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Schaverien MV, Singh P, Smith BD, Qiao W, Akay CL, Bloom ES, Chavez-MacGregor M, Chu CK, Clemens MW, Colen JS, Ehlers RA, Hwang RF, Joyner MM, Largo RD, Mericli AF, Mitchell MP, Shuck JW, Tamirisa N, Tripathy D, Villa MT, Woodward WA, Zacharia R, Kuerer HM, Hoffman KE. Premastectomy Radiotherapy and Immediate Breast Reconstruction: A Randomized Clinical Trial. JAMA Netw Open 2024; 7:e245217. [PMID: 38578640 PMCID: PMC10998161 DOI: 10.1001/jamanetworkopen.2024.5217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Accepted: 02/08/2024] [Indexed: 04/06/2024] Open
Abstract
Importance Premastectomy radiotherapy (PreMRT) is a new treatment sequence to avoid the adverse effects of radiotherapy on the final breast reconstruction while achieving the benefits of immediate breast reconstruction (IMBR). Objective To evaluate outcomes among patients who received PreMRT and regional nodal irradiation (RNI) followed by mastectomy and IMBR. Design, Setting, and Participants This was a phase 2 single-center randomized clinical trial conducted between August 3, 2018, and August 2, 2022, evaluating the feasibility and safety of PreMRT and RNI (including internal mammary lymph nodes). Patients with cT0-T3, N0-N3b breast cancer and a recommendation for radiotherapy were eligible. Intervention This trial evaluated outcomes after PreMRT followed by mastectomy and IMBR. Patients were randomized to receive either hypofractionated (40.05 Gy/15 fractions) or conventionally fractionated (50 Gy/25 fractions) RNI. Main Outcome and Measures The primary outcome was reconstructive failure, defined as complete autologous flap loss. Demographic, treatment, and outcomes data were collected, and associations between multiple variables and outcomes were evaluated. Analysis was performed on an intent-to-treat basis. Results Fifty patients were enrolled. Among 49 evaluable patients, the median age was 48 years (range, 31-72 years), and 46 patients (94%) received neoadjuvant systemic therapy. Twenty-five patients received 50 Gy in 25 fractions to the breast and 45 Gy in 25 fractions to regional nodes, and 24 patients received 40.05 Gy in 15 fractions to the breast and 37.5 Gy in 15 fractions to regional nodes, including internal mammary lymph nodes. Forty-eight patients underwent mastectomy with IMBR, at a median of 23 days (IQR, 20-28.5 days) after radiotherapy. Forty-one patients had microvascular autologous flap reconstruction, 5 underwent latissimus dorsi pedicled flap reconstruction, and 2 had tissue expander placement. There were no complete autologous flap losses, and 1 patient underwent tissue expander explantation. Eight of 48 patients (17%) had mastectomy skin flap necrosis of the treated breast, of whom 1 underwent reoperation. During follow-up (median, 29.7 months [range, 10.1-65.2 months]), there were no locoregional recurrences or distant metastasis. Conclusions and Relevance This randomized clinical trial found PreMRT and RNI followed by mastectomy and microvascular autologous flap IMBR to be feasible and safe. Based on these results, a larger randomized clinical trial of hypofractionated vs conventionally fractionated PreMRT has been started (NCT05774678). Trial Registration ClinicalTrials.gov Identifier: NCT02912312.
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Affiliation(s)
- Mark V. Schaverien
- Division of Surgery, Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston
| | - Puneet Singh
- Division of Surgery, Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Benjamin D. Smith
- Division of Radiation Oncology, Department of Breast Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Wei Qiao
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston
| | - Catherine L. Akay
- Division of Surgery, Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Elizabeth S. Bloom
- Division of Radiation Oncology, Department of Breast Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Mariana Chavez-MacGregor
- Division of Cancer Medicine, Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Carrie K. Chu
- Division of Surgery, Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston
| | - Mark W. Clemens
- Division of Surgery, Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston
| | - Jessica S. Colen
- Division of Surgery, Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Richard A. Ehlers
- Division of Surgery, Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Rosa F. Hwang
- Division of Surgery, Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Melissa M. Joyner
- Division of Radiation Oncology, Department of Breast Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Rene D. Largo
- Division of Surgery, Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston
| | - Alexander F. Mericli
- Division of Surgery, Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston
| | - Melissa P. Mitchell
- Division of Radiation Oncology, Department of Breast Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - John W. Shuck
- Division of Surgery, Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston
| | - Nina Tamirisa
- Division of Surgery, Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Debasish Tripathy
- Division of Cancer Medicine, Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Mark T. Villa
- Division of Surgery, Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston
| | - Wendy A. Woodward
- Division of Surgery, Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Rensi Zacharia
- Division of Radiation Oncology, Department of Breast Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Henry M. Kuerer
- Division of Surgery, Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Karen E. Hoffman
- Division of Radiation Oncology, Department of Breast Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
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Camacho L, Chu CK, Mitchell MP, Nguyen T, Correa A, Mericli AF. Oncoplastic Reconstruction in the Setting of Prior Cosmetic Augmentation. Plast Reconstr Surg 2024:00006534-990000000-02258. [PMID: 38376232 DOI: 10.1097/prs.0000000000011366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2024]
Abstract
BACKGROUND This study explores the surgical management and reconstruction options for augmented breasts in the context of breast conservation therapy (BCT) for breast cancer. We hypothesized that there would be no difference in the rates of complications, revisions, or patient satisfaction in patients who maintained their breast augmentation versus those that had their implants removed in the context of BCT. METHODS We conducted a retrospective review of 142 patients who underwent BCT at a single center from March 2016 to March 2022. The study included patients who had a preexistent cosmetic augmentation at the time of breast cancer diagnosis and BCT. Patient demographics, clinical and treatment characteristics, breast implant details, reconstructive technique, complications, and revisions were recorded. Patient-reported outcomes were assessed using the BREAST-Q Breast-Conserving Therapy module. RESULTS Ninety-three (65.5%) patients chose to maintain their implants, while 49 (34.5%) elected to have them removed during BCT. Patients with submuscular implants were more likely to maintain their implants. Oncoplastic mastopexy was associated with higher complication rates, particularly in patients opting for implant downsizing. However, multivariate logistic regression did not identify implant management strategy as an independent predictor for complications or revisions. Surgical site infection was the only predictor of implant explantation. Patient-reported outcomes did not differ significantly between the different implant management cohorts. CONCLUSIONS This study demonstrates that maintaining breast implants during BCT does not increase the risk of complications or revisions. Overall, BCT in augmented women was found to be a safe approach, with high patient satisfaction.
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Affiliation(s)
- Luis Camacho
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Carrie K Chu
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Melissa P Mitchell
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Thuy Nguyen
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Arlene Correa
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Alexander F Mericli
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX
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Chu CK, Largo RD, Lee ZH, Adelman DM, Egro F, Winocour S, Reece EM, Selber JC, Butler CE. Introduction of the L-PAP Flap: Bipedicled, Conjoined, and Stacked Thigh-Based Flaps for Autologous Breast Reconstruction. Plast Reconstr Surg 2023; 152:1005e-1010e. [PMID: 37010466 DOI: 10.1097/prs.0000000000010487] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2023]
Abstract
SUMMARY Thigh-based flaps are increasingly popular options for autologous breast reconstruction in the setting of abdominal donor-site inadequacy, previous surgery, or patient preference, but the volume and skin associated with these flaps are often lacking relative to the abdomen. An individualized, shared decision-making approach to donor-site selection was adopted based on body shape, surgical history, lifestyle, reconstructive needs, and patient expectations. Different thigh-based flaps combined in stacked, bipedicled, or conjoined configurations were selected to maximize efficient use of available soft-tissue skin and volume while optimizing donor-site aesthetics. A total of 23 thigh-based stacked, bipedicled, or conjoined profunda artery perforator (PAP), lateral thigh perforator (LTP), or gracilis musculocutaneous flap components were used in six patients. Configurations included bilateral stacked PAP and LTP flaps, bipedicled posterolateral thigh flaps based on the LTP and PAP (L-PAP), and bipedicled thigh flaps based on the gracilis and PAP pedicles. Most anastomoses were performed to the antegrade and retrograde internal mammary vessels; intraflap anastomoses were performed in one case. There were no partial or total flap losses. There was one donor-site seroma. Design of stacked, bipedicled, and conjoined thigh-based flaps using multiple conventional flap components allows for tailored approaches to donor-site utilization based on individual body shape in selected patients. Bipedicled design with the L-PAP flap represents one strategy in appropriate cases to overcome skin and volume deficiencies while facilitating coning and projection. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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Affiliation(s)
- Carrie K Chu
- From the Department of Plastic Surgery, University of Texas MD Anderson Cancer Centers
| | - Rene D Largo
- From the Department of Plastic Surgery, University of Texas MD Anderson Cancer Centers
| | - Z-Hye Lee
- From the Department of Plastic Surgery, University of Texas MD Anderson Cancer Centers
| | - David M Adelman
- From the Department of Plastic Surgery, University of Texas MD Anderson Cancer Centers
| | - Francesco Egro
- From the Department of Plastic Surgery, University of Texas MD Anderson Cancer Centers
| | | | | | - Jesse C Selber
- From the Department of Plastic Surgery, University of Texas MD Anderson Cancer Centers
| | - Charles E Butler
- From the Department of Plastic Surgery, University of Texas MD Anderson Cancer Centers
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Hassan AM, Paidisetty P, Ray N, Govande JV, Largo RD, Chu CK, Mericli AF, Schaverien MV, Clemens MW, Hanasono MM, Chang EI, Butler CE, Garvey PB, Selber JC. Ensuring Safety While Achieving Beauty: An Evidence-Based Approach to Optimizing Mastectomy and Autologous Breast Reconstruction Outcomes in Patients with Obesity. J Am Coll Surg 2023; 237:441-451. [PMID: 37144798 DOI: 10.1097/xcs.0000000000000736] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
BACKGROUND Although obesity has previously been associated with poor outcomes after mastectomy and breast reconstruction, its impact across the WHO obesity classification spectrum and the differential effects of various optimization strategies on patient outcomes have yet to be delineated. We sought to examine the impact of WHO obesity classification on intraoperative surgical and medical complications, postoperative surgical and patient-reported outcomes of mastectomy and autologous breast reconstruction, and delineate outcomes optimization strategies for obese patients. STUDY DESIGN This is a review of consecutive patients who underwent mastectomy and autologous breast reconstruction from 2016 to 2022. Primary outcomes were complication rates. Secondary outcomes were patient-reported outcomes and optimal management strategies. RESULTS We identified 1,640 mastectomies and reconstructions in 1,240 patients with mean follow-up of 24.2 ± 19.2 months. Patients with class II/III obesity had higher adjusted risk of wound dehiscence (odds ratio [OR] 3.20; p < 0.001), skin flap necrosis (OR 2.60; p < 0.001), deep venous thrombosis (OR 3.90; p < 0.033), and pulmonary embolism (OR 15.3; p = 0.001) than nonobese patients. Obese patients demonstrated significantly lower satisfaction with breasts (67.3 ± 27.7 vs 73.7 ± 24.0; p = 0.043) and psychological well-being (72.4 ± 27.0 vs 82.0 ± 20.8; p = 0.001) than nonobese patients. Unilateral delayed reconstructions were associated with independently shorter hospital stay (β -0.65; p = 0.002) and lower adjusted risk of 30-day readmission (OR 0.45; p = 0.031), skin flap necrosis (OR 0.14; p = 0.031), and pulmonary embolism (OR 0.07; p = 0.021). CONCLUSIONS Obese women should be closely monitored for adverse events and lower quality of life, offered measures to optimize thromboembolic prophylaxis, and advised on the risks and benefits of unilateral delayed reconstruction.
