Pub Date : 2020-01-01DOI: 10.1097/PRS.0000000000006359
T. Weaver
{"title":"\"Reply: Diversity in Plastic Surgery: Trends in Minority Representation among Applicants and Residents\".","authors":"T. Weaver","doi":"10.1097/PRS.0000000000006359","DOIUrl":"https://doi.org/10.1097/PRS.0000000000006359","url":null,"abstract":"","PeriodicalId":20168,"journal":{"name":"Plastic & Reconstructive Surgery","volume":"32 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2020-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"89780739","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2020-01-01DOI: 10.1097/PRS.0000000000006361
Widya Adidharma, K. Latack, S. Colohan, S. Morrison, P. Cederna
{"title":"Breast Implant Illness: Are Social Media and the Internet Worrying Patients Sick?\"","authors":"Widya Adidharma, K. Latack, S. Colohan, S. Morrison, P. Cederna","doi":"10.1097/PRS.0000000000006361","DOIUrl":"https://doi.org/10.1097/PRS.0000000000006361","url":null,"abstract":"","PeriodicalId":20168,"journal":{"name":"Plastic & Reconstructive Surgery","volume":"1986 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2020-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"90333963","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2020-01-01DOI: 10.1097/PRS.0000000000006328
Hyun-Jin Kwon, J. O, T. Cho, You-Jin Choi, Hun-Mu Yang
BACKGROUND The nasolabial fold (NLF) is known to be a challenging midface feature for aesthetic physicians. However, the steric conformation of the structures related to the NLF has remained undefined since the composition and topography of this region is highly intricate. Therefore, this study aimed to clarify the three-dimensional structures of the NLF using micro-computed tomography and verify their detailed composition via histological observation. METHODS Twenty-four specimens were collected from the area beside the alar nasi to the area above the oral angle of 12 cadavers (mean age, 80.3 years) bilaterally. Twelve specimens were evaluated via phosphotungstic acid contrast staining, and the rest were evaluated via histological staining. All specimens were divided into three regions and comprehensively analyzed. RESULTS The medial region of the NLF had dense irregular connective tissue intermingled with muscle fibers; the lateral region of NLF had numerous fibrous septa with abundant adipose tissue. The levator labii alaeque nasi and the zygomaticus minor were attached to the medial part of the NLF, and the fascial septa were intermittently tethered to the dermis, lateral to the NLF. The extension of the adipose tissue within the fascial septa was limited by the lateral border of the muscle attachment. CONCLUSIONS Dimensional and distributional alterations of the adipose tissues with senescence could render the NLF deeper by increasing the depth of the subcutaneous layer, lateral to the fold. Hence, to ameliorate the fold, the adipose tissue, lateral to the fold, or the muscle traction, medial to the fold, should be altered.
{"title":"\"The nasolabial fold: A micro-computed tomography study.\"","authors":"Hyun-Jin Kwon, J. O, T. Cho, You-Jin Choi, Hun-Mu Yang","doi":"10.1097/PRS.0000000000006328","DOIUrl":"https://doi.org/10.1097/PRS.0000000000006328","url":null,"abstract":"BACKGROUND\u0000The nasolabial fold (NLF) is known to be a challenging midface feature for aesthetic physicians. However, the steric conformation of the structures related to the NLF has remained undefined since the composition and topography of this region is highly intricate. Therefore, this study aimed to clarify the three-dimensional structures of the NLF using micro-computed tomography and verify their detailed composition via histological observation.\u0000\u0000\u0000METHODS\u0000Twenty-four specimens were collected from the area beside the alar nasi to the area above the oral angle of 12 cadavers (mean age, 80.3 years) bilaterally. Twelve specimens were evaluated via phosphotungstic acid contrast staining, and the rest were evaluated via histological staining. All specimens were divided into three regions and comprehensively analyzed.