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ABSTRACT: : The aims of the current study were to (1) measure trends in the type of mastectomy performed, (2) evaluate sociodemographic/hospital characteristics of patients undergoing contralateral prophylactic mastectomy versus unilateral mastectomies, and (3) analyze reconstruction rates and method used following different mastectomy types.
: Mastectomies from 1998 to 2008 were analyzed using the Nationwide Inpatient Sample database. Mastectomies (n = 178,603) were classified as either unilateral, contralateral prophylactic, or bilateral prophylactic. Reconstructive procedures were categorized into either implant or autologous. Longitudinal trends were analyzed with Poisson regression and sociodemographic/hospital variables were analyzed with logistic regression.
: Unilateral mastectomies decreased 2 percent per year, whereas contralateral and bilateral prophylactic mastectomies increased significantly by 15 and 12 percent per year, respectively (p < 0.01). Independent predictors for contralateral prophylactic mastectomy (compared with unilateral mastectomy) were patients younger than 39 years, Caucasian and Hispanic race, private insurance carriers, treated in teaching hospitals, and from South and Midwest regions. Contralateral prophylactic mastectomy is the only group with increased reconstruction rates throughout the study period (p < 0.01). Although implant use increased for all mastectomy types, it remains greater in bilateral and contralateral prophylactic mastectomy.
: There is increasing use of bilateral mastectomies in the United States, particularly in patients with unilateral cancer. Although implant use has increased for all mastectomy types, they are used most commonly following bilateral and contralateral prophylactic mastectomies. Changing mastectomy patterns are one factor underlying the paradigm shift away from autologous tissue to implant-based reconstruction.
: Risk, III.
Plastic and reconstructive surgery 03/2013; 131(3):320e-6e. · 2.74 Impact Factor
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ABSTRACT: INTRODUCTION-: Prior breast irradiation increases the rate of post-operative complications including capsular contracture in tissue expander/implant (TE/I) reconstruction. Acellular dermal matrix (ADM) is heralded to decrease capsular contracture; however, recent evidence suggests a possible increase in the rate of postoperative complications. We evaluate outcomes in patients undergoing bilateral, TE/I reconstruction with ADM in the setting of prior unilateral irradiation. METHODS-: A case-control study was conducted on all patients undergoing bilateral, ADM-assisted, TE/I reconstruction with a history of previous unilateral irradiation, at Memorial Sloan Kettering Cancer Center. The rate of complications including, infection, mastectomy skin flap necrosis, hematoma, seroma and capsular, contracture were compared. RESULTS-: Twenty-three patients met inclusion criteria and had an average followup, of 19 months (range: 4-60 months). When comparing radiated breasts to control, breasts, the perioperative infection rate was 21.7% (n=5) versus 4.3% (n=1), (p=0.079). Rates of mastectomy skin flap necrosis, explantation, hematoma, and, seroma were also not significantly different between the groups. Sixty percent of, patients had a contracture in the irradiated breast that was one Baker grade greater, than the non-irradiated breast. BMI >25 and smoking history were significant, independent risk factors for early postoperative complications in univariate analysis, (p=0.01). CONCLUSIONS-: Previous radiation does not appear to increase the risk of early postoperative complications associated with ADM use in TE/I breast reconstruction. However, ADM should be used cautiously, in patients with a BMI >25 or a smoking history. Additionally, ADM does not appear to affect the degree of capsular contracture formation in the setting of prior irradiation. CLINICAL QUESTION-: Therapeutic LEVEL OF EVIDENCE-: Level III.
Plastic and reconstructive surgery 02/2013; · 2.74 Impact Factor
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ABSTRACT: : Despite its benefits in body image, self-esteem, sexuality, and quality of life, historically fewer than 25 percent of patients undergo immediate breast reconstruction. After passage of the Women Health and Cancer Rights Act, studies failed to demonstrate changes in reconstructive rates. A recent single-year report suggests significant shifts in U.S. breast reconstruction patterns. The authors' goal was to assess long-term trends in rates and types of immediate reconstruction.
