Lipotransfer Strategies and Techniques to Achieve Successful Breast Reconstruction in the Radiated Breast.

Radiation therapy is frequently a critical component of breast cancer care but carries with it side effects that are particularly damaging to reconstructive efforts. Autologous lipotransfer has the ability to improve radiated skin throughout the body due to the pluripotent stem cells and multiple growth factors transferred therein. The oncologic safety of lipotransfer to the breasts is demonstrated in the literature and is frequently considered an adjunctive procedure for improving the aesthetic outcomes of breast reconstruction. Using lipotransfer as an integral rather than adjunctive step in the reconstructive process for breast cancer patients requiring radiation results in improved complication rates equivalent to those of nonradiated breasts, expanding options in these otherwise complicated cases. Herein, we provide a detailed review of the cellular toxicity conferred by radiotherapy and describe at length our approach to autologous lipotransfer in radiated breasts.

Successful Immediate Staged Breast Reconstruction with Intermediary Autologous Lipotransfer in Irradiated Patients.

As indications for radiotherapy in mastectomized patients grow, the need for greater reconstructive options is critical. Preliminary research suggests an ameliorating impact of lipotransfer on irradiated patients with expander-to-implant reconstruction. Herein, we present our technique using lipotransfer during the expansion stage to facilitate implant placement. METHODS: A retrospective review of postmastectomy patients with expander-to-implant reconstruction by one reconstructive surgeon was performed. All patients were treated with immediate expander and ADM placement at the time of mastectomy. Irradiated patients underwent a separate lipotransfer procedure after completion of radiotherapy but prior to prosthesis exchange. Our study compared postoperative outcomes between non-radiated patients and irradiated patients who underwent this intermediary lipotransfer. Clinical endpoints of interest included: overall complications, infection, delayed wound healing, dehiscence, capsular contracture, implant failure, and reoperation. RESULTS: One hundred and thirty-one breast reconstructions were performed; 18 (13.74%) were irradiated and 113 (86.26%) were not. Overall complication risk (infection, implant failure, or reoperation) was no higher in irradiated breasts treated with lipotransfer than non-irradiated breasts (p=0.387). Fifteen patients who had one radiated and one non-radiated breast were separately analyzed; no difference in complication by radiotherapy exposure (p=1) was found. Age, BMI, smoking status, and nipple-sparing versus skin-sparing mastectomy did not vary significantly between study groups (p=0.182, p=0.696, p=0.489, p=1 respectively). CONCLUSIONS: Comparable postoperative outcomes were found between non-radiated breasts and radiated breasts treated with intermediary lipotransfer. The ameliorating effects of autologous lipotransfer on radiotoxicity may therefore offer irradiated patients the option of expander-to-implant reconstruction with acceptable risk and cosmesis.

A critical look at the effect of hyperbaric oxygen on the ischemic nipple following nipple sparing mastectomy and implant based reconstruction: a case series.

BACKGROUND: Nipple preservation provides superior aesthetic results as well as patient satisfaction in patients treated with both therapeutic and prophylactic mastectomy. Post-operative nipple ischemia and necrosis presents a unique clinical challenge that may be treated with hyperbaric oxygen therapy or conservative measures alone. To date, the efficacy of hyperbaric oxygen on post-operative nipple ischemia has yet to be evaluated. METHODS: A retrospective review of patients treated with either hyperbaric oxygen or conservative management was performed. Post-operative photographs were evaluated using a novel imaging data pathway to in both groups to determine rates of healing. RESULTS: Although patients treated with hyperbaric oxygen experienced rates of healing nearly twice those of patients treated with conservative measures alone, no statistical significance was found between groups in this series. CONCLUSIONS: No significance difference was found between groups treated with hyperbaric oxygen or conservative management in this series. Further large scale, multi-center studies are warranted to further determine clinical utility and cost-effectiveness of hyperbaric oxygen for nipple ischemia following nipple sparing mastectomy (NSM) and implant based reconstruction.

Torsional stability of the femur after harvest of the medial femoral condyle corticocancellous flap.

