Subareolar Sealant Reduces Minor Complications and Surgery for Necrosis in Prosthetic Reconstruction after Nipple-sparing Mastectomy.

Nipple-sparing mastectomy (NSM) is aesthetically superior to skin-sparing only mastectomy or reconstructed nipples. However, nipple-sparing mastectomy partially preserves nipple ducts, which are remaining communications between the environment and breast pocket that can potentially allow bacteria transfer and compromise the prosthesis. Previous methods to create a subareolar "barrier" to reduce through-duct bacteria penetration involve subpectoral implant placement, adjunct meshes or acellular dermal matrix, and external nipple adhesives. To further protect the implant from nipple-derived contamination, we propose subareolar sealant (SAS). SAS involves the application of a synthetic sealant on the nipple undersurface before implant placement. In our study, we analyzed 77 breasts that received prepectoral prosthetic breast reconstruction. SAS was used in 70 of 77 breasts. All breasts received adjunctive acellular dermal matrix. Comparing SAS versus no-SAS, we found that no-SAS was associated with 10.4-fold more infections (P = 0.032) and 17.3-fold more re-hospitalizations (P = 0.017). No-SAS also resulted in more "at least one major complication" (P < 0.001), capsular contracture (P < 0.001), and necrosis requiring surgery (P < 0.001). Due to the small no-SAS sample size, goodness-of-fit (Quasi-likelihood independence model) criteria was applied, and a post hoc power analysis was calculated. Erythema, all minor complications, dehiscence, and necrosis requiring surgery remained significant (all P < 0.0001). This innovative technique markedly reduces overall minor complications and necrosis requiring surgery. A larger no-SAS sample size is required to adequately determine whether SAS reduces infection and hospitalization rates. Nonetheless, SAS reduces complications and is cost effective compared with other adjunct materials.

To acellular dermal matrix or not to acellular dermal matrix?-outcomes of pre-pectoral prosthetic reconstruction after nipple-sparing mastectomy with and without acellular dermal matrix.

Background: Acellular dermal matrix (ADM) has been the go-to biomaterial in post-mastectomy breast reconstruction, particularly in pre-pectoral reconstruction. ADM is thought to decrease capsular contracture, control the pocket, and increase soft tissue, but may yield more complications. This study evaluated whether ADM is even needed. Methods: All patients undergoing immediate breast reconstruction with pre-pectoral tissue expander (TE) or direct-to-implant (DTI) after nipple-sparing mastectomy (NSM) by the senior author between April 2013 and January 2021, were included in this study. Cohorts were stratified into breasts with ADM or no-ADM. Complications within 30 days post-operatively were analyzed. Results: A total of 115 pre-pectoral reconstructions were performed in 66 patients. ADM was applied to 75 breasts. TEs were used in 80 breasts and DTI in 35 breasts. Controlling for implant type, breasts with ADM exhibited more nipple necrosis (28.0% vs. 10.0%, P=0.02). Controlling for ADM status, DTI compared to TE was associated with less necrosis of the nipple (11.4% vs. 26.3%, P=0.04), implant loss (5.7% vs. 38.8%, P=0.004), and surgery for any complication (14.3% vs. 27.5%, P=0.04). Conclusions: Outcomes of prosthetic reconstructions with ADM and no-ADM were similar. DTI reconstruction was associated with less complications, which was likely due to intraoperative bias and placement of TEs more often in breasts with perceived poorer vascularity.

Combination of Supramicrosurgical Lymphatico-Venular Anastomosis (sLVA) and Lymph-Sparing Liposuction in Treating Cancer-Related Lymphedema: Rationale for a Regional One-Stage Approach.

Objective: Cancer-related lymphedema represents a potential complication of cancer treatment. The aim of this study is to evaluate the effectiveness of the combination of lymphatico-venular anastomosis and liposuction in the treatment of secondary lymphedema. Methods: We present a retrospective analysis of patients affected by cancer-related unilateral limb lymphedema. Inclusion criteria included previous neoplastic pathology with the consequent development of unilateral limb lymphedema, while the exclusion criteria included the presence of comorbidities and the persistence of cancer, as well as previous lymphatic surgery. The outcomes to be included were a reduction in the limb volume and lymphangitis rate, and an improvement in the quality of life. Patients' data were assessed before surgery and 1 year after surgery. Perioperative management included clinical and ultrasonographical evaluations. Under local anesthesia, lymphatico-venular anastomosis with the supramicrosurgical technique and the liposuction of the affected limb was performed in the same surgical session. Results: A total of 24 patients were enrolled in the study. One year after the surgery, an average volume reduction of 37.9% was registered (p = 0.0000000596). The lymphangitis rate decreased after surgery from 4.67 to 0.95 per year (p = 0.000007899). The quality-of-life score improved from 68.7 to 16 according to the LLIS scale. Conclusions: The combination of LVA and liposuction represents a valid strategy for treating cancer-related lymphedema, ensuring stable results over time. In addition, it can be performed under local anesthesia, resulting in being minimally invasive and well-tolerated by patients. This paper reports on the short-term efficacy of this combined technique.

