Complications of Contralateral Prophylactic Mastectomy: Do They Delay Adjuvant Therapy?

BACKGROUND: There is ongoing debate regarding the optimal timing of contralateral prophylactic mastectomy fueled by concern that performing it at the time of the mastectomy for the index breast cancer may delay adjuvant therapy. The study objective was to examine the effect of simultaneous contralateral prophylactic mastectomy with immediate breast reconstruction on the complication rate and adjuvant therapy timing. METHODS: A retrospective study was conducted of consecutive patients who underwent contralateral prophylactic mastectomy with immediate breast reconstruction and received adjuvant therapy over a 6-year period. Demographic, treatment, and outcomes data were collected, and relationships between multiple variables and outcomes were evaluated. RESULTS: Of 241 patients (482 breasts) included, 186 (372 breasts) underwent simultaneous index breast mastectomy and contralateral prophylactic mastectomy with immediate breast reconstruction followed by adjuvant therapy (immediate group), and 55 (110 breasts) underwent index mastectomy, then adjuvant therapy, followed by delayed contralateral prophylactic mastectomy with immediate breast reconstruction (delayed group). Demographics were similar, although breast cancer stage (p < 0.001), tumor category (p = 0.0072), and nodal category (p < 0.001) were significantly higher in the delayed group. In the immediate group, complications before adjuvant therapy occurred in 31 patients (16.7 percent), and in six patients (3.2 percent) complications occurred only in the contralateral prophylactic mastectomy breast; delay to adjuvant therapy occurred in 11 patients (5.9 percent), in four (2.2 percent) of whom the contralateral prophylactic mastectomy breast was responsible for the delay. CONCLUSIONS: Contralateral prophylactic mastectomy with immediate breast reconstruction can be performed safely at the time of the index mastectomy in carefully selected patients. These findings will engage patients seeking contralateral prophylactic mastectomy in shared decision-making regarding optimal timing with respect to the risks and benefits. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Breast Implants and Radiation.

One of the most influential factors in the success of breast reconstruction is whether or not radiation therapy has or will be performed. While traditional teaching is that all breasts treated with radiation therapy must be reconstructed with an autologous component, many reconstructive surgeons perform implant-based breast reconstruction without an autologous component and have success doing so. The purpose of this article is to explore the risks, benefits, and nuances of performing implant-based breast reconstruction in the setting of radiation therapy. The authors performed a review of the literature of all topics relevant to performing implant-based reconstruction with radiation therapy.

The Split Pectoralis Flap: Combining the Benefits of Pectoralis Major Advancement and Turnover Techniques in One Flap.

BACKGROUND: The pectoralis major is a versatile flap used as an advancement or turnover flap for sternal wound treatment. The advancement flap provides suboptimal inferior sternal coverage and poorly fills mediastinal dead space. The turnover flap covers the inferior sternum and fills dead space but requires disinsertion of the muscle from the humerus, resulting in functional loss and cosmetic deformity. METHODS: The authors describe a new technique of splitting the pectoralis muscle along its fibers, using the superior portion as an advancement flap and the inferior portion as a turnover flap. RESULTS: Eleven patients underwent the described technique. Nine patients healed without complications or repeated operations. One patient had a recurrent aortic graft infection requiring reoperation. One patient had a postoperative seroma requiring incision and drainage. CONCLUSION: Using the pectoralis as an advancement and turnover flap allows inferior sternum and mediastinum coverage using one donor site and maintaining the function of the muscle and preventing cosmetic deformity.

Local foreign-body reaction to commercial biodegradable implants: an in vivo animal study.

