Google Ranking of Plastic Surgeons Values Social Media Presence Over Academic Pedigree and Experience.

BACKGROUND: Patients increasingly rely on online resources to make healthcare decisions. Google dominates the search engine market; first-page results receive most of the web traffic and therefore serve as an important indicator of consumer reach. OBJECTIVES: Our objective was to analyze the respective importance of physician academic pedigree, experience, and social media presence on plastic surgeon Google first-page search result placement. METHODS: A Google.com search was conducted in the top 25 United States metropolitan areas to identify the top 20 websites of board-certified plastic surgeons. Social media presence was quantified by tracking the number of followers on Facebook, Twitter, and Instagram for every surgeon as well as medical school and year of graduation. The primary outcome was website ranking in the first page of Google search results. To identify the independent predictors of presence on the front page, we performed a multivariate logistic regression. RESULTS: Total number of social medial followers was associated with Google front-page placement (P < 0.001), whereas medical school ranking and years in practice were not (P = 0.17 and 0.39, respectively). A total 19.6% of plastic surgeon practices in our study cohort still had no social media accounts whatsoever. CONCLUSIONS: For the past few decades, plastic surgery practices relied on referrals, word of mouth, and the surgeon's reputation and academic pedigree to attract new patients. It is now clear that this practice-building model is being rapidly supplanted by a new paradigm based on social media presence to reach potential patients.

Long-term Outcomes After Pediatric Free Flap Reconstruction.

INTRODUCTION: Whereas free tissue transfer has evolved to minimize morbidity in adults, less is known about outcomes after free flaps in children. This study sought to assess short- and long-term outcomes after microvascular reconstruction in the pediatric population. METHODS: Short- and long-term outcomes of free tissue transfer were assessed using chart-review and quality-of-life surveys. The Pediatric Outcomes Data Collection Instrument was used to evaluate overall health, pain, and ability to participate in normal daily and more vigorous activities. Patient or parent responses were compared against normative data. RESULTS: Forty-two patients underwent 48 flap reconstructions at a mean age of 8 years. Median follow-up was 14.9 years. Indications included congenital nevi (n = 19, 42%), lymphatic/vascular malformations (n = 8, 19%), and trauma/burns (n = 6, 14%). There were 21 fasciocutaneous (44%), 19 muscle/myocutaneous (40%), 6 fascial/peritoneal (13%), and 2 osteocutaneous flaps (4%). Major flap complications were observed in 4 patients (9%), whereas major donor-site complications occurred in 2% (1 patient). Valid contact information was available for 25 patients; 16 of these completed surveys (64%). Pediatric Outcomes Data Collection Instrument scores for mobility (median, 52), sports/physical functioning (median, 56), happiness (median, 50), and pain/comfort (median, 56) were not significantly different from normative population score of 50. Similarly, median global functioning score was 99 (maximum, 100) and did not differ between flap types. DISCUSSION: Free tissue transfer in the pediatric population is reliable and well-tolerated over time. Surgeons should not hesitate to use free flaps when clinically indicated for pediatric patients.

Evaluating Mastectomy Skin Flap Necrosis in the Extended Breast Reconstruction Risk Assessment Score for 1-Year Prediction of Prosthetic Reconstruction Outcomes.

BACKGROUND: Rates of mastectomy for breast cancer treatment and immediate reconstruction continue to rise. With increasing scrutiny on outcomes and patient satisfaction, there is an impetus for providers to be more deliberate in appropriate patient selection for breast reconstruction. The Breast Reconstruction Risk Assessment (BRA) Score was developed for prediction of complications after primary prosthetic breast reconstruction, focusing on calculating risk estimations for a variety of complications based on individual patient demographic and perioperative characteristics. In this study, we evaluated mastectomy skin flap necrosis (MSFN) as a function of patient characteristics to validate the BRA Score. STUDY DESIGN: We examined our prospective intra-institutional database of prosthetic breast reconstructions from 2004 to 2015. The end point of interest was 1-year occurrence of MSFN after stage I tissue expander placement. RESULTS: Nine hundred and three patients were included; 50% underwent bilateral reconstruction. Median follow-up was 23 months. Mean 1-year complication rates were as follows: MSFN 12.4%, seroma 3.0%, infection 6.9%, dehiscence/exposure 7.1%, and explantation 13.2%. Statistically significantly higher rates of MSFN were found in older patients, smokers, patients with postoperative infections, patients with hypertension, and patients who used aspirin. Neoadjuvant or adjuvant chemotherapy and radiation, diabetes, and seroma formation did not have a statistically significant impact on necrosis rates. CONCLUSIONS: The BRA Score was expanded to estimate complication risk after tissue expander placement up to 1 year postoperatively. The risk of MSFN as calculated by the BRA Score: Extended Length is consistent with published studies demonstrating increased risk with specific comorbidities, and further validates expansion of the BRA score risk calculator.

