PURPOSE: Prosthetic-based breast reconstruction is performed with increasing frequency in the United States. Major mastectomy skin flap necrosis is a significant complication with outcomes ranging from poor aesthetic appearance to reconstructive failure. The present study aimed to explore the interactions between intraoperative fill and other risk factors on the incidence of flap necrosis in patients undergoing mastectomy with immediate expander/implant-based reconstruction. METHODS: A retrospective review of 966 consecutive patients (1,409 breasts) who underwent skin or nipple sparing mastectomy with immediate tissue expander reconstruction at a single institution was conducted. Age, body mass index, hypertension, smoking status, premastectomy and postmastectomy radiation, acellular dermal matrix use, and application of the tumescent mastectomy technique were analyzed as potential predictors of flap necrosis both independently and as synergistic variables with high intraoperative fill. The following three measures of interaction were calculated: relative excess risk due to interaction, attributable proportion of risk due to interaction, and synergy index (SI). RESULTS: Intraoperative tissue expander fill volume was high (> or =66.7% of the maximum volume) in 40.9% (576 of 1,409 breasts) of cases. The unadjusted flap necrosis rate was greater in the high intraoperative fill cohort than in the low fill cohort (10.4% vs. 7.1%, p=0.027). Multivariate logistic regression did not identify high intraoperative fill volume as an independent risk factor for flap necrosis (odds ratio 1.442, 95% confidence interval 0.973-2.137, p=0.068). However, four risk factors were identified that interacted significantly with intraoperative fill volume, namely tumescence, age, hypertension, and obesity. The SI, or the departure from additive risks, was largest for tumescence (SI, 25.3), followed by hypertension (SI, 2.39), obesity (SI, 2.28), and age older than 50 years (SI, 1.17). CONCLUSION: In the postmastectomy, hypovascular milieu, multiple risk factors decreasing flap perfusion interact with high intraoperative fill volume to cross a threshold and synergistically increase the risk of flap necrosis.
Acellular Dermis ; Body Mass Index ; Cohort Studies ; Female ; Humans ; Hypertension ; Incidence ; Logistic Models ; Mammaplasty ; Mastectomy* ; Necrosis* ; Nipples ; Obesity ; Perfusion ; Retrospective Studies ; Risk Factors ; Skin ; Smoke ; Smoking ; Tissue Expansion Devices ; United States

The purpose of this systematic review and meta-analysis is to assess existing literature and determine the association between the Hounsfield unit (HU) value and the vertebral body quality (VBQ) score with mechanical complications (MCs) after adult spinal deformity (ASD) surgery. Although bone quality is considered an increasingly important factor for MCs after ASD surgery, the utility of the HU value assessed by computed tomography and the VBQ score assessed by magnetic resonance imaging remains unknown. A systematic review of PubMed, Embase, and Cochrane Library databases was performed to find studies evaluating the association between the HU value and the VBQ score with MCs after ASD surgery. In the subsequent meta-analysis, MC outcomes were combined using a random-effects model, and the standardized mean difference and 95% confidence interval were calculated. The final analysis included a total of 20 studies. Nineteen studies reported HU values, and two studies reported VBQ scores. Proximal junctional kyphosis/failure (PJK/PJF) was reported as the MC in 16 studies, whereas other MCs were included in 6 studies. Six studies with a pool of 506 patients with ASD revealed that preoperative HU values at the upper instrumented vertebra (UIV) and UIV+1 were significantly lower in patients with PJK/PJF (standardized mean difference, −0.74; 95% confidence interval, −1.09 to −0.40). Three studies suggested an cutoff HU value of approximately ≤120, yielding a pooled sensitivity of 0.77, specificity of 0.67, and diagnostic odds ratio of 7.01. However, two studies reported conflicting results on the relationship between the VBQ score and PJK/PJF. Low HU values predicted the risk of certain MCs, particularly PJK/PJF, after ASD surgery. An HU value of <120 should alert surgeons to be cautious about the postoperative occurrence of PJK/PJF. Future studies are needed to validate the cutoff HU value and evaluate the utility of the VBQ score.

