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Annals of Plastic Surgery Jun 2024Individual outcomes may not accurately reflect the quality of perioperative care. Textbook outcomes (TOs) are composite metrics that provide a comprehensive evaluation...
BACKGROUND
Individual outcomes may not accurately reflect the quality of perioperative care. Textbook outcomes (TOs) are composite metrics that provide a comprehensive evaluation of hospital performance and surgical quality. This study aimed to investigate the prevalence and predictors of TOs in a multi-institutional cohort of patients who underwent breast reconstruction with deep inferior epigastric artery perforator flaps.
METHODS
For autologous reconstruction, a TO was previously defined as a procedure without intraoperative complications, reoperation, infection requiring intravenous antibiotics, readmission, mortality, systemic complications, operative duration ≤12 hours for bilateral and ≤10 hours for unilateral/stacked reconstruction, and length of stay (LOS) ≤5 days. We investigated associations between patient-level factors and achieving a TO using multivariable regression analysis.
RESULTS
Of 1000 patients, most (73.2%) met a TO. The most common reasons for deviation from a TO were reoperation (9.6%), prolonged operative time (9.5%), and prolonged LOS (9.2%). On univariate analysis, tobacco use, obesity, widowed/divorced marital status, and contralateral prophylactic mastectomy or bilateral reconstruction were associated with a lower likelihood of TOs (P < 0.05). After adjustment, bilateral prophylactic mastectomy (odds ratio [OR], 5.71; P = 0.029) and hormonal therapy (OR, 1.53; P = 0.050) were associated with a higher likelihood of TOs; higher body mass index (OR, 0.91; P = <0.001) was associated with a lower likelihood.
CONCLUSION
Approximately 30% of patients did not achieve a TO, and the likelihood of achieving a TO was influenced by patient and procedural factors. Future studies should investigate how this metric may be used to evaluate patient and hospital-level performance to improve the quality of care in reconstructive surgery.
Topics: Humans; Female; Mammaplasty; Middle Aged; Perforator Flap; Adult; Retrospective Studies; Breast Neoplasms; Epigastric Arteries; Microsurgery; Treatment Outcome; Postoperative Complications; Mastectomy; Length of Stay
PubMed: 38857013
DOI: 10.1097/SAP.0000000000003950 -
Annals of Plastic Surgery Jun 2024Skin-sparing mastectomy (SSM) is often used when tumor location prohibits performing a nipple-sparing mastectomy (NSM). We examined a square excision of the...
INTRODUCTION
Skin-sparing mastectomy (SSM) is often used when tumor location prohibits performing a nipple-sparing mastectomy (NSM). We examined a square excision of the nipple-areolar complex (NAC) and an X-shaped purse string closure after implant-based reconstruction.
METHODS
A retrospective review was performed on patients undergoing periareolar SSM and immediate implant-based reconstruction from January 2015 through December 2022, specifically identifying those patients who had square NAC excision and skin closure.
RESULTS
Twenty-nine patients met the inclusion criteria. They underwent 54 periareolar SSM and immediate implant-based reconstruction (bilateral 25, unilateral 4). Indications for surgery were cancer (30) and prophylactic (24; 2 patients had bilateral cancer). Reconstructive methods included tissue expander (TE) (36 [66.7%]) and direct-to-implant (DTI) (18 [33.3%]). The mean mastectomy weights and final implant sizes were similar between the 2 groups. Overall wound complications occurred in 13 (24.1%) of the breasts: mastectomy skin flap necrosis (MSFN; 10 [18.5%]) and infection (3 [5.6%]). Reconstructive failure occurred in 3 cases: TE, 1 (infection); DTI, 2 (MSFN/exposure). MSFN by reconstructive method: TE, 4 (11.1%); DTI, 6 (33.3%) (P = 0.05, comparing MSFN rates between TE and DTI methods). The mean initial TE fill volume was 247.1 cc; mean implant size in the DTI group was 417.8 cc (P < 0.0001).
CONCLUSIONS
The square NAC excision and closure can minimize the surgical incision in implant reconstruction. Two-stage TE reconstruction permits lower initial fill volumes, which reduces the risk of MSFN after box to X closure of SSM and implant-based reconstruction. It is useful in small- to moderate-sized breasts with mild ptosis in patients who are not candidates for NSM.
