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Breast reconstruction during the COVID-19 pandemic: Single institution experience from the pandemic's epicenter in the United States

Boyd, Carter J; Hemal, Kshipra; Ramesh, Sruthi; Bekisz, Jonathan M; Salibian, Ara A; Thanik, Vishal; Levine, Jamie P; Choi, Mihye; Karp, Nolan S
INTRODUCTION/BACKGROUND:The coronavirus disease-19 (COVID-19) pandemic dramatically changed the delivery of breast cancer care. The objective of this study was to quantify the effect of the pandemic on breast cancer screening, treatment, and reconstruction at a single institution in New York City. METHODS:A retrospective chart review was conducted to determine the number of mammograms, lumpectomies, mastectomies, and breast reconstruction operations performed between January 1, 2019 and June 30, 2021. Outcomes analyzed included changes in mammography, oncologic surgery, and breast reconstruction surgery volume before, during and after the start of the pandemic. RESULTS:Mammography volume declined by 11% in March-May of 2020. Oncologic breast surgeries and reconstructive surgeries similarly declined by 6.8% and 11%, respectively, in 2020 compared with 2019, reaching their lowest levels in April 2020. The volume of all procedures increased during the summer of 2020. Mammography volumes in June and July 2020 were found to be at pre-COVID levels, and in October-December 2020 were 15% higher than in 2019. Oncologic breast surgeries saw a similar rebound in May 2020, with 24.6% more cases performed compared with May 2019. Breast reconstruction volumes increased, though changes in the types of reconstruction were noted. Oncoplastic closures were more common during the pandemic, while two-stage implant reconstruction and immediate autologous reconstruction decreased by 27% and 43%, respectively. All procedures are on track to increase in volume in 2021 compared to that in 2020. CONCLUSION/CONCLUSIONS:The COVID-19 pandemic reduced the volume of breast cancer surveillance, surgical treatment, and reconstruction procedures. While it is reassuring that volumes have rebounded in 2021, efforts must be made to emphasize screening and treatment procedures in the face of subsequent surges, such as that recently attributable to the Delta and Omicron variants.
PMID: 35317981
ISSN: 1878-0539
CID: 5200492

Gender-affirming Phalloplasty: A Postoperative Protocol for Success

Rifkin, William J; Daar, David A; Cripps, Courtney N; Mars, Ginger; Zhao, Lee C; Levine, Jamie P; Bluebond-Langner, Rachel
Increased access to care and insurance coverage has led to an increase in gender-affirming surgeries performed in the United States. Gender-affirming phalloplasty has a variety of donor sites and surgical techniques including both pedicled and free flaps. Although surgical techniques and patient outcomes are well-described, no reports in the literature specifically discuss postoperative management, which plays a crucial role in the success of these operations. Here, we present a postoperative protocol based on our institution's experience with gender-affirming phalloplasty with the hope it will serve as a standardized, reproducible reference for centers looking to offer these procedures.
PMID: 35747259
ISSN: 2169-7574
CID: 5282242

Single Versus Double Venous Anastomosis Microvascular Free Flaps for Head and Neck Reconstruction

