Publications by authors named "Stephanie Caterson"

35 Publications

Impact of surgical complications on patient reported outcomes (PROs) following nipple sparing mastectomy.

Am J Surg 2020 11 14;220(5):1230-1234. Epub 2020 Jul 14.

Breast Oncology Program, Dana Farber Cancer Institute, Boston, MA, USA; Division of Breast Surgery, Brigham and Women's Hospital, Boston, MA, USA. Electronic address:

Introduction: Nipple sparing mastectomy (NSM) is oncologically safe and provides excellent cosmetic outcomes. Complications after surgery may impact patient reported outcomes (PROs). We assessed the impact of complications on PROs after NSM.

Methods: We enrolled 63 patients (pts) who met eligibility criteria for NSM from September 2011 until August 2014. PROs were administered before surgery and at 1 year. Clinical data were collected from the electronic health record. Analyses were performed in SPSS Statistics for Windows (version 21.0). Pts with and without complications were compared using a one-way ANOVA.

Data: Sixty-three women were enrolled with a median age of 46. Postoperative complications requiring surgical treatment were seen in 10 patients (15.9%). Two patients required nipple excision due to necrosis (3.1%). No statistically significant differences in BREAST-Q scores were seen between pts with and without complications.

Conclusion: Experiencing a complication after initial NSM surgery is not associated with decrease in PROs.
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http://dx.doi.org/10.1016/j.amjsurg.2020.06.066DOI Listing
November 2020

Patterns of breast reconstruction in patients diagnosed with inflammatory breast cancer: The Dana-Farber Cancer Institute's Inflammatory Breast Cancer Program experience.

Breast J 2020 03 25;26(3):384-390. Epub 2019 Aug 25.

Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, Massachusetts.

Inflammatory breast cancer (IBC) exhibits dermal lymphatic involvement at presentation, and thus, the standard surgical approach is a nonskin-sparing modified radical mastectomy (MRM) without breast reconstruction (BR). In this study, we evaluated immediate and delayed BR receipt and its outcomes in IBC. Using an IRB-approved database, we retrospectively evaluated stage III IBC patients who received trimodality therapy (preoperative systemic therapy, followed by MRM and postmastectomy chest wall/regional nodal radiation). Patients with an insufficient response to preoperative systemic therapy and/or who required preoperative radiotherapy were excluded. BR receipt, timing, and morbidity were evaluated. Among 240 stage III IBC patients diagnosed between 1997 and 2016, 40 (17%) underwent BR. Thirteen (33%) had immediate, and 27 (67%) had delayed BR. Four patients had complications (1 [8%] immediate BR and 3 [11%] delayed BR); only 1 BR (delayed) was unsuccessful. From the MRM date, the median time to recurrence was 35 months (<1-212) and median overall survival was 87 months (<1-212). In this cohort of stage III IBC patients, only 11% pursued delayed BR following trimodality therapy, possibly attributable to the observed high recurrence rates hindering BR. Further studies addressing BR outcomes in IBC are needed for better counseling patients regarding their reconstructive options.
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http://dx.doi.org/10.1111/tbj.13509DOI Listing
March 2020

Genetic Testing for Breast Cancer Susceptibility Should Be Offered before Unilateral Abdominally Based Free Flap Breast Reconstruction.

Plast Reconstr Surg 2019 07;144(1):12-20

From the Harvard Plastic Surgery Combined Residency Program; the Center for Cancer Genetics and Prevention, Dana-Farber Cancer Institute; Harvard Medical School; and the Division of Plastic Surgery, Brigham and Women's Hospital.

Background: Pathogenic mutations have been identified in approximately 10 percent of patients who present with breast cancer. Notably, failure to identify deleterious genetic mutations has particular implications for patients undergoing abdominally based breast reconstruction, as the donor site can be used only once. The authors sought to determine: (1) how many patients underwent genetic testing before unilateral abdominally based free flap breast reconstruction; (2) how often deleterious mutations were detected after abdominally based free flap breast reconstruction; and (3) the cost-effectiveness of expanding genetic testing in this patient population.

Methods: The authors retrospectively identified all patients who underwent unilateral abdominally based free flap breast reconstruction at Brigham and Women's Hospital/Dana-Farber Cancer Institute between 2007 and 2016. Chart review was performed to collect relevant demographic and clinical data. Relevant hospital financial data were obtained.

Results: Of the 713 who underwent free flap breast reconstruction, 160 patients met inclusion criteria, and mean follow-up was 5.8 years. Three patients (1.9 percent of 160) underwent contralateral surgery after completing reconstruction, two of whom had BRCA2 and one with ATM mutation. One hundred eleven patients met National Comprehensive Cancer Network guidelines for genetic testing, but of those only 55.9 percent (62 patients) were tested. Financial data revealed that testing every patient in the cohort would result in a net savings of $262,000.

Conclusions: During a relatively short follow-up period, a small percentage of patients were diagnosed with pathogenic mutations and underwent contralateral mastectomy and reconstruction. However, because of the costliness of surgery and the decreased cost of genetic testing, it is cost-effective to test every patient before unilateral abdominally based free flap breast reconstruction.
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http://dx.doi.org/10.1097/PRS.0000000000005693DOI Listing
July 2019

Implementation of a Venous Thromboembolism Prophylaxis Protocol Using the Caprini Risk Assessment Model in Patients Undergoing Mastectomy.