Topics: Humans; Female; Retrospective Studies; Middle Aged; Breast Neoplasms; Adult; Mastectomy, Subcutaneous; Mammaplasty; Breast Implants; Breast Implantation; Nipples; Organ Sparing Treatments; Aged; Mastectomy; Treatment Outcome
PubMed: 38857011
DOI: 10.1097/SAP.0000000000003946 -
Annals of Plastic Surgery Jun 2024The Goldilocks breast reconstruction utilizes redundant mastectomy skin flaps to fashion a breast mound; however, there is concern that imbrication of these skin flaps...
BACKGROUND
The Goldilocks breast reconstruction utilizes redundant mastectomy skin flaps to fashion a breast mound; however, there is concern that imbrication of these skin flaps may predispose to fat necrosis and make detection of local breast cancer recurrence more difficult. Goldilocks patients follow a traditional postmastectomy screening pathway that includes clinical examination for locoregional recurrence, but it is unclear if this is sufficient. We evaluate our Goldilocks reconstruction case series to determine rates of diagnostic imaging, biopsy, and locoregional and distant recurrence.
METHODS
Sixty-six patients (94 breasts) undergoing Goldilocks breast reconstruction were retrospectively reviewed. Any diagnostic postoperative imaging/biopsies performed and that confirmed local or distant breast cancer recurrence were noted.
RESULTS
Average time of follow-up was 45 months. Most patients in this cohort had stage 0 (27.3%) or stage I (40.9%) breast cancer. There were a total of 11 (11.7%) concerning breast masses identified. Seven (7.4%) masses were biopsied, of which 5 were benign and 2 were invasive cancer recurrence. Four masses (4.3%) underwent diagnostic imaging only, all with benign findings. Five patients in this series were found to have either distant disease or a second primary cancer in the nonoperative contralateral breast.
CONCLUSIONS
Rates of local recurrence following Goldilocks are not higher than expected after other types of postmastectomy reconstruction. Clinical monitoring successfully detected local recurrence in all affected patients in this series. More definite guidelines around the routine screening of Goldilocks mastectomy patients may aid in early detection of local breast cancer recurrence.
Topics: Humans; Female; Breast Neoplasms; Neoplasm Recurrence, Local; Retrospective Studies; Middle Aged; Adult; Mammaplasty; Aged; Mastectomy; Follow-Up Studies; Surgical Flaps
PubMed: 38857009
DOI: 10.1097/SAP.0000000000003952 -
Annals of Plastic Surgery Jun 2024Tissue expander-based breast reconstruction is associated with high rates of infectious complications, often leading to tissue expander explants and delays in receipt of...
BACKGROUND
Tissue expander-based breast reconstruction is associated with high rates of infectious complications, often leading to tissue expander explants and delays in receipt of definitive breast reconstruction and adjuvant therapy. In this study, we describe a single-stage technique where deep inferior epigastric artery perforator (DIEP) flaps are used to salvage actively infected tissue expanders among patients originally planning for free flap reconstruction.
METHODS
In this technique, patients with tissue expander infections without systemic illness are maintained on oral antibiotics until the day of their DIEP flap surgery, at which time tissue expander explant is performed in conjunction with aggressive attempt at total capsulectomy and immediate DIEP flap reconstruction. Patients are maintained on 1-2 weeks of oral antibiotics tailored to culture data. Patients undergoing this immediate salvage protocol were retrospectively reviewed, and complications and length of stay were assessed.
RESULTS
In a retrospective series, a total of six consecutive patients with culture-proven tissue expander infections underwent tissue expander removal and DIEP flap reconstruction in a single stage and were maintained on 7-14 days of oral antibiotics postoperatively. Within this cohort, no surgical site infections, microvascular complications, partial flap losses, reoperations, or returns to the operating room were noted within a 90-day period.
CONCLUSIONS
Among a select cohort of patients, actively infected tissue expanders may be salvaged with free flap breast reconstruction in a single surgery with a low incidence of postoperative complications. Prospective studies are needed to evaluate the influence of this treatment strategy on costs, number of surgeries, and dissatisfaction after staged breast reconstruction complicated by tissue expander infections.
