Breast Implant-associated Squamous Cell Carcinoma: Initial Review and Early Recommendations.

The purpose of this study is to identify and describe all published cases of breast implant-associated squamous cell carcinoma (BIA-SCC) to gain a greater understanding of the incidence, presentation, diagnosis, treatment, and prognosis and to support development of recommendations that promote prompt diagnosis and management in clinical practice. Methods: A scoping review of PubMed and social media sites was performed in August and September 2022 to identify published cases of SCC arising in the breast capsule. No limits were set on search results. Additional data review was begun on deidentified cases reported directly to American Society of Plastic Surgeons. Results: Twelve articles met inclusion criteria and reported data on 16 total cases. Mean age of patients was 55.56 years (range, 40-81 years). Mean duration from initial implant placement to presentation was 23.56 years (range, 11-40 years). Cases occurred with silicone, saline, textured, and smooth implants. At the time of case publication or reporting, seven patients were alive, five were deceased and/or presumed deceased, and four were unreported. Conclusions: BIA-SCC seems to be a rare complication of breast implantation that can result in significant morbidity and mortality. Physicians should be aware of the presentation of BIA-SCC to promote prompt diagnosis and treatment. BIA-SCC should be discussed with all patients considering breast implantation as part of the informed-consent process.

Pathology Examination of Breast Reduction Specimens: Dispelling the Myth.

More than 100,000 reduction mammaplasties are performed in the United States each year. There is large variance in reported incidence of cancerous/high-risk lesions, ranging from 0.06% to 4.6%. There has been debate whether histological review of breast reduction specimen is necessary. This study aimed to determine the incidence of cancerous/high-risk lesions and to evaluate risk factors for their occurrence. METHODS: A retrospective review was conducted for all patients who underwent reduction mammaplasty in 2018 by the senior author. Variables collected included demographics, comorbidities, history of breast surgery, family/personal history of breast cancer, weight of specimen, and pathologic findings. All specimens underwent pathologic evaluation and categorized as benign, proliferative, or malignant. RESULTS: A total of 155 patients underwent 310 reduction mammaplasties. Pathologic evaluations found that 11 patients (7.1%) had positive findings, 9 (5.8%) had proliferative lesions, and 2 (1.29%) had cancerous lesions. Patients with pathology were older (P = 0.038), had a family history of breast cancer (P = 0.026), and had a greater weight of resected tissue (P = 0.005). Multivariable analysis showed family history of breast cancer (P = 0.001), prior breast surgery (P = 0.026), and greater weight of resected breast tissue (P = 0.008) had a higher likelihood of positive pathology. CONCLUSIONS: These findings demonstrate an incidence of positive pathology higher than that reported and illustrate the importance of histologic review of breast reduction specimens. Family history of breast cancer, prior breast surgery, and a greater weight of resected tissue increase risk for proliferative/cancerous lesions.

The Economics of Prepectoral Breast Reconstruction.

The world of breast reconstruction over the last several years has seen a dramatic shift in focus to discussion and the application of placing tissue expanders and implants back into the prepectoral space. Although this technique failed during the early advent of breast reconstruction, newer technologies such as advances in fat grafting, improved acellular dermal matrices, better methods of assessing breast flap viability, and enhanced implants appear to have set the stage for the resurgence and positive early results seen with this technique. The main benefits of a switch to prepectoral breast reconstruction clinically appears to be less associated pain, lower incidence of animation deformities, and its associated symptoms as well as presumably better aesthetics. Early data suggest that the results are extremely promising and early adopters have attempted to define the ideal patients for prepectoral breast reconstruction. As with any new operative procedure, an assessment of finances and costs are crucial to its successful implementation. Although current data are minimal, this article attempts to build the fundamentals of an economic model that exhibits and displays potential savings through the use of prepectoral breast reconstruction.

Regulatory Advocacy Update: American Society of Plastic Surgeons Comments in Response to the U.S. Food and Drug Administration Draft Guidance Documents on Human Cell and Tissue Products.

The U.S. Food and Drug Administration released draft guidance documents on human cells, tissues, and cellular and tissue-based products regulations. These proposed guidance documents can impact the practice of plastic surgery in the area of tissue grafting procedures. This article describes the relevant issues in these draft guidance documents, and presents the comments provided to the U.S. Food and Drug Administration by the American Society of Plastic Surgeons.

Single-surgeon experience of 87 buccal mucosal graft harvests.

UNLABELLED: Although buccal mucosa has been the preferred graft material for use in the reconstruction of anterior urethral strictures for approximately 20 years, the plastic surgery literature is lacking in studies describing and evaluating this technique. The authors sought to report their experience with the technique of buccal mucosa graft harvest for use in urethral reconstruction. The authors identified 87 consecutive patients who underwent buccal mucosal graft harvesting during a 15-year period from 1995 to 2010. All donor sites were closed primarily. Preoperatively, a specialty-specific evaluation was performed by plastic surgeons and urologists. Postoperative donor-site morbidity was followed clinically. Eighty-seven patients underwent buccal harvesting. A single buccal graft was harvested in 75 patients (86.2 percent) and bilateral grafts were harvested in 12 patients (13.8 percent). The median patient age of the patients was 42 years (range, 16 to 78 years). There were no major intraoperative or postoperative complications. Minor complications included mild discomfort, numbness, cheek swelling, and restriction of oral movement, all of which resolved by the 3-month postoperative visit. The ability to eat and drink postoperatively was diminished during only the first 24 to 48 hours in all patients. Our series provides a 1-year follow-up in a substantial cohort looking at clinical outcomes after buccal harvesting. These results confirm the safety and efficacy of buccal mucosal harvesting to provide an effective and cosmetically superior option for urethral reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

AlloDerm and Strattice in breast reconstruction: a comparison and techniques for optimizing outcomes.

