Kamakshi Zeidler

Stanford University, Palo Alto, California, United States

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Publications (11)30.49 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: Breast reconstruction improves quality-of-life of breast cancer patients. Different reconstructive options exist, yet commentary in the plastic surgery literature suggests that financial constraints are limiting access to autologous reconstruction (AR). This study follows national trends in breast reconstruction and identifies factors associated with reconstructive choices. Data were obtained from the Nationwide Inpatient Sample from 1998 to 2008. Patients were categorized as having either implant or ARs. Bivariate and multivariate regression analysis identified variables associated with receiving implants versus AR. Physician fee schedules were analyzed using national average Medicare physician reimbursement rates. From 1998 to 2008, 324,134 breast reconstructions were performed. Reconstructions increased 4% per year. The proportion of implant reconstructions increased 11% per year, whereasARs decreased 5% per year (p < 0.05). Our model showed that the odds of having implant-based versus AR were significantly associated with age, disease severity, payer type, hospital teaching status, and year of surgery. Year of surgery was the strongest predictor of implant reconstruction; patients receiving breast reconstructive surgery in 2009 were three times more likely to have implant breast reconstructive surgery compared with similar patients in 2002. Medicare reimbursement steadily declined for AR over a similar time frame. From 1998 to 2008, autologous breast reconstruction has significantly declined, parallel to a decrease in physician reimbursement. Our data found no significant change in patient characteristics supporting the lack of choice of AR. Further research is warranted to better understand this shift to implant reconstruction and to ensure future access of these complex reconstructive procedures.
    The Breast Journal 06/2013; 19(5). DOI:10.1111/tbj.12148 · 1.43 Impact Factor
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    ABSTRACT: INTRODUCTION: During microvascular breast reconstruction, exposure of internal mammary vessels (IMVs) is facilitated by the removal of a portion of the rib resulting in occasional chest contour deformity (CCD). The use of rib plating may reduce CCD and reduce postoperative pain. METHODS: All patients underwent microvascular breast reconstruction using IMVs. In the retrospective arm, photographs were assessed by a blinded reviewer for CCDs. In the prospective cohort, patients were randomized to rib plating with the Synthes Matrix Rib Plating System or no rib plating. Postoperatively, patients were assessed for CCD and pain. RESULTS: In the retrospective arm, 11 of 98 (11.2%) patients representing 12 of 130 (9.2%) breast reconstructions had a noticeable contour deformity. The average body mass index (BMI) of patients with CCDs was 26.6 kg/m. In the prospective arm, there was 16% (3 of 19) rate of visible and palpable CCDs among controls, compared to 0% rate of palpable and visible contour deformity in the rib plating group. Pain was decreased in the rib plating group on all postoperative days. The pain reduction was statistically significant at rest by postoperative day 30. CONCLUSION: The majority of patients (9 of 11) with compromised aesthetic outcomes had a BMI less than 30 kg/m, suggesting a paucity of overlying soft tissue contributed to visibility of these bony defects. Rib plating prevented chest contour deformity, reduced postoperative pain, and added limited additional morbidity. We believe that rib plating is a safe, useful adjunct to microvascular breast reconstruction using IMVs, as it may improve aesthetic outcomes and reduce postoperative pain.
    Annals of plastic surgery 03/2013; DOI:10.1097/SAP.0b013e3182853d86 · 1.46 Impact Factor
  • Kamakshi R Zeidler · Ji H Son · Joseph N Carey · Andrew J Watt · Oscar H Ho · Gordon K Lee
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    ABSTRACT: The transverse tensor fascia lata (TTFL) flap is an important alternative flap for autologous breast reconstruction. It is a horizontal variant of the tensor fascia lata myocutaneous flap and contains fat from the prominence of the upper lateral thigh (saddle bag). We present the surgical management of a woman with trochanteric lipodystrophy, who underwent staged bilateral mastectomy and autologous breast reconstruction with TTFL flaps. We discuss technical points in TTFL flap design and harvest. Breast reconstruction was successful and the thigh donor sites had excellent aesthetic contour. There were no complications at either recipient or donor sites. The TTFL flap is an important alternative flap for autologous breast reconstruction when other options are less optimal, and has a secondary benefit of thigh donor site closure with lateral thigh lift techniques. The TTFL flap should be presented as an option for autologous breast reconstruction in women with prominent trochanteric lipodystrophy of the upper lateral thighs.
