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BACKGROUND: Breast cancer-related lymphedema is a devastating condition that negatively affects the quality of life of breast cancer survivors. We sought to identify risk factors that predicted the timing and development of lymphedema. METHODS: Women with breast cancer that underwent sentinel lymph node biopsy (SLNB) or axillary lymph node dissection (ALND) at our institution between 2007 and 2022 were identified and sociodemographic and clinical information was extracted. We used logistic regression analysis to identify risk factors for lymphedema and performed cox-regression analysis to predict the timing of lymphedema presentation after surgery. RESULTS: We identified 1,223 patients, of which 161 (13.2%) developed lymphedema within 1.8 (mean, SD = 2.5) years postoperatively. Patients with SLNB had significantly lower odds for lymphedema development (vs. ALND, OR = 0.29 [0.14-0.57]). Patients between 40 and 49 years of age, and 50-59 (vs. <40 years, OR = 2.14 [1.00-4.60]; OR = 2.42, [1.13-5.16] respectively), African American patients (vs. Caucasian, OR = 1.86 [1.12-3.09]), patients with stage II, III, and IV disease (vs. stage 0, OR = 3.75 [1.36-10.33]; OR = 6.62 [2.14-20.51]; OR = 9.36 [2.94-29.81]), and patients with Medicaid (vs. private insurance, OR = 3.56 [1.73-7.28]) had higher rates of lymphedema. Cox-regression analysis showed that African American (HR = 1.71 [1.08-2.70]), higher BMI (HR = 1.03 [1.00-1.06]), higher stage (stage II, HR = 2.22 [1.05-7.09]; stage III, HR = 5.26 [1.86-14.88]; stage IV, HR = 6.13 [2.12-17.75]), and Medicaid patients (HR = 2.15 [1.12-3.80]) had higher hazards for lymphedema. Patients with SLNB had lower hazards for lymphedema (HR = 0.43 [0.87-2.11]). CONCLUSION: Lymphedema has identifiable risk factors that can reliably be used to predict the chances of lymphedema development and enable clinicians to educate patients better and formulate treatment plans accordingly. LEVEL OF EVIDENCE: III (Retrospective study).
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Background: Immuno-oncology (IO) therapies targeting the PD-1/PD-L1 axis, such as immune checkpoint inhibitor (ICI) antibodies, have emerged as promising treatments for early-stage breast cancer (ESBC). Despite immunotherapy's clinical significance, the number of benefiting patients remains small, and the therapy can prompt severe immune-related events. Current pathologic and transcriptomic predictions of IO response are limited in terms of accuracy and rely on single-site biopsies, which cannot fully account for tumor heterogeneity. In addition, transcriptomic analyses are costly and time-consuming. We therefore constructed a computational biomarker coupling biophysical simulations and artificial intelligence-based tissue segmentation of dynamic contrast-enhanced magnetic resonance imaging (DCE-MRIs), enabling IO response prediction across the entire tumor. Methods: By analyzing both single-cell and whole-tissue RNA-seq data from non-IO-treated ESBC patients, we associated gene expression levels of the PD-1/PD-L1 axis with local tumor biology. PD-L1 expression was then linked to biophysical features derived from DCE-MRIs to generate spatially- and temporally-resolved atlases (virtual tumors) of tumor biology, as well as the TumorIO biomarker of IO response. We quantified TumorIO within patient virtual tumors (n = 63) using integrative modeling to train and develop a corresponding TumorIO Score. Results: We validated the TumorIO biomarker and TumorIO Score in a small, independent cohort of IO-treated patients (n = 17) and correctly predicted pathologic complete response (pCR) in 15/17 individuals (88.2% accuracy), comprising 10/12 in triple negative breast cancer (TNBC) and 5/5 in HR+/HER2- tumors. We applied the TumorIO Score in a virtual clinical trial (n = 292) simulating ICI administration in an IO-naïve cohort that underwent standard chemotherapy. Using this approach, we predicted pCR rates of 67.1% for TNBC and 17.9% for HR+/HER2- tumors with addition of IO therapy; comparing favorably to empiric pCR rates derived from published trials utilizing ICI in both cancer subtypes. Conclusion: The TumorIO biomarker and TumorIO Score represent a next generation approach using integrative biophysical analysis to assess cancer responsiveness to immunotherapy. This computational biomarker performs as well as PD-L1 transcript levels in identifying a patient's likelihood of pCR following anti-PD-1 IO therapy. The TumorIO biomarker allows for rapid IO profiling of tumors and may confer high clinical decision impact to further enable personalized oncologic care.
