Paradigm Shifts in Alloplastic Breast Reconstruction: A Nationwide Analysis of Direct-To-Implant Trends.

BACKGROUND: Direct-to-implant breast reconstruction is an attractive choice for appropriately-selected patients, as a single-stage procedure can enhance global metrics of care. In an era of high-value healthcare, therefore, it is important to investigate utilization of such procedures. This study investigated direct-to-implant trends over the past decade on a nationwide basis. METHODS: This was a retrospective investigation of direct-to-implant reconstruction between 2010-2018 in the United States, using the National Inpatient Sample (NIS) database. All study analyses were undertaken using Stata v15.0. RESULTS: The weighted sample included 287,093 women who underwent implant-based reconstruction between 2010-2018, of whom 43,064 (15%) underwent direct-to-implant reconstruction. Across the study period, the proportion of direct-to-implant procedures significantly increased (p=0.03), relative to staged and delayed implant-based procedures. While direct-to-implant patients were younger, more likely to be white and privately-insured, the proportion of non-white, publicly-insured patients undergoing direct-to-implant reconstruction significantly increased by 2018 (p<0.05). Furthermore, direct-to-implant utilization amongst Medicaid patients increased at 2.2 times the rate in Medicaid expansion states compared to non-expansion states. Direct-to-implant patients had significantly higher APR-DRG risk scores in 2018 than in 2010 (p=0.02), indicating expanding clinical indications for this procedure. Direct-to-implant reconstruction had significantly lower inpatient charges than staged procedures (p=0.03), when considering expander placement and expander-implant exchange. CONCLUSION: Overall, utilization of direct-to-implant breast reconstruction has significantly increased over the past decade, facilitated by expanding clinical indications and improved insurance coverage. However, certain disparities continue to exist. Further work should investigate drivers of disparities to allow continued expansion of direct-to-implant reconstruction as clinically appropriate.

Examining the Effects of Postmastectomy Radiation Therapy in Prepectoral Versus Subpectoral Autologous Breast Reconstruction.

BACKGROUND: Postmastectomy radiation therapy (PMRT) is known to increase the risk of multiple adverse outcomes after breast reconstruction. In the context of delayed-immediate autologous breast reconstruction, PMRT is typically conducted after placement of subpectoral (SP) tissue expanders. With the re-emergence of prepectoral (PP) reconstruction, there are little data assessing the outcomes of PP reconstruction in breasts receiving PMRT. We compared postoperative outcomes of PMRT patients undergoing delayed-immediate, autologous breast reconstruction with placement of tissue expanders in either the PP or SP plane. METHODS: A retrospective chart review was conducted on all consecutive patients who underwent delayed-immediate autologous breast reconstruction and received PMRT at either the Stanford University or the Johns Hopkins University Hospitals between January 2009 and December 2018. Demographics, comorbidities, perioperative information, and oncologic data were collected for all patients. Complications were collected and analyzed after stage 1 surgery, between 30 days of stage 1 and up to stage 2 surgery, and after stage 2 surgery. Multivariable regressions were used to determine predictors of 1 or more complications. RESULTS: A total of 71 patients (73 breasts) were included. Prepectoral reconstruction comprised of 52.2% of the cohort, and the remaining 47.8% were SP reconstructions. Demographics and comorbidities were similar between groups, except for premastectomy radiation, which was more prevalent in the PP cohort (P = 0.010). Complications were similar between cohorts after stage 1 surgery (P = 0.420), between stages 1 and 2 (P = 0.100), and after stage 2 (P = 0.570). There were higher rates of skin necrosis in the SP cohort between stages 1 and 2 (PP: 2.6%, SP: 20%, P = 0.004). Multivariable analysis revealed body mass index to be the only predictor of complication (P = 0.041). The mean number of revisionary surgeries was higher in the SP cohort (PP: 0.8 vs SP: 1.9, P = 0.002). The mean follow-up was 385.5 days and similar between groups (P = 0.870). CONCLUSIONS: Rates of overall complication were similar between PP and SP expander placement. However, in SP reconstructions, skin necrosis was significantly higher between stages 1 and 2. The patients in the SP cohort also underwent a greater number of revisionary surgeries, although overall rates of pursuing any revisionary surgery were similar between groups.

