Publications by authors named "Nho V Tran"

59 Publications

"Breast Resection Weight Prediction and Insurance Reimbursement in Reduction Mammoplasty: Which Scale is Reliable?"

Plast Reconstr Surg 2022 Jul 22. Epub 2022 Jul 22.

Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, MN.

Background: Many insurance companies in the United States rely on the Schnur Sliding Scale to predict resection weights to determine medical necessity for breast reduction surgery. Accurate methods to predict resection weights are needed to avoid insurance denials. Our aim is to compare the accuracy of formulas such as Schnur, Appel, Descamps and Galveston in predicting resection weights, and to assess if it influences insurance coverage decision.

Methods: A retrospective review of bilateral reduction mammoplasty procedures from June 2017-June 2019 was performed at Mayo Clinic, Rochester. Oncoplastic reduction surgeries were excluded. The accuracy of each formula-based estimate was evaluated with linear regression analysis.

Results: 154 patients (308 breasts) were reviewed. The Schnur had low correlation with actual resection weight (r2=0.381, b1=1.153, p<0.001). Appel was the most accurate (r2=0.642, b1=1.01, p<0.001), followed by Descamps (r2=0.572, b1=0.934, p<0.001) and Galveston (r2=0.672, b1=0.654, p<0.001) scales. Appel, Descamps and Galveston were more accurate for resection weights≥500g, BMI>30kg/m² and patients<50 years of age. For resection weights ≥500g, the median difference between the estimated and actual resection weight for Schnur, Appel, Descamps and Galveston were -211.4g ±272.3, -17.5g ±272.3, -9.6g ±229.5 and -99.2g ±238.5, respectively. None of the scales were accurate for resection weights <500g. Insurance reimbursement was denied in 15.56% patients, of these, 23% had resection weights<500g. The Schnur overestimated the resection weights in 28.9% of patients.

Conclusion: The Schnur scale is a poor predictor of breast resection weight. Appel is the most accurate estimator, especially in the young and obese population with larger resections.
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http://dx.doi.org/10.1097/PRS.0000000000009536DOI Listing
July 2022

Postmastectomy Breast Reconstruction is Safe in Patients on Chronic Anticoagulation.

Arch Plast Surg 2022 May 27;49(3):346-351. Epub 2022 May 27.

Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, Minnesota.

 Postmastectomy breast reconstruction (PMR) increases patient satisfaction, quality of life, and psychosocial well-being. There is scarce data regarding the safety of PMR in chronic anticoagulated patients. Perioperative complications can reduce patient satisfaction; therefore, it is important to elucidate the safety of PMR in these patients.  A retrospective case-control study of patients who underwent PMR with implants and were on chronic anticoagulation was performed at our institution. Inclusion criteria were women ≥ 18 years old. Exclusion criteria included autologous reconstructions, lumpectomy, and oncoplastic procedures. Two controls for every one patient on anticoagulation were matched by age, body mass index, radiotherapy, smoking history, type of reconstruction, time of reconstruction, and laterality.  From 2009 to 2020, 37 breasts (20 patients) underwent PMR with implant-based reconstruction and were on chronic anticoagulation. A total of 74 breasts (40 patients) who had similar demographic characteristics to the cases were defined as the control group. Mean age for the case group was 53.6 years (standard deviation [SD] = 16.1), mean body mass index was 28.6 kg/m (SD = 5.1), and 2.7% of breasts had radiotherapy before reconstruction and 5.4% after reconstruction. Nine patients were on long-term warfarin, six on apixaban, three on rivaroxaban, one on low-molecular-weight heparin, and one on dabigatran. The indications for anticoagulation were prior thromboembolic events in 50%. Anticoagulated patients had a higher risk of capsular contracture (10.8% vs. 0%,  = 0.005). There were no differences regarding incidence of hematoma (2.7% vs. 1.4%,  = 0.63), thromboembolism (5% vs. 0%,  = 0.16), reconstructive-related complications, or length of hospitalization (1.6 days [SD = 24.2] vs. 1.4 days [SD = 24.2],  = 0.85).  Postmastectomy implant-based breast reconstruction can be safely performed in patients on chronic anticoagulation with appropriate perioperative management of anticoagulation. This information can be useful for preoperative counseling on these patients.
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http://dx.doi.org/10.1055/s-0042-1744405DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9142228PMC
May 2022

Defining the Role for Topically Administered Tranexamic Acid in Panniculectomy Surgery.

Aesthet Surg J Open Forum 2022 5;4:ojac033. Epub 2022 May 5.

Background: Abdominal panniculectomy after weight loss is a commonly performed procedure with high patient satisfaction yet continues to have a high post-operative complication profile. Several risk-reducing surgical approaches, such as preservation of Scarpa's fascia, use of tissue adhesives, and progressive tension suture techniques have been described. However, the use of tranexamic acid (TXA) has not been previously reported in panniculectomy surgery.

Objectives: To improve the safety and predictability of this procedure, the authors investigate whether the use of topically administered TXA during panniculectomy surgery reduces seroma, hematoma, and drain duration.

Methods: Consecutive patients who underwent panniculectomy (January 2010 to January 2022) were retrospectively reviewed. Outcome measures included hematoma requiring surgical evacuation, seroma requiring percutaneous aspiration, and drain duration. Patients with thromboembolic diseases and those taking anticoagulation/antiplatelet medications were excluded. Patients who had received TXA were compared with a historical control group who had not received TXA.

Results: A total of 288 consecutive patients were included. Topical TXA was administered in 56 (19.4%) cases. The mean (standard deviation [SD]) follow-up was 43.9 (37.4) months (3.7 years). The median (range) resection weight was 2.6 kg (0.15-19.96 kg). Regarding seroma and hematoma formation, the use of TXA did not reduce the likelihood of developing seroma or hematoma (odds ratio [OR] = 1.7, 95% CI [0.56- 4.8], = 0.38 and OR = 2.1, 95% CI [0.4-11.8], = 0.42), respectively. The mean (SD) duration of drains was slightly lower in the TXA group (18.1 [12.1] days vs 19.8 [13.9] days); however, this difference was not statistically significant, albeit clinically significant.

Conclusions: As the use of TXA in plastic surgical procedures continues to expand, the utility of TXA in panniculectomy and abdominoplasty has not been elucidated. Although previous studies report hematoma and seroma risk reduction, the use of TXA was not associated with a statistically significant reduction in seroma, hematoma, or drain duration following panniculectomy surgery. Prospective, randomized controlled studies on the use of TXA in body contouring are needed.

Level Of Evidence 3:
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http://dx.doi.org/10.1093/asjof/ojac033DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9174740PMC
May 2022

Lymphatic Mapping Using US Microbubbles before Lymphaticovenous Anastomosis Surgery for Lymphedema.

Radiology 2022 07 5;304(1):218-224. Epub 2022 Apr 5.

From the Departments of Radiology (S.J., C.U.L., G.K.H., J.M.K.), Pharmacy (N.J.B.), and Plastic Surgery (N.V.T.), Mayo Clinic, 200 First St SW, Rochester, MN 55905.