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BACKGROUND: Generalizable population-based studies are unable to account for individual tumor heterogeneity that contributes to variability in a patient's response to physician-chosen therapy. Although molecular characterization of tumors has advanced precision medicine, in early-stage and locally advanced breast cancer patients, predicting a patient's response to neoadjuvant therapy (NAT) remains a gap in current clinical practice. Here, we perform a study in an independent cohort of early-stage and locally advanced breast cancer patients to forecast tumor response to NAT and assess the stability of a previously validated biophysical simulation platform. METHODS: A single-blinded study was performed using a retrospective database from a single institution (9/2014-12/2020). Patients included: ≥ 18 years with breast cancer who completed NAT, with pre-treatment dynamic contrast enhanced magnetic resonance imaging. Demographics, chemotherapy, baseline (pre-treatment) MRI and pathologic data were input into the TumorScope Predict (TS) biophysical simulation platform to generate predictions. Primary outcomes included predictions of pathological complete response (pCR) versus residual disease (RD) and final volume for each tumor. For validation, post-NAT predicted pCR and tumor volumes were compared to actual pathological assessment and MRI-assessed volumes. Predicted pCR was pre-defined as residual tumor volume ≤ 0.01 cm3 (≥ 99.9% reduction). RESULTS: The cohort consisted of eighty patients; 36 Caucasian and 40 African American. Most tumors were high-grade (54.4% grade 3) invasive ductal carcinomas (90.0%). Receptor subtypes included hormone receptor positive (HR+)/human epidermal growth factor receptor 2 positive (HER2+, 30%), HR+/HER2- (35%), HR-/HER2+ (12.5%) and triple negative breast cancer (TNBC, 22.5%). Simulated tumor volume was significantly correlated with post-treatment radiographic MRI calculated volumes (r = 0.53, p = 1.3 × 10-7, mean absolute error of 6.57%). TS prediction of pCR compared favorably to pathological assessment (pCR: TS n = 28; Path n = 27; RD: TS n = 52; Path n = 53), for an overall accuracy of 91.2% (95% CI: 82.8% - 96.4%; Clopper-Pearson interval). Five-year risk of recurrence demonstrated similar prognostic performance between TS predictions (Hazard ratio (HR): - 1.99; 95% CI [- 3.96, - 0.02]; p = 0.043) and clinically assessed pCR (HR: - 1.76; 95% CI [- 3.75, 0.23]; p = 0.054). CONCLUSION: We demonstrated TS ability to simulate and model tumor in vivo conditions in silico and forecast volume response to NAT across breast tumor subtypes.
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Neoplasias de la Mama , Neoplasias de la Mama Triple Negativas , Humanos , Femenino , Neoplasias de la Mama/diagnóstico por imagen , Neoplasias de la Mama/tratamiento farmacológico , Terapia Neoadyuvante/métodos , Estudios Retrospectivos , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéutico , Neoplasias de la Mama Triple Negativas/diagnóstico por imagen , Neoplasias de la Mama Triple Negativas/tratamiento farmacológico , Pronóstico , Receptor ErbB-2/análisisRESUMEN
OBJECTIVE: We developed an application (https://rush-covid19.herokuapp.com/) to aid US hospitals in planning their response to the ongoing Coronavirus Disease 2019 (COVID-19) pandemic. MATERIALS AND METHODS: Our application forecasts hospital visits, admits, discharges, and needs for hospital beds, ventilators, and personal protective equipment by coupling COVID-19 predictions to models of time lags, patient carry-over, and length-of-stay. Users can choose from 7 COVID-19 models, customize 23 parameters, examine trends in testing and hospitalization, and download forecast data. RESULTS: Our application accurately predicts the spread of COVID-19 across states and territories. Its hospital-level forecasts are in continuous use by our home institution and others. DISCUSSION: Our application is versatile, easy-to-use, and can help hospitals plan their response to the changing dynamics of COVID-19, while providing a platform for deeper study. CONCLUSION: Empowering healthcare responses to COVID-19 is as crucial as understanding the epidemiology of the disease. Our application will continue to evolve to meet this need.