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Affiliation(s)
- Abbas M Hassan
- From the Division of Plastic & Reconstructive Surgery, Indiana University School of Medicine, Indianapolis, IN (Hassan)
| | - Praneet Paidisetty
- McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, YX (Paidisetty, Ray, Govande)
| | - Nicholas Ray
- McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, YX (Paidisetty, Ray, Govande)
| | - Janhavi V Govande
- McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, YX (Paidisetty, Ray, Govande)
| | - Rene D Largo
- Department of Plastic & Reconstructive Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX (Largo, Chu, Mericli, Schaverien, Clemens, Hanasono, Chang, Butler, Garvey)
| | - Carrie K Chu
- Department of Plastic & Reconstructive Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX (Largo, Chu, Mericli, Schaverien, Clemens, Hanasono, Chang, Butler, Garvey)
| | - Alexander F Mericli
- Department of Plastic & Reconstructive Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX (Largo, Chu, Mericli, Schaverien, Clemens, Hanasono, Chang, Butler, Garvey)
| | - Mark V Schaverien
- Department of Plastic & Reconstructive Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX (Largo, Chu, Mericli, Schaverien, Clemens, Hanasono, Chang, Butler, Garvey)
| | - Mark W Clemens
- Department of Plastic & Reconstructive Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX (Largo, Chu, Mericli, Schaverien, Clemens, Hanasono, Chang, Butler, Garvey)
| | - Matthew M Hanasono
- Department of Plastic & Reconstructive Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX (Largo, Chu, Mericli, Schaverien, Clemens, Hanasono, Chang, Butler, Garvey)
| | - Edward I Chang
- Department of Plastic & Reconstructive Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX (Largo, Chu, Mericli, Schaverien, Clemens, Hanasono, Chang, Butler, Garvey)
| | - Charles E Butler
- Department of Plastic & Reconstructive Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX (Largo, Chu, Mericli, Schaverien, Clemens, Hanasono, Chang, Butler, Garvey)
| | - Patrick B Garvey
- Department of Plastic & Reconstructive Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX (Largo, Chu, Mericli, Schaverien, Clemens, Hanasono, Chang, Butler, Garvey)
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Danker S, Shuck JW, Taher A, Mujtaba B, Chang EI, Chu CK, Liu J, Garvey PB, Hanna E, Yu P, Largo RD. The lateral forearm flap versus traditional upper extremity flaps: A comparison of donor site morbidity and flap thickness. Head Neck 2023; 45:2413-2423. [PMID: 37464915 DOI: 10.1002/hed.27446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 06/14/2023] [Accepted: 06/20/2023] [Indexed: 07/20/2023] Open
Abstract
INTRODUCTION The lateral forearm flap (LFF) is a thin fasciocutaneous flap with a donor site that can be closed primarily. METHODS A retrospective analysis of donor site morbidity and hand function was performed in patients who underwent a radial forearm flap (RFF), ulnar artery perforator flap (UAPF), or LFF. Flap thickness was evaluated radiographically in 50 control patients. RESULTS Of 134 patients (lateral forearm flap: n = 49, RFF: n = 47, UAPF: n = 38), the LFF demonstrated significantly faster return to baseline hand grip strength (3 months vs. 12 months in RFF and UAPF; p < 0.001), had significantly fewer donor site complications (6.1% compared to 6.4% in RFF and 28.9% in UAPF; p = 0.003) and fewer sensory deficits (2.0% compared to 6.4% in RFF and 15.8% in UAPF sites; p = 0.013). The radiographic study confirmed the LFF to be the thinnest of all upper extremity flap options. CONCLUSIONS The LFF is an excellent forearm-based flap option with thin, pliable tissue and low donor site morbidity.
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Affiliation(s)
- Sara Danker
- Department of Plastic Surgery, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
| | - John W Shuck
- Department of Plastic Surgery, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Ahmed Taher
- Department of Radiology, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Bilal Mujtaba
- Department of Radiology, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Edward I Chang
- Department of Plastic Surgery, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Carrie K Chu
- Department of Plastic Surgery, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Jun Liu
- Department of Plastic Surgery, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Patrick B Garvey
- Department of Plastic Surgery, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Ehab Hanna
- Department of Head and Neck Surgery, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Peirong Yu
- Department of Plastic Surgery, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Rene D Largo
- Department of Plastic Surgery, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
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Hassan AM, Ray N, Govande JG, Paidisetty P, Largo RD, Chu CK, Mericli AF, Schaverien MV, Clemens MW, Hanasono MM, Chang EI, Garvey PB, Phillips BT, Selber JC. Long-term Surgical and Patient-Reported Outcomes Comparing Skin-Preserving, Staged Versus Delayed Microvascular Breast Reconstruction. Ann Surg Oncol 2023; 30:5711-5722. [PMID: 37285093 DOI: 10.1245/s10434-023-13470-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 03/21/2023] [Indexed: 06/08/2023]
Abstract
BACKGROUND Skin-preserving, staged, microvascular, breast reconstruction often is preferred in patients requiring postmastectomy radiotherapy (PMRT) but may lead to complications. We compared the long-term surgical and patient-reported outcomes between skin-preserving and delayed microvascular breast reconstruction with and without PMRT. METHODS We conducted a retrospective, cohort study of consecutive patients who underwent mastectomy and microvascular breast reconstruction between January 2016 and April 2022. The primary outcome was any flap-related complication. The secondary outcomes were patient-reported outcomes and tissue-expander complications. RESULTS We identified 1002 reconstructions (672 delayed; 330 skin-preserving) in 812 patients. Mean follow-up was 24.2 ± 19.3 months. PMRT was required in 564 reconstructions (56.3%). In the non-PMRT group, skin-preserving reconstruction was independently associated with shorter hospital stay (β - 0.32, p = 0.045) and lower odds of 30-days readmission (odds ratio [OR] 0.44, p = 0.042), seroma (OR 0.42, p = 0.036), and hematoma (OR 0.24, p = 0.011) compared with delayed reconstruction. In the PMRT group, skin-preserving reconstruction was independently associated with shorter hospital stay (β - 1.15, p < 0.001) and operative time (β - 97.0, p < 0.001) and lower odds of 30-days readmission (OR 0.29, p = 0.005) and infection (OR 0.33, p = 0.023) compared with delayed reconstruction. Skin-preserving reconstruction had a 10.6% tissue expander loss rate and did not differ from delayed reconstruction in terms of patient-reported satisfaction with breast, psychosocial well-being, or sexual well-being. CONCLUSIONS Skin-preserving, staged, microvascular, breast reconstruction is safe regardless of the need for PMRT, with an acceptable tissue expander loss rate, and is associated with improved flap outcomes and similar patient-reported quality of life to that of delayed reconstruction.
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Affiliation(s)
- Abbas M Hassan
- Department of Plastic and Reconstructive Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Nicholas Ray
- The University of Texas McGovern Medical School, Houston, TX, USA
| | | | | | - Rene D Largo
- Department of Plastic and Reconstructive Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Carrie K Chu
- Department of Plastic and Reconstructive Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Alexander F Mericli
- Department of Plastic and Reconstructive Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mark V Schaverien
- Department of Plastic and Reconstructive Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mark W Clemens
- Department of Plastic and Reconstructive Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Matthew M Hanasono
- Department of Plastic and Reconstructive Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Edward I Chang
- Department of Plastic and Reconstructive Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Patrick B Garvey
- Department of Plastic and Reconstructive Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Brett T Phillips
- Division of Plastic, Maxillofacial, and Oral Surgery, Department of Surgery, Duke University School of Medicine, Durham, NC, USA
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Hassan AM, Ray N, Govande JG, Paidisetty P, Largo RD, Chu CK, Mericli AF, Schaverien MV, Clemens MW, Hanasono MM, Chang EI, Garvey PB, Phillips BT, Selber JC. ASO Visual Abstract: Long-Term Surgical and Patient-Reported Outcomes Comparing Skin-Preserving, Staged Versus Delayed Microvascular Breast Reconstruction. Ann Surg Oncol 2023; 30:5725-5726. [PMID: 37335352 DOI: 10.1245/s10434-023-13662-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Affiliation(s)
- Abbas M Hassan
- Department of Plastic and Reconstructive Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Nicholas Ray
- The University of Texas McGovern Medical School, Houston, TX, USA
| | | | | | - Rene D Largo
- Department of Plastic and Reconstructive Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Carrie K Chu
- Department of Plastic and Reconstructive Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Alexander F Mericli
- Department of Plastic and Reconstructive Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mark V Schaverien
- Department of Plastic and Reconstructive Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mark W Clemens
- Department of Plastic and Reconstructive Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Matthew M Hanasono
- Department of Plastic and Reconstructive Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Edward I Chang
- Department of Plastic and Reconstructive Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Patrick B Garvey
- Department of Plastic and Reconstructive Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Brett T Phillips
- Division of Plastic, Maxillofacial, and Oral Surgery, Department of Surgery, Duke University School of Medicine, Durham, NC, USA
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Hassan AM, Chu CK, Liu J, Angove R, Rocque G, Gallagher KD, Momoh AO, Caston NE, Williams CP, Wheeler S, Offodile Ii AC. A nationwide cross-sectional study on the association of patient-level factors with financial anxiety in the context of chronic medical conditions. Sci Rep 2023; 13:10363. [PMID: 37365187 DOI: 10.1038/s41598-023-36282-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Accepted: 05/31/2023] [Indexed: 06/28/2023] Open
Abstract
Patient-level characteristics associated with the prevalence and severity of financial anxiety have yet to be described. We conducted a cross-sectional analysis of survey data assessing financial anxiety in patients with chronic medical conditions in December 2020. 1771 patients (42.6% response rate) participated in the survey. Younger age (19-35 age compared to ≥ 75 age) (β, 5.86; 95% CI 2.10-9.63), male sex (β, - 1.9; 95% CI - 3.1 to - 0.73), Hispanic/Latino race/ethnicity (compared with White patients) (β, 2.55; 95% CI 0.39-4.71), household size ≥ 4 (compare with single household) (β, 4.54; 95% CI 2.44-6.64), household income of ≥ $96,000-$119,999 (compared with ≤ $23,999) (β, - 3.2; 95% CI - 6.3 to 0.04), single marital status (compared with married) (β, 2.18; 95% CI 0.65-3.71), unemployment (β, 2.07; 95% CI 0.39-3.74), high-school education (compared with advanced degrees) (β, 3.10; 95% CI 1.32-4.89), lack of insurance coverage (compared with private insurance) (β, 6.05; 95% CI 2.66-9.45), more comorbidities (≥ 3 comorbidities compared to none) (β, 2.95; 95% CI 1.00-4.90) were all independently associated with financial anxiety. Patients who are young, female, unmarried, and representing vulnerable sub-populations are at elevated risk for financial anxiety.
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Affiliation(s)
- Abbas M Hassan
- Department of Plastic and Reconstructive Surgery, The University of Texas MD Anderson Cancer Center, 1400 Pressler St., Unit 1488, Houston, TX, 77030, USA
| | - Carrie K Chu
- Department of Plastic and Reconstructive Surgery, The University of Texas MD Anderson Cancer Center, 1400 Pressler St., Unit 1488, Houston, TX, 77030, USA
| | - Jun Liu
- Department of Plastic and Reconstructive Surgery, The University of Texas MD Anderson Cancer Center, 1400 Pressler St., Unit 1488, Houston, TX, 77030, USA
| | | | - Gabrielle Rocque
- Division of Hematology and Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | | | - Adeyiza O Momoh
- Section of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Nicole E Caston
- Division of Hematology and Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Courtney P Williams
- Division of Hematology and Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Stephanie Wheeler
- Department of Health Policy and Management, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Anaeze C Offodile Ii
- Department of Plastic and Reconstructive Surgery, The University of Texas MD Anderson Cancer Center, 1400 Pressler St., Unit 1488, Houston, TX, 77030, USA.
- Department of Health Policy Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
- Baker Institute for Public Policy, Rice University, Houston, TX, USA.