Topics: Humans; Perforator Flap; Female; Retrospective Studies; Tissue Expansion Devices; Mammaplasty; Middle Aged; Epigastric Arteries; Salvage Therapy; Adult; Prosthesis-Related Infections; Anti-Bacterial Agents; Tissue Expansion; Breast Neoplasms; Treatment Outcome; Device Removal
PubMed: 38857007
DOI: 10.1097/SAP.0000000000003947 -
Annals of Plastic Surgery Jun 2024Hourly flap checks are the most common means of flap monitoring during the first 24 hours following autologous breast reconstruction (ABR). This practice often requires...
BACKGROUND
Hourly flap checks are the most common means of flap monitoring during the first 24 hours following autologous breast reconstruction (ABR). This practice often requires intensive care unit (ICU) admission, which is a key driver of health care costs and decreased patient satisfaction. This study addresses these issues by demonstrating decreased cost and length of admission associated with a 4-hour interval between flap checks during the first 24 hours following ABR.
METHODS
This is a retrospective review of ABR surgeries performed by multiple surgeons from 2017 to 2020. Two cohorts were identified, one that underwent flap checks every hour in the ICU (Q1 cohort) and the other that underwent flap checks every 4 hours on the hospital floor (Q4 cohort). Our primary outcome measures were length of stay (LOS), flap takebacks, flap loss, and encounter cost.
RESULTS
Rates of flap takeback and loss did not differ between cohorts (P = 0.18, P = 0.21). The Q4 cohort's average LOS was shorter than the Q1 cohort (P = 0.002). The Q4 cohort's average cost was also $25,554.80 less than the Q1 cohort (P < 0.001). This association persisted after controlling for LOS, operating room takeback, timing and laterality of reconstruction, and flap configuration (hazard ratio = 0.65, P = 0.0007).
CONCLUSION
This study demonstrates the benefits of lengthened flap check intervals during the first 24 hours following ABR. These intervals decrease the cost of ABR while also maintaining safety, making ABR a more accessible option for breast reconstruction patients.
Topics: Humans; Mammaplasty; Female; Retrospective Studies; Middle Aged; Surgical Flaps; Time Factors; Length of Stay; Adult; Postoperative Care; Monitoring, Physiologic; Transplantation, Autologous
PubMed: 38857006
DOI: 10.1097/SAP.0000000000003977 -
Annals of Plastic Surgery Jun 2024Ultrasound-guided regional field blocks are not widely used in outpatient plastic surgeries. The efficacy of truncal blocks (PEC1 + SAP) has not been established in... (Comparative Study)
Comparative Study
Local Infiltration Anesthesia Versus Ultrasound-Guided Pectoralis (PEC1) + Serratus Anterior Plane (SAP) Blocks on Postanesthetic Care Unit Pain Control in Patients Undergoing Primary Submuscular Augmentation Mammoplasty.
BACKGROUND
Ultrasound-guided regional field blocks are not widely used in outpatient plastic surgeries. The efficacy of truncal blocks (PEC1 + SAP) has not been established in plastic surgery. The purpose of this study was to analyze the outcomes of these newer anesthetic techniques compared with traditional blind local anesthetic infiltration in patients undergoing breast augmentation.
METHODS
This retrospective institutional review board-approved cohort study compared the outcomes of the different practices of 2 plastic surgeons at the same accredited outpatient surgery center between 2018 and 2022. Group 1 received an intraoperative blind local infiltration anesthetic. Group 2 underwent surgeon-led, intraoperative, ultrasound-guided PEC1 (Pectoralis 1) + SAP (serratus anterior plane) blocks. Patients who underwent any procedure other than primary submuscular augmentation mammoplasty were excluded from the study. The outcomes measured included operative time, opioid utilization in morphine milligram equivalents (MME), pain level at discharge, and time spent in the post anesthetic care unit (PACU).
RESULTS
Sixty patients met the inclusion criteria for each group for a total of 120 patients. The study groups were similar to each other. Patients receiving PEC1 + SAP blocks (group 2) had significantly lower average MME requirements in the PACU (3.04 MME vs 4.52 MME, P = 0.041) and required a shorter average PACU stay (70.13 minutes vs 80.38 minutes, P = 0.008). There were no significant differences in the pain level at discharge, operative time, or implant size between the 2 groups.
