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Association of preoperative opioid use and postoperative complications following breast reconstruction. J Plast Reconstr Aesthet Surg 2023; 83:258-265. [PMID: 37285777 DOI: 10.1016/j.bjps.2023.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 03/14/2023] [Accepted: 05/02/2023] [Indexed: 06/09/2023]
Abstract
BACKGROUND Previous studies in orthopedics and general surgery have linked negative patient outcomes with preoperative opioid use. In this study, we investigated the association of preoperative opioid use on breast reconstruction outcomes and quality of life (QoL). METHODS We reviewed our prospective registry of patients who underwent breast reconstruction for documented preoperative opioid use. Postoperative complications were recorded at 60 days after the first reconstructive surgery and 60 days after the final staged reconstruction. We used a logistic regression model to assess the association between opioid use and postoperative complications, controlling for smoking, age, laterality, BMI, comorbidities, radiation, and previous breast surgery; linear regression to analyze RAND36 scores to evaluate the impact of preoperative opioid use on postoperative QoL, controlling for the same factors; and Pearson chi-squared test to assess factors that may be associated with opioid use. RESULTS Of the 354 patients eligible for inclusion, 29 (8.2%) were prescribed preoperative opioids. There were no differences in opioid use by race, BMI, comorbidities, previous breast surgery, or laterality. Preoperative opioids were associated with increased odds of postoperative complications within 60 days after the first reconstructive surgery (OR: 6.28; 95% CI: 1.69-23.4; p = 0.006) and within 60 days after the final staged reconstruction (OR: 8.38; 95% CI: 1.17-59.4; p = 0.03). Among patients using opioids preoperatively, the RAND36 physical and mental scores decreased but were not statistically significant. CONCLUSION We found that preoperative opioid use is associated with increased odds of postoperative complications among patients who underwent breast reconstruction and may contribute to clinically significant declines in postoperative QoL.
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The Use of Alloderm® Coverage to Reinforce Tissues in Two-Stage Tissue Expansion Placement in the Subcutaneous (Prepectoral) Plane: A Prospective Pilot Study. Cureus 2022; 14:e27680. [PMID: 36072166 PMCID: PMC9440738 DOI: 10.7759/cureus.27680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/31/2022] [Indexed: 11/17/2022] Open
Abstract
Purpose: Two-stage tissue expander (TE) to implant breast reconstruction is commonly performed by plastic surgeons. Prepectoral implant placement with acellular dermal matrix (ADM, e.g., AlloDerm®) reinforcement is evidenced by minimal postoperative pain. However, the same is not known for TE-based reconstruction. We performed this study to explore the use of complete AlloDerm® reinforcement of breast pocket tissues in women undergoing unilateral or bilateral mastectomies followed by immediate, two-stage tissue expansion in the prepectoral plane. Methods: Patients (n = 20) aged 18-75 years were followed prospectively from their preoperative consult to 60 days post-TE insertion. The pain visual analog scale (VAS), Patient Pain Assessment Questionnaire, Subjective Pain Survey, Brief Pain Inventory-Short Form (BPI-SF), postoperative nausea and vomiting (PONV) survey, BREAST-Q Reconstruction Module, and short-form 36 (SF-36) questionnaires were administered. Demographic, intraoperative, and 30- and 60-day complications data were abstracted from medical records. After TE-to-implant exchange, patients were followed until 60 days postoperatively to assess for complications. Results: Pain VAS and BPI-SF pain interference scores returned to preoperative values by 30 days post-TE insertion. Static and moving pain scores from the Patient Pain Assessment Questionnaire returned to preoperative baseline values by day 60. The mean subjective pain score was 3.0 (0.5 standard deviation) with seven patients scoring outside the standard deviation; none of these seven patients had a history of anxiety or depression. Median PONV scores remained at 0 from postoperative day 0 to day 7. Patient-reported opioid use dropped from 89.5% to 10.5% by postoperative day 30. BREAST-Q: Sexual well-being scores significantly increased from preoperative baseline to day 60 post-TE insertion. Changes in SF-36 physical functioning, physician limitations, emotional well-being, social functioning, and pain scores were significantly different from preoperative baseline to day 60 post-TE insertion. Five participants had complications within 60 days post-TE insertion. One participant experienced a complication within 60 days after TE-to-implant exchange. Conclusions: We describe pain scores, opioid usage, patient-reported outcomes data, and complication profiles of 20 consecutive patients undergoing mastectomy followed by immediate, two-stage tissue expansion in the prepectoral plane. We hope this study serves as a baseline for future research.
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Prepectoral breast reconstruction is safe in the setting of post-mastectomy radiation therapy. J Plast Reconstr Aesthet Surg 2022; 75:3041-3047. [PMID: 35599219 DOI: 10.1016/j.bjps.2022.04.030] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 03/06/2022] [Accepted: 04/12/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Many breast reconstruction patients undergo post-mastectomy radiation therapy (PMRT), which is well known to increase the risk of complications. There is limited data on outcomes and safety of prepectoral breast reconstruction in this setting. The purpose of this study was to compare the outcomes of prepectoral versus subpectoral two-stage breast reconstruction in patients undergoing PMRT. METHODS We conducted a retrospective cohort study of two-stage breast reconstructions performed at our institution during a 22-month period. Patients who received PMRT were identified, and two cohorts were created: those who underwent prepectoral versus subpectoral reconstruction. We collected data including patient characteristics, operative variables, and clinical outcomes. Bivariate analyses and multivariable logistic regressions were conducted. RESULTS We captured 313 patients (492 breasts) that had undergone two-stage reconstruction. A total of 69 breasts received PMRT; 28 were reconstructed prepectorally, and 41 breasts subpectorally. The two cohorts were well matched. We detected no differences in clinical outcomes between the two groups after a median follow-up time of 24 months. There, however, were differences in perioperative variables. Prepectoral reconstruction was associated with a shorter operative time, shorter length of hospital stay, higher cost, and shorter time to final reconstruction. Multivariable logistic regression demonstrated that prepectoral reconstruction is not an independent predictor of adverse events. CONCLUSIONS Although radiation is a known risk factor for many complications following breast reconstruction, prepectoral device placement is safe in this high-risk population. Although the rate of capsular contracture is reported to be higher in the general prepectoral population, this was not found in our radiated prepectoral population.
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Correction: The Effects of Depression and Anti-Depressants on Quality of Life After Breast Reconstruction: A Post-Hoc Analysis. Cureus 2021; 13:c54. [PMID: 34926088 PMCID: PMC8654196 DOI: 10.7759/cureus.c54] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Biomaterials direct functional B cell response in a material-specific manner. SCIENCE ADVANCES 2021; 7:eabj5830. [PMID: 34851674 PMCID: PMC8635437 DOI: 10.1126/sciadv.abj5830] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 10/13/2021] [Indexed: 05/13/2023]
Abstract
B cells are an adaptive immune target of biomaterials development in vaccine research but, despite their role in wound healing, have not been extensively studied in regenerative medicine. To probe the role of B cells in biomaterial scaffold response, we evaluated the B cell response to biomaterial materials implanted in a muscle wound using a biological extracellular matrix (ECM), as a reference for a naturally derived material, and synthetic polyester polycaprolactone (PCL), as a reference for a synthetic material. In the local muscle tissue, small numbers of B cells are present in response to tissue injury and biomaterial implantation. The ECM materials induced mature B cells in lymph nodes and antigen presentation in the spleen. The synthetic PCL implants resulted in prolonged B cell presence in the wound and induced an antigen-presenting phenotype. In summary, the adaptive B cell immune response to biomaterial induces local, regional, and systemic immunological changes.
