Relationship between Body Mass Index and Outcomes in Microvascular Abdominally Based Autologous Breast Reconstruction.

BACKGROUND: Increasing body mass index (BMI) is a known risk factor for autologous microsurgical breast reconstruction. No prior studies have stratified outcomes across BMI ranges or defined the BMI at which complication rates dramatically increase. METHODS: The authors performed a retrospective chart review of all patients who underwent abdominally based autologous free flap breast reconstruction at their institution between 2004 and 2021. Clinical, surgical, and outcomes data were collected. Patients were stratified into five BMI categories: 25, 25.01 to 30, 30.01 to 35, 35.01 to 40, and greater than 40 kg/m 2 . Complication rates were analyzed across these groups, and a receiver-operating characteristic analysis was used to determine an optimal BMI cutoff point. RESULTS: A total of 365 patients (545 breasts) were included in this study. The rates of several breast complications significantly increased with increasing BMI at distinct levels, including any breast complication (BMI >30 kg/m 2 ), unplanned reoperation (BMI >35 kg/m 2 ), fat necrosis (BMI >40 kg/m 2 ), wound breakdown requiring re-operation (BMI >35 kg/m 2 ), any infection (BMI >30 kg/m 2 ), infection requiring oral antibiotics (BMI >25 kg/m 2 ), infection requiring intravenous antibiotics (BMI >35 kg/m 2 ), and mastectomy flap necrosis (BMI >35 kg/m 2 ). The rates of many abdominal complications significantly increased with increasing BMI at distinct levels as well, including delayed wound healing (BMI >30 kg/m 2 ), wound breakdown requiring re-operation (BMI >40 kg/m 2 ), any infection (BMI >25 kg/m 2 ), and infection requiring oral antibiotics (BMI >25 kg/m 2 ). Optimal BMI cutoffs of 32.7 and 30.0 kg/m 2 were determined to minimize the occurrence of any breast complication and any abdomen complication, respectively. CONCLUSIONS: Preoperative weight loss has great potential to alleviate surgical risk in overweight and obese patients pursuing autologous breast reconstruction. The authors' results quantify the risk reduction based on a patient's preoperative BMI. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Nipple-Sparing Mastectomies in Patients over the Age of 60 Years: Factors Associated with Surgical Outcomes.

BACKGROUND: Nipple-sparing mastectomy (NSM) outcomes in the elderly have not been well characterized. The goal of this study was to evaluate NSM outcomes in patients over age 60. PATIENTS AND METHODS: A single-institution retrospective cohort study was performed for NSM patients over the age of 60 from January 2004 to January 2022. Demographic, intraoperative, and postoperative variables were collected. RESULTS: We identified 136 women who underwent a total of 200 NSMs at a mean age 65.2 years and with mean body mass index of 25. Most (56%) had invasive breast cancer, requiring neoadjuvant chemotherapy in 15%, and 17.5% had radiation prior to NSM. A total of 91% had immediate tissue expander placement. The infection rate was 19%, with 11.5% requiring expander explantation in the follow-up period. In binomial logistic regression analysis, prior radiation increased the odds of any complication by 2.9 (OR 2.93, CI 1.30-6.58, p = 0.009) and increased the odds of infection by 5.7 (OR 5.70, CI 1.95-16.66, p = 0.001), but no associations were seen for other covariates including age, comorbidities, prior chemotherapy, or presence of invasive disease. Diabetes increased the odds of wound breakdown specifically by 9.0 (OR 8.97, CI 2.01-39.92, p = 0.004). Local recurrence was 3% in mean 3.4-year follow-up. CONCLUSIONS: Our data support NSM in patients over the age of 60 years with acceptable outcomes within the standard of care. Locoregional recurrence was within the cited range of 0-5%, and only diabetes and prior radiation were associated with reconstructive complications. NSM should thus be offered when appropriate regardless of increased age to achieve oncologic and reconstructive goals.

Evaluation of Microvascular Autologous Breast Reconstruction in Patients Older Than 60 Years.