Objective: While minimally invasive-transforaminal lumbar interbody fusion (MIS-TLIF) has shown superiority in key clinical metrics over the open approach, evidence regarding patient-reported outcomes remains limited. This study compared postoperative recovery trajectories and symptomatic improvement phases between MIS and open TLIF. Methods: This retrospective review included patients who underwent single-level MIS or open TLIF. Oswestry Disability Index (ODI) and Numerical Rating Scale (NRS) for back and leg pain were collected preoperatively and postoperatively. Segmented regression analysis with mixed-effects modeling, allowing for identification of distinct recovery phases, compared symptomatic trends between approaches. Results: Of 324 patients (268 MIS, 56 open), baseline demographics were similar except for greater preoperative leg pain in the MIS group (NRS: 6.0 vs. 5.0, p = 0.027). A segmented regression model identified 4 ODI recovery phases: postoperative disability phase (PDP, day 0 to 13), early improvement phase (day 13 to 28), late improvement phase (day 28 to 110), and plateau phase (later than day 110). The MIS group exhibited significantly lower disability exacerbation during PDP (β = 0.93 vs. 1.42 points per day, p = 0.008). Additionally, the plateau of NRS back occurred significantly earlier in the MIS group than in the open group (MIS, 26.7 ± 2.6 days vs. open, 51.7 ± 6.6 days, p < 0.001). Conclusion MIS-TLIF resulted in lower postoperative disability during the first 2 weeks compared to the open approach. Furthermore, low back pain achieved an earlier plateau in back pain by about 4 weeks in the MIS approach.

Objective: While minimally invasive-transforaminal lumbar interbody fusion (MIS-TLIF) has shown superiority in key clinical metrics over the open approach, evidence regarding patient-reported outcomes remains limited. This study compared postoperative recovery trajectories and symptomatic improvement phases between MIS and open TLIF. Methods: This retrospective review included patients who underwent single-level MIS or open TLIF. Oswestry Disability Index (ODI) and Numerical Rating Scale (NRS) for back and leg pain were collected preoperatively and postoperatively. Segmented regression analysis with mixed-effects modeling, allowing for identification of distinct recovery phases, compared symptomatic trends between approaches. Results: Of 324 patients (268 MIS, 56 open), baseline demographics were similar except for greater preoperative leg pain in the MIS group (NRS: 6.0 vs. 5.0, p = 0.027). A segmented regression model identified 4 ODI recovery phases: postoperative disability phase (PDP, day 0 to 13), early improvement phase (day 13 to 28), late improvement phase (day 28 to 110), and plateau phase (later than day 110). The MIS group exhibited significantly lower disability exacerbation during PDP (β = 0.93 vs. 1.42 points per day, p = 0.008). Additionally, the plateau of NRS back occurred significantly earlier in the MIS group than in the open group (MIS, 26.7 ± 2.6 days vs. open, 51.7 ± 6.6 days, p < 0.001). Conclusion MIS-TLIF resulted in lower postoperative disability during the first 2 weeks compared to the open approach. Furthermore, low back pain achieved an earlier plateau in back pain by about 4 weeks in the MIS approach.