Ann Surg Oncol 2018 Nov 20;25(12):3548-3555. Epub 2018 Aug 20.

Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA.

Background: Guidelines for venous thromboembolism (VTE) prophylaxis are not well-established for breast surgery patients. An individualized VTE prophylaxis protocol using the Caprini score was adopted at our institution for patients undergoing mastectomy ± implant-based reconstruction. In this study, we report our experience during the first year of implementation.

Methods: In August 2016, we adopted a VTE prophylaxis protocol for patients undergoing mastectomy ± implant-based reconstruction. We used the Caprini score, a validated risk assessment tool for VTE, to determine each patient's perioperative prophylaxis regimen. Detailed chart review was performed to record patient and treatment details, the Caprini score, pharmacologic VTE prophylaxis administration, and 30-day incidence of VTE and bleeding complications. We performed univariate analysis to identify factors associated with protocol compliance.

Results: Overall, 522 patients met the inclusion criteria. Median age was 51 years, 486 (93.1%) patients had malignancy, 234 (44.8%) underwent bilateral mastectomy, and 350 (67.0%) underwent reconstruction. Caprini scores ranged from 2 to 11, with 431 (82.6%) patients having a score from 5 to 7. Overall protocol compliance was 60.5%, and was associated with bilateral mastectomy (p = 0.02), reconstruction (p = 0.03), and longer procedures (p < 0.001). The rate of VTE was 0.2% (95% confidence interval [CI] 0.03-1.1%), rate of reoperation for hematoma was 2.7% (95% CI 1.6-4.5%), and rate of blood transfusion was 0.4% (95% CI 0.1-1.4%).

Conclusions: The implementation of an individualized VTE prophylaxis protocol for patients undergoing mastectomy ± implant-based reconstruction is safe and feasible. Despite a high-risk cohort, the incidence of VTE was very low and bleeding complications were consistent with reported rates for breast surgery. Continued evaluation of this strategy is warranted.
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http://dx.doi.org/10.1245/s10434-018-6696-yDOI Listing
November 2018

Evidence-Based Clinical Practice Guideline: Autologous Breast Reconstruction with DIEP or Pedicled TRAM Abdominal Flaps.

Plast Reconstr Surg 2017 Nov;140(5):651e-664e

Boston, Mass.; Salt Lake City, Utah; New York, N.Y.; Arlington Heights, Ill.; Durham, N.C.; Chicago, Ill.; Phoenix, Ariz.; Tulsa, Okla.; Jacksonville, Fla.; Beverly Hills, Calif.; Southbury, Conn.; Baltimore, Md.; and Hamilton, Ontario, Canada.

The American Society of Plastic Surgeons commissioned a multistakeholder Work Group to develop recommendations for autologous breast reconstruction with abdominal flaps. A systematic literature review was performed and a stringent appraisal process was used to rate the quality of relevant scientific research. The Work Group assigned to draft this guideline was unable to find evidence of superiority of one technique over the other (deep inferior epigastric perforator versus pedicled transverse rectus abdominis musculocutaneous flap) in autologous tissue reconstruction of the breast after mastectomy. Presently, based on the evidence reported here, the Work Group recommends that surgeons contemplating breast reconstruction on their next patient consider the following: the patient's preferences and risk factors, the setting in which the surgeon works (academic versus community practice), resources available, the evidence shown in this guideline, and, equally important, the surgeon's technical expertise. Although theoretical superiority of one technique may exist, this remains to be reported in the literature, and future methodologically robust studies are needed.
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http://dx.doi.org/10.1097/PRS.0000000000003768DOI Listing
November 2017

Bilateral Free Flap Breast Reconstruction Outcomes: Do Abdominal Scars Affect Bilateral Flaps?

Plast Reconstr Surg Glob Open 2017 Sep 20;5(9):e1493. Epub 2017 Sep 20.

Brigham and Women's Hospital, Harvard Medical School, Boston, Mass.

Background: The incidence of bilateral mastectomies is increasing along with the rates of breast reconstructions. A substantial number of patients will present with abdominal scars after Cesarean section, laparoscopy, laparotomy, and so on. The aim of this study was to evaluate the impact of prior abdominal scars on complication rates in abdominal bilateral free flap breast reconstruction.

Methods: All consecutive patients with autologous free flap breast reconstruction between 2007 and 2014 were eligible. The relevant demographic and clinical data were prospectively collected into a study-specific database. Complications and reoperations were prospectively registered after postoperative outpatient visits.

Results: Overall, 493 patients underwent abdominally based breast reconstruction during the study period: unilateral (n = 250; 50.7%) or bilateral (n = 243; 49.3%). In the bilateral group, the abdominal scar locations were Pfannenstiel (n = 73; 30.1%), midline (n = 16; 6.6%), lower oblique (n = 17; 7.0%), upper oblique (n = 5; 2.1%), and laparoscopic (n = 69; 28.4%). Four (1.7%) flap failures (including 1 converted to a pedicled transverse rectus abdominis flap) were registered, all occurring in patients from the scar group: 3 with Pfannenstiel incision and 1 patient with prior laparoscopy. Pfannenstiel scar was associated with higher risk of hematoma at the recipient site when compared with no scar group (13.7% versus 2.2%; = 0.006). Partial flap necrosis, infection, and seroma occurred in 14 (5.9%), 8 (3.4%), and 5 (2.1%) patients, respectively, and no differences between the scar groups were identified.

