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The tumor microenvironment within the breast is rich in adipose elements. The interaction between adipose cells and breast cancer is poorly understood, particularly as it pertains to patients with genetic susceptibility to breast cancer. This study focuses on the phenotype of human adipose-derived stem cells with the BRCA1 mutation and the effect they may have on breast cancer cell behavior.CRISPR/Cas9 was used to generate de novo BRCA1-knockdown human adipose-derived stem cells. The effect of the BRCA1 knockdown on the adipose-derived stem cell phenotype was compared to wild-type adipose-derived stem cells and patient-derived breast adipose-derived stem cells with known BRCA1 mutations. Interactions between adipose-derived stem cells and the MDA-MB-231 breast cancer cell line were evaluated.BRCA1-knockdown adipose-derived stem cells stimulated MDA-MB-231 proliferation (1.4-fold increase on day 4; p = 0.0074) and invasion (2.3-fold increase on day 2; p = 0.0171) compared to wild-type cells. Immunofluorescence staining revealed higher levels of phosphorylated ataxia telangiectasia-mutated activation in BRCA1-knockdown cells (72.9 ± 5.32 percent versus 42.9 ± 4.97 percent; p = 0.0147), indicating higher levels of DNA damage. Beta-galactosidase staining demonstrated a significantly higher level of senescence in BRCA1-knockdown cells compared with wild-type cells (7.9 ± 0.25 percent versus 0.17 ± 0.17 percent; p0.0001). Using quantitative enzyme-linked immunosorbent assay to evaluate conditioned media, the authors found significantly higher levels of interleukin-8 in BRCA1-knockdown cells (2.57 ± 0.32-fold; p = 0.0049).The authors show for the first time that the BRCA1 mutation affects the adipose-derived stem cell phenotype. Moreover, CRISPR/Cas9-generated BRCA1-knockdown adipose-derived stem cells stimulate a more aggressive behavior in breast cancer cells than wild-type adipose-derived stem cells. This appears to be related to increased inflammatory cytokine production by means of a DNA damage-mediated cell senescence pathway.

Purpose Most triple-negative breast cancer (TNBC) patients exhibit an incomplete response to neoadjuvant chemotherapy, resulting in chemo-residual tumor cells that drive tumor recurrence and patient mortality. Accordingly, strategies for eliminating chemo-residual tumor cells are urgently needed. Although stromal cells contribute to tumor cell invasion, to date, their ability to influence chemo-residual tumor cell behavior has not been examined. Our study is the first to investigate cross-talk between adipose-derived stem cells (ASCs) and chemo-residual TNBC cells. We examine if ASCs promote chemo-residual tumor cell proliferation, having implications for tumor recurrence. Methods ASC migration toward chemo-residual TNBC cells was tested in a transwell migration assay. Importance of the SDF-1α/CXCR4 axis was determined using neutralizing antibodies and a small molecule inhibitor. The ability of ASCs to drive tumor cell proliferation was analyzed by culturing tumor cells ± ASC conditioned media (CM) and determining cell counts. Downstream signaling pathways activated in chemo-residual tumor cells following their exposure to ASC CM were studied by immunoblotting. Importance of FGF2 in promoting proliferation was assessed using an FGF2-neutralizing antibody. Results ASCs migrated toward chemo-residual TNBC cells in a CXCR4/SDF-1α-dependent manner. Moreover, ASC CM increased chemo-residual tumor cell proliferation and activity of extracellular signal-regulated kinase (ERK). An FGF2-neutralizing antibody inhibited ASC-induced chemo-residual tumor cell proliferation. Conclusions ASCs migrate toward chemo-residual TNBC cells via SDF-1α/CXCR4 signaling, and drive chemo-residual tumor cell proliferation in a paracrine manner by secreting FGF2 and activating ERK. This paracrine signaling can potentially be targeted to prevent tumor recurrence.

Breast reconstruction is associated with improved patient well-being after mastectomy; however, factors that contribute to post-surgical dissatisfaction remain poorly characterized.Adult women who underwent post-mastectomy implant-based or autologous breast reconstruction between 2015 and 2019 were recruited to participate in semi-structured interviews regarding their lived experiences with reconstructive care. Participants completed the BREAST-Q, and tabulated scores were used to dichotomize patient-reported outcomes as satisfied or dissatisfied (high or low) for each BREAST-Q domain. A convergent mixed-methods analysis was used to evaluate interviews for content related to satisfaction or dissatisfaction with breast reconstruction.Overall, we interviewed 21 women and identified 17 subcodes that corresponded with the five BREAST-Q domains. Sources of dissatisfaction were found to be related to the following domains: (a) low breast satisfaction due to asymmetry, cup size, and lack of sensation and physical feeling (n = 8, 38%); (b) poor sexual well-being due to shape, look and feel (n = 7, 78% [of 9 who discussed sexual well-being]); (c) reduced physical well-being of the chest due to persistent pain and weakness (n = 11, 52%); (d) reduced abdominal well-being due to changes in abdominal strength, numbness, and posture (n = 6, 38% [of 16 who underwent abdominally based reconstruction]); and (e) low psychosocial well-being impacted by an unexpected appearance that negatively influenced self-confidence and self-identity (n = 13, 62%).Patients may be unprepared for the physical, sexual, and psychosocial outcomes of breast reconstruction. Targeted strategies to improve preoperative education and shared decision making are needed to mitigate unexpectedness associated with breast reconstruction and related outcomes.

