Analysis of Popular Social Media Addressing Breast Augmentation, Implants, and Anaplastic Large Cell Lymphoma.

BACKGROUND: Social media is part of modern life, for better or worse. Patients seek counsel on treatments, their side-effects, and the surgeon performing the surgery. Previous study has found several "dos" and "don'ts" regarding social media. The aim of this study was to specifically look for social media posts addressing breast augmentation, breast implants, and breast implant associated anaplastic large cell lymphoma (BIA-ALCL).The aims of this study were to examine social media posting regarding BIA-ALCL and to analyze the ways general public receive information regarding this disease. METHODS: A prospective analysis of 3 popular, global social media networks was performed, using the key phrase in English "anaplastic large cell lymphoma" or "ALCL" or "#ALCL." Three hundred posts related to breast cancer published on Instagram, YouTube, and Facebook in June 2018 were assessed by the following parameters: author identity, subject, "social media currency" (likes, shares, comments), presence of special effects (videos, photographs, research, etc.). RESULTS: Most posts were posted by professional entity (ie, plastic surgeon, company, or general practitioner), with YouTube being the social media least used by patients (P < 0.001). Facebook was the only social network that had more posts authored by non-professional authors (P < 0.001). Social currency did not change between the professional and non-professional authors. The highest return for investment was seen on Instagram (P < 0.001, "likes" only). YouTube, having the most posts published by professionals, was more positive toward breast augmentation and the use of implants (P < 0.001). CONCLUSIONS: Social media is here to stay and not a trend. It is a tool for the patient when searching for treatment and surgeon. It would be wise to invest and understand these communication platforms, since this is where our patients are, and the way they are researching.

What Is the Color of Your Lymph Node?

We describe a case of tattoo ink in an axillary lymph node, which was observed during an axillary dissection and mastectomy surgery. It is important to be aware of this phenomenon and correctly identify it at the time of surgery, as a misdiagnosis can have serious consequences.

The lateral chest wall: a separate aesthetic unit in breast surgery.

BACKGROUND: The lateral chest wall is an aesthetic unit often overlooked in breast surgery. Abnormalities are often seen in candidates for aesthetic and reconstructive breast surgery and in the massive weight loss population. Preoperative evaluation of the lateral chest wall is necessary to address this area properly. These deformities are intimately associated with the final outcome of any breast operation. METHODS: To better define deformities of the lateral chest wall, a series of 522 patients who had aesthetic or reconstructive breast surgery was reviewed retrospectively. The preoperative and postoperative photographs were evaluated by two surgeons independently. Any surgical approaches used to correct lateral chest wall deformities were documented. RESULTS: In evaluating the lateral chest wall, the authors identified three subunit areas that need to be addressed to maximize aesthetic result: the axilla, the lateral breast, and the chest wall. Deficiency and excess of skin and fat contribute to any deformities in this region; deficiency or excess was found in 39 percent of patients. These deformities, when identified, were surgically addressed in 40 percent of patients, as management strategies included transfer of autologous tissue, fat injection, liposuction, or direct excision. CONCLUSIONS: Lateral chest wall deformities are often found among breast surgery candidates and can affect the final outcome. This area should be treated as a separate aesthetic unit from the breast. Patients with deficiency or excess should be counseled appropriately, as proper treatment may require procedures in addition to the primary breast procedure. The classification system presented can serve as a guideline for management of deformities in this region.

Postoperative Pain Management in DIEP Flap Breast Reconstruction: Identification of Patients With Poor Pain Control.

OBJECTIVE: Adequate control of postoperative pain directly improves patient satisfaction and outcomes, and timely identification of patients with poorly controlled pain is essential. Pain management protocols are best studied in patients recovering from the same operation. In our institution, the postoperative pain regimen for patients undergoing deep inferior epigastric perforator (DIEP) flap breast reconstruction is standardized using patient-controlled analgesia (PCA) followed by conversion to oral narcotics. From this uniform population, we were able to identify a subgroup of patients with poor pain control. METHODS: Over a 44-month period, 179 consecutive patients underwent DIEP flap breast reconstruction with 242 flaps performed. A retrospective chart review recorded PCA usage, visual analog scale pain scores, and length of stay. RESULTS: Pain management with PCA after DIEP flap breast reconstruction was uniformly controlled. Most patients (74.9%) required PCA usage in the first 2 days with conversion to oral analgesics. A subgroup of patients (25.1%) continued to require PCA usage on the third postoperative day. These "nonresponder" patients had a higher visual analog scale score on the first postoperative day, higher total intravenous morphine use, and a longer length of stay (all, P < .05). A multivariate analysis revealed more nonresponders among patients undergoing immediate breast reconstruction (P < .05); however, all other factors analyzed had no correlation. CONCLUSION: We report a subgroup of patients with poor pain control after DIEP flap breast reconstruction. This group of patients required a longer course of pain management and subsequently a longer hospital stay. Pain management protocols that identify these patients promptly can allow for appropriate modifications.

