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Background Radiation-associated soft tissue injury is a potentially devastating complication for head and neck cancer patients. The damage can range from minor sequelae such as xerostomia, which requires frequent daily maintenance, to destructive degenerative processes such as osteoradionecrosis, which can contribute to flap failure and delay or reverse oral rehabilitation. Despite the need for effective radioprotectants, the literature remains sparse, primarily focused on interventions beyond the surgeon's control, such as maintenance of good oral hygiene or modulation of radiation dose. Methods This narrative review aggregates and explores noninvasive, systemic treatment modalities for prevention or amelioration of radiation-associated soft tissue injury. Results We highlighted nine modalities with the most clinical potential, which include amifostine, melatonin, palifermin, hyperbaric oxygen therapy, photobiomodulation, pentoxifylline–tocopherol–clodronate, pravastatin, transforming growth factor-β modulators, and deferoxamine, and reviewed the benefits and limitations of each modality. Unfortunately, none of these modalities are supported by strong evidence for prophylaxis against radiation-associated soft tissue injury. Conclusion While we cannot endorse any of these nine modalities for immediate clinical use, they may prove fruitful areas for further investigation.

Introduction There is currently no consensus as to the comparative complication profiles of mini-plate (MP) and reconstruction bar (RB) osseous fixation in fibula flap mandibular reconstruction. The aim of this study is to compare complication rates associated with the use of MP versus RB fixation for vascularized fibula free flap (FFF) reconstruction of oncologic mandibular defects in an effort to better guide hardware utilization and pre-operative virtual surgical planning methods. Methods A systematic review and meta-analysis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed, EMBASE, and Cochrane Library databases were queried to identify studies related to FFF-based mandibular reconstruction with either MP or RB fixation. Primary endpoints of interest were plate complications, wound infection, mal- or non-union, and total flap loss. Complication rates were calculated as weighted proportions and compared via Fisher's exact testing. Results Sixteen studies met inclusion criteria, which examined 1,513 patients. Only three studies directly compared MP fixation with RB fixation. MP fixation was used in 828 (54.7%) cases and RB fixation in 685 (45.3%) cases. MP fixation demonstrated greater rates of plate-related complications (32.5% versus 18.8%, p 0.01, respectively), fistula formation (15.8% versus 4.7%, p = 0.04), total flap loss (9.4% versus 4.7%, p = 0.02), partial flap loss (20.6% versus 6.1%, p 0.01), and re-operation for vascular compromise (13.3% versus 4.0%, p 0.01). Rates of infection, mal-union/non-union, and wound dehiscence were similar across both groups. Conclusion Our results suggest that MP use may be associated with higher rates of plate-related complications. Though limited by outcome reporting heterogeneity, this review can serve as a template for future investigations evaluating the safety profiles of MP and RB fixation in head and neck surgery.

Background Nipple-sparing mastectomy is associated with a higher risk of mastectomy skin-flap necrosis than conventional skin-sparing mastectomy. There are limited prospective data examining modifiable intraoperative factors that contribute to skin-flap necrosis after nipple-sparing mastectomy. Methods Data on consecutive patients undergoing nipple-sparing mastectomy between April 2018 and December 2020 were recorded prospectively. Relevant intraoperative variables were documented by both breast and plastic surgeons at the time of surgery. The presence and extent of nipple and/or skin-flap necrosis was documented at the first postoperative visit. Necrosis treatment and outcome was documented at 8–10 weeks after surgery. The association of clinical and intraoperative variables with nipple and skin-flap necrosis was analysed, and significant variables were included in a multivariable logistic regression analysis with backward selection. Results Some 299 patients underwent 515 nipple-sparing mastectomies (54.8 per cent (282 of 515) prophylactic, 45.2 per cent therapeutic). Overall, 23.3 per cent of breasts (120 of 515) developed nipple or skin-flap necrosis; 45.8 per cent of these (55 of 120) had nipple necrosis only. Among 120 breasts with necrosis, 22.5 per cent had superficial, 60.8 per cent had partial, and 16.7 per cent had full-thickness necrosis. On multivariable logistic regression analysis, significant modifiable intraoperative predictors of necrosis included sacrificing the second intercostal perforator (P = 0.006), greater tissue expander fill volume (P < 0.001), and non-lateral inframammary fold incision placement (P = 0.003). Conclusion Modifiable intraoperative factors that may decrease the likelihood of necrosis after nipple-sparing mastectomy include incision placement in the lateral inframammary fold, preserving the second intercostal perforating vessel, and minimizing tissue expander fill volume.