Boczar, Daniel; Colon, Ricardo Rodriguez; Anzai, Lavinia; Daar, David A; Chaya, Bachar F; Trilles, Jorge; Levine, Jamie P; Jacobson, Adam S
ABSTRACT/UNASSIGNED:Venous congestion accounts for most microvascular free tissue flaps failures. Given the lack of consensus on the use of single versus dual venous outflow, the authors present our institutional experience with 1 versus 2 vein anastomoses in microvascular free flap for head and neck reconstruction. A retrospective chart review was performed on all patients undergoing free flaps for head and neck reconstruction at our institution between 2008 and 2020. The authors included patients who underwent anterolateral thigh, radial forearm free flap, or fibula free flaps. The authors classified patients based on the number of venous anastomoses used and compared complication rates. A total of 279 patients with a mean age of 55.11 years (standard deviation 19.31) were included. One hundred sixty-eight patients (60.2%) underwent fibula free flaps, 59 (21.1%) anterolateral thigh, and 52 (18.6%) radial forearm free flap. The majority of patients were American Society of Anesthesiologists classification III or higher (N = 158, 56.6%) and had history of radiation (N = 156, 55.9%). Most flaps were performed using a single venous anastomosis (83.8%). Univariate analysis of postoperative outcomes demonstrated no significant differences in overall complications (P = 0.788), flap failure (P = 1.0), return to the Operating Room (OR) (P = 1.0), hematoma (P = 0.225), length of hospital stay (P = 0.725), or venous congestion (P = 0.479). In our cohort, the rate of venous congestion was not statistically different between flaps with 1 and 2 venous anastomoses. Decision to perform a second venous anastomoses should be guided by anatomical location, vessel lie, flap size, and intraoperative visual assessment.
PMID: 34643603
ISSN: 1536-3732
CID: 5244642

Robotic deep inferior epigastric perforator flap harvest in breast reconstruction

Daar, David A; Anzai, Lavinia M; Vranis, Neil M; Schulster, Michael L; Frey, Jordan D; Jun, Min; Zhao, Lee C; Levine, Jamie P
INTRODUCTION/BACKGROUND:Reducing donor site morbidity after deep inferior epigastric artery perforator (DIEP) flap harvest relies mainly upon maintaining integrity of the anterior rectus sheath fascia. The purpose of this study is to describe our minimally-invasive technique for robotic DIEP flap harvest. METHODS:), respectively. Average follow-up was 6.31 months (range: 5.73-7.27 months). Robotic flap harvest was performed with intramuscular perforator dissection in standard fashion, followed by the transabdominal preperitoneal (TAPP) approach to DIEP pedicle harvest using the da Vinci Xi robot. Data was collected on demographic information, perioperative characteristics. Primary outcomes included successful flap harvest as well as donor site morbidity (e.g., abdominal bulge, hernia, bowel obstruction, etc.). RESULTS:All four patients underwent bilateral abdominally-based free flap reconstruction. Three patients received bilateral robotic DIEP flaps, and one patient underwent unilateral robotic DIEP flap reconstruction. The da Vinci Xi robot was used in all cases. Average flap weight and pedicle length were 522 g (range: 110-809 g) and 11.2 cm (range: 10-12 cm), respectively. There were no flap failures, and no patient experienced abdominal wall donor site morbidity on physical exam. CONCLUSION/CONCLUSIONS:While further studies are needed to validate its use, this report represents the largest series of robotic DIEP flap harvests to date and is a valuable addition to the literature.
PMID: 34984741
ISSN: 1098-2752
CID: 5107102

Salvage Superficial Temporal Artery to Middle Cerebral Artery Direct Bypass Using an Interposition Graft for Failed Encephaloduroarteriosynangiosis in Moyamoya Disease

Kim, Nora C; Raz, Eytan; Shapiro, Maksim; Riina, Howard A; Nelson, Peter K; Levine, Jamie P; Nossek, Erez
BACKGROUND:Moyamoya disease may present with either hemorrhagic or ischemic strokes. Surgical bypass has previously demonstrated superiority when compared to natural history and medical treatment alone. The best bypass option (direct vs. indirect), however, remains controversial in regard to adult ischemic symptomatic moyamoya disease. Multiple studies have demonstrated clinical as well as angiographic effectiveness of direct bypass in adult hemorrhagic moyamoya disease. In particular, there are limited data regarding strategies in the setting of failed indirect bypass with recurrent hemorrhagic strokes. Here, we describe a salvage procedure. METHODS:We describe a case of a 52-year-old man who presented with hemorrhagic moyamoya disease and failed previous bilateral encephaloduroarteriosynangiosis (EDAS) procedures at an outside institution. On a 3-year follow-up diagnostic cerebral angiogram, no synangiosis was noted on the right side and only minimal synangiosis was present on the left. The left hemisphere was significant for a left parietal hypoperfusion state. We performed a salvage left proximal superficial temporal artery to distal parietal M4 middle cerebral artery bypass using the descending branch of the lateral circumflex artery as an interposition graft with preservation of the existing EDAS sites. RESULTS:The patient underwent the procedure successfully and recovered well with resolution of headaches and no further strokes or hemorrhages on the 1-year follow-up magnetic resonance imaging of the brain. CONCLUSIONS:This case presents the use of a salvage direct bypass technique for recurrent symptomatic hemorrhagic moyamoya disease after failed EDAS. The strategy, approach, and technical nuances of this unique case have implications for revascularization options.
PMID: 35421586
ISSN: 1878-8769
CID: 5219102