Plastic Surgery-Related Hashtag Utilization on Instagram: Implications for Education and Marketing.

BACKGROUND: Recent data suggest patients are seeking aesthetic surgery to improve their appearance on Instagram and other social media. Despite the rising influence of Instagram in plastic surgery, few academic publications address Instagram, let alone evaluate its utilization in plastic surgery. OBJECTIVES: We set out to answer the following three questions: 1) what plastic surgery-related content is being posted to Instagram; 2) who is posting this content; and 3) what specific hashtags are they using? METHODS: Our study queried 21 Instagram plastic surgery-related hashtags. Content analysis was used to qualitatively evaluate each of the nine "top" posts associated with each hashtag (189 posts). Duplicate posts and those not relevant to plastic surgery were excluded. RESULTS: A total of 1,789,270 posts utilized the 21 hashtags sampled in this study. Of the top 189 posts for these 21 queried hashtags, 163 posts met inclusion criteria. Plastic surgeons eligible for membership in American Society for Aesthetic Plastic Surgery (ASAPS) accounted for only 17.8% of top posts, whereas noneligible physicians accounted for 26.4%. All nonplastic surgery trained physicians marketed themselves as "cosmetic surgeons." Nine top posts (5.5%) were by nonphysicians, including dentists, spas with no associated physician, and a hair salon. The majority of these posts were self-promotional (67.1%) as opposed to educational (32.9%). Board-certified plastic surgeons were significantly more likely to post educational content to Instagram as compared to nonplastic surgeons (62.1% vs 38.1%, P = 0.02). CONCLUSIONS: ASAPS eligible board-certified plastic surgeons are underrepresented amongst physicians posting top plastic surgery-related content to Instagram.

Vertical Skin Paddle Orientation for the Latissimus Dorsi Flap in Breast Reconstruction: A Modification to Simultaneously Correct Inferior Pole Constriction and Improve Projection.

The latissimus dorsi myocutaneous flap is a reliable and frequently used option to bring vascularized skin and soft tissue to improve the stability and aesthetic result in breast reconstruction. Standard techniques with skin paddle inset in a horizontal or oblique fashion preferentially improve anterior projection (when inset at the mastectomy scar) or lower pole and inframammary fold constriction (when inset into the inframammary fold). Here, the authors describe a modification for inset of the latissimus dorsi myocutaneous flap that improves both anterior projection and lower pole/inframammary fold constriction, and also allows the latissimus muscle to fan out and provide complete implant coverage. The vertical inset modification brings new skin and soft tissue into both the inferior pole and the central mastectomy scar, allowing simultaneous improvement in both areas and full use of the latissimus muscle to cover the implant or expander. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Beyond 30 Days: A Risk Calculator for Longer Term Outcomes of Prosthetic Breast Reconstruction.

BACKGROUND: Despite growing use of surgical risk calculators, many are limited to 30-day outcomes due to the constraints of their underlying datasets. Because complications of breast reconstruction can occur well beyond 30 days after surgery, we endeavored to expand the Breast Reconstruction Risk Assessment (BRA) Score to prediction of 1-year complications after primary prosthetic breast reconstruction. METHODS: We examined our prospective intrainstitutional database of prosthetic breast reconstructions from 2004 to 2015. Patients without 1-year follow-up were excluded. Pertinent patient variables include those enumerated in past iterations of the BRA Score. Outcomes of interest include seroma, surgical site infection (SSI), implant exposure, and explantation occurring within 1 year of tissue expander placement. Risk calculators were developed for each outcome using multivariate logistic regression models and made available online at www.BRAScore.org. Internal validity was assessed using C-statistic, Hosmer-Lemeshow test, and Brier score. RESULTS: Nine-hundred three patients met inclusion criteria. Within 1-year, 3.0% of patients experienced seroma, 6.9% infection, 7.1% implant exposure, and 13.2% explantation. Thirty-day, 90-day, and 180-day windows captured 17.6%, 39.5%, and 59.7% of explantations, respectively. One-year risk calculators were developed for each complication of interest, and all demonstrated good internal validity: C-statistics for the 5 models ranged from 0.674 to 0.739, Hosmer-Lemeshow tests were uniformly nonsignificant, and Brier scores ranged from 0.027 to 0.154. CONCLUSIONS: Clinically significant complications of prosthetic breast reconstruction usually occur beyond the 30-day window following tissue expander placement. To better reflect long-term patient experiences, the BRA Score was enhanced with individualized risk models that predicted 1-year complications after prosthetic reconstruction (BRA Score XL). All models performed as well as, if not better than, the original BRA Score models and other popular risk calculators such as the CHA2DS2VASc Score. The patient-friendly BRA Score XL risk calculator is available at www.brascore.org to facilitate operative decision-making and heighten the informed consent process for patients.

