Person: Tobias, Adam
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Tobias
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Adam
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Tobias, Adam
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Publication Testosterone Therapy and Breast Histopathological Features in Transgender Individuals(Springer Science and Business Media LLC, 2020-09-16) Baker, Gabrielle; Guzman-Arocho, Yaileen D.; Bret-Mounet, Vanessa C.; Torous, Vanda; Schnitt, Stuart; Tobias, Adam; Bartlett, Richard; Fein-Zachary, Valerie J.; Collins, Laura; Wulf, Gerburg; Heng, Yujing J.; Heng, YujingTestosterone therapy (TT) is administered to enhance masculinization in transgender individuals. The long term effect of exogenous testosterone on breast tissues remains unclear. Our study evaluated the modulation of breast morphology by TT in transgender individuals with special attention to duration of TT. We reviewed 447 breast surgical specimens from gender affirming chest-contouring surgery, and compared histopathological findings including degree of lobular atrophy, and atypical and non-atypical proliferations between subjects who did (n=367) and did not (n=79) receive TT. TT for one patient was unknown. TT for >12 months was associated with seven histopathological features. Longer duration of TT was significantly associated with higher degrees of lobular atrophy (p<0.001). This relationship remained significant after accounting for age at surgery, ethnicity, body mass index, and pre-surgical oophorectomy (adjusted p<0.001). Four types of lesions were more likely to be absent in breast tissues exposed to longer durations of TT: cysts (median=16.2 months; p<0.01; adjusted p=0.01), fibroadenoma (median=14.8 months; p=0.02; adjusted p=0.07), pseudoangiomatous stromal hyperplasia (median=17.0 months; p<0.001; adjusted p<0.001), and papillomas (median=14.7 months; p=0.04; adjusted p=0.20). Columnar cell change and mild inflammation were also less likely to occur in subjects receiving TT (p<0.05), but were not linked to the duration of TT. Atypia and ductal carcinoma in situ (DCIS) were detected in 11 subjects (2.5%) all of whom received TT ranging from 10.1 to 64.1 months. The incidental findings of high-risk lesions and carcinoma as well as the risk of cancer in residual breast tissue after chest-contouring surgery warrant the consideration of culturally sensitive routine breast cancer screening protocols for transgender men and masculine-centered gender non-conforming individuals. Long-term follow-up studies and molecular investigations are needed to understand the breast cancer risk of transgender individuals who receive TT.Publication Nipple-areolar Complex Reconstruction following Postmastectomy Breast Reconstruction: A Comparative Utility Assessment Study(Wolters Kluwer Health, 2015) Ibrahim, Ahmed M. S.; Sinno, Hani H.; Izadpanah, Ali; Vorstenbosch, Joshua; Dionisopoulos, Tassos; Mureau, Marc A. M.; Tobias, Adam; Lee, Bernard; Lin, SamuelBackground: Nipple-areola complex (NAC) reconstruction occurs toward the final stage of breast reconstruction; however, not all women follow through with these procedures. The goal of this study was to determine the impact of the health state burden of living with a reconstructed breast before NAC reconstruction. Methods: A sample of the population and medical students at McGill University were recruited to establish the utility scores [visual analog scale (VAS), time trade-off (TTO), and standard gamble (SG)] of living with an NAC deformity. Utility scores for monocular and binocular blindness were determined for validation and comparison. Linear regression and Student’s t test were used for statistical analysis, and significance was set at P < 0.05. Results: There were 103 prospective volunteers included. Utility scores (VAS, TTO, and SG) for NAC deformity were 0.84 ± 0.18, 0.92 ± 0.11, and 0.92 ± 0.11, respectively. Age, gender, and ethnicity were not statistically significant independent predictors of utility scores. Income thresholds of <$10,000 and >$10,000 revealed a statistically significant difference for VAS (P = 0.049) and SG (P = 0.015). Linear regression analysis showed that medical education was directly proportional to the SG and TTO scores (P < 0.05). Conclusions: The absence of NAC in a reconstructed breast can be objectively assessed using utility scores (VAS, 0.84 ± 0.18; TTO, 0.92 ± 0.11; SG, 0.92 ± 0.11). In comparison to prior reported conditions, the quality of life in patients choosing to undergo NAC reconstruction is similar to that of persons living with a nasal deformity or an aging neck requiring rejuvenation.Publication Abstract 7. Prospective, Double-Blind Evaluation of Umbilical Reconstruction of Techniques Using Conventional and Crowdsourcing Methods(Wolters Kluwer Health, 2017) van Veldhuisen, Charlotte L.; Kamali-Sadeghian, Parisa; Wu, Winona; Becherer, Babette E.; Sinno, Hani H.; Ashraf, Azra A.; Ibrahim, Ahmed M.S.; Tobias, Adam; Lee, Bernard; Lin, SamuelPublication Abstract P36. Quantifying the Development of Breast Cancer Surgery-Associated Lymphedema in High-risk Patients Undergoing Axillary Lymph Node Surgery in Consecutive Patients(Wolters Kluwer Health, 2017) Chattha, Anmol; Kamali-Sadeghian, Parisa; Van Veldhuisen, Charlotte L.; Flecha-Hirsch, Renata; Bucknor, Alexandra; Tobias, Adam; Lee, Bernard; Lin, SamuelPublication Functional MRI to Evaluate “Sense of Self” following Perforator Flap Breast Reconstruction(Public Library of Science, 2012) Caterson, Stephanie; Fox, Sharon Elizabeth; Tobias, Adam; Lee, BernardBackground: Breast reconstruction is associated with high levels of patient satisfaction. Previous patient satisfaction studies have been subjective. This study utilizes functional magnetic resonance imaging (fMRI) to objectively evaluate “sense of self” following deep inferior epigastric perforator (DIEP) flap breast reconstruction in an attempt to better understand patient perception. Methods: Prospective fMRI analysis was performed on four patients before and after delayed unilateral DIEP flap breast reconstruction, and on four patients after immediate unilateral DIEP flap breast reconstruction. Patients were randomly cued to palpate their natural breast, mastectomy site or breast reconstruction, and external silicone models. Three regions of interest (ROIs) associated with self-recognition were examined using a general linear model, and compared using a fixed effects and random effects ANOVA, respectively. Results: In the delayed reconstruction group, activation of the ROIs was significantly lower at the mastectomy site compared to the natural breast (p<0.01). Ten months following reconstruction, activation of the ROIs in the reconstructed breast was not significantly different from that observed with natural breast palpation. In the immediate reconstruction group, palpation of the reconstructed breast was also similar to the natural breast. This activity was greater than that observed during palpation of external artificial models (p<0.01). Conclusions: Similar activation patterns were observed during palpation of the reconstructed and natural breasts as compared to the non-reconstructed mastectomy site and artificial models. The cognitive process represented by this pattern may be a mechanism by which breast reconstruction improves self-perception, and thus patient satisfaction following mastectomy.Publication Postoperative Pain Management in DIEP Flap Breast Reconstruction: Identification of Patients With Poor Pain Control(Open Science, 2010) Bar-Meir, Eran D.; Yueh, Janet H.; Hess, Philip; Hartmann, Christoph E. A.; Maia, Munique; Tobias, Adam; Lee, BernardObjective: Adequate control of postoperative pain directly improves patient satisfaction and outcomes, and timely identification of patients with poorly controlled pain is essential. Pain management protocols are best studied in patients recovering from the same operation. In our institution, the postoperative pain regimen for patients undergoing deep inferior epigastric perforator (DIEP) flap breast reconstruction is standardized using