Francesco M. Egro

The Psychosexual Impact of Partial and Total Breast Reconstruction: A Prospective One-Year Longitudinal Study.

BackgroundThis prospective trial sought to explore patients’ satisfaction and expectations for surgery in the areas of sexuality and body image and to evaluate outcomes pertaining to sexual well-being after total and partial breast reconstruction (BR). MethodsPatients who underwent mastectomy and immediate total BR (group 1; n = 60) or lumpectomy and reduction mammoplasty (group 2; n = 10) completed a questionnaire preoperatively and 1 year postoperatively to assess their satisfaction with their sex life and body image, perceptions of breasts as a source of sexuality, and expectations of surgery in these areas. Surveys were scored on a 5-point Likert scale, with 5 indicating strongly agree. Change scores were evaluated in the 2 groups (P = 0.05). ResultsIn group 1, satisfaction with sex life and body image was unchanged. Pursuit of sexual attractiveness (from 3.78 to 3.31, P = 0.02) and an improved body image (from 3.89 to 3.33, P < 0.01) were cited as expectations for surgery but were achieved less often. When stratified by different types of reconstruction, there were no discernible differences in responses. In group 2, the patients reported an unexpected increase in their partner’s perception of them as womanly (from 1.33 to 2.50, P = 0.01) and greater gains in the ability to wear sexually provocative clothing (from 1.78 to 3.11, P < 0.01).Preoperative expectations for improved body image were more often met in group 2 than group 1 (from 3.60 to 4.00 vs from 3.89 to 3.33, P = 0.02). Group 2 experienced greater improvement in body image satisfaction (from 2.80 to 3.80 vs from 3.37 to 3.44, P = 0.03). ConclusionsOverall satisfaction with sex life and body image was preserved for both groups; however, the oncoplastic approach achieved significantly larger gains in body image perception.

Evaluating outcomes after correction of the breast conservation therapy deformity.

BackgroundIn an effort to preserve the native breast shape, most women with breast cancer are treated with breast conservation therapy (BCT). However, a breast deformity can develop after BCT and can be challenging to repair. The goal of this review was to evaluate outcomes based on the extent of the deformity and reconstructive technique. MethodsSixty-three patients treated for a BCT deformity between 2003 and 2012 were included. Data queried included demographics, extent of the deformity, type of reconstruction, and outcomes. A panel judged aesthetic outcomes, and patient satisfaction was determined using the validated Breast Q reconstruction questionnaire. Comparisons were made across reconstructive techniques. ResultsThere were 22 grade I/II deformities, and 29 grade III/IV deformities. Local scar revision procedures and fat grafting were more common for grade I, and myocutaneous flaps were more common for grade IV. Bilateral reduction techniques (n = 20) and contralateral reduction only (n = 6) were most common for grade II/III defects. Augmentation was used in 9 grade III patients. Combined reconstructive techniques were required in 23% of the patients. Eighty-nine percent had a contralateral symmetry procedure. Complications occurred in 34.9%, with no significant variation across the different modes of reconstruction. There was a trend toward higher complication rates with increasing defect severity (0% for grade 1, 32% for grade 2, 39% for grade 3, and 50% for grade 4). Patients required an average of 1.3 procedures (range, 1–3), at an average follow-up of 2.5 years. Eighty percent of patients had only 1 reconstructive operation, 14% required a second operation, and 6% a third. Patient satisfaction was generally high and the mean aesthetic rating was 5 out of 7, and trended down with the extent of the deformity. Patients who underwent contralateral reduction only had the highest aesthetic scores (5.8/7). ConclusionsReconstructive options for the correction of BCT deformities are numerous and need to be appropriately tailored for each patient in part based on the extent of the deformity. Although revisions are not uncommon, good patient satisfaction and esthetic outcomes can be achieved.

A National Curriculum of Fundamental Skills for Plastic Surgery Residency: Report of the Inaugural ACAPS Boot Camp.

