The Modified Frailty Index Predicts Major Complications in Oncoplastic Reduction Mammoplasty.

BACKGROUND: An important component of preoperative counseling and patient selection involves surgical risk stratification. There are many tools developed to predict surgical complications. The Modified Frailty Index (mFI) calculates risk based on the following five elements: hypertension, chronic obstructive pulmonary disease, congestive heart failure, diabetes, and functional status. Recent literature demonstrates the efficacy of the mFI across multiple surgical disciplines. We elected to investigate its utility in oncoplastic reductions (OCR). METHODS: A retrospective review of all patients with breast cancer who underwent OCR from 1998 to 2020 was queried from a prospectively maintained database. Patient demographics, comorbidities, and surgical details were reviewed. The mFI was computed for each patient. The primary clinical outcome was the development of complications. RESULTS: 547 patients were included in the study cohort. The average age was 55 and the average body mass index was 33.5. The overall complication rate was 19% (n = 105) and the major complication rate was 9% (n = 49). Higher frailty scores were significantly associated with the development of major complications (P < 0.05). mFI scores of 0 had a major complication rate of 5.7%; scores of 1, 13%; and scores of 2, 15.1%. The relative risk of a major complication in patients with elevated mFI (>0) was 2.2. Age, body mass index, and resection weights were not associated with complications (P = 0.15, P = 0.87, and P = 0.30 respectively) on continuous analysis. CONCLUSIONS: Elevated mFI scores are associated with an increased major complication profile in patients who are undergoing OCR. Hypertension and diabetes are the most common comorbidities in our population, and this tool may assist with preoperative counseling and risk stratification. Benefits of this risk assessment tool include its ease of calculation and brevity. Our study is the first to demonstrate its utility in OCR; however, further study in high-risk patients would strengthen the applicability of this frailty index.

The Impact of Radiation on Nipple Symmetry After Bilateral Nipple-Sparing Mastectomy and Implant-Based Reconstruction: An Objective Analysis.

INTRODUCTION: Radiation therapy can adversely affect outcomes of implant-based breast reconstruction, potentially complicating procedures like nipple-sparing mastectomy (NSM), which is increasingly popular in breast cancer management. This study aims to evaluate the impact of radiation on nipple symmetry in patients undergoing bilateral NSM with implant-based reconstruction. METHODS: We conducted a retrospective analysis using data from an Emory University review board-approved database. This encompassed bilateral NSMs coupled with immediate implant-based reconstructions. The BCCT.core software was employed to objectively measure nipple asymmetry preoperatively and postoperatively. Metrics, such as Breast Retraction Assessment values, upper nipple retraction, lower breast contour, and nipple to midline (NML) discrepancies were quantified. The study included 80 patients with a minimum of 1 year of follow-up; among them, 15 received radiation therapy (RT) while 65 did not. RESULTS: The reconstructions were divided into tissue expander, used in 39 cases (48.8%), and direct-to-implant (DTI), employed in 41 cases (51.2%). The DTIs were further categorized based on the location of the implant: 22 subpectoral and 19 prepectoral. Radiation was applied to 15 breasts, distributed among prepectoral DTI (4), subpectoral DTI (6), and tissue expander (5). Breast Retraction Assessment scores significantly differed between the nonirradiated and irradiated groups (1.49 vs 2.64, P < 0.0004). Nipple to midline differences and Upper Nipple Retraction also significantly varied postradiation, especially when comparing subpectoral and prepectoral implant placements. CONCLUSIONS: Radiation therapy has a detrimental effect on nipple symmetry after bilateral NSM and implant-based reconstruction, with variations seen regardless of the implant's placement or the reconstructive technique utilized. Specifically, subpectoral reconstructions irradiated were prone to lateral nipple displacement, likely related to radiation-induced pectoralis muscle changes, while prepectoral irradiated reconstructions tended to have increased vertical displacement. These insights are crucial for patient education and surgical planning in the context of radiation and breast reconstruction.

Short-term Satisfaction, Psychosocial Impact, and Complication Profile of Reduction Mammaplasty During Adolescence.

