Implant-based Breast Reconstruction Salvage with Negative Pressure Wound Therapy with Instillation: An Evaluation of Outcomes.

Background: Implant infection is problematic in breast reconstruction. Traditionally, infected tissue expanders (TE)/implants are removed for several months before replacement, resulting in breast reconstruction delay. Salvage involving device removal, negative pressure wound therapy with instillation and dwell (NPWTi-d) placement, and early staged TE/implant replacement within a few days has been described. The purpose of this study was to compare outcomes of the NPWTi-d salvage pathway with traditional implant removal. Methods: A retrospective review was performed on patients who underwent implant-based reconstruction and developed TE/implant infection/exposure requiring removal. Patients were divided into two groups. Group 1 had TE/implant removal, NPWTi-d placement, and TE/implant replacement 1-4 days later. Group 2 (control) underwent standard TE/implant removal and no NPWTi-d. Reinfection after TE/implant salvage, TE/implant-free days, and time to final reconstruction were assessed. Results: The study included 47 patients (76 TE/implants) in group 1 (13 patients, 16 TE/implants) and group 2 (34 patients, 60 TE/implants). The success rate (no surgical-site infection within 90 days) of implant salvage was 81.3% in group 1. No group 1 patients abandoned completing reconstruction after TE/implant loss versus 38.2% (13 of 34) in group 2 (P = 0.0094). Mean implant-free days was 2.5 ± 1.2 in group 1 versus 134.6 ± 78.5 in group 2 (P = 0.0001). The interval to final implant-based reconstruction was 69.0 ± 69.7 days in group 1 versus 225.6 ± 93.6 days in group 2 (P = 0.0001). Conclusions: A breast implant salvage pathway with infected device removal, NPWTi-d placement, and early TE/implant replacement was successful in 81.3%. Patients experienced 132 less implant-free days and faster time to final reconstruction.

Prophylactic absorbable antibiotic beads for prepectoral implant-based breast reconstruction: A single institution early experience.

Infection after implant-based breast reconstruction remains challenging, with infection rates up to 24%. Best clinical practice indicates prophylactic oral antibiotics are ineffective at preventing infection. Absorbable antibiotic beads have been routinely used in other surgical subspecialties such as orthopedic and vascular procedures for continuous local antibiotic delivery to the surgical site when implants are placed. Biodegradable calcium sulfate antibiotic beads have been shown to normalize incidence of infection when used prophylactically for a high-risk prepectoral patient population. The purpose of this study is to evaluate the effect of prophylactic biodegradable antibiotic beads when used non-selectively for all prepectoral immediate tissue expander (TE) reconstruction. Patients who underwent mastectomy and immediate prepectoral TE reconstruction on the same day between 2018 and 2024 were reviewed. Patients were divided into two groups: those who received antibiotic beads (Group 1) and those who did not (Group 2). Absorbable calcium-sulfate beads were reconstituted with 1 g vancomycin and 240 mg gentamicin. There were 33 patients (63 TEs) in Group 1 and 330 patients (545 TEs) in Group 2. TE loss was present in 1.5% (1/65 TEs) Group 1 compared to 9.4% (51/545 TEs) in Group 2 (p = 0.032). The mean follow-up time was 178 days (range 93-266 days). Prophylactic biodegradable antibiotic beads used during immediate tissue expander reconstruction decreased implant loss rate. There was one occurrence of SSI in the antibiotic bead group. Antibiotic beads may potentially decrease complications in immediate TE reconstruction when used non-selectively for all patients.

Same day discharge following mastectomy and immediate tissue expander reconstruction: The effect of patient expectations.

