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The incidence of metabolically unhealthy obesity is rising nationally. In this study, we compare wound and overall complications between metabolically unhealthy obese and healthy patients undergoing elective plastic surgery and model how operative time influences a complication risk.Patients undergoing elective breast and body plastic surgery procedures in the 2009-2019 National Surgical Quality Improvement Program (NSQIP) dataset were identified. Complications were compared between metabolically unhealthy obese (body mass index [BMI]30 with diabetes and/or hypertension) versus metabolically healthy obese patients (BMI30 without diabetes or hypertension). Logistic regression was used to model the probability of wound complications across operative times stratified by metabolic status.Of 139,352 patients, 13.4% (n = 18,663) had metabolically unhealthy obesity and 23.8% (n = 33,135) had metabolically healthy obesity. Compared to metabolically healthy patients, metabolically unhealthy patients had higher incidence of wound complications (6.9% versus 5.6%; P 0.001) and adverse events (12.4% versus 9.6%; P 0.001), in addition to higher 30-d readmission, returns to the operating room, and length of stay (all P 0.001). After adjustment, BMI (Odds ratio [OR] 7.86), hypertension (OR 1.15), and diabetes (OR 1.25) were independent risk factors for wound complications (all P 0.001). Among metabolically unhealthy patients, the operative time was log-linear with a wound complication risk (OR 1.21; P 0.001).Diabetes and hypertension are additive risk factors with obesity for wound complications in elective plastic surgery. Among patients with metabolically unhealthy obesity, a risk of wound complications increases logarithmically with operative time. This distinction with regard to metabolic state might explain the unclear impact of obesity on surgical outcomes within existing surgical literature.

There is growing recognition of a condition known as breast implant illness. Very little information exists about the diagnosis and natural history of breast implant illness. To better understand the patient experience, we surveyed the U.S. Food and Drug Administration's Manufacturer and User Facility Device Experience (MAUDE) database for narratives describing symptoms of breast implant illness.The MAUDE database was queried for all reports that included breast implant illness within the patient narrative between 2010 and 2020. A review of narratives was used to identify and summarize 36 symptoms over nine symptom classes. Event year and reporting year were summarized. Hierarchical clustering analysis using centroid components was conducted on all reported breast implant illness symptoms, and a dendrogram was created to visualize clustering.During the study period from 2010 to 2020, there were 751 captured adverse event reports in the MAUDE database that referenced breast implant illness, with the first report submission in 2014. Of those reports, 60.6 percent were for silicone implants and 39.4 percent were for saline implants. The three most commonly reported symptom categories were neurologic [ n = 544 (72.4 percent)], followed by musculoskeletal [ n = 418 (55.7 percent)], and dermatologic [ n = 273 (36.4 percent)]. The top 10 symptoms, irrespective of category, include fatigue/weakness, numbness/tingling, brain fog, depression/anxiety, arthralgia, myalgia, headache, hair loss, gastrointestinal issues, and weight change. A hierarchical clustering analysis demonstrated that symptoms reported by patients clustered into two major groups.This study demonstrates the utility of public-facing databases, such as the Manufacturer and User Facility Device Experience database, in understanding the patient experience as it relates to breast implant illness.

ChatGPT and similar generative AI have immense potential to revolutionize health care and the field of microsurgery. We found that when it comes to microsurgical procedures, ChatGPT-generated FAQ sheets tend to be highly accurate but somewhat non-specific. At this stage, microsurgeons should read over any ChatGPT-generated patient materials and briefly addend in more specific information while verifying for general accuracy. Overall, it remains to be seen how microsurgeons respond to this exciting new development, to best incorporate ChatGPT in an advantageous yet ethical manner.

Background Rates of postmastectomy breast reconstruction have been shown to vary by racial, ethnic, and socioeconomic factors. In this study, we evaluated disparities across pathways toward breast reconstruction. Methods All women who underwent mastectomy for breast cancer at a single institution from 2017 to 2018 were reviewed. Rates of discussions about reconstruction with breast surgeons, plastic surgery referrals, plastic surgery consultations, and ultimate decisions to pursue reconstruction were compared by race/ethnicity. Results A total of 218 patients were included, with the racial/ethnic demographic of 56% white, 28% Black, 1% American Indian/Native Alaskan, 4% Asian, and 4% Hispanic/Latina. The overall incidence of postmastectomy breast reconstruction was 48%, which varied by race (white: 58% vs. Black: 34%; p Conclusion Despite statistically equivalent rates of plastic surgery discussions and referrals, black women had lower breast reconstruction rates versus white women. Lower rates of breast reconstruction in Black women likely represent an amalgamation of barriers to care; further exploration within our community is warranted to better understand the racial disparity observed.

