Plastic Surgeons' Perspective on the FDA Breast Implant Regulatory Mandates.

BACKGROUND: In 2021, the US FDA issued a new checklist, labeling, and rupture-screening recommendations for breast implants to improve the decision-making process. OBJECTIVES: The aim of this study was to understand plastic surgeons' perspective on these changes and their perceived impact on clinical practice. METHODS: In September 2023, a 27-question multiple-choice cross-sectional survey was distributed to 4352 active members of the American Society of Plastic Surgeons to evaluate attitudes on the FDA's black-box warning, informed decision checklist, and updated rupture-screening recommendations. RESULTS: A total of 591 responses were collected (13.6%). The majority of respondents were between the ages of 45 and 64 years (58%) and had been in practice for more than 20 years (52%). Surgeons felt that some additions were appropriate; however, the majority (57%) stated that the informed decision checklist did not have a positive impact on workflow; 66% were also neutral or disagreed with the reported incidence rates related to complications and cancer. Nearly half of respondents (47%) did not feel the black-box warning improved their patients' understanding of the risks and benefits. Additionally, 47% of respondents also believed these requirements, in combination, did not improve the overall patient experience with implants. CONCLUSIONS: Respondents had an overall positive response towards the addition of risk information provided by the FDA-issued guidance and updates to rupture-screening recommendations. However, they remained divided as to whether the black-box warning and patient decision checklist had an overall positive impact on clinical practice patterns.

Peroxisome Proliferator-Activated Receptor-γ Knockdown Impairs Bone Morphogenetic Protein-2-Induced Critical-Size Bone Defect Repair.

The Food and Drug Administration-approved clinical dose (1.5 mg/mL) of bone morphogenetic protein-2 (BMP2) has been reported to induce significant adverse effects, including cyst-like adipose-infiltrated abnormal bone formation. These undesirable complications occur because of increased adipogenesis, at the expense of osteogenesis, through BMP2-mediated increases in the master regulatory gene for adipogenesis, peroxisome proliferator-activated receptor-γ (PPARγ). Inhibiting PPARγ during osteogenesis has been suggested to drive the differentiation of bone marrow stromal/stem cells toward an osteogenic, rather than an adipogenic, lineage. We demonstrate that knocking down PPARγ while concurrently administering BMP2 can reduce adipogenesis, but we found that it also impairs BMP2-induced osteogenesis and leads to bone nonunion in a mouse femoral segmental defect model. In addition, in vitro studies using the mouse bone marrow stromal cell line M2-10B4 and mouse primary bone marrow stromal cells confirmed that PPARγ knockdown inhibits BMP2-induced adipogenesis; attenuates BMP2-induced cell proliferation, migration, invasion, and osteogenesis; and escalates BMP2-induced cell apoptosis. More important, BMP receptor 2 and 1B expression was also significantly inhibited by the combined BMP2 and PPARγ knockdown treatment. These findings indicate that PPARγ is critical for BMP2-mediated osteogenesis during bone repair. Thus, uncoupling BMP2-mediated osteogenesis and adipogenesis using PPARγ inhibition to combat BMP2's adverse effects may not be feasible.

Evaluating Current Scar Assessment Methods.

Current scar surveys have included many questions to evaluate the physical characteristics of scars, with some expanding to include physical implications and patient opinions. This review provides an analysis of frequently used scar assessment methods to date and highlights potential areas for improvement. We build the case that a new assessment tool is necessary, specifically one that centers on psychosocial consequences of scars that influence patient decision making for treatment, allowing physicians to individualize treatment conversations with patients. We postulate that survey techniques used in consumer product marketing, such as choice-based conjoint analysis, may be effective in determining the factors strongly influencing patient decision making and spending in scar treatment; therefore, more research in this area is warranted. By incorporating these psychosocial and economic considerations driving scar treatment decisions, future scar assessment tools may accomplish much more than characterizing/documenting the clinical aspects of scars. Rather, these patient-centered, holistic tools may be implemented by plastic surgeons and other clinicians specifically to provide patients with personalized treatment options that maximize long-term patient satisfaction.

Latissimus Dorsi Flap Breast Reconstruction-A Nationwide Inpatient Sample Review.