Objective: While minimally invasive-transforaminal lumbar interbody fusion (MIS-TLIF) has shown superiority in key clinical metrics over the open approach, evidence regarding patient-reported outcomes remains limited. This study compared postoperative recovery trajectories and symptomatic improvement phases between MIS and open TLIF. Methods: This retrospective review included patients who underwent single-level MIS or open TLIF. Oswestry Disability Index (ODI) and Numerical Rating Scale (NRS) for back and leg pain were collected preoperatively and postoperatively. Segmented regression analysis with mixed-effects modeling, allowing for identification of distinct recovery phases, compared symptomatic trends between approaches. Results: Of 324 patients (268 MIS, 56 open), baseline demographics were similar except for greater preoperative leg pain in the MIS group (NRS: 6.0 vs. 5.0, p = 0.027). A segmented regression model identified 4 ODI recovery phases: postoperative disability phase (PDP, day 0 to 13), early improvement phase (day 13 to 28), late improvement phase (day 28 to 110), and plateau phase (later than day 110). The MIS group exhibited significantly lower disability exacerbation during PDP (β = 0.93 vs. 1.42 points per day, p = 0.008). Additionally, the plateau of NRS back occurred significantly earlier in the MIS group than in the open group (MIS, 26.7 ± 2.6 days vs. open, 51.7 ± 6.6 days, p < 0.001). Conclusion MIS-TLIF resulted in lower postoperative disability during the first 2 weeks compared to the open approach. Furthermore, low back pain achieved an earlier plateau in back pain by about 4 weeks in the MIS approach.

Objective: While minimally invasive-transforaminal lumbar interbody fusion (MIS-TLIF) has shown superiority in key clinical metrics over the open approach, evidence regarding patient-reported outcomes remains limited. This study compared postoperative recovery trajectories and symptomatic improvement phases between MIS and open TLIF. Methods: This retrospective review included patients who underwent single-level MIS or open TLIF. Oswestry Disability Index (ODI) and Numerical Rating Scale (NRS) for back and leg pain were collected preoperatively and postoperatively. Segmented regression analysis with mixed-effects modeling, allowing for identification of distinct recovery phases, compared symptomatic trends between approaches. Results: Of 324 patients (268 MIS, 56 open), baseline demographics were similar except for greater preoperative leg pain in the MIS group (NRS: 6.0 vs. 5.0, p = 0.027). A segmented regression model identified 4 ODI recovery phases: postoperative disability phase (PDP, day 0 to 13), early improvement phase (day 13 to 28), late improvement phase (day 28 to 110), and plateau phase (later than day 110). The MIS group exhibited significantly lower disability exacerbation during PDP (β = 0.93 vs. 1.42 points per day, p = 0.008). Additionally, the plateau of NRS back occurred significantly earlier in the MIS group than in the open group (MIS, 26.7 ± 2.6 days vs. open, 51.7 ± 6.6 days, p < 0.001). Conclusion MIS-TLIF resulted in lower postoperative disability during the first 2 weeks compared to the open approach. Furthermore, low back pain achieved an earlier plateau in back pain by about 4 weeks in the MIS approach.

Objective: While minimally invasive-transforaminal lumbar interbody fusion (MIS-TLIF) has shown superiority in key clinical metrics over the open approach, evidence regarding patient-reported outcomes remains limited. This study compared postoperative recovery trajectories and symptomatic improvement phases between MIS and open TLIF. Methods: This retrospective review included patients who underwent single-level MIS or open TLIF. Oswestry Disability Index (ODI) and Numerical Rating Scale (NRS) for back and leg pain were collected preoperatively and postoperatively. Segmented regression analysis with mixed-effects modeling, allowing for identification of distinct recovery phases, compared symptomatic trends between approaches. Results: Of 324 patients (268 MIS, 56 open), baseline demographics were similar except for greater preoperative leg pain in the MIS group (NRS: 6.0 vs. 5.0, p = 0.027). A segmented regression model identified 4 ODI recovery phases: postoperative disability phase (PDP, day 0 to 13), early improvement phase (day 13 to 28), late improvement phase (day 28 to 110), and plateau phase (later than day 110). The MIS group exhibited significantly lower disability exacerbation during PDP (β = 0.93 vs. 1.42 points per day, p = 0.008). Additionally, the plateau of NRS back occurred significantly earlier in the MIS group than in the open group (MIS, 26.7 ± 2.6 days vs. open, 51.7 ± 6.6 days, p < 0.001). Conclusion MIS-TLIF resulted in lower postoperative disability during the first 2 weeks compared to the open approach. Furthermore, low back pain achieved an earlier plateau in back pain by about 4 weeks in the MIS approach.