Rectus Abdominis Muscle Atrophy and Asymmetry After Pulmonary Lobectomy

INTRODUCTION

Pulmonary lobectomy can result in intercostal nerve injury, leading to denervation of the rectus abdominis (RA) resulting in asymmetric muscle atrophy or an abdominal bulge. While there is a high rate of intercostal nerve injury during thoracic surgery, there are no studies that evaluate the magnitude and predisposing factors for RA atrophy in a large cohort.

METHODS

A retrospective chart review was conducted of 357 patients who underwent open, thoracoscopic or robotic pulmonary lobectomy at a single academic center. RA volumes were measured on computed tomography scans preoperatively and postoperatively on both the operated and nonoperated sides from the level of the xiphoid process to the thoracolumbar junction. RA volume change and association of surgical/demographic characteristics was assessed.

RESULTS

Median RA volume decreased bilaterally after operation, decreasing significantly more on the operated side (-19.5%) versus the nonoperated side (-6.6%) (P < 0.0001). 80.4% of the analyzed cohort experienced a 10% or greater decrease from preoperative RA volume on the operated side. Overweight individuals (body mass index 25.5-29.9) experienced a 1.7-fold greater volume loss on the operated side compared to normal weight individuals (body mass index 18.5-24.9) (P = 0.00016). In all right-sided lobectomies, lower lobe resection had the highest postoperative volume loss (Median (interquartile range): -28 (-35, -15)) (P = 0.082).

CONCLUSIONS

This study of postlobectomy RA asymmetry includes the largest cohort to date; previous literature only includes case reports. Lobectomy operations result in asymmetric RA atrophy and predisposing factors include demographics and surgical approach. Clinical and quality of life outcomes of RA atrophy, along with mitigation strategies, must be assessed.

Are We Speaking the Same Language? A Systematic Review on the Use of Consistent Language in Reporting Fat Necrosis in Autologous Fat Grafting of the Breast

BACKGROUND

Autologous fat grafting is a widely adopted approach to optimize outcomes in breast reconstruction and augmentation. Although fat necrosis is a well-known consequence of autologous fat grafting, it remains inconsistently defined in the literature. In late 2014, the Food and Drug Administration released a draft guidance to restrict future autologous fat grafting-a statement that was permissively modified in late 2017. In the context of evolving guidelines and autologous fat grafting outcome data, the language and descriptions of fat necrosis are inconsistent in the literature.

METHODS

Five databases were queried for studies reporting fat necrosis following autologous fat grafting for breast reconstruction or augmentation from inception to August 11, 2022. Studies were temporally stratified according to released FDA guidelines: pre-2015, 2015-2017, and 2018-2022.

RESULTS

Sixty-one articles met inclusion criteria. Prior to 2015, 6 of 21 studies (28.6%) offered clear definitions of fat necrosis. In contrast, the 2015-2017 period demonstrated an absence of clear fat necrosis definitions (0/13 studies, p = 0.03). Though the 2018-2022 period exhibited a rise in annual publications compared with the pre-2015 period (5.4 vs. 1.9, respectively, p = 0.04), this was not matched by a rise in clear fat necrosis reporting (14.8% studies, p = 0.45). Across all periods, only 16.4% of articles offered clear definitions, which exhibited wide heterogeneity.

CONCLUSION

Despite the increasing popularity of autologous fat grafting, fat necrosis remains inconsistently defined and described, especially in the context of changing FDA guidelines. This limits the reliable interpretation and application of the current literature reporting fat necrosis outcomes.

LEVEL OF EVIDENCE IV

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 .

Diversity in online resources for breast reconstruction: What do patients see?

BACKGROUND

Online resources are commonly used by patients to obtain information on breast reconstruction. Despite the key role of these resources in patient decision-making, their visual content has not yet been evaluated. This study sought to 1) characterize the presence and content of visual aids in online patient education breast reconstruction resources and 2) determine if the women represented in these visual aids reflect the breast reconstruction patient population in the United States.

METHODS

The top 10 Google websites and the first 400 Google Images containing photographs/graphics depicting human skin for the search phrase "breast reconstruction" were analyzed. Images were categorized by content as "Before/After," "Surgical/Anatomical," "Step-by-Step," or "Breast-Centric Stock Images." Image subjects were classified by skin tone into "White" or "Non-White" using the Fitzpatrick scale and by body type into "Lean" or "Full-Figured."