INTRODUCTION: The latissimus dorsi (LD) myocutaneous flap has been a long term standard for breast reconstruction. The variable indications for the LD flap have not been statistically examined because of the relative infrequency of its use by any single surgeon or institution. METHODS: The Nationwide Inpatient Sample data set was queried for all patient encounters involving a LD myocutaneous flap procedure. The study population was further restricted to female patients with a history of breast cancer or previous mastectomy. Demographics, Charlson Comorbidity Index scores, previous radiation history, and additional simultaneous procedures were extracted. Analysis was performed using nonparametric correlation coefficients and linear regression models. RESULTS: In total, 2304 LD breast reconstruction hospitalizations were identified between 2008 and 2010. Average patient age was 52.1 years, average hospital length of stay (LOS) was 2.8 days, bilateral latissimus reconstruction was performed in 252 (10.9%) patients, and 1414 patients (61.4%) were delayed reconstruction. Previous irradiation was present in 389 (16.9%) patients and was correlated with delayed reconstruction (P < 0.001).Younger age was associated with bilateral latissimus reconstructions (P < 0.05), contralateral free flap reconstruction (P < 0.0001), and combination with implants or tissue expanders (both P < 0.0001).After adjustment for age and Charlson Comorbidity Index, increased LOS was observed in patients undergoing contralateral free flap reconstruction (+1.29 days, P < 0.05) and immediate reconstruction (mastectomy, +0.39 days unilateral, P < 0.05; +0.64 days, bilateral, P < 0.001). The use of tissue expanders and implants were found to decrease hospital LOS (bilateral implant, -0.65 days, P < 0.001; bilateral expander, -0.72 days, P < 0.001), likely from confounding comorbidities. Charlson Comorbidity Index was strongly related to LOS (+0.08 days per point, P < 0.005), whereas age was not statistically significant when considered with comorbidity. CONCLUSIONS: The LD is most commonly used for delayed or salvage breast reconstruction, with particular utility in irradiated patients. Younger patients tend to undergo more involved LD variants with bilateral reconstructions and expanders or implants. After adjusting for comorbidity, age and the use of bilateral latissimus flaps with implants or expanders have no adverse impact on LOS.

The Surfactant Properties of Clindamycin as a Useful Adjunct for Removing Ruptured Silicone Implants.

Background: Silicone gel removal after breast implant rupture is a difficult task. Silicone is hydrophobic and thus cannot be irrigated effectively with saline. Attempts at mechanical removal with sponges are often partially successful. Incomplete removal results in persistent silicone contamination with possible local inflammation, infection, and silicone granulomata. In this partially quantitative investigation, we assess the de-adhesion ability of different clindamycin formulations against known surfactant controls when combined with silicone gel. Methods: To demonstrate surfactant properties in vitro, clindamycin phosphate, clindamycin hydrochloride, and a known surfactant, sodium dodecyl sulfate (SDS), were compared. An amount of 170 g of silicone gel placed in a dry glass container exhibited strong adherence to the container walls. In separate trials, clindamycin phosphate (300 mg in 100 mL), clindamycin HCl (300 mg in 100 mL), and SDS (1 g in 100 mL) solutions with normal saline were added to the silicone aggregate, and de-adhesion properties were compared. Results: All solutions aided in the de-adhesion of the sticky silicone from glass substrate. The SDS had the strongest effect, followed by clindamycin phosphate and then clindamycin HCl. The observed interactions suggested that all of the solutions behaved as ionic surfactant coating the silicone with negative charges via adsorption. However, the phosphate anionic formulation was associated with a greater surfactant effect than HCl. Conclusions: Clindamycin acts as a surfactant to aid in the clinical removal of ruptured silicone gel. Clindamycin phosphate seems to have a stronger effect than clindamycin HCl, likely related to the negative charges on the phosphate groups.

A Single-center Comparison of Surgical Outcomes following Prepectoral and Subpectoral Implant-based Breast Reconstruction.

