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Mazzaferro DM, Patel V, Asport N, Stetson RL, Rose D, Plana N, Serletti JM, DeMatteo RP, Wu LC. The financial impact of COVID-19 on a surgical department: The effects of surgical shutdowns and the impact on a health system. Surgery 2022; 172:1642-1650. [PMID: 36123177 PMCID: PMC9388446 DOI: 10.1016/j.surg.2022.08.014] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 07/13/2022] [Accepted: 08/10/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND The COVID-19 pandemic resulted in sweeping shutdowns of surgical operations to increase hospital capacity and conserve resources. Our institution, following national and state guidelines, suspended nonessential surgeries from March 16 to May 4, 2020. This study examines the financial impact of this decision on our institution's health system by comparing 2 waves of COVID-19 cases. METHODS The total revenue was obtained for surgical cases occurring during the first wave of the pandemic between March 1, 2020 and July 31, 2020 and the second wave between October 1, 2020 and February 29, 2021 for all surgical departments. During the same time intervals, in the prepandemic year 2019, total revenue was also obtained for comparison. Net revenue and work relative value units per month were compared to each respective month for all surgical divisions within the department of surgery. RESULTS Comparing the 5-month first wave period in 2020 to prepandemic 2019 for all surgical departments, there was a net revenue loss of $99,674,376, which reflected 42% of the health system's revenue loss during this period. The department of surgery contributed to a net revenue loss of $58,368,951, which was 24.9% of the health system's revenue loss. Within the department of surgery, there was a significant difference between the net revenue loss per month per division of the first and second wave: first wave median -$636,952 [interquartile range: -1,432,627; 26,111] and second wave median -$274,626 [-781,124; 396,570] (P = .04). A similar difference was detected when comparing percent change in work relative value units between the 2 waves (wave 1: median -13.2% [interquartile range: -41.3%, -1.8%], wave 2: median -7.8% [interquartile range: -13.0%, 1.8%], P = .003). CONCLUSION Stopping elective surgeries significantly decreased revenue for a health system. Losses for the health system totaled $234,839,990 during the first wave, with lost surgical revenue comprising 42% of that amount. With elective surgeries continuing during the second wave of COVID-19 cases, the health system losses were substantially lower. The contribution surgery has to a hospital's cash flow is essential in maintaining financial solvency. It is important for hospital systems to develop innovative and alternative solutions to increase capacity, offer comprehensive care to medical and surgical patients, and prevent shutdowns of surgical activity through a pandemic to maintain financial security.
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Affiliation(s)
- Daniel M Mazzaferro
- Division of Plastic Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Viren Patel
- Division of Plastic Surgery, Cleveland Clinic, OH
| | - Nelson Asport
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Robert L Stetson
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Deborah Rose
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Natalie Plana
- Division of Plastic Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Joseph M Serletti
- Division of Plastic Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Ronald P DeMatteo
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Liza C Wu
- Division of Plastic Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA.
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Hoffman DI, Santos PMG, Goldbach M, Keele LJ, Taunk NK, Bogen HS, Burkbauer L, Jankowitz RC, Fosnot J, Wu LC, Freedman GM, Tchou JC. Immediate Breast Reconstruction for Inflammatory Breast Cancer: Trends in Use and Clinical Outcomes 2004-2016. Ann Surg Oncol 2021; 28:8789-8801. [PMID: 34269937 DOI: 10.1245/s10434-021-10404-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 06/21/2021] [Indexed: 11/18/2022]
Abstract
INTRODUCTION National guidelines specify against immediate breast reconstruction (IBR) among inflammatory breast cancer (IBC) patients. However, limited data exist regarding this practice. We report practice patterns and oncologic outcomes among nonmetastatic IBC patients receiving trimodality therapy, with or without IBR. METHODS Using the National Cancer Database, we identified nonmetastatic IBC patients treated with trimodality therapy from 2004 to 2016. Primary outcome was overall survival (OS), assessed on unadjusted analysis using Kaplan-Meier estimates and on adjusted analysis using multivariable Cox proportional hazards and inverse probability weighting (IPW) models. OS analysis was also conducted with propensity score matched (PSM) cohorts. Secondary outcomes included IBR utilization rates, time to postmastectomy radiotherapy (PMRT), and surgical outcomes. RESULTS 6589 women were included, including 5954 (90.4%) non-reconstructed and 635 (9.6%) IBR. Among IBR recipients, 250 (39.4%) underwent autologous reconstruction, 171 (26.9%) underwent implant-based reconstruction, and 214 (33.7%) unspecified. IBR utilization increased from 6.3% to 10.1% from 2004 to 2016 at a 4% average annual growth rate (P < 0.001). Median follow-up was 43 and 45 months for IBR and non-reconstructed patients, respectively (P = 0.29). On Cox multivariable analysis, IBR was associated with improved OS (HR 0.63, 95% CI 0.44-0.90, P = 0.01), but this association was not significant on IPW analysis (P = 0.06). In PSM cohorts, this association remained significant (HR 0.60, 95% CI 0.40-0.92, P = 0.02). Margin status, time to PMRT, 30-day readmission, and 30-/90-day mortality did not differ between groups (all P > 0.05). CONCLUSION Although not endorsed by national guidelines, IBR is increasing among IBC patients; however, more granular data are needed to determine oncologic safety.
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Affiliation(s)
- Daniel I Hoffman
- Division of Endocrine and Oncologic Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Patricia Mae G Santos
- Department of Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Macy Goldbach
- Division of Endocrine and Oncologic Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Luke J Keele
- Department of Surgery, Department of Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Neil K Taunk
- Department of Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Hannah S Bogen
- Department of Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Laura Burkbauer
- Division of Endocrine and Oncologic Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Rachel C Jankowitz
- Division of Hematology and Oncology, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Joshua Fosnot
- Division of Plastic Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Liza C Wu
- Division of Plastic Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Gary M Freedman
- Department of Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Julia C Tchou
- Division of Endocrine and Oncologic Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
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Hoffman DI, Santos PMG, Goldbach M, Keele LJ, Taunk NK, Bogen HS, Burkbauer L, Jankowitz RC, Fosnot J, Wu LC, Freedman GM, Tchou JC. ASO Visual Abstract: Immediate Breast Reconstruction for Inflammatory Breast Cancer-Trends in Use and Clinical Outcomes, 2004-2016. Ann Surg Oncol 2021. [PMID: 34269945 DOI: 10.1245/s10434-021-10475-3] [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: 11/18/2022]
Affiliation(s)
- Daniel I Hoffman
- Division of Endocrine and Oncologic Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Patricia Mae G Santos
- Department of Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Macy Goldbach
- Division of Endocrine and Oncologic Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Luke J Keele
- Department of Surgery, Department of Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Neil K Taunk
- Department of Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Hannah S Bogen
- Department of Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Laura Burkbauer
- Division of Endocrine and Oncologic Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Rachel C Jankowitz
- Division of Hematology and Oncology, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Joshua Fosnot
- Division of Plastic Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Liza C Wu
- Division of Plastic Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Gary M Freedman
- Department of Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Julia C Tchou
- Division of Endocrine and Oncologic Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
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Yan MJ, Zhao P, Wu LC, Xu K, Yan H, Zeng LX, Mi BB, Dang SN. [Method of double data entry and quality control by REDCap system]. Zhonghua Liu Xing Bing Xue Za Zhi 2021; 42:918-922. [PMID: 34814489 DOI: 10.3760/cma.j.cn112338-20200415-00574] [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] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
In medical research, the quality of data is the key to success. Thus, data quality control becomes an important part of ensuring the research's high quality. REDCap system is an emerging data acquisition system in medical research, which is gradually applied in research at home and abroad. It is a hot issue to realize double data entry and data quality control in using the REDCap system, which researchers are concerned about when this system is supposed to apply. This article will systematically introduce how to use the REDCap system for double data entry and quality control from the aspects of research project creation, data collection tool design, double data entry, data checking and exporting.
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Affiliation(s)
- M J Yan
- Department of Epidemiology and Health Statistics, School of Public Health, Xi'an Jiaotong University, Xi'an 710061,China
| | - P Zhao
- Department of Epidemiology and Health Statistics, School of Public Health, Xi'an Jiaotong University, Xi'an 710061,China
| | - L C Wu
- Department of Epidemiology and Health Statistics, School of Public Health, Xi'an Jiaotong University, Xi'an 710061,China
| | - K Xu
- Department of Epidemiology and Health Statistics, School of Public Health, Xi'an Jiaotong University, Xi'an 710061,China
| | - H Yan
- Department of Epidemiology and Health Statistics, School of Public Health, Xi'an Jiaotong University, Xi'an 710061,China
| | - L X Zeng
- Department of Epidemiology and Health Statistics, School of Public Health, Xi'an Jiaotong University, Xi'an 710061,China
| | - B B Mi
- Department of Epidemiology and Health Statistics, School of Public Health, Xi'an Jiaotong University, Xi'an 710061,China
| | - S N Dang
- Department of Epidemiology and Health Statistics, School of Public Health, Xi'an Jiaotong University, Xi'an 710061,China
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Abstract
Immediate oncoplastic breast reconstruction performed at the time of breast conserving surgery for the treatment of breast cancer merges the therapeutic goals of complete oncologic extirpation with preservation of breast form and function. A constellation of surgical techniques that employs breast volume displacement and/or replacement methods of varying complexity levels have emerged, thus broadening the potential applications for breast conservation therapy to include cases with increased tumor-to-native breast-volume ratios, multicentric or multifocal disease, and/or previous margin-positive resections. This review describes the various reconstructive methods, including the use of local tissue rearrangement, oncoplastic reduction-mastopexy, and locoregional flaps. Classification of the surgical options into levels I and II volume-displacement and volume-replacing techniques is made. Additionally, we explore the oncologic safety and effectiveness of this treatment paradigm by summarizing existing supportive evidence regarding associated risk of surgical complications, rate of margin-positive resection, implications for radiographic surveillance, local recurrence rates, and patient-reported outcomes. In conclusion, surgeons may use a wide variety of oncoplastic techniques for partial breast reconstruction at the time of segmental mastectomy to deliver effective breast conserving treatment for women with breast cancer. A growing body of literature affirms the oncologic safety of this approach. Future directions for research include long-term follow-up data with emphasis on outcomes from patient perspectives.
