Safety Profile Comparison of 2 Smooth Tissue Expander Types: Artoura and CPX4.

INTRODUCTION: With the recent transition to smooth tissue expanders (TEs), functional differences between TE subtypes have not been fully elucidated. This study evaluated the differences in TE characteristics and complications between 2 commonly used Mentor smooth TE models, Artoura and CPX4. METHODS: A retrospective review of patients who received either smooth Mentor Artoura or CPX4 TE from 2012 to 2022 was conducted. Demographic data, perioperative information, pain scores, TE variables, cancer characteristics, and complications were collected. A multivariate analysis was used to evaluate the relationship between TE subtype and complications while controlling for demographic, TE characteristics, radiation, and chemotherapy exposure. RESULTS: During the study period, 62 smooth Artoura TEs and 79 smooth CPX4 TEs were used. Patients who received CPX4 smooth implants tended to be older (51.09 vs 46.18 years old, P = 0.02) and have a higher body mass index (28.66 vs 23.50 kg/m 2 , P < 0.001). There were no differences among patient comorbidities. CPX4 required on average a greater total fill volume (422.23 vs 348.07 mL, P = 0.01) and had a greater drain duration (16.91 vs 14.33 days, P = 0.05). There were no differences in TE plane placement between Artoura and CPX4. Additionally, there were no differences in complication rates, including infection, hematomas, seromas, wound breakdown, TE replacement, and capsular contracture. When controlling for body mass index, diabetes, TE plane placement, acellular dermal matrix use, radiation exposure, and chemotherapy, there was no association between TE subtype and any individual complication. DISCUSSION: Differences in total fill volume and drain duration were significantly different between Mentor Artoura and CPX4 implants, which may influence TE subtype selection. However, Artoura and CPX4 have excellent and equivalent safety profiles with similar complication rates, even when controlling for demographic and TE characteristics.

Immediate Prepectoral Tissue Expander Breast Reconstruction Without Acellular Dermal Matrix Is Equally Safe Following Skin-Sparing and Nipple-Sparing Mastectomy.

BACKGROUND: Prepectoral breast reconstruction has become increasingly popular over the last decade. There is a paucity of data surrounding the impact of mastectomy type on clinical outcomes when comparing prepectoral immediate breast reconstruction without acellular dermal matrix (ADM) using tissue expansion. The purpose of this study was to compare 90-day reconstructive surgical outcomes in immediate prepectoral tissue expander reconstruction between patients with nipple-sparing mastectomy (NSM) and skin-sparing mastectomy (SSM). METHODS: A retrospective review of patient records was carried out on all patients undergoing NSM or SSM with immediate prepectoral tissue expander reconstruction without ADM, in a single institution, from June 2020 to December 2021. All complications were recorded, categorized, and statistically analyzed for significance. RESULTS: Seventy-nine patients (97 breasts) were studied. The mean age was 51 years old (range, 31-77). Twenty-two patients suffered complications recorded in 22 breasts (22.7%). There was no statistically significant difference in the total complications between the NSM (25.7%) and SSM (21.0%) groups or in the incidence of all major and minor complications. CONCLUSIONS: Breast reconstruction using tissue expanders without ADM has similar reconstructive outcomes in both NSM and SSM. There were no significant differences in complication rates between either groups. Breast reconstruction without ADM can confer institutional cost savings without compromising safety.

Multivariate Analysis of Risk Factors for Complications in Pediatric Tissue Expansion.

BACKGROUND: Tissue expanders represent one of the main surgical options for skin reconstruction in cases of tumors, traumalike burn injury, scar contracture, and alopecia. However, the tissue expander device is also associated with complications such as infection and extrusion. The aim of this study was to analyze risk factors for major complications of use of tissue expanders in pediatric patients using multivariate analysis. METHODS: A retrospective, single-center observational study was performed over 10 years in pediatric patients who were treated with tissue expanders for tumors, nevus, scars, burn reconstruction, and alopecia from April 2012 to March 2022. The primary outcome was overall complications per operation and expander, including infection and extrusion. Ten predictor variables were included as risk factors based on previous studies and as new factors considered important from clinical experience. Univariate and multivariate logistic regression analyses were performed to identify risk factors for major complications such as expander infection or extrusion. RESULTS: The study included 44 patients who underwent 92 operations using 238 tissue expanders. The overall complication rate per expander was 14.3%. Univariate logistic regression analysis identified associations of younger age, number of expanders used per operation, history of infection, and tissue expander locations with a higher complication rate. In multivariate logistic regression analysis, younger age (odds ratio, 1.14; P = 0.043) was associated with a high likelihood of expander complications. CONCLUSIONS: Younger age is an independent risk factor for tissue expander complications in pediatric patients. This factor should be considered in preoperative planning and discussions with the patient's family.

