Search

BACKGROUND: In recent years, indocyanine green angiography (ICG-A) has been used increasingly to assist tissue perfusion assessments during plastic and reconstructive surgery procedures, but no guidelines exist regarding its use. We sought to identify areas of consensus and non-consensus among international experts on the use of ICG-A for tissue-perfusion assessments during plastic and reconstructive surgery.METHODS: A two-round, online Delphi survey was conducted of 22 international experts from four continents asking them to vote on 79 statements divided into five modules: module 1 = patient preparation and contraindications (n = 11 statements); module 2 = ICG administration and camera settings (n = 17); module 3 = other factors impacting perfusion assessments (n = 10); module 4 = specific indications, including trauma debridement (n = 9), mastectomy skin flaps (n = 6), and free flap reconstruction (n = 8); and module 5 = general advantages and disadvantages, training, insurance coverage issues, and future directions (n = 18). Consensus was defined as ≥70% inter-voter agreement.RESULTS: Consensus was reached on 73/79 statements, including the overall value, advantages, and limitations of ICG-A in numerous surgical settings; also, on the dose (0.05 mg/kg) and timing of ICG administration (∼20-60 seconds preassessment) and best camera angle (61-90o) and target-to-tissue distance (20-30 cm). However, consensus also was reached that camera angle and distance can vary, depending on the make of camera, and that further research is necessary to technically optimize this imaging tool. The experts also agreed that ambient light, patient body temperature, and vasopressor use impact perfusion assessments.CONCLUSION: ICG-A aids perfusion assessments during plastic and reconstructive surgery and should no longer be considered experimental. It has become an important surgical tool.

BACKGROUND: In addition to its intended purpose of perforator mapping, computed tomography angiography can also identify incidental findings that may require further evaluation. In this multi-institutional study, the authors evaluated the frequency of incidental findings and their significance and effects on treatment course and aimed to identify risk factors for detecting such findings. METHODS: A retrospective review of patients who underwent perforator mapping with computed tomography angiography was performed over a 5-year period from three academic institutions. Relevant sociodemographic and clinicopathologic information, computed tomography angiography reports, follow-up visits, and treatment outcomes were reviewed. Univariate and multivariate analyses were performed to assess the relationship between risk factors and incidental findings. RESULTS: From January of 2015 to July of 2020, a total of 656 patients were identified who met inclusion criteria. Overall, 342 incidental findings were found, 76 of which required additional imaging or consultation. Ultimately, 10 patients (1.5 percent) had findings that altered reconstructive management, including five patients (0.8 percent) having severe disease that resulted in the cancellation of their reconstruction. Advanced age and immediate reconstruction timing were independent risk factors for incidental findings. CONCLUSIONS: Incidental findings are commonly identified on preoperative computed tomography angiography for deep inferior epigastric perforator flap breast reconstruction. Suspicious findings should be investigated thoroughly because they can alter the reconstructive course. Understanding of high-risk groups for incidental findings can further advance patient education during initial consultation. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Background Macromastia is associated with increased opioid consumption, which could potentially be the initial exposure for patients with an opioid use disorder amid an escalating opioid crisis in the United States. Objectives The purpose of this study was to evaluate outpatient cost of care and opioid consumption in patients with macromastia and compare those who underwent reduction mammaplasty vs those who did not have surgery. Methods PearlDiver, a database encompassing a national cohort of private payers with 153 million unique patients, was queried. The study cohort included patients diagnosed with macromastia who did or did not undergo reduction mammaplasty utilizing both ICD-9 and ICD-10 and CPT codes. Outpatient cost of care and morphine milligram equivalents (MME) were calculated up to 5 years postoperatively for both cohorts. Results At 1 to 3 years postoperatively, there was no statistically significant difference in outpatient cost of care between cohorts. At every follow-up thereafter, outpatient cost of care was higher among macromastia patients who did not undergo reduction mammaplasty, with cohort differences of US$240.68 and US$349.90 at 4 years and 5 years, respectively (P < .05). MME consumption was greater in patients who underwent reduction mammaplasty up to 30 days postoperatively (P < .01). Beyond that, there was no significant difference in MME consumption between cohorts. However, patients who did not undergo surgery had opioid consumption levels above 50 MME/day until 3 years after diagnosis of macromastia. Conclusions Patients with macromastia who undergo reduction mammaplasty have lower outpatient care costs than patients who do not undergo reduction mammaplasty, with safer long-term opioid consumption in alignment with current Centers for Disease Control and Prevention guidelines.

