Contact

  • Academic
    shanfran@stanford.edu
    University - Student Department: School of Medicine Position: Graduate, Medicine

Additional Info

  • Mail Code: 3068

All Publications

  • Antibiotic eluting collagen-based hydrogel improves wound healing in a biofilm challenged murine stented wound model. Journal of applied biomaterials & functional materials Smith, R. W., Jarman, E. H., Francis, S., Burgess, J. B., Hayashiganati, K., Sharma, A., Sanchez Rangle, U., Singh, A., Green, A., Fox, P. M. 2026; 24: 22808000261447657

    Abstract

    Biofilm-colonized chronic wounds are difficult to treat due to a constantly evolving microbiome. In this study, a cHG augmented with antibiotics was examined for the topical treatment of biofilm-challenged wounds in vivo. Two studies were performed in series using a murine stented wound model. Mice were divided into four groups: control (wound only), infection only (IO), infection + cHG (IcHG), and infection + cHG + antibiotics (IcHG + Abx). We first examined Pseudomonas aeruginosa biofilms treated with gentamicin, and then MRSA biofilms treated with clindamycin. Wound healing was assessed using photography, immunohistochemistry, and histology. Systemic symptoms were monitored with hematological laboratory tests. Pseudomonas aeruginosa infected wounds treated with cHG + Abx healed faster and were protected from bacteremia. In the MRSA infected mice, wound treatment significantly affected the outcome, explaining 5.56% of total variance (ANOVA: F(3, 366) = 17.38, p < 0.0001). Additionally, infected wounds treated with cHG + Abx demonstrated less inflammatory tissue and accelerated closure rate on day 8 (76.53% ± 7.43% vs 48.40% ± 4.95%, p < 0.0001) and day 14 (96.00% ± 3.07% vs 82.38% ± 8.24%, p = 0.003), as compared to the infection only wounds. cHG offers a biocompatible, topical option with dual functionality: antibiotic augmentation to target biofilm pathogens, and a collagen-rich dressing to accelerate wound healing.

    View details for DOI 10.1177/22808000261447657

    View details for PubMedID 42152808

  • Is Malignancy Associated With Arthroplasty? A Meta-analysis. Clinical orthopaedics and related research Johnstone, T., Sayadi, J. J., Arora, J. S., Francis, S. D., Khattab, N. R., Ha, J. H., Avedian, R., Lee, G. 2025