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Affiliation(s)
- Carrie K Chu
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Summer E Hanson
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Rosa F Hwang
- Department of Breast Surgical Oncology, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Liza C Wu
- Section of Plast Reconstr Surg, Department of Surgery, The University of Pennsylvania Health System, Philadelphia, PA, USA
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Kennedy GT, Huang CY, So A, Hill C, Wu LC, Fosnot J, Farrar JT, Tchou JC. Enhanced Recovery after Surgery Protocol Reduces Narcotic Requirement and Length of Stay in Patients Undergoing Mastectomy with Implant-Based Reconstruction. J Am Coll Surg 2019. [DOI: 10.1016/j.jamcollsurg.2019.08.094] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Wu LC, Zhang Y, Steinberg G, Qu H, Huang S, Cheng M, Bliss T, Du F, Rao J, Song G, Pisani L, Doyle T, Conolly S, Krishnan K, Grant G, Wintermark M. A Review of Magnetic Particle Imaging and Perspectives on Neuroimaging. AJNR Am J Neuroradiol 2019; 40:206-212. [PMID: 30655254 DOI: 10.3174/ajnr.a5896] [Citation(s) in RCA: 75] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Accepted: 07/06/2018] [Indexed: 12/14/2022]
Abstract
Magnetic particle imaging is an emerging tomographic technique with the potential for simultaneous high-resolution, high-sensitivity, and real-time imaging. Magnetic particle imaging is based on the unique behavior of superparamagnetic iron oxide nanoparticles modeled by the Langevin theory, with the ability to track and quantify nanoparticle concentrations without tissue background noise. It is a promising new imaging technique for multiple applications, including vascular and perfusion imaging, oncology imaging, cell tracking, inflammation imaging, and trauma imaging. In particular, many neuroimaging applications may be enabled and enhanced with magnetic particle imaging. In this review, we will provide an overview of magnetic particle imaging principles and implementation, current applications, promising neuroimaging applications, and practical considerations.
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Affiliation(s)
- L C Wu
- From the Departments of Bioengineering (L.C.W.)
| | - Y Zhang
- Radiology (Y.Z., H.Q., S.H., M.W.)
| | - G Steinberg
- Neurosurgery (G.S., M.C., T.B., F.D., G.G.).,Neuroradiology Section, Radiology (J.R., G.S., L.P.)
| | - H Qu
- Radiology (Y.Z., H.Q., S.H., M.W.)
| | - S Huang
- Radiology (Y.Z., H.Q., S.H., M.W.).,Chongqing Medical University (S.H.), Traditional Chinese Medicine College, Chongqing, China
| | - M Cheng
- Neurosurgery (G.S., M.C., T.B., F.D., G.G.)
| | - T Bliss
- Neurosurgery (G.S., M.C., T.B., F.D., G.G.)
| | - F Du
- Neurosurgery (G.S., M.C., T.B., F.D., G.G.)
| | - J Rao
- Neuroradiology Section, Radiology (J.R., G.S., L.P.)
| | - G Song
- From the Departments of Bioengineering (L.C.W.)
| | - L Pisani
- Neuroradiology Section, Radiology (J.R., G.S., L.P.)
| | - T Doyle
- Pediatrics (T.D.), Stanford University, Stanford, California
| | - S Conolly
- Department of Electrical Engineering and Computer Sciences (S.C.), University of California Berkeley, Berkeley, California
| | - K Krishnan
- Departments of Materials Sciences and Engineering and Physics (K.K.), University of Washington, Seattle, Washington
| | - G Grant
- Neurosurgery (G.S., M.C., T.B., F.D., G.G.)
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Williams AD, Wu LC, Fosnot J, Tchou JC. Acellular Dermal Matrix Use Increases Morbidity in Implant-Based Breast Reconstruction. J Am Coll Surg 2018. [DOI: 10.1016/j.jamcollsurg.2018.07.045] [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: 11/29/2022]
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9
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Hill C, So A, Williams AD, Jamil S, Wu LC, De La Cruz LM, Fosnot CD, Fosnot J, Farrar JT, Tchou JC. Enhanced Recovery After Surgery Protocol Reduces Perioperative Narcotic Requirement in Patients Undergoing Mastectomy with Implant-Based Reconstruction. J Am Coll Surg 2018. [DOI: 10.1016/j.jamcollsurg.2018.08.215] [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: 11/26/2022]
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10
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Bauder AR, Samra F, Kanchwala SK, Serletti JM, Kovach SJ, Wu LC. Autologous breast reconstruction in the postbariatric patient population. Microsurgery 2017; 38:134-142. [PMID: 28467614 DOI: 10.1002/micr.30184] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Revised: 03/21/2017] [Accepted: 04/06/2017] [Indexed: 11/07/2022]
Abstract
BACKGROUND Over 175,000 Americans underwent bariatric surgery in 2013 alone, resulting in rapid growth of the massive weight loss population. As obesity is a known risk factor for breast cancer, plastic surgeons are increasingly challenged to reconstruct the breasts of massive weight loss patients after oncologic resection. The goal of this study is to assess the outcomes of autologous breast reconstruction in postbariatric surgery patients at a single institution. METHODS Patients who underwent autologous breast reconstruction between 2008 and 2014 were identified. Those with a history of bariatric surgery were compared to those without a history of bariatric surgery. Analysis included age, ethnicity, BMI, comorbidities, flap type, operative complications, and reoperation rates. Propensity matched analysis was also conducted to control for preoperative differences between the two cohorts. RESULTS Fourteen women underwent breast reconstruction following bariatric surgery, compared to 1,012 controls. Outcomes analysis revealed significant differences in breast revisions (1.35 vs. 0.61, P = .0055), implant placements (0.42 vs. 0.08, P = .0003), and total OR visits (2.78 vs. 1.67, P = .0007). There was no significant difference noted in delayed healing of the breast (57.4% vs. 33.7%, P = .087) or donor site (14.3% vs. 15.8%, P = 1.00). CONCLUSIONS As the rise in bariatric surgery mirrors that of obesity, an increasing amount of massive weight loss patients undergo treatment for breast cancer. We demonstrate profound differences in this patient population, particularly in regards to revision rates, which affects operative planning, patient counseling, and satisfaction.
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Affiliation(s)
- Andrew R Bauder
- Division of Plastic Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Fares Samra
- Division of Plastic Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Suhail K Kanchwala
- Division of Plastic Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joseph M Serletti
- Division of Plastic Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Stephen J Kovach
- Division of Plastic Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Liza C Wu
- Division of Plastic Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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Nelson JA, Chung CU, Bauder AR, Wu LC. Prevention of thrombosis in hypercoagulable patients undergoing microsurgery: A novel anticoagulation protocol. J Plast Reconstr Aesthet Surg 2017; 70:307-312. [DOI: 10.1016/j.bjps.2016.12.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Revised: 10/20/2016] [Accepted: 12/03/2016] [Indexed: 11/30/2022]
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12
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Chang CS, Chu MW, Nelson JA, Basta M, Gerety P, Kanchwala SK, Wu LC. Complications and Cost Analysis of Intraoperative Arterial Complications in Head and Neck Free Flap Reconstruction. J Reconstr Microsurg 2017; 33:318-327. [PMID: 28236793 DOI: 10.1055/s-0037-1598618] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Background Microvascular anastomotic patency is fundamental to head and neck free flap reconstructive success. The aims of this study were to identify factors associated with intraoperative arterial anastomotic issues and analyze the impact on subsequent complications and cost in head and neck reconstruction. Methods A retrospective review was performed on all head and neck free flap reconstructions from 2005 to 2013. Patients with intraoperative, arterial anastomotic difficulties were compared with patients without. Postoperative outcomes and costs were analyzed to determine factors associated with microvascular arterial complications. A regression analysis was performed to control for confounders. Results Total 438 head and neck free flaps were performed, with 24 (5.5%) having intraoperative arterial complications. Patient groups and flap survival between the two groups were similar. Free flaps with arterial issues had higher rates of unplanned reoperations (p < 0.001), emergent take-backs (p = 0.034), and major surgical (p = 0.002) and respiratory (p = 0.036) complications. The overall cost of reconstruction was nearly double in patients with arterial issues (p = 0.001). Regression analysis revealed that African American race (OR = 5.5, p < 0.009), use of vasopressors (OR = 6.0, p = 0.024), end-to-side venous anastomosis (OR = 4.0, p = 0.009), and use of internal fixation hardware (OR =3.5, p = 0.013) were significantly associated with arterial complications. Conclusion Intraoperative arterial complications may impact complications and overall cost of free flap head and neck reconstruction. Although some factors are nonmodifiable or unavoidable, microsurgeons should nonetheless be aware of the risk association. We recommend optimizing preoperative comorbidities and avoiding use of vasopressors in head and neck free flap cases to the extent possible.
