Faculty Bibliography

BACKGROUND:Patients undergoing autologous breast reconstruction have higher rates of patient-reported satisfaction compared to patients undergoing prosthetic reconstruction. Obesity has been shown to increase postoperative complications in both microsurgical and implant reconstructions. The authors evaluated the effects of microsurgical breast reconstruction and prosthetic breast reconstruction on patient-reported outcomes and quality of life in obese patients. METHODS:A retrospective review of obese patients who underwent breast reconstruction from January of 2009 to December of 2017 was conducted. Patients were divided into two cohorts: microsurgical and two-stage tissue expander/implant-based reconstruction. BREAST-Q survey response, demographic information, complications, and need for revision procedures were analyzed. RESULTS:One hundred fifty-five patients met the inclusion criteria: 75 (48.4 percent) underwent microsurgical breast reconstruction and 80 (51.6 percent) underwent implant-based reconstruction. Cohorts were similar in body mass index, mean mastectomy specimen weight, laterality, indication for surgery, smoking status, and postoperative complications. Microsurgical reconstruction patients were younger (49.0 years versus 53.0 years; p = 0.02) and more likely to have delayed reconstruction [n = 70 (64.2 percent) versus n = 0 (0.0 percent); p = 0.0001]. BREAST-Q responses showed that microsurgery patients were more satisfied with their breasts (Q-Score of 63.4 ± 6.9 versus 50.8 ± 12.8; p = 0.0001), overall outcome (Q-Score 70.5 ± 13.0 versus 60.3 ± 10.8; p = 0.0001), and chest physical well-being (Q-Score of 69.1 ± 10.9 versus 63.8 ± 8.2; p = 0.01). CONCLUSIONS:Microsurgical breast reconstruction in obese patients yields higher satisfaction with breasts, overall outcomes, and chest physical well-being than implant-based reconstruction. Despite increased postoperative complications associated with obesity, microsurgical breast reconstruction appears to be a good choice for women who understand its risks and benefits and choose to proceed with it.

BACKGROUND: The pectoralis major muscle flap is a versatile reconstructive option for deep sternal wound infections (DSWI). The timing and surgical technique of bilateral pectoralis major muscle advancement flaps versus unilateral pectoralis major muscle turnover and unilateral pectoralis major muscle advancement flap on patient outcomes remain to be elucidated. The purpose of this investigation was to compare timing, immediate versus delayed reconstruction, and the surgical technique in patients with deep sternal wounds infections on patient outcomes. METHODS: A retrospective review of patients who underwent sternal reconstruction with pectoralis major muscle was conducted. Patients diagnosed with DSWI after undergoing cardiac surgery were included for analysis. Patients were divided by flap timing and flap type for analyses. Bivariate tests were performed to compare patient clinical characteristics. Outcomes of interest were rates of postoperative complications, same admission mortality, reoperation, readmission, operating room time, and length of stay. RESULTS: = 0.019). CONCLUSION/CONCLUSIONS: Patients who underwent pectoralis major muscle advancement flaps had lower incidence of tissue necrosis. Furthermore, the timing of immediate sternal reconstruction was associated with a decreased hospital length of stay.

BACKGROUND: Delayed immediate (DI) autologous breast reconstruction consists of immediate postmastectomy tissue expander placement, radiation therapy, and subsequent autologous reconstruction. The decision between timing of reconstructive methods is challenging and remains to be elucidated. We aim to compare patient reported outcomes and quality of life between delayed and DI reconstruction. METHODS: A retrospective review of all patients, who underwent autologous breast reconstruction at Montefiore Medical Center from January 2009 to December 2016, was conducted. Patients who underwent postmastectomy radiotherapy were divided into two cohorts: delayed and DI autologous breast reconstruction. Patients were mailed a BREAST-Q survey and their responses, demographic information, complications, and need for revisionary procedures were analyzed. RESULTS: = 30) in the DI group. Responses showed similar satisfaction with their breasts, well-being, and overall outcome. CONCLUSIONS: Delayed and DI autologous breast reconstruction yield similar patient-reported satisfaction; however, patients undergoing DI reconstruction have higher rates of major mastectomy necrosis. Furthermore, patients in the DI group risk premature tissue expander removal.