Background: Umbilical complications can be relatively common after breast reconstruction with deep inferior epigastric perforator (DIEP) flaps. The medial umbilical ligaments and the ligamentum teres hepatis can be the sole blood supply to the umbilicus after a DIEP flap harvest. Prior incisions along the epigastric midline may disrupt the ligamentum teres hepatis. In this retrospective study, we assess the influence of previous midline epigastric scars on umbilical complications after DIEP flap harvest. Methods: All patients who underwent breast reconstruction with DIEP flaps were identified at an academic institution over six years. Relevant sociodemographic and clinicopathologic factors were reviewed in the electronic medical records. Univariate and multivariate analyses were performed to determine the role of clinical variables to predict the chance of umbilical complications. Results: A total of 243 patients met inclusion criteria, with 39 patients (16%) having prior surgery utilizing midline epigastric incisions. Twenty-one patients had umbilical complications. No significant difference in patient characteristics was found between patients with and without prior midline epigastric scars. Patients with a history of previous midline epigastric scars had a higher rate of umbilical complications (20.5% vs. 6.4%, p < 0.01). Bilateral medial row perforator-based DIEP flap harvest was also related to a higher rate of umbilical complications (18.4% vs. 6.2% p < 0.01). Conclusion: Previous midline epigastric scars are associated with higher rates of umbilical complications after DIEP flap harvest. Bilateral medial row perforator-based DIEP flap harvest exacerbates the rate of umbilical complications and should be avoided in patients with prior midline epigastric incision whenever possible.

Implant-based reconstruction is the most common procedure for breast reconstruction after mastectomy. Acellular dermal matrix is used to provide additional coverage in subpectoral and prepectoral implant placement. In this study, the authors compared postoperative outcomes between AlloDerm (LifeCell, Branchburg, N.J.) and DermACELL (Stryker, Kalamazoo, Mich.), two acellular dermal matrix brands.A retrospective review of implant-based breast reconstruction from 2016 to 2020 was conducted. Patient demographics and comorbidities, implant size and location, acellular dermal matrix choice, and postoperative outcomes were recorded. Primary outcomes assessed were seroma and infection compared between two acellular dermal matrix brands. Independent clinical parameters were assessed with multiple logistic regression models for the primary outcomes.Reconstruction was performed in 150 patients (241 breasts). Eighty-eight patients underwent expander placement with AlloDerm and 62 patients with DermACELL. There were no significant differences in patient characteristics between the two groups. There was a significantly higher incidence of seroma in the AlloDerm group in univariate (AlloDerm 21.7 percent versus DermACELL 8.2 percent, p0.005) and multivariate analyses ( p = 0.04; 95 percent CI, 1.02 to 6.07). Acellular dermal matrix use (regardless of type) was not associated with higher rates of infection ( p = 0.99), but body mass index was ( p = 0.004).Both AlloDerm and DermACELL had similar infection rates regardless of contributing risk factors. AlloDerm was found to be a risk factor for seroma formation in the postoperative period. As such, it is important to be aware of this complication when performing implant-based reconstruction with this brand of acellular dermal matrix.Therapeutic, III.

Epidermal growth factor receptor (EGFR) is often overexpressed in head and neck squamous cell carcinoma (HNSCC) and represents a top candidate for targeted HNSCC therapy. However, the clinical effectiveness of current Food and Drug Administration (FDA)‐approved drugs targeting EGFR is moderate, and the overall survival rate for HNSCC patients remains low. Therefore, more effective treatments are urgently needed. In this study, we generated a novel diphtheria toxin‐based bivalent human epidermal growth factor fusion toxin (bi‐EGF‐IT) to treat EGFR‐expressing HNSCC. Bi‐EGF‐IT was tested for in vitro binding affinity, cytotoxicity, and specificity using 14 human EGFR‐expressing HNSCC cell lines and three human EGFR‐negative cancer cell lines. Bi‐EGF‐IT had increased binding affinity for EGFR‐expressing HNSCC compared with the monovalent version (mono‐EGF‐IT), and both versions specifically depleted EGFR‐positive HNSCC, but not EGFR‐negative cell lines, in vitro. Bi‐EGF‐IT exhibited a comparable potency to that of the FDA‐approved EGFR inhibitor, erlotinib, for inhibiting HNSCC tumor growth in vivo using both subcutaneous and orthotopic HNSCC xenograft mouse models. When tested in an experimental metastasis model, survival was significantly longer in the bi‐EGF‐IT treatment group than the erlotinib treatment group, with a significantly reduced number of metastases compared with mono‐EGF‐IT. In addition, in vivo off‐target toxicities were significantly reduced in the bi‐EGF‐IT treatment group compared with the mono‐EGF‐IT group. These results demonstrate that bi‐EGF‐IT is more effective and markedly less toxic at inhibiting primary HNSCC tumor growth and metastasis than mono‐EGF‐IT and erlotinib. Thus, the novel bi‐EGF‐IT is a promising drug candidate for further development., In this study, we have developed a diphtheria toxin‐based bivalent human EGF fusion toxin for the treatment of HNSCC with significantly improved efficacy and markedly less in vivo off‐target toxicity compared with the monovalent human EGF fusion toxin. The bivalent human EGF fusion toxin is a promising novel drug candidate for the treatment of EGFR‐positive HNSCC.