Conclusion: Surgical outcomes of bilateral reconstructions in patients with abdominal scars are generally comparable with ones in patients without prior surgery; however, some problems have been identified. These procedures might have some intraoperative considerations and often require increased operative times. Apart from the traditional preoperative computed tomography angiography, intraoperative imaging (e.g., fluorescence angiography) may be advocated in patients with abdominal scars.
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http://dx.doi.org/10.1097/GOX.0000000000001493DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5640364PMC
September 2017

Selective Intraoperative Vasopressor Use Is Not Associated with Increased Risk of DIEP Flap Complications.

Plast Reconstr Surg 2017 Jul;140(1):70e-77e

Boston, Mass.

Background: During deep inferior epigastric perforator (DIEP) flap cases, anesthesiologists commonly avoid intravenous vasopressor administration because of the theoretical concern of inducing vasospasm, thrombosis, or congestion in the vessels of the anastomosis, potentially resulting in poor flap perfusion and ischemia and necessitating revision. In the setting of hypotension, however, vasopressor administration may actually improve outcomes by augmenting flap perfusion by means of increased mean arterial pressure.

Methods: The authors reviewed 475 consecutive DIEP flap cases in 333 patients at a single large academic medical center over a 3-year period, addressing potential confounders using univariate analyses.

Results: Ephedrine administration was significantly associated with decreased risk of intraoperative flap complications (OR, 0.88), including vasospasm, thrombosis, and congestion requiring revision, compared with controls, after controlling for the severity and duration of hypotension. Phenylephrine had no significant association with complication rates. Vasopressor administration was not associated with an increased risk of reoperation in the setting of necrosis within 60 days.

Conclusions: Ephedrine treatment for hypotension during DIEP flap cases is associated with decreased intraoperative flap complication rates compared with controls who did not receive vasopressors, whereas phenylephrine has no significant association. The common clinical practice of complete abstinence from vasopressors out of concern for worsening DIEP flap outcomes is not supported by this study.

Clinical Question/level Of Evidence: Therapeutic, III.
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http://dx.doi.org/10.1097/PRS.0000000000003444DOI Listing
July 2017

Impact of Prior Unilateral Chest Wall Radiotherapy on Outcomes in Bilateral Breast Reconstruction.

Plast Reconstr Surg 2016 Oct;138(4):575e-580e

Brasília, Brazil; Boston, Mass.; Baltimore, Md.; and New York, N.Y.

Background: The purpose of this study was to evaluate the impact of prior unilateral chest wall radiotherapy on reconstructive outcomes among patients undergoing bilateral immediate breast reconstruction.

Methods: A retrospective evaluation of patients with a history of unilateral chest wall radiotherapy was performed. In each patient, the previously irradiated and reconstructed breast was compared to the contralateral nonirradiated side, which served as an internal control. Descriptive and bivariate statistics were computed. Multiple regression statistics were computed to identify adjusted associations between chest wall radiotherapy and complications.

Results: Seventy patients were included in the study. The mean follow-up period was 51.8 months (range, 10 to 113 months). Thirty-eight patients underwent implant-based breast reconstruction; 32 patients underwent abdominal autologous flap reconstruction. Previously irradiated breast had a significantly higher rate of overall complications (51 percent versus 27 percent; p < 0.0001), infection (13 percent versus 6 percent; p = 0.026), and major skin necrosis (9 percent versus 3 percent; p = 0.046). After adjusting for age, body mass index, reconstruction method, and medical comorbidities, prior chest wall radiotherapy was a significant risk factor for breast-related complications (OR, 2.98; p < 0.0001), infection (OR, 2.59; p = 0.027), and major skin necrosis (OR, 3.47; p = 0.0266). There were no differences between implant-based and autologous reconstructions with regard to complications (p = 0.76).

Conclusion: Prior chest wall radiotherapy is associated with a 3-fold increased risk of postoperative complications following immediate breast reconstruction.

Clinical Question/level Of Evidence: Therapeutic, III.
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http://dx.doi.org/10.1097/PRS.0000000000002532DOI Listing
October 2016

Erratum: Development of Standardized Clinical Assessment and Management Plans (SCAMPs) in the Field of Plastic & Reconstructive Surgery: A Quality Improvement Project: Erratum.

Plast Reconstr Surg Glob Open 2016 Jul 8;4(7):e510. Epub 2016 Aug 8.

Division of Plastic Surgery, Brigham and Women's Hospital, Boston, Mass.; and Department of Medicine, Brigham and Women's Hospital, Boston, Mass.

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http://dx.doi.org/10.1097/GOX.0000000000000726DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4977117PMC
July 2016

Immediate breast reconstruction following mastectomy in pregnant women with breast cancer.