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Hassan AM, Nguyen HT, Corkum JP, Liu J, Kapur SK, Chu CK, Tamirisa N, Offodile AC. Area Deprivation Index is Associated with Variation in Quality of Life and Psychosocial Well-being Following Breast Cancer Surgery. Ann Surg Oncol 2023; 30:80-87. [PMID: 36085393 DOI: 10.1245/s10434-022-12506-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 08/18/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Neighborhood-level factors have been shown to influence surgical outcomes through material deprivation, psychosocial mechanisms, health behaviors, and access to resources. To date, no study has examined the relationship between area-level deprivation (ADI) and post-mastectomy outcomes. METHODS A cross-sectional survey of adult female breast cancer patients who underwent lumpectomy or mastectomy between January 2018 to June 2019 was carried out. Patient-specific characteristics and ADI information were abstracted and correlated with postoperative global- (SF-12) and condition-specific (BREAST-Q) quality-of-life performance via multivariable regression. Patients were classified into three ADI terciles: 0-39 (low deprivation), 40-59 (moderate deprivation), and 60-100 (high deprivation). RESULTS A total of 564 consecutive patients were identified, being mostly white (75%) with mean age of 60.2 ± 12.4 years, median body mass index of 27.8 [interquartile range (IQR) 24.3-32.2) kg/m2, median Charlson Comorbidity Index of 3 (IQR 2-5), and mean ADI of 42.3 ± 25.7. African American and Hispanic patients and those with high BMI were more likely to reside in highly deprived neighborhoods (p = 0.003 and p < 0.001). In adjusted models, patients in highly deprived neighborhoods had significantly lower mean SF-12 physical (44.9 [95% CI, 43.8-46.0] versus 44.9 [95% CI, 43.7-46.1] versus 46.3 [95% CI, 45.3-47.3], p = 0.03) and BREAST-Q psychosocial well-being scores (63.5 [95% CI, 59.32-67.8] versus 69.3 [95% CI, 65.1-73.6] versus 69.7 [95% CI, 66.4-73.1], p = 0.01) relative to moderate- and low-deprivation groups. CONCLUSIONS Patients residing in the most deprived neighborhoods were identified to have worse psychological well-being and quality-of-life. The ADI should be incorporated into the shared decision-making process and perioperative counseling to engender value-based and personalized care, especially for vulnerable populations.
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Affiliation(s)
- Abbas M Hassan
- Department of Plastic & Reconstructive Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Huan T Nguyen
- Department of Plastic & Reconstructive Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Joseph P Corkum
- Department of Plastic & Reconstructive Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jun Liu
- Department of Plastic & Reconstructive Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sahil K Kapur
- Department of Plastic & Reconstructive Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Carrie K Chu
- Department of Plastic & Reconstructive Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Nina Tamirisa
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Anaeze C Offodile
- Department of Plastic & Reconstructive Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA. .,Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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10
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Hassan AM, Nguyen HT, Corkum JP, Liu J, Kapur SK, Chu CK, Tamirisa N, Offodile AC. ASO Visual Abstract: The Area Deprivation Index is Associated with Variation in Quality of Life and Psychosocial Well-being After Breast Cancer Surgery. Ann Surg Oncol 2023; 30:90-91. [PMID: 36125569 DOI: 10.1245/s10434-022-12554-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Abbas M Hassan
- Department of Plastic and Reconstructive Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Huan T Nguyen
- Department of Plastic and Reconstructive Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Joseph P Corkum
- Department of Plastic and Reconstructive Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jun Liu
- Department of Plastic and Reconstructive Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sahil K Kapur
- Department of Plastic and Reconstructive Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Carrie K Chu
- Department of Plastic and Reconstructive Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Nina Tamirisa
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Anaeze C Offodile
- Department of Plastic and Reconstructive Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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11
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Chu CK, Hanasono MM, Chang EI. Treatment of multiple limb lymphedema with combined supermicrosurgical techniques. Microsurgery 2023; 43:13-19. [PMID: 35244958 DOI: 10.1002/micr.30878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Revised: 01/01/2022] [Accepted: 02/24/2022] [Indexed: 01/12/2023]
Abstract
INTRODUCTION Lymphedema surgery including lymphovenous anastomosis (LVA) and vascularized lymph node transfer (VLNT) are effective treatments for lymphedema; however, treating multiple limbs in a single operation using both approaches has not been described. We hypothesize multiple limb lymphedema can be treated effectively in one operation. PATIENT AND METHODS Retrospective review of seven patients undergoing extreme lymphedema surgery (mean age: 53.2 years; range: 33-66 years) with an average BMI of 34.8 kg/m2 (range: 17.6-53.6 kg/m2 ). Two patients developed bilateral upper extremity (UE) lymphedema secondary to breast cancer treatment, three had bilateral lower extremity (LE) lymphedema, and two suffered from lymphedema of all four extremities due to breast cancer treatment. RESULTS One patient with bilateral UE lymphedema was treated with bilateral inguinal node transfers with LVA and the other with combined bilateral DIEP flaps and inguinal node transfers with LVA. Three patients had bilateral LE lymphedema: two were treated with split omental/gastroepiploic nodes, and one underwent simultaneous supraclavicular and submental node transfers. LVAs were performed in one leg in each patient. Two patients with four-limb lymphedema underwent bilateral inguinal node transfers with DIEP flaps and bilateral LE LVA. In total, there were eight UE and 10 LE treated. Average follow-up was 15.8 months (range: 12.6-28.4 months), all patients reported subjective improvement in symptoms, were able to decrease use of compression garments and pumps, and no patients developed cellulitis. CONCLUSION Patients suffering from lymphedema of multiple extremities can be treated safely and effectively combining both LVA and VLNT in a single operation.
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Affiliation(s)
- Carrie K Chu
- Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Matthew M Hanasono
- Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Edward I Chang
- Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Elmorsi R, Asaad M, Badawi O, Mahapure KS, Selber J, Clemens MW, Chu CK, Offodile AC, Butler CE. Master's Degrees Among Academic Plastic Surgeons and Plastic Surgery Residents: What Are the Trends? Ann Plast Surg 2022; 89:478-486. [PMID: 36279571 DOI: 10.1097/sap.0000000000003295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND As more plastic surgery clinicians pursue advanced degrees and strive to become stronger physician-scientists, an objective understanding of how such degrees influence careers becomes important. We hypothesized that having a master's degree is associated with higher scholarly activity, research funding, academic progression, and leadership appointments. METHODS Accreditation Council for Graduate Medical Education-accredited integrated plastic surgery residency program Web sites were queried to create a data set of current academic plastic surgeons (APSs) and plastic surgery residents (PSRs). Scholarly metrics such as publications, citations, and H-indices were extracted from the Scopus database. National Institutes of Health and Plastic Surgery Foundation funding information was collected through their respective Web sites. RESULTS Our cohort comprised 799 APSs and 922 PSRs, of whom 8% and 7.4%, respectively, had at least one master's degree. Academic plastic surgeons with master's of public health degrees had a significantly higher median number of publications and citations than APSs without a master's of public health. There was no association between any master's degree and academic rank or being a department chairman or program director. Academic plastic surgeons with master of science degrees were more likely to receive National Institutes of Health grants. Among PSRs, master's of science graduates had a higher median number of publications. Other master's degrees did not significantly influence scholarly productivity or funding. CONCLUSIONS Certain master's degrees had an impact on scholarly productivity, with no significant effect on academic rank or leadership positions. The value of master's degrees in programs focusing on healthcare management, leadership skills, and business acumen likely extends beyond the scope of this study.
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Affiliation(s)
- Rami Elmorsi
- From the Faculty of Medicine, Mansoura University, Dakahlia, Egypt
| | - Malke Asaad
- Department of Plastic and Reconstructive Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Omar Badawi
- From the Faculty of Medicine, Mansoura University, Dakahlia, Egypt
| | - Kiran S Mahapure
- Department of Plastic Surgery, KAHER J. N. Medical College, Belgaum, India
| | - Jesse Selber
- Department of Plastic and Reconstructive Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Mark W Clemens
- Department of Plastic and Reconstructive Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Carrie K Chu
- Department of Plastic and Reconstructive Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Anaeze C Offodile
- Department of Plastic and Reconstructive Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Charles E Butler
- Department of Plastic and Reconstructive Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX
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13
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Hassan AM, Chu CK, Liu J, Angove R, Rocque G, Gallagher KD, Momoh AO, Caston NE, Williams CP, Wheeler S, Butler CE, Offodile AC. Determinants of telemedicine adoption among financially distressed patients with cancer during the COVID-19 pandemic: insights from a nationwide study. Support Care Cancer 2022; 30:7665-7678. [PMID: 35689108 PMCID: PMC9187333 DOI: 10.1007/s00520-022-07204-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Accepted: 06/03/2022] [Indexed: 02/07/2023]
Abstract
PURPOSE Telemedicine use during the COVID-19 pandemic among financially distressed patients with cancer, with respect to the determinants of adoption and patterns of utilization, has yet to be delineated. We sought to systematically characterize telemedicine utilization in financially distressed patients with cancer during the COVID-19 pandemic. METHODS We conducted a cross-sectional analysis of nationwide survey data assessing telemedicine use in patients with cancer during the COVID-19 pandemic collected by Patient Advocate Foundation (PAF) in December 2020. Patients were characterized as financially distressed by self-reporting limited financial resources to manage out-of-pocket costs, psychological distress, and/or adaptive coping behaviors. Primary study outcome was telemedicine utilization during the pandemic. Secondary outcomes were telemedicine utilization volume and modality preferences. Multivariable and Poisson regression analyses were used to identify factors associated with telemedicine use. RESULTS A convenience sample of 627 patients with cancer responded to the PAF survey. Telemedicine adoption during the pandemic was reported by 67% of patients, with most (63%) preferring video visits. Younger age (19-35 age compared to ≥ 75 age) (OR, 6.07; 95% CI, 1.47-25.1) and more comorbidities (≥ 3 comorbidities compared to cancer only) (OR, 1.79; 95% CI, 1.13-2.65) were factors associated with telemedicine adoption. Younger age (19-35 years) (incidence rate ratios [IRR], 1.78; 95% CI, 24-115%) and higher comorbidities (≥ 3) (IRR; 1.36; 95% CI, 20-55%) were factors associated with higher utilization volume. As area deprivation index increased by 10 units, the number of visits decreased by 3% (IRR 1.03, 95% CI, 1.03-1.05). CONCLUSIONS The rapid adoption of telemedicine may exacerbate existing inequities, particularly among vulnerable financially distressed patients with cancer. Policy-level interventions are needed for the equitable and efficient provision of this service.
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Affiliation(s)
- Abbas M Hassan
- Department of Plastic & Reconstructive Surgery, The University of Texas MD Anderson Cancer Center, 1400 Pressler St., Unit 1488, Houston, TX, 77030, USA
| | - Carrie K Chu
- Department of Plastic & Reconstructive Surgery, The University of Texas MD Anderson Cancer Center, 1400 Pressler St., Unit 1488, Houston, TX, 77030, USA
| | - Jun Liu
- Department of Plastic & Reconstructive Surgery, The University of Texas MD Anderson Cancer Center, 1400 Pressler St., Unit 1488, Houston, TX, 77030, USA
| | | | - Gabrielle Rocque
- Division of Hematology and Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | | | - Adeyiza O Momoh
- Section of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Nicole E Caston
- Division of Hematology and Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Courtney P Williams
- Division of Hematology and Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Stephanie Wheeler
- Department of Health Policy and Management, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Charles E Butler
- Department of Plastic & Reconstructive Surgery, The University of Texas MD Anderson Cancer Center, 1400 Pressler St., Unit 1488, Houston, TX, 77030, USA
| | - Anaeze C Offodile
- Department of Plastic & Reconstructive Surgery, The University of Texas MD Anderson Cancer Center, 1400 Pressler St., Unit 1488, Houston, TX, 77030, USA.