Background The Inaugural American Council of Academic Plastic Surgeons Plastic Surgery Boot Camp program was developed in response to ongoing changes in graduate medical education. The Boot Camp is a hands-on, practicum-based, 3-day course to introduce core concepts in plastic surgery for new plastic surgery residents (in both integrated and independent tracks). Methods The course was held in Pittsburgh in July to August 2015. There were 43 attendees (35 integrated/8 independent) representing 22 residency programs across 15 states. Faculty was composed of 8 local personnel and 5 visiting. Lecture topics and practical sessions covered the full spectrum of plastic surgery. All trainees completed an online survey evaluation both during the course and at 6 months. Results Participant responses were overwhelmingly positive. A total of 72% of respondents rated the Boot Camp ≥ 8 on a 1 to 10 scale (10 is excellent) for the overall course rating; 79% of respondents agreed or strongly agreed with the statement that the simulation scenarios were realistic; and 75% of participants agreed or strongly agreed with the statement that they found simulation-based training to be a valuable way to teach this material. Respondents reported an increase in comfort and confidence across topics after attending the Boot Camp at both 0- and 6-month time points. Instructors received positive evaluations across all topics. Conclusions This successful inaugural course serves as a benchmark for development of a logistical blueprint, business plan, and curriculum for a proposed expansion to regional centers, to potentially encompass all incoming residents in plastic surgery.

Seroconversion rate among health care workers exposed to HIV-contaminated body fluids: The University of Pittsburgh 13-year experience

HighlightsThe studies enumerating the risk of HIV transmission to health care workers as 0.3% after percutaneous exposure to HIV‐positive blood, and 0.09% after a mucous membrane exposure, are weakened by outdated data which precede the introduction of highly active antiretroviral therapy (HAART).A review of worldwide literature showed a lower rate of seroconversion after an occupational exposure.Our study found a seroconversion rate of 0% after occupational exposure to HIV‐contaminated body fluids, which could reflect progress over the last 20 years, since the introduction of HAART. Background The studies enumerating the risk of HIV transmission to health care workers (HCWs) as 0.3% after percutaneous exposure to HIV‐positive blood, and 0.09% after a mucous membrane exposure, are weakened by dated literature. Our study aims to demonstrate the seroconversion rate after exposure to HIV‐contaminated body fluids in a major academic center in the United States. Methods A prospectively maintained database of reported occupational injuries occurring between 2002 and 2015 at an academic medical center was analyzed. Data collected included the type of injury, injured body part, type of fluid, contamination of sharps, involvement of resident physicians, use of postexposure prophylaxis, and patients’ HIV, hepatitis B virus, and hepatitis C virus status. Results A total of 266 cases were included in the study. Most exposures were caused by percutaneous injuries (52.6%), followed by 43.2% mucocutaneous injuries. Of the injuries, 52.6% were to the hand and 33.5% to the face and neck. Blood exposure accounted for 64.3% of all cases. Of the patients, 21.1% received postexposure prophylaxis. None of the HCWs exposed to HIV‐contaminated body fluids seroconverted (seroconversion rate, 0%). Conclusions HIV does not seem to be as easily transmitted by needlestick, laceration, or splash injuries as previously surmised. Further large‐scale and multicenter studies are needed for a more accurate estimation of the risk of transmission of HIV in U.S. health care workers.

Abstract: A Qualitative Survey Study of United States Burn Units

CONCLUSION: The study suggests the closed-loop technique significantly decreases time of fat transfer to an average of 15 minutes, a trend towards decreased overall complications, though not statistically significant, and good subjective fat retention beyond 12 months. This suggests the closed-loop method is safe, effective, and significantly decreases operating time. We continue to collect patients in the closed-loop cohort and are also analyzing variation in adipocyte viability between the two methods.