J Surg Oncol 2016 Aug 8;114(2):140-3. Epub 2016 Jul 8.

Dana-Farber/Brigham and Women's Cancer Center, Boston, Massachusetts.

Background: Surgical management of breast cancer in pregnancy (BCP) requires balancing benefits of therapy with potential risks to the developing fetus. Minimal data describe outcomes after mastectomy with immediate breast reconstruction (IR) in pregnant patients.

Methods: Retrospective review was performed of patients who underwent IR after mastectomy within a BCP cohort. Parameters included intra- and post-operative complications, short-term maternal/fetal outcomes, surgery duration, and delayed reconstruction in non-IR cohort.

Results: Of 82 patients with BCP, 29 (35%) had mastectomy during pregnancy: 10 (34%) had IR, 19(66%) did not. All IR utilized tissue expander (TE) placement. Mean gestational age (GA) at IR was 16.2 weeks. Mean surgery duration was 198 min with IR versus 157 min without IR. Those with IR delivered at, or close to, term infants of normal birthweight. No fetal or major obstetrical complications were seen. Post-mastectomy radiation (PMRT) was provided after pregnancy in 2 (20%) patients in the IR cohort and 12 (63%) in the non-IR cohort. All patients in the IR cohort successfully transitioned to permanent implant.

Conclusions: This report represents one of the largest series describing IR during BCP. IR after mastectomy increased surgery duration, but was not associated with adverse obstetrical or fetal outcomes. IR with TE may preserve reconstructive options when PMRT is indicated. J. Surg. Oncol. 2016;114:140-143. © 2016 Wiley Periodicals, Inc.
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http://dx.doi.org/10.1002/jso.24308DOI Listing
August 2016

Implementation of a Breast/Reconstruction Surgery Coordinator to Reduce Preoperative Delays for Patients Undergoing Mastectomy With Immediate Reconstruction.

J Oncol Pract 2016 Mar 16;12(3):e338-43. Epub 2016 Feb 16.

Brigham and Women's Hospital; and Dana-Farber Cancer Institute, Boston, MA.

Purpose: Mastectomy with immediate reconstruction (MIR) requires coordination between breast and reconstructive surgical teams, leading to increased preoperative delays that may adversely impact patient outcomes and satisfaction. Our cancer center established a target of 28 days from initial consultation with the breast surgeon to MIR. We sought to determine if a centralized breast/reconstructive surgical coordinator (BRC) could reduce care delays.

Methods: A 60-day pilot to evaluate the impact of a BRC on timeliness of care was initiated at our cancer center. All reconstructive surgery candidates were referred to the BRC, who had access to surgical clinic and operating room schedules. The BRC worked with both surgical services to identify the earliest surgery dates and facilitated operative bookings. The median time to MIR and the proportion of MIR cases that met the time-to-treatment goal was determined. These results were compared with a baseline cohort of patients undergoing MIR during the same time period (January to March) in 2013 and 2014.

Results: A total of 99 patients were referred to the BRC (62% cancer, 21% neoadjuvant, 17% prophylactic) during the pilot period. Focusing exclusively on patients with a cancer diagnosis, an 18.5% increase in the percentage of cases meeting the target (P = .04) and a 7-day reduction to MIR (P = .02) were observed.

Conclusion: A significant reduction in time to MIR was achieved through the implementation of the BRC. Further research is warranted to validate these findings and assess the impact the BRC has on operational efficiency and workflows.
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http://dx.doi.org/10.1200/JOP.2015.008672DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4960471PMC
March 2016

Anticoagulants and Statins As Pharmacological Agents in Free Flap Surgery: Current Rationale.

Eplasty 2015 20;15:e51. Epub 2015 Nov 20.

the Division of Plastic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass.

Microvascular free flaps are key components of reconstructive surgery, but despite their common use and usual reliability, flap failures still occur. Many pharmacological agents have been utilized to minimize risk of flap failure caused by thrombosis. However, the challenge of most antithrombotic therapy lies in providing patients with optimal antithrombotic prophylaxis without adverse bleeding effects. There is a limited but growing body of evidence suggesting that the vasoprotective and anti-inflammatory actions of statins can be beneficial for free flap survival. By inhibiting mevalonic acid, the downstream effects of statins include reduction of inflammation, reduced thrombogenicity, and improved vasodilation. This review provides a summary of the pathophysiology of thrombus formation and the current evidence of anticoagulation practices with aspirin, heparin, and dextran. In addition, the potential benefits of statins in the perioperative management of free flaps are highlighted.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4660317PMC
November 2015

Skin Excision as an Adjunctive Technique to Rhinoplasty in Middle-Aged and Elderly Patients.

Plast Reconstr Surg Glob Open 2015 Oct 9;3(10):e532. Epub 2015 Oct 9.

Division of Plastic Surgery, Brigham and Women's Hospital, Boston, Mass.