BACKGROUND: Reduction mammaplasty is an effective and safe treatment option for adults with symptomatic macromastia, but there are few data regarding outcomes in adolescents. OBJECTIVES: The purpose of this study was to determine the short-term psychosocial impact, satisfaction, and safety of reduction mammaplasty when performed during adolescence. METHODS: A retrospective review was performed of a single pediatric plastic surgeon's experience with reduction mammaplasty from 2018 to 2021 in patients aged ≤18 years. Patients completed the preoperative and postoperative "Satisfaction with Breasts" and "Psychosocial Well-being" sections of the BREAST-Q survey. Clinical variables gathered included age, weight, BMI, complication profile, specimen resection weight, and follow-up duration. RESULTS: In total, 41 patients met inclusion criteria. The mean converted Rasch scores for BREAST-Q "Satisfaction with Breasts" and "Psychosocial Well-being" increased significantly following reduction mammaplasty ("Satisfaction with Breasts": preoperative, 24.1 vs postoperative, 92.6; "Psychosocial Well-being": preoperative, 37.7 vs postoperative, 90.4; P < .001). Obesity (BMI ≥ 30 kg/m2) was associated with lower preoperative "Psychosocial Well-being" scores (obese, 29.7 vs nonobese, 43.3; P < .001) but a greater improvement in score following surgery (obese, +63.9 vs nonobese, +44.9; P < .001). Specimen weight ≥1000 grams was also associated with greater improvement in score on the "Psychosocial Well-being" section (≥1000 grams, +58 vs <1000 grams, +49.7; P = .046). Overall complication rate was 31.7% while the major complication rate was 2.4%. Mean specimen resection weight was higher in patients who experienced complications (1141.3 grams vs 836.8 grams, P = .008). CONCLUSIONS: Reduction mammaplasty during adolescence predictably improves both short-term satisfaction with breasts and psychosocial well-being while demonstrating a favorable short-term complication profile.

Safety and Efficacy of Liposomal Bupivacaine Supraclavicular Nerve Blocks in Open Treatment of Distal Radius Fractures: A Perioperative Pain Management Protocol.

INTRODUCTION: Distal radius fractures (DRFs) are common fractures requiring surgical fixation. The literature varies regarding opioid prescribing habits, opioid consumption, and postoperative pain scores. We hypothesized that the preoperative administration of a liposomal bupivacaine (LB) supraclavicular nerve block would be safe and effective in controlling postoperative pain. METHODS: A standardized pain management protocol was implemented at a single institution from July 2021 to March 2022 for patients undergoing open reduction internal fixation of DRF. Protocol elements included a preoperative LB supraclavicular nerve block and a multimodal postoperative pain regimen. Primary clinical outcomes included postoperative pain scores and number of opioid tablets consumed. RESULTS: Twenty patients underwent a newly implemented protocol. The average age was 56 years. Mean number of oxycodone 5-mg tablets consumed was 4.1 (median, 2.5), and mean visual analog scale pain score at first postoperative appointment was 2.8. There were no incidences of missed acute carpal tunnel postoperatively. When compared with an institutional historical control (n = 189), number of opioid pills prescribed was reduced by 60% (21.4 vs 8.6 tablets, P < 0.0001), and no patients had unscheduled health care contact because of uncontrolled pain (22% vs 0%, P < 0.016). CONCLUSIONS: Liposomal bupivacaine supraclavicular nerve blocks are safe and effective in the treatment of postoperative pain after open reduction internal fixation of DRF. Patients consumed <5 oxycodone tablets on average, which is less than many recommend prescribed quantities (>20-30 tablets). Patients had low pain scores (2.8/10) at the first postoperative follow-up. To our knowledge, this is the first study demonstrating the utility of LB in this clinical setting.

Fold Flaps to the Rescue in Postmastectomy Breast Reconstruction.