Background Lymphaticovenous anastomosis (LVA) surgery is an effective surgical treatment of secondary lymphedema in the extremities, but indocyanine green (ICG) fluorescent lymphography, the reference standard for imaging target lymphatic vessels, has several limitations. More effective methods are needed for preoperative planning. Purpose To evaluate whether contrast-enhanced US (CEUS) can be used to identify target lymphatic vessels for LVA surgery in patients with secondary upper extremity lymphedema and compare the results with those from ICG fluorescent lymphography. Materials and Methods In this single-center retrospective review, CEUS with intradermal injection of microbubbles was performed in patients before LVA surgery in the upper extremities between October 2019 and September 2021. All patients had secondary upper extremity lymphedema from breast cancer treatment. Technical success rate was defined as lymphatic vessels identified with use of CEUS that led to successful LVAs. Descriptive statistics were used. Results All 11 patients were women (mean age, 56 years ± 8 [SD]). The median number of microbubble injection sites was 11 (range, 8-14). CEUS helped identify lymphatic vessels in all 11 women, including in six women in whom ICG fluorescent lymphography could not be performed or failed to help identify any targets. Thirty-five explorations (median, three per patient; range, two to four) were performed, and 24 LVAs (median, three per patient; range, zero to four) were created. Of the anastomoses, 33% (eight of 24) were mapped with use of both CEUS and ICG fluorescent lymphography, 58% (14 of 24) with CEUS only, and 8% (two of 24) with ICG fluorescent lymphography only. Among the 33 explorations on targets mapped with CEUS, an anastomosis could be made at 22 sites, for a technical success rate of 67%. Seven women had at least one additional LVA created from the use of CEUS. Conclusion Contrast-enhanced US is a promising tool for identifying lymphatic vessels in the upper extremities, especially when indocyanine green fluorescent lymphography fails to depict targets or cannot be used. Published under a CC BY 4.0 license.
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http://dx.doi.org/10.1148/radiol.212351DOI Listing
July 2022

Implant Malposition in Prepectoral Breast Reconstruction: Experience with Natrelle® Cohesive Implants over 6.5 Years.

J Plast Reconstr Aesthet Surg 2022 Mar 6. Epub 2022 Mar 6.

Division of Plastic Surgery, Department of Surgery, Mayo Clinic, Rochester, MN, USA.

Implant malposition has been reported to be a common reason for revision surgery after implant-based breast reconstruction (IBR). With the recent increase in the use of smooth implants due to concerns for breast implant-associated anaplastic large-cell lymphoma with textured implants, we compared and reported the rates of malposition in prepectoral IBR and identified risk factors. A retrospective review of patients who underwent prepectoral IBR with Natrelle® (Allergan, Inc., Irvine, CA) implants at our institution between January 2014 and May 2020 was performed. Clinical characteristics, implant types, and the rate of malposition, defined as implant flipping or rotation, were recorded. Univariate and multivariable time-to-event analyses using the Cox proportional-hazards model were performed to identify predictors of malposition. Three hundred seventy-five patients (660 breasts) were included. Four hundred forty-one (66.8%) breasts had smooth round implants whereas 219 (33.2%) had textured anatomical devices. Malposition requiring either a manual correction or surgical intervention occurred in 26 (5.9%) smooth round implants versus 3 (1.4%) textured anatomical. Multivariable analysis showed that having a smooth round implant (aHR: 7.19, 95% CI: [2.04 - 25.4]) and an increase in implant volume (aHR: 1.003, 95% CI: [1.001 - 1.006]) were associated with having a malposition requiring intervention. Among smooth round implants; INSPIRA® Cohesive implants were more likely to result in a malposition requiring intervention (p<0.0001) compared to other smooth round implants. Overall, malposition requiring intervention occurred in 5.9% of smooth round implants and 1.4% of textured anatomical implants. Statistical analysis demonstrates that smooth round implants and an increase in implant volume both are associated with a malposition requiring intervention.
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http://dx.doi.org/10.1016/j.bjps.2022.02.072DOI Listing
March 2022

Immediate Breast Reconstruction Using the Goldilocks Procedure: A Balance between More Surgery and Patient Satisfaction.

Plast Reconstr Surg 2022 Apr;149(4):801-809

From the Divisions of Plastic and Reconstructive Surgery and Department of Surgery, Mayo Clinic.

Background: Since its first description in 2012, the Goldilocks procedure has become an option for immediate breast reconstruction, particularly for obese patients who are poor candidates for traditional implant or autologous reconstruction. In this work, the authors performed a longitudinal study of patients who underwent mastectomy with Goldilocks reconstruction to assess the incidence of additional surgical procedures, and to assess surgical outcomes and patient satisfaction.

Methods: A retrospective review of patients who underwent mastectomy with the Goldilocks procedure only at Mayo Clinic Rochester between January of 2012 and September of 2019 was performed. Demographics, complications, additional breast procedures performed to attain the final results, and patient-reported outcomes using the BREAST-Q were recorded. Univariate and multivariable analyses were performed to identify statistical associations and risk factors.

Results: Sixty-three patients (108 breasts) were included. Mean age was 57.8 years. Mean body mass index was 37.6 kg/m2. Median follow-up time after the mastectomy with the Goldilocks procedure was 15 months. The major complication rate within the first 30 days was 9.3 percent. Forty-four breasts (40.7 percent) underwent additional surgery. Dyslipidemia was significantly associated with an increased risk of additional surgery (adjusted hazard ratio, 2.00; p = 0.045). Scores in the four BREAST-Q domains were not statistically different between patients who had additional procedures and those who did not.

Conclusions: Based on the results, the authors recommend a thorough preoperative discussion with patients who are candidates for the Goldilocks procedure to explore all options for reconstruction and their expectations, because it is crucial to reduce the necessity for additional operations in this high-risk population.

Clinical Question/level Of Evidence: Risk, III.
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http://dx.doi.org/10.1097/PRS.0000000000008895DOI Listing
April 2022

Efficacy of Tranexamic Acid in Reducing Seroma and Hematoma Formation Following Reduction Mammaplasty.

Aesthet Surg J 2022 05;42(6):616-625

Division of Plastic Surgery, Department of Surgery, Mayo Clinic College of Medicine and Science, Rochester, MN, USA.

Background: Tranexamic acid (TXA) has gained increasing recognition as a valuable pharmacologic agent within plastic surgery.

Objectives: The aim of this study was to investigate the value and safety profile of both intravenous and topically administered TXA in the setting of bilateral reduction mammaplasty.

Methods: A retrospective review was performed to identify consecutive patients who underwent bilateral reduction mammaplasty for symptomatic macromastia (January 2016-July 2021). Pertinent preoperative, intraoperative, and postoperative details were collected/reviewed. Primary outcome measures included hematoma requiring surgical evacuation and clinically significant/symptomatic seroma formation mandating percutaneous aspiration. Patients taking anticoagulation/antiplatelet medication or those with a history of thromboembolic diseases were excluded. Patients who had received TXA were compared to a historical control group who did not receive TXA within the same consecutive cohort.

