Safety and Efficacy of Smooth Surface Tissue Expander Breast Reconstruction.

BACKGROUND: Traditional 2-stage breast reconstruction involves placement of a textured-surface tissue expander (TTE). Recent studies have demonstrated textured surface devices have higher propensity for bacterial contamination and biofilm formation. OBJECTIVES: The purpose of this study was to evaluate the safety and efficacy of smooth surface tissue expanders (STE) in immediate breast reconstruction. METHODS: The authors retrospectively reviewed consecutive women who underwent STE breast reconstruction from 2016 to 2017 at 3 institutions. Indications and outcomes were evaluated. RESULTS: A total 112 patients underwent STE reconstruction (75 subpectoral, 37 prepectoral placement), receiving 173 devices and monitored for a mean follow-up of 14.1 months. Demographics of patients included average age of 53 years and average BMI of 27.2 kg/m2, and 18.6% received postmastectomy radiation therapy. Overall complication rates were 15.6% and included mastectomy skin flap necrosis (10.4%), seroma (5.2%), expander malposition (2.9%), and infection requiring intravenous antibiotic therapy (3.5%). Six (3.5%) unplanned reoperations with explantation were reported for 3 infections and 3 patients requesting change of plan with no reconstruction. CONCLUSIONS: STEs represent a safe and efficacious alternative to TTE breast reconstruction with at least equitable outcomes. Technique modification including tab fixation, strict pocket control, postoperative bra support, and suture choice may contribute to observed favorable outcomes and are reviewed. Early results for infection control and explantation rate are encouraging and warrant comparative evaluation for potential superiority over TTEs in a prospective randomized trial.

Options in reconstructing the irradiated breast.

BACKGROUND: As radiation therapy becomes more prevalent in the treatment of breast cancer, more patients requesting breast reconstruction for mastectomy defects will have a history of radiation therapy. METHODS: A retrospective chart review study was performed of a single surgeon's 5-year experience with reconstruction of the irradiated breast. RESULTS: Sixty-six primary patients and 13 secondary patients were treated over a 5-year period (2001-2005). Of the 66 primary patients, 25 (38 percent) presented for reconstruction after recurrence following prior breast conservation therapy: 12 had prosthetic based reconstructions (with or without a latissimus flap) and 13 had autologous reconstructions. Twenty-five patients (38 percent) presented after mastectomy followed by radiation therapy: six had prosthetic-based constructions and 19 had autologous reconstructions. Twelve patients (18 percent) had their reconstructions performed before radiation therapy: nine had implant-based reconstructions and three had autologous reconstructions. Four patients (6 percent) presented for corrections of breast conservation therapy deformities. One hundred seventy-five total operations were performed for the primary patients, with an average of 2.65 operations per patient. Thirteen patients were treated secondarily after previous reconstruction at other institutions with a variety of reconstruction methods used. Twenty-eight total operations were performed for the secondary patients, with an average of 2.2 operations per patient. Capsular contracture rates using the prosthetic score are reported. CONCLUSIONS: Because of the variability of presentation of the irradiated breast cancer patient, there is no one method of reconstruction ideally suited for all irradiated patients. In this 5-year review, the authors found that with careful patient evaluation and selection, good results can be attained regardless of reconstructive method.

Synmastia after breast augmentation.

BACKGROUND: Synmastia after breast augmentation is a condition of aberrant communication of the breasts caused by violation of the chest midline by medial migration of one or both implants. This condition, though rare, has been seen with increasing frequency in the authors' practice. METHODS: The records of 20 women with synmastia were reviewed. Data collection for these women included their preoperative repair history, implant sizes, and breast to chest wall proportions. RESULTS: All of the previous augmentations were subpectoral. Ten of the patients had undergone multiple augmentation operations. Twelve patients had implants that appeared excessively wide for their chest. CONCLUSIONS: Synmastia is a difficult surgical complication to address. Patients with multiple breast operations, excessively large implants, and overaggressive medial dissection are susceptible to developing synmastia. Understanding these potential risk factors leading to synmastia should help prevent its occurrence.

Radial sensory neurotization of the thumb and index finger for prehension after proximal median and ulnar nerve injuries.

Proximal median nerve injuries are functionally disabling, secondary to both motor and sensory deficits. Reestablishment of sensation relies on slow axonal regeneration originating from the site of injury after either primary nerve repair or the use of autogenous nerve grafts. This regeneration can take 2 or more years to restore sensation to the hand, depending on injury location. Distal sensory nerve transfers shorten the recovery time by decreasing the required regeneration distance. The authors present two case reports of patients with proximal median nerve injury, who underwent radial sensory nerve transfers to the ulnar digital nerve of the thumb and the radial digital nerve of the index finger. Protective sensation returned to the index and thumb fingertips at 3 months. By 6 months, both patients attained sufficient sensation to permit active lateral key pinch. At 9 months, each patient had moving sensation; and by 14 months, each patient attained proper localization. Successful digital nerve transfers of the dorsal radial sensory nerves in patients with high proximal median nerve injuries return sensation faster than traditional median nerve repairs. Use of this technique will significantly reduce the insensate time in patients with this unfortunate injury.