Scrotal Reconstruction with Integra Following Necrotizing Fasciitis.

Scrotal loss from Fournier's gangrene can be a devastating injury with esthetic and functional consequences. Local reconstructive options can be limited by the presence of infection or the loss of neighboring tissue from debridement. IntegraTM bilayer matrix wound dressing is a well-established reconstructive modality, but only one report exists of its use in scrotal reconstruction and this was not in the setting of Fournier's gangrene. We report the successful use of Integra and a subsequent split-thickness skin graft for reconstruction of the anterior scrotum and coverage of the exposed testes in a 43-year-old man who developed Group A Streptococcus necrotizing fasciitis of his right lower extremity, groin, and scrotum requiring serial operative debridements. Stable testicular coverage was achieved with closely matched skin and minimal donor-site morbidity. Further study and a larger sample size will be necessary to better understand the advantages and disadvantages of scrotal reconstruction with Integra.

Tumor-to-Nipple Distance as a Predictor of Nipple Involvement: Expanding the Inclusion Criteria for Nipple-Sparing Mastectomy.

BACKGROUND: A tumor-to-nipple distance of greater than 2 cm has traditionally been considered a criterion for nipple-sparing mastectomy. This study evaluates whether magnetic resonance imaging and sonographic measurements of tumor-to-nipple distance accurately reflect the risk of nipple involvement by disease. METHODS: All nipple-sparing mastectomy cases with implant-based reconstruction performed by the senior author between July 2006 and December 2014 were retrospectively reviewed. Therapeutic cases with preoperative magnetic resonance imaging or sonography were included. RESULTS: One hundred ninety-five cases were included. Preoperative imaging consisted of sonography (n = 169), magnetic resonance imaging (n = 152), or both (n = 126). With sonography, nipple involvement did not differ between nipple-sparing mastectomy candidates and noncandidates using a tumor-to-nipple distance cutoff of 2 cm (10.7 percent versus 10.6 percent; p = 0.988) or 1 cm (9.3 percent versus 15.0 percent; p = 0.307). With magnetic resonance imaging, nipple involvement did not differ between candidates and noncandidates using a cutoff of 2 cm (11.6 percent versus 12.5 percent; p = 0.881) or 1 cm (11.4 percent versus 13.8 percent; p = 0.718). When sonography and magnetic resonance imaging findings were both available and concordant, nipple involvement still did not differ between candidates and noncandidates using a cutoff of 2 cm (8.8 percent versus 11.8 percent; p = 0.711) or 1 cm (7.6 percent versus 14.3 percent; p = 0.535). CONCLUSION: A tumor-to-nipple distance as small as 1 cm, as measured by sonography or magnetic resonance imaging, should not be considered a contraindication to nipple-sparing mastectomy. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Nipple Resection and Reconstruction After Attempted Nipple-Sparing Mastectomy.

BACKGROUND: Occult nipple malignancy is detected in 0% to 58% of attempted nipple-sparing mastectomies (NSM), prompting excision of the nipple. We report our experience with nipple resection following attempted NSM and our outcomes with subsequent nipple reconstruction. METHODS: An institutional review board-approved retrospective review was performed of attempted NSM cases with immediate implant-based reconstruction from July 2006 to April 2015. Patients who underwent nipple excision were identified. Indications for excision, pathology reports, and reconstructive outcomes were reviewed. RESULTS: Five hundred sixty-eight NSMs were performed in 330 patients. Thirty-four (6%) cases underwent nipple excision, 53% for positive frozen sections, 29% for positive permanent sections, 3% for clinical suspicion, and 15% either at patient request or for symmetry. All of the cases with positive frozen sections had disease on permanent section and 56% had residual disease in the resection specimen. Of the cases with positive permanent sections, frozen sections were negative in 50%, suspicious or atypical in 30%, and not sent in 20% of cases. Thirty percent had residual disease in the resection specimen. Frozen section sensitivity was 64% (or 75% if suspicious and atypical findings are included). There were no false-positive results on frozen section. Sixty-eight percent of cases have undergone nipple reconstruction by CV flap (57%), skate flap (39%), or nipple-sharing technique (4%). The aesthetic result after reconstruction was excellent in 83% of cases. CONCLUSIONS: Our findings support the benefit of intraoperative subareolar frozen section for detection of occult disease. When nipple excision is required, patients can still achieve an excellent aesthetic result with reconstruction.

Nipple-Sparing Mastectomy via an Inframammary Fold Incision with Implant-Based Reconstruction in Patients with Prior Cosmetic Breast Surgery.

