Publications by authors named "Rahim Nazerali"

74 Publications

Labiaplasty and Insurance: To Cover or Not to Cover?

Arch Plast Surg 2022 Mar 6;49(2):285-286. Epub 2022 Apr 6.

Division of Plastic Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, California.

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http://dx.doi.org/10.1055/s-0042-1744428DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9045511PMC
March 2022

Smooth versus textured tissue expanders in breast reconstruction - A retrospective review of post-operative surgical site infections.

J Plast Reconstr Aesthet Surg 2022 May 2. Epub 2022 May 2.

Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University Medical Center, Stanford, CA, United States. Electronic address:

Background: Textured tissue expanders (TTEs) were introduced to limit migration and reduce capsular contracture, which were inherent to smooth tissue expanders (STEs). Previous reports suggest that textured devices have increased rates of bacterial contamination and biofilm formation in comparison with smooth devices. Recently, the relative increased association of anaplastic large cell lymphoma (ALCL) with textured versus smooth devices has led to increased adoption of smooth devices. The aim of our study is to evaluate the post-operative surgical site infection (SSI) rates of STEs versus TTEs.

Methods: A retrospective case series was conducted at a single academic teaching hospital from April 2016 to December 2019. The primary outcome variable was the development of a post-operative SSI.

Results: One hundred seventy-seven breasts underwent reconstruction with TTEs and 109 breasts underwent reconstruction with STE. In total, 54 SSIs were recorded (n = 34 TTE; n = 20 STE), with the majority of infections occurring within the first 30 post-operative days (TTE 65%, STE 70%). There was no statistically significant difference in overall post-operative infection rates between TTE and STE groups when broken down into the following time points: <30 day, 30-60 days, and >90 days (p = 0.924). There was no statistically significant difference between infection type (superficial vs. deep, p = 0.932), infection management (medical, surgical, or both, p = 0.409) or salvage results (p = 0.078) seen in STE versus TTE cohort. On multivariate analysis, seroma history was associated with SSI development (OR 3.18, p = 0.041).

Conclusion: There was no significant difference in the rate of post-operative SSI following breast reconstruction with STE relative to TTE.
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http://dx.doi.org/10.1016/j.bjps.2022.04.087DOI Listing
May 2022

Does Higher Intraoperative Fraction of Inspired Oxygen Improve Complication Rates Following Implant-Based Breast Reconstruction?

Aesthet Surg J Open Forum 2022 7;4:ojac039. Epub 2022 May 7.

Division of Plastic & Reconstructive Surgery, Stanford University School of Medicine, Palo Alto, CA, USA.

Background: The surgical literature debates about whether an average intraoperative fractional inspired level of oxygen (FiO) greater than 80% confers lower postsurgical complication rates. Although some evidence demonstrates minimal or no difference in short-term mortality or surgical site infections, few studies suggest negative long-term outcomes.

Objectives: To the best of our knowledge, this is the first study examining the relationship between intraoperative FiO levels and postoperative outcomes in the setting of immediate prepectoral implant-based breast reconstruction.

Methods: The authors retrospectively reviewed the complication profiles of 309 patients who underwent prepectoral 2-stage breast reconstruction following mastectomy between 2018 and 2021 at a single institution. Two cohorts were created based on whether intraoperative FiO was greater than 80% or less than or equal to 80%. Complication rates between the cohorts were analyzed using Chi-squared test, Fisher's exact test, and multivariable logistic regressions. Variables examined included demographic information; smoking history; preexisting comorbidities; history of chemotherapy, radiation, or axillary lymph node dissection; and perioperative information.

Results: Chi-squared and multivariable regression analysis demonstrated no significant difference between cohorts in complication rates other than reoperation. Reoperation rates were significantly increased in the FiO greater than 80% cohort ( = 0.018). Multivariable logistic regression also demonstrated that the use of acellular dermal matrix was significantly associated with increased postoperative complications (odds ratio 11.985; = 0.034).

Conclusions: Complication rates did not statistically differ in patients with varying intraoperative FiO levels outside of reoperation rates. In the setting of implant-based prepectoral breast reconstruction, hyperoxygenation likely does not lead to improved postsurgical outcomes.

Level Of Evidence 3:
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http://dx.doi.org/10.1093/asjof/ojac039DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9155143PMC
May 2022

Air versus Saline: The Effect of Tissue Expander Fill on Outcomes of Prepectoral Breast Reconstruction.

Plast Reconstr Surg 2022 07 2;150(1):28-36. Epub 2022 May 2.

From the Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital; and Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine.

Background: Traditionally, saline is used for intraoperative/postoperative expansion in two-stage alloplastic breast reconstruction. Recently, intraoperative expansion with air has been proposed, to reduce pressure on the mastectomy skin flap in the immediate postoperative setting. The authors examined whether the intraoperative tissue expansion medium (i.e., air versus saline) affected postmastectomy complications in two-stage prepectoral reconstruction.

Methods: This was a retrospective cohort study of 87 patients (144 breasts) undergoing prepectoral breast reconstruction at the authors' institution. Patient data were abstracted from medical records. Stepwise, multivariable-adjusted logistic regression using robust variances was used to identify predictors of postmastectomy complications. Statistical and power analyses were completed.

Results: Of the 87 study patients, 29 (33.3 percent) received intraoperative saline fill and 58 (66.7 percent) received air fill. Demographic/clinical data were well-matched between cohorts. Median follow-up was 165 days, and average patient age was 46.7 years. Initial tissue expander fill volumes were similar between study cohorts ( p = 0.2). The crude association between air versus saline fill on overall complication rates suggested that air-filled tissue expanders may be protective (OR = 0.4; p = 0.03), and the suggested protective effect was maintained with borderline significance even after potential confounders (i.e., American Society of Anesthesiologists class III or higher, body mass index, diabetes, mastectomy specimen weight, smoking status) were added to the model (OR = 0.4; p = 0.05). In addition, fewer complications requiring salvage reoperation were observed with air-filled tissue expanders (adjusted OR = 0.3; p = 0.02).