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Establishing a Culture of Patient Safety, Quality, and Service in Plastic Surgery: Integrating the Fractal Model. J Patient Saf 2021; 17:e1553-e1558. [PMID: 30480648 DOI: 10.1097/pts.0000000000000554] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PROBLEM There are obstacles to effective nationwide implementation of a culture of patient safety. Plastic surgery faces unique challenges in this area because quality measures are not as well-established as in other fields. Plastic surgery may also require emphasis on patient-reported outcomes as a quality-of-life specialty with distinct concomitant analytical methods. APPROACH We devised a dynamic framework, based on our 3-year experience using a Comprehensive Unit-Based Safety Program-a formal quality improvement committee structure, literature review, and work from The Johns Hopkins Armstrong Institute for Patient Safety and Quality. This framework is specific and exportable to the field of plastic surgery. Monthly patient safety, quality, and service committee meetings encourage multilevel participation in a bottom-up fashion, while connecting with other departments and entities in Johns Hopkins Medicine. Our model focuses our work in the following four domains: (1) safety, (2) external measures, (3) patient experience, and (4) value. Our framework identifies and communicates clear goals, creates necessary infrastructure, identifies opportunities and needs, uses robust performance to develop and implement interventions, and includes analytics to track improvement plans and results. OUTCOMES We have gradually implemented this quality improvement structure into the Johns Hopkins Department of Plastic and Reconstructive Surgery successfully since 2012. Outcomes have improved in externally reported measures of patient safety, quality, and service. We have demonstrated exemplary National Surgical Quality Improvement Program performance for morbidity, return to operating room, and readmission rates. Patient satisfaction surveys show improvement related to the high-level patient experience.
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The Effects of Depression and Anti-Depressants on Quality of Life After Breast Reconstruction: A Post-Hoc Analysis. Cureus 2021; 13:e18675. [PMID: 34786255 PMCID: PMC8579962 DOI: 10.7759/cureus.18675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/11/2021] [Indexed: 11/16/2022] Open
Abstract
Background A personal history of depression prior to breast cancer diagnosis and its effect on post-diagnosis quality of life (QOL) in women undergoing breast reconstruction is relatively unknown. We performed the current study to determine if depression alters QOL for patients who undergo breast reconstruction by assessing the pre-to-post-operative change in patient-reported BREAST-Q scores. Methodology We conducted a single-center, post-hoc analysis of 300 patients with completed BREAST-Q data who underwent breast reconstruction from November 2013 to November 2016 following a diagnosis of breast cancer. Patients completed the BREAST-Q at four time points: pre-operatively, six weeks following tissue expander (TE) insertion for patients undergoing staged reconstruction, and six and 12 months following the final reconstruction. Medical records were reviewed to identify patients who had a pre-cancer diagnosis of clinical depression and/or anti-depressant medication use. BREAST-Q scores were compared between groups and within groups. Groups compared were the depression (n = 50) and no depression (n = 250) patients, along with anti-depressant (n = 36) and no anti-depressant (n = 14) use in the depression group. Results Within-group Sexual Well-being scores at the six-week post-TE follow-up for patients in the depression group (median = 37, interquartile range [IQR] = 25-47) were significantly lower (p < 0.01) than the scores for patients in the no depression group (median = 47, IQR = 39-60). There were no statistically significant differences in BREAST-Q scores in other domains. When compared to patients diagnosed with depression who were not taking anti-depressants, anti-depressant medication use did not result in statistically significant higher BREAST-Q scores, although Satisfaction With Breasts six months post-operatively, Psychosocial Well-being at six weeks post-TE, Sexual Well-being at six weeks post-TE and six months post-operatively were clinically higher in patients taking anti-depressants for depression. Conclusions Patients with a diagnosis of depression prior to breast cancer had lower BREAST-Q Sexual Well-being scores in the six-week TE group with or without anti-depressant medication. Patients with a pre-cancer diagnosis of depression considering TEs may benefit from additional counseling prior to breast reconstruction or electing a different method of breast reconstruction. Anti-depressant medications may provide clinically higher BREAST-Q scores in patients with a pre-cancer diagnosis of depression. Adding an anti-depressant medication to a patient’s treatment plan may provide additional benefits. Larger samples are required to properly determine the impact of anti-depressant medications on BREAST-Q scores in patients with a pre-cancer diagnosis of depression.
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Perioperative systemic nonsteroidal anti-inflammatory drugs (NSAIDs) in women undergoing breast surgery. Cochrane Database Syst Rev 2021; 11:CD013290. [PMID: 34753201 PMCID: PMC8577884 DOI: 10.1002/14651858.cd013290.pub2] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Breast surgery encompasses oncologic, reconstructive, and cosmetic procedures. With the recent focus on the over-prescribing of opioids in the literature, it is important to assess the effectiveness and safety of non-opioid pain medication regimens including nonsteroidal anti-inflammatory drugs (NSAIDs) or NSAID pain medications. Clinicians have differing opinions on the safety of perioperative (relating to, occurring in, or being the period around the time of a surgical operation) NSAIDs for breast surgery given the unclear risk/benefit ratio. NSAIDs have been shown to decrease inflammation, pain, and fever, while potentially increasing the risks of bleeding complications. OBJECTIVES To assess the effects of perioperative NSAID use versus non-NSAID analgesics (other pain medications) in women undergoing any form of breast surgery. SEARCH METHODS The Cochrane Breast Information Specialist searched the Cochrane Breast Cancer Group (CBCG) Specialized Register, CENTRAL (the Cochrane Library), MEDLINE, Embase, The WHO International Clinical Trials Registry Platform (ICTRP) and Clinicaltrials.gov registries to 21 September 2020. Full articles were retrieved for potentially eligible trials. SELECTION CRITERIA We considered all randomized controlled trials (RCTs) looking at perioperative NSAID use in women undergoing breast surgery. DATA COLLECTION AND ANALYSIS Two review authors independently screened studies, extracted data and assessed risk of bias, and certainty of the evidence using the GRADE approach. The main outcomes were incidence of breast hematoma within 90 days (requiring reoperation, interventional drainage, or no treatment) of breast surgery and pain intensity 24 hours following surgery, incidence rate or severity of postoperative nausea, vomiting or both, bleeding from any location within 90 days, need for blood transfusion, other side effects of NSAID use, opioid use within 24 hours of surgery, length of hospital stay, breast