May 2024 Edition

thestitchprs
May 1, 2024
7 min read

Welcome to the May edition of The Stitch! We appreciate your continued support and readership.

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Best, The Stitch Editorial Board

Symmetric Breast Surgery vs Prophylactic Contralateral Mastectomy and Reconstruction

Article Review by Reid Smith, Zucker School of Medicine

For patients with unilateral breast cancer, should we be performing symmetrizing procedures or

prophylactic contralateral mastectomies with reconstruction?

Patients with unilateral breast cancer are given multiple options for surgical intervention of the unaffected breast, ranging from no intervention to mastectomy with reconstruction or less invasive symmetric breast surgery (reduction, augmentation, mastopexy) (1). In the past decade, the number of women opting for contralateral prophylactic mastectomies has tripled without evidence of an associated increase in life expectancy.

This study employed a mixed observational methodology of 249 patients who received either symmetric breast surgery or mastectomy with reconstruction over a seven-year period at a single hospital (2).

They found similar surgical safety, oncologic effectiveness, and postoperative satisfaction (BREAST-Q scores) between the two approaches. The only differences were decreased chest physical well-being in patients who received symmetric breast surgery and an increased rate of minor wound dehiscence for women who received prophylactic mastectomy with reconstruction.

Because both studied interventions had similar patient outcomes, surgeons should make their decision based on patient preference, body type, medical history, and surgeon-specific experience. As medical students, we first need to familiarize ourselves with the options available for surgical patients. As we transition to residents, we should begin to develop an approach to determine which intervention is preferred, and this research is one tool to consider.

Sources:

Wong, S. M., Freedman, R. A., Sagara, Y., Aydogan, F., Barry, W. T., & Golshan, M. (2017). Growing use of contralateral prophylactic mastectomy despite no improvement in long-term survival for invasive breast cancer. Annals of surgery, 265(3), 581-589.
Bitoiu, B., Grigor, E., Hardy, J., Zeitouni, C., Arnaout, A., & Zhang, J. (2021). Symmetrical breast surgery: balancing procedures versus prophylactic mastectomy and immediate reconstruction. Plastic and Reconstructive Surgery, 10-1097.

Infection After Lower-Limb Osseointegration

Article Review by Raymond Richards, Jacobs School of Medicine

How should we manage infections after lower limb transcutaneous osseointegration?

Socket-based limb prosthetics, while effective at improving physical function, are plagued by a number of issues, including pain, neuromas, and pressure-related injuries such as ulcers (1). They also require frequent replacement. Transcutaneous osseointegrated prosthetic implants (prosthetics that remain implanted directly into bone through a stoma) have arisen as alternatives to socket-based prosthetics to avoid skin discomfort and reduce replacement of hardware. Transcutaneous osseointegration comes with additional risks, with one major concern being stoma and deep tissue infections. In a 2019 study of patients with osseointegrated prostheses after transfemoral amputation, 34 of 45 patients experienced a combined total of 70 superficial skin infections by 5-year follow-up, and 11 patients experienced deep infections (2).

This 2024 retrospective cohort study by Black and colleagues analyzed 102 patients that received lower limb prosthetic implants with transcutaneous osseointegration, intending to characterize associated infection management and outcomes (3). Infections were categorized as either stoma, deep soft tissue, or osteomyelitis. 50 infections were reported. Patients with osteomyelitis spent more time on IV antibiotics compared to those with deep soft tissue infections, a value that reached statistical significance (p = 0.013). Only 2 patients required explantation of their prosthetics; both of these cases occurred in the setting of osteomyelitis.

The results suggest that while infection is indeed a frequent complication associated with osseointegration, it can be managed according to severity and in most cases does not preclude salvage of the prosthetic implant. More research is needed comparing socket-based implants to osseointegrated implants to allow for thorough cost-benefit analysis, but the relative success in managing the associated infections demonstrated in this study is promising. Look for future investigations to answer the question of whether osseointegration improves patient-reported outcomes of prosthetic use enough to justify the apparent increase in infection prevalence.

Sources:

Dillingham, T. R., Pezzin, L. E., MacKenzie, E. J., & Burgess, A. R. (2001). Use and satisfaction with prosthetic devices among persons with trauma-related amputations: a long-term outcome study. American journal of physical medicine & rehabilitation, 80(8), 563-571.
Brånemark, R. P., Hagberg, K., Kulbacka-Ortiz, K., Berlin, Ö., & Rydevik, B. (2019). Osseointegrated percutaneous prosthetic system for the treatment of patients with transfemoral amputation: a prospective five-year follow-up of patient-reported outcomes and complications. JAAOS-Journal of the American Academy of Orthopaedic Surgeons, 27(16), e743-e751.
Black, G. G., Vaeth, A. M., Kochheiser, M., Chen, Y., Truong, A. Y., Reif, T., ... & Otterburn, D. M. (2024). Infection After Lower-Limb Osseointegration: A Single-Center Retrospective Evaluation of Pathogens, Management, and Outcomes. Annals of Plastic Surgery, 92(4S), S96-S100.