Although greenhouse gases absorb primarily long-wave radiation, they also absorb short-wave radiation. Recent studies have highlighted the importance of methane short-wave absorption, which enhances its stratospherically adjusted radiative forcing by up to ~ 15%. The corresponding climate impacts, however, have been only indirectly evaluated and thus remain largely unquantified. Here we present a systematic, unambiguous analysis using one model and separate simulations with and without methane short-wave absorption. We find that methane short-wave absorption counteracts ~30% of the surface warming associated with its long-wave radiative effects. An even larger impact occurs for precipitation as methane short-wave absorption offsets ~60% of the precipitation increase relative to its long-wave radiative effects. The methane short-wave-induced cooling is due largely to cloud rapid adjustments, including increased low-level clouds, which enhance the reflection of incoming short-wave radiation, and decreased high-level clouds, which enhance outgoing long-wave radiation. The cloud responses, in turn, are related to the profile of atmospheric solar heating and corresponding changes in temperature and relative humidity. Despite our findings, methane remains a potent contributor to global warming, and efforts to reduce methane emissions are vital for keeping global warming well below 2 °C above preindustrial values.

Radiation therapy is increasingly used after breast cancer surgery, which may impact patients' postoperative quality of life. This study assessed differences in long-term patient satisfaction and health-related quality of life after radiation therapy administered at different stages of implant-based breast reconstruction or with no radiation after surgery.In this observational study, long-term outcomes were evaluated for four cohorts of women who completed breast reconstruction and received (1) no radiation, (2) radiation before tissue expander placement, (3) radiation after tissue expander placement, or (4) radiation after permanent implant between 2010 and 2017 at Memorial Sloan Kettering. Satisfaction and health-related quality of life were assessed using the prospectively collected Satisfaction with Breasts and Physical Well-Being of Chest BREAST-Q subscales. Score distributions were examined by radiation exposure status for 3 years after surgery using nonparametric analyses and regression models.Of 2932 patients who met the inclusion criteria, 25.8 percent received radiation during breast cancer treatment, including before tissue expander placement ( n = 239; 8.2 percent), after tissue expander placement ( n = 290; 9.9 percent), and after implant placement ( n = 228; 7.8 percent). Radiotherapy patients had average scores 7 to 9 points lower at all postoperative time points for Satisfaction with Breasts and Physical Well-Being of Chest subscales ( p0.001). Although patient-reported outcomes did not differ by radiation timing, there were higher rates of severe capsular contracture with postimplant radiotherapy ( p0.001).Radiation therapy significantly affected patient satisfaction and health-related quality of life following implant breast reconstruction through 3 years postoperatively. Patient perception of outcome was unaffected by radiotherapy timing; however, capsular contracture was higher after postimplant radiotherapy, suggesting there may be an advantage to performing radiotherapy before placement of the final reconstruction.Therapeutic, III.

Prepectoral placement of tissue expanders for two-stage implant-based breast reconstruction potentially minimizes chest wall morbidity and postoperative pain. The authors explored 90-day clinical and health-related quality-of-life outcomes for prepectoral versus subpectoral tissue expander breast reconstruction.The authors conducted a propensity score-matching analysis (nearest neighbor, 1:1 matching without replacement) of patients who underwent immediate prepectoral or subpectoral tissue expander breast reconstruction between December of 2017 and January of 2019. Matched covariates included age, body mass index, race/ethnicity, smoking status, chemotherapy, radiotherapy, nipple-sparing mastectomy, and laterality of reconstruction. Outcomes of interest were perioperative analgesia use, 90-day postoperative patient-reported pain, complication rates, and BREAST-Q physical well-being of the chest scores.Of the initial cohort of 921 patients, 238 were propensity-matched and included in the final analysis. The matched cohort had no differences in baseline characteristics. Postoperative ketorolac (p = 0.048) use was higher in the subpectoral group; there were no other significant differences in intraoperative and postoperative analgesia use. Prepectoral patients had lower pain on postoperative days 1 to 2 but no differences on days 3 to 10. BREAST-Q physical well-being of the chest scores did not differ. Prepectoral patients had higher rates of seroma than subpectoral patients (p0.001). Rates of tissue expander loss did not differ.This matched analysis of 90-day complications found lower early postoperative pain in prepectoral tissue expander patients but no longer-term patient-reported differences. Although prepectoral reconstruction patients experienced a higher rate of seroma, this did not translate to a difference in tissue expander loss. Long-term analysis of clinical and patient-reported outcomes is needed to understand the full profile of the prepectoral technique.Therapeutic, III.

