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De Lorenzi F, Sala P, Catapano S, Mazzocconi L, Lorenzano V, Borelli F, Ioppolo L, Caldarella P. Postmastectomy dual-plane submuscular-subcutaneous implant-based reconstruction: a series of 100 consecutive patients. Updates Surg 2024; 76:613-621. [PMID: 37964047 DOI: 10.1007/s13304-023-01683-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 10/25/2023] [Indexed: 11/16/2023]
Abstract
BACKGROUND Advances in cancer knowledge and surgical techniques over the last decades have enabled plastic surgeons to use muscle-sparing procedures and more conservative approaches for implant-based reconstructions. In this paper, the authors describe an innovative subpectoral/subcutaneous implant pocket that represents an evolution of the classical submuscular technique and they report on the first consecutive hundred patients undergoing this procedure. METHODS Between April 2019 and May 2022, 100 consecutive patients underwent immediate postmastectomy implant-based reconstruction using the subpectoral/subcutaneous space, for a total of 122 procedures. Medical records were retrospectively reviewed and patients were prospectively followed. During plastic consultations, medical photographs were taken and aesthetic outcomes were scored with patients. RESULTS Mean follow-up was 18 months (range 6-46). Implant loss was observed in two patients (2%). Early minor complications were registered in 19 patients. A total of 80 out of 100 patients completed satisfaction survey assessing their postoperative outcomes. Results were considered satisfactory or very satisfactory by the surgeons and patients in more than 90% of cases. CONCLUSION The submuscular/subcutaneous pocket can be considered a new tool in the armamentarium of reconstructive procedures, in between submuscular/subfascial procedures and prepectoral ones. It is a one-stage procedure, its a simple and short time surgery, reproducible, its very well accepted by patients. It has specific indications, advantages, and drawbacks, a careful indication and an accurate surgical technique are mandatory to achieve good results.
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Affiliation(s)
- Francesca De Lorenzi
- Department of Plastic and Reconstructive Surgery, European Institute of Oncology (IEO), IRCCS, Via Ripamonti, 435, 20141, Milan, Italy
| | - Pietro Sala
- Department of Plastic and Reconstructive Surgery, European Institute of Oncology (IEO), IRCCS, Via Ripamonti, 435, 20141, Milan, Italy
| | - Simone Catapano
- Department of Plastic and Reconstructive Surgery, European Institute of Oncology (IEO), IRCCS, Via Ripamonti, 435, 20141, Milan, Italy
| | - Luca Mazzocconi
- Department of Plastic and Reconstructive Surgery, European Institute of Oncology (IEO), IRCCS, Via Ripamonti, 435, 20141, Milan, Italy.
| | - Valerio Lorenzano
- Department of Plastic and Reconstructive Surgery, European Institute of Oncology (IEO), IRCCS, Via Ripamonti, 435, 20141, Milan, Italy
| | - Francesco Borelli
- Department of Plastic and Reconstructive Surgery, European Institute of Oncology (IEO), IRCCS, Via Ripamonti, 435, 20141, Milan, Italy
- Department of Reconstructive and Aesthetic Plastic Surgery, University of Milan, I.R.C.C.S. Hospital Galeazzi - Sant'Ambrogio, Milan, Italy
| | - Leonardo Ioppolo
- Department of Plastic and Reconstructive Surgery, European Institute of Oncology (IEO), IRCCS, Via Ripamonti, 435, 20141, Milan, Italy
- Marrelli Hospital, Via Gioacchino da Fiore 5, 88900, Crotone, Italy
| | - Pietro Caldarella
- Department of Breast Surgery, European Institute of Oncology (IEO), IRCCS, Via Ripamonti, 435, 20141, Milan, Italy
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Humar P, Moroni E, Raghuram A, Balogun Z, Nguyen XM, Zhang C, De La Cruz C. Upper Extremity Functional Outcomes After Breast Cancer Treatment: An Analysis of DASH Score in Breast Reconstruction Patients. Aesthet Surg J 2024; 44:396-403. [PMID: 38019776 DOI: 10.1093/asj/sjad352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Revised: 11/05/2023] [Accepted: 11/09/2023] [Indexed: 12/01/2023] Open
Abstract