SUMMARY: Ischemic complications following postmastectomy breast reconstruction are not uncommon and can lead to reconstructive failure, especially with implant reconstruction. The authors propose a simple local flap for management of such complications. This flap is easily raised from the upper abdomen or lateral chest as a medially or laterally based fasciocutaneous flap, and the donor site is hidden in the inframammary or lateral mammary fold. The authors present a case series of these "fold flaps" that were used to manage complications following implant-based breast reconstruction. All patients between 2007 and 2021 who underwent a fold flap for breast reconstruction salvage were queried from a prospectively maintained database. Demographic variables, clinical factors, and surgical details were analyzed. Outcomes assessed included complications, appropriate wound healing, and reconstructive salvage. Fourteen patients underwent thoracoepigastric or thoracoabdominal fold flaps following breast reconstruction for soft-tissue coverage with an underlying prosthesis. The mean age was 54 years, mean body mass index was 30 kg/m 2 , and mean follow-up duration was 18.5 months. Fold flap indications included mastectomy skin flap necrosis ( n = 9), infection ( n = 4), and chronic seroma ( n = 1). Eleven reconstructions (79%) were salvaged and three (21%) required eventual prosthesis explantation secondary to infection or delayed wound healing. Fold flaps are a reliable option for managing ischemic complications following postmastectomy breast reconstruction. The benefits include improved soft-tissue coverage with a high salvage rate. These flaps are simple to raise, and their donor site is concealed within the folds. Furthermore, they provide a reliable early option to manage complications and potentially prevent reconstructive failure. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Incidence and Outcomes of Completion Mastectomy following Oncoplastic Reduction: A Case Series.

Background: Patients occasionally need completion mastectomy (CM) following oncoplastic reduction for various reasons necessitating definitive reconstructive techniques. The purpose of this study was to evaluate those patients who required CM following oncoplastic reduction and evaluate indications, technique, and outcomes. Methods: Patients who underwent a completion mastectomy at some time point following the oncoplastic reduction were identified. Factors that influenced CM and additional reconstruction were analyzed. All statistical analysis was conducted using the IBM SPSS Statistics 27.0 (IBM Corp.). Results: A total of 29 patients (5.3%) underwent CM during the study period with an average follow-up of 3 years since the original procedure. The most common reasons were positive margins (20/29, 69.0%) and recurrence (8/29, 27.6%). Twenty-two had reconstructive procedures (75.9%) and seven did not (24.1%). The patients who underwent CM and reconstruction were significantly younger (49.2 years) than those who had no reconstruction (64.3 years, P = 0.004). The most common type of reconstruction was transverse rectus abdominis myocutaneous (TRAM)/deep inferior epigastric perforator (DIEP) flap (12/22, 54.5%), followed by latissimus (6/22, 27.3%) and tissue expander (3/22, 13.6%). The complication rate in the CM group was 24% (N = 7/29), which included two seromas (6.9%), followed by infection, fat necrosis, mastectomy skin necrosis, and donor site necrosis (3.4% each). Conclusions: Completion mastectomy is indicated typically for positive margins or recurrence. Reconstruction is performed more frequently in younger patients, with the TRAM/DIEP flap and latissimus dorsi reconstruction being the most common technique.

Secondary Surgeries After Oncoplastic Reduction Mammoplasty.

PURPOSE: The oncoplastic reduction approach is a popular option for women with breast cancer and macromastia. Although the benefits of this approach are numerous, data on the need for secondary surgeries are limited. We evaluated the need for all secondary surgeries after oncoplastic reduction in an attempt to understand the incidence and indications. METHODS: All patients with breast cancer who underwent an oncoplastic breast reduction at the time of the tumor resection were queried from a prospectively maintained database from 1998 to 2020 (n = 547) at a single institution. Secondary surgical procedures were defined as any unplanned return to the operating room. Demographic and clinical variables were analyzed, and secondary surgeries were classified and evaluated. The timing and rates of secondary surgery were evaluated and compared with clinical variables. RESULTS: There were 547 patients included in this series with a mean age of 55 years and body mass index of 33.5. Mean duration of follow-up was 3.8 years. One hundred and seventeen (21%) patients underwent 235 secondary surgeries, with an average of 1.4 operations until stable reconstruction was obtained. The reason for the secondary surgery was involved margins (7.5%), major complications (8.6%), aesthetic improvement (13.3%), and completion mastectomy (5.3%). Age 65 years and younger age was associated with any subsequent procedure (P = 0.023) and revision for cosmesis (P = 0.006). Patients with body mass index greater than 35 had increased secondary surgeries for operative complications (P = 0.026). CONCLUSIONS: Secondary surgeries after oncoplastic breast reduction procedures are common. Management of margins and complications, such as hematoma and infection, are early indications, with aesthetic improvement, wound healing complications, fat necrosis, and recurrence being late reasons. The most common reason for reoperation is aesthetic improvement, especially in younger patients. Attention to surgical technique and patient selection will help minimize secondary surgeries for the nononcological reasons.

