[This corrects the article DOI: 10.1097/GOX.0000000000007207.].
BACKGROUND: Mastectomy and breast reconstruction aim to restore aesthetics and psychological well-being in breast cancer patients. However, postoperative shoulder pain and stiffness are common, with varying incidence rates across studies. This study assesses the incidence and risk factors for shoulder morbidity following breast reconstruction.
METHODS: A single-institution retrospective review was conducted from January 2015 to November 2023. Female patients who underwent mastectomy followed by reconstruction were included. Data on demographics, surgical details, therapies, and shoulder outcomes were collected. Unpaired t-tests, Fisher's Exact tests, and multivariable logistic regression models identified risk factors for shoulder impairment.
RESULTS: Among 773 patients, 192 (24.8%) reported shoulder impairment, associated with neoadjuvant chemotherapy (p=0.004), radiation (p=0.003), right-sided (p=0.001), and oncologic mastectomies (p<0.001). Axillary lymph node dissection (p<0.001) and lymphedema (p<0.001) were also linked. Shoulder impairment occurred, on average, 244.8 days post-surgery, lasting 293.4 days. Multivariable analysis identified prior shoulder impairment (OR 2.287; p=0.049), axillary lymph node dissection (OR 2.556; p=0.049), lymphedema (OR 5.677; p=0.003), and Hispanic race (OR 9.049; p=0.019) as significant predictors. Age and private insurance were protective factors.
CONCLUSION: Shoulder impairment is a prevalent complication after mastectomy and breast reconstruction, associated with previous shoulder issues and lymph node dissection. Early identification of these risk factors may inform targeted interventions to reduce shoulder morbidity and improve outcomes. Prospective studies are needed to refine prevention strategies for shoulder impairment in breast cancer survivors.
The superficial circumflex iliac perforator flap (SCIP-f) is a thinned adaptation of the superficial circumflex iliac artery flap (SCIA-f) that may have superior use flexibility, smaller scar burden, and lesser need for revision, advantages well-suited to pediatric patients. Despite documented success in adults, the safety and utility of SCIP and SCIA-f are underexplored in pediatric populations.A systematic review of MEDLINE, Web of Science, Embase, and Cochrane databases identified 93 articles reporting SCIP/SCIA-f outcomes in patients ≤ 17 years of age. Patient demographics, clinical characteristics, and postoperative outcomes were collected. Cohorts were stratified by SCIP/SCIA and age group. Mann-Whitney U tests compared cohort outcomes.Thirty-one studies were included, constituting 107 SCIA-f and 57 SCIP-f, with ages 10 weeks to 17 years. Most cases were congenital or traumatic defects in upper/lower extremities. Compared with SCIA-f, SCIP-f demonstrated significantly lower rates of all-cause complications, total flap loss, major and minor complications, and debulking (p < 0.05). All-cause complication rates were also significantly lower across age groups (p < 0.001).This meta-analysis demonstrates favorable efficacy and safety of SCIP-f in children with congenital and traumatic defects, especially of the extremities. SCIP-f may be considered a reliable option for pediatric reconstruction. Additionally, fewer subsequent procedures for contouring may be required.
BACKGROUND: Improving diversity within plastic and reconstructive surgery (PRS) trainees is a crucial step to reduce inequities at the provider level. Trends in minority representation among independent program match applicants are understudied. We analyzed gender, racial, and ethnic demographic trends among independent PRS match applicants.
METHODS: With the approval of the American Council of Educators in Plastic Surgery, the San Francisco Match provided data for the independent PRS match from 2013 to 2023. Trends in the independent PRS match were reviewed, and a Cochran-Armitage test was conducted to evaluate the significance of match trends in minority applicants (Female, Black, Asian, Other Race, Hispanic ethnicity) over time.