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Fístula Bronquial/cirugía , Fístula Cutánea/cirugía , Empiema Pleural/cirugía , Colgajo Miocutáneo/trasplante , Procedimientos de Cirugía Plástica/métodos , Toracotomía/efectos adversos , Anciano , Femenino , Humanos , Enfermedad Iatrogénica , Masculino , Persona de Mediana Edad , Músculos Pectorales/trasplante , Pronóstico , Músculos Superficiales de la Espalda/trasplante , Toracotomía/métodos , Resultado del Tratamiento , Cicatrización de Heridas/fisiologíaRESUMEN
BACKGROUND: Direct-to-implant breast reconstruction offers the intuitive advantages of shortening the reconstructive process and reducing costs. In the authors' practice, direct-to-implant breast reconstruction has evolved from dual-plane to prepectoral implant placement. The authors sought to understand postoperative complications and aesthetic outcomes and identify differences in the dual-plane and prepectoral direct-to-implant subcohorts. METHODS: A retrospective review of a prospectively maintained database was conducted from November of 2014 to March of 2018. Postoperative complication data, reoperation, and aesthetic outcomes were reviewed. Aesthetic outcomes were evaluated by a blinded panel of practitioners using standardized photographs. RESULTS: One hundred thirty-four direct-to-implant reconstructions were performed in 81 women: 42.5 percent were dual-plane (n = 57) and 57.5 percent were prepectoral (n = 77). Statistical analysis was limited to patients with at least 1 year of follow-up. Total complications were low overall (8 percent), although the incidence of prepectoral complications [n = 1 (2 percent)] was lower than the incidence of dual-plane complications [n = 7 (12 percent)], with the difference approaching statistical significance (p = 0.07). Panel evaluation for aesthetic outcomes favored prepectoral reconstruction. Pectoralis animation deformity was completely eliminated in the prepectoral cohort. CONCLUSIONS: The authors present the largest comparative direct-to-implant series using acellular dermal matrix to date. Transition to prepectoral direct-to-implant reconstruction has not resulted in increased complications, degradation of aesthetic results, or an increase in revision procedures. Prepectoral reconstruction is a viable reconstructive option with elimination of animation deformity and potential for enhanced aesthetic results. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.
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Dermis Acelular , Implantación de Mama/métodos , Implantes de Mama , Neoplasias de la Mama/cirugía , Adulto , Implantación de Mama/efectos adversos , Neoplasias de la Mama/patología , Estudios de Cohortes , Bases de Datos Factuales , Estética , Femenino , Humanos , Mastectomía/métodos , Persona de Mediana Edad , Músculos Pectorales/cirugía , Cuidados Posoperatorios/métodos , Falla de Prótesis , Estudios Retrospectivos , Medición de Riesgo , Factores de Tiempo , Cicatrización de Heridas/fisiologíaRESUMEN
BACKGROUND: Prepectoral direct-to-implant breast reconstruction has historically been fraught with complications, including flap necrosis, implant extrusion, and capsular contracture, along with high rates of operative revisions. This may result from a number of factors, including the lack of an algorithmic approach, failure to predict postoperative migration of the implant, use of improper implants, and unsuitable patient selection. Over the past 5 years, the authors have gained significant experience in prepectoral breast reconstruction as they have transitioned their direct-to-implant technique. METHODS: Using video, technical aspects for achieving superior results are demonstrated, including suture technique, application of acellular dermal matrix, creation of the implant pocket, implant selection and placement, and postoperative dressings. Video is used to highlight technical aspects to yield consistent, predictable results using the anterior tenting technique. RESULTS: A systematic review of prepectoral direct-to-implant breast reconstruction was conducted to amalgamate the experience of the authors and others with regard to technique, material, and outcomes. CONCLUSIONS: Prepectoral direct-to-implant breast reconstruction represents a significant paradigm shift in postmastectomy breast reconstruction and warrants reconsideration. Prepectoral direct-to-implant breast reconstruction provides the potential benefits of a single-stage operation, elimination of dynamic deformity, enhanced aesthetic outcomes, and increased patient satisfaction. Although early evidence suggests an increased incidence of complications, our experience and that of others demonstrate favorable outcomes with version 2.0 of prepectoral direct-to-implant breast reconstruction. As the body of literature encompassing a modern approach to prepectoral direct-to-implant breast reconstruction grows, greater appreciation for operative technique, candidate selection, and implant choice may accelerate its adoption and mitigate past concerns.