Although breast reconstruction after bilateral mastectomies including a contralateral prophylactic mastectomy is known to have a higher overall complication profile, whether reconstructive complication rates differ between the therapeutic mastectomy and contralateral prophylactic mastectomy sides remains unclear.Women undergoing bilateral mastectomies with autologous or implant-based breast reconstruction for a unilateral breast cancer at a single institution were identified (2009 to 2019). Postoperative complications were stratified by laterality (therapeutic mastectomy versus contralateral prophylactic mastectomy). Paired data were analyzed to compare the risks of complications between prophylactic and therapeutic reconstruction sides in the same patient.A total of 130 patients (260 reconstructions) underwent bilateral autologous or implant-based reconstruction. Although most women underwent a simple mastectomy, a higher proportion of therapeutic mastectomies were modified radical mastectomies including axillary lymph node dissections compared to contralateral prophylactic mastectomies (15.4 percent versus 0 percent). Forty-four percent of women completed postmastectomy radiation therapy of the therapeutic side before definitive reconstruction. Overall, both therapeutic and prophylactic reconstructions had a similar incidence of reconstructive failure (p = 0.57), return to the operating room (p = 0.44), mastectomy skin flap necrosis (p = 0.32), seroma (p = 0.82), fat necrosis (p = 0.16), wound infection (p = 0.56), and cellulitis (p = 0.56). Nearly one-fifth of patients experienced complications limited to the prophylactic side [contralateral prophylactic mastectomy reconstruction complications, n = 26 (20.0 percent); therapeutic mastectomy reconstruction complications, n = 15 (11.5 percent)].Despite a history of local radiation therapy and more extensive oncologic surgery on the therapeutic side, there are no significant differences in the incidence of postsurgical complications on the therapeutic mastectomy and contralateral prophylactic mastectomy sides after bilateral reconstruction.Risk, II.

IntroductionBreast reconstruction plays an important role for many in restoring form and function of the breast after mastectomy. However, rates of breast reconstruction in the USA vary significantly by race, ethnicity and socioeconomic status. The lower rates of breast reconstruction in non-white women and in women of lower socioeconomic status may reflect a complex interplay between patient and physician factors and access to care. It remains unknown what community-specific barriers may be impacting receipt of breast reconstruction.Methods and analysisThis is a mixed-methods study combining qualitative patient interview data with quantitative practice patterns to develop an actionable plan to address disparities in breast reconstruction in the local community. The primary aims are to (1) capture barriers to breast reconstruction for patients in the local community, (2) quantitatively evaluate practice patterns at the host institution and (3) identify issues and prioritise interventions for change using community-based engagement.Ethics and disseminationEthics approval was obtained at the investigators’ institution. Results from both the quantitative and qualitative portions of the study will be circulated via peer-review publication. These findings will also serve as pilot data for extramural funding to implement and evaluate these proposed solutions.

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.

Background Scar revisions have been increasing in number. Patient-reported outcome measures are one tool to aid scar modulation decision-making. The aims of this study were to determine patient, scar, and clinical risk factors for (1) low SCAR-Q Appearance, Symptom, and Psychosocial Impact scores and how this differs for children; and (2) the potential need for future scar revision surgery to better identify such patients in a clinical setting. Methods A multicenter international cross-sectional cohort study based on survey data of participants with traumatic, surgical, and burn scars attending plastic, hand, and burn clinics in four countries was conducted following the Strengthening the Reporting of Observational Studies in Epidemiology checklist. Univariate analysis to identify risk factors and multivariable logistic analysis to select risk factors were completed. Collinearity for nonindependent factors and C statistic for model discrimination were also calculated. Results Seven hundred thirty-one participants completed the study booklet, and 546 participants (74.7 percent) had full data. Independent risk factors were determined to be a bothersome scar and perception of scarring badly for all three scales. Risk factors for self-reporting the need for future surgery included a health condition, scarring badly, scar diagnosis, prior scar revision, and low Psychosocial Impact scores. We did not identify evidence of multicollinearity. C statistics were high (0.81 to 0.84). Conclusions This study is the first multicenter international study to examine independent risk factors for low patient-reported outcome measure scores and the potential need for future scar revision surgery. Patients that perceive themselves as scarring badly and having a bothersome scar were at a higher risk of scar appearance concern, an increased symptom burden, and poorer psychosocial impact scores. Clinical question/level of evidence Risk, III.

There is a lack of consensus detailing the optimal approach to free-flap breast reconstruction when considering immediate, delayed, or staged techniques. This study compared costs, complications, and healthcare resource utilization (HCRU) across staged, delayed, and immediate free-flap breast reconstruction.Retrospective study using MarketScan databases to identify women who underwent mastectomies and free-flap reconstructions between 2014 and 2018. Complications, costs, and HCRU [readmission, reoperation, emergency department (ED) visits] occurring 90 days after mastectomy and 90 days after free flap were compared across immediate, delayed, and staged reconstruction.Of 3310 women identified, 69.8% underwent immediate, 11.7% underwent delayed, and 18.5% underwent staged free-flap reconstruction. Staged reconstruction was associated with the highest rate (57.8% staged, 42.3% delayed, 32.0% immediate; p0.001) and adjusted relative risk [67% higher than immediate (95% CI: 49-87%; p0.001)] of surgical complications. Staged displayed the highest HCRU (staged 47.9%, delayed, 38.4%, immediate 25.2%; p0.001), with 16.5%, 30.7%, and 26.5% of staged patients experiencing readmission, reoperation, or ED visit, respectively. The adjusted probability of HCRU was 206% higher (95% CI: 156-266%; p0.001) for staged compared with immediate. Staged had the highest mean total cost (staged $106,443, delayed $80,667, immediate $76,756; p0.001) with regression demonstrating the adjusted mean cost for staged is 31% higher (95% CI: 23-39%; p0.001) when compared with immediate.Staged free-flap reconstruction is associated with increased complications, costs, and HCRU, while immediate demonstrated the lowest. The potential esthetic benefits of a staged approach should be balanced with the increased risk for adverse events after surgery.