RESULTS: A total of 1000 applicants participated in the independent plastic surgery match during the study period, of whom 735 matched. A 31% decrease in the number of independent PRS programs was observed. The match rate decreased from 86% to 60%. Statistical analysis by race (White, Black, Asian, Other) and match outcomes revealed significant differences in racial distributions between applicants and matched participants in 2014 (p = 0.002) and 2018 (p = 0.042). The proportion of female applicants and Hispanic applicants correlated yearly to the number of matched females and Hispanics, respectively (p > 0.05). Cochran-Armitage tests showed a significant increase in match trends among female participants over time (p = 0.004).
CONCLUSIONS: We show a significant increase in female representation in the independent PRS match in the last decade. However, representation of racial and ethnic minorities has shown minimal change over the years. Ongoing efforts are needed to identify barriers and reduce inequities.
BACKGROUND: Autologous nasoseptal cartilage grafts are used to correct nasal asymmetry and deviation in rhinoplasty, but patients who have undergone multiple operations may have limited autologous cartilage tissue available. L-strut implants created on a 3-dimensional (3D) printer may address these challenges in the future, but their mechanical strength is understudied. Silk fibroin-gelatin (SFG), polycaprolactone (PCL), and polylactide (PLA) are bioinks known for their strength. The authors present finite element analysis (FEA) models comparing the mechanical strength of 3D-printed SFG, PCL, and PLA implants with nasoseptal cartilage grafts when autologous or allografts are not available.
METHODS: FEA models compared the stress and deformation responses of 3D-printed solid and scaffold implant replacements to cartilage. To simulate a daily force from overlying soft tissue, a unidirectional load was applied at the "keystone" region given its structural role and compared with native cartilaginous properties.
RESULTS: The 3D-printed solid SFG, PCL, and PLA and scaffold PCL and PLA models demonstrated lower deformations compared with cartilage. Solid SFG balanced strength and flexibility. The maximum stress was below all materials' yield stresses, suggesting that their deformations are unlikely permanent under a daily load.
CONCLUSIONS: The authors' FEA models suggest that 3D-printed L-strut implants carry promising mechanical strength. Solid SFG results mimicked cartilage's mechanical behavior. Thus, scaffold SFG merits further geometric optimization for potential use for cartilage substitution. The 3D-printed septal cartilage replacement implants can potentially enhance surgical management of patients who lack available donor cartilage in select settings.
CLINICAL RELEVANCE STATEMENT: Computational simulations can evaluate the strength of 3D-printed implants and their potential to replace septal cartilage in septorhinoplasty.
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.
BACKGROUND: Decreased nipple sensation following reduction mammoplasty can negatively affect a variety of patient-centered outcomes. This observational study examined the impact of dermoglandular pedicle type on subjective postoperative nipple sensation.
METHODS: A total of 178 women who underwent a bilateral reduction mammoplasty at a single institution from 2017 to 2023 and completed an 11-item survey assessing subjective postoperative nipple sensitivity across various tactile modalities were included. Patient-reported nipple sensations were compared across pedicle type and subgrouped by resection volume.
RESULTS: Of the included survey respondents, 72% (128) underwent reduction with an inferior pedicle and 28% (50) with a superior or superomedial pedicle. Over 92% of patients reported the preservation of postoperative nipple sensation. Compared to the inferior pedicle, the superior pedicle cohort reported decreased nipple sensitivity to light touch (56% vs 30%, respectively) and temperature (30% vs 15%). In resection weights greater than 500 grams, the superior pedicle cohort was less satisfied with postoperative nipple sensation (84% vs. 58%), reported decreased sensation in light touch (58% vs 24%), pressure (50% vs 21%), and experienced more numbness and tingling (17% vs 1.4%) (all p-values ≤0.05).
CONCLUSION: The majority of patients maintain some sensation after reduction mammoplasty; however, approximately 10% reported a relative decrease in subjective nipple sensation. Pedicle choice did not significantly affect sensory recovery in resection weights of less than 500 grams. When a greater resection weight is anticipated, the inferior pedicle may be associated with more favorable nipple sensation outcomes.
LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
BACKGROUND: Postamputation pain is a debilitating sequela of upper extremity (UE) amputation. Targeted muscle reinnervation (TMR) is a relatively novel treatment that can help prevent pain and improve quality of life. The purpose of this study was to evaluate national trends in the application of immediate TMR following UE amputations.