Conclusions: The medium used for immediate intraoperative tissue expansion impacted postmastectomy outcomes in patients undergoing two-stage prepectoral breast reconstruction. The results demonstrated that air-filled tissue expanders were associated with fewer postoperative complications/salvage reoperations relative to saline-filled tissue expanders.

Clinical Question/level Of Evidence: Therapeutic, III.
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http://dx.doi.org/10.1097/PRS.0000000000009191DOI Listing
July 2022

Fat Grafts Augmented With Vitamin E Improve Volume Retention and Radiation-Induced Fibrosis.

Aesthet Surg J 2022 Aug;42(8):946-955

Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, Stanford, CA, USA.

Background: Treatments for radiation-induced fibrosis range from vitamin E (VE) and pentoxifylline (PTX) systemically to deferoxamine and fat grafting locally. Regarding fat grafting, volume retention hinders its long-term functionality and is affected by 2 factors: inflammation and necrosis secondary to hypovascularity.

Objective: The authors aimed to simultaneously improve fat graft retention and radiation-induced fibrosis by integrating VE and PTX into fat grafts locally.

Methods: Forty adult CD-1 nude male mice, 6 weeks old, underwent scalp irradiation and recovered for 4 weeks to allow for development of fibrosis. Mice received 200 μL of donor human fat graft to the scalp. Mice were separated into 4 conditions: no grafting, fat graft without treatment, graft treated with PTX, and graft treated with VE. Fat graft volume retention was monitored in vivo with micro-computed tomography scans at weeks 0, 1, 2, 4, 6, and 8 after grafting. Histological and cytokine analysis of the scalp skin and fat grafts were performed.

Results: VE-treated grafts had significant improvement in dermal thickness and collagen density of overlying skin compared with all other groups. VE decreased 8-isoprostane and increased CD31+ staining compared with the other grafted groups. Cytokine analysis revealed decreased inflammatory and increased angiogenic markers in both the fat graft and overlying skin of the VE group. Fat graft volume retention was significantly improved in the VE group starting at 1 week post grafting.

Conclusions: Radiation-induced fibrosis and fat graft volume retention are both simultaneously improved with local administration of VE.
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http://dx.doi.org/10.1093/asj/sjac066DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9342682PMC
August 2022

The Price of Publishing: An Investigation of the Open Access Landscape in Plastic Surgery.

Plast Reconstr Surg 2022 05 21;149(5):1249-1260. Epub 2022 Mar 21.

From the Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital; Division of Plastic and Reconstructive Surgery, Washington University in St. Louis School of Medicine; and Division of Plastic Surgery, Stanford University School of Medicine.

Background: Open access publishing in plastic surgery has rapidly gained traction in the past decade. This study investigated the digital landscape of plastic surgery open access publishing.

Methods: This was a cross-sectional bibliometric investigation of plastic surgery-focused journals. Three publication models were investigated: subscription-only journals, hybrid journals offering both paywalled and open access publishing, and open access-only journals.

Results: Eighty-two journals were investigated. In 2010, open access journals comprised 18 percent of all plastic surgery journals online, subscription journals comprised 79 percent, and hybrid journals comprised 3 percent. Conversely, in 2020, open access journals comprised 55 percent of all journals, hybrid journals comprised 45 percent, and there were no subscription-only journals. Multivariable linear regression adjusting for article type/content demonstrated that open access articles from hybrid journals [beta coefficient, 1.3; F(4, 18) = 790; p = 0.05] and high-quality open access journals [beta coefficient, 0.9; F(4, 19) = 738; p = 0.04] were significantly positively associated with number of full-text views. Although impact factor and article processing charges were positively correlated [Pearson correlation coefficient: r(25) = 0.39, p = 0.04] for open access publishing, some high-quality open access journals were found to offer fee waivers/free publishing. Lastly, level of evidence offered by articles from open access versus hybrid journals differed.

Conclusions: Overall, this study highlighted important distinctions between trustworthy and predatory journals offering open access publishing in plastic surgery. Open access publishing in trustworthy sources offers greater visibility and is not necessarily cost-prohibitive, but some open access journals can be limited in scope (i.e., less coverage of subspecialty topics) and quality of content. Study findings were used to generate recommendations for navigating open access publishing in plastic surgery.
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http://dx.doi.org/10.1097/PRS.0000000000009016DOI Listing
May 2022

Combining Breast and Ovarian Operations Increases Complications.

Plast Reconstr Surg 2022 05 2;149(5):1050-1059. Epub 2022 Mar 2.

From the Division of Plastic and Reconstructive Surgery, Stanford University Medical Center.

Background: Breast cancer resulting from a genetic mutations, such as BRCA1 or BRCA2, is seen in 5 to 10 percent of patients. More widespread genetic testing has increased the number of affected women undergoing prophylactic mastectomy and oophorectomy. Recent studies have yielded mixed results regarding complication rates after combined breast and ovarian operations. The authors compared surgical outcomes of breast operations performed in combination with salpingo-oophorectomies or as separate procedures.

Methods: The authors retrospectively analyzed surgical complications and length of hospital stay in 145 female patients, from which 87 had undergone combined breast surgery and salpingo-oophorectomy, and 58 had undergone these procedures separately. Multivariate logistic regression models were used to calculate odds ratios and 95 percent confidence intervals.

Results: Patients undergoing combined breast and ovarian operations experienced higher rates of overall complications (46.5 percent versus 19 percent; p < 0.001), infections (22.2 percent versus 8.6 percent; p < 0.05), and delayed wound healing (13.2 percent versus 0 percent; p < 0.05) related to the breast surgery, when compared with patients undergoing separate procedures. Multivariate logistic regression analysis confirmed a significant association between combined surgery and overall postoperative complications (OR, 5.87; 95 percent CI, 2.03 to 16.91; p = 0.02). Patients undergoing tissue expander-based breast reconstruction combined with ovarian surgery had significantly longer hospital stays compared to patients undergoing separate procedures (3.5 days versus 1.8 days; p < 0.001).