The clinical application of vascularized composite allografts (VCA) has continue to expand each year as new transplants are performed. However, chronic rejection and the many side effects from chronic immunosuppression continue to inhibit widespread application of VCA. Immune tolerance to VCA would address these two issues and shift the risk-benefit ratio to allow for the more widespread application of these transplants. Future development of clinical tolerance protocols will be generated from pre-clinical experiments performed in large animal models. This article reviews the current state of large animal tolerance protocols published for VCA. The most successful tolerance protocols thus far include the use of hematopoietic stem cell transplant with non-myeloablative preconditioning and establishment of donor cell chimerism. In addition to this strategy, several groups have examined the inclusion of mesenchymal and adipose-derived stem cells to address the complications related to the use of hematopoietic stem cell transplant (such as graft versus host disease). These large animal models are critical to development of a viable pre-clinical model for tolerance in vascularized composite allografts that can deliver a tolerant state with minimal harm to the recipient of these non-life-saving transplants.

The majority of clinically diagnosed cutaneous T‐cell lymphomas (CTCL) highly express the cell‐surface markers CC chemokine receptor 4 (CCR4) and/or CD25. Recently, we have developed diphtheria toxin‐based recombinant Ontak®‐like human IL2 fusion toxin (IL2 fusion toxin) and anti‐human CCR4 immunotoxin (CCR4 IT). In this study, we first compared the efficacy of the CCR4 IT vs IL2 fusion toxin for targeting human CD25+CCR4+ CTCL. We demonstrated that CCR4 IT was more effective than IL2 fusion toxin. We further constructed an IL2‐CCR4 bispecific IT. The bispecific IT was significantly more effective than either IL2 fusion toxin or CCR4 IT alone. The bispecific IT is a promising novel targeted therapeutic drug candidate for the treatment of refractory and recurrent human CD25+ and/or CCR4+ CTCL., We have developed an IL2‐CC chemokine receptor 4 (CCR4) bispecific immunotoxin (IT). The bispecific IT was significantly more effective than either IL2 fusion toxin or CCR4 IT alone. The bispecific IT is a promising novel targeted therapeutic drug candidate for the treatment of refractory and recurrent human CD25+ and/or CCR4+ cutaneous T‐cell lymphoma.

Background Venous flow couplers are typically used to monitor free flaps during the postoperative period, with a continuous venous signal available immediately after completion of the anastomosis. Intraoperative loss of the coupler signal is not uncommon and may require adjustments in free flap inset and even flap thickness to get the venous signal to return. The effects of intraoperative coupler signal loss and the role of this technology on flap outcomes have not been evaluated. We hypothesized that the use of intraoperative coupler can be protective of both early and late flap complications by preventing unfavorable flap insets. Patients and Methods All patients who underwent free flap breast reconstruction between January 2018 and June 2019 by single microsurgery team were included. Flap inset and inset changes based on flow coupler signal problems were reviewed in the procedure notes. Patient demographics data and clinical outcomes were analyzed with comprehensive chart review. Results Forty-four consecutive patients with 69 free flaps were identified. There were no significant differences in patient characteristics or venous coupler size used in venous anastomosis. Although the number of operating room take backs for venous insufficiency was not significantly different between two groups, the free flaps with inset change had significantly higher complications that required later surgical intervention (p = 0.0464). Conclusion Surgeons should be aware that intraoperative coupler signal loss can be associated with poor clinical outcomes postoperatively and these flaps may require more perfusion imaging, flap debulking, or even additional venous anastomosis.

