Jonathan Winograd - Academia.edu (original) (raw)
Papers by Jonathan Winograd
Plastic and Reconstructive Surgery, Mar 1, 2018
have served as consultants for Allergan and LifeCell, and Dr. Liao has served as a consultant for... more have served as consultants for Allergan and LifeCell, and Dr. Liao has served as a consultant for Musculoskeletal Transplant Foundation. There are no other disclosures.
Annals of Surgery, Oct 25, 2019
Objectives: This study evaluates complications and reconstructive failure rates in implant-based ... more Objectives: This study evaluates complications and reconstructive failure rates in implant-based reconstruction with radiotherapy. Background: Postmastectomy radiotherapy may adversely affect breast reconstructive outcomes. However, the comparative effect of radiotherapy on direct-to-implant versus tissue expander-implant reconstruction has not been examined. Methods: Single institution retrospective review was performed and patients were followed 2 to 10 years. Results: Of 1566 patients, 265 patients received radiation (149 immediate implants and 116 tissue expanders). Demographics were similar except more smokers in the expander group (7.7% vs 1.3%; P ¼ 0.012). Patients who received radiation with an expander in place had overall more complications (32.8% vs 11.4%; P < 0.001), skin necrosis (10.3% vs 4.0%; P ¼ 0.043), wound breakdown (9.5% vs 2.7%; P ¼ 0.029), and infections (16.4% vs 4.03%; P ¼ 0.001) leading to a higher rate of explantation (16.4% vs 4.0%; P < 0.001). A radiation boost likewise predicted complications [odds ratio (OR) 2.199, 95% confidence interval (CI) 1.154-4.188, P ¼ 0.017]. When comparing reconstructive outcomes, radiated expanders had a higher failure rate (21.6% vs 11.4%; P ¼ 0.025). Revision for capsular contracture was similar between the 2 cohorts (11.4% vs 11.2%; P ¼ 0.959) as were revision rates for contour asymmetry and breast asymmetry. In our multivariable logistic regression analysis, radiation to the expander had a higher risk of reconstruction failure than radiation to the permanent implant (OR 2.020, 95% CI 1.010-4.037, P ¼ 0.047). Conclusion: Most patients had successful implant-based reconstructions after mastectomy and radiotherapy. Our study showed radiotherapy after direct-to-implant breast reconstruction had a lower rate of complications and reconstructive failure compared to tissue expander-implant reconstruction.
Plastic and Reconstructive Surgery, Apr 1, 2014
ABSTRACT
Plastic and Reconstructive Surgery, Apr 1, 2015
Breast Cancer Research and Treatment, Jun 30, 2020
Purpose To explore the optimal type of breast reconstruction and the time interval to postmastect... more Purpose To explore the optimal type of breast reconstruction and the time interval to postmastectomy radiotherapy (PMRT) associated with lower complications in breast cancer patients receiving neoadjuvant chemotherapy. Methods We reviewed the medical records of 300 patients who received neoadjuvant chemotherapy, mastectomy with breast reconstruction and PMRT at our institution from 2000 to 2017. Reconstruction types included autologous flaps (AR), single-stage-direct-to-implant and two-stages expander/implant (TE/I). The primary endpoint was the rate of reconstruction complications including infection, skin and fat necrosis. Subgroup analysis compared rates of capsular contracture, implant rupture, implant exposure and overall implant failure in single-stage-direct-to-implant to TE/I. The secondary endpoint was identifying the time interval between surgery with immediate implant-based reconstruction and PMRT associated with lower probability of implant failure. Logistic regression models, Kaplan-Meier estimates and Polynomial regression were used to assess endpoints. Results The median follow-up was 43.5 months. 29.3%, 28.3% and 42.4% of the cohort had AR, TE/I and single-stage-directto-implant D, respectively. The 5-year cumulative incidence rate of complications was 14.0%, 29.7% and 19.4% for AR, TE/I and single-stage-direct-to-implant, respectively (Log rank p = 0.02). Multivariate analysis showed significant association between TE/I and higher risk of infection (OR 8.1, p = 0.009) compared to AR, while single-stage-direct-to-implant and AR were comparable (OR 3.2, p = 0.2). On subgroup analysis, TE/I was significantly associated with higher rates of implant failure. The mean wait time to deliver PMRT after immediate reconstruction with no adjuvant chemotherapy was 8.4 and 10.7 weeks in single-stage-direct-to-implant and TE/I, respectively (p < 0.005). Delivering PMRT after 8 weeks of surgery yielded 10% probability of reconstruction failure in single-stage-direct-to-implant versus 40% in TE/I. Conclusion In comparison to two stages reconstruction, single-stage-direct-to-implant following neoadjuvant chemotherapy has lower complications and offers timely delivery of PMRT.