Revision Rates in Prepectoral Versus Subpectoral Delayed-Immediate Autologous Breast Reconstruction.

INTRODUCTION: Breast reconstruction in the prepectoral plane has recently fallen into favor. Minimizing the number of revisionary procedures after reconstruction is an important factor in improving patient care, but long-term studies on the effects of prepectoral reconstruction are limited. In this study, we compare the revision rates after delayed-immediate, autologous reconstruction between prepectoral and subpectoral reconstructions. METHODS: Postoperative charts for all patients undergoing subpectoral or prepectoral delayed-immediate autologous breast reconstruction were retrospectively reviewed at our single tertiary-care institution between 2009 and 2018. Patient demographics, comorbidities, and oncologic history were recorded. Charts after second stage reconstruction were reviewed for up to eighteen months to determine if revisions were necessary. Data collected included the total number of surgeries performed, the average number of procedures performed during each surgery, and the type of revision that was performed. Statistical tests included the chi squared test, unpaired t-test, and logistic regressions. RESULTS: Data from 89 patients with 125 breast reconstructions were collected. There was a 41.6% of these that were prepectoral reconstructions (P), and 58.4% were subpectoral reconstructions (S). For both groups, nipple sparing, followed by skin sparing mastectomies were most common. Mastectomy rates were not statistically different. Fewer breasts in the prepectoral cohort required any revisions (P, 21.2% vs S, 47.9%; P = 0.002). The subpectoral cohort had higher rates of soft tissue rearrangement (P, 7.7% vs S, 21.9%, P = 0.032), fat grafting (P, 9.6% vs S, 27.4%; P = 0.014), and nipple reconstruction (P: 5.8% vs 20.5%, P = 0.020). Mean follow-up time was not significantly different between patient groups (P, 290.5 days vs S, 375.0 days, P = 0.142). Subpectoral expander placement was found to be the only variable independently predictive of requiring 1 or more revision (P = 0.034). CONCLUSIONS: Breast reconstruction performed in the prepectoral plane is associated with lower overall rates of revisionary surgery. Rates of soft tissue rearrangement, fat grafting, and nipple reconstruction after autologous reconstruction trended higher in subpectoral reconstructions.

The safety and efficacy of autologous fat grafting during second stage breast reconstruction.

BACKGROUND: Patients often pursue revisions following implant-based breast reconstruction (IBR) to achieve their desired result. Fat grafting is a popular choice for patients and can be performed at second stage reconstruction or at a future date as a revisionary surgery. We investigate the best time to fat graft in IBR by comparing the outcomes of patients who received fat grafting during implant placement with those who pursued fat grafting during a tertiary procedure. METHODS: We retrospectively reviewed the charts of 157 patients (270 breasts) who underwent immediate two-stage IBR and fat grafting over a five-year period (2012-2016) at our institution. Two cohorts were created based on timing of first fat grafting procedure: immediate (IFG) and delayed (DFG). Charts were reviewed for postoperative complications or revisions. RESULTS: Complication rates were lower when fat grafting was performed during the second stage (p = 0.0331). Patients in the DFG cohort required more than one additional revision (p < 0.001) until the completion of reconstruction. Patients in the IFG cohort completed their reconstruction and revisions more than one year earlier than the DFG cohort (p < 0.001). Multivariable regressions showed IFG to be associated with decreased revisions (p < 0.001) and total fat grafting procedures (p = 0.008). CONCLUSIONS: These results indicate that fat grafting at the second stage does not increase overall complication rates, require fewer additional surgeries, and enables patients to reach their desired aesthetic appearance in a shorter time frame. Fewer total surgeries translate not only to a more economical option but also obviate the risk of complications that come with additional surgeries.

Simplified Lateral Brow Lift under Local Anesthesia for Correction of Lateral Hooding.