BACKGROUND Given the competition in the integrated plastic surgery Match, away rotations are ubiquitous among plastic surgery applicants to differentiate their applications. This study aimed to characterize how performing an away rotation affects rank order and Match outcomes for integrated plastic surgery programs. METHODS An online survey was designed and distributed to the top 25 integrated plastic surgery programs in the United States as determined by Doximity. Programs were polled about away rotation structure, position of rotators on their 2018 to 2019 rank list, and composition of current resident classes. RESULTS Twenty-five programs completed the survey (response rate, 100 percent). On average, programs interviewed 34.9 applicants (range, 22 to 50 applicants) and ranked 32.8 applicants (range, 10 to 50 applicants). Most "ranked-to-match" positions were occupied by home students or away rotators (60.9 percent). Rank order of home students, away rotators, and nonrotators varied significantly (p < 0.001), with median rank order of home students [5 (interquartile range, 1 to 9)] and rotators [14 (interquartile range, 6 to 27)] higher than nonrotators [17 (interquartile range, 10 to 29)]. Rank orders of away rotators tended to follow a bimodal distribution. Furthermore, 64.4 percent of integrated residents were either a home student or away rotator at their matched integrated program, with 20 percent of residency programs composed of greater than 70 percent of away rotators/home students across postgraduate years 1 through 6 classes. CONCLUSIONS For integrated plastic surgery programs, the majority of ranked-to-match students on rank lists and current residents were either home students or away rotators at their respective program. Performing well on an away rotation appears to confer significant benefit to the applicant applying in the integrated plastic surgery Match.

Background While bipedicled free flaps enable increased soft tissue volume and potential for contralateral symmetry in unilateral breast reconstruction, the influence of bipedicled flap reconstruction on patient-reported outcomes remains unclear. Methods Patients undergoing unilateral free flap breast reconstruction at a single institution from 2014 to 2019 were retrospectively reviewed and sent the BREAST-Q and Decision Regret Scale. Complication rates and the BREAST-Q and Decisional Regret Scale scores (0–100) were compared between patients receiving bipedicled total abdominal and unipedicled hemiabdominal free flaps. Results Sixty-five patients undergoing unilateral breast reconstruction completed the BREAST-Q and Decision Regret Scale with median (interquartile range [IQR]) follow-up time of 32 [22–55] months. Compared with bipedicled flaps, patients receiving unipedicled hemiabdominal flaps had higher mean body mass index (BMI; p = 0.009) and higher incidence of fat grafting (p = 0.03) and contralateral reduction mammaplasties (p = 0.03). There was no difference in incidence of major or minor complications, abdominal hernias or bulges, or total operative time between bipedicled and unipedicled flaps (p > 0.05). Overall, BREAST-Q scores for satisfaction with breast, sexual wellbeing, psychosocial wellbeing, physical wellbeing (chest), and physical wellbeing (abdomen) and the Decision Regret Scale scores did not significantly vary between bipedicled and unipedicled reconstructions (all p > 0.05). However, among large-breasted patients (≥C cup), mean (standard deviation [SD]) sexual wellbeing was significantly higher after bipedicled total abdominal free flap reconstruction ([60.2 (23.3) vs. 46.2 (22.0)]; p = 0.04), though this difference did not reach significance after multivariate adjustment. Conclusion Unilateral breast reconstruction with bipedicled total abdominal free flaps results in similar complication risk, patient satisfaction, and decisional regret without the need for as many contralateral reduction procedures.

Background Psychosocial distress, depression, or anxiety can occur in up to 50% of women after a breast cancer diagnosis and mastectomy. The purpose of this study was to assess the potential benefit of lavender oil as a perioperative adjunct to improve anxiety, depression, pain, and sleep in women undergoing microvascular breast reconstruction. Methods This was a prospective, single-blinded, randomized, controlled trial of 49 patients undergoing microvascular breast reconstruction. Patients were randomized to receive lavender oil or placebo (coconut oil) throughout their hospitalization. The effect of lavender oil on perioperative stress, anxiety, depression, sleep, and pain was measured using the hospital anxiety and depression scale, Richards–Campbell Sleep Questionnaire, and the visual analogue scale. Results Twenty-seven patients were assigned to the lavender group and 22 patients were assigned to the control group. No significant differences were seen in the perioperative setting between the groups with regard to anxiety (p = 0.82), depression (p = 0.21), sleep (p = 0.86), or pain (p = 0.30) scores. No adverse events (i.e., allergic reaction) were captured, and no significant differences in surgery-related complications were observed. When evaluating the entire cohort, postoperative anxiety scores were significantly lower than preoperative scores (p Conclusion In the setting of microvascular breast reconstruction, lavender oil and aromatherapy had no significant adverse events or complications; however, there were no measurable advantages pertaining to metrics of depression, anxiety, sleep, or pain as compared with the control group.

