Simultaneous Mastopexy Explantation With a Vertical Bipedicle and Novel Open Pattern Marking Technique.

There are limited studies in the plastic surgery literature that detail technical considerations in simultaneous breast implant removal and mastopexy procedures. These procedures are difficult, with significant potential for complications and poor cosmesis. The current plastic surgery literature describes a limited number of techniques that address these concerns, virtually all of which are variants of superior or superior medial pedicle vertical pattern mastopexy. This paper details a safe technique for simultaneous explantation and mastopexy with a novel open marking pattern and vertical bipedicle, which can restore breast cosmesis following implant removal. The study will briefly retrospectively review the results of a consecutive series of 86 patients who underwent this procedure from November 2018 to November 2019, with no incidence of partial or total nipple-areola complex necrosis. Thus, the technique is safe and allows the flexibility for intraoperative adjustments that are necessary for these procedures. A future study will conduct a more in-depth analysis of the results.

Outcomes After Elevation of Serratus Anterior Fascia During Prosthetic Breast Reconstruction.

BACKGROUND: Achieving optimal inferolateral coverage is critical to successful prosthetic breast reconstruction. Serratus anterior fascia (SF) elevation, a promising alternative to muscle flaps and acellular dermis (ADM), has not been rigorously studied. This study evaluates complication rates after mastectomy and immediate tissue expander (TE) coverage using SF, relative to other existing methods of reconstruction. METHODS: Retrospective review of consecutive patients undergoing mastectomy with immediate TE reconstruction over 10 years at 1 institution was performed. Patients with serratus muscle (SM) or SF elevation were analyzed. ADM reconstructions were used for comparative analysis only. Relevant demographic and clinical data were recorded. Complications were categorized by type and end outcome, including nonoperative (no further surgery), operative (surgery except explantation), and explantation. RESULTS: The SM and SF elevation was performed in 375 (487 breasts) and 177 (255 breasts) patients, respectively. Mean follow-up was 43.8 months. The SM and SF patients were demographically similar, but SF had higher intraoperative fill volumes (P < 0.0001) and required fewer postoperative expansions (P < 0.0001). There were no differences in complications between SM and SF patients. Regression analysis, adjusted for several variables, revealed that SF was not an independent risk factor for complications. The ADM- and SF-assisted reconstruction also showed no differences in outcomes. CONCLUSIONS: Our review demonstrates that SF elevation is a safe, feasible alternative for achieving inferolateral coverage during prosthetic breast reconstruction. Furthermore, this technique allows for greater fill volumes and less expansions than SM. As a readily available alternative to muscle flaps and ADM, SF elevation should be considered integral to any prosthetic breast reconstruction algorithm.

Comparison of Delayed and Immediate Tissue Expander Breast Reconstruction in the Setting of Postmastectomy Radiation Therapy.

BACKGROUND: Despite the continued demand for immediate prosthetic breast reconstruction, some suggest that delayed reconstruction may reduce complications. However, with limited comparative data available, the extent of this benefit is unclear, particularly in the setting of postmastectomy radiation therapy (PMRT). This study evaluates outcomes after mastectomy and delayed tissue expander reconstruction (DTER) or immediate tissue expander reconstruction (ITER). METHODS: A retrospective review of 893 consecutive patients (1201 breasts) who underwent mastectomy with DTER or ITER at one institution during a 10-year period was performed. Relevant patient factors, including the use of PMRT and complication rates, were recorded. Complications were categorized by type and end-outcome, including nonoperative (no further surgery), operative (further surgery except explantation), and explantation. Statistics were done using Student t test and Fisher exact test. RESULTS: There were no differences in clinical risk factors between ITER (n = 1127 breasts) and DTER (n = 74 breasts) patients. Delayed tissue expander reconstruction breasts had lower rates of mastectomy flap necrosis (P = 0.003), and nonoperative (P = 0.01) and operative (P = 0.001) complications relative to ITER. In ITER breasts, PMRT increased operative complications (P = 0.02) and explantation (P = 0.0005), resulting in a decrease in overall, 2-stage success rate (P < 0.0001). In contrast, there were no differences in outcomes between PMRT and non-PMRT DTER breasts. CONCLUSIONS: This comparative study, the largest to date, suggests that DTER is a viable reconstructive alternative that may minimize certain complications over ITER, including in patients needing PMRT. However, unlike with ITER, surgeons can evaluate patients' potential for success with DTER based on skin flap appearance after both mastectomy and PMRT (when present). As a result, the benefits of DTER may also be due to a careful patient selection process preoperatively. The choice of DTER should, therefore, be balanced against both individual patient risk factors and the psychological appeal of immediate reconstruction.