Direct-to-Implant vs Tissue Expander Placement in Immediate Breast Reconstruction: A Prospective Cohort Study.

BACKGROUND: Direct-to-implant (DTI) breast reconstruction after mastectomy has gained increasing popularity. While concerns over ischemic complications related to tension on the mastectomy flap persist, newer techniques and technologies have enhanced safety of this technique. OBJECTIVES: To compare clinical and patient-reported outcomes of DTI and 2-stage tissue expander (TE) reconstruction. METHODS: A prospective cohort design was utilized to compare the incidence of reconstructive failure among patients undergoing DTI and TE reconstruction by unadjusted bivariate and adjusted multivariable logistic regression analyses. Secondary clinical outcomes of interest included specific complications requiring intervention (infection, seroma, hematoma, mastectomy flap necrosis, incisional dehiscence, device exposure) and time to final drain removal. Patient-reported outcomes on BREAST-Q were also compared. RESULTS: A total of 134 patients (257 breasts) underwent DTI reconstruction and 222 patients (405 breasts) received TEs. DTI patients were significantly younger with lower BMIs; less diabetes, hypertension, and smoking; and smaller breast sizes; they also underwent more nipple-sparing mastectomies with prepectoral reconstructions. Rates of any complication (18% DTI vs 24% TE, P = .047), reconstructive failure (5.1% vs 12%, P = .004), and seroma (3.9% vs 11%, P < .001) were significantly lower in the DTI cohort on unadjusted analyses; however, there were no significant differences on adjusted regressions. Patient-reported satisfaction with breasts, psychosocial well-being, and sexual well-being were more substantively improved with DTI reconstruction. CONCLUSIONS: Prepectoral DTI reconstruction is a viable option for postmastectomy reconstruction in carefully selected patients, with no significant increase in reconstructive failure or other complications.

Comparison of Different Acellular Dermal Matrix in Breast Reconstruction: A Skin-to-Skin Study.

BACKGROUND: Since the early 2000s, acellular dermal matrix has been a popular adjunct to prepectoral breast reconstruction to enhance outcomes. OBJECTIVES: The aim of this study was to investigate the differences in the postoperative course of 2 standard acellular dermal matrix products, AlloDerm SELECT Ready To Use and DermACELL. METHODS: A prospective, patient-blind study of patients undergoing bilateral nipple and/or skin-sparing mastectomies with either tissue expander or silicone implant insertion between 2019 and 2022 were selected for this study. The study design used patients as their own controls between 2 products randomly assigned to the left or right breast. Outcomes between the products included average time for drain removal, infection rate, seroma rate, and incorporation rates. RESULTS: The prospective clinical data of 55 patients (110 breasts) were recorded for 90 days. There were no significant differences between drain removal time, average drain output, or seroma aspiration amount. A higher percentage of seromas was recorded in the breasts with AlloDerm (30.91%) compared with breasts containing DermACELL (14.55%, P < .05), and a statistically significant difference between the incorporation rates of AlloDerm (93.4%) and DermACELL (99.8%, P < .05) was observed. CONCLUSIONS: Irrespective of patient demographic disparities, both products had a 94.55% success rate for reconstruction outcomes. AlloDerm was determined to have a higher incidence of seromas as a postoperative complication and a trend to lower incorporation.

Air Versus Saline in Tissue Expanders: A Systematic Review of the Literature.

