Safety of Routine Pedicle Division during Delayed Breast Augmentation following Free Flap Breast Reconstruction.

BACKGROUND: Autologous free flap breast reconstruction is a common reconstructive procedure, with the ability to produce a natural breast shape and a long history of success. Despite its benefits, there are special situations in which patients lack sufficient donor-site tissue to achieve adequate breast size and projection. With this study, the authors describe their institutional experience of delayed implant augmentation after autologous breast reconstruction with a particular focus on pedicle division as a technique to improve aesthetic results. METHODS: A retrospective chart review of patients that underwent free flap autologous breast reconstruction with delayed implant augmentation was conducted over a 13-year period. Flaps were divided into a control group without pedicle division and a divided pedicle group. Groups were compared in terms of demographics, clinical and surgical characteristics, implant details, and postoperative implant and flap complications. RESULTS: No significant differences in terms of age, body mass index, comorbidities, radiation therapy, or surgical indications were noted. The most common reason for delayed implant augmentation after autologous breast reconstruction was change in breast size and breast asymmetry. In terms of implant and flap complications, we found no significant differences between the control and divided pedicle groups after delayed implant augmentation. CONCLUSIONS: From the authors' institutional experience, pedicle division in delayed breast augmentation with implants after free flap breast reconstruction can be safety performed in selected cases. This technique can be a powerful tool for plastic surgeons to improve the final aesthetic appearance of the reconstructed breast. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

The Influence of Obesity on Outcomes After Pediatric Reduction Mammaplasty: A Retrospective Analysis of the Pediatric National Surgical Quality Improvement Program-Pediatric Database.

BACKGROUND: Symptomatic macromastia causes negative physical and psychosocial effects, which support the need for early intervention, even in the adolescent population (Plast Reconstr Surg 2012;130:785-789). Reduction mammaplasty is a proven treatment that reliably addresses symptoms from macromastia. The National Surgical Quality Improvement Program-Pediatric is the leading nationally validated, risk-adjusted, outcomes-based program to measure and improve the quality of surgical care (Pediatrics 2012;130:e339-e346). In adults, obesity is associated with increased early postoperative complications after mammaplasty (Pediatrics 2017;140(5)). We hypothesized that obesity would increase the incidence of postoperative complications in pediatric patients undergoing reduction mammaplasty. METHODS: The National Surgical Quality Improvement Program-Pediatric database was queried for female patients 18 years or younger who underwent reduction mammaplasty from January 2012 to December 2017 using Current Procedural Terminology code 19318. Demographic, clinical, and outcomes data were abstracted from the database. A composite postoperative adverse events variable was created from a list of 21 individual adverse events. Patients were stratified by presence of obesity (body mass index ≥30 kg/m) on univariate analyses. Multivariable logistic regression was used to determine factors associated with any postoperative adverse events. RESULTS: A total of 542 female patients underwent reduction mammaplasty, with 48% of the cohort being obese. Patients were similar in age (median, 17 years) and comorbidities between obese and nonobese groups. Obese patients were more likely to be African American, have higher American Society of Anesthesiologists class, and endure longer operations. Composite adverse event rates were significantly higher in the obese group (7% vs 2%, P = 0.013). Individual adverse events were similar between groups, with the exception of 30-day readmissions, which was higher in the obese group (3% vs 1%, P = 0.04). On multivariable logistic regression, obesity increased the odds of having a postoperative adverse event by 3-fold after adjusting for operative duration. CONCLUSIONS: Obesity was significantly associated with greater postoperative adverse events in obese adolescent females after reduction mammaplasty compared with their nonobese counterparts. Although recorded rates of adverse events after reduction mammaplasty were low, preoperative weight loss programs may further improve outcomes for obese pediatric populations undergoing reduction mammaplasty.

An Analysis of Specialty-Specific Microsurgical Head and Neck Reconstruction: A Look at a Single Institution and National Trends Over a Decade.