BACKGROUND: Women of color with breast cancer are less likely to undergo post-mastectomy reconstruction compared with White women, but it is unclear whether their perioperative outcomes are worse. The goal of this study was to investigate differences in preoperative comorbidities and postoperative complications by race/ethnicity among women with breast cancer undergoing postmastectomy reconstruction. STUDY DESIGN: Data were collected from the National Inpatient Sample database of the Healthcare Cost and Utilization Project from 2012 to 2016. Patient demographics, types of reconstruction, comorbid conditions, Charlson-Deyo Combined Comorbidity (CDCC) scores, length of stay (LOS), and perioperative complications were abstracted. Multivariate linear and logistic regression were performed to model LOS and likelihood of postoperative complications, respectively. RESULTS: Compared with White women (n = 19,730), Black women (n = 3,201) underwent autologous reconstruction more frequently (40.7% vs 28.3%), had more perioperative comorbidities (eg diabetes: 12.9% vs 5.8%), higher CDCC scores (% CDCC ≥ 4: 5.5% vs 2.7%), and longer LOS (median 3 vs 2 days, all p < 0.001). Being Black (vs white: +0.13 adjusted days, 95% CI 0.06 to 0.19) was also associated with longer LOS and an increased likelihood of surgical complications (vs White: odds ratio 1.24, 95% CI 1.09 to 1.42, both p < 0.01), but this association did not persist when outcomes were limited to microsurgical complications. CONCLUSION: Disparities in postmastectomy breast reconstruction between Black and White women extend beyond access to care and include perioperative factors and outcomes. These findings suggest an important opportunity to mitigate inequities in reconstruction through perioperative health optimization and improved access to and co-management with primary care.

Purpose: Adipose tissue constitutes a significant volume of the breast. However its influence on breast cancer initiation remains poorly understood. Breast adipose stromal cells (breast ASCs), essential progenitors of breast fat tissue, are abundant in breast adipose tissue. We studied the biology of primary human bASCs and their contribution to the tumor microenvironment.Methods: We generated a bASC cell repository from women undergoing prophylactic or therapeutic mastectomies (n=6 breast cancer patients; n=2 high risk patients). bASCs were isolated from the stromal vascular fraction of breast adipose tissue. Senescence was measured in bASCs using the senescence-associated beta-galactosidase detection kit. Senescence-associated-cytokines and chemokines in conditioned media collected from bASCs were measured by ELISA. The ability of bASCs to support cytokine signaling was determined by immunoblotting. Adipogenic potential of bASCs was determined by AdipoRed staining.Results: bASCs from 63% (5/8) of women in our cohort scored positive for senescence, with only some secreting senescence-associated cytokines (IL-6; TGF-beta) and chemokines (IL-8). Only in select cases was bASC secretion of cytokine associated with their ability to support cytokine-specific signaling pathways (e.g. TGFb/Smad2 signaling). bASCs from 38% (3/8) of these women exhibited an adipogenesis defect, and 2/3 (67%) also scored positive for senescence.Conclusion: bASC biology shows notable biologic variability in women undergoing prophylactic or therapeutic mastectomies, with some exhibiting a senescent phenotype, some exhibiting an adipogenesis defect, and some supporting TGFb or IL-6 signaling. Our results establish an important foundation for larger studies examining the impact of aberrant bASC biologies on breast cancer risk.

Limited visibility characteristic of cleft palate repair presents both ergonomic and educational challenges to cleft surgeons. Despite widespread recognition and reporting, posture-related spine disorders continue to represent a significant and potentially career-limiting problem for cleft/craniofacial surgeons. In addition, education and participation during palate repairs is difficult because of visual field constraints. At the authors' institution, a novel videoscope system was designed and implemented to (1) provide visualization for all surgical team members during palate operations, (2) facilitate active resident education, and (3) improve surgeon ergonomics. The authors' prior report demonstrated proof of concept for this method, which is now used in all cleft palate operations at their center. The purpose of this report is to share the detailed methodology to facilitate implementation by others and a retrospective review of the authors' experience before and after implementation. Video demonstration of the videoscope setup and a representative, recorded case are provided. The use of the videoscope was feasible in palatoplasties regardless of palatal phenotype and repair technique and did not have an effect on operative time. Subjectively, the authors report reduced procedure time in cervical flexion and subjectively improved musculoskeletal strain associated with videoscope use. Importantly, use of this system also provided complete visualization for all operating room team members and enabled enhanced resident autonomy during palate operations. Finally, it has facilitated the creation and archive of high-definition educational videos with unparalleled perspective. The equipment required to implement the system is likely already available in many medical centers. Adoption of this system may provide an opportunity to improve posture and teaching capabilities for cleft surgeons. CLINICAL QUESTION/LEVEL OF EVIDENCE:: Therapeutic, III.

