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Simple Summary: This research explores how the increase in telemedicine during the COVID-19 pandemic has impacted the accessibility of breast reconstruction for breast cancer patients. This study compares patient data from before and during the widespread adoption of telehealth, focusing on how far patients traveled for surgery and their follow-up care. The findings indicate that while the rate of breast reconstruction surgeries remained consistent, telehealth significantly enhanced follow-up care, suggesting it plays a crucial role in improving healthcare access and continuity for breast cancer patients. This underscores the potential of telemedicine to bridge gaps in healthcare delivery, particularly for post-mastectomy care. Objective: To examine how the recent sharp rise in telemedicine has impacted trends in accessibility of breast reconstruction (BR). Patients and Methods: A retrospective study reviewed patients who underwent a total mastectomy at our institution from 1 August 2016 to 31 January 2022. By comparing cohorts before and during the widespread implementation of telemedicine, we assessed telehealth's impact on healthcare accessibility, measured by distance from patients' residences to our institution. Results: A total of 359 patients were included in this study. Of those, 176 received total mastectomy prior to the availability of telemedicine, and 183 in the subsequent period. There were similar baseline characteristics among patients undergoing mastectomy, including distance from place of residence to hospital (p = 0.67). The same proportion elected to receive BR between groups (p = 0.22). Those declining BR traveled similar distances as those electing the procedure, both before the era of widespread telemedicine adoption (40.3 and 35.6 miles, p = 0.56) and during the height of telemedicine use (22.3 and 61.3 miles, p = 0.26). When tracking follow-up care, significantly more patients during the pandemic pursued at least one follow-up visit with their original surgical team, indicative of the increased utilization of telehealth services. Conclusions: While the rate of BR remained unchanged during the pandemic, our findings reveal significant shifts in healthcare utilization, highly attributed to the surge in telehealth adoption. This suggests a transformative impact on breast cancer care, emphasizing the need for continued exploration of telemedicine's role in enhancing accessibility and patient follow-up in the post-pandemic era. [ABSTRACT FROM AUTHOR]

IntroductionAlthough various methods exist for monitoring flaps during reconstructive surgery, surgeons primarily rely on assessment of clinical judgment. Early detection of vascular complications improves rate of flap salvage. Spatial frequency domain imaging (SFDI) is a promising new technology that provides oxygenation images over a large field of view. The goal of this clinical pilot study is to use SFDI in perforator flap breast reconstruction.MethodsThree women undergoing unilateral breast reconstruction after mastectomy were enrolled for our study. The SFDI system was deployed in the operating room, and images acquired over the course of the operation. Time points included images of each hemiabdominal skin flap before elevation, the selected flap after perforator dissection, and after microsurgical transfer.ResultsSpatial frequency domain imaging was able to measure tissue oxyhemoglobin concentration (ctO2Hb), tissue deoxyhemoglobin concentration, and tissue oxygen saturation (stO2). Images were created for each metric to monitor flap status and the results quantified throughout the various time points of the procedure. For 2 of 3 patients, the chosen flap had a higher ctO2Hb and stO2. For 1 patient, the chosen flap had lower ctO2Hb and stO2. There were no perfusion deficits observed based on SFDI and clinical follow-up.ConclusionsThe results of our initial human pilot study suggest that SFDI has the potential to provide intraoperative oxygenation images in real-time during surgery. With the use of this technology, surgeons can obtain tissue oxygenation and hemoglobin concentration maps to assist in intraoperative planning; this can potentially prevent complications and improve clinical outcome.

