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.
Background: Implementation of patient-reported outcomes (iPROs) represents a critical barrier to their widespread use and poses challenges to workflow and patient satisfaction. We sought to implement PRO surveys into surgical practice while identifying principles for successful/broader implementation. Methods: Outpatient surgical encounters (2016-2019) related to hernia, breast surgery, and post-bariatric body-contouring were assessed for the use of Abdominal-Hernia-Q (AHQ), BREAST-Q™, and BODY-Q™ surveys (implemented in that order). Outcomes were implementation rates/quarter and time to optimal implementation (≥80%). Successful implementation principles were identified during the first implemented PRO instrument and applied to subsequent ones. Logistic regression models were used to estimate increase in rate of implementation/quarter by instrument controlling for clinic volume. Risk-adjusted generalized linear models determined predicted mean differences in total clinic time and patient satisfaction. Results: 1,206 encounters were identified. Overall survey implementation rate increased from 15% (first-quarter) to 90% (last-quarter; p <0.01). AHQ optimal implementation was reached by 15 months. Principles for successful iPROs were workflow optimization, appropriate patient selection, staff engagement, and electronic survey integration. Consistent application of these principles optimized time to optimal implementation for BREAST-Q™ (9 months; 18.1% increase in implementation/quarter [95% CI 1.5-37.5%]; p<0.01) and BODY-Q™ (3 months; 56.3% increase in implementation/quarter [95% CI 26.8-92.6%]; p=0.03). Neither patient clinic time ( p =0.16) nor patient satisfaction differed during the iPRO process ( p =0.98). Conclusions: Prospective iPROs can be achieved in surgical practice without an adverse effect on patient satisfaction or workflow. The proposed principles of implementation may be used to optimize efficiency for iPROs.
Microbe entry through catheter ports can lead to biofilm accumulation and complications from catheter-related bloodstream infection and ultimately require antimicrobial treatment and catheter replacement. Although strides have been made with microbial prevention by applying standardized antiseptic techniques during catheter implantation, both bacterial and fungal microbes can present health risks to already sick individuals. To reduce microbial adhesion, murine and human catheters were coated with polyurethane and auranofin using a dip coating method and compared to non-coated materials. Upon passage of fluid through the coated material in vitro, flow dynamics were not impacted. The unique antimicrobial properties of the coating material auranofin has shown inhibitory activity against bacteria such as Staphylococcus aureus and fungi such as Candida albicans. Auranofin coating on catheters at 10mg/mL reduced C. albicans accumulation in vitro from 2.0 x 108 to 7.8 x 105 CFU for mouse catheters and from 1.6 x 107 to 2.8 x 106 for human catheters, showing an impact to mature biofilms. Assessment of a dual microbe biofilm on auranofin-coated catheters resulted in a 2-log reduction in S. aureus and a 3-log reduction in C. albicans compared to uncoated catheters. In vivo assessment in a murine subcutaneous model demonstrated that catheters coated with 10 mg/mL auranofin reduced independent S. aureus and C. albicans accumulation by 4-log and 1-log, respectively, compared to non-coated catheters. In conclusion, the auranofin-coated catheters demonstrate proficiency at inhibiting multiple pathogens by decreasing S. aureus and C. albicans biofilm accumulation.
PURPOSE: To examine breast aesthetic revisions (AR) following free flap autologous breast reconstruction (FFABR) and identify factors associated with these procedures. METHODS: Using a prospectively maintained health-system wide registry, patients undergoing immediate and delayed FFABR following mastectomy from 2008-2020 were identified. ARs encompassed scar revisions, fat grafting, liposuction, dog ear excision, reduction mammaplasty, mastopexy, local tissue rearrangement and implant-related changes. Using survival analysis and Cox regression modeling, we discerned patient and operative factors associated with AR. RESULTS: From 3,057 patients with 4,896 free flaps were followed up for a median of 4.3 years, 75.1% were bilateral, and most were muscle-sparing TRAM (66.9%) and DIEP (26.9). The median age was 51 years old (IQR, 44-59), 72.1% of patients were non-Hispanic White, with a median BMI of 28.2 (IQR 24.7-32.4). A total of 2,538 flaps required AR (51.8%), and the median time to first and last revisions were 320 and 479 days. The most common ARs were fat grafting (35.4%) and local tissue rearrangement (29%) for contour- (60.4%) and volume-related (31%) reasons. Factors independently associated with increased risk for AR included White race, younger age, non-abdominally based free flaps, adjuvant chemotherapy or radiotherapy, and postoperative complication within 90 days (all p<0.01). CONCLUSIONs: Roughly half of free flaps require ARs post-FFABR, predominantly within two years. Factors like race, flap type, and complications significantly impact AR rates. This information aids in setting patient expectations and understanding the FFABR timeline.
