Faculty Bibliography

BACKGROUND:The Affordable Care Act sought to improve access to health care for low-income individuals. This study aimed to assess whether expansion of Medicaid coverage increased rates of post-mastectomy reconstruction (PMR) for patients who had Medicaid or no insurance. METHODS:A retrospective analysis performed through the National Cancer Database examined women who underwent PMR and were uninsured or had Medicaid, private insurance, or Medicare, and whose race/ethnicity, age, and state expansion status were known. Trends in the use of PMR after passage of Medicaid expansion in 2014 were evaluated. RESULTS:In all states and at all time periods, patients with private insurance were about twice as likely to undergo PMR as patients who had Medicaid or no insurance. In 2016, only 28.7 % of patients with Medicaid or no insurance in nonexpansion states underwent PMR (p < 0.001) compared with 38.5 % of patients in expansion states (p < 0.001). Patients in expansion states also have higher levels of education, higher income, and greater likelihood of living in metropolitan areas. Additionally, patients in all states saw an increase in early-stage disease, with a concomitant reduction in late disease, but this change was greater in expansion states than in non-expansion states. CONCLUSIONS:Expansion states have larger proportions of patients undergoing PMR than non-expansion states. This difference stems from significant differences in income, education, comorbidities, race, and location. Large metropolitan areas have the largest number of patients undergoing PMR, whereas rural areas have the least.

BACKGROUND:Numerous studies have evaluated the effect of post-mastectomy radiotherapy (PMRT) on autologous breast reconstruction, but the variability of PMRT regimens and inadequate controls have made results difficult to interpret. Therefore, in this study, irradiated free-flaps are compared to non-irradiated internal controls in patients who underwent immediate bilateral reconstruction followed by unilateral PMRT to better delineate the effect of PMRT. The role of regional nodal irradiation (RNI) is also specifically assessed. METHODS:Appropriate patients were identified through retrospective review. Complications such as fat necrosis, fibrosis, infection, delayed healing, and flap loss, as well as revision surgeries, among the irradiated free-flaps were compared to those on the contralateral non-irradiated side. Additional analyses were performed to evaluate the effect of patient demographics and treatment characteristics, such as RNI, on complications involving the irradiated free-flaps. RESULTS:Seventy-three women were included. There was no significant difference between complication rates for the irradiated and non-irradiated free-flaps (39.7% vs. 38.4%, p = .78), although irradiated free-flaps were more likely to have fibrosis (17.0% vs. 0.0%; p < .0001) and multiple complications (9.6% vs. 0.0%; p = .02). Both groups underwent a similar number of revision surgeries (42.5% vs. 41.1%; p = .29). Looking at the irradiated free-flaps, internal mammary node (IMN) irradiation was the only factor predictive of complications (IRR 3.80, CI 1.32-10.97; p = .01). CONCLUSIONS:PMRT may contribute to free-flap fibrosis, but does not appear to affect the overall risk of complications or revision surgeries. However, additional counseling is warranted if IMN irradiation is likely, as it is potentially associated with increased complications.

Breast reconstruction is a common procedure that is performed in both community and academic settings. At Yale-New Haven Hospital (YNHH), both academic (AP) and community-based (CP) plastic surgeons perform breast reconstructions. We aim to compare practice patterns in breast reconstruction between two practice environments within a single institution. A retrospective chart review of all breast reconstructions at YNHH between 2013 and 2018 was performed. Data collected included demographics, preoperative history, and postoperative outcomes. Results were further subdivided by practice setting. A total of 1045 patients (1683 breasts) underwent breast reconstruction during the study period. About 52.8% were performed by AP while 47.2% were performed by CP. CP had higher rates of autologous reconstruction (P < .001) and nipple-sparing mastectomy (P < .0001). Age and BMI were similar between the cohorts. However, patients cared for by AP had 2.6% increased prevalence of diabetes (P = .064), 5.5% greater prevalence of psychiatric diagnoses (P = .004), and 7.1% higher open abdominal surgery rates (P < .001). Outcomes were similar between the groups except for higher infection rates (P = .027) and explant rates (P = .003) in the CP cohort. When evaluating insurance status, the AP cohort had 30.5% fewer patients with commercial insurance, 16.7% more patients with Medicaid and 6.1% more patients with Medicare (P < .001). Within our institution, academic and community-based plastic surgeons perform breast reconstruction with overall similar complication rates. Patients treated by AP have a higher rate of preoperative medical and psychiatric comorbidities. Patients treated by CP have higher rates of infection and implant explant. AP plastic surgeons care for a significantly higher rate of Medicare and Medicaid patients with proportionally fewer patients with commercial insurance.