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Affiliation(s)
- Catherine S Chang
- Division of Plastic and Reconstructive Surgery, University of Pennsylvania, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael W Chu
- Division of Plastic and Reconstructive Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Jonas A Nelson
- Division of Plastic and Reconstructive Surgery, University of Pennsylvania, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Marten Basta
- Division of Plastic and Reconstructive Surgery, Brown University, Providence, Rhode Island
| | - Patrick Gerety
- Division of Plastic and Reconstructive Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Suhail K Kanchwala
- Division of Plastic and Reconstructive Surgery, University of Pennsylvania, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Liza C Wu
- Division of Plastic and Reconstructive Surgery, University of Pennsylvania, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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13
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Nelson JA, Fischer JP, Grover R, Nelson P, Au A, Serletti JM, Wu LC. Intraoperative vasopressors and thrombotic complications in free flap breast reconstruction. J Plast Surg Hand Surg 2017; 51:336-341. [DOI: 10.1080/2000656x.2016.1269777] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Jonas A. Nelson
- Division of Plastic Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - John P. Fischer
- Division of Plastic Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Ritwik Grover
- Division of Plastic Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
- Department of Plastic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Priscilla Nelson
- Division of Plastic Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
- Department of Anesthesiology, Lankenau Medical Center, Wynnewood, PA, USA
| | - Alex Au
- Division of Plastic Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Joseph M. Serletti
- Division of Plastic Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Liza C. Wu
- Division of Plastic Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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14
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Gao LL, Basta M, Kanchwala SK, Serletti JM, Low DW, Wu LC. Cost‐effectiveness of microsurgical reconstruction for head and neck defects after oncologic resection. Head Neck 2016; 39:541-547. [DOI: 10.1002/hed.24644] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Accepted: 10/21/2016] [Indexed: 11/08/2022] Open
Affiliation(s)
- Lin Lin Gao
- Department of Plastic and Reconstructive SurgeryUniversity of Pennsylvania Health SystemPhiladelphia Pennsylvania
| | - Marten Basta
- Department of Plastic and Reconstructive SurgeryBrown UniversityProvidence Rhode Island
| | - Suhail K. Kanchwala
- Department of Plastic and Reconstructive SurgeryUniversity of Pennsylvania Health SystemPhiladelphia Pennsylvania
| | - Joseph M. Serletti
- Department of Plastic and Reconstructive SurgeryUniversity of Pennsylvania Health SystemPhiladelphia Pennsylvania
| | - David W. Low
- Department of Plastic and Reconstructive SurgeryUniversity of Pennsylvania Health SystemPhiladelphia Pennsylvania
| | - Liza C. Wu
- Department of Plastic and Reconstructive SurgeryUniversity of Pennsylvania Health SystemPhiladelphia Pennsylvania
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Momeni A, Tecce MG, Lanni MA, Aggarwal S, Pannucci C, Kovach SJ, Kanchwala SK, Wu LC, Serletti JM. Increased Lower Extremity Venous Stasis May Contribute to Deep Venous Thrombosis Formation after Microsurgical Breast Reconstruction-An Ultrasonographic Study. J Reconstr Microsurg 2016; 33:173-178. [PMID: 27894155 DOI: 10.1055/s-0036-1594297] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Background Despite guideline-compliant prophylaxis, an increased rate of deep venous thrombosis (DVT) formation has been reported following autologous versus implant-based breast reconstruction. We hypothesized that tight abdominal fascia closure might decrease lower extremity venous return and promote venous stasis. Methods An observational crossover study of patients who underwent autologous breast reconstruction using transverse rectus abdominis musculocutaneous/deep inferior epigastric artery perforator flaps was conducted. Ultrasonographic measurements of the left common femoral vein (CFV) and right internal jugular vein (IJV) were performed preoperatively, in the postanesthesia care unit, and on postoperative day (POD) 1. Parameters of interest included vessel diameter, circumference, area, and maximum flow velocity. Results Eighteen patients with a mean age and body mass index of 52.7 years (range, 29-76 years) and 31.3 kg/m2 (range, 21.9-43.4 kg/m2) were included, respectively. A 29.8% increase in CFV diameter was observed on POD 1 (p < 0.0001). Similarly, a 24.3 and 69.9% increase in CFV circumference (p = 0.0007) and area (p < 0.0001) were noted, respectively. These correlated with a 28.4% decrease in maximum flow velocity in the CFV (p = 0.0001). Of note, none of these parameters displayed significant changes for the IJV, thus indicating that observed changes in the CFV were not the result of changes in perioperative fluid status. Conclusion Postoperative changes observed in the CFV reflect increased lower extremity venous stasis after microsurgical breast reconstruction and may contribute to postoperative DVT formation.
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Affiliation(s)
- Arash Momeni
- Division of Plastic and Reconstructive Surgery, Stanford University Medical Center, Palo Alto, California
| | - Michael G Tecce
- Division of Plastic Surgery, University of Pennsylvania Health Systems, Philadelphia, Pennsylvania
| | - Michael A Lanni
- Division of Plastic Surgery, University of Pennsylvania Health Systems, Philadelphia, Pennsylvania
| | - Shagun Aggarwal
- Division of Plastic Surgery, University of Pennsylvania Health Systems, Philadelphia, Pennsylvania
| | | | - Stephen J Kovach
- Division of Plastic Surgery, University of Pennsylvania Health Systems, Philadelphia, Pennsylvania
| | - Suhail K Kanchwala
- Division of Plastic Surgery, University of Pennsylvania Health Systems, Philadelphia, Pennsylvania
| | - Liza C Wu
- Division of Plastic Surgery, University of Pennsylvania Health Systems, Philadelphia, Pennsylvania
| | - Joseph M Serletti
- Division of Plastic Surgery, University of Pennsylvania Health Systems, Philadelphia, Pennsylvania
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Wu LC, Liu C, Jiang MR, Jiang YM, Wang QH, Lu ZY, Wang SJ, Yang WL, Shao YX. Defective eyelid leading edge cell migration in C57BL/6-corneal opacity mice with an "eye open at birth" phenotype. Genet Mol Res 2016; 15:gmr6741. [PMID: 27706598 DOI: 10.4238/gmr.15036741] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Development of the eyelid requires coordination of the cellular processes involved in proliferation, cell size alteration, migration, and cell death. C57BL/6J-corneal opacity (B6-Co) mice are mutant mice generated by the administration of N-ethyl-N-nitrosourea (100 mg/kg). They exhibit the eyelids open at birth phenotype, abnormal round cell shape from tightened F-actin bundles in leading edge keratinocytes at E16.5, and gradual corneal opacity with neovessels. The tip of the leading edge in B6-Co mice did not move forward, and demonstrated a sharp peak shape without obvious directionality. Analysis of the biological characteristics of B6-Co mice demonstrated that abnormal migration of keratinocytes could affect eyelid development, but proliferation and apoptosis in B6-Co mice had no effect. Mutant gene mapping and sequence analysis demonstrated that in B6-Co mice, adenosine was inserted into the untranslated regions, between 3030 and 3031, in the mRNA 3'-terminal of Fgf10. In addition, guanine 7112 was substituted by adenine in the Mtap1B mRNA, and an A2333T mutation was identified in Mtap1B. Quantitative real-time polymerase chain reaction analysis showed that expression of the Hbegf gene was significantly down-regulated in the eyelids of B6- Co mice at E16.5, compared to B6 mice. However, the expression of Rock1, Map3k1, and Jnk1 genes did not show any significant changes. Abnormal keratinocyte migration and down-regulated expression of the Hbegf gene might be associated with impaired eyelid development in B6-Co mice.