\u0000\u0000\u0000RESULTS\u0000The medial region of the NLF had dense irregular connective tissue intermingled with muscle fibers; the lateral region of NLF had numerous fibrous septa with abundant adipose tissue. The levator labii alaeque nasi and the zygomaticus minor were attached to the medial part of the NLF, and the fascial septa were intermittently tethered to the dermis, lateral to the NLF. The extension of the adipose tissue within the fascial septa was limited by the lateral border of the muscle attachment.\u0000\u0000\u0000CONCLUSIONS\u0000Dimensional and distributional alterations of the adipose tissues with senescence could render the NLF deeper by increasing the depth of the subcutaneous layer, lateral to the fold. Hence, to ameliorate the fold, the adipose tissue, lateral to the fold, or the muscle traction, medial to the fold, should be altered.","PeriodicalId":20168,"journal":{"name":"Plastic & Reconstructive Surgery","volume":"33 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2020-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"73506679","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2020-01-01DOI: 10.1097/PRS.0000000000006408
Brett T. Phillips, David H. Chi, Geoffrey E. Hespe, E. Karamanos, K. Kolegraff, Kerry-Ann Mitchell, Ines D. Prasidha, Rami D. Sherif, Andrew T. Timberlake, A. Gosain
{"title":"Spotlight in Plastic Surgery","authors":"Brett T. Phillips, David H. Chi, Geoffrey E. Hespe, E. Karamanos, K. Kolegraff, Kerry-Ann Mitchell, Ines D. Prasidha, Rami D. Sherif, Andrew T. Timberlake, A. Gosain","doi":"10.1097/PRS.0000000000006408","DOIUrl":"https://doi.org/10.1097/PRS.0000000000006408","url":null,"abstract":"","PeriodicalId":20168,"journal":{"name":"Plastic & Reconstructive Surgery","volume":"1 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2020-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"78543148","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-12-01DOI: 10.1097/PRS.0000000000006280
Anna-Theresa Bauer, Dominik von Lukowicz, Katrin Lossagk, Matthias M Aitzetmueller, P. Moog, M. Cerny, H. Erne, D. Schmauss, D. Duscher, H. Machens
BACKGROUND Although a large number of adult women worldwide are affected by lipedema, the physiologic conditions triggering onset and progression of this chronic disease remain enigmatic. In the present study, a descriptive epidemiologic situation of postoperative lipedema patients is presented. METHODS The authors developed an online survey questionnaire for lipedema patients in Germany. The survey was conducted on 209 female patients who had been diagnosed with lipedema and had undergone tumescent liposuction. RESULTS Most of the participants (average age, 38.5 years) had noticed a first manifestation of the disease at the age of 16. It took a mean of 15 years to accomplish diagnosis. Liposuction led to a significant reduction of pain, swelling, tenderness, and easy bruising as confirmed by the majority of patients. Hypothyroidism [n = 75 (35.9 percent) and depression [n = 48 (23.0 percent)] occurred at a frequency far beyond the average prevalence in the German population. The prevalence of diabetes type 1 [n = 3 (1.4 percent)], and diabetes type 2 [n = 2 (1 percent)] was particularly low among the respondents. Forty-seven of the lipedema patients (approximately 22.5 percent) suffered from a diagnosed migraine. Following liposuction, the frequency and/or intensity of migraine attacks became markedly reduced, as stated by 32 patients (68.1 percent). CONCLUSIONS Quality of life increases significantly after surgery with a reduction of pain and swelling and decreased tendency to easy bruising. The high prevalence of hypothyroidism in lipedema patients could be related to the frequently observed lipedema-associated obesity. The low prevalence of diabetes, dyslipidemia, and hypertension appears to be a specific characteristic distinguishing lipedema from lifestyle-induced obesity.