INTRODUCTION: Head and neck free flap (HNFF) reconstructions have historically utilized a multidisciplinary approach between otolaryngology head and neck surgery (OHNS) and plastic surgery (PS). However, there seems to be a trend toward both the extirpative and reconstructive portions being performed by OHNS. We aimed to elucidate the volume trend in HNFF reconstruction over the last decade. METHODS: Data were collected by 3 modalities: electronic medical record search of patients who underwent HNFF surgery at our institution (2013-2018), survey data from microsurgery fellowship programs (2007-2017), and National Surgical Quality Improvement Program (NSQIP) query of cases receiving designated HNFF Current Procedural Terminology codes (2011-2016). Data were analyzed with trends in HNFF reconstruction as our primary outcome. RESULTS: At our institution, HNFF reconstructions increased 4-fold (59-227). Percentage of cases by PS decreased from 18.6% to 6.0%, whereas that of OHNS increased 81.4% to 94.0% (P = 0.009). Survey data, completed by microsurgery fellowship program directors (23/81 [27.2%]), revealed the number of OHNS programs in 2007 performing 100 or more HNFF cases compared with PS was 40% (6/15) to 12.5% (1/8) (P = 0.172). By 2016, that number increased significantly for OHNS to 73.3% (11/15), whereas that of PS remained stagnant at 12.5% (1/8) (P = 0.005). According to NSQIP data, the percentage of cases performed by PS in 2011 was 52%, which was greater than OHNS's share of 43%. The other 5% was allotted to either orthopedic, oral and maxillofacial surgery, or general surgery. In 2013, those numbers reached a peak for PS at 55% and a nadir for OHNS at 36%. However, by 2016, the percentage of HNFF cases reversed. where 58% of cases were performed by OHNS and only 38% by PS. When comparing the 2011 data to the 2016 data, OHNS had a 134% increase, whereas PS had a 27% decrease (P = 0.003). CONCLUSIONS: Head and neck free flap reconstruction has grown dramatically over the last 10 years. Plastic surgeons are performing fewer cases, whereas otolaryngology head and neck surgeons perform more as indicated by institutional, microsurgery fellowship program director survey, and NSQIP data.

Nipple viability after nipple-sparing mastectomy in patients with prior circum-areolar incisions.

Nipple-areola-sparing mastectomy (NSM) is becoming more commonplace as it offers a more esthetic breast appearance while still appropriately treating malignancy. However, patients with prior circum-areolar incisions are often considered at risk for nipple viability. The authors present a case series of all patients undergoing NSM at their institution between 2012 and 2016. Eighteen consecutive female nonsmoking patients underwent 32 NSMs. None of the patients had reconstructive failures including those relating to the nipple-areola complex (NAC), such as nipple necrosis. NSM is therefore feasible in cases with prior circum-areolar incisions. These patients can be safely reconstructed with both prosthetic devices and autologous tissue.

Implications of Internal Mammary Lymph Node Sampling During Microsurgical Breast Reconstruction.

INTRODUCTION: Internal mammary lymph node (IMN) chain assessment for breast cancer is controversial; however, current oncologic data have shed new light on its importance. Metastatic involvement of the IMN chain has implications for staging, prognosis, treatment, and survival. Here, we analyzed our data gathered during sampling of the IMN and the oncologic treatment changes that resulted from our findings. METHODS: A retrospective chart review was performed on 581 patients who underwent free-flap breast reconstruction performed by the senior author. All dissected IMNs were submitted for pathological examination. Patient demographics, oncologic data, and the results of IMN sampling were reviewed. RESULTS: 581 patients undergoing 981 free flaps were identified. A total of 400 lymph node basins were harvested from 273 patients. Of these, nine had positive IMNs. Two of these nine patients had positive IMNs of the contralateral nonaffected breast. Five patients had positive axillary lymph nodes. Four patients had multifocal tumors, one of which was bilateral. Seven patients had an increase in cancer stage as a result of having positive IMNs. Six patients had a change in treatment: two patients required additional chemotherapy, one received adjuvant radiation therapy, and three necessitated both supplemental chemotherapy and radiation. CONCLUSIONS: Opportunistic biopsy of the IMN while dissecting the recipient vessels is simple and results in no added morbidity. We recommend that biopsy of the IMN chain be performed whenever internal mammary vessels are dissected for microsurgical anastomosis in breast cancer patients. Positive IMN involvement should encourage thorough oncological workup and treatment reevaluation. LEVEL OF EVIDENCE IV: Case series.