BACKGROUND: There has been a greater focus in recent literature proposing air to be a superior medium to saline in tissue expanders. This study aims to review the literature and assess the quality of data on the efficacy and safety of air as an alternative medium to saline in tissue expanders, in the setting of postmastectomy two-stage reconstruction. METHODS: A systematic review regarding air inflation of tissue expanders was conducted using PubMed, Embase, Cochrane Library, and Web of Science. The methods followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Three reviewers separately performed data extraction and comprehensive synthesis. RESULTS: A total of 427 articles were identified in our search query, of which 11 met the inclusion criteria. Three pertained to inflation with room air, and eight pertained to inflation with CO2 using the AeroForm device. They were comparable to decreased overall complication rates in the room air/CO2 cohort compared to saline, although statistical significance was only observed in one of five two-arm studies. Investigating specific complications in the five two-arm studies, significantly lower rates of skin flap necrosis were only observed in two CO2-based studies. Studies rarely discussed other safety profile concerns, such as the impacts of air travel, radiation planning, and air extravasation beyond descriptions of select patients within the cohort. CONCLUSION: There is insufficient evidence to suggest improved outcomes with room air inflation of tissue expanders. Further work is needed to fully characterize the benefits and safety profiles of air insufflation before being adopted into clinical practice.

Post-mastectomy Breast Reconstruction With Gas vs Saline Tissue Expanders: Does the Fill Type Matter?

The most common reconstruction technique following mastectomy is a 2-stage technique that involves tissue expansion followed by definitive implant-based reconstruction (IBR). Tissue expanders (TEs) have classically used saline for initial fill; however, TEs with an initial gas fill (GTE)-including the CO2-based AeroForm (AirXpanders, San Francisco, CA) TE and TEs initially filled with atmospheric air-have been increasingly used in the past decade. We aimed to compare the outcomes in breast reconstruction for tissue expanders initially filled with saline vs gas. PubMed was queried for studies comparing gas- and saline-filled tissue expanders (STEs) used in IBR. A meta-analysis was performed on major postoperative outcomes and the required expansion and definitive reconstruction time. Eleven studies were selected and included in the analysis. No significant differences existed between tissue expansion with GTEs vs STEs for 11 of the 13 postoperative outcomes investigated. Out of the complications investigated, only the risk of infection/cellulitis/abscess formation was significantly lower in the GTE cohort (odds ratio 0.62; 95% CI, 0.47 to 0.82; P = .0009). The time to definitive reconstruction was also significantly lower in the GTE cohort (mean difference [MD], 45.85 days; 95% CI, -57.80 to -33.90; P < .00001). The total time to full expansion approached significance in the GTE cohort (MD, -20.33 days; 95% CI, -41.71 to 1.04; P = .06). A cost analysis considering TE cost and infection risk determined that GTE use saved a predicted $2055.34 in overall healthcare costs. Surgical outcomes for both fill types were predominantly similar; however, GTEs were associated with a significantly decreased risk of postoperative infection compared to saline-filled TEs. GTEs could also reduce healthcare expenditures and require less time until definitive reconstruction after placement.

Pre-pectoral Immediate Breast Reconstruction Following Conservative Mastectomy Using Acellular Dermal Matrix and Semi-smooth Implants.

BACKGROUND/AIM: Improvements in acellular dermal matrix (ADM) and surgical techniques have facilitated pre-pectoral immediate breast reconstruction (IBR). Outer shell texturing is a key risk factor for anaplastic large cell lymphoma, prompting this evaluation of reconstruction with nano-textured rounded implants. PATIENTS AND METHODS: Fifty-one consecutive patients underwent 72 pre-pectoral ADM-assisted (fenestrated SurgiMend™) IBRs using nano-textured implants (Sebbin™). Patients were invited to complete a satisfaction questionnaire, including aesthetic outcome (linear scale 0-10) during follow-up. RESULTS: Average mastectomy weight was 300 g (range=83-1,018 g). After a mean follow-up of 18.3 month, 2 patients (2.8%) had minor wound complications. One patient suffered nipple necrosis. Capsular contracture occurred in 5 cases (6.9%) and significant rippling in one case. No implants were lost. Patient-reported aesthetic outcomes had a mean score of 9.3 (range=3-10; N=71). CONCLUSION: Pre-pectoral ADM-assisted IBR using semi-smooth implants following NSM is reliable and safe, with a low incidence of complications and high patient satisfaction.

From Salvage to Prevention: A Single-Surgeon Experience with Acellular Dermal Matrix and Infection in Prepectoral Breast Reconstruction.