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Implantación de Mama/métodos , Neoplasias de la Mama/cirugía , Mastectomía/efectos adversos , Complicaciones Posoperatorias/epidemiología , Colgajos Quirúrgicos/trasplante , Dermis Acelular , Vendajes , Implantación de Mama/efectos adversos , Implantación de Mama/instrumentación , Implantes de Mama/efectos adversos , Protocolos Clínicos , Estética , Femenino , Humanos , Satisfacción del Paciente , Selección de Paciente , Músculos Pectorales/cirugía , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/prevención & control , Pronóstico , Resultado del TratamientoRESUMEN
BACKGROUND: Given the current trends in skin preservation during mastectomy, improved biofilm reduction algorithms, and advancements in tissue bioengineering and perfusion assessment, acellular dermal matrix (ADM)-reinforced single stage, direct to implant insertion in the pre-pectoral space has become a viable alternative to two-stage expander-based, sub-pectoral reconstruction. METHODS: The authors performed a retrospective review of their pre-pectoral cases evaluating outcomes for all single stage, direct to implant procedures. Outcomes reviewed included hematoma, seroma, infection, device loss or change, animation deformity and revisional procedures such as fat grafting. The anterior tenting surgical technique is also reviewed. RESULTS: The authors have carried out 305 direct to implant pre-pectoral breast reconstructions using an anterior tenting technique with low complication rates and superior clinical and functional outcomes. The benefits of this technique include less patient discomfort, no need for postoperative expansion, virtually no subjective negative impact on upper extremity function and elimination of animation deformity. Longer-term follow-up demonstrates maintenance of the integrity and quality of the reconstructions over time. CONCLUSIONS: The authors consider single stage, pre-pectoral direct to implant breast reconstruction to be a state-of-the-art breast reconstruction technique and have found it to be safe and reproducible. This technique is their primary choice for immediate implant-based reconstruction following mastectomy.
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While neck dissection is an important primary and adjunctive procedure in the treatment of head and neck cancer, there is a paucity of studies evaluating outcomes. A retrospective review of the National Surgical Quality Improvement Program (NSQIP) database was performed to identify factors associated with adverse events (AEs) in patients undergoing neck dissection. A total of 619 patients were identified, using CPT codes specific to neck dissection. Of the 619 patients undergoing neck dissection, 142 (22.9%) experienced an AE within 30 days of the surgical procedure. Risk factors on multivariate regression analysis associated with increased AEs included dyspnea (odds ratio [OR] 2.57; 95% confidence interval [CI] 1.06 to 6.22; p = 0.037), previous cardiac surgery (OR 3.38; 95% CI 1.08 to 10.52; p = 0.036), increasing anesthesia time (OR 1.005; 95% CI 1 to 1.009; p = 0.036), and increasing total work relative value units (OR 1.09; CI 1.04 to 1.13; p < 0.001). The current study is the largest, most robust analysis to identify specific risk factors associated with AEs after neck dissection. This information will assist with preoperative optimization, patient counseling, and appropriate risk stratification, and it can serve as benchmarking for institutions comparing surgical outcomes.
