The Influence of BIA-ALCL on the Use of Textured Breast Implant and its Placement: A Survey of Dutch Plastic Surgeons.

BACKGROUND: Breast implant-associated anaplastic large-cell lymphoma (BIA-ALCL) and its association with macrotextured breast implants may have induced plastic surgeons to change their breast augmentation and breast reconstruction practice. OBJECTIVES: The aim of this study was to survey Dutch plastic surgeons about the effects of BIA-ALCL on their choice of breast implant texture and placement technique. METHODS: An online questionnaire was distributed to all members of the Dutch Association of Plastic Surgeons. Descriptive data were presented as frequencies and percentages. Technique alterations were analyzed by the marginal homogeneity test for paired nominal data. RESULTS: A total of 63 plastic surgeons completed the questionnaire. The majority of respondents altered their use of textured implants due to BIA-ALCL concerns for both breast augmentation and reconstruction (75.4% and 69.8%, respectively; both being statistically significant, P < .001). Microtextured and smooth/nanotextured breast implants are now most frequently used. BIA-ALCL did not influence the placement technique in breast augmentation and reconstruction (87.7% and 94.3%, respectively). Dual-plane breast implant placement is still the most favored technique for breast augmentation, and submuscular placement is still most favored for breast reconstruction. CONCLUSIONS: BIA-ALCL has had a significant impact on the use of macrotextured breast implants by Dutch plastic surgeons in both aesthetic and reconstructive breast surgery. Breast implant placement technique has not been affected.

[An atypical presentation of tuberculosis]. / Een atypische presentatie van tuberculose.

BACKGROUND: In 2020 there were 623 known TB infections in the Netherlands according to the Dutch ministry of health (RIVM). About 4% were located in bones and joints. The incidence of Multi Drug Resistant (MDR) TB in The Netherlands is about 1%. CASE: We describe the case of a 46-year-old female with a painful and swelling of the mid phalangeal bone of the fourth left digit. Quantiferon was positive and PCR of the biopsy for Mycobacterium tuberculosis complex (MTC) in Ziehl-Neelsen staining confirmed tuberculous osteomyelitis. The strain was resistant for rifampicin, isoniazid, ethambutol and pyrazinamid classifying it as MDR. Treatment in a specialized center with second line drugs was indicated due to rare resistance. CONCLUSION: Tuberculosis may manifest anywhere throughout the body, also as an (atypical) swelling of the hand. The golden diagnostic standard for bone and joint TB is biopsy with Ziehl-Neelsen staining.

Determining breast volume preference among patients, plastic surgeons, and laypeople: Is there a perfect breast size?

BACKGROUND: The female breast comes in many different shapes and sizes. The literature remains inconclusive on the ideal breast size. This study aims to investigate and compare breast size preferences among three cohorts (patients, plastic surgeons, and laypeople) to provide a better understanding of Western European ideals. METHODS: Patients, plastic surgeons, and laypeople were interviewed using a survey containing three-dimensional simulations of nine females, each depicted using five simulations with increasing breast size (1 = natural breast without breast implants, 2 = moderate, 3 = moderate plus, 4 = high, and 5 = ultra-high). Linear regression models were performed to define statistically significant associations between preferred breast size and predictor variables. RESULTS: In total, 28 patients, 45 plastic surgeons, and 100 laypeople (50 males and 50 females) participated in this study. On average, patients (3.5 ± 0.7) preferred larger breast sizes compared to surgeons (3.0 ± 0.7) and laypeople (3.1 ± 0.8). The difference between patients and surgeons was statistically significant. Overall, males preferred larger breast sizes than women. Patients of older age and with a higher BMI preferred larger breast sizes, while higher educational level was significantly associated with smaller breast size preference. Female plastic surgeons would undergo breast augmentation, while male plastic surgeons and female lay participants seem more skeptical. CONCLUSIONS: Significant preferential differences exist between patients and surgeons. It is important for professionals to be aware of societal ideals and preferential differences to adequately consult patients and achieve more satisfactory results.