This study aimed to investigate the impact of performing neurotization during breast reconstruction on total operating time and post-operative morbidity. The 2015 through 2019 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) databases were utilized to identify patients who underwent breast reconstruction with and without neurotization. Baseline demographics, comorbidities, operative characteristics and outcomes were examined for each group. Thirty-day complication and readmission rates were compared using univariable and multivariable logistic regressions. Of 73,507 patients identified who underwent breast reconstruction, 240 had reconstruction with neurotization. Autologous reconstruction was more prevalent for patients with neurotization (90.8% vs. 18.5%, p<.001). Average operating time was longer when neurotization was performed during both autologous (527.1 ± 152.4 vs. 414.8 ± 186.3, p<.001) and alloplastic-only reconstruction (310.9 ± 115.9 vs. 173.0 ± 94.3, p<.001). The likelihood total operating time exceeded 521 min (two standard deviations above average) increased when neurotization was performed (OR 2.464, CI 1.864–3.255, p<.001). Thirty-day complications occurred in 13.8% of patients with neurotization and 6.8% without (p<.001). Similarly, 30-day readmission rates were higher for patients with neurotization (7.5% vs. 4.2%, p<.001). However, when adjusted for comorbidities and operative characteristics, neurotization did not significantly impact 30-day complication rates (OR 0.802, CI 0.548–1.174, p=.256) or 30-day readmission rates (OR 1.352, CI 0.822–2.223, p=.077). Although neurotization during breast reconstruction increases operating time, comorbidities and procedural characteristics play a greater role in post-operative outcomes than neurotization alone. [ABSTRACT FROM AUTHOR]

Traditionally, patients with breast reconstruction (BR) were hospitalized at least one day postoperatively. However, new trends suggest that outpatient surgery is a viable and safe alternative. This study aims to assess trends among patients with breast cancer who underwent outpatient mastectomy alone, with immediate BR (IBR) or delayed BR (DBR). A retrospective analysis of the 2013–2019 ACS NSQIP® database was conducted. All women who underwent outpatient mastectomy were included in this study. The cohort was divided as follows: (1) mastectomy without BR, (2) IBR, and (3) DBR. A Cochran–Armitage test and adjusted multivariable logistic regression models were performed to evaluate linear trends over time within groups, and overall and pairwise comparisons between groups across the years, respectively. A total of 84,954 women were included in this study. Overall, 54.9%, 16.2%, and 28.9% underwent mastectomy without BR, IBR, and DBR, respectively. From the BR groups, the majority had implant placement. A significant difference in incidence trends between the three groups was evidenced over time (p <0.001). The greatest increase was evidenced in the IBR group and the lowest in the mastectomy without BR group. In this cohort of patients, a significant difference in linear trends was evidenced over time within and between the three groups. Our results suggest that outpatient IBR procedures are increasing in a greater proportion compared to other surgical approaches. Further studies are required to better characterize this population and comprehend the decision-making process toward a surgical procedure within each of the three groups. [Display omitted] [ABSTRACT FROM AUTHOR]

Background  In various surgical specialties, racial disparities in postoperative complications are widely reported. It is assumed that the effect of race can also be found in plastic surgical outcomes, although this remains largely undefined in literature. This study aims to provide data on the impact of race on outcomes of reconstructive breast surgery. Methods  Data were collected using the NSQIP (National Surgical Quality Improvement Program) database (2008–2016). Outcomes of the reconstructive breast surgery of White patients were compared with those of African American, Asian, or other races. Logistic regression was performed to control for variations between all groups. Analysis of racial disparities was further sub-stratified according to four different types of breast reconstruction: delayed or immediate autologous, and delayed or immediate prosthesis-based reconstruction. Results  In total, this study included 51,362 patients of which 43,864 were Caucasian, 5,135 African American, 2,057 Asian, and 332 of other races. When compared with White patients, patients of African American race had larger body mass indices (31.3 ± 7.0 vs. 27.6 ± 6.3, p -value < 0.001) in addition to higher rates of diabetes (12.3 vs 4.6%, p -value < 0.001) and hypertension (44.7 vs. 23.4%, p -value < 0.001). Both multivariate analysis and the sub-stratified analysis of different types of reconstruction showed no differences in overall complication rate. Conclusion  Among the four types of reconstructive procedures, differences in surgical outcomes do not appear to be based on race and therefore seem to be less evident in reconstructive breast surgery compared with the current literature within other surgical specialties. [ABSTRACT FROM AUTHOR]