Rhinoplasty in middle-aged and elderly patients comes with its own set of challenges. There is relative lengthening of the nose with drooping of the nasal tip. With aging, the skin loses its elasticity, and the combination of nasal skeletal reduction along with overlying inelastic skin provides a setup for skin redundancy and poor postoperative outcome. We describe a surgical technique involving lenticular skin excision as a part of rhinoplasty in 12 patients older than 50 years to improve the aesthetic outcome. Skin width up to 1.6 cm was excised. Included is a literature review of skin excision in rhinoplasty. In elderly patients with thin, inelastic skin and long nose with a drooping tip, a reduction rhinoplasty technique might result in skin redundancy. Lenticular skin excision along the radix of the nose in these 12 patients improved the aesthetic outcome by decreasing the redundancy and preventing nasal tip ptosis. The wound from the skin resection healed in all the patients with minimal scar, and no complication was noted after at least 1 year of follow-up for each patient.
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http://dx.doi.org/10.1097/GOX.0000000000000509DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4634169PMC
October 2015

Does "Two is Better Than One" Apply to Surgeons? Comparing Single-Surgeon Versus Co-surgeon Bilateral Mastectomies.

Ann Surg Oncol 2016 Apr 29;23(4):1111-6. Epub 2015 Oct 29.

Department of Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, MA, USA.

Background: Bilateral mastectomies (BM) are traditionally performed by single surgeons (SS); a co-surgeon (CS) technique, where each surgeon concurrently performs a unilateral mastectomy, offers an alternative approach. We examined differences in general surgery time (GST), overall surgery time (OST), and patient complications for BM performed by CS and SS.

Methods: Patients undergoing BM with tissue expander reconstruction (BMTR) between January 2010 and May 2014 at our center were identified through operative case logs. GST (incision to end of BM procedure), reconstruction duration (RST) (plastic surgery start to end of reconstruction) and OST (OST = GST + RST) was calculated. Patient age, presence/stage of cancer, breast weight, axillary procedure performed, and 30-day postoperative complications were extracted from medical records. Differences in GST and OST between CS and SS cases were assessed with a t test. A multivariate linear regression was fit to identify factors associated with GST.

Results: A total of 116 BMTR cases were performed [CS, n = 67 (57.8 %); SS, n = 49 (42.2 %)]. Demographic characteristics did not differ between groups. GST and OST were significantly shorter for CS cases, 75.8 versus 116.8 min, p < .0001, and 255.2 versus 278.3 min, p = .005, respectively. Presence of a CS significantly reduces BMTR time (β = -38.82, p < .0001). Breast weight (β = 0.0093, p = .03) and axillary dissection (β = 28.69, p = .0003) also impacted GST.

Conclusions: The CS approach to BMTR reduced both GST and OST; however, the degree of time savings (35.1 and 8.3 %, respectively) was less than hypothesized. A larger study is warranted to better characterize time, cost, and outcomes of the CS-approach for BM.
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http://dx.doi.org/10.1245/s10434-015-4956-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4775338PMC
April 2016

Saved by De-epithelialization: DIEP Flap Dermal Skin Regeneration Salvage after Mastectomy Skin Flap Loss.

Plast Reconstr Surg Glob Open 2015 Sep 10;3(9):e511. Epub 2015 Sep 10.

Division of Plastic Surgery, Brigham and Women's Hospital, Boston, Mass.

Background: Wound re-epithelialization has been traditionally described to occur from the dermal appendages of the wound edges. As such, the role of the dermal wound bed in re-epithelialization has been questioned. In a patient undergoing breast reconstruction with free tissue transfer, the buried portions of the free flap skin paddle could be either de-epithelialized or deskinned. In case of mastectomy skin flap loss, the role of de-epithelialized skin in wound healing has not been described before.

Methods: We report a patient with bilateral mastectomies and bilateral deep inferior epigastric perforator flaps whose postoperative course was complicated by bilateral full-thickness mastectomy skin flap loss. Multiple debridements of nonviable skin resulted in exposure of previously buried de-epithelialized skin paddle of the deep inferior epigastric perforator flap.

Results: Our study demonstrates self re-epithelialization of the dermal wound bed from the dermal appendages. We noticed multiple noncontiguous neoepidermal islands in the dermal wound bed, which did not communicate with the wound edges.

Conclusions: In case of full-thickness mastectomy skin flap loss, deep vascular plexus present in the dermal bed of the underlying de-epithelialized skin paddle of the free flap converts an otherwise full-thickness wound to a partial-thickness wound. Our study demonstrates the self-epithelialization potential of the de-epithelialized dermal wound bed from the dermal appendages when exposed to air and in the presence of wound healing elements.
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http://dx.doi.org/10.1097/GOX.0000000000000466DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4596436PMC
September 2015

Development of Standardized Clinical Assessment and Management Plans (SCAMPs) in Plastic and Reconstructive Surgery.

Plast Reconstr Surg Glob Open 2015 Sep 9;3(9):e510. Epub 2015 Sep 9.

Division of Plastic Surgery, Brigham and Women's Hospital, Boston, Mass.; and Department of Medicine, Brigham and Women's Hospital, Boston, Mass.

Background: With rising cost of healthcare, there is an urgent need for developing effective and economical streamlined care. In clinical situations with limited data or conflicting evidence-based data, there is significant institutional and individual practice variation. Quality improvement with the use of Standardized Clinical Assessment and Management Plans (SCAMPs) might be beneficial in such scenarios. The SCAMPs method has never before been reported to be utilized in plastic surgery.