Background: Prepectoral implant placement continues to gain widespread acceptance as a safe and effective option for breast reconstruction. Current literature demonstrates comparable rates of complications and revisions between prepectoral and subpectoral placement; however, these studies are underpowered and lack long-term follow-up. Methods: We performed a retrospective cohort study of patients who underwent immediate two-staged tissue expander or direct-to-implant breast reconstruction at a single center from January 2017 to March 2021. Cases were divided into prepectoral and subpectoral cohorts. The primary outcomes were postoperative complications, aesthetic deformities, and secondary revisions. Descriptive statistics and multivariable regression models were performed to compare the demographic characteristics and outcomes between the two cohorts. Results: We identified 996 breasts (570 patients), which were divided into prepectoral (391 breasts) and subpectoral (605 breasts) cohorts. There was a higher rate of complications (P < 0.001) and aesthetic deformities (P = 0.02) with prepectoral breast reconstruction. Secondary revisions were comparable between the two cohorts. Multivariable regression analysis confirmed that prepectoral reconstruction was associated with an increased risk of complications (odds ratio 2.39, P < 0.001) and aesthetic deformities (odds ratio 1.62, P = 0.003). Conclusions: This study evaluated outcomes in patients undergoing prepectoral or subpectoral breast reconstruction from a single center with long-term follow-up. Prepectoral placement was shown to have an inferior complication and aesthetic profile compared with subpectoral placement, with no difference in secondary revisions. These findings require validation with a well-designed randomized controlled trial to establish best practice for implant-based breast reconstruction.

Same-Day Discharge for Immediate Breast Reconstruction: A National Surgical Quality Improvement Program Study.

BACKGROUND: Patients undergoing immediate breast reconstruction with tissue expanders are frequently admitted after surgery for monitoring and pain control, which introduces additional costs and risks of nosocomial infection. Same-day discharge could conserve resources, mitigate risk, and return patients home for faster recovery. The authors used large data sets to investigate the safety of same-day discharge after mastectomy with immediate postoperative expander placement. METHODS: A retrospective review was performed of patients in the National Surgical Quality Improvement Program database who underwent breast reconstruction using tissue expanders between 2005 and 2019. Patients were grouped based on date of discharge. Demographic information, medical comorbidities, and outcomes were recorded. Statistical analysis was performed to determine efficacy of same-day discharge and identify factors that predict safety. RESULTS: Of the 14,387 included patients, 10% were discharged the same day, 70% on postoperative day 1, and 20% later than postoperative day 1. The most common complications were infection, reoperation, and readmission, which trended upward with length of stay (6.4% versus 9.3% versus 16.8%), but were statistically equivalent between same-day and next-day discharge. The complication rate for later-day discharge was statistically higher. Patients discharged later had significantly more comorbidities than same or next-day discharge counterparts. Predictors of complications included hypertension, smoking, diabetes, and obesity. CONCLUSIONS: Patients undergoing mastectomy with immediate tissue expander reconstruction are usually admitted overnight. However, same-day discharge was demonstrated to have an equivalent risk of perioperative complications as next-day discharge. For the otherwise healthy patient, going home the day of surgery is a safe and cost-effective option, although the decision should be made based on the individual patient. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Salvage rates of compromised free flap breast reconstruction after recurrent thrombosis.

BACKGROUND: Microvascular complications after free flap breast reconstruction are devastating problems that increase patient morbidity and potentially lead to flap loss. Yet, there is a dearth of literature about rates of free flap salvage after recurrent vascular thromboses. METHODS: A retrospective review of all patients undergoing microvascular breast reconstruction at UCLA Medical Center from January 1991 to June 2010 was conducted. The incidence of microvascular thrombosis was evaluated and rates of flap salvage and complications were specifically analyzed after a single microvascular revision (Single Event), 2 or more revisions (Multiple Event), and delayed presentation (>2 days) with attempted salvage (Delayed Event). RESULTS: During the study period, 2094 free flap breast reconstructions were evaluated. Of these, 75 (3.6%) flaps suffered a microvascular complication and 16 (0.76%) flaps were lost. The overall salvage rate was 78.7% (59/75) with the highest salvage rate of 95.9% (47/49) for Single Events. Multiple Events had a salvage rate of 53.3% (8/15), whereas Delayed Events had a salvage rate of 27.3% (3/11). The salvage rate decreased with repeated microvascular events (P < 0.01). In the Multiple Event group, vascular conversion (alternate recipient vessel) correlated with improved flap salvage (87.5%), whereas the lack thereof was associated with flap loss (P < 0.001). CONCLUSIONS: The salvage rate of free flap breast reconstruction diminishes dramatically with recurrent microvascular complications, but can be improved with vascular conversion. The salvage rate in cases of delayed presentation is even worse confirming the need for vigilant postoperative monitoring and aggressive intervention in the setting of flap compromise.

Surgical management of silicone mastitis: case series and review of the literature.