Conclusions: The authors' data indicate that combining breast and ovarian operations is associated with a higher risk of postoperative complications related to the breast procedure and increases the duration of hospital stay in patients with tissue expander-based reconstructions. The authors' study provides valuable information for preoperative counseling of patients considering both breast and ovarian surgery.

Clinical Question/level Of Evidence: Therapeutic, III.
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http://dx.doi.org/10.1097/PRS.0000000000008984DOI Listing
May 2022

Reinforced Biologic Mesh Reduces Postoperative Complications Compared to Biologic Mesh after Ventral Hernia Repair.

Plast Reconstr Surg Glob Open 2022 Feb 7;10(2):e4083. Epub 2022 Feb 7.

Division of Plastic and Reconstructive Surgery, Stanford University Medical Center, Stanford, Calif.

Background: The use of biologic mesh to reinforce the abdominal wall in ventral hernia repair has been proposed as a viable alternative to synthetic mesh, particularly for high-risk patients and in contaminated settings. However, a comparison of clinical outcomes between the currently available biologic mesh types has yet to be performed.

Methods: We performed a retrospective analysis of 141 patients who had undergone ventral hernia repair with biologic mesh, including noncross-linked porcine ADM (NC-PADM) (n = 51), cross-linked porcine ADM (C-PADM) (n = 17), reinforced biologic ovine rumen (RBOR) (n = 36), and bovine ADM (BADM) (n = 37) at the Stanford University Medical Center between 2002 and 2020. Postoperative donor site complications and rates of hernia recurrence were compared between patients with different biologic mesh types.

Results: Abdominal complications occurred in 47.1% of patients with NC-PADM, 52.9% of patients with C-PADM, 16.7% of patients with RBOR, and 43.2% of patients with BADM ( = 0.015). Relative risk for overall complications was higher in patients who had received NC-PADM (RR = 2.64, = 0.0182), C-PADM (RR = 3.19, = 0.0127), and BADM (RR = 2.11, = 0.0773) compared with those who had received RBOR. Furthermore, relative risk for hernia recurrence was also higher in all other mesh types compared with RBOR.

Conclusion: Our data indicate that RBOR decreases abdominal complications and recurrence rates after ventral hernia repair compared with NC-PADM, C-PADM, and BADM.
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http://dx.doi.org/10.1097/GOX.0000000000004083DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8820910PMC
February 2022

Single Institution's Plastic Surgery Case Trends and Considerations in the Midst of COVID-19.

Plast Reconstr Surg 2022 01;149(1):169e-171e

Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University, Palo Alto, Calif.

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http://dx.doi.org/10.1097/PRS.0000000000008657DOI Listing
January 2022

Dress to Impress: Public Perception of Plastic Surgeon Attire.

Aesthet Surg J 2022 05;42(6):697-706

Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA.

Background: Physician attire has been shown to impact patients' perceptions of their provider with regards to professionalism, competency, and trustworthiness in various surgical subspecialties, except in plastic and reconstructive surgery.

Objectives: The authors sought to address this knowledge gap and obtain objective information regarding patients' preferences.

Methods: A survey was distributed to adult, English-speaking participants in the United States using the Amazon MTurk platform from February 2020 to December 2020. Participants were asked to evaluate with a 5-point Likert scale 6 attires (scrubs, scrubs with white coat, formal attire, formal attire with white coat, casual, casual with white coat) in terms of professionalism, competency, and trustworthiness for male and female plastic surgeons during their first encounter in clinic.

Results: A total of 316 responses were obtained from 43.4% men and 56.6% women. The mean age of participants was 53.2 years. The highest scores across all metrics of professionalism, competency, trustworthiness, willingness to share information, confidence in the provider, and confidence in surgical outcomes were given to the formal attire with white coat group, with average scores of 4.85, 4.71, 4.69, 4.73, 4.79, and 4.72, respectively. The lowest scores across all metrics belonged to the casual attire group with scores of 3.36, 3.29, 3.31, 3.39, 3.29, and 3.20, respectively. Patients preferred formal attire for young plastic surgeons (P = 0.039).

Conclusions: This study suggests that physician attire impacts patients' perception of plastic surgeons regarding their professionalism, competency, and trustworthiness. White coats continue to remain a powerful entity in clinical settings given that attires with white coats were consistently ranked higher.
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http://dx.doi.org/10.1093/asj/sjab408DOI Listing
May 2022

System-Level Determinants of Access to Flap Reconstruction after Abdominoperineal Resection.

Plast Reconstr Surg 2022 Jan;149(1):225-232

From the University of California, San Francisco, School of Medicine; and Division of Plastic Surgery, Department of Surgery, Stanford University School of Medicine.

Background: Reconstruction following abdominoperineal resection improves outcomes by reducing wound-related complications, particularly in irradiated patients. Little is known regarding system-level factors that impact patients' access to reconstructive surgery following abdominoperineal resection. This study aimed to identify barriers to undergoing reconstruction following abdominoperineal resection.

Methods: Using the National Inpatient Sample database from 2012 to 2014, all encounters with colorectal or anorectal carcinoma patients who underwent abdominoperineal resection were extracted based on International Classification of Disease, Ninth Revision, diagnosis and procedure codes. Multivariable logistic regression analyzed the outcome of undergoing reconstruction.

Results: The weighted sample included encounters with 19,205 abdominoperineal resection patients, of whom 1243 (6.5 percent) received a flap. Notable patient-level predictors of receiving a flap included age younger than 55 years (OR, 1.82; 95 percent CI, 1.23 to 2.74; p = 0.003) and neoadjuvant chemoradiation therapy (OR, 1.37; 95 percent CI, 1.01 to 1.88; p = 0.041). Race, sex, income level, insurance type, and Elixhauser Comorbidity Index were not associated with increased odds of receiving a flap. For facility-level factors, urban teaching hospitals (OR, 23.6; 95 percent CI, 3.29 to 169.4; p = 0.002) and larger hospital bedsize (OR, 2.64; 95 percent CI, 1.53 to 4.56; p = 0.000) were associated with higher odds of reconstruction. Plastic surgery facility volume was not found to be a significant predictor of undergoing flap reconstruction (p > 0.05).