BACKGROUND: While free-flap breast reconstruction becomes more common, it is still approached with caution in older patients. Outcomes in the elderly population have not been well characterized, especially with regard to donor-site sequalae. This study compares microvascular autologous breast reconstruction outcomes in patients older and younger 60 years. METHODS: A single-institution retrospective review was performed for microvascular autologous breast reconstruction from January 2004 through January 2021. Demographic, intraoperative, and postoperative variables, including breast flap and donor-site complications, were evaluated. RESULTS: Five hundred forty-five breast free flaps were identified, of which 478 (87.8%) were performed on patients younger than 60 years (mean, 46.2 years) and 67 (12.2%) older than 60 years (mean, 64.8 years; P = 0.000). Hyperlipidemia was significantly higher in older patients (19.4% vs 9.6%, P = 0.016). Mean operative time was 46.3 minutes faster in the older cohort ( P = 0.030). There were no significant differences in free-flap loss, venous congestion, takeback, hematoma, seroma, wound healing, or infection. Interestingly, there were significantly more total breast flap complications (28.5% vs 16.4%, P = 0.038) and higher rates of fat necrosis (9.6% vs 1.5%, P = 0.026) in the younger cohort. Significantly more abdominal donor-site complications (43.3% vs 21.3%, P = 0.000) were seen in the older people, with increased wound breakdown ( P = 0.000) and any return to the operating room (20.9% vs 9.8%, P = 0.007). Older patients were also significantly more likely to require surgical correction of an abdominal bulge or hernia (10.4% vs 4%, P = 0.020). The mean follow-up was 1.8 years. CONCLUSIONS: Our data showed no worsening of individual breast flap outcomes in the older people. However, there were significantly more abdominal complications including surgical correction of abdominal bulge and hernia. This may be related to the inherent qualities of tissue aging and should be taken into consideration for flap selection. These results support autologous breast reconstruction in patients older than 60 years, but patients should be counseled regarding potentially increased abdominal donor-site sequelae.

Modifiable Post-Mastectomy Radiation Therapy Factors and Impact on Implant-Based Breast Reconstruction Outcomes.

INTRODUCTION: Intensity modulated radiation therapy (IMRT) and other modifiable radiation factors have been associated with decreased radiation toxicity. These factors could allow for improved reconstructive outcomes in patients requiring post-mastectomy radiation therapy (PMRT). However, they have not yet been well-studied in implant-based breast reconstruction (IBBR). METHODS: We performed a retrospective chart review of patients who underwent mastectomy with immediate tissue expander placement followed by PMRT. Radiation characteristics were collected, including radiation technique, bolus regimen, X-ray energy, fractionation, maximum radiation hot spot (DMax), and tissue volume receiving >105% (V105%) or >107% (V107%) of the prescription dose. Reconstructive complications occurring after initiation of PMRT were analyzed with respect to these radiation characteristics. RESULTS: 68 patients (70 breasts) were included in this study. The overall complication rate was 28.6%, with infection being the most common complication (24.3%), requiring removal of the tissue expander or implant in greater than half of infections (15.7%). DMax was greater in patients who required explant after PMRT, and this approached statistical significance (114.5+/-7.2% v. 111.4+/-4.4%, p=0.059). V105% and V107% were also greater in patients who required explant after PMRT (42.1+/-17.1% v. 33.0+/-20.9% and 16.4+/-14.5% v. 11.3+/-14.6%, respectively), however this was not statistically significant (p=0.176 and p=0.313, respectively). There were no significant differences in complication rates between patients with respect to radiation technique or other radiation characteristics studied. CONCLUSIONS: Minimizing the radiation hot spots and volumes of tissue receiving greater than the prescription dose of radiation may improve reconstructive outcomes in patients undergoing IBBR followed by PMRT.

Immediate Versus Delayed-Immediate Autologous Breast Reconstruction After Nipple-Sparing Mastectomy.

INTRODUCTION: Autologous reconstruction following nipple-sparing mastectomy (NSM) is either performed in a delayed-immediate fashion, with a tissue expander placed initially at the time of mastectomy and autologous reconstruction performed later, or immediately at the time of NSM. It has not been determined which method of reconstruction leads to more favorable patient outcomes and lower complication rates. METHODS: We performed a retrospective chart review of all patients who underwent autologous abdomen-based free flap breast reconstruction after NSM between January 2004 and September 2021. Patients were stratified into 2 groups by timing of reconstruction (immediate and delayed-immediate). All surgical complications were analyzed. RESULTS: One hundred one patients (151 breasts) underwent NSM followed by autologous abdomen-based free flap breast reconstruction during the defined time period. Fifty-nine patients (89 breasts) underwent immediate reconstruction, whereas 42 patients (62 breasts) underwent delayed-immediate reconstruction. Considering only the autologous stage of reconstruction in both groups, the immediate reconstruction group experienced significantly more delayed wound healing, wounds requiring reoperation, mastectomy skin flap necrosis, and nipple-areolar complex necrosis. Analysis of cumulative complications from all reconstructive surgeries revealed that the immediate reconstruction group still experienced significantly greater cumulative rates of mastectomy skin flap necrosis. However, the delayed-immediate reconstruction group experienced significantly greater cumulative rates of readmission, any infection, infection requiring PO antibiotics, and infection requiring IV antibiotics. CONCLUSIONS: Immediate autologous breast reconstruction after NSM alleviates many issues seen with tissue expanders and delayed autologous reconstruction. Although mastectomy skin flap necrosis occurs at a significantly greater rate after immediate autologous reconstruction, it can often be managed conservatively.