BACKGROUND: Free silicone injection for breast augmentation, which became widespread in the 1960s and continues illicitly to this day, has well-known adverse effects. In this retrospective chart review of 14 patients treated for silicone mastitis from 1990 to 2002, we present our experience with the surgical management of patients with silicone mastitis. METHODS: All the patients were women, ranging in age from 49 to 76 years old (mean age = 58.8). Patients presented to us a mean of 29.9 years after their free silicone breast injection. Treatment modalities were analyzed, and, specifically, methods of breast reconstruction involving autologous tissue transfers, implants, or a combination were evaluated. RESULTS: The majority of patients (12 of 14) required mastectomies for extensive silicone-infiltrated tissues. The remaining two patients had focal areas of disease and were successfully treated with excision and local breast parenchyma flaps. Autologous reconstruction was performed with a total of 20 flaps, including 12 free transverse rectus abdominis myocutaneous flaps, 4 free superior gluteal artery perforator (SGAP) flaps, and 4 pedicled latissimus dorsi (LD) flaps. Two patients had bilateral implant-based breast reconstruction. CONCLUSION: A variety of reconstructive options are available for patients presenting with silicone mastitis. Once an appropriate breast cancer workup has been performed, the surgical goal is to excise as much of the silicone-infiltrated tissues as possible before reconstruction. To our knowledge, this is the first reported series that incorporates the use of SGAP and LD flaps as a means of autologous tissue reconstruction for silicone-infiltrated breasts. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Sarcopenia Best Predicts Complications in Free Flap Breast Reconstruction.

Breast reconstruction remains a major component of the plastic surgeon's repertoire, especially free-flap breast reconstruction (FFBR), though this is a high-risk surgery in which patient selection is paramount. Preoperative predictors of complication remain mixed in their utility. We sought to determine whether the sarcopenia score, a validated measure of physiologic health, outperforms the body mass index (BMI) and modified frailty index (mFI) in terms of predicting outcomes. Methods: All patients with at least 6-months follow-up and imaging of the abdomen who underwent FFBR from 2013 to 2022 were included in this study. Appropriate preoperative and postoperative data were included, and sarcopenia scores were extracted from imaging. Complications were defined as any unexpected outcome that required a return to the operating room or readmission. Statistical analysis and regression were performed. Results: In total, 299 patients were included. Patients were split into groups, based on sarcopenia scores. Patients with lower sarcopenia had significantly more complications than those with higher scores. BMI and mFI both did not correlate with complication rates. Sarcopenia was the only independent predictor of complication severity when other factors were controlled for in a multivariate regression model. Conclusions: Sarcopenia correlates with the presence of severe complications in patients who undergo FFBR in a stronger fashion to BMI and the mFI. Thus, sarcopenia should be considered in the preoperative evaluation in patients undergoing FFBR.

A novel injectable fibromodulin-releasing granular hydrogel for tendon healing and functional recovery.

A crucial component of the musculoskeletal system, the tendon is one of the most commonly injured tissues in the body. In severe cases, the ruptured tendon leads to permanent dysfunction. Although many efforts have been devoted to seeking a safe and efficient treatment for enhancing tendon healing, currently existing treatments have not yet achieved a major clinical improvement. Here, an injectable granular hyaluronic acid (gHA)-hydrogel is engineered to deliver fibromodulin (FMOD)-a bioactive extracellular matrix (ECM) that enhances tenocyte mobility and optimizes the surrounding ECM assembly for tendon healing. The FMOD-releasing granular HA (FMOD/gHA)-hydrogel exhibits unique characteristics that are desired for both patients and health providers, such as permitting a microinvasive application and displaying a burst-to-sustained two-phase release of FMOD, which leads to a prompt FMOD delivery followed by a constant dose-maintaining period. Importantly, the generated FMOD-releasing granular HA hydrogel significantly augmented tendon-healing in a fully-ruptured rat's Achilles tendon model histologically, mechanically, and functionally. Particularly, the breaking strength of the wounded tendon and the gait performance of treated rats returns to the same normal level as the healthy controls. In summary, a novel effective FMOD/gHA-hydrogel is developed in response to the urgent demand for promoting tendon healing.

Current Trends in Breast Reconstruction following Bilateral Prophylactic Mastectomy.

