Evaluating Postoperative Narcotic Use in Prepectoral Versus Dual-plane Breast Reconstruction Following Mastectomy.

BACKGROUND: The majority of postmastectomy breast reconstruction performed in the United States is device-based. Typically, a tissue expander or implant is placed in the dual-plane (ie, subpectoral). Prepectoral breast reconstruction with acellular dermal matrices following mastectomy is a relatively new technique that has favorable outcomes with minimal complications and satisfactory aesthetic results. Few studies have compared opioid use between the 2 approaches. This study compares duration of postoperative opioid use among patients undergoing prepectoral device-based breast reconstruction with those in whom dual-plane devices were placed. METHODS: We reviewed the records of adult female patients aged 18 years or older who underwent prepectoral or dual-plane device-based breast reconstructions following mastectomy by one of the 2 plastic surgeons (A.M. or M.V.) from 2015 to 2017 at a large tertiary care hospital. Patients with a history of substance abuse, chronic pain, or who were already receiving opioid medication were excluded. Electronic medical records were reviewed and patient surveys were conducted during postoperative visits to determine postoperative opioid requirements. RESULTS: During the study period, 58 patients underwent dual-plane breast reconstruction and 94 underwent prepectoral reconstruction. Demographics and comorbidities of the groups were similar. By multivariate regression analysis, the prepectoral reconstruction group required 33% fewer days on opioid analgesic medication (P = 0.016) and were 66% less likely to require opioid prescription refills (P = 0.027). There were no statistically significant differences in other outcomes or complications. CONCLUSION: Patients undergoing prepectoral tissue expander or implant-based reconstruction required fewer days of opioid pain medication than those managed with the dual-plane technique.

SPY Elite's Ability to Predict Nipple Necrosis in Nipple-Sparing Mastectomy and Immediate Tissue Expander Reconstruction.

BACKGROUND: Nipple-sparing techniques have improved the aesthetics of reconstruction following mastectomy, but nipple necrosis complicates up to 37% of procedures, distressing patients, delaying adjuvant therapy, and compromising outcomes. No method reliably detects nipple necrosis better than clinical assessment of tissue perfusion. We prospectively assessed the accuracy of intraoperative indocyanine green laser angiography to predict nipple necrosis. METHODS: Twenty consecutive women undergoing immediate tissue expander breast reconstruction following 32 nipple-sparing mastectomies underwent indocyanine green fluorescence imaging to assess nipple perfusion immediately before and after intraoperative tissue expansion. Imaging findings were correlated with postoperative nipple viability. RESULTS: Among the 32 nipple-sparing mastectomies (8 unilateral, 12 bilateral) in 20 women (mean age, 48 years), partial or full-thickness necrotic changes developed in 3 breasts of 2 patients (10%). Imaging identified impaired perfusion and predicted necrosis in these cases. CONCLUSIONS: In this initial series, intraoperative indocyanine green laser angiography correctly identified patients who developed nipple necrosis during mastectomy and tissue expander breast reconstruction.

Hyperbaric Oxygen following Bilateral Skin-sparing Mastectomies: A Case Report.

We describe a case in which hyperbaric oxygen therapy was used to salvage ischemic skin flaps after nipple-sparing mastectomy.

Evaluating sterile human acellular dermal matrix in immediate expander-based breast reconstruction: a multicenter, prospective, cohort study.

BACKGROUND: Human acellular dermal matrices have gained increasing use in immediate expander-based breast reconstruction. However, some studies suggest that these grafts may be associated with a higher incidence of infection and seroma. To evaluate complication rates after matrix-based breast reconstruction, the authors conducted a prospective, multicenter, cohort study to evaluate a sterile human acellular dermal matrix in immediate expander-based breast reconstruction, specifically, to determine whether it offered a more favorable risk profile with respect to infection and seroma. A secondary purpose was to determine whether the sterilization process affects graft incorporation. METHODS: The authors performed 65 consecutive tissue expander-based breast reconstructions in a cohort of patients over a 1-year period using a single protocol. Sterile human matrix was used in all cases. The patients were evaluated for early complications (infection, seroma) and graft incorporation at the time of exchange or definitive reconstruction. Biopsies were performed in the first 20 reconstructions to provide histologic correlation of graft incorporation. RESULTS: Complications occurred in three breasts (4.6 percent), including one case of cellulitis (1.5 percent) and two cases of partial mastectomy flap necrosis (3.0 percent) that required débridement. There were no seromas or explantations. The grafts were incorporated in all cases and verified histologically in the first 20 biopsies. CONCLUSIONS: Sterile human acellular dermal matrix can offer reliable matrix incorporation and a low complication rate. Sterilization does not negatively impact incorporation of the graft. The infection and seroma rates in this prospective study compare favorably to those in previous studies with nonsterilized (aseptic) acellular dermal matrix.