- Institute for Cancer Care Innovation, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
- Baker Institute for Public Policy, Rice University, Houston, TX, USA.
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14
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Mitchell D, Asaad M, Slovacek C, Selber JC, Clemens MW, Chu CK, Mericli AF, Largo RD, Butler CE. Outcomes of Autologous Free Flap Reconstruction Following Infected Device Explantation. J Reconstr Microsurg 2022; 39:327-333. [PMID: 35988578 DOI: 10.1055/s-0042-1755263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
Abstract
Background Following implant-based breast reconstruction (IBR) infection and explantation, autologous reconstruction is a common option for patients who desire further reconstruction. However, few data exist about the outcomes of secondary autologous reconstruction (i.e., free flap breast reconstruction) in this population. We hypothesized that autologous reconstruction following infected device explantation is safe and has comparable surgical outcomes to delayed-immediate reconstruction.
Methods We conducted a retrospective analysis of patients who underwent IBR explantation due to infection from 2006 through 2019, followed by secondary autologous reconstruction. The control cohort comprised patients who underwent planned primary delayed-immediate reconstruction (tissue expander followed by autologous flap) in 2018.
Results We identified 38 secondary autologous reconstructions after failed primary IBR and 52 primary delayed-immediate reconstructions. Between secondary autologous and delayed-immediate reconstructions, there were no significant differences in overall complications (29 and 37%, respectively, p = 0.45), any breast-related complications (18 and 21%, respectively, p = 0.75), or any major breast-related complications (13 and10%, respectively, p = 0.74). Two flap losses were identified in the secondary autologous reconstruction group while no flap losses were reported in the delayed-immediate reconstruction group (p = 0.18).
Conclusion Autologous reconstruction is a reasonable and safe option for patients who require explantation of an infected prosthetic device. Failure of primary IBR did not confer significantly higher risk of complications after secondary autologous flap reconstruction compared with primary delayed-immediate reconstruction. This information can help plastic surgeons with shared decision-making and counseling for patients who desire reconstruction after infected device removal.
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Affiliation(s)
- David Mitchell
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Malke Asaad
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Cedar Slovacek
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jesse C. Selber
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Mark W. Clemens
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Carrie K. Chu
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Alexander F. Mericli
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Rene D. Largo
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Charles E. Butler
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
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15
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Hassan A, Nguyen HT, Corkum JP, Liu J, Kapur SK, Chu CK, Butler CE, Offodile AC. Association between area deprivation index and quality of life and psychosocial well-being following breast cancer surgery. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.e18612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e18612 Background: Neighborhood-level factors have been shown to influence surgical outcomes through material deprivation, psychosocial mechanisms, health behaviors, and access to resources. To date, no study has been conducted to examine the relationship between area-level deprivation (ADI) and post-mastectomy outcomes. Methods: We conducted a cross-sectional survey of all adult female breast cancer patients who underwent lumpectomy or mastectomy between January 2018 to June 2019. Patient-specific demographics, clinical history and ADI information were abstracted and correlated with post-operative global- (SF-12) and condition-specific (Breast-Q) quality-of-life performance via multivariable regression. Patients were classified into three groups based on their ADI scores: 0–39 (prosperous/comfortable), 40–59 (mid-tier), and 60–100 (at risk/distressed). Results: A total of 564 consecutive patients were identified; mostly white (75%) with a mean age of 60.2±12.4, mean body mass index (BMI) of 28.8±7.1, mean Charlson Comorbidity Index of 3.5±2.0, and mean ADI of 42.3±25.7. Minority patients and those with high BMI were more likely to reside in highly-deprived neighborhoods (p = 0.003 and p < 0.001). In adjusted models, Patients at risk/distressed had significantly lower mean SF-12 physical (44.9 [95%CI, 43.8-46.0] vs. 44.9 [95%CI, 43.7-46.1] vs. 46.3 [95%CI, 45.3-47.3], p = 0.03) and BREAST-Q psychosocial well-being scores (63.5 [95%CI, 59.32-67.8] vs. 69.3 [95%CI, 65.1-73.6] vs. 69.7 [95%CI, 66.4-73.1], p = 0.01) than the mid-tier and prosperous/comfortable groups. Conclusions: Patients residing in deprived neighborhoods were more likely to have worse psychological well-being and quality of life. ADI should be incorporated in the shared-decision making process and perioperative counselling to engender value-based and personalized care, especially for vulnerable populations.
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Affiliation(s)
| | - Huan T Nguyen
- University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Jun Liu
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Sahil K Kapur
- University of Texas MD Anderson Cancer Center, Houston, TX
| | - Carrie K. Chu
- University of Texas MD Anderson Cancer Center, Houston, TX
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16
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Hassan A, Chu CK, Liu J, Angove R, Rocque GB, Gallagher KD, Momoh AO, Caston NE, Williams C, Wheeler SB, Butler CE, Offodile AC. Telemedicine adoption and utilization among financially distressed patients with cancer during the COVID-19 pandemic: Insights from a longitudinal nationwide survey. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.1596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
1596 Background: Telemedicine use during the COVID-19 pandemic among financially distressed patients with cancer, with respect to the determinants of adoption and patterns of utilization, has yet to be delineated. We sought to systematically characterize telemedicine utilization in financially distressed patients with cancer during the COVID-19 pandemic. Methods: We conducted an analysis of survey data assessing the use of telemedicine in patients with cancer during the COVID-19 pandemic collected by Patient Advocate Foundation (PAF) from May 2020 to December 2020. Primary study outcome was telemedicine utilization rate. Secondary outcomes were independent predictors of telemedicine utilization patterns, volume, and utilization preferences. Multivariate and poisson regression analyses were used to identify predictive factors. Results: Of the 1,390 respondents, 627 completed two survey waves and were included in this study. Telemedicine adoption during the pandemic was reported by 67% of patients, with most (63%) preferring video visits. Younger age (odds ratio, 6.07; 95% CI, 1.47-25.1), and higher comorbidities (odds ratio, 1.79; 95% CI, 1.13-2.65) were independent predictors associated with telemedicine adoption. Younger age (19-35 yrs.) (incidence rate ratios [IRR], 1.78; 95%CI, 24-115%) and higher comorbidities (≥3) (IRR; 1.36; 95%CI, 20-55%) were independent predictors associated with higher utilization volume. As area deprivation index increased by 10 units, the number of visits decreased by 3% (IRR 1.03, 95%CI, 1.03-1.05). Conclusions: The rapid adoption of telemedicine may exacerbate existing inequities, particularly among vulnerable financially under-resourced patients with cancer. Policy-level interventions are needed for the equitable and efficient provision of this service.
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Affiliation(s)
| | - Carrie K. Chu
- University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jun Liu
- The University of Texas MD Anderson Cancer Center, Houston, TX
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17
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Pettit RW, Kaplan J, Delancy MM, Reece E, Winocour S, Offodile AC, Kumar A, Chu CK. Industry Payments to Plastic Surgeons: What Has Changed Over the Last 6 Years Following Implementation of the Physician Payments Sunshine Act? Aesthet Surg J 2022; 42:210-221. [PMID: 33780536 DOI: 10.1093/asj/sjab158] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The Open Payments Program, as designated by the Physician Payments Sunshine Act, is the single largest repository of industry payments made to licensed physicians within the United States. Though sizeable in its dataset, the database and user interface are limited in their ability to permit expansive data interpretation and summarization. OBJECTIVES The authors sought to comprehensively compare industry payments made to plastic surgeons with payments made to all surgeons and all physicians to elucidate industry relationships since implementation. METHODS The Open Payments Database was queried between 2014 and 2019, and inclusion criteria were applied. These data were evaluated in aggregate and for yearly totals, payment type, and geographic distribution. RESULTS A total 61,000,728 unique payments totaling $11,815,248,549 were identified over the 6-year study period; 9089 plastic surgeons, 121,151 surgeons, and 796,260 total physicians received these payments. Plastic surgeons annually received significantly less payment than all surgeons (P = 0.0005). However, plastic surgeons did not receive significantly more payment than all physicians (P = 0.0840). Cash and cash equivalents proved to be the most common form of payment; stock and stock options were least commonly transferred. Plastic surgeons in Tennessee received the most in payments between 2014 and 2019 (mean $76,420.75). California had the greatest number of plastic surgeons who received payments (1452 surgeons). CONCLUSIONS Plastic surgeons received more in industry payments than the average of all physicians but received less than all surgeons. The most common payment was cash transactions. Over the past 6 years, geographic trends in industry payments have remained stable.
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Affiliation(s)
- Rowland W Pettit
- Baylor College of Medicine, Department of Medicine, Houston, TX, USA
| | - Jordan Kaplan
- Baylor College of Medicine, Department of Plastic Surgery, Houston, TX, USA
| | | | - Edward Reece
- Baylor College of Medicine, Division of Plastic Surgery, Houston, TX, USA
| | - Sebastian Winocour
- Baylor College of Medicine, Division of Plastic Surgery, Houston, TX, USA
| | - Anaeze C Offodile
- Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Anand Kumar
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Carrie K Chu
- Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston, TX, USA
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18
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Conlon C, Pupa L, Reece EM, Chu CK, Yu JZ, Vorstenbosch J, Winocour S. When Benign Becomes Cancer: Malignant Degeneration of Chronic Inflammation. Semin Plast Surg 2021; 35:159-163. [PMID: 34526863 DOI: 10.1055/s-0041-1731462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Chronic inflammation, long implicated in the genesis of malignancy, is now understood to underlie an estimated 25% of all cancers. The most pertinent malignancies, to the plastic surgeon, associated with the degeneration of chronic inflammation include Marjolin's ulcer, breast implant-associated large cell lymphoma, radiation-induced sarcoma, and Kaposi's sarcoma. The cellular and genetic damage incurred by a prolonged inflammatory reaction is controlled by an increasingly understood cytokinetic system. Advances in understanding the chronic inflammatory cascade have yielded new therapeutics and therapeutic targets.
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Affiliation(s)
- Christopher Conlon
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Lauren Pupa
- School of Medicine, Baylor College of Medicine, Houston, Texas
| | - Edward M Reece
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas.,Division of Plastic Surgery, Texas Children's Hospital, Houston, Texas
| | - Carrie K Chu
- Department of Plastic Surgery, MD Anderson Cancer Center, University of Texas, Houston, Texas
| | - Jessie Z Yu
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | | | - Sebastian Winocour
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
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19
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Normandin S, Safran T, Winocour S, Chu CK, Vorstenbosch J, Murphy AM, Davison PG. Negative Pressure Wound Therapy: Mechanism of Action and Clinical Applications. Semin Plast Surg 2021; 35:164-170. [PMID: 34526864 DOI: 10.1055/s-0041-1731792] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Negative pressure wound therapy (NPWT) promotes healing by evenly applying negative pressure on the surface of the wound. The system consists of a sponge, a semiocclusive barrier, and a fluid collection system. Its effectiveness is explained by four main mechanisms of action, including macrodeformation of the tissues, drainage of extracellular inflammatory fluids, stabilization of the environment of the wound, and microdeformation. Rarely will complications linked to NPWT occur, but special care must be taken to prevent events such as toxic shock syndrome, fistulization, bleeding, and pain. New NPWT modalities have been recently developed to make NPWT suitable for a wider variety of wounds. These include NPWT with instillation therapy (NPWTi-d), different cleansing options, and application of NPWT on primarily closed incisions. Finally, vacuum-assisted wound closure therapy has been demonstrated to be efficient for various clinical settings, such as the management of diabetic foot ulcers, pressure ulcerations, chronic wounds, and skin grafts.