Pedicled perforator flaps: a new principle in reconstructive surgery.

BACKGROUND: In the evolution of flap physiology and reconstruction, there has been a trend of decreased donor-site morbidity. In this article, the chronology of flap reconstruction is discussed, with particular emphasis on the current state of nonmicrosurgical perforator based flaps. METHODS: A literature search was conducted to study the evolution of flap physiology and reconstruction. Using this database, the authors describe the evolution of pedicled perforator flap reconstruction. Various examples of perforator-based flaps are discussed in this article. RESULTS: The literature review identified examples of scenarios where pedicled perforator flaps from various regions of the body are viable options. Several clinical cases are presented with respect to each region. CONCLUSION: Pedicled perforator flaps are a new concept in nonmicrosurgical perforator flap reconstruction.

Sociodemographics, referral patterns, and Internet use for decision-making in microsurgical breast reconstruction.

BACKGROUND: Increasing numbers of patients are choosing to undergo microsurgical breast reconstruction. Currently, no information is available about the sociodemographic profile, referral patterns, or decision-making process of women who choose this reconstructive modality. METHODS: All women who underwent breast reconstruction at a single institution between 2004 and 2007 were surveyed regarding demographic information, referral patterns, and decision-making processes. For data analysis, the cohort was separated by reconstructive method: nonmicrosurgical reconstruction (i.e., implant, latissimus, and pedicled transverse rectus abdominis musculocutaneous flaps) or microsurgical reconstruction (i.e., free transverse rectus abdominis musculocutaneous, deep inferior epigastric artery perforator, superficial inferior epigastric artery, and superior gluteal artery perforator flaps). RESULTS: Overall, 332 women were surveyed, with a response rate of 77 percent. Patients who underwent microsurgical reconstruction were more likely to be 40 to 49 years old (p = 0.014), whereas nonmicrosurgical patients were clustered at the extremes of age. Microsurgery patients self-referred to a reconstructive surgeon, whereas other patients were sent by surgical oncologists (p < 0.001). The Internet was an important decision-making aid to help microsurgery patients identify their reconstructive modality (p < 0.001). Compared with nonmicrosurgical counterparts, microsurgery patients were independent decision-makers and more active in choosing their reconstructive procedure (p = 0.001). CONCLUSIONS: Microsurgical breast reconstruction is highly sought after by a subset of patients with breast cancer. These patients are independent decision-makers in their health care choices. They use the Internet to learn about breast reconstruction techniques and are more likely to self-refer to a reconstructive surgeon. It remains unclear how many patients would choose microsurgical reconstruction if offered more widely or if awareness of the procedure were greater.

Impact of regional referral centers for microsurgical breast reconstruction: the New England perforator flap program experience.

BACKGROUND: Development of new, microsurgical techniques for breast reconstruction has led to more natural and durable reconstruction while minimizing morbidity. Despite these advances, institutions are slow to integrate subspecialized programs because of the additional resources required. In February 2004, our institution developed a microsurgery program for perforator flap breast reconstruction. The purpose of this study is to analyze the impact of this program with attention to reconstruction rates, patient satisfaction, and referral patterns. STUDY DESIGN: A retrospective chart review was performed on all women who had undergone mastectomy or breast reconstruction at our hospital. A total of 1,172 patients were identified between 1999 and 2006. Patients who had breast reconstruction received a validated questionnaire on satisfaction, health-related quality of life, and sociodemographic data. A 75.4% response rate was obtained. RESULTS: Since the program's inception, there has been a significant increase in the immediate reconstruction rate from 51.5% to 63.9% (p < 0.001). Between the two time periods, general patient satisfaction after breast reconstruction increased from 58.5% to 74.4% (p < 0.001), and aesthetic satisfaction increased from 58.5% to 69.9% (p = 0.010). In addition, we have seen a 4.1-fold increase in the number of patients per year from outside institutions for delayed breast reconstruction. CONCLUSIONS: The addition of a perforator flap program for breast reconstruction to accredited cancer centers can increase both patient satisfaction and reconstruction rates. The shift in referral patterns emphasizes the role of breast reconstruction within a regional referral center.

