Mitchell H Brown

University of Toronto, Toronto, Ontario, Canada

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Publications (14)31.61 Total impact

  • 11/2015; DOI:10.1097/GOX.0000000000000388

  • 11/2015; DOI:10.1097/GOX.0000000000000510
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    ABSTRACT: Purpose In 2010, Women’s College Hospital (WCH) in Toronto transitioned from an inpatient hospital to an ambulatory care hospital. In order to continue offering autogenous breast reconstruction, a multidisciplinary team developed a perioperative pain management protocol to facilitate early discharge. The purpose of this study was to evaluate quality of recovery (QoR) in women undergoing pedicled transverse rectus abdominis myocutaneous (TRAM) or latissimus flap breast reconstruction in an ambulatory setting. Methods A prospective cohort study was performed of all women presenting for autogenous breast reconstruction at WCH between 2011-2013. Patient-reported quality of recovery was measured on postoperative days 0, 2, 4 and 7 using the QoR-27. Self-report pain and general health were also evaluated. Linear regression assessed trends in mean postoperative QoR-27, pain, and general health scores over time. Predictors of postoperative QoR-27 and pain scores were analyzed using panel regression analysis. Secondary analyses of delayed discharge (>24 hours) and complications are also provided. Results Forty women (28-69 years) were included with an average body mass index (BMI) of 26.7 kg/m2. QoR-27 scores consistently improved over the postoperative period, with the greatest lag seen in the physical independence score. Lower total QoR-27 scores were associated with the extremes of BMI and higher American Society of Anaesthesiology (ASA) classification (p<0.05). Worst pain scores were associated with the extremes of BMI (p<0.05) and younger age (p=0.07). Delayed discharge (24.1-28.25 hours) occurred in 40% of patients; all ASA class III patients experienced a delay in discharge. Conclusion Patients undergoing expedited discharge following pedicled flap breast reconstruction demonstrated satisfactory quality of recovery and well-controlled pain over the first postoperative week. Patient selection is key to successfully performing autogenous reconstruction in an ambulatory setting, with the extremes of BMI and higher ASA class being risk factors for worse quality of recovery and delayed discharge.
    Plastic &amp Reconstructive Surgery 10/2014; 134(4S-1 Suppl):90. DOI:10.1097/01.prs.0000455438.50755.b8 · 2.99 Impact Factor
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    ABSTRACT: BACKGROUND: Clinical evidence concerning the potential risks and benefits associated with surgical incision, anatomical pocket and implant device type in primary breast augmentation is lacking. OBJECTIVES: This study assesses relative risk (RR) of adverse events stratified by surgical incision, anatomical pocket and breast implant device in primary augmentation patients enrolled in Core (NCT00689871, round/silicone devices) and 410 (NCT00690339, anatomically shaped/highly cohesive silicone devices) long-term clinical trials. METHODS: RR for time-to-first-event of Baker grade 3-4 capsular contracture (CC), moderate-severe malposition, and secondary procedure were calculated using multivariate time-to-event regression analysis. RESULTS: Risk of CC was increased with periareolar (unadjusted model only) and with axillary (adjusted model) versus inframammary incision. Risk of CC was significantly reduced with subpectoral versus subglandular placement (adjusted model), and with textured surface/round/silicone-filled devices and textured surface/shaped/highly cohesive silicone-filled devices versus smooth surface/round/silicone-filled devices (adjusted model). Risk of CC was significantly reduced with textured surface devices independent of subpectoral or subglandular placement (adjusted model). In a number-needed-to-treat analysis, 7-9 patients needed to be treated with a textured surface device to prevent one Baker grade 3-4 CC over 10 years. Risk of moderate-severe malposition was significantly increased with periareolar (adjusted model) and axillary (adjusted model) versus inframammary incision; and significantly lower with textured surface/shaped/highly cohesive silicone-filled devices than with smooth surface/round/silicone-filled devices (adjusted model). Risk of secondary procedures was significantly increased with periareolar (adjusted model) and axillary (adjusted model) versus inframammary incision; and significantly reduced with textured surface/shaped/highly cohesive silicone-filled devices versus smooth surface/round/silicone-filled devices (adjusted model). CONCLUSIONS: In primary breast augmentation, surgical incision, anatomical pocket, and device were significant predictors of clinical outcomes: capsular contracture, malposition and secondary procedure.