BACKGROUND Patients undergoing postoncologic breast reconstruction can experience upper extremity (UE) functional deficits. OBJECTIVES In this study, we utilized the disabilities of the arm, shoulder, and hand (DASH) questionnaire to identify patient factors that impacted UE functional recovery. METHODS Patients who underwent oncologic followed by reconstructive surgery by a single surgeon from 2014 to 2019 and completed the DASH survey were included. A DASH score was calculated for each patient, with values ranging from 0 (no impairment) to 100 (severe impairment). Regression analysis was conducted to identify significant predictors for DASH score with a significance level for entry and stay set at P = .15. RESULTS Among 289 patients who underwent breast reconstruction, 157 completed the questionnaire. The average patient age was 52.6yrs ± 8.6 at the time of reconstruction. A total of 111 had implant-based reconstruction, 15 had autologous reconstruction, and 24 had a combination of both. Average DASH score was 7.7 (range 0.0-52.5), with 74.1% of patients having a score greater than 0. Regression analysis showed 5 variables associated with significantly higher DASH scores: age between 50 and 60 years (P = .13), history of radiation (P = .01), placement of a subpectoral implant (P = .06), postoperative complications (P = .10), and lymphedema (P < .01). Autologous breast reconstruction (P = .04) was associated with a significantly lower DASH score. CONCLUSIONS Implant-based reconstruction, radiation history, postoperative complications, and age at reconstruction were associated with increased UE functional impairment in patients who underwent breast reconstructive surgery. Identification of these factors can inform areas for potential practice changes and improve patient counseling regarding postoperative expectations. LEVEL OF EVIDENCE: 3
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Vingan PS, Kim M, Rochlin D, Allen RJ, Nelson JA. Prepectoral Versus Subpectoral Implant-Based Reconstruction: How Do We Choose? Surg Oncol Clin N Am 2023; 32:761-776. [PMID: 37714642 DOI: 10.1016/j.soc.2023.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/17/2023]
Abstract
Aspects of a patient's lifestyle, their state of health, breast size, and mastectomy skin flap quality are factors that influence the suggested plane of dissection in implant-based breast reconstruction. This article aims to review developments in prosthetic breast reconstruction and provide recommendations to help providers choose whether prepectoral or subpectoral reconstruction in the best approach for each of their patients.
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Affiliation(s)
- Perri S Vingan
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Minji Kim
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Danielle Rochlin
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Robert J Allen
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Jonas A Nelson
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA.
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Montorfano L, Hung YC, Chaker S, Saad M, Kalmar CL, Ferri F, Higdon KK, Perdikis G. Examination of Outcome Disparities in Reports of Prepectoral and Subpectoral Direct-to-Implant Reconstruction: A Systematic Review and Meta-analysis. Ann Plast Surg 2023; 90:506-515. [PMID: 36975095 DOI: 10.1097/sap.0000000000003524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
Abstract
BACKGROUND There are mixed results in surgical complications regarding the usage of prepectoral versus subpectoral implant placement in direct-to-implant breast reconstruction. This study aimed to provide a comprehensive synthesis of surgical complications between the subpectoral and prepectoral reconstructive method. METHODS PubMed, Embase, and Cochrane were searched for literature published up until December 2022. Studies that compared subpectoral and prepectoral breast reconstruction and reported at least one postoperative complication were included. The following 8 major outcomes were included: revision and reoperation, capsular contracture, explantation, seroma, hematoma, infection, skin necrosis, and animation deformity. Systematic review and meta-analysis were performed to compare outcomes of the 2 techniques. Subgroup analysis was performed to compare whether practice differences in different countries may have an impact on outcomes. RESULTS A total of 18 studies were identified in our literature search. Two thousand three hundred sixty patients were included, representing a total of 3135 breasts. Our analysis demonstrated that prepectoral reconstruction had significantly lower odds of developing postoperative hematoma [odds ratio (OR), 0.62; P = 0.05], seroma (OR, 0.67; P = 0.01), infection (OR, 0.64; P = 0.03), revision and reoperation (OR, 0.44; P < 0.00001), and animation deformity (OR, 0.01; P < 0.00001), compared with the subpectoral method. Subgroup analysis showed that differences between 3 countries (United States, Korea, Italy) are low (all subgroup heterogeneity test P > 0.1). CONCLUSIONS While both subpectoral and prepectoral are safe methods for breast reconstruction, the prepectoral technique may lead to lower odds of developing multiple major postoperative complications.