BACKGROUND: Increasing amounts of acellular dermal matrix are being used with the adoption of prepectoral breast reconstruction. Postoperative infection remains a challenge in breast reconstruction, and the contribution of acellular dermal matrix type, processing, and sterility assurance level to risk of complications in prepectoral reconstruction is not well studied. METHODS: The authors performed a retrospective review of patients who underwent immediate prepectoral breast reconstruction from February of 2017 to July of 2020. Because of an increase in the rate of infection, the drain protocol was changed and acellular dermal matrix type was switched from AlloDerm (sterility assurance level, 10-3) to DermACELL (sterility assurance level, 10-6) in January of 2019. Demographic and surgical variables were collected, in addition to details regarding development and management of infection. RESULTS: Despite higher rates of direct-to-implant reconstruction and bilateral procedures and increased implant volumes, the rate of infection was significantly lower in patients who received DermACELL instead of AlloDerm [two of 38 (5.3 percent) versus 11 of 41 (26.8 percent); p = 0.014]. Drain duration was slightly longer in the DermACELL group, consistent with the change in drain protocol. Baseline demographic and clinical characteristics remained similar between the two groups. CONCLUSIONS: With increased reliance on large amounts of acellular dermal matrix for prepectoral breast reconstruction, it directly follows that the properties of acellular dermal matrix with respect to incorporation, sterility, and implant support are that much more important to consider. There have been few studies comparing different types of acellular dermal matrix in prepectoral breast reconstruction, and further research is required to determine the contribution of acellular dermal matrix type and processing techniques to development of postoperative infection. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Ear Reconstruction with the Combination of Expanded Skin Flap and Medpor Framework: 20 Years of Experience in a Single Center.

BACKGROUND: In ear reconstruction, the difficulty lies in reestablishing the ear's bionic form with adequate skin coverage and an appropriate framework. Skin expansion and a porous polyethylene (i.e., Medpor) framework are often used for ear reconstruction. However, a long-term review of the combined application of the expanded skin and Medpor framework has not been reported. This article reviews ear reconstruction combining these two factors over the past 20 years in the authors' center to summarize the surgical technique and analyze the postoperative results and complications. METHODS: A retrospective review was performed that included all patients who underwent ear reconstruction with expanded skin and Medpor framework in the authors' center between 1998 and 2018. RESULTS: A total of 68 patients with microtia who were admitted to the authors' center for surgical ear reconstruction were included, and 70 ears were reconstructed. Fifty-seven of the patients (83.82 percent) felt satisfied with their reconstructed ear, five patients (7.35 percent) were not satisfied with the reconstructed ear, and six patients (8.82 percent) had the frameworks removed. Fifteen patients (22.06 percent) developed complications, including framework exposure (13.24 percent), infection (4.41 percent), scar hypertrophy (4.41 percent), and hematoma (2.94 percent). CONCLUSIONS: Framework exposure limits the combined application of expanded skin flap and Medpor framework when reconstructing the ear without additional fascial interposition. Using a temporoparietal fascia or postauricular fascia flap during the operation is effective to decrease the exposure rate; however, this complication cannot be completely avoided. Using postauricular fascia and skin graft may lead to scar hypertrophy; thus, these techniques should be used with caution. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Acellular Dermal Matrix-Associated Contracture: A Clinical and Histologic Analysis of Patients Undergoing Prosthetic Breast Reconstruction.

BACKGROUND: Capsular contracture is a well-recognized complication following prosthetic breast reconstruction. It has been the authors' observation that some patients undergoing breast reconstruction experience contracture specifically of the acellular dermal matrix placed at the time of their tissue expander insertion. The goal of the authors' study was to identify clinical and histologic findings associated with the development of acellular dermal matrix-associated contracture. METHODS: The authors performed a retrospective cohort study of all patients undergoing bilateral implant-based breast reconstruction performed by the senior author (M.S.A.). Patients were excluded if they had radiation therapy to the breast. Patients with suspected acellular dermal matrix-associated contracture were identified by clinical photographs and review of operative notes. Histologic analysis was performed on specimens taken from two patients with acellular dermal matrix contracture. RESULTS: The authors included a total of 46 patients (92 breasts), of which 19 breasts had suspected acellular dermal matrix-associated contracture. Acellular dermal matrix contracture was less common in direct-to-implant reconstruction (4.2 percent versus 26.5 percent; p = 0.020) and more common in breasts that had seromas (0 percent versus 15.8 percent; p = 0.001) or complications requiring early expander replacement. Contracted acellular dermal matrix had less vascularity and a lower collagen I-to-collagen III ratio, and was twice as thick as noncontracted acellular dermal matrix. CONCLUSIONS: The authors have described a distinct phenomenon of acellular dermal matrix-associated contracture that occurs in a small subset of breasts where acellular dermal matrix is used. This merits further investigation. Future work will be required to better characterize the clinical factors that make acellular dermal matrix-associated contracture more likely to occur. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

