Preoperative Risk Factors for Lymphedema in Inflammatory Breast Cancer

BACKGROUND

 Prophylactic lymphatic bypass or LYMPHA (LYmphatic Microsurgical Preventive Healing Approach) is increasingly offered to prevent lymphedema following breast cancer treatment, which develops in up to 47% of patients. Previous studies focused on intraoperative and postoperative lymphedema risk factors, which are often unknown preoperatively when the decision to perform LYMPHA is made. This study aims to identify preoperative lymphedema risk factors in the high-risk inflammatory breast cancer (IBC) population.

METHODS

 Retrospective review of our institution's IBC program database was conducted. The primary outcome was self-reported lymphedema development. Multivariable logistic regression analysis was performed to identify preoperative lymphedema risk factors, while controlling for number of lymph nodes removed during axillary lymph node dissection (ALND), number of positive lymph nodes, residual disease on pathology, and need for adjuvant chemotherapy.

RESULTS

 Of 356 patients with IBC, 134 (mean age: 51 years, range: 22-89 years) had complete data. All 134 patients underwent surgery and radiation. Forty-seven percent of all 356 patients (167/356) developed lymphedema. Obesity (body mass index > 30) (odds ratio [OR]: 2.7, confidence interval [CI]: 1.2-6.4, p = 0.02) and non-white race (OR: 4.5, CI: 1.2-23, p = 0.04) were preoperative lymphedema risk factors.

CONCLUSION

 Patients with IBC are high risk for developing lymphedema due to the need for ALND, radiation, and neoadjuvant chemotherapy. This study also identified non-white race and obesity as risk factors. Larger prospective studies should evaluate potential racial disparities in lymphedema development. Due to the high prevalence of lymphedema, LYMPHA should be considered for all patients with IBC.

Impact of Prepectoral vs. Subpectoral Tissue Expander Placement on Post-mastectomy Radiation Therapy Delivery: A Retrospective Cohort Study

Background

Implant-based reconstruction is the most common method of postmastectomy reconstruction. Many patients require postmastectomy radiation (PMRT). Tissue expanders (TEs), typically inserted as a first stage, have historically been placed subpectorally. More recently, prepectoral reconstruction has gained popularity, but its impact on PMRT is unknown. Prior studies focus on complication rates and aesthetic outcomes. This study examines whether there is a difference in radiation dosimetry among patients undergoing prepectoral versus subpectoral TE reconstruction.

Methods

Electronic medical records and radiation plans of 50 patients (25 prepectoral, 25 subpectoral) who underwent mastectomy with immediate TE reconstruction at our institution or affiliate site were reviewed. Pectoralis major muscle and chest wall structures were contoured and mean percentage volumes of these structures receiving less than 95%, 100%, and more than 105% target radiation dose were calculated, as were heart and ipsilateral lung doses. Welch two sample t test, Fisher exact test, and Pearson chi-squared tests were performed.

Results

The groups had comparable patient and tumor characteristics and underwent similar ablative and reconstructive procedures and radiation dosimetry. Subpectoral patients had larger mean areas receiving less than 95% target dose ("cold spots"); prepectoral patients had larger mean areas receiving greater than 105% ("hot spots") and 100% target doses. There were no differences in chest wall, heart, and lung doses.

Conclusions

Our results demonstrate an increased mean percentage area of pectoralis cold spots with subpectoral reconstruction and increased area of hot spots and 100% dose delivery to the pectoralis in prepectoral patients. Larger studies should analyze long-term effects of prepectoral reconstruction on radiation dosing and recurrence rates.

Evaluation of Artificial Intelligence-generated Responses to Common Plastic Surgery Questions

Background

Artificial intelligence (AI) is increasingly used to answer questions, yet the accuracy and validity of current tools are uncertain. In contrast to internet queries, AI generates summary responses as definitive. The internet is rife with inaccuracies, and plastic surgery management guidelines evolve, making verifiable information important.

Methods

We posed 10 questions about breast implant-associated illness, anaplastic large lymphoma, and squamous carcinoma to Bing, using the "more balanced" option, and to ChatGPT. Answers were reviewed by two plastic surgeons for accuracy and fidelity to information on the Food and Drug Administration (FDA) and American Society of Plastic Surgeons (ASPS) websites. We also presented 10 multiple-choice questions from the 2022 plastic surgery in-service examination to Bing, using the "more precise" option, and ChatGPT. Questions were repeated three times over consecutive weeks, and answers were evaluated for accuracy and stability.

