Lemaine, Valérie

Background: Subpectoral tissue expander breast reconstruction is often associated with muscle spasms, pain, and discomfort during tissue expansion. In this study, we hypothesized that an intraoperative injection of botulinum toxin A (BTX-A) in the pectoralis major muscle reduces the pain associated with tissue expansion and improves women’s physical well-being. Methods: Between May 2012 and May 2017, women undergoing immediate subpectoral tissue expander breast reconstruction were randomized to administer 100 units of BTX-A or a placebo injection. A numeric pain intensity scale and the physical well-being scale of the BREAST-Q: Reconstruction Module were used to test our hypothesis. Data on postoperative oral narcotic consumption were not collected. Results: Of the 131 women included in the analysis, 48% were randomized to placebo and 52% to BTX-A. The preoperative median pain intensity score was 0 [interquartile range (IQR), 0–1], and the median preoperative BREAST-Q score was 91 (IQR, 81–100). The median slopes for the change in pain intensity scores from baseline throughout tissue expansion for those randomized to placebo and BTX-A were −0.01 (IQR, −0.02 to 0.00) and −0.01 (IQR, −0.02 to 0.00), respectively (P = 0.55). The median slopes for the change in BREAST-Q scores from baseline throughout tissue expansion for those randomized to placebo and BTX-A were 0.04 (IQR, −0.17 to 0.14) and 0.02 (IQR, −0.06 to 0.13), respectively (P = 0.89). Conclusion: In this study, we found that an intraoperative intramuscular injection of 100 units of BTX-A in the pectoralis major muscle did not reduce postoperative pain and patient-reported physical well-being when compared with placebo.

Background: The authors compared long-term health care use and cost in women undergoing immediate autologous breast reconstruction and implant-based breast reconstruction. Methods: This study was conducted using the OptumLabs Data Warehouse, which contains deidentified retrospective administrative claims data, including medical claims and eligibility information from a large U.S. health insurance plan. Women who underwent autologous or implant-based breast reconstruction between January of 2004 and December of 2014 were included. The authors compared 2-year use rates and predicted costs of care. Comparisons were tested using the t test. Results: Overall, 12,296 women with immediate breast reconstruction were identified; 4257 with autologous (35 percent) and 8039 with implant-based (65 percent) breast reconstruction. The proportion of autologous breast reconstruction decreased from 47.2 percent in 2004 to 32.7 percent in 2014. The mean predicted reconstruction cost of autologous reconstruction was higher than that of implant-based reconstruction in both unilateral and bilateral surgery. Similar results for mean predicted 2-year cost of care were seen in bilateral procedures. However, in unilateral procedures, the 2-year total costs were higher for implant-based than for autologous reconstruction. Two-year health care use rates were higher for implant-based reconstruction than for autologous reconstruction for both unilateral and bilateral procedures. Women undergoing unilateral implant-based reconstruction had higher rates of hospital admissions (30.3 versus 23.1 per 100; p < 0.01) and office visits (2445.1 versus 2283.6 per 100; p < 0.01) than those who underwent autologous reconstruction. Emergency room visit rates were similar between the two methods. Bilateral procedures yielded similar results. Conclusion: Although implant-based breast reconstruction is a less expensive index operation than autologous breast reconstruction, it was associated with higher health care use, resulting in similar total cost of care over 2 years.

AbstractThere has been a shift in recent years toward a growing popularity of implant-based breast reconstruction, especially in the setting of increased frequency of concurrent contralateral prophylactic mastectomy. Advancements in implant safety and technology have also allowed for an expanding implant reconstruction practice across the country. The traditional approach is immediate two-stage implant reconstruction with placement of a tissue expander within a subpectoral pocket. The introduction of acellular dermal matrix has revolutionized implant-based breast reconstruction, allowing surgeons the opportunity to minimize morbidity while maximizing aesthetic outcomes. There have also been advances in the management of postoperative pain control as well as secondary revision surgery.