What Is the Impact of Postoperative Antibiotic Prophylaxis on Tissue Expander Infection Rates in Pediatric Patients?

BACKGROUND: Tissue expansion in the pediatric population can be complicated by high rates of infection and extrusion. The aim of this study was to examine the impact of postoperative antibiotic prophylaxis on infectious complications. METHODS: A retrospective study of all pediatric patients who underwent tissue expander insertion at a children's hospital over a 12-year period was performed. Predictor variables included age, sex, race, indication, anatomical location, number of expanders inserted, serial expansion, history of infection or extrusion, and postoperative antibiotics. Outcome variables included infection and extrusion. Bivariate and multivariate analyses were performed to identify factors associated with infection and/or extrusion. RESULTS: A total of 180 patients who underwent 317 operations for tissue expander insertion were included in this study. Postoperative infection and/or extrusion occurred after 73 operations (23 percent). Postoperative prophylactic antibiotics were prescribed after 232 operations (75 percent), and only perioperative (≤24 hours) antibiotics were administered in 85 cases (25 percent). There were no significant differences in the rate of infection (12.1 percent versus 8.9 percent; p = 0.46), extrusion (16.8 percent versus 17.7 percent; p = 0.88), or infection and/or extrusion (23.7 percent versus 24.1 percent; p = 0.95) between these two groups. Multivariate analysis revealed that postoperative antibiotics did not have a significant association with infection and/or extrusion (OR, 0.84; 95 percent CI, 0.44 to 1.63; p = 0.61). CONCLUSIONS: The rates of infection/extrusion were similar between pediatric patients who received only perioperative antibiotics (≤24 hours) and those who were prescribed a course of postoperative antibiotics. Based on these results, a course of postoperative prophylactic antibiotics may be unnecessary after insertion of tissue expanders in pediatric patients. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Prepectoral versus Subpectoral Tissue Expander Breast Reconstruction: A Historically Controlled, Propensity Score-Matched Comparison of Perioperative Outcomes.

BACKGROUND: The rising popularity of prepectoral tissue expander placement with acellular dermal matrices in immediate breast reconstruction has prompted many studies on the safety of this technique. However, a comprehensive propensity-matched, historically controlled trial comparing perioperative outcomes following prepectoral versus partial subpectoral (dual-plane) placement of tissue expanders is lacking. METHODS: Retrospective propensity-matched cohort analysis was performed on all patients of two senior reconstructive surgeons who underwent bilateral tissue expander placement following a mastectomy with one of three breast surgeons at a single academic institution from 2012 onward (n = 260). Two matched groups (prepectoral and partial subpectoral) each consisted of 102 patients. Univariate and multivariable analyses were also performed to contextualize the risks associated with prepectoral reconstruction relative to demographic characteristics and other clinical factors. RESULTS: Compared to dual-plane subpectoral placement, prepectoral placement resulted in similar rates of overall perioperative complications (32 percent versus 31 percent; p = 1.00) and perioperative complications that required operative treatment (21 percent versus 21 percent; p = 1.00). There were no significant differences between the groups in complication rates for hematomas, seromas, impaired wound healing, and infection. Although prepectoral placement was associated with prolonged time to drain removal, those patients completed the expansion process twice as fast, were expanded further in the operating room, and were more than twice as likely to forgo clinic-based expansion. Prepectoral reconstruction was not associated with increased risk for any complications in univariate or multivariable analysis. CONCLUSIONS: Prepectoral tissue expander placement permitted greater intraoperative filling of expanders and a reduced likelihood of clinic-based expansion, with no increase in adverse outcomes compared to partial subpectoral placement. Adoption of this technique may reduce unnecessary clinic visits; shorten the delay before adjuvant therapy; and minimize patient apprehension, pain, and discomfort related to clinic-based expansion. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Comparative study of patient outcomes between direct to implant and two-stage implant-based breast reconstruction after mastectomy.

