Follow-Up Study: One-Step Salvage of Infected Prosthetic Breast Reconstructions Using Antibiotic-Impregnated Polymethylmethacrylate Plates and Concurrent Tissue Expander Exchange.

BACKGROUND: Periprosthetic infections represent major complications in breast reconstruction, frequently leading to expander-implant loss. No consensus regarding a management algorithm for attempted salvage currently exists. This study assessed outcomes of the authors' salvage protocol using an antibiotic-impregnated polymethylmethacrylate implant with expander device exchange. METHODS: A retrospective chart review identified infected implant-based breast reconstruction cases treated between 2009 and 2017. Of 626 cases initially identified, a total of 62 cases had severe prosthetic infections, and underwent either prosthetic salvage (n = 45) or immediate explantation (n = 17). All the prosthetic salvage patients received intravenous antibiotics followed by surgical débridement, insertion of polymethylmethacrylate plates, device exchange, and postoperative antibiotics. After clinical resolution of infection, tissue expansion was performed, with the polymethylmethacrylate plates remaining in situ until exchanged for permanent implants. RESULTS: The authors' study demonstrated a primary infection clearance rate of 82.2 percent (n = 37). Compared to the traditional explantation group, a significantly higher percentage of the salvage patients completed final reconstruction (84.4 percent versus 35.3 percent; p < 0.001). Fewer patients abandoned reconstruction efforts after infection clearance (2.2 percent versus 58.8 percent; p < 0.001). The majority of cases (78.8 percent) that succeeded the salvage protocol ultimately received implant-based reconstruction; 62.5 percent that failed the salvage protocol still went on to receive autologous tissue reconstruction. CONCLUSIONS: Sustained local antibiotic delivery using polymethylmethacrylate implants and expander device exchange can successfully salvage an infected breast expander/implant. Compared with the traditional explantation approach, more patients complete final reconstruction. Other benefits include preserved skin envelope integrity and possibly improved long-term aesthetic outcomes. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Salvage of Infected Prosthetic Breast Reconstructions.

Periprosthetic infection is a major complication in breast reconstruction, leading to implant loss and delayed and sometimes abandoned reconstruction. Traditional management of persistent infections requires explantation followed by secondary reconstruction after 6 months of delay. Although effective in treating the infection, this approach often leads to distortion and/or loss of tissue envelope, making secondary reconstruction very difficult. As a result, there is significant interest in salvaging infected prosthetic breast reconstructions. Recent studies reported variable success through systemic antibiotic therapy and surgical interventions. The aim of this article is to review the management of periprosthetic infection and to provide a potential salvage algorithm.

One-Step Salvage of Infected Prosthetic Breast Reconstructions Using Antibiotic-Impregnated Polymethylmethacrylate Plates and Concurrent Tissue Expander Exchange.

PURPOSE: Periprosthetic infection represents a major complication in breast reconstruction, frequently leading to expander-implant loss. Recent studies report variable success in the salvage of infected breast prostheses through systemic antibiotic therapy and surgical intervention. There is currently no consensus regarding a management algorithm for attempted salvage. The purpose of this pilot study was to evaluate the early outcomes of a protocol using antibiotic-impregnated polymethylmethacrylate (PMMA) implant placement with expander device exchange. METHODS: A retrospective database was queried to identify all patients with infected implant-based breast reconstruction who were treated by the study authors and who underwent attempted salvage under the study protocol. All patients received intravenous antibiotics followed by surgical debridement of the infected pocket, insertion of antibiotic-impregnated PMMA plates and/or beads, device exchange, and postoperative antibiotics. After clinical resolution of infection, tissue expansion was performed with the PMMA implants remaining in situ until exchanged to permanent implants. RESULTS: All patients with infected prosthetic breast reconstructions achieved implant pocket sterilization using this method. At a mean follow-up of 8.2 months (range, 1-19 months), none of these patients have required reoperation for capsular contracture. One patient, while under treatment with prednisone for a rash, developed recurrent infection, which led to explantation of her implant. Two patients underwent radiation therapy while an antibiotic plate and tissue expander were in place, with no observed exposure or infection recurrence. CONCLUSIONS: Sustained local antibiotic delivery using PMMA implants and expander device exchange can successfully salvage an infected breast implant. Perceived benefits include shorter time to completed reconstruction, preserved skin envelope integrity, and possibly improved long-term aesthetic outcomes.