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Affiliation(s)
- Lisandro Montorfano
- From the Department of Plastic Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Ya-Ching Hung
- From the Department of Plastic Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Sara Chaker
- From the Department of Plastic Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Mariam Saad
- From the Department of Plastic Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Christopher L Kalmar
- From the Department of Plastic Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Francisco Ferri
- Department of Plastic Surgery, Cleveland Clinic Florida, Weston, FL
| | - Kent K Higdon
- From the Department of Plastic Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Galen Perdikis
- From the Department of Plastic Surgery, Vanderbilt University Medical Center, Nashville, TN
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Xie J, Wang M, Cao Y, Zhu Z, Ruan S, Ou M, Yu P, Shi J. ADM-assisted prepectoral breast reconstruction is not associated with high complication rate as before: a Meta-analysis. J Plast Surg Hand Surg 2023; 57:7-15. [PMID: 34581645 DOI: 10.1080/2000656x.2021.1981351] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Implant-related breast reconstruction can be divided into subpectoral breast reconstruction (SPBR) and prepectoral breast reconstruction (PPBR) according to the different anatomical planes. The previous stereotype was that PPBR had a high complication rate and was not suitable for clinical use. However, with the emergence of acellular dermal matrix (ADM), the clinical effect of PPBR has been improved. To compare the outcomes difference between SPBR and PPBR, We conducted this meta-analysis. Articles on SPBR versus PPBR were searched in PubMed, Web of Sciences, Embase, and Cochrane databases, strictly following the PRISMA guidelines. According to the set criteria, we included the literature that met the requirements. Extracted data were the incidence of adverse events and the duration of drainage. Results show that SPBR has a higher incidence rate in capsular contracture, animation deformity, infection, hematoma and delayed healing wound than PPBR. There are no significant differences in skin flap necrosis, seroma, implant loss, reoperation and duration of drainage between the two groups. Hence, PPBR is no longer a high complication surgical method and can be used in the clinical practice. However, there are few large sample studies at present, so it is necessary to carry out further studies on PPBR.
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Affiliation(s)
- Jiaheng Xie
- Department of Burn and Plastic Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Ming Wang
- Department of Burn and Plastic Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Yuan Cao
- Fourth School of Clinical Medicine, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Zhechen Zhu
- Department of Burn and Plastic Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Shujie Ruan
- Department of Burn and Plastic Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Mengmeng Ou
- Department of Burn and Plastic Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Pan Yu
- Department of Burn and Plastic Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Jingping Shi
- Department of Burn and Plastic Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
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Silva J, Carvalho F, Marques M. Direct-to-Implant Subcutaneous Breast Reconstruction: A Systematic Review of Complications and Patient's Quality of Life. Aesthetic Plast Surg 2023; 47:92-105. [PMID: 36097081 DOI: 10.1007/s00266-022-03068-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 08/11/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND The use of direct-to-implant subcutaneous breast reconstruction has increased over the last years. The goal of this systematic review is to deliver an updated review of the safety of this technique and its impact on quality of life. We also compare subcutaneous vs submuscular complications, through meta-analysis. METHODS Literature review through PubMed and Cochrane Library databases were performed by PRISMA criteria. Thirty-nine studies met inclusion criteria for subcutaneous review and 15 studies met inclusion criteria for meta-analysis. All included studies were evaluated for complications and answers to the BREAST-Q. Data were analysed using Microsoft Excel, IBM SPSS, and Cochrane RevMan. RESULTS In 2863 patients and 3988 breasts that undergone direct to implant subcutaneous breast reconstruction, 8,21% had rippling, 5,64% seroma, 1,74% hematoma, 3,40% infection, 3,01% wound dehiscence, 3,93% skin necrosis, 3,34% nipple-areolar-complex (NAC) necrosis, 3,07% capsular contracture, 0,00% animation deformity, and 3,83% an implant removal. Meta-analysis showed a statistically significant decrease in the odds ratio of animation deformity, a but statistically significant higher odds ratio of rippling. Subcutaneous and submuscular reconstructions had similar BREAST-Q scores. CONCLUSIONS Direct-to-implant subcutaneous breast reconstruction does not harm the patient's quality of life, comparatively with submuscular, saving the pectoral muscle from dissection and preventing animation deformity, but increasing the risk of rippling. 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 the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
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Affiliation(s)
- José Silva
- Faculty of Medicine, University of Porto, Al. Prof. Hernâni Monteiro, 4200-319, Porto, Portugal.
