Background: An increasing number of women are entering the medical profession, but plastic surgery remains a male-dominated profession, especially within academia. As academic aspirations and advancement depend largely on research productivity, the authors assessed the number of articles authored by women published in the journal Plastic and Reconstructive Surgery . Methods: Original articles in Plastic and Reconstructive Surgery published during the years 1970, 1980, 1990, 2000, 2004, and 2014 were analyzed. First and senior authors with an M.D. degree and U.S. institutional affiliation were categorized by gender. Authorship trends were compared with those from other specialties. Findings were placed in the context of gender trends among plastic surgery residents in the United States. Results: The percentage of female authors in Plastic and Reconstructive Surgery increased from 2.4 percent in 1970 to 13.3 percent in 2014. Over the same time period, the percentage of female plastic surgery residents increased from 2.6 percent to 32.5 percent. By 2014, there were more female first authors (19.1 percent) than senior authors (7.7 percent) ( p < 0.001). As a field, plastic surgery had fewer female authors than other medical specialties including pediatrics, obstetrics and gynecology, general surgery, internal medicine, and radiation oncology ( p < 0.05). Conclusions: The increase in representation of female authors in plastic surgery is encouraging but lags behind advances in other specialties. Understanding reasons for these trends may help improve gender equity in academic plastic surgery.
Background Radiation induces vessel damage and impairs tissue healing. To date, only 1 study has examined radiation's impact in autologous breast reconstruction on intraoperative vascular complications and postoperative outcomes. In this follow-up paper, we examine a larger cohort with an improved study design to better control for patient characteristics. Methods A database of 1780 patients who underwent autologous breast free flap reconstruction at the University of Pennsylvania's Health System between 2003 and 2014 was searched for patients who underwent bilateral breast reconstruction after unilateral radiation, returning 199 patients for review. These were then analyzed for intraoperative vascular complications as well as postoperative complications. McNemar tests were performed on all variables, comparing between radiated and nonradiated fields. Results Fields with prior radiation were significantly more likely to have any type of intraoperative vascular complication and need for arterial anastomotic revision compared to fields without prior radiation (14% versus 7%, P = 0.03 and 8% versus 3%, P = 0.04, respectively). Although there was a trend for more frequent arterial thrombosis in radiated compared to nonradiated fields, this was nonsignificant (7% versus 3%, P = 0.08). There was no significant difference in venous thrombosis or need for venous anastomotic revision. Radiated fields were significantly more likely to have postoperative wound infections compared to nonradiated fields (4% versus 0.5%, P = 0.04). There was no difference in other postoperative complications, including postoperative thrombosis, flap loss, mastectomy flap necrosis, fat necrosis, hematoma, seroma, or delayed wound healing. Conclusions Intraoperative vascular complications and postoperative wound infections are significantly more likely to occur in autologous breast free flap reconstruction with previous radiation therapy. It is important to plan for and counsel patients that fields with previous radiation are at higher risk for these complications.
PURPOSE: Restoration of breast sensation following autologous breast reconstruction (ABR) is integral to the reconstructive paradigm for breast cancer patients. We hypothesize that innervation of reconstructed breast flaps will improve sensation and quality of life (QoL). MATERIALS/METHODS: Free flap ABR patients with and without nerve allograft neurotization were recruited prospectively. Sensation testing was performed with a Pressure Specified Sensory Device (PSSD) at 12–24 months postoperatively in superior, lateral, medial, and inferior poles on both the mastectomy skin and the flap skin. The BREAST-Q was administered. RESULTS: Thirty-two women were enrolled with a total of 54 reconstructed breasts (neurotized: n = 22; nonneurotized: n = 32). Average age was 51.9 years (range, 21–77) with a mean body mass index of 28.9 (range, 20–47). Average follow-up was 15.8 months (range, 12–24). Free TRAM flaps were most commonly performed (87%). Mastectomy skin exhibited greater sensation than flap skin (P = 0.20) and 1-point moving tests elicited a greater response than 1-point static (P < 0.00). In all but one area (inferior mastectomy), the neurotized group had more sensation with 1-point static (P = 0.01–0.99) and 1-point moving testing (P = 0.33–0.92). The superior mastectomy pole experienced significantly greater sensation in the neurotized group (P < 0.001). There was no difference in surgical site outcomes between the groups. Nine percentage neurotized versus 5% nonneurotized patients reported “more sensation” after reconstruction (P = 0.32). QoL demonstrated that the neurotized group was more satisfied in 9 of the 11 parameters (P = 0.09–0.89). CONCLUSION: The return of breast sensation after ABR has become an important topic in reconstructive plastic surgery. Although multiple modalities have been proposed to increase postoperative sensation (eg, nerve conduits, allografts, and autografts), there is a paucity of prospective clinical trials investigating sensory outcomes. This abstract highlights the largest cohort to date, which quantitatively and qualitatively measures the effect of neurotization with nerve allografts on the return of sensation following ABR. To do so, we have directly measured sensation, patient-reported return of sensation, and breast-associated QoL. These preliminary results suggest that neurotization during ABR may lead to increased sensation and improved QoL. We hope that these results will further the knowledge of this topic, potentially improve patient outcomes, and stimulate a discussion regarding clinical management.