    Annals of plastic surgery 03/2013; DOI:10.1097/SAP.0b013e31828a0c80 · 1.46 Impact Factor
  • Ji Son · Kamakshi R Zeidler · Anthony Echo · Leo Otake · Michael Ahdoot · Gordon K Lee
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    ABSTRACT: The Accreditation Council of Graduate Medical Education has defined 6 core competencies that residents must master before completing their training. Objective structured clinical examinations (OSCEs) using standardized patients are effective educational tools to assess and teach core competencies. We developed an OSCE specific for microsurgical head and neck reconstruction. Fifteen plastic surgery residents participated in the OSCE simulating a typical new patient consultation, which involved a patient with oral cancer. Residents were scored in all 6 core competencies by the standardized patients and faculty experts. Analysis of participant performance showed that although residents performed well overall, many lacked proficiency in systems-based practice. Junior residents were also more likely to omit critical elements of the physical examination compared to senior residents. We have modified our educational curriculum to specifically address these deficiencies. Our study demonstrates that the OSCE is an effective assessment tool for teaching and assessing all core competencies in microsurgery.
    Annals of plastic surgery 03/2013; DOI:10.1097/SAP.0b013e3182853f2c · 1.46 Impact Factor
  • Paige M Fox · Kamakshi Zeidler · Joseph Carey · Gordon K Lee
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    ABSTRACT: White light spectroscopy non-invasively measures hemoglobin saturation at the capillary level rendering an end-organ measurement of perfusion. We hypothesized this technology could be used after microvascular surgery to allow for early detection of ischemia and thrombosis. The Spectros T-Stat monitoring device, which utilizes white light spectroscopy, was compared with traditional flap monitoring techniques including pencil Doppler and clinical exam. Data were prospectively collected and analyzed. Results from 31 flaps revealed a normal capillary hemoglobin saturation of 40-75% with increase in saturation during the early postoperative period. One flap required return to the operating room 12 hours after microvascular anastomosis. The T-stat system recorded an acute decrease in saturation from ∼50% to less than 30% 50 min prior to identification by clinical exam. Prompt treatment resulted in flap salvage. The Spectros T-Stat monitor may be a useful adjunct for free flap monitoring providing continuous, accurate perfusion assessment postoperatively. © 2012 Wiley Periodicals, Inc. Microsurgery, 2012.
    Microsurgery 03/2013; 33(3). DOI:10.1002/micr.22069 · 2.42 Impact Factor
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    ABSTRACT: Plastic surgery training has traditionally been modeled as an "apprenticeship," where faculty teach surgical skills to residents on live patients. Although this is a well-established process, the demand by the public and healthcare agencies for improved patient care, outcomes, and patient safety has led to the development of adjunct methods of teaching. The goal of this project is to assess the effectiveness of a web-based microsurgical curriculum. We developed an interactive Web site to teach essential microsurgical competencies. Residents were randomly divided into 2 cohorts: one experimental group completed this online resource and the other control group did not. Pre- and postassessments were administered, consisting of a written test and a recorded microsurgery skills session. A total of 17 plastic surgery residents of various training levels participated in the study. Residents who completed the web-based curriculum showed dramatic improvement in their knowledge and skills, with a 17-percentage point increase in their test scores (P = 0.01) compared with controls (P = 0.80). The experimental group was more likely to perform microanastomoses faster with an average of 4.5-minute improvement compared with 1.25-minute change among the control group. Residents performed self-assessments, and those who rated themselves as "very confident" had higher overall test scores (85% test score vs. 59%, P = 0.004), as well as shorter times to complete the microsurgical task (7.5 minutes vs. 13.6 minutes, P = 0.007). Overall, 62% of residents rated the online webpage as extremely valuable. The majority of residents reported the webpage improved their knowledge and markedly improved their microsurgical technique, which was confirmed by faculty experts. Our interactive Web-based curriculum is a novel resource, teaching microsurgery in an organized, competency-based manner, which we believe is the first Web site of this nature. An individualized, self-paced Web site is ideal for plastic surgery trainees of all levels. Overall, the widespread implementation of our proposed curriculum--online self-directed training combined with regular practice sessions--will establish a strong foundation of microsurgery knowledge and skills acquisition for all plastic surgery residents.