Results

Compared with answers from the FDA and ASPS, Bing and ChatGPT were accurate. Bing answered 10 of the 30 multiple-choice questions correctly, nine incorrectly, and did not answer 11. ChatGPT correctly answered 16 and incorrectly answered 14. In both parts, responses from Bing were shorter, less detailed, and referred to verified and unverified sources; ChatGPT did not provide citations.

Conclusions

These AI tools provided accurate information from the FDA and ASPS websites, but neither consistently answered questions requiring nuanced decision-making correctly. Advances in applications to plastic surgery will require algorithms that selectively identify, evaluate, and exclude information to enhance the accuracy, precision, validity, reliability, and utility of AI-generated responses.

Outcomes of Extended Pedicle Technique vs Free Nipple Graft Reduction Mammoplasty for Patients With Gigantomastia

BACKGROUND

Optimal reduction mammoplasty techniques to treat patients with gigantomastia have been debated and can involve extended pedicles (EP) or free nipple grafts (FNG).

OBJECTIVES

The authors compared clinical, patient-reported, and aesthetic outcomes associated with reduction mammoplasty employing EP vs FNG.

METHODS

A multi-institutional, retrospective study of adult patients with gigantomastia who underwent reduction mammoplasty at 2 tertiary care centers from 2017 to 2020 was performed. Gigantomastia was defined as reduction weight >1500 g per breast or sternal notch-to-nipple distance ≥40 cm. Surgeons at 1 institution employed the EP technique, whereas those at the other utilized FNG. Baseline characteristics, preoperative and postoperative BREAST-Q, and clinical outcomes were collected. Aesthetic outcomes were assessed in 1:1 propensity score-matched cases across techniques. Preoperative and postoperative photographs were provided to reviewers across the academic plastic surgery continuum (students to faculty) and non-medical individuals to evaluate aesthetic outcomes.

RESULTS

Fifty-two patients met the inclusion criteria (21 FNG, 31 EP). FNG patients had a higher incidence of postoperative cellulitis (23% vs 0%, P < 0.05) but no other differences in surgical or medical complications. Baseline BREAST-Q scores did not differ between groups. Postoperative BREAST-Q scores revealed greater satisfaction with the EP technique (P < 0.01). The aesthetic assessment of outcomes in 14 matched pairs of patients found significantly better aesthetic outcomes in all domains with the EP procedure (P < 0.05), independent of institution or surgical experience.

CONCLUSIONS

This multi-institutional study suggests that, compared with FNG, the EP technique for reduction mammoplasty provides superior clinical, patient-reported, and aesthetic outcomes for patients with gigantomastia.

LEVEL OF EVIDENCE: 4

Predictors of Gastrostomy Tube Placement in Head and Neck Cancer Patients at a Rural Tertiary Care Hospital

Background Head and neck cancer is a leading cause of cancer. Treatment often requires surgical resection, free-flap reconstruction, radiation, and/or chemotherapy. Tumor burden and pain may limit swallowing and impair nutrition, increasing complications and mortality. Patients commonly require gastrostomy tubes (G-tube), but predicting which patients are in need remains elusive. This study identifies predictors of G-tube among head and neck cancer patients undergoing immediate free-flap reconstruction.

Methods Institutional Review Board approval was obtained. Retrospective database review was performed of patients at 18 years of age or older with head and neck cancer who underwent resection with immediate free-flap reconstruction from 2011 to 2019. Patients who underwent nonfree-flap or delayed reconstruction or with mortality within 7 days postoperatively were excluded. Patient demographics and comorbidities, tumor/treatment characteristics, and need for G-tube were analyzed to identify univariate and multivariate predictors.

Results In total, 107 patients were included and 72 required G-tube placement. On multivariate analysis, tracheostomy (odds ratio [OR]: 81.78; confidence interval [CI]: 7.43–1,399.92; p < 0.01), anterolateral thigh flap reconstruction (OR: 16.18; CI: 1.14–429.66; p = 0.04), and age 65 years or younger (OR: 9.35; CI: 1.47–89.11; p = 0.02) were predictors of G-tube placement.