Hospital volume is associated with cost and outcomes variation in 2,942 pelvic reconstructions.

BACKGROUND: Complex pelvic reconstruction is challenging for plastic and reconstructive surgeons following surgical resection of the lower gastrointestinal or genitourinary tract. Complication rates and hospital costs are variable and may be linked to the hospital case volume of pelvic reconstructions performed. A comprehensive examination of these factors has yet to be performed. METHODS: Data were retrieved for patients undergoing pedicled flap reconstruction after pelvic resections in the American National Inpatient Sample database between 2010 and 2014. Patients were then separated into three groups based on hospital case volume for pelvic reconstruction. Multivariate logistic regression and gamma regression with log-link function were used to analyze associations between hospital case volume, surgical outcomes, and cost. RESULTS: In total, 2,942 patients underwent pelvic flap reconstruction with surgical complications occurring in 1,466 patients (49.8%). Total median cost was $38,469.40. Pelvic reconstructions performed at high-volume hospitals were significantly associated with fewer surgical complications (low: 51.4%, medium: 52.8%, high: 34.8%; p < 0.001) and increased costs (low: $35,645.14, medium: $38,714.92, high: $44,967.29; p < 0.001). After regression adjustment, high hospital volume was the strongest independently associated factor for decreased surgical complications (Exp[ß], 0.454; 95% Confidence Interval, 0.346-0.596; p < 0.001) and increased hospital cost (Exp[ß], 1.351; 95% Confidence Interval, 1.285-1.421; p < 0.001). CONCLUSIONS: Patients undergoing pelvic flap reconstruction after oncologic resections experience high complication rates. High case volume hospitals were independently associated with significantly fewer surgical complications but increased hospital costs. Reconstructive surgeons may approach these challenging patients with greater awareness of these associations to improve outcomes and address cost drivers.

Bilateral breast implant associated chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL): A case report.

INTRODUCTION: An estimated 30.000 breast implants are placed in the Netherlands annually. An increasing amount of reports have linked implants to the rare anaplastic large cell lymphoma (ALCL). Other implant-related lymphomas, such as those of B-cell lineage, are much rarer. PRESENTATION OF CASE: A 62-year-old female presented with pain and Baker grade III capsular contraction of the right breast. Subpectorally placed textured anatomical implants had been in situ for 26 years after cosmetic augmentation. Magnetic Resonance Imaging (MRI) showed bilateral implant leakage. Explantation of both implants confirmed bilateral leakage after which symptoms went into remission. Three months later our patient noticed an erythematous area, scar swelling and serous fluid leakage on the lateral side of the inframammary fold of the right breast. Siliconomas were excised bilaterally together with a partial capsulectomy on the left. Histopathology and immunohistochemical analysis showed monotonous small cell B-lymphocytic infiltration (CD20+, CD5+, CD23+, ALK-) in both capsules, highly suggestive for chronic lymphocytic leukemia (CLL)/small lymphocytic lymphoma (SLL). DISCUSSION: CLL/SLL are classified as nearly the same disease. The primary difference is the localization; CLL is found the bone marrow and blood whereas SLL is predominantly in the lymph nodes and spleen. There are no previous descriptions of bilateral CLL/SLL found in periprosthetic capsules. CONCLUSION: Breast implants are increasingly linked to various malignancies. In most cases, including our patient, implant explantation together with long-term follow-up suffices. MRI yields additional value in early stage diagnosis. More research is required to further optimize multidisciplinary care and improve patient outcomes.

International and Geographic Trends in Gender Authorship within Plastic Surgery.