BACKGROUND: Acellular dermal matrices are increasingly used to reinforce the lower pole of the breast during tissue expander/implant breast reconstruction. Although a low complication rate and good aesthetic outcome have been reported, meticulous technique is important for success. This retrospective study compared the clinical course and postoperative outcome of women who underwent breast reconstruction using AlloDerm or Strattice in the authors' practice and highlights key technical considerations that are important for optimizing outcomes. METHODS: Patient records were reviewed for demographic data, operative parameters (length and volume of drainage), and type and frequency of postoperative complications, which were compared between the AlloDerm and Strattice groups. Biopsy specimens of acellular dermal matrices were taken for histologic analyses. RESULTS: Ninety-six patients (126 reconstructions) received AlloDerm, and 90 (144 reconstructions) received Strattice. Total complications were significantly higher with AlloDerm (21.4 percent versus 6.3 percent; p = 0.0003) and were driven by a significantly higher seroma rate (12.7 percent versus 1.4 percent; p = 0.0003). All other complications were similar between the groups. The capsular contracture rate (grade 1 or 2) was 2.4 percent with AlloDerm and 2.8 percent with Strattice, indicating that both may play a role in capsule formation. This was supported by histologic analyses indicating an absence of synovia-like metaplasia at the acellular dermal matrix/tissue expander interface. CONCLUSIONS: : Complications in this series were of low severity, which, together with consistent clinical outcomes seen in the authors' practice, justifies the cost associated with the use of acellular dermal matrices in breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic: III.

Effect of weight loss after bariatric surgery on skin and the extracellular matrix.

BACKGROUND: Obese patients experience dramatic physical and metabolic changes in the skin and its collagen. Bariatric surgery is known to result in significant improvement in obesity-associated comorbid conditions and metabolic disturbances. The aim of this study was to evaluate skin quality following weight loss surgery and its suitability to produce an extracellular matrix for use in reconstructive procedures. METHODS: During circumferential lipectomy, skin tissue was obtained from 10 patients following bariatric surgery. The samples were subjected to histologic examination and to study by differential scanning calorimetry. A retrospective review of patient records was used to determine time between bariatric and body lift procedures and to identify subject demographic and clinical data, including body mass index, excess weight loss, and comorbid conditions. RESULTS: Plastic surgery followed bariatric surgery by 20.5 +/- 11 months, and patients experienced an average weight loss of 132.1 +/- 61.0 lb. Histologic evaluation of post-bariatric surgery skin samples showed a poorly organized collagen structure, elastin degradation, and regions of scar formation within macroscopically normal areas. Differential scanning calorimetry showed increased enthalpy of phase transition and decreased onset temperature for collagen denaturation in striae distensae samples compared with bulk bariatric skin samples, consistent with tissue matrix degradation in striae. CONCLUSION: Skin tissue in this patient population exhibited significant signs of damage to extracellular matrix components despite the duration of time since the bariatric procedure.

Evidence-based patient safety advisory: patient selection and procedures in ambulatory surgery.

Despite the many benefits of ambulatory surgery, there remain inherent risks associated with any surgical care environment that have the potential to jeopardize patient safety. This practice advisory provides an overview of the preoperative steps that should be completed to ensure appropriate patient selection for ambulatory surgery settings. In conjunction, this advisory identifies several physiologic stresses commonly associated with surgical procedures, in addition to potential postoperative recovery problems, and provides recommendations for how best to minimize these complications.

Evidence-based patient safety advisory: blood dyscrasias.

Rarely, patients with blood disorders may seek to undergo plastic surgery. Although plastic surgeons are not expected to diagnose or manage blood disorders, they should be able to recognize which patients are suitable for surgery and which should be referred to a hematologist before a procedure. This practice advisory provides an overview of the perioperative steps that should be completed to ensure appropriate care for patients with blood disorders.

Use of regenerative human acellular tissue (AlloDerm) to reconstruct the abdominal wall following pedicle TRAM flap breast reconstruction surgery.

BACKGROUND: Harvest of transverse rectus abdominis musculocutaneous (TRAM) flaps for breast reconstruction leaves a variable defect in the anterior rectus fascia. Inadequate closure of the defect could lead to the development of hernia or abdominal wall bulging. Various techniques have been developed to reduce the incidence of hernia and abdominal wall bulging. The authors describe a novel technique of using a regenerative human acellular matrix (AlloDerm) as a fascial substitute in closing the defect. METHODS: Fifty-four consecutive patients who opted for pedicle TRAM flap procedures for breast reconstruction postmastectomy were scheduled for donor-site repair with the use of AlloDerm. AlloDerm was placed interpositionally as an inlay graft to mimic the anterior rectus fascia. RESULTS: Hernia or infection did not develop in any of the patients. There was a greater incidence of seroma and bulging among the first 18 patients, with eight seromas (44.4 percent) and six bulges (33.3 percent). When the technique was ameliorated in the next 36 patients, there was a reduction in the incidence of seromas (16.7 percent, p = 0.03) and bulges (16.7 percent, p = 0.17). Of the three patients who experienced wound dehiscence, partial AlloDerm exposure occurred in two, but was resolved without further consequences. Biopsy specimens of AlloDerm, obtained 12 and 14 months after TRAM donor-site repair, showed full tissue integration. The cell density, vasculature, and collagen orientation in the biopsies were consistent with abdominal fascia tissue. CONCLUSION: Based on these results, the authors recommend the use of AlloDerm as an alternative option for abdominal fascia closure after TRAM flap harvest for breast reconstruction.