BACKGROUND: Nipple-sparing mastectomy through an inframammary fold incision (NSM-IMF) with implant-based reconstruction (IBR) is a cosmetically preferable approach to breast cancer treatment in appropriate candidates. However, patients who have undergone prior cosmetic breast surgery (CBS) may be at increased risk for postoperative complications secondary to existing surgical scars. OBJECTIVE: To assess whether prior CBS increases the risk of complications following NSM-IMF with IBR. METHODS: A retrospective chart review was conducted for 398 NSM-IMFs with IBR performed between July 2006 and December 2013. CBS cases were identified. Outcomes were reviewed. RESULTS: Of 398 NSM-IMF cases, 41 had prior CBS: 24 augmentations, 12 reductions, three mastopexies, and two augmentation mastopexies. NSM-IMF was performed an average of 8 years following CBS. CBS cases had lower BMIs (P = .040), more breast tissue resected (P = .021), wider breast bases (P = .0002), more single-stage reconstructions (P < .0001), more ADM use (P < .0001), and larger permanent implants (P = .0051) than those without CBS. Postoperatively, CBS cases had higher rates of mastectomy flap ischemia (P = .0392) and hematoma (P = .0335). Among CBS cases, single-stage reconstruction was associated with increased full-thickness flap ischemia (P = .0066). Compared to prior augmentation cases, prior reduction/mastopexy cases had higher rates of capsular contracture (P = .0409) and seroma (P = .0226). CONCLUSIONS: This series is the largest to date to evaluate the success of NSM-IMF with IBR in CBS patients. These women should be cautiously considered for IBR, particularly in the setting of single-stage reconstruction. LEVEL OF EVIDENCE: 4 Therapeutic.

Nipple-sparing mastectomy via an inframammary fold incision for patients with scarring from prior lumpectomy.

BACKGROUND: Nipple-sparing mastectomy (NSM) through an inframammary fold (IMF) incision can provide superior cosmesis and a high level of patient satisfaction. Because of concerns for nipple-areolar complex (NAC) viability using this incision, selection criteria may be limited. Here, we evaluate the impact of scarring from prior lumpectomy on NAC viability. METHODS: A retrospective chart review was conducted on a prospectively collected database at a single institution between July 2006 and October 2012. A total of 318 NSMs through IMF incisions were performed. We compared the incidence of NAC ischemia in 122 NSM cases with prior lumpectomy with 196 NSM cases without prior lumpectomy. All 318 mastectomies were followed by implant-based reconstruction. Clinicopathologic factors analyzed included indications for surgery, technical details, patient demographics, comorbidities, and adjuvant therapy. RESULTS: The overall incidence of NAC ischemia was 20.4% (65/318). Nipple-areolar complex ischemia occurred in 24.6% (30/122) of cases with prior lumpectomy and 17.9% (35/196) of cases without prior lumpectomy (P = 0.1477). Among the 30 ischemic events in the 122 cases with prior lumpectomy, epidermolysis occurred in 20 (16.4%) and necrosis occurred in 10 (8.2%). Two cases (1.6%) required operative debridement. Seven cases (5.7%) were left with areas of residual NAC depigmentation. All other cases completely resolved with conservative management. There was no significant correlation between the incidence of ischemia and surgical indication, tumor staging, age, body mass index, tissue resection volume, sternal notch to nipple distance, prior radiation, single-stage reconstruction, sentinel or axillary lymph node dissection, acellular dermal matrix use, presence of periareolar lumpectomy scars, diabetes, or smoking history. At a mean follow-up of 505 days (range, 7-1504 days), patient satisfaction was excellent. Local recurrence of breast cancer occurred in 3 cases (2.5%), and distant recurrence occurred in 2 cases (1.6%). CONCLUSIONS: Patients with scarring from prior lumpectomy do not have a higher rate of NAC ischemia and may be considered for NSM via an IMF incision.

A novel technique of preserving internal mammary artery perforators in nipple sparing breast reconstruction.

SUMMARY: As nipple-sparing mastectomy with implant-based reconstruction has increased, attention must be paid to the viability of the nipple-areolar complex. This article describes the use of preoperative Doppler ultrasound to identify the internal mammary artery perforators. Preserving the internal mammary artery improves vascular supply to the nipple-areolar complex.

Nipple-areolar complex ischemia after nipple-sparing mastectomy with immediate implant-based reconstruction: risk factors and the success of conservative treatment.