INTRODUCTION As a profession, plastic surgeons must meet the public demand for aesthetic and reconstructive procedures. Patients search for physicians using Google, which offers insights into patient needs through their search history. METHODS The Google Trends Relative Search Volumes (RSV) were pulled for all searches for “plastic surgery” over 12 months. The number of active plastic surgeons per state was divided by Census Bureau population estimates to calculate the surgeons-per-capita value, or “surgical concentration.” The Google score divided by this concentration yields a “surgical demand index” for each state. RESULTS Florida, New York, and Connecticut had the greatest concentration of surgeons per ten-thousand people (0.220, 0.217, and 0.209, respectively), while Wyoming, Arkansas, and Vermont had the smallest (0.051, 0.071, 0.080). California exhibited the greatest number of Google searches (RSV=100), followed by Florida and Hawaii (RSV=95). Oregon (RSV=38), Virginia (RSV=52), and Alaska (RSV=58) had the fewest searches. The “surgical demand index” was greatest in Wyoming (1187.778), Oklahoma (993.751), and Arkansas (974.664) and smallest in Oregon (264.682), Virginia (320.716), and Connecticut (354.872). CONCLUSION The distribution of US plastic surgeons is not homogeneous. The Google data suggest that some markets (e.g. Oregon) are saturated while others (e.g. Wyoming) have significant demand that is not met by the number of plastic surgeons in those states.

BACKGROUND Musculoskeletal symptoms and injuries among surgeons are underestimated but are increasingly recognized to constitute a major problem. However, it has not been established when symptoms start and what factors contribute to the development of symptoms. METHODS A 19-question survey approved by our institution's review board, and American Council of Academic Plastic Surgery was sent to all plastic surgery residents enrolled in Accreditation Council for Graduate Medical Education-accredited plastic surgery training programs in the United States. The presence of various musculoskeletal symptoms was calculated, and predictors of these symptoms were evaluated. RESULTS We received 104 total responses. Ninety-four percent of residents had experienced musculoskeletal pain in the operating room. The neck was the most commonly affected area (54%) followed by the back (32%) and extremities (12%). Interestingly, 52% of responders developed these symptoms during the first 2 years of their residency. Furthermore, increasing postgraduate year level (P = 0.3) and independent versus integrated status (P = 0.6) had no correlation with pain, suggesting that symptoms began early in training.Pain symptoms were frequent for 47%, whereas 5% reported experiencing symptoms during every case. The use of a headlight correlated with frequent pain (odds ratio, 2.5; P = 0.027). The use of microscope and loupes did not correlate with frequent pain. Eighty-nine percent of responders were aware of having bad surgical posture, but only 22% had received some form of ergonomics training at their institution. Sixty-four percent of responders believe that the operating room culture does not allow them to report the onset of symptoms and ask for adjustments. This was more common among residents reporting frequent pain (odds ratio, 3.12; P = 0.009). CONCLUSIONS Plastic surgeons are at high risk for occupational symptoms and injuries. Surprisingly, symptoms start early during residency. Because residents are aware of the problem and looking for solutions, this suggests an opportunity for educational intervention to improve the health and career longevity of the next generation of surgeons.

Background Limb-threatening lower extremity traumatic injuries can be devastating events with a multifaceted impact on patients. Therefore, evaluating patient-reported outcomes (PROs) in addition to traditional surgical outcomes is important. However, currently available instruments are limited as they were not developed specific to lower extremity trauma patients and lack content validity. The LIMB-Q is being developed as a novel PRO instrument to meet this need, with the goal to measure all relevant concepts and issues impacting amputation and limb-salvage patients after limb-threatening lower extremity trauma. Methods This is a qualitative interview-based study evaluating content validity for the LIMB-Q. Patients aged 18 years and older who underwent amputation, reconstruction, or amputation after failed reconstruction were recruited using purposeful sampling to maximize variability of participant experiences. Expert opinion was solicited from a variety of clinical providers and qualitative researchers internationally. Preliminary items and scales were modified, added, or removed based on participant and expert feedback after each round of participant interviews and expert opinion. Results Twelve patients and 43 experts provided feedback in a total of three rounds, with changes to the preliminary instrument made between each round. One scale was dropped after round one, one scale was added after round two, and only minor changes were needed after round three. Modifications, additions and removal of items, instructions, and response options were made after each round using feedback gathered. Conclusion The LIMB-Q was refined and modified to reflect feedback from patients and experts in the field. Content validity for the LIMB-Q was established. Following a large-scale field test, the LIMB-Q will be ready for use in research and clinical care.

Background Severe lower extremity injuries are challenging to treat. The aspects of limb salvage and amputation most important to patients are not well-defined. This study's aim is to develop a conceptual framework for a patient-reported outcome instrument for lower extremity trauma patients, by defining issues and concepts most important to this patient population. Methods This is an interpretative description of transcripts collected from semistructured qualitative interviews at a single institution. High-energy lower extremity trauma patients were recruited by means of purposeful sampling to maximize variability. Thirty-three participant interviews were needed to reach content saturation. These participants were aged 19 to 79 years; 21 were men (63.6 percent); participation was after reconstruction [n= 15 (45.5 percent)], after amputation [n = 11 (33.3 percent)], or after amputation after failed reconstruction [n = 7 (21.2 percent)]. Interviews were recorded, transcribed, and coded line-by-line. Concepts were labeled with major and minor themes and refined through a process of constant comparison. Analysis led to the development of a conceptual framework and item pool to inform the development of a patient-reported outcome measure. Results In total, 2430 unique codes were identified and used to generate the conceptual framework covering 10 major themes: appearance, environment, finances, physical, process of care, prosthesis, psychological, sexual, social, and treatment. Conclusions This study establishes a comprehensive set of concepts, identifying what is most important to severe lower extremity trauma patients. These findings can be used to inform and focus research and clinical care, and provides the framework to develop a lower extremity trauma-specific patient-reported outcome instrument: the LIMB-Q.