BACKGROUND: A limited incision lateral brow lift has been described as an alternative to the endoscopic or the bicoronal approaches. The senior author has developed a safe and effective lateral brow lift technique that can be performed in an office setting under local anesthesia. METHODS: We retrospectively reviewed 150 consecutive patients who underwent a brow lift by the senior author (TAM). The technique begins with an upper blepharoplasty incision which is used to divide the corrugator under direct vision, followed by a release of the periorbital retaining ligaments. The lateral temporal incision is the access point for dissection above the deep temporal fascia then connecting to the subperiosteal plane, allowing full mobility of the brow. Galea is advanced with sutures and redundant skin is excised. RESULTS: All patients treated with this technique had resolution of lateral brow hooding. Two temporary neuropraxias of the frontal branch of the facial nerve were observed with full resolution and no permanent nerve injuries occurred. The revision rate was 7% and there was a 3% incidence of delayed wound healing at the temporal incision with no infections. One hundred forty-two patients (97%) underwent this procedure with sedation, 52 of which (35%) were in the office with light oral sedation. CONCLUSIONS: The limited incision lateral brow lift as described allows for safe elevation of the lateral brow. When complemented by upper blepharoplasty, this technique provides excellent and natural-appearing rejuvenation of the upper face.

Targeted Muscle Reinnervation Treats Neuroma and Phantom Pain in Major Limb Amputees: A Randomized Clinical Trial.

OBJECTIVE: To compare targeted muscle reinnervation (TMR) to "standard treatment" of neuroma excision and burying into muscle for postamputation pain. SUMMARY BACKGROUND DATA: To date, no intervention is consistently effective for neuroma-related residual limb or phantom limb pain (PLP). TMR is a nerve transfer procedure developed for prosthesis control, incidentally found to improve postamputation pain. METHODS: A prospective, randomized clinical trial was conducted. 28 amputees with chronic pain were assigned to standard treatment or TMR. Primary outcome was change between pre- and postoperative numerical rating scale (NRS, 0-10) pain scores for residual limb pain and PLP at 1 year. Secondary outcomes included NRS for all patients at final follow-up, PROMIS pain scales, neuroma size, and patient function. RESULTS: In intention-to-treat analysis, changes in PLP scores at 1 year were 3.2 versus -0.2 (difference 3.4, adjusted confidence interval (aCI) -0.1 to 6.9, adjusted P = 0.06) for TMR and standard treatment, respectively. Changes in residual limb pain scores were 2.9 versus 0.9 (difference 1.9, aCI -0.5 to 4.4, P = 0.15). In longitudinal mixed model analysis, difference in change scores for PLP was significantly greater in the TMR group compared with standard treatment [mean (aCI) = 3.5 (0.6, 6.3), P = 0.03]. Reduction in residual limb pain was favorable for TMR (P = 0.10). At longest follow-up, including 3 crossover patients, results favored TMR over standard treatment. CONCLUSIONS: In this first surgical RCT for the treatment of postamputation pain in major limb amputees, TMR improved PLP and trended toward improved residual limb pain compared with conventional neurectomy. TRIAL REGISTRATION: NCT02205385 at ClinicalTrials.gov.

Striking a Better Integration of Work and Life: Challenges and Solutions.

Plastic surgeons are a diverse group but share a drive for excellence and dedication to their patients and the advancement of the specialty. Long hours at work and the need to be on call have limited the time that many have to spend on activities outside of the workplace. Reconciliation of the demands of surgery and private life can at times seem impossible. A failure to achieve balance between work and home life is associated with reduced job and life satisfaction, impaired mental health, family conflict, and ultimately burnout. Although the obstacles are many and varied, the authors have attempted to identify the challenges and propose solutions. The authors focus on women in plastic surgery in this article, but acknowledge that these issues are not unique to women or plastic surgery.

Open repair of incisional ventral abdominal hernias with mesh leads to long-term improvement in pain interference as measured by patient-reported outcomes.

