Patients undergoing surgical resection of primary breast tumors confront a risk for metastatic recurrence that peaks sharply 12 to 18 months after surgery. The cause of early metastatic relapse in breast cancer has long been debated, with many ascribing these relapses to the natural progression of the disease. Others have proposed that some aspect of surgical tumor resection triggers the outgrowth of otherwise-dormant metastases, leading to the synchronous pattern of relapse. Clinical data cannot distinguish between these hypotheses, and previous experimental approaches have not provided clear answers. Such uncertainty hinders the development and application of therapeutic approaches that could potentially reduce early metastatic relapse. We describe an experimental model system that definitively links surgery and the subsequent wound-healing response to the outgrowth of tumor cells at distant anatomical sites. Specifically, we find that the systemic inflammatory response induced after surgery promotes the emergence of tumors whose growth was otherwise restricted by a tumor-specific T cell response. Furthermore, we demonstrate that perioperative anti-inflammatory treatment markedly reduces tumor outgrowth in this model, suggesting that similar approaches might substantially reduce early metastatic recurrence in breast cancer patients.

Background Eight novel virtual surgery electives (VSEs) were developed and implemented in April–May 2020 for medical students forced to continue their education remotely due to COVID-19. Methods Each VSE was 1–2 weeks long, contained specialty-specific course objectives, and included a variety of teaching modalities. Students completed a post-course survey to assess changes in their interest and understanding of the specialty. Quantitative methods were employed to analyze the results. Results Eighty-three students participated in the electives and 67 (80.7%) completed the post-course survey. Forty-six (68.7%) respondents reported “increased” or “greatly increased” interest in the course specialty completed. Survey respondents’ post-course understanding of each specialty increased by a statistically significant amount ( p -value = <0.0001). Conclusion This initial effort demonstrated that VSEs can be an effective tool for increasing medical students’ interest in and understanding of surgical specialties. They should be studied further with more rigorous methods in a larger population.

Purpose The oncoplastic reduction approach is a popular option for women with breast cancer and macromastia. Although the benefits of this approach are numerous, data on the need for secondary surgeries are limited. We evaluated the need for all secondary surgeries after oncoplastic reduction in an attempt to understand the incidence and indications. Methods All patients with breast cancer who underwent an oncoplastic breast reduction at the time of the tumor resection were queried from a prospectively maintained database from 1998 to 2020 (n = 547) at a single institution. Secondary surgical procedures were defined as any unplanned return to the operating room. Demographic and clinical variables were analyzed, and secondary surgeries were classified and evaluated. The timing and rates of secondary surgery were evaluated and compared with clinical variables. Results There were 547 patients included in this series with a mean age of 55 years and body mass index of 33.5. Mean duration of follow-up was 3.8 years. One hundred and seventeen (21%) patients underwent 235 secondary surgeries, with an average of 1.4 operations until stable reconstruction was obtained. The reason for the secondary surgery was involved margins (7.5%), major complications (8.6%), aesthetic improvement (13.3%), and completion mastectomy (5.3%). Age 65 years and younger age was associated with any subsequent procedure (P = 0.023) and revision for cosmesis (P = 0.006). Patients with body mass index greater than 35 had increased secondary surgeries for operative complications (P = 0.026). Conclusions Secondary surgeries after oncoplastic breast reduction procedures are common. Management of margins and complications, such as hematoma and infection, are early indications, with aesthetic improvement, wound healing complications, fat necrosis, and recurrence being late reasons. The most common reason for reoperation is aesthetic improvement, especially in younger patients. Attention to surgical technique and patient selection will help minimize secondary surgeries for the nononcological reasons.