Background  This study examines the effect of prior abdominal surgery on flap, donor-site, and overall complications in women undergoing deep inferior epigastric artery perforator (DIEP) flap breast reconstruction and assesses whether preoperative computed tomography angiography (CTA) affects outcomes. Methods  All DIEP flaps performed at our institution between 2004 and 2015 were identified retrospectively. Patients were stratified based on a history of prior abdominal surgery and whether or not they underwent a preoperative CTA. A subgroup analysis was performed to compare operative times and incidence of complications using adjusted odds ratios (ORs). Results  Over a 12-year period, 425 patients (640 flaps) had prior abdominal surgery, and 393 patients (547 flaps) had no prior abdominal surgery. Of the patients with previous abdominal surgery, 67 (15.7%) underwent preoperative CTA and 333 (78.4%) did not. Patients with prior abdominal surgery were more likely to have donor-site wound complications (OR: 1.82, 95% confidence interval [CI]: 1.15–2.87, p  = 0.01), fat necrosis ≥2cm of the transferred flap (OR: 1.39, 95% CI: 1.0–1.94, p  = 0.05), and were more likely to have bilateral DIEP flap reconstruction (OR: 1.61, 95% CI: 1.22–2.12, p  < 0.001). Preoperative CTA did not reduce the risk of complications and did not affect operative times. Conclusion  DIEP flap reconstruction can be safely performed in women with prior abdominal surgery. However, these patients should be counseled that they are at an increased risk for donor-site wound breakdown and fat necrosis of the reconstructed breast. Preoperative CTA does not reduce complication rate, overall operative time, or time needed to dissect perforators in women with abdominal scars. [ABSTRACT FROM AUTHOR]

Background: Evidence of racial disparities in the receipt of postmastectomy breast reconstruction is well documented. The objective of this study was to describe trends in racial disparities overall and by reconstructive technique.Methods: The American College of Surgeons National Surgical Quality Improvement Program database was used to identify women who underwent mastectomy and/or breast reconstruction from 2005 to 2014. Patient demographics were recorded, and cases were grouped by reconstructive status and technique. Trends were assessed with the Cochran-Armitage test and the index of disparity.Results: Over the study period, 92,960 postmastectomy patients were identified (77,049 white women, 10,396 black women, 4939 Asian women, and 576 Native American women), of whom 46,931 underwent reconstruction. Of these, 7692 women underwent autologous reconstructions (3913 free flaps and 3696 pedicled flaps). From 2005 to 2014, receipt of breast reconstruction by postmastectomy patients rose from 33.2% to 60.0%, receipt of autologous reconstruction by patients who underwent breast reconstruction fell from 30.4% to 15.9%, and receipt of free-flap reconstruction by patients who underwent autologous reconstruction rose from 15.0% to 70.8%. These trends were significant in all racial subgroups (P < .001), except for Native Americans (P = .269). The index of disparity decreased from 51.4% to 22.6% for overall receipt of breast reconstruction, decreased from 10.7% to 7.0% for tissue expander and implant-based reconstruction, increased from 18.0% to 27.3% for autologous reconstruction, and decreased from 66.7% to 4.3% for free-flap reconstruction.Conclusions: The use of postmastectomy breast reconstruction is steadily rising in the United States. Racial disparities persist, but progress has been made. Further efforts are needed to reduce racial disparities. Cancer 2018;124:2774-2784. © 2018 American Cancer Society. [ABSTRACT FROM AUTHOR]

Background The gold standard for the treatment of breast cancer includes mastectomy surgery. Our goal was to quantify the health state utility assessment of living with unilateral mastectomy. Methods The visual analogue scale (VAS), time trade-off (TTO), and standard gamble (SG) were used to obtain utilities for unilateral mastectomy, monocular blindness and binocular blindness from a prospective sample of the general population and medical students. Results All measures (VAS, TTO, SG) for unilateral mastectomy (0.75 SD 0.17, 0.87 SD 0.14, and 0.86 SD 0.18, respectively) of the 140 volunteers were significantly different from the corresponding scores for monocular (0.61 SD 0.18, 0.84 SD 0.17, and 0.84 SD 0.18, respectively) and binocular blindness (0.38 SD 0.17, 0.67 SD 0.24, and 0.69 SD 0.23, respectively). Age, gender, race, education, and income were not statistically significant independent predictors of utility scores. Conclusion In a sample of the general population and medical students, utility assessments for living with unilateral mastectomy were comparable with those of living with bilateral mastectomy and severe breast hypertrophy. Our sample population, if faced living with unilateral mastectomy was willing to gamble a theoretical 14% chance of death and willing to trade 4.2 years of existing life-years. [ABSTRACT FROM AUTHOR]