The ACAPS Plastic Surgery Boot Camp Program: Evaluation of the University of Pittsburgh 3-year Experience

BACKGROUND The American Council of Academic Plastic Surgeons sponsored Plastic Surgery Boot Camp program was developed in response to ongoing changes in graduate medical education. The purpose of this new program was to facilitate the transition of both Integrated and Independent residents into Plastic Surgery training, as current trainees are required to rapidly assimilate knowledge and gain clinical skills to which they have had limited and/or inconsistent exposure during their prior education. The Boot Camp program was introduced in July 2015 in Pittsburgh, PA, and has subsequently expanded to 4 regional sites across the United States due to the use of standardized presentations, increased practical sessions, and streamlined evaluations. The aim of this study was to evaluate the Pittsburgh Plastic Surgery Boot Camp experience over the past 3 years and its impact on participant performance.

Deltoid Compartment Syndrome: A Rare Complication after Humeral Intraosseous Access

Summary: We present a case of a 65-year-old woman who developed a delayed deltoid compartment syndrome after resuscitation via humeral intraosseous access. Initially she was treated conservatively but then was taken emergently for a fasciotomy. After confirming the diagnosis with compartment pressures, a 2-incision approach was employed and a large hematoma was evacuated from the inferior margin of the anterior deltoid. The rest of the deltoid was inspected and debrided to healthy bleeding tissue. Her fasciotomy wounds were left open to heal on their own due to her tenuous clinical condition. At most recent follow-up, she had full range of motion in her shoulder and no residual pain. Our unique case study is the first documented incidence of upper extremity compartment syndrome after intraosseous access. Additionally, our case supports using humeral access only as a second-line option if lower extremity access is not available and prolonged vigilant monitoring after discontinuing intraosseous access to prevent disastrous late complications.

Craniofacial Surgery Fellowship Selection Criteria: A National Program Director Survey

Background: Candidate characteristics for craniofacial fellowship training still remain unknown, as no data are available in the literature. This study aims to provide information on the criteria that are used to select and rank applicants for the craniofacial surgery fellowship match. Method: A 38-question survey was sent in April 2015 to all craniofacial surgery fellowship program directors (n = 29) involved in the US match using QuestionPro Survey Software. The survey investigated factors used for selection of applicants, including medical school, residency training, research experience, fellowship interview, and candidate characteristics. A 5-point Likert scale was used to grade 33 factors from “not at all important” (1) to “essential in making my decision” (5); or for 5 controversial factors from “very negative impact” (1) to “very positive impact in making my decision” (5). Results: A total of 62% (18 out of 29) of responses were received from craniofacial surgery program directors. The most important factors were professionalism and ethics (4.7 ± 0.5), perceived commitment to craniofacial surgery (4.6 ± 0.8), interactions with faculty and staff (4.5 ± 0.5), interpersonal skills (4.5 ± 0.5), and overall interview performance (4.4 ± 0.6). Factors that have a negative impact on the selection process include graduation from a nonplastic surgery residency program (1.9 ± 0.7) or a non-US plastic surgery residency program (2.2 ± 0.6), and visa requirement (2.2 ± 0.5). Conclusion: This study provides data on craniofacial surgery program directors’ perception on the criteria important for fellowship applicant selection. It is our hope that program directors, residency programs, and applicants find this data useful as they prepare for the craniofacial fellowship match.

Hand Surgery Fellowship Selection Criteria: A National Fellowship Director Survey

Background Candidate characteristics for hand surgery fellowship training remains unknown, as very little data is available in the literature. This study aims to provide information on the criteria that are employed to select candidates for the hand surgery fellowship match. Methods A 38-question survey was sent in April 2015 to all Accreditation Council for Graduate Medical Education recognized hand surgery fellowship program directors (n=81) involved in the U.S. match. The survey investigated factors used for the selection of applicants, including medical school, residency training, research experience, fellowship interview, and candidate characteristics. A 5-point Likert scale was used to grade 33 factors from “not at all important” (1) to “essential in making my decision” (5); or for five controversial factors from “very negative impact” (1) to “very positive impact in making my decision” (5). Results A total of 52% (42 out of 81) of responses were received from hand surgery fellowship program directors. The most important influential factors were interactions with faculty during interview and visit (4.6±0.6), interpersonal skills (4.6±0.5), overall interview performance in the selection process (4.6±0.6), professionalism and ethics (4.6±0.7), and letters of recommendation from hand surgeons (4.5±0.7). Factors that have a negative impact on the selection process include visa requirement (2.1±1.2), graduate of non-plastic surgery residency program (2.4±1.3), and graduate of a foreign medical school (2.4±1.1). Conclusions This study provides data on hand surgery fellowship directors’ perception on the criteria important for fellowship applicant selection, and showed that interview-related criteria and letters of recommendation are the important factors.

