Outcomes of Immediate versus Delayed Autologous Reconstruction in the Setting of Post-Mastectomy Radiation Therapy: A Meta-analysis

INTRODUCTION

Post-mastectomy autologous breast reconstruction can be immediate (IBR) or delayed (DBR). The safety of performing IBR and the impact of radiation on the newly reconstructed breast is not yet validated.

METHODS

A Pubmed, EMBASE, and Google scholar search was conducted from inception to September 17th 2023. We included comparative studies that assessed complications or aesthetic outcomes of IBR versus DBR in the setting of post-mastectomy radiotherapy (PMRT).

RESULTS

The search identified 2693 articles. Thirteen were eligible for inclusion. A total of 565 patients underwent IBR followed by radiotherapy while 699 had DBR. Mean follow-up time and age for both groups were comparable (p > 0.1). None of revision surgery, infection, total flap failure, seroma, hematoma, dehiscence, or delayed wound healing was significantly different across groups (p > 0.1). IBR was found to have a higher risk of flap fibrosis (OR 28.18 [5.15 - 154.12]; p = 0.0001, I 2 of 44%) and skin flap necrosis (OR 6.12 [2.71 - 13.82]; p < 0.0001, I 2 of 27%) but a lower risk of partial flap failure (OR 0.18 [0.06 - 0.58]; p 0.004, I 2 of 0%) when compared to DBR. Results of fat necrosis should be interpreted with caution. Patient-reported as well as objective aesthetic outcomes were mostly comparable between groups.

CONCLUSION

IBR in the setting of PMRT is increasingly being performed and poses a specific set of challenges that surgeons usually consider. The choice between IBR or DBR in the setting of PMRT should be an individualized decision based on patient risk factors and desires.

LEVEL OF EVIDENCE

III.

Meta-Analysis and Meta-Regression of Complications and Failures of Autologous Heterotopic Cranial Bone versus Alloplastic Cranioplasties

BACKGROUND

Fresh autologous cranial bone graft has been traditionally regarded as the ideal cranioplasty material, however long-term comparisons of outcomes with modern alloplastic materials are absent in the literature. In this work, we evaluated complications and failures among cranioplasties performed with fresh, heterotopic, cranial bone graft versus three common alloplastic materials.

METHODS

Random-effects meta-analyses of logit-transformed proportions were performed on studies published between 1971-2021 to evaluate complications and failures of cranioplasties performed with fresh, autologous, heterotopic cranial bone, polyetheretherketone (PEEK), polymethylmethacrylate (PMMA), or titanium with a mean follow-up ≥12 months. Generalized mixed model meta-regressions were performed to account for heterogeneity and to evaluate the contributions of moderators to outcomes variables.

RESULTS

1490 patients (mean age 33.9±10.8 years) were included. Pooled, all-cause complications were 6.2% for fresh, heterotopic, autologous cranial bone (95% confidence interval [CI]:2.1-17.0%; I2=55.0%, p=0.02), 18.5% for PEEK (95%CI:14.0-24.0%; I2=0.0%, p=0.58), 26.1% for titanium (95%CI:18.7-35.1%; I2=60.6%, p<0.01), and 28.4% for PMMA (95%CI:12.9-51.5%; I2=88.5%, p<0.01). Pooled all-cause failures were 2.2% for fresh, autologous cranial bone (95%CI:0.4-10.6%; I2=0.0%, p=0.45), 6.3% for PEEK (95%CI:3.2-12.3%; I2=15.5%, p=0.31), 11.4% for titanium (95%CI:6.7-18.8%; I2=60.8%, p<0.01), and 12.7% for PMMA (95%CI:6.9-22.0%; I2=64.8%, p<0.01). Meta-regression models indicated that each alloplastic subtype significantly and independently predicted higher complications, while titanium and PMMA were significant predictors for all-cause failures compared to autologous bone. All three subtypes were predictive of higher cranioplasty failures secondary to infection compared to autologous bone.

CONCLUSIONS

Cranioplasties performed with fresh, autologous heterotopic cranial bone grafts resulted in lower complications and failures compared to alloplastic materials.

COVID-19 Pandemic Associated With Increased Self-reported Depressive Symptoms in Patients With Congenital Craniofacial Diagnoses

OBJECTIVE

The current study investigated the influence of the coronavirus (COVID-19) pandemic on patients with congenital craniofacial diagnoses.