BACKGROUND: Nipple-sparing mastectomy performed via an inframammary fold incision with implant-based reconstruction is an oncologically safe procedure that provides excellent cosmesis. OBJECTIVES: The authors report their experience with conservative treatment of postoperative nipple-areolar complex (NAC) ischemia and an analysis of risk factors for NAC ischemia and conservative treatment failure. METHODS: A retrospective chart review was conducted of 318 nipple-sparing mastectomies performed through inframammary fold incisions with implant-based reconstruction between July 2006 and October 2012. NAC dressings consisted of topical nitroglycerin, external warming for 24 hours, antibacterial petrolatum gauze, and a loose bra for 1 week. Patients were monitored for NAC ischemia as the primary endpoint. NAC ischemia was treated with bacitracin ointment. In cases of full-thickness ischemia, expanders were also partially deflated. RESULTS: Partial- and full-thickness NAC ischemia occurred in 44 (13.8%) and 21 (6.6%) cases, respectively. All partial- and 17 full-thickness cases resolved with conservative treatment. Of these, 7 partial- and 2 full-thickness cases suffered residual depigmentation. Four full-thickness cases required operative debridement. Factors associated with NAC ischemia included increasing age (P = .035), higher body mass index (P = .0009), greater breast volume (P = .0023), and diabetes (P = .0046). Factors associated with conservative treatment failure included increasing age (P < .0001), higher body mass index (P = .014), greater breast volume (P = .020), smoking (P = .0449), acellular dermal matrix use (P < .0001), and single-stage reconstruction (P = .0090). CONCLUSIONS: Postoperative NAC ischemia can be effectively managed conservatively to preserve cosmesis and implant viability. Knowledge of risk factors for NAC ischemia and conservative treatment failure may improve future patient counseling and outcomes.

Surgical treatment of nipple malposition in nipple-sparing mastectomy device-based reconstruction.

BACKGROUND: This article discusses the senior author's (M.T.) experience with nipple-areola complex malposition following nipple-sparing mastectomy, surgical options for treatment, and an analysis of risk factors. METHODS: A retrospective review was conducted on a prospectively collected institutional review board-approved database of nipple-sparing mastectomy cases with immediate device-based reconstruction performed between July of 2006 and October of 2012. Malposition was graded as mild (1 cm), moderate (2 cm), or severe (>3 cm) displacement. RESULTS: Three hundred nineteen nipple-sparing mastectomies were reviewed. Malposition occurred in 44 (13.79 percent). Significant factors were age (p < 0.0001), diabetes mellitus (p = 0.0025), body mass index (p = 0.0093), preoperative sternal notch-to-nipple distance (p = 0.015), preoperative breast base width (p = 0.0001), periareolar mastectomy incision with lateral extension (p < 0.0001), prior radiation (p = 0.0004), prior lumpectomy (p = 0.0125), unilateral nipple-sparing mastectomy (p = 0.0004), and postoperative nipple-areola complex ischemia (p = 0.0174). Smoking status, breast volume resected, implant size, ablative surgeon, acellular dermal matrix, and single-stage reconstruction were not significant. Nineteen patients were satisfied. Eight were not offered surgical correction because of an inadequate skin envelope. Eight had crescent mastopexy, three had implant exchange and pocket revision, four had free nipple grafts, and two had pedicled nipple transposition. There were no incidences of necrosis or malposition after surgical correction. CONCLUSIONS: Nipple-sparing mastectomy followed by immediate device-based reconstruction has a risk of nipple malposition. Various surgical procedures are available to correct nipple malposition based on clinical presentation and are safe in certain populations. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Body contouring after bariatric surgery: how much is really being done?

The proportion of postbariatric surgery patients who undergo body contouring (BC) procedures is unknown. We designed a study to explore demographic features and patient education regarding BC in the bariatric surgery (BS) population. A survey was mailed to 1158 patients who underwent BS by 2 surgeons between 2003 and 2011. A total of 284 (24.5%) patients responded. Seventy-two patients (25.4%) reported discussing BC surgery with their bariatric surgeon perioperatively. Forty patients (14.1%) were referred for plastic surgery consultation. Thirty-three patients (11.6%) underwent BC procedures. The most frequent reasons cited for not undergoing BC were expense (29.2%) and lack of awareness regarding options (23.6%). Thirty-nine percent of respondents reported that they might have chosen differently, had they received more information. As a result of insufficient perioperative counseling, the majority of BS patients are unaware of the multitude of BC procedures available. Additional efforts toward improving patient (and surgeon) education regarding postbariatric BC options are warranted.