About

Rebecca W Knackstedt is an Assistant Professor of Surgery at Duke University, affiliated with the Duke Cancer Institute. She is a member of the Duke Department of Surgery and specializes in Plastic, Maxillofacial, and Oral Surgery, with a focus on integrated plastic and reconstructive surgery. Her role involves contributing to the education and training of residents and fellows, as well as engaging in research activities within her field.

Research topics

• Medicine
• Surgery
• Internal medicine
• Biology
• Anatomy
• Psychology
• Immunology
• Pathology
• Bioinformatics
• Neuroscience

Selected publications

• Indocyanine Green–Guided Sentinel Lymph Node Biopsy in Melanoma: Assessing Clinical Value in a Cohort Over 1000 Patients

  Journal of Surgical Oncology · 2026-04-19

  article

  BACKGROUND: The sentinel lymph node biopsy (SLNB) remains the standard for identifying micrometastasis in melanoma. In this study, we utilized our prospectively maintained database to assess whether adding indocyanine green (ICG) fluorescence imaging to radioisotope lymphoscintigraphy improved sentinel node detection and, consequently, clinical outcomes. METHODS: Consecutive patients with cutaneous melanoma who underwent dual technique SLNB by the senior author (B.R.G.) from 2012 to 2022 were enrolled. All patients with a negative SLNB result were subjected to a minimum follow-up period of 12 months. Positive and false-negative rates were calculated, and recurrence-free survival (RFS) was used as a measure of clinical outcomes. RESULTS: A total of 1267 patients were identified. The average age was 62 years, with 526 females (41.6%). The mean Breslow depth was 1.82 mm (range 0.2-24 mm). Among 3403 SLNs sampled, 358 were positive (91.1% identified by both modalities). The false-negative rate was 8.5% (25/293), and the median time to recurrence was 13.7 months (range: 2.8-60.4 months). The 12-month RFS for stages IA-IIC were 99%, 98%, 95%, 97%, and 84%, respectively (p = 0.016). CONCLUSIONS: These findings support the use of an ICG-based dual technique in SLNB for melanoma, demonstrating diagnostic precision with excellent patient outcomes.

  PublisherDOI

• Antibiotics and Surgical Site Infection in Expander-Based Breast Reconstruction Trial (ASSERT)

  Annals of Surgical Oncology · 2025-10-14 · 1 citations

  articleOpen access

  BACKGROUND: The use of prophylactic antibiotics following postmastectomy tissue expander breast reconstruction (TE-BR) varies widely. The Centers for Disease Control and Prevention (CDC) recommends a single preoperative antibiotic dose for clean and clean-contaminated procedures. This multi-institutional, prospective, randomized controlled trial (RCT) examined whether the CDC-recommended single preoperative dose (SPD) of antibiotics is not inferior to an additional week of postoperative (WPO) prophylactic antibiotics in preventing surgical site infection (SSI) in immediate TE-BR following mastectomy. METHODS: Women aged ≥ 18 years undergoing immediate TE-BR were randomized to SPD or WPO groups. The primary outcome was SSI by CDC guidelines within 30 days of surgery. The study used a noninferiority trial design to examine whether the test product (single preoperative dose (SPD)) was not worse than the comparator (1 week of postoperative (WPO) prophylactic antibiotics) by more than a set noninferiority margin of 6%. RESULTS: In total, five participating centers screened 499 women; 235 were enrolled. A total of 102 patients were randomized to the SPD arm and 112 to the WPO arm, with 21 patients withdrawn. The SSI rate in the SPD arm was 17% as compared with 11% in WPO arm, which is within the noninferiority margin set for this study but not significantly noninferior (p = 0.496). The rate of unplanned TE removal for infection, hospitalization rate, and return to OR rate within 30 days of surgery were comparable between the two groups. CONCLUSIONS: This multi-institutional RCT did not definitively demonstrate that a single preoperative dose of antibiotics is not inferior to a 7-day postoperative antibiotic regimen in preventing SSI in immediate TE-BR; there was also no evidence to support that the 7-day regimen was significantly better. As this represents one of the largest multi-institutional study of its kind, these results have practice-management considerations.