Expanding Candidacy for Nipple-sparing Mastectomy in Women with Large or Ptotic Breasts: Staged Reconstruction Outcomes.

Development of the nipple-sparing mastectomy (NSM) technique has dramatically improved breast reconstruction, and preservation of the nipple-areolar complex (NAC) positively influences patient satisfaction. However, women with large, ptotic breasts have historically not been candidates for NAC preservation due to impaired perfusion of the NAC leading to NAC loss. Although reduction mammoplasty has been reported as a strategy to increase candidacy for NSM, success rates and surgical outcomes for this staged approach are not well described in heterogeneous clinical scenarios. Methods: We performed a retrospective chart review of all patients who underwent reduction mammoplasty followed by NSM at our institution between January 2014 and September 2020. Clinical and surgical characteristics were collected. All surgical complications, including NAC loss rates, were analyzed. Results: Forty-one patients (74 breasts) underwent staged NSM during the defined time period. The average time between breast reduction mammoplasty and NSM was 213 days. Overall, 94.6% of NSM resulted in successful nipple preservation. There was no significant difference in the time interval from breast reduction mammoplasty to NSM between patients who had NAC loss (208 days) and those who did not (213 days, P = 0.87). Increasing age was significantly associated with risk of NAC loss (P = 0.002) in our cohort. Conclusions: In women with breast ptosis (which precludes safe NSM), it is possible to first offer reduction mammoplasty to preserve the NAC for future NSM. Our data suggest that 3 months between staged procedures is a safe time frame.

Gender-Affirming Facial Feminization Surgery at a Public, Safety-Net Hospital: A Single-Center Early Experience.

BACKGROUND: Facial feminization surgery (FFS) remains inaccessible to many transgender patients. Zuckerberg San Francisco General Hospital (ZSFG) was among the first public, safety-net hospitals to perform FFS. The purpose of this study is to examine the postoperative outcomes of patients who underwent FFS at ZSFG and describe barriers to providing FFS in a public hospital setting. METHODS: A retrospective review identified patients who underwent FFS at ZSFG. Demographic data, comorbidity profiles, postoperative outcomes, and hospital utilization data were collected from the medical records. FACE-Q modules (scored 0-100) were used to survey patient satisfaction at least 1 year postoperatively. RESULTS: Seventeen patients underwent comprehensive FFS surgery at ZSFG. The median age was 41 years [interquartile range (IQR): 38-55], median body mass index was 26.4 (IQR: 24.1-31.3). Patients underwent a median of 9 procedures, the most common of which included frontal cranioplasty (n=13, 77%), open brow lift (n=13, 77%), rhinoplasty (n=12, 71%), and mandible contouring (n=12, 71%). There were no complications, readmissions, or reoperations within 30 days. Patients reported high satisfaction with the surgical outcome (median: 87, IQR: 87-100), excellent postoperative psychological functioning (median: 100, IQR: 88-100), and low levels of appearance-related distress (median: 3, IQR: 0-35). An estimated 243 operating room hours and 51 inpatient bed days were required to cover all FFS procedures. CONCLUSIONS: Performing FFS in a public, safety-net hospital was associated with zero postoperative complications, few revision procedures, and excellent patient satisfaction. Limited operating room hours and inpatient availability represented barriers to providing FFS in this setting.

Surgical Treatment of Granulomatous Breast Deformities Caused by Injection of Foreign Substances in Transgender Women: A Case Series and Algorithm.

SUMMARY: Despite potentially devastating complications, free foreign substance injections for feminizing breast augmentation remain common among transgender women. To date, the literature regarding surgical treatment of these deformities among transgender women remains limited. The authors present a case series of transgender women presenting for surgical management of granulomatous breast deformities secondary to free foreign substance injections between January of 2016 and February of 2020. Seven transgender women presented for surgical management of complications secondary to free foreign substance injections of the breast. These patients ranged in age from 29 to 53 years, all identified as Hispanic/Latinx, and five were primarily Spanish speakers. All were recipients of public insurance. Six of the seven patients received free foreign substance injections outside of the United States, with an average time from initial injections to presentation of 19.3 ± 15.7 years. Three patients presented with a history of prior revisions by other surgeons. Four underwent staged reconstruction at the authors' institutions. Patients were followed for, on average, 10.7 ± 12.6 months after their initial surgery. There were no major complications. The most common minor complication was delayed wound healing. In the present series, the authors illustrate that, with careful consideration and patient selection, it is possible to perform safe and successful breast reconstruction for the management of foreign substance granulomas in transgender women. They also provide an algorithm based on patient-specific factors to guide treatment decisions in this patient population. Further research is needed to determine the generalizability and applicability of this algorithm. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Treatment of Breast Animation Deformity in Implant-Based Reconstruction with Selective Nerve Ablation.