Background: Breast reduction surgery has consistently fallen within the top 10 surgical procedures performed by plastic surgeons. This is because of its capability to relieve the physical and psychological impact of macromastia. Although numerous women pursue consultation, many never undergo the procedure. The authors aim to quantify the impact of breast reduction surgery on quality of life by comparing patients who underwent breast reduction surgery with those who did not. Methods: Patients seeking breast reduction surgery between 2016 and 2019 were identified. As standard-of-care, patients are surveyed during the consultation visit and postoperative visits using the BREAST-Q. The preoperative survey was readministered a second time for those who did not undergo breast reduction surgery. Propensity score matching, based on patient demographics, comorbidities, and breast examination, was used to balance baseline characteristics. Results: A total of 100 propensity-matched patients were identified (operative, n = 78; nonoperative, n = 22). Mean participant age was 39.5 ± 25 years and mean body mass index was 31.1 ± 7.4 kg/m 2 . Quality of life significantly improved in each domain for those in the operative group ( p < 0.05). Those who did not undergo breast reduction surgery realized no improvement in quality of life and had a downward trend in quality of life across two of the four domains. Conclusions: Breast reduction surgery offers a significant improvement in quality of life for macromastia. This matched study demonstrates that patients who are able to undergo breast reduction surgery have a statistically significant improvement in all aspects of quality of life, whereas nonsurgical patients experience no benefit with time, with a trend toward deterioration in specific domains.
PURPOSE: Autologous breast reconstruction (ABR) offers high patient satisfaction with a low risk-profile. Improved outcomes have led to a decreased tolerance for flap loss complications over time. This study provides an individualized risk prediction tool for flap loss after ABR. METHODS: IRB-approved, institutional review of patients undergoing ABR between 2010-2019 was conducted. Baseline characteristics, perioperative data, and postoperative flap loss were recorded. Multivariable regression generated a predictive risk model for flap loss. RESULTS: 2,355 patients received ABR. Patients averaged 51.6 +/- 9.8 years with BMI of 28.9 +/- 6.0 kg/m2. 33% had prior radiation and 45% neoadjuvant chemotherapy. 74% were immediate reconstructions, and 58% were bilateral. Flap choice included msTRAM (69%), DIEP (23%), SIEA (4%), thigh-based/other (4%). 73 flap losses (Complete: 51 (2.2%), Partial: 22 (0.9%)) occurred. Predictors included: age>75 years (OR=3.0, p=0.047), SIEA or non-abdominal-based flaps (OR=2.7-3.0, p<0.05), immediate reconstruction (OR=2.7, p=0.01), smoking history (OR=2.3, p=0.001). msTRAMs were protective against flap loss (OR=0.54, p=0.042). Flap loss was stratified from Low (1.4%) to Extreme Risk (20%) with high accuracy (C-statistic=0.76). CONCLUSION: This risk-stratification tool quantifies patient-specific flap loss risk after ABR. In addition to managing patient expectations, it may aid in surgical decision-making and postoperative resource allocation.
BACKGROUND: Prior studies suggest that trauma services are inequitably distributed throughout the United States. However, it is unknown whether this trend applies to the burden of craniofacial trauma. We aimed to describe the geographical distribution of craniofacial trauma, craniofacial surgeons and training positions nationwide. METHODS: State-level data were obtained on craniofacial trauma admissions (Healthcare Cost and Utilization Project [HCUPnet] databases), craniofacial surgeons (plastic and reconstructive [PR], head and neck, and oral-maxillo-facial surgeons; American Board of Medical Specialties and American Association of Oral and Maxillofacial Surgeons data), craniofacial surgery fellowship positions (American Medical Association FREIDA and National Resident Matching Program data), population size, and household income (US Census data) for 2016–2017. Normalized densities (per million population [PMP]) were ascertained. State-level variation in densities were compared between highest and lowest quartiles using Kruskal–Wallis tests. Risk-adjusted generalized linear models were used to determine the independent association between craniofacial surgeon density, training positions, and income with craniofacial trauma density. RESULTS: There were 790,415 craniofacial trauma admissions (2,447 PMP), 28,004 craniofacial surgeons (86.7 PMP), and 746 craniofacial training positions (2.3 PMP) nationwide. There was significant state-level variation in the density PMP of craniofacial trauma (median, 1,999.6 versus 2,983.5; P < 0.01), surgeon (70.8 versus 98.7; P < 0.01), training positions (0 versus 3.5; P < 0.01) between lowest and highest quartiles. Distribution of surgeons was not associated with craniofacial trauma density (P = 0.27) and was positively associated with income and training positions density (P < 0.01). Subanalysis of specialties revealed that only the distribution of PR surgeons was positively associated with craniofacial trauma density, yielding an increase in 5.6 PR surgeons/PMP for every increase of 1,000 craniofacial trauma admissions/PMP (P < 0.01). CONCLUSIONS: There is an uneven state-level distribution of craniofacial surgeons across the United States that is associated with income. Head and neck and oral-maxillo-facial craniofacial surgeons’ location does not follow the craniofacial trauma care need whereas PR surgeons’ location does. As we move toward regionalization of trauma care, further work will be necessary to close the gap between workforce availability and clinical need.
