One Size Does Not Fit All; Patient Preference for Breast Reconstruction.

Background: A myriad of patient education modalities for breast reconstruction exist, although the optimal tools for patient education remain undetermined. The aim of this study is to determine patient preferences for breast reconstruction education modalities based on demographic variables. Methods: A prospective observational study at a tertiary care university health system was conducted between November 2020 and May 2021. A questionnaire was administered to breast reconstruction patients to collect information on demographics, research sources used before the initial appointment, and preferred education modalities. Differences based on age were analyzed using an independent samples t test, whereas a Fisher exact test was used to analyze differences based on ethnicity and education level. Statistical significance was defined as P < .05. Results: The most preferred patient education tools overall were books/written materials and videos. Younger patients were significantly more likely than older patients to have referenced additional physician sources (P = .0174) and to seek out information on the institution's website (P = .0465). Those with a college degree were significantly more likely to have performed research prior to the initial appointment (P = .0206). White patients were significantly more likely than nonwhite patients to talk to friends/family as a research source (P = .0150). Conclusions: Regardless of age, education, or ethnicity, most patients prefer books/written materials and video presentations for education on breast reconstruction. Providers should strive to include written and video options to meet the needs of this diverse patient population.

The Superficial Vein-Only DIEP Flap.

BACKGROUND: The deep inferior epigastric artery perforator (DIEP) flap, often considered the standard in autologous breast reconstruction, is reliant on robust arterial inflow and venous outflow. Venous outflow issues remain a critical part in determining the success of the DIEP flap. Previously, the superficial inferior epigastric vein (SIEV) has been used to augment venous outflow, or as a salvage option when flow through the deep inferior epigastric vein is compromised or insufficient. The authors describe a variant of the DIEP flap, the superficial vein-only DIEP flap, using the deep inferior epigastric artery and the SIEV as a viable alternative when indicated. METHODS: The authors conducted a retrospective review of all patients undergoing autologous breast reconstruction performed by the senior author (B.C.) from July of 2015 to March of 2020 to identify DIEP flaps whose only source of venous outflow was the SIEV, excluding those performed as salvage maneuvers. RESULTS: The authors identified 30 patients (35 flaps) and describe their characteristics, flap characteristics, complications, and details of the flap harvest. Notably, the authors experienced complications in 26.7 percent of flaps, of which 62.5 percent were minor, with no flap loss. This was comparable to the complication rate observed in the standard DIEP flap population. CONCLUSIONS: The authors believe the superficial vein-only DIEP flap is an excellent option for the appropriate patient. It is an added tool to make abdominally based breast reconstruction more reliable and successful. The use of the SIEV in a superficial vein-only flap should be considered as part of any routine DIEP flap reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Revising Prepectoral Breast Reconstruction.

SUMMARY: Prepectoral prosthetic breast reconstruction continues to gain popularity, largely due to its decreased postoperative pain, animation deformity, and operative time as compared to subpectoral reconstruction. Widespread use has led to opportunities for surgical revisions. While some techniques for submuscular reconstruction revisions, such as implant exchange and fat grafting, also apply to prepectoral revisions, others require modification for the prepectoral space. The prosthesis' unique reliance on the mastectomy flaps and acellular dermal matrix for support leads to a progressive alteration of the breast footprint, conus, envelope, and nipple-areola complex position. To date, revisions of prepectoral reconstructions have not been addressed in the literature. This article presents the senior author's (N.P.B.) techniques for (1) revising prepectoral breast reconstructions, including staged and direct-to-implant reconstructions, with a special focus on nipple-sparing reconstruction, and (2) minimizing undesirable outcomes of prepectoral reconstruction.

From Salvage to Prevention: A Single-Surgeon Experience with Acellular Dermal Matrix and Infection in Prepectoral Breast Reconstruction.

BACKGROUND: Increasing amounts of acellular dermal matrix are being used with the adoption of prepectoral breast reconstruction. Postoperative infection remains a challenge in breast reconstruction, and the contribution of acellular dermal matrix type, processing, and sterility assurance level to risk of complications in prepectoral reconstruction is not well studied. METHODS: The authors performed a retrospective review of patients who underwent immediate prepectoral breast reconstruction from February of 2017 to July of 2020. Because of an increase in the rate of infection, the drain protocol was changed and acellular dermal matrix type was switched from AlloDerm (sterility assurance level, 10-3) to DermACELL (sterility assurance level, 10-6) in January of 2019. Demographic and surgical variables were collected, in addition to details regarding development and management of infection. RESULTS: Despite higher rates of direct-to-implant reconstruction and bilateral procedures and increased implant volumes, the rate of infection was significantly lower in patients who received DermACELL instead of AlloDerm [two of 38 (5.3 percent) versus 11 of 41 (26.8 percent); p = 0.014]. Drain duration was slightly longer in the DermACELL group, consistent with the change in drain protocol. Baseline demographic and clinical characteristics remained similar between the two groups. CONCLUSIONS: With increased reliance on large amounts of acellular dermal matrix for prepectoral breast reconstruction, it directly follows that the properties of acellular dermal matrix with respect to incorporation, sterility, and implant support are that much more important to consider. There have been few studies comparing different types of acellular dermal matrix in prepectoral breast reconstruction, and further research is required to determine the contribution of acellular dermal matrix type and processing techniques to development of postoperative infection. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Breast Implants: A Historical Review With Implications for Diagnosis and Modern Surgical Planning.