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Affiliation(s)
- L C Wu
- Laboratory Animals Center, Nantong University, Nantong, China
| | - C Liu
- Institute of Comparative Medicine, Nantong University, Nantong, China
| | - M R Jiang
- Laboratory Animals Center, Nantong University, Nantong, China
| | - Y M Jiang
- Laboratory Animals Center, Nantong University, Nantong, China
| | - Q H Wang
- Laboratory Animals Center, Nantong University, Nantong, China
| | - Z Y Lu
- Laboratory Animals Center, Nantong University, Nantong, China
| | - S J Wang
- Laboratory Animals Center, Nantong University, Nantong, China
| | - W L Yang
- Laboratory Animals Center, Nantong University, Nantong, China
| | - Y X Shao
- Laboratory Animals Center, Nantong University, Nantong, China .,Institute of Comparative Medicine, Nantong University, Nantong, China
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Erdmann-Sager J, Wu LC. Advances in Immediate Breast Reconstruction and Reconstruction after Breast Conservation. Curr Surg Rep 2016. [DOI: 10.1007/s40137-016-0153-2] [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: 11/29/2022]
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18
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Butler PD, Nelson JA, Fischer JP, Wink JD, Chang B, Fosnot J, Wu LC, Serletti JM. Racial and age disparities persist in immediate breast reconstruction: an updated analysis of 48,564 patients from the 2005 to 2011 American College of Surgeons National Surgery Quality Improvement Program data sets. Am J Surg 2016; 212:96-101. [DOI: 10.1016/j.amjsurg.2015.08.025] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Revised: 06/29/2015] [Accepted: 08/06/2015] [Indexed: 11/28/2022]
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Yan C, Fischer JP, Freedman GM, Basta MN, Kovach SJ, Serletti JM, Lin L, Wu LC. The Timing of Breast Irradiation in Two-Stage Expander/Implant Breast Reconstruction. Breast J 2016; 22:322-9. [DOI: 10.1111/tbj.12572] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Chen Yan
- Division of Plastic Surgery; Perelman School of Medicine at the University of Pennsylvania; Philadelphia Pennsylvania
| | - John P. Fischer
- Division of Plastic Surgery; Perelman School of Medicine at the University of Pennsylvania; Philadelphia Pennsylvania
| | - Gary M. Freedman
- Division of Radiation Oncology; Perelman School of Medicine at the University of Pennsylvania; Philadelphia Pennsylvania
| | - Marten N. Basta
- Division of Plastic Surgery; Perelman School of Medicine at the University of Pennsylvania; Philadelphia Pennsylvania
| | - Stephen J. Kovach
- Division of Plastic Surgery; Perelman School of Medicine at the University of Pennsylvania; Philadelphia Pennsylvania
| | - Joseph M. Serletti
- Division of Plastic Surgery; Perelman School of Medicine at the University of Pennsylvania; Philadelphia Pennsylvania
| | - Lilie Lin
- Division of Radiation Oncology; Perelman School of Medicine at the University of Pennsylvania; Philadelphia Pennsylvania
| | - Liza C. Wu
- Division of Plastic Surgery; Perelman School of Medicine at the University of Pennsylvania; Philadelphia Pennsylvania
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Ligh CA, Nelson JA, Wink JD, Gerety PA, Fischer JP, Wu LC, Kanchwala SK. An analysis of early oncologic head and neck free flap reoperations from the 2005-2012 ACS-NSQIP dataset. J Plast Surg Hand Surg 2015; 50:85-92. [PMID: 26571114 DOI: 10.3109/2000656x.2015.1106407] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND There are limited population-based studies that examine perioperative factors that influence postoperative surgical take-backs to the OR following free flap (FF) reconstruction for head/neck cancer extirpation. The purpose of this study was to critically analyse head/neck free flaps (HNFF) captured in the ACS-NSQIP dataset with a specific focus on postoperative complications and the incidence of factors associated with re-operation. METHODS The 2005-2012 ACS-NSQIP datasets were accessed to identify patients undergoing FF reconstruction after a diagnosis of head/neck cancer. Patient demographics, comorbidities, and perioperative risk factors were examined as covariates, and the primary outcome was return to OR within 30 days of surgery. A multivariate regression was performed to determine independent preoperative factors associated with this complication. RESULTS In total, 855 patients underwent FF for head/neck reconstruction most commonly for the Tongue (24.7%) and Mouth/Floor/cavity (25.0%). Of these, 153 patients (17.9%) returned to the OR within 30 days of surgery. Patients in this cohort had higher rates of wound infections and dehiscence (p < 0.01). Medical complications were significantly higher and included pneumonia (12.4% vs 5.0%, p < 0.01), prolonged ventilation (16.3% vs 4.8%, p < 0.01), myocardial infarction (2.6% vs 0.6%, p = 0.017), and sepsis (7.2% vs 3.4%, p = 0.033). Regression analysis demonstrated that visceral flaps (OR = 9.7, p = 0.012) and hypoalbuminemia (OR = 2.4, p = 0.009) were significant predictors of a return to the OR. CONCLUSION Based on data from the nationwide NSQIP dataset, up to 17% of HNFF return to the OR within 30 days. Although this data-set has some significant limitations, these results can cautiously help to improve preoperative patient optimisation and surgical decision-making.
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Affiliation(s)
- Cassandra A Ligh
- a Division of Plastic Surgery , Hospital of the University of Pennsylvania , Philadelphia , PA , USA
| | - Jonas A Nelson
- a Division of Plastic Surgery , Hospital of the University of Pennsylvania , Philadelphia , PA , USA
| | - Jason D Wink
- a Division of Plastic Surgery , Hospital of the University of Pennsylvania , Philadelphia , PA , USA
| | - Patrick A Gerety
- a Division of Plastic Surgery , Hospital of the University of Pennsylvania , Philadelphia , PA , USA
| | - John P Fischer
- a Division of Plastic Surgery , Hospital of the University of Pennsylvania , Philadelphia , PA , USA
| | - Liza C Wu
- a Division of Plastic Surgery , Hospital of the University of Pennsylvania , Philadelphia , PA , USA
| | - Suhail K Kanchwala
- a Division of Plastic Surgery , Hospital of the University of Pennsylvania , Philadelphia , PA , USA
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21
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Butler PD, Nelson J, Fischer JP, Wink JD, Chang B, Fosnot J, Wu LC, Serletti JC. Racial and age disparities persist in immediate breast reconstruction: an updated analysis of 48,564 patients from the 2005-2011 American College of Surgeons NSQIP datasets. J Am Coll Surg 2015. [DOI: 10.1016/j.jamcollsurg.2015.08.225] [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: 11/28/2022]
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22
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Basta MN, Fox JP, Kanchwala SK, Wu LC, Serletti JM, Kovach SJ, Fosnot J, Fischer JP. Complicated breast cancer-related lymphedema: evaluating health care resource utilization and associated costs of management. Am J Surg 2015; 211:133-41. [PMID: 26421413 DOI: 10.1016/j.amjsurg.2015.06.015] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [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: 04/29/2015] [Revised: 06/05/2015] [Accepted: 06/16/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND Lymphedema can become a disabling condition necessitating inpatient care. This study aimed to estimate complicated lymphedema incidence after breast cancer surgery and calculate associated hospital resource utilization. METHODS We identified adult women undergoing lumpectomy and/or mastectomy with axillary lymph node surgery between 2006 and 2012 using 5-state inpatient databases. Patients were grouped according to the development of complicated lymphedema. The primary outcomes were all-cause hospitalizations and health care charges within 2 years of surgery. Multivariate regression models were used to compare outcomes. RESULTS Of 56,075 women included, 2.3% had at least 1 hospital admission for complicated lymphedema within 2 years of surgery. Despite confounder adjustment, women with complicated lymphedema experienced 5 fold more all-cause (incidence rate ratio = 5.02, 95% confidence interval: 4.76 to 5.29) admissions compared with women without lymphedema. This resulted in substantially higher health care charges ($58,088 vs $31,819 per patient, P < .001). Although axillary dissection and certain comorbidities were associated with complicated lymphedema, breast reconstruction appeared unrelated. CONCLUSIONS Complicated lymphedema develops in a quantifiable number of patients. The health care burden of lymphedema underscored here mandates further investigation into targeted, anticipatory management strategies for breast cancer-related lymphedema.
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Affiliation(s)
- Marten N Basta
- Division of Plastic Surgery, Perelman School of Medicine at the University of Pennsylvania, University of Pennsylvania Health System, 10 Penn Tower, 3400 Civic Center Blvd., Philadelphia, PA 19103
| | - Justin P Fox
- Division of Plastic Surgery, Perelman School of Medicine at the University of Pennsylvania, University of Pennsylvania Health System, 10 Penn Tower, 3400 Civic Center Blvd., Philadelphia, PA 19103
| | - Suhail K Kanchwala
- Division of Plastic Surgery, Perelman School of Medicine at the University of Pennsylvania, University of Pennsylvania Health System, 10 Penn Tower, 3400 Civic Center Blvd., Philadelphia, PA 19103
| | - Liza C Wu
- Division of Plastic Surgery, Perelman School of Medicine at the University of Pennsylvania, University of Pennsylvania Health System, 10 Penn Tower, 3400 Civic Center Blvd., Philadelphia, PA 19103
| | - Joseph M Serletti
- Division of Plastic Surgery, Perelman School of Medicine at the University of Pennsylvania, University of Pennsylvania Health System, 10 Penn Tower, 3400 Civic Center Blvd., Philadelphia, PA 19103
| | - Stephen J Kovach
- Division of Plastic Surgery, Perelman School of Medicine at the University of Pennsylvania, University of Pennsylvania Health System, 10 Penn Tower, 3400 Civic Center Blvd., Philadelphia, PA 19103
| | - Joshua Fosnot
- Division of Plastic Surgery, Perelman School of Medicine at the University of Pennsylvania, University of Pennsylvania Health System, 10 Penn Tower, 3400 Civic Center Blvd., Philadelphia, PA 19103
| | - John P Fischer
- Division of Plastic Surgery, Perelman School of Medicine at the University of Pennsylvania, University of Pennsylvania Health System, 10 Penn Tower, 3400 Civic Center Blvd., Philadelphia, PA 19103.
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Abstract
Abdominally based free flaps have become the mainstay for women that desire to use their own tissue as a means of breast reconstruction after mastectomy. As the techniques have evolved, significant effort has been invested in finding the best means of minimizing morbidity to the abdominal donor site while ensuring a viable reconstructed breast that is aesthetically pleasing. This manuscript reviews and compares the muscle sparing free transverse rectus abdominis myocutaneous (MsfTRAM), the deep inferior epigastric artery perforator (DIEP), and the superficial inferior epigastric artery (SIEA) flaps, regarding flap success rate, operative times, abdominal donor site morbidity and residual functionality, hospital lengths of stay and associated costs, impact of co-morbid conditions, and resilience after adjuvant radiation treatment.