: A serial cross-sectional study of immediate breast reconstruction trends was performed using the Nationwide Inpatient Sample database from 1998 to 2008. Data on mastectomies, reconstructive method (autologous/implant), and sociodemographic/hospital predictors were obtained.
: Immediate breast reconstruction rates increased on average 5 percent per year, from 20.8 percent to 37.8 percent (p < 0.01). Autologous reconstruction rates were unchanged. Implant use increased by an average of 11 percent per year (p < 0.01), surpassing autologous methods as the leading reconstructive modality after 2002. The strongest predictors of implant use were procedures performed after 2002, bilateral mastectomies, patients operated on in Midwest/West regions, and Medicare recipients. In contrast to bilateral mastectomies, which increased by 17 percent per year (p < 0.01), unilateral mastectomies decreased by 2 percent per year (p < 0.01). Bilateral mastectomy defects had significantly higher reconstruction rates than unilateral counterparts (p < 0.01).
: The significant rise in immediate reconstruction rates in the United States correlates closely to a 203 percent expansion in implant use. Although the reason for the increase in implant use is multifactorial, changes in mastectomy patterns, such as increased use of bilateral mastectomies, are one important contributor.
Plastic and reconstructive surgery 01/2013; 131(1):15-23. · 2.74 Impact Factor
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Plastic and reconstructive surgery 12/2012; 130(6):889e-90e. · 2.74 Impact Factor
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ABSTRACT: Microsurgical breast reconstruction has gained popularity because of associations with decreased abdominal morbidity and high satisfaction. Nationwide use of these procedures is unknown. Although many factors can influence the method of breast reconstruction, sociodemographic and hospital characteristics have not been specifically evaluated. The authors studied the importance of microsurgical flaps among the techniques available for breast reconstruction and evaluated the effect of sociodemographic and hospital characteristics on the technique chosen.
A cross-sectional study of breast reconstructions was performed using the Nationwide Inpatient Sample database for 2008. National estimates of breast reconstructive procedures including microsurgery were obtained. Impact of variables on reconstructive method was analyzed using logistic regression.
Among women undergoing breast reconstruction in 2008, implants were the most common procedure (60.5 percent), followed by pedicled flaps (34 percent) and microsurgical flaps (5.5 percent). Multivariable analysis showed that women aged 50 to 59 years, treated at teaching hospitals, with private insurance, or undergoing delayed reconstruction were more likely to have autologous than implant reconstruction. Implant use was associated with young patients, Caucasians, Asians, higher income, and all regions except the Northeast. Analysis of autologous reconstructions showed the likelihood for a microsurgical versus a pedicle flap was greater in teaching hospitals, private insurance carriers, and delayed reconstructions.
Microsurgical techniques are currently used in only a minority of reconstructions. Sociodemographic variables and teaching hospital status influence the method of breast reconstruction. The presence of disparities in care suggests that current decision making for breast reconstruction is not based solely on patient preference or anatomical features.
Plastic and reconstructive surgery 05/2012; 129(5):1071-9. · 2.74 Impact Factor
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ABSTRACT: This article focuses on the contribution of acellular dermal matrices (ADMs) to immediate breast reconstruction. The current literature on ADMs is reviewed and the potential advantages and disadvantages of their use are highlighted. Technical considerations on how to effectively use these materials is presented.
Clinics in plastic surgery 04/2012; 39(2):113-8. · 0.95 Impact Factor
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Plastic and reconstructive surgery 03/2012; 129(3):551e-2e. · 2.74 Impact Factor
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ABSTRACT: Melanoma of the lentigo maligna subtype presents diagnostic and treatment challenges because of ill-defined clinical margins in cosmetically and functionally sensitive areas of the head and neck with extensive sun damage. This review highlights the natural history, varied clinical presentations, and pitfalls in histologic diagnosis. The focus is on the surgical management, comparing excision and pathologic tissue processing techniques of wide excision, Mohs micrographic surgery, and staged excision. Staged excision is recommended for optimal surgical margin control. Nonsurgical treatment modalities are also reviewed for the elderly or unresectable cases.