A Pilot Assessment of Ethnic Differences in Cosmetic Outcomes following Breast Conservation Therapy.

BACKGROUND: One of the primary benefits of breast conserving therapy (BCT) is the potential ability to preserve the aesthetic appearance of the breast. However, current literature and clinical experience suggest that the aesthetic benefits of BCT may not be equally shared among ethnic groups. This is a pilot study that uses novel techniques to evaluate the cosmetic outcomes of African American and white women following BCT. METHODS: A total of 21 participants (10 African American and 11 white) completed the study. Cosmetic outcomes following BCT were evaluated by a multidisciplinary team using both quantitative and qualitative measures, including 3-dimensional photographic analysis and a pilot questionnaire. Preliminary measures were taken to evaluate the validity of the questionnaire. RESULTS: There were no statistically significant differences in objective measures of breast symmetry between African American patients and white patients (P > 0.05 in all cases). However, all raters reported the African American patients to have worse breast symmetry and appearance when compared with white patients. Interrater reliability was found to be fair with regard to the nipple complex questions [intraclass correlation (ICC), 0.56], good with regard to the breast mound questions (ICC, 0.66), and poor with regard to the scar appearance questions (ICC = 0.32). CONCLUSIONS: Although generalizing the results of this study is limited by the small sample size, it seems that there is a difference in the perception of cosmetic outcomes between white and African American patients. The novel techniques of cosmetic evaluation used in this study show promise toward identifying variables that can affect cosmetic outcome following BCT.

Analysis of risk factors for complications in expander/implant breast reconstruction by stage of reconstruction.

BACKGROUND: Expander/implant breast reconstruction is a common approach to breast reconstruction. Although several studies evaluate risk factors for complications during the overall reconstructive process, no studies currently evaluate risk factors by stage of reconstruction. This information is important, as it can help guide physician and patient decision making. METHODS: This is a retrospective review of the records of 876 patients who underwent expander/implant breast reconstruction. Average follow-up time was 42 months. Multivariate analysis and odds ratios were used to calculate the significance of the variables of interest and to compare the risk of complications attributable to each of the independent variables during each stage of the procedure. RESULTS: During the expander stage, body mass index greater than 30 kg/m had the strongest effect on the development of complications leading to explantation/conversion to flap (OR, 3.07). During the permanent implant stage, history of prereconstruction irradiation had the strongest association with the development of complications leading to explantation/conversion to flap (OR, 3.45). The only risk factors that had a statistically significant effect on the development of complications during both stages were age older than 50 years, smoking within the past month, and a history of premastectomy or postmastectomy radiation therapy. CONCLUSIONS: The results of this study indicate that the risk factors for complications during expander/implant breast reconstruction differ during each stage of the procedure. The individual impact of risk factors must be considered within the context of each patient's oncologic and surgical needs so that surgeons and patients may make more informed decisions toward their goal of a successful breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Body mass index as a continuous predictor of outcomes after expander-implant breast reconstruction.