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Affiliation(s)
- Shanel Normandin
- Faculty of Medicine, Universite de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Tyler Safran
- Division of Plastic Surgery, McGill University, Montreal, Quebec, Canada
| | - Sebastian Winocour
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Carrie K Chu
- Department of Plastic Surgery, MD Anderson Cancer Center, Houston, Texas
| | | | - Amanda M Murphy
- Division of Plastic Surgery, McGill University, Montreal, Quebec, Canada
| | - Peter G Davison
- Division of Plastic Surgery, McGill University, Montreal, Quebec, Canada
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Safran T, Nepon H, Chu CK, Winocour S, Murphy AM, Davison PG, Dionisopolos T, Vorstenbosch J. Current Concepts in Capsular Contracture: Pathophysiology, Prevention, and Management. Semin Plast Surg 2021; 35:189-197. [PMID: 34526867 DOI: 10.1055/s-0041-1731793] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Over 400,000 women in the United States alone will have breast implant surgery each year. Although capsular contracture represents the most common complication of breast implant surgery, surgeons continue to debate the precise etiology. General agreement exists concerning the inflammatory origin of capsular fibrosis, but the inciting events triggering the inflammatory cascade appear to be multifactorial, making it difficult to predict why one patient may develop capsular contracture while another will not. Accordingly, researchers have explored many different surgical, biomaterial, and medical therapies to address these multiple factors in an attempt to prevent and treat capsular contracture. In the current paper, we aim to inform the reader on the most up-to-date understanding of the pathophysiology, prevention, and treatment of capsular contracture.
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Affiliation(s)
- Tyler Safran
- Division of Plastic Surgery, McGill University, Montreal, Quebec, Canada
| | - Hillary Nepon
- Division of Experimental Surgery, McGill University, Montreal, Quebec, Canada
| | - Carrie K Chu
- Department of Plastic Surgery, MD Anderson Cancer Center, Houston, Texas
| | - Sebastian Winocour
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Amanda M Murphy
- Division of Plastic Surgery, McGill University, Montreal, Quebec, Canada
| | - Peter G Davison
- Division of Plastic Surgery, McGill University, Montreal, Quebec, Canada
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Abstract
Wounds resulting from wide local excision of melanoma vary in size and complexity, and require individualized solutions to achieve satisfactory closure. Goals of reconstruction include restoration of form, function, and aesthetics while minimizing donor site morbidity without compromising the effectiveness and safety of oncologic melanoma treatment. Optimal reconstruction relies on an in-depth understanding of the defect, locoregional anatomy and vasculature, available donor tissues, and basic wound healing and surgical principles. This article provides a broad overview of preoperative patient, timing, and wound considerations; various surgical techniques for complex reconstruction throughout the body; and postoperative care and complication management.
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Affiliation(s)
- Alejandro R Gimenez
- Division of Plastic Surgery, Baylor College of Medicine, 6701 Fannin Street, Suite 610, Houston, TX 77030, USA. https://twitter.com/AGimenezMD
| | - Sebastian J Winocour
- Division of Plastic Surgery, Baylor College of Medicine, 1977 Butler Boulevard, Suite E6.100, Houston, TX 77030, USA. https://twitter.com/WinocourMD
| | - Carrie K Chu
- Department of Plastic Surgery, The University of Texas M. D. Anderson Cancer Center, 1400 Pressler Street, Unit 1488, Houston, TX 77030, USA.
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Manolidis S, Mentz JA, Davis MJ, Abu-Ghname A, Chu CK, Buchanan EP, Winocour S. Bringing Your Idea to the Market: A Primer for Plastic Surgeons. Plast Reconstr Surg 2021; 148:475-481. [PMID: 34398102 DOI: 10.1097/prs.0000000000008231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
SUMMARY The progress of biotechnology, medical instruments, and applied sciences contributes to a rapidly expanding space for the advancement of the medical field. Surgeons experience first-hand the limitations of current medical devices and thus have unique insight into problems that could be solved with new products. The process of turning an idea into a product capable of success in the marketplace, however, is often unfamiliar to surgeons. The authors seek to illuminate this process and provide an ordered list of tasks that can make bringing ideas to market more achievable for surgeons. The first step in this process is the generation and protection of a new idea. Next, the process of making an idea into a product is outlined. This phase involves team assembly, business planning, and product development. Market research and valuation are key to understanding how a product can be applied in the market, and meticulous research during this phase allows for informed decision-making that will help secure funding down the road. Finally, various options for financing are discussed and compared to help surgeon-entrepreneurs find an option that best fits their project, and steps to maximize leverage are described. The development of new products can be a complicated process for surgeons. Organized into four phases, with ordered instructional steps to advance through each phase, the process of bringing an idea to the market is clarified. Facilitating this process will possibly contribute to the continual improvement of medical and surgical abilities through the introduction of new devices and technologies.
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Affiliation(s)
- Spiros Manolidis
- From the Department of Otology, Neurotology, Texas Health Care PLLC; Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine; Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital; and Department of Plastic Surgery, University of Texas M. D. Anderson Cancer Center
| | - James A Mentz
- From the Department of Otology, Neurotology, Texas Health Care PLLC; Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine; Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital; and Department of Plastic Surgery, University of Texas M. D. Anderson Cancer Center
| | - Matthew J Davis
- From the Department of Otology, Neurotology, Texas Health Care PLLC; Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine; Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital; and Department of Plastic Surgery, University of Texas M. D. Anderson Cancer Center
| | - Amjed Abu-Ghname
- From the Department of Otology, Neurotology, Texas Health Care PLLC; Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine; Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital; and Department of Plastic Surgery, University of Texas M. D. Anderson Cancer Center
| | - Carrie K Chu
- From the Department of Otology, Neurotology, Texas Health Care PLLC; Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine; Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital; and Department of Plastic Surgery, University of Texas M. D. Anderson Cancer Center
| | - Edward P Buchanan
- From the Department of Otology, Neurotology, Texas Health Care PLLC; Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine; Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital; and Department of Plastic Surgery, University of Texas M. D. Anderson Cancer Center
| | - Sebastian Winocour
- From the Department of Otology, Neurotology, Texas Health Care PLLC; Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine; Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital; and Department of Plastic Surgery, University of Texas M. D. Anderson Cancer Center
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Nemir S, Hanson SE, Chu CK. Surgical Decision Making in Autologous Fat Grafting: An Evidence-Based Review of Techniques to Maximize Fat Survival. Aesthet Surg J 2021; 41:S3-S15. [PMID: 34002765 DOI: 10.1093/asj/sjab080] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Autologous fat grafting is an important tool in plastic surgery and is widely used for a variety of applications, both aesthetic and reconstructive. Despite an ever-increasing list of indications and extensive research over many years into improving outcomes, fat grafting remains plagued by incomplete and often unpredictable graft survival. Decisions made at each stage of surgery can potentially contribute to ultimate success, including donor site selection and preparation, fat harvest, processing, and purification of lipoaspirate, recipient site preparation, and delivery of harvested fat to the recipient site. In this review, we examine the evidence for and against proposed techniques at each stage of fat grafting. Areas of consensus identified include use of larger harvesting and grafting cannulas and slow injection speeds to limit cell damage due to shearing forces, grafting techniques emphasizing dispersion of fat throughout the tissue with avoidance of graft pooling, and minimizing exposure of the lipoaspirate to the environment during processing. Safety considerations include use of blunt-tipped needles or cannulas to avoid inadvertent intravascular injection as well as awareness of cannula position and avoidance of danger zones such as the subgluteal venous plexus. We believe that using the evidence to guide surgical decision-making is the key to maximizing fat grafting success. Level of Evidence: 4.
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Affiliation(s)
- Stephanie Nemir
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Texas Tech University Health Sciences Center El Paso, El Paso, TX, USA
| | - Summer E Hanson
- Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, IL, USA
| | - Carrie K Chu
- Department of Plastic Surgery, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Chu CK, Roubaud MS, Butler CE. An introduction to "New Frontiers in Breast Reconstruction". Gland Surg 2021; 10:395-397. [PMID: 33633997 DOI: 10.21037/gs-2020-nfbr-13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Carrie K Chu
- Department of Plastic and Reconstructive Surgery, University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Margaret S Roubaud
- Department of Plastic and Reconstructive Surgery, University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Charles E Butler
- Department of Plastic and Reconstructive Surgery, University of Texas, MD Anderson Cancer Center, Houston, TX, USA
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Abstract
Immediate oncoplastic breast reconstruction performed at the time of breast conserving surgery for the treatment of breast cancer merges the therapeutic goals of complete oncologic extirpation with preservation of breast form and function. A constellation of surgical techniques that employs breast volume displacement and/or replacement methods of varying complexity levels have emerged, thus broadening the potential applications for breast conservation therapy to include cases with increased tumor-to-native breast-volume ratios, multicentric or multifocal disease, and/or previous margin-positive resections. This review describes the various reconstructive methods, including the use of local tissue rearrangement, oncoplastic reduction-mastopexy, and locoregional flaps. Classification of the surgical options into levels I and II volume-displacement and volume-replacing techniques is made. Additionally, we explore the oncologic safety and effectiveness of this treatment paradigm by summarizing existing supportive evidence regarding associated risk of surgical complications, rate of margin-positive resection, implications for radiographic surveillance, local recurrence rates, and patient-reported outcomes. In conclusion, surgeons may use a wide variety of oncoplastic techniques for partial breast reconstruction at the time of segmental mastectomy to deliver effective breast conserving treatment for women with breast cancer. A growing body of literature affirms the oncologic safety of this approach. Future directions for research include long-term follow-up data with emphasis on outcomes from patient perspectives.