BACKGROUND: Increasingly large segments of medial femoral condyle (MFC) corticocancellous flaps have been harvested for transfer. Biomechanical evaluations demonstrated no osseous stability impairment under axial loading regardless of flap size harvested. The purpose of this study was to determine the donor site's response to torsional forces. METHODS: Dual-energy X-ray absorptiometry (DEXA) scanning was performed on 16 pairs of cadaver legs followed by removal of all soft tissues, except knee capsule and ligaments. Specimens were randomly assigned to three groups with bone harvest defects measuring 3, 5, or 7 cm in length and a control group with no osseous resection. Torsional load was applied until fracture or ligamentous failure. RESULTS: Bone failure rates were 12.5, 12.5, 28.6, and 55.6% for control, 3, 5, and 7 cm groups, respectively. Bone failure rate increased with increasing harvest size; the 7 cm group demonstrated a significantly higher rate compared with the other groups combined (55.6 vs. 17.4%; p = 0.03). Failure torque was 45.5, 29.35, 27.4, and 30.83 Nm for the control, 3, 5, and 7 cm groups, respectively (p = 0.11). Harvest of any size segment resulted in a significant decrease in failure torque (p = 0.01). Bone mineral density (BMD) and Z-scores were no different among groups (p = 0.79 and 0.59, respectively). A direct relationship was identified between force required for failure and BMD (p = 0.02) and Z-scores (p = 0.05) but not for failure location and BMD (p = 0.09) or Z-scores (p = 0.94). CONCLUSION: MFC corticocancellous flap harvest of any size decreases donor site failure torque. Flap harvests > 7 cm demonstrate a higher frequency of iatrogenic fracture and therefore warrant caution with torsional loading of the knee postoperatively. Routine preoperative DEXA scans may not be warranted.

The management of festoons.

The management of patients with festoons is a highly challenging undertaking with potential to drastically alter the appearance of those afflicted. Traditional teaching has focused on excision and tightening of the pathologic muscle with subsequent removal of excess skin. Recognition of the interactions between all subunits of the face has resulted in a recent shift in focus, with the new trend being techniques aimed at redraping the soft tissues with the intent of reproducing a more natural rejuvenation of the lower lid­cheek interface. Where direct excision techniques simply remove the deformed tissue, redraping techniques actually elevate the midface soft tissues and tighten the pathologically lax orbicularis muscle, thereby counteracting the downward descent associated with the aging process. The optimal treatment is as yet unclear but seems to be a combination of elevation of soft tissue, tightening of orbicularis muscle, and removal of excess skin and or muscle to properly address all the manifestations of this interesting process.

Applications of fat grafting in facial aesthetic skeletal surgery.

BACKGROUND: Aesthetic skeletal surgery of the face is a powerful tool to alter the facial skeleton; the facial form is enhanced through the use of alloplastic implants and osteotomies of the facial bones. However, the ultimate aesthetic appearance is dictated by how the soft tissue envelope drapes over the altered skeletal foundation. Intraoperative and postoperative fat grafting enhances the final aesthetic result in patients who undergo skeletal aesthetic procedures. OBJECTIVES: The authors describe cases in which selective fat grafting has been successful in optimizing facial soft tissue symmetry in patients undergoing skeletal aesthetic surgery of the face. METHODS: A retrospective chart review of all patients who underwent aesthetic skeletal surgery of the face between November 1, 2003, and October 31, 2011, in the Department of Surgery at Georgetown University Hospital was performed, and any patient who required fat grafting either at the time of aesthetic facial skeletal surgery or in the postoperative period was identified (n = 21). Common indications for fat grafting and the surgical plans are reviewed and presented in this article. RESULTS: Twenty-one patients were identified who required 37 fat grafting procedures either at the time of aesthetic skeletal surgery of the face or in the postoperative period. The procedures most frequently requiring fat grafting were genioplasty, facial shape modifications, and facial symmetry improvement. Fat grafting most commonly corrected irregularities or asymmetries and improved the soft tissue contour overlying repositioned bone or alloplastic implants. Most patients were female (72%) with a mean age of 42 years (range, 4-58 years). There were 4 complications in total: 3 surgical site infections (managed conservatively in 1 patient and with incision and drainage in the remaining 2) and 1 hematoma requiring drainage and closure on the day of surgery. CONCLUSIONS: Knowledge of which procedures are likely to require fat grafting and the techniques for doing so can improve the plastic surgeon's ability to provide optimal aesthetic results following facial skeletal alterations.