ABSTRACT: Modern breast surgery was first introduced in the United States in 1962 with the use of silicone gel-filled breast implants. Over the past 6 decades, development of breast implants has been challenged by a variety of influencers including aesthetic appeal in shape, texture, and material; challenges in managing outcomes such as contracture, disease, and rupture; and public perception of risks associated with implants. In 1992, silicone breast prostheses were banned by the US Food and Drug Administration with exception for use in breast reconstruction, congenital deformities, or to replace existing implants.The ban led to heightened concerns about implants and possible disease manifestations. Knowledge of the historical evolution of breast prostheses is useful for understanding the associated risks and outcomes unique to each breast implant era. This article aimed to explore characteristics of breast implants by generation, with implications for diagnosis and assistance to modern surgical planning for novice plastic surgeons.

Should We Stick with Surgical Glues? The Incidence of Dermatitis after 2-Octyl Cyanoacrylate Exposure in 102 Consecutive Breast Cases.

Skin adhesives have become standard in wound closure as alternatives to traditional sutures or as sterile occlusive dressings after surgery of all types. The literature is replete with case reports of contact dermatitis following exposure to cyanoacrylate-based adhesives, such as 2-octyl cyanoacrylate. Nonetheless, it has been the impression of the senior author and others that the incidence of allergic and/or contact dermatitis is much higher than commonly considered. The authors prospectively studied 102 consecutive patients who underwent breast surgery performed by the senior author with 2-octyl cyanoacrylate placed over incisions as an occlusive dressing. Two patients with a known glue allergy did not receive cyanoacrylate at surgery but were scratch tested to confirm the diagnosis. All patients were followed postoperatively. Twelve patients went on to develop significant dermatitis postoperatively after glue placement. Cyanoacrylate was confirmed as the cause of all rashes by allergy scratch testing for a total incidence of 14 percent (14 patients). Given the popularity of cyanoacrylate products across emergency rooms, clinics, and operating rooms, awareness of the true incidence of these reactions may caution against their use in the future. CLINICAL QUESTION/LEVEL OF EVIDENCE:: Therapeutic, IV.

The Use of a Lumbrical Muscle Flap for Treatment of Chronic Tenocutaneous Fistula.

Tenocutaneous fistulas after trauma or open release of the A1 pulley provide a unique reconstructive challenge. We describe the use of a lumbrical muscle turnover flap as a novel technique for managing these wounds and present its successful use in a patient with a tenocutaneous fistula after A1 pulley release of the middle finger. This flap provides a simple, local reconstructive option in patients with an array of palmar wounds that have failed conservative management.

Burn in an Irradiated Prepectoral Breast Reconstruction: A Cautionary Tale.

Burns to breast reconstructions, both autologous and implant-based, are well described in the plastic surgery literature. The mechanism has often been contact; however, burns secondary to sun exposure have also been reported. With the increasing number of prepectoral breast reconstructions, including irradiated prepectoral reconstructions, we would like to highlight the increased susceptibility of these reconstructions to thermal and ultraviolet injury. We present the case of a patient who underwent prepectoral implant-based breast reconstruction years after irradiation, who subsequently developed full-thickness injury to her mastectomy flap after minor sun exposure. After weeks of daily wound care and hyperbaric oxygen treatments, the patient eventually reepithelialized over her exposed acellular dermal matrix tissue layer, allowing for implant salvage. Postmastectomy flaps overlying implants in the prepectoral plane are delicate; major burns can develop from minor thermal injury, even months after surgery. Irradiated prepectoral reconstruction patients should be educated about the susceptibility of their breast flaps to even minor burn injury and should maintain vigilance beyond the immediate postoperative period. It remains to be seen whether prepectoral reconstruction in an irradiated breast can be a viable, long-term option.

A Model to Improve Detection of Nonaccidental Pediatric Burns.

CONTEXT: Pediatric burn patients warrant thorough evaluation because a sizeable proportion of pediatric burns are nonaccidental. DESIGN: A multidisciplinary method involving an internal child protection team (CPT) was developed and used to identify suspected nonaccidental pediatric burns in all pediatric burn patients 5 years of age or younger who were evaluated by the CPT and social workers at our institution over a 55-month period. RESULTS: We identified 343 cases for review that fit our age criteria, 6 of which we identified as cases of suspected abuse or neglect. On average, these patients were younger, suffered greater total body surface area burns (TBSA), and required a longer length of stay in the hospital than the total population. We have not had readmissions for repeat nonaccidental pediatric burn injuries in this group of patients since this model was implemented. CONCLUSIONS: Our multidisciplinary method might provide a more consistent and reliable method for identifying cases of suspected abuse.