  PublisherOA PDFDOI

• Leveraging Online Patient Forums to Understand Breast Reduction Concerns: A Machine-Learning Analysis of 3078 Patient Questions Over 15 Years

  Aesthetic Surgery Journal · 2025-05-13 · 1 citations

  articleSenior author

  BACKGROUND: Patients are increasingly using social media and online forums to learn about plastic surgery, which can influence their expectations. Understanding patient concerns on these platforms will facilitate productive clinic discussion and ensure patients are receiving accurate, evidence-based information. OBJECTIVES: The aim of this study was to analyze breast reduction questions posted on RealSelf (Seattle, WA), an online plastic surgery forum. METHODS: The website www.realself.com/questions/breast-reduction was accessed on June 9, 2023. Posting date and poster self-reported location were extracted. Question header and text were manually reviewed. Questions were categorized by timing (preoperative vs postoperative) and topic. Regional and temporal trends were assessed. A machine-learning (ML) algorithm was applied to identify the top (most representative) preoperative and postoperative questions. RESULTS: In total, 3078 questions from August 2008 to May 2023 were analyzed. Questions most frequently originated from the southern United States (34.5%) and were asked preoperatively (58.4%). The most common question topics were postoperative care (24.9%), postoperative appearance/sensation (15.7%), and surgical logistics (10.2%). The distribution of topics varied significantly between location (P < .01), with topics such as insurance (P < .01) more likely to be asked in the south. CONCLUSIONS: This is the first study to leverage ML workflows to analyze a large volume of patient questions about breast reduction from an online plastic surgery forum. Analyzing patient questions on social media and online forums such as RealSelf with ML techniques can provide valuable insight into common concerns and informational gaps surrounding plastic surgery. Plastic surgeons should consider these results to guide patient conversations, combat misinformation, and facilitate deliverance of efficient care.

  PublisherDOI

• Liposomal Bupivacaine Analgesia in Deep Inferior Epigastric Perforator Flap Breast Reconstruction: A Retrospective Cohort Study

  Plastic & Reconstructive Surgery Global Open · 2024-06-01 · 7 citations

  articleOpen access1st authorCorresponding

  Background: Liposomal bupivacaine (LB) can be used for postsurgical analgesia after breast reconstruction. We examined real-world clinical and economic benefits of LB versus bupivacaine after deep inferior epigastric perforator (DIEP) flap breast reconstruction. Methods: This retrospective cohort study used the IQVIA claims databases to identify patients undergoing primary DIEP flap breast reconstruction in 2016–2019. Patients receiving LB and those receiving bupivacaine were compared to assess opioid utilization in morphine milligram equivalents (MMEs) and healthcare resource utilization during perioperative (2 weeks before surgery to 2 weeks after discharge) and 6-month postdischarge periods. A generalized linear mixed-effects model and inverse probability of treatment weighting method were performed. Results: Weighted baseline characteristics were similar between cohorts (LB, n = 669; bupivacaine, n = 348). The LB cohort received significantly fewer mean MMEs versus the bupivacaine cohort during the perioperative (395 versus 512 MMEs; rate ratio [RR], 0.771 [95% confidence interval (CI), 0.677–0.879]; P = 0.0001), 72 hours after surgery (63 versus 140 MMEs; RR, 0.449 [95% CI, 0.347–0.581]; P &lt; 0.0001), and inpatient (154 versus 303 MMEs; RR, 0.508 [95% CI, 0.411–0.629]; P &lt; 0.0001) periods; postdischarge filled opioid prescriptions were comparable. The LB cohort was less likely to have all-cause inpatient readmission (odds ratio, 0.670 [95% CI, 0.452–0.993]; P = 0.046) and outpatient clinic/office visits (odds ratio, 0.885 [95% CI, 0.785–0.999]; P = 0.048) 3 months after discharge than the bupivacaine cohort; other all-cause healthcare resource utilization outcomes were not different. Conclusions: LB was associated with fewer perioperative MMEs and all-cause 3-month inpatient readmissions and outpatient clinic/office visits than bupivacaine in patients undergoing DIEP flap breast reconstruction.