cancer recurrence, and non-prescribed NSAID use. Data were presented as risk ratios (RRs) for dichotomous outcomes and standardized mean differences (SMDs) for continuous outcomes. MAIN RESULTS We included 12 RCTs with a total of 1596 participants. Seven studies compared NSAIDs (ketorolac, diclofenac, flurbiprofen, parecoxib and celecoxib) to placebo. Four studies compared NSAIDs (ketorolac, flurbiprofen, ibuprofen, and celecoxib) to other analgesics (morphine, hydrocodone, hydromorphone, fentanyl). One study compared NSAIDs (diclofenac) to no intervention. NSAIDs compared to placebo Most outcomes are judged to have low-certainty evidence unless stated otherwise. There may be little to no difference in the incidence of breast hematomas within 90 days of breast surgery (RR 0.33, 95% confidence interval (CI) 0.05 to 2.02; 2 studies, 230 participants; I2 = 0%). NSAIDs may reduce pain intensity 24 (± 12) hours following surgery compared to placebo (SMD -0.26, 95% CI -0.49 to -0.03; 3 studies, 310 participants; I2 = 73%). There may be little to no difference in the incidence rates or severities of postoperative nausea, vomiting, or both (RR 1.15, 95% CI 0.58 to 2.27; 4 studies, 939 participants; I2 = 81%), bleeding from any location within 90 days (RR 1.05, 95% CI 0.89 to 1.24; 2 studies, 251 participants; I2 = 8%), or need for blood transfusion compared to placebo groups, but we are very uncertain (RR 4.62, 95% CI 0.23 to 91.34; 1 study, 48 participants; very low-certainty evidence). There may be no difference in other side effects (RR 1.12, 95% CI 0.44 to 2.86; 2 studies, 251 participants; I2 = 0%). NSAIDs may reduce opioid use within 24 hours of surgery compared to placebo (SMD -0.45, 95% CI -0.85 to -0.05; 4 studies, 304 participants; I2 = 63%). NSAIDs compared to other analgesics There is little to no difference in the incidence of breast hematomas within 90 days of breast surgery, but we are very uncertain (RR 0.33, 95% CI 0.01 to 7.99; 1 study, 100 participants; very low-certainty evidence). NSAIDs may reduce pain intensity 24 (± 12) hours following surgery (SMD -0.68, 95% CI -0.97 to -0.39; 3 studies, 200 participants; I2 = 89%; low-certainty evidence) and probably reduce the incidence rates or severities of postoperative nausea, vomiting, or both compared to other analgesics (RR 0.18, 95% CI 0.06 to 0.57; 3 studies, 128 participants; I2 = 0%; moderate-certainty evidence). There is little to no difference in the development of bleeding from any location within 90 days of breast surgery or in other side effects, but we are very uncertain (bleeding: RR 0.33, 95% CI 0.01 to 7.99; 1 study, 100 participants; other side effects: RR 0.11, 95% CI 0.01 to 1.80; 1 study, 48 participants; very low-certainty evidence). NSAIDs may reduce opioid use within 24 hours of surgery compared to other analgesics (SMD -6.87, 95% CI -10.93 to -2.81; 3 studies, 178 participants; I2 = 96%; low-certainty evidence). NSAIDs compared to no intervention There is little to no difference in pain intensity 24 (± 12) hours following surgery compared to no intervention, but we are very uncertain (SMD -0.54, 95% CI -1.09 to 0.00; 1 study, 60 participants; very low-certainty evidence). AUTHORS' CONCLUSIONS Low-certainty evidence suggests that NSAIDs may reduce postoperative pain, nausea and vomiting, and postoperative opioid use. However, there was very little evidence to indicate whether NSAIDs affect the rate of breast hematoma or bleeding from any location within 90 days of breast surgery, the need for blood transfusion and incidence of other side effects compared to placebo or other analgesics. High-quality large-scale RCTs are required before definitive conclusions can be made.
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Interleukin 17 and senescent cells regulate the foreign body response to synthetic material implants in mice and humans. Sci Transl Med 2021; 12:12/539/eaax3799. [PMID: 32295900 DOI: 10.1126/scitranslmed.aax3799] [Citation(s) in RCA: 81] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 11/12/2019] [Indexed: 12/11/2022]
Abstract
Medical devices and implants made of synthetic materials can induce an immune-mediated process when implanted in the body called the foreign body response, which results in formation of a fibrous capsule around the implant. To explore the immune and stromal connections underpinning the foreign body response, we analyzed fibrotic capsules surrounding surgically excised human breast implants from 12 individuals. We found increased numbers of interleukin 17 (IL17)-producing γδ+ T cells and CD4+ T helper 17 (TH17) cells as well as senescent stromal cells in the fibrotic capsules. Further analysis in a murine model demonstrated an early innate IL17 response to implanted synthetic material (polycaprolactone) particles that was mediated by innate lymphoid cells and γδ+ T cells. This was followed by a chronic adaptive CD4+ TH17 cell response that was antigen dependent. Synthetic materials with varying chemical and physical properties implanted either in injured muscle or subcutaneously induced similar IL17 responses in mice. Mice deficient in IL17 signaling established that IL17 was required for the fibrotic response to implanted synthetic materials and the development of p16INK4a senescent cells. IL6 produced by senescent cells was sufficient for the induction of IL17 expression in T cells. Treatment with a senolytic agent (navitoclax) that killed senescent cells reduced IL17 expression and fibrosis in the mouse implant model. Discovery of a feed-forward loop between the TH17 immune response and the senescence response to implanted synthetic materials introduces new targets for therapeutic intervention in the foreign body response.
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Tissue Expander-Based Breast Reconstruction in the Prepectoral Versus Subpectoral Plane: An Analysis of Short-Term Outcomes. Ann Plast Surg 2021; 86:19-23. [PMID: 32568752 DOI: 10.1097/sap.0000000000002415] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Breast reconstruction is becoming an increasingly important and accessible component of breast cancer care. We hypothesize that prepectoral patients benefit from lower short-term complications and shorter periods to second-stage reconstruction compared with individuals receiving reconstruction in the subpectoral plane. METHODS An institutional review board-approved retrospective review of all adult postmastectomy patients receiving tissue expanders (TEs) was completed for a 21-month period (n = 286). RESULTS A total of 286 patients underwent mastectomy followed by TE placement, with 59.1% receiving prepectoral TEs and 40.9% receiving subpectoral TEs. Participants receiving prepectoral TEs required fewer clinic visits before definitive reconstruction (6.4 vs 8.8, P <0.01) and underwent definitive reconstruction 71.6 days earlier than individuals with subpectoral TE placement (170.8 vs 242.4 days, P < 0.01). Anesthesia time was significantly less for prepectoral TE placement, whether bilateral (68.0 less minutes, P < 0.01) or unilateral (20.7 minutes less, P < 0.01). Operating room charges were higher in the prepectoral subgroup ($31,276.8 vs $22,231.8, P < 0.01). Partial necrosis rates were higher in the prepectoral group (21.7% vs 10.9%, P < 0.01). CONCLUSIONS Patients undergoing breast reconstruction using prepectoral TE-based reconstruction benefit from less anesthesia time, fewer postoprative clinic visits, and shorter time to definitive reconstruction, at the compromise of higher operating room charges.