{"title":"New Insights on Lipedema: The Enigmatic Disease of the Peripheral Fat.","authors":"Anna-Theresa Bauer, Dominik von Lukowicz, Katrin Lossagk, Matthias M Aitzetmueller, P. Moog, M. Cerny, H. Erne, D. Schmauss, D. Duscher, H. Machens","doi":"10.1097/PRS.0000000000006280","DOIUrl":"https://doi.org/10.1097/PRS.0000000000006280","url":null,"abstract":"BACKGROUND\u0000Although a large number of adult women worldwide are affected by lipedema, the physiologic conditions triggering onset and progression of this chronic disease remain enigmatic. In the present study, a descriptive epidemiologic situation of postoperative lipedema patients is presented.\u0000\u0000\u0000METHODS\u0000The authors developed an online survey questionnaire for lipedema patients in Germany. The survey was conducted on 209 female patients who had been diagnosed with lipedema and had undergone tumescent liposuction.\u0000\u0000\u0000RESULTS\u0000Most of the participants (average age, 38.5 years) had noticed a first manifestation of the disease at the age of 16. It took a mean of 15 years to accomplish diagnosis. Liposuction led to a significant reduction of pain, swelling, tenderness, and easy bruising as confirmed by the majority of patients. Hypothyroidism [n = 75 (35.9 percent) and depression [n = 48 (23.0 percent)] occurred at a frequency far beyond the average prevalence in the German population. The prevalence of diabetes type 1 [n = 3 (1.4 percent)], and diabetes type 2 [n = 2 (1 percent)] was particularly low among the respondents. Forty-seven of the lipedema patients (approximately 22.5 percent) suffered from a diagnosed migraine. Following liposuction, the frequency and/or intensity of migraine attacks became markedly reduced, as stated by 32 patients (68.1 percent).\u0000\u0000\u0000CONCLUSIONS\u0000Quality of life increases significantly after surgery with a reduction of pain and swelling and decreased tendency to easy bruising. The high prevalence of hypothyroidism in lipedema patients could be related to the frequently observed lipedema-associated obesity. The low prevalence of diabetes, dyslipidemia, and hypertension appears to be a specific characteristic distinguishing lipedema from lifestyle-induced obesity.","PeriodicalId":20168,"journal":{"name":"Plastic & Reconstructive Surgery","volume":"204 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"77687795","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-12-01DOI: 10.1097/PRS.0000000000006262
L. Hollier
www.PRSJournal.com 1429 I this article, the authors report the results of a systematic literature review and meta-analysis comparing computer-assisted mandibular reconstruction to conventional freehand mandibular reconstruction using free fibula flaps.1 This is one of the first studies to compare these two different techniques. After reviewing 647 articles and applying exclusion criteria, 12 articles were selected. Many different variables were studied, including ischemic time, operative time, patient length of stay, accuracy, and cost. In conducting these results, accuracy was the most difficult variable to compare. There was such a diversity of measurements used in the studies that a meta-analysis could not be conducted. However, computer-assisted mandibular reconstruction did appear to have superior or equivalent accuracy in most of the studies, when parameters such as condylar and gonial shift were compared to computer-assisted mandibular reconstruction. In addition, computer-assisted mandibular reconstruction showed reduced ischemic time, operative time, and length of stay. These findings are not surprising given the complexity of free fibular reconstruction of the mandible. With conventional freehand mandibular reconstruction, many decisions are made intraoperatively that affect subsequent aspects of the operation. The amount of resection determines the amount of fibula that must be harvested, and this in turn must be secured to the contoured reconstruction plate. Bending the plates is very complex and time consuming, and there is little tolerance for inaccuracies, as remaining teeth need to be placed in occlusion. An additional element of complexity is cutting the fibula to the contours of the reconstruction plate, maintaining bone-to-bone contact at each cut. With computer-assisted mandibular reconstruction, almost all of these elements can be planned preoperatively. The physician spends time before surgery with technicians to plan the resection and the reconstruction, including the shape of the plate and the appropriate cutting of the free fibular flap. At the time of surgery, the surgeon is typically