Results: A total of 385 consecutive patients (770 breasts) were included. TXA was used in 514 (66.8%) cases (topical, 318 [61.9%]; intravenous, 170 [33.1%]; intravenous and topical, 26 [5.1%]). Neither seroma nor hematoma were impacted/reduced with TXA (P > 0.05). Increased age (hazards ratio, 1.06 per 1-year increase; 95% CI, 1.004-1.118) significantly increased the risk of hematoma (P = 0.032). The use of drains significantly decreased the risk of seroma (P < 0.0001). Increased BMI increased the risk of seroma (hazards ratio, 1.16 per 1-kg/m2 increase; 95% CI, 1.06-1.26; P = 0.0013). The use of TXA did not impact drain duration.

Conclusions: This study, the largest to date on the use of IV and topical TXA, did not find any reduction in risk when using TXA in breast reduction surgery.

Level Of Evidence: 3:
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http://dx.doi.org/10.1093/asj/sjab399DOI Listing
May 2022

Abdominal Panniculectomy: An Analysis of Outcomes in 238 Consecutive Patients over 10 Years.

Plast Reconstr Surg Glob Open 2021 Nov 24;9(11):e3955. Epub 2021 Nov 24.

Division of Plastic Surgery, Department of Surgery, Mayo Clinic, Rochester, Minn.

Panniculectomy is a commonly performed body contouring procedure to address skin laxity and its related complications. This study aimed to assess clinical outcomes of abdominal panniculectomy and identify predictors of complications at a tertiary academic healthcare center.

Methods: A retrospective review of patients who underwent panniculectomy between January 2010 and January 2020 at our institution was performed. Exclusion criteria were a history of prior panniculectomy or abdominoplasty. Patient characteristics and clinical outcomes were collected. Univariate and multivariable analyses were performed to assess the risk factors of complications.

Results: The mean age in the included 238 patients was 51.7 ± 12.7 years, and the mean body mass index (BMI) at the time of panniculectomy was 33 ± 7.5 kg/m. Median resection weight was 2.7 kg (range: 0.15-14.6) and median length of hospital stay was 2 days (range: 0-24). Mean follow-up time was 50 ± 37 months. The rate of major complications was 22.3%. Revision surgery was performed in 3.4% of the cases. Multivariable analyses demonstrated that increase in BMI ( 0.007) and active smoking ( 0.026) were significantly associated with increased odds of major complication, and increase in BMI ( 0.0004), history of venous thromboembolism ( 0.034) and having a concomitant ventral hernia repair ( 0.0044) were significantly associated with having a length of hospital stay of 3 days or more.

Conclusions: Panniculectomy is generally safe to perform, with major postoperative complication rate of 22.3% in our series. Increase in BMI and active smoking were significantly associated with having a major complication. Higher BMI, concomitant hernia repair, and a history of venous thromboembolism were associated with length of hospital stay of 3 days or more.
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http://dx.doi.org/10.1097/GOX.0000000000003955DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8613336PMC
November 2021

The Goldilocks Procedure with and without Implant-Based Immediate Breast Reconstruction in Obese Patients: The Mayo Clinic Experience.

Plast Reconstr Surg 2021 10;148(4):703-716

From the Divisions of Plastic and Reconstructive Surgery and Departments of Surgery, Mayo Clinic Rochester, Jacksonville, and Scottsdale; and Mayo Clinic Alix School of Medicine.

Background: Obesity is a risk factor for complications in breast reconstruction. Thus, implant-based immediate breast reconstruction in obese women may be controversial. The authors analyzed obese patients who underwent skin-sparing mastectomy using Wise-pattern incisions (Goldilocks procedure) and compared outcomes between two groups: Goldilocks with immediate breast reconstruction and Goldilocks only.

Methods: A retrospective review was performed of patients with a body mass index of 30 kg/m2 or higher who underwent the Goldilocks procedure at the Mayo Clinic Health System from 2012 to 2019. Data were extracted from electronic medical records. Minor complications (partial-thickness wound dehiscence or flap necrosis, or tissue expander/implant malposition) and major complications (full-thickness wound dehiscence or flap necrosis, capsular contracture, tissue expander/implant explantation, or unplanned reoperation or readmission) were compared between groups. Patient-reported outcomes using BREAST-Q questionnaires were also assessed.

Results: One hundred five patients (181 breasts) were included. Mean ± SEM age and body mass index were 57.1 ± 10.4 years and 37.9 ± 5.8 kg/m2 for the Goldilocks-only group and 51.5 ± 1.1 years and 35.5 ± 0.4 kg/m2 for the Goldilocks with immediate breast reconstruction group, respectively. Median follow-up time was 15.1 months (interquartile range, 10.0 to 28.6 months). Overall, 96 breasts underwent the Goldilocks-only procedure and 85 Goldilocks with immediate breast reconstruction. Multivariable analyses revealed a higher rate of minor complications (adjusted hazard ratio, 2.83; 95 percent CI, 1.22 to 7.02) and major complications (adjusted hazard ratio, 2.26; 95 percent CI, 1.25 to 4.24) in the Goldilocks with immediate breast reconstruction group compared with the Goldilocks-only group, at any given time. Patient satisfaction was not statistically different between groups.

Conclusions: The Goldilocks procedure is a feasible breast reconstructive option in obese patients; however, when it is performed with immediate breast reconstruction, it is associated with higher rates of complications. For patients with a body mass index of 40 kg/m2 or greater, the authors recommend the Goldilocks-only procedure or delayed reconstruction.

Clinical Question/level Of Evidence: Therapeutic, III.
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http://dx.doi.org/10.1097/PRS.0000000000008362DOI Listing
October 2021

Gender Disparity in Abstract Presentation at Plastic Surgery Meetings.

J Surg Res 2021 09 2;265:204-211. Epub 2021 May 2.

Division of Plastic Surgery, Department of Surgery, Mayo Clinic, Rochester, MN. Electronic address:

Background: Medical and surgical fields continue to be marred by gender disparities. The "leaky pipeline" effect, representing a gradual decline in female representation along the academic ladder, has been well documented in plastic surgery. However, gender differences in abstract presentation at national plastic surgery meetings and subsequent publications remains elusive.

Methods: We reviewed abstracts presented at the 2014 and 2015 annual meetings of the American Association of Plastic Surgeons (AAPS); American Society of Plastic Surgeons (ASPS), and the Plastic Surgery Research Council (PSRC). Several abstract characteristics including the names of the first and last authors were extracted. Genderize.io and Google search were used to identify the authors' gender.