BACKGROUND: Studies show that obesity is a risk factor for complications after expander/implant breast reconstructions. However, reports vary on the precise threshold of body mass index (BMI) as a predictor of heightened risk. We endeavored to link BMI as a continuous variable to overall complications in a single-surgeon series of expander-implant reconstructions. METHODS: From 399 patients undergoing expander-implant reconstruction, 551 breasts were stratified to normal weight, overweight, and obese groups for analysis and comparison with previous studies. Logistic regression was performed to predict changes to risk profile per increment of BMI. RESULTS: Complication rates for obese and overweight patients were significantly greater than for normal weight patients, that is, 21.1% and 24.0% versus 10.4%, respectively (P < 0.005). A unit increase in BMI predicted a 5.9% increase in the odds of a complication occurring, and 7.9% increase in the odds of reconstruction ending in failure. CONCLUSIONS: By expanding the analysis of BMI to include patients who do not meet the traditional definition of obesity (BMI ≥ 30 kg/m), we demonstrated that simply overweight patients (25 ≤ BMI < 30 kg/m) had an elevated complication rate. Moreover, through regression analysis, we established that BMI as a continuous variable predicts outcomes from expander-based breast reconstruction.

Reconstruction of the inframammary fold using barbed suture.

Achieving accurate inframammary fold (IMF) position and definition during breast reconstruction is a critical step toward obtaining optimal aesthetic outcomes. This article presents a simple technique for IMF reconstruction after implant-based breast reconstruction with an internal running, barbed suture. The results of this technique are retrospectively reviewed in 45 patients, with only 2 patients requiring additional procedures to adjust IMF position for a total revision rate of 4.4%. There have been neither instances of permanent contour deformity due to suture placement nor any instances of suture extrusion through the skin. Thus, this technique appears to be safe and effective and should be considered when surgeons are faced with an IMF asymmetry.

Outcomes of immediate tissue expander breast reconstruction followed by reconstruction of choice in the setting of postmastectomy radiation therapy.

A common sequence for performing staged tissue expander breast reconstruction is to immediately insert a tissue expander, complete expansion before radiotherapy, and then perform the definitive reconstruction after radiotherapy is complete. This study evaluates the outcomes of this treatment regimen in 237 patients over a 10-year period at Northwestern Memorial Hospital. Overall, 62% of the patients successfully completed tissue expander/implant reconstruction, 22.3% experienced major complications leading to explantations or conversions to flap, and 13.5% completed tissue expander/elective autologous reconstruction. Of the patients who underwent second-stage tissue expander to implant exchange, 87.5% successfully completed reconstruction without experiencing complications leading to explantation or conversion to autologous reconstruction. Thus, this study indicates that immediate tissue expander followed by reconstruction of choice breast reconstruction in the setting of postmastectomy radiation therapy can be successfully performed in most of the patients.

The differential effect of BMI on prosthetic versus autogenous breast reconstruction: a multivariate analysis of 12,986 patients.

BACKGROUND: The comparative safety of breast reconstruction in obese patients remains to be clearly defined. This study utilized multi-institutional data to characterize the effect of body mass index (BMI) on breast reconstruction outcomes. METHODS: Utilizing Current Procedural Terminology (CPT) codes, patients undergoing tissue expander, pedicled transverse rectus abdominis myocutaneous (TRAM) flap, latissimus dorsi flap, and free flap breast reconstruction were identified in the National Surgical Quality Improvement Program (NSQIP) database. Patients were stratified as obese (BMI ≥ 30) and non-obese (BMI < 30). Overall postoperative morbidity, flap complications, non-flap complications, and reoperation rates were compared among the groups. RESULTS: Of 12,986 patients who underwent breast reconstruction, 3636 (28.0%) were obese. Overall morbidity was significantly elevated in obese patients across all forms of reconstruction (p < 0.05). BMI was correlated with increased surgical complications for tissue expander, pedicled TRAM, and free flap reconstructions (OR = 1.09, OR = 1.05, OR = 1.10, respectively; p < 0.05). Medical complications were higher in obese patients undergoing tissue expander and pedicled TRAM reconstructions (p = 0.001 and p < 0.001), but no significant difference was observed in latissimus and free flap reconstruction patients. Compared with obese tissue expander recipients, obese patients reconstructed using autologous tissue had higher rates of reoperations (12.8% versus 9.1%), overall morbidity (18.0% versus 9.5%), surgical (12.7% versus 8.3%), and medical complications (9.0% versus 2.2%). CONCLUSIONS: The NSQIP database allows for evaluation and comparison of reconstructive outcomes in the obese population. Increased BMI was associated with higher morbidity in autologous reconstruction than tissue expander reconstruction. Among autologous procedures, latissimus flaps experienced the lowest captured 30 day morbidity.