Biodegradable plates have been used extensively in fracture fixation since the 1960s. They rarely cause stress-protection atrophy or problems requiring secondary plate removal, common complications seen with metallic plates. However, aseptic foreign-body reactions have been reported, sometimes years after the original implantation. Both inadequate polymer degradation and debris accumulation have been implicated as causes. The current generation of commercial biodegradable plates is formulated to minimize this complication by altering the ratio of polylactic and polyglycolic acids. This in vivo study compares the degree of local foreign-body reaction of two commercially available resorbable plates in rabbits. Two types of biodegradable plates were examined: poly(D/L)lactide acid (PDLLA) and polylactide-co-glycolide acid (PLGA). Each plate was placed into a periosteal pericalvarial pocket created beneath the anterior or posterior scalp of a rabbit. Humane killing occurred at 3, 6, and 12 months postoperatively. Foreign-body reaction was evaluated histologically. The PDLLA plates demonstrated marked local foreign-body reactions within the implant capsule as early as 3 months after implantation, with presence of inflammatory cells and granulomatous giant cells in close association with the implant material. All local foreign-body reactions were subclinical with no corresponding tissue swelling requiring drainage. PLGA plates did not demonstrate any signs of inflammatory reactions. In addition, the PLGA plates did not appear to resorb or integrate at 12 months. Neither PDLLA nor PLGA plates demonstrated inflammation of the soft tissue or adjacent bone outside the implant capsule. In our study, the PDLLA plates demonstrated histological evidence of foreign-body reaction that is confined within the implant capsule, which was not seen with the PLGA plates. This finding may be attributable to the lack of significant resorption seen in the PLGA plates. Both PDLLA and PLGA plates were biocompatible with the rabbit tissue environment and should be considered for continued use in craniofacial, maxillofacial, and orthopedic reconstruction.

Effect of dietary zinc and phytase supplementation on botulinum toxin treatments.

PURPOSE: To determine whether oral zinc supplementation might affect the efficacy and duration of botulinum toxin treatments. METHODS: In a double-blind, placebo-controlled, crossover pilot study, we examined the efficacy of three botulinum toxin preparations (onabotulinumtoxinA, abobotulinumtoxinA, and rimabotulinumtoxinB) following oral supplementation with zinc citrate 50 mg and phytase 3,000 PU, zinc gluconate 10 mg, or lactulose placebo in individuals treated for cosmetic facial rhytids, benign essential blepharospasm, and hemifacial spasm. RESULTS: In seventy-seven patients, 92% of subjects supplemented with zinc 50 mg and phytase experienced an average increase in toxin effect duration of nearly 30%, and 84% of participants reported a subjective increase in toxin effect, whereas no significant increase in duration or effect was reported by patients following supplementation with lactulose placebo or 10 mg of zinc gluconate. The dramatic impact of the zinc/phytase supplementation on some patients' lives clinically unmasked the study and prompted an early termination. CONCLUSIONS: This study suggests a potentially meaningful role for zinc and/or phytase supplementation in increasing the degree and duration of botulinum toxin effect in the treatment of cosmetic facial rhytids, benign essential blepharospasm, and hemifacial spasm.

A comparative, long-term assessment of four soft tissue substitutes.

BACKGROUND: The ideal product for soft tissue replacement is durable, nonimmunogenic, and noninfectious. AlloDerm (LifeCell Corp., Branchburg, New Jersey), Enduragen (Stryker Corp., Kalamazoo, Michigan), and DermaMatrix (Synthes, Inc., West Chester, Pennsylvania) are frequently used for soft tissue replacement, but comparative analysis of these materials over an extended time period has not been reported. DuraMatrix (bovine tendon matrix; Stryker Corp.) is also promising, demonstrating desirable properties not only as a dural substitute but also for soft tissue replacement. OBJECTIVES: The authors analyze in vivo gross and microscopic changes over time with four commercially available dermal matrices, utilizing the murine model for a controlled environment. METHODS: AlloDerm, Enduragen, DermaMatrix, and DuraMatrix implants measuring 1 × 1 cm were each implanted in 40 adult mice, in individual dorsal submuscular pockets. The mice were then sacrificed in groups of 10 at three, six, nine, and 12 months. The implants and surrounding tissues were excised and evaluated for gross and microscopic appearance. RESULTS: Histological analysis of the specimens demonstrated similar encapsulation, implant infiltration, and surrounding inflammation over time. Enduragen implants demonstrated the least amount of host cell infiltration, whereas AlloDerm demonstrated the most. Grossly, Enduragen maintained its original shape and became firmer over time, whereas AlloDerm became spherical and softer. DermaMatrix and DuraMatrix both maintained their original shape and consistency. Implant migration, explantation, infection, or allergic reactions were not noted. CONCLUSIONS: All of the materials studied demonstrated high levels of host tolerance and tissue integration. AlloDerm demonstrated signs of resorption, whereas Enduragen maintained its size and became firmer in consistency. Together with the histological results, this suggests a proportional relationship between the amount of host cell integration and implant resorption.