BACKGROUND: Professional advancement in academic plastic surgery may depend on scholarly activity. The authors evaluate gender-based publishing characteristics in three international plastic surgery journals. METHODS: A retrospective review of all articles published in 2016 in the following journals was undertaken: Plastic and Reconstructive Surgery, Journal of Plastic, Reconstructive and Aesthetic Surgery, European Journal of Plastic Surgery, Annals of Surgery, and New England Journal of Medicine. Data were collected on lead author gender (first or senior author) and differences in author gender proportions, by journal, by article topic, and by geographic location were evaluated. RESULTS: Overall, 2610 articles were retrieved: 34.1 percent were from plastic surgery journals, 12.8 percent were from the Annals of Surgery, and 53.1 percent were from the New England Journal of Medicine. There was a lower proportion of female lead authors among plastic surgery journals compared with the Annals of Surgery and the New England Journal of Medicine (31 percent versus 39 percent versus 39 percent; p = 0.001). There were no differences in female lead author geographic location in the Annals of Surgery or the New England Journal of Medicine; within the plastic surgery journals, there were differences (p = 0.005), including a lower proportion arising from East Asia (15 percent) and a higher proportion arising from Canada (48 percent). Within plastic surgery, Plastic and Reconstructive Surgery had the lowest proportion of female lead author (p < 0.001). The proportion of female lead author varied by article topic (p < 0.001) and was notably higher in breast (45.6 percent) and lower in head and neck/craniofacial-orientated articles (25.0 percent). CONCLUSIONS: There are gender disparities in three mainstream plastic surgery journals-Plastic and Reconstructive Surgery, the Journal of Plastic, Reconstructive and Aesthetic Surgery, the European Journal of Plastic Surgery-and there are lower proportions of lead female authorship compared with the Annals of Surgery and the New England Journal of Medicine. Further research should focus on understanding any geographic disparities that may exist.

Social Media: Is the Message Reaching the Plastic Surgery Audience?

BACKGROUND: The aim of this study was to assess readability of articles shared on Twitter and analyze differences between them to determine whether messages and written posts are at reading levels comprehended by the general public. METHODS: Top-rated #PlasticSurgery tweets (per Twitter algorithm) in January of 2017 were reviewed retrospectively. Text from tweeted links to full, open-access, and society/institutional patient information articles were extracted. Readability was analyzed using the following established tests: Coleman-Liau, Flesch-Kincaid, FORCAST Readability Formula, Fry Graph, Gunning Fog Index, New Dale-Chall Formula, New Fog Count, Raygor Readability Estimate, and Simple Measure of Gobbledygook Readability Formula. Ease-of-reading was analyzed using the Flesch Reading Ease Index. RESULTS: Of 234 unique articles, there were 101 full journal (43 percent), 65 open-access journal (28 percent), and 68 patient information (29 percent) articles. When compared using the Simple Measure of Gobbledygook Readability Formula, full and open-access journal articles attained similar mean reading levels of 17.7 and 17.5, respectively (p = 0.475). In contrast, patient information articles had a significantly lower mean readability level of 13.9 (p < 0.001). Plastic surgeons posted 128 articles (55 percent) and non-plastic surgeon individuals posted 106 articles (45 percent). Mean readability levels between the two were 16.2 and 16.9, respectively (p < 0.001). All tweeted articles were above the sixth-grade recommended reading level. CONCLUSIONS: Readability of #PlasticSurgery articles may not be appropriate for many American adults. Consideration should be given to improving readability of articles targeted toward the general public to optimize delivery of social media messages.

Institutional Collaboration in Plastic Surgery Research: A Solution to Resource Limitations.