Purpose: Our laboratory studies contributions of breast adipose stromal cells (bASCs) to breast cancer initiation and progression. To date, most studies of ASC biology have focused on abdominal ASCs. We hypothesize that bASC biology impacts the breast microenvironment in a manner that influences a woman’s risk of developing breast cancer. Methods: In order to better understand how aberrant bASC biology contributes to breast cancer, we built a bASC cell repository from women undergoing mastectomies at Duke University Hospital (Duke IRB Pro00100739). Some of these women are at high risk for developing breast cancer. High risk biology includes women with genetic predispositions to cancer, as well as obese and post-menopausal women. bASCs were isolated from the stromal vascular fraction of breast adipose tissue from patients. Additionally, commercially-available ASCs isolated from the abdomen were obtained from Zenbio. Senescence was measured in bASCs using the SPiDER beta gal senescence detection kit (Dojingo). Senescence-associated cytokines were measured in conditioned media collected from these bASCs by ELISA (R&D Systems). The ability of bASCs to differentiate into adipocytes was measured using the Adipo-Red adipocyte differentiation assay (Lonza). Results: To date, we have isolated bASCs from 16 patients undergoing mastectomies at Duke University Hospital. We have studied differences in the biology of these bASCs that may be associated with increased breast cancer risk. A commonality observed in high risk patients was senescence, demonstrated by bASCs undergoing growth arrest and secretion of beta-galactosidase. Similarly, bASCs from high risk patients demonstrated secretion of inflammatory cytokines such as Interleukin-6 (IL-6), Interleukin-8 (IL-8), and Interleukin-1beta (IL-1 beta) that are associated with the senescence-associated secretory phenotype. We hypothesize that the secretion by these bASCs of such cytokines creates an inflammatory breast microenvironment that increases breast cancer risk. Our data also indicate that bASCs from high risk patients exhibit a defect in their ability to differentiate into adipocytes. Conclusion: Our studies are the first to report on a repository of breast ASCs (bASCs) from patients undergoing mastectomies. Results indicate that bASC biology differs significantly amongst patients, with a subset exhibiting a senescent secretory phenotype associated with a block in their ability to differentiate into adipocytes. We hypothesize bASC senescence, associated with a senescence secretory phenotype, results in: 1) the inability of these bASCs to differentiate into adipocytes, and 2) a senescence-associated secretory phenotype that impacts the breast tumor microenvironment. As we continue to build the repository, studies are in progress to test if inflammatory cytokines secreted by senescent bASCs work in a paracrine fashion on breast epithelium to drive breast cancer initiation/ progression.

Background Fat grafting to the reconstructed breast may result in the development of benign lesions on physical examination, prompting further investigation with imaging and biopsy. The aim of this study was to assess the influence of fat grafting on the incidence of imaging and biopsies after postmastectomy reconstruction. Methods Patients who underwent autologous or implant-based reconstruction following mastectomy from 2010 to 2018 were identified. Those receiving fat grafting as part of their reconstructive course were propensity matched 1:1 to those that did not with body mass index, reconstruction timing, and reconstruction type as covariates in a multivariable logistic regression model. Results A total of 186 patients were identified, yielding 93 propensity-matched pairs. Fat-grafted patients had higher incidences of palpable masses (38.0 percent versus 18.3 percent; p = 0.003) and postreconstruction imaging (47.3 percent versus 29.0 percent; p = 0.01), but no significant difference in the number of biopsies performed (11.8 percent versus 7.5 percent; p = 0.32). Imaging was predominately interpreted as normal (Breast Imaging-Reporting and Data System 1, 27.9 percent) or benign (Breast Imaging-Reporting and Data System 2, 48.8 percent), with fat necrosis being the most common finding [n = 20 (45.5 percent)]. No demographic, oncologic, reconstructive, or fat grafting-specific variables were predictive of receiving postreconstruction imaging on multivariate analysis. Fat grafting was not associated with decreased 5-year overall survival or locoregional recurrence-free survival. Conclusions Fat grafting to the reconstructed breast is associated with increased incidences of palpable masses and subsequent postreconstruction imaging with benign radiographic findings. Although the procedure is oncologically safe, both patients and providers should be aware that concerning physical examination findings can be benign sequelae of fat grafting and may lead to increased imaging after breast reconstruction. Clinical question/level of evidence Therapeutic, III.

Background Each year, millions of individuals develop scars secondary to surgery, trauma, and/or burns. Scar-specific patient-reported outcome measures to evaluate outcomes are needed. To address the gap in available measures, the SCAR-Q was developed following international guidelines for patient-reported outcome measure development. This study field tested the SCAR-Q and examined its psychometric properties. Methods Patients aged 8 years and older with a surgical, traumatic, and/or burn scar anywhere on their face or body were recruited between March of 2017 and April of 2018 at seven hospitals in four countries. Participants answered demographic and scar questions, the Fitzpatrick Skin Typing Questionnaire, the Patient and Observer Scar Assessment Scale (POSAS), and the SCAR-Q. Rasch measurement theory was used for the psychometric analysis. Cronbach's alpha, test-retest reliability, and concurrent validity were also examined. Results Consent was obtained from 773 patients, and 731 completed the study. Participants were aged 8 to 88 years, and 354 had surgical, 184 had burn, and 199 had traumatic scars. Analysis led to refinement of the SCAR-Q Appearance, Symptoms, and Psychosocial Impact scales. Reliability was high, with person separation index values of 0.91, 0.81, and 0.79; Cronbach alpha values of 0.96, 0.91, and 0.95; and intraclass correlation coefficient values of 0.92, 0.94, and 0.88, respectively. As predicted, correlations between POSAS scores and the Appearance and Symptom scales were higher than those between POSAS and Psychosocial Impact scale scores. Conclusions With increasing scar revisions, a scar-specific patient-reported outcome measure is needed to measure outcomes that matter to patients from their perspective. The SCAR-Q represents a rigorously developed, internationally applicable patient-reported outcome measure that can be used to evaluate scars in research, clinical care, and quality improvement initiatives.

Background Unplanned returns to the operating room (OR) may be necessary at times to salvage a compromised free flap. The aim of this study was to assess the influence of attending surgeon continuity on free flap outcomes following a return to the OR. Methods We retrospectively reviewed patients who underwent free flap reconstruction and experienced an unplanned return to the OR within 30 days from 2002 to 2017. Logistic regression modeling was used to determine factors that predict unplanned returns to the OR. Results Of the 1,177 patients were identified, 267 (22.5%) had an unplanned return to the OR. Of these, 69 (5.9%) patients experienced total flap loss. Overall, 216 take-back procedures were performed by the primary surgeons (80.2%), while 50 were performed by covering surgeons (18.8%). Flap loss occurred more frequently during a weekend procedure (p = 0.013). Additionally, when the take-back procedure was performed within 5 days of the original surgery by the primary as opposed to a covering surgeon, patients experienced lower estimated blood loss (75 vs. 150 cc, p = 0.04). Overall, there was a significantly lower incidence of flap loss when the take-back procedure was performed by the primary, as opposed to the covering, surgeon (20 vs. 47%, p = 0.0001). Conclusion Higher rates of flap loss occur when a covering surgeon performs a take-back procedure in comparison to the primary surgeon. It is important to ensure the availability of the primary surgeon in the first few postoperative days following free flap reconstruction. When transfer of care is necessary, photographic or video documentation of the microvascular anastomosis may be helpful in addition to a verbal sign out.