| | - Francisco Carvalho
- Department of Plastic and Reconstructive Surgery, Centro Hospitalar de São João, Porto, Portugal
- Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Marisa Marques
- Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Porto, Portugal
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Comparison of Outcomes Following Prepectoral and Subpectoral Implants for Breast Reconstruction: Systematic Review and Meta-Analysis. Cancers (Basel) 2022; 14:cancers14174223. [PMID: 36077760 PMCID: PMC9455042 DOI: 10.3390/cancers14174223] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 08/24/2022] [Accepted: 08/26/2022] [Indexed: 12/02/2022] Open
Abstract
(1) Background: Implant-based breast reconstruction following mastectomy helps to restore quality of life while aiming at providing optimal cosmetic outcomes. Both prepectoral (PP) and subpectoral (SP) breast implants are widely used to fulfill these objectives. It is, however, unclear which approach offers stronger postoperative benefits. (2) Methods: We performed a systematic review of the literature through PubMed, Cochrane Library, and ResearchGate, following the PRISMA guidelines. Quantitative analysis for postoperative pain as the primary outcome was conducted. Secondary outcomes included patient satisfaction and postoperative complications such as seroma, implant loss, skin necrosis, wound infection, and hematoma. (3) Results: Nine articles involving 1119 patients were retrieved. Our results suggested increased postoperative pain after SP implants and significantly higher rates of seroma following PP implants (p < 0.05). Patient satisfaction was found to be similar between the two groups; however, the heterogeneity of measurement tools did not allow us to pool these results. The rates of implant loss, skin necrosis, wound infection, and hematoma showed no significant differences between the two cohorts. (4) Conclusion: Our data suggest that both implant placements are safe and effective methods for breast reconstruction following mastectomy. However, homogeneity in outcome measurements would allow one to provide stronger statistical results.
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Harvey KL, Sinai P, Mills N, White P, Holcombe C, Potter S. Short-term safety outcomes of mastectomy and immediate prepectoral implant-based breast reconstruction: Pre-BRA prospective multicentre cohort study. Br J Surg 2022; 109:530-538. [PMID: 35576373 PMCID: PMC10364707 DOI: 10.1093/bjs/znac077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 01/18/2022] [Accepted: 02/22/2022] [Indexed: 11/14/2022]
Abstract
BACKGROUND Prepectoral breast reconstruction (PPBR) has recently been introduced to reduce postoperative pain and improve cosmetic outcomes in women having implant-based procedures. High-quality evidence to support the practice of PPBR, however, is lacking. Pre-BRA is an IDEAL stage 2a/2b study that aimed to establish the safety, effectiveness, and stability of PPBR before definitive evaluation in an RCT. The short-term safety endpoints at 3 months after surgery are reported here. METHODS Consecutive patients electing to undergo immediate PPBR at participating UK centres between July 2019 and December 2020 were invited to participate. Demographic, operative, oncology, and complication data were collected. The primary outcome was implant loss at 3 months. Other outcomes of interest included readmission, reoperation, and infection. RESULTS Some 347 women underwent 424 immediate implant-based reconstructions at 40 centres. Most were single-stage direct-to-implant (357, 84.2 per cent) biological mesh-assisted (341, 80.4 per cent) procedures. Conversion to subpectoral reconstruction was necessary in four patients (0.9 per cent) owing to poor skin-flap quality. Of the 343 women who underwent PPBR, 144 (42.0 per cent) experienced at least one postoperative complication. Implant loss occurred in 28 women (8.2 per cent), 67 (19.5 per cent) experienced an infection, 60 (17.5 per cent) were readmitted for a complication, and 55 (16.0 per cent) required reoperation within 3 months of reconstruction. CONCLUSION Complication rates following PPBR are high and implant loss is comparable to that associated with subpectoral mesh-assisted implant-based techniques. These findings support the need for a well-designed RCT comparing prepectoral and subpectoral reconstruction to establish best practice for implant-based breast reconstruction.