Plastic and reconstructive surgery 02/2012; 129(2):288e-299e. · 2.74 Impact Factor
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ABSTRACT: Tibial resection in children presents a unique reconstructive challenge because of technical demands, future growth potential, and repetitive loading of the lower extremity. Positioned in a tibial defect, the free fibula undergoes primary bone healing while maintaining intrinsic resistance to infection and the ability to hypertrophy. The authors' aim was to evaluate surgical and functional outcomes in this selected group of pediatric patients.
This is a retrospective review of 13 consecutive pediatric oncology patients who underwent reconstruction of segmental tibial defects with intercalated vascularized fibula flaps from 1992 to 2007. Perioperative and long-term complications were noted. Functional outcomes were analyzed.
Thirteen patients with a mean age of 12.6 years (range, 6 to 17 years) were included. Median follow-up was 63 months (range, 8 to 168 months). Overall survival was 77 percent. Flap survival was 100 percent. Perioperative local complication rate was 23 percent secondary to infection (two of 13 patients) and minor wound breakdown (one of 13 patients). Perioperative infection and chemotherapy did not significantly impact union or fracture rates. Hypertrophy of the fibula approached native tibial size in 90 percent of surviving patients. Median time to union was 10 months, average time to partial weight bearing was 5 months (range, 2 to 10 months), and time to full weight bearing was 16 months (range, 9 to 34 months). Of surviving patients, 91 percent achieved full weight bearing by 2 years, all of whom were ultimately able to participate in athletics.
Functional reconstruction of segmental tibial defects in children can be achieved safely and reliably with the vascularized fibula. Infectious complications are low, but problems with union and fracture at this lower extremity site can be common until graft hypertrophy occurs. Those who achieve disease control may ultimately enjoy an active lifestyle.
Therapeutic, IV.
Plastic and reconstructive surgery 01/2012; 129(1):195-206. · 2.74 Impact Factor
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ABSTRACT: Melanoma in situ and early squamous cell carcinoma can be treated successfully with excision with narrow margins. However, as the extent of disease is known only after pathologic examination of the entire lesion, the appropriate initial surgical margin is a dilemma. Lesions that involve the nail complex present an additional challenge for surgeons-whether to excise the nail complex partially or completely. The ideal form of reconstruction is also in question. We elect to completely excise the nail complex with immediate reconstruction using a full-thickness skin graft, allowing complete tumor clearance and preserving the distal phalanx. We retrospectively reviewed records of patients who had undergone complete nail complex excision and immediate skin grafting. We assessed the need for additional procedures for positive resection margins, full-thickness skin graft take on the bare bone of the distal phalanx, and final aesthetic appearance. Our study included 9 patients who had surgery on a total of 10 digits. One patient underwent repeat resection with distal phalanx disarticulation after pathologic assessment revealed a positive margin for an invasive tumor No patients had a local recurrence. Two patients required a second procedure-one for excision of a nail remnant and another for excision of an epidermal inclusion cyst. All patients were satisfied with the results, with none wanting further nail reconstruction, and all returned to presurgery use of the hand. This technique is effective for managing melanoma in situ and early squamous cell carcinoma that affect the nail complex.
Techniques in hand & upper extremity surgery 06/2011; 15(2):84-6.
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Plastic and reconstructive surgery 02/2011; 127(2):1000-1. · 2.74 Impact Factor
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ABSTRACT: The omentum, external oblique musculocutaneous, and thoracoepigastric flaps are uncommonly used for chest wall reconstruction. Nevertheless, awareness and knowledge of these flaps is essential for reconstructive surgeons because they fill specific niche indications or serve as lifeboats when workhorse flaps are unavailable. The current report describes the anatomic basis, technical aspects of flap elevation, and indications for these unusual flaps.
Seminars in Plastic Surgery 02/2011; 25(1):55-9.