Results: We identified 1174 abstracts presented at the three identified meetings. Females comprised 29% of the presenters and 16% of abstract senior authors (ASAs). No gender differences were identified between the meetings, type of presentation (oral versus poster), and year of presentation. The only difference was in the subspecialty of the abstracts. Successful conversion to full-text articles was similar for male and female presenters (68% versus 62%, P = 0.065) but higher for male ASAs (68% versus 59%, P = 0.01). When an author change occurred, female presenters and ASAs were more likely to be replaced by males (P < 0.001).

Conclusion: Gender differences continue to be evident in academic plastic surgery with women constituting a minority of both presenters and senior authors on abstracts presented at national plastic surgery meetings. Future work should assess whether flexible and supportive work policies can foster greater female representation in academic plastic surgery.
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http://dx.doi.org/10.1016/j.jss.2021.02.010DOI Listing
September 2021

The Evolving Trends in the Impact Factor of Plastic Surgery Journals: A 22-Year Analysis.

Ann Plast Surg 2021 03;86(3):329-334

From the Division of Plastic Surgery, Department of Surgery, Mayo Clinic, Rochester, MN.

Background: The journal impact factor (IF) is one of the most widely adopted metrics to assess journal value. We aimed to investigate the trends in the IF and ranking of plastic surgery journals (PSJs) over a 22-year period.

Methods: The Journal Citation Report 2018 was used to identify all journals within the field of plastic surgery from 1997 to 2018. We analyzed the IF of PSJs and that of the category surgery.

Results: A total of 34 PSJs were identified. The mean IF increased from 0.584 (median, 0.533) in 1997 to 1.58 (median, 1.399) in 2018 (P < 0.0001). Over the same time, the median IF of the journals in the category surgery increased from 0.914 to 1.883. The mean journal IF percentile of PSJs within surgery remained fairly stable (P = 0.999). A strong positive correlation was identified between the IF of PSJs and both the 5-year IF (r = 0.943, P < 0.0001) and the immediacy index (r = 0.736, P < 0.0001). The percentage of self-citations across the study period was fairly stable at a mean of 19.2%. A weak positive correlation was found between the IF and the percentage of self-citations (r = 0.171, P < 0.0001).

Conclusions: The mean journal IF in PSJs has been trending upward over the last 22 years. Ranking of PSJs IF within the category surgery has remained unchanged. The self-citation rate has been fairly stable and correlated weakly with the IF. A strong positive correlation exists between the IF and both the immediacy index and the 5-year IF.
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http://dx.doi.org/10.1097/SAP.0000000000002452DOI Listing
March 2021

Local Infiltration of Tranexamic Acid (TXA) in Liposuction: A Single-Surgeon Outcomes Analysis and Considerations for Minimizing Postoperative Donor Site Ecchymosis.

Aesthet Surg J 2021 06;41(7):NP820-NP828

Division of Plastic Surgery, Department of Surgery, Mayo Clinic College of Medicine and Science, Rochester, MN, USA.

Background: Tranexamic acid (TXA) has gained increasing recognition in plastic surgery as a dependable adjunct capable of minimizing blood loss, ecchymosis, and edema. To date, there have been limited data on the utilization of TXA to mitigate liposuction donor site ecchymosis.

Objectives: The authors sought to investigate whether infiltration of TXA into liposuction donor sites safely reduces postoperative ecchymosis.

Methods: A single-surgeon retrospective cohort study was performed to analyze patients undergoing autologous fat transfer for breast reconstruction between 2016 and 2019. Following lipoaspiration, patients in the intervention group received 75 mL of TXA (3 g in NaCl 0.9%) infiltrated into the liposuction donor sites, whereas the historical controls did not. Patient demographics, degree of ecchymosis, surgical complications, and thromboembolic events were examined. A blinded assessment of postoperative photographs of the donor sites was performed.

Results: Overall, 120 autologous fat grafting procedures were reviewed. Sixty patients received TXA, whereas 60 patients did not. Patient demographics and comorbidities were similar among the groups. No difference existed between groups regarding donor site locations, tumescent volume, lipoaspirate volume, or time to postoperative photograph. Ten blinded evaluators completed the assessment. The median bruising score of patients who received TXA was significantly lower than that of patients who did not (1.6/10 vs 2.3/10, P = 0.01). Postoperative complications were similar among the groups. Adverse effects of TXA were not observed.

Conclusions: Patients who received local infiltration of TXA into the liposuction donor sites were found to have less donor site ecchymosis than patients who did not. Further prospective randomized studies are warranted.

Level Of Evidence: 4:
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http://dx.doi.org/10.1093/asj/sjaa437DOI Listing
June 2021

Inferior pedicle breast reduction and long nipple-to-inframammary fold distance: How long is safe?

J Plast Reconstr Aesthet Surg 2021 03 20;74(3):495-503. Epub 2020 Sep 20.

Division of Plastic and Reconstructive Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, United States. Electronic address:

Background: Free nipple grafting indications in breast reduction surgery are outdated. Safety of inferior pedicle technique for large resections and long pedicles has not been clearly defined. We evaluated patients who underwent inferior pedicle reduction mammoplasty to define the safety constraints of the inferior pedicle.

Methods: A retrospective review of patients who underwent inferior pedicle reduction mammoplasty due to symptomatic macromastia at Mayo Clinic over a six-year period was conducted. Patients with prior breast surgeries were excluded. Demographics, breast measurements, and surgical outcomes were collected. Univariate and multivariate analyses were performed to assess for predictors of necrosis.

Results: Overall, 288 patients (576 breasts) underwent inferior pedicle breast reduction from 2014 to 2019. The mean sternal notch-to-nipple (SNN) distance was 31.5 cm (standard deviation[SD]:4.2; range[r]:16-48), and the mean nipple-to-inframammary fold (N-IMF) distance was 14.8 cm (SD:4.0; r:7.5-27). The mean resection weight was 699.6 g (SD:310.4; r:125-2,385). The median follow-up was 3.9 months (interquartile range[IQR]:2.8-9.0). The overall skin or nipple areolar complex necrosis rate was 2.1%; the overall complication rate was 14.8%. On multivariate analysis, overall necrosis was not found to be associated with the N-IMF distance (adjusted odds ratio[aOR]:1.05, 95%-CI 0.88-1.16). Resection weight was statistically associated with an increased risk of overall necrosis (aOR:1.003, 95%-CI 1.001-1.005), adjusting for N-IMF and SNN distances.

Conclusion: Inferior pedicle breast reduction offers low risk of necrosis and can be safely performed in patients regardless of the N-IMF distance. No association was found between N-IMF distance and overall necrosis in our cohort, including lengths >15 cm. However, large resections could increase the risk of necrosis.
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http://dx.doi.org/10.1016/j.bjps.2020.08.123DOI Listing
March 2021

Botulinum Toxin A in Tissue Expander Breast Reconstruction: A Double-blinded Randomized Controlled Trial.

Plast Reconstr Surg Glob Open 2020 Aug 18;8(8):e3030. Epub 2020 Aug 18.

Division of Plastic Surgery, Department of Surgery, Mayo Clinic, Rochester, Minn.