Abstract: Background: Mastectomy is a common treatment for breast cancer. We set out to quantify the health state utility assessment of living with bilateral mastectomy using previously described validated methods. Methods: Utility assessments using visual analogue scale (VAS), time trade-off (TTO), and standard gamble (SG) were used to obtain utilities for mastectomy, monocular blindness and binocular blindness from a prospective sample of the general population and medical students. Results: All measures (VAS, TTO, SG) for mastectomy (0.70 ± 0.18, 0.85 ± 0.16, and 0.86 ± 0.17, respectively) of the 120 volunteers were significantly different (p < 0.0001) from the corresponding scores for binocular blindness (0.38 ± 0.17, 0.67 ± 0.24, and 0.69 ± 0.23, respectively). Utility scores for mastectomy were not statistically different (p > 0.05) when compared to those for monocular blindness (0.67 ± 0.13, 0.86 ± 0.15, and 0.86 ± 0.15, respectively). Age, gender, race, and income were not statistically significant independent predictors of utility scores. Medical education was associated with statistically significant higher SG compared to general population (0.90 ± 0.11 versus 0.84 ± 0.19; p < 0.05). Conclusion: In a sample of the general population and medical students, utility assessments for living with bilateral mastectomy were comparable with those of living with the loss of sight from one eye. Our sample population, if faced with living with bilateral mastectomy, would consent to undergo a procedure such as breast reconstruction with a theoretical 14 percent chance of mortality and be willing to trade 5.4 years of existing life-years for such a procedure. [Copyright &y& Elsevier]

Summary: The superficial inferior epigastric artery (SIEA) flap is an excellent option for free tissue transfer breast reconstruction. Similar to the free transverse rectus myocutaneous (TRAM) and deep inferior epigastric perforator (DIEP) flaps, the SIEA pedicle supplies the fasciocutaneous tissues of the lower abdomen. The SIEA flap does not involve removal of or potential damage to the rectus muscles. Nonetheless, the vascular pedicle may be a challenge to dissect and variable in its presence and caliber. This article presents a case report and an extended delay technique to augment the SIEA system in a patient with prior bilateral deep inferior epigastric artery ligation. [Copyright &y& Elsevier]

Background Implant-based breast reconstruction is the most common type of reconstruction after postmastectomy radiation therapy (PMRT). The impact of the timing of PMRT to a tissue expander or permanent implant is not well understood. The purpose of this systematic review was to evaluate outcomes in implant-based reconstruction and the timing of PMRT. Methods A review of the English literature in the PubMed/MEDLINE database (2000-2016) was performed to identify all articles on implant-based breast reconstruction and PMRT. Cases from each study were grouped by PMRT to a tissue expander or PMRT to a permanent implant. Outcomes of interest included reconstructive failure and capsular contracture as overall rates and associations were pooled. Effect sizes (z values), risk ratios (RRs), and heterogeneity scores ( I 2 ) were calculated on meta-analysis. Results There were 20 studies meeting inclusion criteria with 2348 patients identified. Pooled analysis revealed an overall rate of reconstructive failure of 17.6% and Baker grade III/IV capsular contracture of 37.5%. PMRT applied to tissue expanders resulted in higher rates of reconstructive failure compared with PMRT applied to permanent silicone implants (20% versus 13.4%, RR = 2.33, P = 0.0083, 95% confidence interval 1.24-4.35), but lower rates of capsular contracture (24.5% versus 49.4%, RR = 0.53, P = 0.083, 95% confidence interval 0.26-1.09). Conclusions Regardless of timing, PMRT applied to implant-based breast reconstruction was associated with high risk of reconstructive failure and capsular contracture. Surgeons should consider alternative strategies, such as autologous tissue reconstructions, in patients requiring PMRT. [ABSTRACT FROM AUTHOR]

