Successful Immediate Staged Breast Reconstruction with Intermediary Autologous Lipotransfer in Irradiated Patients.

As indications for radiotherapy in mastectomized patients grow, the need for greater reconstructive options is critical. Preliminary research suggests an ameliorating impact of lipotransfer on irradiated patients with expander-to-implant reconstruction. Herein, we present our technique using lipotransfer during the expansion stage to facilitate implant placement. METHODS: A retrospective review of postmastectomy patients with expander-to-implant reconstruction by one reconstructive surgeon was performed. All patients were treated with immediate expander and ADM placement at the time of mastectomy. Irradiated patients underwent a separate lipotransfer procedure after completion of radiotherapy but prior to prosthesis exchange. Our study compared postoperative outcomes between non-radiated patients and irradiated patients who underwent this intermediary lipotransfer. Clinical endpoints of interest included: overall complications, infection, delayed wound healing, dehiscence, capsular contracture, implant failure, and reoperation. RESULTS: One hundred and thirty-one breast reconstructions were performed; 18 (13.74%) were irradiated and 113 (86.26%) were not. Overall complication risk (infection, implant failure, or reoperation) was no higher in irradiated breasts treated with lipotransfer than non-irradiated breasts (p=0.387). Fifteen patients who had one radiated and one non-radiated breast were separately analyzed; no difference in complication by radiotherapy exposure (p=1) was found. Age, BMI, smoking status, and nipple-sparing versus skin-sparing mastectomy did not vary significantly between study groups (p=0.182, p=0.696, p=0.489, p=1 respectively). CONCLUSIONS: Comparable postoperative outcomes were found between non-radiated breasts and radiated breasts treated with intermediary lipotransfer. The ameliorating effects of autologous lipotransfer on radiotoxicity may therefore offer irradiated patients the option of expander-to-implant reconstruction with acceptable risk and cosmesis.

Torsional stability of the femur after harvest of the medial femoral condyle corticocancellous flap.

BACKGROUND: Increasingly large segments of medial femoral condyle (MFC) corticocancellous flaps have been harvested for transfer. Biomechanical evaluations demonstrated no osseous stability impairment under axial loading regardless of flap size harvested. The purpose of this study was to determine the donor site's response to torsional forces. METHODS: Dual-energy X-ray absorptiometry (DEXA) scanning was performed on 16 pairs of cadaver legs followed by removal of all soft tissues, except knee capsule and ligaments. Specimens were randomly assigned to three groups with bone harvest defects measuring 3, 5, or 7 cm in length and a control group with no osseous resection. Torsional load was applied until fracture or ligamentous failure. RESULTS: Bone failure rates were 12.5, 12.5, 28.6, and 55.6% for control, 3, 5, and 7 cm groups, respectively. Bone failure rate increased with increasing harvest size; the 7 cm group demonstrated a significantly higher rate compared with the other groups combined (55.6 vs. 17.4%; p = 0.03). Failure torque was 45.5, 29.35, 27.4, and 30.83 Nm for the control, 3, 5, and 7 cm groups, respectively (p = 0.11). Harvest of any size segment resulted in a significant decrease in failure torque (p = 0.01). Bone mineral density (BMD) and Z-scores were no different among groups (p = 0.79 and 0.59, respectively). A direct relationship was identified between force required for failure and BMD (p = 0.02) and Z-scores (p = 0.05) but not for failure location and BMD (p = 0.09) or Z-scores (p = 0.94). CONCLUSION: MFC corticocancellous flap harvest of any size decreases donor site failure torque. Flap harvests > 7 cm demonstrate a higher frequency of iatrogenic fracture and therefore warrant caution with torsional loading of the knee postoperatively. Routine preoperative DEXA scans may not be warranted.

Applications of fat grafting in facial aesthetic skeletal surgery.

BACKGROUND: Aesthetic skeletal surgery of the face is a powerful tool to alter the facial skeleton; the facial form is enhanced through the use of alloplastic implants and osteotomies of the facial bones. However, the ultimate aesthetic appearance is dictated by how the soft tissue envelope drapes over the altered skeletal foundation. Intraoperative and postoperative fat grafting enhances the final aesthetic result in patients who undergo skeletal aesthetic procedures. OBJECTIVES: The authors describe cases in which selective fat grafting has been successful in optimizing facial soft tissue symmetry in patients undergoing skeletal aesthetic surgery of the face. METHODS: A retrospective chart review of all patients who underwent aesthetic skeletal surgery of the face between November 1, 2003, and October 31, 2011, in the Department of Surgery at Georgetown University Hospital was performed, and any patient who required fat grafting either at the time of aesthetic facial skeletal surgery or in the postoperative period was identified (n = 21). Common indications for fat grafting and the surgical plans are reviewed and presented in this article. RESULTS: Twenty-one patients were identified who required 37 fat grafting procedures either at the time of aesthetic skeletal surgery of the face or in the postoperative period. The procedures most frequently requiring fat grafting were genioplasty, facial shape modifications, and facial symmetry improvement. Fat grafting most commonly corrected irregularities or asymmetries and improved the soft tissue contour overlying repositioned bone or alloplastic implants. Most patients were female (72%) with a mean age of 42 years (range, 4-58 years). There were 4 complications in total: 3 surgical site infections (managed conservatively in 1 patient and with incision and drainage in the remaining 2) and 1 hematoma requiring drainage and closure on the day of surgery. CONCLUSIONS: Knowledge of which procedures are likely to require fat grafting and the techniques for doing so can improve the plastic surgeon's ability to provide optimal aesthetic results following facial skeletal alterations.