METHODS

Patients (n = 66) with craniofacial diagnoses aged between 8 and 17 were prospectively evaluated with longitudinal psychosocial assessments using the anger, anxiety, depressive symptoms, and peer relationships instruments within the pediatric Patient-Reported Outcomes Measurement Information System (PROMIS). The COVID-19 cohort (n = 33) included patients with assessments within 2 years prior to the pandemic (t0) and during the pandemic (t1; March 2020 to March 2021). An age-matched comparison cohort (n = 33) with similar demographics and diagnoses included patients assessed twice over 3 years prior to the pandemic.

RESULTS

All PROMIS measures were in the average range clinically for both groups across time points. However, the COVID-19 group reported a significant increase in depressive symptoms during the pandemic (t1) compared to pre-pandemic (t0) scores (48.2 ± 10.1 vs 44.3 ± 9.4, P = .04, d = -0.37), while the comparison group did not demonstrate any differences in psychosocial functioning between t0 and t1. For the COVID-19 cohort, only the pandemic timeframe (r = 0.21, P = .03) was significantly associated with increased depressive symptom scores, and no other sociodemographic or medical variables were associated with depressive symptoms.

CONCLUSIONS

Self-reported depressive symptoms increased during the COVID-19 pandemic in patients with congenital craniofacial diagnoses. Longitudinal studies are needed to elucidate whether such changes will be persistent or compound known variables associated with psychosocial functioning.

Effect of Gender-affirming Facial Feminization Surgery on Psychosocial Outcomes

OBJECTIVE

This study investigates the effect of gender-affirming facial feminization surgery (FFS) on psychosocial outcomes in patients with gender dysphoria.

BACKGROUND

Comprehensive analyses of psychosocial outcomes after gender-affirming FFS are absent in the literature resulting in a paucity of information on the impact of FFS on quality of life as well as ramifications in health insurance coverage of FFS.

METHODS

Scores from 11 validated, quantitative instruments from the Patient-Reported Outcomes Measurement Information System (PROMIS) assessing anxiety, anger, depression, global mental health, global physical health, satisfaction with sex life, positive affect, emotional support, social isolation, companionship, and meaning and purpose. Patients within the preoperative group (pre-FFS) were evaluated >30 days before surgery and patients within the postoperative group (post-FFS) were evaluated ≥10 weeks after surgery.

RESULTS

A total of 169 patients [mean (SD) age, 33.5 (10.8) years] were included. Compared with the pre-FFS group (n=107), the post-FFS group (n=62) reported improved scores anxiety (56.8±8.8 vs 60.1±7.9, P =0.01), anger (47.4±7.6 vs 51.2±9.6, P =0.01), depression (52.2±9.2 vs 57.0±8.9, P =0.001), positive affect (46.6±8.9 vs 42.9±8.7, P =0.01), meaning and purpose (49.9±10.7 vs 46.2±10.5, P =0.03), global mental health (46.7±7.6 vs 43.1±9.2, P =0.01), and social isolation (52.2±7.5 vs 55.4±7.4, P =0.01). Multivariable analysis to account for the effects of other gender-affirming surgeries, hormone therapy duration, preexisting mental health diagnoses, socioeconomic disparities, and patient-reported quality of social relationships on psychosocial functioning demonstrated that completion of FFS was independently predictive of improved scores.

CONCLUSIONS

Gender-affirming FFS improves the quality of life by multiple psychosocial domains in transfeminine patients.

Racial/Ethnic and Gender Disparities Over the Last Decade Within Microsurgery and Craniofacial Fellowship Training

BACKGROUND

Racial/ethnic and gender disparities persist in plastic surgery at nearly all levels of training, becoming more pronounced at each stage. Recent studies have demonstrated that the proportion of female plastic surgery residents has increased to nearly 40%, yet only 11% of full professors of plastic surgery are female. Other studies have identified severe declines in underrepresented minority plastic surgery representation between plastic surgery residents and academicians with only 1.6% of Black/African American and 4.9% of Hispanic/Latinx full professors of plastic surgery. Often, residents seek fellowship for advanced training before seeking an academic professorship. This study aims to describe the racial/ethnic and gender representation of microsurgery and craniofacial fellows.