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Neoplasias de Cabeza y Cuello/cirugía , Disección del Cuello/efectos adversos , Complicaciones Posoperatorias/etiología , Anciano , Anciano de 80 o más Años , Anestesia/efectos adversos , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Bases de Datos Factuales , Disnea/complicaciones , Femenino , Humanos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Disección del Cuello/normas , Tempo Operativo , Mejoramiento de la Calidad , Análisis de Regresión , Estudios Retrospectivos , Factores de RiesgoRESUMEN
Previous studies have investigated reconstructive decisions after mastectomy and such studies document a preference among African American women for autologous tissue-based procedures and among Latin American women for implant-based reconstructions, however, there is a paucity of studies evaluating the current relationship between ethnicity and reconstructive preferences. This institutional review provides a unique, up-to-date evaluation of an understudied urban population composed of majority ethnic minority patients and explores reconstructive trends. Consecutive breast reconstruction patients were entered into a prospectively maintained database at the University of Illinois at Chicago and affiliate hospitals between July 2010 and October 2013. Demographics and oncologic characteristics including tumor stage, pathology, BRCA status, and adjuvant treatment were reviewed, and reconstructive trends were assessed by racial group with a focus on reconstructive procedure, mastectomy volume, and implant characteristics. Statistical analysis was performed using SAS (version 9.2). One-hundred and sixty breast reconstructions were performed in 105 women; of which 50 per cent were African American, 26 per cent Hispanic, 22 per cent Caucasian, and 2 per cent Asian. Age, tumor stage, prevalence of triple negative disease, chemotherapy, and radiation treatment was comparable between groups. Rates of obesity, hypertension, and diabetes mellitus were slightly higher in African American and Hispanic cohorts, with more African American patients having one or more of these comorbidities as compared with the Caucasian and Hispanic cohorts (P = 0.047). Despite comparable positive BRCA testing rates, significant differences were seen in the percentage of bilateral mastectomy; 68 per cent African American, 48 per cent Caucasian, and 30 per cent Hispanic (P = 0.004). Hispanics predominantly underwent flap-based reconstruction (56%), while African American (74%) and Caucasian (60%) patients had a preference toward tissue expander reconstruction (P = 0.04 across all groups). African American and Hispanic presented with increased mastectomy weights and thus required higher implant volumes as compared with Caucasians that approached significance (P = 0.06 and P = 0.06). Implant size utilization followed a unimodal distribution for Caucasians, peaking at 500 cc; while African American and Hispanic demonstrated a bimodal distribution, peaking once at 550 cc and again at the max implant volume of 800 cc. This study of a large proportion of minority patients in an urban geographic setting offers an evolving understanding of breast reconstruction patterns. The data demonstrated unique findings of increased rates of bilateral implant-based reconstruction in African American women and unilateral flap-based reconstructions in Hispanic patients. Reconstructive decision-making seems to be greatly influenced by cultural and geographically driven preferences.
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Neoplasias de la Mama/etnología , Etnicidad/estadística & datos numéricos , Mamoplastia/estadística & datos numéricos , Grupos Minoritarios/estadística & datos numéricos , Población Urbana/estadística & datos numéricos , Población Blanca/estadística & datos numéricos , Implantes de Mama , Neoplasias de la Mama/cirugía , Femenino , Humanos , Mastectomía/estadística & datos numéricos , Persona de Mediana Edad , Prioridad del Paciente/etnologíaRESUMEN
Hidradenitis suppurativa (HS) is characterized by chronic inflammation, recurrent abscesses, and scarring. Surgery is performed when medical management and antibiotic therapy fails. This study sought to evaluate the demographics, surgical procedures, bacteriology, pharmacologic intervention, and quality of life of patients with recalcitrant HS requiring surgical intervention. A retrospective chart review was performed of 76 recalcitrant HS patients at the University of Illinois Medical Center. Patient demographics, bacterial culture, and surgery data were reviewed. Quality of life was assessed using the 36-item short-form health survey. Patients were mostly female (73.7%) and African American (81.6%) with a mean duration of symptoms of 8.6 years before surgery. Patients underwent at least one surgical procedure, most often to the axillae (57.6%) and 73.7 per cent received antibiotics. The most common culture isolates were Corynebacterium species (14.0%), Staphylococcus epidermidis (13.1%), and Staphylococcus aureus (10.4%) with varying resistance patterns. Surveyed patients had depressed 36-item short-form health survey physical functioning and social functioning scores. Recalcitrant HS patients with progressive symptomology over approximately nine years before surgical intervention were more likely to be African American women with axillary HS. Quality of life was diminished. We recommend initial treatment of HS with clindamycin and trimethoprim-sulfamethoxazole in clindamycin refractory cases.
