Immediate permanent implant reconstruction following mastectomy with capsule preservation in patients with prior augmentation mammoplasty.

Prior breast augmentation in patients desiring post-mastectomy reconstruction provides a unique opportunity for capsular preservation and immediate, single-step implant reconstruction. We report a case series of a single-surgeon experience with immediate implant reconstruction after skin-sparing mastectomy in patients with prior subpectoral augmentation. Final implant volumes, complications, and outcomes were examined. Twenty patients (15 bilateral, total 35 breasts) were included. Eighteen (90%) patients were treated for cancer. Mean augmentation-to-reconstruction interval was 9 years (range, 3-19 years). Mean patient age was 45.1 years (range, 37-64 years). Eight patients (40%) received postoperative chemotherapy and two (10%) radiation. Mean mastectomy weight was 321 g. Mean weight of the implants removed was 346 g. Mean volume of new implants was 487 mL. All patients underwent capsulotomy (100% superior, 85% medial, 30% inferior, 5% lateral). Mean operative time was less than 1 hour for bilateral reconstruction. With average follow-up of 25.6 months, 2 patients were re-operated on for asymmetry (implant malposition, synmastia). Thirty-day complications included 1 implant loss due to infection, 1 drain placement with implant salvage, 1 hematoma requiring evacuation, and 1 cellulitis treated with antibiotics. There were no late complications and no capsular contractures. None have required further oncologic surgery. No cancer recurrences have been detected. In patients who desire prosthetic reconstruction similar to their original submuscular augmentation, capsule preservation and implant replacement with a larger prosthetic inserted within the old capsule is safe, fast, and aesthetically pleasing without compromising oncologic principles.

The use of autologous platelet-leukocyte-enriched plasma to minimize drain burden and prevent seroma formation in latissimus dorsi breast reconstruction.

INTRODUCTION: Seromas and drains are major sources of morbidity associated with latissimus dorsi breast reconstruction. Our goal was to look at an autologous platelet-leukocyte-enriched plasma spray and to assess its efficacy in reducing drain burden and seroma formation. METHODS: We performed a single surgeon, patient-controlled, blinded study on bilateral latissimus dorsi breast reconstruction patients in which we applied autologous platelet-leukocyte-enriched plasma to one side and measured drain amounts, time to drain removal, and seroma rate. RESULTS: Twelve patients were included in this study. The average age was 41.1 years, and the average body mass index was 21.6 kg/m. Average volume of drain output showed neither difference (789 mL spray side vs. 790 mL control side) nor average time to drain removal (11.83 days spray side vs. 11.5 days control side). There were 2 complications reported: 1 hematoma (8.33%) and 1 seroma (8.33%) that required aspiration in a postoperative visit. CONCLUSIONS: It appears after 12 patients that there is no demonstrable difference regarding drain output, time to drain removal, or seroma incidence between the study and the control group. We feel a larger study population would add power and confirm these findings.

The scarless latissimus dorsi flap for full muscle coverage in device-based immediate breast reconstruction: an autologous alternative to acellular dermal matrix.

BACKGROUND: Thin patients have fewer autologous options in postmastectomy reconstruction and are frequently limited to device-based techniques. The latissimus dorsi flap remains a viable option with which to provide autologous coverage, although for certain patients the donor scar can be a point of contention. The scarless latissimus dorsi flap is a way of mitigating these concerns. The authors present their 6-year single-surgeon experience with scarless latissimus dorsi flap reconstruction. METHODS: A retrospective review of scarless latissimus dorsi flap reconstruction was performed. Charts from 2003 to 2009 were queried for demographic characteristics, nonoperative therapies, and short- and long-term complications. Results were compared with historical data. RESULTS: Thirty-one patients with 52 flaps were identified. Fifty-one flaps were immediate reconstructions, with an average age of 47 years and body mass index of 22.8 kg/m. Thirteen patients were treated with chemotherapy and four were irradiated, two preoperatively. The single drain was removed on average at 21 days. Complications included three hematomas (5.8 percent), two capsular contractures (3.8 percent), and two infections (3.8 percent). Average time to secondary reconstruction was 143 days. There were five unplanned revisions (9.6 percent). There were no flap failures or tissue expander losses. CONCLUSIONS: The scarless latissimus dorsi flap is an effective method for providing durable homogenous device coverage in the thinner patient (body mass index <24). With the advent of acellular dermal matrices, device coverage has been made simpler, but this comes at a cost. Coverage is thin, the matrix is not initially vascularized, and products are expensive. For these reasons, use of the scarless latissimus dorsi flap is an excellent alternative, particularly in the patient with a low body mass index. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.(Figure is included in full-text article.).