METHODS

Names and photos of graduated fellows for the past 10 years (2012-2021) were extracted from microsurgery and craniofacial fellowship Web sites. Using a 2-person evaluation method, race/ethnicity and gender were primarily determined by photographic and surname and verified, when possible, through online confirmation methods (articles, social media). Distributions were analyzed with descriptive statistics and compared with the US population.

RESULTS

Among 30 microsurgery fellowships, 180 graduated fellows (52.7%) were identified, resulting in 66 female fellows (36.7%) and the following racial/ethnic distribution: 113 (62.8%) White, 49 (27.2%) Asian, 12 (6.7%) Hispanic/Latinx, and 6 (3.3%) Black/African American. Among 31 craniofacial fellowships, 136 graduated fellows (45.0%) were identified, resulting in 38 female fellows (27.9%) and the following racial/ethnic distribution: 75 (55.1%) White, 45 (33.1%) Asian, 8 (5.9%) Hispanic/Latinx, and 8 (5.9%) Black/African American. The intersection between race/ethnicity and gender revealed the most disproportionately low representation among Black women. Relative to the US population, Hispanic/Latinx (0.31-fold) and Black/African American (0.48-fold) fellows were underrepresented, White (0.90-fold) fellows were nearly equally represented, and Asian (5.42-fold) fellows are overrepresented relative to the US population. Furthermore, despite pursuing fellowships at a greater rate, Asian and Black fellows are not reaching adequate representation among academic plastic surgeons.

CONCLUSION

This study demonstrates that female racial/ethnic minorities are disproportionately underrepresented among microsurgery and craniofacial fellowships. Efforts should be made to improve the recruitment of fellows of underrepresented backgrounds and thus improve the pipeline into academic careers.

Association of Patient-Reported Anxiety and Pain After Alveolar Bone Grafting

OBJECTIVE

To evaluate the role of psychosocial well-being on perioperative pain and opioid use among patients with cleft lip and palate (CLP) undergoing alveolar bone grafting (ABG).

DESIGN

Retrospective review.

SETTING

Tertiary level craniofacial clinic.

PARTICIPANTS

34 patients with CLP (median age: 11.7 years), including 25 (73.5%) unilateral CLP and 9 (26.5%) bilateral CLP, who underwent ABG from 2015 to 2022.

INTERVENTIONS

ABG using iliac crest bone graft. Patients were prospectively administered four patient-reported psychosocial instruments from the Patient-Reported Outcomes Measurement Information System.

MAIN OUTCOME MEASURES

Perioperative opioid use in morphine equivalent dosage/kilogram, patient-reported pain scores, and length of hospital stay after ABG.

RESULTS

Patient-reported anxiety (r = 0.41, p = 0.02) and depressive symptoms (r = 0.35, p = 0.04) correlated to higher perioperative opioid usage. Multivariable regression models including psychosocial scores, total acetaminophen usage, length of surgery, and other simultaneous surgeries were developed for total opioid usage, patient-reported pain, and length of hospital stay. Patient-reported anxiety was independently predictive of higher perioperative opioid use (β=0.36, p = 0.01) and higher pain scores (β=0.39, p = 0.02), but not length of hospital stay.

CONCLUSIONS

We identified an association for patient-reported anxiety and perioperative opioid use and pain in a CLP cohort undergoing ABG. Future considerations in preoperative patient and family consultation may be indicated in patients self-reporting higher anxiety in an effort to minimize perioperative opioid usage.

Osteoprotegerin-eluting nanoparticulate mineralized collagen scaffolds improve skull regeneration

