Supporting Women's BIA-ALCL Decision-making: Role of the Individual Consult in Empowering the Patient-Physician Team.

BACKGROUND: Breast implant associated anaplastic large cell lymphoma (BIA-ALCL) is a T-cell non-Hodgkin's lymphoma and an uncommon risk of textured breast implants. Over the past decade, concern about BIA-ALCL has been increasing among both patients and surgeons. Patients are seeking a better understanding of their BIA-ALCL risk toward identifying a personalized care plan. This quality improvement project examines the value added by pairing group-based patient education seminars with one-on-one consults. METHODS: Individual consults were held following educational group seminars. Consult field notes underwent qualitative thematic analysis. Themes were cross referenced against a quantitative chart review of patient BIA-ALCL prophylaxis decisions over time. RESULTS: Four key themes were identified: weighing, perceiving, guiding, and supporting. Weighing considers the risk-benefit assessments patients make when weighing their BIA-ALCL risk. Perceiving describes the underlying psychosocial factors that frame patient perceptions of BIA-ALCL risk. Guiding presents the levels of guidance that patients require when making BIA-ALCL prophylaxis decisions. Supporting explores the therapeutic value of the individual consult. Ultimately, 41% of post-seminar consult attendees sought explantation, compared with 4% among patients who did not participate in this program (P < 0.001). CONCLUSIONS: Key lessons include the following: (1) patients weigh BIA-ALCL risk against perceived surgical risks and the value of their reconstruction; (2) patients can benefit from a personalized balance of autonomy and surgeon guidance when selecting a BIA-ALCL prevention plan; (3) surgeons should seek to understand the psychosocial factors that may underlie patient perceptions of BIA-ALCL risk; and (4) individual consults can be therapeutic and help strengthen the patient-surgeon relationship.

Assessing exposure to dermoscopy in plastic surgery training programs.

BACKGROUND: Dermoscopy is a noninvasive tool that improves the diagnostic accuracy of melanoma and other cutaneous malignancies; yet, it is not widely used by plastic surgeons, who commonly manage skin lesions. Thus, the purpose of this study was to explore current practice patterns and knowledge of dermoscopy among plastic surgeons and postgraduate plastic surgery trainees. Additionally, interest to establish a formal dermoscopy curriculum as part of plastic surgery residency training was evaluated. METHODS: An online electronic questionnaire was developed and distributed through email to practicing plastic surgeons and plastic surgery trainees at two Canadian universities. RESULTS: Of the 59 potential participants, 27 (46%) responded. While the majority of participants were familiar with dermoscopy (n = 26; 96%), only one respondent reported using dermoscopy in clinical practice. However, all respondents reported exposure to melanoma clinically (n = 26; one participant did not provide a response). A lack of training, along with lack of access to dermatoscopes, were the most frequently cited reasons for not using dermoscopy. Knowledge scores with regard to dermoscopic features were also low; coupled with a noted propensity toward diagnostic or excisional biopsy, whichcould raise the benign to malignant ratio. Overall, 89% (n = 24) of respondents expressed interest in dermoscopy training in plastic surgery postgraduate training. CONCLUSIONS: Few responding plastic surgeons or plastic surgery residents currently use dermoscopy in training or practice but are interested in formal dermoscopy training in residency.

Navigating Women's BIA-ALCL Information Needs: Group Seminars May Offer an Opportunity to Empower the Patient-Surgeon Team.

BACKGROUND: Breast Implant Associated Anaplastic Large Cell Lymphoma (BIA-ALCL) is a T-cell non-Hodgkin's lymphoma that has been linked to textured breast implants, and is an emerging concern within the plastic and reconstructive surgery community. Many surgeons are struggling with how best to inform their patients and manage BIA-ALCL care without overwhelming their standard clinical practice. METHODS: Five educational group seminars were held for 53 patients. A thematic analysis of the field notes taken at each seminar was conducted to identify recurring patient and surgeon behaviors. RESULTS: The thematic analysis identified 5 key themes: seeking, amplifying, framing, trusting, and empowering. Seeking describes the knowledge sought by patients and their varying engagement in their care. Amplifying underlines how the emotionally charged topic of BIA-ALCL impacted patient and surgeon behaviors. Framing presents surgeon efforts to help patients understand the risk level of BIA-ALCL. Trusting addresses the ways BIA-ALCL has impacted patient trust in the medical community and the mechanisms to rebuild this trust. Empowering outlines surgeon efforts to engage patients in shared decision-making. CONCLUSIONS: Herein is presented a possible framework for efficient BIA-ALCL patient education that can be adapted to different surgical practices. Lessons learned are: (1) patients want information on BIA-ALCL's clinical features and prophylactic implant removal; (2) BIA-ALCL discussions are emotionally charged and surgeons must remain cognizant of group dynamics and that the physician-patient power differential may impact patient decision-making; (3) patient trust has been strained but can be restored; and (4) patient responses to BIA-ALCL are variable and subjective; thus, surgeons should emphasize patient-centered care.

