Plastic and Reconstructive Surgeons' Knowledge and Comfort of Contralateral Prophylactic Mastectomy: A Survey of the American Society of Plastic Surgeons

Background: Despite limited oncologic benefit, contralateral prophylactic mastectomy (CPM) rates have increased in the United States over the past 15 years. CPM is often accompanied by breast reconstruction, thereby requiring an interdisciplinary approach between breast and plastic surgeons. Despite this, little is known about plastic surgeons' (PS) perspectives of CPM. The purpose of this study was to assess PS practice patterns, knowledge of CPM oncologic benefits, and perceptions of the CPM decision-making process.Methods: An electronic survey was sent to 2,642 members of the American Society of Plastic Surgeons (ASPS). Questions assessed demographics, practice patterns, knowledge of CPM oncologic benefits, and perceptions of the CPM decision-making process.Results: ASPS response rate was 12.5% (n = 329). Most responders worked in private practice (69%), were male (81%) and had been in practice for ≥15 years (60%). The median number of CPM reconstructions performed per month was 2–4. Fifty-five percent of PS reported routine attendance at a breast multidisciplinary conference. Responders reported CPM discussion was most likely to be initiated by the patient (51%) followed by the breast surgeon (38%), and plastic surgeon (7.3%). According to PS, the most common reason patients choose CPM is a perceived increased contralateral cancer risk (86%). Most plastic surgeons (63%) assessed the benefits of CPM as worth the risk of additional surgery and the majority (53%) estimated the complication rate at 2X the risk of unilateral surgery. The majority (61%) of PS estimated risk of contralateral cancer in an average risk patient between <2 and 5% over 10 years, which is consistent with data reported from the current literature. Most plastic surgeons (87%) reported that there was no evidence or limited evidence for breast cancer specific survival benefit with CPM. A minority of PS (18.5%) reported discomfort with a patient's choice for CPM. Of those surgeons reporting discomfort, the most common reasons for their reservations were a concern with the risk/benefit ratio of CPM and with lack of patient understanding of expected outcomes. Common reasons for PS comfort with CPM were a respect for autonomy and non-oncologic benefits of CPM.Discussion: To our knowledge, this is the first survey reporting PS perspectives on CPM. According to PS, CPM dialogue appears to be patient driven and dominated by a perceived increased risk of contralateral cancer. Few PS reported discomfort with CPM. While many PS acknowledge both the limited oncologic benefit of CPM and the increased risk of complications, the majority have the opinion that the benefits of CPM are worth the additional risk. This apparent contradiction may be due to an appreciation of the non-oncologic benefits CPM and a desire to respect patients' choices for treatment

A Prospective, Randomized, Multicenter Trial Assessing a Novel Lysine-Derived Urethane Adhesive in a Large Flap Surgical Procedure without Drains

Objective To evaluate the safety and effectiveness of a lysine-derived urethane adhesive as a noninvasive alternative to closed suction drains in a commonly performed large flap surgical procedure.MethodsOne hundred thirty subjects undergoing abdominoplasty at five centers were prospectively randomized to standard flap closure with surgical drains (Control group) or a lysine-derived urethane adhesive (Treatment group) without drains. The primary outcome measured was the number of post-operative procedures, including drain removals (as the event marking the use of a surgical drain) and needle aspirations. Secondary endpoints included total wound drainage, cumulative days of treatment, and days to drain removal. A patient questionnaire evaluating quality of life measures was also administered.ResultsSubjects in the Treatment group required significantly fewer post-operative procedures compared to the Control group (1.8±3.8 vs. 2.4±1.2 procedures; p<0.0001) and fewer cumulative days of treatment (1.6±0.4 vs. 7.3±3.3; p<0.0001). A procedure to address fluid accumulation was required for only 27.3% of the subjects in the Treatment group versus 100% of Control group, which by study design required the use of drains. The mean duration of use of indwelling surgical drains for the Control group was 6.9±3.3days. All fluid collections treated with percutaneous aspiration were resolved and there were no unanticipated adverse events.ConclusionThe results of the study support that the use of a lysine-derived urethane adhesive is a safe and effective alternative to drains in patients undergoing a common large flap surgical procedure.Level of Evidence IThis journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266

Finishing the euchromatic sequence of the human genome

The sequence of the human genome encodes the genetic instructions for human physiology, as well as rich information about human evolution. In 2001, the International Human Genome Sequencing Consortium reported a draft sequence of the euchromatic portion of the human genome. Since then, the international collaboration has worked to convert this draft into a genome sequence with high accuracy and nearly complete coverage. Here, we report the result of this finishing process. The current genome sequence (Build 35) contains 2.85 billion nucleotides interrupted by only 341 gaps. It covers ∼99% of the euchromatic genome and is accurate to an error rate of ∼1 event per 100,000 bases. Many of the remaining euchromatic gaps are associated with segmental duplications and will require focused work with new methods. The near-complete sequence, the first for a vertebrate, greatly improves the precision of biological analyses of the human genome including studies of gene number, birth and death. Notably, the human enome seems to encode only 20,000-25,000 protein-coding genes. The genome sequence reported here should serve as a firm foundation for biomedical research in the decades ahead

