Safety of Augmenting Breast Volume in Direct-to-Implant Breast Reconstruction With Contralateral Breast Augmentation: Comparison With 2-Stage Reconstruction.

BACKGROUND: Direct-to-implant breast reconstruction is a standard method of implant-based reconstruction; however, the risk of skin necrosis and implant failure exists. During simultaneous contralateral augmentation, an implant larger than the resected tissue must be inserted to balance both sides, which may increase the risk of complications. This study examined the differences in the incidence of complications between the single-stage direct-to-implant reconstruction and 2-stage reconstruction when contralateral augmentation was performed simultaneously. METHODS: This study included 99 patients who underwent implant-based breast reconstruction with contralateral augmentation between 2012 and 2020. A retrospective chart review was conducted and the patients were divided into 2 groups: the single-stage reconstruction (n = 61) and 2-stage reconstruction (TSR, n = 38) groups. Demographic data and surgical and oncological information were collected. Complications including skin necrosis and reconstruction failure were investigated as the primary outcome. RESULTS: Implant volume and contralateral implant volume were significantly greater in TSR group than in the single-stage reconstruction group. There were no significant differences in the incidence of complications and reconstruction failure rates between both groups. The nipple-sparing mastectomy was the risk factor for complications. Furthermore, the risk factors for mastectomy skin necrosis were implant volume and differences in the volume of both implants. CONCLUSIONS: Single-stage reconstruction did not increase the risk of complications compared with TSR when implants that were larger than the resected tissue were inserted after mastectomy. Proper patient selection and selection of implants that are not excessively large could satisfy patients' cosmetic needs in a single operation.

Oncologic outcomes of immediate breast reconstruction in young women with breast cancer receiving neoadjuvant chemotherapy.

BACKGROUND: Oncologic safety of postmastectomy breast reconstruction in young women with breast cancer is not well-defined, especially in the setting of neoadjuvant chemotherapy (NACT). We retrospectively compared the oncologic outcomes following nipple-sparing (NSM)/skin-sparing mastectomy (SSM) with immediate breast reconstruction (IBR) and conventional mastectomy (CM) alone in young breast cancer patients after NACT. METHODS: A total of 1266 women with primary breast cancer who underwent NACT followed by total mastectomy with or without IBR were reviewed. Of these, only young patients (age ≤ 40 years at diagnosis) were included in the outcome analysis (n = 375). After propensity score-matching by clinical T and N stage, molecular subtype, response to NACT, and adjuvant radiotherapy status, 228 patients were 1:1 matched, comprising balanced IBR group (with NSM/SSM) and CM-alone group. RESULTS: The 5-year locoregional recurrence-free, disease-free, distant metastasis (DM)-free, and breast cancer-specific survival (BCSS) rates for the entire cohort of young patients were 83.4%, 65.3%, 71.7%, and 85.4%, respectively. Locoregional recurrence rates between the matched groups were similar (14% vs. 15.8%; p = 0.710); however, IBR group had significantly lower DM rate (27.2% vs. 40.4%; p = 0.036) and breast cancer mortality (14.9% vs. 27.2%; p = 0.023) than CM-alone group. IBR group showed significantly improved 5-year DM-free survival (74.1% vs. 62.6%; p = 0.043) and BCSS (89.1% vs. 77.6%; p = 0.048) rates than CM-alone group. CONCLUSIONS: Our results indicated that IBR with NSM/SSM does not negatively affect long-term oncologic outcomes compared to CM alone in young women with breast cancer receiving NACT.

Outcome Analysis Depending on the Different Types of Incision following Immediate Breast Reconstruction.