Custom synthesis of extracellular matrix (ECM)-inspired materials for condition-specific reconstruction has emerged as a potentially translatable regenerative strategy. In skull defect reconstruction, nanoparticulate mineralized collagen glycosaminoglycan scaffolds (MC-GAG) have demonstrated osteogenic and anti-osteoclastogenic properties, culminating in the ability to partially heal in vivo skull defects without the addition of exogenous growth factors or progenitor cell loading. In an effort to reduce catabolism during early skull regeneration, we fabricated a composite material (MCGO) of MC-GAG and recombinant osteoprotegerin (OPG), an endogenous anti-osteoclastogenic decoy receptor. In the presence of differentiating osteoprogenitors, MCGO demonstrated an additive effect with endogenous OPG limited to the first 14 days of culture with total eluted and scaffold-bound OPG exceeding that of MC-GAG. Functionally, MCGO exhibited similar osteogenic properties as MC-GAG, however, MCGO significantly reduced maturation and resorptive activities of primary human osteoclasts. In a rabbit skull defect model, MCGO scaffold-reconstructed defects displayed higher mineralization as well as increased hardness and microfracture resistance compared to non-OPG functionalized MC-GAG scaffolds. The current work suggests that MCGO is a development in the goal of reaching a materials-based strategy for skull regeneration.

Students Teaching Students: Student-Led Ultrasound Curriculum in Medical School Education

Introduction

With the expanding use of point-of-care ultrasound throughout medical specialties for the rapid bedside assessment integral to patient care, medical schools have sought to incorporate ultrasound education into their curriculum. Second-year medical students (MS2s) at our institution met this demand by forming the Ultrasound Student Instructor Cadre (USSIC), a longitudinal ultrasound curriculum where MS2s teach first-year medical students (MS1s). The objectives of this study were to assess the ultrasound knowledge of medical students and their perceptions of ultrasound incorporation into their medical education.

Methods

Our flipped classroom curriculum consisted of four lessons (cardiopulmonary, gastrointestinal, genitourinary, and musculoskeletal) composed of videos, didactic lessons, and hands-on probe-time, with 15-minute pre- and post-assessments. Paired Wilcoxon signed-rank tests were performed to evaluate the differences in the pre- and post-assessment scores for each teaching session. Additionally, an end-of-the-year survey assessed the perceived preparedness and overall satisfaction of the MS1s with the course.

Results

The differences between the pre- and post-assessments for each teaching session were statistically significant: cardiopulmonary (45.6 ± 16.9% vs. 82.9 ± 9.4%, p < 0.0001, n = 55), gastrointestinal (53.9 ± 18.0% vs. 84.1 ± 13.5%, p < 0.0001, n = 54), genitourinary (68.9 ± 19.1% vs. 91.4 ± 14.4%, p < 0.0001, n = 64), and musculoskeletal (33.6 ± 14.7% vs. 78.2 ± 18.2%, p < 0.0001, n = 55).

Conclusion

Our study suggests that MS1s met the learning objective for each teaching session. Furthermore, MS1s who became USSIC instructors as MS2s felt more prepared and were more satisfied with the course. This study demonstrates the efficacy of student-led instruction in ultrasound, and we offer our model for adoption into other medical schools.

β-Catenin Limits Osteogenesis on Regenerative Materials in a Stiffness-Dependent Manner

Targeted refinement of regenerative materials requires mechanistic understanding of cell-material interactions. The nanoparticulate mineralized collagen glycosaminoglycan (MC-GAG) scaffold is shown to promote skull regeneration in vivo without additive exogenous growth factors or progenitor cells, suggesting potential for clinical translation. This work evaluates modulation of MC-GAG stiffness on canonical Wnt (cWnt) signaling. Primary human bone marrow-derived mesenchymal stem cells (hMSCs) are differentiated on two MC-GAG scaffolds (noncrosslinked, NX-MC, 0.3 kPa vs conventionally crosslinked, MC, 3.9 kPa). hMSCs increase expression of activated β-catenin, the major cWnt intracellular mediator, and the mechanosensitive YAP protein with near complete subcellular colocalization on stiffer MC scaffolds. Overall Wnt pathway inhibition reduces activated β-catenin and osteogenic differentiation, while elevating BMP4 and phosphorylated Smad1/5 (p-Smad1/5) expression on MC, but not NX-MC. Unlike Wnt pathway downregulation, isolated canonical Wnt inhibition with β-catenin knockdown increases osteogenic differentiation and mineralization specifically on the stiffer MC. β-catenin knockdown also increases p-Smad1/5, Runx2, and BMP4 expression only on the stiffer MC material. Thus, while stiffness-induced activation of the Wnt and mechanotransduction pathways promotes osteogenesis on MC-GAG, activated β-catenin is a limiting agent and may serve as a useful target or readout for optimal modulation of stiffness in skeletal regenerative materials.