Keeping abreast of shark bite reconstruction: a case report and brief literature review.

Shark attack-related injuries (SARIs) are rare but may result in highly complex wounds requiring reconstruction by plastic surgeons. Here, we present an unusual case of SARI of the breast and briefly review literature on reconstructive management of (1) breast injuries from other large animals and (2) SARIs to other parts of the body. Our patient was a 39-year-old woman who experienced massive bilateral breast tissue loss from a shark attack. After primary surgical wound management, including debridement and washout, the patient underwent completion mastectomy with bilateral deep inferior epigastric perforator flap breast reconstruction. Literature review revealed that reports of animal-related injuries to the breast are rare, with ours being the first on SARI to the breast and the only describing major reconstruction of animal-related breast injury. Literature on reconstruction of non-breast SARI wounds is limited to two case reports describing severe tissue damage akin to that seen in our patient, both necessitating extensive debridement followed by reconstruction. Overall, our findings demonstrate the uniquely devastating damage resulting from SARIs and the value of primary wound management and abdominally based free flaps in successfully reconstructing these wounds. Level of evidence: Level V, therapeutic study.

Total Muscle Coverage versus AlloDerm Human Dermal Matrix for Implant-Based Breast Reconstruction.

BACKGROUND: Prosthetic breast reconstruction is the most common method for treatment of patients undergoing mastectomy. Acellular dermal matrix has become more popular in implant-based breast reconstruction. METHODS: The authors conducted a retrospective review of all patients undergoing prosthetic breast reconstruction between August of 2002 and December of 2013. Patients were analyzed in terms of demographics, fill volumes, number of expansions, costs, and complications. RESULTS: A total of 284 patients underwent mastectomy surgery with 481 implant-based breast reconstructions. Four hundred eight tissue expanders had total muscle coverage, whereas 73 had AlloDerm. The rate of overall complications and major complications was significantly higher in the AlloDerm group: 20.5 percent versus 8.8 percent (p = 0.005), and 13.7 percent versus 5.1 percent (p = 0.0001), respectively. The mean initial fill volume was significantly lower in the total muscle coverage group compared to the acellular dermal matrix group (54 ± 47 versus 167 ± 139; p = 0.00003), resulting in a higher number of expansions (8.1 versus 5.8; p = 0.000051) and longer time to full expansion (60.2 days versus 43.3 days; p = 0.0002). This did not translate into a faster time to expander exchange (162.4 days versus 162.3 days; p = 0.13). Use of AlloDerm added a mean cost of $2217 for each breast. CONCLUSIONS: Implant-based breast reconstruction has evolved with the advent of acellular dermal matrices. Although the use of acellular dermal matrix allows increased initial fill volumes and fewer total expansions, there is an increased risk of complications and increased costs, especially in patients undergoing bilateral reconstruction. Total muscle coverage remains an excellent option for providing quality breast reconstruction without increased complications. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.