Background: Individuals with genetic susceptibility to breast cancer may pursue bilateral prophylactic mastectomy (BPM) and subsequent breast reconstruction. This study aimed to characterize immediate reconstructive trends following BPM. Methods: The ACS-NSQIP database (2010 -2019) was used to examine differences in demographics and operative outcomes based on breast reconstruction technique following BPM and factors predicting reconstruction type. Results: Of 1945 patients (mean age, 43.8 ± 11.3 years), implant-based reconstruction (IBR) was most frequently (71.8%) performed following BPM. Patients who underwent IBR (n = 1396) were younger (42.6 years, P < 0.001), more likely to be White (P < 0.05), and more likely to have a BMI less than 25 (P < 0.001). Patients who underwent autologous reconstruction (AR) (n = 186, 45.8 years) were more likely to be Black or African American and have a BMI of 25-30. Patients who underwent mastectomy only (MO) without immediate reconstruction (n = 363) were older (47.6 years), more likely to be Asian, and more likely to have a BMI greater than 35. The MO cohort had the highest frequency of diabetes or smoking history. AR was associated with longer operations, longer lengths of stay, and increased complications. Increasing age and BMI were predictive of AR or MO compared to IBR. Smoking was predictive of MO. Conclusion: This is the first large-scale study of genetically susceptible patients who underwent BPM demonstrating a significant relationship between patient demographics, operative outcomes, and immediate reconstruction technique. These results provide valuable insight for surgeons and patients during the shared decision-making process.

Vascular complications and microvascular free flap salvage: the role of thrombolytic agents.

BACKGROUND: Vascular thrombosis with flap loss is the most dreaded complication of microvascular free tissue transfer. Thrombolytic agents such as tissue plasminogen activator have been used clinically for free flap salvage in cases of pedicle thrombosis. Yet, there is a paucity of data in the literature validating the benefit of their use. METHODS: A retrospective review of the breast reconstruction free flap database was performed at a single institution between the years of 1991-2010. The incidence of vascular complications (arterial and/or venous thrombosis) was examined to determine the role of adjuvant thrombolytic therapy in flap salvage. Pathologic examination was used to determine the incidence of fat necrosis after secondary revision procedures. RESULTS: Seventy-four cases were identified during the study period. In 41 cases, revision of the anastamoses was performed alone without thrombolytics with 38 cases of successful flap salvage (92.7%). In 33 cases, anastamotic revision was performed with adjuvant thrombolytic therapy, and successful flap salvage occurred in 28 of these cases (84.8%). Thrombolysis did not appear to significantly affect flap salvage. Interestingly, only two of the salvaged flaps that had received thrombolysis developed fat necrosis, whereas 11 of the nonthrombolysed flaps developed some amount fat necrosis (7.1% vs. 28.9%, P < 0.05). CONCLUSIONS: The decreased incidence of fat necrosis may be attributable to dissolution of thrombi in the microvasculature with the administration of thrombolytics. Although the use of adjuvant thrombolytic therapy does not appear to impact the rate of flap salvage, their use may have secondary benefits on overall flap outcomes.

The COVID-19 Pandemic and Plastic Surgery: Literature Review, Ethical Analysis, and Proposed Guidelines.

BACKGROUND: Coronavirus disease 2019 (COVID-19), known as the "coronavirus," has spread to over 170 countries. In response, many organizations have spoken out and called for cancellation of all elective surgical procedures. This study aimed to provide clear recommendations for plastic surgeons to follow by addressing the following issues: (1) What defines elective surgery, and where does one draw the line between essential versus nonessential services? (2) How does this differ in the hospital versus private practice setting? (3) If called on to operate on a patient with COVID-19, how do plastic surgeons protect themselves and still provide excellent medical care? METHODS: A Preferred Reporting Items for Systematic Reviews and Meta-Analyses systematic review of the literature on plastic surgery in the setting of a pandemic was performed on March 19, 2020. An ethical analysis was conducted using the four principles of medical ethics. RESULTS: The initial search yielded 118 articles. Eighteen articles were relevant and included for analysis. Only one editorial article was published in a plastic surgery journal. Accordingly, no peer-reviewed published COVID-19 guidelines exist for plastic surgery. Given that this pandemic may place health care systems under undue stress with an unpredictable trajectory, it is the responsibility of the plastic surgeon to assess and postpone cases whenever possible to properly contribute to adequate resource allocation and patient safety measures. CONCLUSIONS: This article fills an important gap in the literature by addressing COVID-19 and providing guidelines for upholding ethics and responsible resource allocation. By upholding these standards, plastic surgeons can do their part to help minimize the spread of this virus.

