Prepectoral Two Stage Implant-Based Breast Reconstruction with Poly-4-Hydroxybutyrate (P4HB) for Pocket Control without the use of Acellular Dermal Matrix (ADM): A 4-Year Review.

BACKGROUND: As an alternative to biologic materials, absorbable meshes have been utilized to mitigate the potential drawbacks of ADM based breast reconstruction. Poly-4-hydroxybutyrate has been demonstrated to be a lower cost, safe, and effective alternative to ADM in subpectoral breast reconstruction. The aim of this study is to present the largest long-term observational study to date using P4HB for pocket control and implant support in immediate two stage pre-pectoral breast reconstruction looking at non-integration, capsular contracture, and implant malposition, along with patient comorbidities and risk factors. METHODS: A retrospective review of a single surgeon's (KM) experience was performed over a 4year span for patients who had undergone immediate two-stage prepectoral implant-based breast reconstruction with P4HB mesh. The review examined complications including implant loss, rippling, capsular contracture, malposition, and patient satisfaction throughout follow up. RESULTS: From 2018 to 2022, 105 patients underwent breast reconstruction using P4HBmesh for a total of 194 breasts. P4HBmesh integration was 97%. Overall, 16 breasts (8.2%) experienced minor complications while 10.3% of devices required explantation which was significantly higher in the radiated group at 28.6% (P<0.01). Older patients, higher BMI, active smokers, or increased mastectomy specimen size were more likely to undergo explantation. The rate of capsular contracture was 1.0 %. The overall rate of lateral malposition was also 1.0%. Visible rippling was present in 15.6% of breasts. There was no significant difference between smile mastopexy and inferolateral incision with regards to capsular contracture, lateral malposition, or rippling. Overall, patients demonstrated a high level of satisfaction and there were no significant predictors of capsular contracture, lateral malposition, or visible rippling. CONCLUSIONS: We have shown the safety and efficacy of P4HB in 2-stage pre-pectoral breast reconstruction. There appears to be equal, if not reduced, capsular contracture rates when compared to the published data on the use of ADM. Lastly, this represents a large cost reduction to both the patient and health care system.

The "Smile Mastopexy": A Novel Technique to Aesthetically Address the Excess Skin Envelope in Large, Ptotic Breasts While Preserving Nipple Areolar Complex During Prosthetic Breast Reconstruction.

BACKGROUND: Classically large, ptotic breasts have been a contraindication for nipple preservation during breast reconstruction. We present a technique of "smile mastopexy" (SM) to reduce the excess skin in both vertical and transverse directions, avoid a T-junction, preserve the nipple areolar complex, and add thickness to the upper pole of the breast at the time of mastectomy. OBJECTIVES: The authors sought to demonstrate the safety and reliability of a novel technique that addresses the excess skin envelope during breast reconstruction while preserving the nipple-areola complex in large, ptotic breasts. METHODS: This is a retrospective review of a single surgeon performing the SM for immediate 2-stage prosthetic breast reconstruction. All were performed in the prepectoral pocket without utilization of acellular dermal matrices. RESULTS: Thirty patients (total 54 breasts) aged a mean 50 years with BMI of 30 kg/m2 and mastectomy specimen weight of 683 g were included. All had class 2 or 3 ptosis. There were no cases of complete nipple loss. The overall complication rate was 14.8%. There were 3 explantations: 1 (1.8%) due to infection and 2 (3.7%) due to implant exposure. Radiation was associated with a higher complication rate. CONCLUSIONS: The SM is a safe and reliable technique in large, ptotic breasts during prosthetic breast reconstruction. It preserves the nipple-areola complex, reduces the excess skin envelope, adds thickness to the upper pole, and allows for future skin revisions with the same scar if necessary.Level of Evidence: 4.

Infectious Flexor Tenosynovitis Following Trigger Finger Release: Incidence and Risk Factors.

Background: Trigger finger release (TFR) is one of the most commonly performed hand procedures and typically results in restoration of normal finger function. However, uncommon postoperative complications such as deep infection can have devastating consequences. The goal of this study was to evaluate the incidence, risk factors, and characteristics of infectious flexor tenosynovitis occurring after TFR. Methods: We searched billing records for the Current Procedural Terminology code for TFR to identify all adult patients who underwent TFR at our institution over a 10-year period. We defined infectious tenosynovitis as any case where the patient underwent tendon sheath drainage or postoperative wound debridement within 6 months of the index TFR procedure. Medical records were reviewed to obtain patient demographic information, body mass index (BMI), tobacco use, history of diabetes mellitus, surgical setting (clinic vs outpatient surgery center), and surgical digit for all patients. In those patients treated for infection, we recorded hospital length of stay, number of operative procedures, and any culture results. Results: We identified a total of 18 infections out of 2307 procedures (1827 patients), for an incidence of 0.99%. Current smokers had a significantly higher incidence of infection than nonsmokers (1.77% vs 0.29%). On univariate analysis, smoking was closely associated with infection (P ≤ .05). All infections occurred in overweight or obese patients by BMI criteria, but there was no difference in average BMI between patients with and without infection. History of diabetes, in-office surgery, patient age, and patient sex were not associated with a higher incidence of infection. Patients with infections spent an average of 4.1 days in the hospital, and 40% required multiple surgical procedures. The most common infectious organism cultured was Staphylococcus aureus, which was present in 67% of infections. Patients with isolated methicillin-sensitive S aureus on culture showed signs of infection within 3 weeks of the index procedure, whereas polymicrobial, coagulase-negative staphylococci or beta hemolytic streptococci were identified in patients presenting with infectious symptoms later. Conclusion: Infections after TFR are uncommon but are more likely to occur in patients who are current smokers and overweight or obese by BMI criteria. Methicillin-sensitive S aureus is the most likely causative organism, especially in patients presenting during the early postoperative course.

