Rippling Associated with Pre-Pectoral Implant Based Breast Reconstruction: A New Grading System.

BACKGROUND: The incidence of breast cancer and immediate breast reconstruction is on the rise particularly in the US and Western Europe. Over the last decade, implant based breast reconstructions have gained popularity. The prepectoral breast reconstruction has emerged as a novel technique, minimally invasive, preserves the chest wall anatomy while restoring body image. However, implant rippling appears to be an adverse effect associated with this technique. METHODS: We have described a new grading system for rippling following prepectoral implant breast reconstruction and discussed its management. We then evaluated the new grading system in our practice. RESULTS: We looked at the first 50 consecutive patients who underwent prepectoral implant based breast reconstruction. In our experience, 45 patients (90%) had grade 1, 3 patients (6%) had grade 2, 1 patient (2%) had grade 3 and 1 patient (2%) had grade 4 rippling. The observed rippling was seen more often in patients with low BMI<20 and in those who had poor subcutaneous fat preoperatively (pinch test<2 cm). CONCLUSION: Prepectoral implant based breast reconstruction adds a whole new dimension to breast reconstruction. However rippling can be an undesired adverse effect associated with this technique and patients need to be informed.

Tissue Contraction-A New Paradigm in Breast Reconstruction.

BACKGROUND: Skin expansion is commonly needed in order to reconstruct the breast following modified radical mastectomy. With the advent of skin-sparing and nipple-sparing techniques, expansion is no longer necessary. The natural ability of healing tissues to contract can be advantageously used to improve the outcomes of immediate prepectoral breast reconstruction. METHODS: A prospective analysis of the results of 20 prepectoral breast reconstructions following skin-sparing or nipple-sparing mastectomies was performed. Reconstruction was performed using the adjustable breast implant initially underfilled with air. No acellular dermal matrix or mesh support was used. Further air was added during the follow-up office visits. Air was replaced with normal saline when the desired breast size was achieved. The adjustable implants were replaced with silicone gel implants when necessary. RESULTS: Contraction of the skin flap over the underfilled implant was noticed in all patients. Five patients (25%) developed a seroma, and 2 patients had hematoma of the breast pocket. Wound-edge necrosis required debridement in 2 patients (10%). Complications were all resolved without implant loss. CONCLUSIONS: Tissue contraction can be successfully utilized in breast reconstruction following skin-sparing and nipple-sparing mastectomy. Contraction results in thickening and elevation of the flap, eliminating the need for skin excision or the use of acellular dermal matrix. The partially filled implant functions as a spacer, preventing the flap from adhering to the underlying muscle and avoiding pressure on the skin flap.

Surgical Site Irrigation in Plastic Surgery.

BACKGROUND: The incidence of infection following breast implant reconstruction remains high at the level of 24%. Surgical site irrigation is commonly used for its prevention. However, the lack of evidence-based guidelines for antibiotic prophylaxis in breast implant surgery necessitates research for optimal irrigation technique. OBJECTIVES: composition and exposure time of irrigation solution for surgical site infection (SSI) prophylaxis using an in vitro model of a surgical site. METHODS: The study design was an in vitro model to assess antibiotic irrigation of a surgical site. Strains of Staphylococcus aureus, Methicillin-resistant Staphylococcus aureus, Group A Streptococcus, and Pseudomonas aeruginosa were seeded on blood agar growth medium and irrigated with various antibiotic and antiseptic solutions under different exposure times. The presence and quantity of the colonies grown were estimated after 24-hour incubation. Repetition of the studies for 5 times with each investigated irrigation solution and microorganism was performed. Optimal irrigation agents were chosen based on the ability to achieve sterility with minimal tissue toxicity. RESULTS: The optimal wound irrigation agents for SSI prophylaxis in our study were found to be 0.05% chlorhexidine or triple antibiotic antibiotic solutions. Adding of vancomycin to the irrigation solutions did not show an increase in their effectiveness. Prolonged irrigation exposure time was necessary to achieve sterility of the in vitro model of a surgical site. CONCLUSIONS: We recommend 0.05% chlorhexidine or triple antibiotic solution for topical SSI prophylaxis in breast implant surgery. Sufficient time of irrigation can be achieved by maintaining some of the solution in the pocket and delaying drainage for at least 30 minutes.

Filling the Spectrum Expander with Air-A New Alternative.

The Spectrum adjustable saline implant is optimal for prepectoral breast reconstruction as it can be placed virtually empty and thus flat, applying no pressure on the overlying skin flap. However, when saline is added, it tends to pool at the bottom of the implant resulting in its uneven surface and rippling. Air filling results in the uniform distribution within the implant shell and smooth even implant surface, which facilitates acellular dermal matrix adhesion. Pressure to the skin flap is averted, patients are more comfortable, and rippling is not seen.