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MS Colleen M. McCarthy MD,
Anne F. Klassen DPhil,
Stefan J. Cano PhD,
Amie Scott BSc,
Nancy VanLaeken MD,
Peter A. Lennox MD,
MPH Amy K. Alderman MD,
Babak J. Mehrara MD,
Joseph J. Disa MD,
Peter G. Cordeiro MD, [......],
Anne F. Klassen,
Stefan J. Cano,
Amie Scott,
Nancy VanLaeken,
Peter A. Lennox,
Amy K. Alderman,
Babak J. Mehrara, Joseph J. Disa,
Peter G. Cordeiro,
Andrea L. Pusic
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ABSTRACT: BACKGROUND.At a time when the safety and effectiveness of breast implants remains under close scrutiny, it is important to provide reliable and valid evidence regarding patient outcomes. In the setting of postmastectomy reconstruction, patient satisfaction and quality of life may be the most significant outcome variables when evaluating surgical success. The objective of the current study was to identify predictors of patient satisfaction with breast appearance, including implant type, in a large sample of women who underwent breast reconstruction surgery using implants.METHODS.A multicenter, cross-sectional study design was used. A total of 672 women who had completed postmastectomy, implant-based reconstruction at 1 of 3 centers in North America were asked to complete the BREAST-Q (Reconstruction Module). Multivariate linear regression modeling was performed.RESULTS.Completed questionnaire data were available for 482 of the 672 patients. In 176 women, silicone implants were placed and in 306, saline implants were used. The multivariate model confirmed that patients' satisfaction with their breasts was significantly higher in patients with silicone implants (P = .016). The receipt of postmastectomy radiotherapy was found to have a significant, negative effect on breast satisfaction (P<.000) in both silicone and saline implant recipients. In addition, for women who received either silicone or saline implants, satisfaction diminished over time (P = .017).CONCLUSIONS.In the setting of postmastectomy reconstruction, patients who received silicone breast implants reported significantly higher satisfaction with the results of reconstruction than those who received saline implants. This information can be used to optimize shared medical decision-making by providing patients with realistic postoperative expectations. Cancer 2010. © 2010 American Cancer Society.
Cancer 12/2010; 116(24):5584 - 5591. · 4.77 Impact Factor
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Colleen M McCarthy,
Anne F Klassen,
Stefan J Cano,
Amie Scott,
Nancy Vanlaeken,
Peter A Lennox,
Amy K Alderman,
Babak J Mehrara, Joseph J Disa,
Peter G Cordeiro,
Andrea L Pusic
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ABSTRACT: At a time when the safety and effectiveness of breast implants remains under close scrutiny, it is important to provide reliable and valid evidence regarding patient outcomes. In the setting of postmastectomy reconstruction, patient satisfaction and quality of life may be the most significant outcome variables when evaluating surgical success. The objective of the current study was to identify predictors of patient satisfaction with breast appearance, including implant type, in a large sample of women who underwent breast reconstruction surgery using implants.
A multicenter, cross-sectional study design was used. A total of 672 women who had completed postmastectomy, implant-based reconstruction at 1 of 3 centers in North America were asked to complete the BREAST-Q (Reconstruction Module). Multivariate linear regression modeling was performed.
Completed questionnaire data were available for 482 of the 672 patients. In 176 women, silicone implants were placed and in 306, saline implants were used. The multivariate model confirmed that patients' satisfaction with their breasts was significantly higher in patients with silicone implants (P = .016). The receipt of postmastectomy radiotherapy was found to have a significant, negative effect on breast satisfaction (P<.000) in both silicone and saline implant recipients. In addition, for women who received either silicone or saline implants, satisfaction diminished over time (P = .017).
In the setting of postmastectomy reconstruction, patients who received silicone breast implants reported significantly higher satisfaction with the results of reconstruction than those who received saline implants. This information can be used to optimize shared medical decision-making by providing patients with realistic postoperative expectations.
