Predicting and preventing pressure ulcers in adults with paralysis

A questionnaire mailed to all 2,295 members of the Eastern Paralyzed Veterans Association measured 45 potential risk factors for pressure ulcers. Logistic-regression analysis and Cox proportional-hazards analyses were used to identify the variables that were independently associated with pressure ulcers. The survey response rate was 42.2%. Among 15 risk factors from a previously published scale by the authors, 7 were independent predictors of pressure ulcer development: level of activity, level of mobility, complete spinal cord injury, urine incontinence or moisture, autonomic dysreflexia, pulmonary disease, and renal disease. In addition, 2 new variables added significant predictive value: being prone to infections that cause breathing problems and paralysis caused by trauma (as opposed to disease). Using these 9 risk factors, a new pressure ulcer risk assessment scale was designed specifically for persons with paralysis who are living in a community setting. It appears to be a more accurate method of predicting pressure ulcers than currently used risk assessment scales.

Minimizing Nipple-Areolar Complex Complications in Prepectoral Breast Reconstruction After Nipple-Sparing Mastectomy

PURPOSE

Nipple-areolar complex (NAC) viability remains a significant concern following prepectoral tissue expander (TE) reconstruction after nipple-sparing mastectomy (NSM). This study assesses the impact of intraoperative TE fill on NAC necrosis and identifies strategies for mitigating this risk.

METHODS

A chart review of all consecutive, prepectoral TEs placed immediately after NSM was performed between March 2017 and December 2022 at a single center. Demographics, mastectomy weight, intraoperative TE fill, and complications were extracted for all patients. Partial NAC necrosis was defined as any thickness of skin loss including part of the NAC, whereas total NAC necrosis was defined as full-thickness skin loss involving the entirety of the NAC. P < 0.05 was considered statistically significant.

RESULTS

Forty-six patients (83 breasts) with an average follow-up of 22 months were included. Women were on average 46 years old, nonsmoker (98%), and nondiabetic (100%) and had a body mass index of 23 kg/m2. All reconstructions were performed immediately following prophylactic mastectomies in 49% and therapeutic mastectomies in 51% of cases. Three breasts (4%) were radiated, and 15 patients (33%) received chemotherapy. Mean mastectomy weight was 346 ± 274 g, median intraoperative TE fill was 150 ± 225 mL, and median final TE fill was 350 ± 170 mL. Partial NAC necrosis occurred in 7 breasts (8%), and there were zero instances of complete NAC necrosis. On univariate analysis, partial NAC necrosis was not associated with any patient demographic or operative characteristics, including intraoperative TE fill. In multivariable models controlling for age, body mass index, mastectomy weight, prior breast surgery, and intraoperative TE fill, partial NAC necrosis was associated with lower body mass index (odds ratio, 0.53; confidence interval [CI], 0.29-0.98; P < 0.05) and higher mastectomy weight (odds ratio, 1.1; CI, 1.01-1.20; P < 0.05). Prior breast surgery approached significance, as those breasts had a 19.4 times higher odds of partial NAC necrosis (95% CI, 0.88-427.6; P = 0.06).

CONCLUSIONS

Nipple-areolar complex necrosis following prepectoral TE reconstruction is a rare but serious complication. In this study of 83 breasts, 7 (8%) developed partial NAC necrosis, and all but one were able to be salvaged.

Finding the Right Fill: The Ideal Tissue Expander Fill in Immediate Prepectoral Breast Reconstruction

PURPOSE

Although many factors in prepectoral breast reconstruction such as mastectomy weight and flap quality are out of the plastic surgeon's control, some elements such as intraoperative tissue expander (TE) fill can be optimized. This study assesses the impact of intraoperative TE fill on postoperative complications in prepectoral breast reconstruction and posits the optimal fill.

METHODS

All consecutive, prepectoral TE reconstructions performed between March 2017 and December 2022 at a single center were reviewed. A "fill ratio" or ratio of intraoperative TE fill to mastectomy weight (TEF/MW) was constructed to quantify deadspace in the breast pocket, with values closer to 1 signifying less deadspace. Major complications include those requiring readmission or reoperation and minor complications include those that could be treated as an outpatient. A P < 0.05 was considered statistically significant.