BACKGROUND: The current climate of health care reform and research funding restrictions presents new challenges for academic plastic surgery. Collaboration with private enterprise has been associated with greater research productivity in the general biomedical literature. This study seeks to analyze publication trends in Plastic and Reconstructive Surgery (PRS) to evaluate any changes in institutional collaboration over time. METHODS: Bibliographic data were retrospectively analyzed for all original research and discussion articles published in PRS from 2012 to 2016. The institutional affiliation for each publication was characterized from its author list as solely academic, private, government, or combinations of these (defined here as "institutional collaborations"). Annual National Institutes of Health (NIH) funding data were also collected over the same period, and associations were analyzed by linear regression. RESULTS: In total, 2,595 publications were retrieved from PRS between 2012 and 2016, of which 2,027 (78.1%) originated solely from academic institutions and 411 (15.8%) from institutional collaborations. Although the proportion of academic-only publications decreased from 82% to 74%, the proportion of institutional collaborations increased from 10% to 20% (P = 0.038). Concurrently, NIH funding declined from $33.4 billion to a low of $30.7 billion, which was associated with the decreasing proportion of academic-only publications (P = 0.025) and increasing proportion of institutional collaborations (P = 0.0053). CONCLUSIONS: Traditional sources of academic research funding have been restricted during the politically and financially tumultuous recent years. With no signs of improving access to financial resources from the NIH, academic plastic surgeons may consider diversifying their institutional partnerships to continue pioneering advances in the field.

The National Surgical Quality Improvement Program 30-Day Challenge: Microsurgical Breast Reconstruction Outcomes Reporting Reliability.

BACKGROUND: The aim was to assess reliability of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) 30-day perioperative outcomes and complications for immediate, free-tissue transfer breast reconstruction by direct comparisons with our 30-day and overall institutional data, and assessing those that occur after 30 days. METHODS: Data were retrieved for consecutive immediate, free-tissue transfer breast reconstruction patients from a single-institution database (2010-2015) and the ACS-NSQIP (2011-2014). Multiple logistic regressions were performed to compare adjusted outcomes between the 2 datasets. RESULTS: For institutional versus ACS-NSQIP outcomes, there were no significant differences in surgical-site infection (SSI; 30-day, 3.6% versus 4.1%, P = 0.818; overall, 5.3% versus 4.1%, P = 0.198), wound disruption (WD; 30-day, 1.3% versus 1.5%, P = 0.526; overall, 2.3% versus 1.5%, P = 0.560), or unplanned readmission (URA; 30-day, 2.3% versus 3.3%, P = 0.714; overall, 4.6% versus 3.3%, P = 0.061). However, the ACS-NSQIP reported a significantly higher unplanned reoperation (URO) rate (30-day, 3.6% versus 9.5%, P < 0.001; overall, 5.3% versus 9.5%, P = 0.025). Institutional complications consisted of 5.3% SSI, 2.3% WD, 5.3% URO, and 4.6% URA, of which 25.0% SSI, 28.6% WD, 12.5% URO, and 7.1% URA occurred at 30-60 days, and 6.3% SSI, 14.3% WD, 18.8% URO, and 42.9% URA occurred after 60 days. CONCLUSION: For immediate, free-tissue breast reconstruction, the ACS-NSQIP may be reliable for monitoring and comparing SSI, WD, URO, and URA rates. However, clinicians may find it useful to understand limitations of the ACS-NSQIP for complications and risk factors, as it may underreport complications occurring beyond 30 days.

Evaluation of anatomical and round breast implant aesthetics and preferences in Dutch young lay and plastic surgeon cohort.

BACKGROUND: Literature remains inconclusive on the attractiveness and natural aspect of anatomical breast implants, and thus far, studies have failed to demonstrate the visible difference in implants that are in practice compared to those that are round. This study was undertaken to evaluate (1) whether lay and professional participants can distinguish between breasts augmented with either round or anatomical breast implants and (2) their opinion with regard to naturalness and attractiveness of these augmented breasts. METHODS: Twenty breast augmentations (10 anatomical and 10 round implants), each depicted by two postoperative pictures, were scored by 100 lay participants and 15 plastic surgeons. Implant volume ranged from 275 to 400 g. Ptotic or malformed breasts were excluded. Finally, they had to score the most natural, unnatural, attractive, and unattractive breast shapes on a schematic depiction of breast types with varying upper poles. RESULTS: The rate of correct implant identifications was 74.0% (1480/2000 observations, p < 0.001) in the lay and 67.3% (202/300 observations, p < 0.001) in the surgeon cohort. Breasts with anatomical implants were rated as significantly more natural (3.3 ± 1.0 vs. 2.6 ± 1.0, p < 0.001 and 3.3 ± 1.0 vs. 2.2 ± 0.9, p < 0.001, respectively) and more attractive (3.1 ± 1.0 vs. 2.6 ± 1.0, p < 0.001 and 3.6 ± 0.9 vs. 2.7 ± 0.9, p < 0.001, respectively) versus round implants by both lay participants and surgeons. Participants preferred breasts with a neutral or slightly negative upper pole contour. CONCLUSION: Participants were able to distinguish between the results achieved with either anatomical or round textured Allergan breast implants and found augmented breasts with the anatomical implants more natural and attractive.