Background More than 85 patients have received over 100 hand/arm transplants and more than 35 patients have received full or partial face transplants at institutions around the world. Given over two decades of experience in the field and in the light of successful outcomes with up to 17 years follow up time, should we still consider vascularized composite allograft (VCA) as a research/clinical investigation? We present the results of a nationwide electronic survey whose intent was to gather institutional bias with regard to this question. Methods An 11 question survey that was developed by VCA advisory committee of American Society of Transplantation was sent to all identified Internal Review Board chairs or directors in the United States. Results We received a total of 54 responses (25.3%) to the survey. The majority (78%) of responses came from either the chairperson, director, or someone who is administratively responsible for an IRB. Conclusion Though certainly not an exhaustive investigation into each institution's preference, we present a representative sampling. The results of which favor VCA as an accepted clinical procedure given the appropriate setting. Further research is needed to fully ascertain practices at each individual institution.

Nontuberculous mycobacterial hardware infections are extremely challenging to treat. Multidisciplinary care involving removal of infected hardware, thorough debridement, and durable soft tissue coverage in conjunction with antibiotic therapy is essential for successful management. This case report presents a patient with chronic mycobacterial spinal hardware infection that underwent successful treatment with aggressive serial debridements and reconstruction with a large pedicled superior gluteal artery perforator flap coverage.

Dopamine has a favorable therapeutic profile but has not been widely used to treat hypotension during microvascular breast reconstruction. The purpose of this study was to evaluate outcomes in patients who received dopamine during breast reconstruction using deep inferior epigastric perforator (DIEP) free flaps and compare them with patients who did not receive dopamine.A single-center retrospective review was performed for patients who underwent breast reconstruction with DIEP free flaps between October 2018 and March 2020. Patient demographics, comorbidities, fluid balance, hospital stay, and adverse outcomes were compared between patients who received at least 1 h of dopamine (DA) and patients who did not receive dopamine (ND). Subgroup analyses were performed for bilateral procedures and patients who received dopamine.Twenty-five patients in the DA group and 43 patients in the ND group met the inclusion criteria. There were no flap-related complications. Patients who had dopamine initiated to maintain blood pressures had a higher total volume of intravenous fluid (ND:3.81L vs. DA:5.04L, p = 0.005). However, DA patients exhibited decreased fluid requirements (ND:839 mL/h vs. DA:479 mL/h, p = 0.004) and increased urine output (ND:98.0 mL/h vs. DA:340 mL/h, p = 0.001) once dopamine was initiated. Intraoperative urine output (ND:1.37 L vs. DA:3.48 L, p 0.001) and rate (ND:1.9 ml/kg/h vs. DA:3.7 ml/kg/h, p 0.001) were increased in the DA group. The fluid balance of patients undergoing bilateral procedures was closer to neutral for patients who received dopamine (ND:+3.43 L vs. DA:+2.26 L, p = 0.03).Dopamine is safe to use in microvascular breast reconstruction. It may be beneficial for hemodynamically labile patients by stabilizing blood pressure and facilitating a neutral fluid balance.

Background The superficial fascial system is routinely closed to alleviate tension at the abdominal donor site after harvest of the deep inferior epigastric artery perforator flap (DIEP) for breast reconstruction. This is thought to decrease rates of wound dehiscence and improve contour postoperatively. There has been no comparative analysis on closure of the superficial fascial system and its effect on donor-site outcomes. Methods The authors retrospectively evaluated outcomes of DIEP flap breast reconstructions performed between 2017 and 2019. After May of 2018, the surgeons collectively agreed to stop closure of the superficial fascial system. All subsequent patients underwent closure of rectus abdominis fascia followed by skin closure. Patient demographic data and abdominal donor-site comorbidities were recorded between the superficial fascial system closure and no-superficial fascial system closure groups. Representative photographs of patients from the two groups were blindly assessed for scar appearance and contour using previously published grading scales. The results were compared. Results DIEP flap breast reconstruction was performed in 103 consecutive women. Among patients with abdominal donor-site reconstruction, 66 had superficial fascial system closure and 37 did not. There was not a significant difference in fat necrosis or wound dehiscence between the two groups (p = 0.29 and p = 0.39, respectively). Postoperative abdominal scar and contour were evaluated by 10 independent raters and showed no significant difference between the two groups. Conclusion Omission of superficial fascial system closure resulted in no difference in wound dehiscence or fat necrosis rates and aesthetic appearance of the abdominal scar and contour. Clinical question/level of evidence Therapeutic, III.