BACKGROUND AND PURPOSE: Within, we compare the short-term outcomes of patients receiving same day mastectomy and tissue expander reconstruction for those discharged on postoperative day one versus those discharged immediately following surgery to explore the safety, efficacy, and potential impact on hospital processes. METHODS: This was a retrospective review of patients undergoing mastectomy with immediate TE reconstruction from March 2019 to March 2021. Patients were stratified into two cohorts; observation overnight (OBS), and discharge on same day of surgery (DC). RESULTS: In total, 153 patients underwent 256 mastectomies with immediate TE reconstruction. All patients were female and the mean age was 48 years old. The DC cohort contained 71 patients (125 mastectomies) and there were 82 patients (131 mastectomies) within the OBS cohort. On average the DC cohort had a lower BMI than the OBS group (mean ± SD; DC 26.8 kg/m2 ± 5.3 kg/m2, OBS 28.7 kg/m2 ± 6.1 kg/m2, p = 0.05), the DC cohort had higher rates of adjuvant chemotherapy (DC 40.1%, OBS 23.2%, p = 0.02), and were more likely to undergo bilateral TE reconstruction (DC 76%, OBS 60%, p = 0.03) than the OBS group. No differences were observed between cohorts in complication rates regarding primary or secondary outcomes. CONCLUSION: These findings indicate that it is safe and effective within the immediate 7-day post-operative period to immediately discharge patients undergoing mastectomy with immediate TE reconstruction. Additionally, alteration of patient management practices can have a profound impact on the operational flow within hospitals.

Biofilm-derived oxylipin 10-HOME-mediated immune response in women with breast implants.

This study investigates a mechanistic link of bacterial biofilm-mediated host-pathogen interaction leading to immunological complications associated with breast implant illness (BII). Over 10 million women worldwide have breast implants. In recent years, women have described a constellation of immunological symptoms believed to be related to their breast implants. We report that periprosthetic breast tissue of participants with symptoms associated with BII had increased abundance of biofilm and biofilm-derived oxylipin 10-HOME compared with participants with implants who are without symptoms (non-BII) and participants without implants. S. epidermidis biofilm was observed to be higher in the BII group compared with the non-BII group and the normal tissue group. Oxylipin 10-HOME was found to be immunogenically capable of polarizing naive CD4+ T cells with a resulting Th1 subtype in vitro and in vivo. Consistently, an abundance of CD4+Th1 subtype was observed in the periprosthetic breast tissue and blood of people in the BII group. Mice injected with 10-HOME also had increased Th1 subtype in their blood, akin to patients with BII, and demonstrated fatigue-like symptoms. The identification of an oxylipin-mediated mechanism of immune activation induced by local bacterial biofilm provides insight into the possible pathogenesis of the implant-associated immune symptoms of BII.

Utilizing large volume fat grafting in breast reconstruction after nipple sparing mastectomies.

Nipple sparing mastectomy (NSM) has gained popularity especially in prophylactic mastectomies allowing improved cosmetics. Traditionally reconstruction has utilized implants or autologous tissue. With the development of large volume fat grafting additional reconstructive techniques can be utilized in NSM reconstruction. This can either complement a technique or be a standalone form of reconstruction. This paper is intended to serve as a broad overview of fat grafting and its potential role in reconstructing the breast following nipple sparing mastectomies.

Primary intra-aneurysmal surgical repair of a celiomesenteric trunk aneurysm.

We describe the surgical management of an asymptomatic 3-cm saccular aneurysm originating from a celiomesenteric trunk in a 45-year-old man. Surgical management was influenced by the location of the aneurysm, involving hepatic, splenic, and superior mesenteric arterial branches, by the young age of the patient, which made use of a synthetic graft less ideal, and by the lack of endovascular options.

Air pockets trapped during routine coupling in dry head lithotripsy can significantly decrease the delivery of shock wave energy.