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Breast Reduction in Adults: Identifying Risk Factors for Overall 30-Day Postoperative Complications. Aesthet Surg J 2020; 40:NP676-NP685. [PMID: 32506130 DOI: 10.1093/asj/sjaa146] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Breast reduction is a commonly performed procedure. Understanding the postoperative complication profile is important for preoperative planning and patient education. OBJECTIVES The authors sought to assess complication rates following breast reduction in females and identify potential risk factors. METHODS We assessed the records of the American College of Surgeons National Surgical Quality Improvement Program participant use files that include patients who underwent breast reduction for macromastia between 2005 and 2016. Relevant patient and postoperative data were extracted, and factors affecting complications were analyzed utilizing the logistic regression model. RESULTS We identified 20,001 women aged a mean 43.9 years who underwent breast reduction. The number of patients who developed ≥1 complication was 1009 (4.3%). Our adjusted analysis revealed that outpatient setting (odds ratio [OR] = 0.600) and performance of the surgery by the attending surgeon alone (OR = 0.678) were associated with lower odds, whereas higher body mass index (OR = 1.046) and smoking (OR = 1.518) were associated with higher odds for complications following breast reduction. Outpatient setting (OR = 0.317) was also associated with lower odds whereas smoking (OR = 1.613) and American Society of Anesthesiologists class were associated with higher odds of returning to the operative room. These findings were consistent in our subgroup analysis for wound-related complications. CONCLUSIONS Our study shows that patient characteristics such as smoking and body mass index may increase complication rates after breast reduction. Clinical factors such as inpatient setting may also increase risk of complications following breast reduction. It is critical to understand the effect of these factors to better predict postoperative outcomes and ensure thorough patient education.
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Pure fat grafting for breast reconstruction: An alternative autologous breast reconstruction. Breast J 2020; 26:1788-1792. [PMID: 32945041 DOI: 10.1111/tbj.13887] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2019] [Revised: 04/27/2020] [Accepted: 04/29/2020] [Indexed: 11/29/2022]
Abstract
Plastic surgeons offer various options for breast reconstruction based on patient preference, underlying disease, and comorbidities. An alternative form of breast reconstruction exists, which includes tissue expansion with tissue expander and subsequent fat grafting without the use of implant or flap. We retrospectively reviewed the breast cancer patients who underwent breast reconstruction at our institution to identify those with pure fat grafting. Demographic information, complications, operative details, and BREAST-Q scores were abstracted. From 2010-2015, 10 patients were identified. Patients with unilateral or bilateral mastectomy followed by pure fat grafting had a median of 3.5 or 4 sessions and a total median fat grafting volume of 380 or 974.5 cc, respectively. Patients were followed for 12 months, and no complications or breast cancer recurrences were noted. Finally, BREAST-Q scores at the 12-month follow-up were comparable to the preoperative values.
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Establishing Institution-Specific Normative Data for the BREAST-Q Reconstruction Module: A Prospective Study. Aesthet Surg J 2020; 40:NP348-NP355. [PMID: 31678996 DOI: 10.1093/asj/sjz296] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Breast satisfaction in general female populations is relatively unknown and prior research populations do not reflect our community. OBJECTIVES We sought to assess breast satisfaction in a cohort of female participants utilizing the BREAST-Q and determine the impact of participant-related factors. METHODS Females with no history of breast cancer or breast surgery attending gynecology appointments completed preoperative BREAST-Q reconstruction modules and demographic forms in this prospective, single-center, patient-reported outcomes study. We also assessed participant-related factors capable of influencing BREAST-Q scores. RESULTS Three hundred females were included. Increasing body mass index had significant associations with lower Satisfaction with Breasts and Psychosocial Well-being scores. Increasing age was associated with significantly lower Sexual Well-being scores. African Americans had significantly higher scores for Satisfaction with Breasts, Psychosocial Well-being, and Sexual Well-being compared with Caucasians. Bra cup sizes A and C were associated with significantly higher Psychosocial Well-being scores than other sizes. Bra cup sizes A, B, and C were associated with significantly higher Sexual Well-being and Physical Well-being: Chest scores than larger sizes. Bra cup sizes B and C were associated with significantly higher Physical Well-being: Abdomen scores than size DD. Bra cup size A was associated with significantly higher Satisfaction with Breasts scores than sizes DD and >DD. Bra cup size C was associated with significantly higher Satisfaction with Breasts scores than larger sizes. CONCLUSIONS Body mass index, age, race, and bra cup sizes significantly impact BREAST-Q scores in our population. Determining normative BREAST-Q scores in female populations could represent important baselines for breast outcomes research. Level of Evidence: 2.
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Abstract
BACKGROUND Malpractice litigation has a significant impact on healthcare costs and important professional implications for healthcare providers. OBJECTIVES The authors sought to comprehensively characterize the litigation landscape in plastic surgery across its different subspecialties. METHODS The authors utilized the Westlaw legal database to conduct a comprehensive search of malpractice cases in the United States in the following categories: cosmetic, reconstructive, hand, craniofacial, and gender affirmation surgery. They conducted both a Boolean and a natural language search to identify cases in which a plastic surgeon was the defendant. Data were analyzed employing descriptive statistics, logistic regression, and relative risk calculations. RESULTS In total, 165 cases were included. Most surgeons accused of malpractice worked in a private setting (148 [90%]). Among the 22 (13%) cases that contained information on board certification status, most surgeons were board certified (17 [77%]). Resident involvement was mentioned in only 5 (3%) cases. The majority of cases were successfully defended by surgeons (98 [60%] vs 65 [40%]), particularly in craniofacial surgery (risk ratio: 1.54; P = 0.03; 95% CI: 1.03-2.3). Surgeons who successfully defended a case were more likely to benefit from summary judgment (P = 0.005). CONCLUSIONS Malpractice litigation is commonplace in medical practice, and no specialty is spared. Legal outcomes were in favor of plastic surgeons in the majority of cases, particularly those that proceeded to summary judgment. Surgeons can avoid litigation by maintaining detailed office and surgical notes, always obtaining informed consent, adequately following and monitoring patients after surgery, and ensuring compliance by communicating frequently and effectively.
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Interventions for reducing the use of opioids in breast reconstruction. Hippokratia 2020. [DOI: 10.1002/14651858.cd013568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Women Continue to Be Underrepresented in Surgery: A Study of AMA and ACGME Data from 2000 to 2016. JOURNAL OF SURGICAL EDUCATION 2020; 77:362-368. [PMID: 31889693 DOI: 10.1016/j.jsurg.2019.10.001] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 09/16/2019] [Accepted: 10/01/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVE In the past decade women have comprised nearly half of U.S. medical school graduates. However, women remain underrepresented among surgical residents and practicing surgeons. We conducted the current study to assess recent trends in the female-to-male (F:M) ratios among residents and physicians pursuing careers in surgery. DESIGN We used retrospective population statistics published by the American Medical Association and the Accreditation Council for Graduate Medical Education from 2000 to 2016. We compared trends of female-to-male ratios among residents and surgeons in surgical subspecialties to evaluate for potential differences over time. SETTING Published online population statistics. PARTICIPANTS We stratified both board-certified surgeons and surgical residents by sex and specialty. RESULTS From 2000 to 2013, the proportion of female surgeons among all female physicians remained constant (12%-13%). The proportion of board-certified female surgeons to all surgeons increased (from 15% in 2000 to 25% in 2013). The F:M ratios of board-certified surgeons in neurosurgery and orthopedic surgery were 1:10.6 and 1:13.9, with resident ratios 1:4.8 and 1:5.9, respectively. One specialty with increasingly equivalent ratios is plastic surgery with integrated resident F:M ratios of 1:3.1 in 2008 to 1:1.4 in 2015, and board-certified plastic surgeons of 1:9.2 in 2008 to 1:5.3 in 2013. CONCLUSION Although the gender gap is narrowing, women continue to be underrepresented in surgical specialties. It is important for fields with disproportionate representation to be aware of these differences and take steps toward creating and supporting a more diverse workforce.
