Disparities in Breast Reconstruction: An Analysis of Treatment Choices

BACKGROUND

Breast reconstruction methods vary based on factors such as medical history, breast size, and personal preferences. However, disparities in healthcare exist, and the role race plays in accessing to different reconstruction methods is unclear. This study aimed to investigate the influence of race and/or ethnicity on the type of breast reconstruction chosen.

METHODS

This retrospective cohort study analyzed the University of Pittsburgh Medical Center Magee Women's Hospital database, including patients who underwent breast cancer surgery from 2011 to 2022. Multivariate analysis examined race, reconstruction, and reconstruction type (P < 0.05).

RESULTS

The database included 13,260 women with breast cancer; of whom 1763 underwent breast reconstruction. We found that 91.8% of patients were White, 6.8% Black, and 1.24% were of other races (Asian, Chinese, Filipino, Vietnamese, unknown). Reconstruction types were 46.8% implant, 30.1% autologous, and 18.7% combined. Among Black patients, autologous 36.3%, implant 32.2%, and combined 26.4%. In White patients, autologous 29.5%, implant 48%, and combined 18.2%. Among other races, autologous 36.3%, implant 40.9%, and combined 22.7%. In patients who underwent breast reconstruction, 85.2% underwent unilateral and 14.7% of patients underwent bilateral. Among the patients who had bilateral reconstruction, 92.3% were White, 6.1% were Black, and 1.5% were of other ethnicities.

CONCLUSIONS

Our analysis revealed differences in breast reconstruction methods. Autologous reconstruction was more common among Black patients, and implant-based reconstruction was more common among Whites and other races. Further research is needed to understand the cause of these variations.

Early Return of Motion in Patients With Intramedullary Screw Placement for Metacarpal and Phalangeal Fracture Fixation

INTRODUCTION

Hand fractures are associated with significant morbidity. Current management standards often result in prolonged immobilization, stiffness, and delayed return to functional use. Intramedullary (IM) compression screws offer minimal soft tissue disruption and early postoperative active motion. In this study, we describe our outcomes after intraosseous fracture fixation using IM cannulated headless screws for a multitude of fracture patterns.

METHODS

This study is a retrospective review of patients who underwent IM screw placement for fixation of metacarpal and phalangeal fractures by a single surgeon from 2017 to 2022. Data were collected to include patient demographics, fracture details, postoperative complications, and follow-up. Time to range of motion and return to unrestricted motion was recorded.

RESULTS

There were 69 patients with 92 fractures (n = 54 metacarpal, n = 38 phalanx). The median patient age was 45 years (range, 18-89 years) with 75.4% males. Majority presented with a single fracture (n = 50, 72.5%), and 38 patients (55.1%) had open fractures. Small finger was the most affected digit (n = 35, 37.6%). The median time to allow range of motion from surgery was 8.7 days (interquartile range, 0-32) with 32 days (interquartile range, 10-62) for unrestricted use of the hand. Thirty-five patients (50.7%) were allowed controlled motion from the first postoperative day. One patient had loss of reduction requiring reintervention for hardware removal, and 1 patient had superficial skin infection managed with oral antibiotics.

CONCLUSIONS

Our findings indicate that the IM screw provides reliable fixation for a wide variety of fracture patterns with a low complication rate and offers early return to functional use.

A Model to Study Wound Healing Over Exposed Avascular Structures in Rodents With a 3D-Printed Wound Frame

BACKGROUND

Soft tissue defects with exposed avascular structures require reconstruction with well-vascularized tissues. Extensive research is ongoing to explore tissue engineered products that provide durable coverage. However, there is a lack of controlled and affordable testbeds in the preclinical setting to reflect this challenging clinical scenario. We aimed to address this gap in the literature and develop a feasible and easily reproducible model in rodents that reflects an avascular structure in the wound bed.

METHODS

We created 20 × 20 mm full thickness wounds on the dorsal skin of Lewis rats and secured 0.5-mm-thick silicone sheets of varying sizes to the wound bed. A 3D-printed wound frame was designed to isolate the wound environment. Skin graft and free flap survival along with exposure of the underlying silicone was assessed. Rats were followed for 4 weeks with weekly dressing changes and photography. Samples were retrieved at the endpoint for tissue viability and histologic analysis.

