A Meta-analysis of Outcomes Using Acellular Dermal Matrix in Breast and Abdominal Wall Reconstructions: Event Rates and Risk Factors Predictive of Complications.

BACKGROUND: The use of acellular dermal matrix (ADM) has gained acceptance in breast and abdominal wall reconstructions. Despite its extensive use, there is currently a wide variation of reported outcomes in the literature. This study definitively elucidates the outcome rates associated with ADM use in breast and abdominal wall surgeries and identifies risk factors predisposing to the development of complications. METHODS: A literature search was conducted using the Medline database (PubMed, US National Library of Medicine) and the Cochrane Library. A total of 464 articles were identified, of which 53 were eligible for meta-analysis. The endpoints of interest were the incidences of seroma, cellulitis, infection, wound dehiscence, implant failure, and hernia. The effects of various risk factors such as smoking, radiation, chemotherapy, and diabetes on the development of complications were also evaluated. RESULTS: A majority of the studies were retrospective (68.6%) with a mean follow-up of 16.8 months (SD ± 10.1 months) in the breast group and 14.2 months (SD ± 7.8 months) in the abdominal wall reconstructive group. The overall risks and complications were as follows: cellulitis, 5.1%; implant failure, 5.9%; seroma formation, 8%; wound dehiscence, 8.1%; wound infection, 16.1%; hernia, 27.6%; and abdominal bulging, 28.1%. Complication rates were further stratified separately for the breast and abdominal cohorts, and the data were reported. This provides additional information on the associated abdominal wall morbidity in patients undergoing autologous breast reconstruction in which mesh reinforcement was considered as closure of the abdominal wall donor site. Radiation resulted in a significant increase in the rates of cellulitis (P = 0.021), and chemotherapy was associated with a higher incidence of seroma (P = 0.014). CONCLUSION: This study evaluates the overall complication rates associated with ADM use by conducting a meta-analysis of published data. This will offer physicians a single comprehensive source of information during informed consent discussions as well as an awareness of the risk factors predictive of complications.

Fibrous dysplasia: an overview of disease process, indications for surgical management, and a case report.

INTRODUCTION: First described by Von Recklinghausen in 1891, fibrous dysplasia is a developmental defect of osseous tissue such that bone is produced with an abnormally thin cortex and marrow is replaced with fibrous tissue that demonstrates characteristic ground-glass appearance on x-ray examination. The underlying defect in fibrous dysplasia is a mutation of the GNAS1 gene, which leads to constitutive activation of gene products that preclude the maturation of osteoprogenitor cells and lead to development of abnormal bone matrix, trabeculae, and collagen, produced by undifferentiated mesenchymal cells. There exists a mainly self-limiting form of fibrous dysplasia classified as monostotic, which is characterized by dysplastic bone in a single location that remains relatively stable throughout life and a polyostotic form, which can exhibit aggressive growth placing adjacent structures at risk for compressive sequelae. METHODS: We present the surgical management of an unusual case of monostotic fibrous dysplasia, which exhibited aggressive growth with mass effect, and late presentation, both uncharacteristic features for the monostotic form. The authors also performed a comprehensive review of the literature and discuss the disease process, management options, and indications for surgical treatment. RESULTS: An overview of the disease process and management options is presented. The authors also present details of reconstruction in an unusual form of symptomatic monostotic fibrous dysplasia. CONCLUSION: Conservative management is usually the mainstay of therapy in asymptomatic cases of fibrous dysplasia. In patients fulfilling criteria for surgical management, craniofacial reconstruction offers a viable option in the surgeon's armamentarium, providing good functional and cosmetic outcomes.

The battle of words and the reality of never events in breast reconstruction: incidence, risk factors predictive of occurrence, and economic cost analysis.

BACKGROUND: The Centers for Medicare and Medicaid Services has a list of 10 hospital-acquired conditions for which hospitals and physicians will not be reimbursed because it deems such conditions are preventable and should be considered "never events." To evaluate the validity of this premise, the authors conducted a real-life analysis of the incidence and categories of never events occurring in a breast reconstruction cohort of a multisurgeon plastic surgery practice. Cost analysis of estimated revenue loss and risk factors associated with the development of never events are enumerated. METHODS: A retrospective chart review of postmastectomy patients undergoing breast reconstruction from 2008 to August of 2010 was conducted. A total of 297 patients were identified and International Classification of Diseases, Ninth Revision codes corresponding to the never events of interest were applied to the study population. RESULTS: Of the 297 patients, 24 (8.08 percent) developed never events in two categories: surgical-site infections (7.74 percent) and catheter-related urinary tract infections (0.34 percent). There were no complications in the remaining eight categories. Overweight body mass index and diabetes were strong independent risk factors for the development of never events (p < 0.0001). Cost estimates of associated revenue loss and economic analysis reveal substantial financial burdens to physicians and hospitals as a result of nonreimbursement. CONCLUSIONS: The "one-size-fits-all" approach of the Centers for Medicare and Medicaid Services may be misplaced and misleading. Certain risk factors are independent predictors of developing a never event, making it impossible to classify certain outcomes as "never" occurrences. The never events pendulum may have swung immensely to the left, and it is time to attain a much-needed equilibrium. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.