Subpectoral tissue expander breast reconstruction is often associated with muscle spasms, pain, and discomfort during tissue expansion. In this study, we hypothesized that an intraoperative injection of botulinum toxin A (BTX-A) in the pectoralis major muscle reduces the pain associated with tissue expansion and improves women's physical well-being.

Methods: Between May 2012 and May 2017, women undergoing immediate subpectoral tissue expander breast reconstruction were randomized to administer 100 units of BTX-A or a placebo injection. A numeric pain intensity scale and the physical well-being scale of the BREAST-Q: Reconstruction Module were used to test our hypothesis. Data on postoperative oral narcotic consumption were not collected.

Results: Of the 131 women included in the analysis, 48% were randomized to placebo and 52% to BTX-A. The preoperative median pain intensity score was 0 [interquartile range (IQR), 0-1], and the median preoperative BREAST-Q score was 91 (IQR, 81-100). The median slopes for the change in pain intensity scores from baseline throughout tissue expansion for those randomized to placebo and BTX-A were -0.01 (IQR, -0.02 to 0.00) and -0.01 (IQR, -0.02 to 0.00), respectively ( = 0.55). The median slopes for the change in BREAST-Q scores from baseline throughout tissue expansion for those randomized to placebo and BTX-A were 0.04 (IQR, -0.17 to 0.14) and 0.02 (IQR, -0.06 to 0.13), respectively ( = 0.89).

Conclusion: In this study, we found that an intraoperative intramuscular injection of 100 units of BTX-A in the pectoralis major muscle did not reduce postoperative pain and patient-reported physical well-being when compared with placebo.
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http://dx.doi.org/10.1097/GOX.0000000000003030DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7489665PMC
August 2020

Intravenous Tranexamic Acid in Implant-Based Breast Reconstruction Safely Reduces Hematoma without Thromboembolic Events.

Plast Reconstr Surg 2020 08;146(2):238-245

From the Division of Plastic Surgery, Department of Surgery, Mayo Clinic College of Medicine and Science.

Background: Antifibrinolytic medications, such as tranexamic acid, have recently garnered increased attention. Despite its ability to mitigate intraoperative blood loss and need for blood transfusion, there remains a paucity of research in breast reconstruction. The authors investigate whether intravenous tranexamic acid safely reduces the risk of hematoma following implant-based breast reconstruction.

Methods: A single-center retrospective cohort study was performed to analyze all consecutive patients undergoing immediate two-stage implant-based breast reconstruction following mastectomy between 2015 and 2016. The incidence of postoperative hematomas and thromboembolic events among all patients was reviewed. The patients in the intervention group received 1000 mg of intravenous tranexamic acid before mastectomy incision and 1000 mg at the conclusion of the procedure. Fisher's exact test and the Mann-Whitney-Wilcoxon test were used. Multivariate logistic regression models were performed to study the impact of intravenous tranexamic acid after adjusting for possible confounders.

Results: A total of 868 consecutive breast reconstructions (499 women) were reviewed. Overall, 116 patients (217 breasts) received intravenous tranexamic acid, whereas 383 patients (651 breasts) did not. Patient characteristics and comorbidities were similar between the two the groups. Patients who received tranexamic acid were less likely to develop hematomas [n = 1 (0.46 percent)] than patients who did not [n = 19 (2.9 percent)] after controlling for age, hypertension, and type of reconstruction (prepectoral and subpectoral) (p = 0.018). Adverse effects of intravenous tranexamic acid, including thromboembolic phenomena were not observed. Multivariate analysis demonstrated that age and hypertension independently increase risk for hematoma.

Conclusions: Intravenous tranexamic acid safely reduces risk of hematoma in implant-based breast reconstruction. Further prospective randomized studies are warranted to further corroborate these findings.

Clinical Question/level Of Evidence: Therapeutic, III.
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http://dx.doi.org/10.1097/PRS.0000000000006967DOI Listing
August 2020

Audio Articles: The Future of Academic Publishing.

Plast Reconstr Surg 2020 10;146(4):521e-522e

Division of Plastic Surgery, Department of Surgery, Mayo Clinic, Rochester, Minn.

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http://dx.doi.org/10.1097/PRS.0000000000007193DOI Listing
October 2020

Altmetrics in Plastic Surgery Journals: Does It Correlate With Citation Count?

Aesthet Surg J 2020 10;40(11):NP628-NP635

Division of Plastic Surgery, Mayo Clinic, Rochester, MN.

Background: Altmetrics (alternative metrics) have become one of the most commonly utilized metrics to track the impact of research articles across electronic and social media platforms.

Objectives: The goal of this study was to identify whether the Altmetric Attention Score (AAS) is a good proxy for citation counts and whether it can be employed as an accurate measure to complement the current gold standard.

Methods: The authors conducted a citation analysis of all articles published in 6 plastic surgery journals during the 2016 calendar year. Citation counts and AAS were abstracted and analyzed.

Results: A total of 1420 articles were identified. The mean AAS was 11 and the median AAS was 1. The journal with the highest mean AAS was Aesthetic Surgery Journal (31), followed by Plastic and Reconstructive Surgery (19). A weak positive correlation was identified (r = 0.33, P < .0001) between AAS and citations. Articles in the top 1% in terms of citation counts showed strong positive correlation between AAS and citation counts (r = 0.64, P = .01). On the contrary, articles in the top 1% of AAS had no significant correlation with citation counts (r = -0.31, P = .29).

Conclusions: Overall correlation between citations and AAS was weak, and therefor AAS may not be an accurate early predictor of future citations. The 2 metrics seem to measure different aspects of the impact of scholarly work and should be utilized in tandem for determining the reach of a scientific article.
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http://dx.doi.org/10.1093/asj/sjaa158DOI Listing
October 2020

Two Non-gadolinium-based, Innovative Approaches to Preoperative Lymphangiography.

Plast Reconstr Surg Glob Open 2020 Apr 22;8(4):e2805. Epub 2020 Apr 22.

Department of Plastic Surgery, Mayo Clinic Rochester, Minn.

Most magnetic resonance lymphangiography techniques employ intravenous gadolinium-based contrast agents, which carry a US Food and Drug Administration warning about gadolinium retention in the body when used intravenously. Because of this, there may be reluctance to perform intradermal injections of gadolinium-based contrast agents in patients with obstructed lymphatic drainage due to concerns about gadolinium retention in the skin and soft tissues and potential-related toxicity. The aim of this study was to show proof of concept of 2 preoperative lymphangiographic techniques that do not use gadolinium-based contrast agents. One technique used contrast-enhanced ultrasound with intradermal injections of microbubbles (Lumason) in a patient with stage 3, nonpitting left upper extremity edema. Another technique used magnetic resonance imaging with intradermal injections of 0.03 mg/mL or 0.003% ferumoxytol (Feraheme) in a patient with stage 3, nonpitting right lower extremity edema. Both contrast-enhanced ultrasound with microbubbles and magnetic resonance lymphangiogram with ferumoxytol were able to identify candidates for lymphovenous bypass surgery. These candidates were not identified by conventional indocyanine green injections. The authors conclude that (1) low-dose ferumoxytol is a potentially effective non-gadolinium-based contrast alternative to gadolinium-based contrast agent in magnetic resonance lymphangiography and (2) contrast-enhanced ultrasound can identify candidate lymphatic vessels for anastomosis.
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http://dx.doi.org/10.1097/GOX.0000000000002805DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7209876PMC
April 2020

Reconstruction of Complex Abdominal Wall Defect With Autogenous Pedicled Demucosalized Seromuscular Flap.