The Ethics of Sharing Plastic Surgery Videos on Social Media: Systematic Literature Review, Ethical Analysis, and Proposed Guidelines.

Recent videos shared by plastic surgeons on social media applications such as Snapchat, Instagram, and YouTube, among others, have blurred the line between entertainment and patient care. This has left many in the plastic surgery community calling for the development of more structured oversight and guidance regarding video sharing on social media. To date, no official guidelines exist for plastic surgeons to follow. Little is known about the ethical implications of social media use by plastic surgeons, especially with regard to video sharing. A systematic review of the literature on social media use in plastic surgery was performed on October 31, 2016, with an emphasis on ethics and professionalism. An ethical analysis was conducted using the four principles of medical ethics. The initial search yielded 87 articles. Thirty-four articles were included for analyses that were found to be relevant to the use of social media in plastic surgery. No peer-reviewed articles were found that mentioned Snapchat or addressed the ethical implications of sharing live videos of plastic surgery on social media. Using the four principles of medical ethics, it was determined that significant ethical concerns exist with broadcasting these videos. This analysis fills an important gap in the plastic surgery literature by addressing the ethical issues concerning live surgery broadcasts on social media. Plastic surgeons may use the guidelines proposed here to avoid potential pitfalls.

External validation of the breast reconstruction risk assessment calculator.

INTRODUCTION: The Breast reconstruction Risk Assessment (BRA) Score estimates patient-specific risk for postsurgical complications using an individual's unique combination of preoperative variables. In this report, we externally validate the BRA Score models for surgical site infection, seroma, and explantation in a large sample of intra-institutional patients who underwent prosthetic breast reconstruction. METHODS: We reviewed all initiated tissue expander/implant reconstructions by the senior authors from January 2004 to December 2015. BRA Score risk estimates were computed for each patient and compared against observed rates of complications. Hosmer-Lemeshow goodness-of-fit test, concordance statistic, and Brier score were used to assess the calibration, discrimination, and accuracy of the models, respectively. RESULTS: Of the 1152 patients (1743 breasts) reviewed, 855 patients (1333 breasts) had complete data for BRA-score calculations and were included for analysis. Hosmer-Lemeshow tests for calibration demonstrated a good agreement between observed and predicted outcomes for surgical site infection (SSI) and seroma models (P-values of 0.33 and 0.16, respectively). In contrast, predicted rates of explantation deviated from observed rates (Hosmer-Lemeshow P-value of 0.04). C statistics demonstrated good discrimination for SSI, seroma, and explantation (0.73, 0.69, and 0.78, respectively). CONCLUSIONS: In this external validation study, the BRA Score tissue expander/implant reconstruction models performed with generally good calibration, discrimination, and accuracy. Some weaknesses in certain models were identified as targets for future improvement. Taken together, these analyses validate the clinical utility of the BRA score risk models in predicting 30-day outcomes.

Shaped versus Round Implants in Breast Reconstruction: A Multi-Institutional Comparison of Surgical and Patient-Reported Outcomes.