The Central Mound Pedicle: A Safe and Effective Technique for Reduction Mammaplasty.

BACKGROUND: The central mound technique offers a relatively less common approach for breast reduction. This study evaluated the expected safety and efficacy outcomes using this technique in a large patient series. METHODS: A retrospective review of all patients undergoing central mound breast reduction at the authors' institution between June of 1999 and November of 2018 was performed. Both bilateral macromastia and unilateral symmetrizing reduction patients were included but evaluated separately for some outcomes. Patient demographics and comorbidities, operative details, postoperative adverse events, and BREAST-Q scores were recorded. Associations between preoperative variables and outcomes were assessed with chi-square tests, Wilcoxon tests, and Kendall tau-b correlations. RESULTS: A total of 325 patients were identified for inclusion (227 bilateral and 98 unilateral; 552 breasts). The average patient age was 46 years, and the average body mass index was 27.4 kg/m. Among the bilateral macromastia patients, the average operative time was 3 hours 34 minutes, and average breast tissue removed was 533 g (right breast) and 560 g (left breast). Among all patients, average follow-up was 169 days. On a per-breast basis for all patients, the following complication rates were observed: seroma, 0.2 percent; hematoma, 1.1 percent; dehiscence, 2.9 percent; infection, 1.5 percent; hypertrophic scar, 4.6 percent; nipple necrosis, 0.4 percent; fat necrosis, 0.9 percent; and skin flap necrosis, 1.7 percent. Using the BREAST-Q Reduction/Mastopexy questions on a Likert scale ranging from 1 to 5, restricted to the bilateral macromastia patient population, all scores improved with statistical significance. CONCLUSION: The central mound pedicle is a safe and effective approach for reduction mammaplasty for both bilateral macromastia patients and unilateral symmetrizing operations. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Overview of Host Defense Peptides and Their Applications for Plastic and Reconstructive Surgeons.

BACKGROUND: Host defense peptides are a family of endogenous short peptides that are found in all living beings and play a critical role in innate immunity against infection. METHODS: A nonsystematic review of host defense peptides was conducted with specific interest in properties and applications relevant to plastic and reconstructive surgery. RESULTS: In addition to their direct antimicrobial actions against pathogens, including multidrug-resistant bacteria, they also demonstrate important functions in immunomodulation, tumor cell lysis, and tissue regeneration. These properties have made them a topic of clinical interest for plastic surgeons because of their potential applications as novel antibiotics, wound healing medications, and cancer therapies. The rising clinical interest has led to a robust body of literature describing host defense peptides in great depth and breadth. Numerous mechanisms have been observed to explain their diverse functions, which rely on specific structural characteristics. However, these peptides remain mostly experimental, with limited translation to clinical practice because of numerous failures to achieve acceptable results in human trials. CONCLUSIONS: Despite the broad ranging potential of these peptides for use in the field of plastic and reconstructive surgery, they are rarely discussed in the literature or at scientific meetings. In this review, the authors provide a summary of the background, structure, function, bacterial resistance, and clinical applications of host defense peptides with the goal of stimulating host defense peptide-based innovation within the field of plastic and reconstructive surgery.

Systematic Review of the Impact of Acellular Dermal Matrix on Aesthetics and Patient Satisfaction in Tissue Expander-to-Implant Breast Reconstructions.

BACKGROUND: Acellular dermal matrix is used in most postmastectomy implant-based breast reconstructions in the United States. It is believed to be safe, despite a slightly increased complication rate. Although never established in a unifying study, the primary advantage of acellular dermal matrix is believed to be an enhanced aesthetic result, thus justifying the added expense. The purpose of this study was to assess the aesthetic benefits of acellular dermal matrix in expander-to-implant breast reconstruction. METHODS: A systematic review adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses methodology was performed including all original studies examining aesthetic outcomes of expander-to-implant breast reconstructions with acellular dermal matrix compared to muscular coverage. Direct-to-implant and prepectoral studies were excluded from the evaluation. The results were aggregated and reported as a summary. RESULTS: Among 883 studies identified, 49 full-text articles were reviewed and nine articles ultimately met inclusion criteria. All nine studies were not randomized. Of these, three articles (1448 total patients) evaluated reconstruction aesthetic outcomes by patient satisfaction, whereas six articles evaluated the aesthetic outcomes by external observer (504 total patients). None of the articles evaluating patient satisfaction reported a difference between acellular dermal matrix and muscular reconstruction. Five of the six articles using objective outcomes demonstrated significant improvement in aesthetic outcome in the acellular dermal matrix group. CONCLUSIONS: Although little evidence exists evaluating the aesthetic benefits of acellular dermal matrix for expander-to-implant breast reconstruction, the data suggest that objective observers consider acellular dermal matrix-assisted expander-to-implant breast reconstructions aesthetically superior to reconstruction with only muscular coverage, but patients appear to be equally satisfied with both reconstructive options.