Evaluation of the single medial circummuscular perforator DIEP flap: Outcomes and comparison to traditional transmuscular single perforator flap.

INTRODUCTION: Successful breast reconstruction using deep inferior epigastric perforator (DIEP) flaps depends on optimal perforator choice. Circummuscular wraparound medial perforators allow for no rectus dissection and minimal fascial incisions, often presenting as an ideal option. The aim of our study is to evaluate outcomes of the single medial wraparound perforator flap in comparison to more traditional transmuscular single-perforator DIEP flaps. PATIENTS AND METHODS: A retrospective chart review was conducted of all DIEP flaps performed by the senior author from 2011 to 2016, yielding 269 flaps on 157 patients. For this study, we included all patients who underwent reconstruction of the breast(s) and possessed circummuscular perforators arising from the DIE vessels. A control group consisted of all consecutive patients with transmuscular one-perforator DIEP flaps. Patient details and their postoperative outcomes were collected. RESULTS: In our study, eight patients (5.1%) were of the medial wraparound variety. Sixteen control patients (10.2%) with similar comorbidities had flaps that were of the more traditional single perforator transmuscular variety. There was a slight trend toward decreased operative time in the medial wraparound group, however, it was not found to be statistically significant (536 ± 81 vs. 572 ± 84 min, P = .377). Complication profiles were similar between groups (25.0 vs. 18.8%, P = .722), with no increased rates of fat necrosis in the wraparound cohort. CONCLUSION: Based on our findings, using a medial wraparound perforator is a safe and reliable option when compared with a single transmuscular perforator DIEP flap. Choosing the wraparound perforator may show benefit as it eliminates muscular dissection and nerve damage, and tends to minimize fascial incision length.

Revision Breast Augmentation at the Time of Cardiac Sarcoma Resection: The Importance of Pocket Control When Inframammary Approach Is Combined with Simultaneous Sternotomy.

Sternotomy in patients with previous breast augmentation becomes an aesthetic challenge when an inframammary approach is utilized over the traditional midline skin incision. Although the inframammary fold approach offers a well-concealed scar when compared with the midline chest incision, patients with a history of previous breast augmentation are at risk for alteration of the anatomy leading to symmastia, implant malposition, and asymmetry. We present a case report of sternotomy and resection of a mediastinal perivascular epithelioid cell tumor with concomitant revision augmentation with silicone implants and SERI Scaffold. Our patient had an uncomplicated postoperative course and a good cosmetic result 1 year after concomitant revision augmentation in conjunction with cardiac tumor resection. In conclusion, the authors feel that despite the difficulties in performing breast augmentation in patients undergoing thoracic surgery, it is possible to obtain good results. It is necessary to reinforce the repair with a mesh to recreate support and proper anatomy.

Does Acellular Dermal Matrix Thickness Affect Complication Rate in Tissue Expander Based Breast Reconstruction?

Background. While the benefits of using acellular dermal matrices (ADMs) in breast reconstruction are well described, their use has been associated with additional complications. The purpose of this study was to determine if ADM thickness affects complications in breast reconstruction. Methods. A retrospective chart review was performed including all tissue expander based breast reconstructions with AlloDerm (LifeCell, Branchburg, NJ) over 4 years. We evaluated preoperative characteristics and assessed postoperative complications including seroma, hematoma, infection, skin necrosis, and need for reintervention. We reviewed ADM thickness and time to Jackson-Pratt (JP) drain removal. Results. Fifty-five patients underwent 77 ADM-associated tissue expander based breast reconstructions, with average age of 48.1 years and average BMI of 25.9. Average ADM thickness was 1.21 mm. We found higher complication rates in the thick ADM group. Significant associations were found between smokers and skin necrosis (p < 0.0001) and seroma and prolonged JP drainage (p = 0.0004); radiated reconstructed breasts were more likely to suffer infections (p = 0.0085), and elevated BMI is a significant predictor for increased infection rate (p = 0.0037). Conclusion. We found a trend toward increased complication rates with thicker ADMs. In the future, larger prospective studies evaluating thickness may provide more information.