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Affiliation(s)
- Kate L Harvey
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Parisa Sinai
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Nicola Mills
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Paul White
- Applied Statistics Group, University of the West of England, Bristol, UK
| | | | - Shelley Potter
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
- Bristol Breast Care Centre, North Bristol NHS Trust, Bristol, UK
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Saldanha IJ, Broyles JM, Adam GP, Cao W, Bhuma MR, Mehta S, Pusic AL, Dominici LS, Balk EM. Implant-based Breast Reconstruction after Mastectomy for Breast Cancer: A Systematic Review and Meta-analysis. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2022; 10:e4179. [PMID: 35317462 PMCID: PMC8932484 DOI: 10.1097/gox.0000000000004179] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 01/13/2022] [Indexed: 12/26/2022]
Abstract
Women undergoing implant-based reconstruction (IBR) after mastectomy for breast cancer have numerous options, including timing of IBR relative to radiation and chemotherapy, implant materials, anatomic planes, and use of human acellular dermal matrices. We conducted a systematic review to evaluate these options. Methods We searched Medline, Embase, Cochrane CENTRAL, CINAHL, and ClinicalTrials.gov for studies, from inception to March 23, 2021, without language restriction. We assessed risk of bias and strength of evidence (SoE) using standard methods. Results We screened 15,936 citations. Thirty-six mostly high or moderate risk of bias studies (48,419 patients) met criteria. Timing of IBR before or after radiation may result in comparable physical, psychosocial, and sexual well-being, and satisfaction with breasts (all low SoE), and probably comparable risks of implant failure/loss or explantation (moderate SoE). No studies addressed timing relative to chemotherapy. Silicone and saline implants may result in clinically comparable satisfaction with breasts (low SoE). Whether the implant is in the prepectoral or total submuscular plane may not impact risk of infections (low SoE). Acellular dermal matrix use probably increases the risk of implant failure/loss or need for explant surgery (moderate SoE) and may increase the risk of infections (low SoE). Risks of seroma and unplanned repeat surgeries for revision are probably comparable (moderate SoE), and risk of necrosis may be comparable with or without human acellular dermal matrices (low SoE). Conclusions Evidence regarding IBR options is mostly of low SoE. New high-quality research is needed, especially for timing, implant materials, and anatomic planes of implant placement.
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Affiliation(s)
- Ian J. Saldanha
- From the Center for Evidence Synthesis in Health, Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, R.I
- Department of Epidemiology, Brown University School of Public Health, Providence, R.I
| | - Justin M. Broyles
- Division of Plastic and Reconstructive Surgery, Department of Plastic Surgery, Harvard Medical School, Boston, Mass
| | - Gaelen P. Adam
- From the Center for Evidence Synthesis in Health, Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, R.I
| | - Wangnan Cao
- From the Center for Evidence Synthesis in Health, Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, R.I
| | - Monika Reddy Bhuma
- From the Center for Evidence Synthesis in Health, Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, R.I
| | - Shivani Mehta
- From the Center for Evidence Synthesis in Health, Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, R.I
| | - Andrea L. Pusic
- Division of Plastic and Reconstructive Surgery, Department of Plastic Surgery, Harvard Medical School, Boston, Mass
| | - Laura S. Dominici
- Division of Breast Surgery, Department of Surgery, Harvard Medical School, Boston, Mass
| | - Ethan M. Balk
- From the Center for Evidence Synthesis in Health, Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, R.I
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