Correction of Breast Ptosis in Immediate Breast Reconstruction.

Nipple-sparing mastectomy is psychologically advantageous and can result in superior cosmetic outcomes. However, nipple position adjustment is challenging, and ischemic complications may arise. For patients who require timely mastectomies and reconstructions, concurrent mastopexy may prevent nipple malposition and reduce the risk for future corrections. Methods: A retrospective chart review of all patients undergoing immediate prosthetic reconstruction after nipple-sparing mastectomy were analyzed. Data regarding patient characteristics; surgical indications; reconstructive modality, including presence or absence of simultaneous nipple lift; and early and late complications were examined. Results: In total, 142 patients underwent 228 nipple-sparing mastectomies and prosthetic reconstructions. Correction of ptosis (lift) was performed in 22 patients and 34 breasts. The remaining 122 patients and 194 breasts did not receive mastopexy (no-lift). Two patients received bilateral reconstructions involving both lift and no-lift. Comparing the lift and no-lift cohorts demonstrated no differences in major complications (47.1% versus 57.7%; P = 0.25) and minor complications (76.5% versus 74.7%; P = 0.83). Control for plane of implant placement also did not show differences in major (P = 0.31) or minor (P = 0.97) complications. Similarly, control of application of acellular dermal matrix found major (P = 0.25) and minor (P = 0.83) complications uniform and not affected by lift status. Nipple lift distance was not associated with increased major (P = 0.10) complications. Conclusion: Simultaneous correction of nipple position in immediate prosthetic breast reconstruction seem safe with uniform complications rates that are unaffected by acellular dermal matrix use or plane of implant placement.

Immediate Ear Lobule Reconstruction After Melanoma Resection.

EAR LOBULE RECONSTRUCTION: Cancer removal from aesthetically vulnerable areas of the face strikes a delicate balance between oncologically appropriate excision and preservation of a unique structure. A 72-year-old male presented with melanoma of the right earlobe requiring complete excision. Partial or complete absence of an ear causes a deformity and is difficult to conceal. Thus, lobule reconstruction postmelanoma excision eliminates deformity and aids in psychological recovery. In this case report, we describe our novel technique of a 2-stage lobule reconstruction immediately after melanoma resection using a direct template of the excised lobule. This template allowed us to sculpt its identical size and shape using harvested contralateral conchal cartilage graft. After the cartilage was banked in a subcutaneous pocket for 8.5 weeks, the second stage liberated the reconstructed lobule. This immediate 2-stage technique eliminated a period of soft tissue contracture and presented a rare surgical opportunity to recreate a structure using its direct template. LEVEL OF EVIDENCE: Level IV-case report.

Peri-prosthetic Fat Grafting Decreases Collagen Content, Density, and Fiber Alignment of Implant Capsules.

BACKGROUND: Lower capsular contracture rates have been observed with peri-prosthetic fat grafting. We investigated the effect of fat grafting on capsular characteristics and peri-prosthetic collagen density, content, and fiber alignment. METHODS: Forty miniature tissue expanders were placed on the backs of 20 rats. After four weeks, both inguinal fat pads were harvested, homogenized, and injected into peri-prosthetic tissue of the right tissue expander (fat graft) while the left served as control. The animals were killed at three (10 rats) and 12 weeks (10 rats), and full thickness peri-prosthetic samples were histologically processed for morphology (H&E) and collagen type and content (picrosirius red). RESULTS: An 8.1% increase in adipose peri-prosthetic thickness was associated with a 10% decrease in collagen content at any time point (P = 0.004). Fat-grafted capsules displayed a 59% reduction in % total collagen when compared with controls (P < 0.001). There were no differences in capsular thickness. Fat-grafted samples were 54 times more likely to have a higher inflammation score and 69 times more likely to have a lower capsular density score than their nongrafted counterparts (P < 0.001 and P = 0.001, respectively). The extent of inflammation decreased over time in all samples (P = 0.002). Additionally, fat-grafted samples were 67 times more likely to have a lower fiber alignment score than the controls (P < 0.001). CONCLUSIONS: Enhancement of peri-prosthetic tissue with fat grafting decreases collagen content, density, and fiber alignment of implant capsules. These findings support clinical application of fat grafting in prosthetic breast surgery to potentially decrease capsular contracture.

Subcutaneous Prosthetic Breast Reconstructions following Skin Reduction Mastectomy.