Breast animation deformity is a known complication of subpectoral implant placement that is usually corrected by repositioning the implant to the prepectoral position. Other less common treatment options include performing the muscle splitting biplanar technique, triple plane technique, neuromodulator injections, and secondary neurotomies via transection of the pectoral muscle. We report a patient with animation deformity successfully treated with direct identification and ablation of the medial and lateral pectoral nerves using selective bipolar electrocautery. The patient is a woman with a history of invasive ductal carcinoma who underwent bilateral mastectomy and breast reconstruction with subpectoral implant placement and autologous fat grafting. Within 1 year of her breast reconstruction, she developed hyperactive pectoralis muscle contraction with resulting distortion of both breasts. Given the disadvantages of repositioning the implant to the prepectoral position and transecting the pectoralis muscles via secondary neurotomy, we chose to directly identify and selectively ablate distal branches of the medial and lateral pectoral nerves. This offers a novel technique for correcting breast animation deformity without transecting the pectoralis muscles, causing muscle atrophy, and preserving the subpectoral implant position.Level of Evidence V 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 .

Structural connectome differences in HIV infection: brain network segregation associated with nadir CD4 cell count.

This study investigated structural brain organization using diffusion tensor imaging (DTI) in 35 HIV-positive and 35 HIV-negative individuals. We used global and nodal graph theory metrics to investigate whether HIV was associated with differences in brain network organization based on fractional anisotropy (FA) and mean diffusivity (MD). Participants also completed a comprehensive neuropsychological testing battery. For global network metrics, HIV-positive individuals displayed a lower FA clustering coefficient relative to HIV-negative individuals. For nodal network metrics, HIV-positive individuals had less MD nodal degree in the left thalamus. Within HIV-positive individuals, the FA global clustering coefficient was positively correlated with nadir CD4 cell count. Across the sample, cognitive performance was negatively correlated with characteristic path length and positively correlated with global efficiency for FA. These results suggest that, despite management with combination antiretroviral therapy, HIV infection is associated with altered structural brain network segregation and thalamic centrality and that low nadir CD4 cell count may be a risk factor. These graph theory metrics may serve as neural biomarkers to identify individuals at risk for HIV-related neurological complications.

The use of osteopathic manipulative treatment as adjuvant therapy in children with recurrent acute otitis media.

OBJECTIVE: To study effects of osteopathic manipulative treatment as an adjuvant therapy to routine pediatric care in children with recurrent acute otitis media (AOM). STUDY DESIGN: Patients 6 months to 6 years old with 3 episodes of AOM in the previous 6 months, or 4 in the previous year, who were not already surgical candidates were placed randomly into 2 groups: one receiving routine pediatric care, the other receiving routine care plus osteopathic manipulative treatment. Both groups received an equal number of study encounters to monitor behavior and obtain tympanograms. Clinical status was monitored with review of pediatric records. The pediatrician was blinded to patient group and study outcomes, and the osteopathic physician was blinded to patient clinical course. MAIN OUTCOME MEASURES: We monitored frequency of episodes of AOM, antibiotic use, surgical interventions, various behaviors, and tympanometric and audiometric performance. RESULTS: A total of 57 patients, 25 intervention patients and 32 control patients, met criteria and completed the study. Adjusting for the baseline frequency before study entry, intervention patients had fewer episodes of AOM (mean group difference per month, -0.14 [95% confidence interval, -0.27 to 0.00]; P =.04), fewer surgical procedures (intervention patients, 1; control patients, 8; P =.03), and more mean surgery-free months (intervention patients, 6.00; control patients, 5.25; P =.01). Baseline and final tympanograms obtained by the audiologist showed an increased frequency of more normal tympanogram types in the intervention group, with an adjusted mean group difference of 0.55 (95% confidence interval, 0.08 to 1.02; P =.02). No adverse reactions were reported. CONCLUSIONS: The results of this study suggest a potential benefit of osteopathic manipulative treatment as adjuvant therapy in children with recurrent AOM; it may prevent or decrease surgical intervention or antibiotic overuse.