BACKGROUND: Racial disparities are evident in multiple aspects of the perioperative care of breast cancer patients, but data examining if such differences translate to clinical and patient-reported outcomes are limited. This study examined the impact of race on perioperative outcomes in autologous breast reconstruction. METHODS: A retrospective cohort study including all breast cancer patients who underwent immediate autologous breast reconstruction at a single institution from 2010 to 2017 was conducted. Self-reported race was used to classify patients into 3 groups: white, African American, and other. The primary and secondary endpoints were occurrence of any major complications within 30 days of surgery and patient-reported outcomes (measured with the BREAST-Q), respectively. Regression models were constructed to identify factors associated with the outcomes. RESULTS: Overall, 404 patients, including 259(64%) white, 63(16%) African American, and 82(20%) patients from other minority groups, were included. African American patients had a significantly higher proportion of preoperative comorbidities. Postoperatively, African American patients had a higher incidence of 30-day major complications (p = 0.004) and were more likely to return to the operating room (p = 0.006). Univariable analyses examining complications demonstrated that race was the only factor associated with 30-day major complications (p = 0.001). Patient-reported outcomes were not statistically different at each time point through 3 years postoperatively. CONCLUSIONS: African American patients continue to present with increased comorbidities and may be more likely to experience major complications following immediate autologous breast reconstruction. However, patient-reported satisfaction or physical wellbeing outcomes may not differ between groups.

BACKGROUND Although rates of microvascular thrombosis following free-flap breast reconstruction are low, debate persists about the optimal methods to restore blood flow and prevent ensuing flap shrinkage or fibrosis. Here we evaluate our management of microvascular compromise, including both a review of our approach for restoring blood flow and addressing the ensuing inflammatory changes following ischemia reperfusion. METHODS We conducted a retrospective review of autologous free tissue transfer breast reconstructions from 1/2010 to 1/2020. Patients who had flaps requiring take-back for salvage were identified. Management of microvascular compromise and ischemia reperfusion injury were recorded. RESULTS Of 2103 flaps were used in the breast reconstructions, 47 flaps required take-back for microvascular compromise (2.2%). Most flaps were either completely salvaged (n = 29, 61.7%) or partially salvaged (n = 5, 10.6%). Thirteen (27.7%) were a total flap loss, for an overall rate of 0.8% (including 3 flaps with no salvage attempt). Management of microvascular compromise most often included revision of the anastomosis (n = 33, 70.2%), thrombectomy (n = 27, 57.4%), tissue plasminogen activator administration (n = 26, 55.3%), and vein grafts (n = 18, 38.3%). Management of ischemia reperfusion included intraoperative steroids (n = 33, 70.2%), postoperative steroids (n = 17, 38.6%), and postoperative therapeutic anticoagulation (n = 27, 61.3%). Of 34 salvaged flaps, 5 (14.7%) had partial flap loss and/or fat necrosis on clinical examination at an average follow-up of 2.7 ± 2.8 years. CONCLUSIONS Salvage of microvascular compromise in autologous breast reconstruction should include restoration of blood flow and management of ischemia reperfusion injury. Attention to both is paramount for successful outcomes.

Background Little is known about the risk factors associated with complications after free flap scalp reconstruction. The purpose of this study was to identify patient, scalp defect, and flap characteristics associated with increased risk of surgical complications. Methods A retrospective study was performed of free-flap scalp reconstruction in oncologic patients at Memorial Sloan Kettering Cancer Center from 2002 to 2017. Data collection included patient, defect, flap, and complication characteristics. Complications were classified into major, defined as complications requiring surgical intervention, and minor, defined as complications requiring conservative treatment. Risk factors and outcome variables were compared using chi-square with Fisher's exact test. Results A total of 63 free flaps to the scalp in 58 patients were performed; average follow-up was 3.5 years. Most flaps were muscle-only or musculocutaneous. One-third of patients with free flaps experienced complications (n = 21, 15 major and 6 minor). Examining risk factors for complications, patients with cardiovascular disease were nearly three times more likely to have suffered a major complication than patients without cardiovascular disease (36.7 vs. 12.1%, p = 0.04). This was the only significant risk factor noted. Perioperative radiotherapy, prior scalp surgery, flap type, and recipient vessel selection were found to be nonsignificant risk factors. Conclusion Cardiovascular disease may be a significant marker of risk for major complications in patients undergoing free-flap reconstruction of the scalp. This information should be used to help guide perioperative counseling and decision making in this challenging patient population.