Conclusions: Patients undergoing abdominoperineal resection at academic centers were over 23 times more likely to undergo reconstruction, after adjusting for available confounders. Patients undergoing abdominoperineal resection at smaller, nonacademic centers may not have equitable access to reconstruction despite being appropriate candidates. Given the morbidity of abdominoperineal resection, patients should be referred to large, academic centers to have access to flap reconstruction.

Clinical Question/level Of Evidence: Risk, III.
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http://dx.doi.org/10.1097/PRS.0000000000008661DOI Listing
January 2022

The Plane of Mesh Placement Does Not Impact Abdominal Donor Site Complications in Microsurgical Breast Reconstruction.

Ann Plast Surg 2021 11;87(5):542-546

From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University Medical Center, Stanford, CA.

Background: Reinforcement of the abdominal wall with synthetic mesh in autologous breast reconstruction using abdominal free tissue transfer decreases the risk of bulging and herniation. However, the impact of the plane of mesh placement on donor site complications has not yet been investigated.

Methods: We performed a retrospective analysis of 312 patients who had undergone autologous breast reconstruction with muscle-sparing transverse rectus abdominis myocutaneous (MS-TRAM) flaps or deep inferior epigastric perforator (DIEP) flaps as well as polypropylene mesh implantation at the donor site. Donor site complications were compared among patients with different flap types and different mesh positions including overlay (n = 90), inlay and overlay (I-O; n = 134), and sublay (n = 88).

Results: Abdominal hernias occurred in 2.86% of patients who had undergone MS-TRAM reconstructions and in 2.63% of patients who had undergone DIEP reconstructions. When comparing patients with different mesh positions, donor site complications occurred in 14.4% of patients with overlay mesh, 13.4% of patients with I-O mesh, and 10.2% of patients with sublay mesh (P = 0.68). Abdominal hernias occurred in 4.44% of patients with overlay mesh, 2.24% of patients with I-O mesh, and 2.27% of patients with sublay mesh (P = 0.69). Multivariable logistic regression analysis did not identify a significant association between mesh position and hernia rates as well as wound complications.

Conclusions: Our data indicate that the plane of synthetic mesh placement in relation to the rectus abdominis muscle does not impact the rate of postoperative donor site complications in patients undergoing breast reconstruction with MS-TRAM or DIEP flaps.
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http://dx.doi.org/10.1097/SAP.0000000000002897DOI Listing
November 2021

The Zoom Effect: A Google Trends Analysis.

Aesthet Surg J 2022 01;42(1):NP76-NP82

Division of Plastic Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA.

Background: Increased video-chatting, stimulated by the COVID-19 pandemic, has been correlated with increased appearance concerns. Initial lockdown restrictions correlated with a decrease in aesthetic/cosmetic plastic surgery case volumes.

Objectives: The authors aimed to delineate public interest in aesthetic procedures surrounding the COVID-19 pandemic via Google Trends. They hypothesized that because of the pandemic, public interest in plastic surgery procedures increased, especially localized above the shoulder.

Methods: Trends in the United States for given search terms and volumes were gathered via Google Trends between January 2015 and March 2021. The search volumes were normalized, and a bivariate regression analysis of panel data was then applied to the aggregate trendlines to determine if a statistically significant change in search volume occurred following the stay-at-home orders.

Results: The following search terms had statistically significant (P < 0.000) increases in search volumes after February 2020: blepharoplasty, Botox, brachioplasty, breast implant removal, breast reduction, brow lift, buccal fat removal, hair transplantation, lip augmentation, mentoplasty, otoplasty, platysmaplasty, rhinoplasty, and thighplasty. Chi-squared analysis demonstrated a statistically significant association (chi-squared = 4.812, P = 0.028) between increases in search volume and above-the-shoulder procedures.

Conclusions: Public interest in above-the-shoulder surgical procedures statistically significantly increased following February 2020 compared with below-the-shoulder procedures. Continued examination of specific procedure trends and determining correlations with more accurate procedural datasets will provide increased insight into consumers' mindsets and to what extent video conferencing plays a role in the public's interest in pursuing aesthetic surgery.
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http://dx.doi.org/10.1093/asj/sjab347DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8513406PMC
January 2022

Masking Gender: The Impact of Facial Coverings on Gender Recognition.

Plast Reconstr Surg 2021 Sep;148(3):521e-522e

The Facialteam Group, HC Marbella International Hospital, Marbella, Málaga, Spain.

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http://dx.doi.org/10.1097/PRS.0000000000008273DOI Listing
September 2021

Decellularized Adipose Matrices Can Alleviate Radiation-Induced Skin Fibrosis.

Adv Wound Care (New Rochelle) 2022 Oct 6;11(10):524-536. Epub 2021 Sep 6.

Hagey Laboratory for Pediatric Regenerative Medicine, Division of Plastic Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, California, USA.

Radiation therapy is commonplace for cancer treatment but often results in fibrosis and atrophy of surrounding soft tissue. Decellularized adipose matrices (DAMs) have been reported to improve these soft tissue defects through the promotion of adipogenesis. These matrices are decellularized by a combination of physical, chemical, and enzymatic methods to minimize their immunologic effects while promoting their regenerative effects. In this study, we aimed at exploring the regenerative ability of a DAM (renuva; MTF biologics, Edison, NJ) in radiation-induced soft tissue injury. Fresh human lipoaspirate or DAM was injected into the irradiated scalp of CD-1 nude mice, and volume retention was monitored radiographically over 8 weeks. Explanted grafts were histologically assessed, and overlying skin was examined histologically and biomechanically. Irradiated human skin was also evaluated from patients after fat grafting or DAM injection. However, integrating data between murine and human skin in all cohorts is limited given the genetic variability between the two species. Volume retention was found to be greater with fat grafts, though DAM retention was, nonetheless, appreciated at irradiated sites. Improvement in both mouse and human irradiated skin overlying fat and DAM grafts was observed in terms of biomechanical stiffness, dermal thickness, collagen density, collagen fiber networks, and skin vascularity. This is the first demonstration of the use of DAMs for augmenting the regenerative potential of irradiated mouse and human skin. These findings support the use of DAMs to address soft tissue atrophy after radiation therapy. Morphological characteristics of the irradiated skin can also be improved with DAM grafting.
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http://dx.doi.org/10.1089/wound.2021.0008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9354001PMC
October 2022

Assessing Gender-Affirming Chest Surgery Outcomes: Does Gender Identity Alter Gaze?

