Initial Experience with Unidirectional Barbed Suture for Abdominal Donor Site Closure in Deep Inferior Epigastric Perforator Flap Breast Reconstruction.

Background: The deep inferior epigastric perforator (DIEP) flap is a predominant technique for autologous breast reconstruction. However, the best method of abdominal fascial closure in this technique is not well defined. This study details our initial experience with unidirectional barbed suture-only repair of abdominal donor site fascia. Methods: Patients who underwent DIEP flap breast reconstruction and abdominal fascial closure with Stratafix Symmetric Polydioxanone PDS Plus were retrospectively reviewed. Information regarding pertinent patient history, medical comorbidities, risk factors, and surgical technique was extracted, along with the incidence of eight separate postoperative abdominal surgical site occurrences. Results: Retrospective review identified 43 patients who underwent 19 unilateral and 24 bilateral DIEP flap breast reconstruction procedures (n = 67). Average patient follow-up was 791 days (range 153-1769). Six patients (14%) had a complication of the donor site. Seroma was most frequent (n = 3, 7%), followed by surgical site infection (n = 2, 5%). One patient had incisional dehiscence (2%) and another patient developed bulging (2%). No patients had chronic pain, weakness, hematoma, or hernia postoperatively. Patients with donor site complications had a history of abdominal/pelvic surgery significantly more often than the patients without donor site complications (100% versus 49%; P = 0.032). Conclusions: Abdominal fascial repair with Stratafix Symmetric suture alone led to low rates of abdominal donor site morbidity, including no hernia and rare bulging, following DIEP flap breast reconstruction. Additional advantages of this technique may be reduced operative times and lower operative costs compared with alternative methods of fascial repair, although prospective and randomized studies are warranted.

Risk stratification of surgical-site outcomes by BMI and flap type in autologous breast reconstruction.

INTRODUCTION: Afflicting 2 million lives annually worldwide, breast cancer remains devastating. This study utilized a continuously updated network of electronic medical records (TriNetX Inc, Cambridge, MA) for analysis of 90-day postoperative outcomes of autologous breast reconstruction by increasing body mass index (BMI). METHODS: The deidentified electronic medical records (EMRs) of 29,453,000 females, age 18-99 years, were retrospectively screened from 45 healthcare organizations. A combined cohort of 7136 patients undergoing autologous breast reconstruction via transverse rectus abdominus muscle (TRAM), deep inferior epigastric perforator (DIEP), or latissimus flap was categorized by BMI into 5 subgroups: normal (n = 3568), overweight (n = 1239), class I (n = 1166), class II (n = 807), and class III (n = 356) obesity. The normal BMI cohort was then compared with each elevated BMI cohort. BMI strata were analyzed for risk of surgical-site occurrences within 90 days of surgery using CPT codes. Stringent propensity score matching was performed. RESULTS: For the combined group (N = 7136), significant linear increases in risk were observed with increasing BMI for infection (risk ratio [RR] 1.39-2.91,p < 0.05) and dehiscence (RR 2.65-5.17, p < 0.05). Similar linear increases were observed for the abdominally based group (N = 5454) for infection (RR 1.45-2.47, p < 0.05) and dehiscence (RR 2.54-4.77, p < 0.05). For DIEP (N = 4874), near-linear increases were observed for infection (RR 1.60-2.79, p < 0.05) and dehiscence (RR 1.57-5.59, p < 0.05). For TRAM (N = 714), significant increases were observed for seroma, infection, dehiscence, deep vein thrombosis (DVT), sepsis, and PE while increased risks of seroma, DVT, PE, and hernia were observed for latissimus (N = 1380). CONCLUSIONS: Regardless of flap type, our analysis suggests that a BMI> 39.9 is the inflection point beyond which it may be beneficial not to perform autologous breast reconstruction. Limitations include this study's retrospective nature; thus, future prospective studies would be beneficial.

The impact of influenza vaccination on surgical outcomes in COVID-19 positive patients: An analysis of 43,580 patients.

BACKGROUND: Multiple recent studies suggest a possible protective effect of the influenza vaccine against severe acute respiratory coronavirus 2 (SARS-CoV-2). This effect has yet to be evaluated in surgical patients. This study utilizes a continuously updated federated electronic medical record (EMR) network (TriNetX, Cambridge, MA) to analyze the influence of the influenza vaccine against post-operative complications in SARS-CoV-2-positive patients. METHODS: The de-identified records of 73,341,020 patients globally were retrospectively screened. Two balanced cohorts totaling 43,580 surgical patients were assessed from January 2020-January 2021. Cohort One received the influenza vaccine six months-two weeks prior to SARS-CoV-2-positive diagnosis, while Cohort Two did not. Post-operative complications within 30, 60, 90, and 120 days of undergoing surgery were analyzed using common procedural terminology(CPT) codes. Outcomes were propensity score matched for characteristics including age, race, gender, diabetes, obesity, and smoking. RESULTS: SARS-CoV-2-positive patients receiving the influenza vaccine experienced significantly decreased risks of sepsis, deep vein thrombosis, dehiscence, acute myocardial infarction, surgical site infections, and death across multiple time points(p<0.05, Bonferroni Correction p = 0.0011). Number needed to vaccinate (NNV) was calculated for all significant and nominally significant findings. CONCLUSION: Our analysis examines the potential protective effect of influenza vaccination in SARS-CoV-2-positive surgical patients. Limitations include this study's retrospective nature and reliance on accuracy of medical coding. Future prospective studies are warranted to confirm our findings.