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Infecciones por Corynebacterium , Hidradenitis Supurativa , Infecciones Estafilocócicas , Adolescente , Adulto , Negro o Afroamericano , Anciano , Antibacterianos/uso terapéutico , Axila/cirugía , Terapia Combinada , Infecciones por Corynebacterium/diagnóstico , Infecciones por Corynebacterium/etnología , Infecciones por Corynebacterium/terapia , Demografía , Femenino , Hidradenitis Supurativa/diagnóstico , Hidradenitis Supurativa/etnología , Hidradenitis Supurativa/microbiología , Hidradenitis Supurativa/terapia , Humanos , Illinois/epidemiología , Masculino , Persona de Mediana Edad , Evaluación del Resultado de la Atención al Paciente , Calidad de Vida , Estudios Retrospectivos , Infecciones Estafilocócicas/diagnóstico , Infecciones Estafilocócicas/etnología , Infecciones Estafilocócicas/terapia , Adulto JovenRESUMEN
Breast reconstruction is an important aspect of treatment after breast cancer. Postmastectomy reconstruction bears a significant impact on a woman's postsurgical confidence, sexuality, and overall well-being. Previous studies have inferred that women under age 40 years have unique characteristics that distinguish them from an older cohort. Identifying age-dependent trends will assist with counseling women on mastectomy and reconstruction. To identify age-dependent trends, 100 consecutive women were sampled from a prospectively maintained breast reconstruction database at an urban academic institution from June 2010 through June 2013. Women were placed into two cohorts <40 and ≥40 as well cohorts by decade (20s, 30s, 40s, 50s, and 60s). Statistical trends were reported as odds of risk per year of increasing age using logistic regression; linear regression, χ(2), and Fischer's exact were used to compare <40 and ≥40 and split cohorts for comparison. Comorbidities, tumor staging, oncologic treatment including chemotherapy and radiation, disease characteristics and genetics, and mastectomy, reconstructive and symmetry procedures were evaluated. Statistical analysis was performed using SAS software. In 100 patients of the sample study cohort, 151 reconstructions were performed. Increasing age was associated with one or more comorbidities [odds ratio (OR) = 1.07, P = 0.005], whereas younger age was associated with metastatic disease (OR = 0.88, P = 0.006), chemotherapy (OR = 0.94, P = 0.01), and radiation (OR = 0.94, P = 0.006); split cohorts demonstrated similar trends (P < 0.005). Mastectomy and reconstructive characteristics associated with younger age included bilateral mastectomy (OR = 0.94, P = 0.004), tissue expander (versus autologous flap) (OR = 0.94, P = 0.009), extra high implant type (OR = 0.94, P = 0.049), whereas increasing use of autologous flaps and contralateral mastopexy symmetry procedures (OR = 1.09, P = 0.02) were associated with an aging cohort. Increasing age was not associated with an increasing likelihood of complications (P = 0.75). Age-related factors play a role in the treatment of patients with breast cancer. Younger women typically present with more aggressive features requiring oncologic treatment including chemotherapy and radiation. Mastectomy and reconstructive choices also demonstrate age-dependent characteristics. Women in younger age groups are more likely to pursue risk-reduction procedures and implant-based strategies, whereas older women had a higher propensity for abdominal-based autologous reconstruction. In addition, preferential reconstructive strategies correlate with age-dependent archetypical features of the breast (higher profile implants in younger patients; autologous reconstruction on affected side mimicking natural ptosis, and contralateral mastopexy in older patients). These trends seem to be consistent with each increasing year of age. Age-related preferences and expectations, age-dependent body habitus and breast shape, and lifetime risk play a role in the choices pursued for mastectomy and reconstruction.
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Neoplasias de la Mama/cirugía , Mamoplastia/tendencias , Mastectomía , Adulto , Factores de Edad , Femenino , Hospitales de Enseñanza , Hospitales Urbanos , Humanos , Persona de Mediana Edad , Adulto JovenRESUMEN
BACKGROUND: Parry-Romberg syndrome (PRS) is a rare craniofacial disease that causes progressive hemifacial atrophy of the soft tissue before spontaneously entering remission. Autologous fat grafting may provide a less invasive alternative, producing aesthetically pleasing results while avoiding the need for traditional microsurgical free flap coverage. METHODS: A systematic review of the literature was conducted. Inclusion and exclusion criteria were applied. The case report highlights the technique using two-dimensional and three-dimensional photography. RESULTS: Our review yielded 31 articles in addition to our case describing 147 cases of lipofilling to correct PRS soft-tissue defects. Patients underwent an average of 2.2 procedures, receiving on average 95 mL of grafted fat. Disease severity was classified into mild (41%), moderate (42%), and severe (17%) in the identified patients. Increasing disease severity correlated with an increasing number of procedures and fat-grafting volumes to achieve adequate aesthetic outcomes (mean, 1.5 and 38 mL; 2.3 and 81 mL; 3.7 and 129 mL, respectively). Reported benefits over flap-based reconstructions included reductions in cost (40%), operative time (50%), donor-site morbidity (52%), and rate of complications (33%). Aesthetic benefits cited included improved skin quality (65%), more natural contours (1%), and more natural facial expressions (10%). CONCLUSION: Fat grafting for correction of PRS-associated soft-tissue defects is receiving heightened acceptance for its ability to restore natural facial contours. While additional fat-grafting procedures may be required with increased disease severity, autologous fat grafting may be a beneficial option as a sole modality to correct PRS-associated soft-tissue atrophy.