DermACELL: a novel and biocompatible acellular dermal matrix in tissue expander and implant-based breast reconstruction.

BACKGROUND: Acellular dermal matrices present a new alternative to supporting expanders and implants for breast reconstruction in breast cancer patients following mastectomy. However, some studies have suggested that acellular dermal matrix may increase the complication rates in certain clinical settings. DermACELL acellular dermal matrix offers advanced processing in order to attempt to decrease bio-intolerance and complications. METHODS: Ten consecutive patients that presented for breast reconstruction and were candidates for tissue expanders underwent the procedure with the use of an acellular dermal matrix. The patients underwent postoperative expansion/adjuvant cancer therapy, then tissue expander exchange for permanent silicone breast prostheses. Patients were followed through the postoperative course to assess complication outcomes. Histologic evaluation of host integration into the dermal matrix was also assessed. RESULTS: Of the ten patients, eight completed reconstruction while two patients failed reconstruction. The failures were related to chronic seromas and infection. Histology analysis confirms rapid integration of mesenchymal cells into the matrix compared to other acellular dermal matrices. CONCLUSIONS: Based on our observations, DermACELL is an appropriate adjunct to reconstruction with expanders. Histological analysis of vascularization and recellularization support the ready incorporation of DermACELL into host tissue. Level of Evidence: Level IV, therapeutic study.

An alternative mucosal flap for nasal lining: the superior labial artery mucosal flap-an anatomic study.

Reconstruction of nasal lining and septal defects is a challenging problem. An ideal reconstructive option provides ample thin, like tissue with reliable perfusion in a relatively short, single-staged procedure. The purpose of this study is to describe the vascular anatomy of the superior labial artery and an axial mucosal flap, the superior labial artery mucosal flap, based on this vascular pedicle, proposed for a single-stage reconstruction of nasal lining and septal defects.Dissection of the 10 facial arteries and their branches with a focus on the superior labial arteries was performed in a total of 5 fresh human cadavers. Objective findings on the vascular anatomy were assessed and upper lip mucosal flaps, medially based on the superior labial artery, were elevated. The case of a 30-year-old man who sustained a dog bite to the nose with a resulting full-thickness loss of his entire nasal tip and partial loss of his alar subunits is presented.In complex cases of nasal reconstruction in which nasal lining of associated defects cannot be accomplished with local flaps, we describe the anatomic basis for a regional single-staged, axial flap alternative for reconstruction.

Treatment of mandibular angle fractures with a matrix strut miniplate.

New innovative techniques and more efficacious hardware allowing rapid and reliable fixation have resulted in better mandibular angle fracture management. This article presents follow-up data to our previous report, "Treatment of mandibular angle fracture with a matrix miniplate: a preliminary report," regarding the safety and efficacy of the 2.0 matrix strut miniplate in clinical practice. Mandibular angle fractures repaired with a single 2.0 matrix strut miniplate, using an intraoral approach, were selected for chart review over a 10-year period. Demographics including patient information, fracture etiology, site of fracture, treatment, surgical duration, and follow-up were collected. Complications were recorded along with the method of treatment. The significance (P = 0.05) of association between demographic and clinical factors with surgical complications was examined using Fisher exact tests. Thirty-four patients with mandibular angle fractures underwent matrix miniplate fixation via an intraoral approach. These patients were followed up for a mean follow-up period of 12 months. Four patients developed complications: 2 with infection requiring hardware removal and external fixation (5.9%), 1 infection treated with incision and drainage (2.9%), and 1 nonunion (2.9%). The matrix strut miniplate offers surgeons another tool to successfully accomplish mandibular fixation expediently while minimizing additional risk to patients. This system adds superior stability without negatively impacting other aspects of care and should be strongly considered for angle fixation.