BACKGROUND: Breast reconstruction plays a central role in the outcome management of patients with breast cancer, particularly in terms of quality of life (QoL), which must be weighed carefully when considering the available surgical options. In the context of implant-based breast reconstruction, immediate replacement with prosthesis (direct-to-implant (DTI)) and acellular dermal matrix (ADM) is gaining popularity, at the expense of the traditional two-stage implant-based breast reconstruction with tissue expander (TE), and the literature suggests that patients tend to prefer interventions with "immediate" therapeutic efficacy and aesthetic satisfaction that obviate the need for further invasive surgery. We investigated this hypothesis by administering the BREAST-Q™ questionnaire to two groups of patients who had undergone the respective procedures. METHODS: We performed a cross-sectional observational study of 192 consecutive mastectomy patients who received implant-based reconstruction, comparing health-related quality of life (HR-QoL), patient-related outcomes (PROs) and satisfaction in patients who had undergone immediate dual plane DTI with ADM (96) versus the two-stage submuscular approach (96). We also counted the number of surgeries required in each group to achieve a definitive outcome. FINDINGS: Our study revealed no major differences in terms of QoL scores, with the two approaches being largely comparable. However, single-stage reconstruction seems to offer the additional advantages of better satisfaction with the care received, sparing the patient temporary body image dissatisfaction and reducing the number of surgeries required, thereby lessening the burden on the patient, the healthcare system and society as a whole.

Does the Textured-Type Tissue Expander Affect the Outcomes of Two-Stage Prosthetic Breast Reconstruction? A Propensity Score Matching Analysis between Macrotextured and Microtextured Expanders.

BACKGROUND: In two-stage prosthetic breast reconstruction, two types of tissue expanders are used for the first stage: microtextured Siltex and macrotextured Biocell. Despite emerging concerns regarding the safety of macrotextured prostheses, the association between the use of macrotextured expanders and adverse outcomes remains unknown clinically. This study aimed to evaluate potential impacts of the type of tissue expander on the long-term outcomes of implant-based breast reconstruction. METHODS: Patients who underwent immediate two-stage tissue expander/implant breast reconstruction between 2014 and 2018 were evaluated and categorized into two groups according to the expander type. Those two were propensity score matched for baseline characteristics and compared for complication rates after the first- and second-stage operations. The impacts of several variables, including type of tissue expander used, on outcomes were assessed using multivariable logistic regression analyses. RESULTS: Of the 1391 cases in 1294 patients, 276 pairs (552 cases) were successfully propensity score matched. In the first-stage operation, the macrotextured group showed a significantly shorter drain indwelling period and lower rate of seroma than the microtextured group. These differences retained influences after adjusting for other variables. Incidence rates of other complications were similar between the groups. Regarding the second-stage operation, the use of macrotextured expanders showed a significant association, with an increased rate of severe capsular contracture on the multivariable analyses in cases using textured implants. Development of other complications was not affected by the expander type. CONCLUSION: The type of tissue expander might influence the outcomes of two-stage implant-based breast reconstruction, and generally acceptable safety of both microtextured and macrotextured expanders was shown. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

A controlled cost and outcomes analysis of acellular dermal matrix and implant-based reconstruction.

INTRODUCTION: The use of acellular dermal matrix (ADM) for breast reconstruction continues to change in both single- and two-stage reconstruction. Determining optimal outcomes clinically, aesthetically, financially as well as for the patient's quality of life has become a priority. METHODS: A retrospective review of implant-based reconstructions was performed at a single center from 2010 to 2016, with patients blindly matched 1:1:1 into three cohorts based on reconstruction type: 1) single stage direct to implant with ADM, 2) two-stage tissue expander to implant (TE/I) without ADM, and 3) two-stage TE/I with ADM. Relative cost between groups, esthetic outcomes, and quality of life within each group was analyzed. RESULTS: Group 1 was more likely to be older and use intraoperative angiography, but with fewer overall surgeries and postoperative visits (p<0.001). There was no statistically significant difference in reconstructive success among all three groups (p = 0.85). Cost was significantly higher for group 3 relative to groups 1 and 2. Overall appearance was higher in groups 1 and 3 relative to group 2, with radiation therapy the only independent factor. Group 1 had higher scores using Breast-Q for the physical well-being domain (p = 0.01). CONCLUSION: This is the first study to incorporate clinical outcomes, esthetic visual grading, and patient-reported quality within the same cohort of individuals, considering both use of ADM and staging. Despite the added ADM cost, it is proven safe, eliminates time and cost associated with tissue expanders, decreases post-operative visits and can lead to equally as functional and aesthetically pleasing outcomes in single- and two-stage breast reconstructions.