Two surgeons, one patient: the impact of surgeon-surgeon familiarity on patient outcomes following mastectomy with immediate reconstruction.

BACKGROUND: Mastectomy with immediate reconstruction requires the coordination and expertise of two distinct surgeons. This often results in several different combinations of mastectomy and reconstructive surgeons, but with an unknown impact on patient outcomes. We evaluate the effect of different surgical teams on complication rates following mastectomy and immediate reconstruction. METHODS: Retrospective review of consecutive patients that underwent mastectomy with immediate prosthetic reconstruction from 4/1998 to 10/2008 at one institution was performed. Patients of the three highest-volume mastectomy and reconstructive surgeons were stratified by their individual combination of surgeons, resulting in nine different surgical teams. Complications were categorized by end-outcome. Appropriate statistics, including multiple linear regression, were performed. RESULTS: Clinical characteristics were similar among patients (n = 511 patients, 699 breasts) with the same mastectomy surgeon but different reconstructive surgeon. Mean follow-up was 38.4 ± 25.7 months. For each mastectomy surgeon, the choice of reconstructive surgeon did not affect complication rates. Furthermore, the combined complication rates of the three highest-volume teams (n = 384 breasts) were similar to the remaining lower-volume teams (n = 315 breasts). Patient factors, but not the individual surgeon or surgical team, were independent risk factors for complications. DISCUSSION: Our study suggests that among high-volume surgeons, complication rates following mastectomy with immediate reconstruction are not affected by the surgeon-surgeon familiarity. The individual surgeon's expertise, and patient risk factors, may have a greater impact on outcomes than the team's experience with each other. These results validate the efficacy and safety of the surgeon distribution model currently used by many breast surgery practices.

A multi-institutional perspective of complication rates for elective nonreconstructive breast surgery: an analysis of NSQIP data from 2006 to 2010.

BACKGROUND: As elective nonreconstructive breast surgery increases in popularity, there is greater demand for accurate multi-institutional data on minor and major postoperative complications. OBJECTIVE: The authors utilized a multi-institutional database to compare 30-day morbidities and reoperation rates among the different types of elective nonreconstructive breast surgery. METHODS: Patients in the National Surgical Quality Improvement Program (NSQIP) participant use file who underwent elective nonreconstructive breast surgery between 2006 and 2010 were identified. Twenty defined morbidities were compared among mastopexy, reduction mammaplasty, and augmentation mammaplasty patients using analysis of variance and χ(2) tests for continuous variables and categorical variables, respectively. Logistic regression modeling was employed to identify preoperative risk factors for complications. RESULTS: Of the 3612 patients identified, 380 underwent mastopexy, 2507 underwent reduction mammaplasty, and 725 underwent augmentation mammaplasty. Complication rates were low in all cohorts, and patients undergoing augmentation mammaplasty had the lowest overall complication rate compared with mastopexy and reduction mammaplasty (1.24%, 2.37%, and 4.47%). Patients undergoing reduction mammaplasty had a modestly elevated incidence of overall morbidity, superficial surgical site infections, and wound disruptions (P < .05). Moreover, 30-day reoperation rates for mastopexy, reduction mammaplasty, and augmentation mammaplasty were low (1.58%, 2.07%, and 0.97%), as were the rates of life-threatening complications (0%, 0.16%, and 0%). One death was observed for all 3612 procedures (0.03%). CONCLUSIONS: Elective breast surgery is a safe procedure with an extremely low incidence of life-threatening complications and mortality. Comprehensive data collated from the NSQIP initiative add to the literature, and the findings of this multi-institutional study may help further guide patient education and expectations on potentially deleterious outcomes.