Outcomes of Nipple-sparing Mastectomy with Reconstruction after Recent Oncoplastic Wise-pattern Reduction.

For patients with large and/or ptotic breasts, a planned staged approach to nipple-sparing mastectomy (NSM) has been described. Less is known about surgical outcomes of unplanned staged NSM for management of positive margins after partial mastectomy with oncoplastic reduction. It is not clear from earlier studies whether an interval of less than 10 weeks between oncoplastic reduction and NSM is feasible, when a shorter interval is important for oncologic reasons. Methods: This is a single institution analysis of patients from 2018 to 2021 with a diagnosis of invasive cancer or ductal carcinoma in situ who underwent NSM after oncoplastic breast reduction for positive margins or nodes. The primary endpoint measured was nipple loss. Secondary outcomes were need for operative re-intervention and wound complications. Results: Nine patients (14 breasts) underwent partial mastectomy with oncoplastic Wise-pattern breast reduction, followed by NSM. Three patients underwent intersurgery chemotherapy. The average interval between oncoplastic reduction and NSM was 11.3 weeks when excluding patients undergoing chemotherapy (range 8-13 weeks). Thirteen breasts (93%) underwent pre-pectoral direct-to-implant reconstruction. One breast (7%) received autologous reconstruction. One breast required reoperation for seroma. The rate of partial or total nipple loss was 0%, with an average follow-up of 1.6 years. Conclusions: Our experience demonstrates excellent outcomes from NSM after oncoplastic breast reduction, with the majority of patients undergoing single-stage pectoral direct-to-implant breast reconstruction. Overall, patients had a shorter intersurgery interval, compared with prior studies, with no cases of nipple loss. An intersurgery interval of 8 weeks may be feasible when avoiding delays is important for oncologic reasons.

The influence of SARS-CoV-2 vaccination on post-operative outcomes in microsurgery patients.

BACKGROUND: The healthcare industry's efforts to immunize the global community against severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) have been unprecedented. Given the fast-tracking of the novel vaccine, its short- and long-term medical implications remain largely to-be-determined in most patient populations. This study aims to analyze 90-day post-operative outcomes in microsurgical patients, who have received or not received SARS-CoV-2-vaccination, using a continuously updated federated electronic medical record network (TriNetX Inc, Cambridge, MA). METHODS: After screening 70 million de-identified records, 16,799 microsurgery patients aged 18-99 meeting medical coding criteria were allocated into two cohorts. Cohort One received SARS-CoV-2-vaccination prior to undergoing microsurgery whereas Cohort Two did not. Two equally sized cohorts, totaling 818 patients were created after propensity score matching for characteristics including: age, race, ethnicity, smoking, hypertension, heart disease, diabetes, obesity, chronic obstructive pulmonary disease, and history of SARS-CoV-2 exposure. Postoperative outcomes within 30-, 60-, and 90-days of microsurgery were analyzed. RESULTS: Patients who were SARS-CoV-2-immunized experienced significantly lower (p < .01) surgical site infections (Absolute Risk Reduction (ARR)[95%CI]) = (3.79%-5.36% [0.84-8.54]) ICU admission (9.47%-9.82%[5.45-13.88]), generalized infections (7.68%-9.92%[3.15-14.64]), and hospitalizations (28.48%-32.57%[20.99-40.13]) within 30-, 60-, and 90-days of microsurgery. Additionally, SARS-CoV-2-vaccinated patients also experienced significantly less flap failure (2.49%[0.97-4.02]) and death (2.46%[0.96-3.97]) within 30- and 60-days post-operatively. CONCLUSION: Our analysis examines the potential protective effect of SARS-CoV-2-vaccination in microsurgical patients. Limitations include the retrospective nature of this analysis and the inherent reliance on medical coding. Future prospective studies are warranted to better understand if in fact pre-operative SARS-CoV-2-vaccination has the potential to protect against post-operative microsurgery outcomes.

Examining the potential benefits of the influenza vaccine against SARS-CoV-2: A retrospective cohort analysis of 74,754 patients.