  PublisherDOI

• Unveiling the Landmark Case: The First Face Transplant in the United States: Postmortem Biopsy Series Findings

  American Journal of Dermatopathology · 2023-09-14 · 2 citations

  article

  To the Editor: Since the first successful procedure in 2005, few successful facial transplantations have been performed.1 In December of 2008, our institution performed a near-total face transplant on a 56-year-old woman.2 During her 12-year post-transplant course, the patient experienced intermittent Grades II-III composite graft rejection (2007 Banff classification), which was treated with minimal increase in her immunosuppression.3 In 2018–2019, after experiencing large necrotic facial graft ulcerations, we reported on a biopsy series demonstrating autoimmune plasma cell composite graft rejection. This was treated successfully with biologic therapy and an increase in immunosuppression and correlated with a subsequently decreased plasma cell infiltrate on follow-up biopsy.4 In 2020, our patient was admitted for dyspnea and found to have hepatitis E viremia but killed to the disease in the setting of multiple infections and eventual multisystem organ failure. In the weeks leading up to the presentation, her immunosuppressive regimen was being monitored and was within acceptable limits. A postmortem biopsy series was performed. Specimens submitted included bilateral: eyelids, nasal cartilage, cheeks, parotid glands, facial nerves, facial and carotid arteries/veins, and liver. Immunohistochemical stains and special stains were performed for cytomegalovirus, periodic acid-Schiff, and trichrome/colloidal iron (liver biopsy specimen). Histologic sections demonstrated a sparse perivascular inflammation and no significant evidence of acute composite graft rejection (Banff 2007 working classification of skin-containing composite tissue allograft pathology Grades 0–1 of 4) (Fig. 1). The findings of chronic graft rejection included only focal dermal fibrosis, with no evidence of deep adnexal inflammatory infiltrates or vascular damage (Fig. 2). There was no hypomelanosis, melanin incontinence, interface change, diffuse fibrosis, or loss of adnexal structures. The examination of the bilateral facial arteries and nerves demonstrated sparse lymphocytic inflammation of the adventitia, without significant evidence of vascular injury, and no perineural inflammation. The findings for other arteries and veins were similar (Figs. 3,4). There was no inflammation of the parotid gland (Fig. 5). The stains for periodic acid-Schiff/fungus and cytomegalovirus immunohistochemistry were negative. The findings in the liver included canalicular cholestasis and hepatic parenchymal collapse with patchy acute necrosis (Fig. 6).FIGURE 1.: Relatively unremarkable epidermis with sparse superficial perivascular inflammation (H&E 200×).FIGURE 2.: Sparse perivascular inflammation with focal dermal fibrosis (H&E 200×).FIGURE 3.: Cross-section from the right facial artery with a sparse lymphocytic inflammation of the adventitia, without significant evidence of vascular injury, and no perineural inflammation (H&E 40×).FIGURE 4.: Section from the right facial vein with a sparse lymphocytic inflammation of the adventitia, without significant evidence of vascular injury, and no perineural inflammation (H&E 40×).FIGURE 5.: Section from the right parotid gland without inflammation (40×).FIGURE 6.: Section from the partially autolyzed liver with canalicular cholestasis and hepatic parenchymal collapse with patchy acute necrosis (200×).The aim of the biopsy series was to elucidate the long-term post-transplantation changes including chronic rejection. There have been few reports of both antibody-mediated and cellular chronic facial vascularized composite allotransplantation rejections in the past.5–9 Three characteristic cutaneous histologic features of chronic rejection have been described, namely, hypomelanosis and melanin incontinence (vitiligo-like chronic rejection), interface dermatitis with epidermal atrophy, dense perifollicular chronic inflammatory infiltrates, and keratotic plugging or lichen planus-like root sheath hypertrophy (lichen planus-like chronic rejection), and dermal fibrosis with disruption of dermal elastic fibers with loss of adnexal structures (scleroderma-like chronic rejection).8 Despite a history of intermittent Grades II-III composite graft rejection and autoimmune plasma cell composite graft rejection, our case did not show any significant cutaneous histologic features related to chronic rejection. In addition, since the biopsy series was performed postmortem, we were able to examine various mucosal, cartilaginous, vascular, and neural components of the allograft, all of which did not reveal any significant histologic changes. To the best of our knowledge, this is the only published follow-up study that includes histologic findings from these tissues. In summary, face-transplant composite grafts can have excellent long-term viability when properly managed with minimal evidence of chronic rejection. Our findings suggest an excellent twelve-year graft survival.