Breast reconstruction following nipple-sparing mastectomy: a systematic review of the literature with pooled analysis.

BACKGROUND: Nipple-sparing mastectomy is a controversial option for breast cancer treatment due to locoregional recurrence and distant metastasis. In addition to these oncologic factors, technical factors such as ideal incision type or reconstructive options are also debatable. This systematic review examines current trends with nipple-sparing mastectomy, including selection criteria, locoregional and distant metastasis rates, incision choice, and reconstructive options. METHODS: Systematic electronic searches were performed in the PubMed and Ovid databases using search terms for studies reporting outcomes following nipple-sparing mastectomy and all forms of reconstruction. Studies between 1970 and 2013 were reviewed. Pooled descriptive statistics with separate analyses for incision type and reconstructive method were performed. RESULTS: Forty-eight studies met inclusion criteria, yielding 6615 nipple-sparing mastectomies for analysis. The overall pooled complication rate was 22 percent, the nipple necrosis rate was 7 percent, the locoregional recurrence rate was 1.8 percent, and the distant metastasis rate was 2.2 percent. Comparing combined patient cohorts for two-stage expander to implant, one-stage direct to implant, and autologous reconstruction demonstrated overall complication rates of 52.8, 16.7, and 23.7 percent and nipple necrosis rates of 4.5, 4.1, and 17.3 percent, respectively. Incision types were divided into five categories: radial, periareolar/circumareolar, inframammary, mastopexy, and transareolar, with nipple necrosis rates of 8.83, 17.81, 9.09, 4.76, and 81.82 percent, respectively CONCLUSIONS: Nipple-sparing mastectomy appears to be an oncologically safe option for properly selected patients, with low rates of locoregional and distant metastasis. Overall complication and nipple necrosis rates are affected by incision location and reconstruction method. Randomized controlled trials are warranted to determine best incision and reconstructive methods. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

The role of chronic and perioperative glucose management in high-risk surgical closures: a case for tighter glycemic control.

BACKGROUND: The exact risk that poor glucose control introduces to patients undergoing surgical closure has yet to be fully defined. METHODS: The authors retrospectively analyzed a prospectively collected database of patients seen at their wound care center to evaluate the effects of chronic and perioperative glucose control in high-risk patients undergoing surgical wound closure. Hemoglobin A1c and blood glucose levels for the 5 days before and after surgical closure were recorded and compared with the primary endpoints of dehiscence, infection, and reoperation. Univariate and multivariate analyses were performed. RESULTS: Seventy-nine patients had perioperative glucose levels and 64 had hemoglobin A1C levels available for analysis. Preoperative and postoperative hyperglycemia (defined as any blood glucose measurement above 200 mg/dl) as well as elevated A1C levels (above 6.5 percent or 48 mmol/ml) were significantly associated with increased rates of dehiscence (odds ratio, 3.2, p = 0.048; odds ratio, 3.46, p = 0.028; and odds ratio, 3.54, p = 0.040, respectively). Variability in preoperative glucose (defined as a range of glucose levels exceeding 200 points) was significantly associated with increased rates of reoperation (odds ratio, 4.14, p = 0.025) and trended toward significance with increased rates of dehiscence (p = 0.15). In multivariate regression, only perioperative hyperglycemia and elevated A1c were significantly associated with increased rates of dehiscence. CONCLUSIONS: In primary closure of surgical wounds in high-risk patients, poor glycemic control is significantly associated with worse outcomes. Every effort should be made to ensure tight control in both the chronic and subacute perioperative periods. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Free Tissue Transfer for Limb Salvage in High-Risk Patients: Worth the Risk.