An algorithmic approach to the management of limb ischemia in infants and young children.

BACKGROUND: Vascular injuries in newborns are rare and most commonly occur in the process of obtaining vascular access for monitoring organ system functions or interventions in critical care. Care of vascular injuries in neonates poses several challenges, with the most significant arguably being the lack of clinical experience with such injuries. An algorithm for the management of arterial injuries in pediatric patients is investigated and reported. METHODS: A retrospective chart analysis was performed on all patients consulted for the management of vascular injury by the plastic surgery service at Texas Children's Hospital between 1997 and 2005. The outcomes and procedures were reviewed. RESULTS: Thirty vascular insults in 28 patients were evaluated and treated by the senior author (J.D.F.) using this protocol. Thirty-seven percent (11 of 30) were approached surgically, including two cases treated with thrombolysis alone. The remaining 63 percent (19 of 30) were managed with more conservative interventions, including anticoagulation and clinical optimization. When color Doppler imaging was used preoperatively to locate and describe the characteristics of vascular injuries, visualized lesions coincided with the surgical findings in 100 percent (11 of 11 cases). Twenty-three limbs (77 percent) were salvaged completely using this algorithm, one was initially salvaged but later developed limb-length discrepancy requiring amputation, and one experienced complete limb loss. The remaining patients (five of 30) died as a result of complications of their primary medical conditions before limb salvage could be assessed. CONCLUSION: This evaluation demonstrates the efficacy of the proposed algorithm used to determine direction of care in the event of arterial injury in small children.

Tip nuances for the nose of African descent.

Patients of African descent are seeking rhinoplasties today more than ever. As a result, the rhinoplasty surgeon must be aware of the ethnic, cultural, anatomic, and surgical issues pertaining to this patient population. In this article, the nuances of rhinoplasty as it pertains to the nasal tip in patients of African descent are discussed.

The treatment of an unusual complication associated with a HeartMate II LVAD in an adolescent.

The HeartMate II LVAD has provided a bridge to heart transplantation or a permanent fixture for destination therapy for patients with heart failure. LVAD infections are associated with significant morbidity even when treated with explantation, device exchange, or a salvage procedure. We present an unusual complication following the placement of the HeartMate II device in an adolescent, whereby a pocket infection resulted in a large soft tissue defect overlying and surrounding the device. The novel use of a VRAM flap was successfully used to repair the defect and salvage the device.

Late seroma during pregnancy, a rare complication in prosthetic breast augmentation: case report.

A 29 year old Hispanic woman with a history of breast augmentation and a pregnancy complicated by placental abruption presented to the plastic surgery service for evaluation of a swollen right breast. The patient was examined and several tests were performed to rule out infection, galactocele, and malignancy. The swelling was attributed to fluid adjacent to her implant which was aspirated and found to contain red blood cells and foam cells but no infectious agent or malignant cells. One month after aspiration and continued drainage, the patient returned with recurrent swelling and pain. Repeat imaging showed recurrent fluid collection in the right breast. Excision and capsulectomy were performed and the patient was found to have a double capsule with a seroma. This article presents the first known case of pregnancy-associated late implant seroma formation, as well as a brief review of the literature regarding this rare finding in prosthetic breast augmentation.

Perioperative steroids for minimizing edema and ecchymosis after rhinoplasty: a meta-analysis.