Conclusion Head and neck cancer treatment commonly involves extensive resection, reconstruction, and/or chemoradiation. These patients are at high risk for malnutrition and need G-tube. Determining who requires a pre- or postoperative G-tube remains a challenge. In this study, the need for tracheostomy or ALT flap reconstruction and age 65 years or younger were predictive of postoperative G-tube placement. Future research will guide a multidisciplinary perioperative pathway to facilitate the optimization of nutrition management.

Predictors of gastrostomy tube placement in patients with head and neck cancer undergoing resection and flap-based reconstruction: systematic review and meta-analysis

BACKGROUND

Nutritional status may be impaired in patients with head and neck cancer undergoing surgical treatment, often necessitating gastrostomy tube (G-tube) placement. Identifying which patients will require a G-tube remains a challenge. This study identifies predictors of G-tube requirement in patients undergoing tumor resection and reconstruction with pedicled or free flaps.

METHODS

Systematic review of the PubMed, Cochrane, and Scopus databases was performed of English language articles, discussing risk factors of perioperative G-tube placement among patients >18 years. Data on patient, tumor, and treatment factors, as well as need for G-tube, were collected. Univariable meta-analysis was conducted to identify predictors for G-tube placement.

RESULTS

Eleven studies (1,112 patients) met inclusion criteria. Overall pooled prevalence of postoperative G-tube placement was 25%. Patients with advanced cancer stage IV/recurrence were more likely to require a G-tube (OR 2.81 [CI 1.03-7.69]; p<0.05), as were those who had undergone preoperative radiation (OR 3.55 [CI 2.03-6.20], p<0.05). Reconstruction with a radial forearm free flap was associated with a lower need for G-tube versus rectus abdominis (OR 0.25 [CI 0.08-0.83], p=0.02) and latissimus dorsi flap (OR 0.21 [CI 0.04-1.09], p=0.06). There was no difference in G-tube placement between those receiving pedicled flaps versus free flaps (OR 1.54 [CI 0.38-6.20], p=0.54).

CONCLUSIONS

Among patients with head and neck cancer undergoing resection with immediate pedicled or free flap reconstruction, advanced tumor stage and history of prior radiation therapy are associated with increased likelihood of G-tube placement. More randomized controlled trials are needed to develop a decision-making algorithm.

BRCA2-associated Breast Cancer in Transgender Women: Reconstructive Challenges and Literature Review

Breast cancer in trans women is rare. Only 21 cases have been reported worldwide. Multidisciplinary teams must balance oncologic treatment with patient goals. Here we describe a case of invasive ductal carcinoma in a transgender woman who was found to have a BRCA2 gene mutation. A shared decision-making process led to the patient undergoing bilateral nipple-sparing mastectomy with immediate tissue expander placement. Later findings prompted discussions about adjuvant chemotherapy and radiation. Additionally, we discuss the complexities associated with reconstructing a transfeminine chest.

Correction of the tuberous breast deformity in a prepubescent male patient: A surgical approach to an unusual problem

Purpose

The management of the tuberous breast deformity in the female patient is well described. However, the presence of this variant in male patients is particularly rare, and few reports on the management of this condition are available.

Case presentation

A 12-year-old prepubescent male with bilateral gynecomastia and tuberous breast deformities was referred to our department for treatment. Our surgical management, including free nipple areolar complex harvest, mastectomy, removal of excess skin and subsequent nipple grafting, is presented in detail. We observed a cosmetically acceptable result with restoration of a masculine-appearing nipple-areolar complex and good patient satisfaction at 6-month follow-up.

Conclusions

Tuberous breast deformities in male patients are rare. Our treatment of a prepubertal male patient with this deformity using mastectomies and free nipple areolar complex grafting provided a cosmetically acceptable result. Here, we review the current literature on tuberous breast deformities in males and describe our approach to treatment.