    Abstract

    Although implants have been linked to malignancies in other medical contexts, such as the relationship between anaplastic large cell lymphoma and breast implants, the potential association between orthopaedic implants and cancer remains unclear. Several studies have investigated this question, but findings have been inconsistent. A comprehensive meta-analysis is needed to clarify whether total joint arthroplasty increases the risk of malignancy.(1) Is receiving a THA or TKA associated with an increased risk of cancer? (2) Are certain implant types (such as metal-on-metal or cemented) associated with increased cancer risk? (3) Is follow-up duration associated with changes in observed cancer risk estimates?A systematic review and meta-analysis were conducted using PubMed, Embase, and SCOPUS to identify studies assessing cancer incidence rates in patients who received hip or knee arthroplasty compared to patients in control groups who did not receive arthroplasty. Databases were queried from inception through the final search date (November 23, 2024). Eligible studies reported or allowed derivation of an effect estimate comparing overall cancer incidence rates in recipients of THA or TKA with an external reference population. From 1838 screened articles, 16 studies were included, all of which provided extractable effect estimates that were entered into one or more of our meta-analyses. Included studies consisted primarily of record-linkage studies connecting national, longitudinally maintained arthroplasty registers to similarly longitudinal national mortality and cancer registers. Study quality was assessed using the Newcastle-Ottawa Scale, which awards up to nine points across three categories, with higher scores indicating lower risk of bias. The 16 included studies scored between 6 and 8 (mean ± SD 7.1 ± 0.8), reflecting generally high methodological quality. The primary analysis included data from 977,465 patients of both sexes and all age groups who underwent hip or knee arthroplasty and were followed up for over 7,415,134 person-years. Effect estimates were pooled with a random-effects model because heterogeneity was present (between-study σ2 = 0.016 versus within-study σ2 = 0.002; Q = 1195, p < 0.001), and a funnel plot showed no evidence of publication bias. To explore associations between implant type and cancer risk for patients undergoing THA, we conducted separate meta-analyses for studies reporting on metal-on-metal bearing surfaces and those reporting on cemented fixation. To assess latency effects, we compared cancer incidence rates in patients with more or less than 10 years of follow-up and conducted a meta-regression to evaluate the association between follow-up duration and cancer risk. We did not perform an a priori power analysis.Patients who underwent THA or TKA did not have an increased risk of cancer compared with the general population (pooled random-effects estimate [REE] = 0.99 [95% confidence interval (CI) 0.92 to 1.07]; p = 0.88). Subgroup analyses showed no increased cancer risk after TKA (pooled REE = 1.02 [95% CI 0.85 to 1.21]; p = 0.83) or THA (pooled REE = 0.99 [95% CI 0.91 to 1.07]; p = 0.73). Cancer risk did not increase among patients undergoing THA who received cemented implants (pooled REE = 1.00 [95% CI 0.87 to 1.15]; p = 0.93) or metal-on-metal implants (pooled REE = 1.02 [95% CI 0.85 to 1.21]; p = 0.86) compared with the general population. Among patients with ≥ 10 years of follow-up, cancer incidence did not differ from the general population (pooled REE = 1.05 [95% CI 0.97 to 1.14]; p = 0.21); similarly, among patients with < 10 years of follow-up, no increased cancer risk was observed (pooled REE = 0.93 [95% CI 0.81 to 1.06]; p = 0.27). Meta-regression showed no association between follow-up duration and cancer risk (β = -0.004 [95% CI -0.024 to 0.015]; p = 0.66).Based on these findings, clinicians can continue to recommend arthroplasty without additional cancer-related concern based on current evidence. However, future studies should ensure longer follow-up, improved global representation in large linkage studies, and detailed patient- and implant-specific data to better characterize potential rare or long-latency malignancies.Level III, therapeutic study.

    View details for DOI 10.1097/CORR.0000000000003654

    View details for PubMedID 40828988

  • Implant-associated malignancies in the genitourinary system: a comprehensive review of evidence and gaps. International urology and nephrology Francis, S., Arora, J., Sayadi, J., Vu, C., Khattab, N. R., Malapati, H., Johnstone, T., Ha, J. H., Jang, Y., Enemchukwu, E., Lee, G. 2025

    Abstract

    BACKGROUND: The relationship between foreign material implantation and cancer development has been investigated since the 1940s, yet many questions remain regarding the mechanisms and risks associated with these interactions. This scoping review examines the potential oncogenic effects of foreign material implantation within the genitourinary system (GUS), focusing on neoplasms linked to chronic mucosal irritation from medical devices.METHODS: A systematic literature search of PubMed and Embase screened 15,925 studies for malignancies linked to implants (final search July 2023). Inclusion criteria involved clinical studies, cohort studies, case control studies, case reports and case series of human subjects with a history of genitourinary foreign devices or prosthesis implantation and de novo malignancies at the site of implantation or metastases of any tumor that were found adjacent to or near the prosthesis. Meta-analyses, systematic reviews, practice guidelines, narrative reviews, and studies with non-human subjects or benign masses were excluded. There were no date or language restrictions.RESULTS: Twenty-six case reports and series (46 cases) and 21 cohort studies were identified. GU implants identified included transurethral and suprapubic catheters, transvaginal mesh, midurethral slings, and ureteral stents. The mean duration of implant exposure before malignancy diagnosis was 16.8years. Chronic irritation from indwelling catheters was frequently linked to malignancies, including squamous cell carcinoma (54.5%) and transitional cell carcinoma (38.6%), with the bladder as the most common tumor site (68.2%). However, materials used in catheters were rarely documented, underscoring a critical gap in reporting. Smoking, a significant bladder cancer risk factor, was often undocumented, complicating risk attribution.CONCLUSION: Our findings underscore the need for robust data on implant material and smoking history to refine our understanding of carcinogenesis. Clinicians should maintain vigilance for malignancy in patients with prolonged implant exposure, particularly in high-risk populations like those with spinal cord injuries. This review highlights the importance of balancing implant benefits with risks and provides guidance for future research and clinical practice.