  PublisherDOI

• The Influence of Age on Complications After Correction of Congenital Breast Deformities: A National Analysis of the Pediatric and Adult NSQIP Data Sets

  Aesthetic Surgery Journal · 2023-05-09 · 1 citations

  articleOpen access

  BACKGROUND: Timing of surgical intervention is controversial among patients seeking correction of congenital breast deformities. OBJECTIVES: This study aimed to assess the influence of age on 30-day complications and unplanned healthcare utilization after reconstruction of congenital breast deformities. METHODS: Female patients undergoing breast reconstruction for congenital breast deformities and Poland syndrome were identified on the basis of International Classification of Diseases (ICD) codes in the 2012 to 2021 pediatric and adult National Surgical Quality Improvement Project (NSQIP) data sets. Complications based on age at correction were compared, and multivariate logistic regression was used to identify predictors of overall and wound healing complications. RESULTS: Among 528 patients meeting inclusion criteria, mean (SD) age at surgical correction was 30.2 (13.3) years. Patients most commonly underwent implant placement (50.5%), mastopexy (26.3%), or tissue expander placement (11.6%). Across the cohort, overall incidence of postoperative complications was 4.4%, most commonly superficial surgical site infection (1.0%), reoperation (1.1%), or readmission (1.0%). After multivariate adjustment, increasing age at time of correction was associated with higher incidence of wound complications [odds ratio (OR) 1.001; 95% confidence interval (CI) 1.0003-1.002; P = .009], in addition to BMI (OR 1.002; 95% CI 1.0007-1.004; P = .006) and tobacco use (OR 1.06; 95% CI 1.02-1.11; P = .003). CONCLUSIONS: Breast reconstruction for congenital breast deformities may be safely undertaken at a young age with a low associated risk of postoperative complications. Large, multi-institutional studies are needed to assess the influence of surgical timing on psychosocial outcomes in this population.

  PublisherOA PDFDOI

• 172. A Retrospective Study Of Liposomal Bupivacaine Versus Conventional Bupivacaine On Opioid Use And Healthcare Resource Utilization Following Diep Flap Breast Reconstruction