    Journal of Plastic Reconstructive & Aesthetic Surgery 05/2013; 66(9). DOI:10.1016/j.bjps.2013.04.046 · 1.42 Impact Factor
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    Plastic and Reconstructive Surgery 08/2011; 128(2):593-5. DOI:10.1097/PRS.0b013e31821eee8c · 2.99 Impact Factor
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    ABSTRACT: The goal of this consensus is to establish an algorithm for the management of patients who develop a late or delayed periprosthetic fluid collection. A work group of practicing plastic surgeons and device industry physicians met periodically by teleconference and discussed issues pertinent to the diagnosis and management of late periprosthetic fluid collections in patients with breast implants. Based on these meetings, treatment recommendations and a treatment algorithm were prepared in association with an editorial assistant. The work group participants discussed optimal care approaches developed in their private practices and from evidence in the literature. The consensus algorithm and treatment and management recommendations represent the consensus of the group. The group concluded that late periprosthetic fluid collection (arbitrarily defined as occurring ≥ 1 year after implant) is an infrequently reported occurrence (0.1 percent) after breast implant surgery and that, at a minimum, management should include clinically indicated ultrasound-guided aspiration of fluid, with appropriate cultures and cytologic testing. Further evaluation and additional treatment is recommended for recurrence of periprosthetic fluid collection after aspiration, or clinical suspicion of infection or neoplasia.
    Plastic and Reconstructive Surgery 03/2011; 128(1):1-7. DOI:10.1097/PRS.0b013e318217fdb0 · 2.99 Impact Factor
  • Kristen M. Davidge · Ronald Levine · Mitchell H. Brown ·
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    ABSTRACT: An abstract is unavailable. This article is available as HTML full text and PDF.
    Plastic &amp Reconstructive Surgery 09/2010; 126:66. DOI:10.1097/01.prs.0000388786.75457.ed · 2.99 Impact Factor
  • Vivek Panchapakesan · Mitchell H Brown ·
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    ABSTRACT: Tuberous breast deformity is a rare congenital condition that often requires surgical correction. Numerous surgical techniques have been described, reflecting the reconstructive challenge of this deformity. The anatomic cohesive gel breast implant is a powerful tool in both aesthetic and reconstructive breast surgery. In the authors' experience, its use in treating tuberous breast deformity has provided the opportunity for a single-stage approach, with very good results. The senior author has managed more than 50 cases of single-stage reconstruction for tuberous breast deformity using anatomic cohesive gel breast implants. His surgical technique is described with suggestions for achieving optimal results. Representative case examples are provided. The anatomic cohesive silicone gel breast implant is an excellent device for treating tuberous breast deformity. It often can be used as a single-stage correction of the deformity with very good results. The authors strongly advocate consideration of its use in tuberous breast deformity reconstruction.