RESULTS

In total, 471 images were analyzed. These were predominantly "Before/After" images (43.9%), followed by "Breast-Centric Stock Images" (27.4%), "Surgical/Anatomical" (24.2%), and "Step-by-Step" (4.5%). The majority of all images depicted "White" skin types (90.7%) and "Lean" body types (73.0%). "Before/After" images were more likely to show "Full-Figured" women than the other content categories (p < 0.0001) and had the highest percentage of "Non-White" skin types (35.3%).

CONCLUSIONS

Our findings demonstrate that breast reconstruction online resources are not reflective of the patient population seeking reconstruction. Improving the diversity of online image resources can both better represent our diverse patient population as well as better align patient expectations with postoperative outcomes, likely improving patient satisfaction.

Evaluating Diversity Promotion on Integrated Plastic Surgery Residency Program Websites and Instagram Accounts

BACKGROUND

Medical students applying to residency, including those from underrepresented groups, strongly value cultural fit and program diversity. Program websites and social media are thus an influential information source for prospective applicants and recruitment tool for residencies. We evaluated whether and how integrated plastic surgery residency program websites and social media display commitments to diversity online.

METHODS

We evaluated program websites for 8 predetermined diversity elements, (1) nondiscrimination and (2) diversity statements, (3) community resources, (4) faculty and (5) resident biographies, (6) faculty and (7) resident photographs, and (8) resident resources, and assessed Instagram accounts for diversity-related images, captions, and hashtags. Our analysis used Mann-Whitney U , chi-squared, and t tests; significance level was P < 0.05.

RESULTS

We reviewed 82 program websites with a mean of 3.4 ± 1.4 diversity elements. Resident (n = 76, 92.7%) and faculty photographs (n = 65, 79.3%) and resident biographies (n = 43, 52.4%) were the most common. Seventy programs (85.4%) had Instagram accounts, the majority of which (n = 41, 58.6%) shared content related to diversity in race, ethnicity, gender, and/or sexual orientation. Programs located in smaller cities were more likely to have ≥4 website diversity elements ( P = 0.014) and mention diversity on Instagram ( P = 0.0037). Programs with women chairs/chiefs were more likely to mention diversity on Instagram ( P = 0.007).

CONCLUSIONS

In the age of virtual recruitment, program websites and social media should provide sufficient information, described in our diversity element checklist, to help prospective applicants determine fit from a diversity perspective. Residents, who often contribute to program social media, and women chairs/chiefs may be critical to driving diversity promotion.

Prior COVID-19 Infection Predisposes to Worse Outcomes After Autologous Breast Reconstruction: A Propensity Score-Matched Analysis

BACKGROUND

Major shifts in health care systems worldwide have occurred because of coronavirus disease 2019 (COVID-19). With nearly half of all Americans now having a history of COVID-19 infection, there is a pressing need to better understand the importance of prior COVID-19 infection as a potential surgical risk factor. The aim of this study was to investigate the impact of a history of prior COVID-19 infection on patient outcomes after autologous breast reconstruction.

METHODS

We performed a retrospective study using the TriNetX research database, which contains deidentified patient records from 58 participating international health care organizations. All patients who underwent autologous breast reconstruction between March 1, 2020, and April 9, 2022, were included and were grouped based on history of a prior COVID-19 infection. Demographic, preoperative risk factors, and 90-day postoperative complication data were compared. Data were analyzed by propensity score-matched analysis on TriNetX. Statistical analyses were performed by Fisher exact, χ2, and Mann-Whitney U tests as appropriate. Significance was set at P values of <0.05.

RESULTS

Patients with a history of autologous breast reconstruction within our temporal study window (N = 3215) were divided into groups with (n = 281) and without (n = 3603) a prior COVID-19 diagnosis. Nonmatched patients with prior COVID-19 had increased rates of select 90-day postoperative complications, including wound dehiscence, contour deformities, thrombotic events, any surgical site complications, and any complications overall. Use of anticoagulant, antimicrobial, and opioid medications was also found to be higher in those with prior COVID-19.After performing propensity-score matching, each cohort consisted of 281 patients without statistically significant differences between any baseline characteristics. When comparing outcomes between matched cohorts, patients with a history of COVID-19 had increased rates of wound dehiscence (odds ratio [OR], 1.90; P = 0.030), thrombotic events (OR, 2.83; P = 0.0031), and any complications (OR, 1.52; P = 0.037).