BACKGROUND: Since the 2012 approval of shaped implants, their use in breast reconstruction has increased in the United States. However, large-scale comparisons of complications and patient-reported outcomes are lacking. The authors endeavored to compare surgical and patient-reported outcomes across implant types. METHODS: The Mastectomy Reconstruction Outcomes Consortium database was queried for expander/implant reconstructions with at least 1-year postexchange follow-up (mean, 18.5 months). Outcomes of interest included postoperative complications, 1-year revisions, and patient-reported outcomes. Bivariate and mixed-effects regression analyses evaluated the effect of implant type on patient outcomes. RESULTS: Overall, 822 patients (73.5 percent) received round and 297 patients (26.5 percent) received shaped implants. Patients undergoing unilateral reconstructions with round implants underwent more contralateral symmetry procedures, including augmentations (round, 18.7 percent; shaped, 6.8 percent; p = 0.003) and reductions (round, 32.2 percent; shaped, 20.5 percent; p = 0.019). Shaped implants were associated with higher rates of infection (shaped, 6.1 percent; round, 2.3 percent; p = 0.002), that remained significant after multivariable adjustment. Other complication rates did not differ significantly between cohorts. Round and shaped implants experienced similar 2-year patient-reported outcome scores. CONCLUSIONS: This prospective, multicenter study is the largest evaluating outcomes of shaped versus round implants in breast reconstruction. Although recipients of round implants demonstrated lower infection rates compared with shaped implants, these patients were more likely to undergo contralateral symmetry procedures. Both implant types yielded comparable patient-reported outcome scores. With appropriate patient selection, both shaped and round implants can provide acceptable outcomes in breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Outcomes After Elevation of Serratus Anterior Fascia During Prosthetic Breast Reconstruction.

BACKGROUND: Achieving optimal inferolateral coverage is critical to successful prosthetic breast reconstruction. Serratus anterior fascia (SF) elevation, a promising alternative to muscle flaps and acellular dermis (ADM), has not been rigorously studied. This study evaluates complication rates after mastectomy and immediate tissue expander (TE) coverage using SF, relative to other existing methods of reconstruction. METHODS: Retrospective review of consecutive patients undergoing mastectomy with immediate TE reconstruction over 10 years at 1 institution was performed. Patients with serratus muscle (SM) or SF elevation were analyzed. ADM reconstructions were used for comparative analysis only. Relevant demographic and clinical data were recorded. Complications were categorized by type and end outcome, including nonoperative (no further surgery), operative (surgery except explantation), and explantation. RESULTS: The SM and SF elevation was performed in 375 (487 breasts) and 177 (255 breasts) patients, respectively. Mean follow-up was 43.8 months. The SM and SF patients were demographically similar, but SF had higher intraoperative fill volumes (P < 0.0001) and required fewer postoperative expansions (P < 0.0001). There were no differences in complications between SM and SF patients. Regression analysis, adjusted for several variables, revealed that SF was not an independent risk factor for complications. The ADM- and SF-assisted reconstruction also showed no differences in outcomes. CONCLUSIONS: Our review demonstrates that SF elevation is a safe, feasible alternative for achieving inferolateral coverage during prosthetic breast reconstruction. Furthermore, this technique allows for greater fill volumes and less expansions than SM. As a readily available alternative to muscle flaps and ADM, SF elevation should be considered integral to any prosthetic breast reconstruction algorithm.

Impact of Postoperative Antibiotic Prophylaxis Duration on Surgical Site Infections in Autologous Breast Reconstruction.

BACKGROUND: Although some surgeons prescribe prolonged postoperative antibiotics after autologous breast reconstruction, evidence is lacking to support this practice. We used the Tracking Operations and Outcomes for Plastic Surgeons database to evaluate the association between postoperative antibiotic duration and the rate of surgical site infection (SSI) in autologous breast reconstruction. STUDY DESIGN: The intervention of interest for this study was postoperative duration of antibiotic prophylaxis: either discontinued 24 hours after surgery or continued beyond 24 hours. The primary outcome variable of interest for this study was the presence of SSI within 30 days of autologous breast reconstruction. Cohort characteristics and 30-day outcomes were compared using χ² and Fischer exact tests for categorical variables and Student t tests for continuous variables. Multivariate logistic regression was used to control for confounders. RESULTS: A total of 1036 patients met inclusion criteria for our study. Six hundred fifty-nine patients (63.6%) received antibiotics for 24 hours postoperatively, and 377 patients (36.4%) received antibiotics for greater than 24 hours. The rate of SSI did not differ significantly between patients given antibiotics for only 24 hours and those continued on antibiotics beyond the 24-hour postoperative time period (5.01% vs 2.92%, P = 0.109). Furthermore, antibiotic duration was not predictive of SSI in multivariate regression modeling. CONCLUSIONS: We did not find a statistically significant difference in the rate of SSI in patients who received 24 hours of postoperative antibiotics compared to those that received antibiotics for greater than 24 hours. These findings held for both purely autologous reconstruction as well as latissimus dorsi reconstruction in conjunction with an implant. Thus, our study does not support continuation of postoperative antibiotics beyond 24 hours after autologous breast reconstruction.