PURPOSE: Over 175,000 Americans underwent bariatric surgery in 2013 alone, and the number of patients with massive weight loss is growing at an astonishing rate. As obesity is a known risk factor for breast cancer, and there are an increasing amount of post-bariatric surgery patients being diagnosed with malignancy, plastic surgeons are now being challenged to reconstruct the breasts of massive weight loss patients after oncologic resection. The goal of this study is to assess the outcomes of autologous breast reconstruction in post-bariatric surgery patients at a single institution. METHODS: Patients who underwent autologous breast reconstruction with a history of bariatric surgery were identified and compared to patients who underwent autologous reconstruction without a history of bariatric surgery. Analysis included age, ethnicity, BMI, comorbidities, flap type, operative complications, and reoperation rates. Propensity matched analysis was also conducted to control for preoperative differences. RESULTS: Fourteen women underwent breast reconstruction following bariatric surgery, compared against 1,012 controls. Table 1 demonstrates demographic comparisons. Outcomes analysis revealed significant differences in breast revisions (p=0.0055), implant placements (p=0.0003), and total OR visits (p=0.0007). Of note, there was no significant difference noted in delayed healing of the breast (p=0.087) or at the donor site (p=1). Table 2 compiles complete outcomes analysis.Table 1: Preoperative demographics identify our patient cohorts and highlight comorbidities.Table 2: Outcomes analysis demonstrates the significant differences in rates of revision, implant/expander placement, and total OR visits.CONCLUSIONS: As the rise in bariatric surgery mirrors that of obesity, an increasing amount of massive weight loss patients undergo treatment for breast cancer. We present the largest review of postoperative outcomes in autologous breast reconstruction in the post-bariatric patient. Our findings highlight profound differences in this patient population, particularly the amount of operative revisions required. This large difference in revisions is not completely accounted for by differences in complication rates, and remains significant despite propensity matching for preoperative differences. This could indicate a major difference in post-reconstruction rates of satisfaction resulting in a higher likelihood to return to the operating room, or a true difference in healing that is not captured by deficiencies noted preoperatively.
Immediate breast reconstruction (IBR) after mastectomy for cancer has increased in recent years, yet long-term, modality-specific comparative data are lacking. We performed this study to compare short- and long-term outcomes after expander, autologous (AT), and direct-to-implant (DI) breast reconstruction.Using four state-level inpatient and ambulatory surgery databases, we conducted a retrospective cohort study of adult women who underwent mastectomy with immediate breast reconstruction from 2008 to 2009. Our primary outcomes were complications within 90 days of surgery, rate of secondary breast surgery within 3 years, and cumulative healthcare charges.The final cohort included 15,154 women who underwent mastectomy with tissue expander (TE: 70.5%), autologous (AT: 18.1%), or direct to implant (DI: 11.3%) reconstruction. Ninety-day complications were lowest after expander and highest after AT breast reconstruction (TE = 6.5% [reference] vs AT = 13.1% [2.09, 1.82-2.41] vs DI = 6.6% [1.03, 0.84-1.27], P < 0.001). However, adjusted rates of secondary breast procedures were most frequent after expander (2021/1000 discharges) and least frequent after AT (949.0/1000 discharges) reconstruction (P < 0.001). Specifically, unplanned revisions were highest among the tissue expander cohort (TE = 59.2% vs AT = 34.4% vs DI = 45.9%, P < 0.001). The cumulative, adjusted healthcare charges for secondary breast procedures differed slightly across groups (TE = $63,806 vs AT = $66,882 vs DI = $64,145, P < 0.001).Complications and secondary breast procedures, including unplanned revisions, after breast reconstruction are common and vary by reconstructive modality. The frequency of these secondary procedures adds substantial healthcare charges to the care of the breast reconstruction patient.