  Plastic & Reconstructive Surgery Global Open · 2023-05-01

  articleOpen access1st authorCorresponding

  INTRODUCTION: Patients undergoing breast reconstruction can experience significant postoperative pain and are prone to develop persistent pain. Little is known about the postdischarge outcomes among this patient population: the impact of postsurgical analgesia on the outcomes remains unstudied. This study aimed to assess (a) opioids in morphine milligram equivalent (MME) at the hospital and postdischarge, and (b) hospital length of stay (LOS) and postdischarge healthcare resource utilization among patients receiving liposomal bupivacaine (LipoB) versus those with conventional bupivacaine (ConvB) analgesia after breast reconstruction. METHODS: This retrospective study included patients from de-identified IQVIA Linked Claims Databases (2016-2019) who underwent inpatient deep inferior epigastric perforator (DIEP) flap reconstruction (defined by the ICD-10 procedure codes). Women receiving postsurgical LipoB or ConvB analgesia were included if they were ≥18 years, with ≥6 months of continuous enrollment before and after surgery. To remove extreme outcome values, patients were excluded if their LOS or MME were above the 95th percentile of the respective distribution. The LipoB patients were compared with the ConvB patients regarding the outcomes of (1) opioid use in MME during perioperative period and 6 months postdischarge, (2) LOS, and (3) inpatient admissions, emergency department visits, and outpatient visits at 3-month postdischarge. Generalized linear modeling with the inverse probability of treatment weighting method was used to balance difference in baseline characteristics between the 2 cohorts. RESULTS: In total, 649 LipoB and 348 ConvB patients were included. After the inverse treatment probability weighting, the 2 cohorts were balanced in all characteristics with a standardized differences <20%. Both weighted cohorts had an average age of 51 years and mean Quan-Charlson comorbidity index of 2.6; 57% of patients were opioid naive. During the perioperative period, the LipoB cohort consumed 23% less MME than the ConvB cohort (395 vs. 512 MME, P=0.0001). Specifically, approximately 50% MME reduction in the LipoB cohort was observed relative to the ConvB cohort during the 3 days after surgery (63 vs. 140 MME, P<0.0001) and entire hospital stay (154 vs. 303 MME, P<0.0001). LOS was not different between the 2 cohorts (4.5 vs. 4.6 days, P=0.334). Similar amount of MME dispensed was observed at 6 months postdischarge in both cohorts (153 vs. 148 MME, P=0.715). At 3-month postdischarge, the LipoB cohort was 33% less likely than the ConvB cohort to be admitted to the hospital (rate: 4.35% vs. 6.50%, P<0.05) and 11% less likely to have outpatient visits (rate: 69.2 % vs. 78.2%, P<0.05). CONCLUSIONS: This real-world assessment shows pain management with LipoB for DIEP flap breast reconstruction, relative to ConvB, was associated with reduced in-hospital opioid intake and a potential trend toward lower inpatient admissions and outpatient visits. Prolonged opioid use in both cohorts after discharge underscores the need for judicious opioid practices.

  PublisherDOI

• D62. Sentinel Lymph Node Biopsy in Melanoma: A Single-surgeon, 1,000 Patient Experience

  Plastic & Reconstructive Surgery Global Open · 2023-04-01

  articleOpen access

  PURPOSE: With widespread use of sentinel lymph node biopsy (SLNB) in melanoma, the accuracy of this procedure has been examined, quantified, and improved. However, the reported sensitivity and specificity of the procedure have ranged from 64 to 100%, with false-negative rates (FNR) ranging from 5.6 to 21%. Herein, we review a single-surgeon’s experience in a large patient cohort with the purpose of evaluating the accuracy of gamma and Indocyanine green (ICG) combination technique in SLNB. METHODS: All melanoma patients who underwent SLNB surgery by the senior author at Cleveland Clinic in February 2011 to December 2021 were included. All patients underwent SLNB using a combination of gamma and ICG for SLN identification. RESULTS: 1,000 patients with mean age of 61 years met the inclusion criteria. 220 patients had a positive SLNB with a mean number of 1.25 positive nodes of from an average of 2.86 nodes removed. From the 277 positive nodes, 247 (90%) were identified using combination of gamma and ICG (n=180/220), 21 (7%) using gamma only (n= 26/ 220) and 8 (2%) using ICG only (n=14/220). 470 had a negative SLNB with an average of 2.9 nodes removed and a FNR of 2.3%. Mean follow-up was 2.3 years. CONCLUSION: We report one of the lowest false negative rates using a combination technique of gamma and ICG in SLNB, proving it a reliable technique in detecting melanoma nodal involvement.

  PublisherDOI

• SP39. Sentinel Lymph Node Biopsy in Melanoma: A Single-surgeon, 1,000 Patient Experience