Ann Plast Surg 2020 06;84(6):697-699

From the Division of Plastic Surgery, Department of Surgery, Mayo Clinic, Rochester, MN.

Abdominal wall reconstruction is indicated when 1 or more of the abdominal wall components (skin, fascia, or muscle) are either injured or absent. When faced with defects requiring flap reconstruction, the decision regarding flap choice should take into consideration the volume of soft tissue required, the extent of the defect, donor site morbidity, and prior surgical scars that affect flap vascularity. We present a case of an abdominal wall defect with limited reconstructive options in which a spare ileal bowel segment was filleted to create a seromuscular flap for improving the abdominal wall blood supply. The postoperative course was complicated by abdominal fluid collection, which resolved following an ultrasound-guided drain. The patient had normal wound healing and recovery without further postoperative complications at the 7-month follow-up. Seromuscular flaps are a practical option in the armamentarium of plastic surgeons performing abdominal wall reconstruction, especially when other alternatives are limited.
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http://dx.doi.org/10.1097/SAP.0000000000002317DOI Listing
June 2020

Do We Publish What We Present? A Critical Analysis of Abstracts Presented At Three Plastic Surgery Meetings.

Plast Reconstr Surg 2020 06;145(6):1555-1564

From the Division of Plastic Surgery, Department of Surgery, Mayo Clinic; and Aleppo University, Faculty of Medicine.

Background: Presentation of research at scientific conferences provides an opportunity for researchers to disseminate their work and gain peer-feedback. However, much of the presented work is never published in peer-reviewed journals. We aimed to analyze the conversion rate of abstracts presented at three national plastic surgery meetings.

Methods: Abstracts presented at the American Association of Plastic Surgeons(AAPS), American Society of Plastic Surgeons(ASPS), and Plastic Surgery Research Council(PSRC) annual meetings in 2014 and 2015 were identified to analyze the rates of successful conversion into full-text publications. Meeting administrators were contacted to obtain the respective acceptance rates of submitted abstracts.

Results: A total of 1174 abstracts were analyzed. The overall conversion rate was 65%. AAPS was the meeting with the highest conversion rate(73%) followed by PSRC(66%) and ASPS(61%). Conversely, AAPS had a lower acceptance rate(28%) compared to ASPS(42%) and PSRC(49%). The conversion rate was significantly higher for abstracts from native English-speaking countries while no significant differences were noted between oral and poster presentations. Plastic and Reconstructive Surgery(PRS) was the journal with the highest percentage of published manuscripts(34%). Abstracts presented at PSRC had the highest mean impact factor for the journal of publication. First authors changed in 31% and last authors in 18% of publications. The overall median time to publication from the date of presentation was 13 months.

Conclusion: Almost two-thirds of abstracts presented at AAPS, ASPS, and PSRC successfully converted into full-text publications. Plastic surgery departments/divisions should follow unpublished work in their institutions to benefit both patients and the scientific community.
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http://dx.doi.org/10.1097/PRS.0000000000006849DOI Listing
June 2020

Should Obesity Be Considered a Contraindication for Prepectoral Breast Reconstruction?

Plast Reconstr Surg 2020 03;145(3):619-627

Rochester, Minn.

Background: Prepectoral implant-based reconstruction reemerged as a viable approach following recent advances in reconstructive techniques and technology. To achieve successful outcomes, careful patient selection is critical. Obesity increases the risk of complications and has been suggested as a relative contraindication for prepectoral breast reconstruction.

Methods: Retrospective chart review of patients who underwent immediate two-stage implant-based reconstruction at the authors' institution was performed. Only women having a body mass index of 30 kg/m or greater were included. Patient demographics, operative details, and surgical outcomes of prepectoral and subpectoral reconstruction were compared.

Results: One hundred ten patients (189 breasts) who underwent prepectoral and 83 (147 breasts) who underwent subpectoral reconstruction were included. Complications were comparable between the two groups. Twelve devices (6.4 percent), including implants and tissue expanders, required explantation in the prepectoral group, and 12 devices (8.2 percent) required explantation in the subpectoral group (p =0.522). Final implant-based reconstruction was achieved in 180 breasts (95.2 percent) in the prepectoral group and 141 breasts (95.9 percent) in the subpectoral group. Regardless of type of reconstruction (prepectoral or subpectoral), for each point increase in body mass index, the odds of complications and device explantation increased by 3.4 percent and 8.6 percent, respectively; and the optimal cutoff to predict higher complications and explantation rates was a body mass index of 34.8 kg/m and 34.1 kg/m, respectively.

Conclusions: Obesity increases complications and failure rates in a positive correlation; however, complications and final reconstruction rates are comparable between the prepectoral and subpectoral groups. The authors believe that obesity should not be a contraindication for prepectoral breast reconstruction but that care should be taken in patients with a body mass index above 35 kg/m.

Clinical Question/level Of Evidence: Therapeutic, III.
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http://dx.doi.org/10.1097/PRS.0000000000006540DOI Listing
March 2020

Prepectoral Breast Reconstruction in Nipple-Sparing Mastectomy With Immediate Mastopexy.

Ann Plast Surg 2020 07;85(1):18-23

From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Mayo Clinic, Rochester, MN.

Background: Nipple-areola preservation positively impacts quality of life of the patients and helps them to achieve a better psychological and sexual well-being, as well as higher satisfaction with their reconstruction. Patients with large or ptotic breasts, however, represent a technical challenge to surgeons, and nipple-areola preservation may be deferred in this clinical scenario. The aim of this study is to report our experience in patients with large or ptotic breasts who underwent nipple-sparing mastectomy (NSM) and prepectoral implant-based breast reconstruction with immediate mastopexy.

Methods: A single-institution retrospective chart review was performed in all consecutive patients who underwent NSM and prepectoral implant-based breast reconstruction, simultaneously with mastopexy. This procedure was offered preoperatively to patients who had ptotic or large breasts, which could benefit from mastopexy to obtain a better result. Aesthetic outcomes were evaluated using a modified 5-point Likert scale, and satisfaction and quality of life were evaluated using the reconstruction module of the BREAST-Q questionnaire.

Results: Seventeen NSMs with simultaneous mastopexy were performed on 9 patients. All completed reconstruction successfully, and there were no cases of nipple ischemia or necrosis. Global aesthetic evaluation score was 3.77 (±0.95). The Q-scores were as follows: satisfaction with breast was 90, psychosocial well-being was 95, sexual well-being was 80, and physical well-being with chest was 86.