Dogma without Data: A Clinical Decision-Making Tool for Postoperative Blood Cultures

Bacteremia is a worrisome postoperative complication and blood cultures (BCx) are often nondiagnostic. We previously reported a 4 per cent overall yield of positive cultures in postoperative patients. To reduce unnecessary testing, we present a predictive model to identify patients in whom growth of pathogens is unlikely and provide a clinical decision-making guide. Retrospective analysis of nonpregnant patients ≥18 years who had BCx within 10 days postoperatively was performed. Generalized linear mixed models identified clinical predictors of high- and low-yield cultures. A clinical algorithm was created using significant predictors, and positive predictive value, negative predictive value, sensitivity, and specificity calculated. Among 1759 BCx, hypotension, maximum temperature ≥101.5 °F within 24 hours of culture, and culture collected after postoperative day (POD) two were statistically significant predictors of positive cultures. Forty nine per cent of BCx were sent ≤ POD 2, and <1 per cent of these were positive. When all three criteria were met, the probability of a positive culture increased to 17 per cent. When absent, the probability of a negative culture was 99 per cent. When applied to the initial data set, the model resulted in 85 per cent reduction of cultures with 9 per cent yield of positive cultures. Drawing BCx based on a single predictor is inadequate. Reducing the number of cultures reflexively ordered within the first two POD could significantly reduce the number of unnecessary BCx. Several clinical features identified patients most likely to have positive BCx within the first 10 POD and could reduce unnecessary BCx. This model should be validated in an independent, prospective cohort.

Dogma without Data: A Clinical Decision-Making Tool for Postoperative Blood Cultures

Bacteremia is a worrisome postoperative complication and blood cultures (BCx) are often nondiagnostic. We previously reported a 4 per cent overall yield of positive cultures in postoperative patients. To reduce unnecessary testing, we present a predictive model to identify patients in whom growth of pathogens is unlikely and provide a clinical decision-making guide. Retrospective analysis of nonpregnant patients ≥18 years who had BCx within 10 days postoperatively was performed. Generalized linear mixed models identified clinical predictors of high- and low-yield cultures. A clinical algorithm was created using significant predictors, and positive predictive value, negative predictive value, sensitivity, and specificity calculated. Among 1759 BCx, hypotension, maximum temperature ≥101.5 °F within 24 hours of culture, and culture collected after postoperative day (POD) two were statistically significant predictors of positive cultures. Forty nine per cent of BCx were sent ≤ POD 2, and <1 per cent of these were positive. When all three criteria were met, the probability of a positive culture increased to 17 per cent. When absent, the probability of a negative culture was 99 per cent. When applied to the initial data set, the model resulted in 85 per cent reduction of cultures with 9 per cent yield of positive cultures. Drawing BCx based on a single predictor is inadequate. Reducing the number of cultures reflexively ordered within the first two POD could significantly reduce the number of unnecessary BCx. Several clinical features identified patients most likely to have positive BCx within the first 10 POD and could reduce unnecessary BCx. This model should be validated in an independent, prospective cohort.

Computer-Aided Surgical Simulation in Head and Neck Reconstruction: A Cost Comparison among Traditional, In-House, and Commercial Options

BACKGROUND

 Computer-aided surgical simulation (CASS) has redefined surgery, improved precision and reduced the reliance on intraoperative trial-and-error manipulations. CASS is provided by third-party services; however, it may be cost-effective for some hospitals to develop in-house programs. This study provides the first cost analysis comparison among traditional (no CASS), commercial CASS, and in-house CASS for head and neck reconstruction.

METHODS

 The costs of three-dimensional (3D) pre-operative planning for mandibular and maxillary reconstructions were obtained from an in-house CASS program at our large tertiary care hospital in Northern Virginia, as well as a commercial provider (Synthes, Paoli, PA). A cost comparison was performed among these modalities and extrapolated in-house CASS costs were derived. The calculations were based on estimated CASS use with cost structures similar to our institution and sunk costs were amortized over 10 years.

RESULTS

 Average operating room time was estimated at 10 hours, with an average of 2 hours saved with CASS. The hourly cost to the hospital for the operating room (including anesthesia and other ancillary costs) was estimated at $4,614/hour. Per case, traditional cases were $46,140, commercial CASS cases were $40,951, and in-house CASS cases were $38,212. Annual in-house CASS costs were $39,590.

CONCLUSIONS

 CASS reduced operating room time, likely due to improved efficiency and accuracy. Our data demonstrate that hospitals with similar cost structure as ours, performing greater than 27 cases of 3D head and neck reconstructions per year can see a financial benefit from developing an in-house CASS program.