Background: Immediate breast reconstruction following nipple-sparing mastectomy (NSM) is widely used for its cosmetic benefits. Due to the lack of guidelines, the types of incisions in NSM vary and which method is superior remains a debate. In this study, we hypothesized that the periareolar incision has a higher risk of complications, such as nipple-areolar complex (NAC) necrosis, than other incisions. Methods: A retrospective chart review was conducted and divided into three groups: the periareolar, radial, and lateral incision groups. The reconstruction method and complications of NAC necrosis, wound dehiscence, seroma, hematoma, infection, and reconstruction failure were investigated. Results: A total of 103 patients (periareolar incision (33%, n = 34), radial incision (39.8%, n = 41), and lateral incision (27.2%, n = 28)) who underwent NSM and immediate breast reconstruction from 2018 to 2020 were included. The reconstruction methods were direct-to-implant, DIEP flap, LD flap, and PAP flap, and there was all of which had no statistically significant difference between the groups regarding the reconstruction method (p=0.257). In terms of complications, there was no significant difference in NAC necrosis (29.4%, 19.5%, and 21.4%, in the periareolar, radial, and lateral groups, respectively; p=0.578), wound dehiscence, seroma or hematoma, infection, and reconstruction failure. Conclusion: Breast reconstruction following NSM through periareolar incision does not increase the incidence of complications, including NAC necrosis. However, since only Asian patients with low BMI were included, if an appropriate patient group is selected for immediate reconstruction after NSM, reconstruction can be safely performed through the periareolar incision, and good cosmetic results can be obtained.

Is There a Difference in the Diagnosis and Prognosis of Local Recurrence between Autologous Tissue and Implant-Based Breast Reconstruction?

Introduction: Breast reconstruction has become common after total mastectomy; however, certain types of breast reconstruction may be associated with delayed local recurrence or poor survival. Here, we investigated whether there are differences in the diagnosis and prognosis of local recurrence between autologous reconstruction and implant reconstruction. Materials and Methods: A retrospective analysis was performed on patients undergoing breast cancer surgery with autologous tissue or immediate implant reconstruction in a single center (January 2003-December 2017). Patient data including the period from cancer surgery to local recurrence diagnosis, tumor size at the time of recurrence, and survival time after cancer surgery and recurrence detection were analyzed. Results: There was a significant difference (p = 0.021) in the time from surgery to recurrence between the autologous tissue (1,246 days) and implant (909 days) groups. Recurrence tumor size did not differ (autologous: 1.00 cm2 vs. implant: 0.90 cm2; p = 0.813). Survival time after surgery (p = 0.63) and recurrence detection (p = 0.74) did not statistically significant. Conclusions: Statistical difference in the detection time was observed between autologous tissue and implant group. On the other hand, there is no difference in recurrence tumor size or survival time. A further study is necessary to identify the different detection time of local recurrence.

Treatment of Pediatric Sternotomy Wound Complications: A Minimally Invasive Approach.

BACKGROUND: Pediatric sternal wound complications (SWCs) include sterile wound dehiscence (SWD) and superficial/deep sternal wound infections (SSWI/DSWI), and are generally managed by repetitive debridement and surgical wound approximation. Here, we report a novel nonsurgical management strategy of pediatric sternotomy wound complications, using serial noninvasive wound approximation technique combined with single-use negative pressure wound therapy (PICO) device. METHODS: Nine children with SWCs were managed by serial approximation with adhesive skin tapes and serial PICO device application. Thorough surgical debridement or surgical approximations were not performed. RESULTS: Three patients were clinically diagnosed as SWD, two patients as SSWI, and four patients as DSWI. None of the wounds demonstrated apparent mediastinitis or bone destructions. PICO device was applied at 16.1 days (range: 6-26 days) postoperatively, together with serial wound approximation by skin tapes. The average duration of PICO use was 16.9 days (range: 11-29 days) and the wound approximation was achieved in all patients. None of the patients underwent aggressive surgical debridement or invasive surgical approximation by sutures. CONCLUSION: We report our successful management of selected pediatric SWCs, using serial noninvasive wound approximation technique combined with PICO device.

Seasonal and Temperature-associated Effect on Infection in Implant-based Breast Reconstruction.

BACKGROUND AND OBJECTIVES: Despite advances in medicine, infection at the surgical site is an impregnation problem that most surgeons confront. Although studies on the seasonality of infection have been conducted in various areas, no study has confirmed the relationship between seasonal temperature and infection after breast reconstruction. METHODS: From 2008 to 2018, a retrospective study was conducted on patients who underwent implant-based breast reconstruction. Patient demographics, intraoperative data, postoperative data, and temperature information were collected. Temperature differences between cases with and without infection were examined. The differences in the incidence and risk of infection by season were estimated according to the hot season (July to August) and the nonhot season (September to June). RESULTS: Of the 460 cases enrolled, 42 cases developed an infection. Among them, 15 (35.71%) cases developed infection during the hot season (P = 0.003). According to the logistic regression model, the risk of infection was 2.639 times higher in the hot season than in the nonhot season (95% confidence interval, 1.282-5.434; P = 0.008). When the temperature was higher than 25°C, the risk of infection increased by 45.2% for every 1°C increase, which was statistically significant (odds ratio, 1.452; 95% confidence interval, 1.198-1.76; P < 0.001). CONCLUSION: In conclusion, the hot season or average temperatures higher than 25°C increase the risk of infection in patients undergoing implant-based breast reconstruction. It is essential to focus on skin hygiene during the healing of the incision site.