Direct-to-implant Breast Reconstruction with Autoderm.

BACKGROUND: Traditional transverse mastectomies yield suboptimal results in women with higher body mass index, wide breast footprint, and ptotic breasts. An option for this patient population is a reduction-pattern style mastectomy, and recruiting an inferiorly based dermal flap using the lower mastectomy flap. This is analogous to a vascularized dermal matrix supporting the lower pole of the implant, termed "Autoderm" breast reconstruction. This allows for aesthetically appealing skin reduction mastectomies with the added safety of a vascularized dermal flap to facilitate an immediate direct-to-implant breast reconstruction. This study assesses patient satisfaction using the validated BRECON-31 questionnaire to enhance shared-decision making with women contemplating breast reconstruction. METHODS: A 2-year retrospective review of women who underwent Autoderm direct-to-implant breast reconstruction comparing patients who underwent unilateral and bilateral reconstruction in terms of characteristics, complications, and BRECON-31 scoring. RESULTS: Overall patient scores were high (81.6 of 100). In particular, women scored very high on self-image (85.0), arm concerns (86.4), intimacy (87.4), satisfaction (88.3), and expectations subscales (85.5). Women choosing bilateral reconstruction outperformed unilateral reconstruction in every subgroup, but only attained statistical significance in the "self-consciousness" subgroup. Compared with a historical cohort of a mix of implant reconstruction types, Autoderm patients showed improved satisfaction (88.3 versus 82.5; P = 0.07) and breast appearance (73.9 versus 66.8; P = 0.06), approaching significance. Safety was demonstrated by low major complications (4.7%) and low implant loss rates (2.3%). CONCLUSIONS: Autoderm breast reconstruction is a safe option in women with large, ptotic breasts, with patients reporting high satisfaction using a validated instrument.

Improved Recovery Experience Achieved for Women Undergoing Implant-Based Breast Reconstruction Using an Enhanced Recovery after Surgery Model.

BACKGROUND: Enhanced recovery after surgery was compared with traditional recovery after surgery for postmastectomy alloplastic breast reconstruction. METHODS: Length of stay, emergency room visits, and complications within 30 days of surgery were compared among three groups: traditional recovery after surgery, transition (some elements of enhanced recovery protocol, not transitioned to outpatient care), and enhanced recovery after surgery (day surgery, provided with standardized perioperative education and multimodal analgesia). Prospective data collection allowed quality-of-recovery assessment using a validated questionnaire for enhanced recovery/transition groups. Results were statistically analyzed (analysis of variance/chi-square). RESULTS: The traditional recovery, transition, and enhanced recovery cohorts comprised 29, 11, and 29 patients, respectively. No significant differences were present regarding age, smoking status, preoperative radiation, single stage direct-to-implant versus tissue expander, bilateral versus unilateral surgery, or immediate versus delayed reconstruction among groups. Average length of stay was 1.6 nights in both the traditional recovery and transition groups, compared with 0 nights in the enhanced recovery group (p < 0.001). Enhanced recovery patients had less severe pain (p = 0.02) and nausea (p = 0.01), and better enjoyed their food (p = 0.0002) and felt more rested (p = 0.02) than their transition counterparts. There were no differences in the number of emergency room visits among the three groups (p = 0.88). There was no difference in the rate of hematoma (p = 0.36), infection requiring intravenous antibiotics (p = 0.36), or infection requiring explantation (p = 0.36) among the three groups. CONCLUSION: An enhanced recovery protocol for alloplastic breast reconstruction treated patients safely, with improved patient satisfaction and same-day discharge and with no increase in complications. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Enhanced Recovery After Surgery (ERAS) Protocol Enables Safe Same-Day Discharge After Alloplastic Breast Reconstruction.