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Postoperative Free Flap Breast Protocol Optimizing Resources and Patient Safety. J Reconstr Microsurg 2020; 36:379-385. [DOI: 10.1055/s-0040-1701698] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Abstract
Background As deep inferior epigastric artery perforator (DIEP) flaps have gained popularity in breast reconstruction, the postoperative care of these patients, including the appropriate hospital length-of-stay and the need for intensive care unit (ICU) admission, has become a topic of debate. At our institution, we have adopted a pathway that aims for discharge on postoperative day 3, utilizing continuous tissue oximetry without ICU admission. This study aims to evaluate outcomes with this pathway to assess its safety and feasibility in clinical practice.
Methods A retrospective review was performed of patients undergoing DIEP flap breast reconstruction between January 2013 and August 2014. Data of interest included patient demographics and medical history as well as complication rates and date of hospital discharge.
Results In total, 153 patients were identified undergoing 239 DIEP flaps. The mean age was 50 years (standard deviation [SD] = 10.2) and body mass index (BMI) 29.4 kg/m2 (SD = 5.2). Over the study period, the flap failure rate was 1.3% and reoperation rate 3.9%. Seventy-one percent of patients were discharged on postoperative day 3. Nine patients required hospitalization beyond 5 days. Theoretical cost savings from avoiding ICU admissions were $1,053 per patient.
Conclusion A pathway aiming for hospital discharge on postoperative day 3 without ICU admission following DIEP flap breast reconstruction can be feasibly implemented with an acceptable reoperation and flap failure rate.
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Determinants of receiving immediate breast reconstruction: An analysis of patient characteristics at a tertiary care center in the US. Surg Oncol 2020; 34:1-6. [PMID: 32103789 DOI: 10.1016/j.suronc.2020.02.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 01/14/2020] [Accepted: 02/14/2020] [Indexed: 10/25/2022]
Abstract
BACKGROUND Breast reconstruction is an option for women undergoing mastectomy for breast cancer. Previous studies have reported underutilization of reconstructive surgery. This study aims to examine the role demographic, clinical and socio-economic factors may have on patients' decisions to undergo breast reconstruction. METHODS We analyzed data from our institutional database. Using multivariable and multinomial logistic regression, we compared breast cancer patients who had undergone mastectomy-only to those who had immediate breast reconstruction (overall and by type of reconstruction). RESULTS We analyzed data on 1459 women who underwent mastectomy during the period 2003-2015. Of these, 475 (32.6%) underwent mastectomy-only and 984 (67.4%) also underwent immediate breast reconstruction. After adjusting for potential confounders, older age (OR = 0.18, 95%CI:0.08-0.40), Asian race (OR = 0.29, 95%CI:0.19-0.45), bilateral mastectomy (OR = 0.71, 95%CI:0.56-0.90), and higher stage of disease (OR = 0.44, 95%CI:0.26-0.74) were independent risk factors for not receiving immediate breast reconstruction. Furthermore, patients with Medicare or Medicaid insurance were less likely than patients with private insurance to receive an autologous reconstruction. There was no evidence for changes over time in the way socio-demographic and clinical factors were related to receiving immediate breast reconstruction after mastectomy. CONCLUSIONS Clinical characteristics, sociodemographic factors like age, race and insurance coverage affect the decision for reconstructive surgery following mastectomy.
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Comparison of arterial and venous implantable Doppler postoperative monitoring of free flaps: Systematic review and meta-analysis of diagnostic test accuracy. Microsurgery 2020; 40:501-511. [PMID: 32031735 DOI: 10.1002/micr.30564] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 12/05/2019] [Accepted: 01/14/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND Early detection of vascular compromise following free flap microsurgical reconstruction is essential. This can lead to timely reoperations and flap salvage. Both arteries and veins are monitored postoperatively with implantable ultrasound Dopplers based on surgeon preference with no consensus as to which method is best. This systematic review and meta-analysis compared arterial to venous implantable Dopplers for postoperative monitoring of microsurgical free flap reconstruction. METHODS Five databases (MEDLINE via PubMed, EMBASE, Cochrane Library, Web of Science, and Scopus) were systematically and independently searched. PRISMA and Cochrane guidelines were strictly followed. Clinical characteristics, donor and recipient sites, specific arterial or venous vessels, diagnostic data, outcomes, and complications were recorded. RESULTS The seven studies included in the meta-analysis were published from 1994 to 2018, with results from 38 of the possible 64 outcomes and complications queried. A total of 763 flaps with implantable Doppler probes on 527 arteries and 388 veins were included in the study. Compared to patients monitored with venous implantable Dopplers, arterial monitoring was associated with a risk of false-positives reduced by 74% (RR:0.26, 95% CI:0.12, 0.55, I2 = 40%, p = .0004) and risk of signal loss reduced by 63% (RR:0.37, 95% CI:0.24, 0.59, I2 = 26%, p < .0001). Patients being monitored with a venous implantable Doppler did not show significantly different sensitivities, specificities, true-positives, false-negatives, true-negatives, positive predictive values, negative predictive values, time to signal loss, take-backs, salvage rates, flap failures, flap failure rates, arterial, venous, vascular, and hematoma compromise compared to an arterial implantable Doppler. CONCLUSION These findings suggest arteries may be the best vessels to monitor when using an implantable Doppler following free flap microsurgical reconstruction. Caution is advised when interpreting these findings for clinical significance due to no significant differences in take-backs, SR, flap failures, and FFR.
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Failure-to-Progress Through Surgical Residency: A 9-Year Analysis. JOURNAL OF SURGICAL EDUCATION 2020; 77:178-188. [PMID: 31492637 DOI: 10.1016/j.jsurg.2019.07.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Revised: 07/20/2019] [Accepted: 07/27/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVE General surgery and surgical subspecialty residents account for nearly 19% of US medical residents; however, it is well known that many surgical residents fail to graduate from their residency training program. We sought to comprehensively evaluate recent trends in nonprogression rates among surgical residents. DESIGN This is a retrospective study on residents during the 2007 to 2016 academic years. We calculated the annualized progression failure rate by extracting the total number of residents who progress to the next level of training per year, total number of residents who failed to progress per year, and reasons for discontinuing residency. Proportions of residents who failed to progress were calculated to estimate potential differences in progression failure rates among different specialties across time. SETTING We evaluated information provided by the Accreditation Council for Graduate Medical Education during the 2007 to 2016 academic years. PARTICIPANTS Surgical and nonsurgical residents of Accreditation Council for Graduate Medical Education accredited programs during the period 2007 to 2016. RESULTS Overall, 2.67% of surgical residents did not progress to the next level each year. This proportion is higher in surgical specialties than in nonsurgical ones. Nonprogression rates for individual surgical specialties ranged from 0.4% to 4.1% on average per year. In addition, observed changes in rates and reasons for attrition varied across individual specialties. Of the surgical residents who failed to progress, more than 50% transferred to a different program, 40% withdrew, and 9% were dismissed. CONCLUSIONS Our findings indicate that surgical residents are more likely to leave their initial residency program prior to completion than residents in medical specialties. Annualized ratios among subspecialties vary. General surgeons were the most likely and otolaryngology residents the least likely to discontinue their training.