Aesthetic Plast Surg 2021 08 10;45(4):1860-1868. Epub 2021 Jun 10.

Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford Hospital and Clinics, Palo Alto, CA, USA.

Background: Outcomes of gender-affirming chest surgery can be variable. Placement of nipple-areolar complexes and orientation of scars can drastically affect the aesthetic outcomes of these procedures, as may observer gender identity. Here, we compared attention and perception of outcomes following gender-affirming chest surgery between laypersons, based on gender identity.

Methods: Transgender and cisgender participants were enrolled and shown images of surgery naïve chests and postoperative masculinized and feminized chests, blinded to the gender identity of the photographed subject. Gaze data were captured using the Tobii X2 60 eye-tracking device. Participants scored the perceived gender and aesthetic appearance of each image.

Results: Eighteen cisgender and 14 transgender participants were enrolled. When viewing male chests, transgender participants spent significantly longer fixated on the nipples (naïve: 802 vs. 395 ms; p = 0.02, masculinized: 940 vs. 692 ms, p = 0.002). For masculinized chests, cisgender participants spent significantly longer fixated on the inframammary scar (483 vs. 391 ms; p = 0.04). On images of feminized chests, transgender participants spent longer viewing the nipples when compared to cisgender participants (1017 vs. 847 ms; p = 0.04). Cisgender viewers spent longer fixating on the postoperative scar on feminized chests (113 vs. 59 ms; p = 0.02) and also viewed feminized chests as significantly more masculine and masculinized chests as more feminine, when compared to transgender participants (p < 0.05).

Conclusions: This is the first study to use eye-tracking to assess how laypersons assess chests for gender determination. The findings suggest that observer gender identity has an effect on areas of focus and gender perception of chests that underwent gender-affirmation surgery.

Level Of Evidence Iii: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine Ratings, please refer to Table of Contents or online Instructions to Authors www.springer.com/00266 .
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http://dx.doi.org/10.1007/s00266-021-02378-1DOI Listing
August 2021

Comparing Outcomes of Flap-Based Salvage Reconstructions in the Radiated Breast.

Ann Plast Surg 2021 05;86(5S Suppl 3):S403-S408

Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University Medical Center, Stanford, CA.

Introduction: Chest wall irradiation significantly decreases the strength and quality of breast tissue supporting prostheses, increasing the risk of skin breakdown and implant or tissue expander extrusion. Autologous tissue, including the latissimus dorsi (LD) or abdominal-based flaps, including the muscle-sparing transverse rectus abdominis myocutaneous or deep inferior epigastric perforator flaps, may be used to salvage reconstructions. However, data comparing outcomes of the two flap options remains limited. We compare postoperative outcomes from both flap types after autologous salvage reconstruction in irradiated breasts.

Methods: Charts were retrospectively reviewed from patients who underwent either chest wall radiation or postmastectomy radiation therapy followed by salvage autologous reconstruction with either a LD and an implant or an abdominal-based flap (muscle-sparing transverse rectus abdominis myocutaneous or deep inferior epigastric perforator flaps). Patients with a history of tissue expander or implant failure requiring autologous salvage as part of 2-staged or delayed-immediate breast reconstruction that were operated on between January 2005 and November 2015 were included. Basic demographics, comorbidities, and recipient site complications (infection, wound dehiscence, seroma, hematoma, fat necrosis, and flap failure) were collected.

Results: A total of 72 patients met the inclusion criteria which included 72 flaps; 35 LD and 37 abdominally based flaps. Demographics and comorbidities did not vary significantly between patient groups. Mean follow-up was 767.6 weeks, and all reconstructions were unilateral. Nineteen (26.4%) patients had at least one complication, most commonly minor infections (9.7%). Overall complication rates were not significantly different between flap groups (P = 0.083). Wound dehiscence was significantly higher in the abdominal group (P = 0.045), and fat necrosis also trended higher in this group (P = 0.085). Major infection trended higher in the latissimus group (P = 0.069).

Conclusions: When comparing outcomes of salvage flap-based reconstruction in radiated breast tissue, overall complication rates were similar when comparing postoperative outcomes between the LD- and abdominal-based flaps. Wound dehiscence was significantly higher when salvage reconstruction used an abdominal flap. Understanding the complications after salvage procedures can help inform decision making and optimize patient care to improve outcomes after breast reconstruction in the radiated breast.
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http://dx.doi.org/10.1097/SAP.0000000000002761DOI Listing
May 2021

Examining the Effects of Postmastectomy Radiation Therapy in Prepectoral Versus Subpectoral Autologous Breast Reconstruction.

Ann Plast Surg 2021 05;86(5S Suppl 3):S390-S394

Division of Plastic and Reconstructive Surgery, Stanford University Medical Center, Palo Alto, CA.

Background: Postmastectomy radiation therapy (PMRT) is known to increase the risk of multiple adverse outcomes after breast reconstruction. In the context of delayed-immediate autologous breast reconstruction, PMRT is typically conducted after placement of subpectoral (SP) tissue expanders. With the re-emergence of prepectoral (PP) reconstruction, there are little data assessing the outcomes of PP reconstruction in breasts receiving PMRT. We compared postoperative outcomes of PMRT patients undergoing delayed-immediate, autologous breast reconstruction with placement of tissue expanders in either the PP or SP plane.

Methods: A retrospective chart review was conducted on all consecutive patients who underwent delayed-immediate autologous breast reconstruction and received PMRT at either the Stanford University or the Johns Hopkins University Hospitals between January 2009 and December 2018. Demographics, comorbidities, perioperative information, and oncologic data were collected for all patients. Complications were collected and analyzed after stage 1 surgery, between 30 days of stage 1 and up to stage 2 surgery, and after stage 2 surgery. Multivariable regressions were used to determine predictors of 1 or more complications.

