One-stop autologous breast reconstruction: A safe and effective cost-saving pathway.

INTRODUCTION: Patients undergoing autologous breast reconstruction usually require further operations as part of their reconstructive journey. This involves contralateral breast symmetrization and nipple-areola complex (NAC) reconstruction. Restrained access to elective operating space led us to implement a one-stop breast reconstruction pathway. METHODS: Patients undergoing contemporaneous contralateral breast symmetrization and immediate NAC reconstruction with free nipple grafts between July 2020 and June 2021 were identified. A retrospective review of our prospectively maintained database was conducted, to retrieve surgical notes, postoperative complications, and length of inpatient stay. A cost analysis was performed considering savings from contralateral symmetrization. RESULTS: A total of 50 eligible cases were identified, which had unilateral one-stop breast reconstructions. Complication rates and length of stay were not affected by this approach, with only one free flap being lost for this cohort. This approach resulted in £181,000 being saved for our service over a calendar year. DISCUSSION: A one-stop breast reconstruction pathway has proven to be safe and effective in our unit. During these uncertain times, it has streamlined the management of eligible patients, while releasing capacity for other elective operations. Patients avoid having to wait for secondary procedures, finishing their reconstructive pathway earlier. We plan to continue providing this service which has shown to be beneficial clinically and financially.

Ethnicity and Nonsurgical Rhinoplasty.

Background: Nonsurgical rhinoplasty is a procedure that is gaining popularity in aesthetic clinics particularly because of its minimally invasive nature compared with surgery. It is recognized that there are ethnic variations in nose injection techniques and planned aesthetic outcomes. Objectives: The objective of this study was to explore experts' views about the ethnic differences in the anatomical features of the nose and procedure-related considerations in nonsurgical rhinoplasty. Methods: Using a priori set topics and questions, 4 expert aesthetic physicians, from 4 different ethnic backgrounds and working in 4 different regions, were asked to describe the essential elements to be considered when planning a nonsurgical rhinoplasty, including product choice, injection technique, safety measures, and any practical hints to facilitate achieving the desired outcome. Results: All invited experts responded to the full set of questions. There were similarities between the treating physicians in some of the technical steps. Nevertheless, there were several differences identified regarding baseline anatomy and patient expectations that could be attributed to ethnicity. Patients' and physicians' expectations regarding a successful nonsurgical rhinoplasty can vary depending on their ethnic backgrounds. Therefore, with the current global ethnic and cultural diversities, in addition to the knowledge of the nasal anatomy and safe injection techniques, it is imperative that aesthetic practitioners have full awareness and a good understanding of these ethnic variations. Conclusions: Nonsurgical rhinoplasty is a highly demanded aesthetic procedure. Patients' ethnic differences need to be carefully taken into consideration when discussing, planning, and performing nasal fillers injection.

Capsular contracture in implant based breast reconstruction-the effect of porcine acellular dermal matrix.

BACKGROUND: Irradiation of implant-based breast reconstructions (BR) is known to increase capsular contracture (CC) rates on average by 4-fold over non-irradiated reconstructions. The use of acellular dermal matrix (ADM) has been associated with lower CC rates in non-irradiated reconstructions (0-3%). Experimental and clinical studies suggest that ADM may also reduce CC rates in irradiated breasts. The aim of this study was to evaluate CC rates in non-irradiated and irradiated one- and two-stage BRs performed with the assistance of porcine ADM (PADM). METHODS: A single centre, retrospective, cohort study was designed from December 2008 to October 2012. A total of 200 immediate implant-based BRs were performed using PADM for inferior pole reinforcement. We included non-irradiated BR with a minimum follow up of 6 month from primary surgery (one stage) or from explantation of expander and implantation of the definitive implant (two stage). Of the postoperatively irradiated BR we included patients with 1 year or more follow up time from termination of radiotherapy. CC was graded using the conventional Spear-Baker classification and modified version for irradiated BR. According to the literature Grade III and IV CC were defined as clinically significant CC. RESULTS: Of 200 BRs with PADM, 122 were included in this study (84 non-irradiated and 38 irradiated). Sixty-five BR were one stage and 57 were two stage BR. Grade III/IV CC was remarkable low in non-irradiated (6%) and irradiated BR (13%). There was a non-significant trend to increased Grade III and IV CC in irradiated BR vs. non-irradiated BR (13% vs. 6%, P=0.216). In this study follow up time (P<0.001) and the stage of ADM reconstruction (two vs. one stage, P=0.022) were significant risk factors for occurrence of grade III/IV CC on univariate analysis and remained significant for the follow up time (P=0.013) and remarkable for the stages (P=0.093) in multivariate analysis. CONCLUSIONS: Our data support the current clinical evidence that ADM use in implant-based BR is associated with a reduced risk of CC when compared to the standard submuscular techniques in literature. The reduced risk is maintained in the setting of radiotherapy. Two stage procedures in our study population showed increased grade III/IV CC compared to one stage procedures with or without exposure to radiation.