Plastic and Reconstructive Surgery, Nov 1, 2012
results: 1952 immediate implant-based reconstructions were performed in 1241 patients. 99 (5.1%) ... more results: 1952 immediate implant-based reconstructions were performed in 1241 patients. 99 (5.1%) reconstructions were admitted for infection. These patients had a higher incidence of smoking (p<0.01), chemotherapy (p<0.01) and radiation (p<0.001). There was no difference in age, BMI, or acellular dermal matrix (ADM) usage. With intravenous antibiotics, 25 (25.3%) reconstructions cleared infection while 74 (74.7%) underwent attempted operative salvage (18) or explant (56). Patients who failed to clear infection medically had a higher average wbc (p<0.002) and higher absolute wbc >10,000 (p<0.03). There was no difference in ADM usage.
Plastic and reconstructive surgery. Global open, Oct 1, 2016
Background: Sensation is decreased or absent after breast reconstruction. This leaves reconstruct... more Background: Sensation is decreased or absent after breast reconstruction. This leaves reconstructed breasts vulnerable to injury from common household thermal sources such as heating pads and hot water bottles. We sought to categorize these injuries, provide a treatment plan, and prevent these injuries in the future. Methods: A retrospective review of patients who had sustained burns to reconstructed breasts with household devices was performed at a single institution. A PubMed search was performed to identify and summarize articles cataloguing patients who had suffered burns to breast reconstructions. Results: Five patients in our practice were affected. Fifteen articles were identified in the literature search. A total of 40 patients had sustained thermal injury to reconstructed breasts, with the majority being full thickness burns (67.5%). Patients who sustained full thickness burns to reconstructed breasts were more likely to require an operative procedure compared with patients who sustained partial thickness burns (P = 0.0076). Conclusions: Reconstructed breasts are at risk for injury from commonly used household warming devices and ambient heat from the sun. As a result, patients should be counseled about these risks accordingly, to avoid injury or loss of reconstruction. These injuries require immediate vigilant treatment.
Plastic and Reconstructive Surgery, Apr 1, 2015
Background: Few studies in the literature examine outcomes of immediate breast reconstruction aft... more Background: Few studies in the literature examine outcomes of immediate breast reconstruction after mastectomy with nipple preservation and radiation therapy. Methods: Retrospective analysis of multisurgeon consecutive implant-based reconstructions after nipple-sparing mastectomy from June of 2007 to December of 2012 was conducted at a single institution. Results: Six hundred five immediate breast reconstructions were performed following nipple-sparing mastectomy, of which 88 were treated with radiation therapy. There was a trend toward more complications in patients with radiation (19.3 percent versus 12.8 percent; p = 0.099) associated with a higher rate of implant loss (6.8 percent versus 1.0 percent; p = 0.001). Preoperative radiotherapy had a higher risk of total complications (p = 0.04; OR, 2.225; 95 percent CI, 1.040 to 4.758) and postoperative radiotherapy had a higher risk of explantation (p = 0.015; OR, 5.634; 95 percent CI, 1.405 to 22.603). There were no significant differences in nipple removal secondary to malposition or positive oncologic margins in patients with radiation compared to those without radiation. Patients with radiation did have a higher incidence of secondary procedures for capsular contracture (12.5 percent versus 2.3 percent; p < 0.001) and fat grafting (13.6 percent versus 3.9 percent; p < 0.001). The total nipple retention rate in patients with radiation therapy was 90 percent (79 of 88), and the reconstruction failure rate was 8 percent. Conclusions: Nipple-sparing mastectomy and immediate reconstruction in patients who had or will receive radiation therapy is associated with a higher incidence of complications and operative revisions compared with patients without radiation. However, most patients have successful reconstructions with nipple retention and no recurrences.