CONCLUSIONS

Our results suggest that prior COVID-19 infection is a significant risk factor for adverse outcomes after autologous breast reconstruction. Patients with a history of COVID-19 have 183% higher odds of postoperative thromboembolic events, warranting careful patient selection and postoperative management.

TIAM1 acts as an actin organization regulator to control adipose-derived pericyte cell fate

Pericytes are multipotent mesenchymal precursor cells that demonstrate tissue-specific properties. In this study, by comparing human adipose and periosteal-derived pericyte microarrays, we identified TIAM1 as a key regulator of cell morphology and differentiation decisions. TIAM1 represents a tissue-specific determinant between predispositions for adipocytic versus osteoblastic differentiation in human pericytes. TIAM1 overexpression promotes an adipogenic phenotype, whereas its downregulation amplifies osteogenic differentiation. These results were replicated in vivo xenograft animal model, in which TIAM1 misexpression altered bone or adipose tissue generation in an intramuscular xenograft animal model. Changes in pericyte differentiation potential induced by TIAM1 misexpression correlated with actin organization and altered cytoskeletal morphology. Small molecule inhibitors of either Rac1 or RhoA/ROCK signaling reversed TIAM1-induced morphology and differentiation in pericytes. Finally, pericytes within calcified vessels demonstrated decreased TIAM1 expression in the diseased area compared to the healthy tissue. In summary, our results demonstrate that TIAM1 regulates the cellular morphology and differentiation potential of human pericytes, representing a molecular switch between osteogenic and adipogenic cell fates.

Frailty is the New Age: A Retrospective Study of Modified Frailty Index for Preoperative Risk Assessment in Autologous Breast Reconstruction

BACKGROUND

 Age is a poor predictor of postoperative outcomes in breast reconstruction necessitating new methods for risk-stratifying patients preoperatively. The 5-item modified frailty index (mFI-5) is a validated measure of frailty which assesses patients' global health. The purpose of this study was to compare the effectiveness of mFI-5 and age as independent predictors of 30-day postoperative complications following autologous breast reconstruction.

METHODS

 Patients who underwent autologous breast reconstruction between 2005 and 2019 were identified from the American College of Surgeons National Surgical Quality Improvement Program. Patients were stratified based on presence of major, minor, both minor and major, and no complications. Univariate and multivariate logistic regression were performed to determine the predictive power of mFI-5, age, and other preoperative risk factors for development of minor and major 30-day postoperative complications in all patients and stratified by flap type.

RESULTS

 A total of 25,215 patients were included: 20,366 (80.8%) had no complications, 2,009 (8.0%) had minor complications, 1,531 (6.1%) had major complications, and 1,309 (5.2%) had both minor and major complications. Multivariate regression demonstrated age was not a predictor of minor (odds ratio [OR]: 1.0, p = 0.045), major (OR: 1.0, p = 0.367), or both minor and major (OR: 1.0, p = 0.908) postoperative complications. mFI-5 was a significant predictor of minor complications for mFI-5 scores 1 (OR: 1.3, p < 0.001), 2 (OR: 1.8, p < 0.001), and 3 (OR: 2.8, p = 0.043). For major complications, mFI-5 was a significant predictor for scores 1 (OR: 1.2, p = 0.011) and 2 (OR: 1.3, p = 0.03).

CONCLUSION

 Compared with age, mFI-5 scores were better predictors of 30-day postoperative complications following autologous breast reconstruction regardless of flap type. Additionally, higher mFI-5 scores were associated with increased odds of minor and major complications. Our findings indicate that reconstructive breast surgeons should consider using the mFI-5 in lieu of age to risk-stratify patients prior to autologous breast reconstruction surgery.

Reintroducing Flap Reconstruction: One Institution's Safe Return to Flap Surgery during the COVID-19 Pandemic

BACKGROUND

 Prevention of nosocomial coronavirus disease 2019 (COVID-19) infection for patients undergoing flap-based reconstructive surgery is crucial to providing care and maintaining operative volume and income to support plastic surgery programs. We conducted this study to (1) determine the postoperative incidence of COVID-19 among patients undergoing flap reconstruction from December 1, 2019 to November 1, 2020 and (2) compare 30-day outcomes between patients who underwent surgery before and during the early pandemic.