BACKGROUND: The Patient-Reported Outcomes Measurement Information System was used to evaluate the effects of open incisional ventral hernia repair on hernia-related pain. METHODS: All patients who underwent elective repair of a primary or recurrent midline incisional hernia over a 3-year period completed Patient-Reported Outcomes Measurement Information System pain surveys and rated their pain intensity on a visual analogue scale. A retrospective review of these patients was performed. RESULTS: Seventy-seven patients underwent midline incisional ventral hernia repair and completed preoperative and postoperative surveys. Thirty-eight patients completed surveys at least 6 months after surgery. These patients demonstrated significant improvement in pain interference postoperatively (P < .05) but not in pain behavior. Patients with higher pain intensity scores preoperatively had greater improvements in pain behavior and pain interference postoperatively. CONCLUSIONS: Patients with incisional ventral hernias have improvement in pain interference 6 months after open surgical repair. Changes are most pronounced in patients who experience higher magnitudes of pain preoperatively.

Resolution of Cosmetic Buttock Injection-induced Inflammatory Reaction and Heart Failure after Excision of Filler Material.

We present a case of a 66-year-old woman who developed heart failure and severe inflammatory reaction after the illicit cosmetic injections of polymethyl-methacrylate or polyacrylamide hydrogel from a primary care provider. After medical optimization, an en bloc excision of all injectable materials and gluteus muscle was performed, which resulted in exposure of bilateral sciatic nerves. Within 10 days, the patient's heart failure resolved and inflammatory state improved. This is the first known report of heart failure due to buttock injections and subsequent improvement after surgery.

Treatment of Foot and Ankle Neuroma Pain With Processed Nerve Allografts.

BACKGROUND: Localized nerve pain in the foot and ankle can be a chronic source of disability after trauma and has been identified as the most common complication following operative interventions in the foot and ankle. The superficial location of the injured nerves and lack of suitable tissue for nerve implantation make this pain refractory to conventional methods of neuroma management. We describe a novel strategy for management using processed nerve allografts to bridge nerve gaps created by resection of both end neuromas and neuromas-in-continuity. METHODS: A retrospective review of a prospectively maintained database was performed of all patients who received a processed nerve allograft for treatment of painful neuromas in the foot and ankle between May 2010 and June 2015. Patient demographic and operative information was obtained, as well as preoperative and postoperative pain assessments using a conventional ordinal scale and PROMIS (Patient Reported Outcomes Measurement Information System) Pain Behavior and Pain Interference assessments. Twenty-two patients were identified, with postoperative pain assessments occurring at a mean of 15.5 months after surgery. RESULTS: Neuromas of the sural and superficial peroneal nerves were the most common diagnoses, with 3-cm nerve allografts being used as the interposition graft in the majority of cases. Eight patients had end neuromas and 18 patients had neuromas in continuity. Analysis of paired data demonstrated a mean ordinal pain score decrease of 2.6, with 24 and 31 percentage-point decreases in PROMIS Pain Behavior and Pain Interference measures, respectively. All changes were significant (P < .002). CONCLUSION: The painful sequelae of superficial nerve injuries in the foot and ankle was significantly improved with complete excision of the involved nerve segment followed by bridging of the resulting nerve gap with a processed nerve allograft. This approach limits surgery to the site of injury and reconstitutes the peripheral nerve anatomy. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Prospective repair of Ventral Hernia Working Group type 3 and 4 abdominal wall defects with condensed polytetrafluoroethylene (MotifMESH) mesh.

BACKGROUND: Treatment of clean-contaminated and contaminated ventral hernia defects remains controversial. Newer prosthetic materials may play an important role in these patients. METHODS: Ten patients with Ventral Hernia Working Group types 3 and 4 were prospectively enrolled and subsequently treated with direct supported repairs with condensed fenestrated polytetrafluoroethylene mesh. The primary outcome was hernia occurrence at 1 year after surgery. Secondary outcomes included surgical site infection, surgical site occurrence, medical complications, pain, and other patient-reported outcomes. RESULTS: There were no immediate postoperative infections and one minor postoperative hematoma treated in the office. One patient required delayed mesh removal 9 months after placement. Importantly, the mesh removal procedure was straightforward because of the material properties of the mesh. Of the 9 patients still with mesh, there were no hernia recurrences at the repair site with one full year of follow-up. CONCLUSION: Contaminated and clean-contaminated abdominal wall defects can be effectively and durably treated with condensed polytetrafluoroethylene mesh.