BACKGROUND: To compare enhanced recovery after surgery (ERAS) with traditional recovery after surgery (TRAS) for patients undergoing alloplastic breast reconstruction. METHODS: A retrospective chart review of 2 patient groups (ERAS and TRAS) undergoing alloplastic breast reconstruction was performed. Data were collected from 2012 to 2013 (TRAS) and from 2013 to 2016 (ERAS). The ERAS protocol included day surgery, multimodal analgesia, and preoperative anti-emetic. The TRAS pathway involved overnight admission, narcotic-based analgesia, and no preoperative anti-emetic. Demographics, operative variables, and complications were compared between groups. RESULTS: Seventy-eight ERAS patients and 78 TRAS patients were included. Length of stay was shorter for ERAS patients (0.38 nights ERAS and 1.45 nights TRAS; P < .001). The ERAS patients underwent significantly more bilateral surgery (80.8% ERAS and 55.1% TRAS; P < .001), immediate reconstruction (98.6% ERAS and 89.3% TRAS; P = .004), and had more implants versus expanders placed (66% [93/141] ERAS and 24.8% TRAS; P < .001). There were no differences in the number of post-operative emergency department visits (8% ERAS and 14% TRAS; P = .2) and readmissions (8% ERAS and 3.8% TRAS; P = .3) between the groups. There was no difference in the rate of hematoma (0.7% ERAS and 0% TRAS; P = .35), infection requiring explantation (1.4% ERAS and 0.8% TRAS; P = .65), infection requiring outpatient IV antibiotics (1.4% ERAS and 2.5% TRAS; P = .53), and infection requiring IV antibiotics and readmission (2.1% ERAS and 1.7% TRAS; P = .78) between the groups. There were no differences in the number of minor complications (22% ERAS and 23% TRAS; P = .82). CONCLUSION: The ERAS protocol for alloplastic breast reconstruction is safe, without increased readmission or complication rates compared to TRAS, and significantly decreased length of stay.

HISTORIQUE: Comparer la récupération rapide après la chirurgie (RRAC) à la récupération habituelle après la chirurgie (RHAC) chez les patientes qui subissent une récupération mammaire alloplastique. MÉTHODOLOGIE: Les chercheurs ont procédé à l'analyse rétrospective des dossiers de deux groupes de patientes (RRAC et RHAC) qui subissaient une reconstruction mammaire alloplastique. Ils ont recueilli les données de 2012 et 2013 (RHAC) et de 2013 à 2016 (RRAC). Le protocole RRAC incluait une chirurgie d'un jour, une analgésie multimodale et un anti-émétique préopératoire. La voie RHAC incluait l'admission d'une nuit, une analgésie narcotique et l'absence d'anti-émétique préopératoire. Les chercheurs ont comparé les données démographiques, les variables opératoires et les complications entre les groupes. RÉSULTATS: Au total, 78 patientes RRAC et 78 patientes RHAC ont participé à l'étude. Les patientes RRAC étaient hospitalisées moins longtemps (0,38 nuit RRAC, 1,45 nuit RHAC, p<0,001). Les patientes RRAC ont subi beaucoup plus de chirurgies bilatérales (80,8 % RRAC, 55,1 % RHAC, p<0,001) et de reconstructions immédiates (98,6 % RRAC, 89,3 % RHAC, p=0,004) et se sont fait installer plus d'implants que d'expanseurs (66 % RRAC [93 sur 141], 24,8 % RHAC, p<0,001). Les groupes ne présentaient pas de différence quant au nombre de rendez-vous postopératoires à l'urgence (8 % RRAC, 14 % RHAC, p=0,2) et de réhospitalisations (8 % RRAC, 3,8 % RHAC, p=0,3). Ils ne présentaient pas de différences quant au taux d'hématomes (0,7 % RRAC, 0 % RHAC, p=0,35) ni d'infection exigeant l'explantation (1,4 % RRAC, 0,8 % RHAC, p=0,65), la prise d'antibiotiques IV ambulatoires (1,4 % RRAC, 2,5 % RHAC, p=0,53) ou la prise d'antibiotiques IV et une réhospitalisation (2,1 % RRAC, 1,7 % RHAC, p=0,78). Le nombre de complications mineures ne différait pas davantage (22 % RRAC, 23 % RHAC, p=0,82). CONCLUSION: Le protocole RRAC de reconstruction mammaire alloplastique est sécuritaire, n'accroît pas le taux de réhospitalisations ou de complications par rapport à la RHAC et réduit le séjour hospitalier de manière significative.