Improving plastic surgery resident education and quality of care with outcomes feedback using the surgery report card: An initial experience.

BACKGROUND: The practice of tracking and analyzing surgical outcomes is essential to becoming better surgeons. However, this feedback system is largely absent in residency training programs. Thus, we developed a Surgery Report Card (SRC) for residents performing tissue expander (TE)-based breast reconstruction and report our initial experience with its implementation. METHODS: We performed a systematic review and meta-analysis for TE-based breast reconstructions and compared outcomes to our retrospective cohort. The primary outcome was overall complications. The SRC compares patient and complication statistics for resident-led teams to the meta-analysis. RESULTS: The meta-analysis included 12 studies, with 2093 patients (2982 breasts) that underwent TE-based reconstruction. The pooled complication rate was 26.9%; infection was most common (8.3%); failure rate was 5.9%. Our cohort included 144 patients (245 breasts) among 13 resident-led teams. Overall complication rate was 31.8%; infections were most frequent (17.6%) and failure rate was 7.3%. Our cohort had significantly higher BMIs (29.7 vs 25.4, p<0.0001) more diabetics (6.9% vs. 3.2%, p = 0.02), and more patients receiving adjuvant radiation therapy (41.4 vs 26.3%, p<0.0001). Every 3 months, residents receive a customized SRC of their cases, with the meta-analysis used as a benchmark. A survey demonstrated the SRC made residents reconsider surgical technique and more conscientious surgeons, and would like it implemented for other procedures during residency. CONCLUSIONS: The implementation of our SRC for TE-based breast reconstruction establishes a baseline for surgical performance comparison for residents, demonstrates that residents can safely perform the procedure, and allows for critiquing of surgical techniques to improve patient care.

Evaluation of Modifications to Tissue-Expander Breast Reconstruction, a Quality Improvement Assessment Within a Private Practice.

BACKGROUND: As technology advances, surgical practice evolves over time. The author assesses a new approach to implant-based breast reconstruction and the impact of two changes implemented over several years. METHODS: A series of tissue-expander reconstructions performed early in the author's experience were retrospectively compared with a similar number of cases prospectively performed. Demographics, perioperative characteristics, and postoperative outcomes were assessed. RESULTS: Fifty-three patients (87 breasts) were analyzed, 29 treated earlier with one of the early acellular dermal matrices (ADMs) available and 24 current cases using a no-touch operative approach and pliable, perforated ADM. Demographics and perioperative characteristics between the cohorts were comparable. Mean age was 47.6 years, body mass index (BMI) of 25.8 and 18.9% had current or former nicotine use. Immediate reconstruction was performed in 75 (86.2%) breasts. Drains remained in situ 16 ± 8.9 days, with a significantly lower number of days required in latter patients. At a mean follow-up of 9.6 months, complications included early capsular thickening in 7 (13.2%) patients requiring capsulectomy at the second stage exchange surgery, prosthetic (expander) removal in 3 (3.4%) breasts, significant infection requiring intervention in 3 (5.7%) patients, seroma in 3 (5.7%) patients, 2 (3.8%) cases of wound dehiscence, and 1 (1.9%) case of flap necrosis and hematoma. Incomplete ADM incorporation was observed in 9 (10.3%) breasts. Three reconstructive failures occurred in the early cohort. Patients in the later cohort reported significantly improved BREAST-Q scores (P < 0.005) postoperatively with a high level of satisfaction. CONCLUSIONS: Using a no-touch technique and an ADM designed with functional characteristics advantageous to breast reconstructive surgery appears to have improved patient outcomes.

The effect of tissue expansion on the random flap viability and wound tensile strength of previously irradiated rabbit skin.

Tissue expansion facilitates coverage of cutaneous defects both through the generation of additional skin surface area and by increasing random flap length/width viability factors. The opportunity to apply tissue expansion techniques to head and neck defects within previously irradiated skin fields continues to increase. To study the effect of tissue expansion on the cutaneous perfusion and wound-healing capacity of irradiation-damaged skin, rabbit scalps were subjected to 5 weeks of fractionated radiation followed at 4 months by prolonged tissue expansion. Standardized random flaps were then created and reset within the expanded skin and analyzed in parallel with nonirradiated and nonexpanded control animals. Flap viability as expressed by area and mean maximum length was determined at 10 days postwounding followed by determination of wound-breaking strength. Irradiated tissues demonstrated a significantly reduced flap viability that was significantly increased by expansion. However, tissue expansion-related increases in flap length exceeded those expressed as percent of total area surviving for irradiated animals. Tissue expansion resulted in significant increases in wound tensile strength only in nonirradiated animals. These findings suggest that, compared with controls, several of the benefits of tissue expansion are less appreciable in radiation-damaged skin.

[Skin expansion in plastic surgery. (University Hospital Center of Treichville-Abidjan)]. / L'expansion cutanée en chirurgie plastique. (Centre Hospitalier Universitaire de Treichville-Abidjan).

The skin expansion by inflatable prosthesis is a recent method to resolve insufficient tissue a short series of 7 cases. But the authors think that despite these inconveniences this technique needs to be largely diffused and used judiciously.

The use of tissue expansion for immediate breast reconstruction after mastectomy.

A series of 139 patients who had a total mastectomy underwent breast reconstruction using the method of tissue expansion. In 127 patients a tissue expander was inserted at the time of mastectomy and in 12 patients this was done as a delayed procedure. The reconstruction was successfully completed in 87% of cases and the patient acceptance of this method of reconstruction has been high. We believe that tissue expansion should be offered to all women having immediate reconstruction after total mastectomy and that it also has a significant role in delayed breast reconstruction after mastectomy.