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Abstract
Introduction: Medicaid beneficiaries are a generally disadvantaged population with access to elective specialty services. We sought to better understand utilization of breast reconstruction by Medicaid beneficiaries.Methods: We systematically searched PubMed, Scopus, Web of Science, and CINAHL databases for studies comparing breast reconstruction rates by insurance type. We extracted the information of interest to qualitatively and quantitatively synthesize the results of the studies.Results: We identified seven eligible studies. Overall, the rates of breast reconstruction have increased across insurance groups. However, our results show that Medicaid beneficiaries were on average less likely to receive breast reconstruction in comparison to patients with private insurance. Although, Medicaid patients again were more likely to receive breast reconstruction in comparison to Medicare beneficiaries.Conclusion: There is wide disparity in reconstruction rates by insurance status. However, with continued increase in the adult Medicaid population due to widening eligibility expansion, disparities involving this vulnerable population should be examined for causes and solutions.
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Reply: The Use of Tumescent Technique in Mastectomy and Related Complications: A Meta-Analysis. Plast Reconstr Surg 2019; 144:705e-706e. [PMID: 31568327 DOI: 10.1097/prs.0000000000006030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Perturbed myoepithelial cell differentiation in BRCA mutation carriers and in ductal carcinoma in situ. Nat Commun 2019; 10:4182. [PMID: 31519911 PMCID: PMC6744561 DOI: 10.1038/s41467-019-12125-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2018] [Accepted: 08/21/2019] [Indexed: 12/24/2022] Open
Abstract
Myoepithelial cells play key roles in normal mammary gland development and in limiting pre-invasive to invasive breast tumor progression, yet their differentiation and perturbation in ductal carcinoma in situ (DCIS) are poorly understood. Here, we investigated myoepithelial cells in normal breast tissues of BRCA1 and BRCA2 germline mutation carriers and in non-carrier controls, and in sporadic DCIS. We found that in the normal breast of non-carriers, myoepithelial cells frequently co-express the p63 and TCF7 transcription factors and that p63 and TCF7 show overlapping chromatin peaks associated with differentiated myoepithelium-specific genes. In contrast, in normal breast tissues of BRCA1 mutation carriers the frequency of p63+TCF7+ myoepithelial cells is significantly decreased and p63 and TCF7 chromatin peaks do not overlap. These myoepithelial perturbations in normal breast tissues of BRCA1 germline mutation carriers may play a role in their higher risk of breast cancer. The fraction of p63+TCF7+ myoepithelial cells is also significantly decreased in DCIS, which may be associated with invasive progression.
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Evolution of Workforce Diversity in Surgery ✰. JOURNAL OF SURGICAL EDUCATION 2019; 76:1015-1021. [PMID: 30638794 DOI: 10.1016/j.jsurg.2018.12.009] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 12/11/2018] [Accepted: 12/15/2018] [Indexed: 06/09/2023]
Abstract
OBJECTIVE Assessing workforce diversity over time is essential to understanding how it has evolved and anticipating its future. We conducted the current study to evaluate gender, racial/ethnic, and duty trends over the past decade in general surgery and surgical subspecialties. DESIGN This is a cross-sectional study. We calculated ratios and relative changes to assess potential differences of physicians' characteristics across time and surgical subspecialties. SETTING We evaluated data acquired by the Association of American Medical Colleges. PARTICIPANTS We extracted data from the 2000 to 2013 including the overall number of surgeons, surgeon race/ethnicity, gender, and primary professional activity. RESULTS During 2000 to 2013, the total number of surgeons increased 11.5%, reaching 172,062 active surgeons and residents, the majority of whom were White (64%) or male (75%). However, from 2000 to 2013, most specialties showed some improvement in terms of including minorities and females. Most surgeons (98%) participate in patient care while a small portion are devoted to other activities (e.g., administrative, research, teaching; 2%). Both groups increased over the study period. CONCLUSIONS Our findings suggest that the face of surgery is changing. Continuous monitoring of the surgical workforce is important to anticipate future needs and to serve a diverse patient population.
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Integrated Transcriptomic and Proteomic Analysis of Human Eccrine Sweat Glands Identifies Missing and Novel Proteins. Mol Cell Proteomics 2019; 18:1382-1395. [PMID: 30979791 PMCID: PMC6601213 DOI: 10.1074/mcp.ra118.001101] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 03/22/2019] [Indexed: 12/12/2022] Open
Abstract
The eccrine sweat gland is an exocrine gland that is involved in the secretion of sweat for control of temperature. Malfunction of the sweat glands can result in disorders such as miliaria, hyperhidrosis and bromhidrosis. Understanding the transcriptome and proteome of sweat glands is important for understanding their physiology and role in diseases. However, no systematic transcriptome or proteome analysis of sweat glands has yet been reported. Here, we isolated eccrine sweat glands from human skin by microdissection and performed RNA-seq and proteome analysis. In total, ∼138,000 transcripts and ∼6,100 proteins were identified. Comparison of the RNA-seq data of eccrine sweat glands to other human tissues revealed the closest resemblance to the cortex region of kidneys. The proteome data showed enrichment of proteins involved in secretion, reabsorption, and wound healing. Importantly, protein level identification of the calcium ion channel TRPV4 suggests the importance of eccrine sweat glands in re-epithelialization of wounds and prevention of dehydration. We also identified 2 previously missing proteins from our analysis. Using a proteogenomic approach, we identified 7 peptides from 5 novel genes, which we validated using synthetic peptides. Most of the novel proteins were from short open reading frames (sORFs) suggesting that many sORFs still remain to be annotated in the human genome. This study presents the first integrated analysis of the transcriptome and proteome of the human eccrine sweat gland and would become a valuable resource for studying sweat glands in physiology and disease.
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The notion of the ideal breast and its variability: Reviewing the difficulty of perceiving beauty through defined margins. Breast J 2019; 25:938-941. [DOI: 10.1111/tbj.13374] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Revised: 01/16/2019] [Accepted: 01/17/2019] [Indexed: 11/29/2022]
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Classification of breast tissue expander infections: Back to the basics. J Surg Oncol 2019; 120:142-147. [PMID: 31102461 DOI: 10.1002/jso.25500] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Revised: 04/24/2019] [Accepted: 04/27/2019] [Indexed: 11/08/2022]
Abstract
BACKGROUND Infections following tissue expander (TE) placement are frequent complications in breast reconstruction. While breast surgery is a clean case, implant-based breast reconstruction has rates of infection up to 31%, decidedly higher than the typical 1% to 2% rate of surgical site infections (SSI). Few authors use the Center for Disease Control's (CDC) SSI definition for TE infections. We highlight how adoption of a consistent definition of TE infection may change how infections are researched, categorized, and ultimately managed. METHODS Two researchers with definitional discrepancies of infection performed an independent analysis of all postmastectomy patients receiving TEs (n = 175) in 2017. RESULTS Researcher One, using a clinical definition, delineated an infection rate of 19.4%. Antibiotics alone successfully treated 50% of cases. Researcher Two found an infection rate of 13.7% using CDC criteria. These infections were further delineated by a SSI rate of 6.3% and a TE infection rate post port access of 7.4%. Only 45.5% SSI's and 15.4% of TE infections were salvaged with antibiotics alone. CONCLUSIONS Rigorous adoption of CDC criteria for infection characterization in published research will help standardize the definition of infection and allow surgeons to create evidence-based infection prevention regimens.