  Plastic & Reconstructive Surgery Global Open · 2023-05-01

  articleOpen access

  PURPOSE: With widespread use of sentinel lymph node biopsy (SLNB) in melanoma, the accuracy of this procedure has been examined, quantified, and improved. However, the reported sensitivity and specificity of the procedure have ranged from 64 to 100%, with false-negative rates (FNR) ranging from 5.6 to 21%. Herein, we review a single-surgeon’s experience in a large patient cohort with the purpose of evaluating the accuracy of a combination technique in SLNB. METHOD: All melanoma patients who underwent SLNB surgery by the senior author at Cleveland Clinic in February 2011 to December 2021 were included. All patients underwent SLNB using a combination of gamma and ICG for SLN identification. RESULTS: 1,000 patients with mean age of 61 met the inclusion criteria. 220 patients had a positive SLNB with a mean number of 1.25 positive nodes of from an average of 2.86 nodes removed. From the 277 positive nodes, 247 (90%) were identified using combination of gamma and ICG (n=180/220), 21 (7%) using Gamma only (n= 26/ 220) and 8 (2%) using ICG only (n=14/220). 470 had a negative SLNB with an average of 2.9 nodes removed and a FNR of 2.3%. Mean follow-up was 2.3 years. CONCLUSION: We report one of the lowest false negative rates in a large patient cohort using a combination technique of gamma and ICG in SLNB, proving it a reliable technique in detecting melanoma nodal involvement.

  PublisherDOI

• Outcomes of stage IV melanoma in the era of immunotherapy: a National Cancer Database (NCDB) analysis from 2014 to 2016

  Journal for ImmunoTherapy of Cancer · 2022-08-01 · 19 citations

  articleOpen access

  BACKGROUND: To evaluate factors affecting the utilization of immunotherapy and to stratify results based on the approval of ipilimumab in 2011 and programmed death-1 inhibitors in 2014, an analysis of available data from the National Cancer Database (NCDB) was performed. METHODS: The NCDB was analyzed to identify patients with stage IV melanoma from 2004 to 2016. Patients were categorized during the time periods 2004-2010, 2011-2014, and 2015-2016. Overall survival (OS) was analyzed by Kaplan-Meier, log-rank, and Cox proportional hazard models; IO status was analyzed using logistic regression. RESULTS: 24,544 patients were analyzed. Overall, 5238 patients (21.3%) who received IO had improved median OS compared with those who did not (20.2 months vs 7.4 months; p<0.0001). Between 2004 and 2010, 9.7% received immunotherapy; from 2011 to 2014, 21.9% received immunotherapy; and from 2015 to 2016, 43.5% received immunotherapy. Three-year OS significantly improved in patients treated with IO across treatment years: 31% (95% CI 29% to 34%) from 2004 to 2010, 35% (95% CI 33% to 37%) from 2011 to 2014, and 46% (95% CI 44% to 48%) from 2015 to 2016 (p<0.0001). Survival was worse in patients who did not receive IO during these treatment years: 16% (15%-17%), 21% (20%-22%), and 27% (25%-28%), respectively. In the overall cohort, age <65 years, female gender, private insurance, no comorbidities, residence in metropolitan area, and treatment at academic centers were associated with better OS (p<0.0001 for all). In the multivariate analysis, receipt of IO from 2015 to 2016 was associated with age <65 years (OR 1.27, 95% CI 1.08 to 1.50), African American race (OR 5.88, 95% CI 1.60 to 28.58), lack of comorbidities (OR 1.43, 95% CI 1.23 to 1.66), and treatment at academic centers (OR 1.44, 95% CI 1.26 to 1.65) (p<0.05 for all). CONCLUSIONS: OS improved in patients with stage IV melanoma receiving IO, with the highest OS rate in 2015-2016. Our findings, which represent a real-world population, are slightly lower than recent trials, such as KEYNOTE-006 and CheckMate 067. Significant socioeconomic factors may impact receipt of IO and survival.

  PublisherOA PDFDOI

Frequent coauthors

• Brian Gastman

  72 shared

• James Gatherwright

  Cleveland Clinic

  70 shared

• Risal Djohan

  56 shared

• Michelle Djohan

  MetroHealth Medical Center

  51 shared

• Thomas Knackstedt

  University of North Carolina at Chapel Hill

  46 shared

• David R. Crowe

  MetroHealth Medical Center

  36 shared

• Raisal Djohan

  Case Western Reserve University

  36 shared

• Graham S. Schwarz

  Cleveland Clinic

  29 shared