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Given that a woman can be a candidate for multiple medically appropriate methods of breast reconstruction, making a decision on which method to pursue can be a difficult one.1 Normative decision-making is a framework that could be used to help women make difficult decisions about breast reconstruction. Normative decision-making is an exhaustive, iterative process that involves identifying alternatives, obtaining information about the uncertainty of the outcomes, and clarifying preferences and values.2–4 For the case of breast reconstruction, the alternatives, that is, different reconstruction procedures, are very well understood.1,5,6 However, information about the uncertainties of the outcomes (eg, number of revisions needed, chances of experiencing a complication, or the final aesthetic result) is more difficult to obtain because large quantities of data may not exist for uncommon procedures or rare patient profiles. Clarifying preferences and values about breast reconstruction is also challenging7–9; however, the focus of this study is on the difficulty of estimating the probabilities of reconstruction outcomes. Such probabilities may be employed by future computational decision support systems to aid in patient decision-making and may make use of surgeon predictions obtained before system deployment. In the clinical decision-making literature, it is suggested that, in the absence of large quantities of data, probabilities of outcomes can be estimated by experts,10–12 that is, plastic surgeons in the case of breast reconstruction. Of course, estimating probabilities about breast reconstruction outcomes is difficult because there are numerous variables involved. Moreover, to provide the information needed for decision support, plastic surgeons must be able to estimate outcome probabilities in general, not simply for their own patients. However, we are unaware of any prior studies that address the validity of expert-elicited probabilities about breast reconstruction outcomes. The clinical impact of this study is in the context of a future computational decision support system for shared breast reconstruction decision-making. Such systems require patient-specific probability information that surgeons may provide. The goal of this study was to investigate to what extent plastic surgeons can predict breast reconstruction outcomes. The purpose of the system is to inform both the patient and the surgeon of risk and help them make better decisions regarding breast reconstruction.

Learning Objectives Describe the significant locoregional clinical interaction that may result from ixabepilone chemotherapy following radiation. Explain the importance of awareness, detection, and management of radiation recall by both the medical and the radiation oncologist. Describe the spectrum of toxicity represented by radiation recall that can range from erythema to chest wall necrosis requiring reconstructive surgery. Background. Radiation recall is an acute inflammatory reaction within a previously irradiated field triggered by chemotherapy administration. We observed a series of patients with unexpectedly severe reactions that included radiation recall and delayed healing when patients received the microtubule stabilizer ixabepilone (Ixempra; Bristol-Myers Squibb, Princeton, NJ) after radiation. We therefore decided to evaluate our experience in patients receiving ixabepilone following radiotherapy. Methods. We performed a retrospective chart review of all patients treated with curative intent in the Department of Radiation Oncology at the MD Anderson Cancer Center from 2008–2011 who received any ixabepilone after completion of external-beam radiation therapy. These patients received adjuvant ixabepilone on one of two protocols, either for locally advanced breast cancer or for metastatic breast cancer. In total, 19 patients were identified and their charts were subsequently reviewed for evidence of ixabepilone-related toxicity. Results. Of the 19 patients identified who received ixabepilone following radiation therapy, three (15.8%) had unexpectedly serious reactions in the months following radiation therapy. Complications included delayed wound closure and drain placement into the seroma, intense erythema, and delayed wound closure and grade 4 chest wall necrosis requiring latissimus flap and skin grafting. The average number of days between the end of radiation therapy and documentation of reaction was 99. Conclusions. Ixabepilone chemotherapy may induce radiation recall and delayed wound healing when used shortly after the completion of external-beam radiotherapy. Significant clinical interactions have not been previously reported and merit further evaluation.

Mesh materials have undergone a considerable evolution over the last several decades. There has been enhancement of biomechanical properties, improvement in manufacturing processes, and development of antiadhesive laminate synthetic meshes. The evolution of bioprosthetic mesh materials has markedly changed our indications and methods for complex abdominal wall reconstruction. The authors review the optimal properties of bioprosthetic mesh materials, their evolution over time, and their indications for use. The techniques to optimize outcomes are described using bioprosthetic mesh for complex abdominal wall reconstruction. Bioprosthetic mesh materials clearly have certain advantages over other implantable mesh materials in select indications. Appropriate patient selection and surgical technique are critical to the successful use of bioprosthetic materials for abdominal wall repair.