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Affiliation(s)
- Carrie K Chu
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Summer E Hanson
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Rosa F Hwang
- Department of Breast Surgical Oncology, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Liza C Wu
- Section of Plast Reconstr Surg, Department of Surgery, The University of Pennsylvania Health System, Philadelphia, PA, USA
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27
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Largo RD, Chu CK, Chang EI, Liu J, Abu-Ghname A, Wang H, Schaverien MV, Mericli AF, Hanasono MM, Yu P. Perforator Mapping of the Profunda Artery Perforator Flap: Anatomy and Clinical Experience. Plast Reconstr Surg 2020; 146:1135-1145. [PMID: 32826732 DOI: 10.1097/prs.0000000000007262] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Discovering alternatives to workhorse flaps that have more consistent anatomy and lower donor-site morbidity has become a focus of reconstructive surgery research. This study provides a simplified approach to profunda artery perforator flap design and harvest based on reliable anatomical landmarks. METHODS A retrospective review was conducted of 70 patients who underwent 83 profunda artery perforator flap reconstructions for postoncologic defects from 2016 to 2018. The authors recorded and analyzed the profunda artery perforator flap sizes and clinical applications, the numbers and locations of the perforators, and the patient outcomes. RESULTS Most of the profunda artery perforator flaps were for head and neck [46 patients (65.7 percent)] and breast [21 patients (30 percent)] reconstructions. Flaps were most commonly based on perforator A (33.7 percent) and perforator B (33.7 percent), followed by perforators B and C combined (18.1 percent). Perforators were located a mean of 7.5 cm (perforator A), 12.7 cm (B), and 17.6 cm (C) distal to the pubic tubercle parallel to the axis between the pubic tubercle and the medial femoral condyle and 7.9 cm (A), 7.3 cm (B), and 6.1 cm (C) posterior from the axis. There was no flap loss. One patient underwent successful salvage surgery after arterial flap thrombosis. Eight patients (9.6 percent) developed superficial wound dehiscence that was managed conservatively. CONCLUSIONS Perforator mapping demonstrated consistent anatomical locations of sizeable profunda artery perforators in the inner thigh. Along with its consistent and robust vascular anatomy and minimal donor-site morbidity, the profunda artery perforator flap's volume and pliability make it a reliable option for soft-tissue reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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Affiliation(s)
- Rene D Largo
- From the Department of Plastic Surgery, University of Texas M. D. Anderson Cancer Center
| | - Carrie K Chu
- From the Department of Plastic Surgery, University of Texas M. D. Anderson Cancer Center
| | - Edward I Chang
- From the Department of Plastic Surgery, University of Texas M. D. Anderson Cancer Center
| | - Jessie Liu
- From the Department of Plastic Surgery, University of Texas M. D. Anderson Cancer Center
| | - Amjed Abu-Ghname
- From the Department of Plastic Surgery, University of Texas M. D. Anderson Cancer Center
| | - Hui Wang
- From the Department of Plastic Surgery, University of Texas M. D. Anderson Cancer Center
| | - Mark V Schaverien
- From the Department of Plastic Surgery, University of Texas M. D. Anderson Cancer Center
| | - Alex F Mericli
- From the Department of Plastic Surgery, University of Texas M. D. Anderson Cancer Center
| | - Matthew M Hanasono
- From the Department of Plastic Surgery, University of Texas M. D. Anderson Cancer Center
| | - Peirong Yu
- From the Department of Plastic Surgery, University of Texas M. D. Anderson Cancer Center
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Winocour S, Tarassoli S, Chu CK, Liu J, Clemens MW, Selber JC. Comparing Outcomes of Robotically Assisted Latissimus Dorsi Harvest to the Traditional Open Approach in Breast Reconstruction. Plast Reconstr Surg 2020; 146:1221-1225. [PMID: 33234946 DOI: 10.1097/prs.0000000000007368] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND Robotically assisted latissimus dorsi harvest permits harvest of the latissimus dorsi muscle without a back incision, as compared to the traditional open technique. The authors hypothesized that robotic harvest has lower donor-site complication rates, decreased opioid requirements, and a shorter length of stay than the traditional open technique. METHODS A retrospective review was performed of all consecutive pedicled latissimus dorsi flaps for breast reconstruction between 2011 and 2015. All procedures were conducted by two surgeons who performed both robotic and open cases. RESULTS Fifty-two patients were identified; 25 underwent robotically assisted latissimus dorsi harvest and 27 underwent the open technique. Demographic data between the two groups were similar. Median length of stay for robotic harvest was shorter than that for the traditional technique (2 days versus 3 days; p = 0.031). Postoperative morphine requirement was less in the robotic compared to the traditional technique, but the difference was not significant (158 mg versus 184 mg; p = 0.826). Seroma rate was higher in the robotic group (16 percent versus 0 percent; p = 0.034). The mean duration of surgery was longer in the robotic cohort (388 minutes versus 311 minutes; p = 0.002). CONCLUSIONS This study demonstrates robotically assisted latissimus dorsi harvest as an effective alternative to the traditional open technique in select patients. Advantages of robotic harvest include no back scar, a shorter length of stay, and lower opioid requirements, although the difference was not significant; disadvantages include longer operative time and a higher seroma rate. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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Affiliation(s)
- Sebastian Winocour
- From the Division of Plastic Surgery, Baylor College of Medicine; and the Department of Plastic Surgery, University of Texas M. D. Anderson Cancer
| | - Sam Tarassoli
- From the Division of Plastic Surgery, Baylor College of Medicine; and the Department of Plastic Surgery, University of Texas M. D. Anderson Cancer
| | - Carrie K Chu
- From the Division of Plastic Surgery, Baylor College of Medicine; and the Department of Plastic Surgery, University of Texas M. D. Anderson Cancer
| | - Jun Liu
- From the Division of Plastic Surgery, Baylor College of Medicine; and the Department of Plastic Surgery, University of Texas M. D. Anderson Cancer
| | - Mark W Clemens
- From the Division of Plastic Surgery, Baylor College of Medicine; and the Department of Plastic Surgery, University of Texas M. D. Anderson Cancer
| | - Jesse C Selber
- From the Division of Plastic Surgery, Baylor College of Medicine; and the Department of Plastic Surgery, University of Texas M. D. Anderson Cancer
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Chu CK. Commentary on: The Leaky Pipeline of Women in Plastic Surgery: Embracing Diversity to Close the Gender Disparity Gap. Aesthet Surg J 2020; 40:1251-1252. [PMID: 32050019 DOI: 10.1093/asj/sjz365] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Carrie K Chu
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Chu CK, Butler CE. How Much Flap to Take? Invited Commentary on "Comparisons Between Normal Body Mass Index and Overweight Patients Who Underwent Unilateral Microsurgical Breast Reconstructions". Ann Surg Oncol 2020; 28:22-23. [PMID: 32996018 DOI: 10.1245/s10434-020-09185-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 09/18/2020] [Indexed: 11/18/2022]
Affiliation(s)
- Carrie K Chu
- Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Charles E Butler
- Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Asaad M, Xu Y, Chu CK, Shih YCT, Mericli AF. The impact of co-surgeons on complication rates and healthcare cost in patients undergoing microsurgical breast reconstruction: analysis of 8680 patients. Breast Cancer Res Treat 2020; 184:345-356. [DOI: 10.1007/s10549-020-05845-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 07/28/2020] [Indexed: 11/30/2022]
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Chu CK, Fang L, Kaplan J, Liu J, Hanasono MM, Yu P. The chicken or the egg? Relationship between venous congestion and hematoma in free flaps. J Plast Reconstr Aesthet Surg 2020; 73:1442-1447. [PMID: 32209324 DOI: 10.1016/j.bjps.2020.02.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Accepted: 02/11/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Postoperative hematoma and venous congestion after free tissue transfer may occur independently or concurrently. We aimed to explore the association between these two events. METHODS All free flap reconstructions for head and neck (HN) and breast from a single institution between 2004 and 2014 were retrospectively reviewed for reoperation for venous congestion and/or hematoma. RESULTS There were 2985 free flap cases for HN reconstruction and 2345 cases for breast reconstruction. In HN, 100 patients developed a hematoma (3.4%) and 84 patients developed venous congestion (2.8%). The prevalence of hematoma was 17.8% and 2.9% in the presence and absence of congestion, respectively (p<0.001). Among the 15 patients who had both hematoma and venous congestion were separate events that occurred from 1 to 9 days apart in 8 patients. Hematoma caused the compression of the pedicle vein in 4 patients, while venous congestion possibly caused hematoma in 3 patients. In breast, 56 patients developed a hematoma (2.4%) and 64 patients developed venous congestion (2.7%). The prevalence of hematoma was 12.5% and 2.1% in the presence and absence of congestion, respectively (p<0.001). In the 8 patients who developed both, hematoma and congestion were separate events in 4 patients. Venous congestion caused hematoma in 3 patients, and hematoma caused venous congestion in 1 patient. CONCLUSIONS Although postoperative hematoma and venous congestion often present concurrently, most events are not causally associated. When related, however, venous congestion leading to hematoma is more common in breast reconstruction, while hematoma preceding venous congestion is more common in HN reconstruction.
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Affiliation(s)
- Carrie K Chu
- Department of Plastic Surgery, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA.
| | - Lin Fang
- The Plastic Surgery Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Jordan Kaplan
- Department of Plastic Surgery, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Jun Liu
- Department of Plastic Surgery, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Matthew M Hanasono
- Department of Plastic Surgery, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Peirong Yu
- Department of Plastic Surgery, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
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Abstract
The past two decades have witnessed a growing application of autologous fat grafting in the setting of breast reconstruction after surgical treatment of breast cancer. While traditionally used to correct contour deformities during secondary revisions, fat grafting has since evolved to achieve desired breast shape and size both as a complementary adjunct to established reconstructive techniques as well as a standalone technique for whole breast reconstruction. In this article, we will review fat grafting as an adjunct to autologous and implant-breast based reconstruction, an option for primary breast reconstruction, and a treatment of postmastectomy pain.
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Affiliation(s)
- Acara Turner
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Amjed Abu-Ghname
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Matthew J Davis
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Sebastian J Winocour
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Summer E Hanson
- Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Carrie K Chu
- Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas
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Chu CK, Bedrosian I. Prophylactic Mastectomy and Breast Reconstruction in Patients at High Risk for Breast Cancer. Curr Breast Cancer Rep 2020. [DOI: 10.1007/s12609-020-00355-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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DeFazio MV, Arribas EM, Ahmad FI, Le-Petross HT, Liu J, Chu CK, Santiago L, Clemens MW. Application of Three-Dimensional Printed Vascular Modeling as a Perioperative Guide to Perforator Mapping and Pedicle Dissection during Abdominal Flap Harvest for Breast Reconstruction. J Reconstr Microsurg 2020; 36:325-338. [PMID: 32000277 DOI: 10.1055/s-0039-1700991] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Advancements in three-dimensional (3D) printing have enabled production of patient-specific guides to aid perforator mapping and pedicle dissection during abdominal flap harvest. We present our early experience using this tool to navigate deep inferior epigastric artery (DIEA) topography and evaluate its impact on operative efficiency and clinical outcomes. PATIENTS AND METHODS Between January 2013 and December 2018, a total of 50 women underwent computed tomographic angiography (CTA)-guided perforator mapping prior to abdominal flap breast reconstruction, with (n = 9) and without (n = 41) 3D-printed vascular modeling (3DVM). Models were assessed for their accuracy in identifying perforator location and source-vessel anatomy, as determined by operative findings from 18 hemi-abdomens. The margin of error (MOE) for perforator localization using 3DVM was calculated and compared with CTA-derived measurements for the same patients. Flap harvest times, outcomes, and complications for patients who were preoperatively mapped using 3DVM versus CTA alone were analyzed. RESULTS Overall, complete concordance was observed between 3DVM and operative findings with regards to perforator number, source-vessel origin, and DIEA branching pattern. By comparison, CTA interpretation of these parameters inaccurately identified branching pattern and perforator source-vessel origin in 28 and 33% of hemi-abdomens, respectively (p = 0.045 and p = 0.02). Compared with operative measurements, the average MOE for perforator localization using 3DVM was significantly lower than that obtained from CTA alone (0.81 vs. 8.71 mm, p < 0.0001). Reference of 3D-printed models, intraoperatively, was associated with a mean reduction in flap harvest time by 21 minutes (60.7 vs. 81.7 minutes, p < 0.001). Although not statistically significant, rates of perforator-level injury, microvascular insufficiency, and fat necrosis were lower among patients mapped using 3DVM. CONCLUSION The results of this study support the accuracy of 3DVM for identifying DIEA topography and perforator location. Application of this technology may translate to enhanced operative efficiency and fewer perfusion-related complications for patients undergoing abdominal free flap breast reconstruction.
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Affiliation(s)
- Michael V DeFazio
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Elsa M Arribas
- Department of Radiology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Faisal I Ahmad
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Huong T Le-Petross
- Department of Radiology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jun Liu
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Carrie K Chu
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Lumarie Santiago
- Department of Radiology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Mark W Clemens
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
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Chu CK, DeFazio M, Largo RD, Ross M. Bilateral Breast Reconstruction With Profunda Artery Perforator Flaps and Immediate Implant Augmentation. Aesthet Surg J Open Forum 2020; 2:ojz036. [PMID: 33791635 PMCID: PMC7671255 DOI: 10.1093/asjof/ojz036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
The smaller volume of the profunda artery perforator (PAP) flap relative to that of abdominal flaps limits the size of breast reconstruction that may be achieved. Immediate implant augmentation of abdominal free flaps has been performed, but immediate implant augmentation of PAP flaps has never been described. A 54-year-old woman with BRCA2 mutation, submuscular implants, and previous abdominoplasty presented for nipple-sparing mastectomies (NSM). Autologous tissue volume was inadequate to support reconstruction to the desired size. She wished to avoid serial expansion. Skin quality was unsuitable for direct-to-implant reconstruction. The patient underwent bilateral NSM. The previous implants were removed with capsule preservation. Bilateral PAP flaps were harvested and anastomosed to the internal mammary vessels. Moderate classic profile 170-mL smooth round silicone implants were placed into the existing capsule pockets with lateral capsulorraphy. There were no flap, implant, or infectious complications. Initial mastectomy skin and nipple ischemia completely resolved without necrosis. Donor site healing was uneventful. At 8 months, the reconstruction is supple and the implants remain well-positioned without rippling. One minor revision was performed for fat grafting and to correct lateral nipple deviation. PAP flap breast reconstruction with immediate implant augmentation is technically feasible. Advantages include improved prosthetic coverage, allowing for immediate reconstruction to a larger size with reduced concern regarding mastectomy skin necrosis and threat to the device, optimal implant camouflage, and improved substrate for secondary fat grafting if necessary. Level of Evidence: 5 ![]()
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Affiliation(s)
- Carrie K Chu
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Michael DeFazio
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Rene D Largo
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Merrick Ross
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
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Abstract
Nipple sparing mastectomy has been popularized in the modern era of breast cancer treatment due to its touted advantages with regard to resultant body image and reconstructive outcome. Implant-based techniques remain the most prevalent means of breast reconstruction. Special considerations regarding patient selection and technique are reviewed for implant reconstruction in the setting of mastectomy with nipple preservation. Applications for prepectoral and direct-to-implant reconstruction are discussed and published outcomes are summarized.