Results: A total of 71 patients (73 breasts) were included. Prepectoral reconstruction comprised of 52.2% of the cohort, and the remaining 47.8% were SP reconstructions. Demographics and comorbidities were similar between groups, except for premastectomy radiation, which was more prevalent in the PP cohort (P = 0.010). Complications were similar between cohorts after stage 1 surgery (P = 0.420), between stages 1 and 2 (P = 0.100), and after stage 2 (P = 0.570). There were higher rates of skin necrosis in the SP cohort between stages 1 and 2 (PP: 2.6%, SP: 20%, P = 0.004). Multivariable analysis revealed body mass index to be the only predictor of complication (P = 0.041). The mean number of revisionary surgeries was higher in the SP cohort (PP: 0.8 vs SP: 1.9, P = 0.002). The mean follow-up was 385.5 days and similar between groups (P = 0.870).

Conclusions: Rates of overall complication were similar between PP and SP expander placement. However, in SP reconstructions, skin necrosis was significantly higher between stages 1 and 2. The patients in the SP cohort also underwent a greater number of revisionary surgeries, although overall rates of pursuing any revisionary surgery were similar between groups.
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http://dx.doi.org/10.1097/SAP.0000000000002762DOI Listing
May 2021

Tenth Dedicated CSPS Annals.

Ann Plast Surg 2021 05;86(5S Suppl 3):S353

From the Division of Plastic Surgery, Stanford University, Palo Alto, CA.

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http://dx.doi.org/10.1097/SAP.0000000000002914DOI Listing
May 2021

Patient and surgeon experiences with video visits in plastic surgery-toward a data-informed scheduling triage tool.

Surgery 2021 08 1;170(2):587-595. Epub 2021 May 1.

Division of Plastic and Reconstructive Surgery, Stanford Health Care, Stanford, CA.

Background: Coronavirus disease 2019 provided the impetus for unprecedented adoption of telemedicine. This study aimed to understand video visit adoption by plastic surgery providers; and patient and surgeon perceptions about its efficacy, value, accessibility, and long-term viability. A secondary aim was to develop the proposed 'Triage Tool for Video Visits in Plastic Surgery' to help determine visit video eligibility.

Methods: This mixed-methods evaluation assessed provider-level scheduling data from the Division of Plastic and Reconstructive Surgery at Stanford Health Care to quantify telemedicine adoption and semi-structured phone interviews with patients (n = 20) and surgeons (n = 10) to explore stakeholder perspectives on video visits.

Results: During the 13-week period after the local stay-at-home orders due to coronavirus disease 2019, 21.4% of preoperative visits and 45.5% of postoperative visits were performed via video. Video visits were considered acceptable by patients and surgeons in plastic surgery in terms of quality of care but were limited by the inability to perform a physical examination. Interviewed clinicians reported that long-term viability needs to be centered around technology (eg, connection, video quality, etc) and physical examinations. Our findings informed a proposed triage tool to determine the appropriateness of video visits for individual patients that incorporates visit type, anesthesia, case, surgeon's role, and patient characteristics.

Conclusion: Video technology has the potential to facilitate and improve preoperative and postoperative patient care in plastic surgery but the following components are needed: patient education on taking high-quality photos; standardized clinical guidelines for conducting video visits; and an algorithm-assisted triage tool to support scheduling.
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http://dx.doi.org/10.1016/j.surg.2021.03.029DOI Listing
August 2021

Autologous Fat Grafting and the Occurrence of Radiation-Induced Capsular Contracture.

Ann Plast Surg 2021 05;86(5S Suppl 3):S414-S417

Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University Medical Center, Stanford, CA.

Introduction: Radiation therapy is a known risk factor for capsular contracture formation after implant-based breast reconstruction. Although autologous fat grafting (AFG) has been shown to reverse radiation-induced tissue fibrosis, its use as a prophylactic agent against capsular contraction has not been assessed in the clinical setting. In the setting of 2-stage implant-based reconstruction and postmastectomy radiation therapy, we explored the effect AFG has on the prevalence of capsular contracture.

Materials And Methods: A retrospective chart review of patients who underwent immediate tissue expander (TE) placement followed by postmastectomy radiation therapy and secondary implant-based reconstruction at our institution between January 2012 and December 2019 was performed. Patients were divided into 2 cohorts based on whether or not AFG was performed at the time of secondary reconstruction. The primary outcome of interest was the occurrence of capsular contracture after TE exchange.

Results: Overall 57 patients (57 breasts) were included, 33 of whom received AFG at the time of TE exchange. All but 1 patient underwent submuscular implant placement, and the mean follow-up was 1.96 years. There was no significant difference in the prevalence of medical comorbidities between the study groups.Capsular contracture occurred in 24 patients (42.1%). Seventeen of these patients had undergone AFG at the time of TE exchange (17/33 patients, 51.5%), and 7 of these patients had not (7/24 patients, 29.2%). Most of the capsular contracture cases were Baker grades III or IV (14 patients, 58.3%), and 50% of patients with capsular contracture of any grade ultimately required operative intervention. Multivariate logistic regression analysis demonstrated that AFG did not significantly influence the occurrence or severity of capsular contracture, or did not impact the need for operative intervention in this patient population.

Conclusions: Implant-based reconstruction of the irradiated breast is associated with high postoperative capsular contracture rates. Although AFG has shown promise in reversing radiation-induced dermal fibrosis, no protective effect on the development of capsular contracture after stage 2 reconstruction was observed in this study population. Further investigation in the form of randomized, prospective studies is needed to better assess the utility of AFG in preventing capsular contracture in irradiated patients.
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http://dx.doi.org/10.1097/SAP.0000000000002817DOI Listing
May 2021

Revision Rates in Prepectoral Versus Subpectoral Delayed-Immediate Autologous Breast Reconstruction.

Ann Plast Surg 2021 05;86(5S Suppl 3):S409-S413

Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University Medical Center, Stanford, CA.