The 3-hour muscle-sparing free TRAM flap: safe and effective treatment review of 111 consecutive free TRAM flaps in a private practice setting.

BACKGROUND: The muscle-sparing free transverse rectus abdominis muscle (TRAM) flap is a reliable technique that provides great versatility, with potentially decreased donor-site morbidity. However, because of the inherent nature of microvascular techniques, it is still regarded as a time-consuming and technically difficult procedure. The goal of this retrospective study was to document the validity of this technique in the private practice setting. METHODS: Data were reviewed retrospectively and included patient demographics, total operative time, choice of recipient vessels, outcome, and perioperative morbidities. RESULTS: One hundred one consecutive patients underwent 111 muscle-sparing free TRAM flap procedures for breast reconstruction (immediate, 89 patients; delayed, 12 patients). The internal mammary artery was used in 75 cases and the thoracodorsal artery was used in 36 cases. Average operative time was 185 minutes (3 hours 5 minutes). Average blood loss was 195 cc. There was no total flap loss. Revision of the microvascular anastomosis was performed in four patients, with flap salvage in all of them. Thirteen patients (13 percent) required primary mesh for abdominal wall closure. Fourteen (14 percent) had fat necrosis. Two patients had hematoma that required surgical evacuation. Abdominal wall weakness was detected in two patients (2 percent) and required mesh repair. CONCLUSIONS: The technical difficulties associated with the free TRAM flap have been ameliorated using a well-designed surgical plan and consistent technique performed by a team familiar with the procedure to achieve an acceptable average 3-hour operating time, with minimal complications. The authors advocate the muscle-sparing free TRAM flap as the operation of choice for unilateral breast reconstruction using autogenous tissue. The technique is expeditious and relatively safe.

Infonomics and breast reconstruction: are patients using the internet?

The World Wide Web provides access to an enormous amount of medical information. In particular, it enables the nonmedical community a chance to better understand breast reconstruction. The purpose of this survey is to determine patient access to the Internet for information related to their breast reconstruction and to evaluate the role of internet-based information in patient education. One hundred six consecutive breast reconstruction patients over a 7-month period were included in the study. All patients were given an anonymous survey querying patient demographics, education, type of reconstruction, internet usage, and how it affected their decision. Data were evaluated and comparisons were made. The average age was 50 years, with the majority of the reconstructions being pedicled TRAM flaps (50%). Ninety-two percent of the patients had internet access, most of them at home (71%). Sixty-eight percent of the patients reported having used the internet for information related to breast reconstruction. The categories searched were procedure (39%), risks/outcome (35%), surgeon (13%), pictures (11%), and hospital (4%). Seventy-two percent found it helpful, 69% easy to understand, and 63% trusted the information. The information they found influenced their decision regarding procedure (53% yes), surgeon (36% yes), and hospital (25% yes). Eighty-one percent felt that it would be useful to communicate with their surgeon via e-mail. Breast-reconstruction patients are using the internet as a research tool. They are influenced by this information on multiple levels. Infonomics is a growing field, and plastic surgeons must take an active role in guiding patients towards accurate online sources and becoming more accessible in the information superhighway.