RESULTS

A total of 200 patients (318 breasts) with average follow-up of 22 months were included. Patients were, on average, 53 years old, were nonsmoker (98%), were nondiabetic (91%), and had a body mass index of 26 kg/m2. Only immediate reconstructions were included and were performed following prophylactic mastectomies in 34% and therapeutic mastectomies in 66% of cases. Seventy-six (24%) breasts were radiated, and 93 (47%) patients received chemotherapy. Mean mastectomy weight was 546 g, median intraoperative TE fill was 175 ± 250 cc, and median final TE fill was 390 ± 220 cc.Major complications occurred in 64 (20%) breasts and were associated with less deadspace (0.49 vs 0.36, P < 0.05). In multivariable models, a higher fill ratio was associated with 2.4 times higher odds of major complications (95% CI, 1.2-4.7; P = 0.01). Optimal intraoperative TE fill for avoiding major complications was 80 cc, and optimal fill ratio was 0.09.Explantation occurred in 44 (14%) breasts and was associated with less deadspace (0.51 vs 0.35, P < 0.05); the optimal fill for avoiding explantation was 80 cc, and optimal ratio was 0.12.

CONCLUSIONS

Higher intraoperative TE fill and less deadspace were associated with postoperative complications. Filling a TE to 80 cc or approximately a tenth of mastectomy weight may reduce complications.

Racial and Ethnic Disparities Among Patients Enrolled in Breast Reconstruction-Related Clinical Trials

INTRODUCTION

Breast reconstruction clinical trials that reflect the racial and ethnic makeup of breast cancer disease burden are fundamental in improving breast reconstruction accessibility and outcomes. We aim to evaluate race and ethnicity reporting in breast reconstruction-related clinical trials (BRRCTs) and determine whether reported race and ethnicity of enrollees aligns with their breast cancer incidence rates in the general US population.

METHODS

All completed, US-based BRRCTs were retrospectively reviewed via ClinicalTrials.gov in February 2024. Age, race, ethnicity, and BRRCT funding source were recorded. BRRCT enrollment rates of racial and ethnic groups were compared to their expected representation rates, calculated using breast cancer incidence rate. Descriptive statistics and univariate analyses were performed.

RESULTS

Twenty-five studies representing 2603 patients were included. The mean age of enrollees was 49.4 ± 2.2 years. Seven (28%) reported enrollees' race, and 5 (20%) reported both race and ethnicity. Most enrollees were White (90.8%), followed by Black (3.5%), Asian (1.5%), and American Indian/Alaska Native (AI/AN) (0.1%). Fewer enrollees identified as Hispanic/Latino than non-Hispanic/Latino (7.6% vs 91.5%, P < 0.01). Observed enrollment rates of minority groups were lower than their respective expected representation rates (Black: 3.5% vs 24.9%, P < 0.01; Asian: 1.5% vs 23.9%, P < 0.01; AI/AN: 0.1% vs 24.9%, P < 0.01; Hispanic/Latino: 7.6% vs 45.2%, P < 0.01). Conversely, White enrollees were overrepresented when compared to the group's overall breast cancer burden (90.8% vs 26.4%; P < 0.01).

CONCLUSIONS

Over 70% of BRRCTs did not report the race or ethnicity of enrollees. When reported, racial and ethnic minorities were significantly underrepresented in BRRCTs. More diligent reporting and proactive initiatives to increase recruitment of minority groups in clinical trials are needed to strengthen the validity of BRRCTs.

Breast Implant Illness as a Clinical Entity: A Systematic Review of the Literature

BACKGROUND

Breast implant illness (BII) has become a contentious subject in recent years. Although some studies have reported associations between breast implants and autoimmune diseases, others have failed to establish a definitive link.

OBJECTIVES

The objective of this study was to provide a comprehensive, up-to-date evaluation of the literature surrounding BII, with an emphasis on identifying patient-related factors that may be associated with BII.

METHODS

A systematic review was performed following PRISMA guidelines by searching the PubMed (MEDLINE), Embase, and Cochrane databases for relevant studies published in the last 20 years.

RESULTS

Thirty-one studies were included, which covered 39,505 implant patients with a mean [standard deviation] age of 44.2 [9.30] years. Fifteen studies reported implant explantation status, with 72.4% patients choosing to remove their implants. Among these, 9 studies reported symptom improvement in 83.5% patients. Fifty-three percent of patients undergoing explantation had total capsulectomy. Twenty-eight studies documented total numbers of patients experiencing symptoms related to BII, with 31.3% patients reporting such symptoms. Among these, 16 studies of 4109 BII patients distinguished whether the reason for implantation was cosmetic augmentation or reconstruction. When specified, more patients experiencing BII-related symptoms received implants for "cosmetic" vs "reconstructive" reasons (cosmetic, 3864/4109 [94.0%] vs reconstruction, 245/4109 [5.96%]; P < .001).

CONCLUSIONS

This review provides an overview of the current state of knowledge regarding BII. The study highlights a potential relationship between BII and indication for implants (cosmetic vs reconstructive) among other variables, offering valuable insight on factors associated with BII and directions for future research.

LEVEL OF EVIDENCE: 3