INTRODUCTION: Recently, several single center studies have suggested a protective effect of the influenza vaccine against severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). This study utilizes a continuously updated Electronic Medical Record (EMR) network to assess the possible benefits of influenza vaccination mitigating critical adverse outcomes in SARS-CoV-2 positive patients from 56 healthcare organizations (HCOs). METHODS: The de-identified records of 73,346,583 patients were retrospectively screened. Two cohorts of 37,377 patients, having either received or not received influenza vaccination six months-two weeks prior to SARS-CoV-2 positive diagnosis, were created using Common Procedural Terminology (CPT) and logical observation identifiers names and codes (LOINC) codes. Adverse outcomes within 30, 60, 90, and 120 days of positive SARS-CoV-2 diagnosis were compared between cohorts. Outcomes were assessed with stringent propensity score matching including age, race, ethnicity, gender, hypertension, diabetes, hyperlipidemia, chronic obstructive pulmonary disease (COPD), obesity, heart disease, and lifestyle habits such as smoking. RESULTS: SARS-CoV-2-positive patients who received the influenza vaccine experienced decreased sepsis (p<0.01, Risk Ratio: 1.361-1.450, 95% CI:1.123-1.699, NNT:286) and stroke (p<0.02, RR: 1.451-1.580, 95% CI:1.075-2.034, NNT:625) across all time points. ICU admissions were lower in SARS-CoV-2-positive patients receiving the influenza vaccine at 30, 90, and 120 days (p<0.03, RR: 1.174-1.200, 95% CI:1.003-1.385, NNT:435), while approaching significance at 60 days (p = 0.0509, RR: 1.156, 95% CI:0.999-1.338). Patients who received the influenza vaccine experienced fewer DVTs 60-120 days after positive SARS-CoV-2 diagnosis (p<0.02, RR:1.41-1.530, 95% CI:1.082-2.076, NNT:1000) and experienced fewer emergency department (ED) visits 90-120 days post SARS-CoV-2-positive diagnosis (p<0.01, RR:1.204-1.580, 95% CI: 1.050-1.476, NNT:176). CONCLUSION: Our analysis outlines the potential protective effect of influenza vaccination in SARS-CoV-2-positive patients against adverse outcomes within 30, 60, 90, and 120 days of a positive diagnosis. Significant findings favoring influenza vaccination mitigating the risks of sepsis, stroke, deep vein thrombosis (DVT), emergency department (ED) & Intensive Care Unit (ICU) admissions suggest a potential protective effect that could benefit populations without readily available access to SARS-CoV-2 vaccination. Thus further investigation with future prospective studies is warranted.

Comparing Surgical Site Occurrences in 1 versus 2-stage Breast Reconstruction via Federated EMR Network.

TriNetX (TriNetX Inc., Cambridge, Mass.) is a federated electronic medical record network. The TriNetX system conducts customized search queries of over 36 million electronic medical records, and returns results in just minutes. To our group's knowledge, TriNetX has not been previously used in plastic surgery research. This study aimed to utilize a continuously updated federated network of 36,000,000 electronic medical records (TriNetX) for comparing 90-day postoperative outcomes between prosthetic breast reconstruction techniques. METHODS: Using TriNetX, we analyzed the records of approximately 36 million patients in 31 health care organizations. The de-identified records of 18,744,519 women (age 18-9) were retrospectively screened. A cohort of 4747 patients with a diagnosis of malignant neoplasm of the breast, any stage, having undergone mastectomy, and breast reconstruction with tissue expander was compared with a second cohort of 870 patients diagnosed with malignant neoplasm of the breast, any stage, mastectomy, and immediate insertion of breast implant following mastectomy. Surgical site occurrences occurring within 90 days postoperatively were compared using propensity score matching. RESULTS: Propensity score matching resulted in 870 patients in both well-balanced cohorts. There were no statistically significant differences between the balanced cohorts with respect to 90-day surgical site occurrences. CONCLUSIONS: TriNetX enables data-driven clinical research such as retrospective cohort comparison. During the 90-day postoperative period, there were fewer complications noted in the single-stage cohort for all outcomes studied; although this comparison was not statistically significant, we believe it demonstrates a clinically significant finding that single-stage direct-to-implant is at least as safe as the more complicated 2-stage approach.

Use of Closed-Incision Negative-Pressure Therapy in Aesthetic Surgery.

BACKGROUND: Recently published studies have demonstrated clinical effectiveness of closed-incision negative-pressure therapy (ciNPT) in many fields of surgery including vascular, cardiac, colorectal, orthopedic, and reconstructive surgery. A review of current literature was conducted to determine whether the application of negative-pressure therapy to closed incisions post aesthetic procedures was beneficial. METHODS: The PubMed/MEDLINE databases were searched for preclinical and clinical studies published through June 2018. Higher quality publications that met the following criteria were included: adult patients undergoing aesthetic or body contouring procedures, comparison of ciNPT with conventional dressings, and documentation of wound complications and/or incision quality. RESULTS: One animal and multiple small, retrospective comparison articles are discussed. Scientific mechanism of action and economic analysis are also discussed. There are no level 1 randomized prospective controlled trials that directly evaluate the effects of ciNPT dressings in cosmetic patients. CONCLUSION: For patients undergoing certain cosmetic procedures, preliminary data support the idea that ciNPT dressings provide aesthetic benefit, but more research is clearly needed.