    View details for DOI 10.1007/s11255-025-04712-x

    View details for PubMedID 40783898

  • Role of aging in nerve and muscle changes after chronic nerve compression in mice. Experimental neurology Green, A., Arora, J. S., Burgess, J. J., Emefiele, J., Francis, S. D., Singh, A., Fox, P. M. 2025: 115348

    Abstract

    BACKGROUND AND AIMS: Chronic nerve compression (CNC) impacts over one million Americans annually, causing substantial functional and economic burdens. Despite its prevalence, the translational relevance of murine CNC models is limited by the use of young animals and a lack of studies investigating post-decompression recovery. This study aims to characterize CNC in aged mice compared to young mice and assess nerve and muscle recovery following surgical release in aged animals.METHODS: Young (20-week) and aged (67-week) male C57BL/6 J mice underwent 16 weeks of sciatic nerve compression. A subset of aged mice received surgical decompression, followed by a 4-week recovery. Electrophysiological, histological, and molecular analyses were performed on nerve and muscle tissues to evaluate changes induced by CNC and decompression.RESULTS: CNC induced demyelination in both young and aged mice, with aged mice exhibiting greater axonal atrophy. Young mice muscle demonstrated increased expression of atrophic and fibrotic markers such as Atrogin1, MuRF1, and alpha-SMA. Conversely, we observed increased expression of MyoD and MyoG myogenic markers in aged mice muscle, correlating with increased average muscle fiber cross-sectional area. In aged mice, surgical release restored electrophysiological parameters, normalized histological features, and reversed molecular gene adaptations.CONCLUSION: The molecular and structural responses to CNC in affected muscle differ with age, with aged mice demonstrating a shift from atrophic to myogenic pathways compared to young mice. Surgical release effectively mitigates CNC-induced deficits, emphasizing its therapeutic value. This study highlights the importance of age-appropriate models for understanding CNC pathophysiology and recovery dynamics.

    View details for DOI 10.1016/j.expneurol.2025.115348

    View details for PubMedID 40516807

  • Investigating orbital foreign device-associated malignancies: a scoping review. BMC cancer Ha, J. H., Arora, J. S., Sayadi, J. J., Khattab, N. R., Francis, S. D., Johnstone, T. M., Jang, Y., Lee, G. K. 2025; 25 (1): 167

    Abstract

    While prosthesis-associated malignancies have been acknowledged, awareness among surgeons and patients in the ophthalmologic field remains limited, despite the frequent occurrence of prosthesis-related surgeries. We aim to address this gap through a scoping review of malignancies following ophthalmologic surgeries involving various foreign device/prosthesis/implants.Following PRISMA guidelines, we conducted a review using PubMed and Embase for studies on cancer and ophthalmic prostheses/implants. The final selection of articles for the ophthalmology aspect underwent rigorous investigation.We analyzed 30 studies, identifying 41 cases of malignancies following interventions involving orbital foreign devices. Foreign devices linked to malignancies included scleral shells, orbital implants, scleral buckles, encircling bands, and gold plates. Ocular surface squamous neoplasm was most common, with 29 cases. Other malignancies observed were pleomorphic sarcoma, synovial sarcoma, marginal zone B-cell lymphoma, sebaceous carcinoma, malignant melanoma, adenocarcinoma, and metastatic lung adenocarcinoma. These malignancies varied in characteristics and demographics, with some showing metastasis or local invasion. The median time to tumor development was 40 years.This study highlights a spectrum of malignancies following orbital foreign device procedures and suggests a potential association between different types of orbital foreign devices and malignancies. Future studies, including well-designed epidemiologic studies and scientific experiments, are warranted to elucidate the causal relationship.