Background Lower extremity reconstruction is often a challenging prospect with major implications on a patient’s quality of life. For complex defects of the lower extremity, special consideration must be given to ensure suitable and durable coverage. In the following article, we present the essential local muscle flaps for lower extremity reconstruction and discuss guiding principles for the reconstructive surgeon to consider. Methods A thorough literature review was performed using PubMed to identify commonly used local muscle flaps for lower extremity reconstruction. Common considerations for each identified flap were noted. Results The essential local muscle flaps for lower extremity reconstruction were identified and classified based on anatomical region of the defect to be reconstructed. General considerations and postoperative management were discussed to aid in operative decision making. Conclusion While many factors must be taken into account when performing lower extremity reconstruction, there are numerous reliable local muscle flaps which can be used to successfully provide durable coverage for a variety of soft tissue defects of the lower extremity.

BACKGROUND Enhanced recovery after surgery (ERAS) initiatives improve postoperative function and expedite recovery, leading to a decrease in length of stay. The authors noted a high rate of postoperative symptomatic hypotension in patients undergoing abdominal free flap breast reconstruction and wished to explore this observation. METHODS Subjects undergoing abdominal free flap breast reconstruction at the authors' institution from 2013 to 2017 were identified. The ERAS protocol was initiated in 2015 at the authors' hospital; thus, 99 patients underwent traditional management and 138 patients underwent ERAS management. Demographics and perioperative data were collected and analyzed. Postoperative symptomatic hypotension was defined as mean arterial pressure below 80 percent of baseline with symptoms requiring evaluation. RESULTS A significantly higher rate of postoperative symptomatic hypotension was observed in the ERAS cohort compared with the traditional management cohort (4 percent versus 22 percent; p < 0.0001). Patients in the ERAS cohort received significantly less intraoperative intravenous fluid (4467 ml versus 3505 ml; p < 0.0001) and had a significantly increased amount of intraoperative time spent with low blood pressure (22 percent versus 32 percent; p =0.002). Postoperatively, the ERAS cohort had significantly lower heart rate (77 beats per minute versus 88 beats per minute; p < 0.0001) and mean arterial pressure (71 mmHg versus 78 mmHg; p < 0.0001), with no difference in urine output or adverse events. CONCLUSIONS The authors report that ERAS implementation in abdominal free flap breast reconstruction may result in a unique physiologic state with low mean arterial pressure, low heart rate, and normal urine output, resulting in postoperative symptomatic hypotension. Awareness of this early postoperative finding can help better direct fluid resuscitation and prevent episodes of symptomatic hypotension. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.

Limb-threatening injuries can have a profound impact on patient lives. The impact on a patient's psychosocial well-being is widespread yet not well understood. This study aims to explore which psychosocial elements are central to patient experiences after limb-threatening lower extremity trauma.This is a qualitative interview-based study to identify psychosocial experiences after limb-threatening lower extremity trauma in a patient-centered manner. Data were collected via semi-structured qualitative interviews and analyzed via an interpretive description approach. Interviews were performed until content saturation was reached.A total of 33 interviews were performed until reaching content saturation. Eleven participants underwent early amputation, 7 delayed amputation after an attempt at limb salvage, and 15 underwent limb salvage. A total of 533 unique psychosocial codes were identified, comprised of eight concepts: acceptance, body image, coping, distress, positive impact, emotional support, isolation, and intrapsychic.This study identified the concerns central to this patient population and developed a conceptual framework for how patients cope with these psychosocial experiences. These findings underscore the importance of developing resilience by actively practicing acceptance and reaching more positive mental health outcomes. Additionally, these findings highlight the importance of increasing access to early and routine psychological and social support for patients with severe lower extremity trauma.

Background Free-flap breast reconstruction after failed implant reconstruction is associated with improved patient outcomes. How the level of satisfaction achieved compares between patients with and without previously failed implant reconstruction remains unknown. The aim of this study was to assess the influence of prior failed implant-based reconstruction on long-term patient-reported outcomes after free-flap breast reconstruction. Methods All patients undergoing free-flap breast reconstruction between 2015 and 2019 were identified. Patient satisfaction using the BREAST-Q and decisional regret using the Decision Regret Scale were compared between patients with and without a history of implant breast reconstruction. Results Overall, 207 patients were contacted and 131 completed the BREAST-Q and Decision Regret Scale. A total of 23 patients had a history of failed implant-based reconstruction requiring free-flap-flap salvage, most commonly due to infection (39.1%), chronic pain (34.8%), capsular contracture (26%), and implant malposition (26.1%). Following definitive free-flap reconstruction, patients with prior failed implant reconstruction had significantly lower BREAST-Q scores for satisfaction with breast (61.2 ± 16.7 vs. 70.4 ± 18.7; p = 0.04) and sexual well-being (38.5 ± 18.2 vs. 52.8 ± 24.7; p = 0.01) and reported higher decision regret (19.1 ± 18.6 vs. 9.6 ± 15.6, respectively). There were no significant differences for psychosocial well-being (p = 0.67), physical well-being (chest; p = 0.27), and physical well-being (abdomen; p = 0.91). Conclusion A history of failed implant-based reconstruction is associated with reduced satisfaction and increased decision regret with the final reconstructive outcome. This data underscores the importance of appropriate patient selection at the initial consultation, and informed preoperative counseling regarding long-term outcomes in patients presenting for free-flap reconstruction after a failed implant-based reconstruction.