BACKGROUND:Integrated plastic surgery residency applicants sometimes complete research fellowships before residency. The average productivity and the impact of these fellowships on subsequent application to residency are unknown. The purpose of this study was to provide objective data to better understand the utility and productivity of a research fellowship. METHODS:A national survey was conducted in which integrated plastic surgery residency applicants from 2013 to 2016 were surveyed regarding their experiences with research fellowships. American Council of Academic Plastic Surgeons members were also surveyed to elicit their perspectives on the value of these fellowships. RESULTS:Six hundred twenty-one integrated plastic surgery applicants from 2013 to 2016 were included in the study. Twenty-five percent of applicants participated in a research fellowship. Applicants who completed research fellowships were more likely to match into plastic surgery compared to those who did not (97 percent versus 81 percent, respectively; p < 0.05). Fellows were highly satisfied with their fellowship experience and produced an average of five publications and presentations per fellowship year. Sixty-three percent of research fellowships were performed to strengthen applications to categorical integrated plastic surgery residency. American Council of Academic Plastic Surgeons members considered three or four publications/presentations productive. Most do not recommend research fellowships to all medical students. CONCLUSIONS:Research fellowships can effectively prepare for categorical plastic surgery by improving publication and presentation experience. This is the first study to show that applicants who completed research fellowships were highly satisfied with their experience, accomplished higher than expected levels of productivity, and statistically significantly matched into an integrated plastic surgery residency more often than applicants without research fellowships.

BACKGROUND:Determinants of residency program reputation are multifactorial and include operative training, academic productivity, and geographic location. However, little is known about these relationships. This study aims to investigate the correlation between academic reputation of integrated plastic surgery programs and the research productivity of their respective full time faculty members. METHODS:Program rankings were identified from the 2016 Doximity standings and divided into 4 quartiles (Q1-Q4). Full-time faculty and program directors were identified through program websites. Publications by faculty members from 2000 to 2015 were identified through PubMed. Variables collected included affiliated institution, date of publication, authorship position, and journal. RESULTS:A total of 67 programs with 607 full-time faculty members were identified. Although not significantly different, program directors had a higher mean number of publications compared with faculty members for Q1, Q2, and Q4. Program departmental chairs had a significantly higher mean number of publications for Q1 and Q2. The Q1 faculty had a significantly higher mean number of publications as compared with Q2, Q3, and Q4. Although all quartiles had similar mean first author publications, Q1 and Q2 had more middle and last author publications. In addition, the higher-ranked programs were more likely to have faculty as middle authors of articles with more contributors. They were also more likely to publish in Plastic Reconstructive Surgery compared with other journals. CONCLUSIONS:Academic reputation of integrated plastic surgery residency programs is correlated with the scholarly activity of full-time faculty.

BACKGROUND: Venous thromboembolism (VTE) is a significant cause of postoperative morbidity and a focus of patient safety initiatives. Despite giving appropriate prophylaxis in accordance with the Caprini risk assessment model, we observed a high incidence of VTE in patients undergoing microsurgical breast reconstruction at our institution. To explore factors contributing to these events, we compared patients undergoing microsurgical breast reconstruction who sustained postoperative VTEs to those who did not. METHODS: A retrospective review of all patients who underwent microsurgical free flap breast reconstruction at Montefiore Medical Center from January 2009 to January 2016 was conducted. Patients were divided into two cohorts; those sustaining postoperative VTE and those who did not. Patients were compared based on demographics, comorbidities, operative time, estimated intraoperative blood loss, need for transfusion, volume of transfusion, and discharge on postoperative aspirin. RESULTS: = 0.003). CONCLUSION/CONCLUSIONS: Patients sustaining postoperative VTE after microsurgical breast reconstruction are more likely to have an increased volume of blood transfusions and lack of discharge on postoperative aspirin.