PURPOSE: Current lithotriptors use a dry treatment head that must be coupled to the patient with gel or oil. We determined how the quality of coupling affects stone breakage under conditions that simulated patient treatment. MATERIALS AND METHODS: Experiments were performed with a Dornier (DoLi-50 electromagnetic lithotriptor. The test tank had a clear Mylar membrane for coupling with the treatment head water cushion. Thus, air pockets trapped at the coupling interface could be photographed for quantitation. Coupling efficiency was assessed using a fiberoptic hydrophone and different coupling regimes were tested for the effect on gypsum stone breakage. RESULTS: The quality of coupling was variable with air pockets covering 1.5% to 19% of the coupling area, resulting in a mean decrease in shock wave amplitude of approximately 20%. Breaking and reestablishing contact, as when a patient is repositioned during treatment, decreased acoustic pressure almost 32%, representing a 57% decrease in acoustic energy transmission. Stone breakage was also decreased when air was trapped in coupling and only 2% coverage by air pockets decreased stone breakage by 20% to 40%. CONCLUSIONS: These in vitro results suggest that coupling in lithotripsy can pose a significant barrier to the transmission of shock wave energy to the patient. Stone breakage was sensitive to air pockets at the coupling interface. Recoupling was particularly disruptive, suggesting that repositioning the patient could substantially degrade coupling quality. It seems reasonable that variability in the quality of coupling could contribute to variability in clinical outcomes.

Detection of significant variation in acoustic output of an electromagnetic lithotriptor.

PURPOSE: We describe the observation of significant instability in the output of an electromagnetic lithotriptor. This instability had a form that was not detected by routine assessment, but rather was observed only by collecting many consecutive shock waves in nonstop regimen. MATERIALS AND METHODS: A Dornier DoLi-50 lithotriptor used exclusively for basic research was tested and approved by the regional technician. This assessment included hydrophone measures at select power levels with the collection of about 25 shock waves per setting. Subsequent laboratory characterization used a fiberoptic hydrophone and storage oscilloscope for data acquisition. Waveforms were collected nonstop for hundreds of pulses. RESULTS: Output was typically stable for greater than 1,000 shock waves but substantial fluctuations in acoustic pressures were also observed. For example, output at power level 3 (mean peak positive acoustic pressure +/- SD normally 44 +/- 2 MPa) increased dramatically to greater than 50 MPa or decreased significantly to approximately 30 MPa for hundreds of shock waves. The cause of instability was eventually traced to a faulty lithotriptor power supply. CONCLUSIONS: Instability in lithotriptor acoustic output can occur and it may not be detected by routine assessment. Collecting waveforms in a nonstop regimen dramatically increases sampling size, improving the detection of instability. Had the instability that we observed occurred during patient treatment, the energy delivered may well have exceeded the planned dose. Since the potential for adverse effects in lithotripsy increases as the dose is increased, it would be valuable to develop ways to better monitor the acoustic output of lithotriptors.

Why stones break better at slow shockwave rates than at fast rates: in vitro study with a research electrohydraulic lithotripter.

BACKGROUND AND PURPOSE: Stones break better when the rate of shockwave (SW) delivery is slowed. It has been hypothesized that the greater cavitation accompanying a fast rate shields pulse propagation, thus interfering with the delivery of SW energy to the stone. We tested this idea by correlating waveforms measured at the SW focus with cavitation viewed using high-speed imaging. MATERIALS AND METHODS: A series of U30 gypsum stones held in a 2-mm mesh basket were exposed to 200 SWs at 30 or 120 SW/min from a research electrohydraulic lithotripter (HM3 clone). Waveforms were collected using a fiberoptic probe hydrophone. High-speed imaging was used to observe cavitation bubbles in the water and at the stone surface. RESULTS: Stone breakage was significantly better at 30 SW/min than at 120 SW/min. The rate had little effect on SW parameters in the water free field. In the presence of particulates released from stones, the positive pressure of the SW remained unaffected, but the trailing tensile phase of the pulse was significantly reduced at 120 SW/min. CONCLUSIONS: Cavitation bubbles do not persist between SWs. Thus, mature bubbles from one pulse do not interfere with the next pulse, even at 120 SW/min. However, cavitation nuclei carried by fine particles released from stones can persist between pulses. These nuclei have little effect on the compressive wave but seed cavitation under the influence of the tensile wave. Bubble growth draws energy from the negative-pressure phase of the SW, reducing its amplitude. This likely affects the dynamics of cavitation bubble clusters at the stone surface, reducing the effectiveness of bubble action in stone comminution.