equipped with a customized prebent plate and cutting guides for the fibula. One can see that this should certainly diminish time spent in the operating room and inaccuracies resulting from intraoperative decision-making. That having been said, the comparisons around cost are much more difficult to discern. One of the studies found an extra cost with computer-assisted mandibular reconstruction of $1231.50 with a prebent plate and over $3000.00 with a patientspecific surgical plate. The differential would be higher, but with the computer-assisted mandibular reconstruction, the time savings from the shorter procedure reduce the cost of the operating room time. However, costs are variable from country to country and the coverage of these costs by insurers is highly variable. Further complicating the issue with computer-assisted mandibular recon
{"title":"Discussion: Computer-Assisted versus Conventional Freehand Mandibular Reconstruction with Fibula Free Flap: A Systematic Review and Meta-Analysis.","authors":"L. Hollier","doi":"10.1097/PRS.0000000000006262","DOIUrl":"https://doi.org/10.1097/PRS.0000000000006262","url":null,"abstract":"www.PRSJournal.com 1429 I this article, the authors report the results of a systematic literature review and meta-analysis comparing computer-assisted mandibular reconstruction to conventional freehand mandibular reconstruction using free fibula flaps.1 This is one of the first studies to compare these two different techniques. After reviewing 647 articles and applying exclusion criteria, 12 articles were selected. Many different variables were studied, including ischemic time, operative time, patient length of stay, accuracy, and cost. In conducting these results, accuracy was the most difficult variable to compare. There was such a diversity of measurements used in the studies that a meta-analysis could not be conducted. However, computer-assisted mandibular reconstruction did appear to have superior or equivalent accuracy in most of the studies, when parameters such as condylar and gonial shift were compared to computer-assisted mandibular reconstruction. In addition, computer-assisted mandibular reconstruction showed reduced ischemic time, operative time, and length of stay. These findings are not surprising given the complexity of free fibular reconstruction of the mandible. With conventional freehand mandibular reconstruction, many decisions are made intraoperatively that affect subsequent aspects of the operation. The amount of resection determines the amount of fibula that must be harvested, and this in turn must be secured to the contoured reconstruction plate. Bending the plates is very complex and time consuming, and there is little tolerance for inaccuracies, as remaining teeth need to be placed in occlusion. An additional element of complexity is cutting the fibula to the contours of the reconstruction plate, maintaining bone-to-bone contact at each cut. With computer-assisted mandibular reconstruction, almost all of these elements can be planned preoperatively. The physician spends time before surgery with technicians to plan the resection and the reconstruction, including the shape of the plate and the appropriate cutting of the free fibular flap. At the time of surgery, the surgeon is typically equipped with a customized prebent plate and cutting guides for the fibula. One can see that this should certainly diminish time spent in the operating room and inaccuracies resulting from intraoperative decision-making. That having been said, the comparisons around cost are much more difficult to discern. One of the studies found an extra cost with computer-assisted mandibular reconstruction of $1231.50 with a prebent plate and over $3000.00 with a patientspecific surgical plate. The differential would be higher, but with the computer-assisted mandibular reconstruction, the time savings from the shorter procedure reduce the cost of the operating room time. However, costs are variable from country to country and the coverage of these costs by insurers is highly variable. Further complicating the issue with computer-assisted mandibular recon","PeriodicalId":20168,"journal":{"name":"Plastic & Reconstructive Surgery","volume":"67 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"76266428","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-12-01DOI: 10.1097/PRS.0000000000006228
T. Myckatyn