Breast cancer survival continues to improve, with women living longer after treatment. It is not well understood how long-term satisfaction and well-being differ following treatment or how types of reconstruction differ when compared to the norm.In a propensity-matched sample, the authors compared patient-reported outcomes in breast cancer patients at various time intervals from surgery with normative BREAST-Q data. All data were obtained using the Army of Women, an online community fostering breast cancer research. Breast cancer patients were stratified by surgical treatment and reconstruction type. Regression lines were estimated and differences in slope tested between cancer patients and noncancer controls.The authors compared normative (n = 922) and breast cancer (n = 4343) cohorts in a propensity-matched analysis. Among the breast cancer patients, 49.4 percent underwent lumpectomy, 17.0 percent underwent mastectomy, 21.7 percent underwent implant reconstruction, and 11.9 percent underwent autologous reconstruction. Median time since surgery was 4.7 years, with 21.1 percent more than 10 years after surgery. At the time of survey, breast cancer patients reported higher Satisfaction with Breasts and Psychosocial Well-being scores compared to noncancer controls (p0.01), with the cohorts undergoing lumpectomy and autologous reconstruction both reporting higher scores than the normative controls. After mastectomy, scores averaged lower than the noncancer controls, but improved over time. However, all breast cancer groups reported significantly lower Physical Well-being scores than the noncancer cohort (all p0.01).Breast cancer patients undergoing lumpectomy or autologous reconstruction reported higher psychosocial well-being compared to noncancer controls. These differences were influenced both by time since treatment and by choice of surgical procedure.

Wounds in the knee region are very common, secondary to trauma or orthopedic procedures. When hardware is associated with the wound, flap coverage is often needed. Additionally, because the knee is a very flexible joint, secondary healing and skin grafting are seldom adequate primary options for wound closure.

In the absence of extensive local trauma, edema, or radiation injury, local flaps may be a reasonable option for lower extremity reconstruction. When the defect is large and deep, a muscle flap may be required to obliterate the dead space, but when the defect is limited in its size and complexity, a local fasciocutaneous flap may suffice. These flaps can be elevated and positioned using a number of techniques described in this chapter.

Wounds that overlie the greater trochanter are common and at times require flap coverage. Two local flaps are well suited for these defects. The tensor fascia lata (TFL) flap and the anterolateral thigh (ALT) flap both have vascular origins from the lateral circumflex femoral artery and can be positioned proximally for hip coverage (Fig. 18.1).

Wounds in the upper knee region can occur after trauma, but they are typically associated with orthopedic procedures. They are often secondary to vascular procedures and may involve exposed prosthetics. The lower knee area is amenable to coverage with a gastrocnemius flap, but the upper knee is often out of the reach of this flap. In these circumstances, the reconstructive surgeon should be familiar with several other options (Fig. 19.1).

Wounds in the groin region are very common. They are often secondary to vascular procedures and may involve exposed prosthetics [1]. Additionally, some of these patients have previously compromised peripheral vascular systems, so it is necessary to have a knowledge of a variety of flaps and their associated vascular supply (Fig. 17.1). Likewise, wounds in the medial thigh, groin, and perineum are commonly related to oncologic resections. This chapter is specifically focused on groin wounds, but the same principles can apply to wounds of the medial thigh and some perineal wounds.

Wounds in the lower extremity may not be amenable to coverage with local tissue. In these instances, free tissue transfer is needed. Finding suitable recipient blood vessels for a microsurgical anastomosis is critical to success. Arterial inflow may be limited because of trauma or atherosclerotic disease. An angiogram can serve as a vascular roadmap for assessing recipient vessels. In general, when large vessels are used as recipient sites, a side branch of the main vessel can be used in an end-to-end fashion. If there are no available side branches, an end-to-side or end-to-end anastomosis to the main vessels may be performed. A thorough vascular exam must be done prior to sacrificing a large artery in the leg. In the lower leg, the tibial vessels are often used in an end-to-end or end-to-side fashion, depending on the overall vascular status.

The primary goal in foot reconstruction after trauma is to preserve function of the entire lower limb by helping to restore a stable weight-bearing surface that allows for painless ambulation. Additional considerations include ease of shoe fitting and aesthetic form of the reconstructed foot. When foot reconstruction is not possible or is complicated by failure or infection, the patient is at risk for undergoing a below-knee amputation.

Lower extremity reconstruction is unique in that there is high variability in tissue types and demands throughout the leg. Many soft tissue defects will involve concomitant bony injury, so an orthoplastic approach is required. Once it is determined that flap reconstruction is required, there are three main considerations

Background Breast implant placement is the most common method for postmastectomy reconstruction. For patients who develop complications associated with implant-based reconstruction, additional surgeries may be challenging. This study examined implant-based reconstruction failure in patients undergoing salvage with abdominal free tissue transfer. Methods We conducted an Institutional Review Board approved, multicenter retrospective study of patients with implant-based primary breast reconstruction followed by implant removal and subsequent abdominal free tissue transfer between 2006 and 2016. Patient demographics, treatment details, and complications were evaluated. Severity of implant failure was graded as either (1) not severe (delayed salvage reconstruction) or (2) severe (immediate salvage reconstruction). Results Between 2006 and 2016, 115 patients with 180 mastectomy defects underwent primary implant-based reconstruction with subsequent implant removal and abdominally based free tissue reconstruction. Of these, 68 were delayed and 47 were immediate salvage reconstruction. Factors leading to elective removal were capsular contracture, asymmetry, and implant malposition. Factors leading to obligatory removal were infection, delayed wound healing, and implant extrusion. Postmastectomy radiation was significantly associated with immediate salvage reconstruction (p Conclusion Our findings suggest that abdominal free tissue transfer remains a safe and effective salvage modality for implant-based breast reconstruction failure. Patients with severe implant failure were more likely to have received radiation. Surgeons should remain cognizant of this during care of patients.

Background:Clinical indications are expanding for the use of fasciocutaneous free flaps in lower extremity traumatic reconstruction. The authors assessed the impact of muscle versus fasciocutaneous free flap coverage on reconstructive and functional outcomes.Methods:A multicenter retrospective revie

Summary Background Intraoperative resident education is an integral mission of academic medical centers and serves as the basis for training the next generation of surgeons. The actual effort associated with teaching residents is unknown as it pertains to additional operative time. Using a large validated multi-institutional dataset, this study aims to quantify the effect of having a resident present in common plastic surgery procedures on operative time. Future directions for developing standardized methods to record and report teaching time are proposed, which can help inform prospective studies. Study design The 2006–2012 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried to identify seven isolated plastic surgical procedures that were categorized based on resident involvement and supervision. Linear regression models were used to calculate the difference in operative time with respect to resident participation while controlling for patient and operative factors. Results Resident involvement was associated with longer operative times for muscle flap trunk procedures (53 min, 95% CI = [25, 80], p-value = 0.0002) and breast reconstruction procedures with a latissimus dorsi flap (55 min, 95% CI = [22, 88], p-value = 0.001). For six of the seven surgeries evaluated, resident involvement was associated with longer operative times, as compared to no resident involvement. Conclusion Resident involvement is associated with an increase in operative time for certain plastic surgery procedures. This finding underscores the need for a mechanism to quantify the time and effort that the attending surgeons allocate toward intraoperative resident education. Further study is also necessary to determine the causal impact on patient care.