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Affiliation(s)
- Carrie K Chu
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Matthew J Davis
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Amjed Abu-Ghname
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Sebastian J Winocour
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Albert Losken
- Division of Surgical Oncology, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia.,Division of Plastic and Reconstructive Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Grant W Carlson
- Division of Surgical Oncology, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia.,Division of Plastic and Reconstructive Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
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Jabbour SF, DeFazio MV, Yu P, Chu CK. The Superficial Ulnar Artery "Trap" Flap: Pearls and Pitfalls to Guide Aberrant Flap Harvest. J Reconstr Microsurg 2019; 35:e1-e2. [PMID: 31450250 DOI: 10.1055/s-0039-1695730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Samer F Jabbour
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Michael V DeFazio
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Peirong Yu
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Carrie K Chu
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
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Chang EI, Chu CK, Chang EI. Advancements in imaging technology for microvascular free tissue transfer. J Surg Oncol 2018; 118:729-735. [DOI: 10.1002/jso.25194] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 07/10/2018] [Indexed: 11/06/2022]
Affiliation(s)
| | - Carrie K. Chu
- Department of Plastic SurgeryThe University of Texas MD Anderson Cancer CenterHouston Texas
| | - Edward I. Chang
- Department of Plastic SurgeryThe University of Texas MD Anderson Cancer CenterHouston Texas
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Weiss A, Chu CK, Lin H, Shen Y, Shaitelman SF, Garvey PB, Bedrosian I, Babiera GV. Reconstruction in the Metastatic Breast Cancer Patient: Results from the National Cancer Database. Ann Surg Oncol 2018; 25:3125-3133. [PMID: 30109538 DOI: 10.1245/s10434-018-6693-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2018] [Indexed: 11/18/2022]
Abstract
PURPOSE Modern treatments are prolonging life for metastatic breast cancer patients. Reconstruction in these patients is controversial. The purpose of this study was to characterize de novo metastatic breast cancer patients who undergo mastectomy and reconstruction and to report complication and survival rates. METHODS We queried the National Cancer Database for de novo metastatic breast cancer patients, who underwent systemic therapy and mastectomy with reconstruction (R) or without reconstruction (NR) between 2004 and 2013. Patient-tumor characteristics, mortality, and readmissions were compared. Propensity score matched analysis was performed, and survival was calculated using the Kaplan-Meier method. RESULTS A total of 8554 patients fulfilled study criteria (n = 980/11.5% R vs. n = 7574/88.5% NR). There was a significant increase in reconstruction rates by year: 5.2% in 2004, 14.3% in 2013 (p < 0.0001). Compared with the NR patients, R patients were younger (mean age 49 vs. 58 years, p < 0.0001), more hormone receptor-positive (76.1% vs. 70.5%, p = 0.0004), had lower grade disease (p = 0.0082), and fewer sites of metastases (85.7% had 1 metastasis; 14.3% had ≥ 2 R vs. 79% had 1; 21% had ≥ 2 NR, p = 0.0002). R patients received more hormonal and chemotherapy than NR but equally received radiation. Median overall survival of the total cohort was 45 months, and median overall survivals of R and NR groups by matched analysis were 56.7 and 55.3 months respectively (p = 0.86). Thirty-day mortality (0.2%-R, 0.3%-NR, p = 0.56) and readmissions (5.9%-R, 5.8%-NR, p = 0.81) were similar; 90-day mortality also was similar (1.1%-R vs. 1.6%-NR, p = 0.796). CONCLUSIONS There is an increasing trend to reconstruct metastatic breast cancer patients with low complication rates, without survival compromise. Impact on quality of life warrants further assessment.
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Affiliation(s)
- Anna Weiss
- Department of Surgical Oncology, Brigham and Women's Hospital, Boston, MA, USA.
| | - Carrie K Chu
- Plastic Surgery, UT MD Anderson, Houston, TX, USA
| | - Heather Lin
- Department of Biostatistics, UT MD Anderson, Houston, TX, USA
| | - Yu Shen
- Department of Biostatistics, UT MD Anderson, Houston, TX, USA
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Rawal RK, Konreddy AK, Chu CK. Mechanism of Adefovir, Tenofovir and Entecavir Resistance: Molecular Modeling Studies of How A Novel Anti-HBV Agent (FMCA) Can Overcome the Drug Resistance. Curr Med Chem 2016; 22:3922-32. [PMID: 26336997 DOI: 10.2174/0929867322666150904144802] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2015] [Revised: 08/27/2015] [Accepted: 08/28/2015] [Indexed: 11/22/2022]
Abstract
Regardless of significant improvement in the area of anti-HBV therapy, resistance and cross-resistance against available therapeutic agents are the major consideration in drug discovery of new agents. The present study is to obtain the insight of the molecular basis of drug resistance conferred by the B and C domain mutations of HBV-polymerase on the binding affinity of four anti-HBV agents [Adefovir (ADV), Tenofovir (TNF), Entecavir (ETV) & 2'-Fluoro-6'-methylene-carbocyclic adenosine (FMCA)]. In this regard, homology modeled structure of HBV polymerase was used for minimization, conformational search and Glide XP docking followed by binding energy calculation on wild-type as well as on mutant HBV-polymerases (N236T, L180M+M204V+S202G & A194T). Our studies suggest a significant correlation between the fold resistances and the binding affinity of anti-HBV nucleosides. The domain B residue, L180 is indirectly associated with other active-site hydrophobic residues such as A87, F88 and M204, whereas the domain C residue, M204 is closely associated with sugar/pseudosugar ring positioning in the active site. These hydrophobic residues can directly influence the interaction of the incoming nucleoside triphosphates and change the binding efficacy. The carbohydrate ring part of natural substrate dATP, dGTP, FMCA and ETV, are occupied in similar passion in the grooves of HBV polymerase active site. The exocyclic double bond of Entecavir and FMCA occupies in the backside hydrophobic pocket (made by residues A87, F88, L180and M204), which enhances the overall binding affinity. Additional hydrogen bonding interaction of 2'-fluorine of FMCA with R41 residue of polymerase promotes a positive binding in wild-type as well as in ADVr, ETVr and TNFr with respect to that of entecavir.
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Affiliation(s)
| | | | - C K Chu
- Department of Biomedical & Pharmaceutical Sciences, The University of Georgia College of Pharmacy, Athens, Georgia 30602.
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Manouilov KK, Xu ZS, Manouilova LS, Boudinot FD, Schinazi RF, Chu CK. Lymphatic Targeting of Anti-Human Immunodeficiency Virus Nucleosides: Pharmacokinetics of G′-Deoxy-2′,3′-Didehydrothymidine after Intravenous and Oral Administration of Dipalmitoylphosphatidyl Prodrug to Mice. ACTA ACUST UNITED AC 2016. [DOI: 10.1177/095632029700800503] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The lymphatic system is a primary target for early anti-human immunodeficiency virus drug therapy. Strategies are currently being sought to enhance the delivery of nucleoside analogues such as 3′-deoxy-2′,3′-didehydrothymidine (stavudine; d4T) toward the lymph and lymph nodes. The purpose of this study was to synthesize dipalmitoylphosphatidyl-d4T (DPP-d4T) as a lipophilic prodrug of d4T and to evaluate the lymphatic distribution of d4T following administration of d4T and DPP-d4T to mice. The pharmacokinetics of d4T were characterized following administration of a single intravenous or oral dose of 50 mg kg−1 d4T and an equimolar dose (214 mg kg−1) of DPP-d4T. Concentrations of d4T in serum and lymph nodes were determined by HPLC. Following administration of d4T, the distribution of d4T into lymph nodes was rapid with maximum concentrations observed within 5 min after dosing. The AUC and half-life values of d4T in three groups of lymph nodes were similar to those in serum. Administration of DPP-d4T resulted in significantly lower concentrations of d4T in serum and lymph nodes. Approximately 67% of the intravenously administered DPP-d4T was biotransformed to parent compound. The apparent oral bioavailability of DPP-d4T was low. While the phospholipid prodrug did not increase d4T concentrations in the lymph nodes, it did provide an extended release of the parent nucleoside, resulting in sustained concentrations of d4T.
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Affiliation(s)
- KK Manouilov
- College of Pharmacy, University of Georgia, Athens, GA 30602, USA
| | - Z-S Xu
- College of Pharmacy, University of Georgia, Athens, GA 30602, USA
| | - LS Manouilova
- College of Pharmacy, University of Georgia, Athens, GA 30602, USA
| | - FD Boudinot
- College of Pharmacy, University of Georgia, Athens, GA 30602, USA
| | - RF Schinazi
- Georgia Research Center for AIDS and HIV Infections, Veterans Affairs Medical Center and Laboratory of Biochemical Pharmacology, Department of Pediatrics, Emory University School of Medicine, Decatur, GA 30322, USA
| | - CK Chu
- College of Pharmacy, University of Georgia, Athens, GA 30602, USA
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Chu CK, Carlson G, Losken A. Impact of nipple preservation on implant-based reconstruction outcome. J Am Coll Surg 2014. [DOI: 10.1016/j.jamcollsurg.2014.07.741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Abstract
Nipple sparing mastectomy (NSM) has become an accepted approach in selected cases of breast cancer and prophylactic mastectomy. Various surgical techniques have been described and nipple ischemia has been a common complication. Potential risk factors for nipple ischemia after NSM are examined. To examine predisposing factors for nipple ischemia after NSM. Prospective evaluation of 71 consecutive NSM in 45 patients from 2009 to 2011 was performed. There were 40 mastectomies for cancer (56.3%), and 31 (43.7%) prophylactic mastectomies. In cases of cancer, the ducts were excised from the undersurface of the nipple. Reconstructive methods included: expander 58, latissimus flap/expander 2, implant 10, and free TRAM flap 1. Various patient and technical factors were examined for impact on nipple ischemia. Partial nipple necrosis occurred in 20 cases (28.2%). Nineteen cases healed uneventfully and one required secondary nipple reconstruction. Operations for cancer (OR 10.54, CI 1.88-59.04, p = 0.007) and periareolar incisions (OR 9.69, CI 1.57-59.77, p = 0.014) predisposed to nipple ischemia. Periareolar incisions and dissection of the nipple ducts for cancer have a higher risk of nipple necrosis after NSM.