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Tejido Adiposo/trasplante , Hemiatrofia Facial/cirugía , Procedimientos de Cirugía Plástica , Adolescente , Colgajos Tisulares Libres , Humanos , MasculinoRESUMEN
OBJECTIVE: While neck dissection is important in the treatment of head and neck cancer, there is a paucity of studies evaluating outcomes. We sought to compare preoperative variables and outcomes between clean and contaminated neck dissections, using the 2006-2011 American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) data sets. STUDY DESIGN: Retrospective review of prospectively maintained database. SETTING: Multicenter (university hospitals; tertiary referral centers). SUBJECTS AND METHODS: A retrospective review was performed of the NSQIP database to identify patients undergoing neck dissection in clean vs oropharyngeal contaminated cases. Clinical factors, comorbidities, epidemiologic factors, and procedural characteristics were analyzed to identify factors associated with 30-day postoperative adverse events, including medical and surgical complications, unplanned reoperation, and mortality. Bivariate and multivariable analyses were performed for the outcome of one or more adverse events. RESULTS: In total, 8890 patients had clean neck dissections, while 572 patients had neck wound contamination with oropharyngeal flora. On multivariable regression analysis, oropharyngeal contamination was a significant risk factor for surgical complications (odds ratio [OR], 3.42; 95% confidence interval [CI], 1.96-5.96; P < .001). However, medical complications and mortality were not significantly different between the 2 cohorts. This finding persisted after subgroup analysis, with removal of all thyroidectomy patients from analysis (OR, 2.33; 95% CI, 1.25-4.36; P = .008). CONCLUSION: Using the ACS-NSQIP data set, this study found an increased risk of surgical complications in the setting of contaminated neck dissections. These data should be used for patient risk stratification, informed consent, and to guide further research.
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Neoplasias de Cabeza y Cuello/cirugía , Boca/metabolismo , Disección del Cuello/efectos adversos , Orofaringe , Faringe/metabolismo , Infección de la Herida Quirúrgica/epidemiología , Adulto , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Factores de RiesgoRESUMEN
BACKGROUND: With the rising cost of healthcare delivery and bundled payments for episodes of care, there has been impetus to minimize hospitalization and increase utilization of outpatient surgery mechanisms. Given the increase in outpatient mastectomy and immediate tissue expander (TE)-based reconstruction and the paucity of data on its comparative safety to inpatient procedures, we sought to understand the risk for early postoperative complications in an outpatient model compared with more traditional inpatient status using the National Surgical Quality Improvement Program database. METHODS: NSQIP data files from 2005 to 2012 were queried to identify patients undergoing immediate TE-based breast reconstruction after mastectomy. Patients were stratified by whether they received outpatient or inpatient care and then propensity score matched based on preoperative baseline characteristics to produce matched cohorts. Multivariate regression analysis was used to determine whether outpatient versus inpatient status conferred differing risk for 30-days complications. RESULTS: Of the 2014 patients who met criteria, 1:1 propensity matching yielded 634 patients in each of the matched cohorts. Overall complications (5.2 vs. 5.4 %), overall surgical complications (4.3 vs. 3.9 %), overall medical complications (1.3 vs. 2.1 %), and return to the operating room (6.6 vs. 7.3 %) were similar between outpatient and inpatients cohorts (p > .2), respectively. There was a small, but significant increased risk of organ/space SSI in outpatients (1.9 vs. 0.5 %, p = .02) and trend for increased risk for pulmonary embolus (PE) and urinary tract infection (UTI) in inpatients (0.3 vs. 0 %, p = .16; 0.3 vs. 0 %, p = .16). CONCLUSIONS: Our studies suggest that outpatient TE confers similar safety profiles to inpatient TE with regards to 30-day postoperative overall complications, medical and surgical morbidity, and return to the operating room. A slightly increased risk for surgical site infection must be balanced against potential risk for known inpatient-related complications such as UTI and PE.