BACKGROUND:Breast cancer is the most commonly diagnosed malignancy in women. Mastectomy and breast-conserving surgery (BCS) have equivalent survival for early stage breast cancer. However, each surgery has different benefits and harms that women may value differently. Women of lower socioeconomic status (SES) diagnosed with early stage breast cancer are more likely to experience poorer doctor-patient communication, lower satisfaction with surgery and decision-making, and higher decision regret compared to women of higher SES. They often play a more passive role in decision-making and are less likely to undergo BCS. Our aim is to understand how best to support women of lower SES in making decisions about early stage breast cancer treatments and to reduce disparities in decision quality across socioeconomic strata. METHODS:We will conduct a three-arm, multi-site randomized controlled superiority trial with stratification by SES and clinician-level randomization. At four large cancer centers in the United States, 1100 patients (half higher SES and half lower SES) will be randomized to: (1) Option Grid, (2) Picture Option Grid, or (3) usual care. Interviews, field-notes, and observations will be used to explore strategies that promote the interventions' sustained use and dissemination. Community-Based Participatory Research will be used throughout. We will include women aged at least 18 years of age with a confirmed diagnosis of early stage breast cancer (I to IIIA) from both higher and lower SES, provided they speak English, Spanish, or Mandarin Chinese. Our primary outcome measure is the 16-item validated Decision Quality Instrument. We will use a regression framework, mediation analyses, and multiple informants analysis. Heterogeneity of treatment effects analyses for SES, age, ethnicity, race, literacy, language, and study site will be performed. DISCUSSION:Currently, women of lower SES are more likely to make treatment decisions based on incomplete or uninformed preferences, potentially leading to poorer decision quality, quality of life, and decision regret. This study hopes to identify solutions that effectively improve patient-centered care across socioeconomic strata and reduce disparities in decision and care quality. TRIAL REGISTRATION:NCT03136367 at ClinicalTrials.gov Protocol version: Manuscript based on study protocol version 2.2, 7 November 2017.

LEARNING OBJECTIVES/OBJECTIVE:After studying this article, the participant should be able to: 1. Understand the anatomy of the peripelvic area. 2. Understand the advantages and disadvantages of performing peripelvic reconstruction in patients undergoing oncologic resection. 3. Select the appropriate local, pedicled, or free-flap reconstruction based on the location of the defect and donor-site characteristics. SUMMARY/CONCLUSIONS:Peripelvic reconstruction most commonly occurs in the setting of oncologic ablative surgery. The peripelvic area contains several distinct reconstructive regions, including vagina, vulva, penis, and scrotum. Each area provides unique reconstructive considerations. In addition, prior or future radiation therapy or chemotherapy along with cancer cachexia can increase the complexity of reconstruction.

BACKGROUND:Fifteen million U.S. patients each year seek medical care abroad; however, there are no data on outcomes and follow-up of these procedures. This study aims to identify, evaluate, and survey patients presenting with complications from aesthetic procedures abroad and estimate their cost to the U.S. health care system. METHODS:A single-center retrospective review was conducted. A cohort of patients presenting with complications from aesthetic procedures performed abroad was generated. Demographic, complication, and cost data were compiled. Patients were surveyed to assess their overall experience. RESULTS:Over a 36-month period, 42 patients met inclusion criteria (one man and 41 women), with an average age of 35 ± 11.4 years (range, 20 to 60 years). Comorbidities included four active smokers, two patients with hypertension, and one patient with diabetes. Average body mass index was 29 ± 4.4 kg/m (range, 22 to 38 kg/m). Procedures performed abroad included abdominoplasty (n = 28), liposuction (n = 20), buttock augmentation (n = 10), and breast augmentation (n = 7), with several patients undergoing combined procedures. Eleven patients presented with abscesses and eight presented with wound dehiscence. Eight of the 18 patients who were surveyed were not pleased with their results and 11 would not go abroad again for subsequent procedures. Average cost of treating the complications was $18,211, with an estimated cost to the U.S. health care system of $1.33 billion. The main payer group was Medicaid. CONCLUSIONS:Complications from patients seeking aesthetic procedures abroad will continues to increase. Patients should be encouraged to undergo cosmetic surgery in the United States to improve patient outcomes and satisfaction and because it is economically advantageous. CLINICAL QUESTION/LEVEL OF EVIDENCE/METHODS:Therapeutic, IV.