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Affiliation(s)
- Paris D Butler
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, Philadelphia, PA 19104, USA
| | - Liza C Wu
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, Philadelphia, PA 19104, USA
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Nelson JA, Fischer JP, Grover R, Kovach SJ, Low DW, Kanchwala SK, Levin LS, Serletti JM, Wu LC. Vein grafting your way out of trouble: Examining the utility and efficacy of vein grafts in microsurgery. J Plast Reconstr Aesthet Surg 2015; 68:830-6. [PMID: 25812752 DOI: 10.1016/j.bjps.2015.02.008] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [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: 11/19/2014] [Accepted: 02/03/2015] [Indexed: 10/24/2022]
Abstract
INTRODUCTION There is limited data on the indications, outcomes, and associated complications with use of interpositional vein grafts (IVG) in microsurgery. This study sought to critically examine and update the utility of this microsurgical technique. METHODS All microsurgical cases at a single institution from 2005 to 2011 were examined for use of IVGs in the primary procedure or during take back or salvage attempts. We examined the cohort overall and performed a subgroup analysis by timing of initial IVG. RESULTS In the study period, 1718 patients underwent 2368 free flaps. 51 IVGs were utilized in 38 patients (2.2%) and 38 flaps (1.6%). Eight (42.1%) of the primary procedure IVGs (n = 19) were planned preoperatively. Nine total flap losses (24%) occurred when IVGs were utilized, 89% of which occurred in the take back cohort (p = 0.02). However, planned IVG had a 100% success rate, and IVG utilized in the primary procedure overall had a 95% success rate. Importantly, A significantly higher rate of thrombotic events was noted in all primary cases where IVGs were utilized (p = 0.005). CONCLUSIONS This study demonstrates that IVGs can be utilized in primary free flap reconstructions with success rates exceeding 95%. However, in salvage procedures, the use of vein grafts does not approach the same rate of success likely due to multiple factors. Yet when utilized appropriately with thrombectomy and resection of the thrombosed vessel to healthy intima, IVGs can provide an important tool for flap salvage. LEVEL OF EVIDENCE prognostic/risk category, level II.
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Affiliation(s)
- Jonas A Nelson
- Division of Plastic Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.
| | - John P Fischer
- Division of Plastic Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Ritwik Grover
- Department of Plastic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Stephen J Kovach
- Division of Plastic Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA; Department of Orthopaedic Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - David W Low
- Division of Plastic Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Suhail K Kanchwala
- Division of Plastic Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - L Scott Levin
- Division of Plastic Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA; Department of Orthopaedic Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Joseph M Serletti
- Division of Plastic Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Liza C Wu
- Division of Plastic Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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Yan C, Fischer JP, Wes AM, Basta MN, Rohrbach JI, Kovach SJ, Serletti JM, Wu LC. The cost of major complications associated with immediate two-stage expander/implant-based breast reconstruction. J Plast Surg Hand Surg 2014; 49:166-71. [DOI: 10.3109/2000656x.2014.970639] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Butler PD, Nelson JA, Fischer JP, Chang B, Kanchwala S, Wu LC, Serletti JM. African-American women have equivalent outcomes following autologous free flap breast reconstruction despite greater preoperative risk factors. Am J Surg 2014; 209:589-96. [PMID: 25576165 DOI: 10.1016/j.amjsurg.2014.11.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [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: 08/11/2014] [Revised: 09/30/2014] [Accepted: 11/21/2014] [Indexed: 01/21/2023]
Abstract
BACKGROUND Disparities along racial and ethnic lines exist in breast cancer treatment and reconstruction. This study compares preoperative characteristics among female breast cancer patients who received autologous breast reconstruction to determine if race affects clinical outcomes. METHODS Women receiving autologous breast reconstruction at a single institution from 2005 to 2011 were identified within a prospectively maintained database. Preoperative risk factors and rates of postoperative morbidity and mortality were assessed with respect to race. RESULTS African-American patients had significantly higher rates of preoperative comorbidities than Caucasian patients. Despite the heightened preoperative risk factors, postoperative complications did not significantly differ between racial categories. CONCLUSION As the alleviation of healthcare disparities remains a focus of healthcare reform, these findings are beneficial in further educating African-American breast cancer patients and their providers of the safe and viable option of autologous tissue transfer for breast reconstruction.
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Affiliation(s)
- Paris D Butler
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, 10 Penn Tower, 3400 Spruce Street, Philadelphia, PA 19104, USA.
| | - Jonas A Nelson
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, 10 Penn Tower, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - John P Fischer
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, 10 Penn Tower, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Benjamin Chang
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, 10 Penn Tower, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Suhail Kanchwala
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, 10 Penn Tower, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Liza C Wu
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, 10 Penn Tower, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Joseph M Serletti
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, 10 Penn Tower, 3400 Spruce Street, Philadelphia, PA 19104, USA
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Nelson JA, Fischer JP, Grover R, Mirzabeigi MN, Nelson P, Wes AM, Au A, Serletti JM, Wu LC. Intraoperative perfusion management impacts postoperative outcomes: an analysis of 682 autologous breast reconstruction patients. J Plast Reconstr Aesthet Surg 2014; 68:175-83. [PMID: 25456289 DOI: 10.1016/j.bjps.2014.10.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2014] [Revised: 07/22/2014] [Accepted: 10/01/2014] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Anesthetic management remains an understudied aspect of free autologous breast reconstruction. This study aims to critically examine intraoperative anesthetic management as it relates to free flap perfusion and its effect on major complications. METHODS A retrospective cohort study was performed examining all abdominally based free autologous breast reconstructions from 2005 to 2011 at a single institution. Analysis focused on perioperative care and specifically fluid administration, urine output (UOP), vasopressor administration, and case duration. Outcomes included major intraoperative and postoperative complications. A post-hoc analysis was performed to determine anesthetic factors associated with thrombotic events. RESULTS Overall, 682 patients (1033 flaps) were included. Patients with low UOP had lower rates of intraoperative fluid infusion rates/kg (p=0.0001), Estimated Blood Loss (EBL) (p=0.006) and pressor administration (p=0.03), but no significant differences were noted in intraoperative thrombotic events according to UOP. However, the below normal UOP cohort demonstrated a significant increased rate of delayed postoperative thromboses (p=0.03). A post hoc analysis of postoperative thrombotic events revealed that low rates of fluid resuscitation (OR=3.01, p=0.04) and low intraoperative UOP (OR=3.67, p=0.04) were independently associated with delayed thrombosis. A sub-analysis demonstrated that patients with ≥2 comorbidities and below normal UOP were at particular risk (any delayed thrombotic event OR=4.3, p=0.03; any delayed venous thrombosis OR=9.1, p=0.03). CONCLUSIONS This study demonstrates that intraoperative fluid under-resuscitation may place patients at increased risk for postoperative flap thrombosis, and low UOP is an important metric whereby intraoperative resuscitation should be gauged. Patients with comorbid conditions and below normal intraoperative UOP should be monitored particularly closely for delayed thrombotic events. LEVEL OF EVIDENCE Prognostic/risk category, level II.
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Affiliation(s)
- Jonas A Nelson
- Division of Plastic Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.
| | - John P Fischer
- Division of Plastic Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Ritwik Grover
- Division of Plastic Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Michael N Mirzabeigi
- Division of Plastic Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | | | - Ari M Wes
- Division of Plastic Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Alex Au
- Division of Plastic Surgery, Yale New-Haven Hospital, New Haven, CT, USA
| | - Joseph M Serletti
- Division of Plastic Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Liza C Wu
- Division of Plastic Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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Butler PD, Nelson J, Fischer JP, Chang B, Serletti JC, Wu LC. Despite elevated preoperative risk factors, equivalent outcomes for autologous breast reconstruction in African American women. J Am Coll Surg 2014. [DOI: 10.1016/j.jamcollsurg.2014.07.797] [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: 11/30/2022]
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Wes AM, Fischer JP, Nelson JA, Serletti JM, Kovach SJ, Wu LC. Venous Thromboembolism in Body Contouring. Plast Reconstr Surg 2014. [DOI: 10.1097/01.prs.0000455487.25206.60] [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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Fischer JP, Wes AM, Tuggle CT, Nelson JA, Tchou JC, Serletti JM, Kovach SJ, Wu LC. Mastectomy with or without immediate implant reconstruction has similar 30-day perioperative outcomes. J Plast Reconstr Aesthet Surg 2014; 67:1515-22. [PMID: 25175274 DOI: 10.1016/j.bjps.2014.07.021] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2013] [Revised: 05/13/2014] [Accepted: 07/22/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Immediate breast reconstruction (IBR) using implants remains a favorable reconstructive option in breast cancer. Understanding the added risk associated with IBR continues to enhance the risk counseling process and management of these patients. METHODS Women undergoing mastectomy alone and mastectomy with tissue expander (TE) were identified in the ACS-NSQIP datasets. Specific complications examined included any, wound, medical complications, and deep infections. Bivariate and multivariate analyses were performed to identify predictors of outcomes, and propensity-matching was used to compare cohorts. RESULTS A total of 42,823 patients who underwent either mastectomy alone (N = 30,440) or mastectomy with immediate TE placement (N = 12,383) were identified. Notable independently associated perioperative differences between mastectomy and TE patients included: race (P < 0.001), comorbidity burden (P < 0.001), year of surgery (P < 0.001), ASA physical status (P < 0.001), functional status (P < 0.001), inpatient procedures (P < 0.001), bilateral procedures (P < 0.001), BMI (P < 0.001), age (P < 0.001), and lymphadenectomy (P < 0.001). IBR using TE was not found to be associated with greater risk of wound (3.3% vs. 3.2%, P = 0.855), medical (1.7% vs. 1.6%, P = 0.751), or overall (9.6% vs. 10.0%, P = 0.430) complications. TE placement was associated with higher rates of deep wound infections (2.0% vs. 1.0%, P < 0.001) and unplanned reoperations (6.9% vs. 6.1%, P = 0.025). Additionally, the rate of 30-day device loss was 0.8% in patients receiving reconstruction. Multivariate conditional (fixed-effects) logistic regression analysis failed to demonstrate significantly associated independent risk of wound, medical, or overall complications with the addition of TE. CONCLUSIONS Undergoing IBR with TE placement does not confer added risk of wound, medical, or overall morbidity relative to mastectomy alone based upon propensity-matched 30-day complication rates in 15,238 patients from the 2005-2011 ACS-NSQIP datasets. These findings further confirm the safety profile of prosthetic-based IBR. LEVEL OF EVIDENCE Prognostic/risk category, level II.