Hitting the Books: A Nationwide Analysis of Advanced Degrees in Academic Plastic

Surgery Faculty

Article Review by Isha Joshi, Pennsylvania State College of Medicine

Is there an advantage to attaining an advanced degree as a plastic surgeon?

Advanced degrees have gained popularity in medicine, with many physicians seeking to broaden their knowledge of health care administration, medical education, and policy. A comparative study from 2021 examines the impact of advanced degrees for a career in academic plastic surgery (1).

949 faculty members were identified from all US plastic surgery program websites. Approximately 18% of all faculty were found to have an advanced degree, with 22.6% having attained an advanced degree prior to medical school, 33.6% during medical school, 17.8% during residency, and 26.0% post- residency. Faculty with advanced degrees were associated with receiving NIH funding, having a greater number of publications, and journal editorial board positions (p < 0.05). Attaining an advanced degree prior to residency was significantly associated with matching into a higher ranked and integrated program (p < 0.05).

While the type and timing of acquiring an advanced degree may vary, these findings suggest that an advanced degree is advantageous at every stage for an academic plastic surgery career. As the research year has become popular among plastic surgery applicants, medical students should consider the option of an advanced degree as many medical schools are providing earlier opportunities through accelerated MBA and MPH programs.

Sources:

Falkner F, Mayer SA, Heuer M, Brune J, Helt H, Bigdeli AK, Dimmler A, Heimel P, Thiele W, Sleeman JP, Bergmeister H, Schneider KH, Kneser U, Thomas B. Comparison of Decellularized Human Dermal Scaffolds versus Bovine Collagen/Elastin Matrices for Engineering of Soft-Tissue Flaps. Plast Reconstr Surg. 2024 Jan 1;153(1):130-141. doi: 10.1097/PRS.0000000000010511. Epub 2023 Apr 5. PMID: 37014963.

Should Insurance Companies Cover Breast Reduction Procedures?

Opinion by Zeinab Mhanna, Michigan State College of Medicine

Macromastia, or breast enlargement beyond normal proportions, is a significant cause of shoulder, neck, and back pain in those with breasts (1). Macromastia can have many effects on patient health, from chronic pain to declined mental health. And yet, despite the health implications of macromastia, many health insurance plans do not cover breast reduction procedures, and those that do will use outdated or inconsistent scales to assess the amount of breast tissue to be removed (2). For example, some insurance companies use the Schnur scale, which uses a patient’s body surface area to determine the amount of breast tissue that would need to be removed. This is not a "perfect" scale and has often resulted in a reduction that is not satisfactory to the patient (3, 4).

So, the question remains - why won’t all health insurance companies cover this procedure? The pain associated with macromastia can result in missed work, pain medication misuse, and an overall lowered quality of life. Considering over 90% of people that undergo a breast reduction procedure feel mental and physical symptom relief (5), more work must be done to ensure that everyone is getting access to the care they deserve.

Sources:

Bruhlmann, Y., & Tschopp, H. (1998). Breast reduction improves symptoms of macromastia and has a long-lasting effect. Annals of plastic surgery, 41(3), 240.
Rawes, C. M., Ngaage, L. M., Borrelli, M. R., Puthumana, J., Slezak, S., & Rasko, Y. M. (2020). Navigating the insurance landscape for coverage of reduction mammaplasty. Plastic and reconstructive surgery, 146(5), 539e-547e.
Yan, M., Bustos, S. S., Kuruoglu, D., Manrique, O. J., Tran, N. V., Sharaf, B. A., ... & Nguyen, M. D. T. (2022). Breast resection weight prediction and insurance reimbursement in reduction mammaplasty: which scale is reliable?. Plastic and reconstructive surgery, 150(4), 723e-730e.
Ochoa, P. C., Salinas, C. A., Zheng, E. E., Martinez-Jorge, J., Harless, C. A., Vijayasekaran, A., & Sharaf, B. A. (2021). Revisiting Breast Reduction Insurance Coverage: How the Schnur Scale Discriminates Against Women Based on Body Habitus. Plastic and Reconstructive Surgery, 10-1097.
Lonie, S., Sachs, R., Shen, A., Hunter-Smith, D. J., Rozen, W. M., & Seifman, M. (2019). A systematic review of patient reported outcome measures for women with macromastia who have undergone breast reduction surgery. Gland surgery, 8(4), 431.

Educational Pearls: Suturing Techniques

Sarah Moffitt, Morsani School of Medicine

Here are some YouTube videos to help you get started or continue to practice suturing at home!

The first video is how to “palm” an instrument. I was encouraged to practice this alone (locking and unlocking the needle driver) before attempting to suture. This may help you feel more comfortable with the instrument when it comes time to suture.

The second video is a collection of a few common suture techniques. There are many suture pads you can get from Amazon, or even practice on chicken feet if you’re feeling brave! There are also many more videos and resources on YouTube that you can watch as well, but these are here to get you started. Hopefully practicing them will help you feel more confident when shadowing or on your rotations!

Sources:

Palming the Needle Driver: https://youtu.be/wNjAp5d1p1M?si=YYj7qMfV85RauJIW

Suturing Techniques: https://youtu.be/TFwFMav_cpE?si=nb--Z_j91Vu8ybFv

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opportunities, please complete the form at the link below.

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