Use of the tabbed expander in latissimus dorsi breast reconstruction.

Latissimus dorsi (LD) myocutaneous flap breast reconstruction with a tissue expander/implant is a post-mastectomy option often used as a salvage procedure for a failed tissue expander (TE). The patient is traditionally placed in the lateral decubitus position for flap dissection and is re-prepped and re-draped in the supine position for placement of the tissue expander. A new generation of anatomically-shaped, tabbed tissue expanders are increasingly being used in place of traditional untabbed expanders. The innovative suture tabs allow for more predictable and controlled expander placement while the patient is in the lateral decubitus position, eliminating the need to reposition the patient intraoperatively. The objective of this study was to evaluate the use of tabbed tissue expanders in latissimus dorsi breast reconstruction, with respect to total operative time, complication rates, and aesthetic outcomes. The outcomes of 34 LD breast reconstruction procedures with tissue expanders were evaluated. Eight patients received tabbed tissue expanders with no position change, while 26 patients underwent an intraoperative position change. Demographic information, total operative time, and follow-up complication data were collected. Aesthetic outcomes were evaluated by three blinded individuals using a validated scoring scale. The mean operative time for procedures with no position change was 107 minutes. The mean operative time for position change cohort was 207 minutes. There was no statistical difference in complication rates or aesthetic outcomes between the two groups. In conclusion, tabbed tissue expanders decrease operative time by eliminating the need for an intraoperative position change without influencing complication rates while maintaining equivalent aesthetic outcomes.

Hematoma after mastectomy with immediate reconstruction: an analysis of risk factors in 883 patients.

BACKGROUND: Mastectomy followed by breast reconstruction presents unique circumstances, such as 2 operating teams, that may affect the likelihood of postoperative bleeding. This study evaluates risk factors for hematoma formation in patients undergoing mastectomy with immediate implant reconstruction. METHODS: The charts of 883 patients (1199 breasts) who underwent mastectomy and immediate tissue expander reconstruction between April 1998 and August 2008 at a single institution were retrospectively reviewed. Demographic and operative factors and information on hematoma location were recorded. Fisher exact test, Student t test, and multiple linear regression were used for statistical analysis. RESULTS: There were no differences in preoperative, operative, and oncologic characteristics between hematoma (n = 28 breasts) and nonhematoma (n = 1171 breasts) groups. Multiple linear regression analysis revealed no independent risk factors for hematoma formation, except an individual mastectomy and reconstructive surgeon (odds ratio, 3.58; 95% confidence interval, 1.03-12.37; P = 0.03; odds ratio, 2.54; 95% confidence interval, 1.06-6.08; P = 0.03, respectively). Most hematomas were diagnosed on postoperative day 0 or 1 (23/28, 82.1%) and found to originate from the pectoralis muscle (14/28, 50.0%) or axillary region (6/28, 21.4%). CONCLUSIONS: The risk of postoperative hematoma after mastectomy with immediate reconstruction is not affected by any measurable preoperative, operative, or oncologic factors. With no definitive risk factor for bleeding, surgeons should remain meticulous and vigilant throughout the operation. In particular, hemostasis should be focused on the chest wall musculature given its propensity for being the primary source of hematoma formation.

Utility of acellular dermis-assisted breast reconstruction in the setting of radiation: a comparative analysis.