www.PRSJournal.com 993e D et al. seek to study a potential role of bacterial biofilms in the development of red breast syndrome.1 As the authors note, red breast syndrome is essentially a diagnosis of exclusion, where erythema of the skin overlying acellular dermal matrix develops days to weeks after implant reconstruction with no systemic signs of infection.2 As the authors themselves point out, the cause, incidence, time to onset, exact clinical definition, and appropriate treatment of red breast syndrome are either unknown, variable, or unclear. I commend the authors for their willingness to study red breast syndrome. In my view, fundamental methodologic flaws limit the value of this study. The authors describe prospective recruitment of study patients; however, an internal review board statement is lacking. This study has no control group against which samples from patients with red breast syndrome can be compared. The breast parenchyma and skin are known reservoirs of bacteria with substantial diversity that includes Gram-positive and Gram-negative organisms.3–6 The authors refer to a historical control of acellular dermal matrices from asymptomatic patients where bacteria were imaged on some, but not all, acellular dermal matrices.7 Experimental conditions, however, vary substantively between the studies. For one, the majority of patients presented with red breast syndrome within 3 to 4 weeks of implantation,1 whereas specimens were procured 4 to 16 months after implantation in the authors’ former work.7 Recovery time alone could have impacted the inflammatory and host immune response between cohorts. Sampling bias is another major issue with this work. Understandably, the authors limited their acellular dermal matrix biopsy specimens to a lateral 1-cm2 piece for culture and another for scanning electron microscopy to avoid aesthetic deformity. To put this in context, though, these two specimens represent only 1.5 percent of the surface area of a 128-cm2 sheet of acellular dermal matrix. Leaders in the field of biofilm research recommend a multiprong approach that speciates bacteria and then visually confirms their presence through imaging.8–16 The authors do perform cultures and scanning electron microscopy; however, as presented, we have no idea whether imaged and cultured bacteria correlated with one another. In fact, although I presume that the presented micrographs are from specific study patients, the authors do not actually confirm this. As the authors point out, characterizing bacterial biofilms can be challenging, but the authors should have leveraged other modalities to improve the relevance of their work.9,13,16 Immunohistochemistry with bacteria-specific antibodies could confirm the presence of (and inform the distribution of) cultured bacteria on acellular dermal matrix specimens. Background noise can limit the effectiveness of this approach on occasion. 16S rRNA sequencing of specific ribosomal hypervariable regions accompanie
{"title":"Discussion: Preliminary Results Supporting the Bacterial Hypothesis in Red Breast Syndrome following Postmastectomy Acellular Dermal Matrix- and Implant-Based Reconstructions.","authors":"T. Myckatyn","doi":"10.1097/PRS.0000000000006228","DOIUrl":"https://doi.org/10.1097/PRS.0000000000006228","url":null,"abstract":"www.PRSJournal.com 993e D et al. seek to study a potential role of bacterial biofilms in the development of red breast syndrome.1 As the authors note, red breast syndrome is essentially a diagnosis of exclusion, where erythema of the skin overlying acellular dermal matrix develops days to weeks after implant reconstruction with no systemic signs of infection.2 As the authors themselves point out, the cause, incidence, time to onset, exact clinical definition, and appropriate treatment of red breast syndrome are either unknown, variable, or unclear. I commend the authors for their willingness to study red breast syndrome. In my view, fundamental methodologic flaws limit the value of this study. The authors describe prospective recruitment of study patients; however, an internal review board statement is lacking. This study has no control group against which samples from patients with red breast syndrome can be compared. The breast parenchyma and skin are known reservoirs of bacteria with substantial diversity that includes Gram-positive and Gram-negative organisms.3–6 The authors refer to a historical control of acellular dermal matrices from asymptomatic patients where bacteria were imaged on some, but not all, acellular dermal matrices.7 Experimental conditions, however, vary substantively between the studies. For one, the majority of patients presented with red breast syndrome within 3 to 4 weeks of implantation,1 whereas specimens were procured 4 to 16 months after implantation in the authors’ former work.7 Recovery time