Comparison of Delayed and Immediate Tissue Expander Breast Reconstruction in the Setting of Postmastectomy Radiation Therapy.

BACKGROUND: Despite the continued demand for immediate prosthetic breast reconstruction, some suggest that delayed reconstruction may reduce complications. However, with limited comparative data available, the extent of this benefit is unclear, particularly in the setting of postmastectomy radiation therapy (PMRT). This study evaluates outcomes after mastectomy and delayed tissue expander reconstruction (DTER) or immediate tissue expander reconstruction (ITER). METHODS: A retrospective review of 893 consecutive patients (1201 breasts) who underwent mastectomy with DTER or ITER at one institution during a 10-year period was performed. Relevant patient factors, including the use of PMRT and complication rates, were recorded. Complications were categorized by type and end-outcome, including nonoperative (no further surgery), operative (further surgery except explantation), and explantation. Statistics were done using Student t test and Fisher exact test. RESULTS: There were no differences in clinical risk factors between ITER (n = 1127 breasts) and DTER (n = 74 breasts) patients. Delayed tissue expander reconstruction breasts had lower rates of mastectomy flap necrosis (P = 0.003), and nonoperative (P = 0.01) and operative (P = 0.001) complications relative to ITER. In ITER breasts, PMRT increased operative complications (P = 0.02) and explantation (P = 0.0005), resulting in a decrease in overall, 2-stage success rate (P < 0.0001). In contrast, there were no differences in outcomes between PMRT and non-PMRT DTER breasts. CONCLUSIONS: This comparative study, the largest to date, suggests that DTER is a viable reconstructive alternative that may minimize certain complications over ITER, including in patients needing PMRT. However, unlike with ITER, surgeons can evaluate patients' potential for success with DTER based on skin flap appearance after both mastectomy and PMRT (when present). As a result, the benefits of DTER may also be due to a careful patient selection process preoperatively. The choice of DTER should, therefore, be balanced against both individual patient risk factors and the psychological appeal of immediate reconstruction.

SERI surgical scaffold, prospective clinical trial of a silk-derived biological scaffold in two-stage breast reconstruction: 1-year data.

BACKGROUND: SERI Surgical Scaffold is a long-term bioresorbable silk-derived biological scaffold developed to provide soft-tissue support and repair. METHODS: SURE-001 (ClinicalTrials.gov identification no. NCT01256502) is a prospective, single-arm study in the United States of patients undergoing two-stage, implant-based breast reconstruction using SERI. RESULTS: A total of 139 patients were enrolled and will be followed for 2 years; in this article, the authors report interim data on 71 patients followed for 1 year. Investigator satisfaction scores (mean ± SD) at 6 and 12 months were 9.2 ± 0.98 and 9.4 ± 0.91, respectively (10 = very satisfied). SERI was rated easy/very easy to use in 98 percent or more of cases across five categories in stage I surgery. Patient satisfaction with the treated breast(s) (mean ± SD) was higher at 6 (4.3 ± 0.87; 5 = very satisfied) and 12 months (4.5 ± 0.82) compared with screening (3.6 ± 1.09; p < 0.0001). Key complication rates (per breast) were tissue necrosis (6.7 percent), seroma (5.7 percent), hematoma (4.8 percent), implant loss (3.8 percent), capsular contracture (1.9 percent), and breast infection (1.0 percent). None were attributed to SERI by the investigators. In 13 patients (14 breasts) who underwent unplanned radiation therapy, one complication was reported. CONCLUSIONS: In this interim report, high levels of investigator and patient satisfaction, and ease of use of SERI were reported. Prospectively collected complication rates were similar to those reported in primarily retrospective studies of two-stage, implant-based breast reconstructions using other implantable soft-tissue support materials such as acellular dermal matrices. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Risk Factors for Complications Differ Between Stages of Tissue-Expander Breast Reconstruction.