METHODS

 We conducted an 11-month retrospective cohort study of all patients who underwent flap reconstruction across our institution. We abstracted patient demographics, intraoperative management, COVID-19 testing history, and 30-day postoperative complications from electronic health records. Nosocomial COVID-19 infection was defined as reverse transcription polymerase chain reaction (RT-PCR) viral ribonucleic acid detection within 30 days of patients' postoperative course or during initial surgical admission. We used chi-squared tests to compare postoperative outcomes between patients who underwent surgery before (prior to March 12, 2021, when our institution admitted its first COVID-19 patient) versus during (on/after March 12, 2021) the pandemic.

RESULTS

 Among the 220 patients (mean [standard deviation] age = 53.8 [18.1] years; female = 54.8%) who underwent flap reconstruction, none had nosocomial COVID-19 infection. Five (2%) patients eventually tested COVID-19 positive (median time from surgery to diagnosis: 9 months, range: 1.5-11 months) with one developing partial flap loss while infected. Between patients who underwent free flap surgery before and during the pandemic, there were no significant differences in 30-day takebacks (15.6% vs. 16.6%, respectively; p > 0.999), readmissions (9.4% vs. 12.6%, respectively; p = 0.53), and surgical complications (e.g., total flap loss 1.6% vs. 2.1%, p = 0.81).

CONCLUSION

 Robust precautions can ensure the safety of patients undergoing flap surgeries across an academic medical institution, even during periods of high COVID-19 admission rates. Further studies are needed to generate evidence-based guidelines that optimize infection control and flap survival for patients undergoing reconstruction.

A 10-Year Review of Surgical Outcomes at the Johns Hopkins and University of Maryland Resident Aesthetic Clinic

Background

In 2014, the Plastic Surgery Residency Review Committee of the Accreditation Council for Graduate Medical Education (ACGME) increased minimum aesthetic surgery requirements. Consequently, the resident aesthetic clinic (RAC) has become an ever more important modality for training plastic surgery residents.

Objectives

To analyze demographics and long-term surgical outcomes of aesthetic procedures performed at the Johns Hopkins and University of Maryland (JH/UM) RAC. A secondary objective was to evaluate the JH/UM RAC outcomes against those of peer RACs as well as board-certified plastic surgeons.

Methods

We performed a retrospective chart review of all patients who underwent aesthetic procedures at the JH/UM RAC between 2011 and 2020. Clinical characteristics, minor complication rates, major complication rates, and revision rates from the JH/UM RAC were compared against 2 peer RACs. We compared the incidence of major complications between the JH/UM RAC and a cohort of patients from the CosmetAssure (Birmingham, AL) database. Pearson's chi-square test was used to compare complication rates between patient populations, with a significance set at 0.05.

Results

Four hundred ninety-five procedures were performed on 285 patients. The major complications rate was 1.0% (n = 5). Peer RACs had total major complication rates of 0.2% and 1.7% (P = .07 and P = .47, respectively). CosmetAssure patients matched to JH/UM RAC patients were found to have comparable total major complications rates of 1.8% vs 0.6% (P = .06), respectively. At JH/UM, the minor complication rate was 13.9%, while the revision rate was 5.9%.

Conclusions

The JH/UM RAC provides residents the education and training necessary to produce surgical outcomes comparable to peer RACs as well as board-certified plastic surgeons.

Level of Evidence 3

The Effects of Depression and Anti-Depressants on Quality of Life After Breast Reconstruction: A Post-Hoc Analysis

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.

The Zoom Boom: How Video Calling Impacts Attitudes Towards Aesthetic Surgery in the COVID-19 Era

Background

The COVID-19 pandemic has led to the widespread adoption of video calling. A parallel growth in aesthetic surgery demand has been documented.

Objectives

To identify associations between video call engagement and aesthetic surgery attitudes.