    Annals of plastic surgery 04/2012; 68(4):410-4. DOI:10.1097/SAP.0b013e31823b6a1a · 1.46 Impact Factor
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    ABSTRACT: To assess the efficacy of using concurrent partial mastectomy and reduction mammoplasty for resection of a wide range of tumor sizes and compare oncologic outcomes and postoperative complications on the basis of tumor size. Although tumor size greater than 4 cm has been considered an indication for undergoing a mastectomy, this dictum may not apply in women with breast hypertrophy, where the ratio of tumor size to breast size may still permit breast conservation. We wished to evaluate whether an approach combining partial mastectomy with reduction mammoplasty could provide a safe oncologic procedure with immediate breast reconstruction that could technically be applied even for large (>4 cm) lesions. A retrospective review of all patients undergoing partial mastectomy and concurrent reduction mammoplasty performed at our institution from 2000 to 2009. Clinical characteristics at presentation, pathologic data, and follow-up data were collected and analyzed. Eighty-five consecutive simultaneous partial mastectomy/reduction mammoplasty procedures were performed in 79 patients. Average tumor size was 2.8 cm for ductal carcinoma in situ (0.05-17.0 cm), 2.4 cm for invasive ductal carcinoma (IDC) (0.2-8.9 cm), 3.5 cm for lobular carcinoma (1.6-8.0 cm), and 5.7 cm for phyllodes tumors (3.7-7.6 cm). Twenty-five of 85 tumors (29.4%) were larger than 4 cm. Distribution for stage 0, I, II, III, and IV disease was 15, 12, 35, 19, and 2 tumors respectively, with an additional 2 phyllodes tumors. Median follow-up was 39 months (10-130 months). Seventy-five patients (94.9%) achieved successful breast conservation, whereas 4 patients (5.1%) went on to completion mastectomy. Thirteen patients (16.4%) required 1 reexcision to achieve clear margins, and 2 (2.5%) required multiple reexcisions. Two patients had a local recurrence during the follow-up period, one of whom underwent reexcision and the other underwent mastectomy. The overall complication rate was 14.1%, which included 4 major complications (4.7%) requiring an unplanned return to the operating room and need for hospital readmission, and 8 minor wound-related complications (9.4%). Neither recurrence nor complication rates were increased in patients with tumors greater than 4 cm when compared with tumors less than or equal to 4 cm. A partial mastectomy with concurrent reduction mammoplasty technique is a viable option for breast conservation even for larger tumors, combining a safe oncologic procedure with excellent cosmesis. A combined effort between breast surgeons and reconstructive surgeons has a high probability of success with low recurrence rates. In carefully selected patients, this approach may be preferable to mastecomy and breast reconstruction, particularly when postmastectomy radiation therapy is anticipated.
    Annals of surgery 03/2012; 255(6):1151-7. DOI:10.1097/SLA.0b013e31824f9769 · 7.19 Impact Factor
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    ABSTRACT: In the elderly population with significant medical comorbidities, the safety of general anesthesia is often in question. In the head and neck, where regional and extradural anesthesia are not options, reconstruction of defects requiring free tissue transfer becomes a particular challenge for patients in whom general anesthesia is contraindicated. We present a case of a scalp reconstruction utilizing a latissimus dorsi free flap in a 91-year-old man performed entirely under local and regional anesthesia. General anesthesia was contraindicated secondary to the patient's multiple medical comorbidities. A paravertebral block was used for the harvest of the latissimus dorsi muscle and skin grafts. The microvascular portion of the procedure and the inset were performed under local anesthesia alone. The patient tolerated the procedure, and the operation was successful. This case is unique in that there are no published reports of head and neck free tissue transfer being performed entirely under local-regional anesthesia. We conclude that despite the medical challenges of performing complex reconstruction in elderly patients, expedient free tissue transfer can offer patients access to successful reconstruction.