Early Experience with External Negative Pressure Delay in Free Anterolateral Thigh Perforator Flap Reconstruction.

Negative pressure therapy has been utilized in the treatment of open and closed wounds to increase blood flow and improve wound healing. More recently, external negative pressure has been shown to induce a noninvasive delay phenomenon in animal models by increasing vessel size and density within a planned flap, leading to improvement in flap survival. Although successful in animal models, this new method of delay has not been demonstrated in clinical practice. We present our initial experience with preoperative external negative pressure delay of free anterolateral thigh flaps in upper extremity reconstruction to detail the technique and safety profile of this innovative new technique. External negative pressure delay has the potential to provide results similar to those of traditional surgical delay, while being cost effective, safer, and more convenient for patients. More research is needed to investigate the clinical benefit and cost effectiveness of external negative pressure delay.

How to Optimize Aesthetics for the Partial Mastectomy Patient.

Aesthetic concern is one of the main driving forces behind the popularity of the oncoplastic approach to breast conservation therapy. Oncoplastic options at the time of lumpectomy include volume replacement techniques such as flaps and volume displacement techniques such as the oncoplastic reduction. These techniques can be employed to ensure preservation of breast shape and contour, size and symmetry, inframammary fold position, and position of the nipple-areola complex. The importance of aesthetic outcomes is not only to improve overall patient satisfaction but also to minimize the need for revisional surgeries for shape and symmetry. The purpose of this review is to discuss ways to optimize the aesthetic result and to review the evidence behind aesthetic outcomes.

Program Director Survey of Aesthetic Plastic Surgery Fellowships in the United States: Current State-of-the-Art.

BACKGROUND: Aesthetic surgery is a core component of plastic and reconstructive surgery. In 2014, the Accreditation Council for Graduate Medical Education established aesthetic surgery minimums for plastic surgery residents in training. Although many plastic surgery graduates successfully enter practice as an attending plastic surgeon after completion of plastic surgery training, others choose subspecialization. Aesthetic surgery fellowships offer further instruction in surgical and nonsurgical aesthetic procedures in addition to a unique opportunity for mentorship. The American Society for Aesthetic Plastic Surgery currently endorses 25 aesthetic fellowships. However, the literature regarding fellowship specifics is lacking. OBJECTIVES: This study aimed to better define the current aesthetic surgery fellowships programs regarding operative experience, fellowship autonomy, program strengths, didactic learning, research experience/opportunities, compensation, and geographic region. METHODS: This study was performed by Emory University, Division of Plastic and Reconstructive Surgery, Atlanta, Georgia. In February 2019, an anonymous survey was sent via e-mail to all American Society for Aesthetic Plastic Surgery-endorsed aesthetic fellowship program directors. Three weeks later, a reminder e-mail was sent. No incentives were provided for survey completion. RESULTS: A 40% survey response rate was achieved (10/25). Aesthetic surgery fellowships are diverse in exposure, number of procedures, and training environment. In all programs, the fellow functioned as the first assistant in most cases. The percentages of face, breast, and total body procedures varied greatly among fellowships, as well as fellow involvement in critical portions of a case. Nearly all fellowships (9/10) offered a fellow's clinic. Didactic learning and research are components of all programs. CONCLUSION: This study provides an overview of the current state of plastic surgery aesthetic fellowships in the United States, serving as the first of its kind.

Mucinous Adenocarcinoma of the Scalp: Primary Cutaneous Neoplasm Versus Underlying Metastatic Disease.

Primary cutaneous mucinous carcinoma (PCMC) is a rare mucin-producing malignancy derived from epithelial glandular structures. The literature regarding this topic is mostly in the form of case reports and case series. PCMC tends to present in the elderly with predilection for the head and neck and on initial assessment it can be easily mistaken for a simple inclusion cyst. Although PCMC is often indolent in nature, in rare instances it can metastasize and should remain a differential diagnosis in a selected population. The significance in identifying PCMC is reliably differentiating it from metastatic mucinous adenocarcinoma. We present a review of literature and case of PCMC on the scalp of a 67-year-old female.