BACKGROUND Weight gain is common in breast cancer patients and increases the risk of recurrence and mortality. The authors assessed the impact of autologous breast reconstruction on body mass index patterns after diagnosis in mastectomy patients. METHODS Women undergoing therapeutic mastectomy at the authors' institution from 2008 to 2010 were identified. Patients undergoing no breast reconstruction or autologous breast reconstruction were propensity-matched by age at diagnosis, baseline obesity, mastectomy laterality, and adjuvant therapies. Multivariable regression was used to estimate covariate associations with percentage body mass index change and percentage body mass index change greater than 5.0 percent at 1 to 4 years after diagnosis. RESULTS Of 524 total patients, 80 propensity-matched pairs were identified. In multivariable regression, women undergoing immediate autologous breast reconstruction had reduced body mass index changes after diagnosis, compared with nonreconstruction patients, at 1 year (β = -5.25 percent; p < 0.01), 2 years (β = -8.78 percent; p < 0.01), and 3 years (β = -7.21 percent; p < 0.01). After 4 years, all autologous reconstruction was predictive of reduced body mass index changes (β = -3.54 percent; p = 0.02). Higher body mass index increases were observed among women who were leaner at diagnosis (p < 0.01 at 1 year) and received chemotherapy (p = 0.02 at 3 years; p = 0.04 at 4 years). CONCLUSIONS Women undergoing autologous breast reconstruction gained less weight after diagnosis than nonreconstruction patients. Normal baseline body mass index and chemotherapy were predictive of greater body mass index increases. These findings may guide targeted weight management strategies in high-risk patients to maximize survival rates. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.

The American Society of Plastic Surgeons commissioned a multistakeholder Work Group to develop recommendations for autologous breast reconstruction with abdominal flaps. A systematic literature review was performed and a stringent appraisal process was used to rate the quality of relevant scientific research. The Work Group assigned to draft this guideline was unable to find evidence of superiority of one technique over the other (deep inferior epigastric perforator versus pedicled transverse rectus abdominis musculocutaneous flap) in autologous tissue reconstruction of the breast after mastectomy. Presently, based on the evidence reported here, the Work Group recommends that surgeons contemplating breast reconstruction on their next patient consider the following: the patient's preferences and risk factors, the setting in which the surgeon works (academic versus community practice), resources available, the evidence shown in this guideline, and, equally important, the surgeon's technical expertise. Although theoretical superiority of one technique may exist, this remains to be reported in the literature, and future methodologically robust studies are needed.

Bridget M Crawford,1,2,* Ronnie L Shammas,3,* Andrew M Fales,1,2 David A Brown,4 Scott T Hollenbeck,4 Tuan Vo-Dinh,1,2,5 Gayathri R Devi6,7 1Fitzpatrick Institute for Photonics, Duke University, 2Department of Biomedical Engineering, Duke University, 3Duke University School of Medicine, 4Department of Surgery, Division of Plastic, Maxillofacial, and Oral Surgery, Duke University Medical Center, 5Department of Chemistry, Duke University, 6Department of Surgery, Division of Surgical Sciences, 7Duke Cancer Institute, Women’s Cancer Program, Duke University School of Medicine, Durham, NC, USA *These authors contributed equally to this work Abstract: Inflammatory breast cancer (IBC) is rare, but it is the most aggressive subtype of breast cancer. IBC has a unique presentation of diffuse tumor cell clusters called tumor emboli in the dermis of the chest wall that block lymph vessels causing a painful, erythematous, and edematous breast. Lack of effective therapeutic treatments has caused mortality rates of this cancer to reach 20%–30% in case of women with stage III–IV disease. Plasmonic nanoparticles, via photothermal ablation, are emerging as lead candidates in next-generation cancer treatment for site-specific cell death. Plasmonic gold nanostars (GNS) have an extremely large two-photon luminescence cross-section that allows real-time imaging through multiphoton microscopy, as well as superior photothermal conversion efficiency with highly concentrated heating due to its tip-enhanced plasmonic effect. To effectively study the use of GNS as a clinically plausible treatment of IBC, accurate three-dimensional (3D) preclinical models are needed. Here, we demonstrate a unique in vitro preclinical model that mimics the tumor emboli structures assumed by IBC in vivo using IBC cell lines SUM149 and SUM190. Furthermore, we demonstrate that GNS are endocytosed into multiple cancer cell lines irrespective of receptor status or drug resistance and that these nanoparticles penetrate the tumor embolic core in 3D culture, allowing effective photothermal ablation of the IBC tumor emboli. These results not only provide an avenue for optimizing the diagnostic and therapeutic application of GNS in the treatment of IBC but also support the continuous development of 3D in vitro models for investigating the efficacy of photothermal therapy as well as to further evaluate photothermal therapy in an IBC in vivo model. Keywords: inflammatory breast cancer, photothermal therapy, hyperthermia, plasmonics, gold nanostars, nanoparticles

Background Treatment algorithms for large soft tissue defects in lower extremity trauma are not clearly defined. The aim of this study is to determine if there are geographic or demographic differences in the management of open tibia fractures with soft tissue defects requiring either soft tissue reconstruction or amputation in the United States (US). Methods A retrospective analysis was performed on the Nationwide Inpatient Sample (NIS), 2000 to 2011. We evaluated flap and amputation rates in the open tibia fractures with soft tissue defects based on geographic and socioeconomic factors. Results From 2000 to 2011, there were 175,283 open tibia fractures in the US; 7.2% (n = 12,620) had a concomitant soft tissue defect requiring either flap or amputation. The overall flap rate was 73.2% (n = 9,235). When compared with the South at 68%, flap rates were highest in the West at 79% (adjusted odds ratio [AOR] = 2.06; 95% confidence interval [CI] = 1.49, 2.86; p Conclusions Reconstruction rates were significantly higher in three major US regions when compared with the South, urban hospitals in the West and Northeast, and the highest income quartile.