Patient safety is defined as freedom from accidental or preventable harm produced by medical care. The identification of patient- and procedure-related risk factors enables the surgical team to carry out prophylactic measures to reduce the rate of complications and adverse events.The purpose of this review is to identify the characteristics of patients, practitioners, and microvascular surgical procedures that place patients at risk for preventable harm, and to discuss evidence-based prevention practices that can potentially help to generate a culture of patient safety.

Keloids are benign fibroproliferative skin tumors that can cause disfigurement and disability. Although they frequently recur after excision or medical management and can affect 6 to 16 percent of African Americans, there is no gold standard therapy. Keloids are challenging to study because there are no animal or in vitro models of this disorder. This makes it very difficult to validate data from treated tissue samples or cells and develop targeted therapies for this disease. In this study, the authors demonstrate that intralesional 5-fluorouracil injection after keloid excision prevents recurrence for 2 years, with no reported adverse events. The authors analyze the expression of treated and untreated biopsy specimens of the same keloids in their native context to capture insights that may be missed by in vitro cell culture models and correct for intrakeloid variability. Random forest analysis of the microarray data dramatically increased the statistical power of the authors' results, permitting hypothesis-free creation of a gene expression profile of 5-fluorouracil-treated keloids. Through this analysis, the authors found a set of genes, including YAP1 and CCL-2, whose expression changes predict 5-fluorouracil therapy status and include genes that have not previously been associated with keloid biology and are of unknown function. The authors further describe keloid heterogeneity for the first time using multidimensional analysis of their microarray results. The methods and tools the authors developed in this research may overcome some of the challenges in studying keloids and developing effective treatments for this disease. CLINICAL QUESTION/LEVEL OF EVIDENCE:: Therapeutic, V.

Human acellular dermal matrix (HADM) is an increasingly used adjunct to breast reconstruction. Previous meta-analyses demonstrate increased risks of complications, but these studies largely represent one product. The purpose of this study is to stratify outcomes on the basis of a meta-analysis of complications incorporating all new studies after 2012 and their associated new human-based products.A query of the MEDLINE database for articles on HADM and breast reconstruction from January 2012 to October 2015 yielded 172 citations. Two levels of screening identified 47 relevant studies. Thirteen studies were used in comparative meta-analysis.Complication rates were higher in HADM patients: total complications, 17.7% versus 6.1%; seroma, 8.3% versus 5.4%; infection, 7.2% versus 5.9%; and flap necrosis, 14.7% versus 7.1%. Meta-analysis revealed a statistically significant increased risk of total complications in patients who underwent reconstruction with HADM when compared with their submuscular reconstruction cohort (p = 0.03; relative risk (RR) = 1.46; confidence interval (CI): 1.04-2.04). Patients who underwent reconstruction with HADM demonstrated a significantly increased risk of flap necrosis (p 0.01; RR = 2.39; CI: 1.8-3.16) and infection (p = 0.02; RR = 1.5; CI: 1.07-2.09) when compared with those who underwent submuscular reconstruction. There was no significant difference in seroma, hematoma, or implant explantation between these two groups.This study suggests an increased risk of overall complications, specifically infection and flap necrosis, in patients who underwent tissue expander/implant breast reconstruction with HADM when compared with those who underwent submuscular placement. This must be weighed against the advantages in enhancing aesthetic outcomes, increasing intraoperative fill volume, and ameliorating capsular contracture.

Background:. Keloids are an abnormal proliferation of scars that can involve large areas of tissue beyond the original injury site. Hypertrophic scars are similar clinically, but do not exceed the original scar limits. These scarring abnormalities can cause noxious symptoms such as pain, tenderness, itching, and ulcerations. The aim of this review is to discuss current therapies for both types of abnormal scarring, and to determine if guidelines can be provided for excisional treatment with adjuvant therapies versus non-excisional methods. Methods:. A systematic literature search was performed through the Web of Science database. The search revolved around keywords such as “keloid,” “hypertrophic scars,” and “treatment.” Articles were reviewed and screened for inclusion and exclusion criteria. The review focuses on an analysis and summarization of randomized control trials regarding keloid or hypertrophic scar treatments. Results:. The original searches produced 1161 and 1275 articles for keloid and hypertrophic scars, respectively. In total, 316 duplicates were found. After accounting for 2014–2019 publication time, 655 keloid and 893 hypertrophic scar articles were reviewed. This resulted in 15 articles that pertained to treatment and randomized control trials. Conclusions:. Keloids and hypertrophic scars present a clinical challenge. Based on qualitative review of recurrence, neither excision plus adjuvant therapy or nonsurgical treatments can be recommended preferentially at this time. More research is needed to determine if recurrence rate bias exists between the treatment regimens, as excisional treatment plus adjuvant therapy is reserved for refractory scars.