Background For some patients seeking autologous breast reconstruction, there may be insufficient abdominal skin and soft tissue to reconstruct an adequately sized breast. Perfusion from a single-pedicle deep inferior epigastric perforator artery flap has a high degree of variability across the midline, and this further limits perfusion. We have found that bipedicle-conjoined abdominal perforator flaps are a novel and reliable technique for reconstruction in these women, and this study examines our experience. Materials and methods A retrospective review was performed over a 2-y period of bipedicle-conjoined abdominal perforator flaps in 28 patients. For each reconstruction, the pedicle of one flap was anastomosed to the anterograde internal mammary artery vessels and the pedicle of the second flap to a side branch of the primary flap or the retrograde internal mammary vessels. Results Mean age and body mass index were 50.2 y (standard deviation, 8.0) and 25.9 kg/m² (standard deviation, 2.8), respectively. In total, 15 patients (53.6%) received radiation therapy before surgery. There were no flap losses; fat necrosis was found in one flap (3.2%). The large contiguous skin island of the bipedicle-conjoined deep inferior epigastric perforator flaps allowed for extensive replacement of damaged or absent breast skin when necessary. Aesthetically satisfactory results were achieved in all patients. Conclusions Bipedicle-conjoined abdominal perforator flaps represent a novel technique in select patients seeking breast reconstruction. The added complexity was safe and reliable in this series of patients. Compared to unipedicle flaps, the increased skin and volume allow greater flexibility to achieve the desired shape and projection. [ABSTRACT FROM AUTHOR]

Background Umbilical stalk necrosis represents a rare, yet important complication after abdominal-based microsurgical breast reconstruction, which is both underrecognized and understudied in the literature. Once identified, umbilical reconstruction can be an extremely challenging problem. Methods All consecutive breast free flaps at a single institution from February 2004 to February 2016 were reviewed, excluding non–abdominal-based flaps. Patients were divided based on the development of umbilical necrosis postoperatively. Demographics, surgical characteristics, and other complications were compared between the groups. Results A total of 918 patients met the inclusion criteria, with 29 developing umbilical necrosis identified (3.2%). Patients developing necrosis tended to be older (49.4 yrs versus 52.9 yrs; P < 0.01); have higher BMI (31.3 versus 27.8; P < 0.01); and were more likely to be smokers (27.5% versus 11.6%; P = 0.01). Umbilical necrosis was also associated with increased flap weight (830 g versus 656 g; P < 0.01), decreased time of perforator dissection (151 min versus 169 min; P = 0.02); bilateral cases (68.9% versus 44.7%; P < 0.01), and increased number of perforators per flap (2.5 versus 2.2; P = 0.03). There was no association with flap type (deep inferior epigastric perforator, superficial inferior epigastric artery, or free TRAM), diabetes, previous abdominal surgery, or use of preoperative imaging. Umbilical necrosis was not associated with any concomitant complications. Conclusions Umbilical stalk necrosis was found to occur in 3.2% of patients and was associated with several preoperative comorbidities and intraoperative characteristics. This information should help influence intraoperative decision-making to prevent the development of this undesirable complication. [ABSTRACT FROM AUTHOR]

Background Use of the tumescent mastectomy technique has been reported to facilitate development of a hydrodissection plane, reduce blood loss, and provide adjunct analgesia. Previous studies suggest that tumescent dissection may contribute to adverse outcomes after immediate implant reconstruction; however, its effect on autologous microsurgical reconstruction has not been established. Methods A retrospective review was conducted of all immediate microsurgical breast reconstruction procedures at a single academic center between January 2004 and December 2013. Records were queried for age, body mass index, mastectomy weight, diabetes, hypertension, smoking, preoperative radiation, reconstruction flap type, and autologous flap weight. Outcomes of interest were mastectomy skin necrosis, complete and partial flap loss, return to the operating room, breast hematoma, seroma, and infection. Results There were 730 immediate autologous breast reconstructions performed during the study period; 46% with the tumescent dissection technique. Groups were similar with respect to baseline patient and procedural characteristics. Univariate analysis revealed no significant difference in the incidence of mastectomy skin necrosis, complete or partial flap loss, return to the operating room, operative time, estimated blood loss, recurrence, breast hematoma, seroma, or infection in patients undergoing tumescent mastectomy. Multivariate analysis also demonstrated no significant association between the use of tumescent technique and postoperative breast mastectomy skin necrosis ( P = 0.980), hematoma ( P = 0.759), or seroma ( P = 0.340). Conclusions Use of the tumescent dissection technique during mastectomy is not significantly associated with adverse outcomes after microsurgical breast reconstruction. Despite concern for its impact on implant reconstruction, our findings suggest that this method can be used safely preceding autologous procedures. [ABSTRACT FROM AUTHOR]