Methods: The topic of immediate breast reconstruction was identified as a possible SCAMPs project. The initial stages of SCAMPs development, including planning and implementation, were entered. The SCAMP Champion, along with the SCAMPs support team, developed targeted data statements. The SCAMP was then written and a decision-tree algorithm was built. Buy-in was obtained from the Division of Plastic Surgery and a SCAMPs data form was generated to collect data.

Results: Decisions pertaining to "immediate implant-based breast reconstruction" were approved as an acceptable topic for SCAMPs development. Nine targeted data statements were made based on the clinical decision points within the SCAMP. The SCAMP algorithm, and the SDF, required multiple revisions. Ultimately, the SCAMP was effectively implemented with multiple iterations in data collection.

Conclusions: Full execution of the SCAMP may allow better-defined selection criteria for this complex patient population. Deviations from the SCAMP may allow for improvement of the SCAMP and facilitate consensus within the Division. Iterative and adaptive quality improvement utilizing SCAMPs creates an opportunity to reduce cost by improving knowledge about best practice.
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http://dx.doi.org/10.1097/GOX.0000000000000504DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4596435PMC
September 2015

Use of Tumescence for Outpatient Abdominoplasty and Other Concurrent Body Contouring Procedures: A Review of 65 Consecutive Patients.

Eplasty 2015 1;15:e38. Epub 2015 Sep 1.

Division of Plastic Surgery, Brigham & Women's Hospital, Boston, Mass.

Introduction: Abdominoplasty is being increasingly performed as an outpatient procedure. The role of tumescent technique in decreasing postoperative pain and hospital stay has not been extensively studied.

Methods: We reviewed 65 consecutive patients who underwent tumescent abdominoplasty over 20 months by a single surgeon. All the patients were followed up for at least 1 year. The outcomes were evaluated in terms of systemic complications such as deep vein thrombosis and pulmonary embolism and local complications such as seroma, wound infection, and skin necrosis.

Results: Of the 65 patient records analyzed, 61 were of females and 4 of males. Average age for the patient population was 45.2 years. Mean follow-up was at least 1 year for all the patients. Ninety-five percent of patients could be discharged the same day with tumescent abdominoplasty, whereas 71% of the patients who underwent concurrent procedures with abdominoplasty were also able to go home the same day. All the patients reported excellent postoperative pain control. There was no report of deep vein thrombosis or pulmonary embolism in any of these patients. Wound complications occurred in 14 patients (21.6%), of which 12 patients had seroma (18.5%) and 2 had wound infection (3.1%). The seromas were treated with repeated aspirations or Jackson-Pratt drain placement, whereas the wound infections resolved with outpatient antibiotics.

Conclusions: The safety and efficiency of outpatient abdominoplasty can be further facilitated by utilizing tumescence. Tumescence helps the patients be discharged sooner, usually the same day, mobilize sooner, and rely less on oral narcotics at home.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4559067PMC
September 2015

Reconstruction of Areolar Projection Using a Purse-String Suture Technique.

Plast Reconstr Surg Glob Open 2015 Jul 10;3(7):e453. Epub 2015 Aug 10.

Division of Plastic Surgery, Brigham and Women's Hospital, Boston, Mass.

Background: Nipple-areolar complex creation is the last step in the breast reconstruction process and plays a significant role in patients' overall satisfaction. Although numerous surgical techniques have been described to create the nipple, very few procedures address the natural contour of the areola.

Methods: We describe a surgical technique using a purse-string suture for improved areolar projection. After creation of nipple-areolar complex using a CV flap, evenly spaced stab incisions are made in a circular pattern, approximately 5 mm outside of the boundary of the proposed areola. Using these incisions, a nonabsorbable purse-string suture is placed in the deep dermis. The diameter is cinched down to the desired measurement, providing areolar projection.

Results: Our experience using this technique has provided a satisfactory and stable projection of the areola in 10 patients with at least 1 year follow-up for each patient. There was no spitting of purse-string sutures in any of these patients, and there was no late areolar widening after at least 1 year follow-up. This provides a means for symmetry with an unreconstructed contralateral side.

Conclusions: Improving aesthetic outcomes for areola reconstruction may further refine our goals of an ideal breast reconstruction.
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http://dx.doi.org/10.1097/GOX.0000000000000431DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4527627PMC
July 2015

Evolving options for breast reconstruction.

Curr Probl Surg 2015 May 14;52(5):192-224. Epub 2015 Apr 14.

In summary, if the abdomen cannot be used for a donor site, alternative flap selection is based on individual patient anatomy and body habitus, targeting the buttocks and upper thigh. Intraoperative repositioning may be required for ease in flap harvest and donor site closure, adding time to the procedure. Flap dissection is performed in the subfascial plane to avoid injury to the perforator vessels. Deep suspension sutures may be required to maintain the gluteal fold location.
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http://dx.doi.org/10.1067/j.cpsurg.2015.04.001DOI Listing
May 2015

Bilateral synchronous benign phyllodes tumors.

Am Surg 2015 May;81(5):E192-4

Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts.

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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4477195PMC
May 2015

Discussion: Natrelle round silicone breast implants: core study results at 10 years.