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Affiliation(s)
- John P Fischer
- Division of Plastic Surgery, Department of Surgery, Perelman School of Medicine at the Hospital of the University of Pennsylvania, Philadelphia, PA, USA.
| | - Ari M Wes
- Division of Plastic Surgery, Department of Surgery, Perelman School of Medicine at the Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Charles T Tuggle
- Section of Plastic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Jonas A Nelson
- Division of Plastic Surgery, Department of Surgery, Perelman School of Medicine at the Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Julia C Tchou
- Division of Endocrine and Oncologic Surgery, Department of Surgery, Perelman School of Medicine at the Hospital of the University of Pennsylvania, Philadelphia, PA, USA; Abramson Cancer Center and the Rena Rowan Breast Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Joseph M Serletti
- Division of Plastic Surgery, Department of Surgery, Perelman School of Medicine at the Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Stephen J Kovach
- Division of Plastic Surgery, Department of Surgery, Perelman School of Medicine at the Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Liza C Wu
- Division of Plastic Surgery, Department of Surgery, Perelman School of Medicine at the Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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Pannucci CJ, Nelson JA, Chung CU, Fischer JP, Kanchwala SK, Kovach SJ, Serletti JM, Wu LC. Medicinal leeches for surgically uncorrectable venous congestion after free flap breast reconstruction. Microsurgery 2014; 34:522-6. [DOI: 10.1002/micr.22277] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2014] [Revised: 04/29/2014] [Accepted: 05/02/2014] [Indexed: 11/06/2022]
Affiliation(s)
| | - Jonas A. Nelson
- Division of Plastic Surgery; University of Pennsylvania; Philadelphia PA
| | - Cyndi U. Chung
- Division of Plastic Surgery; University of Pennsylvania; Philadelphia PA
| | - John P. Fischer
- Division of Plastic Surgery; University of Pennsylvania; Philadelphia PA
| | | | - Stephen J. Kovach
- Division of Plastic Surgery; University of Pennsylvania; Philadelphia PA
| | - Joseph M. Serletti
- Division of Plastic Surgery; University of Pennsylvania; Philadelphia PA
| | - Liza C. Wu
- Division of Plastic Surgery; University of Pennsylvania; Philadelphia PA
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Fischer JP, Wes AM, Nelson JA, Basta M, Rohrbach JI, Wu LC, Serletti JM, Kovach SJ. Propensity-matched, longitudinal outcomes analysis of complications and cost: comparing abdominal free flaps and implant-based breast reconstruction. J Am Coll Surg 2014; 219:303-12. [PMID: 24916480 DOI: 10.1016/j.jamcollsurg.2014.02.028] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Revised: 02/14/2014] [Accepted: 02/17/2014] [Indexed: 01/09/2023]
Abstract
BACKGROUND Choosing a breast reconstructive modality after mastectomy is an important step in the reconstructive process. The authors hypothesized that autologous tissue is associated with a greater success rate and cost efficacy over time, relative to implant reconstruction. STUDY DESIGN A retrospective review was performed of patients undergoing free tissue (FF) transfer and expander implant (E/I) reconstruction between 2005 and 2011. Variables evaluated included comorbidities, surgical timing, complications, overall outcomes, unplanned reoperations, and costs. A propensity-matching technique was used to account for the nonrandomized selection of modality. RESULTS A total of 310 propensity-matched patients underwent 499 reconstructions. No statistically significant differences in preoperative variables were noted between propensity-matched cohorts. Operative characteristics were similar between FF and E/I reconstructions. The E/I reconstruction was associated with a significantly higher rate of reconstructive failure (5.6% vs 1.2%, p < 0.001). Expander implant reconstructions were associated with higher rates of seroma (p = 0.009) and lower rates of medical complications (p = 0.02), but overall significantly higher rates of unplanned operations (15.5% vs 5.8%, p = 0.002). The total cost of reconstruction did not differ significantly between groups ($23,120.49 ± $6,969.56 vs $22,739.91 ± $9,727.79, p = 0.060), but E/I reconstruction was associated with higher total cost for secondary procedures ($10,157.89 ± $8,741.77 vs $3,200.71 ± $4,780.64, p < 0.0001) and a higher cost of unplanned revisions over time (p < 0.05). CONCLUSIONS Our matched outcomes analysis does demonstrate a higher overall, 2-year success rate using FF reconstruction and a significantly lower rate of unplanned surgical revisions and cost. Although autologous reconstruction is not ideal for every patient, these findings can be used to enhance preoperative discussions when choosing a reconstructive modality.
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Affiliation(s)
- John P Fischer
- Division of Plastic Surgery, Perelman School of Medicine at the Hospital of the University of Pennsylvania, Philadelphia, PA.
| | - Ari M Wes
- Division of Plastic Surgery, Perelman School of Medicine at the Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Jonas A Nelson
- Division of Plastic Surgery, Perelman School of Medicine at the Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Marten Basta
- Division of Plastic Surgery, Perelman School of Medicine at the Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Jeffrey I Rohrbach
- Division of Finance, Perelman School of Medicine at the Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Liza C Wu
- Division of Plastic Surgery, Perelman School of Medicine at the Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Joseph M Serletti
- Division of Plastic Surgery, Perelman School of Medicine at the Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Stephen J Kovach
- Division of Plastic Surgery, Perelman School of Medicine at the Hospital of the University of Pennsylvania, Philadelphia, PA
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Wes AM, Fischer JP, Tuggle CT, Nelson JA, Tchou JC, Serletti JM, Kovach SJ, Wu LC. Abstract 36. Plast Reconstr Surg 2014. [DOI: 10.1097/01.prs.0000445819.54375.26] [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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Wink JD, Fischer JP, Nelson JA, Serletti JM, Wu LC. Direct-to-implant breast reconstruction: An analysis of 1612 cases from the ACS-NSQIP surgical outcomes database. J Plast Surg Hand Surg 2014; 48:375-81. [DOI: 10.3109/2000656x.2014.899240] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Lu SM, Nelson JA, Fischer JP, Fosnot J, Goldstein J, Selber JC, Serletti JM, Wu LC. The impact of complications on function, health, and satisfaction following abdominally based autologous breast reconstruction: a prospective evaluation. J Plast Reconstr Aesthet Surg 2014; 67:682-92. [PMID: 24553313 DOI: 10.1016/j.bjps.2014.01.017] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [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: 08/12/2013] [Revised: 11/26/2013] [Accepted: 01/15/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND The impact of surgical complications following autologous reconstruction on abdominal strength, health, and satisfaction is not completely understood. We prospectively examined the effect of complications on these aspects in patients undergoing abdominally-based autologous reconstruction. METHODS A prospective study of patients who underwent autologous breast reconstruction between 2005 and 2010 was performed at a single teaching hospital. Patients enrolled in the study completed an abdominal strength functional assessment, the Short Form 36 (SF-36), and a satisfaction survey. Data were obtained at preoperative, early (<90 d), intermediate (90-365 d), and late (>365 d) follow-up visits. Patients who experienced surgical complications were compared with patients who did not. A subgroup analysis examined the specific impact of abdominal complications. RESULTS Overall, 97 enrolled patients had preoperative, early and intermediate follow up. Forty of these patients had late follow-up. Fifty-six (58%) experienced surgical complications. After reconstruction, the complications group had decreased upper abdominal strength and function scores through early (p = 0.009, p = 0.01) and intermediate (p = 0.01, p = 0.06) follow-up. SF-36 physical health (p = 0.053) trended towards being lower in the early follow-up period. The complications group was less satisfied with the overall cosmetic result (p = 0.01) and shape of breasts (p = 0.02) through intermediate follow-up. At late follow-up, both cohorts recovered to baseline values in all study aspects. Patients with abdominal complications alone followed similar trends, with decreased upper abdominal strength and FIM scores through intermediate follow up. CONCLUSIONS Having a major postoperative complication can significantly impact early physical health, mental health, abdominal strength, and patient satisfaction. Beyond one year, recovery towards baseline may occur in the majority of patients. LEVEL OF EVIDENCE Prognostic/Risk Study, Level II.