Free-tissue transfers have become the preferred surgical technique to treat complex reconstructive defects. Because these procedures typically require longer operative times and recovery periods, the applicability of free-flap reconstruction in the elderly continues to require ongoing review. The authors performed a retrospective analysis of 100 patients aged 65 years and older who underwent free-tissue transfers to determine preoperative and intraoperative predictors of surgical complications, medical complications, and reconstructive failures. The parameters studied included patient demographics, past medical history, American Society of Anesthesiology (ASA) status, site and cause of the defect, the free tissue transferred, operative time, and postoperative complications, including free-flap success or failure. The mean age of the patients was 72 years. A total of 46 patients underwent free-tissue transfer after head and neck ablation, 27 underwent lower extremity reconstruction in the setting of peripheral vascular disease, 10 had lower extremity traumatic wounds, nine had breast reconstructions, four had infected wounds, two had chronic wounds, and two underwent transfer for lower extremity tumor ablation. Two patients had an ASA status of 1, 49 patients had a status of 2, 45 patients had a status of 3, and four had a status of 4. A total of 104 flaps were transferred in these 100 patients. There were 49 radial forearm flaps, 34 rectus abdominis flaps, seven latissimus dorsi flaps, seven fibular osteocutaneous flaps, three omental flaps, three jejunal flaps, and one lateral arm flap. Four patients had planned double free flaps for their reconstruction. Mean operative time was 7.8 hours (range, 3.5 to 16.5 hours). The overall flap success rate was 97 percent, and the overall reconstructive success rate was 92 percent. There were six additional reconstructive failures related to flap loss, all of which occurred more than 1 month after surgery. Patients with a higher ASA designation experienced more medical complications (p = 0.03) but not surgical complications. Increased operative time resulted in more surgical complications (p = 0.019). All eight cases of reconstructive failure occurred in patients undergoing limb salvage surgery in the setting of peripheral vascular disease. Free-tissue transfer in the elderly population demonstrates similar success rates to those of the general population. Age alone should not be considered a contraindication or an independent risk factor for free-tissue transfer. ASA status and length of operative time are significant predictors of postoperative medical and surgical morbidity. The higher rate of reconstructive failure in the elderly peripheral vascular disease population compares favorably with other treatment modalities for this disease process.
Background: The number of independent plastic surgery residency programs and applicants have consistently declined over the past decade. A prior study by the authors demonstrated trends and predictors associated with increased match success up until 2018. The purpose of this study was to analyze recent match trends and predictors to aid prospective applicants. Methods: After approval from the American Council of Academic Plastic Surgeons, the San Francisco Match provided data for the independent match (2019-2022). Applicant variables were analyzed to determine correlation with a successful match. Outcomes were compared between candidates utilizing chi square tests, t-tests, univariate and multivariate logistic regressions. Results: 428 applicants participated in the independent plastic surgery match from 2019 to 2022, of whom 243 matched. In this period, the number of independent plastic surgery residency programs and positions decreased from 40 to 36 (10%), and 63 to 57 (9.5%), respectively. The number of applicants increased from 90 in 2019 to 124 in 2022 (37.8%), and match rate decreased from 82% to 56%. Osteopathic and international medical graduates increased from 9 to 21 (133%), and 20 to 28 (40%) respectively. A successful match was associated with US medical school graduates, prerequisite training at a university-affiliated general surgery program, greater number of interviews (13 ± 6 vs. 3 ± 3), higher USMLE step 1/2 scores, and AOA status (p<0.05). By multivariate regression, number of interviews completed (odd ratio [OR] 1.40 95% confidence interval [CI] 1.23-1.59 p <0.001) and allopathic medical school background (OR 3.65 95% CI 1.1 – 12 p = 0.003) were predictive of a successful match. Conclusion: Despite residency review committee's ongoing support of the independent plastic surgery track, program participation during the period examined has decreased while applicant interest increased, likely contributing to a decreased match rate. Although more interviews and allopathic medical school background correlate with a successful match, continued support for the independent plastic surgery track is encouraged.