alone could have impacted the inflammatory and host immune response between cohorts. Sampling bias is another major issue with this work. Understandably, the authors limited their acellular dermal matrix biopsy specimens to a lateral 1-cm2 piece for culture and another for scanning electron microscopy to avoid aesthetic deformity. To put this in context, though, these two specimens represent only 1.5 percent of the surface area of a 128-cm2 sheet of acellular dermal matrix. Leaders in the field of biofilm research recommend a multiprong approach that speciates bacteria and then visually confirms their presence through imaging.8–16 The authors do perform cultures and scanning electron microscopy; however, as presented, we have no idea whether imaged and cultured bacteria correlated with one another. In fact, although I presume that the presented micrographs are from specific study patients, the authors do not actually confirm this. As the authors point out, characterizing bacterial biofilms can be challenging, but the authors should have leveraged other modalities to improve the relevance of their work.9,13,16 Immunohistochemistry with bacteria-specific antibodies could confirm the presence of (and inform the distribution of) cultured bacteria on acellular dermal matrix specimens. Background noise can limit the effectiveness of this approach on occasion. 16S rRNA sequencing of specific ribosomal hypervariable regions accompanie","PeriodicalId":20168,"journal":{"name":"Plastic & Reconstructive Surgery","volume":"21 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"82227749","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-12-01DOI: 10.1097/PRS.0000000000006224
Shailesh Agarwal, D. Chang
www.PRSJournal.com 986e A lymphedema affects over 250 million people in the world—5 to 10 million from the United States alone—it is a disease that has been largely neglected.1–4 However, over the past decade, there has been a tremendous increase in awareness of lymphedema and advances in lymphatic surgery. Consequently, lymphatic surgery is increasingly being offered in select hospitals throughout the United States. In 2016, Dr. Singhal and his team established a lymphatic surgery program at the Beth Israel Deaconess Medical Center.1 They developed a core team with a multidisciplinary approach to coordinate the diagnostic workup, management, and surveillance of patients. An electronic Research Electronic Data Capture (REDCap) database was established to monitor care delivery and facilitate future research. Their program has three arms, which constitute a “clinical triad”: (1) lymphatic surgery (plastic surgeon with a focus on lymphedema care); (2) lymphatic medicine (cardiologist with specialized training in vascular medicine and focus on lymphatic care); and (3) the lymphatic treatment clinic (certified lymphedema therapists). In addition, their program is supported by body and nuclear imaging. The lymphedema team meets bimonthly to discuss and formalize patient-specific care plans.1 Their experience has included patients undergoing immediate lymphatic reconstruction (e.g., lymphatic microsurgical preventative healing approach) or delayed lymphatic reconstruction (e.g. lymphovenous bypass and/or vascularized lymph node transplantation). Similar to ours and the experience of others, a majority of patients diagnosed with lymphedema had a history of breast cancer.1–6 Overall, Singhal et al. report seeing 142 patients for evaluation during the 1-year period, of which 40 patients were seen for immediate lymphatic reconstruction and 69 for cancer-related delayed lymphatic reconstruction.1 That nearly 30 percent of patients (40 of 142) were seen in consultation for immediate lymphatic reconstruction is notable.5 In our experience, integrating the lymphatic microsurgical preventative healing approach into surgical practice requires a close relationship between the breast surgical oncologist(s) and the reconstructive surgeons. Logistic challenges include coordinating scheduling, uncertainty regarding the potential need for axillary lymph node dissection, and insurance coverage. Furthermore, identifying the patients who are at highest risk for developing lymphedema continues to be a challenge that impacts treatment efficacy. However, Singhal et al. are apt to point out that patients referred for immediate lymphatic reconstruction require less workup before their surgery. Of the 102 patients presenting for delayed lymphatic reconstruction, only 49 patients underwent a presurgical workup. Patients were excluded because of poor surgical candidacy (47 percent), a desire to pursue conservative therapy (47 percent), or a diagnosis inconsistent with lymphedema