Plastic and Reconstructive Surgery, Jun 1, 2013
rosthesis-based breast reconstruction accounts for over 70 percent of all breast reconstructions ... more rosthesis-based breast reconstruction accounts for over 70 percent of all breast reconstructions in the United States. 1 Immediate implantbased breast reconstruction offers psychological benefit to patients, decreases the number of surgical procedures, and may improve aesthetic outcome (Fig. 1). As demonstrated in the literature, immediate implant-based breast reconstruction is
International Journal of Radiation Oncology Biology Physics, Oct 1, 2016
Plastic and Reconstructive Surgery, Oct 1, 2013
International Journal of Radiation Oncology Biology Physics, Mar 1, 2020
This is a PDF file of an article that has undergone enhancements after acceptance, such as the ad... more This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Plastic and Reconstructive Surgery, Mar 1, 2014
Background: Nipple-sparing mastectomy is increasingly used for treatment and prevention of breast... more Background: Nipple-sparing mastectomy is increasingly used for treatment and prevention of breast cancer. Few data exist on risk factors for complications and reconstruction outcomes. Methods: A single-institution retrospective review was performed between 2007 and 2012. Results: Two hundred eighty-five patients underwent 500 nipple-sparing mastectomy procedures for breast cancer (46 percent) or risk reduction (54 percent). The average body mass index was 24, and 6 percent were smokers. The mean follow-up was 2.17 years. Immediate breast reconstruction (reconstruction rate, 98.8 percent) was performed with direct-to-implant (59 percent), tissue expander/implant (38 percent), or autologous (2 percent) reconstruction. Acellular dermal matrix was used in 71 percent and mesh was used in 11 percent. Seventy-seven reconstructions had radiotherapy. Complications included infection (3.3 percent), skin necrosis (5.2 percent), nipple necrosis (4.4 percent), seroma (1.7 percent), hematoma (1.7 percent), and implant loss (1.9 percent). Positive predictors for total complications included smoking (OR, 3.3; 95 percent CI, 1.289 to 8.486) and periareolar incisions (OR, 3.63; 95 percent CI, 1.850 to 7.107). Increasing body mass index predicted skin necrosis (OR, 1.154; 95 percent CI, 1.036 to 1.286) and preoperative irradiation predicted nipple necrosis (OR, 4.86; 95 percent CI, 1.0197 to 23.169). An inframammary fold incision decreased complications (OR, 0.018; 95 percent CI, 0.0026 to 0.12089). Five-year trends showed increasing numbers of nipple-sparing mastectomy with immediate reconstruction and more single-stage versus two-stage reconstructions (p < 0.05). Conclusions: Nipple-sparing mastectomy reconstructions have a low number of complications. Smoking, body mass index, preoperative irradiation, and incision type were predictors of complications.
American Surgeon, Jun 1, 2015
Modern sarcoma treatment has created new challenges for plastic surgeons. This study was designed... more Modern sarcoma treatment has created new challenges for plastic surgeons. This study was designed to review the recent experience and practice patterns following complex sarcoma resection at a large sarcoma center. All cases from October 2013 to October 2014 involving rare nonepithelial tumors, a multidisciplinary surgical team, radiation and/or chemotherapy treatments, and plastic surgical reconstruction were included in the analysis. In addition to evaluating clinical outcomes, cases were reviewed to identify factors associated with excellent or poor patient care. Review of these cases formed the basis of the greatest healing opportunity for soft tissue (GHOST) protocol. Our patient population included seven males (64%) and four females (36%). All except one patient was exposed to radiotherapy, chemotherapy, or some combination. Diverse procedures were used for reconstruction. Early complications occurred in two patients (18%), and late complications in four patients (36%). Sarcoma resection was found to be highly morbid in our series. Patients with poor preoperative nutritional status were more likely to experience complications postoperatively. The decision to stage a reconstruction was complex and influenced by several factors. Multimodal sarcoma treatments may involve highly morbid procedures and create complex wounds. The GHOST protocol is a useful reference for plastic surgeons.
Burns, Nov 1, 2020
Electrical burns are an uncommon yet devastating class of burn injuries. Shriners Hospitals for C... more Electrical burns are an uncommon yet devastating class of burn injuries. Shriners Hospitals for Children-Boston a pediatric burn center in New England and cares for both domestic and international patients. We utilized our experience over the past 13 years to review surgical management and evaluate historical trends for this unique patient group. A retrospective chart review was conducted on 68 patients aged 0À18 years admitted to our pediatric center with an electrical burn from January 2005 to December 2018. We collected and analyzed data pertaining to patient demographics, burn characteristics, clinical course, and surgical interventions. Our cohort included 31 patients from the US (46%) and 37 transferred from a variety of international countries (54%). The majority of US patients were admitted with low voltage burns (81%), whereas the majority of international patients were admitted with high voltage burns (95%). Acute and reconstructive surgical interventions were performed mainly for high voltage burns (94% and 89%). Based on our experience, epidemiology and surgical intervention varied based on voltage of the burn injury and residence of the patient. We have seen a reduction in US pediatric high voltage injuries over the past two decades, likely due to enhancement of electrical safety. It may be possible to use a similar strategy to reduce the frequency of severe high voltage electrical burn injuries in developing countries.