Plast Reconstr Surg 2014 Jun;133(6):1362-1363

Boston, Mass. From the Division of Plastic Surgery, Brigham and Women's Hospital.

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http://dx.doi.org/10.1097/PRS.0000000000000167DOI Listing
June 2014

Why we are here: early reflections on the role of reconstructive plastic surgery in the 2013 Boston marathon bombings.

Plast Reconstr Surg 2013 Dec;132(6):1623-1627

Boston, Mass. From the Division of Plastic Surgery, Department of Surgery, Brigham & Women's Hospital, and Harvard Plastic Surgery Combined Residency Program.

The 2013 Boston Marathon bombings resulted in a large and unexpected influx of patients requiring acute multidisciplinary surgical care. The authors describe the surgical management experience of these patients at Brigham & Women's Hospital and Brigham & Women's Faulkner Hospital, with a particular focus on the important role played by reconstructive plastic surgery. The authors suggest that this experience illustrates the value of reconstructive plastic surgery in the treatment of these patients specifically and of trauma patients in general, and argue for the increasing importance of promoting our identity as a specialty.
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http://dx.doi.org/10.1097/PRS.0b013e3182a98054DOI Listing
December 2013

Functional MRI to evaluate "sense of self" following perforator flap breast reconstruction.

PLoS One 2012 27;7(11):e49883. Epub 2012 Nov 27.

Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.

Background: Breast reconstruction is associated with high levels of patient satisfaction. Previous patient satisfaction studies have been subjective. This study utilizes functional magnetic resonance imaging (fMRI) to objectively evaluate "sense of self" following deep inferior epigastric perforator (DIEP) flap breast reconstruction in an attempt to better understand patient perception.

Methods: Prospective fMRI analysis was performed on four patients before and after delayed unilateral DIEP flap breast reconstruction, and on four patients after immediate unilateral DIEP flap breast reconstruction. Patients were randomly cued to palpate their natural breast, mastectomy site or breast reconstruction, and external silicone models. Three regions of interest (ROIs) associated with self-recognition were examined using a general linear model, and compared using a fixed effects and random effects ANOVA, respectively.

Results: In the delayed reconstruction group, activation of the ROIs was significantly lower at the mastectomy site compared to the natural breast (p<0.01). Ten months following reconstruction, activation of the ROIs in the reconstructed breast was not significantly different from that observed with natural breast palpation. In the immediate reconstruction group, palpation of the reconstructed breast was also similar to the natural breast. This activity was greater than that observed during palpation of external artificial models (p<0.01).

Conclusions: Similar activation patterns were observed during palpation of the reconstructed and natural breasts as compared to the non-reconstructed mastectomy site and artificial models. The cognitive process represented by this pattern may be a mechanism by which breast reconstruction improves self-perception, and thus patient satisfaction following mastectomy.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0049883PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3507931PMC
June 2013

Three patients with full facial transplantation.

N Engl J Med 2012 Feb 28;366(8):715-22. Epub 2011 Dec 28.

Department of Surgery, Division of Plastic Surgery, Brigham and Women's Hospital, Boston, MA 02115, USA.

Unlike conventional reconstruction, facial transplantation seeks to correct severe deformities in a single operation. We report on three patients who received full-face transplants at our institution in 2011 in operations that aimed for functional restoration by coaptation of all main available motor and sensory nerves. We enumerate the technical challenges and postoperative complications and their management, including single episodes of acute rejection in two patients. At 6 months of follow-up, all facial allografts were surviving, facial appearance and function were improved, and glucocorticoids were successfully withdrawn in all patients.
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http://dx.doi.org/10.1056/NEJMoa1111432DOI Listing
February 2012

Metastatic breast cancer after delayed deep inferior epigastric perforator flap reconstruction.

Ann Plast Surg 2011 Mar;66(3):233-4

Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA.

Locoregional breast cancer recurrence is a relatively rare event, occurring more frequently in patients diagnosed with more advanced stages of cancer and those with inflammatory features. While typical signs of recurrence after reconstruction include the development of a mass in the native skin or deep chest wall, oncologic relapse may also rarely be heralded by subtle cutaneous changes. This article describes a patient with inflammatory breast cancer who underwent neoadjuvant chemotherapy, mastectomy, radiation therapy, and hormonal therapy followed by delayed reconstruction with a deep inferior epigastric artery perforator flap and subsequently presented with a recurrence manifest as a localized rash over the upper abdomen. Surgeons who perform breast reconstruction should be attuned to both common and uncommon recurrence symptoms, as they may be the first to diagnose recrudescent disease.
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http://dx.doi.org/10.1097/SAP.0b013e3181ee70b2DOI Listing
March 2011

CASE REPORT Superior Gluteal Artery Perforator Flap Breast Reconstruction Salvage Following Late Venous Congestion After Discharge.

Eplasty 2010 Oct 13;10:e63. Epub 2010 Oct 13.

Objective: Microvascular thrombosis is a dreaded complication of free tissue transfer, especially in breast reconstruction. Failure often leads to complete loss of the reconstruction and affects the patient both physically and psychologically. Fortunately, most vascular compromises occur early (within 24-36 hours) while the patient is still in the hospital and intervention takes place prior to irreversible thrombosis of the microvasculature. However, failures beyond 96 hours generally have dismal prognosis, especially because the patient is already home.