BACKGROUND Plastic surgeons are evaluated not only by the number of patients served but also by relative value, quantified by the Medicare relative value unit system, which can affect advancement and compensation. Procedures that demand a high operative time without an increase in relative value units are, by definition, inefficient. The purpose of this study was to determine whether the number of relative value units actually corresponds to operative time. METHODS The National Surgical Quality Improvement Program data sets over a 9-year period were queried for plastic surgery operations. The primary CPT codes representing the 100 most common operations were compared for operative time and total relative value units. RESULTS A total of 53,701 cases were included. There was a high degree of correlation between operative time and number of relative value units (Pearson correlation coefficient, 0.82). The average efficiency was 10.201 ± 3.386 relative value units per hour. Pressure ulcer excisions and breast reconstruction were among the most efficient (e.g., Excision, sacral pressure ulcer, CPT 19357, generated 20.819 relative value units per hour). Skin excisions, debridements, and flap delays were among the least efficient (e.g., Excision, excessive skin and subcutaneous tissue, CPT 15847, generated 1.752 relative value units per hour). CONCLUSIONS As a general trend, the most common plastic surgical procedures requiring longer operative times are associated with more relative value units. Cases with higher relative value units assigned tended to be more efficient. For the 100 most common procedures, relative value units and operative time are not evenly distributed. These data suggest modifications to the current relative value unit designation system to more equally allocate these units based on effort and time.

BACKGROUND Patients undergoing mastectomy may not be candidates for immediate free-flap breast reconstruction because of medical comorbidities or postmastectomy radiation therapy. In this setting, flap reconstruction may be intentionally delayed or staged with tissue expander placement ("delayed-immediate" reconstruction). The optimal reconstructive choice and incidence of complications for these approaches remain unclear. METHODS The authors retrospectively identified patients who underwent delayed [n = 140 (72 percent)] or staged [n = 54 (28 percent)] abdominal free-flap breast reconstruction between 2010 and 2018 and compared the incidence of postoperative complications. RESULTS Patients undergoing staged reconstruction had a higher overall incidence of perioperative complications, including surgical-site infection (40.7 percent versus 6.5 percent; p < 0.001), wound healing complications (29.6 percent versus 12.3 percent; p = 0.004), hematoma (11.1 percent versus 0.7 percent; p < 0.001), and return to the operating room (27.8 percent versus 4.4 percent; p < 0.0001). These complications occurred predominately during the expansion stage, resulting in an 18.5 percent (n = 10) rate of tissue expander failure. Mean time from mastectomy to flap reconstruction was 476.8 days (delayed, 536.4 days; staged, 322.4 days; p < 0.001). At the time of flap reconstruction, there was no significant difference in the incidence of complications between the staged cohort versus the delayed cohort, including microsurgical complications (1.9 percent versus 4.3 percent; p = 0.415), total flap loss (0 percent versus 2.1 percent; p = 0.278), or fat necrosis (5.6 percent versus 5.0 percent; p = 0.875). CONCLUSIONS The aesthetic and psychosocial benefits of staged free-flap breast reconstruction should be balanced with the increased risk of perioperative complications as compared to a delayed approach. Complications related to definitive flap reconstruction do not appear to be affected by the approach taken at the time of mastectomy. . CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.

Background In the setting of radiation therapy or significant medical comorbidities, free-flap breast reconstruction may be intentionally delayed or staged with tissue expander placement ("delayed-immediate" approach). The effect of a staged approach on patient satisfaction and decisional regret remains unclear. Methods All patients undergoing free-flap breast reconstruction (n = 334) between 2014 and 2019 were identified. Complication rates, patient satisfaction using the BREAST-Q, and decisional regret using the Decision Regret Scale were compared between patients undergoing immediate, delayed, and staged approaches. Results Overall, 100 patients completed the BREAST-Q and Decision Regret Scale. BREAST-Q scores for psychosocial well-being (P = 0.19), sexual well-being (P = 0.26), satisfaction with breast (P = 0.28), physical well-being (chest, P = 0.49), and physical well-being (abdomen, P = 0.42) did not significantly vary between patients undergoing delayed, staged, or immediate reconstruction. Overall, patients experienced low regret after reconstruction (mean score, 11.5 ± 17.1), and there was no significant difference in regret scores by reconstruction timing (P = 0.09). Compared with normative BREAST-Q data, unlike immediate and delayed approaches, staged reconstruction was associated with lower sexual well-being (P = 0.006). Furthermore, a significantly higher infection rate was seen among staged patients (immediate 0%, delayed 5%, staged 20%, P = 0.01). Conclusions Staged free-flap breast reconstruction confers similar long-term satisfaction and decisional regret as immediate and delayed reconstruction but may be associated with worsened sexual well-being, when compared with normative data, and an increased risk of surgical site infection. When counseling patients regarding the timing of reconstruction, it is important to weigh these risks in the context of equivalent long-term satisfaction and decisional regret between immediate, delayed, and staged approaches.