Multiple, recurrent, refractory vascular malformations as the primary presenting feature of a PTEN mutation.

Complete history and physical examinations are very important in patients with a vascular anomaly. This brief report highlights the case of a five-year-old male who presented with recurrent arteriovenous malformations of the hand and forearm. The patient also demonstrated additional clinical and diagnostic imaging features consistent with a PTEN Hamartoma-Tumor syndrome. The prompt identification of individuals with this condition is important, given the more locally aggressive nature to the malformations and the increased potential for future malignant disease. The etiology and clinical features associated with PTEN Hamartoma-Tumor syndromes are reviewed in this case.

The subtarsal incision: where should it be placed?

PURPOSE: The subtarsal incision is a frequently used approach to orbital floor fractures. Compared with the subciliary incision, there is a lower rate of lower lid retraction. Unlike the transconjunctival incision, there is no need to perform a lateral canthoplasty to restore canthal integrity. Despite its widespread use, the exact location of the subtarsal incision is not uniform among surgeons. MATERIALS AND METHODS: Twenty patients underwent open reduction and internal fixation of orbital floor fractures by a single surgeon over a 4-month period, using the subtarsal incision. Postoperative photographs of the first 7 consecutive patients were analyzed by 4 nonmedical personnel and 4 plastic surgeons regarding scar visibility. Pearson correlation coefficients were calculated to determine if a correlation existed between more inferior placement of the scar and scar visibility. RESULTS: No patients in the series developed any complications such as lower lid retraction or enophthalmos. One patient developed transient facial palsy. The results of the survey showed a positive correlation between distance from lash line to scar and scar visibility at the level of the lateral limbus (Pearson r coefficient, 0.73) and at the level of the lateral canthal angle (Pearson r coefficient, 0.65). CONCLUSIONS: The results of this study indicate that the optimal placement of the subtarsal incision is as close as possible to the inferior border of the tarsal plate. The incision should be placed within an existing skin crease, if possible, and should be made with the knowledge that the more inferior the incision is placed, the greater the visualization of the fracture, but the more visible the scar.

Facial fractures.

Fractures of the facial skeleton can result in the loss of an aesthetically pleasing appearance and basic function, and many cases subsequently require an operative intervention. The surgeon managing these facial fractures must, at the same time, be cognizant of concomitant injuries, including neurologic, ophthalmologic, and cervical spine issues. For most situations, early stabilization in anatomical position using rigid fixation will give the most accurate reduction for the optimal return of preoperative appearance and function, while reducing long-term soft-tissue contracture.

The variable position of the ear in lambdoid synostosis.

Isolated unilateral lambdoid craniosynostosis is often confused with posterior positional plagiocephaly because of a general overlap in their clinical presentations; however, distinction between these 2 entities is important because of the differences in appropriate management. Historical literature teaches that ear position is posterior in lambdoid synostosis, whereas it is anterior in positional plagiocephaly. Recently, several cases of anterior ear position in isolated unilateral lambdoid synostosis presented to the Texas Children's Hospital. A review of the cases and literature revealed that there are now 37 cases of unilateral lambdoid synostosis in the literature in which ipsilateral ear position is reported. Twelve cases (32%) had anteriorly displaced ears, 6 cases (16%) were nondisplaced, 7 cases (19%) were displaced posteriorly, 4 cases (11%) anteroinferiorly, 1 case (3%) inferiorly, and 7 cases (19%) posteroinferiorly. Based on this review, it seems that the diagnostic significance of the external ear position is unclear at this point.

The need for breast cancer screening in women undergoing elective breast surgery: an assessment of risk and risk factors for breast cancer in young women.