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Affiliation(s)
- Stephen M Lu
- Division of Plastic Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Jonas A Nelson
- Division of Plastic Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.
| | - John P Fischer
- Division of Plastic Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Joshua Fosnot
- Division of Plastic Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Jesse Goldstein
- Division of Plastic Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Jesse C Selber
- Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Joseph M Serletti
- Division of Plastic Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Liza C Wu
- Division of Plastic Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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Fischer JP, Shang EK, Nelson JA, Wu LC, Serletti JM, Kovach SJ. Patterns of preoperative laboratory testing in patients undergoing outpatient plastic surgery procedures. Aesthet Surg J 2014; 34:133-41. [PMID: 24334303 DOI: 10.1177/1090820x13515880] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [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: 11/16/2022] Open
Abstract
BACKGROUND Preoperative laboratory testing is commonplace in the clinical setting and is often utilized at surgeon discretion. We searched the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) data set to determine the impact of preoperative laboratory testing in ambulatory plastic surgery patients. OBJECTIVE The authors assess the utilization and predictive value of preoperative laboratory testing in outpatient plastic surgery procedures. METHODS Patients undergoing ambulatory plastic surgery were identified from the 2005 to 2010 NSQIP databases. Laboratory tests were categorized by group: hematologic, chemistry, coagulation, and liver function tests (LFT). We defined complications in 2 groups: major postoperative and wound complications. Multivariate analyses were used to identify patient characteristics associated with testing and to assess the ability of laboratory testing to predict postoperative complications. RESULTS A total of 5359 (62.0%) patients underwent testing; 881 (16.4%) tests were performed on the day of surgery. In patients with no defined NSQIP comorbidities, 59.4% underwent preoperative testing and had a significantly lower rate of abnormal findings (33.4% vs 25.3%, P < .0001). In multivariate analyses, testing was associated with older age, American Society of Anesthesiologists class >2, Hispanic or African American race, body contouring procedures, epidural or spinal procedures, and with diabetes, hypertension, and cancer. Major complications occurred in 0.34% of patients. Our analysis demonstrated that neither testing nor abnormal results were associated with postoperative complications, either major (P = .178) or wound (P = .150). CONCLUSIONS We found no association between abnormal laboratory testing and postoperative morbidity. Preoperative testing in low-risk ambulatory plastic surgery patients may be costly and has limited direct clinical benefit.
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Affiliation(s)
- John P Fischer
- Department of Surgery, Division of Plastic Surgery, Hospital of the University of Pennsylvania, Philadelphia
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Nelson JA, Fischer JP, Yan C, Fosnot J, Selber JC, Wu LC, Serletti JM, Kanchwala S. The impact of obesity on abdominal wall function after free autologous breast reconstruction. Microsurgery 2013; 34:352-60. [DOI: 10.1002/micr.22218] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2013] [Revised: 12/02/2013] [Accepted: 12/12/2013] [Indexed: 11/06/2022]
Affiliation(s)
- Jonas A. Nelson
- Division of Plastic Surgery, Hospital of the University of Pennsylvania; Philadelphia PA
| | - John P. Fischer
- Division of Plastic Surgery, Hospital of the University of Pennsylvania; Philadelphia PA
| | - Chen Yan
- Division of Plastic Surgery, Hospital of the University of Pennsylvania; Philadelphia PA
| | - Joshua Fosnot
- Division of Plastic Surgery, Hospital of the University of Pennsylvania; Philadelphia PA
| | - Jesse C. Selber
- Department of Plastic Surgery; MD Anderson Cancer Center; Houston TX
| | - Liza C. Wu
- Division of Plastic Surgery, Hospital of the University of Pennsylvania; Philadelphia PA
| | - Joseph M. Serletti
- Division of Plastic Surgery, Hospital of the University of Pennsylvania; Philadelphia PA
| | - Suhail Kanchwala
- Division of Plastic Surgery, Hospital of the University of Pennsylvania; Philadelphia PA
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Fischer JP, Wes AM, Tuggle CT, Serletti JM, Wu LC. Risk Analysis of Early Implant Loss after Immediate Breast Reconstruction: A Review of 14,585 Patients. J Am Coll Surg 2013; 217:983-90. [DOI: 10.1016/j.jamcollsurg.2013.07.389] [Citation(s) in RCA: 81] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2013] [Revised: 07/10/2013] [Accepted: 07/10/2013] [Indexed: 11/25/2022]
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Nelson JA, Fischer JP, Grover R, Cleveland E, Erdmann-Sager J, Serletti JM, Wu LC. The impact of anemia on microsurgical breast reconstruction complications and outcomes. Microsurgery 2013; 34:261-70. [DOI: 10.1002/micr.22202] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2013] [Revised: 10/14/2013] [Accepted: 10/21/2013] [Indexed: 12/14/2022]
Affiliation(s)
- Jonas A. Nelson
- Division of Plastic Surgery; Hospital of the University of Pennsylvania; Philadelphia PA
| | - John P. Fischer
- Division of Plastic Surgery; Hospital of the University of Pennsylvania; Philadelphia PA
| | - Ritwik Grover
- Division of Plastic Surgery; Hospital of the University of Pennsylvania; Philadelphia PA
| | - Emily Cleveland
- Division of Plastic Surgery; Hospital of the University of Pennsylvania; Philadelphia PA
| | - Jessica Erdmann-Sager
- Division of Plastic Surgery at Brigham and Women's Hospital; Harvard University; Boston MA
| | - Joseph M. Serletti
- Division of Plastic Surgery; Hospital of the University of Pennsylvania; Philadelphia PA
| | - Liza C. Wu
- Division of Plastic Surgery; Hospital of the University of Pennsylvania; Philadelphia PA
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Fischer JP, Nelson JA, Serletti JM, Wu LC. Peri-operative risk factors associated with early tissue expander (TE) loss following immediate breast reconstruction (IBR): A review of 9305 patients from the 2005–2010 ACS-NSQIP datasets. J Plast Reconstr Aesthet Surg 2013; 66:1504-12. [DOI: 10.1016/j.bjps.2013.06.030] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2013] [Revised: 06/10/2013] [Accepted: 06/17/2013] [Indexed: 10/26/2022]
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Fischer JP, Mirzabeigi MN, Sieber BA, Nelson JA, Wu LC, Kovach SJ, Low DW, Serletti JM, Kanchwala S. Outcome analysis of 244 consecutive flaps for managing complex groin wounds. J Plast Reconstr Aesthet Surg 2013; 66:1396-404. [DOI: 10.1016/j.bjps.2013.06.014] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2013] [Revised: 04/06/2013] [Accepted: 06/03/2013] [Indexed: 10/26/2022]
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Fischer JP, Wes AM, Tuggle CT, Serletti JM, Wu LC. Risk analysis and stratification of surgical morbidity after immediate breast reconstruction. J Am Coll Surg 2013; 217:780-7. [PMID: 24074811 DOI: 10.1016/j.jamcollsurg.2013.07.004] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2013] [Accepted: 07/01/2013] [Indexed: 11/27/2022]
Abstract
BACKGROUND Surgical complications after breast reconstruction can be associated with significant morbidity, dissatisfaction, and cost. We used the ACS-NSQIP datasets from 2005 to 2011 to derive predictors of morbidity and to stratify risk after immediate breast reconstruction (IBR). STUDY DESIGN Surgical complications after implant and autologous reconstruction were assessed using the ACS-NSQIP 2005 to 2011 datasets. Patient demographics, clinical characteristics, and operative factors were associated with the likelihood of experiencing a surgical complication. A "model cohort" of 12,129 patients was randomly selected from the study cohort to derive predictors. Weighted odds ratios derived from logistic regression analysis were used to create a composite risk score and to stratify patients. The remaining one-third of the cohort (n = 6,065) were used as the "validation cohort" to assess the accuracy value of the risk model. RESULTS On adjusted analysis, autologous reconstruction (odds ratio [OR] 1.41, p < 0.001), American Society of Anesthesiologists physical status ≥ 3 (OR 1.25, p = 0.004), class I obesity (OR 1.38, p < 0.001), class II obesity (OR 1.91, p < 0.001), class III obesity (OR 1.70, p < 0.001), and active smoking (OR 1.46, p < 0.001) were associated with complications. Risk factors were weighted and patients were stratified into low (0 to 2, n = 9,133, risk = 7.14%), intermediate (3 to 4, n = 1,935, risk = 10.90%), high (5 to 7, n = 1,024, risk = 16.70%), and very high (8 to 9, n = 37, risk = 27.02%) risk categories based on their total risk score (p < 0.001). Internal validation of the "model cohort" using the "validation cohort" was performed demonstrating accurate prediction of risk across groups: low (7.1% vs 7.1%, respectively, p = 0.9), intermediate (10.9% vs 12.0%, respectively, p = 0.38), high (16.7% vs 16.8%, respectively, p = 0.95), and very high (27.0% vs 30.0%, respectively, p = 1.0). CONCLUSIONS Surgical complications after IBR are related to preoperatively identifiable factors that can be used to accurately risk stratify patients, which may assist with counseling, selection, and perioperative decision-making.
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Affiliation(s)
- John P Fischer
- Division of Plastic Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA.
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Nelson JA, Fischer JP, Radecki MA, Pasick C, McGrath J, Serletti JM, Wu LC. Delayed autologous breast reconstruction: factors which influence patient decision making. J Plast Reconstr Aesthet Surg 2013; 66:1513-20. [PMID: 23886556 DOI: 10.1016/j.bjps.2013.06.020] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2012] [Revised: 03/20/2013] [Accepted: 06/04/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Autologous breast reconstruction timing continues to be controversial. The purpose of this study was to examine delayed autologous breast reconstruction at a center favouring immediate reconstruction to better understand factors driving the decision to delay reconstruction. METHODS We performed a retrospective cohort study of all free autologous breast reconstruction patients between 2005 and 2009, focussing on ethnicity, cancer stage, unilateral or bilateral reconstructions, initial management, distance from the institution, and average income. Delayed reconstructions were compared to immediate reconstructions. All delayed reconstructions were surveyed to examine treatment and reconstruction decisions and satisfaction. RESULTS Of 709 patients, 169 (24%) underwent delayed treatment. Delayed reconstruction patients had higher cancer stages (p < 0.001), higher rates of pre-reconstruction radiation therapy (64% vs. 20%, p < 0.0001) and higher rates of unilateral reconstruction (64% vs. 48%, p < 0.001). Seventy delayed patients responded to the survey (41%), with 75% having had their initial mastectomy at an outside health system. Only 51% discussed immediate reconstruction prior to electing delayed treatment and 41% had no discussion regarding advantages or disadvantages to reconstructive options. Approximately 30% noted no choice in their reconstructive timing. Forty five percent would elect immediate reconstruction if given the option. CONCLUSIONS This study demonstrates that women may not be receiving all available information prior to undergoing mastectomy for initial breast cancer treatment. As a significant portion of women electing delayed reconstruction would elect immediate autologous reconstruction if given the option again, there is room for improvement in pre-operative patient education and in the education of our oncology colleagues.