Methods

We distributed a cross-sectional survey via Amazon Mechanical Turk in November 2020. Respondents were asked to report their time spent video calling, video calling applications and features (eg, virtual backgrounds) they used, and aesthetic surgery attitudes using the 15-item Acceptance of Cosmetic Surgery Scale (ACSS; higher scores indicate greater acceptance). We compared ACSS scores between video call users and non-users using Student’s t-tests. We used Pearson’s correlation coefficient to quantify associations between ACSS scores and time spent on calls and multivariable analysis to estimate associations between video call engagement and ACSS scores.

Results

A total of 295 respondents (mean age, 37.6; 49.5% female) completed the survey. Across all video call applications surveyed, video call users had higher ACSS scores than non-users. Increased time respondents spent looking at their own face on video call was moderately associated with higher ACSS scores (r=0.48, P<0.01), while time spent looking at another person’s face was not associated with a change in ACSS scores (r=0.09, P=0.11). Increased video call use was associated with higher ACSS scores.

Conclusions

Increased video calling use is associated with increased acceptance of aesthetic surgery. Although the clinical significance of ACSS scores can be better elucidated, plastic surgeons should consider the effects of video calling on patient motivations for aesthetic surgery in the COVID-19 era.

An Analysis of Gender Bias in Plastic Surgery Resident Assessment

BACKGROUND

Previous studies have shown men and women attending physicians rate or provide operating room (OR) autonomy differently to men and women residents, with men attendings providing higher ratings and more OR autonomy to men residents. Particularly with the advent of competency-based training in plastic surgery, differential advancement of trainees influenced by gender bias could have detrimental effects on resident advancement and time to graduation.

OBJECTIVE

We determined if plastic surgery residents are assessed differently according to gender.

METHODS

Three institutions' Operative Entrustability Assessment (OEA) data were abstracted from inception through November 2018 from MileMarker, a web-based program that stores trainee operative skill assessments of CPT-coded procedures. Ratings are based on a 5-point scale. Linear regression with postgraduate year adjustment was applied to all completed OEAs to compare men and women attendings' assessments of men and women residents.

RESULTS

We included 8377 OEAs completed on 64 unique residents (25% women) by 51 unique attendings (29% women): men attendings completed 83% (n = 6972; 5859 assessments of men residents; 1113 of women residents) and women attendings completed 17% (n = 1405; 1025 assessments of men residents; 380 of women residents). Adjusted analysis showed men attendings rated women residents lower than men residents (P < .001); scores by women attendings demonstrated no significant difference (P = .067).

CONCLUSIONS

Our dataset including 4.5 years of data from 3 training programs showed men attendings scored women plastic surgery residents lower than their men counterparts.

Examining the Effects of Postmastectomy Radiation Therapy in Prepectoral Versus Subpectoral Autologous Breast Reconstruction

BACKGROUND

Postmastectomy radiation therapy (PMRT) is known to increase the risk of multiple adverse outcomes after breast reconstruction. In the context of delayed-immediate autologous breast reconstruction, PMRT is typically conducted after placement of subpectoral (SP) tissue expanders. With the re-emergence of prepectoral (PP) reconstruction, there are little data assessing the outcomes of PP reconstruction in breasts receiving PMRT. We compared postoperative outcomes of PMRT patients undergoing delayed-immediate, autologous breast reconstruction with placement of tissue expanders in either the PP or SP plane.

METHODS

A retrospective chart review was conducted on all consecutive patients who underwent delayed-immediate autologous breast reconstruction and received PMRT at either the Stanford University or the Johns Hopkins University Hospitals between January 2009 and December 2018. Demographics, comorbidities, perioperative information, and oncologic data were collected for all patients. Complications were collected and analyzed after stage 1 surgery, between 30 days of stage 1 and up to stage 2 surgery, and after stage 2 surgery. Multivariable regressions were used to determine predictors of 1 or more complications.

RESULTS

A total of 71 patients (73 breasts) were included. Prepectoral reconstruction comprised of 52.2% of the cohort, and the remaining 47.8% were SP reconstructions. Demographics and comorbidities were similar between groups, except for premastectomy radiation, which was more prevalent in the PP cohort (P = 0.010). Complications were similar between cohorts after stage 1 surgery (P = 0.420), between stages 1 and 2 (P = 0.100), and after stage 2 (P = 0.570). There were higher rates of skin necrosis in the SP cohort between stages 1 and 2 (PP: 2.6%, SP: 20%, P = 0.004). Multivariable analysis revealed body mass index to be the only predictor of complication (P = 0.041). The mean number of revisionary surgeries was higher in the SP cohort (PP: 0.8 vs SP: 1.9, P = 0.002). The mean follow-up was 385.5 days and similar between groups (P = 0.870).

