Has the Increase of Women in Surgical Training Programs Led to a Concomitant Increase in Female Leadership Positions? A 10-Year Analysis.

INTRODUCTION: Women represent greater than 50% of medical students in America and are becoming increasingly well represented in surgical fields. However, parity at the trainee level has yet to be accomplished, and surgical leadership positions have remained disproportionately biased toward men. To date, there have been no comparisons on the progress within plastic surgery and other surgical specialties. This investigates the gender disparity in resident and leadership representation over the past 10 years within surgical specialties and how these disparities compare to plastic surgery. METHODS: Counts of female and male residents and surgical society leaders were collected from 2008 to 2018. Surgical fields included plastic, vascular, urologic, neurologic, orthopedic, cardiothoracic, and general surgery. Leadership positions were defined as board seats on executive committees of major surgical societies or board associations. Data were acquired from publicly available sources or provided directly from the organizations. Resident data were obtained from the Accreditation Council of Graduate Medical Education residents' reports. Individuals holding more than 1 leadership position within a year were counted only once. RESULTS: In our aggregated analysis, the proportion of women in surgical leadership lags behind women in surgical residency training across all specialties (13.2% vs 27.3%, P < 0.01). General surgery had the highest proportion of female residents and leaders (35% and 18.8%, P < 0.01), followed by plastic (32.2% and 17.3%, P < 0.01), vascular (28.2% and 11.3%, P < 0.01), urologic (24.3% and 5.1%), and cardiothoracic surgery (20.5% and 7.8%, P < 0.01). Women in surgical leadership, however, increased at a faster rate than women in surgical training (11% vs 7%, P < 0.05). Plastic surgery showed the greatest rate of increase in both residents and leaders (17% and 19%, P < 0.05) followed by cardiothoracic surgery (16% and 9%, P < 0.05) and general surgery (8% and 14%, P < 0.05). For neurologic and orthopedic surgery, neither the difference in proportions between residents and leaders nor the yearly growth of these groups were significant. CONCLUSIONS: Between 2008 and 2018, women in plastic surgery training and leadership positions have shown the most significant growth compared with other surgical subspecialties, demonstrating a strong concerted effort toward gender equality among surgical professions.

Reconstructive Trends After Tissue-Expander Loss in Breast Reconstruction.

PURPOSE: Tissue-expander breast reconstruction (TEBR) is a common method of reconstruction after mastectomy but may result in complications that may necessitate removal. Although complications in TEBR have been well studied, there is a paucity of data regarding outcomes after tissue-expander loss. In this study, we examine the eventual reconstructive pathways and associated factors of patients who required tissue-expander removal after infection. METHODS: This retrospective study examines patients undergoing breast reconstruction at a single institution. Patients included underwent mastectomy, immediate TEBR, and subsequent tissue-expander loss. Patients who underwent autologous reconstruction after mastectomy or had successful TEBR were excluded. Patients were followed for an average of 7 years, with a minimum of 2 years and a maximum of 13 years. RESULTS: A total of 674 TEBR patients were initially screened, of which 60 patients (8.9%) required tissue-expander removal because of infection or skin necrosis. Thirty-one of these patients (group 1) did not complete reconstruction after initial tissue-expander loss, whereas the remaining 29 patients (group 2) underwent either TEBR or autologous reconstruction after tissue-expander loss. Group 1 had a significantly higher mean body mass index than group 2 (32.61 ± 8.88 vs 28.69 ± 5.84; P = 0.049) and also lived further away from our institution than group 2 (P = 0.052), which trended toward significance. There were otherwise no significant differences in demographics between the 2 groups.Among the 29 patients in group 2, 18 patients underwent a second TEBR (group 2a), and 11 patients underwent autologous reconstruction (group 2b). Patients in group 2b had a significantly greater mean number of complication related admissions (1.11 ± 0.323 vs 1.55 ± 0.688; P = 0.029) and also had higher occurrence of postmastectomy radiation therapy (16.7% vs 45.5%; P = 0.092), although this was not significant. There were otherwise no differences between the 2 groups. CONCLUSION: Our data demonstrate the trends in breast reconstruction decision making after initial tissue-expander loss. This study elucidates the factors associated with patients who undergo different reconstructive options. Further work is needed to delineate the specific reasons between the decision to pursue different reconstructive pathways among a larger cohort of patients.

Clinical Outcomes After Hematoma Development: A Study of 627 Tissue Expander Breast Reconstructions.

