Double VOLT to the mid-level and proximal extremity is a safe and viable option.

Introduction: There is a subset of patients who initially had implant based breast reconstruction but later change to autologous reconstruction after failure of the implant reconstruction. The purpose of this study was to examine our series of patients in whom autologous reconstruction was performed after initial failed implant reconstruction, using the BREAST-Q to examine patient satisfaction and quality of life. Methods: After Institutional Review Board approval, a retrospective chart review of a prospectively maintained database was performed as well as evaluation of BREAST-Q surveys. Results: One hundred thirty-seven patients underwent autologous breast reconstruction following failed implant based reconstruction with 192 total flaps. Failure of implant reconstruction was defined as follows: capsular contracture causing pain and/or cosmetic deformity (n=106, 77%), dissatisfaction with the aesthetic result without capsular contracture (n=15, 11%), impending exposure of the implant/infection (n=8, 6%), and unknown (n=8, 6%). Complications requiring operative intervention included: partial flap loss (n=5, 3%), hematoma (n=5, 3%), vascular compromise requiring intervention for salvage (n=2, 1%), and total flap loss (n=1, 1%). Thirtyfour patients (23%) had BREAST-Q surveys available for analysis both during implant and autologous phases of reconstruction. There was a statistically significant increase in satisfaction with appearance of breasts(p<0.001), psychosocial well-being(p<0.001), and physical well-being of the chest(p=0.003). Satisfaction with overall outcomes also significantly increased(p<0.001). A statistically significant decrease in physical well-being of the abdomen was observed(p=0.001). Conclusion: Autologous breast reconstruction after failed implant based reconstruction is associated with significantly improved patient satisfaction and quality of life. The procedure has an acceptable complication rate.

Introduction: The purpose of this study was to evaluate the most commonly used preoperative assessment tools for patients undergoing surgical treatment for secondary upper extremity lymphedema. Methods: This was a prospective cohort study performed at a tertiary cancer center specializing in the treatment of secondary lymphedema. Lymphedema evaluation included limb volume measurements, bio-impedance, indocyanine green lymphography, lymphoscintigraphy, magnetic resonance angiography, lymphedema life impact scale (LLIS) and upper limb lymphedema 27 (ULL-27) questionnaires. Results: 118 patients were evaluated. Limb circumference underestimated lymphedema compared to limb volume. Bioimpedance (L-Dex) scores highly correlated with limb volume excess (r2 = 0.714, p < 0.001). L-Dex scores were highly sensitive and had a high positive predictive value for diagnosing lymphedema in patients with a volume excess of 10% or more. ICG was highly sensitive in identifying lymphedema. Lymphoscintigraphy had an overall low sensitivity and specificity for the diagnosis of lymphedema. MRA was highly sensitive in diagnosing lymphedema and adipose hypertrophy as well as useful in identifying axillary vein obstruction and occult metastasis. Patients with minimal limb volume difference still demonstrated significantly impaired quality of life. Conclusion: Preoperative assessment of lymphedema is complex and requires multimodal assessment. MRA, L-Dex, ICG, and PROMs are all valuable components of preoperative assessment.

Normal flap perfusion is a requisite for successful VOLT harvest. However, over half the patients had some degree of abnormal perfusion irrespective of prior abdominal surgery. Indocyanine green angiography is an important tool in ensuring a healthy lymphatic reconstruction.

Purpose Longitudinal, routine utilization of patient-reported outcome measures (PROMs) in clinical care has been challenging. The purpose of this study is to describe a quality improvement initiative to improve patient engagement with the BREAST-Q, a gold-standard PROM for breast reconstruction. Methods In 2011, we implemented the BREAST-Q as part of routine care. In 2018, we began a quality improvement initiative to increase BREAST-Q patient participation. The BREAST-Q was administered at every clinic visit via an institutional patient portal or an in-clinic tablet; digital dashboard technologies were used to improve workflow integration, real-time accountability, and immediate data availability at clinic visits. High clinical staff engagement was encouraged by assigning “BREAST-Q Champions.” BREAST-Q completion data and patient characteristics were examined to understand non-response to the assessment. Results Following quality improvement, the average annual BREAST-Q completion rate increased from 42.8% in 2011–2017 to 87.6% in 2019, the last full year of our study period. High completion rates were maintained January–July 2020; however, a significantly larger proportion of BREAST-Qs were completed at home in 2020 versus the same period in 2019 (49.7 vs. 38.8%, p < 0.001), potentially due to the COVID-19 pandemic. Compared with non-responders, responders were younger (49.7 vs. 52.2 years, p < 0.001), more likely to be white (76.9 vs. 73.6%, p < 0.001), and had private insurance (79.4 vs. 69.8%, p < 0.001). Conclusion Our quality improvement initiative successfully increased routine completion of the BREAST-Q. Similar implementation techniques may prove beneficial at other institutions interested in incorporating PROMs into routine care.