    Aesthetic Plastic Surgery 09/2008; 33(1):49-53. DOI:10.1007/s00266-008-9234-7 · 0.96 Impact Factor
  • Mitchell H Brown · Robert Shenker · Samuel A Silver ·
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    ABSTRACT: Cohesive silicone gel breast implants are composed of a textured silicone elastomer shell and are filled with cohesive silicone gel. Cohesive gel is formed by increasing the number of cross-links between gel molecules, which results in an implant that has better retention of shape and is less likely to fold or collapse, especially in the upper pole. The initial 150 consecutive patients who received cohesive gel breast implants by the senior author (Brown) were included in the study. A retrospective chart review was carried out to analyze patient demographics, diagnosis, indication for cohesive gel selection, procedure performed, implant selected, and complications. All implants were manufactured by Inamed Aesthetics and were either style 410, CML, or CMH. One woman underwent unilateral augmentation for breast asymmetry and 117 women underwent bilateral breast augmentation. Of the 235 implants used, all were model 410 anatomical implants, with the majority being MM, MF, FM, or FF styles. Complications occurred in four of 118 patients (3.4 percent). There was one immediate postoperative hematoma, two cases of unilateral Baker II contracture, and one case of asymmetry related to excessive lowering of an inframammary fold. There were no cases of rotation, malposition, infection, rippling, or loss of implant integrity. Thirty-two women underwent breast reconstruction with cohesive gel implants. A total of 50 implants were used in the 32 patients (27 style 410, 19 style CML, and four style CMH). Complications occurred in six of 32 patients (18.8 percent), although five of the six were minor and only one of 32 patients (3.1 percent) required a secondary procedure. There were two seromas, three capsular contractures, and one implant exposure following a skin-sparing mastectomy. Cohesive gel implants have the potential for providing a natural breast shape, minimizing the risk of postoperative rippling, and providing a greater degree of safety should the implant lose its integrity. The wide variety of implant shapes and sizes allows for great flexibility in reconstructive surgery, in cases of breast asymmetry, and in primary breast augmentation. Results in our initial 150 patients have been excellent, with a high degree of patient satisfaction, excellent aesthetic outcomes, and very few implant-related complications. Cohesive gel implants are likely to play an important role in aesthetic and reconstructive breast surgery when silicone gel implants are reintroduced into the North American market.
    Plastic and Reconstructive Surgery 10/2005; 116(3):768-79; discussion 780-1. DOI:10.1097/01.prs.0000176259.66948.e7 · 2.99 Impact Factor
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    ABSTRACT: This study was a formative evaluation of a 2-year Surgical Skills Center Curriculum (SSCC) using objective measures of surgical performance and self-reported process-oriented evaluations. Fifty postgraduate third-year (PGY-3) residents participated in an Objective Structured Assessment of Technical Skills (OSATS) examination. Nineteen residents underwent the SSCC and 31 residents did not. During the SSCC, self-reported student and faculty evaluations were completed after each session. For the OSATS examination, scores were not significantly different between treatment and control groups, on either the checklist (66.4 +/- 6.1 versus 64.1 +/- 10.8) or global rating scale scores (66.9 +/- 6.9 versus 68.0 +/- 9.6). Further comparisons between groups on individual OSATS stations revealed no significant differences between groups. The majority of student and faculty evaluation remarks were highly positive. The OSATS results failed to support our hypothesis that training on a core procedure in a single session during a SSCC would have an appreciable and sustained effect after 2 years. Self-reported process-oriented evaluations support the utility of our SSCC.
    The American Journal of Surgery 05/2003; 185(4):378-85. DOI:10.1016/S0002-9610(02)01403-4 · 2.29 Impact Factor
  • Kyle R Wanzel · Mitchell H Brown · Dimitri J Anastakis · Glenn Regehr ·
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    ABSTRACT: Despite the positive impact that reconstructive breast surgery can have on a woman's quality of life, the percentage of eligible candidates that have this procedure remains surprisingly low. The authors hypothesized that this may be attributable to inadequate knowledge, inadequate information, and/or misinformation available to physicians caring for these patients. A needs assessment of primary care physicians, general surgeons, oncologists, and plastic surgeons was conducted to determine referring physicians' current level of knowledge of reconstructive breast surgery and to discover potential learning needs. This comprised a survey, focus groups, and individual interviews. Referring physicians rated their own knowledge of reconstructive breast surgery as low. Plastic surgeons rated their referring physicians' knowledge as even lower. Specific learning needs were identified, as large discrepancies between referring physicians' self-reported knowledge of individual breast reconstruction topics and their own opinion of their relevance were revealed. In addition, despite evidence to the contrary, more than one-third of referring physicians indicated a belief that a breast reconstruction delayed the detection of local cancer recurrence and adversely interfered with adjuvant oncologic therapy. This lack of knowledge and misinformation may be negatively affecting patient referrals to plastic surgeons, as more than one-third of referring physicians and 90 percent of plastic surgeons believed that eligible candidates were not being offered referrals because of inadequate referring physician knowledge of this topic. Furthermore, patients older than 49 years were not being referred despite the fact that plastic surgeons would consider these patients as potential surgical candidates. Referring physician gender affected both referral patterns and perceived importance of reconstructive breast surgery. Finally, personal beliefs and past experiences played a role both in physicians' decisions to refer patients and in patients' decisions to have breast reconstructions. These deficiencies in information, knowledge, and learning needs should be addressed by educational interventions during residency training and through continuing education endeavors.