Osteoradionecrosis following radiation to reconstructed mandible with titanium plate and osseointegrated dental implants

Byun, David J; Daar, David A; Spuhler, Karl; Anzai, Lavinia; Witek, Lukasz; Barbee, David; Jacobson, Adam S; Levine, Jamie P; Hu, Kenneth S
PMID: 34706296
ISSN: 1879-8519
CID: 5042562

Wound Closure Following Intervention for Closed Orthopedic Trauma

Gotlin, Matthew J; Catalano, William; Levine, Jamie P; Egol, Kenneth A
The method of skin closure and post-operative wound management has always been important in orthopedic surgery and plays an even larger role now that surgical site infection (SSI) is a national healthcare metric for both surgeons and hospitals. Wound related issues remain some of the most feared complications following orthopedic trauma procedures and are associated with significant morbidity. In order to minimize the risk of surgical site complications, surgeons must be familiar with the physiology of wound healing as well as the patient and surgical factors affecting healing potential. The goal of all skin closure techniques is to promote rapid healing with acceptable cosmesis, all while minimizing risk of infection and dehiscence. Knowledge of the types of closure material, techniques of wound closure, surgical dressings, negative pressure wound therapy, and other local modalities is important to optimize wound healing. There is no consensus in the literature as to which closure method is superior but the available data can be used to make informed choices. Although often left to less experienced members of the surgical team, the process of wound closure and dressing the wound should not be an afterthought, and instead must be part of the surgical plan. Wounds that are in direct communication with bony fractures are particularly at risk due to local tissue trauma, resultant swelling, hematoma formation, and injured vasculature.
PMID: 34865820
ISSN: 1879-0267
CID: 5082872

Robotic-Assisted Testicular Autotransplantation

Chao, Brian W; Shakir, Nabeel A; Hyun, Grace S; Levine, Jamie P; Zhao, Lee C
Silber and Kelly first described the successful autotransplantation of an intra-abdominal testis in 1976. Subsequent authors incorporated laparoscopy and demonstrated the viability of transplanted testes based on serial postoperative exams. We sought to extend this experience with use of the da Vinci surgical robot, thereby demonstrating a novel robotic technique for the management of cryptorchidism. The procedure was performed for an 18-year-old male with a solitary left intra-abdominal testis. Following establishment of pneumoperitoneum, the robot is docked with four trocars oriented towards the left lower quadrant. Testicular dissection is carried out as shown. The gonadal and inferior epigastric vessels are isolated and mobilized; once adequate length is achieved, the former is clipped and transected, and the testicle and inferior epigastric vessels are delivered out of the body. The robot is then undocked and exchanged for the operating microscope. Arterial and venous anastomoses are completed with interrupted and running 9-0 Nylon, respectively, and satisfactory re-anastomosis is confirmed visually and with Doppler. The transplanted testicle is then fixed inferiorly and laterally within the left hemiscrotum, and all incisions are closed. We note that intraoperative testicular biopsy was not performed, for three reasons: (1) to avoid further risk to an already tenuous, solitary organ, (2) because our primary aim was to preserve testicular endocrine function, and (3) because the presence of ITGCN would neither prompt orchiectomy nor obviate the need for ongoing surveillance via periodic self-examination and ultrasonography. The patient is maintained on bed rest for two days and discharged on postoperative day seven in good condition. Over one year since autotransplantation, his now intra-scrotal testicle remains palpable and stable in size. Serum testosterone is unchanged from preoperative measurements. Robotic-assisted testicular autotransplantation is a feasible and efficacious management option for the solitary intra-abdominal testis.
PMID: 34627870
ISSN: 1527-9995
CID: 5061912