Protocol for the prevention and management of complications related to ADM implant-based breast reconstructions.

Acellular dermal matrix (ADM) implant-based reconstructions have transformed direct-to-implant breast reconstruction (DTI). But like all surgery, it is not deplete of complications such as seroma, infections and wound healing problems. These are cited with varying frequencies in the literature. With increased experience and through a series of measures instituted to minimize complications, we have been able to improve outcomes for our patients. We report our technical refinements for prevention of ADM reconstruction associated complications including patient selection, implant selection, drains, dressing and our post operative antibiotic regime. We also outline our protocol for the management of ADM associated complications including seroma, simple and complex infection and red breast syndrome, such that the sequelae of complications are minimized and patients achieve a better long-term outcome.

An evaluation of resource utilisation of single stage porcine acellular dermal matrix assisted breast reconstruction: A comparative study.

OBJECTIVES: To evaluate resource utilization of single stage porcine acellular dermal matrix (ADM) assisted breast reconstruction compared with tissue expander (TE), latissimus dorsi flap and implant (LD/I) and latissimus dorsi flap and TE (LD/TE) reconstructive techniques. MATERIALS AND METHODS: Clinical data was collected for length of stay, operative time, additional hospitalisations and operative procedures, and outpatient appointments for 101 patients undergoing unilateral implant based breast reconstruction. Resources utilised by ADM (Strattice Reconstructive Tissue Matrix™) patients were analysed and compared to the resource usage of traditional techniques. RESULTS: 25 patients undergoing single stage ADM (ADM/I) were compared with 27 having TE, 32 having LD/I and 17 having LD/TE reconstructions. Follow up was 24 months. Compared to TE, ADM/I had similar length of stay and operative time, lower rate and number of additional procedures, fewer, shorter re-admissions (p < 0.05) and fewer appointments (p < 0.05). Compared to LD/TE, ADM/I had shorter length of stay and operative time (p < 0.05), lower rate and number of additional procedures, fewer, shorter re-admissions (p < 0.05) and fewer appointments (p < 0.05). Compared to LD/I, ADM/I had shorter length of stay (p < 0.05) and operative time (p < 0.05), fewer appointments, similar rate and number of additional procedures but required more and longer re-admissions. CONCLUSION: In our experience, unilateral single stage ADM/I was associated with fewer resources utilised in comparison with two staged TE and LD/TE reconstructions in both complication-free and complicated settings over a 24-month period, despite requiring aesthetic revision in 60.9% of patients. Compared to LD/I, resource utilisation was commensurate in complication-free and complicated settings.

Immediate breast reconstruction with acellular dermal matrix: factors affecting outcome.

BACKGROUND: The use of acellular dermal matrix (ADM) for coverage of the lower pole in immediate implant-based breast reconstruction has changed surgeons' practice. We present our experience using a porcine ADM (Strattice), focusing on short-term outcomes, patient selection, and technique adaptations that may influence outcome. METHODS: A two-center, retrospective, cohort study was performed from December 2008 to October 2012 at Guy's and St. Thomas' Hospitals, London, and Clinic Pyramide, Zürich. The study period was divided into two periods: Period 1 which spanned from December 2008 to October 2010 and Period 2 from January 2011 to October 2012 wherein technique adaptations were introduced. Short-term complications after reconstructive surgery were compared between Periods 1 and 2. RESULTS: A total of 149 patients underwent 200 reconstructions (110 one-stage and 90 two-stage) following oncologic (134 breasts) or prophylactic (66 breasts) mastectomy. The mean follow-up was 22.2 months. The total complication rate was 32.5%, including infection, 11.5%; hematoma, 5%; seroma, 10.5%; skin necrosis, 3.5%; and serious wound breakdowns with implant exposure, 1.5%. Complications resulted in 3% requiring an early exchange of implant/expander and in 12.5% requiring explantation. A significant reduction in total complications, infection, implant exposure, and implant loss were noted in Period 2. Multivariate analysis showed time period of surgery (Period 1), single-stage reconstruction, and patient characteristics (mastectomy weight>600 g, or body mass index (BMI)>30, or smoking) to be statistically significant risk factors for the development of postoperative complications. Neoadjuvant chemotherapy showed a trend towards higher complication rates. CONCLUSION: The high rate of early complications in this study was mostly related to patient characteristics and learning curves and highlights the importance of patient selection and technique principles in optimizing the outcome.

An exploration of patient decision-making for autologous breast reconstructive surgery following a mastectomy.