Inadvertent Rupture of a Silicone Breast Implant during Fat Grafting: Surgical and Radiological Findings.

Autologous fat grafting is a common, relatively safe procedure for breast augmentation and reconstruction. The most commonly reported complications tend to be fat necrosis and oil cysts. The incidence of rare events, such as breast implant rupture, is likely underreported. Here we present the case of a patient who underwent fat grafting and sustained implant rupture with injection of fat within the silicone implant. She complained of her implant changing shape and magnetic resonance imaging (MRI) showed classic signs of implant rupture (linguini sign). At the time of surgery however, fat was surprisingly found to be within the implant itself. To our knowledge this finding has yet to be reported. Here we review the radiologic and surgical findings of implant rupture following fat grafting and present some suggestions to prevent this occurrence and ensure safe, aesthetically pleasing outcomes.

Validation of the "Wisconsin Criteria" for Obtaining Dedicated Facial Imaging and Its Financial Impact at a Level 1 Trauma Center.

INTRODUCTION: According to national trauma databases, 25% of all people injured have some type of facial injury. The gold standard for diagnosing bony trauma of the facial skeleton has been computed tomography (CT) scan. In 2011, the "Wisconsin criteria" were established and subsequently validated as a method to predict which patients truly have a facial fracture and warrant further imaging. The purpose of this study is to externally validate these criteria and determine the economic impact they might have on avoiding unnecessary CT scans. METHODS: This was a retrospective chart review. We collected 1000 patients who had undergone facial CT related to trauma and retrospectively applied the "Wisconsin criteria" based on physical exam documentation. RESULTS: Of the 1000 facial CT scans obtained, we identified 408 fractures, 12% of which required operative intervention. The "Wisconsin criteria" applied to our patient population had a sensitivity of 90% and a negative predictive value of 93%. Using these criteria resulted in a missed fracture rate of 2.8%. Finally, had these criteria been used to determine when a facial CT scan was indicated, our institution could be saving over US$300 000 annually. CONCLUSION: The "Wisconsin criteria" are a reliable method to screen for facial fracture in trauma patients. Using a validated instrument tool to guide decision-making, we can avoid obtaining low-value imaging studies. This can have a large economic impact while maintaining safety and reliability in accurate diagnosis.

Periprosthetic Fluid Analysis in the Diagnosis of Breast Implant Infections Using Cell Count and Differential.

BACKGROUND: One of the most devastating complications following implant-based breast reconstruction is periprosthetic infection. Making a prompt and accurate diagnosis has been a challenge as plastic surgeons are limited by nonspecific systemic markers of infection, clinical examination findings, or imaging modalities. OBJECTIVES: The aim of this study is to evaluate the use of periprosthetic fluid using cell count and differential as an aid in the diagnosis of infection. METHODS: This is a retrospective chart review. The authors selected patients who underwent breast reconstruction and had periprosthetic fluid analysis during the previous 10 years based on CPT 89051 (cell count and differential, body fluid). Only patients with clinical concerns for infection were included (cellulitis, fever, etc.); all others were excluded. RESULTS: A total of 54 samples were included in the study. Twenty-seven samples were associated with periprosthetic breast infections based on positive cultures or intraoperative findings consistent with infection. On fluid analysis, those with infection had a significantly higher neutrophil percentage (84.2% vs 19.3%, P < 0.0001). A cutoff value of 77% neutrophils had a sensitivity of 89% and a specificity of 93% in diagnosing infection. Delayed treatment in patients with high neutrophil percentage was associated with poorer outcomes. Lastly, there was a strong correlation between higher neutrophil percentage and increased rate of capsular contracture. CONCLUSIONS: Early and accurate diagnosis of periprosthetic breast infections can lead to earlier treatment and potentially improved the outcomes. Aspiration and analysis of periprosthetic fluid for neutrophil percentage can be a reliable method to guide clinical decision making.

Transfusion-Free Cranial Vault Remodeling: A Novel, Multifaceted Approach.

BACKGROUND: Approximately one in 2000 babies are born with craniosynostosis, and primary open repair is typically performed before 1 year of age. Historically, the procedure has been associated with nearly 100 percent transfusion rates. To decrease the rates of transfusion, the authors' center has developed a novel multimodal blood conservation protocol. METHODS: The authors administered their standard of care to children aged 1 year or younger undergoing primary repair of craniosynostosis between 2008 and 2014. In 2014, the authors implemented the following protocol: (1) preoperative erythropoietin and ferrous sulfate, (2) local anesthetic with epinephrine infiltration of the incision, (3) PlasmaBlade incision and subgaleal dissection, (4) hypervolemic hemodilution, and (5) intravenous tranexamic acid. Procedures performed before the protocol implementation served as controls. The authors performed classic fronto-orbital advancement with anterior cranial vault remodeling for coronal and metopic craniosynostosis. For lambdoid and sagittal craniosynostosis, barrel stave osteotomies, cranial base outfracture, and interposition bone grafting were performed. RESULTS: A total of 279 children with a mean age of 6 months who had craniosynostosis repairs were included. One hundred forty-five underwent repair before the authors' protocol, and 134 had repairs during the authors' blood conservation protocol. Both groups were similar in demographics. Overall blood loss and operative times were significantly reduced by 73 percent and 11 percent, respectively. Blood transfusion rate decreased 92 percent (p < 0.001). CONCLUSIONS: These results show a strong association between the authors' blood conservation protocol and significantly reduced transfusion rates. The authors believe this is a significant step forward and can be safely applied in the great majority of children undergoing craniosynostosis repairs. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.