Porcine Acellular Dermal Matrix for Hernia Repair in Transplant Patients

PURPOSEThe purpose of this study was to compare clinical outcomes of incisional hernia repair in solid organ transplant patients using non–cross-linked porcine acellular dermal matrix (PADM), human derived acellular dermal matrix (HADM) and synthetic mesh. METHODSA retrospective review of patients who underwent hernia repair with PADM after pancreas and/or renal transplant at the University of Maryland Medical Center from 2008 to 2012 was conducted. Repair type, postoperative infection, hernia recurrence, mesh removal, and length of follow-up were recorded. Results were compared with our previously published data evaluating HADM and synthetic mesh used in transplant patients between 2000 and 2005. RESULTSTwenty-seven patients underwent ventral hernia repair with PADM, 34 patients were repaired with HADM and 26 were repaired with synthetic mesh. The rate of wound infection in those repaired with PADM, HADM, and synthetic mesh were 14.8%, 14.7%, and 65.4%, respectively. Rates of recurrence were 13.3%, 23.5%, and 76.9%, respectively. Rate of mesh removal was found to be 7.4%, 11.8%, and 69.2%, respectively. These complication rates were significantly lower in patients who received HADM or PADM compared with patients repaired with synthetic mesh (P < 0.001). There was no statistically significant difference in the outcomes between the groups repaired with HADM or PADM. CONCLUSIONSThe use of PADM for incisional hernia repair after kidney and/or pancreas transplant significantly reduces the incidence of hernia recurrence, wound infection, and need for mesh removal compared to synthetic mesh. No difference in morbidity between HADM and PADM was observed in the study population; however, longer follow-up in the PADM group is warranted

Follow the money: Investigating gender disparity in industry payments among senior academics and leaders in plastic surgery.

IntroductionDifferences in academic qualifications are cited as the reason behind the documented gender gap in industry sponsorship to academic plastic surgeons. Gendered imbalances in academic metrics narrow among senior academic plastic surgeons. However, it is unknown whether this gender parity translates to industry payments.MethodsWe conducted a cross-sectional analysis of industry payments disbursed to plastic surgeons in 2018. Inclusion criteria encompassed (i) faculty with the rank of professor or a departmental leadership position. Exclusion criteria included faculty (i) who belonged to a speciality besides plastic surgery; (ii) whose gender could not be determined; or (iii) whose name could not be located on the Open Payment Database. Faculty and title were identified using departmental listings of ACGME plastic surgery residency programs. We extracted industry payment data through the Open Payment Database. We also collected details on H-index and time in practice. Statistical analysis included odds ratios (OR) and Pearson's correlation coefficient (R).ResultsWe identified 316 senior academic plastic surgeons. The cohort was predominately male (88%) and 91% held a leadership role. Among departmental leaders, women were more likely to be an assistant professor (OR 3.9, p = 0.0003) and heads of subdivision (OR 2.1, p = 0.0382) than men. Industry payments were distributed equally to male and female senior plastic surgeons except for speakerships where women received smaller amounts compared to their male counterparts (median payments of $3,675 vs$7,134 for women and men respectively, pConclusionDisparity in industry funding narrows at senior levels in academic plastic surgery. At higher academic levels, industry sponsorship may preferentially fund individuals based on academic productivity and career length. Increased transparency in selection criteria for speakerships is warranted

Comparison of 3 techniques of fat grafting and cell-supplemented lipotransfer in athymic rats: a pilot study

Given the wide application of autologous fat grafting, a new emphasis on fat processing techniques has emerged in an effort to limit unpredictable degrees of resorption often seen with this procedure. With the growing interest in regenerative medicine, approaches to supplement fat grafts with adipose-derived stem cells are evolving in hopes of promoting vascularization and neoadipogenesis. The authors evaluated the outcomes of the most common processing techniques for fat grafting--decantation, washing, high-speed centrifugation--and stromal vascular cell-supplemented lipotransfer to determine which method yields a higher percentage of retention and better quality graft. A total of 32 subcutaneous injections of processed human lipoaspirate were carried out in 8 athymic rats. Each animal received all 4 processing conditions, with end points at 4, 8, and 12 weeks postinjection. Evaluation of graft survival included serial measurements of volume retention and histologic analysis. At 12 weeks postinjection, cell-supplemented and centrifuged grafts showed the most consistent volume maintenance. Based on histologic analysis, cell-supplemented and washed grafts had higher scores of viability and vascularity, with the former presenting the least cystic necrosis and calcification as well as minimal inflammation. Cell-supplemented lipotransfer had optimal outcomes for graft retention, viability, and vascularity, while washing resulted in high viability with a less intensive process. High-speed centrifugation resulted in consistent volume retention but lower viability. Each of these approaches is ideal under different circumstances and contributes to the versatility and reliability of fat grafting

Pectoralis major turnover versus advancement technique for sternal wound reconstruction

We compared the efficacy of pectoralis turnover versus advancement technique for sternal wound reconstruction. A retrospective chart review was performed, December 1989 to December 2010, to compare postoperative complication rates between pectoralis major turnover versus pectoralis major advancement reconstruction techniques. Complications included hematomas, wound infections, tissue necrosis, dehiscence, and need for reoperation. Pearson χ and logistic regression were used and significance was P < 0.05. Sixty-seven patients received 91 tissue flaps. Eleven patients (16%) required reoperation due to complications, including recurrent wound infection, tissue necrosis, wound dehiscence, mediastinitis, and hematoma formation. Four patients (6%) were treated conservatively for minor complications. Overall, complication rates were significantly higher after pectoralis major advancement reconstruction (32.5% vs. 3.7%, P = 0.004). When feasible, pectoralis major turnover flap offers a superior reconstructive technique for complex sternal wounds, with diminished complications compared with the pectoralis advancement flap