BACKGROUND:The impact of insurance and socioeconomic status on breast reconstruction modalities when access to care is controlled is unknown. METHODS:Records for patients who underwent breast reconstruction at an academic medical center between 2013 and 2017 were reviewed and analyzed using chi-square analysis and logistic regression. RESULTS:One thousand six hundred eighty-three breast reconstructions were analyzed. The commercially insured were more likely to undergo microvascular autologous breast reconstruction (44.4 percent versus 31.3 percent; p < 0.001), with an odds ratio of 2.22, whereas patients with Medicare and Medicaid were significantly more likely to receive tissue expander/implant breast reconstruction, with an odds ratio of 1.42 (41.7 percent versus 47.7 percent; p = 0.013). Comparing all patients with microvascular reconstruction, the commercially insured were more likely to receive a perforator flap (79.7 percent versus 55.3 percent versus 43.9 percent), with an odds ratio of 4.23 (p < 0.001). When stratifying patients by median household income, those in the highest income quartile were most likely to receive a perforator flap (82.1 percent) (p < 0.001), whereas those in the lowest income quartile were most likely to receive a muscle-sparing transverse rectus abdominis myocutaneous flap (36.4 percent) (p < 0.001). CONCLUSIONS:Patients at the same academic medical center had significantly different breast reconstruction modalities when stratified by insurance and household income. Despite similar access to care, differences in insurance types may favor higher rates of perforator flap breast reconstruction among the commercially insured. CLINICAL QUESTION/LEVEL OF EVIDENCE/METHODS:Risk, II.

BACKGROUND:CT angiography (CTA) can be performed pre-operatively for perforator mapping in autologous breast reconstruction. The full impact of incidental CTA findings on breast reconstruction remains unclear. METHODS:CTAs were reviewed for all patients who underwent imaging prior to autologous breast reconstruction at Yale New Haven Hospital from 2013-2018. CTA findings and all resulting follow-up imaging, treatment, and change in management were catalogued. Our findings were compared to other published reports in the literature to better categorize the impact of CTA findings on patient care. RESULTS:Records from 341 patients were reviewed. One hundred fifty-four patients (45.2%) had incidental findings with 15.6% requiring further imaging or biopsy. Three patients (0.9%) underwent a change in management. One patient was diagnosed with metastatic disease prior to mastectomy. Another two patients required gynecologic procedures as a result of the CTA findings. Data was pooled with three other series in the literature for aggregate analysis of 959 operative planning CTAs. In total, incidental findings were present in 53.7% of patients. In the meta-analysis, 10.4% of patients required additional imaging or biopsy and 1.4% of screening CTAs impacted medical management. CONCLUSION/CONCLUSIONS:Pre-operative autologous breast reconstruction planning reveals incidental findings in approximately half of all imaging studies. In an analysis of nearly 1000 CTAs, patient care was impacted in 1.4% of cases. If imaging is obtained for planning purposes, the reconstructive microsurgeon should carefully review the full imaging report given its potential impact on patient care.

BACKGROUND:Racial disparities among patients who receive breast mastectomy and reconstruction have not been well characterized. METHODS:Records of patients undergoing breast extirpative and reconstructive surgery at a high-volume university-affiliated hospital over 5 consecutive years were reviewed. Patient demographics, breast cancer profiles, reconstructive modality, and outcomes were compared by race. RESULTS:A total of 1045 patients underwent 1678 breast reconstructions during the five-year period. Mean age and standard deviation was 49.8 ± 10.6 years with a BMI of 27.9 ± 6.5. Hispanic and African American patients had significantly higher BMIs (p < 0.001), higher rates of ASA class III or IV (p = 0.025), obesity, diabetes, hypertension (p < 0.001 for these three comparisons), and smoking (p = 0.003), and had more prior abdominal surgeries (p = 0.007). Comparing oncologic characteristics, this population subset had higher rates of neoadjuvant chemotherapy (p = 0.036), history of radiation (p = 0.016), and were more likely to undergo modified radical mastectomy (p = 0.002) over nipple-sparing mastectomy (p = 0.035). Reconstructive complications revealed a higher overall complication rate (p = 0.023), higher rates of partial mastectomy flap necrosis (p = 0.043), as well as arterial (p = 0.009) and venous insufficiency (p = 0.026) during microvascular reconstruction among Hispanic and African American patients. CONCLUSIONS:Compared to other patients, the present study identifies higher comorbidity burdens, higher rates of prior radiation and neoadjuvant chemotherapy, and higher post-surgical complication rates among Hispanic and African American patients with breast cancer.