SIGNIFICANCE: Mircosurgical free tissue transfer is a powerful tool in the arsenal of reconstructive surgeons, oftentimes as the final option in limb salvage before amputation. Patients presenting for limb salvage frequently carry with them multiple co-morbidities such as diabetes mellitus, end-stage renal disease, and peripheral vascular disease. Surgeons are oftentimes hesitant to attempt free tissue tranfer in these medically complex individuals due to beliefs that the patient would not tolerate prolonged anesthesia, the surgery is doomed to fail, or the patient would be better off with an amputation. Because amputees actually demonstrate higher mortality rates, the decision to not to proceed with limb salvage should be made with great care. RECENT ADVANCES: By reviewing the success rates with free tissue transfer for limb salvage in high-risk patients, the target articles have shown that this option is indeed viable even in this patient population. Specifically, reasonable success rates are presented for limb salvage using free tissue transfer in patients with end-stage renal disease, a single-vessel leg and critical limb ischemia. CRITICAL ISSUES: The articles reviewed demonstrate that free tissue transfer for limb salvage in properly selected patients with end-stage renal disease or severe peripheral vascular disease is worth attempting. Before surgery, these patients must undergo a complete cardiac work-up regardless of previous cardiac history. FUTURE DIRECTIONS: When necessary, free tissue transfer should be pursued by the reconstructive surgeon even in high-risk medically complex patients.

Using color to guide debridement.

Chronic wounds are typically halted in the inflammatory stage of wound healing secondary to a prolonged inflammatory response of the body to bacterial colonization, as planktonic bacteria and biofilm and senescent cells present at the wound's edges. Surgical debridement of these wounds is a critical step taken by the treating physician to attain complete healing. In order for debridement to successfully reset the stages of wound healing, residual biofilm and senescent cells must be removed. Despite the importance of complete and thorough debridement, few methods exist, and even fewer articles have been written describing techniques to ensure that all portions of a wound are equally addressed with each procedure. Using methylene blue dye to color the wound allows the surgeon to address and debride all portions of the wound adequately. In addition, the surgeon must be very familiar with what the normal tissue colors are following removal of the methylene blue-dyed tissue. Getting to tissue with those colors provides an end point to the debridement and helps prevent removal of excess healthy tissue. This article describes the primary author's technique for staining tissues with methylene blue dye prior to wound debridement, as well as the colors to look for to signal completion of surgery. In addition, a review of biofilm and senescent cells is presented as both are targeted but frequently missed when wounds are incompletely debrided.

Postoperative headache following acoustic neuroma resection: occipital nerve injuries are associated with a treatable occipital neuralgia.

OBJECTIVE: To demonstrate that occipital nerve injury is associated with chronic postoperative headache in patients who have undergone acoustic neuroma excision and to determine whether occipital nerve excision is an effective treatment for these headaches. BACKGROUND: Few previous reports have discussed the role of occipital nerve injury in the pathogenesis of the postoperative headache noted to commonly occur following the retrosigmoid approach to acoustic neuroma resection. No studies have supported a direct etiologic link between the two. The authors report on a series of acoustic neuroma patients with postoperative headache presenting as occipital neuralgia who were found to have occipital nerve injuries and were treated for chronic headache by excision of the injured nerves. METHODS: Records were reviewed to identify patients who had undergone surgical excision of the greater and lesser occipital nerves for refractory chronic postoperative headache following acoustic neuroma resection. Primary outcomes examined were change in migraine headache index, change in number of pain medications used, continued use of narcotics, patient satisfaction, and change in quality of life. Follow-up was in clinic and via telephone interview. RESULTS: Seven patients underwent excision of the greater and lesser occipital nerves. All met diagnostic criteria for occipital neuralgia and failed conservative management. Six of 7 patients experienced pain reduction of greater than 80% on the migraine index. Average pain medication use decreased from 6 to 2 per patient; 3 of 5 patients achieved independence from narcotics. Six patients experienced 80% or greater improvement in quality of life at an average follow-up of 32 months. There was one treatment failure. Occipital nerve neuroma or nerve entrapment was identified during surgery in all cases where treatment was successful but not in the treatment failure. CONCLUSION: In contradistinction to previous reports, we have identified a subset of patients in whom the syndrome of postoperative headache appears directly related to the presence of occipital nerve injuries. In patients with postoperative headache meeting diagnostic criteria for occipital neuralgia, occipital nerve excision appears to provide relief of the headache syndrome and meaningful improvement in quality of life. Further studies are needed to confirm these results and to determine whether occipital nerve injury may present as headache types other than occipital neuralgia. These findings suggest that patients presenting with chronic postoperative headache should be screened for the presence of surgically treatable occipital nerve injuries.