Targeted muscle reinnervation and advanced prosthetic arms.

Targeted muscle reinnervation (TMR) is a surgical procedure used to improve the control of upper limb prostheses. Residual nerves from the amputated limb are transferred to reinnervate new muscle targets that have otherwise lost their function. These reinnervated muscles then serve as biological amplifiers of the amputated nerve motor signals, allowing for more intuitive control of advanced prosthetic arms. Here the authors provide a review of surgical techniques for TMR in patients with either transhumeral or shoulder disarticulation amputations. They also discuss how TMR may act synergistically with recent advances in prosthetic arm technologies to improve prosthesis controllability. Discussion of TMR and prosthesis control is presented in the context of a 41-year-old man with a left-side shoulder disarticulation and a right-side transhumeral amputation. This patient underwent bilateral TMR surgery and was fit with advanced pattern-recognition myoelectric prostheses.

Simultaneous prosthetic mesh abdominal wall reconstruction with abdominoplasty for ventral hernia and severe rectus diastasis repairs.

BACKGROUND: Standard abdominoplasty rectus plication techniques may not suffice for severe cases of rectus diastasis. In the authors' experience, prosthetic mesh facilitates the repair of severe rectus diastasis with or without concomitant ventral hernias. METHODS: A retrospective review of all abdominal wall surgery patients treated in the past 8 years by the senior author (G.A.D.) was performed. Patients with abdominoplasty and either rectus diastasis repair with mesh or a combined ventral hernia repair were analyzed. RESULTS: Thirty-two patients, 29 women and three men, underwent mesh-reinforced midline repair with horizontal or vertical abdominoplasty. Patient characteristics included the following: mean age, 53 years; mean body mass index, 26 kg/m; average width of diastasis or hernia, 6.7 cm; and average surgery time, 151 minutes. There were no surgical-site infections and two surgical-site occurrences-two seromas treated with drainage in the office. After an average of 471 days' follow-up, none of the patients had recurrence of a bulge or a hernia. CONCLUSIONS: For patients with significant rectus diastasis, with or without concomitant hernias, the described mesh repair is both safe and durable. Although this operation requires additional dissection and placement of prosthetic mesh in the retrorectus plane, it may be safely combined with standard horizontal or vertical abdominoplasty skin excision techniques to provide an aesthetically pleasing overall result. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Targeted muscle reinnervation in the initial management of traumatic upper extremity amputation injury.

Targeted muscle reinnervation (TMR) was initially designed to provide cortical control of upper limb prostheses through a series of novel nerve transfers. Early experience has suggested that TMR may also inhibit symptomatic neuroma formation. We present the first report of TMR performed at the time of a traumatic shoulder disarticulation. The procedure was done to prevent painful neuroma pain and allow for myoelecteric prosthetic use in the future. Eight months post-operatively, the patient demonstrates multiple successful nerve transfers and exhibits no evidence of neuroma pain on clinical exam. Using the Patient Reported Outcomes Measurement Information System (PROMIS), the patient demonstrates minimal pain interference or pain behavior. Targeted muscle reinnervation may be considered in the acute trauma setting to prevent neuroma pain and to prepare patients for myoelectric prostheses in the future.

Targeted muscle reinnervation: a novel approach to postamputation neuroma pain.