RESULTS

The total wound surface area was constant throughout the duration of the experiment in all groups and the wound frames were well tolerated. The portion of the skin graft without underlying silicone demonstrated integration with the underlying fascia and a histologically intact epidermis. Gradual necrosis of the portion of the skin graft overlying the silicone sheet was observed with varying sizes of the silicone sheet. When the size of the silicone sheet was reduced from 50% of the wound surface area, the portion surviving over the silicone sheet increased at the 4-week timepoint. The free flap provided complete coverage over the silicone sheet.

CONCLUSION

We developed a novel model of rodent wound healing to maintain the same wound size and isolate the wound environment for up to 4 weeks. This model is clinically relevant to a complex wound with an avascular structure in the wound bed. Skin grafts failed to completely cover increasing sizes of the avascular structure, whereas the free flap was able to provide viable coverage. This cost-effective model will establish an easily reproducible platform to evaluate more complex bioengineered wound coverage solutions.

A Strong Approach to a Weak Gastric Wall in Bariatric Surgery: Concurrent Diverticulectomy and Sleeve Gastrectomy

A gastric diverticulum is a rare finding in which the wall of the stomach forms an abnormal sac-like projection. Gastric diverticula can be problematic causing symptoms including but not limited to chronic gastroesophageal reflux, abdominal pain, and bloating. When a gastric diverticulum becomes symptomatic, removal is indicated. In specific cases, laparoscopic gastric diverticula resection can be completed with concurrent bariatric surgery. We report the perioperative approach used in a 34-year-old obese woman with a confirmed symptomatic gastric diverticulum undergoing a gastric diverticulum resection with a concurrent laparoscopic sleeve gastrectomy.

Restricting Intraoperative Fluid Volume Allows Earlier Return of Bowel Function After Colon and Rectal Surgery

BACKGROUND

Return of bowel function (ROBF) after abdominal surgery is an important determinant of patient outcomes. The role of intraoperative fluids (IOFs) in colon surgery remains unclear. The aim of this study was to assess the impact of IOF on ROBF in patients undergoing colon surgery. We hypothesized that minimizing IOFs allows earlier ROBF.

METHODS

A 2-year (2016-2017) retrospective analysis of all patients undergoing elective colon resection was performed at our tertiary hospital using a protocol limiting IOF and postoperative narcotics. Patients were divided into two groups: preprotocol (2016) and postprotocol (PoP) (2017). Patients were matched using propensity score matching for age, gender, comorbidities, Anesthesiology Severity Score, indication for procedure, and procedure type. The outcome measured was ROBF. Secondary outcome measures were complication rates and hospital length of stay.

RESULTS

A total of 360 patients were analyzed. After propensity matching, 90 patients (preprotocol: 45; PoP: 45) were included. The mean age was 62.2 ± 14.8 y, 43.3% male, and 44.4% of procedures were performed laparoscopically. There was no difference in demographics and comorbidities between groups. PoP patients received lower IOF (P = 0.036, 2016: 1198.8 ± 1096.5 mL, 2017: 2176.7 ± 1458.3 mL) and lower postoperative narcotics (P = 0.042). PoP patients had earlier ROBF 2[2-4], 4[3-5] (odds ratio: 1.18 [1.05-1.52], P = 0.04), shorter length of stay 3[2-5] d versus 5[4-7] (odds ratio: 1.11 [1.09-1.89], P = 0.043), and trended toward lower complication rates (P = 0.09).

CONCLUSIONS

IOF volume independently impacts ROBF after colon surgery. Restricting IOF allows for earlier bowel function and shorter hospital stay. Further studies defining optimum fluid management impacting ROBF may help optimize patient care.

A Backwards Approach to Bariatric Surgery: The Perioperative Approach Used in a Woman with Situs Inversus Totalis Undergoing a Laparoscopic Sleeve Gastrectomy

Situs inversus totalis is a rare congenital condition where organs are mirrored across the sagittal plane of the body. In the absence of associated comorbidities, most people have normal health and lifespan. Challenges with mirrored image anatomy arise when needing an operative procedure involving the intraabdominal organs. There are few reported cases in the literature of laparoscopic surgery in patients with situs inversus, with even fewer in the field of bariatric surgery. Obesity and obesity-related comorbidities continue to increase in our society, and bariatric surgery is a treatment option for weight loss. We report the perioperative approach used in a 59-year-old obese woman with confirmed situs inversus totalis undergoing laparoscopic sleeve gastrectomy.