Does industry funding mean more publications for subspecialty academic plastic surgeons?

BACKGROUND: Conflict of interest among physicians in the context of private industry funding led to the introduction of the Physician Payments Sunshine Act in 2010. This study examined whether private industry funding correlated with scholarly productivity in the respective subspecialties of plastic surgery and the wider academic plastic surgery community. MATERIALS AND METHODS: Full-time plastic surgeons and their academic attributes were identified via institutional websites. Fellowship-trained individuals were segregated into subspecialties of microsurgery, craniofacial surgery, hand surgery, esthetic surgery, and burn surgery. The Center for Medicare and Medicaid Services Open Payment database was used to extract industry funding information. Each individual's bibliometric data were then collected through Scopus to determine the correlation between selected surgeon characteristics, academic productivity, and industry funding. RESULTS: Nine hundred and thirty-five academic plastic surgeons were identified, with 532 having defined subspecialty training. Academic bibliometrics among subspecialty surgeons were comparable among the five groups with esthetic and craniofacial surgeons displaying a preponderance of attaining more industry funding (P = 0.043) and career publications respectively, with the latter not attaining statistical significance (P = 0.12). Overall, research-specific funding (P = 0.014) and higher funding amounts (P < 0.0001) correlated with higher Hirsch indices in tandem with higher academic rank. A funding level of $2000 appeared to be the approximate cutoff above which scholastic productivity became apparent. CONCLUSIONS: Our study demonstrated in detail the association between industry funding and academic bibliometrics in academic plastic surgery of every subspecialty. Even at modest amounts, industry support, especially when research designated, positively influenced research and therefore, academic output.

Evaluation of Contralateral and Bilateral Prophylactic Mastectomy and Reconstruction Outcomes: Comparing Alloplastic and Autologous Reconstruction.

BACKGROUND: Over the last decade, there has been a 12% increase in prophylactic mastectomy (PM) per year. The aim of the study was to analyze complication rates and associated risk factors in patients undergoing PM and reconstruction. METHODS: We reviewed patients undergoing PM (contralateral and bilateral) from 2010 to 2015 at a single academic institution. Data on patient characteristics and postoperative outcomes were obtained. Postoperative complications were categorized into minor and major groups. We compared complication rates between autologous and alloplastic reconstruction. Patient characteristics were assessed using univariable and multivariable models. RESULTS: Reconstruction after PM was performed on 390 breasts over the study period: 214 underwent autologous and 176 underwent alloplastic reconstruction. When comparing autologous and alloplastic reconstruction, significant differences were seen between the number of immediate breast reconstructions (96.3% vs 48.9%, P < 0.001, respectively) and 2-stage reconstructions (0.5% vs 44.9%, P < 0.001, respectively). The overall complication rate was 15.9%: 14.6% were minor complications, and 6.9% were major. Autologous reconstruction compared with alloplastic reconstruction had a lower incidence of minor complications (11.2% vs 18.8%, P = 0.036), breast infection (1.9% vs 13.1%, P < 0.001), and breast seroma (2.3% vs 7.4%, P = 0.018), respectively. Risk factors for complications included age (≥65), obesity, American Society of Anesthesiology class (≥3), smoking, hypertension, anxiety, tissue expander (with acellular dermal matrix), and implant-only reconstructions. CONCLUSION: In our study, autologous reconstruction appeared to have a better complication profile than alloplastic reconstruction. Clinicians may potentially use this information to guide preoperative counseling of women considering PM and reconstruction.