BACKGROUND: Prepectoral prosthetic breast reconstruction is gaining popularity, offering muscle preservation and outcomes similar to subpectoral implant placement in small or moderate size breasts. This study compares the complications of prepectoral and subpectoral immediate prosthetic breast reconstructions following skin reduction mastectomy in large and ptotic breasts. METHODS: All consecutive patients who underwent immediate tissue expander-based reconstruction following Wise pattern skin reduction mastectomy from November 2011 through August 2017 by a single surgeon were reviewed. The collected data included patient demographics and complications (eg, skin necrosis, hematoma, infection, seroma, implant loss, capsular contracture). RESULTS: A total of 54 patients underwent 87 immediate breast reconstructions including 45 subpectoral and 42 prepectoral tissue expander placements. The subpectoral patients had greater body mass indexes (32.5 ± 6.6 versus 29.9 ± 5.4, P = 0.026), higher initial (518 ± 168 ml versus 288 ± 140 ml, P < 0.001) and final (694 ± 123 ml versus 585 ± 122 ml, P = 0.014) implant volumes, more skin flap necrosis (40.0% versus 16.7%, P = 0.044) and infections (37.8% versus 11.9%, P = 0.01) than their prepectoral counterparts, whereas seromas were more common in the prepectoral group (4.4% versus 26.2%, P = 0.015). The overall complication rate, although higher in the subpectoral group compared with the prepectoral group, was not significantly different (62.2% versus 40.5%, P = 0.072). CONCLUSIONS: Prepectoral tissue expander placement after skin reduction mastectomy is an appealing reconstructive option in patients with large and ptotic breasts. Prosthetic reconstruction following Wise-pattern skin reduction mastectomy is invariably associated with high complication rates irrespective of the plane of implant placement. Greater emphasis should be placed on patient counseling and complication prevention in this challenging patient population.

Volume Retention, Metabolism, and Cellular Composition of Human Fat Xenografts.

BACKGROUND: To optimize the take of transferred fat, better understanding of fat graft morphology and growth properties in vivo is critical. We aim to evaluate survival, volume retention, metabolism, and cellular composition of various aliquots of human fat xenografts. METHODS: Twenty athymic nude mice were injected subcutaneously in opposing flanks with 0.1 ml (small) and 1.0 ml (large) aliquots of human fat graft. Volume (ultrasound) of fat aliquots was measured at baseline, 1, 3, and 12 weeks after implantation. Tissue metabolism (18F-FDG), Hematoxylin and Eosin, special stains, and immunohistochemical analysis were performed at 3 and 12 weeks to determine graft viability, cell origin, and proliferative activity. RESULTS: Only 1 of 10 small grafts were detected after 12 weeks by ultrasound and 5 of 10 were found at necropsy. Volume of large grafts decreased significantly from baseline at 3 (827 ± 195 mm3 versus 953 ± 122 mm3; P = 0.004) and 12 weeks (515 ± 163 mm3 versus 953 ± 122 mm3; P = 0.0001). Metabolism increased with time in small (0.6 ± 0.4%ID/g versus 2.0 ± 1.1%ID/g, P = 0.01) and large grafts (0.4 ± 0.3%ID/g versus 1.4 ± 0.9 %ID/g; P = 0.005). Large grafts viability decreased between 3 and 12 weeks (72 ± 20% versus 31 ± 30%; P = 0.012) although small graft viability remained unchanged. Viable and proliferating human and mouse adipocytes and chimeric blood vessels were seen within grafts at both time points. CONCLUSIONS: Larger graft aliquot was associated with better volume retention by ultrasound but lower viability by histology. Graft metabolism increased with time irrespective of aliquot size potentially due to regenerative processes of both donor and recipient origin.

Endoscopy-Assisted Frontal Sinus Obliteration.

Comminuted fractures of the anterior table of the frontal sinus involving frontonasal ducts are traditionally treated with sinus obliteration. This technique entails precise mucosa removal which requires unimpeded visualization of the bony recesses. To achieve adequate access to the mucosa, temporary removal of a large part of the frontal bone may often be necessary. This in turn increases fracture comminution requiring placement of additional hardware associated with the risk for bony malalignment, infection, plate palpability, and visibility, especially in thin-skin individuals. Endoscopy, offering magnified visualization and less invasive access, is reported to be beneficial in sinus injury management. Therefore, it may be also considered an adjunct in open-approach management of severely comminuted fractures.The authors' patient suffered from comminuted fractures of the anterior and posterior tables of the frontal sinus and nasal bone fractures with involvement of the frontonasal ducts. Due to the extent of the injury he underwent frontal sinus obliteration procedure using the pericranial flap. To avoid additional osteotomy, endoscopic approach was undertaken to achieve the complete removal of the sinus mucosa. The fracture by itself offered an "access port" for the endoscope and electrical cautery. The patient's recovery was uneventful.Endoscopy employed in frontal sinus obliteration appears to be instrumental in obtaining meticulous mucosa removal, obviating the need for additional osteotomy of the frontal bone.