The New England Journal of Medicine, Mar 14, 2013
From the Department of Surgery, Memorial Sloan-Kettering Cancer Center, and the Department of Sur... more From the Department of Surgery, Memorial Sloan-Kettering Cancer Center, and the Department of Surgery, Weill Cornell Medical College — both in New York (M.M.); and the Departments of Surgery (J.M.W.), Radiology (P.E.F.), and Pathology ( J.H.E.), Massachusetts General Hospital; and the Departments of Surgery ( J.M.W.), Radiology (P.E.F.), and Pathology ( J.H.E.), Harvard Medical School — both in Boston.
Journal of Reconstructive Microsurgery, Aug 21, 2009
Free functional muscle transfer for acquired facial paralysis most often involves two stages. In ... more Free functional muscle transfer for acquired facial paralysis most often involves two stages. In this report, we describe single-stage free muscle transfer using the phrenic nerve as the donor motor nerve. Six patients with unilateral facial paralysis underwent single-stage facial reanimation using a free latissimus dorsi muscle with the ipsilateral phrenic nerve as the donor nerve. These cases were retrospectively studied to review technique and to determine outcomes including time to muscle reinnervation, patient satisfaction, smile symmetry, and complications. The mean age was 33 years. Five patients had complete unilateral facial paralysis and one had incomplete. There was no flap loss. The transferred muscle demonstrated active contraction in all patients at a mean of 14 weeks postoperatively (range, 12 to 16 weeks). Good dynamic symmetry was achieved by 6 to 9 months in all patients. All patients underwent rehabilitation including nerve reeducation. No clinically significant pulmonary morbidity was observed after the unilateral transection of the phrenic nerve. Using the phrenic nerve in free muscle transfer for facial paralysis allows a single-stage procedure with no requirement for nerve grafting and a rapid reinnervation time, shortening the time required for restoring facial animation.
Plastic and Reconstructive Surgery, Feb 1, 2009
Conclusions.-The results of this study suggest that hand surgeons and therapists caring for patie... more Conclusions.-The results of this study suggest that hand surgeons and therapists caring for patients with nerve compression and nerve injury should discuss strategies to improve activity participation, and decrease pain and depression, to improve overall effect on quality of life throughout the recovery process. Depression screening and referral when indicated should be included in the overall treatment plan for patients with upper extremity nerve damage. Type of Study/Level of Evidence.-Prognostic IV. : This article is one of a series of recent articles assessing the recovery of patients from a more holistic point of view. It is well known that peripheral nerve injuries are associated with long-term disability, and this study evaluates the interplay of different health factors on the recovery of these patients. Specifically, the authors looked at how activity participation, pain, and depression impacted the perceived quality of life in people with nerve injuries. The respondents had moderate pain and experienced a high rate of psychological distress with 39% meeting the criteria for clinical depression. These patients had given up many activities with an average 21% decrease in activities of daily living. When the impact on quality of life of all the different health-related domains was considered, depression and activity participation had the largest effect. This study highlights the complex relationships that injury, function, and psychology have on quality of life. For the hand surgeon, there should be heightened awareness of the presence of depression in patients with nerve pathology. Depression will impact the patient's overall recovery and may hinder compliance with postoperative regimens. Also therapists should focus on assisting the patient's return to activities, which is another key component to improved quality of life. The limitations of this study are its small sample size and heterogeneous population. The participants included patients who had nerve compression and those with nerve injury. These 2 disease processes are quite different and merging them in the models may muddy the results.
Plastic and Reconstructive Surgery - Global Open
Background: Despite promising pilot study results, adoption of neurotization of immediate implant... more Background: Despite promising pilot study results, adoption of neurotization of immediate implant-based reconstructions has not occurred. Methods: For surgeons interested in adopting breast reinnervation techniques, we present ways to overcome initial barriers by decreasing operative time and maximizing chances of sensory recovery. Results: We discuss the combined experience at two academic teaching hospitals, where neurotization of both immediate tissue expander cases and direct-to-implant reconstructions are performed through varying mastectomy incisions. Conclusion: Initial barriers can be overcome by shortening operative time and providing an individualized reinnervation approach that aims to increase the chance of meaningful sensation.