BACKGROUND: Tissue-expander (TE) placement followed by implant exchange is currently the most popular method of breast reconstruction. There is a relative paucity of data demonstrating patient factors that predict complications specifically by stage of surgery. The present study attempts to determine what complications are most likely to occur at each stage and how the risk factors for complications vary by stage of reconstruction. METHODS: A retrospective chart review was performed on all 1275 patients who had TEs placed by the 2 senior authors between 2004 and 2013. Complication rates were determined at each stage of reconstruction, and these rates were further compared between patients who had pre-stage I radiation, post-stage I radiation, and no radiation exposure. Multivariate logistic regression was used to identify independent predictors of complications at each stage of reconstruction. RESULTS: A total of 1639 consecutive TEs were placed by the senior authors during the study period. The overall rate for experiencing a complication at any stage of surgery was 17%. Complications occurred at uniformly higher rates during stage I for all complications (92% stage I vs 7% stage II vs 1% stage III, P < 0.001). Predictors of stage I complications included increased body mass index [odds ratio (OR), 1.04; 95% confidence interval (CI), 1.01-1.07], current smoking status (OR, 3.0; 95% CI, 1.7-4.8), and higher intraoperative percent fill (OR, 3.3; 95% CI, 1.7-6.3). Post-stage I radiation was the only independent risk factor for a stage II complication (OR, 4.5; 95% CI, 1.4-15.2). CONCLUSIONS: Complications occur at higher rates after stage I than after stage II, and as expected, stage III complications are exceedingly rare. Risk factors for stage I complications are different from risk factors for stage II complications. Body mass index and smoking are associated with complications at stage I, but do not predict complications at stage II surgery. The stratification of risk factors by stage of surgery will help surgeons and patients better manage both risk and expectations.

A Multi-institutional Analysis of Insurance Status as a Predictor of Morbidity Following Breast Reconstruction.

BACKGROUND: Although recent literature suggests that patients with Medicaid and Medicare are more likely than those with private insurance to experience complications following a variety of procedures, there has been limited evaluation of insurance-based disparities in reconstructive surgery outcomes. Using a large, multi-institutional database, we sought to evaluate the potential impact of insurance status on complications following breast reconstruction. METHODS: We identified all breast reconstructive cases in the 2008 to 2011 Tracking Operations and Outcomes for Plastic Surgeons clinical registry. Propensity scores were calculated for each case, and insurance cohorts were matched with regard to demographic and clinical characteristics. Outcomes of interest included 15 medical and 13 surgical complications. RESULTS: Propensity-score matching yielded 493 matched patients for evaluation of Medicaid and 670 matched patients for evaluation of Medicare. Overall complication rates did not significantly differ between patients with Medicaid or Medicare and those with private insurance (P = 0.167 and P = 0.861, respectively). Risk-adjusted multivariate regressions corroborated this finding, demonstrating that Medicaid and Medicare insurance status does not independently predict surgical site infection, seroma, hematoma, explantation, or wound dehiscence (all P > 0.05). Medicaid insurance status significantly predicted flap failure (odds ratio = 3.315, P = 0.027). CONCLUSIONS: This study is the first to investigate the differential effects of payer status on outcomes following breast reconstruction. Our results suggest that Medicaid and Medicare insurance status does not independently predict increased overall complication rates following breast reconstruction. This finding underscores the commitment of the plastic surgery community to providing consistent care for patients, irrespective of insurance status.

Analysis of risk factors for complications in expander/implant breast reconstruction by stage of reconstruction.

BACKGROUND: Expander/implant breast reconstruction is a common approach to breast reconstruction. Although several studies evaluate risk factors for complications during the overall reconstructive process, no studies currently evaluate risk factors by stage of reconstruction. This information is important, as it can help guide physician and patient decision making. METHODS: This is a retrospective review of the records of 876 patients who underwent expander/implant breast reconstruction. Average follow-up time was 42 months. Multivariate analysis and odds ratios were used to calculate the significance of the variables of interest and to compare the risk of complications attributable to each of the independent variables during each stage of the procedure. RESULTS: During the expander stage, body mass index greater than 30 kg/m had the strongest effect on the development of complications leading to explantation/conversion to flap (OR, 3.07). During the permanent implant stage, history of prereconstruction irradiation had the strongest association with the development of complications leading to explantation/conversion to flap (OR, 3.45). The only risk factors that had a statistically significant effect on the development of complications during both stages were age older than 50 years, smoking within the past month, and a history of premastectomy or postmastectomy radiation therapy. CONCLUSIONS: The results of this study indicate that the risk factors for complications during expander/implant breast reconstruction differ during each stage of the procedure. The individual impact of risk factors must be considered within the context of each patient's oncologic and surgical needs so that surgeons and patients may make more informed decisions toward their goal of a successful breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Tracking the aesthetic outcomes of prosthetic breast reconstructions that have complications.