Introduction: Due to the aggressive nature of inflammatory breast cancer (IBC) and insensitive imaging techniques, patients diagnosed with IBC have a poor prognosis. IBC's unique ability to form emboli leads to rapid growth and distant invasion. New therapies aimed at disrupting the formation of tumor emboli are needed. Gold nanostars (GNS) are unique nanoparticles that can be imaged in real time with high sensitivity, and are rapidly endocytosed into cancer cells. Due to their sharp spikes, GNS exhibit plasmonic properties, which strongly enhance the electromagnetic field upon laser excitation. In addition to their use as highly intense and stable fluorescent labels, these nanoparticles can be photothermally activated to trigger cellular ablation. The use of GNS as an imaging and therapeutic modality for IBC should be investigated. Methods: IBC (SUM-149/SUM190), non-IBC (BT474M1/MD-MBA-231), and drug resistant isotype variant (rSUM-149) cell lines were incubated with GNS, stained with Hoechst33342, and imaged with multiphoton microscopy (MPM). The dose and time dependent effects of GNS on SUM-149 proliferation was assessed with MTT assays. Photothermal treatment was performed on GNS-labeled IBC, non-IBC, and drug resistant cancer cell lines. The effects of photothermal therapy on cell viability were assessed using fluorescein diacetate and propidium iodide. Using a tumor emboli model, SUM-149, rSUM-149, and SUM-190 tumor emboli were labeled with GNS on the 3rd day of embolic maturation. Emboli were sectioned, stained with H/E, and imaged with MPM to demonstrate the depth of GNS penetrance. The potential for photothermal ablation of the GNS-labeled tumor emboli was assessed using various laser intensities. Propidium iodide was used to examine emboli viability following treatment. Results: In all cell lines, GNS displayed rapid cellular uptake without nuclear involvement. MTT assay showed that GNS concentrations of 0.15 and 0.20 nM caused decreases in cell proliferation at 6 and 12 hours. Proliferative capacity was unaltered at 24 hours for all concentrations, however this may be due to spectrophotometric interference with high intracellular GNS concentrations. Live/dead staining confirmed effective photothermal treatment in all cultures with a clear zone of cellular death. For tumor emboli studies, GNS allowed bright fluorescent monitoring of tumor emboli using MPM, and cross sectional imaging demonstrated GNS penetrance into the embolic core. Photothermal ablation of GNS-labeled tumor emboli was successfully demonstrated following laser irradiation. Cell death was confirmed with propidium iodide. Conclusion: Gold nanostars provide a highly fluorescent intracellular label for cancer cell lines, and tumor emboli without significantly altering cell proliferation. Furthermore, the inherent optical properties of the GNS allows for a combined therapeutic application following phototoactivation. This is the first study to demonstrate the nanothernostic application of GNS in IBC tumor emboli. Prior studies have shown the effectiveness of photothermal ablation in in vivo sarcoma models; we are currently extending our studies to an IBC mouse model. Supported by the P30 Cancer Center Support Grant (GRD) and Duke Exploratory Funds (TVD). Citation Format: Shammas RL, Fales AM, Crawford BM, Hollenbeck ST, Vo-Dinh T, Devi GR. Nanotheranostics using plasmonic gold nanostars to target inflammatory breast cancer cells and tumor emboli [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P3-16-02.

Background:. With growing concerns about the overuse of contralateral prophylactic mastectomy, optimizing unilateral mastectomy reconstruction outcomes becomes a priority. However, there remains a paucity of objective data that describe volumetric symmetry between a natural and autologous-reconstructed breast. Methods:. We evaluated patients who underwent unilateral mastectomy reconstruction with free-flap abdominal tissue transfer from 04/2006 to 01/2015, and had at least 2 postoperative magnetic resonance images (MRIs; n = 28). Using these MRI data, volumetric measurements of the reconstructed and natural breast were performed at the first postoperative MRI (after all revisions were complete) and the most recent MRI. Relationships were analyzed using Spearman correlation coefficients. A symmetry score (SS) was calculated such that values closer to 1.0 reflected volumetric symmetry. Results:. The mean age (years) and BMI of the patients was 44.8 and 26.8, respectively. The mean interval time between the MRIs was 3.03 years (range 0.43–6.6). After surgical revisions were complete, volumetric symmetry between reconstructed and nonreconstructed breasts was typically achieved (mean SS 0.92). This symmetry was also retained at the end of follow-up (mean SS 0.96), despite a mean change in BMI of 3.9% (range 1.1–7.7). Additionally, the mean number of flap revisions was 0.75 (range 0–2), and 39% of patients had a procedure performed on the natural breast. Conclusion:. In patients undergoing unilateral abdominal-based breast reconstruction, volumetric symmetry is attainable; however, it can require flap revisions and procedures to natural breast. Interestingly, this study does show that initial symmetry is retained postoperatively, regardless of changes in BMI.

Revision procedures address contour irregularities and aesthetic concerns following autologous breast reconstruction. Mental health diagnoses are known to influence patient satisfaction with reconstruction. The authors aimed to identify oncologic, reconstructive, and demographic factors, including mental health diagnoses, associated with the number of revisions after autologous breast reconstruction.The medical records of all adult women undergoing abdominal free flap-based breast reconstruction at a major academic institution between 2011 and 2016 were reviewed. Multivariate logistic regression was used to identify factors associated with receipt of revisions. Negative binomial regression was used to identify characteristics associated with number of revisions received.Of 272 patients identified, 55.2 percent received one revision, 23.2 percent received two revisions, and 10.3 percent received three or more revisions after autologous breast reconstruction (median, one; range, zero to five). After adjustment on multivariate analysis, anxiety (OR, 4.34; p = 0.016) and bilateral reconstruction (OR, 3.10; p = 0.017) were associated with receipt of any revisions; other oncologic and reconstructive factors including breast cancer stage, receipt of radiation therapy, and type or timing of free flap reconstruction were not associated with revisions. Using univariate negative binomial regression, anxiety (incidence rate ratio, 1.34; p = 0.006), Caucasian race (incidence rate ratio, 1.24; p = 0.02), and bilateral reconstruction (incidence rate ratio, 1.39; p = 0.04) were predictive of increased numbers of revisions received. After stepwise selection on multivariate analysis, anxiety remained the only significant predictor of increased numbers of revisions.Preoperative anxiety significantly influences the number of revisions after autologous breast reconstruction. Further research is necessary to better understand the interplay among mental health, patient preference, and outcomes in breast reconstruction.Risk, III.