OBJECTIVE: The aim of this study was to examine patients' experiences of the decision to undergo breast reconstructive surgery following mastectomy. METHOD: 21 Women, who had undergone reconstruction, took part in a semi-structured qualitative interview, which examined the participants' experience of the decision-making process. The recorded interviews were transcribed verbatim and analyzed using "framework analysis". RESULTS: Women who underwent immediate reconstruction spoke of the convenience of undergoing only one operation with regards to juggling work and childcare arrangements. For women who underwent delayed reconstructive surgery the reasons centre on dissatisfaction with wearing prosthesis. Others spoke of no choice, as immediate reconstruction was not offered as an option. However both groups did report similar influential factors and received and used similar informational content and informational sources in order to make their decision. CONCLUSION: The study outlines the different motivations for undergoing immediate or delayed breast reconstruction and highlights that there is not always a choice offered to patients. PRACTICE IMPLICATIONS: Future patients who are considering breast reconstruction should be provided with the relevant information to make a well informed decision and may benefit from different methods of information delivery that could include decision aids such as informational booklets, photographs, and videos.

Breast reconstruction using the entire transverse abdominal adipocutaneous flap based on unilateral superficial or deep inferior epigastric vessels.

BACKGROUND: Among various alternatives for autologous breast reconstruction, the superficial inferior epigastric artery abdominal flap provides the least donor-site morbidity, as dissection of the rectus abdominis sheath and muscle is not required. However, because of inconsistencies in the existence and size of the superficial inferior epigastric artery, its use is limited. In addition, whether the perfusion from the superficial system is adequate across the midline is still a question to be answered. METHODS: Over a period of 16 months, the authors performed a total of 44 breast reconstructions using either the deep inferior epigastric artery perforator flap (n = 30) or the superficial inferior epigastric artery flap (n = 14). In all cases, the superficial inferior epigastric artery system was explored first and used as the pedicle if the diameter of the available vessels was larger than 1 mm. If the vessels were unavailable or the diameters were smaller than 1 mm, the deep inferior epigastric artery and vein were used as the pedicle. The diameter of the superficial inferior epigastric artery ranged between 0.8 and 3.0 mm, and the mean pedicle length was 6 cm. The superficial inferior epigastric artery was not available in 21 cases (48 percent), and in nine cases (20 percent) the diameter was smaller than 1 mm. In six cases where the superficial inferior epigastric artery was judged to be appropriate, laser Doppler study was performed perioperatively to assess the perfusion of each zone (I through IV) from the deep and superficial systems consecutively. In all cases, the superficial and deep systems ipsilateral to the defect were dissected. During inset, zone IV was not discarded routinely, and 92.3 percent and 86.7 percent of the harvested superficial inferior epigastric artery flap and deep inferior epigastric artery perforator flap, respectively, were used. RESULTS: The flap survival rates were 93 and 100 percent in the superficial inferior epigastric artery and deep inferior epigastric artery perforator groups, respectively. Adequate perfusion of all zones from the superficial system was documented by laser Doppler flowmetry, and the perfusion rates were comparable to the deep system. CONCLUSIONS: The entire abdominal adipocutaneous flap based on the unilateral superficial inferior epigastric artery is as reliable as one based on the deep inferior epigastric artery perforator flap. As a result, initially, the superficial inferior epigastric artery flap should be explored, as it provides less donor-site morbidity. A sizable superficial artery and vein is sufficiently safe for microsurgical transfer, similar to the deep inferior epigastric system.

A new method of subcutaneous placement of free jejunal flaps to reconstruct a diversionary conduit for swallowing in complicated pharyngoesophageal injury.

Choking is a serious problem in pharyngoesophageal reconstruction, which may occur following tumor ablation of the pharynx or following corrosive injury involving the epiglottis and other parts of the upper airway. To prevent choking and the risk of severe pulmonary complications, patients have to give up oral intake and assume feeding via jejunostomy for the rest of their lives. After reconstruction of the esophagus, eight patients experienced frequent choking and aspiration. With a free jejunal flap, the inlet for food could be separated from the route of the upper airway by a diversion technique. The jejunum segment was transferred microsurgically to reconstruct the cervical esophagus, with its inlet at the buccogingival sulcus. There were no surgical complications related to either the free jejunal flap transfer or the donor site. Postoperatively, patients require re-education of their pattern of swallowing, but after the rehabilitation period all patients reported a satisfactory oral intake through the reconstructed esophagus to the abdomen without choking. There were no episodes of aspiration following reconstruction. With this new method to create a separate food pathway, patients can resume oral intake safely without choking and without permanent jejunostomy. This technique offers a useful solution for patients who suffer from recurrent choking and aspiration following injury or ablation of the pharynx.

Nipple reconstruction in Asian females using banked cartilage graft and modified top hat flap.

Nipple reconstruction is usually the final stage of breast reconstruction and there are over 50 articles that describe different techniques. The majority of methods use local soft tissue as local flaps but they face the disadvantage of reduction in nipple projection after the initial two months. This is particularly troublesome in Asian females who may have wider nipples with prominent projection but small areola surface area. We developed a method to correct this problem using cartilage graft harvested during the initial breast reconstruction operation and banked beneath the skin flap. Using the modified 'top hat' flap, we found that no excess soft tissue is required to compensate for the reduction. We have used this method in 25 cases of nipple reconstruction and have obtained satisfactory result in projection.