A short-term comparison of expander prosthesis and DIEP flap in breast reconstructions: A prospective randomized study.

BACKGROUND: There is yet no clear consensus on which method is preferable in secondary breast reconstructions, prosthesis, or autologous tissue. METHODS: In this first prospective randomized study, 29 women underwent reconstruction with expander prosthesis (EP) and 44 with deep inferior epigastric perforator (DIEP) flap. Inclusion started in 2012 and ended in 2018. Demographic data, complications, surgery time, hospital days, and consulting visits were recorded. Patient satisfaction was evaluated pre- and postoperatively using the BREAST-Q questionnaire. Health care costs were calculated based on rates from the financial year 2018. Here, we report the results related to the surgery and the first 30 postoperative days. RESULTS: The two groups were comparable regarding demographics and clinical characteristics. Satisfaction with breasts, measured with BREAST-Q, was significantly higher in patients who had undergone reconstruction with DIEP flap compared with EP. Within 30 days after breast reconstruction, significantly fewer women (n = 2) in the EP group suffered complications compared to the DIEP flap group (n = 16; p < 0.01). The health care cost was also significantly higher in the DIEP flap group relative to the EP group (p < 0.01). DISCUSSION: This patient cohort will be studied systematically over time, and results concerning the need for complementary surgery, costs, esthetics, and the patient-reported outcome (PRO) will be reported in future work. In this short-term report, EP seems to be preferable in regard to cost and complications, and DIEP flap is to choose from the patient's perspective.

Surgical management of pediatric renovascular hypertension and midaortic syndrome at a single-center multidisciplinary program.

OBJECTIVE: To evaluate the outcomes of various surgical approaches in the treatment of renovascular hypertension and midaortic syndrome (MAS) in children. METHODS: We performed a retrospective medical record review of patients who had undergone surgery for renovascular hypertension from 2010 to 2018 at our center under the care of a multidisciplinary team. The operative interventions included mesenteric artery growth improves circulation (MAGIC), tissue expander-stimulated lengthening of arteries (TESLA), aortic bypass using polytetrafluorethylene, renal artery reimplantation, and autotransplantation. The MAGIC procedure uses the meandering mesenteric artery as a free conduit for aortic bypass. The TESLA procedure is based on lengthening the normal distal aorta and iliac arteries by gradual filling of a retroaortic tissue expander for several weeks, followed by resection of the stenotic aorta and subsequent primary reconstruction. RESULTS: A total of 39 patients were identified, 10 with isolated renal artery stenosis, 26 with MAS, and 3 with systemic inflammatory vasculitis. The median age at presentation and surgery was 6.4 years (range, 0-16.3 years) and 9.3 years (range, 0-9.2 years), respectively. The MAS-associated syndromes included neurofibromatosis type 1 (15.4%) and Williams syndrome (5.1%), although most cases were idiopathic. At surgery, 33.3% had had stage 1 hypertension (HTN), 53.8% stage 2 HTN, and 12.8% normal blood pressure with a median of three antihypertensive medications. Follow-up of 37 patients at a median of 2.5 years demonstrated normal blood pressure in 86.1%, stage 1 HTN in 8.3%, and stage 2 HTN in 5.6%, with a median of one antihypertensive medication for the entire cohort. CONCLUSIONS: The patterns of vascular involvement leading to renovascular hypertension in children are variable and complex, requiring thoughtful multidisciplinary planning and surgical decision-making. The MAGIC and TESLA procedures provide feasible approaches for aortic bypass and reconstruction using autologous tissues and will result in normalization of blood pressure in 85% of children 2.5 years after surgery.