BACKGROUND: Despite increasing emphasis on reducing racial disparities in breast cancer care in the United States, it remains unknown whether access to breast reconstruction has improved over time. The authors characterized contemporary patterns of breast reconstruction by race and ethnicity. METHODS: The Surveillance, Epidemiology, and End Results database was used to identify women undergoing mastectomy for stage 0 to III breast cancer from 1998 to 2014. Multivariable logistic regression was used to estimate the association of demographic factors with likelihood of postmastectomy reconstruction. Multivariable logistic regression was used to predict reconstruction subtype. Patients undergoing reconstruction were grouped by diagnosis year to assess change in the population over time by race and ethnicity. RESULTS: Of 346,418 patients, 21.8 percent underwent immediate reconstruction. Non-Hispanic black race (OR, 0.71) and Hispanic ethnicity (OR, 0.63) were associated with a decreased likelihood of reconstruction (all p < 0.001). Race was predictive of reconstruction type, with non-Hispanic black (OR, 1.52) and Hispanic women (OR, 1.22) more likely to undergo autologous versus implant-based reconstruction (p < 0.001). Although rates of reconstruction increased over time across all races, non-Hispanic black and Hispanic patients had a higher adjusted per-year increase in rate of reconstruction compared with non-Hispanic white patients (interaction p < 0.001). CONCLUSIONS: Rates of postmastectomy reconstruction have increased more quickly over time for minority women compared with white women, suggesting that racial disparities in breast reconstruction may be improving. However, race continues to be associated with differences in types and rates of reconstruction. Further research is necessary to continue to improve access to breast reconstruction in the United States. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Open tibia fractures are often associated with considerable soft tissue injuries. Management of open tibia fractures can be challenging, and some patients require amputation. The patient and treatment factors have not been described on a population level in the United States. A retrospective analysis was completed using the 2000 to 2011 Nationwide Inpatient Sample. Amputation rates during the index hospitalization after open tibia fracture were computed based on injury, patient, and hospital characteristics in patients 18 years or older. The overall amputation rate in open tibia fractures during the index hospitalization was 2.2% (n=3769). Patients with midshaft tibia fractures comprised the largest portion of patients undergoing amputation (46.8% of total amputations) compared with distal tibia (34.0%) and proximal tibia (19.3%) fractures. Patients with no neurovascular injury comprised the largest portion of patients undergoing amputation (85.9%), followed by isolated arterial injury (11.1%), combined neurovascular injury (1.9%), and isolated nerve injury (1.1%). Amputation rates were significantly increased for midshaft tibia fractures with neurovascular injury (odds ratio, 12.39; 95% CI, 5.52–27.83) and distal tibia fractures with neurovascular injury (odds ratio, 5.45; 95% CI, 1.73–17.19) compared with tibia fractures with no neurovascular injury while controlling for confounders. On the basis of a review of the Nationwide In-patient Sample during the past decade, the authors have shown that the early amputation rate in open tibia fractures for all-comers is 2.2%. Rates of amputation varied based on fracture site, associated neurovascular injury, medical comorbidities, and hospital location. [ Orthopedics . 2021;44(1):48–53.]

Background:. Advances in fracture fixation and soft tissue coverage continue to improve the care of patients after limb-threatening lower extremity (LE) trauma. However, debate continues regarding which treatment option—reconstruction or amputation—is most appropriate. Many authors have attempted to quantify the patient experience in this treatment paradigm; however, they have not used patient-reported outcome (PRO) instruments specific to this population. Our aim was to identify and evaluate PRO instruments developed specifically for LE trauma, applicable to reconstruction and amputation, using established PRO instrument development and validation guidelines. Methods:. A multidisciplinary team used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses method to query PubMed, Medline Ovid, EMBASE, Cochrane, Medline Web of Science, and Psych Info databases from inception to November 2016. Publications were included that described the development and/or validation of a PRO instrument assessing satisfaction and/or quality of life in LE trauma, applicable to both amputation and reconstruction. Two authors independently reviewed each full-text citation. Results:. After removing duplicates, 6,290 abstracts were identified via the database query. Following a preliminary title and abstract screen, 657 full-text citations were reviewed. Of these references, none satisfied the previously established inclusion criteria. Conclusions:. No studies were identified that described a PRO instrument developed to assess outcomes in LE trauma patients applicable to both reconstruction and amputation. There is thus a need for a PRO instrument designed specifically for patients who have sustained limb-threatening LE trauma to guide treatment decisions.

Background This study described the prevalence of bleeding complications necessitating blood transfusion across plastic surgery procedures and identified those procedures that may be associated with higher rates of bleeding. Methods The authors retrospectively identified patients who suffered from postoperative bleeding complications from 2010 to 2015 using the National Surgical Quality Improvement Program database. This is defined by the National Surgical Quality Improvement Program as the need for transfusion of at least one unit of packed or whole red blood cells. Patient characteristics were described using summary statistics, and National Surgical Quality Improvement Program and univariate analysis of patient characteristics and bleeding complications was performed. Results Overall, 1955 of 95,687 patients experienced bleeding complications. Patients with bleeding complications were more likely to be diagnosed with hypertension, have a longer total operative time, and have a previously diagnosed bleeding disorder. The most common primary plastic surgery procedure associated with bleeding complications was breast reconstruction with a free flap, and breast reconstruction with a pedicled transverse rectus abdominis musculocutaneous flap had the highest rate of bleeding. A return to the operating room was required in 539 patients (27.6 percent) who suffered a postoperative bleeding complication. Patients with a preexisting bleeding disorder [n = 1407 (1.5 percent)] were more likely to be diabetic, have a lower preoperative hematocrit, and have a longer operative time. In addition, these patients were more likely to suffer from other nonbleeding complications (1.29 percent versus 0.35 percent; p Conclusions Complex procedures (i.e., free flap breast reconstruction) have a higher prevalence of bleeding requiring a transfusion. Furthermore, patients undergoing combined procedures-specifically, breast oncologic and reconstructive cases-may be at a higher risk for experiencing bleeding-related complications. Clinical question/level of evidence Therapeutic, III.