Background: Locoregional recurrence of the previously reconstructed breast poses a diagnostic and operative challenge. This study examines detection, management, and reconstructive strategies of locoregional recurrence following postmastectomy breast reconstruction. Methods: A retrospective review of records was performed on patients treated within the health system for breast cancer from January of 2000 to July of 2014. Of these patients, descriptive factors and operative details were collected for those that developed locoregional recurrence. Subsequent reconstructive operations were also examined. Using a multidisciplinary team, a surveillance/management algorithm was generated. Results: A total of 41 patients with locoregional recurrence were identified (mean time to recurrence, 4.6 years). Two- and 5-year survival following locoregional recurrence was 88 percent and 39 percent, respectively. Locoregional recurrence was found to occur in the following tissue planes: subcutaneous (27 percent), subcutaneous/pectoralis (24 percent), chest wall (37 percent), and axillary (12 percent). The most frequent method of detection was patient concern leading to examination. Older age at the time of locoregional recurrence ( p = 0.028), increased time to recurrence/detection ( p = 0.024), and chemotherapy before locoregional recurrence ( p = 0.014) were associated with the need for a secondary salvage flap. Patients who experienced a subcutaneous recurrence were far less likely to undergo a secondary flap ( p = 0.011). Factors associated with loss of the index reconstruction included lower body mass index ( p = 0.009), pectoralis invasion ( p = 0.05), and implant reconstruction ( p = 0.03). Conclusions: Detection and management of locoregional recurrence requires appropriate physical examination and imaging. Significant factors associated with failure to salvage the initial reconstruction included body mass index, plane of recurrence, and type of initial reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.
The autogenous TRAM flap represents the gold standard in post–mastectomy breast reconstruction. However, multiple studies on postoperative outcomes have shown high rates of abdominal–wall morbidity, including decreased strength, abdominal laxity, abnormal contour, and frank bulge or hernia formation. The SIEA flap for autogenous breast reconstruction represents an abdominal–wall- sparing technique for post–mastectomy breast reconstruction. This study explored outcomes related to its use.
BACKGROUND: The online reputation of a practicing plastic surgeon is becoming increasingly important. Physician review websites (PRWs) offer patients an opportunity to search their surgeon, but many providers argue these ratings can be misused. The purpose of this study was to evaluate the landscape of online reviews in a national cohort of plastic surgeons. METHODS: Twenty plastic surgery residency programs were selected randomly (5 from each US region). Affiliated, full-time academic plastic surgeon faculty served as the basis of the study cohort. Gender, age, region, city size, and practice type were recorded. The American Society of Plastic Surgeons’ “Find a Plastic Surgeon” feature was used to select a matched cohort of plastic surgeons in private practice. A Google search was performed with “name, MD” and the position of personal, academic, and PRW was noted among the search results. The number of reviews and scaled rating scores (out of 5) were recorded from the three most popular PRWs. A “malicious” rating was defined as a “1/5” review on either Vitals or RateMDs. Data were collected during December 2014 and comparisons were made via Mann-Whitney and Kruskal-Wallis tests. RESULTS: Of 440 plastic surgeons, 99.9% had a profile on HealthGrades, 98.6% on Vitals, and 81.9% on RateMDs. The median search result position for academic website was 2, HealthGrades 3, personal website 4, and Vitals 6. Ratings were based on 15.6 +/- 13.1 reviews for HealthGrades, 14.5 +/- 16.5 for Vitals, and 4.7 +/- 6.1 for RateMDs respectively. Average scores were 4.1 +/- 0.7 for HealthGrades, 4.3 +/- 0.7 for Vitals, and 4.0 +/- 1.1 for RateMDs. 40.1% of plastic surgeons had at least one “malicious” rating on Vitals and 20.8% on RateMDs. No difference was seen in the median number or quality of reviews with regards to gender, age, US region, city size, or practice type (p > 0.05). CONCLUSIONS: Awareness of online reviews may help plastic surgeons better manage their online reputation. While mostly positive, a significant number of negative reviews exist. We suggest plastic surgeons monitor these sites given their high visibility and potential influence on patients.