Methods: A case of successful salvage is reported after an uncomplicated superior gluteal artery perforator flap performed for breast reconstruction returned from home with thrombosis of the venous pedicle the morning of postoperative day 5.

Results: The pedicle was promptly explored and the venous patency reestablished using a combination of mechanical and chemical thrombolysis. At her 2-year follow-up, there was no evidence of fat necrosis and a satisfactory aesthetic outcome was achieved.

Conclusion: Late salvage of failing free flap breast reconstruction from home is possible. Educating the patient on importance of self-examination is critical to salvage. The hospital system also needs to have the resources to handle such emergencies in order for rapid operative mobilization to expedite the patient's care.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2955459PMC
October 2010

Pyoderma gangrenosum following bilateral deep inferior epigastric perforator flap breast reconstruction.

J Reconstr Microsurg 2010 Sep 9;26(7):475-9. Epub 2010 Jun 9.

Division of Plastic Surgery, Brigham and Women's Hospital, Beth Israel Deaconess Medical Center, Boston, Massachusetts 02215, USA.

Pyoderma gangrenosum (PG) is a relatively rare condition of ulcerative cutaneous dermatosis. Usually seen in the setting of systemic inflammatory disease, PG can be difficult to distinguish from infection. We present a case of an otherwise healthy 37-year-old woman, a BRCA-1 gene mutation carrier, who was evaluated several months after bilateral mastectomies with deep inferior epigastric perforator (DIEP) flap breast reconstruction with open wounds on the right DIEP flap. Multiple interventions were employed without success. As the disease progressed, the patient eventually developed new open wounds on the left DIEP flap as well. Ultimately, rigorous dermatopathology evaluation revealed PG, and the patient was treated appropriately with a high-dose prednisone course. The wounds healed completely, and despite significant cutaneous scarring, the breast reconstructions were salvaged. There was no fat necrosis within the DIEP flap tissue itself. PG should be considered in the differential diagnosis of chronic nonhealing cutaneous ulcers following surgical intervention that do not respond to standard initial care.
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http://dx.doi.org/10.1055/s-0030-1261699DOI Listing
September 2010

Case report. The use of both antegrade and retrograde internal mammary vessels in a folded, stacked deep inferior epigastric artery perforator flap.

Eplasty 2010 Apr 30;10:e32. Epub 2010 Apr 30.

Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA 02445, USA.

Objective: Deep inferior epigastric artery perforator (DIEP) flap is an excellent option for breast reconstruction in young and active patients who have a history of chest wall radiation. One drawback, however, is that the entire capacity of abdominal pannus cannot be reliably transferred on a single pedicle. The purpose of this case report is to demonstrate a method of maximizing the volume of reconstruction with a dual-pedicled DIEP flap.

Methods: A case is reported in which both antegrade and retrograde internal mammary vessels were used as recipient sites for a dual-pedicled, folded, stacked DIEP flap.

Results: Good flows were observed in both sets of recipient vessels intraoperatively. Postoperative imaging revealed patent vascular anastomoses of both pedicles. At 1-year follow-up, there was no evidence of fat necrosis and a satisfactory aesthetic outcome was achieved.

Conclusion: To maximize the volume of the reconstructed breast, the entire abdominal pannus can be utilized. The retrograde limb of internal mammary vessels can act as the recipient site for the second pedicle, minimizing donor site morbidity.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2864064PMC
April 2010

Regeneration in medicine: a plastic surgeons "tail" of disease, stem cells, and a possible future.

Birth Defects Res C Embryo Today 2008 Dec;84(4):322-34

Division of Plastic Surgery, Harvard Medical School, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA.

Regeneration in medicine is a concept that has roots dating back to the earliest known records of medical interventions. Unfortunately, its elusive promise has still yet to become a reality. In the field of plastic surgery, we use the common tools of the surgeon grounded in basic operative principles to achieve the present day equivalent of regenerative medicine. These reconstructive efforts involve a broad range of clinical deformities, both congenital and acquired. Outlined in this review are comments on clinical conditions and the current limitations to reconstruct these clinical entities in the effort to practice regenerative medicine. Cleft lip, microtia, breast reconstruction, and burn reconstruction have been selected as examples to demonstrate the incredible spectrum and diverse challenges that plastic surgeons attempt to reconstruct. However, on a molecular level, these vastly different clinical scenarios can be unified with basic understanding of development, alloplastic integration, wound healing, cell-cell, and cell-matrix interactions. The themes of current and future molecular efforts involve coalescing approaches to recapitulate normal development in clinical scenarios when reconstruction is needed. It will be a better understanding of stem cells, scaffolding, and signaling with extracellular matrix interactions that will make this future possible. Eventually, reconstructive challenge will utilize more than the current instruments of surgical steel but engage complex interventions at the molecular level to sculpt true regeneration. Immense amounts of research are still needed but there is promise in the exploding fields of tissue engineering and stem cell biology that hint at great opportunities to improve the lives of our patients.
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http://dx.doi.org/10.1002/bdrc.20139DOI Listing
December 2008