    View details for DOI 10.1186/s12885-024-13422-z

    View details for PubMedID 39875819

    View details for PubMedCentralID 1042479

  • The effect of prophylactic antibiotics on second-stage breast reconstruction: A retrospective analysis. Journal of plastic, reconstructive & aesthetic surgery : JPRAS Barrera, J., Lakhlani, D., Francis, S., Maheta, B., Gonzalez, C., Nino, G., Choi, H., Buckman, C., Baah, C. A., Johnstone, T., Yesantharao, P., Goli, R., Thawanyarat, K., Sivaraj, D., Nazerali, R. 2025; 102: 176-184

    Abstract

    Implant-based breast reconstruction has a higher infection risk than cosmetic augmentation, leading to routine prophylactic antibiotic use. We previously found extended prophylaxis reduced infections during the first-stage reconstruction with tissue expander/acellular dermal matrix placement. However, the most appropriate antibiotic class and duration of prophylaxis in the second-stage reconstruction remains unclear. This retrospective study aims to address this gap, focusing on antibiotic selection and duration during second-stage implant-based breast reconstruction.A single-center retrospective cohort study involved 359 patients undergoing second-stage breast reconstruction with tissue expander-implant exchange between January 2018 and January 2021. Chart reviews were performed to collect patient and surgical factors, antibiotic prophylaxis information, and postoperative outcomes. Multivariate logistic regression and likelihood ratio tests assessed associations between prophylaxis, covariates, and complications.Beyond a single perioperative dose of cefazolin, extended antibiotic prophylaxis did not significantly affect postoperative infection likelihood after second-stage breast reconstruction. Patients were grouped by antibiotic prophylaxis duration: 0 days (62 patients), 1 to 6 days (58 patients), and 7 or more days (239 patients). Extending antibiotic prophylaxis duration did not improve the prediction of 3-month postoperative infection rate (p = 0.581). A previous history of breast infection was a significant predictor for infection (p < 0.001).Extending antibiotics prophylaxis beyond a single preoperative dose of intravenous cefazolin does not reduce complication rates for patients undergoing second-stage breast reconstruction. Limiting prolonged prophylactic antibiotic use beyond the anesthetic period may reduce side effects (e.g., upset GI tract) and associated complications, including allergic reactions, Clostridium difficile colitis, and the emergence of new antibiotic-resistant pathogens.

    View details for DOI 10.1016/j.bjps.2025.01.032

    View details for PubMedID 39933364

  • Comparative analysis of comorbidity indexes in implant-based breast reconstruction. Journal of plastic, reconstructive & aesthetic surgery : JPRAS Green, A., Francis, S. D., Akhter, M. F., Nazerali, R. S. 2024; 100: 120-128

    Abstract

    Recent studies have used comorbidity indexes to stratify postsurgical complication risk across multiple surgical fields, including plastic surgery. However, such studies are lacking in implant-based breast reconstruction (IBBR). Understanding how comorbidity scores affect postsurgical outcomes in IBBR can help identify patients who may require additional medical surveillance after surgery.We conducted a retrospective analysis of adult female patients who underwent IBBR between January 2017 and December 2022 using the Merative™ Marketscan® Research Databases. ICD-10 diagnosis codes were used to calculate patients' scores on four different comorbidity indexes. Chi-squared tests were performed for demographic analysis, and multivariable logistic regression controlling for demographic and surgical variables, was conducted to determine associations between comorbidity indexes and adverse outcomes.Among 16,287 IBBR patients, 3145 (19.3%) experienced a complication within 90 days. On regression analysis, the Modified Frailty Index 5-Item (mFI-5) demonstrated the strongest associations with complications (odds ratio=1.25 [1.18, 1.32]), compared to the Charlson Comorbidity Index, Elixhauser Comorbidity Index, and Modified Frailty Index 11-Item. Further regression analysis revealed that four out of the five mFI-5 comorbidities were independent risk factors for postsurgical complications.This study highlights important associations between comorbidity indexes and adverse postoperative outcomes in IBBR. mFI-5 demonstrated superior performance in postoperative risk stratification compared to the other indexes analyzed. These findings suggest that using mFI-5 in clinical settings may help identify high comorbidity patients who may benefit from additional monitoring and prophylactic measures. Further research is needed to understand how to mitigate the increased postoperative complication risk in these patients.