Reduction and Mastopexy Techniques for Optimal Results in Oncoplastic Breast Reconstruction.

Breast conservation therapy has emerged as an important option for select cancer patients as survival rates are similar to those after mastectomy. Large tumor size and the effect of radiation create cosmetic deformities in the shape of the breast after lumpectomy alone. Volume loss, nipple displacement, and asymmetry of the contralateral breast are just a few concerns. Reconstruction of lumpectomy defects with local tissue rearrangement in concert with reduction and mastopexy techniques have allowed for outstanding aesthetic results. In patients who have a reasonable tumor- to breast-size ratio, this oncoplastic surgery can successfully treat the patient's cancer while often improving upon preoperative breast shape. Specific surgical guidelines in reduction and mastopexy help achieve predictable aesthetic results, despite the effects of radiation, and can allow for a single surgical procedure for cancer removal, reconstruction, and contralateral symmetry in one stage.

Split-thickness skin grafting the high-risk diabetic foot.

OBJECTIVE: The application of split-thickness skin grafts (STSGs) to chronic extremity wounds has often been considered undesirable because of the perceived high incidence of failure, especially in neuropathic patients with plantar diabetic foot wounds. The purpose of this study was to evaluate the outcomes of STSG placement in patients with chronic lower extremity wounds. METHODS: We abstracted data from consecutive patients at our institution from January 2007 through April 2013 who underwent STSG placement by vascular and podiatric surgeons for chronic wounds of the lower limb and foot. Patients were monitored for at least 24 weeks, unless the wounds healed sooner. RESULTS: There were 94 patients (72% male) in the study group, with a mean age of 61.0 ± 12.8 years. Of these, 66 patients had diabetes, including 13 who were dialysis-dependent; the remaining 28 had other chronic nondiabetic wounds. The average duration of follow-up was 12.0 ± 12.9 months. After STSG placement, 65 (69.1%) experienced complete graft incorporation and healing, and 18 (19.1%) required revision, five (5.3%) of whom ultimately required major limb amputation. There were no differences in healing when wounds in patients with and without diabetes or plantar vs nonplantar wound locations were compared (P > .05). Similar results were observed after adjusting the results for initial wound size. Although dialysis patients had a threefold higher rate of STSG revision (46.2% vs 14.8%; P = .01), the cumulative rate of wound healing as a function of time was independent of end-stage renal disease (P = .83). CONCLUSIONS: The results of this study suggest that STSG may be an effective method for promotion of wound healing in the management of chronic lower extremity wounds irrespective of wound location and presence of diabetes.

Endovascular treatment of ruptured axillary and large internal mammary artery aneurysms in a patient with Marfan syndrome.

Marfan syndrome is an autosomally inherited disorder affecting the synthesis of connective tissues. Vascular manifestations of Marfan syndrome include aneurysmal dilatation of the aortic root, aortic dissection, and rupture. Peripheral aneurysms are mostly reported in the iliac, femoral, and subclavian arteries. We report a Marfan patient with a ruptured axillary artery aneurysm and a large left internal mammary artery aneurysm. The axillary aneurysm was successfully excluded using covered stent grafts, and the left internal mammary artery aneurysm was effectively coiled. Duplex ultrasound imaging at 4 months and computed tomography at 9 months demonstrated complete thrombosis and exclusion of both aneurysms with patent subclavian-axillary stent grafts.