BACKGROUND: Given the 11% lifetime risk of breast cancer and increasing popularity of elective breast surgery, the role of preoperative screening begs further investigation. There are currently no guidelines that indicate which women younger than 40 years of age should be screened preoperatively. OBJECTIVES: A meta-analysis of studies regarding the odds ratio (OR) and relative risk ratio for breast cancer risk factors in women younger than 40 was completed. METHODS: Of a total of 240 results in the PubMed database for articles referencing breast cancer risk factors in young women, eight were selected for review. A total of 5381 patients were included in the studies in this meta-analysis; 26 risk factors were identified. A meta-analysis was performed to determine the OR of each specific risk factor, with a 95% confidence interval. RESULTS: The most significant risk factors were having a sister with breast cancer (OR, 11.66), having a first-degree relative with breast cancer (OR, 2.66), having a mother with breast cancer (OR, 2.31), never having breastfed (OR, 1.77), and having undergone a breast biopsy (OR, 1.66). From these data, the authors developed a clinical questionnaire to estimate the risk of breast cancer in young women. In addition, an algorithm was developed for preoperative breast cancer screening for women of all ages undergoing elective breast procedures. CONCLUSIONS: For women younger than 40, the preoperative risk assessment involves two steps. First, the possibility of existing breast cancer should be evaluated with a preoperative screening survey. Second, the patient's risk for future development of cancer should be assessed, with a focus on genetic mutations. Women older than 40 years of age should be stratified to receive either a preoperative mammogram or MRI. The clinical questionnaire and preoperative screening algorithm provide an evidence-based guideline on which to base the discussion with patients regarding preoperative breast cancer screening.

Is primary thinning of the anterolateral thigh flap recommended?

BACKGROUND: Although primary thinning of the anterolateral thigh (ALT) flap has been successful in Asia, clinical and anatomic studies have demonstrated that this may be inadvisable in Western patients. Recent reports have demonstrated successful thinning of the ALT using smaller flaps. A systematic review was attempted, to assess whether ALT size affects the incidence of vascular compromise after primary thinning. METHODS: A systematic review was undertaken to examine the relevant literature. Student t-test was used to compare flaps that did and did not have complications. Fisher exact test was used to compare outcomes of flaps measuring less than and greater than 150 cm2. RESULTS: Eleven articles met the inclusion criteria. Eighty-eight ALT flaps were reported, and vascular compromise was seen in 11 (12.5%). The average size of flaps that demonstrated necrosis was 180.73 cm2; those without necrosis averaged 123.19 cm2 (P = 0.06). Flaps >150 cm2 had a significantly increased rate of compromise (25.93% vs. 6.56%; P < 0.05). CONCLUSIONS: A systematic literature review confirms that it is inadvisable to primarily thin large ALT flaps in the Western population. When large ALT flaps are required, primary thinning must be avoided to keep linking vessels intact.

Surgical mission (not) impossible--now what?

International surgical missions, particularly those that address patients with clefts of the lip and palate, have become increasingly common. Numerous groups have been organized to provide these services. A plastic surgeon participating in these endeavors should have full knowledge of the details involved not just for himself but to maximize safety and optimize outcomes for these patients. An understanding of the issues surrounding trip preparation, the in-country logistics, proper preoperative patient selection, and intraoperative and postoperative issues are all essential to a successful experience. In this article, the authors review and discuss lessons learned from a combined total of more than 100 international trips. Relevant literature is reviewed, and additional pearls from this body of knowledge are presented.

Breast implant infections: is cefazolin enough?

BACKGROUND: Bacterial infection is a well-known risk of breast implant surgery, occurring in 2.0 to 2.5 percent of cosmetic cases and up to 20 percent of reconstructive cases. The Centers for Disease Control and Prevention recommends a first-generation cephalosporin for perioperative prophylaxis; however, no guidelines exist for the empiric treatment of established breast implant infections. A recent increase in methicillin-resistant Staphylococcus aureus infections has prompted interest in using alternative antibiotics with anti-methicillin-resistant S. aureus activity for both prophylactic and empiric therapy. The goal of the present study was to assess the bacteriology and antibiotic susceptibility of breast implant-related infections at two tertiary care hospitals in the Texas Medical Center to determine whether a baseline for empiric therapy for breast implant infections could be established. METHODS: A retrospective review of patients who developed periprosthetic infections within 1 month after breast implant placement between 2001 and 2006 was completed. One hundred six patients with 116 infected breasts were identified. Patients were included in the study only if they had documented culture data. RESULTS: Thirty-one breasts in 26 patients met inclusion criteria. Sixty-seven percent of the infected breasts had S. aureus infections; of these, 68 percent were methicillin-resistant S. aureus infections and 32 percent were methicillin-susceptible S. aureus infections. We noted Gram-negative rods and sterile cultures in 6 percent and 26 percent of breasts, respectively. CONCLUSIONS: Because of the high incidence of methicillin-resistant S. aureus infections in breast implant recipients, we believe that choosing an antibiotic with anti-methicillin-resistant S. aureus activity is justified for empiric treatment of breast implant infections, until culture and sensitivity data, if obtained, become available.