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Affiliation(s)
- Jonas A Nelson
- Division of Plastic Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States.
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Fischer JP, Nelson JA, Au A, CT T, Serletti JM, Wu LC. Complications and morbidity following breast reconstruction – a review of 16,063 cases from the 2005–2010 NSQIP datasets. J Plast Surg Hand Surg 2013; 48:104-14. [DOI: 10.3109/2000656x.2013.819003] [Citation(s) in RCA: 85] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Yang RL, Newman AS, Lin IC, Reinke CE, Karakousis GC, Czerniecki BJ, Wu LC, Kelz RR. Trends in immediate breast reconstruction across insurance groups after enactment of breast cancer legislation. Cancer 2013; 119:2462-8. [PMID: 23585144 DOI: 10.1002/cncr.28050] [Citation(s) in RCA: 86] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2012] [Revised: 01/07/2013] [Accepted: 01/28/2013] [Indexed: 11/07/2022]
Abstract
BACKGROUND To improve access to breast reconstruction for mastectomy patients, the United States enacted the Women's Health and Cancer Rights Act in January of 1999. The objective of the current study was to evaluate the impact of this legislation on patients with different insurance plans. METHODS Women aged ≥18 years who underwent mastectomy for cancer were identified in the Nationwide Inpatient Sample database (2000-2009) and were classified according to their immediate breast reconstruction (IBR) status. Trends in rates of IBR were described for each insurance category. Multivariable logistic regression analysis with adjustment for age, race, estimated household income, and Elixhauser comorbidity index was performed to evaluate the relation between insurance status and IBR. RESULTS In total, 168,236 patients were identified who underwent a mastectomy during the study interval. Across the 10-year study period, rates of IBR increased 4.2-fold in Medicaid patients, 2.9-fold in Medicare patients, 2.6-fold in privately insured patients, and 2.1-fold in self-pay patients (P < .01). However, after adjustment for confounders, women without private insurance were less likely to undergo IBR compared with women who had private insurance (Medicaid: odds ratio [OR], 0.34; 95% confidence interval [CI], 0.32-0.37; Medicare: OR, 0.53; 95% CI, 0.49-0.58; self-pay: OR, 0.43; 95% CI, 0.37-0.50; other types of nonprivate insurance: OR, 0.64, 95% CI, 0.56-0.73). CONCLUSIONS After the enactment of policy designed to improve access to IBR, Medicaid and Medicare patients experienced the greatest relative increase in rates of IBR. Although policy changes had the most impact on traditionally underserved populations, disparities still exist. Future studies should endeavor to understand why such disparities have persisted.
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Affiliation(s)
- Rachel L Yang
- Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA.
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Piao MZ, Zhou XT, Wu LC, Chu RY. Arg555Gln mutation of TGFBI gene in geographical-type Reis-Bücklers corneal dystrophy in a Chinese family. J Int Med Res 2013; 40:1149-55. [PMID: 22906289 DOI: 10.1177/147323001204000335] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE Mutations of the transforming growth factor β-induced (TGFBI) gene were studied in a Chinese family with Reis-Bücklers corneal dystrophy (RBCD). METHODS Six family members with RBCD and six unaffected family members were investigated. The pedigree showed a typical dominant inheritance pattern. Genomic DNA was extracted from peripheral leucocytes from all study participants. Exons 4, 12 and 14 of the TGFBI gene were analysed using polymerase chain reaction, and standard automated sequencing was performed. Corneal tissue sampled from the proband during phototherapeutic keratectomy was examined using transmission electron microscopy (TEM). RESULTS A typical geographical pattern of fine opacities in Bowman's layer of the cornea was seen in all six patients on slit-lamp examination. An Arg555Gln (R555Q) mutation of the TGFBI gene was identified in all six patients but was absent in all unaffected family members. TEM revealed rod-shaped bodies in Bowman's layer of the cornea. CONCLUSIONS In this Chinese family an R555Q mutation of the TGFBI gene was associated with RBCD. As the RBCD phenotype is usually associated with an R124L mutation, this novel genotype-phenotype correlation may prompt further investigation of Bowman's layer corneal dystrophy.
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Affiliation(s)
- M Z Piao
- National Ministry of Health Key Laboratory of Myopia, Eye and ENT Hospital Affiliated to Fudan University, Shanghai, China
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Fischer JP, Sieber B, Nelson JA, Kovach SJ, Taylor JA, Serletti JM, Wu LC, Kanchwala S, Bartlett SP, Low DW. A 15-year experience of complex scalp reconstruction using free tissue transfer-analysis of risk factors for complications. J Reconstr Microsurg 2012; 29:89-97. [PMID: 23254537 DOI: 10.1055/s-0032-1329918] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
PURPOSE Large, complex scalp defects represent a significant reconstructive challenge, thus a variety of free tissue transfer techniques have been employed to optimally provide soft tissue coverage. The aim of this study is to determine factors associated with complications. METHODS A retrospective cohort study was performed on patients undergoing free tissue transfer for scalp defects from 1997 to 2011. Patients were compared with respect to demographics, defect characteristics, intraoperative factors, flap choice, and postoperative complications. RESULTS Forty-three flaps were performed in 37 patients with a success rate of 97.7%. Multivariate regression demonstrated that defect characteristics (size of defect) and patient-related factors (age and smoking) were associated with wound complications in scalp reconstruction. Outcomes were similar between the latissimus dorsi (LD) and anterolateral thigh (ALT) groups and the immediate cranioplasty patients with respect to all forms of complications. CONCLUSIONS We report a 98% success rate using free tissue transfer for complex scalp defects and identify defect size, patient age, and smoking as factors associated with wound complications. Patient comorbidities were associated with major complications. We report equal efficacy in using the ALT and LD, as well as immediate cranioplasty. LEVEL OF EVIDENCE Prognostic/risk, level III.
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Affiliation(s)
- John P Fischer
- Division of Plastic Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, USA.
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Yang RL, Newman AS, Reinke CE, Lin IC, Karakousis GC, Czerniecki BJ, Wu LC, Kelz RR. Racial Disparities in Immediate Breast Reconstruction After Mastectomy: Impact of State and Federal Health Policy Changes. Ann Surg Oncol 2012; 20:399-406. [DOI: 10.1245/s10434-012-2607-9] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2012] [Indexed: 11/18/2022]
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Nelson JA, Tchou J, Domchek S, Sonnad SS, Serletti JM, Wu LC. Breast reconstruction in bilateral prophylactic mastectomy patients: factors that influence decision making. J Plast Reconstr Aesthet Surg 2012; 65:1481-9. [PMID: 22640643 DOI: 10.1016/j.bjps.2012.05.001] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [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: 02/10/2012] [Revised: 04/17/2012] [Accepted: 05/01/2012] [Indexed: 01/02/2023]
Abstract
BACKGROUND Utilization of bilateral prophylactic mastectomy (BPM) and reconstruction has increased secondary to numerous medical advances. The purpose of this study was to examine decision making in women electing this therapy to further understand what influences and drives this decision. METHODS The authors conducted a survey study, enrolling patients who elected BPM and reconstruction. Participants were mailed structured questionnaires utilizing validated and study specific tools addressing: demographics, treatment decisions, autonomy, decision making and information seeking preferences, and breast cancer treatment knowledge. Analysis was performed overall and by reconstruction. RESULTS 40 patients responded (20 autologous, 19 implant and 1 combination, 66% response rate). The cohort was well educated and wealthy. Reconstructive options played a large role in the consideration of BPM. Patients were influenced by their physicians and less so by non-traditional means (media, internet, etc). Autologous reconstructions had a stronger desire to utilize their own tissue (p < 0.001) and were less concerned with the amount of surgery (0.02) and resulting scars (p = 0.01). Implant reconstructions more often stated that they did not have enough tissue for autologous reconstruction (p < 0.001) and did have a lower BMI, 24.2 vs. 27.5 (p = 0.03). Additionally, they were more influenced by non-traditional means (p < 0.001) and by other patients (p = 0.02). CONCLUSIONS Multiple factors influence decision making in BPM and reconstruction, with the ultimate choice in reconstruction involving tissue availability, appearance of implant reconstructions, total amount of surgery required, and extent of visible scars. Patients were strongly influenced by their physicians, and less so by non-traditional means.
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Affiliation(s)
- Jonas A Nelson
- Division of Plastic Surgery, Perelman School of Medicine at University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA
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Fischer JP, Nelson JA, Mirzabeigi MN, Wang GJ, Foley PJ, Wu LC, Woo EY, Kanchwala S. Prophylactic muscle flaps in vascular surgery. J Vasc Surg 2012; 55:1081-6. [DOI: 10.1016/j.jvs.2011.10.110] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2011] [Revised: 10/12/2011] [Accepted: 10/19/2011] [Indexed: 10/14/2022]
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