of $546.81/QALY favoring LVOS was calculated based off of its clinical-effectiveness gain of 7.67 QALY at an additional cost of $4194. One-way sensitivity analyses underscored the degree by which LVOS was cost-effective. For example, LVOS became cost-ineffective when a successful LVOS cost more than $50,000. Similarly, probabilistic sensitivity analysis using Monte-Carlo simulation showed that even with varying multiple variables at once, results tended to favor our conclusion supporting the cost-effectiveness of LVOS. CONCLUSIONS For the appropriate patients with moderate to large sized breasts with breast cancer, large volume displacement oncoplastic surgery is cost-effective compared to mastectomy with single staged implant reconstruction.
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Affiliation(s)
- Ammar Asban
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Christopher Homsy
- Department of Surgery, Tufts University Medical Center, Boston, MA, United States
| | - Lilian Chen
- Department of Surgery, Tufts University Medical Center, Boston, MA, United States
| | - Carla Fisher
- Department of Surgery, Indiana University, IN, United States
| | - Albert Losken
- Department of Plastic Surgery, Emory University, GA, United States
| | - Abhishek Chatterjee
- Department of Surgery, Tufts University Medical Center, Boston, MA, United States.
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46
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Razavi SA, Desai KA, Hart AM, Thompson PW, Losken A. The Impact of Mesh Reinforcement with Components Separation for Abdominal Wall Reconstruction. Am Surg 2018; 84:959-962. [PMID: 29981631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
The goal in abdominal wall reconstruction (AWR) is to minimize morbidity and prevent hernia recurrence. Components separation and mesh reconstruction are two options, however, with advantages and disadvantages. The purpose of this review was to investigate outcomes in patients with abdominal wall hernia undergoing primary closure with component separation (CS) versus CS with acellular dermal matrix (ADM) reinforcement (CS + mesh). Medical records of consecutive patients who underwent abdominal wall reconstruction using CS with or without ADM reinforcement were retrospectively reviewed. Primary fascial closure was achieved in all patients. ADM reinforcement when used was performed using the underlay technique. Reconstructive technique and postoperative complications including delayed healing, skin necrosis, fistula, seroma, hematoma and surgical site infection, recurrence, and reoperation were recorded. Comparisons between the two groups were assessed. One hundred and seven patients were included (mean age, 55.7; 51.4% male; median follow-up 297 days). Twenty-six patients (24%) underwent CS alone; whereas 81 patients (76%) CS + mesh placement. Patient comorbidities, including smoking (26%), diabetes (20%), and hypertension (46%); body mass index (mean 32.3 ± 7.6); and albumin level on the day of surgery (mean 3.4 ± 0.5 mg/dL) were not significantly different between groups. Surgical site infection was significantly higher among CS + mesh patients (22.2%) versus CS only patients (3.9%) (P = 0.02). The recurrence rate of abdominal hernia was significantly lower in CS + mesh patients compared with CS only (14.8% vs 34.6%; P = 0.02). No significant differences in other postoperative complications were identified between the two groups. ADM reinforcement at the time of components separation is often selected in more complex, higher risk patients. Although the incidence of infection was higher in these patients, it was usually treated without mesh removal and recurrence rate was significantly lower when compared to CS alone.
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Abstract
The goal in abdominal wall reconstruction (AWR) is to minimize morbidity and prevent hernia recurrence. Components separation and mesh reconstruction are two options, however, with advantages and disadvantages. The purpose of this review was to investigate outcomes in patients with abdominal wall hernia undergoing primary closure with component separation (CS) versus CS with acellular dermal matrix (ADM) reinforcement (CS + mesh). Medical records of consecutive patients who underwent abdominal wall reconstruction using CS with or without ADM reinforcement were retrospectively reviewed. Primary fascial closure was achieved in all patients. ADM reinforcement when used was performed using the underlay technique. Reconstructive technique and postoperative complications including delayed healing, skin necrosis, fistula, seroma, hematoma and surgical site infection, recurrence, and reoperation were recorded. Comparisons between the two groups were assessed. One hundred and seven patients were included (mean age, 55.7; 51.4% male; median follow-up 297 days). Twenty-six patients (24%) underwent CS alone; whereas 81 patients (76%) CS + mesh placement. Patient comorbidities, including smoking (26%), diabetes (20%), and hypertension (46%); body mass index (mean 32.3 ± 7.6); and albumin level on the day of surgery (mean 3.4 ± 0.5 mg/dL) were not significantly different between groups. Surgical site infection was significantly higher among CS + mesh patients (22.2%) versus CS only patients (3.9%) (P = 0.02). The recurrence rate of abdominal hernia was significantly lower in CS + mesh patients compared with CS only (14.8% vs 34.6%; P = 0.02). No significant differences in other postoperative complications were identified between the two groups. ADM reinforcement at the time of components separation is often selected in more complex, higher risk patients. Although the incidence of infection was higher in these patients, it was usually treated without mesh removal and recurrence rate was significantly lower when compared to CS alone.