Cancer 12/2010; 116(24):5584-91. · 4.77 Impact Factor
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ABSTRACT: Free flap breast reconstruction involves major risk factors for postsurgical venous thromboembolism. The main study objectives were (1) to estimate objectively the incidence of symptomatic and asymptomatic lower extremity deep vein thrombosis in patients who received postoperative thromboprophylaxis after free flap breast reconstruction, (2) to evaluate the safety of low-molecular-weight heparin postoperatively, and (3) to assess the incidence of symptomatic pulmonary embolism or sudden death.
A cohort study of 225 consecutive patients who underwent abdominally based free flap breast reconstruction at a single cancer center was conducted. The postoperative thromboprophylaxis regimen was based on the American College of Chest Physicians guidelines. A study group of 118 patients systematically underwent bilateral lower extremity duplex ultrasound before hospital discharge to assess objectively the status of the lower extremity deep venous system. A retrospective cohort of 107 women who were not systematically screened for deep vein thrombosis was used for comparison.
The incidence of postoperative deep vein thrombosis confirmed by duplex ultrasound was 3.4 percent in the study group, all events being clinically silent. Bleeding complications in the entire patient sample were estimated at 5.3 percent. Partial flap loss and total flap loss rates were 2.7 and 1.9 percent, respectively. No venous thromboembolism event was diagnosed in the control group.
This report shows that the objective incidence of deep vein thrombosis was 3.4 percent within 5 postoperative days in this patient population. The authors' findings support the use of triple thromboprophylaxis and demonstrate that low-molecular-weight heparin is a safe and effective method for prevention of venous thromboembolism in this population.
Plastic and reconstructive surgery 12/2010; 127(4):1399-406. · 2.74 Impact Factor
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ABSTRACT: A subset of patients with recurrent or second intraoral tumors undergo both primary and secondary mandibular reconstruction using bilateral fibula flaps. The objective of this report is to describe indications and outcomes for these patients.
A retrospective analysis of a prospectively collected database was performed. Charts were reviewed to identify demographics, operative features, and functional outcomes.
Ten patients underwent mandibular reconstruction with a second fibula flap for recurrent or second oral tumors. Time between flaps averaged 20 months. Bone gap size measured 8 cm after both resections. Eighty percent of secondary resections included the mandibular arch, in contrast to 20 percent of primary resections (p=0.070). Compared with primary resections, secondary soft-tissue defects were larger and more frequently included composite tissues. There were low complication rates and no flap failures after both reconstructions. Functional evaluation showed a greater dependency on supplemental enteral nutrition after the second resection (p=0.033). Five patients died at a median of 12.5 months after the second resection and the remaining patients have survived for a median of 18.6 months.
The principal indication for second fibula flaps in mandibular reconstruction is central segment defects where rigid support is required to prevent sequelae of the Andy Gump deformity. For lateral resections, the large soft-tissue deficits of secondary extirpation may be better served by reconstruction with soft-tissue flaps. Second osseous free flaps can be performed safely, but with a significant decline in postoperative oropharyngeal function. Goals of surgery and quality of life need to be addressed before ablation of recurrent or second oral tumors is performed.
Plastic and reconstructive surgery 11/2010; 126(5):1539-47. · 2.74 Impact Factor
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ABSTRACT: Little information exists on the incidence of complications after acellular human dermis implantation in two-stage tissue expander breast reconstruction. The purpose of this study was to evaluate the incidence of postoperative adverse events and identify significant predictors of complications in acellular human dermis tissue expander breast reconstruction.
This study accrued all patients from January of 2004 through April of 2008 undergoing two-stage immediate tissue expander breast reconstruction using acellular human dermis. A total of 153 expanders were placed. Complications were assessed. Univariate and multivariate logistic regression modeling was performed. Comparison of complication rates using the traditional (non-acellular human dermis) technique from concurrent (2004 to 2008) and consecutive time periods (2001 to 2003) for 2910 and 1170 expanders, respectively, is provided.