    View details for DOI 10.1016/j.bjps.2024.11.015

    View details for PubMedID 39612519

  • National trends in revision procedures in post-mastectomy breast reconstruction: Autologous vs implant-based approaches. Journal of plastic, reconstructive & aesthetic surgery : JPRAS Francis, S. D., Kang, A. W., Maheta, B. J., Sangalang, B. R., Salingaros, S., Wu, R. T., Nazerali, R. S. 2024; 95: 127-133

    Abstract

    BACKGROUND: Breast reconstruction involves collaborative decision-making between patients and surgeons, but the need for multiple revisions after the initial reconstructive surgery process can burden patients and the healthcare system. This study explored how the type of breast reconstruction (autologous [ABR], immediate implant-based reconstruction [IBR], or two-stage IBR) impacts postreconstruction revision rates.METHOD: Using MarketScan Databases, a retrospective database study (2007-2021) was conducted, identifying revision procedures through Current Procedural Terminology codes. Statistical analysis with linear models, adjusted for patient characteristics and surgical factors, used a significance threshold of p<0.05.RESULTS: Among 58,264 patients, 6.2% of ABR patients, 3.8% of immediate IBR patients, and 3.6% of two-stage IBR patients underwent future revisions. IBR had a 51% lower incidence rate of revision operations than ABR (incidence rate ratio = 0.49, p<0.001). Within IBR, there was no significant difference in the number of operations between immediate IBR (0.06±0.32) and two-stage IBR (0.05±0.32, p=0.95). Immediate IBR demonstrated 12% (OR = 0.88, p=0.0022) and 70% (OR = 0.30, p<0.001) lower odds of requiring breast revision and fat grafting compared to ABR, respectively. Two-stage reconstruction had 66% lower odds of requiring only fat grafting than ABR (OR = 0.34, p<0.001).CONCLUSION: ABR necessitated a higher number of total revision procedures after completion of the initial reconstruction. These findings will better equip providers and patients to counsel patients in understanding their reconstructive journey, planning their reconstructions and timing, and provide more accurate estimates of the number of procedures that will be required to reach their aesthetic goals and final outcome.

    View details for DOI 10.1016/j.bjps.2024.05.048

    View details for PubMedID 38905789

  • Impact of post-operative infection on revision procedures in breast reconstruction: A marketscan database analysis. Journal of plastic, reconstructive & aesthetic surgery : JPRAS Francis, S. D., Kang, A. W., Maheta, B. J., Sangalang, B. R., Salingaros, S., Wu, R. T., Nazerali, R. S. 2024; 93: 103-110

    Abstract

    Esthetic complications, such as capsular contracture and soft-tissue contour defects, hinder the desired outcomes of breast reconstruction. As subclinical infection is a prevailing theory behind capsular contracture, we investigated the effects of post-operative infections on these issues and revision procedures.We conducted a retrospective database study (2007-2021) on breast reconstruction patients from the MarketScan® Databases. Esthetic complications were defined by their associated revision procedures and queried via CPT codes. Severe capsular contracture (Grade 3-4) was defined as requiring capsulotomy or capsulectomy with implant removal or replacement. Moderate and severe soft-tissue defects were determined by the need for fat grafting or breast revision, respectively. Generalized linear models were used, adjusting for comorbidities and surgical factors (p < 0.05).We analyzed the data on 62,510 eligible patients. Post-operative infections increased the odds of capsulotomy (OR 1.59, p < 0.001) and capsulectomy (OR 2.30, p < 0.001). They also raised the odds of breast revision for severe soft-tissue defects (OR 1.21, p < 0.001). There was no significant association between infections and fat grafting for moderate defects. Patients who had post-operative infections were also more likely to experience another infection after fat grafting (OR 3.39, p = 0.0018). In two-stage reconstruction, infection after tissue expander placement was associated with greater odds of infection after implant placement.Post-operative infections increase the likelihood of developing severe soft-tissue defects and capsular contracture requiring surgical revision. Our data reinforce the role of infections in the pathophysiology of capsular contracture. Additionally, infections elevate the risk of subsequent infections after fat grafting for moderate defects, further increasing patient morbidity.