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Reconstruction options and outcomes for breast sarcoma patients. Breast J 2019; 25:702-705. [PMID: 31025484 DOI: 10.1111/tbj.13243] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Revised: 05/24/2018] [Accepted: 06/05/2018] [Indexed: 12/01/2022]
Abstract
Breast sarcomas constitute a rare and heterogeneous group of tumors. Given their aggressive nature and the potential for extensive resections, rates of reconstruction have been low. We retrospectively reviewed subjects derived from our institutional registry presented between 2003 and 2015. Thirty-four patients with primary breast sarcoma were identified. The average age was 51.9 years and the average follow-up was 58 months. The most common histological type was malignant phyllodes (61.8%). Two patients suffered cancer recurrence. Twelve patients (35.3%) underwent reconstruction. Four underwent implant-based reconstruction, seven had autologous-based reconstruction, and one had combined reconstruction. Major complications were one flap loss and one implant removal. Our relatively high rates of breast reconstruction suggest a newly increased willingness to offer reconstruction to this rarer patient population.
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Perioperative systemic nonsteroidal anti-inflammatory drugs (NSAIDs) in women undergoing breast surgery. Hippokratia 2019. [DOI: 10.1002/14651858.cd013290] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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A large-volume academic center retrospective audit of the temporal evolution of immediate breast reconstruction protocols and the effect on breast prosthetic infection. J Plast Reconstr Aesthet Surg 2019; 72:225-231. [DOI: 10.1016/j.bjps.2018.10.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 08/18/2018] [Accepted: 10/28/2018] [Indexed: 10/28/2022]
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The Role of Antifibrinolytics in Reducing Blood Loss During Craniofacial or Orthognathic Surgical Procedures: A Meta-Analysis. J Oral Maxillofac Surg 2019; 77:1245-1260. [PMID: 30796910 DOI: 10.1016/j.joms.2019.01.032] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Revised: 01/19/2019] [Accepted: 01/21/2019] [Indexed: 12/12/2022]
Abstract
PURPOSE Use of antifibrinolytic drugs in craniofacial and orthognathic surgery seems quite promising and has strong advocates. However, supporting evidence is controversial and limited by a small sample of individual studies. We sought to systematically review and meta-analyze the available data regarding the role of preoperative or intraoperative antifibrinolytic drugs (eg, tranexamic acid, aprotinin, or aminocaproic acid) in craniofacial and orthognathic surgery. MATERIALS AND METHODS We searched PubMed, Scopus, Embase, the Cochrane Library, and Web of Science through April 19, 2018, according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Outcomes of interest included the volume of blood loss, volume of transfusions, and operative time. A meta-analysis was performed with a random-effects model using Review Manager (RevMan) software (The Cochrane Collaboration, Copenhagen, Denmark). RESULTS We identified 32 eligible studies with 749 patients undergoing craniofacial surgery and 546 undergoing orthognathic surgery. Meta-analysis showed that antifibrinolytic use led to statistically significant decreases in blood loss and blood transfusions for craniofacial procedures in adult or pediatric patients and to significantly less blood loss during orthognathic surgical procedures. Operative time did not significantly differ for either type of surgery. CONCLUSIONS Antifibrinolytics can significantly reduce blood loss in craniofacial surgical procedures including pediatric craniosynostosis and adult rhinoplasties and in orthognathic surgical procedures, as well as transfusion requirements in pediatric craniofacial surgical procedures. However, the clinical significance of the medications is still questionable because of the relative paucity of information on adverse effects and the usual small volume loss during those operations.
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The reliability of operative rating tool evaluations: How late is too late to provide operative performance feedback? Am J Surg 2018; 216:1052-1055. [DOI: 10.1016/j.amjsurg.2018.04.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Revised: 03/31/2018] [Accepted: 04/09/2018] [Indexed: 11/30/2022]
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Understanding Surgical Resident and Fellow Perspectives on Their Operative Performance Feedback Needs: A Qualitative Study. JOURNAL OF SURGICAL EDUCATION 2018; 75:1498-1503. [PMID: 29685786 DOI: 10.1016/j.jsurg.2018.04.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Revised: 03/30/2018] [Accepted: 04/01/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVE Operative performance feedback is essential for surgical training. We aimed to understand surgical trainees' views on their operative performance feedback needs and to characterize feedback to elucidate factors affecting its value from the resident perspective. DESIGN Using a qualitative research approach, 2 research fellows conducted semistructured, one-on-one interviews with surgical trainees. We analyzed recurring themes generated during interviews related to feedback characteristics, as well as the extent to which performance rating tools can help meet trainees' operative feedback needs. SETTING Departments or divisions of general or plastic surgery at 9 US academic institutions. PARTICIPANTS Surgical residents and clinical fellows in general or plastic surgery. RESULTS We conducted 30 interviews with 9 junior residents, 14 senior residents, and 7 clinical fellows. Eighteen (60%) participants were in plastic and 12 (40%) were in general surgery. Twenty-four participants (80%) reported feedback as very or extremely important during surgical training. All trainees stated that verbal, face-to-face feedback is the most valuable, especially if occurring during (92%) or immediately after (65%) cases. Of those trainees using performance rating tools (74%), most (57%) expressed positive views about them but wanted the tools to complement and not replace verbal feedback in surgical education. Trainees value feedback more if received within 1 week or the case. CONCLUSIONS Verbal, face-to-face feedback is very or extremely important to surgical trainees. Residents and fellows prefer to receive feedback during or immediately after a case and continue to value feedback if received within 1 week of the event. Performance rating tools can be useful for providing formative feedback and documentation but should not replace verbal, face-to-face feedback. Considering trainee views on feedback may help reduce perceived gaps in feedback demand-versus-supply in surgical training, which may be essential to overcoming current challenges in surgical education.