www.PRSJournal.com 986e淋巴水肿影响着世界上超过2.5亿人，仅在美国就有500万到1000万，这种疾病在很大程度上被忽视了。1-4然而，在过去的十年中，人们对淋巴水肿的认识有了极大的提高，淋巴手术也取得了进展。因此，淋巴手术越来越多地在美国各地的精选医院提供。2016年，Singhal博士和他的团队在贝斯以色列女执事医疗中心(Beth Israel Deaconess Medical center)建立了一个淋巴手术项目。他们组建了一个核心团队，采用多学科方法来协调患者的诊断检查、管理和监测。建立了一个电子研究电子数据采集(REDCap)数据库，以监测护理服务并促进未来的研究。他们的项目有三个部分，构成了一个“临床三位一体”:(1)淋巴外科(专注于淋巴水肿护理的整形外科医生);(2)淋巴医学(在血管医学方面接受过专门培训并专注于淋巴护理的心脏病专家);(3)淋巴治疗门诊(经认证的淋巴水肿治疗师)。此外，他们的计划是由身体和核成像支持。淋巴水肿小组每两个月召开一次会议，讨论并正式制定针对患者的护理计划他们的经验包括接受即时淋巴重建(例如，淋巴显微外科预防性愈合方法)或延迟淋巴重建(例如，淋巴静脉旁路和/或血管化淋巴结移植)的患者。与我们和其他人的经历类似，大多数被诊断为淋巴水肿的患者都有乳腺癌病史。1-6总的来说，Singhal等人在1年的时间里报告了142例患者的评估，其中40例患者接受了立即淋巴重建，69例患者接受了与癌症相关的延迟淋巴重建值得注意的是，近30%的患者(142名患者中的40名)接受了立即淋巴重建的咨询根据我们的经验，将淋巴显微外科预防性愈合方法整合到外科实践中需要乳房外科肿瘤学家和重建外科医生之间的密切关系。后勤挑战包括协调调度，不确定的潜在需要腋窝淋巴结清扫，和保险范围。此外，确定患淋巴水肿风险最高的患者仍然是一个影响治疗效果的挑战。然而，Singhal等人倾向于指出，立即进行淋巴重建的患者在手术前需要较少的检查。在102例延迟淋巴重建患者中，只有49例患者接受了术前检查。患者被排除的原因是不适合手术(47%)，希望进行保守治疗(47%)，或诊断与淋巴水肿不一致(33%)。虽然目前尚不清楚如何评估患者的手术候选资格，但随着转诊网络中患者和提供者教育的改善，总体而言，值得进行全面术前检查的患者比例可能会增加。在53例符合术前检查条件的患者中(52%)，Singhal等人报告对13例患者进行了手术。在13例接受手术的患者中，2例行淋巴静脉旁路，7例行血管化淋巴结移植，4例行切除手术为淋巴水肿患者提供外科治疗的关键是需要长期治疗
{"title":"Discussion: Developing a Lymphatic Surgery Program: A First-Year Review.","authors":"Shailesh Agarwal, D. Chang","doi":"10.1097/PRS.0000000000006224","DOIUrl":"https://doi.org/10.1097/PRS.0000000000006224","url":null,"abstract":"www.PRSJournal.com 986e A lymphedema affects over 250 million people in the world—5 to 10 million from the United States alone—it is a disease that has been largely neglected.1–4 However, over the past decade, there has been a tremendous increase in awareness of lymphedema and advances in lymphatic surgery. Consequently, lymphatic surgery is increasingly being offered in select hospitals throughout the United States. In 2016, Dr. Singhal and his team established a lymphatic surgery program at the Beth Israel Deaconess Medical Center.1 They developed a core team with a multidisciplinary approach to coordinate the diagnostic workup, management, and surveillance of patients. An electronic Research Electronic Data Capture (REDCap) database was established to monitor care delivery and facilitate future research. Their program has three arms, which constitute a “clinical triad”: (1) lymphatic surgery (plastic surgeon with a focus on lymphedema care); (2) lymphatic medicine (cardiologist with specialized training in vascular medicine and focus on lymphatic care); and (3) the lymphatic treatment clinic (certified lymphedema therapists). In addition, their program is supported by body and nuclear imaging. The lymphedema team meets bimonthly to discuss and formalize patient-specific care plans.1 Their experience has included patients undergoing immediate lymphatic reconstruction (e.g., lymphatic microsurgical preventative healing approach) or delayed lymphatic reconstruction (e.g. lymphovenous bypass and/or vascularized lymph node transplantation). Similar to ours and the experience of others, a majority of patients diagnosed with lymphedema had a history of breast cancer.1–6 Overall, Singhal et al. report seeing 142 patients for evaluation during the 1-year period, of which 40 patients were seen for immediate lymphatic reconstruction and 69 for cancer-related delayed lymphatic reconstruction.1 That nearly 30 percent of patients (40 of 142) were seen in consultation for immediate lymphatic reconstruction is notable.5 In our experience, integrating the lymphatic microsurgical preventative healing approach into surgical practice requires a close relationship between the breast surgical oncologist(s) and the reconstructive surgeons. Logistic challenges include coordinating scheduling, uncertainty regarding the potential need for axillary lymph node dissection, and insurance coverage. Furthermore, identifying the patients who are at highest risk for developing lymphedema continues to be a challenge that impacts treatment efficacy. However, Singhal et al. are apt to point out that patients referred for immediate lymphatic reconstruction require less workup before their surgery. Of the 102 patients presenting for delayed lymphatic reconstruction, only 49 patients underwent a presurgical workup. Patients were excluded because of poor surgical candidacy (47 percent), a desire to pursue conservative therapy (47 percent), or a diagnosis inconsistent with lymphedema ","PeriodicalId":20168,"journal":{"name":"Plastic & Reconstructive Surgery","volume":"1 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"89210258","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-12-01DOI: 10.1097/PRS.0000000000006223