BACKGROUND: The role of acellular dermis in immediate prosthetic breast reconstruction remains unclear, particularly within a radiated field. The authors evaluated and compare outcomes following reconstruction with and without acellular dermis, and analyzed patients exposed to radiation therapy. METHODS: Retrospective review of 417 consecutive patients (592 breasts) treated from January of 2006 to October of 2008 at one institution was performed. Relevant patient characteristics and follow-up were recorded. Complications were categorized by type and end outcome, including nonoperative, operative, or explantation. Both groups had comparable follow-up (acellular dermis, 23.2 ± 8.9 months; no acellular dermis, 24.4 ± 12.7 months; p = 0.23). Appropriate statistical analyses, including multiple regression, were performed. RESULTS: Acellular dermis patients (n = 199 breasts) had larger body mass indexes (p = 0.0001) and more nipple-sparing mastectomies (p = 0.04) than non-acellular dermis patients (n = 393 breasts). Breasts with acellular dermis had larger intraoperative fill volumes (p < 0.0001) and decreased postoperative expansions (p = 0.02), but no decrease in time to implant exchange. There were no significant differences in complication profiles between acellular dermis and non-acellular dermis breasts, after adjusting for other relevant patient variables on regression analysis. After stratifying patients by exposure to radiation, acellular dermis breasts had a decreased risk of all complications related to radiation as compared with non-acellular dermis breasts. CONCLUSIONS: This study suggests that acellular dermis does not adversely affect complication rates following prosthetic breast reconstruction. It may be advantageous, however, in select patients, particularly those undergoing postoperative radiation therapy. Therefore, the choice to use acellular dermis does not compromise outcomes but should be individualized to each patient.

Long-term outcomes following fat grafting in prosthetic breast reconstruction: a comparative analysis.

BACKGROUND: Autologous fat grafting has become a common technique for optimizing aesthetic outcomes following breast reconstruction. Its long-term oncologic implications, however, remain unclear. The authors evaluated long-term outcomes following tissue expander breast reconstruction with and without fat grafting. METHODS: A retrospective review was performed of consecutive patients undergoing mastectomy with immediate tissue expander reconstruction from April of 1998 to August of 2008. Demographic, operative, oncologic, and postoperative factors were recorded, including the use of fat grafting. Mean follow-up was 42.1 ± 28.8 and 43.6 ± 27.2 months for non-fat-grafting and fat-grafting patients, respectively (p = 0.63), including 24.8 ± 5.9 months after the first fat-grafting procedure. Fisher's exact test, t test, and regression analysis were used for statistics. RESULTS: A review of 886 patients (n = 1202 breasts) revealed no significant differences in demographics, operative characteristics, tumor staging, or radiation therapy exposure between fat-grafting (n = 90 breasts) and non-fat-grafting (n = 1112 breasts) patients. Ninety-nine fat-grafting procedures were performed an average of 18.3 months after reconstruction, with one complication (fat necrosis). Grafting did not affect local tumor recurrence or survival when compared with non-fat-grafted breasts. Complication following reconstruction, including a poor cosmetic result, was an independent predictor of undergoing subsequent fat grafting (p < 0.0001). CONCLUSIONS: The analysis suggests that fat grafting after breast reconstruction does not adversely affect local tumor recurrence or survival on long-term follow-up. Autologous fat grafting can be used as an aesthetic adjunct to prosthetic reconstruction with minimal complications. These results also indicate the need for multi-institutional, prospective studies to definitively establish its oncologic safety. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Ascending necrotizing fasciitis of the face following odontogenic infection.

Necrotizing fasciitis (NF) of the face is a rare but extremely dangerous complication of dental infection associated with a nearly 30% mortality rate. This infection spreads rapidly along the superficial fascial planes of the head and neck and can lead to severe disfigurement. Reports in the literature of cases of NF of the face caused by dental infection are few. We report such a case in a 36-year-old woman and review the current standards of diagnosis and management. The patient initially presented with pain and severe swelling in the left side of her face subsequent to a dental infection. The symptoms had progressed quickly and had not improved with administration of oral antibiotics in the outpatient setting. The patient had no palpable crepitus despite its classic association with NF. The infection also took a rare, ascending route of spread with involvement of the temporalis muscle. Cultures taken during debridement grew Streptococcus anginosus and Bacteroides. Biopsies of involved muscle showed histologic evidence of necrosis. Through early surgical intervention including aggressive debridement, and the adjunctive use of appropriate antibiotics, the patient recovered with minimal loss of facial mass and no skin loss. Although NF of the face is rare, the surgeon must maintain a high index of suspicion with any patient presenting after a dental infection with rapid progression of swelling and a disproportionate amount of pain that is unresponsive to antibiotics.