CONCLUSIONS
Surgeon-led, intraoperative, ultrasound-guided PEC1 + SAP blocks significantly decreased opioid utilization in the PACU by 33% and patient time in the PACU by 13%, while achieving similar patient pain scores and operating times.
Topics: Humans; Female; Retrospective Studies; Ultrasonography, Interventional; Adult; Nerve Block; Pain, Postoperative; Anesthesia, Local; Mammaplasty; Pain Management; Pectoralis Muscles; Middle Aged; Pain Measurement; Anesthesia Recovery Period; Anesthetics, Local; Cohort Studies
PubMed: 38857002
DOI: 10.1097/SAP.0000000000003948 -
Annals of Plastic Surgery Jun 2024An important component of preoperative counseling and patient selection involves surgical risk stratification. There are many tools developed to predict surgical...
BACKGROUND
An important component of preoperative counseling and patient selection involves surgical risk stratification. There are many tools developed to predict surgical complications. The Modified Frailty Index (mFI) calculates risk based on the following five elements: hypertension, chronic obstructive pulmonary disease, congestive heart failure, diabetes, and functional status. Recent literature demonstrates the efficacy of the mFI across multiple surgical disciplines. We elected to investigate its utility in oncoplastic reductions (OCR).
METHODS
A retrospective review of all patients with breast cancer who underwent OCR from 1998 to 2020 was queried from a prospectively maintained database. Patient demographics, comorbidities, and surgical details were reviewed. The mFI was computed for each patient. The primary clinical outcome was the development of complications.
RESULTS
547 patients were included in the study cohort. The average age was 55 and the average body mass index was 33.5. The overall complication rate was 19% (n = 105) and the major complication rate was 9% (n = 49). Higher frailty scores were significantly associated with the development of major complications (P < 0.05). mFI scores of 0 had a major complication rate of 5.7%; scores of 1, 13%; and scores of 2, 15.1%. The relative risk of a major complication in patients with elevated mFI (>0) was 2.2. Age, body mass index, and resection weights were not associated with complications (P = 0.15, P = 0.87, and P = 0.30 respectively) on continuous analysis.
CONCLUSIONS
Elevated mFI scores are associated with an increased major complication profile in patients who are undergoing OCR. Hypertension and diabetes are the most common comorbidities in our population, and this tool may assist with preoperative counseling and risk stratification. Benefits of this risk assessment tool include its ease of calculation and brevity. Our study is the first to demonstrate its utility in OCR; however, further study in high-risk patients would strengthen the applicability of this frailty index.
Topics: Humans; Female; Frailty; Mammaplasty; Middle Aged; Retrospective Studies; Breast Neoplasms; Postoperative Complications; Risk Assessment; Aged; Adult
PubMed: 38856997
DOI: 10.1097/SAP.0000000000003959 -
The Journal of Craniofacial Surgery Jun 2024The thyroid cartilage, an androgen-sensitive structure, enlarges during puberty in individuals assigned male at birth, often resulting in a pronounced neck protuberance....
INTRODUCTION
The thyroid cartilage, an androgen-sensitive structure, enlarges during puberty in individuals assigned male at birth, often resulting in a pronounced neck protuberance. This feature can exacerbate gender dysphoria in transfeminine patients. Chondrolaryngoplasty, commonly known as tracheal shave, is a procedure incorporated into facial feminization surgery (FFS) to address this issue. This study reports on the implementation of an endoscopic-assisted chondrolaryngoplasty technique, its safety, and the outcomes observed.
METHODS
The authors conducted a retrospective review of chondrolaryngoplasty cases at our center, examining patient outcomes and procedural safety. The analysis included a breakdown of concurrent gender-affirming surgeries performed. An endoscopic-guided technique was utilized, and its procedural steps were documented in a video.
RESULTS
In the past five years, 32 patients received chondrolaryngoplasty at our facility. Postoperative complications were minimal, with no infections, wound separations, or surgical site complications reported. Only one patient experienced temporary hoarseness, which resolved within 6 weeks without intervention. The procedure was frequently combined with other surgical interventions, with the average patient undergoing 3 additional procedures, the most common being augmentation mammaplasty, brow lifting, and frontal bone reduction.