A. Johnson, A. Fleishman, B. Tran, Kathy Shillue, B. Carroll, L. Tsai, K. Donohoe, T. James, Bernard T. Lee, D. Singhal
BACKGROUND Lymphedema is a chronic condition that carries a significant physical, psychosocial, and economic burden. The authors' program was established in 2017 with the aims of providing immediate lymphatic reconstruction in high-risk patients undergoing lymphadenectomy and performing delayed lymphatic reconstruction in patients with chronic lymphedema. The purpose of this study was to describe the authors' clinical experience in the first year. METHODS A retrospective review of our clinical database was performed on all individuals presenting to the authors' institution for lymphatic surgery consideration. Patient demographics, clinical characteristics, and surgical management were reviewed. RESULTS A total of 142 patients presented for lymphatic surgery evaluation. Patients had a mean age of 54.8 years and an average body mass index of 30.4 kg/m. Patients with lymphedema were more likely to be referred from an outside facility compared to patients seeking immediate lymphatic reconstruction (p < 0.001). For patients with lymphedema, the most common cause was breast cancer related. Thirty-two percent of all patients evaluated underwent a lymphatic procedure. Of these, 32 were immediate lymphatic reconstructions and 13 were delayed lymphatic reconstructions. In the authors' first year, 94 percent of eligible patients presenting for immediate lymphatic reconstruction underwent an intervention versus only 38 percent of eligible lymphedema patients presenting for delayed lymphatic reconstruction (p < 0.001). CONCLUSIONS First-year review of our lymphatic surgery experience has demonstrated clinical need evidenced by the number of patients and high percentage of outside referrals. As a program develops, lymphatic surgeons should expect to perform more time-sensitive immediate lymphatic reconstructions, as evaluation of chronic lymphedema requires development of a robust team for workup and review.
{"title":"Developing a Lymphatic Surgery Program: A First-Year Review.","authors":"A. Johnson, A. Fleishman, B. Tran, Kathy Shillue, B. Carroll, L. Tsai, K. Donohoe, T. James, Bernard T. Lee, D. Singhal","doi":"10.1097/PRS.0000000000006223","DOIUrl":"https://doi.org/10.1097/PRS.0000000000006223","url":null,"abstract":"BACKGROUND\u0000Lymphedema is a chronic condition that carries a significant physical, psychosocial, and economic burden. The authors' program was established in 2017 with the aims of providing immediate lymphatic reconstruction in high-risk patients undergoing lymphadenectomy and performing delayed lymphatic reconstruction in patients with chronic lymphedema. The purpose of this study was to describe the authors' clinical experience in the first year.\u0000\u0000\u0000METHODS\u0000A retrospective review of our clinical database was performed on all individuals presenting to the authors' institution for lymphatic surgery consideration. Patient demographics, clinical characteristics, and surgical management were reviewed.\u0000\u0000\u0000RESULTS\u0000A total of 142 patients presented for lymphatic surgery evaluation. Patients had a mean age of 54.8 years and an average body mass index of 30.4 kg/m. Patients with lymphedema were more likely to be referred from an outside facility compared to patients seeking immediate lymphatic reconstruction (p < 0.001). For patients with lymphedema, the most common cause was breast cancer related. Thirty-two percent of all patients evaluated underwent a lymphatic procedure. Of these, 32 were immediate lymphatic reconstructions and 13 were delayed lymphatic reconstructions. In the authors' first year, 94 percent of eligible patients presenting for immediate lymphatic reconstruction underwent an intervention versus only 38 percent of eligible lymphedema patients presenting for delayed lymphatic reconstruction (p < 0.001).\u0000\u0000\u0000CONCLUSIONS\u0000First-year review of our lymphatic surgery experience has demonstrated clinical need evidenced by the number of patients and high percentage of outside referrals. As a program develops, lymphatic surgeons should expect to perform more time-sensitive immediate lymphatic reconstructions, as evaluation of chronic lymphedema requires development of a robust team for workup and review.","PeriodicalId":20168,"journal":{"name":"Plastic & Reconstructive Surgery","volume":"42 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"90532854","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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