A Prospective Analysis of Dynamic Loss of Breast Projection in Tissue Expander-Implant Reconstruction

BACKGROUND: Breast projection is a critical element of breast reconstruction aesthetics, but little has been published regarding breast projection as the firm expander is changed to a softer implant. Quantitative data representing this loss in projection may enhance patient education and improve our management of patient expectations. METHODS: Female patients who were undergoing immediate tissue-expander breast reconstruction with the senior author were enrolled in this prospective study. Three-dimensional camera software was used for all patient photographs and data analysis. Projection was calculated as the distance between the chest wall and the point of maximal projection of the breast form. Values were calculated for final tissue expander expansion and at varying intervals 3, 6, and 12 months after implant placement. RESULTS: Fourteen breasts from 12 patients were included in the final analysis. Twelve of the 14 breasts had a loss of projection at three months following the implant placement or beyond. The percentage of projection lost in these 12 breasts ranged from 6.30% to 43.4%, with an average loss of projection of 21.05%. CONCLUSIONS: This study is the first prospective quantitative analysis of temporal changes in breast projection after expander-implant reconstruction. By prospectively capturing projection data with three-dimensional photographic software, we reveal a loss of projection in this population by three months post-implant exchange. These findings will not only aid in managing patient expectations, but our methodology provides a foundation for future objective studies of the breast form.

Tabbed Tissue Expanders Improve Breast Symmetry Scores in Breast Reconstruction

BACKGROUND: Achieving symmetry is a key goal in breast reconstruction. Anatomically shaped tabbed expanders are a new tool in the armamentarium of the breast reconstruction surgeon. Suture tabs allow for full control over the expander position and thus inframammary fold position, and, in theory, tabbed expanders mitigate many factors responsible for poor symmetry. The impact of a tabbed expander on breast symmetry, however, has not been formally reported. This study aims to evaluate breast symmetry following expander-implant reconstruction using tabbed and non-tabbed tissue expanders. METHODS: A chart review was performed of 188 consecutive expander-implant reconstructions that met the inclusion criteria of adequate follow-up data and postoperative photographs. Demographic, oncologic, postoperative complication, and photographic data was obtained for each patient. The photographic data was scored using a 4-point scale assessing breast symmetry by three blinded, independent reviewers. RESULTS: Of the 188 patients, 74 underwent reconstruction with tabbed expanders and 114 with non-tabbed expanders. The tabbed cohort had significantly higher symmetry scores than the non-tabbed cohort (2.82/4+/-0.86 vs. 2.55/4+/-0.92, P=0.034). CONCLUSIONS: The use of tabbed tissue expanders improves breast symmetry in tissue expander-implant-based breast reconstruction. Fixation of the expander to the chest wall allows for more precise control over its location and counteracts the day-to-day translational forces that may influence the shape and location of the expander pocket, mitigating many factors responsible for breast asymmetry.

Predictors of Readmission after Inpatient Plastic Surgery

BACKGROUND: Understanding risk factors that increase readmission rates may help enhance patient education and set system-wide expectations. We aimed to provide benchmark data on causes and predictors of readmission following inpatient plastic surgery. METHODS: The 2011 National Surgical Quality Improvement Program dataset was reviewed for patients with both "Plastics" as their recorded surgical specialty and inpatient status. Readmission was tracked through the "Unplanned Readmission" variable. Patient characteristics and outcomes were compared using chi-squared analysis and Student's t-tests for categorical and continuous variables, respectively. Multivariate regression analysis was used for identifying predictors of readmission. RESULTS: A total of 3,671 inpatient plastic surgery patients were included. The unplanned readmission rate was 7.11%. Multivariate regression analysis revealed a history of chronic obstructive pulmonary disease (COPD) (odds ratio [OR], 2.01; confidence interval [CI], 1.12-3.60; P=0.020), previous percutaneous coronary intervention (PCI) (OR, 2.69; CI, 1.21-5.97; P=0.015), hypertension requiring medication (OR, 1.65; CI, 1.22-2.24; P or =30) (OR, 1.43; CI, 1.09-1.88, P=0.011) to be significant predictors of readmission. CONCLUSIONS: Inpatient plastic surgery has an associated 7.11% unplanned readmission rate. History of COPD, previous PCI, hypertension, ASA class 3 or 4, bleeding disorders, and obesity all proved to be significant risk factors for readmission. These findings will help to benchmark inpatient readmission rates and manage patient and hospital system expectations.

The Relationship between Preoperative Wound Classification and Postoperative Infection: A Multi-Institutional Analysis of 15,289 Patients

BACKGROUND: Despite advances in surgical techniques, sterile protocols, and perioperative antibiotic regimens, surgical site infections (SSIs) remain a significant problem. We investigated the relationship between wound classification (i.e., clean, clean/contaminated, contaminated, dirty) and SSI rates in plastic surgery. METHODS: We performed a retrospective review of a multi-institutional, surgical outcomes database for all patients undergoing plastic surgery procedures from 2006-2010. Patient demographics, wound classification, and 30-day outcomes were recorded and analyzed by multivariate logistic regression. RESULTS: A total of 15,289 plastic surgery cases were analyzed. The overall SSI rate was 3.00%, with superficial SSIs occurring at comparable rates across wound classes. There were similar rates of deep SSIs in the clean and clean/contaminated groups (0.64%), while rates reached over 2% in contaminated and dirty cases. Organ/space SSIs occurred in less than 1% of each wound classification. Contaminated and dirty cases were at an increased risk for deep SSIs (odds ratios, 2.81 and 2.74, respectively); however, wound classification did not appear to be a significant predictor of superficial or organ/space SSIs. Clean/contaminated, contaminated, and dirty cases were at increased risk for a postoperative complication, and contaminated and dirty cases also had higher odds of reoperation and 30-day mortality. CONCLUSIONS: Analyzing a multi-center database, we found that wound classification was a significant predictor of overall complications, reoperation, and mortality, but not an adequate predictor of surgical site infections. When comparing infections for a given wound classification, plastic surgery had lower overall rates than the surgical population at large.