BACKGROUND:Two-stage implant breast reconstruction is the most commonly performed breast reconstruction procedure. Limited data exists regarding reconstruction complication rates examined by mastectomy indication. METHODS:Patients who underwent two-stage implant breast reconstruction at Yale New Haven Hospital from 2011-2017 were included in the study. Peri-operative complications were compared. T-tests, Chi-square analysis, and Fisher's exact tests were used to determine significant associations. A binary logistic regression was used to determine variables with a significant impact on the likelihood of mastectomy flap necrosis. RESULTS:Between 2011 and 2017, complete perioperative records were available for 141 patients who underwent 226 mastectomies followed by two-stage tissue expander/permanent implant reconstruction. Of the 226 mastectomies, 134 were therapeutic and 92 were prophylactic. On regression analysis, there were no significant differences in demographics, comorbidities, or mastectomy and reconstructive details between the two breast groups except for there being more modified radical mastectomies in therapeutic breasts (p=.003). When comparing complications, there was a significantly higher risk of mastectomy flap necrosis in the therapeutic group (p=0.017). Therapeutic mastectomies had a 9.5 times higher risk of mastectomy flap necrosis than prophylactic mastectomies when adjusted for confounding variables. There were no significant differences in other reconstructive complications between the two groups. CONCLUSIONS:Patients undergoing therapeutic mastectomies have a significantly higher risk of mastectomy flap necrosis than prophylactic mastectomies. Although the underlying etiology still needs to be determined, differences in technique may be related to mastectomy flap necrosis.

PURPOSE: The dependent nature of the lower extremity predisposes to venous congestion, especially following significant trauma. The benefit of a second venous anastomosis, however, remains unclear in lower extremity trauma free flap reconstruction. This study investigated the effect of an additional venous anastomosis on flap outcomes in lower extremity trauma reconstruction. METHODS: Retrospective review between 1979 and 2016 identified 361 soft tissue flaps performed for Gustilo IIIB/C coverage meeting inclusion criteria. Muscle flaps were performed in 287 cases (79.9%) and fasciocutaneous flaps in 72 cases (20.1%). Single-vein anastomosis was performed in 76% of cases and dual-vein anastmoses in 24% of cases. Patient demographics, flap characteristics, and outcomes were examined. RESULTS: Fasciocutaneous flaps were more likely to have two veins performed (P < .001). Complications occurred in 143 flaps (39.8%): 45 take-backs (12.4%), 37 partial losses (10.3%), 31 complete losses (8.6%). Compared to single-vein flaps, two veins reduced major complications (P = .005), partial flap failures (P = .008), and any flap failure (P = .018). Multivariable regression analysis demonstrated two veins to be protective against complications (RR = 2.58, P = .009). Subset regression analysis by flap type demonstrated an even more significant reduction in complications among muscle flaps (RR = 3.92, P = .005). Additionally, a >1 mm vein size mismatch was predictive of total flap failure (RR = 3.02, P = .038). CONCLUSION: Lower extremity trauma free flaps with two venous anastomoses demonstrated a fourfold reduction in complication rates compared to single-vein flaps. Additionally, venous size mismatch >1 mm was an independent predictor of total flap failure, suggesting beneficial effects of both two-vein outflow and matched vessel diameter.

PURPOSE/OBJECTIVE:Mandibular defects involving the condyle represent a complex reconstructive challenge for restoring proper function of the temporomandibular joint (TMJ) because it requires precise bone graft alignment for full restoration of joint function. The use of computer-aided design and manufacturing (CAD/CAM) technology can aid in accurate reconstruction of mandibular condyle defects with a vascularized free fibula flap without the need for additional adjuncts. The purpose of this study was to analyze clinical and functional outcomes after reconstruction of mandibular condyle defects using only a free fibula graft with the help of virtual surgery techniques. MATERIALS AND METHODS/METHODS:A retrospective review was performed to identify all patients who underwent mandibular reconstruction with only a free fibula flap without any TMJ adjuncts after a total condylectomy. Three-dimensional modeling software was used to plan and execute reconstruction for all patients. RESULTS/RESULTS:From 2009 through 2014, 14 patients underwent reconstruction of mandibular defects involving the condyle with the aid of virtual surgery technology. The average age was 38.7 years (range, 11 to 77 yr). The average follow-up period was 2.6 years (range, 0.8 to 4.2 yr). Flap survival was 100% (N = 14). All patients reported improved facial symmetry, adequate jaw opening, and normal dental occlusion. In addition, they achieved good functional outcomes, including normal intelligible speech and the tolerance of a regular diet with solid foods. Maximal interincisal opening range for all patients was 25 to 38 mm with no lateral deviation or subjective joint pain. No patient had progressive joint hypomobility or condylar migration. One patient had ankylosis, which required release. CONCLUSION/CONCLUSIONS:TMJ reconstruction poses considerable challenges in bone graft alignment for full restoration of joint function. The use of CAD/CAM technology can aid in accurate reconstruction of mandibular condyle defects with a vascularized free fibula flap through precise planning and intraoperative manipulation with optimal functional outcomes.