Complications from breast reconstruction may delay postmastectomy radiation therapy and impact breast cancer outcomes. The authors hypothesized that immediate breast reconstruction may be associated with delays in the initiation of radiation, but that this delay would not significantly impact overall patient survival.Using the National Cancer Database, the authors identified women with breast cancer who underwent mastectomy and received postmastectomy radiation therapy. Delayed radiation was defined as treatment initiated 6 months or more after surgery in patients who received adjuvant chemotherapy or 12 weeks or more after surgery in patients who received neoadjuvant or no chemotherapy.Women undergoing breast reconstruction had an increased time to postmastectomy radiation therapy, 154 days versus 132 days (p0.001), and were more likely to experience a delay in initiating radiation (OR, 1.25; 95 percent CI, 1.188 to 1.314). Other factors associated with delayed radiation included increased Charlson/Deyo scores, neoadjuvant chemotherapy, nonprivate insurance, and black race. Cox proportional hazards models revealed no evidence of a reduced adjusted overall survival in the immediate breast reconstruction group (hazard ratio, 0.836; 95 percent CI, 0.802 to 0.871; p0.001). Restricted cubic spline analysis identified the threshold number of days at which the start of radiation began to impact survival at 169 days (95 percent CI, 160 to 190 days), 75 days (95 percent CI, 42 to 90 days), and 71 days (95 percent CI, 41 to 90 days) in patients undergoing adjuvant, neoadjuvant, and no chemotherapy, respectively.Immediate breast reconstruction is associated with a modest delay in initiating postmastectomy radiation therapy but does not impact overall survival.Therapeutic, III.

Marital status is known to influence quality of life, survival, and treatment decision-making after breast cancer diagnosis. We aimed to determine whether relationship status impacts contemporary patterns of immediate breast reconstruction.Surveillance, Epidemiology, and End Results (SEER)-18 was used to identify females undergoing mastectomy for stage 0-III breast cancer from 1998 to 2014. Multivariate logistic regression was used to estimate the association of relationship status with the likelihood of postmastectomy reconstruction. Patients were grouped by diagnosis year to assess change in the reconstructed population with time. Among younger patients ≤45 years, a generalized logistic model was used to predict reconstruction subtype.Among 346,418 patients, reconstruction after mastectomy was more likely to occur in women with relationship support in the form of a marriage or partner [odds ratio (OR) 1.31; 95% confidence interval (CI), 1.28-1.34; p0.001]. Women who were separated (OR 0.76), single (OR 0.73), or widowed (OR 0.56) were significantly less likely than married women to undergo reconstruction (all p0.001). During the 17-year study period, change in reconstruction rates with time varied by relationship status (interaction p=0.02), with reconstruction rates among divorced patients increasing more slowly than those among married and partnered women. Among younger women, subtype patterns varied by relationship status (p=0.004), with divorced women less likely to receive autologous over implant reconstruction (OR 0.87; p = 0.03).Relationship status may influence decision-making regarding pursuit and type of postmastectomy reconstruction. Consideration of support networks of patients with breast cancer could facilitate tailored preoperative counseling by reconstructive surgeons.

The hypoxia-inducible factor (HIF) pathway, regulated by prolyl hydroxylase, is central to tissue adaptation to ischemia. The authors tested whether the prolyl hydroxylase inhibitor dimethyloxalylglycine reduces skin flap necrosis.Dorsal skin flaps were raised on hairless rats, with dimethyloxalylglycine delivered intraperitoneally and/or topically for 7 days before and after surgery. After 14 treatment days, percentage of flap necrosis was compared grossly and tissue perfusion compared with an in vivo imaging system. Angiogenesis was compared using immunohistochemical CD31 staining and enzyme-linked immunosorbent assay for tissue vascular endothelial growth factor. Expression levels of HIF-1α and terminal deoxynucleotidyl transferase-mediated dUDP end-labeling were compared using immunohistochemical staining. Complete blood counts and gross necropsy specimens were obtained to assess systemic toxicity.Dimethyloxalylglycine administration significantly improved postoperative flap viability, with combined topical and intraperitoneal dimethyloxalylglycine administration leading to reduced necrosis on postsurgical day 7 at 6 mg/kg/day, 12 mg/kg/day, 24 mg/kg/day, and 48 mg/kg/day versus controls (all p0.05). Compared with controls (unperfused, 39.9 ± 3.8 percent), dimethyloxalylglycine treatment led to a dose-dependent decrease in unperfused tissue at 6 mg/kg/day (11.4 ± 1.7 percent), 12 mg/kg/day (9.4 ± 4.2 percent), 24 mg/kg/day (4.7 ± 2.6 percent), and 48 mg/kg/day (1.4 ± 0.9 percent) (all p0.001). Topical dimethyloxalylglycine application alone administered at 48 mg/kg/day was sufficient to improve flap viability (p = 0.005). Dimethyloxalylglycine-treated flaps exhibited higher CD31 staining (p = 0.004), tissue vascular endothelial growth factor (p = 0.007), HIF-1α staining (p0.001), and reduced terminal deoxynucleotidyl transferase-mediated dUDP end-labeling staining (p = 0.045). There were no differences in hematocrit or macroscopic organ changes on gross necropsy.Topical and systemic targeting of the HIF-1 pathway may be a promising therapeutic approach to improve flap resistance to ischemia.