    Plastic &amp Reconstructive Surgery 12/2002; 110(6):1441-50; discussion 1451-4. DOI:10.1097/01.PRS.0000030458.86726.50 · 2.99 Impact Factor
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    ABSTRACT: The subject of microbial growth within the saline medium of prosthetic breast implants has been one of great controversy in recent years. Although several articles have described microbial growth within the tissue surrounding implanted breast prostheses, few have attempted to determine the possibility of such contamination of the luminal saline. The authors studied the intraluminal saline medium of a series of explanted breast prostheses with the objective of identifying any microbial contamination. Over a 6-month period, a consecutive series of saline-filled breast implants and tissue expanders were removed from 37 patients. Under the supervision of a microbiologist, saline extracted from each implant was subjected to bacterial and fungal cultures, Gram staining, and acid-fast staining. A total of 24 saline-filled breast implants were removed from 15 patients, and 32 saline-filled tissue expanders were removed from 22 patients. The average length of implantation was 28.1 months for the implants and 7.1 months for the expanders. None of the saline within the implants or expanders within our series displayed any evidence of microbial contamination. These results suggest that microbial contamination of the luminal saline of prosthetic breast implants is an extremely unlikely event.
    Plastic &amp Reconstructive Surgery 07/2002; 109(7):2242-4; discussion 2245-6. DOI:10.1097/00006534-200206000-00011 · 2.99 Impact Factor
  • Alexis D. Armour · Brian W. Rotenberg · Mitchell H. Brown ·
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    ABSTRACT: The superwet technique has been shown in previous studies to dramatically reduce blood loss in breast reduction surgery, compared with standard infiltration. A retrospective chart review of 303 consecutive patients undergoing bilateral breast reduction surgery was undertaken to demonstrate additional differences in complication rate, operative time, or sponge use in the operating room. In this series, 132 consecutive patients received standard infiltration along incision lines (25 cc per breast of 1:100,000 epinephrine), and 171 patients received superwet infiltration with 240 cc per breast of 1:1,000,000 epinephrine. The average operative time was significantly reduced in the superwet group, from 78.5 minutes to 70.7 minutes (p < 0.01 level). The average number of sponges used intraoperatively was also decreased significantly (p < 0.01), from 26 to 20 sponges. Complication rates were equally low in both groups, demonstrating the safety of the superwet technique. In addition to limiting blood loss, the superwet infiltration effectively reduces operative time and sponge use without increasing complications in breast reduction surgery.
    Plastic &amp Reconstructive Surgery 08/2001; 108(2):343-7. DOI:10.1097/00006534-200108000-00009 · 2.99 Impact Factor
  • Mitchell H. Brown · John L. Semple · Peter C. Neligan ·
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    ABSTRACT: Currently, little is known about which variables are most critical to the subjective appearance of symmetry of the nipple-areola complex. Clinical photographs were transferred onto a compact disc and then imported into a computer photoshop program. Alterations to the nipple-areola complex were then performed, creating 1 symmetrical image and 19 asymmetrical images. The asymmetries were produced by altering position, diameter, or pigmentation. The images were converted to 35-mm slides and shown to four separate panels of three members each. A "symmetry score" was given for each slide. Results showed that any deviation from symmetrical was reliably detectable by the observers. Changes in areola diameter were detected most easily, and the specific direction of positional change was not found to be a significant factor. Differences were seen between individual panel assessments. This study has shown an application for CD-ROM technology in analyzing well-identified variables and has helped in delineating which factors are most critical to the subjective impression of symmetry of the nipple-areola complex.
    Plastic &amp Reconstructive Surgery 10/1995; 96(4):846-51. DOI:10.1097/00006534-199509001-00013 · 2.99 Impact Factor