Background Patient access to breast reconstruction is an important component of comprehensive breast cancer care. There is currently considerable variability in the timing of consultation with a plastic and reconstructive surgeon after the initial diagnosis of breast cancer. This study aims to elucidate patients' preferences for the timing of plastic surgery consultation as part of the preoperative evaluation and planning process. Methods A 16-question electronic survey instrument was developed based on formative patient comments and discussion between the breast oncology and plastic surgery teams. The survey was administered to all patients referred to the plastic and reconstructive surgery clinic for initial reconstructive consultation during the study period. Results A total of 31 responses were collected. The largest number of patients (48%) indicated they would prefer to see a plastic surgeon 1 wk after their first consultation with a breast surgeon. Only one patient reported a desire to see both surgeons on the same day. Most patients indicated that having a family member or friend accompany them to the appointment (45%) and having time to process their cancer diagnosis before seeing the plastic surgeon (32%) were key factors in deciding when they would like to discuss reconstruction. [ABSTRACT FROM AUTHOR]

Abstract: Background: Administration of statins or other cardiovascular medications (CVMs) could potentially protect against the development of ischemia–reperfusion (I/R) injury in free flap reconstruction. The aim of this study was to examine whether the use of statins and other CVMs decreased the rate of I/R injury in autologous free flap breast reconstruction. Methods: Retrospective chart review was performed on women who had undergone mastectomy and autologous free flap breast reconstruction between 2004 and 2010. Patient characteristics, use of statin and/or CVMs, and I/R–related complications were ascertained. Multivariable logistic regression was used to identify associations between independent risk factors and specific complications. Results: There were 702 free flap breast reconstructions included in this study; 45 performed in patients on statins, 70 in patients on CVMs, and 38 in patients on both. Overall complication rate in patients on statins and patients on CVMs was significantly higher than those not on any medication (46.7% versus 31.5%, P = 0.037 and 45.7% versus 31.5%, P = 0.017, respectively). When I/R complications were pooled, there were no significant differences between patients not on any medications and those on statins (P = 0.26), CVMs (P = 0.18), and both (P = 0.83.) Conclusions: Although there may be theoretical pharmacologic benefits of statins and/or CVMs to reduce the incidence of IR injury in autologous free flap breast reconstruction, the results of this study showed no clear advantages when these drugs were used. [Copyright &y& Elsevier]

Abstract: Background: The patient-physician relationship has evolved from the paternalistic, physician-dominant model to the shared-decision-making and informed-consumerist model. The level of patient involvement in this decision-making process can potentially influence patient satisfaction and quality of life. In this study, patient-physician decision models are evaluated in patients undergoing postmastectomy breast reconstruction. Methods: All women who underwent breast reconstruction at an academic hospital from 1999–2007 were identified. Patients meeting inclusion criteria were mailed questionnaires at a minimum of 1 y postoperatively with questions about decision making, satisfaction, and quality of life. Results: There were 707 women eligible for our study and 465 completed surveys (68% response rate). Patients were divided into one of three groups: paternalistic (n = 18), informed-consumerist (n = 307), shared (n = 140). There were differences in overall general satisfaction (P = 0.034), specifically comparing the informed group to the paternalistic group (66.7% versus 38.9%, P = 0.020) and the shared to the paternalistic group (69.3% versus 38.9%, P = 0.016). There were no differences in aesthetic satisfaction. There were differences found in the SF-12 physical component summary score across all groups (P = 0.033), and a difference was found between the informed and paternalistic groups (P < 0.05). There were no differences in the mental component score (P = 0.42). Conclusions: Women undergoing breast reconstruction predominantly used the informed model of decision making. Patients who adopted a more active role, whether using an informed or shared approach, had higher general patient satisfaction and physical component summary scores compared with patients whose decision making was paternalistic. [Copyright &y& Elsevier]