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Affiliation(s)
- Grant W Carlson
- Division of Plastic Surgery, Emory University School of Medicine, Atlanta, Georgia
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Kneuertz PJ, Patel SH, Chu CK, Fisher SB, Maithel SK, Sarmiento JM, Weber SM, Staley CA, Kooby DA. Laparoscopic distal pancreatectomy: trends and lessons learned through an 11-year experience. J Am Coll Surg 2012; 215:167-76. [PMID: 22632910 DOI: 10.1016/j.jamcollsurg.2012.03.023] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2012] [Revised: 03/12/2012] [Accepted: 03/13/2012] [Indexed: 01/12/2023]
Abstract
BACKGROUND As compared with open distal pancreatectomy, laparoscopic distal pancreatectomy (LDP) is associated with lower morbidity and shorter hospital stays. Existing reports do not elucidate trends in patient selection, technique, and outcomes over time. We aimed to determine outcomes after LDP at a specialized center, analyze trends of patient selection and operative technique, and validate a complication risk score (CRS). STUDY DESIGN Patients undergoing LDP between January 2000 and January 2011 were identified and divided into 2 equal groups to represent our early and recent experiences. Demographics, tumor characteristics, operative technique, and perioperative outcomes were examined and compared between groups. A CRS was calculated for the entire cohort and examined against observed outcomes. RESULTS A total of 132 LDPs were attempted, of which 8 (6.1%) were converted to open procedures. Thirty-day overall and major complication rates were 43.2% and 12.9%, respectively, with mortality < 1%. Pancreatic fistulas occurred in 28 (21%) patients, of which 14 (11%) were clinically significant. Recent LDPs (n = 66) included patients with increasingly severe comorbidities (Charlson scores > 2, 40.9% vs 16.7%, p = 0.003), more proximal tumors (74.2% vs 26.2%, p < 0.001), more extended resections (10.6 vs 8.3 cm, p < 0.001), shorter operative times (141 vs 172 minutes, p = 0.007), and less frequent use of a hand port (25.8% vs 66.6%, p < 0.001). No significant differences were found in perioperative outcomes between the groups. As compared with the hand access technique, the total laparoscopic approach was associated with shorter hospital stays (5.3 vs 6.8 days, p = 0.032). Increasing CRS was associated with longer operative time, significant fistulas, wound infections, blood transfusions, major complications, ICU readmissions, and rehospitalizations. CONCLUSIONS This large, single-institution series demonstrates that despite a shift in patient selection to sicker patients with more proximal tumors, similar perioperative outcomes can be achieved with laparoscopic distal pancreatectomy. The CRS appears to be a reliable preoperative assessment tool for assessing other adverse perioperative outcomes in addition to predicting overall complications and fistulas as originally published.
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Affiliation(s)
- Peter J Kneuertz
- Department of Surgery, Emory University School of Medicine, Atlanta, GA 30322, USA
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Cannon RM, LeGrand R, Chagpar RB, Ahmad SA, McClaine R, Kim HJ, Rupp C, Cho CS, Brinkman A, Weber S, Winslow ER, Kooby DA, Chu CK, Staley CA, Glenn I, Hawkins WG, Parikh AA, Merchant NB, McMasters KM, Martin RCG, Callender GG, Scoggins CR. Multi-institutional analysis of pancreatic adenocarcinoma demonstrating the effect of diabetes status on survival after resection. HPB (Oxford) 2012; 14:228-35. [PMID: 22404260 PMCID: PMC3371208 DOI: 10.1111/j.1477-2574.2011.00432.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND The effect of diabetes on survival after resection pancreatic ductal carcinoma (PDAC) is unclear. The present study was undertaken to determine whether pre-operative diabetes has any predictive value for survival. METHODS A retrospective review from seven centres was performed. Metabolic factors, tumour characteristics and outcomes of patients undergoing resection for PDAC were collected. Univariate and multivariable analyses were performed to determine factors associated with disease-free (DFS) and overall survival (OS). RESULTS Of the 509 patients in the present study, 31.2% had diabetes. Scoring systems were devised to predict OS and DFS based on a training set (n= 245) and were subsequently tested on an independent set (n= 264). Pre-operative diabetes (P < 0.001), tumour size >2 cm (P= 0.001), metastatic nodal ratio >0.1 (P < 0.001) and R1 margin (P < 0.001) all correlated with DFS and OS on univariate analysis. Scoring systems were devised based on multivariable analysis of the above factors. Diabetes and the metastatic nodal ratio were the most important factors in each system, earning two points for OS and four points for DFS. These scoring systems significantly correlated with both DFS (P < 0.001) and OS (P < 0.001). CONCLUSION Pre-operative diabetes status provides useful information that can help to stratify patients in terms of predicted post-operative OS and DFS.
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Affiliation(s)
| | | | | | | | | | - Hong Jin Kim
- Surgery, University of North CarolinaChapel Hill, NC
| | | | | | | | | | | | | | | | | | - Ian Glenn
- Surgery, Washington UniversitySt. Louis, MO
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Evans KK, Attinger CE, Al-Attar A, Salgado C, Chu CK, Mardini S, Neville R. The importance of limb preservation in the diabetic population. J Diabetes Complications 2011; 25:227-31. [PMID: 21447444 DOI: 10.1016/j.jdiacomp.2011.02.001] [Citation(s) in RCA: 94] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2010] [Accepted: 02/15/2011] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Limb salvage in the diabetic population is complex, controversial, costly and variable throughout the world. Within the diabetic population, the indications and morbidity surrounding major leg amputation have not been well defined. RESEARCH DESIGN AND METHODS A retrospective study of the Georgetown Limb Salvage Registry was conducted to determine outcomes in diabetic patients undergoing proximal forefoot/midfoot (PF/M) amputations and to help define the indications for major leg amputation in ambulatory diabetic patients. RESULTS Of the 937 ambulatory diabetic patients identified during this time period, 808 who presented with superficial ulcers or distal forefoot disease and who did not go on to PF/M or higher amputation were eliminated. Records of 88 patients (92 limbs) in the PF/M amputation group and 25 patients in the below the knee amputation (BKA) group were reviewed (no above knee amputations were performed). At 2 years in the PF/M amputation group, 80% (70/88) of patients were still alive, 73% (68/92) of the limbs remained intact, and 64% of patients (56/88) were ambulatory. In contrast, in the BKA population at 2 years, 52% (13/25) of patients were deceased and 64% (16/25) were ambulating with a prosthetic limb (or had been ambulating at the time of death). The only statistically significant difference between these two groups was the presence of Charcot collapse and rear-foot disease in the BKA group. CONCLUSION Aggressive efforts at salvage with PF/M amputation procedures should be entertained prior to higher level amputations due to the increased morbidity and mortality evidenced.
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Affiliation(s)
- Karen Kim Evans
- The Limb Center, Department of Plastic Surgery, Georgetown University Medical Center, 3800 Reservoir Road, N.W., Washington, DC 20007, USA.
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Mayo SC, de Jong MC, Bloomston M, Pulitano C, Clary BM, Reddy SK, Clark Gamblin T, Celinski SA, Kooby DA, Staley CA, Stokes JB, Chu CK, Arrese D, Ferrero A, Schulick RD, Choti MA, Geschwind JFH, Strub J, Bauer TW, Adams RB, Aldrighetti L, Mentha G, Capussotti L, Pawlik TM. Surgery versus intra-arterial therapy for neuroendocrine liver metastasis: a multicenter international analysis. Ann Surg Oncol 2011; 18:3657-65. [PMID: 21681380 DOI: 10.1245/s10434-011-1832-y] [Citation(s) in RCA: 140] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2011] [Indexed: 12/16/2022]
Abstract
BACKGROUND Management of patients with neuroendocrine liver metastasis (NELM) remains controversial. We sought to examine the relative efficacy of surgical management versus intra-arterial therapy (IAT) for NELM and determine factors predictive of survival. METHODS A total of 753 patients who had surgery (n = 339) or IAT (n = 414) for NELM from 1985 to 2010 were identified from nine hepatobiliary centers. Clinicopathologic data were assessed with regression modeling and propensity score matching. RESULTS Most patients had a pancreatic (32%) or a small bowel (27%) primary tumor; 47% had a hormonally active tumor. There were statistically significant differences in characteristics between surgery versus IAT groups (hormonally active tumors: 28 vs. 48%; hepatic tumor burden >25%: 52% vs. 76%) (all P < 0.001). Among surgical patients, most underwent hepatic resection alone without ablation (78%). The median number of IAT treatments was 1 (range, 1-4). Median and 5-year survival of patients treated with surgery was 123 months and 74% vs. 34 months and 30% for IAT (P < 0.001). In the propensity-adjusted multivariate Cox model, asymptomatic disease (hazard ratio 2.6) was strongly associated with worse outcome (P = 0.001). Although surgical management provided a survival benefit over IAT among symptomatic patients with >25% hepatic tumor involvement, there was no difference in long-term outcome after surgery versus IAT among asymptomatic patients (P = 0.78). CONCLUSIONS Asymptomatic patients with a large (>25%) burden of liver disease benefited least from surgical management and IAT may be a more appropriate treatment strategy. Surgical management of NELM should be reserved for patients with low-volume disease or for those patients with symptomatic high-volume disease.
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Affiliation(s)
- Skye C Mayo
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Chu CK, Delman KA, Carlson GW, Hestley AC, Murray DR. Inguinopelvic lymphadenectomy following positive inguinal sentinel lymph node biopsy in melanoma: true frequency of synchronous pelvic metastases. Ann Surg Oncol 2011; 18:3309-15. [PMID: 21541825 DOI: 10.1245/s10434-011-1750-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2010] [Indexed: 02/05/2023]
Abstract
BACKGROUND True frequency of synchronous pelvic metastases with positive inguinal sentinel lymph node (SLN) biopsy is unknown. Role of pelvic dissection in the SLN era is unclear. METHODS From 1994 to 2004, 1 surgeon routinely performed nonselective, complete inguinopelvic lymphadenectomy after positive inguinal SLN biopsy. All cases were identified from a prospectively maintained database. Clinicopathologic features associated with pelvic disease were assessed. RESULTS A total of 40 patients with positive inguinal SLN underwent, without additional selection, 42 complete inguinopelvic lymphadenectomies. Median age was 46.5 years (range 25-79 years); 79% had lower extremity primaries. Median Breslow depth was 2.3 mm (range 1.0-10.0 mm), Clark's IV/V 98%, ulceration 26%. Frequency of synchronous pelvic disease upon completion lymphadenectomy was 5 of 42 (11.9%). Patients with and without pelvic disease were similar in age, sex, Breslow depth, Clark's level, ulceration, and mitoses. All 5 cases with pelvic metastases had extremity primaries (4 distal, 1 proximal). Of the 5, 3 (60%) had ≥3 total involved inguinal nodes, compared with only 1 (2.7%) of the 37 cases without pelvic disease (P=.003). Ratio of positive to total number inguinal nodes retrieved was >0.20 in 80% of cases with pelvic disease and 8.6% of cases without (P=.002). Upon lymphoscintigraphy review, secondary pelvic drainage was present in 80% of cases with pelvic disease compared with 56% of cases without pelvic disease, though the trend was statistically insignificant (P=.63). CONCLUSIONS In this cohort of unselected, SLN-positive patients with complete inguinopelvic lymphadenectomy, frequency of synchronous pelvic disease was 11.9%. Patients with ≥3 total involved inguinal nodes or inguinal node ratio >0.20 appear more likely to harbor pelvic disease.
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Affiliation(s)
- Carrie K Chu
- Division of Surgical Oncology, Department of Surgery, Emory University School of Medicine & The Winship Cancer Institute, Atlanta, GA, USA.
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Schiffman SC, Chu CK, Park J, Russell M, Keilin S, Kooby DA, Scoggins CR, McMasters KM, Martin RC. Is prior cholecystectomy associated with decreased survival in patients with resectable pancreatic adenocarcinoma following pancreaticoduodenectomy? Am J Surg 2011; 201:519-24. [DOI: 10.1016/j.amjsurg.2010.02.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2009] [Accepted: 02/04/2010] [Indexed: 01/23/2023]
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