Journal of Surgical Oncology
Plastic and Reconstructive Surgery, Mar 1, 2018
have served as consultants for Allergan and LifeCell, and Dr. Liao has served as a consultant for... more have served as consultants for Allergan and LifeCell, and Dr. Liao has served as a consultant for Musculoskeletal Transplant Foundation. There are no other disclosures.
Annals of Surgery, Oct 25, 2019
Objectives: This study evaluates complications and reconstructive failure rates in implant-based ... more Objectives: This study evaluates complications and reconstructive failure rates in implant-based reconstruction with radiotherapy. Background: Postmastectomy radiotherapy may adversely affect breast reconstructive outcomes. However, the comparative effect of radiotherapy on direct-to-implant versus tissue expander-implant reconstruction has not been examined. Methods: Single institution retrospective review was performed and patients were followed 2 to 10 years. Results: Of 1566 patients, 265 patients received radiation (149 immediate implants and 116 tissue expanders). Demographics were similar except more smokers in the expander group (7.7% vs 1.3%; P ¼ 0.012). Patients who received radiation with an expander in place had overall more complications (32.8% vs 11.4%; P < 0.001), skin necrosis (10.3% vs 4.0%; P ¼ 0.043), wound breakdown (9.5% vs 2.7%; P ¼ 0.029), and infections (16.4% vs 4.03%; P ¼ 0.001) leading to a higher rate of explantation (16.4% vs 4.0%; P < 0.001). A radiation boost likewise predicted complications [odds ratio (OR) 2.199, 95% confidence interval (CI) 1.154-4.188, P ¼ 0.017]. When comparing reconstructive outcomes, radiated expanders had a higher failure rate (21.6% vs 11.4%; P ¼ 0.025). Revision for capsular contracture was similar between the 2 cohorts (11.4% vs 11.2%; P ¼ 0.959) as were revision rates for contour asymmetry and breast asymmetry. In our multivariable logistic regression analysis, radiation to the expander had a higher risk of reconstruction failure than radiation to the permanent implant (OR 2.020, 95% CI 1.010-4.037, P ¼ 0.047). Conclusion: Most patients had successful implant-based reconstructions after mastectomy and radiotherapy. Our study showed radiotherapy after direct-to-implant breast reconstruction had a lower rate of complications and reconstructive failure compared to tissue expander-implant reconstruction.
Plastic and Reconstructive Surgery, Apr 1, 2014
ABSTRACT
Plastic and Reconstructive Surgery, Apr 1, 2015
Breast Cancer Research and Treatment, Jun 30, 2020
Purpose To explore the optimal type of breast reconstruction and the time interval to postmastect... more Purpose To explore the optimal type of breast reconstruction and the time interval to postmastectomy radiotherapy (PMRT) associated with lower complications in breast cancer patients receiving neoadjuvant chemotherapy. Methods We reviewed the medical records of 300 patients who received neoadjuvant chemotherapy, mastectomy with breast reconstruction and PMRT at our institution from 2000 to 2017. Reconstruction types included autologous flaps (AR), single-stage-direct-to-implant and two-stages expander/implant (TE/I). The primary endpoint was the rate of reconstruction complications including infection, skin and fat necrosis. Subgroup analysis compared rates of capsular contracture, implant rupture, implant exposure and overall implant failure in single-stage-direct-to-implant to TE/I. The secondary endpoint was identifying the time interval between surgery with immediate implant-based reconstruction and PMRT associated with lower probability of implant failure. Logistic regression models, Kaplan-Meier estimates and Polynomial regression were used to assess endpoints. Results The median follow-up was 43.5 months. 29.3%, 28.3% and 42.4% of the cohort had AR, TE/I and single-stage-directto-implant D, respectively. The 5-year cumulative incidence rate of complications was 14.0%, 29.7% and 19.4% for AR, TE/I and single-stage-direct-to-implant, respectively (Log rank p = 0.02). Multivariate analysis showed significant association between TE/I and higher risk of infection (OR 8.1, p = 0.009) compared to AR, while single-stage-direct-to-implant and AR were comparable (OR 3.2, p = 0.2). On subgroup analysis, TE/I was significantly associated with higher rates of implant failure. The mean wait time to deliver PMRT after immediate reconstruction with no adjuvant chemotherapy was 8.4 and 10.7 weeks in single-stage-direct-to-implant and TE/I, respectively (p < 0.005). Delivering PMRT after 8 weeks of surgery yielded 10% probability of reconstruction failure in single-stage-direct-to-implant versus 40% in TE/I. Conclusion In comparison to two stages reconstruction, single-stage-direct-to-implant following neoadjuvant chemotherapy has lower complications and offers timely delivery of PMRT.