Intramuscular Deep Inferior Epigastric Vessels Are Insulated by Perimysial Fibroadipose Tissue Network.

BACKGROUND: The difficulty of elevating a deep inferior epigastric perforator (DIEP) flap largely depends on the intramuscular course of the vessel and the perforator. Previous studies, however, have lacked histologic descriptions of the vessels and surrounding structures. The present study analyzed the histologic aspects of the deep inferior epigastric vessels and perforators, focusing on their perivascular relationships with muscle fibers. METHODS: The abdomen of a cadaver was histologically evaluated to identify intramuscular deep inferior epigastric vessels. Tissue samples were stained with hematoxylin and eosin and with Masson trichrome stain to visualize fibrous components. Twenty-one DIEPs from 12 patients were also evaluated to determine the histologic aspects of the perivascular structure. In the cross-section of each perforator and adjacent tissue, the perforator-to-muscle distance and trichrome-stained area were measured, and the correlation of the perforator size with the perforator-to-muscle distance and the percent collagenous portion of the distance were determined. RESULTS: Histologic analysis showed that the deep inferior epigastric vessels and perforators were encased by perimysial connective tissue and were not in direct contact with the muscle fibers. The smaller perimysia branched out from the larger perimysia, forming an interconnecting network structure. Correlation analysis showed that larger vessels had more collagenous portions in the perimysial structures (Spearman's ρ = 0.537, p = 0.012). CONCLUSION: The deep inferior epigastric vessels and perforators reside in a perimysial fibroadipose tissue network. This may provide surgeons with a microscopic perspective during DIEP dissections. Having an idea of the perforator anatomy in microscopic level can help us to perform safer perforator dissections.

Inframammary Fold Approach for Second-stage Operation in Expander-Implant Breast Reconstruction.

BACKGROUND AND OBJECTIVES: Despite expander-based breast reconstruction being used as a reliable reconstruction method, implant removal due to wound dehiscence and infection still occurs in 0.5% to 15% of cases. This study aimed to compare the outcomes of the new inframammary fold (IMF) incision approach with previous incision in second-stage operation of expander-based 2-stage breast reconstruction. METHODS: Patients who underwent expander-based 2-stage breast reconstruction between February 2014 and May 2019 were included. After expander inflation, patients undergoing second-stage reconstruction were divided into the previous incision and IMF incision groups and their outcomes were compared. Propensity score matching analysis was performed to compare postoperative 1-year results. RESULTS: The previous incision and IMF incision groups comprised 79 and 31 patients, respectively. There were no intergroup differences in general demographics or intraoperative data, except for total inflation volume (426.87 ± 102.63 mL in the previous incision group and 375.48 ± 94.10 mL in the IMF incision group, P = 0.017). Wound dehiscence occurred in 12 and 0 cases in the previous and IMF incision groups, respectively (P = 0.018). Implant removal was performed due to dehiscence in 9 cases (8.18%) and 0 cases (0%) in the previous and IMF incision groups, respectively (P = 0.049). In 1-to-1 propensity score matching analysis, the IMF incision group showed better results at 1-year follow-up (odds ratio: 0, 95% confidence interval: 0-1.09; P = 0.063). CONCLUSIONS: The IMF approach is a safe method for replacing the expander with an implant, with lower incidence of wound dehiscence and implant explantation.

Phenotype categorization of neurofibromatosis type I and correlation to NF1 mutation types.