Background: Surgical-site infection after implant-based breast reconstruction adversely affects surgical outcomes and increases health care costs. This 11-year case-control study examines risk factors specific for surgical-site infection after immediate tissue expander/implant-based breast reconstruction. Methods: The authors performed a retrospective review to identify all consecutive patients with breast implant infections between 2006 and 2016. Patients who developed surgical-site infection after immediate tissue expander/implant-based breast reconstruction were included. Surgical-site infection was defined using the Centers for Disease Control and Prevention criteria; specifically, infections requiring hospital admission, intravenous antibiotics, or surgical intervention were included. The authors matched a control patient to each infection case by patient age and date of surgery. Patient demographics, medical comorbidities, and perioperative surgical variables were examined. Univariate and multivariable conditional logistic regression models were constructed. Results: A total of 270 breasts in 252 patients were evaluated. On multivariate analysis, patients with a higher body mass index (OR, 1.1 per 1 body mass index point increase; 95 percent CI, 1.0 to 1.2; p = 0.02), hypertension (OR, 6.5; 95 percent CI, 1.9 to 22.3; p = 0.002), neoadjuvant chemotherapy (OR, 2.6; 95 percent CI, 1.0 to 6.3; p = 0.04), axillary lymph node dissection (OR, 7.1; 95 percent CI, 1.7 to 29.2; p = 0.006), seroma formation (OR, 15.34; 95 percent CI, 3.7 to 62.5; p = 0.0001), and wound healing complications (OR, 23.91; 95 percent CI, 6.1 to 93.4; p < 0.0001) were significantly associated with surgical-site infection. Conclusions: Women with obesity, women with hypertension, and those treated with neoadjuvant chemotherapy are at increased risk of surgical-site infection. Further risks are also associated with postoperative seroma and wound complications. This may help patient selection and counseling, adjusted based on risk factors regarding complications of immediate implant-based breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Introduction: Long, complex surgical procedures with non-ergonomic postures, headlights, loupe magnification, and microscope use may put craniofacial and maxillofacial surgeons at an increased risk of work-related musculoskeletal discomfort (WRMD). Identifying the prevalence and impact of WRMD may guide preventive strategies to prolong well-being, job satisfaction, and career duration. Methods: A 31-question survey was designed to evaluate WRMD. The survey was sent to American Society of Craniofacial Surgeons and American Society of Maxillofacial Surgeons members. The survey was created and distributed electronically through a private survey research center (Qualtrics Survey Software). Results: There were 95 respondents (23.75% response rate): 75% male, 56% aged 31 to 50 years old, and 73% in academic practice. On a scale of 0 to 10 (0 no pain, 10 worst pain), WRMD for surgery without loupes/microscope had a median of 3, with loupes 4, and with microscope 5. Pain was most common in the neck. Pain within 4 hours of surgery was present in 55% and 38% feared pain would influence future surgical performance. Surgeon discomfort affects posture (72%), stamina (32%), sleep (28%), surgical speed (24%), relationships (18%), and concentration (17%). Medical treatment for discomfort was sought by 22%. Time off work for treatment occurred in 9%. Conclusion: The WRMD can affect many aspects of a craniofacial or maxillofacial surgeon's life and has the potential to shorten or end a career. Occupational health and surgical ergonomics should be emphasized during surgical training and in surgical practice.

Background Long surgical procedures with loupe magnification and microscopes may put microsurgeons at an increased risk of musculoskeletal discomfort. Identifying the prevalence and impact of work-related musculoskeletal discomfort may guide preventive strategies to prolong well-being, job satisfaction, and career duration. Methods An online 29-question survey was designed to evaluate work-related musculoskeletal discomfort. The survey was created and distributed electronically through a private survey research center and was sent to the members of the American Society for Reconstructive Microsurgery. Results There were 117 respondents (16.7% response rate): 80% were men; 69% were aged 31 to 50 years; and 68% were in academic practice. On a scale of 0 to 10 (0, no pain and 10, worst pain), the median for work-related musculoskeletal discomfort for surgery without loupes or microscope was 2; with loupes, 4; and with a microscope, 5. Pain was most common in the neck. Half of the surgeons reported pain within 4 hours of surgery, and 57% feared that pain would influence future surgical performance. Surgeon discomfort affected posture (72%), stamina (36%), sleep (29%), relationships (25%), concentration (22%), and surgical speed (19%). Tremor caused by the discomfort occurred in 8%. Medical treatment for discomfort was sought by 29%. Time off work for treatment occurred for 8%. Conclusion Work-related musculoskeletal discomfort can affect many aspects of a microsurgeon's life and has the potential to limit a surgeon's ability to operate. Therefore, more emphasis is needed in the surgical community on the important issues of occupational health and surgical ergonomics for microsurgeons.