Plastic and Reconstructive Surgery, Nov 1, 2012
results: 1952 immediate implant-based reconstructions were performed in 1241 patients. 99 (5.1%) ... more results: 1952 immediate implant-based reconstructions were performed in 1241 patients. 99 (5.1%) reconstructions were admitted for infection. These patients had a higher incidence of smoking (p<0.01), chemotherapy (p<0.01) and radiation (p<0.001). There was no difference in age, BMI, or acellular dermal matrix (ADM) usage. With intravenous antibiotics, 25 (25.3%) reconstructions cleared infection while 74 (74.7%) underwent attempted operative salvage (18) or explant (56). Patients who failed to clear infection medically had a higher average wbc (p<0.002) and higher absolute wbc >10,000 (p<0.03). There was no difference in ADM usage.
Plastic and reconstructive surgery. Global open, Oct 1, 2016
Background: Sensation is decreased or absent after breast reconstruction. This leaves reconstruct... more Background: Sensation is decreased or absent after breast reconstruction. This leaves reconstructed breasts vulnerable to injury from common household thermal sources such as heating pads and hot water bottles. We sought to categorize these injuries, provide a treatment plan, and prevent these injuries in the future. Methods: A retrospective review of patients who had sustained burns to reconstructed breasts with household devices was performed at a single institution. A PubMed search was performed to identify and summarize articles cataloguing patients who had suffered burns to breast reconstructions. Results: Five patients in our practice were affected. Fifteen articles were identified in the literature search. A total of 40 patients had sustained thermal injury to reconstructed breasts, with the majority being full thickness burns (67.5%). Patients who sustained full thickness burns to reconstructed breasts were more likely to require an operative procedure compared with patients who sustained partial thickness burns (P = 0.0076). Conclusions: Reconstructed breasts are at risk for injury from commonly used household warming devices and ambient heat from the sun. As a result, patients should be counseled about these risks accordingly, to avoid injury or loss of reconstruction. These injuries require immediate vigilant treatment.
Plastic and Reconstructive Surgery, Apr 1, 2015
Background: Few studies in the literature examine outcomes of immediate breast reconstruction aft... more Background: Few studies in the literature examine outcomes of immediate breast reconstruction after mastectomy with nipple preservation and radiation therapy. Methods: Retrospective analysis of multisurgeon consecutive implant-based reconstructions after nipple-sparing mastectomy from June of 2007 to December of 2012 was conducted at a single institution. Results: Six hundred five immediate breast reconstructions were performed following nipple-sparing mastectomy, of which 88 were treated with radiation therapy. There was a trend toward more complications in patients with radiation (19.3 percent versus 12.8 percent; p = 0.099) associated with a higher rate of implant loss (6.8 percent versus 1.0 percent; p = 0.001). Preoperative radiotherapy had a higher risk of total complications (p = 0.04; OR, 2.225; 95 percent CI, 1.040 to 4.758) and postoperative radiotherapy had a higher risk of explantation (p = 0.015; OR, 5.634; 95 percent CI, 1.405 to 22.603). There were no significant differences in nipple removal secondary to malposition or positive oncologic margins in patients with radiation compared to those without radiation. Patients with radiation did have a higher incidence of secondary procedures for capsular contracture (12.5 percent versus 2.3 percent; p < 0.001) and fat grafting (13.6 percent versus 3.9 percent; p < 0.001). The total nipple retention rate in patients with radiation therapy was 90 percent (79 of 88), and the reconstruction failure rate was 8 percent. Conclusions: Nipple-sparing mastectomy and immediate reconstruction in patients who had or will receive radiation therapy is associated with a higher incidence of complications and operative revisions compared with patients without radiation. However, most patients have successful reconstructions with nipple retention and no recurrences.