Reply: The Use of Reduction Mammaplasty with Breast Conservation Therapy

Reply: The Use of Reduction Mammaplasty with Breast Conservation Therapy: An Analysis of Timing and Outcomes Sir: We are most grateful for the comments proposed by Bonomi et al. and their views on the role of pedicled perforator-based breast reconstruction to correct breast conservation therapy deformities. As pointed out by the authors, radiation therapy is a major culprit for the exacerbation of lumpectomy deformities. This causes an increase in breast parenchymal density, skin thickness and tightening, pigmentation changes, breast distortion, and breast shrinkage and fibrosis, with an average of 10 to 20 percent reduction in breast volume.1–4 Moody et al.2 and Gray et al.5 showed that these defects are further enhanced in large breasts as patients develop more asymmetry, retraction, and late irradiation changes. The approach of using oncoplastic reduction mammaplasty at the time of lumpectomy is ideal for patients with macromastia, because it not only reduces the aesthetic burden caused by breast conservation therapy, but also frees the patient from symptoms related to large breasts. However, our article6 did not imply that oncoplastic reduction mammaplasty should be used in all patients undergoing breast conservation therapy; rather, our article aimed to discuss the timing of oncoplastic reduction mammaplasty in women with macromastia: immediate, delayed immediate, and delayed. We agree that, ideally, partial breast reconstruction should be undertaken as an immediate procedure; however, many patients in the United States do not have the option of undergoing reduction mammaplasty at the time of lumpectomy because of lack of resources or adequately trained surgeons. Thus, patients still often present in a delayed fashion. Although complication rates are higher than with an immediate approach, appropriate patient and technique selection can achieve improved outcomes in the delayed group of patients. Reduction mammaplasty is only one of the many techniques at the disposal of the plastic surgeon and does not replace other oncoplastic techniques: volume replacement (e.g., fat grafting, implant placement, local or distant flaps) and volume displacement techniques (e.g., mastopexy). The selection of the appropriate reconstructive technique is based on breast size, tumor site, breast and skin quality, and degree of breast conservation therapy–related deformities. As shown by our previous series and other studies,7–9 less severe deformities and asymmetries tend to be more amenable to local procedures and fat grafting, whereas the more pronounced deformities often required reconstruction with pedicled myocutaneous flaps, with latissimus dorsi myocutaneous flap being the most versatile. The use of perforator flaps (i.e., thoracodorsal artery, lateral intercostal artery, and superior epigastric artery perforator flaps) in oncoplastic surgery has been advocated to reconstruct breasts that are small, with defects that are larger than 30 percent of the breast, or in women who, despite having adequate tissue for volume displacement surgery, prefer to maintain their original breast volume without reducing the contralateral breast.10–13 The main advantages of these techniques, compared with myocutaneous flaps, include a reduction in donor-site morbidity and sparing of muscle function. As our experience with perforator flaps increases, they will likely replace many of the myocutaneous flaps used today. Partial breast reconstruction has greatly evolved over the past two decades with the addition of reduction mammaplasty and pedicled perforator-based flaps to the methods available to the plastic surgeon. We feel that the use of one technique should not exclude the other, and only careful patient selection and the plastic surgeon’s level of experience will dictate surgical morbidity, aesthetic result, and patient satisfaction. DOI: 10.1097/01.prs.0000480004.57551.23