Conclusions: In patients with large and/or ptotic breasts, NSM with prepectoral breast reconstruction and immediate mastopexy showed promising results. However, adequate preoperative planning and intraoperative flap assessment are necessary in order to minimize complications.
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http://dx.doi.org/10.1097/SAP.0000000000002136DOI Listing
July 2020

Infections following Immediate Implant-Based Breast Reconstruction: A Case-Control Study over 11 Years.

Plast Reconstr Surg 2019 12;144(6):1270-1277

From the Division of Plastic Surgery, the Division of Breast, Endocrine, Metabolic, and Gastrointestinal Surgery, Department of Surgery, the Division of Biomedical Statistics and Informatics, and the Division of Infectious Diseases, Department of Medicine, Mayo Clinic; Plastic Surgery Consultants; Jacobson Plastic Surgery; and Department of Plastic and Reconstructive Surgery, Jeonbuk National University Hospital.

Background: Surgical-site infection after implant-based breast reconstruction adversely affects surgical outcomes and increases health care costs. This 11-year case-control study examines risk factors specific for surgical-site infection after immediate tissue expander/implant-based breast reconstruction.

Methods: The authors performed a retrospective review to identify all consecutive patients with breast implant infections between 2006 and 2016. Patients who developed surgical-site infection after immediate tissue expander/implant-based breast reconstruction were included. Surgical-site infection was defined using the Centers for Disease Control and Prevention criteria; specifically, infections requiring hospital admission, intravenous antibiotics, or surgical intervention were included. The authors matched a control patient to each infection case by patient age and date of surgery. Patient demographics, medical comorbidities, and perioperative surgical variables were examined. Univariate and multivariable conditional logistic regression models were constructed.

Results: A total of 270 breasts in 252 patients were evaluated. On multivariate analysis, patients with a higher body mass index (OR, 1.1 per 1 body mass index point increase; 95 percent CI, 1.0 to 1.2; p = 0.02), hypertension (OR, 6.5; 95 percent CI, 1.9 to 22.3; p = 0.002), neoadjuvant chemotherapy (OR, 2.6; 95 percent CI, 1.0 to 6.3; p = 0.04), axillary lymph node dissection (OR, 7.1; 95 percent CI, 1.7 to 29.2; p = 0.006), seroma formation (OR, 15.34; 95 percent CI, 3.7 to 62.5; p = 0.0001), and wound healing complications (OR, 23.91; 95 percent CI, 6.1 to 93.4; p < 0.0001) were significantly associated with surgical-site infection.

Conclusions: Women with obesity, women with hypertension, and those treated with neoadjuvant chemotherapy are at increased risk of surgical-site infection. Further risks are also associated with postoperative seroma and wound complications. This may help patient selection and counseling, adjusted based on risk factors regarding complications of immediate implant-based breast reconstruction.

Clinical Question/level Of Evidence: Risk, III.
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http://dx.doi.org/10.1097/PRS.0000000000006202DOI Listing
December 2019

Citation Skew in Plastic Surgery Journals: Does the Journal Impact Factor Predict Individual Article Citation Rate?

Aesthet Surg J 2020 09;40(10):1136-1142

Division of Plastic Surgery, Department of Surgery, Mayo Clinic, Rochester, MN.

Background: Citation skew refers to the unequal distribution of citations to articles published in a particular journal.

Objectives: We aimed to assess whether citation skew exists within plastic surgery journals and to determine whether the journal impact factor (JIF) is an accurate indicator of the citation rates of individual articles.

Methods: We used Journal Citation Reports to identify all journals within the field of plastic and reconstructive surgery. The number of citations in 2018 for all individual articles published in 2016 and 2017 was abstracted.

Results: Thirty-three plastic surgery journals were identified, publishing 9823 articles. The citation distribution showed right skew, with the majority of articles having either 0 or 1 citation (40% and 25%, respectively). A total of 3374 (34%) articles achieved citation rates similar to or higher than their journal's IF, whereas 66% of articles failed to achieve a citation rate equal to the JIF. Review articles achieved higher citation rates (median, 2) than original articles (median, 1) (P < 0.0001). Overall, 50% of articles contributed to 93.7% of citations and 12.6% of articles contributed to 50% of citations. A weak positive correlation was found between the number of citations and the JIF (r = 0.327, P < 0.0001).

Conclusions: Citation skew exists within plastic surgery journals as in other fields of biomedical science. Most articles did not achieve citation rates equal to the JIF with a small percentage of articles having a disproportionate influence on citations and the JIF. Therefore, the JIF should not be used to assess the quality and impact of individual scientific work.
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http://dx.doi.org/10.1093/asj/sjz336DOI Listing
September 2020

Time from submission to publication in plastic surgery journals: The story of accepted manuscripts.

J Plast Reconstr Aesthet Surg 2020 Feb 1;73(2):383-390. Epub 2019 Oct 1.

Division of Plastic Surgery, Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, United States. Electronic address:

Background: Publication of research in highly regarded journals is a laborious journey that requires a considerable amount of effort and time. The objective of this article is to obtain insight into the time required for articles to be accepted and published in the top six plastic surgery journals and to study the effects of article characteristics on their publication time.

Methods: A comprehensive review of all articles published by six scientific plastic surgery journals during a one-year period (2018) was performed. Time taken from submission to acceptance, online, and in-print publication was abstracted and analyzed.

Results: A total of 1141 articles were reviewed. The median total time (TT) from submission to in-print publication was 10.3 months (IQR 8-12.6), with a median time of 4.6 months (3-6.8) from submission to acceptance and 5.4 months (4.2-6.3) from acceptance to publication. TT varied among journals, ranging from 7.2 months for Aesthetic Plastic Surgery to 16.1 months for Microsurgery. The articles were available online after a median of 21 days from their acceptance date. When comparing our results to publication times in 2005, most journals showed a decrease in their total publication time.

Conclusion: Our study highlights the time taken for publication and the differences between plastic surgery journals and study characteristics. Most journals have demonstrated a quicker turnaround time during the last 13 years. Online publication has greatly decreased the time between acceptance and in-print publication. We advocate for improving certain areas of this timeline, but this improvement should not be at the expense of review quality.
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http://dx.doi.org/10.1016/j.bjps.2019.09.029DOI Listing
February 2020

The American College of Surgeons National Quality Improvement Program Incompletely Captures Implant-Based Breast Reconstruction Complications.

Ann Plast Surg 2020 03;84(3):271-275

From the Division of Plastic Surgery, Department of Surgery.

Background: Implant-based breast reconstruction (IBR) accounts for 70% of postmastectomy reconstructions in the United States. Improving the quality of surgical care in IBR patients through accurate measurements of outcomes is necessary. The purpose of this study is to compare the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) data from our institution to our complete institutional health records database.

Methods: Data were collected and recorded for all patients undergoing IBR at our institution from 2015 to 2017. The data were completely identified and compared with our institutional NSQIP database for demographics and complications.