Aggressive or restricted perioperative fluid management has been shown to increase complications in patients undergoing microsurgery. Goal-directed fluid therapy (GDFT) aims to administer fluid, vasoactive agents, and inotropes according to each patient's hemodynamic indices. This study assesses GDFT impact on perioperative outcomes of autologous breast reconstruction (ABR) patients, as there remains a gap in management understanding. We hypothesize that GDFT will have lower fluid administration and equivocal outcomes compared to patients not on GDFT.A single-center retrospective review was conducted on ABR patients from January 2010-April 2017. An enhanced recovery after surgery (ERAS) using GDFT was implemented in April 2015. With GDFT, patients were administered intraoperative fluids and vasoactive agents according to hemodynamic indices. Patients prior to April 2015 were included in the pre-ERAS cohort. Primary outcomes included the amount and rate of fluid delivery, urine output (UOP), vasopressor administration, major (i.e., flap failure) and minor (i.e., seroma) complications, and length of stay (LOS).Overall, 777 patients underwent ABR (ERAS: 312 and pre-ERAS: 465). ERAS patients received significantly less total fluid volume (ERAS median: 3750 mL [IQR: 3000-4500 mL]; pre-ERAS median: 5000 mL [IQR 4000-6400 mL]; and p0.001), had lower UOP, were more likely to receive vasopressor agents (47% vs 35% and p0.001), and had lower LOS (ERAS: 4 days [4-5]; pre-ERAS: 5 [4-6]; and p0.001) as compared to pre-ERAS patients. Complications did not differ between cohorts.GDFT, as part of ERAS, and the prudent use of vasopressors were found to be safe and did not increase morbidity in ABR patients. GDFT provides individualized perioperative care to the ABR patient.

Changes in anthropogenic aerosol emissions have strongly contributed to global and regional trends in temperature, precipitation, and other climate characteristics, and have been one of the dominant drivers of decadal trends in Asian and African precipitation. These, and other, influences on regional climate from changes in aerosol emissions are expected to continue, and potentially strengthen, in the coming decades. However, a combination of large uncertainties in emissions pathways, radiative forcing, and the dynamical response to forcing makes anthropogenic aerosol a key factor in the spread in near-term climate projections, particularly on regional scales, and therefore an important one to constrain. For example, in terms of future emissions pathways, the uncertainty in future global aerosol and precursor gas emissions by 2050 is as large as the total increase in emissions since 1850. In terms of aerosol effective radiative forcing, which remains the largest source of uncertainty in future climate change projections, CMIP6 models span a factor of five, from -0.3 to -1.5 W m-2. Both of these sources of uncertainty are exacerbated on regional scales. The Regional Aerosol Model Intercomparison Project (RAMIP) will deliver experiments designed to quantify the role of regional aerosol emissions changes in near-term projections. This is unlike any prior MIP, where the focus has been on changes in global emissions and/or very idealized aerosol experiments. Perturbing regional emissions makes RAMIP novel from a scientific standpoint, and links the intended analyses more directly to mitigation and adaptation policy issues. From a science perspective, there is limited information on how realistic regional aerosol emissions impact local as well as remote climate conditions. Here, RAMIP will enable an evaluation of the full range of potential influences of realistic and regionally varied aerosol emission changes on near-future climate. From the policy perspective, RAMIP addresses the burning question of how local and remote decisions affecting emissions of aerosols influence climate change in any given region. Here, RAMIP will provide the information needed to make direct links between regional climate policies and regional climate change. RAMIP experiments are designed to explore sensitivities to aerosol type and location, and provide improved constraints on uncertainties driven by aerosol radiative forcing and the dynamical response to aerosol changes. The core experiments will assess the effects of differences in future global and regional (East Asia, South Asia, Africa and the Middle East) aerosol emission trajectories through 2051, while optional experiments will test the nonlinear effects of varying emission location and aerosol types along this future trajectory. All experiments are based on the Shared Socioeconomic Pathways, and are intended to be performed with sixth Climate Model Intercomparison Project (CMIP6) generation models, initialised from the CMIP6 historical experiments, to facilitate comparisons with existing projections. Requested outputs will enable analysis of the role of aerosol in near-future changes in, for example, temperature and precipitation means and extremes, storms, and air quality.

The superficial inferior epigastric artery (SIEA) flap allows transfer of tissue without violating the rectus fascia. Traditionally it is best used in single stage reconstruction when vessel caliber is 1.5 mm; 56% to 70% of SIEAs are less than 1.5 mm and, therefore, not reliable. We aim to demonstrate the increased reliability of SIEA through surgical delay by quantifying reconstructive outcomes and delay-induced hemodynamic alterations.Patients presenting for autologous breast reconstruction between May 2019 and October 2020 were evaluated with preoperative imaging and received either delayed SIEA or delayed deep inferior epigastric (DIEP) reconstruction based on clinical considerations, such as prior surgery and perforator size/location. Prospective data were collected on operative time, length of stay, and complications. Arterial diameter and peak flow were quantified with Doppler ultrasound predelay and postdelay.Seventeen delayed SIEA flaps were included. The mean age (± SD) was 46.2 ± 10.55 years, and body mass index was 26.7 ± 4.26 kg/m2. Average hospital stay after delay was 0.85 ± 0.90 days, and duration before reconstruction was 6 days to 14.5 months. Delay complications included 1 abdominal seroma (n = 1, 7.7%). Superficial inferior epigastric artery diameter predelay (mean ± 95% confidence interval) was 1.37 ± 0.20 mm and increased to 2.26 ± 0.24 mm postdelay. A significant increase in diameter was noted 0.9 ± 0.22 mm (P0.0001). Mean peak flow predelay was 14.43 ± 13.38 cm/s and 44.61 ± 60.35 cm/s (n = 4, P = 0.1822) postdelay.Surgical delay of the SIEA flap augments SIEA diameter, increasing the reliability of this flap for breast reconstruction. Superficial inferior epigastric artery delay results in low rates of complications and no failures in our series. Although more patients are needed to assess increase in arterial flow, use of surgical delay can expand the use of SIEA flap reconstruction and reduce abdominal morbidity associated with abdominal flap breast reconstruction.