Background All women undergoing a mastectomy have the right to reconstruction. However, many women do not receive reconstruction and many more are not aware of all the reconstructive options available to them. Travel distance to a center that provides reconstruction and subsequent follow-up may be a contributing factor to this disparity especially among those who seek microsurgical options. Telehealth, which provides patients with remote video consultations and decreases the travel burden, may be a solution to optimize the accessibility of breast reconstruction for these patients. The purpose of this study was to discuss the efficacy and reliability of telehealth to overcome geographic barriers. Methods Patients who received breast reconstruction and participated in video telehealth visits between February and May 2020 were included in this study. Patient demographics, comorbidities, and clinical outcomes were collected. Video telehealth encounters were reviewed to determine specific concerns and questions discussed during these encounters. Results A total of 235 breast reconstruction surgery patient encounters were recorded for 4 plastic surgeons who offer microsurgical breast reconstruction. Eighty-eight patients (37.4%) were seen as telehealth visits, 20 (22.7%) of which were new patient visits. Eight (9.09%) patients were microsurgical breast reconstruction candidates and 25 (28.4%) were following-up after microsurgical breast reconstruction. The majority of telehealth visits included normally healing wounds in the postoperative patient. Conclusion Telehealth provides an avenue for premastectomy consultation, second opinion visits, and postoperative follow-up for patients who have geographical barriers precluding them from reaching plastic surgeons who perform all types of breast reconstruction.

CT angiogram (CTA) has become the preferred method for the planning of abdominal-based microsurgical breast reconstruction to gather information about location, number, caliber and trajectory of the abdominal perforators and to decrease overall flap dissection and operating room time. However, the high-level evidence to support its utility has been limited to nonrandomized retrospective and prospective studies.Patients undergoing deep inferior epigastric artery perforator (DIEP) flap breast reconstruction were prospectively randomized to preoperative CTA and no imaging groups. Patient demographics, operative times, selected row and number of perforators for flap harvest, agreement in perforator selection between radiologist and surgeon, and clinical outcomes data were collected. Two-way ANOVA, Fisher's exact and Student's t-tests were used for statistical analysis.Overall, 37 patients with 63 flaps were included in this study. Seventeen patients had CT scan prior to surgery. Mean age was 50.5 ± 9.6 years. Flap dissection time was significantly shorter in the CT group (150.8 ± 17.8 vs 184.7 ± 25.1 min and p0.001). Although overall odds ratio (OR) time was also shorter in the CT group, this only reached a statistical significance in bilateral surgeries (575.9 ± 70.1 vs 641.9 ± 79.6 min and p = 0.038). Hemiabdomen side, selected DIEP row, and the number of dissected perforators did not affect the overall dissection time. Complication rates were similar between the two groups.This prospective, randomized study demonstrates that preoperative CTA analysis of perforators decreases flap harvest and overall OR time with equivalent postoperative outcomes.

Lower extremity wounds can be secondary to a variety of sources, including trauma, oncologic resection, neuropathy, or vascular disease, so they can require a variety of techniques for successful reconstruction. This chapter discusses some of the local muscle flaps generally utilized for lower extremity wounds.

Background In 2014, SSO-ASTRO published guidelines which recommended “no ink on tumor” as adequate margins for patients undergoing breast conservation for invasive breast cancer. In 2016, new SSO-ASTRO-ASCO guidelines recommended 2 mm margins for DCIS. We evaluated whether these guidelines affected re-excision rates at our institution. Methods Patients treated with breast conservation surgery from January 1, 2010–March 1, 2016 were identified. Re-excision rates, tumor characteristics, and presence of residual disease were recorded. The 2016 guidelines were retrospectively applied to the same cohort and expected re-excision rates calculated. Results Re-excision rates did not significantly decline before and after 2014 guideline adoption (11.9% before, 10.9% after; p = 0.65) or when the 2016 guidelines were retrospectively applied (8.4%; p = 0.10). Conclusions The 2014 and 2016 guidelines had minimal impact on our re-excision rates, as most re-excisions were done for DCIS and 2016 guidelines supported our prior institutional practices of 2 mm margins for these patients.