BACKGROUND: Aesthetic results following breast reconstruction have been shown to be a major contributor to patient satisfaction. While many presume that complications after reconstruction impact final aesthetic results, little data exist to substantiate this putative relationship. OBJECTIVE: To track and evaluate aesthetic outcomes following implant reconstructions with complications. METHODS: A chart review was conducted on a series of consecutive expander-implant breast reconstructions performed by the senior author between 2004 and 2012. Included patients completed their prosthetic reconstruction or converted to autologous methods and had a minimum follow-up period of 130 days. Four blinded members of the division of plastic surgery independently rated postoperative anterior photographs of patients' breasts using a validated scoring scale with respect to five distinct aesthetic domains: breast mound volume, contour, placement, scarring and inframammary fold. RESULTS: Of the 172 patients who met the inclusion criteria, 36 experienced a complication. The tissue expander in one-half of these patients was salvaged and the remaining patients converted to autologous reconstruction. The average aesthetic scores for each domain did not differ significantly between patients who experienced a complication and retained their expander and those who did not experience a complication. Patients who converted to autologous tissue reconstruction after experiencing a complication had the highest aesthetic scores. DISCUSSION: The ability to obtain aesthetic results following a complication that were not statistically different from results in those without complications may reflect the surgeon's refined attempt to salvage the initial implant reconstruction; in other circumstances, the improved cosmesis was achieved through conversion to an autologous tissue-based method. CONCLUSION: The present study quantitatively assessed the impact of complications on aesthetic outcomes following implant breast reconstruction. Continuance of prosthetic reconstruction and conversion to autologous reconstruction serve as viable options to obtain adequate aesthetic scores following a complication. Information gained from the present analysis will help manage patient expectations.

HISTORIQUE: Il est démontré que les résultats esthétiques après une reconstruction mammaire contribuent énormément à la satisfaction des patientes. On présume souvent que les complications observées après une reconstruction nuisent aux résultats esthétiques finaux, mais il existe peu de données pour corroborer ce prétendu lien. OBJECTIF: Suivre et évaluer les résultats esthétiques après des reconstructions par prothèse s'associent à des complications. MÉTHODOLOGIE: Les chercheurs ont examiné les dossiers consécutifs de reconstructions mammaires par prothèses d'expansion effectuées par l'auteur principal entre 2004 et 2012. Les patientes participantes ont subi une reconstruction prothétique complète ou sont passées à une méthode autologue et ont été suivies pendant au moins 130 jours. Quatre membres de la division de chirurgie plastique ont évalué de manière indépendante et en insu les photographies postopératoires antérieures des seins des patientes au moyen d'une échelle d'évaluation validée dans cinq domaines esthétiques : volume du monticule mammaire, contour, emplacement, cicatrices et pli inframammaire. RÉSULTATS: Chez les 172 patientes qui respectaient les critères d'inclusion, 36 ont présenté une complication. La moitié d'entre elles ont pu conserver leur prothèse d'expansion, mais les autres sont passées à une reconstruction autologue. Les résultats esthétiques moyens de chaque domaine ne différaient pas de manière significative entre les patientes qui avaient subi une complication et conservé leur prothèse et celles qui n'avaient pas subi de complication. Les patientes qui sont passées à une reconstruction par tissus autologues après une complication obtenaient les meilleurs résultats esthétiques. EXPOSÉ: Les résultats esthétiques après une complication qui n'étaient pas statistiquement différents de ceux des patientes n'ayant pas vécu de complication reflètent peut-être la tentative perfectionnée du chirurgien de sauvegarder la prothèse initiale. Dans les autres situations, la conversion aux tissus autologues favorisait une meilleure esthétique. CONCLUSION: La présente étude visait à obtenir une évaluation quantitative des effets des complications sur les résultats esthétiques après une reconstruction mammaire par prothèse. Le maintien de la reconstruction par prothèse et la conversion à une reconstruction autologue permettaient d'obtenir des résultats esthétiques satisfaisants après une complication. L'information tirée de la présente analyse contribuera à gérer les attentes des patients.