By regulating the global transport of heat, freshwater, and carbon, the Atlantic meridional overturning circulation (AMOC) serves as an important component of the climate system. During the late 20th and early 21st centuries, indirect observations and models suggest a weakening of the AMOC. Direct AMOC observations also suggest a weakening during the early 21st century but with substantial interannual variability. Long-term weakening of the AMOC has been associated with increasing greenhouse gases (GHGs), but some modeling studies suggest the build up of anthropogenic aerosols (AAs) may have offset part of the GHG-induced weakening. Here, we quantify 1900–2020 AMOC variations and assess the driving mechanisms in state-of-the-art climate models from the Coupled Model Intercomparison Project phase 6 (CMIP6). The CMIP6 forcing (GHGs, anthropogenic and volcanic aerosols, solar variability, and land use and land change) multi-model mean shows negligible AMOC changes up to ∼ 1950, followed by robust AMOC strengthening during the second half of the 20th century (∼ 1950–1990) and weakening afterwards (1990–2020). These multi-decadal AMOC variations are related to changes in North Atlantic atmospheric circulation, including an altered sea level pressure gradient, storm track activity, surface winds, and heat fluxes, which drive changes in the subpolar North Atlantic surface density flux. To further investigate these AMOC relationships, we perform a regression analysis and decompose these North Atlantic climate responses into an anthropogenic aerosol-forced component and a subsequent AMOC-related feedback. Similar to previous studies, CMIP6 GHG simulations yield robust AMOC weakening, particularly during the second half of the 20th century. Changes in natural forcings, including solar variability and volcanic aerosols, yield negligible AMOC changes. In contrast, CMIP6 AA simulations yield robust AMOC strengthening (weakening) in response to increasing (decreasing) anthropogenic aerosols. Moreover, the CMIP6 all-forcing AMOC variations and atmospheric circulation responses also occur in the CMIP6 AA simulations, which suggests these are largely driven by changes in anthropogenic aerosol emissions. More specifically, our results suggest that AMOC multi-decadal variability is initiated by North Atlantic aerosol optical thickness perturbations to net surface shortwave radiation and sea surface temperature (and hence sea surface density), which in turn affect sea level pressure gradient and surface wind and – via latent and sensible heat fluxes – sea surface density flux through its thermal component. AMOC-related feedbacks act to reinforce this aerosol-forced AMOC response, largely due to changes in sea surface salinity (and hence sea surface density), with temperature-related (and cloud-related) feedbacks acting to mute the initial response. Although aspects of the CMIP6 all-forcing multi-model mean response resembles observations, notable differences exist. This includes CMIP6 AMOC strengthening from ∼ 1950 to 1990, when the indirect estimates suggest AMOC weakening. The CMIP6 multi-model mean also underestimates the observed increase in North Atlantic ocean heat content, and although the CMIP6 North Atlantic atmospheric circulation responses – particularly the overall patterns – are similar to observations, the simulated responses are weaker than those observed, implying they are only partially externally forced. The possible causes of these differences include internal climate variability, observational uncertainties, and model shortcomings, including excessive aerosol forcing. A handful of CMIP6 realizations yield AMOC evolution since 1900 similar to the indirect observations, implying the inferred AMOC weakening from 1950 to 1990 (and even from 1930 to 1990) may have a significant contribution from internal (i.e., unforced) climate variability. Nonetheless, CMIP6 models yield robust, externally forced AMOC changes, the bulk of which are due to anthropogenic aerosols.

The gold standard for autologous reconstruction in the post-mastectomy patient remains the deep inferior epigastric artery perforator flap, although many women may not be candidates for abdominally based free tissue transfer. In this scenario, there are several other donor site options based from the thigh (transverse and diagonal upper gracilis flaps, profunda artery perforator flap, lateral thigh flap) and trunk (lumbar artery perforator flap, superior and inferior gluteal artery perforator flaps). This study will review the history, relevant anatomy, surgical technique and outcomes for alternative flaps in autologous reconstruction. Additionally, preoperative imaging (CTA, MRA) and novel applications (stacking flaps, neurotization) in breast reconstructive microsurgery will be discussed.