BACKGROUND: Minimizing complications after rhinoplasty is a priority for every surgeon performing the procedure. Perioperative steroid administration has been shown to decrease postoperative edema and ecchymosis in a number of prospective randomized trials. OBJECTIVES: In an effort to further elucidate the significance of the data and develop an evidence-based algorithm for steroid administration, the authors offer a meta-analysis of the existing literature. METHODS: A systematic review of the literature was performed. All articles were reviewed for relevant data, which were extracted, pooled, and compared. Seven prospective randomized trials investigating perioperative steroid use in rhinoplasty have been conducted and reported. Four of these studies had the same method of patient edema and ecchymosis assessment, and their data were compared. RESULTS: Based on results from the four relevant studies, perioperative steroid use significantly reduces postoperative edema and ecchymosis of the upper and lower eyelids at one day and seven days postoperatively (P < .0001). Preoperative steroid administration decreases postoperative upper and lower eyelid edema at one day preoperatively, when compared to postoperative administration (P < .05). Extended dosing is superior to one-time dosing (P < .05). CONCLUSIONS: Perioperative steroid use decreases postoperative edema and ecchymosis associated with rhinoplasty. Preoperative administration is superior to postoperative, and extended dosing is superior to singular. Based on these results, evidence-based guidelines for perioperative steroid administration can be given.

A novel autologous scaffold for diced-cartilage grafts in dorsal augmentation rhinoplasty.

BACKGROUND: Diced-cartilage grafts have been used for dorsal nasal augmentation for several years with good results. However, compounds such as Surgicel and temporalis fascia used as a wrap have inherent problems associated with them, predominantly inflammation and graft resorption. An autologous carrier could provide stabilization of cartilage grafts while avoiding the complications seen with earlier techniques. METHODS: In our patients, a malleable construct was used for dorsal nasal augmentation in which autologous diced-cartilage grafts were stabilized with autologous tissue glue (ATG) created from platelet-rich plasma (platelet gel) and platelet-poor plasma (fibrin glue). RESULTS: A prospective analysis of 68 patients, who underwent dorsal nasal augmentation utilizing ATG and diced-cartilage grafts between 2005 and 2008, were included in the study. Although there was notable maintenance of the dorsal height, no complications occurred that required explantation over a mean follow-up of 15 months. CONCLUSION: The use of ATG to stabilize diced-cartilage grafts is a safe, reliable technique for dorsal nasal augmentation. The platelet gel provides growth factors while the fibrin glue creates a scaffold that allows stabilization and diffusion of nutrients to the cartilage graft.

Use of the descending branch of the lateral femoral circumflex vessels as a composite interposition graft in lower extremity reconstruction.

The prevailing treatment for distal third lower extremity defects is with autologous free tissue transfers. In the trauma patient, these reconstructions are wrought with challenges, including the selection of appropriate recipient vessels, avoiding the zone of injury, and choosing the appropriate flap for transfer, all while maintaining perfusion to the foot. With distal defects and a large zone of injury, the free flap pedicle may need additional length to cover the defect and reach the recipient vessels without excess tension. The creation of an arteriovenous loop from an autologous vein graft is the usual solution. We present a case where additional pedicle length was needed to have a free flap completely cover a distal leg defect and connect to the anterior tibial vessels proximally. The saphenous vein was not available as an interposition graft; therefore, the descending branch of the lateral femoral circumflex artery and venae comitantes were used as a composite arteriovenous interposition graft.

The need for breast cancer screening in women undergoing elective breast surgery: an assessment of risk and risk factors for breast cancer in young women.

BACKGROUND: Given the 11% lifetime risk of breast cancer and increasing popularity of elective breast surgery, the role of preoperative screening begs further investigation. There are currently no guidelines that indicate which women younger than 40 years of age should be screened preoperatively. OBJECTIVES: A meta-analysis of studies regarding the odds ratio (OR) and relative risk ratio for breast cancer risk factors in women younger than 40 was completed. METHODS: Of a total of 240 results in the PubMed database for articles referencing breast cancer risk factors in young women, eight were selected for review. A total of 5381 patients were included in the studies in this meta-analysis; 26 risk factors were identified. A meta-analysis was performed to determine the OR of each specific risk factor, with a 95% confidence interval. RESULTS: The most significant risk factors were having a sister with breast cancer (OR, 11.66), having a first-degree relative with breast cancer (OR, 2.66), having a mother with breast cancer (OR, 2.31), never having breastfed (OR, 1.77), and having undergone a breast biopsy (OR, 1.66). From these data, the authors developed a clinical questionnaire to estimate the risk of breast cancer in young women. In addition, an algorithm was developed for preoperative breast cancer screening for women of all ages undergoing elective breast procedures. CONCLUSIONS: For women younger than 40, the preoperative risk assessment involves two steps. First, the possibility of existing breast cancer should be evaluated with a preoperative screening survey. Second, the patient's risk for future development of cancer should be assessed, with a focus on genetic mutations. Women older than 40 years of age should be stratified to receive either a preoperative mammogram or MRI. The clinical questionnaire and preoperative screening algorithm provide an evidence-based guideline on which to base the discussion with patients regarding preoperative breast cancer screening.