CONCLUSIONS

Rates of overall complication were similar between PP and SP expander placement. However, in SP reconstructions, skin necrosis was significantly higher between stages 1 and 2. The patients in the SP cohort also underwent a greater number of revisionary surgeries, although overall rates of pursuing any revisionary surgery were similar between groups.

Women Continue to Be Underrepresented in Surgery: A Study of AMA and ACGME Data from 2000 to 2016

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.

Determinants of receiving immediate breast reconstruction: An analysis of patient characteristics at a tertiary care center in the US

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.

Neutrophil extracellular traps, B cells, and type I interferons contribute to immune dysregulation in hidradenitis suppurativa

Hidradenitis suppurativa (HS), also known as acne inversa, is an incapacitating skin disorder of unknown etiology manifested as abscess-like nodules and boils resulting in fistulas and tissue scarring as it progresses. Given that neutrophils are the predominant leukocyte infiltrate in HS lesions, the role of neutrophil extracellular traps (NETs) in the induction of local and systemic immune dysregulation in this disease was examined. Immunofluorescence microscopy was performed in HS lesions and detected the prominent presence of NETs. NET complexes correlated with disease severity, as measured by Hurley staging. Neutrophils from the peripheral blood of patients with HS peripheral also displayed enhanced spontaneous NET formation when compared to healthy control neutrophils. Sera from patients recognized antigens present in NETs and harbored increased antibodies reactive to citrullinated peptides. B cell dysregulation, as evidenced by elevated plasma cells and IgG, was observed in the circulation and skin from patients with HS. Peptidylarginine deiminases (PADs) 1 to 4, enzymes involved in citrullination, were differentially expressed in HS skin, when compared to controls, in association with enhanced tissue citrullination. NETs in HS skin coexisted with plasmacytoid dendritic cells, in association with a type I interferon (IFN) gene signature. Enhanced NET formation and immune responses to neutrophil and NET-related antigens may promote immune dysregulation and contribute to inflammation. This, along with evidence of up-regulation of the type I IFN pathway in HS skin, suggests that the innate immune system may play important pathogenic roles in this disease.

Specimen Collection for Translational Studies in Hidradenitis Suppurativa

Hidradenitis suppurativa (HS) is a chronic inflammatory disorder characterized by painful nodules, sinus tracts, and scars occurring predominantly in intertriginous regions. The prevalence of HS is currently 0.053-4%, with a predominance in African-American women and has been linked to low socioeconomic status. The majority of the reported literature is  retrospective, population based, epidemiologic studies. In this regard, there is a need to establish a repository of biospecimens, which represent appropriate gender and racial demographics amongst HS patients. These efforts will diminish knowledge gaps in understanding the disease pathophysiology. Hence, we sought to outline a step-by-step protocol detailing how we established our HS biobank to facilitate the formation of other HS tissue banks. Equipping researchers with carefully detailed processes for collection of HS specimens would accelerate the accumulation of well-organized human biological material. Over time, the scientific community will have access to a broad range of HS tissue biospecimens, ultimately leading to more rigorous basic and translational research. Moreover, an improved understanding of the pathophysiology is necessary for the discovery of novel therapies for this debilitating disease. We aim to provide high impact translational research methodology for cutaneous biology research and foster multidisciplinary collaboration and advancement of our understanding of cutaneous diseases.

Evolution of Workforce Diversity in Surgery✰

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.

Oncoplastic Breast Reconstruction: Should All Patients be Considered?

Oncoplastic surgery of the tissue defect from partial mastectomy should be considered for all patients. It can result in in significant asymmetries from scar contraction, skin tethering, and alterations in the nipple areolar complex location. Indications, risks, and benefits are discussed. Optimal procedures are described, considering resected specimen volume, primary tumor location, tumor to breast size ratio, and the impact on the nipple areolar complex. Indications for plastic surgery consultation and joint surgery are discussed. Surgical management includes incision planning, preservation of the nipple areolar complex pedicle and position, patient positioning, incision location, and recovery.