Precise planning and evaluation of the fibula bone are necessary if immediate endosseous implant placement is considered. Limited information is available on the anatomical dimensions or density of fibula used in mandibular reconstructions. This study aimed to describe the morphology and dimensions of the fibula used to reconstruct segmental mandibular defects and contrast the findings with the native mandible.A retrospective analysis was performed of patients who underwent segmental mandibulectomy reconstructed with osteocutaneous fibula flaps and had at least one postoperative computed tomography scan. Fibula cross sectional dimensions and densities were evaluated with three-dimensional software. Radiographic measurements were obtained from the contralateral mandible medial to the first molar for comparison.Four hundred seventy-seven fibula cross sections from 159 segments were evaluated. Cross-sectional oval, quadrilateral, triangular, and pentagonal shapes differed significantly in proportion (p0.001). Thirty-eight percent of segments (95 percent CI, 30 to 46 percent) had differences in cross-section height greater than 1 mm (p0.001). Between segments within the same patient, the median height difference was 1.58 mm (range, 0.14 to 6 mm). The superior cortex density was significantly higher for the fibula than the native mandible; however, the medullary space density was significantly lower (p0.001).The current study comprises the most comprehensive description of fibula morphology in mandibular reconstructions and highlights the significant variability that exists. The findings provide justification for the added time and cost of computer-aided design and computer-aided manufacturing in centers interested in performing immediate dental implant placement, as the technology provides the necessary precision and accuracy.

Oral cancer treatment involving the maxilla and/or mandible often results in esthetic and functional deficits that can diminish the patient's quality of life. As a result, expeditious reconstruction of the defect and dental rehabilitation is desirable. Dental rehabilitation shortly after reconstruction with an osteocutaneous free flap and resection prosthesis is a persistent challenge for patients with oncologic defects where immediate dental rehabilitation is not a possibility. Additionally, conventional prosthesis fabrication techniques are impractical or impossible due to postoperative anatomical changes and limitations in clinical armamentarium. To address these limitations, a technique and a novel implant-supported prosthetic workflow for the oncologic patient were developed to provide interim dental rehabilitation for such clinical situations. This article describes the prosthesis fabrication technique, reports short-term outcomes, and evaluates patient-reported quality-of-life outcomes using the FACE-Q Head and Neck Cancer Module.

BACKGROUND Rates of autologous breast reconstruction are stagnant compared with prosthetic techniques. Insufficient physician payment for microsurgical autologous breast reconstruction is one possible explanation. The payment difference between governmental and commercial payers creates a natural experiment to evaluate its impact on method of reconstruction. This study assessed the influence of physician payment differences for microsurgical autologous breast reconstruction and implants by insurance type on the likelihood of undergoing microsurgical reconstruction. METHODS The Massachusetts All-Payer Claims Database was queried for women undergoing immediate autologous or implant breast reconstruction from 2010 to 2014. Univariate analyses compared demographic and clinical characteristics between different reconstructive approaches. Logistic regression explored the relative impact of insurance type and physician payments on breast reconstruction modality. RESULTS Of the women in this study, 82.7 percent had commercial and 17.3 percent had governmental insurance. Implants were performed in 80 percent of women, whereas 20 percent underwent microsurgical autologous reconstruction. Women with Medicaid versus commercial insurance were less likely to undergo microsurgical reconstruction (16.4 percent versus 20.3 percent; p = 0.063). Commercial insurance, older age, and obesity independently increased the odds of microsurgical reconstruction (p < 0.01). When comparing median physician payments, governmental payers reimbursed 78 percent and 63 percent less than commercial payers for microsurgical reconstruction ($1831 versus $8435) and implants ($1249 versus $3359, respectively). Stratified analysis demonstrated that as physician payment increased, the likelihood of undergoing microsurgical reconstruction increased, independent of insurance type (p < 0.001). CONCLUSIONS Women with governmental insurance had lower odds of undergoing microsurgical autologous breast reconstruction compared with commercial payers. Regardless of payer, greater reimbursement for microsurgical reconstruction increased the likelihood of microsurgical reconstruction. Current microsurgical autologous breast reconstruction reimbursements may not be commensurate with physician effort when compared to prosthetic techniques. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, II.

Climate change modulates the concentration of fine particulate matter (PM2.5) via modifying atmospheric circulation, temperature, and the hydrological cycle. Furthermore, PM2.5is associated with cardiopulmonary diseases and premature mortality. Here, we use seven models to assess the response of PM2.5to end of the twenty-first century climate change under Representative Concentration Pathway 8.5, and the corresponding impact on premature mortality. The majority of models yield an increase in both PM2.5and premature mortality associated with lung cancer and cardiopulmonary disease in all world regions except Africa. These results are robust across five different future population projections, although the magnitude of premature deaths can vary by up to a factor of two. Much larger uncertainty is related to uncertainty in model physics and the representation of aerosol processes. Although our analysis requires several assumptions related to future population estimates, as well as the concentration-response function, results suggest that future emission reductions are necessary to avoid the likely health risks associated with increasing PM2.5in a warmer world.