    View details for DOI 10.1016/j.bjps.2024.04.031

    View details for PubMedID 38678812

  • Analyzing the Visibility of Gender-Affirming Surgery Education on US Plastic Surgery Residency Program Web Sites. Annals of plastic surgery Camacho, J. M., Najafali, D., Francis, S., Tople, T. L., Patel, H. S., Thawanyarat, K., Eggert, G. R., Calderon, T., Nazerali, R. S., Morrison, S. D. 2023; 91 (5): 518-523

    Abstract

    As the demand for gender affirmation grows, teaching gender-affirming surgery (GAS) in plastic and reconstructive surgery (PRS) programs has become increasingly important. Residency applicants interested in GAS often use program web sites to explore potential training opportunities. Our study aimed to quantify the GAS training opportunities promoted on residency program web sites and determine the characteristics of programs likely to promote GAS training.An assessment of 88 integrated PRS residency programs' web sites was conducted between 2021 and 2022. Plastic and reconstructive surgery residency and institutional webpages were queried for geographical location, training opportunities in GAS through residency or fellowship, and the number of faculty performing GAS. Descriptive statistics and multivariable regressions were used to describe and identify factors associated with increased GAS residency training opportunities.Twenty-six percent of PRS residencies mentioned training opportunities for GAS on their web sites. Gender-affirming surgery fellowships were offered at 7% of institutions, and an additional 7% were available via adjunct academic programs. Programs with faculty practicing GAS were 54% more likely to mention GAS on their residency page (odds ratio, 1.54; 95% confidence interval, 1.14-2.21; P = 0.009).Few PRS residency programs mention GAS on their web sites. As GAS becomes a more robust component of plastic surgery, appropriate information about the extent of GAS training should be available for applicants. Determining how local, state, and federal policies impact programs' abilities to highlight GAS should be investigated in future studies.

    View details for DOI 10.1097/SAP.0000000000003697

    View details for PubMedID 37823617

  • How Postoperative Infection Affects Reoperations after Implant-based Breast Reconstruction: A National Claims Analysis of Abandonment of Reconstruction. Plastic and reconstructive surgery. Global open Francis, S. D., Thawanyarat, K., Johnstone, T. M., Yesantharao, P. S., Kim, T. S., Rowley, M. A., Sheckter, C. C., Nazerali, R. S. 2023; 11 (6): e5040

    Abstract

    Infection after implant-based breast reconstruction adversely affects surgical outcomes and increases healthcare utilization. This study aimed to quantify how postimplant breast reconstruction infections impact unplanned reoperations, hospital length of stay, and discontinuation of initially desired breast reconstruction.We conducted a retrospective cohort study using Optum's de-identifed Clinformatics Data Mart Database to analyze women undergoing implant breast reconstruction from 2003 to 2019. Unplanned reoperations were identified via Current Procedural Terminology (CPT) codes. Outcomes were analyzed via multivariate linear regression with Poisson distribution to determine statistical significance at P < 0.00625 (Bonferroni correction).In our national claims-based dataset, post-IBR infection rate was 8.53%. Subsequently, 31.2% patients had an implant removed, 6.9% had an implant replaced, 3.6% underwent autologous salvage, and 20.7% discontinued further reconstruction. Patients with a postoperative infection were significantly associated with increased incidence rate of total reoperations (IRR, 3.11; 95% CI, 2.92-3.31; P < 0.001) and total hospital length of stay (IRR, 1.55; 95% CI, 1.48-1.63; P < 0.001). Postoperative infections were associated with significantly increased odds of abandoning reconstruction (OR, 2.92; 95% CI, 0.081-0.11; P < 0.001).Unplanned reoperations impact patients and healthcare systems. This national, claims-level study shows that post-IBR infection was associated with a 3.11× and 1.55× increase in the incidence rate of unplanned reoperations and length of stay. Post-IBR infection was associated with 2.92× increased odds of abandoning further reconstruction after implant removal.