Background A current limitation in the care of patients with severe lower extremity traumatic injuries is the lack of a rigorously developed patient-reported outcome (PRO) instrument specific to lower extremity trauma patients. Objective This mixed methods protocol aims to describe phases I and II of the development of a PRO instrument for lower extremity trauma patients, following international PRO development guidelines. Methods The phase I study follows an interpretive description approach. Development of the PRO instrument begins with identifying the concepts that are important to patients, after which a preliminary conceptual framework is devised from a systematic literature review and used to generate an interview guide. Patients aged 18 years or above with limb-threatening lower extremity traumatic injuries resulting in reconstruction, amputation, or amputation after failed reconstruction will be recruited. The subjects will participate in semistructured, in-depth qualitative interviews to identify all important concepts of interest. The qualitative interview data will be coded with top-level domains, themes, and subthemes. The codes will then be utilized to refine the conceptual framework and generate preliminary items and a set of scales. The preliminary scales will be further refined via a process of conducting cognitive debriefing interviews with lower extremity trauma patients and soliciting expert opinions. Phase III will include a large-scale field test, using Rasch measurement theory to analyze the psychometric properties of the instrument; shortening and finalizing the scales; and determining the reliability, validity, and responsiveness of the instrument. Results Phases I and II of this study have been funded. Phase I of this study has been completed, and phase II began in January 2019 and is expected to be completed in November 2019. Phase III will begin following the completion of phase II. Conclusions This protocol describes the initial phases of development of a novel PRO instrument for use in lower extremity trauma patients. International Registered Report Identifier (IRRID) DERR1-10.2196/14397

Background Despite limited oncologic benefit for women without an increased risk for breast cancer, the rates of contralateral prophylactic mastectomy (CPM) have increased. Patients undergoing CPM are more likely to undergo bilateral and immediate breast reconstruction. This study assessed the relationship between the timing and laterality of free flap-based breast reconstruction and the risk of postoperative bleeding complications. Methods Women undergoing postmastectomy free-flap based breast reconstruction from 2010 to 2015 were identified using the National Surgical Quality Improvement Program (NSQIP) dataset. Patients were categorized according to reconstructive laterality and timing. Modified Poisson regression was used to assess the risk of postoperative bleeding and complications across reconstructive procedures. Results Of the 4,133 patients undergoing free flap-based breast reconstruction, 12% (n = 494) experienced postoperative bleeding complications. Bilateral immediate reconstruction was associated with the highest incidence of bleeding (16.6%, n = 188), followed by bilateral delayed (12.8%, n = 58), unilateral immediate (10%, n = 142), and unilateral delayed reconstruction (9.4%, n = 106). Among patients undergoing immediate reconstruction, bilateral, rather than unilateral, reconstruction was associated with a significantly elevated risk of bleeding complications (RR [rate ratio] = 1.58; 95% CI [confidence interval] =1.19, 2.10; p = 0.0002). Furthermore, immediate bilateral reconstruction was associated with a significantly higher rate of return to the operating room (RR =1.39; 95% CI =1.06, 1.82; adjusted p = 0.009) when compared with a unilateral procedure. Conclusion Patients undergoing immediate bilateral free flap-based breast reconstruction may be at an increased risk for experiencing acute postoperative bleeding complications and a return to the operating room. Patients undergoing CPM and considering immediate reconstruction should be counseled regarding the increased morbidity of a bilateral reconstructive procedure.

IMPORTANCE: An increasing number of patients with breast cancer receiving neoadjuvant chemotherapy (NACT) undergo immediate breast reconstruction (IBR) with nipple-sparing mastectomy (NSM) or skin-sparing mastectomy (SSM) as surgical treatment. However, the oncologic efficacy and safety of this treatment sequencing strategy is unclear. OBJECTIVE: To compare the long-term oncologic outcomes of IBR with NSM/SSM and conventional mastectomy (CM) alone for breast cancer in the NACT setting. DESIGN, SETTING, AND PARTICIPANTS: A retrospective, propensity score–matched case-control study was conducted at Asan Medical Center, Seoul, Korea. A total of 1266 patients with breast cancer who underwent NACT followed by mastectomy with or without breast reconstruction between January 1, 2010, and November 30, 2016, were included. Data analysis was performed from July 1, 2019, to January 24, 2020. After propensity score matching, 323 patients who underwent IBR with NSM/SSM and 323 who underwent CM alone were selected for comparison of long-term oncologic outcomes. MAIN OUTCOMES AND MEASURES: The 5-year local recurrence–free survival, disease-free survival, distant metastasis–free survival, and overall survival rates were calculated using the Kaplan-Meier method and compared using log-rank tests. Hazard ratios (HRs) and 95% CIs were estimated using the Cox proportional hazards regression model. RESULTS: After matching, the median follow-up periods were 67 (range, 17-125) months for the IBR group and 68 (range, 17-126) months for the CM-alone group. Median age of the women in the IBR group was 42 (range, 23-72) years; median age of those in the CM-alone group was 46 (range, 30-75) years. No significant differences were observed between the IBR and CM-alone groups in local recurrence (3.7% vs 3.4%; P = .83), regional recurrence (7.1% vs 5.3%; P = .33), or distant metastasis (17.3% vs 18.6%; P = .68) rates. There was also no significant difference between the IBR and CM-alone groups in 5-year local recurrence–free survival (95.6% vs 96.7%; HR, 1.124; 95% CI, 0.495-2.549; P = .78), disease-free survival (76.5% vs 79.9%; HR, 1.089; 95% CI, 0.790-1.500; P = .60), distant metastasis–free survival (82.5% vs 82.5%; HR, 0.941; 95% CI, 0.654-1.355; P = .74), or overall survival (92.0% vs 89.3%; HR, 0.847; 95% CI, 0.530-1.353; P = .49) rates. CONCLUSIONS AND RELEVANCE: The long-term oncologic outcomes of IBR with NSM/SSM for breast cancer in this study appeared to be comparable to those of CM alone after NACT, suggesting the feasibility of IBR with NSM/SSM in the NACT setting.

Introduction Long-term function following severe burns to the hand may be poor secondary to scar adhesions to the underlying tendons, webspaces, and joints. In this pilot study, we report the feasibility of applying a pasty dermal matrix combined with percutaneous cannula teno- and adhesiolysis. Patients and methods In this 6 month follow-up pilot study, we included eight hands in five patients with hand burns undergoing minimal-invasive, percutaneous cannula adhesiolysis and injection of INTEGRA™ Flowable Wound Matrix for a pilot study of this new concept. The flowable collagen–glycosaminoglycan wound matrix (FCGWM) was applied with a buttoned 2 mm cannula to induce formation of a neo-gliding plane. Post treatment follow-up was performed to assess active range of motion (AROM), grip strength, Disabilities of the Arm, Shoulder and Hand (DASH) score, Vancouver Scar Scale (VSS) and quality of life Short-Form (SF)-36 questionnaire. Results No complications were detected associated with the treatment of FCGWM injection. The mean improvement (AROM) at 6 months was 30.6° for digits 2–5. The improvement in the DASH score was a mean of 9 points out of 100. The VSS improved by a mean of 2 points out of 14. Discussion The study demonstrates the feasibility and safety of percutaneous FCGWM for dermal augmentation after burn. Results from this pilot study show improvements in AROM for digits 2–5, functional scores from the patient's perspective (DASH) and scar quality (VSS). The flowable form of established INTEGRA™ wound matrix offers the advantage of minimal-invasive injection after scar release in the post-burned hand with a reduction in the risk of postsurgical re-scarring.