Breast reconstruction with prosthetic implants.

For patients who undergo mastectomy for the treatment of breast cancer, the restoration of a normal breast form through breast reconstruction is important to body image and quality of life. Implant-based reconstruction has the capability of producing excellent results in the well selected patient. In addition, compared with autogenous tissue reconstruction, implant reconstruction offers a shorter operative procedure with a quicker convalescence and no donor site morbidity. Reconstruction options for implant-based reconstruction include: single-stage reconstruction with a standard or adjustable implant, tissue expansion followed by placement of a permanent implant, or combined autologous tissue/implant reconstruction. Procedure selection is based on a range of patient variables, including: location and type of breast cancer, availability of local, regional and distant donor tissue, size and shape of the desired breast(s), surgical risk, and most importantly, patient preference. Although satisfactory results can be obtained with single-stage reconstruction, in most of patients, a more reliable approach involves two-stage expander/implant reconstruction. Individualizing selection of a reconstructive technique for each patient will be the predominant factor in achieving a reconstructive success.

Nipple areola reconstruction.

Nipple areola reconstruction is often considered the "finishing touch" in the process of breast reconstruction after surgery for breast cancer. Attention to detail with respect to patient selection, timing of reconstruction and surgical technique must therefore be paid to avoid an unsatisfactory result that may taint an otherwise successful reconstructive sequence. There are many surgical techniques available to recreate the nipple areola complex, but each of the various techniques is designed to accomplish similar goals. In every case, regardless of the technique chosen, the surgeon seeks to reconstruct a nipple areola complex that is esthetically pleasing in its color, symmetry, position on the breast mound, and projection.

Vascularized calvarial bone flaps and midface reconstruction.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Identify the fascial layers of the temporalis region. 2. Understand the three-dimensional nature of the orbit and upper maxillectomy defects. 3. Understand the surgical harvest of temporalis flaps and temporoparietal flaps with vascularized bone. 4. Appreciate preoperative risk factors and postoperative complications. BACKGROUND: Although vascularized calvarial bone grafts were originally explored for use in reconstruction of midface hypoplasia defects, they offer significant value in application to oncologic reconstruction of the midface. METHODS: A review of eight cases of midface reconstruction using vascularized calvarial grafts was performed to illustrate the versatility and dependability of these flaps. RESULTS: Adequate bony and soft-tissue contours were achieved with no clinical evidence of bone graft resorption. No immediate postoperative complications including infection and hematoma or seroma formation were noted. One patient experienced a delayed sinusitis from a blocked duct. CONCLUSIONS: The use of vascularized calvarial grafts supported by temporoparietal fascia, combined deep temporal fascia, and temporalis muscle provides excellent soft-tissue coverage and adequate bone stock for reconstruction of complex defects. Maintaining vascularization of the bone graft not only resists infection but also opposes resorption associated with nonvascularized grafts, particularly those in compromised wounds.

The role of peripheral nerve surgery in the treatment of chronic pain associated with amputation stumps.

BACKGROUND: Debilitating pain following amputation surgery can seriously affect the long-term success of the operation and the patient's quality of life. Often, such patients are unable to ambulate because of pain when using a prosthesis; become grouped in the chronic pain category; and are treated with high-dose narcotics, antidepressants, or other methods to treat symptoms that may provide little or no relief. Little attention has been given to the role of peripheral nerve surgery as an early treatment option. METHODS: A retrospective review of 21 consecutive amputees with chronic stump pain was performed. The surgical technique included removal of the neuroma with implantation of the proximal nerve ending into adjacent muscle. In addition to the surgical outcome, other variables evaluated included resolution or optimal improvement in pain and spasms, change in quality of life, and ambulation status. RESULTS: The mean duration of stump pain before surgery was 7.28 months (range, 5 to 18 months). After surgery, there were statistically significant changes with pain and spasms, quality-of-life, and ambulation status. The mean follow-up was 22.8 months, and there was no recurrence of neuroma. CONCLUSIONS: Peripheral nerve surgery plays a significant role in the treatment of chronic pain associated with amputation stumps. After conservative treatment methods have been exhausted, a treatment algorithm for peripheral nerve surgery is successful in improving or resolving chronic pain and the quality-of-life issues associated with amputation patients.