Outcomes of Prosthetic Reconstruction of Irradiated and Nonirradiated Breasts with Fat Grafting.

BACKGROUND: Fat grafting may be beneficial in prosthetic reconstruction of irradiated tissues, but there is a paucity of data on the complication rates associated with this clinical scenario. METHODS: All consecutive patients who had undergone fat grafting and prosthetic reconstruction from 2010 to 2013 were enrolled. Variables obtained related to fat grafting and history of irradiation. Implant-related complications in relation to irradiation status were also noted. RESULTS: Eighty-five patients (age 49 ± 10 years) underwent 117 fat grafting procedures. The mean follow-up was 2.6 ± 0.7 years. Fat grafting was predominantly performed to correct soft-tissue deficiency [112 of 117 (95.7 percent)] or to alter skin after irradiation [five of 117 (4.3 percent)]. Thirty-two procedures (27.4 percent) were associated with a complication, with the most common being palpable fat necrosis (23.1 percent). Volume of transferred fat averaged 151.2 ± 76.6 ml per breast. Fat grafting complications did not depend on donor site, technique of fat processing, volume of transferred fat, number of procedures, or irradiation. Implant-related complications were observed after 26 of 117 overall procedures (22.2 percent). No association between implant-related complications and irradiation was observed (OR, 1.3; 95 percent CI, 0.4 to 4.1; p = 0.63). Overall complications following fat grafting in nonirradiated [37 of 82 (45.1 percent)] and irradiated [16 of 35 (45.7 percent)] breasts were not statistically different (OR, 1.02; 95 percent CI, 0.41 to 2.57; p = 0.96). CONCLUSION: Similar outcomes of irradiated and nonirradiated prosthetic breast reconstruction can be achieved with additional fat grafting. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Spectacles under Pedicles: Eyewear Modification with the Paramedian Forehead Flap.

The paramedian forehead flap is a widely used method of nasal reconstruction. The flap requires a bridge of tissue from forehead to the nose, for a period of 2 to 3 weeks, before it can be divided at a second procedure. During this time, patients often have difficulty positioning and wearing their eyewear underneath the pedicle of the flap. Here we present a novel approach to the problem. It requires only a simple modification to the patient's eyewear and greatly facilitates wear and removal.

Chemotherapy port related lymphedema after axillary lymph node dissection.

UNLABELLED: The Mascagni lymphatic pathway comprises superficial channels along the clavicle that drain upper extremity lymph. A 65 year-old woman with recurrent left breast cancer presented with a non-functioning chemotherapy port in the right deltopectoral groove. She had undergone right mastectomy with axillary lymph node dissection (ALND). After port removal and wound closure she developed right upper extremity lymphedema. Patients who have undergone ALND may depend solely on this pathway for upper extremity lymphatic drainage. LEVEL OF EVIDENCE: level V.

Temporary Areolar Demarcation for Nipple-areola Complex Reconstruction.

We have described a surgical method that enhances the visual aesthetic outcome of the areola periphery in nipple-areola complex reconstruction. This technique is performed immediately following closure of the nipple flap. The created areolar outline can aid the tattoo artist and may result in a more natural-appearing areola periphery than tattooing methods alone.

Breast total male breast reconstruction with fat grafting.

SUMMARY: Cancer of a male breast represents less than 1% of all breast cancer. As with to female patients, mastectomy in men creates a substantial emotional burden. Breast reconstruction may improve the patient's psychological well-being, compliance with adjuvant treatments, and overall outcome. However, due to the unique anatomy of the male breast, standard reconstructive strategies using anatomic or prosthetic modalities are not entirely applicable. We describe a case of a 68-year-old male patient who underwent successful unilateral breast reconstruction solely with fat grafting technique.

Tube-in-a-tube anterolateral thigh flap for reconstruction of a complex esophageal and anterior neck defect.

Restoration of a functional digestive track along with acceptable external neck coverage traditionally requires 2 separate flaps. We present a case of a 65-year-old man with a large cervical and esophageal defect treated successfully with a single anterolateral thigh (ALT) free flap. This patient had been treated with primary chemoradiation for laryngeal cancer, and subsequently, developed a severe esophageal stricture. He had undergone prior multiple attempts at reconstruction with a pectoralis major, radial forearm, and deltopectoral flaps, skin grafts, and gastric pull-up, which had all failed. We used an ALT free flap that was designed in a "tube-in-a-tube" fashion to simultaneously reconstruct the cervical esophagus while resurfacing the anterior neck. The patient successfully restarted a liquid diet on the 19th postoperative day. Tube-in-a-tube ALT flap design is a reliable and efficient way to concurrently restore esophageal continuity and provide anterior neck coverage in a single-stage procedure.