patient-controlled analgesia (PCA) followed by conversion to oral narcotics. From this uniform population, we were able to identify a subgroup of patients with poor pain control. Methods: Over a 44-month period, 179 consecutive patients underwent DIEP flap breast reconstruction with 242 flaps performed. A retrospective chart review recorded PCA usage, visual analog scale pain scores, and length of stay. Results: Pain management with PCA after DIEP flap breast reconstruction was uniformly controlled. Most patients (74.9%) required PCA usage in the first 2 days with conversion to oral analgesics. A subgroup of patients (25.1%) continued to require PCA usage on the third postoperative day. These “nonresponder” patients had a higher visual analog scale score on the first postoperative day, higher total intravenous morphine use, and a longer length of stay (all, P less than .05). A multivariate analysis revealed more nonresponders among patients undergoing immediate breast reconstruction (P less than .05); however, all other factors analyzed had no correlation. Conclusion: We report a subgroup of patients with poor pain control after DIEP flap breast reconstruction. This group of patients required a longer course of pain management and subsequently a longer hospital stay. Pain management protocols that identify these patients promptly can allow for appropriate modifications.Publication The National Surgical Quality Improvement Program 30-Day Challenge: Microsurgical Breast Reconstruction Outcomes Reporting Reliability(Wolters Kluwer Health, 2018) Chen, Austin D.; Kamali-Sadeghian, Parisa; Chattha, Anmol S.; Bucknor, Alexandra; Cohen, Justin B.; Bletsis, Patrick P.; Flecha-Hirsch, Renata; Tobias, Adam; Lee, Bernard; Lin, SamuelBackground: The aim was to assess reliability of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) 30-day perioperative outcomes and complications for immediate, free-tissue transfer breast reconstruction by direct comparisons with our 30-day and overall institutional data, and assessing those that occur after 30 days. Methods: Data were retrieved for consecutive immediate, free-tissue transfer breast reconstruction patients from a single-institution database (2010–2015) and the ACS-NSQIP (2011–2014). Multiple logistic regressions were performed to compare adjusted outcomes between the 2 datasets. Results: For institutional versus ACS-NSQIP outcomes, there were no significant differences in surgical-site infection (SSI; 30-day, 3.6% versus 4.1%, P = 0.818; overall, 5.3% versus 4.1%, P = 0.198), wound disruption (WD; 30-day, 1.3% versus 1.5%, P = 0.526; overall, 2.3% versus 1.5%, P = 0.560), or unplanned readmission (URA; 30-day, 2.3% versus 3.3%, P = 0.714; overall, 4.6% versus 3.3%, P = 0.061). However, the ACS-NSQIP reported a significantly higher unplanned reoperation (URO) rate (30-day, 3.6% versus 9.5%, P < 0.001; overall, 5.3% versus 9.5%, P = 0.025). Institutional complications consisted of 5.3% SSI, 2.3% WD, 5.3% URO, and 4.6% URA, of which 25.0% SSI, 28.6% WD, 12.5% URO, and 7.1% URA occurred at 30–60 days, and 6.3% SSI, 14.3% WD, 18.8% URO, and 42.9% URA occurred after 60 days. Conclusion: For immediate, free-tissue breast reconstruction, the ACS-NSQIP may be reliable for monitoring and comparing SSI, WD, URO, and URA rates. However, clinicians may find it useful to understand limitations of the ACS-NSQIP for complications and risk factors, as it may underreport complications occurring beyond 30 days.Publication Abstract: Autologous or Implant-Based Breast Reconstruction? Crowdsourcing Aesthetic Preferences of the General Population(Wolters Kluwer Health, 2017) Bucknor, Alexandra; Chen, Austin D.; Kamali-Sadeghian, Parisa; Chattha, Anmol S.; Bletsis, Patrick P.; van Veldhuisen, Charlotte; Tobias, Adam; Lee, Bernard; Lin, SamuelPublication Abstract: Surgical Site Infection in Immediate Breast Reconstruction: Does Chemotherapy Timing Make a Difference?(Wolters Kluwer Health, 2017) Chattha, Anmol S.; Bucknor, Alexandra; Chen, Austin D.; Tobias, Adam; Lee, Bernard; Lin, Samuel