The versatility of the superomedial pedicle with various skin reduction patterns.

BACKGROUND: The inferior pedicle technique remains one of the most commonly used techniques in breast reduction surgery, despite lengthy operating times, poor nipple sensation, and bottoming-out over time. The superomedial pedicle in reduction mammaplasty has previously been described using limited incision patterns. This study evaluated the safety and reliability of the superomedial pedicle with various skin reduction patterns and compared the surgical time with the inferior pedicle technique. METHODS: A total of 279 superomedial breast reductions were reviewed over a 6-year period, representing the transition period from inferior pedicle to superomedial pedicle techniques of three attending surgeons. Among these reductions, 215 had complete records and were included in the data analysis. The remaining 64 records were evaluated for viability of the nipple-areola complex. Assessments included skin pattern markings, average size of reduction, average body mass index, and complications. Risk factors and patient comorbidities were also recorded. RESULTS: There were no cases of nipple loss in the series. The overall complication rate was 18 percent; patients' average body mass index was 29. The revision rate for contour or scar improvement was 4 percent. A statistically significant reduction in operating time of 41 minutes (p = 0.0001) was seen in comparison with the inferior pedicle reduction. CONCLUSIONS: The superomedial dermoglandular pedicle is a safe and reliable technique for reduction mammaplasty. Its versatility allows for reproducible results in a broad range of patients with various skin excision patterns. Use of the superomedial pedicle provides consistent results with respect to breast contour, nipple viability, and lasting superomedial fullness, and saves operating time compared with the inferior pedicle technique.

Implant-based reconstruction.

Prosthetic reconstruction of the breast, either with standard or adjustable implants or as a staged procedure with tissue expanders followed by implants, has evolved into a reliable method for breast reconstruction. Advances in implant technology and biomaterials allow for low complication rates, good aesthetic outcomes, and consistent results. Potential advantages over other reconstructive techniques include the relative simplicity of the procedures, the use of adjacent tissue without significant donor site morbidity, reduced operative time, and quicker patient recovery. Although some may still consider autologous tissue reconstruction as the gold standard, today's prosthetic reconstructions play an equally important role in the reconstruction of the breast for many women.

Mechanisms and clinical applications of the vacuum-assisted closure (VAC) Device: a review.

The use of sub-atmospheric pressure dressings, available commercially as the vacuum-assisted closure (VAC) device, has been shown to be an effective way to accelerate healing of various wounds. The optimal sub-atmospheric pressure for wound healing appears to be approximately 125 mm Hg utilizing an alternating pressure cycle of 5 minutes of suction followed by 2 minutes off suction. Animal studies have demonstrated that this technique optimizes blood flow, decreases local tissue edema, and removes excessive fluid from the wound bed. These physiologic changes facilitate the removal of bacteria from the wound. Additionally, the cyclical application of sub-atmospheric pressure alters the cytoskeleton of the cells in the wound bed, triggering a cascade of intracellular signals that increases the rate of cell division and subsequent formation of granulation tissue. The combination of these mechanisms makes the VAC device an extremely versatile tool in the armamentarium of wound healing. This is evident in the VAC device's wide range of clinical applications, including treatment of infected surgical wounds, traumatic wounds, pressure ulcers, wounds with exposed bone and hardware, diabetic foot ulcers, and venous stasis ulcers. VAC has also proven useful in reconstruction of wounds by allowing elective planning of the definitive reconstructive surgery without jeopardizing the wound or outcome. Furthermore, VAC has significantly increased the skin graft success rate when used as a bolster over the freshly skin-grafted wound. VAC is generally well tolerated and, with few contraindications or complications, is fast becoming a mainstay of current wound care.