The use of a pectoralis major flap to improve internal mammary vessels exposure and reduce contour deformity in microvascular free flap breast reconstruction.

Internal mammary vessels are commonly used in microvascular breast reconstruction. Most surgeons resect a portion of the rib to expose these vessels. This resection can lead to contour abnormalities in the chest wall that are difficult to correct. In addition, exposure of these vessels deep in the wound can be problematic. The purpose of this study was to evaluate our experience with a pectoralis major flap designed to improve exposure and fill in the defect created by rib resection. All consecutive patients who underwent autologous breast reconstruction using the internal mammary vessels as recipient vessels between 2000 and 2005 were identified. All procedures were performed by a single surgeon. In each case, a superiorly based flap within the pectoralis major muscle spanning the bottom of the second rib to the top of the fourth costal cartilage was raised. This "L"-shaped flap was reflected and a portion of the third rib cartilage was excised. At the conclusion of the microsurgical anastomosis the pectoralis major flap was repaired and used to cover the defect created by rib resection. Patient demographic, operative details, and postoperative complications were obtained from a prospectively maintained clinical database. Deformity around sternal border was evaluated from the patients' photographs. There were 99 autologous reconstructions in 90 patients. In 71 cases the internal mammary artery/vein were used as recipient vessels. There were no cases of microvascular thrombosis or flap loss. A portion of the third rib was excised in all patients who underwent microsurgical anastomoses to the internal mammary vessels. In 3 patients a portion of both the second and third ribs was removed because of branching of the internal mammary vein proximal to the level of the third rib. A contour deformity was noted in 4 patients (4.4%) after a mean follow-up of 27 months. Of the 4 patients with contour deformity, 2 had a portion of both the third and second costal cartilage removed because of venous branching above the level of the third rib cartilage. The modified pectoralis major L-shaped flap is a useful technique for safe and clear exposure of the internal mammary vessels. In addition, the use of this flap to cover the segment of resected rib cartilage can decrease the contour deformities associated with rib resection as compared with reported rates in the literature. Resection of multiple rib segments, though unavoidable at times because of anatomic considerations, may be associated with an increased rate of postoperative contour deformities.

Comparison of immediate postoperative pain in implant-based breast reconstructions.

BACKGROUND: Implant-based techniques represent the most common form of breast reconstruction. However, substantial postoperative pain has been associated with implant-based breast reconstruction. OBJECTIVE: The objective of this study is to evaluate immediate postoperative pain in implant-based breast reconstruction. METHODS: We reviewed 378 patients who underwent implant-based reconstruction between January 2004 and December 2012. Each patient's visual analog scale (VAS) score, pain medication, and patient-controlled analgesia (PCA) attempts were used to assess in-hospital postoperative pain. We evaluated timing of reconstruction post mastectomy, tissue expander (TE) designed fill volume, TE initial fill volume, and single-stage immediate implant (II) versus TE reconstruction. RESULTS: No significant differences in pain parameters were noted between the immediate and delayed postmastectomy reconstruction cohorts. TEs with larger (>300 cc) designed volumes required significantly more narcotic use (p = 0.02) and PCA attempts (p < 0.01). Narcotic use was higher in the larger (>250-cc) TE initial fill group starting on postoperative day 2, but overall differences in VAS score and PCA attempts were not significant. Morphine equivalence (p < 0.01) and non-opioid oral analgesic use (average p = 0.03) of the TE cohort were significantly higher than those of the II cohort. CONCLUSION: Patients undergoing TE-based implant reconstruction show greater analgesic use than those with single-stage II-based reconstruction. This may indicate a higher immediate postoperative pain in TE procedures than in II procedures. Furthermore, higher initial fill and designed volume of TE require more morphine equivalence postoperatively. These findings may warrant further preoperative discussion for better pain management and patient satisfaction.