Contemporary techniques in inferior turbinate reduction: survey results of the American Society for Aesthetic Plastic Surgery.

BACKGROUND: Nasal airway obstruction is a frequently-encountered problem, often secondary to inferior turbinate hypertrophy. Medical treatment can be beneficial but is inadequate for many individuals. For these refractory cases, surgical intervention plays a key role in management. OBJECTIVE: The authors evaluate the current trends in surgical management of inferior turbinate hypertrophy and review the senior author's (SS) preferred technique. METHODS: A questionnaire was devised and sent to members of the American Society for Aesthetic Plastic Surgery (ASAPS) to determine their preferred methods for assessment and treatment of inferior turbinate hypertrophy. RESULTS: One hundred and twenty-seven physicians responded to the survey, with 85% of surveys completed fully. Of the responses, 117 (92%) respondents were trained solely in plastic surgery and 108 (86.4%) were in private practice. Roughly 81.6% of respondents employ a clinical exam alone to evaluate for airway issues. The most commonly-preferred techniques to treat inferior turbinate hypertrophy were a limited turbinate excision (61.9%) and turbinate outfracture (35.2%). CONCLUSIONS: Based on the results of this study, it appears that limited turbinate excision and turbinate outfracture are the most commonly-used techniques in private practice by plastic surgeons. Newer techniques such as radiofrequency coblation have yet to become prevalent in terms of application, despite their current prevalence within the medical literature. The optimal method of management for inferior turbinate reduction should take into consideration the surgeon's skill and preference, access to surgical instruments, mode of anesthesia, and the current literature.

Preventing the "bottoming out" and "star-gazing" phenomena in inferior pedicle breast reduction with an acellular dermal matrix internal brassiere.

BACKGROUND: The phenomena of "bottoming out" (pseudoptosis) and "star-gazing" (the upward rotation of the nipple-areola complex) is a common postoperative problem when using the inferior pedicle breast reduction technique. Multiple techniques have been described to help prevent this problem, including internal suspension techniques and the use of mesh to support the pedicle. We describe our technique and present a case series in which acellular dermal matrix (AlloDerm(®)) is used as an internal brassiere or sling to support the inferior pedicle and prevent postoperative "bottoming out" and "star-gazing." METHODS: Twenty-seven patients underwent inferior pedicle reduction mammaplasty through a Wise pattern performed by a single surgeon. In each case, acellular dermal matrix (0.79-2.03 mm thick) was sutured to the chest wall as a sling or internal brassiere to support the inferior pedicle. The pedicle was also plicated in a horizontal fashion to increase the projection of the breast and to improve the position of the nipple-areola complex. RESULTS: The mean weight of reduction per breast was 850 g. The mean distance from the nipple to the inframammary fold was 16.4 cm. The mean distance from the sternal notch to the nipple was 32.2 cm. Only one patient developed cellulitis and one patient had partial skin flap necrosis. There was no nipple loss. At routine follow-up it was found that the aesthetic breast shape has been retained and pseudoptosis or "bottoming out" was not significant in any patient. The longest follow-up is 29 months. CONCLUSION: The use of an acellular dermal matrix internal brassiere is a safe and effective technique for preventing the "bottoming out" and "star-gazing" phenomena that occurs after inferior pedicle breast reduction. Longer-term follow-up will be required to assess the longevity of these results.