Comparing Incision Choices in Immediate Microvascular Breast Reconstruction after Nipple-Sparing Mastectomy: Unique Considerations to Optimize Outcomes

Salibian, Ara A; Bekisz, Jonathan M; Frey, Jordan D; Thanik, Vishal D; Levine, Jamie P; Karp, Nolan S; Choi, Mihye
BACKGROUND:Incision planning is a critical factor in nipple-sparing mastectomy outcomes. Evidence on optimal incision patterns in patients undergoing nipple-sparing mastectomy and immediate microvascular breast reconstruction is lacking in the literature. METHODS:A single-institution retrospective review was performed of consecutive patients undergoing nipple-sparing mastectomy and immediate microvascular autologous reconstruction from 2007 to 2019. Outcomes-including major mastectomy flap necrosis, full nipple-areola complex necrosis, and any major ischemic complication of the skin envelope-were compared among incision types. Multivariable logistic regression identified factors associated with major ischemic complication. RESULTS:Two hundred seventy-nine reconstructions (163 patients) were identified, primarily using internal mammary recipient vessels (98.9 percent). Vertical incisions were used in 139 cases; inframammary, in 53; lateral radial, in 51; and inverted-T, in 35. Thirty-two cases (11.5 percent) had major mastectomy flap necrosis, 11 (3.9 percent) had full nipple-areola complex necrosis, and 38 (13.6 percent) had any major ischemic complication. Inframammary incisions had higher rates of major ischemic complication (25 percent) than vertical (5.8 percent; p < 0.001) and lateral radial (7.8 percent; p = 0.032) incisions. Inverted-T incisions also had higher rates of major ischemic complication (36.1 percent) than both vertical (p < 0.001) and lateral radial (p = 0.002) incisions. Inframammary incisions (OR, 4.382; p = 0.002), inverted-T incisions (OR, 3.952; p = 0.011), and mastectomy weight (OR, 1.003; p < 0.001) were independently associated with an increased risk of major ischemic complication. Inframammary incisions with major ischemic complication demonstrated significantly higher body mass index, mastectomy weight, and flap weight compared to those without. CONCLUSIONS:Inframammary and inverted-T incisions are associated with a higher risk of major ischemic skin envelope complications after nipple-sparing mastectomy and immediate microvascular breast reconstruction. Radial incisions can be considered to optimize recipient vessel exposure without compromising perfusion. CLINICAL QUESTION/LEVEL OF EVIDENCE/METHODS:Therapeutic, III.
PMID: 34644280
ISSN: 1529-4242
CID: 5116122

Basal cell carcinoma after breast radiation: An uncommon disease with varying clinical presentations.

Poland, Sarah G.; Guth, Amber A.; Feinberg, Joshua Adam; Ebina, Wataru; Chiu, Ernest; Levine, Jamie; Gonzalez, Leonel Maldonado; Muggia, Franco
Current breast cancer care involves a multidisciplinary clinical approach for diagnosis and treatment including input from radiology, surgery, pathology, radiation, and medical oncology. Radiation is an integral part of the treatment for locoregionally confined breast cancer, and has well-recognized long-term risks of secondary malignancies, such as angiosarcomas. Basal cell carcinoma (BCC), a common skin malignancy, is not typically considered a radiation-induced carcinoma following breast cancer treatment. Our recent experience with 4 patients with vastly different presentations of BCC in previous radiation fields prompts the current report in order to alert clinicians to this entity.
ISSN: 2666-6219
CID: 5315662