It is important to understand how future environmental policies will impact both climate change and air pollution. Although targeting near-term climate forcers (NTCFs), defined here as aerosols, tropospheric ozone, and precursor gases, should improve air quality, NTCF reductions will also impact climate. Prior assessments of the impact of NTCF mitigation on air quality and climate have been limited. This is related to the idealized nature of some prior studies, simplified treatment of aerosols and chemically reactive gases, as well as a lack of a sufficiently large number of models to quantify model diversity and robust responses. Here, we quantify the 2015–2055 climate and air quality effects of non-methane NTCFs using nine state-of-the-art chemistry–climate model simulations conducted for the Aerosol and Chemistry Model Intercomparison Project (AerChemMIP). Simulations are driven by two future scenarios featuring similar increases in greenhouse gases (GHGs) but with “weak” (SSP3-7.0) versus “strong” (SSP3-7.0-lowNTCF) levels of air quality control measures. As SSP3-7.0 lacks climate policy and has the highest levels of NTCFs, our results (e.g., surface warming) represent an upper bound. Unsurprisingly, we find significant improvements in air quality under NTCF mitigation (strong versus weak air quality controls). Surface fine particulate matter (PM2.5) and ozone (O3) decrease by -2.2±0.32 µg m−3 and -4.6±0.88 ppb, respectively (changes quoted here are for the entire 2015–2055 time period; uncertainty represents the 95 % confidence interval), over global land surfaces, with larger reductions in some regions including south and southeast Asia. Non-methane NTCF mitigation, however, leads to additional climate change due to the removal of aerosol which causes a net warming effect, including global mean surface temperature and precipitation increases of 0.25±0.12 K and 0.03±0.012 mm d−1, respectively. Similarly, increases in extreme weather indices, including the hottest and wettest days, also occur. Regionally, the largest warming and wetting occurs over Asia, including central and north Asia (0.66±0.20 K and 0.03±0.02 mm d−1), south Asia (0.47±0.16 K and 0.17±0.09 mm d−1), and east Asia (0.46±0.20 K and 0.15±0.06 mm d−1). Relatively large warming and wetting of the Arctic also occur at 0.59±0.36 K and 0.04±0.02 mm d−1, respectively. Similar surface warming occurs in model simulations with aerosol-only mitigation, implying weak cooling due to ozone reductions. Our findings suggest that future policies that aggressively target non-methane NTCF reductions will improve air quality but will lead to additional surface warming, particularly in Asia and the Arctic. Policies that address other NTCFs including methane, as well as carbon dioxide emissions, must also be adopted to meet climate mitigation goals.

Obesity is a significant public health concern and clear risk factor for complications following breast reconstruction. To date, few have assessed patient-reported outcomes (PROs) focused on this key determinant. Our study aimed to investigate the impact of obesity (body mass index ≥ 30) on postoperative satisfaction and physical function utilizing the BREAST-Q in a cohort of autologous breast reconstruction patients. An Institutional Review Board-approved prospective investigation was conducted to evaluate PROs in patients undergoing autologous breast reconstruction from 2009 to 2017 at a tertiary academic medical center. The BREAST-Q reconstruction module was used to assess outcomes between cohorts preoperatively and at 6 months, 1 year, 2 years, and 3 years after reconstruction. Overall, 404 patients underwent autologous breast reconstruction with abdominal free-tissue transfer (244 non-obese, 160 obese) and completed the BREAST-Q. Although obese patients demonstrated lower satisfaction with breasts preoperatively (p = 0.04), no significant differences were noted postoperatively (p = 0.58). However, physical well-being of the abdomen was lower in the obese cohort compared with their non-obese counterparts at long-term follow-up (3 years; p = 0.04). Obesity significantly impacts autologous breast reconstruction patients. Although obese patients are more likely to present with dissatisfaction with breasts preoperatively, they exhibit comparable PROs overall compared with their non-obese counterparts, despite increased complications.