BACKGROUND: Hematomas after tissue expander immediate breast reconstruction (TE-IBR) pose a significant challenge during the recovery period. In this study, we aim to evaluate whether hematoma formation leads to subsequent complications and how management can impact final reconstructive goals. METHODS: A single-institution retrospective review of TE-IBRs from 2001 to 2018 was performed using an established breast reconstruction database. Demographics, medications, comorbidities, and complications were identified. Implant loss was defined as removal of the tissue expander/implant without immediate reimplantation during that operation. Hematoma size, management, transfusion requirement, reoperations, and final outcome were recorded. Reconstructive failure was defined as an implant loss that was not replaced with another implant or required secondary autologous reconstruction. RESULTS: Six hundred twenty-seven TE-IBR patients were analyzed. Postoperative hematoma (group 1) occurred in 4.1% (n = 26) of TE-IBRs and did not develop in 95.9% (group 2: n = 601). Group 2 had a higher mean body mass index (24.5 vs 27.3 kg/m, P = 0.018); however, there were no significant differences in smoking status, preoperative/postoperative radiation/chemotherapy, or other comorbidities. Group 1 was found to have increased rates of implant loss (15.4% vs 3.7%, P = 0.0033) and reconstructive failure (11.5% vs 2.8%, P = 0.0133) compared with group 2.Eighteen hematomas (69.2%) underwent surgical intervention (group 1a) compared with 30.8% (n = 8) that were clinically managed (group 1b). Group 1a had statistically significant lower rates of subsequent complications (22.2% vs 62.5%, P = 0.046) and reoperations (5.6% vs 27.5%, P = 0.037) than did group 1b, respectively.Lastly, 23.1% (n = 6) of patients who developed a hematoma were on home antithrombotics (group 1c) compared with 76.9% (n = 20) of patients with no antithrombotics (group 1d). There were statistically significant differences in transfusion rates (50% vs 0%, P = 0.001) between groups 1c and 1d, respectively. Differences in hematoma volume (330 vs 169.3 mL, P = 0.078) and reconstructive failure (33.3% vs 5%, P = 0.057) approached significance between both groups. CONCLUSIONS: Hematoma after TE-IBR should be monitored closely, as it may play a role in jeopardizing reconstruction success. Patients on home antithrombotic medication may be at increased risk of larger-volume hematomas and reconstruction failure. Plastic surgeons should consider aggressive surgical evacuation of postoperative TE-IBR hematomas to reduce subsequent complications and reoperations, thus optimizing reconstructive outcomes.

Do Postoperative Prophylactic Antibiotics Reduce Highly Virulent Infections?: An Analysis of 660 Tissue Expander Breast Reconstructions.

BACKGROUND: Many surgeons are reluctant to discontinue prophylactic antibiotics after 24 hours in tissue expander breast reconstruction (TEBR) because of fear of increased risk of surgical site infection (SSI). Currently, there is no consensus regarding antibiotic prophylaxis duration in TEBR. In addition, there remains a lack of research investigating microorganisms involved in SSI across various perioperative antibiotic protocols. The purpose of this study was to examine how 2 different prophylactic antibiotic regimens impacted the bacterial profiles of SSI and rate of implant loss after TEBR. METHODS: A single-institution retrospective review of immediate TEBRs between 2001 and 2018 was performed. Surgical site infections requiring hospitalization before stage 2 were included. Highly virulent organisms were defined as ESKAPE pathogens (Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, Enterobacter species). Implant loss was defined as removal of tissue expander without immediate replacement. RESULTS: Of 660 TEBRs, 85 (12.9%) developed an SSI requiring hospitalization before stage 2. Fifty-six (65.9%) received less than 24 hours of perioperative intravenous antibiotics and oral antibiotics after discharge (group 1), and 29 (34.1%) received less than 24 hours of intravenous antibiotics only (group 2). There was no significant difference in demographics, preoperative chemotherapy/radiation, acellular dermal matrix usage, or treatment of SSI between groups. In group 1, 64% (n = 36) developed culture positive SSIs, compared with 83% (n = 24) in group 2 (P = 0.076). Staphylococcus aureus was the most common bacteria in both groups. Group 2 demonstrated a significantly increased incidence of gram-positive organisms (46.4% vs 72.4%, P = 0.022) and S. aureus (21.4% vs 55.2%, P = 0.002). However, there was no significant difference in overall highly virulent (P = 0.168), gram-negative (P = 0.416), or total isolated organisms (P = 0.192). Implant loss between groups 1 and 2 (62.5% vs 62.1%, P = 0.969) respectively, was nearly identical. CONCLUSIONS: Our study demonstrates that, despite differences in bacterial profiles between 2 antibiotic protocols, prolonged postoperative antibiotic use did not protect against overall highly virulent infections or implant loss. Antibiotic stewardship guidelines against the overuse of prolonged prophylactic regimens should be considered. Further analysis regarding timing of SSIs and antibiotic treatment is warranted.