BACKGROUND: Postamputation neuroma pain can prevent comfortable prosthesis wear in patients with limb amputations, and currently available treatments are not consistently effective. Targeted muscle reinnervation (TMR) is a decade-old technique that employs a series of novel nerve transfers to permit intuitive control of upper-limb prostheses. Clinical experience suggests that it may also serve as an effective therapy for postamputation neuroma pain; however, this has not been explicitly studied. QUESTIONS/PURPOSES: We evaluated the effect of TMR on residual limb neuroma pain in upper-extremity amputees. METHODS: We conducted a retrospective medical record review of all 28 patients treated with TMR from 2002 to 2012 at Northwestern Memorial Hospital/Rehabilitation Institute of Chicago (Chicago, IL, USA) and San Antonio Military Medical Center (San Antonio, TX, USA). Twenty-six of 28 patients had sufficient (> 6 months) followup for study inclusion. The amputation levels were shoulder disarticulation (10 patients) and transhumeral (16 patients). All patients underwent TMR for the primary purpose of improved myoelectric control. Of the 26 patients included in the study, 15 patients had evidence of postamputation neuroma pain before undergoing TMR. RESULTS: Of the 15 patients presenting with neuroma pain before TMR, 14 experienced complete resolution of pain in the transferred nerves, and the remaining patient's pain improved (though did not resolve). None of the patients who presented without evidence of postamputation neuroma pain developed neuroma pain after the TMR procedure. All 26 patients were fitted with a prosthesis, and 23 of the 26 patients were able to operate a TMR-controlled prosthesis. CONCLUSIONS: None of the 26 patients who underwent TMR demonstrated evidence of new neuroma pain after the procedure, and all but one of the 15 patients who presented with preoperative neuroma pain experienced complete relief of pain in the distribution of the transferred nerves. TMR offers a novel and potentially more effective therapy for the management of neuroma pain after limb amputation.

Staged management of the open abdomen and enteroatmospheric fistulae using split-thickness skin grafts.

BACKGROUND: Management of the open abdomen with polyglactin 910 mesh followed by split-thickness skin grafts allows safe, early closure of abdominal wounds. This technique can be modified to manage enteroatmospheric fistulae. Staged ventral hernia is performed in a less inflamed surgical field. METHODS: A retrospective review was performed of 59 consecutive patients who underwent abdominal skin grafting for open abdominal wounds from 2001 to 2011. RESULTS: The median length of follow-up was 215 days. Thirty-one percent of patients presented with preexisting enteroatmospheric fistulae, and 41% required polyglactin 910 mesh placement before skin grafting. Partial or complete skin graft failure occurred in 7 patients. Four patients required repeat skin grafting. All patients ultimately achieved abdominal wound closure, and none developed de novo fistulae. CONCLUSIONS: With proper technique, skin grafting of the open abdomen with a planned ventral hernia repair is a safe and effective alternative to delayed primary closure.

Can balloon aortic valvuloplasty help determine appropriate transcatheter aortic valve size?

OBJECTIVES: We sought to study the potential role of balloon aortic valvuloplasty (BAV) in sizing the aortic annulus in patients before transcatheter heart valve (THV) implantation. BACKGROUND: Despite clinicians' growing experience with THV procedures, the best method of annulus sizing remains unclear. METHODS: Twenty-three patients with aortic stenosis (<1.0 cm(2)) who were undergoing surgical valve replacement were enrolled. Pre-operative echocardiographic measurements of the annulus and computed tomography measurements of valve calcium were made. Intraoperatively, a valvuloplasty balloon of known size and inflatable pressure was inserted into the aortic valve and inflated. The development of intraballoon pressure in addition to the nominal inflation pressure (AIBP) reflected the apposition of balloon and valve. Surgical annulus was measured by cylindrical sizers. RESULTS: In patients with tricuspid valves, AIBP was generated in 11 of 12 patients when the balloon diameter was greater than the surgically measured annulus, regardless of leaflet calcification (2 of 10 patients when balloon < or = surgical annulus). In bicuspid valves, high AIBP ( approximately 1 atm) was encountered with balloons that were within 1 mm of annulus size, and leaflet dehiscence occurred with larger balloons (n = 2 patients). Annulus size was underestimated by transthoracic echocardiogram and transesophageal echocardiogram compared with surgery (p < 0.001): transthoracic echocardiogram = 21.5 +/- 1.8 mm, transesophageal echocardiogram = 22.0 +/- 1.6 mm and surgical = 23.2 +/- 1.9 mm (range 20 to 27 mm, mode 22 mm). CONCLUSIONS: These data suggest that measuring AIBP during balloon aortic valvuloplasty in tricuspid valves is an important adjunctive measurement of the aortic annulus and may help in determining the appropriate THV size.