CONCLUSIONS
Tracheal shave is an effective surgical technique for alleviating gender dysphoria in transfeminine patients. Keys to its success include the accurate identification of thyroid cartilage, especially in patients with enlarged cricoid cartilages, intraoperative coordination with anesthesia for laryngoscopic vocal cord visualization, sub-perichondrial cartilage excision to minimize the risk of bleeding and damage near the vocal cords, and carefully layered closure to optimize scar healing.
PubMed: 38856196
DOI: 10.1097/SCS.0000000000010398 -
Experimental Oncology May 2024Virginal gigantomastia (VGM) is a benign disease of the breasts without a clearly established etiology. The treatment of VGM remains a problem. The conservative...
Virginal gigantomastia (VGM) is a benign disease of the breasts without a clearly established etiology. The treatment of VGM remains a problem. The conservative treatment is not effective while surgery is too traumatic. Most specialists recommend subcutaneous mastectomy with immediate implant reconstruction or reduction mammoplasty. The reduction mammoplasty with adjuvant hormone therapy is a variant of treatment of young patients with a risk of recurrence. We present a case of a patient with VGM who was operated in 2014. Reduction mammoplasty was performed. After 9 years, the patient had a relapse and second surgery, resection of the breasts with reduction mammoplasty. Tissues with cysts, fibrosis, hamartomas, and fibroadenomas were dissected. Histopathology revealed extensive fibrosis with hamartomas and fibroadenomas. The immunohistochemical examination of the breast tissue showed a high level (70%) of estrogen and progesterone receptors expression. We prescribed hormone therapy with tamoxifen 10 mg per day. Dynamic monitoring of the treatment result and control of the disease remission was carried out. Breast-conserving surgery performed in such patients can help alleviate the psychological, social, and physical disorders caused by VGM.
Topics: Humans; Female; Hypertrophy; Breast; Mammaplasty; Adult; Recurrence
PubMed: 38852049
DOI: 10.15407/exp-oncology.2024.01.073 -
Systematic Reviews Jun 2024Breast cancer is the most common malignancy among women in the UK. Following mastectomy, reconstruction is now integral to the surgical management of breast cancer, of...
Does the use of acellular dermal matrices (ADM) in women undergoing pre-pectoral implant-based breast reconstruction increase operative success versus non-use of ADM in the same setting? A systematic review protocol.
BACKGROUND
Breast cancer is the most common malignancy among women in the UK. Following mastectomy, reconstruction is now integral to the surgical management of breast cancer, of which implant-based reconstruction (IBBR) is the most common type. IBBR initially evolved from pre-pectoral to post-pectoral due to complications, but with developments in oncoplastic techniques and new implant technology, interest in pre-pectoral IBBR has increased. Many surgeons use acellular dermal matrices (ADM); however, there is little evidence in literature as to whether this improves surgical outcomes in terms of complications, failure and patient satisfaction. This review aims to assess the available evidence as to whether there is a difference in surgical outcomes for breast reconstructions using ADM versus non-use of ADM.
METHODS
A database search will be performed using Ovid MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews and Clinicaltrials.org. The search timeframe will be 10 years. Studies will be screened using inclusion and exclusion criteria and data extracted into a standardised spreadsheet. Risk of bias will be assessed. Screening, extraction and risk-of-bias assessments will be performed independently by two reviewers and discrepancies discussed and rectified. Data analysis and meta-analysis will be performed using Microsoft Excel and R software. Forest plots will be used for two-arm studies to calculate heterogeneity and p-value for overall effect.
DISCUSSION
With the renaissance of pre-pectoral IBBR, it is important that surgeons have adequate evidence available to assist operative decision-making. Assessing evidence in literature is important to help surgeons determine whether using ADM for IBBR is beneficial compared to non-use of ADM. This has potential impacts for patient complications, satisfaction and cost to healthcare trusts.
SYSTEMATIC REVIEW REGISTRATION
PROSPERO 2023 CRD42023389072.
Topics: Humans; Acellular Dermis; Systematic Reviews as Topic; Female; Breast Neoplasms; Mammaplasty; Mastectomy; Breast Implantation; Breast Implants; Patient Satisfaction
PubMed: 38849880
DOI: 10.1186/s13643-024-02564-7