Animation Deformity in Postmastectomy Implant-Based Reconstruction.

Despite increasing interest in prepectoral implant-based reconstruction to avoid animation deformity (AD), the prevalence of this deformity and patient attitudes toward it have not been extensively studied. The purpose of this study was to report on AD in the breast reconstruction population and identify those at highest risk. METHODS: A retrospective chart review was completed for patients at least 6 months postoperative from subpectoral, implant-based breast reconstruction using acellular dermal matrix in the lower pole. Patient age, BMI, and implant size were collected. A questionnaire was distributed to the patients. Returned questionnaires were compiled and data were analyzed. RESULTS: Eighty-four of 108 patients (77.8%) returned the questionnaire with 62 (75.6%) reporting AD; 75.6% of patients were aware of AD, 14.6% considered it moderate, and 11% considered it severe. No statistically significant differences in age, body mass index, implant size, or athleticism were found between those who noted AD versus those who did not. Forty-one of 79 patients (51.9%) would have been interested in an initial surgical procedure without AD; interest dropped significantly if the alternative surgery involved increased risk, cost, or additional stages of reconstruction. CONCLUSION: The prevalence of AD in subpectoral implant-based breast reconstruction is significantly higher than in subpectoral augmentation. The majority of patients expressed interest in an alternative procedure to avoid AD unless it involved increased risk, cost, or additional surgeries. We found insignificant differences in age, athleticism, BMI, and implant size between patients who note AD and those who do not. Further study is necessary to better define patients at risk for AD to guide patient-centered breast reconstruction.

The Use of Vasopressors in Pedicled Flaps for Chest Wall Reconstruction.

INTRODUCTION: The effect of vasopressors on flaps remains controversial in the literature. Often, surgeons avoid vasopressors with the thought that vasoconstriction reduces flap perfusion resulting in flap loss. METHODS: A retrospective review was performed on patients who required chest wall reconstruction from 1998 to 2013. Patients were identified through the use of Current Procedural Terminology codes. The data collected included demographics, indications for surgery, prior debridement, preoperative albumin levels, and perioperative vasopressor use. Outcomes measures included flap survival, flap complications, reoperation rates, intensive care unit length of stay, and mortality. RESULTS: Of the 1220 patient records reviewed, 88 had chest reconstruction by a plastic surgeon. Twenty-one patient records were excluded due to incomplete data. One patient experienced complete flap loss; these data were excluded from statistical analysis. Fifty patients received perioperative vasopressors whereas 15 did not. There was no significant difference in flap survival or loss between groups who received perioperative vasopressors and those who did not receive vasopressors. Age, intensive care unit length of stay, flap complications, and reoperation rates were significantly higher in those with partial flap survival. CONCLUSIONS: Perioperative vasopressor use does not adversely affect the outcome of pedicled flaps for chest wall reconstruction. Further research is warranted to review the effects of vasopressor dose and type on pedicled flaps.

Pilomatrixoma Presenting as a Rapidly Expanding Mass of the Infant Nasion.

Objective: Pilomatrixomas are benign neoplasms originating from the cells of hair follicles. They typically present as a slowly enlarging, solitary mass on hair-bearing areas of the head and neck. While a common childhood lesion, pilomatrixomas are unusual in infancy. Our objective is to present an atypical pilomatrixoma located on the midline nasion of an 11-month-old as such a lesion and its management has not been previously described. Methods: Despite preoperative diagnostic imaging, including computed tomography and magnetic resonance imaging, the diagnosis was not made until examination by pathology after complete surgical excision. We also completed a thorough review of the literature pertaining to pilomatrixomas, which is presented in a concise fashion. Results: Our patient's clinical presentation did not correlate with traditional descriptions in the literature, skewing preoperative diagnosis. However, surgical management was ultimately appropriate and effective. To date, the patient has not demonstrated evidence of recurrence. Conclusion: We believe that this is the first such reported presentation of a pilomatrixoma. Given its incidence, we encourage readers to consider this diagnosis when evaluating similar pediatric skin lesions of the head and neck. Complete surgical excision is the definitive treatment.

Koenen tumors in tuberous sclerosis: a review and clinical considerations for treatment.

Koenen tumors, or periungual and subungual fibromas, are a benign, cutaneous manifestation of tuberous sclerosis. They are disfiguring, painful, and challenging to treat as they frequently recur. Various laser and chemical ablation techniques have been described with variable long-term results and there is limited published literature to suggest a standard treatment. Through a review of the available literature and a successful experience with a patient with lower extremity Koenen tumor, we present treatment considerations for managing these troublesome tumors.