A modified technique for inferior turbinate reduction: the integration of coblation technology.

BACKGROUND: Many procedures have been described for the surgical management of inferior turbinate hypertrophy. Coblation is a relatively new technology that uses radiofrequency energy to ablate hypertrophied tissues. The standard method of using this technology has been shown to be effective; however, it only partially relieves symptoms of obstruction. The authors present a modified hybrid technique for the surgical reduction of inferior turbinate hypertrophy using a combination of coblation and turbinate outfracture to maximize the nasal airway patency. METHODS: A review was performed of operating room video files to evaluate the senior author's (J.L.E.) technique for performing inferior turbinate reduction using the modified coblation and outfracture technique. The videos were edited to present the technique. RESULTS: The senior author has found this modified hybrid technique to be both efficacious and safe. This Video Plus article presents both the operative technique and postoperative management for cases of inferior turbinate hypertrophy that fail medical management. CONCLUSION: This modified hybrid technique is the mainstay of the senior author's treatment of inferior turbinate hypertrophy reduction and can be a useful surgical tool to achieve adequate outcomes when dealing with patients who have hypertrophied inferior turbinates that fail medical management.

Facial trauma: general principles of management.

Facial fractures are common problems encountered by the plastic surgeon. Although ubiquitous in nature, their optimal treatment requires precise knowledge of the most recent evidence-based and technologically advanced recommendations. This article discusses a variety of contemporary issues regarding facial fractures, including physical and radiologic diagnosis, treatment pearls and caveats, and the role of various synthetic materials and plating technologies for optimal facial fracture fixation.

Bilateral cleft lip revisions: the Abbe flap.

BACKGROUND: Secondary deformities of the bilateral cleft lip are unfortunately very common, and severe cases can involve scar contracture, vermilion deficiency, and a tight upper lip. In these cases, reconstruction often requires replacement of the central philtral unit with full-thickness tissue, including vermilion, orbicularis oris, and skin. The Abbe flap offers full-thickness reconstruction of the central aesthetic unit of the upper lip by replacing the deficient and scarred tissue and restoring functional competence to the oral sphincter. METHODS: A review was performed of the authors' operating room video files to evaluate their technique for performing secondary bilateral cleft lip revision using the Abbe flap. RESULTS: The Abbe flap has been used successfully for secondary revisions of the bilateral cleft lip at the Texas Children's Hospital. A technique video was made using video clips from two secondary bilateral cleft lip revisions. CONCLUSIONS: Results of bilateral cleft lip repair are often poor because of inappropriate use of the hypoplastic prolabial tissue, failure to anatomically reunite the orbicularis muscle, and scarring. The Abbe flap is an effective tool for reconstruction of the philtral landmarks, reconstitution of oral competence of the orbicularis, and recreation of Cupid's bow and the central pout. Although this procedure is relatively straightforward, special attention to designing the new philtrum, marking intact landmarks, and careful dissection of the labial artery are required for successful reconstruction.

Mechanotransduction: the missing link in the facial aging puzzle?

BACKGROUND: Craniofacial bony remodeling has been recognized as an important contributor to the facial aging process. Multiple studies have demonstrated significant craniofacial skeletal changes with age. However, no review has assembled this information in a concise, cogent fashion. Furthermore, the etiology of these skeletal changes has not been elucidated. This information is important for understanding the mechanisms of facial aging and for further development of facial rejuvenation. METHODS: A literature review of all articles discussing remodeling of the craniofacial skeleton with age was performed. Studies that used objective measurements of craniofacial skeletal parameters for different age groups were collected and analyzed. RESULTS: The studies demonstrated consistent morphologic changes in the craniofacial skeleton with age. These changes included trends toward increased facial bony width in women; contour changes of the orbit, anterior maxilla, and mandibular body; and decreased dimensions of the glabellar, pyriform, and maxillary angles. CONCLUSIONS: The craniofacial skeleton remodels with aging. Many of the observed changes in soft tissue contour and position reflect these skeletal changes. Changes in facial muscle function through the process of mechanotransduction may be responsible for these skeletal changes.