Plastic and Reconstructive Surgery, Jun 1, 2013
rosthesis-based breast reconstruction accounts for over 70 percent of all breast reconstructions ... more rosthesis-based breast reconstruction accounts for over 70 percent of all breast reconstructions in the United States. 1 Immediate implantbased breast reconstruction offers psychological benefit to patients, decreases the number of surgical procedures, and may improve aesthetic outcome (Fig. 1). As demonstrated in the literature, immediate implant-based breast reconstruction is
International Journal of Radiation Oncology Biology Physics, Oct 1, 2016
Plastic and Reconstructive Surgery, Oct 1, 2013
International Journal of Radiation Oncology Biology Physics, Mar 1, 2020
This is a PDF file of an article that has undergone enhancements after acceptance, such as the ad... more This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Plastic and Reconstructive Surgery, Mar 1, 2014
Background: Nipple-sparing mastectomy is increasingly used for treatment and prevention of breast... more Background: Nipple-sparing mastectomy is increasingly used for treatment and prevention of breast cancer. Few data exist on risk factors for complications and reconstruction outcomes. Methods: A single-institution retrospective review was performed between 2007 and 2012. Results: Two hundred eighty-five patients underwent 500 nipple-sparing mastectomy procedures for breast cancer (46 percent) or risk reduction (54 percent). The average body mass index was 24, and 6 percent were smokers. The mean follow-up was 2.17 years. Immediate breast reconstruction (reconstruction rate, 98.8 percent) was performed with direct-to-implant (59 percent), tissue expander/implant (38 percent), or autologous (2 percent) reconstruction. Acellular dermal matrix was used in 71 percent and mesh was used in 11 percent. Seventy-seven reconstructions had radiotherapy. Complications included infection (3.3 percent), skin necrosis (5.2 percent), nipple necrosis (4.4 percent), seroma (1.7 percent), hematoma (1.7 percent), and implant loss (1.9 percent). Positive predictors for total complications included smoking (OR, 3.3; 95 percent CI, 1.289 to 8.486) and periareolar incisions (OR, 3.63; 95 percent CI, 1.850 to 7.107). Increasing body mass index predicted skin necrosis (OR, 1.154; 95 percent CI, 1.036 to 1.286) and preoperative irradiation predicted nipple necrosis (OR, 4.86; 95 percent CI, 1.0197 to 23.169). An inframammary fold incision decreased complications (OR, 0.018; 95 percent CI, 0.0026 to 0.12089). Five-year trends showed increasing numbers of nipple-sparing mastectomy with immediate reconstruction and more single-stage versus two-stage reconstructions (p < 0.05). Conclusions: Nipple-sparing mastectomy reconstructions have a low number of complications. Smoking, body mass index, preoperative irradiation, and incision type were predictors of complications.
American Surgeon, Jun 1, 2015
Modern sarcoma treatment has created new challenges for plastic surgeons. This study was designed... more Modern sarcoma treatment has created new challenges for plastic surgeons. This study was designed to review the recent experience and practice patterns following complex sarcoma resection at a large sarcoma center. All cases from October 2013 to October 2014 involving rare nonepithelial tumors, a multidisciplinary surgical team, radiation and/or chemotherapy treatments, and plastic surgical reconstruction were included in the analysis. In addition to evaluating clinical outcomes, cases were reviewed to identify factors associated with excellent or poor patient care. Review of these cases formed the basis of the greatest healing opportunity for soft tissue (GHOST) protocol. Our patient population included seven males (64%) and four females (36%). All except one patient was exposed to radiotherapy, chemotherapy, or some combination. Diverse procedures were used for reconstruction. Early complications occurred in two patients (18%), and late complications in four patients (36%). Sarcoma resection was found to be highly morbid in our series. Patients with poor preoperative nutritional status were more likely to experience complications postoperatively. The decision to stage a reconstruction was complex and influenced by several factors. Multimodal sarcoma treatments may involve highly morbid procedures and create complex wounds. The GHOST protocol is a useful reference for plastic surgeons.
Burns, Nov 1, 2020
Electrical burns are an uncommon yet devastating class of burn injuries. Shriners Hospitals for C... more Electrical burns are an uncommon yet devastating class of burn injuries. Shriners Hospitals for Children-Boston a pediatric burn center in New England and cares for both domestic and international patients. We utilized our experience over the past 13 years to review surgical management and evaluate historical trends for this unique patient group. A retrospective chart review was conducted on 68 patients aged 0À18 years admitted to our pediatric center with an electrical burn from January 2005 to December 2018. We collected and analyzed data pertaining to patient demographics, burn characteristics, clinical course, and surgical interventions. Our cohort included 31 patients from the US (46%) and 37 transferred from a variety of international countries (54%). The majority of US patients were admitted with low voltage burns (81%), whereas the majority of international patients were admitted with high voltage burns (95%). Acute and reconstructive surgical interventions were performed mainly for high voltage burns (94% and 89%). Based on our experience, epidemiology and surgical intervention varied based on voltage of the burn injury and residence of the patient. We have seen a reduction in US pediatric high voltage injuries over the past two decades, likely due to enhancement of electrical safety. It may be possible to use a similar strategy to reduce the frequency of severe high voltage electrical burn injuries in developing countries.