After studying this article, the participant should be able to: 1. Understand the existing principles for lower extremity reconstruction for both traumatic and ablative defects. 2. Understand the important factors for lower extremity reconstruction-based anatomical regions. 3. Discuss perforator flaps and their application in lower extremity reconstruction.The Gustilo-Anderson open fracture classification is briefly reviewed. A comprehensive overview of the available flaps and methods for lower extremity reconstruction is provided.

Few guidelines exist regarding surveillance and diagnostic imaging after breast reconstruction. This study investigated the influence of breast reconstruction on the frequency of post-mastectomy imaging, the relative utility of imaging, and its effect on overall and locoregional recurrence-free survival.A retrospective review identified breast cancer patients (n = 1,216) who underwent mastectomy with or without reconstruction. Logistic regression identified surgical and oncologic predictors of post-reconstruction imaging. Kaplan-Meier method determined the impact of post-reconstruction imaging on overall and locoregional recurrence-free survival.Overall, 662 (54.4%) patients underwent mastectomy only and 554 (45.6%) underwent breast reconstruction. Patients undergoing reconstruction were more likely to receive imaging compared with patients undergoing mastectomy only (n = 205, 37.0% vs n = 168, 25.4%; p0.0001); however, this difference was not statistically significant after adjusting for age and follow-up time (p = 0.16). Most radiographic studies were Breast Imaging Reporting and Data System (BI-RADS) 1 (n = 58, 30%) or 2 (n = 95, 49%) and were ordered by nonsurgical providers (n = 128, 63%). Post-reconstruction imaging did not influence overall or locoregional recurrence-free survival. The 5-year survival probabilities for breast reconstruction patients who underwent imaging for a palpable mass, surveillance, or who did not undergo imaging were 100%, 95% (95% CI 89% to 100%), and 96% (95% CI 94% to 99%), respectively. Post-reconstruction imaging was not a significant predictor of overall survival (hazard ratio [HR] 0.95; 95% CI 0.61 to 1.46; p = 0.30).The limited utility of routine post-reconstruction imaging should be reinforced when evaluating breast reconstruction patients. Multidisciplinary collaboration should be emphasized when attempting to distinguish benign postoperative findings from a malignant process to reduce unnecessary imaging and biopsy after breast reconstruction.

Controversy remains regarding the optimal timing of soft-tissue coverage following severe lower extremity trauma. This study identifies nationwide practice patterns and factors associated with discrepancies in time to first flap surgery following open tibia fractures.A retrospective analysis was performed on the National Trauma Databank from 2008 to 2015 to identify patients who presented with an open tibia fracture and underwent subsequent flap reconstruction. A least absolute shrinkage and selection operator algorithm was performed, revealing those factors most significantly associated with differences in time to flap surgery from hospitalization.A total of 3297 patients were included in the analysis. Mean ± SD and median times to first flap surgery were 230.1 ± 246.7 hours and 169.1 hours, respectively. Older age, nonwhite race, treatment in the South, and non-private insurance status were all independently associated with an increased time to flap surgery. In addition, more surgical débridements; a higher Injury Severity Score and/or Abbreviated Injury Scale score; and a nerve, vascular, and/or crush injury were independent predictors of an increased time to flap surgery.Most patients who present with open tibia fractures requiring soft-tissue coverage undergo flap reconstruction after the historical 72-hour window. Specific sociodemographic and clinical factors were independently predictive of an increased time to flap surgery. These findings suggest that not all patients in the United States are receiving the same level of care in lower extremity trauma reconstruction, emphasizing the need to develop more explicit national standards.Risk, III.

Background Awareness of ergonomics in surgery is growing, but whether musculoskeletal (MSK) injuries in surgery influence trainee career choices remains unknown. This study aimed to characterize medical students’ MSK pain during surgical rotations and determine whether ergonomics influence student interest in surgical fields. Methods An online survey was administered to medical students in North Carolina. Students were asked about specialty interest, MSK pain on surgical rotations, and deterrents from surgical fields. Students were exposed to literature about ergonomics in surgery then queried again about relative specialty interest (medical versus surgical). Differences in specialty interest before and after the exposure were compared using a Wilcoxon signed-rank test. Results Of 243 participants, 44.0% were interested in pursuing a surgical specialty. Overall, 75.3% reported MSK pain during their surgical rotation, with the average daily pain score highest during surgery rotations compared to all other clinical rotations. The worst pain was reported in the feet and low back while “standing in the operating room” (81.2%) or “retracting” (59.4%). Among students initially interested in surgery but whose interest changed to a medical specialty during medical school, “physical demands of the field” was a common deterrent (36.4%). After exposure to literature regarding the incidence of MSK injuries in surgery, student interest in surgical fields on a 10-point scale significantly decreased (average −0.5 points; P Conclusions High incidence of MSK injury among surgeons may be one factor deterring medical students from surgical careers. Ergonomic interventions may be important both to improve surgeon longevity and maintain the surgical workforce.

Background Perforator mapping with computed tomography angiography (CTA) prior to autologous breast reconstruction reduces donor-site morbidity and operative time, but is costly. The aim of this study was to evaluate whether pre-existing CT scans could be used for dominant perforator identification before autologous reconstruction. Methods We identified all female patients who underwent mastectomy with immediate or delayed breast reconstruction with abdominal free flaps at a single institution between 2006 and 2016. Medical records were reviewed to identify patients with pre-existing CT scans of the abdomen/pelvis. CT images were reviewed by the senior surgeon and ranked on a 1 to 3 scale to indicate utility for preoperative planning. An analysis was performed to assess financial savings and radiation avoidance associated with the use of pre-existing scans. Results Of 301 identified patients, 44.9% (n = 135) had an available pre-existing CT. A dominant perforator was identified on 92.6% of scans. A higher proportion of dominant perforators was identified using positron emission tomography (PET)/CT scans compared with CT scans with intravenous (IV) contrast and noncontrast CTs (p Conclusion Our study suggests that pre-existing CT scans represent a viable and economical alternative for perforator mapping before abdominal-based free flap breast reconstruction.