Background . It is well known that vibratory and auditory stimuli from vehicles such as cars and trains can help induce sleep. More recent literature suggests that specific types of vibratory and acoustic stimulation might help promote sleep, but this has not been tested with neuroimaging. Thus, the purpose of this study was to observe the effects of vibroacoustic stimulation (providing both vibratory and auditory stimuli) on functional connectivity changes in the brain using resting state functional magnetic resonance imaging (rs-fMRI), and compare these changes to improvements in sleep in patients with insomnia. Methods . For this study, 30 patients with insomnia were randomly assigned to receive one month of a vibroacoustic stimulation or be placed in a waitlist control. Patients were evaluated pre- and postprogram with qualitative sleep questionnaires and measurement of sleep duration with an actigraphy watch. In addition, patients underwent rs-fMRI to assess functional connectivity. Results . The results demonstrated that those patients receiving the vibroacoustic stimulation had significant improvements in measured sleep minutes as well as in scores on the Insomnia Severity Index questionnaire. In addition, significant changes were noted in functional connectivity in association with the vermis, cerebellar hemispheres, thalamus, sensorimotor area, nucleus accumbens, and prefrontal cortex. Conclusions . The results of this study show that vibroacoustic stimulation alters the brain’s functional connectivity as well as improves sleep in patients with insomnia.
BACKGROUND: For over 25 years, our institution has supported a chief resident aesthetic clinic with the goal to foster autonomy and preparedness for independent practice in a safe environment. The purpose of this study was to compare safety profiles for common aesthetic procedures performed in our resident versus attending clinics. METHODS: Patients (n=525) presenting for aesthetic breast or abdominal surgery at our institution from 2007–2017 were retrospectively reviewed. Two cohorts were identified: subjects undergoing surgery through the chief resident versus attending clinics. Aesthetic procedures queried included 1) augmentation mammoplasty, reduction mammoplasty, or mastopexy, 2) abdominoplasty, 3) combination of 1 and 2, and 4) face lift, blepharoplasty, or rhinoplasty. Demographics, perioperative characteristics, and postoperative complications were compared between cohorts. RESULTS: Two-hundred-and-sixty-two and 255 subjects underwent breast, abdominal-based, and face/eye aesthetic procedures in the resident and attending clinics, respectively. Subjects presenting to the resident clinic tended to be younger (43.4 vs. 51.4, p<0.001), less obese (26.2 vs. 27.4, p=0.02), lower median income ($65,000 vs. $75,000, p<0.001), and healthier with lower rates of diabetes (4.2% vs. 12.6%, p<0.001), COPD (0.4% vs. 3.1%, p=0.02), PVD (2.3% vs. 6.7%, p=0.02), hypertension (13.4% vs. 31.2%, p<0.001), and history of cancer (3.8% vs. 19.2%, p<0.001). Mean length of procedure significantly differed between resident and attending cohorts at 210 and 152 minutes, respectively (p<0.001). Postoperative complications were similar between cohorts (p=0.48). Reoperation (p<0.03) and readmission (p<0.02) rates were greater in the attending cohorts. CONCLUSION: The resident aesthetic clinic provides increases independence and decision-making, while maintaining patient safety in commonly performed breast, abdominal, face/eye procedures. Patients operated on in the resident clinic tended to be younger and healthier, highlighting the importance of careful patient selection to maximize both autonomy and safety.
Purpose: Restoration of breast sensation following autologous breast reconstruction is integral to the reconstructive paradigm for breast cancer patients. We sought to quantify the impact of neurotization in autologous breast reconstruction on sensation and quality of life (QoL). Methods: A patient-blinded prospective study was undertaken for patients undergoing autologous breast reconstruction. Patients were assigned to neurotized group or non-neurotized group. Using the Pressure-Specified Sensory Device™ to quantify sensation (range: 0-100, 100=lowest sensation), mastectomy and flap skin were tested in four poles at a minimum of 12-months postoperatively. Kruskal-Wallis tests were used to compare sensation and Breast-Q QoL scores between cohorts at the flap-level. Results: One-hundred and fifty-five flaps were tested, of which 49.7% were neurotized. Patients tended to be 53 years-old (IQR 46-61), White (82.2%), non-obese (BMI<30: 57.3%), and have TRAM flaps (79.7%). The neurotized group demonstrated higher sensation at the mastectomy superior pole compared to the non-neurotized group (66.2 [33.5-96.4] vs 83.2 [51.3-100]; p=0.03). Sensation was decreased for patients who underwent radiation therapy (p>0.05) irrespective of neurotization. Of the flaps with minimal sensation (scores>90), sensation at the lateral mastectomy and lateral flap sites were significantly less for non-innervated TRAM flaps than non-innervated DIEP flaps (p=0.03 and p=0.03, respectively). However, no flap-type difference existed amongst innervated flaps (p>0.05). The neurotized group exhibited greater QoL compared to the non-neurotized group in 3 of the 11 QoL domains (p<0.05). Conclusions: Neurotization during autologous breast reconstruction appears to increase sensibility in only one of four quadrants, whereas radiation impairs sensation regardless of innervation status. QoL was higher in the innervation cohort. Further analysis inclusive of change over time is needed as the study progresses.