Occult radiation injury following angiographic procedures: recognition and treatment of an evolving complication.

As the indications for fluoroscopically guided procedures increase, so do the potential complications from radiation. Radiation-induced wounds can have an insidious onset and time course that the plastic surgeon and wound specialist must be able to identify early. We review 3 cases of radiation-induced wounds following fluoroscopic procedures, which presented at various stages of diagnosis and healing. The pathophysiology of these wounds is discussed to aid in their diagnosis by providing an understanding of the resultant time course of injury and characteristics of the wounds. In addition, a familiarity of the concepts of interventional procedures and an increased element of caution in those patients most susceptible to injury is critical for prevention. Finally, an appropriate treatment protocol is proposed including early diagnosis, local wound care, hyperbaric oxygen, en bloc resection of the affected tissue, and reconstruction with tissue outside the zone of injury for recalcitrant or late stage wounds.

Minimally invasive peripheral nerve surgery: a short scar technique.

INTRODUCTION: As peripheral nerve specialists can have a wide variety of training backgrounds, few standards of care exist with respect to necessary incision length, amount of dissection, and operative technique for common nerve decompressions. METHODS: Approaches for the following 12 common peripheral nerve surgeries were minimized using shorter incisions and a simple lighted retractor: zygomatico-temporal and auriculotemporal, greater occipital, brachial plexus, ulnar, radial, median, lateral femoral cutaneous nerve of the thigh, peroneal at the groin, fibular neck and lateral calf, and tibial and inner ankle. The new "minimal" incision length was recorded as was that of the "classical" approach as taught to the senior author and frequently represented in atlases. A Mann-Whiney analysis was independently performed to evaluate for significance between the lengths of incisions for each procedure. RESULTS: The average length of the "minimal" incisions was 3.9 ± 0.6 cm (range, 3.1-6.1 cm), with an average reduction in length of 51% as compared with the "classical" incisions (range, 30-75%; P < 0.001). There were no perioperative morbidities. CONCLUSIONS: Minimally invasive peripheral nerve surgery applied to the above procedures yields successful surgical outcomes while shortening incision lengths and maximizing patient satisfaction without sacrificing patient safety.

Routine pathological evaluation of neuroma specimens: is there a rationale?

The routine pathological analysis of therapeutically resected traumatic or postoperative neuroma specimens to confirm diagnosis and rule out occult malignancy remains a controversial issue. Some experts advocate histological analysis of all specimens, and others rely on institutional policy. A retrospective chart review of all patients who underwent excision of clinically diagnosed neuroma over a 6-year period at one institution by a single surgeon was initiated. The correlation of preoperative diagnoses with histological analysis and cost of analyzing specimens individually and over the 6-year period was calculated. Of 515 neuromas resected, 100 were sent for pathological review. Every submitted specimen was histologically confirmed to be a traumatic neuroma, and none of the specimens harbored occult malignancy. Ultimately, no treatment plan was altered after final histology was confirmed. The cost to analyze each specimen (Current Procedural Terminology code 88305) was $495, expressed in U.S. dollars. If every specimen was analyzed, a total cost of $254,925 would have be incurred over the 6-year period. Routine pathological analysis of clinically and intraoperatively confirmed neuromas must be questioned in terms of standard of care requirements given its failure to aid in treatment plans as well as its significant cost to health care systems.