BACKGROUND This study aims to present normative values for satisfaction with breasts among preoperative breast reconstruction patients as assessed using the BREAST-Q instrument and to delineate factors associated with preoperative breast satisfaction. METHODS A retrospective analysis of prospectively collected data was performed examining women undergoing postmastectomy breast reconstruction at a tertiary care center who preoperatively completed the BREAST-Q from 2010 to 2017. Because breast satisfaction scores were nonnormally distributed, scores were categorized into quartiles for analysis. Patient- and treatment-level variables were tested in a multivariable ordinal logistic regression model as predictors of breast satisfaction. Preoperative satisfaction was also tested for association with choice of reconstructive modality. RESULTS Among 1306 postmastectomy reconstruction patients included in the study, mean preoperative Satisfaction with Breasts score was 61.8 ± 21.5 and the median score was 58.0 (interquartile range, 48 to 70). Factors associated with significantly lower preoperative satisfaction included history of psychiatric diagnosis, preoperative radiotherapy, marital status (married), and higher body mass index. Factors associated with significantly higher scores were malignancy (localized tumor), medium bra size (B to C cup), and self-identification as black. Preoperative breast satisfaction was lower among patients who elected autologous reconstruction than among those with implant reconstruction (p < 0.001). CONCLUSIONS Preoperative breast satisfaction is influenced by multiple factors. Understanding these factors may improve preoperative counseling and expectation management for patients who undergo postmastectomy breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, III.

Air pollution is largely attributed to anthropogenic aerosols, with the role of natural aerosols, including sea salt, dust, and other terrestrial emissions considered to be less important. However, natural aerosols have strong geographic gradients and this suggests that spatially invariant air quality guidelines may handicap regions close to natural sources. We use climate models to construct a view of pre‐industrial “pristine” air quality, including fine particulate matter with diameters less than 2.5 µm (PM2.5). Under pristine conditions, PM2.5 levels over regions in geographic proximity to dust sources, including parts of Africa and Asia, exceed World Health Organization air quality guidelines. We estimate that this pristine air pollution, which is unassociated with human activities, impacts up to about one billion people globally. The results show that natural aerosols, with strong geographic gradients, can lead to poor air quality over regions close to sources, and that in many areas no amount of anthropogenic emission reductions will result in clean air.

Chest wall surgery after immunotherapy and radiation can provide cure, prevent catastrophic complications, reduce the duration of immunotherapy, and allow verification of depth of response to therapy., Graphical Abstract Tumor seen before immunotherapy and radiation and then at the time of surgical resection.

Comparisons of autologous breast reconstruction (ABR) and implant-based breast reconstruction (IBR) involve unavoidable confounders, which are often adjusted for in post hoc regression analyses. This study compared patient-reported outcomes between ABR patients and IBR patients by using propensity score matching to control for confounding variables upfront.Propensity score matching analysis (2:1 nearest-neighbor matching with replacement) was performed for patients who underwent ABR or IBR without radiotherapy. Matched covariates included age, body mass index, history of psychiatric diagnosis, race-ethnicity, smoking status, and laterality of reconstruction. Outcomes of interest were BREAST-Q questionnaire scores for breast satisfaction and well-being.Of the 2334 patients identified, 427 were included in the final analysis: 159 who underwent ABR and 268 who underwent IBR. The ABR group matched the IBR group in the selected characteristics. ABR patients did not differ significantly from IBR patients in breast satisfaction or well-being at either 1 or 2 years after reconstructive surgery.This preliminary analysis of immediate breast reconstruction patients not requiring radiation therapy with similar propensities for ABR or IBR suggests comparable levels of breast satisfaction and well-being within 2 years after reconstructive surgery. Further research is needed with larger sample sizes, statistical power, and follow-up to better understand patient reported outcomes in this population, as the current findings differ from studies where patients were not matched on baseline characteristics.

To better understand the long-term patient-reported outcomes (PROs) in satisfaction and health-related quality of life (QOL) following post-mastectomy reconstruction (PMR) using the BREAST-Q, comparing PROs from patients undergoing implant-based breast reconstruction (IBR) or autologous breast reconstruction (ABR).Multiple studies have demonstrated growth in mastectomy rates and concurrent increase in PMR utilization. However, most studies examining PMR PROs focus on short postoperative time periods-mainly within 2 years.BREAST-Q scores from IBR or ABR patients at a tertiary center were prospectively collected from 2009 to 2017. Mean scores and standard deviations (SDs) were calculated for satisfaction with breast, satisfaction with outcome, psychosocial well-being, physical well-being of the chest, and sexual well-being. Satisfaction with breasts and physical well-being of the chest were compared using regression models at postoperative years 1, 3, 5, and 7.Overall, 3268 patients were included, with 336 undergoing ABR and 2932 undergoing IBR. Regression analysis demonstrated that ABR patients had greater postoperative satisfaction with breast scores at all timepoints compared with IBR patients. Postoperative radiation and mental illness adversely impacted satisfaction with breast scores. Furthermore, mental illness impacted physical wellbeing of the chest at all timepoints. IBR patients had satisfaction scores that remained stable over the study period.This study presents the largest prospective examination of PROs in PMR to date. Patients who opted for ABR had significantly higher satisfaction with their breast and QOL at each assessed time point, but IBR patients had stable long-term satisfaction and QOL postoperatively.