Labiaplasty: Indications and Predictors of Postoperative Sequelae in 451 Consecutive Cases.

BACKGROUND: The increasing demand for labiaplasty is well recognized; however, the procedure remains contentious. OBJECTIVES: We aim to provide a large-scale, up-to-date analysis of labiaplasty outcomes and factors influencing postoperative sequelae (POS). METHODS: We analyzed a single-center, prospectively maintained database of females undergoing labiaplasty between 2002 and 2017. Demographic, procedural, and outcomes' data were retrieved. Binary logistic regressions were used to evaluate the odds of developing POS (revisional surgery and complications); presented as odds ratios (OR) with 95% confidence intervals (CI). RESULTS: Data for 451 consecutive patients were retrieved, ten of whom were <18 years of age. Overall, 86% were Caucasian, mean age was 32.6 years, and 11.8% were smokers. Concomitant labia majora reduction was performed in 7.3%, and clitoral hood reduction in 5.8%. There were 32 cases of POS (7.1%), while the complication rate was 3.8%. Comparing those with POS to those without, there were no differences in age (32.8 vs 29.9 years, P = 0.210), operative time (78.5 vs 80.6 minutes, P = 0.246), or comorbidities (P > 0.05 for all). On univariable analysis, increased odds of POS occurred with sexual dysfunction as an indication for surgery (OR 3.778, CI 1.682-8.483). On subgroup analysis of those ≥18 years, both smoking (2.576, CI 1.044-6.357) and sexual dysfunction as an indication (OR 4.022, CI 1.772-9.131) increased the odds of POS. On multivariable analysis of the subgroup, sexual dysfunction as an indication persisted in significance (OR 3.850, CI 1.683-8.807). CONCLUSIONS: Results compare favorably with previously reported complication and revisional surgery rates. Smoking and sexual dysfunction may increase the risk of complications.

The financial impact and drivers of hospital charges in contralateral prophylactic mastectomy and reconstruction: a Nationwide Inpatient Sample hospital analysis.

PURPOSE: Rates of contralateral prophylactic mastectomy (CPM) have increased over the last decade; it is important for surgeons and hospital systems to understand the economic drivers of increased costs in these patients. This study aims to identify factors affecting charges in those undergoing CPM and reconstruction. METHODS: Analysis of the Healthcare Cost and Utilization Project National Inpatient Sample was undertaken (2009-2012), identifying women aged ≥18 with unilateral breast cancer undergoing unilateral mastectomy with CPM and immediate breast reconstruction (IBR) (CPM group), in addition to unilateral mastectomy and IBR alone (UM group). Generalized linear modeling with gamma regression and a log-link function provided mean marginal hospital charge (MMHC) estimates associated with the presence or absence of patient, hospital and operative characteristics, postoperative complications, and length of stay (LOS). RESULTS: Overall, 70,695 women underwent mastectomy and reconstruction for unilateral breast cancer; 36,691 (51.9%) in the CPM group, incurring additional MMHCs of $20,775 compared to those in the UM group (p < 0.001). In the CPM group, MMHCs were reduced in those aged >60 years (p < 0.001), while African American or Hispanic origin increased MMHCs (p < 0.001). Diabetes, depression, and obesity increased MMHCs (p < 0.001). MMHCs increased with larger (p < 0.001) hospitals, Western location (p < 0.001), greater household income (p < 0.001), complications (p < 0.001), and increasing LOS (p < 0.001). MMHCs decreased in urban teaching hospitals and Midwest or Southern regions (p < 0.001). CONCLUSION: There are many patient and hospital factors affecting charges; this study provides surgeons and hospital systems with transparent, quantitative charge data in patients undergoing contralateral prophylactic mastectomy and immediate breast reconstruction.