Sample procurement for cultures of infected wounds: a systematic review

OBJECTIVE

Identifying the responsible pathogen is required in order to select optimum antimicrobial therapy for infected wounds, but the best techniques to use remain the subject of debate. Our aim was to assess the evidence on the value of wound swabs compared with biopsies.

METHOD

We conducted a systematic literature review with the terms 'wound infection', 'wound swab', 'wound swab technique', 'wound biopsy', 'wound culture', 'wound swab comparison', 'Levine swab technique', 'microbiological technique', 'specimen handling', 'bacterial load', 'perioperative care', 'swab', and 'culture'. We examined yields in identifying relevant pathogens, summarised salient features of qualifying studies, and defined knowledge gaps and endpoints that future studies should address.

RESULTS

Studies have been inconsistent, lacking specificity regarding wound types, clinical features, and sampling methods. We found moderate quality evidence that punch biopsies provide qualitative and quantitative information about the bacterial load and tissue reaction with nearly 100% sensitivity, 90% specificity and 95% accuracy for predicting wound closure. Biopsies are relatively invasive, costly, require skilled operators, and potentially exacerbate infection. Needle aspiration samples a limited portion and may enter uninfected tissue and extend infection. Wound swabs are minimally invasive, easier to perform and widely employed in clinical practice, but techniques vary. In comparative studies, the Levine technique was superior to the Z-swab techniques, and biopsies were more sensitive for antibiotic-resistant wounds than Levine or Levine-like swabs, suggesting that swabs may be useful for initial wound monitoring, but biopsies are preferred when antibiotic resistance is suspected.

CONCLUSION

The Levine swab is superior to the Z-swab technique and may be useful for initial wound monitoring, but quantitative biopsies are preferred for evaluation of antibiotic-resistant wounds and to monitor the response to treatment. There is limited evidence on the role of wound swabs for detecting wound colonisation versus infection and the impact of culture-guided therapy on such clinical outcomes as eradication of infection and accelerated healing. Future studies should specify patient populations, wound types, sampling protocols, and outcomes based on culture yield and treatment results, using rigorous statistical methodology.

Complicated triple gallbladder: clinical presentation and surgical approach

We report a patient with previous biliary symptoms and endoscopic interventions who presented with clinical features suggestive of choledocholithiasis. Open surgical exploration disclosed three gallbladders with copious stones and varying degrees of acute and chronic inflammation. Literature review revealed only 16 previously reported cases. We review the aetiology of triple gallbladder as being due to failure of rudimentary bile ducts to regress during embryological development, as well as the classification scheme of triple gallbladder based on size, location and number. We also discuss the clinical evaluation and appropriate surgical management of this entity, as triple gallbladders can be associated with cholecystitis or carcinoma.

The vastus lateralis free flap for lower extremity gustilo grade III reconstruction

BACKGROUND

Orthopedic trauma patients with Gustilo grade III injuries to the distal third of lower extremity present challenges to optimum reconstructive management. There is no consensus on the ideal autologous tissue for transfer in large lower extremity defect reconstruction. We present a large case series utilizing the vastus lateralis (VL) free flap for lower extremity Gustilo grade III reconstruction.

PATIENTS AND METHODS

This is a case series of patients who underwent VL free tissue transfer for Gustilo grade III injuries. A total of 38 free tissue transfers were performed for lower extremity reconstruction, 19 of which were VL flaps. Mean interval between injury and reconstruction was 46 days (range 7-240 days).

RESULTS

The mean wound size was 11.37 cm x 11.42 cm and all cases underwent delayed reconstruction. Seven day flap viability was 100% and 30-day flap viability was 17/19 (89%). There were six complications: two hematomas requiring drainage, one flap dehiscence, one distal flap loss requiring a reverse saphenous vein graft extension, and two complete flap losses. Of the two failed flaps, one was attributed to heparin-induced thrombocytopenia and the other to venous congestion complicated by methicillin-resistant Staphylococcus aureus infection.

CONCLUSIONS

The VL free flap is a reliable and versatile flap that can be tailored and tangentially thinned to match the shape and size of a defect, and the long pedicle allows the surgeon to stay away from the zone of injury. This flap should be strongly considered for lower extremity reconstruction, especially in salvage operations for large defects. © 2015 Wiley Periodicals, Inc. Microsurgery 37:212-217, 2017.