Introduction: Breast reconstruction in the prepectoral plane has recently fallen into favor. Minimizing the number of revisionary procedures after reconstruction is an important factor in improving patient care, but long-term studies on the effects of prepectoral reconstruction are limited. In this study, we compare the revision rates after delayed-immediate, autologous reconstruction between prepectoral and subpectoral reconstructions.

Methods: Postoperative charts for all patients undergoing subpectoral or prepectoral delayed-immediate autologous breast reconstruction were retrospectively reviewed at our single tertiary-care institution between 2009 and 2018. Patient demographics, comorbidities, and oncologic history were recorded. Charts after second stage reconstruction were reviewed for up to eighteen months to determine if revisions were necessary. Data collected included the total number of surgeries performed, the average number of procedures performed during each surgery, and the type of revision that was performed. Statistical tests included the chi squared test, unpaired t-test, and logistic regressions.

Results: Data from 89 patients with 125 breast reconstructions were collected. There was a 41.6% of these that were prepectoral reconstructions (P), and 58.4% were subpectoral reconstructions (S). For both groups, nipple sparing, followed by skin sparing mastectomies were most common. Mastectomy rates were not statistically different. Fewer breasts in the prepectoral cohort required any revisions (P, 21.2% vs S, 47.9%; P = 0.002). The subpectoral cohort had higher rates of soft tissue rearrangement (P, 7.7% vs S, 21.9%, P = 0.032), fat grafting (P, 9.6% vs S, 27.4%; P = 0.014), and nipple reconstruction (P: 5.8% vs 20.5%, P = 0.020). Mean follow-up time was not significantly different between patient groups (P, 290.5 days vs S, 375.0 days, P = 0.142). Subpectoral expander placement was found to be the only variable independently predictive of requiring 1 or more revision (P = 0.034).

Conclusions: Breast reconstruction performed in the prepectoral plane is associated with lower overall rates of revisionary surgery. Rates of soft tissue rearrangement, fat grafting, and nipple reconstruction after autologous reconstruction trended higher in subpectoral reconstructions.
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http://dx.doi.org/10.1097/SAP.0000000000002760DOI Listing
May 2021

Social Perception of Facial Feminization Surgery Outcomes: Does Gender Identity Alter Gaze?

Aesthet Surg J 2021 09;41(10):1207-1215

Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University, Palo Alto, CA, USA.

Background: The evaluation of gender-affirming facial feminization surgery (FFS) outcomes can be highly subjective, which has resulted in a limited understanding of the social perception of favorable gender and aesthetic facial appearance following FFS. Eye-tracking technology has introduced an objective measure of viewer subconscious gaze.

Objectives: The aim of this study was to use eye-tracking technology to measure attention and perception of surgery-naive cisgender female and feminized transgender faces, based on viewer gender identity.

Methods: Thirty-two participants (18 cisgender and 14 transgender) were enrolled and shown 5 photographs each of surgery-naive cisgender female and feminized transgender faces. Gaze was captured with a Tobii Pro X2-60 eye-tracking device (Tobii, Stockholm, Sweden) and participants rated the gender and aesthetic appearance of each face on Likert-type scales.

Results: Total image gaze fixation time did not differ by participant gender identity (6.00 vs 6.04 seconds, P = 0.889); however, transgender participants spent more time evaluating the forehead/brow, buccal/mandibular regions, and chin (P < 0.001). Multivariate regression analysis showed significant associations between viewer gender identity, age, race, and education, and the time spent evaluating gender salient facial features. Feminized faces were rated as more masculine with poorer aesthetic appearance than surgery-naive cisgender female faces; however, there was no significant difference in the distribution of gender appearance ratings assigned to each photograph by cisgender and transgender participants.

Conclusions: These results demonstrate that gender identity influences subconscious attention and gaze on female faces. Nevertheless, differences in gaze distribution did not correspond to subjective rated gender appearance for either surgery-naive cisgender female or feminized transgender faces, further illustrating the complexity of evaluating social perception of favorable FFS outcomes.
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http://dx.doi.org/10.1093/asj/sjaa377DOI Listing
September 2021

Single-Unit technique for the use of acellular dermal matrix in immediate expander-based breast reconstruction.

J Plast Reconstr Aesthet Surg 2021 05 2;74(5):981-986. Epub 2020 Nov 2.

Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University Medical Center, Stanford, CA, USA. Electronic address:

Background: The use of acellular dermal matrices (ADMs) in immediate two-stage prosthetic breast reconstruction following mastectomy is now a common practice. The procedure confers several compelling benefits, including coverage of the inferior pole, enhanced definition of the inframammary fold, and reduction of capsular contracture. However, operative techniques used to create the ADM inferolateral sling can be unwieldy in practice, typically involving the placement of the ADM followed by positioning and anchoring of the prosthetic expander. At best, this may be a relatively minor nuisance, but may potentially influence outcomes, including discrepancies in symmetry.

Methods: We present a novel modification that aims to streamline this procedure. Perforations are made through the allograft, through which the tissue expander tabs are brought through and sutured together ex vivo to allow the ADM and expander to be placed into the inframammary fold position as a single unit. A retrospective chart review was then performed of patients who underwent breast reconstruction utilizing this technique between July 2015 and December 2018. Outcomes including postsurgical complications such as infection, malposition, and reoperation were analyzed.

Results: Sixty-two patients met the inclusion criteria, corresponding to 108 breasts. The average follow-up was 18 months. The overall complication rate was 29.6% of breasts. The most commonly observed complications were mastectomy skin necrosis (9.3%) and major infection (8.3%). There was a 7.4% rate of malposition.

Conclusions: This simple but effective modification in ADM technique is associated with a comparable complication rate and allows for greater ease and consistency in tissue expander placement.
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http://dx.doi.org/10.1016/j.bjps.2020.10.048DOI Listing
May 2021

What Is Your Reality? Virtual, Augmented, and Mixed Reality in Plastic Surgery Training, Education, and Practice.

Plast Reconstr Surg 2021 02;147(2):505-511

From the Division of Plastic and Reconstructive Surgery, Stanford University Medical Center; the University Hospital Miguel Servet; and the Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School.