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Tumor Site and Breast Cancer Prognosis. Clin Breast Cancer 2018; 18:e1045-e1052. [DOI: 10.1016/j.clbc.2018.05.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Accepted: 05/22/2018] [Indexed: 10/16/2022]
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Breast Pocket Irrigation with Antibiotic Solution at Implant Insertion: A Systematic Review and Meta-Analysis. Aesthetic Plast Surg 2018; 42:1179-1186. [PMID: 29948092 DOI: 10.1007/s00266-018-1166-2] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Accepted: 05/28/2018] [Indexed: 10/14/2022]
Abstract
BACKGROUND Antibiotic irrigation is routinely used during implant insertion in augmentation mammoplasty procedures. However, the evidence for whether this reduces the incidence of infection or capsular contracture is unclear. METHODS AND MATERIALS Five databases were used to search for all randomized control trials, retrospective cohort and prospective cohort studies containing original data related to the primary outcomes being investigated in this study. The primary outcomes were the effects of antibiotic breast pocket irrigation on clinical infection and capsular contracture. The literature search was designed to combine three concepts: implant or tissue expander-based breast surgery, antibiotic irrigation and clinical infection or capsular contracture. Studies found were screened using specific eligibility criteria. Risk ratios (RR) and 95% confidence interval (CI) were calculated using pooled acquired data from all included studies. RESULTS The search identified 1256 citations. Three independent screeners identified seven studies that met the inclusion criteria with a pooled population of 4725. This included one prospective and six retrospective studies. A meta-analysis of pooled study data showed significant reductions in clinical infection (RR 0.52, 95% CI 0.33-0.81) and capsular contracture (RR 0.36, 95% CI 0.16-0.83) as a result of antibiotic irrigation. CONCLUSION The meta-analyses support the use of antibiotic irrigation of the breast pocket. However, the results of this study are limited by the large proportion of retrospective studies, the small number of studies included, the lack of randomized controlled trials and the heterogeneity of the antibiotic and control regimes used. LEVEL OF EVIDENCE III This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
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Breast reconstruction and risk of arm lymphedema development: A meta-analysis. J Plast Reconstr Aesthet Surg 2018; 71:807-818. [DOI: 10.1016/j.bjps.2018.01.012] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Revised: 12/13/2017] [Accepted: 01/21/2018] [Indexed: 11/15/2022]
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Evolution of Workforce Diversity in Surgery from 2000 to 2013. J Am Coll Surg 2017. [DOI: 10.1016/j.jamcollsurg.2017.07.258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Patient-Reported Outcomes for Deep Inferior Epigastric Artery Perforator Flap Breast Reconstruction in the Severely Obese. J Am Coll Surg 2017. [DOI: 10.1016/j.jamcollsurg.2017.07.371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Women Continue to Be Underrepresented in Surgery: A Study of American Medical Association and Accreditation Council for Graduate Medical Education from 2000 to 2013. J Am Coll Surg 2017. [DOI: 10.1016/j.jamcollsurg.2017.07.845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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A Cross-Sectional Comparison of Quality of Life Outcomes in 348 Older and Younger Adults after Breast Reconstruction. J Am Coll Surg 2017. [DOI: 10.1016/j.jamcollsurg.2017.07.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Diagnostic Accuracy of Selective 3-T MR Neurography–guided Retroperitoneal Genitofemoral Nerve Blocks for the Diagnosis of Genitofemoral Neuralgia. Radiology 2017; 285:176-185. [DOI: 10.1148/radiol.2017161415] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Failure to Graduate from Surgical Residency: A 10-Year Analysis. J Am Coll Surg 2017. [DOI: 10.1016/j.jamcollsurg.2017.07.940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Psychosocial and Aesthetic Advantages of Reconstruction after Prophylactic Mastectomy: A Quality of Life and Aesthetic Analysis. J Reconstr Microsurg 2017; 33:483-492. [PMID: 28605822 DOI: 10.1055/s-0037-1602785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Background Proper patient counseling regarding reconstruction after prophylactic mastectomy (PM) requires greater understanding of quality of life (QoL) and aesthetic outcomes. Our study evaluates these end points using the validated BREAST-Q and Garbay system.
Methods We performed a retrospective chart review of 1,254 mastectomy patients (July 2008 through July 2012). Of those with completed preoperative BREAST-Q and reconstruction with a minimum of 6-month follow-up, 18 underwent bilateral PM (BPM), 36 underwent contralateral PM (CPM), and 30 matched controls were selected who underwent unilateral therapeutic mastectomy (TM) with contralateral symmetry procedure. Preoperative and 6-month postreconstruction BREAST-Q scores were compared within and between groups. Subsequently, aesthetic evaluation of 21 of a group of randomly selected reconstructions (7 TM, 7 CPM, and 7 BPM) was performed by 14 plastic surgery researchers. Potential correlations between aesthetic evaluations and QoL outcomes were examined.
Results Demographic characteristics, preoperative satisfaction scores, and postoperative morbidity rates were similar among all three groups. Although reconstruction after BPM was associated with improved aesthetic outcomes (p < 0.001), a significant postoperative increase in satisfaction with breasts was noted only in the TM group (p = 0.006). CPM was associated with improved psychosocial well-being (p = 0.039) in our study. No further significant differences were noted.
Conclusion Although BPM with reconstruction is associated with higher aesthetic outcomes compared with CPM or TM, QoL is not significantly increased. Reconstruction after CPM, but not BPM, is associated with increased psychosocial well-being. These valuable findings should be taken into account during preoperative counseling regarding elective PMs.
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Empirical validation of the Operative Entrustability Assessment using resident performance in autologous breast reconstruction and hand surgery. Am J Surg 2017; 213:227-232. [DOI: 10.1016/j.amjsurg.2016.09.054] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Revised: 08/22/2016] [Accepted: 09/07/2016] [Indexed: 11/24/2022]
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A sequence upstream of canonical PDZ-binding motif within CFTR COOH-terminus enhances NHERF1 interaction. Am J Physiol Lung Cell Mol Physiol 2016; 311:L1170-L1182. [PMID: 27793802 DOI: 10.1152/ajplung.00363.2016] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Accepted: 10/18/2016] [Indexed: 01/10/2023] Open
Abstract
The development of cystic fibrosis transmembrane conductance regulator (CFTR) targeted therapy for cystic fibrosis has generated interest in maximizing membrane residence of mutant forms of CFTR by manipulating interactions with scaffold proteins, such as sodium/hydrogen exchange regulatory factor-1 (NHERF1). In this study, we explored whether COOH-terminal sequences in CFTR beyond the PDZ-binding motif influence its interaction with NHERF1. NHERF1 displayed minimal self-association in blot overlays (NHERF1, Kd = 1,382 ± 61.1 nM) at concentrations well above physiological levels, estimated at 240 nM from RNA-sequencing and 260 nM by liquid chromatography tandem mass spectrometry in sweat gland, a key site of CFTR function in vivo. However, NHERF1 oligomerized at considerably lower concentrations (10 nM) in the presence of the last 111 amino acids of CFTR (20 nM) in blot overlays and cross-linking assays and in coimmunoprecipitations using differently tagged versions of NHERF1. Deletion and alanine mutagenesis revealed that a six-amino acid sequence 1417EENKVR1422 and the terminal 1478TRL1480 (PDZ-binding motif) in the COOH-terminus were essential for the enhanced oligomerization of NHERF1. Full-length CFTR stably expressed in Madin-Darby canine kidney epithelial cells fostered NHERF1 oligomerization that was substantially reduced (∼5-fold) on alanine substitution of EEN, KVR, or EENKVR residues or deletion of the TRL motif. Confocal fluorescent microscopy revealed that the EENKVR and TRL sequences contribute to preferential localization of CFTR to the apical membrane. Together, these results indicate that COOH-terminal sequences mediate enhanced NHERF1 interaction and facilitate the localization of CFTR, a property that could be manipulated to stabilize mutant forms of CFTR at the apical surface to maximize the effect of CFTR-targeted therapeutics.
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Impact of Tissue Expander to Final Breast Reconstruction Time Interval on Postoperative Quality of Life: A Cohort Study of 144 Breast Reconstruction Patients using Breast-Q. J Am Coll Surg 2016. [DOI: 10.1016/j.jamcollsurg.2016.06.053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Breast Pocket Irrigation with Antibiotic Solution at Implant or Tissue Expander Insertion: A Systematic Review and Meta-Analysis. J Am Coll Surg 2016. [DOI: 10.1016/j.jamcollsurg.2016.08.202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Severe Deficiency of Reconstructive Surgery for the Hidden Victims of the Syrian Crisis: Challenges and Urgent Call for Solutions for Non-Fatal Injury Victims. J Am Coll Surg 2016. [DOI: 10.1016/j.jamcollsurg.2016.08.320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Health-related quality of life throughout the breast reconstruction process. J Clin Oncol 2016. [DOI: 10.1200/jco.2016.34.15_suppl.10106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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