The Maylard incision: a low transverse incision variant seen in DIEP flap breast reconstruction.

A low transverse abdominal incision, most commonly the Pfannenstiel incision, is often used in obstetric and gynecologic surgery. The Maylard low transverse abdominal incision is a rare variant in which the deep inferior epigastric vessels are ligated. This is clinically important and has significant implications for preoperative planning of reconstructive surgery based on these vessels. Four candidates for deep inferior epigastric perforator (DIEP) flap breast reconstruction were identified with a suspected Maylard incision prior to surgery. Preoperative imaging with Duplex ultrasound was important in select cases for identification of vessel patency and direction of flow. Identification of 'high-risk patients allows for appropriate patient counselling and surgical planning.

Autologous fat grafting: a technique for stabilization of the microvascular pedicle in DIEP flap reconstruction.

Proper orientation of the microvascular pedicle is essential to ensure a high success rate in microvascular surgery. The inset of a deep inferior epigastric perforator (DIEP) flap breast reconstruction can sometimes be problematic given the long vascular pedicle, the acute takeoff from an internal mammary anastomosis, and the positioning of the flap on top of the vascular pedicle. In the postoperative period, the flap can also shift as the patient's activity level increases. We present a technique where nonvascularized autologous fat grafts are used to stabilize and cushion the vascular pedicle. Over a 14-month period, 117 consecutive DIEP flaps were performed to the internal mammary vessels with autologous fat grafting to the microvascular pedicle. Six flaps (5.1%) were explored during the immediate postoperative period for anastomotic compromise. Only one total flap failure (0.8%) was observed during this time. We had no direct complications related to the fat grafts. The use of nonvascularized autologous fat grafts is a simple and safe technique for stabilization of a microvascular pedicle. It should be considered in DIEP flap breast reconstruction and other microvascular cases where the vascular pedicle might be compressed by adjacent structures.

Paradoxical venous Doppler signal: a sentinel sign of early venous congestion.

We present a case of early venous congestion in a superior gluteal artery perforator flap for breast reconstruction. The case is unique because the early detection was based on a paradoxical handheld Doppler signal. During reexploration, the vessels were compressed with intermittent obstruction on inspiration. The vessels were repositioned and the flap was salvaged with no further complications. The pathophysiology of this paradoxical sentinel sign is discussed, along with other reasons leading to the outflow obstruction.

Design and impact of an intraoperative pathway: a new operating room model for team-based practice.

BACKGROUND: The concept of a team-based model for delivery of care has been critical at our institution for improving efficiency and safety. Despite these measures, difficulties continue to occur during lengthy operating room procedures. Using a novel team-based practice model, a multidisciplinary team was organized to improve efficiency in microsurgical breast reconstruction. We describe development of an intraoperative pathway for deep inferior epigastric perforator (DIEP) flap breast reconstruction and its impact on various outcomes. STUDY DESIGN: We evaluated 150 patients who underwent DIEP flap breast reconstruction at Beth Israel Deaconess Medical Center from 2005 to 2008. Patient groups were subdivided into 50 unilateral and 50 bilateral procedures before the intraoperative pathway and 25 unilateral and 25 bilateral procedures after. Outcomes measured included operative time, complications, operating room and hospital costs, proper administration of prophylactic antibiotics and heparin, and staff satisfaction surveys. RESULTS: Mean operative times decreased after pathway implementation in both unilateral (8.2 hours to 6.9 hours; p < 0.001) and bilateral groups (12.8 hours to 10.6 hours; p < 0.001) and complication rates were unchanged. Mean operating room costs decreased in the unilateral group by 10.2% (p = 0.018). Prophylactic heparin administration showed substantial improvements, although antibiotic administration and redosing of antibiotics trended upward. Staff surveys showed improved interdisciplinary communication, transition guidelines, and enhanced efficiency through standardization. CONCLUSIONS: Implementation of an intraoperative pathway led to improvements in operative time, cost, quality measures, and staff satisfaction. Refinement of the pathway with team resolution of variances might continue to improve outcomes. Complex, multi-team procedures can derive benefits from standardization and intraoperative pathway development.