    Journal of Reconstructive Microsurgery 01/2012; 28(3):189-93. DOI:10.1055/s-0031-1301070 · 1.01 Impact Factor
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    ABSTRACT: Introduction: Plastic surgery training has traditionally been modeled as an “apprenticeship,” where faculty teach surgical skills to residents on live patients. While this is a well-established process, the demand by the public and healthcare agencies for improved patient care, outcomes, and patient safety has led to the development of adjunct methods of teaching. The goal of this project is to assess the effectiveness of a web-based microsurgical curriculum. Methods: We developed an interactive website with step-by-step instructions and videos to teach essential microsurgical competencies. Residents were randomly divided into two cohorts: one experimental group completed this online resource and the other control group did not. Pre- and post- assessments were administered, which consisted of a written quiz and skills sessions. The skills session was video recorded and consisted of performing microvascular anastomoses in an animal model, which was subsequently reviewed by a panel of faculty experts. Results: A total of 17 plastic surgery residents of various training levels participated in the study. Residents who completed the web-based curriculum showed dramatic improvement in their knowledge and skills, with a 17-percentage point increase in their test scores (p = 0.01) compared to controls (p = 0.80). The experimental group was more likely to perform microanastomoses faster with an average of 4.5 minute improvement compared to a 1.25 minute change among the control group. Residents performed self-assessments, and those who rated themselves as “very confident” had higher overall test scores (85% test score versus 59%, p = 0.004), as well as shorter times to complete the microsurgical task (7.5 minutes versus 13.6 minutes, p = 0.007). Overall, 62% of residents rated the online webpage as extremely valuable. The majority of residents reported that the webpage improved their knowledge and markedly improved their microsurgical technique, which was confirmed by faculty experts. Conclusions: Our interactive web-based curriculum is a novel resource that teaches microsurgery in an organized, competency-based fashion, which we believe is the first website of this nature. An individualized, self-paced website is ideal for plastic surgery trainees of all levels. We have incorporated this into our plastic surgery educational curriculum, and it has proven to be an invaluable training tool. We hope to offer this resource to other training programs by way of introduction and presentation of our web-based curriculum at ASRM.
    AAHS ASPN ASRM 2012 Annual Meetings; 01/2012
  • Edward I. Chang · Kamakshi R. Zeidler · Brian Schmidt · Pablo Leon
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    ABSTRACT: Introduction: The free fibular osteocutaneous flap has become the workhorse flap for reconstruction of the head and neck when bony support and soft tissue coverage and/or mucosal lining are needed. However, the donor site often requires skin grafting and is a potential site for additional complications and increased morbidity. Here, we describe the free fibula osteofascial flap as a reliable option for composite head and neck reconstruction that allows for primary closure of the donor site defect. Materials and Methods: Preliminary results on four patients undergoing mandible reconstruction with free fibula fascia flaps at the University of California San Francisco were evaluated and included in our study. Medical records were reviewed for demographics, comorbidities, oncologic and reconstructive operations, and postoperative complications. Results: Four patients with squamous cell carcinoma of the oral cavity underwent segmental mandibulectomy with radical neck dissections and were reconstructed using the free fibula osteofascial flap. The soleus/peroneal fascia was dissected from the skin and muscle while preserving the perforators which were included in the composite flap in all patients. Two patients were found to have no cutaneous perforators that would have supported a skin paddle. Fibular osteotomies were performed using custom made templates for mandibular reconstruction. The soleus/peroneal fascia was use to reconstruct the floor of mouth and provide coverage of the bony construct and hardware. The fascia was left to mucosalize, and the donor sites were closed primarily and healed in all cases without complication. There were no flap related complications. Conclusions: The free fibula osteofascial flap is a refinement of the traditional free fibula osteocutaneous flap and provides suitable bone length along with a reliable piece of fascia that can be used to reconstruct bony defects as well as provide soft tissue for coverage and lining. The donor site can then be closed primarily thereby precluding the need for skin grafting and associated donor site complications. While this flap is not indicated for every composite head/neck reconstruction, it represents an innovative option in the reconstructive surgeon's armamentarium.
    Plastic Surgery: The Meeting 2010; 10/2010
  • Cancer Research 02/2010; 69(24 Supplement):4125-4125. DOI:10.1158/0008-5472.SABCS-09-4125 · 9.28 Impact Factor

Publication Stats

49 Citations
30.49 Total Impact Points

Institutions

  • 2012–2013
    • Stanford University
      • • Department of Surgery
      • • Division of Plastic and Reconstructive Surgery
      Palo Alto, California, United States
    • Stanford Medicine
      • Division of Plastic and Reconstructive Surgery
      Stanford, California, United States
  • 2010–2012
    • University of California, San Francisco
      • • Department of Surgery
      • • Division of Plastic and Reconstructive Surgery
      San Francisco, California, United States