Meta-analysis of prepectoral implant-based breast reconstruction: guide to patient selection and current outcomes.

PURPOSE:  This meta-analysis provides a large-scale comparison of prepectoral vs. subpectoral implant-based breast reconstruction, with primary outcomes of patient safety and efficacy. METHODS: Literature review was performed via PRISMA criteria, 33 studies met inclusion criteria for prepectoral review and 13 studies met inclusion criteria for meta-analysis. Patient characteristics and per-breast complications were collected. Data were analyzed using Cochrane RevMan and IBM SPSS. RESULTS: In 4692 breasts of 3014 patients that underwent prepectoral breast reconstruction, rippling was observed as the most common complication, followed by seroma and skin flap necrosis. Meta-analysis demonstrated statistically significant decrease in odds of skin flap necrosis and capsular contracture in prepectoral groups compared to subpectoral groups. Odds of infection, seroma, and hematoma were equal between the two groups. CONCLUSIONS: Prepectoral breast reconstruction has surged in popularity in recent years. This review and large-scale analysis corroborates current literature reporting a favorable safety profile with emphasis on patient selection. Variability in skin flap thickness and vascularity mandates thoughtful selection of patients whose overall health and intra-operative skin flap assessment can tolerate a muscle-sparing reconstruction.

High-Efficiency Same-Day Approach to Breast Reconstruction During the COVID-19 Crisis.

PURPOSE: As our hospitals conserve and re-allocate resources during the COVID-19 crisis, there is urgent need to determine how best to continue caring for breast cancer patients. During the time window before the COVID-19 critical peak and particularly thereafter, as hospitals are able to resume cancer operations, we anticipate that there will be great need to maximize efficiency to treat breast cancer. The goal of this study is to present a same-day protocol that minimizes resource utilization to enable hospitals to increase inpatient capacity, while providing care for breast cancer patients undergoing mastectomy and immediate breast reconstruction during the COVID-19 crisis. METHODS: IRB exempt patient quality improvement initiative was conducted to detail the operationalization of a novel same-day breast reconstruction protocol. Consecutive patients having undergone immediate breast reconstruction were prospectively enrolled between February and March of 2020 at Massachusetts General Hospital during the COVID-19 crisis. Peri-operative results and postoperative complications were summarized. RESULTS: Time interval from surgical closure to patient discharge was 5.02 ± 1.29 h. All patients were discharged home, with no re-admissions or emergency department visits. No postoperative complications were observed. CONCLUSION: This report provides an instruction manual to operationalize a same-day breast reconstruction protocol, to meet demands of providing appropriate cancer treatment during times of unprecedented resource limitations. Pre-pectoral implant-based breast reconstruction can be the definitive procedure or be used as a bridge to autologous reconstruction. Importantly, we hope this work will be helpful to our patients and community as we emerge from the COVID-19 pandemic.

Dental Topics for Plastic Surgeons, Part One: Normal Anatomy, Growth and Development.

Normal and abnormal conditions affecting the dentition and the periodontal structures receive sparse coverage in the plastic surgery literature, textbooks, and training programs. Nevertheless, a working knowledge of this subject matter is important in certain areas of clinical practice, and a fundamental understanding is often part of plastic surgery competency tested for in the In-service and written board examinations. This four-part series is written to provide plastic surgeons with a working knowledge of relevant dental topics. Part 1 covers fundamental aspects of normal dental embryology, growth and anatomy.

Long Term Follow Up of a Vascularized Osteocutaneous Free Flap for Reconstruction in Charcot Neuroarthropathy: A Case Report.

Vascularized osteocutaneous free flaps have seen increasing use in foot and ankle surgery for the repair of bony defects secondary to chronic nonunion, osteomyelitis, and fractures. One example is the Medial Femoral Condyle (MFC) Flap. The utility of the MFC flap for the repair of a bony defect in a diabetic patient, however, has yet to be explored. We report the long-term results of a case describing the use of an MFC flap to reconstruct an osseous defect resulting from first metatarsophalangeal joint resection in a diabetic patient.

The P1 Method: Prepectoral Breast Reconstruction to Minimize the Palpable Implant Edge and Upper Pole Rippling.

BACKGROUND: Prepectoral prosthetic-based breast reconstruction has become increasingly popular as an alternative to the partial or total submuscular approach. Potential issues with the prepectoral approach include a noticeable superior implant edge and implant rippling. These concerns are particularly apparent in thin patients. We introduce a novel muscle-sparing technique in which a partial-thickness slip of pectoralis muscle is created in an otherwise prepectoral plane to mask these upper pole defects, mask superior implant rippling, and provide greater implant support (The P1 Method). METHODS: A retrospective review of all patients undergoing modified prepectoral (P1) breast reconstruction at a single institution over 2 years was undertaken. Data pertaining to patient demographics, mastectomy type/weight, reconstruction type, and esthetic and surgical outcomes were collected. Outcomes were analyzed using Fisher exact and Student t tests. RESULTS: Fifty patients (93 breasts) were identified during the study period. Mean final follow-up was 63 weeks (range, 53-85 weeks). Patients undergoing P1 reconstructions achieved improved esthetic results with less implant rippling and complete elimination of animation deformity seen on postoperative clinical images or at final follow-up. CONCLUSIONS: As prepectoral prosthetic-based breast reconstruction becomes more popular, architectural adaptations will be made to improve surgical and patient-centered outcomes. The P1 Method is effective in improving the superomedial contour in thin patients, minimizes upper pole rippling, and provides greater overall implant support.

Venous thromboembolism in plastic surgery: the current state of evidence in risk assessment and chemoprophylactic options.

The application of venous thromboembolism (VTE) prophylaxis has been the topic of intense debate in plastic surgery. The overall incidence of VTE is low in plastic surgery patients as compared to other surgical subspecialties but may be higher in the inpatient rather than outpatient plastic surgery populations. The Caprini Risk Assessment Model is the most highly studied and validated tool to assess VTE risk in plastic surgery patients. However, the Caprini model lacks procedure-specific risk assessment and patient-specific risk factor calculations. Due to these limitations, such as the low incidence and the heterogeneous nature of the specialty, trials lacked the power to capture proof of benefit, except in the highest-risk inpatient population. The emerging use of aspirin and novel oral anticoagulants may provide an alternative, as noninferiority in terms of efficacy and safety has been demonstrated in other fields. In this review, the authors intend to summarize the current state of evidence for prevention and explore the modalities available for prophylaxis, including novel oral anticoagulants.

Vagal Stimulation as Result of Pleural Stretch Secondary to Retraction during Internal Mammary Anastomosis.

Supplemental Digital Content is available in the text.

Central Mound Mastopexy for the Correction of Tuberous/Tubular Breast Deformity.

Tuberous and tubular breast deformity are well-recognized abnormalities in the plastic surgery community that incur severe physical and psychological consequences in affected patients. Current reconstructive options for the tuberous and tubular breasts favor the use of prosthetic implants and soft-tissue manipulation. We present a case of tuberous and tubular breast deformity treated with a central mound reduction technique and mastopexy with imbricating sutures without the use of prosthetic implants. The patient remained extremely pleased with her results at long-term follow-up. This represents a unique case of successful reconstruction in a patient with a tuberous and tubular breast deformity using a central mound reduction technique with mastopexy and without a prosthetic device.