A total of 153 expanders were implanted in 96 women: 39 unilateral and 57 bilateral. Eleven (7.2 percent) were removed due to infection (n = 5, 3.3 percent), exposure (n = 4, 2.6 percent), or patient preference (n = 2, 1.3 percent). Other complications included cellulitis (3.9 percent), seroma (7.2 percent), hematoma (2.0 percent), mastectomy flap necrosis (4.6 percent), and leak/failed expansion (0.0 percent); 92.8 percent were successfully expanded and exchanged for a permanent implant. Eleven seromas (7.2 percent) were identified; nine underwent aspiration. None of these resulted in infection or reconstructive failure. Univariate analysis revealed age, body mass index, axillary dissection, and postoperative chemotherapy to be associated with reconstructive failure (p < 0.05). Multivariate analysis revealed that age, body mass index, and axillary dissection are independent risk factors for developing complications (p < 0.05).
Acellular human dermis is a useful adjunct for intraoperative pocket development in immediate tissue expander reconstruction but can result in an increased risk of complications, in particular, seroma and reconstructive failure.
Plastic and reconstructive surgery 06/2010; 125(6):1606-14. · 2.74 Impact Factor
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ABSTRACT: LEARNING OBJECTIVES: After reading this article, the participant should be able to: 1. Clinically describe various cutaneous neoplasms. 2. Identify the corresponding histopathologic findings. 3. Discuss the optimal treatment approach for each entity. SUMMARY: Cutaneous neoplasms are broadly viewed as benign, premalignant, or malignant. In dermatology, lesions are classified based on the primary cell of origin or the component of the skin predominantly affected by the pathologic change (epidermis, dermis, or subcutaneous fat). The diagnosis and treatment of skin lesions rely on understanding the clinical presentation and corresponding histopathology. Surgical treatment is not always indicated and is dependent on multiple variables. This review discusses several benign and premalignant neoplasms frequently encountered by the plastic surgeon. The emphasis is on clinical presentation, histopathologic correlation, and management approach.
Plastic and reconstructive surgery 05/2010; 125(5):188e-198e. · 2.74 Impact Factor
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ABSTRACT: The effect of the selection of recipient vessels on the rate of fat necrosis after microsurgical reconstruction of the breast remains largely unknown. Our aim was to evaluate the incidence of fat necrosis after unilateral breast reconstruction with a free transverse rectus abdominis myocutaneous (TRAM) flap after anastomosis with either the internal mammary vessels or the thoracodorsal artery and vein. Consecutive patients who had unilateral reconstruction with a free, muscle-sparing TRAM flap at two tertiary care centres over a 6-year period were identified. The incidence of fat necrosis, defined as postoperative firmness of 1 cm or more persisting for 3 months or more after anastomosis was calculated. To control for the effect of potentially confounding variables (body mass index (BMI), history of preoperative or postoperative radiation, previous abdominal operation, smoking, and hospital) we did a matched-cohort study. A total of 840 unilateral muscle-sparing TRAM flaps were done using either the internal mammary (n = 109) or the thoracodorsal (n = 731) vessels. Evaluation of the entire cohort showed that the incidence of fat necrosis after the two anastomoses was 13 (12%) compared with 130 (18%), respectively (p = 0.17). To control for the effect of confounding variables, 98 patients who had internal mammary anastomoses were matched 1:1 with 98 patients who had thoracodorsal anastomoses. Pair-wise comparisons showed that the incidence of fat necrosis was significantly higher when the thoracodorsal vessels were used (29; 30%) compared to when the internal mammary vessels were used (12; 12%; p = 0.002). Our results showed that a higher rate of fat necrosis may be seen after muscle-sparing TRAM flap reconstruction after anastomosis to the thoracodorsal vessels than with the internal mammary vessels. The exact mechanisms of this association are unknown and warrant additional investigation.
Scandinavian Journal of Plastic and Reconstructive Surgery and Hand Surgery 04/2010; 44(2):96-101. · 0.94 Impact Factor
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Joseph J Disa
Plastic and reconstructive surgery 01/2010; 125(1):10-1. · 2.74 Impact Factor