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Atención Ambulatoria/estadística & datos numéricos , Procedimientos Quirúrgicos Ambulatorios/efectos adversos , Implantación de Mama/efectos adversos , Hospitalización/estadística & datos numéricos , Infección de la Herida Quirúrgica/etiología , Adulto , Atención Ambulatoria/normas , Implantes de Mama/efectos adversos , Femenino , Humanos , Persona de Mediana Edad , Puntaje de Propensión , Embolia Pulmonar/etiología , Reoperación , Factores de Tiempo , Expansión de Tejido/efectos adversos , Infecciones Urinarias/etiologíaRESUMEN
BACKGROUND: With increasing economic healthcare constraints and an evolving understanding of patient selection criteria and patient safety, outpatient thyroidectomy is now more frequently employed. However, robust statistical analyses evaluating outcomes and safety after outpatient thyroidectomy with matched comparisons to inpatient cohorts are lacking. METHODS: The 2011-2012 NSQIP datasets were queried to identify all patients undergoing thyroidectomy. Inpatient and outpatient procedures cohorts were matched 1:1 using propensity score analysis to assess outcomes. Outcomes of interest included surgical and medical complications, reoperation, mortality, and readmission. Univariate and multivariate analyses were utilized to identify predictors of these events. Relative risk ratios were calculated for adverse events between inpatient and outpatient cohorts. RESULTS: In total, 21,508 patients were identified to have undergone a thyroidectomy in 2011-2012. Inpatients and outpatients were matched 1:1 with respect to preoperative and operative characteristics, leaving 8,185 patients in each treatment arm. After matching, overall 30-day morbidity was rare with only 250 patients (1.53 %) experiencing any perioperative morbidity. 476 patients (2.91 %) were readmitted within 30-days of the operation. Both pre- and post-matching, inpatient thyroidectomy was associated with increased risks of readmission, reoperation, and any complication. CONCLUSIONS: Based on this comprehensive population-based study, outpatient thyroidectomy appears to be at least as safe as inpatient thyroidectomy. However, there are still differences in outcomes between inpatient and outpatient cohorts, despite statistical matching of preoperative and intraoperative variables. Future research needs to be spent identifying these as-of-yet unknown risk factors to resolve this discrepancy.
Asunto(s)
Procedimientos Quirúrgicos Ambulatorios , Tiroidectomía , Adulto , Anciano , Current Procedural Terminology , Femenino , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Evaluación de Resultado en la Atención de Salud , Seguridad del Paciente , Puntaje de Propensión , Mejoramiento de la Calidad , Tiroidectomía/métodosRESUMEN
BACKGROUND: Mastery of craniomaxillofacial reconstruction has been traditionally considered to be learning curve dependent, often with inconsistent results during the skill acquisition phase. Until recently, the overall success in bony oncologic reconstruction of the craniomaxillofacial skeleton has relied mainly on the use of 2D imaging modalities, as well as surgical trial-and-error. Virtual surgical planning (VSP) and computer aided design (CAD)/computer aided modeling (CAM) are gaining traction in oncologic applications and offers opportunity for increased accuracy, improved efficiency, and enhanced outcomes. Its role in oncologic head and neck reconstruction has not been formally evaluated. METHODS: A systematic review of the current literature was conducted by three independent reviewers. Three separate search schemes were utilized to identify cases incorporating VSP-CAD/CAM technology in head and neck reconstruction for an oncologic indication. Inclusion and exclusion criteria were applied; articles that met criteria were evaluated for cohort demographics, osteocutaneous flap type and usage, oncologic indication, recipient bone reconstructed, flap survival, follow up, VSP technology usage, specific reported benefits of the technology, and qualitative and quantitative outcome assessments. RESULTS: The systematic literature review yielded 87 articles; of these, 33 met inclusion criteria describing a total of 220 cases of oncologic head and neck reconstruction incorporating virtual planning technology. Numerous qualitative benefits of VSP were reported including increased accuracy of the reconstruction (93%), decreased intraoperative time (80%), and ease of use (24%) among others. However, quantitative results using survey data or preoperative/postoperative CT scan comparisons were given for only 33% (3%, 30% respectively) of cases. CONCLUSION: VSP represents an evolving technology that ushers oncological craniomaxillofacial reconstruction into a modern era that holds potential to advance the field with increased reconstructive accuracy, expedition of the surgical phase, and improved outcomes. While qualitative improvements from the technology are delineated, specific quantifiable benefits and cost-benefit analysis are limited and need to be further investigated.