Summary: Virtual reality and other technological advancements both inside and outside the operating room have shown an exponential increase in the past two decades. Surgical technique and finesse in delicate procedures have become ever more important, and the onus is on plastic surgeons and plastic surgery residents to meet these needs to provide the best outcomes possible to patients. The ability to learn, simulate, and practice operating in a fashion that poses no harm to any patient is truly a gift from technology to surgery that any surgeon could benefit from, whether trainee or attending. This application of technology and simulation has been demonstrated in other fields such as in the airline industry with flight simulation. The ability to learn, synthesize, and incorporate learned materials and ideas through virtual, augmented, and mixed reality tools offers a great opportunity to put our field at the forefront of a paradigm shift in surgical education. The critical utility of digital education could not be further emphasized any more than in the unfortunate and infrequent situation of a worldwide pandemic. This article reviews some of the important recent technologies that have developed and their applications in plastic surgery education and offers a look into what we can expect in the future.
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http://dx.doi.org/10.1097/PRS.0000000000007595DOI Listing
February 2021

Reply: Where Do We Look? Assessing Gaze Patterns in Cosmetic Face-Lift Surgery with Eye Tracking Technology.

Plast Reconstr Surg 2020 12;146(6):821e-822e

Division of Plastic and Reconstructive Surgery, Stanford University, Palo Alto, Calif.

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http://dx.doi.org/10.1097/PRS.0000000000007375DOI Listing
December 2020

The safety and efficacy of autologous fat grafting during second stage breast reconstruction.

J Plast Reconstr Aesthet Surg 2021 Apr 21;74(4):792-799. Epub 2020 Oct 21.

Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University Medical Center, 770 Welch Rd, Suite 400, Stanford, CA 94305, United States. Electronic address:

Background: Patients often pursue revisions following implant-based breast reconstruction (IBR) to achieve their desired result. Fat grafting is a popular choice for patients and can be performed at second stage reconstruction or at a future date as a revisionary surgery. We investigate the best time to fat graft in IBR by comparing the outcomes of patients who received fat grafting during implant placement with those who pursued fat grafting during a tertiary procedure.

Methods: We retrospectively reviewed the charts of 157 patients (270 breasts) who underwent immediate two-stage IBR and fat grafting over a five-year period (2012-2016) at our institution. Two cohorts were created based on timing of first fat grafting procedure: immediate (IFG) and delayed (DFG). Charts were reviewed for postoperative complications or revisions.

Results: Complication rates were lower when fat grafting was performed during the second stage (p = 0.0331). Patients in the DFG cohort required more than one additional revision (p < 0.001) until the completion of reconstruction. Patients in the IFG cohort completed their reconstruction and revisions more than one year earlier than the DFG cohort (p < 0.001). Multivariable regressions showed IFG to be associated with decreased revisions (p < 0.001) and total fat grafting procedures (p = 0.008).

Conclusions: These results indicate that fat grafting at the second stage does not increase overall complication rates, require fewer additional surgeries, and enables patients to reach their desired aesthetic appearance in a shorter time frame. Fewer total surgeries translate not only to a more economical option but also obviate the risk of complications that come with additional surgeries.
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http://dx.doi.org/10.1016/j.bjps.2020.10.008DOI Listing
April 2021

Erratum: Abstract 199: Gender Identity Alters Gaze: The Use of Eye Tracking to Assess Outcomes in Gender-affirming Chest Surgery - Erratum.

Plast Reconstr Surg Glob Open 2020 Aug 25;8(8):e3106. Epub 2020 Aug 25.

Department of Surgery, Division of Plastic and Reconstructive Surgery, Stanford University Medical Center, Palo Alto, CA, USA.

[This corrects the article DOI: 10.1097/01.GOX.0000667852.45222.46.].
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http://dx.doi.org/10.1097/GOX.0000000000003106DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7489693PMC
August 2020

Angiosarcoma of the Breast: Management and Outcomes.

Am J Clin Oncol 2020 11;43(11):820-825

Department of Radiation Oncology.

Objective: Angiosarcoma of the breast is rare and has a poor prognosis. We reviewed our institution's experience with this disease to characterize presentation, identify management patterns, and report outcomes.

Methods: Fifty-eight patients with nonmetastatic angiosarcoma were identified from 1998 to 2019 and retrospectively reviewed. Overall survival (OS) and recurrence-free survival (RFS) were calculated using the Kaplan-Meier analysis and log-rank test.

Results: The median follow-up was 43.4 months (range: 1.8 to 203.3 mo). Twenty-four patients had primary angiosarcoma (PAS) and 34 patients had secondary angiosarcoma (SAS). Patients with PAS were significantly younger than those with SAS (P<0.0001). Mastectomy was the main surgical treatment in our cohort (n=47) and 3 underwent a lumpectomy. The multifocal disease was found in 5/23 patients with PAS and 11/35 patients with SAS. Twenty-eight patients received chemotherapy. Radiation was administered to 13 patients with PAS and 3 patients with SAS. Five-year OS was 73.7% for PAS and 63.5% for SAS. Local recurrence occurred in a greater proportion of patients with margins <5 mm than those with margins ≥5 mm. Chemotherapy did not impact RFS and was not associated with OS in PAS (P=0.35). Those with SAS treated with chemotherapy had significantly greater OS than those who did not receive chemotherapy (P=0.043). Radiation did not significantly influence RFS or OS.

Conclusions: Five-year OS was higher than anticipated. Margins >5 mm appear important for local control. Patients with SAS, but not PAS, may achieve improved survival with chemotherapy. National trials using prespecified agents may be needed to identify an optimal chemotherapy regimen for women with SAS.
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http://dx.doi.org/10.1097/COC.0000000000000753DOI Listing
November 2020

Analysis of Computer Vision Methods for Counting Surgical Instruments.

Surg Innov 2021 Jun 2;28(3):392-393. Epub 2020 Sep 2.

Department of Orthopaedic Surgery, Stanford Medicine, Redwood City, CA, USA.

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http://dx.doi.org/10.1177/1553350620956425DOI Listing
June 2021
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