Purpose Asymmetry of nipple position is common in the female population. There are scant data on the impact of bilateral nipple-sparing mastectomy (NSM) and immediate implant-based reconstruction on nipple asymmetry. Methods A retrospective review was performed of an institutional review board approved prospective database of NSM and immediate implant-based reconstruction was performed. BCCT.core software was used to examine preoperative and postoperative nipple asymmetry. It directly calculates the quantitative differences in nipple position between the breasts expressed as breast retraction assessment (BRA). Nipple to sternal notch (N-SN) asymmetry was calculated from the collected data. Results Sixty-eight patients undergoing bilateral NSM and implant reconstruction were reviewed. Reconstructive methods were tissue expander (TE) 39 (57.4%) and direct to implant (DTI) (prepectoral 13, submuscular 16) 29 (42.6%). The TE group had greater body mass index (BMI) (23.5 vs 22.1, P = 0.02), mastectomy weight (390.7 vs 243.8, P = 0.001) and higher preoperative N-SN asymmetry (TE 0.89 vs DTI 0.59, P = 0.02). Ten patients received radiation (TE group 4, DTI group 6). The TE group had larger implant size (479.1 vs 375.0, P = 0.0001). Overall, TE reconstruction resulted in an increase in nipple asymmetry (mean BRA: preoperative, 1.50 vs postoperative, 1.65), which was not significant. Direct to implant reconstruction increased nipple asymmetry: mean N-SN asymmetry preoperative 0.59 versus postoperative 0.97 (P = 0.04) and mean BRA scores 1.40 and 1.82 (P = 0.06). Both implant locations in the DTI group resulted in an increase in postoperative asymmetry but was significant for the prepectoral group: mean BRA preoperative 1.19 versus postoperative 1.85, P = 0.02 and mean N-SN asymmetry preoperative 0.48 vs postoperative 0.94, P = 0.04. Radiation impacted the final mean BRA score: radiation 2.24 versus no radiation 1.63 (P = 0.05). Conclusions Patients who underwent TE reconstruction had significantly larger breasts and greater preoperative N-SN asymmetry than the DTI group. Despite this, the TE group resulted in mild increase in nipple asymmetry. Both implant locations in DTI reconstruction resulted in increased postoperative asymmetry but was significant for the prepectoral group. Radiation therapy has a significant impact of nipple asymmetry.

Volume 147, Number 4 • Viewpoints 727e Daily 1-hour surgical workshops, taught by residents, covered the basics of knot-tying and suturing to help students develop surgical skills. A two-camera video setup using a cellphone on a tripod and a laptop with an embedded webcam was used for a first-person view (Fig. 2). Students were issued basic suture materials for these sessions.As a result of this course, students gained broad exposure to the field of plastic surgery and increased their interest in plastic surgery as a career. Subjectively, students felt that our methodology was useful and successfully achieved the learning objectives. Objectively, students improved on standardized measures of learning, including posttest learning assessments and fundamental surgical and presentation skills.This will be the first year medical students are not allowed to perform visiting "audition" rotations before applying for the highly competitive integrated plastic surgery match. Institutions across the country are experimenting with ways to recruit and assess candidates, including virtual meet and greets, live-streamed surgery, and virtual anatomy laboratories. Our study demonstrates that a valuable learning experience and meaningful one-on-one interaction can be obtained in virtual format. That we, as a medical community, become more facile with online learning may be one of the greatest "goods" to come out of an otherwise difficult time.

Background: The timing of extubation following placement of mandibular distractors in the setting of Pierre Robin sequence is variable across institutional algorithms. Postoperative maintenance of intubation allows for an improvement in airway dimension and tongue positioning before extubation, theoretically decreasing the impact of postoperative airway edema. Maintenance of intubation, however, is not without risk. The authors analyze their institutional experience with neonatal mandibular distraction followed by immediate extubation to assess feasibility and safety profiles. Methods: A 4-year retrospective review of patients diagnosed with Pierre Robin sequence who underwent mandibular distraction within the first 3 months of life was performed. Patients intubated preoperatively were excluded. Results: Fifty-two patients met inclusion criteria. Thirty-eight patients (73 percent) were extubated immediately, whereas 14 patients (27 percent) remained intubated. No differences between these groups were found when comorbidities, cleft pathology, preoperative respiratory support, or grade of view on direct laryngoscopy were analyzed. Case duration greater than 120 minutes, operation start time after 3 pm, and the subjective designation of a difficult airway by the anesthesiologist were associated with maintaining intubation (p < 0.05). Eight patients (21 percent) in the extubated group required an increase in respiratory support in the postoperative interval. Four of these patients (11 percent) required reintubation. Increased postoperative respiratory support was more likely in patients with certain comorbidities and higher preoperative respiratory support requirements (p < 0.05). Conclusions: The authors’ data suggest that immediate extubation following neonatal mandibular distraction is feasible in patients who are not intubated preoperatively. Careful consideration should be given to patients who require significant respiratory support preoperatively and in those with certain comorbidities. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

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