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Affiliation(s)
| | - Karan A. Desai
- Department of Surgery, Division of Plastic Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Alexandra M. Hart
- Department of Surgery, Division of Plastic Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Peter W. Thompson
- Department of Surgery, Division of Plastic Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Albert Losken
- Department of Surgery, Division of Plastic Surgery, Emory University School of Medicine, Atlanta, Georgia
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Chatterjee A, Offodile II AC, Asban A, Minasian RA, Losken A, Graham R, Chen L, Czerniecki BJ, Fisher C. A Cost-Utility Analysis Comparing Oncoplastic Breast Surgery to Standard Lumpectomy in Large Breasted Women. ACTA ACUST UNITED AC 2018. [DOI: 10.4236/abcr.2018.72011] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Moyer HR, Hart AM, Yeager J, Losken A. A Histological Comparison of Two Human Acellular Dermal Matrix Products in Prosthetic-Based Breast Reconstruction. Plast Reconstr Surg Glob Open 2017; 5:e1576. [PMID: 29632762 PMCID: PMC5889434 DOI: 10.1097/gox.0000000000001576] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [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] [Received: 06/23/2017] [Accepted: 09/29/2017] [Indexed: 12/22/2022]
Abstract
Background Acellular dermal matrices (ADMs) are an integral component of breast reconstruction. The ideal matrix would be relatively immuno-inert, allow rapid vascularization, and be affordable. The purpose of this study was to histologically compare 2 commonly used ADM products. Methods This is a prospective histological study of 17 patients (20 breasts) following prosthetic-based breast reconstruction with ADM: Alloderm (LifeCell Corp, Branchburg, N.J.) or Cortiva (RTI Surgical, Alachua Fla.). Biopsies were taken from the dermal matrix and natural capsules surrounding the expander/implant during secondary surgery [Range, 72-694 days (mean, 217 days)]. Biopsy specimens were prepared via hematoxylin and eosin, Masson's trichrome, elastin, and transforming growth factor (TGF)-1 stains. Quantitative analysis of staining was performed with ImageJ software. The clinical outcome of each patient is analyzed in relation to capsule architecture and ADM performance. Results There were 7 breasts in the Alloderm group and 13 in the Cortiva group. Both groups had similar demographic, aesthetic results, and complication profiles. The TGF-1 staining demonstrated significantly lower levels in the Cortiva capsules (P = 0.0139). The percentage of elastin and collagen are similar in the Cortiva, Alloderm, and natural peri-implant capsules. The native capsules show a significantly greater number of blood vessels when compared with Cortiva and Alloderm (P = 0.0371 and P = 0.0347, respectively); however, there is no difference in vascular pattern between the 2 dermal matrices. Discussion Postoperatively, Cortiva demonstrates equal vascularity with less TGF-1 activation compared with Alloderm. The clinical success and complication profile were similar between the Alloderm and Cortiva patients.
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Affiliation(s)
- Hunter R Moyer
- Emory University, Division of Plastic and Reconstructive Surgery, Atlanta, Ga.; Atlanta Plastic Surgery, Atlanta, Ga
| | - Alexandra M Hart
- Emory University, Division of Plastic and Reconstructive Surgery, Atlanta, Ga.; Atlanta Plastic Surgery, Atlanta, Ga
| | - Jessica Yeager
- Emory University, Division of Plastic and Reconstructive Surgery, Atlanta, Ga.; Atlanta Plastic Surgery, Atlanta, Ga
| | - Albert Losken
- Emory University, Division of Plastic and Reconstructive Surgery, Atlanta, Ga.; Atlanta Plastic Surgery, Atlanta, Ga
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Losken A. Commentary on: Skin-Reducing Mastectomy in Immediate Reconstruction: How to Limit Complications and Failures. Aesthet Surg J 2017; 37:678-679. [PMID: 28475730 DOI: 10.1093/asj/sjx021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Albert Losken
- Dr Losken is the William G. Hamm Professor of Plastic Surgery and Program Director, Division of Plastic and Reconstructive Surgery, Emory University, Atlanta, GA
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