    View details for DOI 10.1097/GOX.0000000000005040

    View details for PubMedID 37325376

    View details for PubMedCentralID PMC10263246

  • The Effect of Postoperative Infection after Implant Breast Reconstruction on Additional Revision Procedures Francis, S., Shah, J. K., Thawanyarat, K., Rowley, M., Kim, T., Sheckter, C., Nazerali, R. LIPPINCOTT WILLIAMS & WILKINS. 2023: S12

    View details for Web of Science ID 000989943300032

  • Racial Disparities in Postoperative Breast Reconstruction Outcomes: A National Analysis. Journal of racial and ethnic health disparities Johnstone, T., Thawanyarat, K., Rowley, M., Francis, S., Camacho, J. M., Singh, D., Navarro, Y., Shah, J. K., Nazerali, R. S. 2023

    Abstract

    Studies have shown that Black patients are more likely to experience complications following breast reconstruction compared to other racial groups. Most of these studies have been conducted on patient populations focusing on either autologous or implant-based reconstruction without possible predictive indicators for complication disparities for all types of reconstruction procedures. The aim of this study is to elucidate disparities among patient demographics by identifying predictors of complications and postoperative outcomes among different racial/ethnic patients undergoing breast reconstruction utilizing multi-state, multi-institution, and national level data.Patients in the Optum Clinformatics Data Mart that underwent all billable forms of breast reconstruction were identified via CPT codes. Demographics, medical history, and postoperative outcome data were collected by querying relevant reports of CPT, ICD-9, and ICD-10 codes. Outcomes analysis was limited to the 90-day global postoperative period. A multivariable logistic-regression analysis was performed to ascertain the effects of age, patient reported ethnicity, coexisting conditions, and reconstruction type on the likelihood of any common postoperative complication occurring. Linearity of the continuous variables with respect to the logit of the dependent variable was confirmed. Odds ratios and corresponding 95% confidence intervals were calculated.From over 86 million longitudinal patient records, our study population included 104,714 encounters for 57,468 patients who had undergone breast reconstruction between January 2003 and June 2019. Black race (relative to White), autologous reconstruction, hypertension, type II diabetes mellitus, and tobacco use were independent predictors of increased likelihood of complication. Specifically, the odds ratios for complication occurrence for Black, Hispanic, and Asian ethnicity (relative to White) were 1.09, 1.03, and 0.77, respectively. Black patients had an overall breast reconstruction complication rate of 20.4%, while the corresponding rate for White, Hispanic, and Asian patients were 17.0%, 17.9%, and 13.2%, respectively.Our analysis of a national-level database shows that Black patients undergoing implant-based or autologous reconstruction have increased risk of complications, likely due to multifactorial components that play a role in the care of this patient population. While higher rates of comorbidities have been cited as a possible cause, providers must consider racial influences involving cultural context, historical mistrust in medicine, and physician/health institution factors that may drive this disparity of outcomes among our patients.

    View details for DOI 10.1007/s40615-023-01599-1

    View details for PubMedID 37074634

    View details for PubMedCentralID 8027914

  • Postoperative Antibiotics Confer No Protective Association After Fat Grafting for Breast Reconstruction. Annals of plastic surgery Thawanyarat, K., Johnstone, T., Rowley, M., Kim, T., Francis, S., Barrera, J., Cheeseborough, J., Sheckter, C., Nazerali, R. 2023