METHODS: An analysis of the Nationwide Inpatient Sample database was conducted from 2016 to 2019. International Classification of Diseases, 10th Revision, codes were used to identify encounters involving UE amputation with and without TMR. Nationwide Inpatient Sample weights were used to estimate national estimates of incidence. Patient-specific and hospital-specific factors were analyzed to assess associations with use of TMR.
RESULTS: A total of 8945 weighted encounters underwent UE amputation, and of those, only 310 (3.5%) received TMR. The majority of TMR occurred in urban hospitals (>95%). Younger patients (47 years versus 54 years; P = 0.008) and patients located in New England were significantly more likely to undergo TMR. There was no difference in total cost of hospitalization among patients who underwent TMR ($55,241.0 versus $59,027.8; P = 0.683) but significantly shorter lengths of hospital stay when undergoing TMR versus other management (10.6 days versus 14.8 days; P = 0.012).
CONCLUSIONS: TMR has purported benefits of pain reduction, neuroma prevention, and increased prosthetic control. Access to this beneficial procedure following UE amputation varies by demographics and geographic region. Given that TMR has not been shown to increase cost while simultaneously decreasing patient length of stay, increased efforts to incorporate this procedure into training and practice will help to ensure equitable care for amputation patients.
BACKGROUND: Postoperative free tissue transfer reexploration procedures are relatively infrequent but associated with increased overall failure rates. This study examines the differences between flaps requiring takeback versus no takeback, as well as trends in reexploration techniques that may increase the odds of successful salvage.
METHODS: A retrospective review was conducted on all free tissue transfers performed at our institution from 2011 to 2022. Patients who underwent flap reexploration within 30 days of the original procedure were compared with a randomly selected control group who underwent free flap procedures without reexploration (1:2 cases to controls). Univariate and multivariate logistic regression analyses were performed.
RESULTS: From 1,213 free tissue transfers performed in the study period, 187 patients were included in the analysis. Of the total flaps performed, 62 (0.05%) required takeback, and 125 were randomly selected as a control group. Free flap indication, flap type, reconstruction location, and number of venous anastomoses differed significantly between the two groups. Among the reexplored flaps, 8 (4.3% of the total) had a subsequent failure while 54 (87.10%) were salvaged, with significant differences in cause of initial flap failure, affected vessel type, and salvage technique.
CONCLUSION: Free tissue transfers least prone to reexploration involved breast reconstruction in patients without predisposition to hypercoagulability or reconstruction history. When takeback operations were required, salvage was more likely in those without microvascular compromise or with an isolated venous injury who required a single exploratory operation.
INTRODUCTION: As medical education increasingly incorporates digital methods such as video lectures, e-learning, and virtual meetings, it becomes crucial to evaluate the effectiveness of virtual classrooms in teaching surgical techniques. This study aims to assess whether live virtual classrooms can effectively convey surgical skills to medical students.
METHODS: First- and second-y medical students were randomized to in-person or live-video sessions once a week, for 2 wk. Students were taught how to perform simple interrupted sutures with instrument-tying. At the end of the workshop, participants were recorded performing simple interrupted sutures. Postinstruction skills videos, blinded to student group placement, were graded from 1 to 5 based on instrument handling, time, efficiency, tissue handling, wound closure, and overall technique.
RESULTS: Out of 114 enrolled students, 42 completed the workshop. Notably, the virtual group had a significantly higher proportion of dropouts than the in-person group. Rubric scores showed no significant differences in various skill categories between the two groups. While both groups acknowledged the helpfulness of their respective methods, a majority expressed a preference for in-person instruction. The postcourse survey revealed that students valued in-person instruction for real-time feedback and multiple-angle demonstrations.
CONCLUSIONS: This study demonstrates that video instruction may be equally effective in improving students' surgical technique compared to live sessions. However, it also highlights a clear personal preference among students for in-person instruction, emphasizing the value of a personalized, hands-on approach and enhanced visibility provided by in-person teaching methods.