The New England Journal of Medicine, Mar 14, 2013
From the Department of Surgery, Memorial Sloan-Kettering Cancer Center, and the Department of Sur... more From the Department of Surgery, Memorial Sloan-Kettering Cancer Center, and the Department of Surgery, Weill Cornell Medical College — both in New York (M.M.); and the Departments of Surgery (J.M.W.), Radiology (P.E.F.), and Pathology ( J.H.E.), Massachusetts General Hospital; and the Departments of Surgery ( J.M.W.), Radiology (P.E.F.), and Pathology ( J.H.E.), Harvard Medical School — both in Boston.
Journal of Reconstructive Microsurgery, Aug 21, 2009
Free functional muscle transfer for acquired facial paralysis most often involves two stages. In ... more Free functional muscle transfer for acquired facial paralysis most often involves two stages. In this report, we describe single-stage free muscle transfer using the phrenic nerve as the donor motor nerve. Six patients with unilateral facial paralysis underwent single-stage facial reanimation using a free latissimus dorsi muscle with the ipsilateral phrenic nerve as the donor nerve. These cases were retrospectively studied to review technique and to determine outcomes including time to muscle reinnervation, patient satisfaction, smile symmetry, and complications. The mean age was 33 years. Five patients had complete unilateral facial paralysis and one had incomplete. There was no flap loss. The transferred muscle demonstrated active contraction in all patients at a mean of 14 weeks postoperatively (range, 12 to 16 weeks). Good dynamic symmetry was achieved by 6 to 9 months in all patients. All patients underwent rehabilitation including nerve reeducation. No clinically significant pulmonary morbidity was observed after the unilateral transection of the phrenic nerve. Using the phrenic nerve in free muscle transfer for facial paralysis allows a single-stage procedure with no requirement for nerve grafting and a rapid reinnervation time, shortening the time required for restoring facial animation.
Plastic and Reconstructive Surgery, Feb 1, 2009
Conclusions.-The results of this study suggest that hand surgeons and therapists caring for patie... more Conclusions.-The results of this study suggest that hand surgeons and therapists caring for patients with nerve compression and nerve injury should discuss strategies to improve activity participation, and decrease pain and depression, to improve overall effect on quality of life throughout the recovery process. Depression screening and referral when indicated should be included in the overall treatment plan for patients with upper extremity nerve damage. Type of Study/Level of Evidence.-Prognostic IV. : This article is one of a series of recent articles assessing the recovery of patients from a more holistic point of view. It is well known that peripheral nerve injuries are associated with long-term disability, and this study evaluates the interplay of different health factors on the recovery of these patients. Specifically, the authors looked at how activity participation, pain, and depression impacted the perceived quality of life in people with nerve injuries. The respondents had moderate pain and experienced a high rate of psychological distress with 39% meeting the criteria for clinical depression. These patients had given up many activities with an average 21% decrease in activities of daily living. When the impact on quality of life of all the different health-related domains was considered, depression and activity participation had the largest effect. This study highlights the complex relationships that injury, function, and psychology have on quality of life. For the hand surgeon, there should be heightened awareness of the presence of depression in patients with nerve pathology. Depression will impact the patient's overall recovery and may hinder compliance with postoperative regimens. Also therapists should focus on assisting the patient's return to activities, which is another key component to improved quality of life. The limitations of this study are its small sample size and heterogeneous population. The participants included patients who had nerve compression and those with nerve injury. These 2 disease processes are quite different and merging them in the models may muddy the results.
Plastic and Reconstructive Surgery - Global Open
Background: Despite promising pilot study results, adoption of neurotization of immediate implant... more Background: Despite promising pilot study results, adoption of neurotization of immediate implant-based reconstructions has not occurred. Methods: For surgeons interested in adopting breast reinnervation techniques, we present ways to overcome initial barriers by decreasing operative time and maximizing chances of sensory recovery. Results: We discuss the combined experience at two academic teaching hospitals, where neurotization of both immediate tissue expander cases and direct-to-implant reconstructions are performed through varying mastectomy incisions. Conclusion: Initial barriers can be overcome by shortening operative time and providing an individualized reinnervation approach that aims to increase the chance of meaningful sensation.
Journal of Surgical Oncology