Microsurgery is considered one of the most demanding surgical techniques. In a recent American Society of Reconstructive Microsurgeons survey, respondents reported that about half their procedures lasted 8 hours or longer and 8% had tremor during their surgery. Thus, the aim of this study was to define user centered design requirements for a microsurgery armrest, create low-fidelity armrest design concepts and evaluate microsurgeons’ perspectives on the advantages/disadvantages of five potential design concepts. Direct and videotaped observations of microsurgery, user brainstorming during a co-creation workshop and semi-structured interviews were used. The resulting five microsurgery armrest concepts were presented pictorially through semi-structured interviews, where microsurgeons defined armrest design requirements as: a) an armrest that allows the surgeons to be as close as possible to the patient; b) adjustable to accommodate different procedures sites and surgeon preferences; c) rigid enough to support arms; d) is not difficult to set up; nor e) large or bulky; and f) complies with operative sterility rules. This study illustrated how involving the users (microsurgeons) early in the design process provides useful perspectives on design requirements and implementation barrier for a cost-effective ergonomic microsurgery armrest to foster sound ergonomic surgical practice and reduce musculoskeletal health risk factors during microsurgery.

6531 Background: Annual mammography is recommended to screen residual breast tissue for new cancers and recurrent disease after treatment for early stage breast cancer. This study aimed to assess mammography rates over time in breast cancer survivors. Methods: We used administrative claims data from a large U.S. commercial insurance database, OptumLabs, to retrospectively identify privately- and Medicare Advantage-insured women with operable breast cancer who had residual breast tissue after definitive breast surgery between 2006 and 2015. We required coverage for at least 13 months following surgery. For each subsequent 13-month time period, we only included women without a loss of coverage, bilateral mastectomy, metastatic breast cancer diagnosis, or non-breast cancer diagnosis. We calculated the proportion of patients who had a mammogram during each 13-month period following breast surgery. We used multivariable logistic regression to test for factors associated with mammography in the first 13 months. Results: The cohort included 26,011 women followed for a median of 2.9 years (IQR 1.9-4.6) after surgery; 63.1% were less than 65 years of age, and 74.4% were white. In their first year of follow-up, 86% underwent mammography, but by year 7, this decreased to 73%. Fewer than 1% underwent MRI instead of mammography. In multivariable analysis, mammograms were less likely during the first year after surgery among women aged < 50 years (odds ratio [OR], 0.7; 95% confidence interval [CI], 0.6 to 0.8), African Americans (OR, 0.7; 95% CI, 0.7 to 0.8), patients who underwent mastectomy (OR, 0.7; 95% CI, 0.6 to 0.7), and patients residing in the Western part of the country (OR, 0.9; 95% CI, 0.7 to 0.9). Those with 1-2 comorbidities were more likely (OR, 1.1; 95% CI 1.1-1.2) than those with none to have a mammogram during that period. Mammography use did not differ significantly by year of diagnosis (2006-2015). Conclusions: Even in an insured cohort, a substantial proportion of breast cancer survivors do not undergo annual surveillance mammography. Mammography use falls as the time from the early stage breast cancer diagnosis increases. Understanding factors associated with lack of mammographic screening may help improve survivorship care.

Background: Two-stage subpectoral implant-based breast reconstruction is the most common method for breast reconstruction. Recent advances in surgical techniques and technology have made prepectoral implant-based breast reconstruction feasible. There are limited data on outcomes after prepectoral implant-based breast reconstruction and postmastectomy radiation therapy. Methods: A retrospective review of consecutive patients undergoing immediate two-stage prepectoral implant-based breast reconstruction with postmastectomy radiation therapy was performed. Outcomes of irradiated breasts were compared with nonirradiated breasts in bilateral cases. Results: Ninety-three cases of prepectoral implant-based breast reconstruction in 54 women who underwent immediate two-stage reconstruction (39 bilateral and 15 unilateral) and unilateral postmastectomy radiation therapy were identified. Mean follow-up was 19 months from mastectomy and tissue expander reconstruction and 9 months from implant placement. Crude complication rates in irradiated versus nonirradiated sides were as follows: surgical-site infection, 18.5 percent versus 7.7 percent; seroma, 5.6 percent versus 5.1 percent; mastectomy skin flap necrosis, 1.9 percent versus 2.6 percent; wound dehiscence, 1.9 percent versus 7.7 percent; capsular contracture, 1.9 percent versus 0 percent; hematoma, 1.9 percent versus 2.6 percent; and extrusion, 1.9 percent versus 0 percent. On univariate analysis, there were no risk factors associated with any complication, including radiation therapy, surgical-site infection, unplanned readmissions, and unplanned return to the operating room. To date, reconstruction has been completed in 96 percent of patients, with successful implant-based breast reconstruction in 81 breasts (45 irradiated breasts and 36 nonirradiated breasts). Conclusions: Early data of prepectoral implant-based breast reconstruction in patients with postmastectomy radiation therapy show promising results. Postmastectomy radiation therapy should not be an absolute contraindication to prepectoral implant-based breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.