    Abstract

    INTRODUCTION: Autologous fat grafting after breast reconstruction is a commonly used technique to address asymmetry and irregularities in breast contour. While many studies have attempted to optimize patient outcomes after fat grafting, a key postoperative protocol that lacks consensus is the optimal use of perioperative and postoperative antibiotics. Reports suggest that complication rates for fat grafting are low relative to rates after reconstruction and have been shown to not be correlated to antibiotic protocol. Studies have additionally demonstrated that the use of prolonged prophylactic antibiotics do not lower the complication rates, stressing the need for a more conservative, standardized antibiotic protocol. This study aims to identify the optimal use of perioperative and postoperative antibiotics that optimizes patient outcomes.METHODS: Patients in the Optum Clinformatics Data Mart who underwent all billable forms of breast reconstruction followed by fat grafting were identified via Current Procedural Terminology codes. Patients meeting inclusion criteria had an index reconstructive procedure at least 90 days before fat grafting. Data concerning these patient's demographics, comorbidities, breast reconstructions, perioperative and postoperative antibiotics, and outcomes were collected via querying relevant reports of Current Procedural Terminology; International Classification of Diseases, Ninth Revision; International Classification of Diseases, Tenth Revision; National Drug Code Directory, and Healthcare Common Procedure Coding System codes. Antibiotics were classified by type and temporal delivery: perioperatively or postoperatively. If a patient received postoperative antibiotics, the duration of antibiotic exposure was recorded. Outcomes analysis was limited to the 90-day postoperative period. Multivariable logistic regression was performed to ascertain the effects of age, coexisting conditions, reconstruction type (autologous or implant-based), perioperative antibiotic class, postoperative antibiotic class, and postoperative antibiotic duration on the likelihood of any common postoperative complication occurring. All statistical assumptions made by logistic regression were met successfully. Odds ratios and corresponding 95% confidence intervals were calculated.RESULTS: From more than 86 million longitudinal patient records between March 2004 and June 2019, our study population included 7456 unique records of reconstruction-fat grafting pairs, with 4661 of those pairs receiving some form of prophylactic antibiotics. Age, prior radiation, and perioperative antibiotic administration were consistent independent predictors of increased all-cause complication likelihood. However, administration of perioperative antibiotics approached a statistically significant protective association against infection likelihood. No postoperative antibiotics of any duration or class conferred a protective association against infections or all-cause complications.CONCLUSIONS: This study provides national, claims-level support for antibiotic stewardship during and after fat grafting procedures. Postoperative antibiotics did not confer a protective benefit association against infection or all-cause complication likelihood, while administering perioperative antibiotics conferred a statistically significant increase in the likelihood that a patient experienced postoperative complication. However, perioperative antibiotics approach a significant protective association against postoperative infection likelihood, in line with current guidelines for infection prevention. These findings may encourage the adoption of more conservative postoperative prescription practices for clinicians who perform breast reconstruction, followed by fat grafting, reducing the nonindicated use of antibiotics.

    View details for DOI 10.1097/SAP.0000000000003420

    View details for PubMedID 36880783

  • The Zoom Effect: A Google Trends Analysis. Aesthetic surgery journal Thawanyarat, K., Francis, S., Kim, T., Arquette, C., Morrison, S., Nazerali, R. 2021

    Abstract

    Increased video-chatting, stimulated by the COVID-19 pandemic, has been correlated with increased appearance concerns. Initial lockdown restrictions correlated with a decrease in aesthetic/cosmetic plastic surgery case volumes.We aim to delineate public interest in aesthetic procedures surrounding the COVID-19 pandemic via Google Trends (GT). We hypothesize that because of the pandemic, public interest in plastic surgery procedures increased, especially localized above the shoulder.Trends in the US for given search terms and volumes were gathered via Google Trends between January 2015 to March 2021. The search volumes were normalized, and a bivariate regression analysis of panel data was then applied to the aggregate trendlines to determine if a statistically significant change in search volume occurred following the stay-at-home orders.The following search terms had statistically significant (p < 0.000) increases in search volumes after February 2020: blepharoplasty, Botox, brachioplasty, breast implant removal, breast reduction, brow lift, buccal fat removal, hair transplantation, lip augmentation, mentoplasty, otoplasty, platysmaplasty, rhinoplasty, and thighplasty. Chi-squared analysis demonstrated a statistically significant association (Chi-squared = 4.812, p = 0.028) between increases in search volume and above the shoulder procedures.Public interest in above the shoulder surgical procedures showed a statistically significant increase following February 2020 compared to below the shoulder procedures. Continued examination of specific procedure trends, as well as determining correlations with more accurate procedural datasets, will provide increased insight into consumers' mindsets and to what extent video conferencing plays on the public's interest in pursuing aesthetic surgery.

    View details for DOI 10.1093/asj/sjab347

    View details for PubMedID 34581762