Results: The electronic health records data search identified 768 IBR patients in 3 years and NSQIP reported on 229 (30%) patients. Demographics were reported similarly among the 2 databases. Rates of tissue expander/implant infections (5.9% vs 1.8%; P = 0.003) and wound dehiscence (3.5% vs 0.4%; P = 0.003) were not reported similarly between our database and NSQIP. However, the rates of hematoma (2.7% vs 1.8%) and skin flap necrosis (2.5% vs 1.8%) were comparable between the two databases. In our database, 43% of all complications presented after 30 days of surgery, beyond NSQIP's capture period.

Conclusions: Databases built on partial sampling, such as the NSQIP, may be useful for demographic analyses, but fall short of providing data for complications after IBR, such as infections and wound dehiscence. These results highlight the utility and importance of complete databases. National comparisons of clinical outcomes for IBR should be interpreted with caution when using partial databases.
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http://dx.doi.org/10.1097/SAP.0000000000002051DOI Listing
March 2020

Single-Stage Direct-to-Implant Breast Reconstruction: A Comparison Between Subpectoral Versus Prepectoral Implant Placement.

Ann Plast Surg 2020 04;84(4):361-365

Division of Breast, Endocrine, Metabolic and GI Surgery, Department of Surgery, Mayo Clinic College of Medicine and Science, Rochester, MN.

Background: Single-stage direct-to-implant (DTI) breast reconstruction can offer several potential benefits. Subpectoral DTI reconstruction can present with animation deformity and pectoralis muscle spasm. To potentially avoid these complications, surgeons have attempted prepectoral placement for DTI; however, the benefits of this approach are mostly unknown. We evaluated the outcomes of DTI between prepectoral and subpectoral placement.

Methods: This was a retrospective review of patients who underwent immediate DTI breast reconstruction (prepectoral vs subpectoral) between 2011 and 2018. Demographics, clinical characteristics, complications, and patient-reported outcomes (BREAST-Q) were compared.

Results: Thirty-three patients (55 breasts) underwent prepectoral DTI, and 42 patients (69 breasts) underwent subpectoral DTI. Demographics were similar among groups. The number of breasts with preoperative ptosis lower than grade 2 was not significantly different between groups (29.1% vs 26.1%; P = 0.699). Median follow-up was 20.3 and 21 months in the prepectoral and subpectoral groups, respectively. Average mastectomy weight was 300 g (180-425 g) and 355 g (203-500 g). Average implant size was 410 cc (330-465 cc) and 425 cc (315-534 cc) in the prepectoral and subpectoral groups, respectively. Alloderm was used in all reconstructions. Total numbers of complications were 4 (7.2%) and 8 (11.6%) in the prepectoral and subpectoral groups, respectively (P = 0.227). BREAST-Q demonstrated mean patient satisfaction was high and similar among groups (75 and 73.9, P = 0.211).

Conclusions: Based on these results, we believe prepectoral DTI is safe, reliable, and a promising reconstructive option for selected patients, with equivalent results to other reconstructive options. Our present treatment recommendations are for patients who wish to maintain the same breast size and have minimal or no breast ptosis.
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http://dx.doi.org/10.1097/SAP.0000000000002028DOI Listing
April 2020

Surgical Outcomes after Abdominoperineal Resection with Sacrectomy and Soft Tissue Reconstruction: Lessons Learned.

J Reconstr Microsurg 2020 Jan 19;36(1):64-72. Epub 2019 Sep 19.

Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota.

Background:  Abdominoperineal resection (APR), which involves resection of the rectum, anal canal, and perianal skin, results in a large dead space in the pelvis, devascularized tissues, and high bacterial loads. This predisposes to wound complications, especially in the setting of neoadjuvant chemoradiotherapy. Additional sacral resection further compounds these effects. We aimed to assess perineal wound outcomes and complications in patients who underwent flap reconstruction for APR with sacrectomy (APRS) at our institution.

Methods:  We reviewed the charts of all patients who underwent flap reconstruction for APRS over a 20-year period (1999-2018). Medical comorbidities, details of the surgical procedure, and major and minor wound complications were recorded and analyzed.

Results:  Forty-six patients underwent flap reconstruction following APRS-28 (60%) for colorectal cancer, 8 (17%) for sacral chordoma, and 10 diagnosed with other malignant histologies. Rectus abdominis myocutaneous (RAM) flap reconstruction was used in 42 patients (91%). The median time to the first major perineal complication was 111 days (interquartile range: 22-660 days). Half of our cohort ( = 23) experienced a major perineal complication. No significant differences were found in major or minor perineal or abdominal wall complications between RAM flap and other flaps. APR with high sacrectomy was performed in 27 patients (59%) and was associated with significantly increased full-thickness dehiscence in the perineal region when compared with APR with low sacrectomy, 33 versus 0%, respectively ( = 0.0076). Complete flap loss occurred in one patient.

Conclusion:  The RAM flap was the workhorse flap for pelvic reconstruction following APRS in our cohort. Wound complications are common following APRS. High sacrectomy is associated with higher incidence of complications compared with low sacrectomy. Optimal surgical planning and patient counseling is fundamental to improve current surgical outcomes.
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http://dx.doi.org/10.1055/s-0039-1697629DOI Listing
January 2020

Two-Staged Implant-Based Breast Reconstruction: A Long-Term Outcome Study in a Young Population.

Medicina (Kaunas) 2019 Aug 14;55(8). Epub 2019 Aug 14.

Department of Surgery, Mayo Clinic, Rochester, MN 55904, USA.

Differences in patient anatomy and physiology exist between young and older patients undergoing breast reconstruction after mastectomy. Breast cancer has been described as being more aggressive, more likely to receive radiation, contralateral mastectomy, as well as bilateral reconstruction in young patients. Our purpose is to report long-term experience on two-staged implant-based breast reconstruction (IBR) in young females, with complication sub-analysis based on obesity and adjuvant radiation. Retrospective chart review of all consecutive young patients who underwent two-staged IBR at our institution, between 2000 and 2016, was performed. Patients between 15 and 40 years old with least 1-year follow-up were included. Univariate logistic regression models and receiver operating characteristic (ROC) curves were created. Overall 594 breasts met our inclusion criteria. The mean age was 34 years, and the median follow-up was 29.6 months. Final IBR was achieved in 98% of breasts. Overall, 12% of breasts had complications, leading to explantations of 5% of the devices. Adjuvant radiation was followed by higher rates of total device explantations ( = 0.003), while obese patients had higher rates of total complications ( < 0.001). For each point increase in BMI, the odds of developing complications increased 8.1% ( < 0.001); the cutoff BMI to predict higher complications was 24.81 kg/m. This population demonstrates high successful IBR completion and low explantation rates. These data suggest that obese women and those with planned adjuvant radiation deserve special counseling about their higher risk of complications.
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http://dx.doi.org/10.3390/medicina55080481DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6723805PMC
August 2019
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