Neurofibromatosis type 1 (NF1) is caused by heterozygous mutation in the NF1 gene. NF1 is one of the most common human genetic diseases. However, the overall genotype-phenotype correlation has not been known, due to a wide spectrum of genotypic and phenotypic heterogeneity. Here we describe the detailed clinical and genetic features of 427 Korean NF1 patients from 389 unrelated families. Long range PCR and sequencing of genomic DNA with multiplex ligation-dependent probe amplification analysis identified 250 different NF1 mutations in 363 families (93%), including 94 novel mutations. With an emphasis on phenotypes requiring medical attention (classified and termed: NF1+), we investigated the correlation of NF1+ and mutation types. NF1+ was more prevalent in patients with truncating/splicing mutations and large deletions than in those with missense mutations (59.6%, 64.3% vs. 36.6%, p = 0.001). This difference was especially significant in the patients younger than age 19 years. The number of items in NF1+ was a higher in the former groups (0.95 ± 0.06, 1.18 ± 0.20 vs. 0.56 ± 0.10, p = 0.002). These results suggest that mutation types are associated not only with higher prevalence of severe phenotypes in NF1 but also with their earlier onset.

Shaping an Anatomical Breast Using Extended Latissimus Dorsi Flap and Lipofilling in Immediate Breast Reconstruction.

BACKGROUND: Although many attempts have been made to augment the volume of the latissimus dorsi (LD) myocutaneous flap in breast reconstruction, only a few studies on the shaping of the LD flap to achieve a natural native breast have been conducted. We introduce our novel method to reconstruct a naturally shaped breast by combining an extended LD myocutaneous flap with immediate lipofilling. METHODS: The patients who underwent an immediate unilateral breast reconstruction with an extended LD myocutaneous flap and lipofilling were retrospectively reviewed. The extended LD myocutaneous flap in 180-degree rotation was combined with an immediate lipofilling procedure followed by suturing to reproduce the constant dimensions of a neobreast. RESULTS: A total of 45 patients with a mean age of 46 years and an average body mass index of 23.1 kg/m were enrolled. The average weight of the mastectomy specimens was 299.0 g. An average 18.8 × 8.7-cm skin paddle within the flap was harvested, and 71.0 mL of fat was injected into the flap. Donor site seroma was found in 9 patients, and no flap or fat necrosis was found. CONCLUSIONS: Our technique of extended LD muscle flap with lipofilling reproduced breasts with constant dimensions and appropriate width, height, and projection. Shaping the LD muscle flap is not difficult or unpredictable. This is a simple and easy technique to shape the LD flap and will provide surgeons with an additional autologous option for breast reconstruction.

Comparison of transverse upper gracilis and profunda femoris artery perforator flaps for breast reconstruction: A systematic review.

BACKGROUND: Thigh-based flaps are generally considered a secondary option for breast reconstruction, with inner thigh-based transverse upper gracilis (TUG) flaps being the preferred choice for many surgeons; however, its well-established drawbacks include short pedicle length, lack of volume, and donor morbidity. The posterior thigh-based profunda femoris artery perforator (PAP) flap was introduced as an alternative approach, but these flaps were not comparatively analyzed with TUG flaps on a large scale. We aimed to systematically review TUG- and PAP-flap breast reconstruction to determine the better secondary option. METHODS: We performed a systematic review of the literature using the PubMed database. Our selected series for systematic analyses included 613 TUG flaps in 432 patients and 475 PAP flaps in 329 patients. Elementary data on the flaps and complications were collected and analyzed. Pooled estimates of proportions of flaps with recipient complications and donor site morbidity were compared using random effect single arm meta-analysis. RESULTS: The basic patient demographics were comparable between the flap types. The mean operation time was comparable. The PAP flap had longer pedicle length and higher flap weight. The total loss (p = .6579), partial loss rate (p = .3247), and fat necrosis rate (p = .0771) were comparable between flap types. Regarding donor morbidity, the PAP flap group had less wound dehiscence (p < .0001) and lower rate of sensory disturbance (p < .0001). CONCLUSIONS: The study findings indicate that the PAP flap, when compared with the TUG flap, could be a better secondary option for breast reconstructions.

Impact of Recipient Vein Selection on Venous Patency and Free Flap Survival in 652 Head and Neck Reconstructions.

BACKGROUND: This study was conducted to evaluate the impact of choosing a particular recipient venous system on venous patency and flap survival in 652 head and neck free flap reconstructions. METHODS: A retrospective review was performed. Patient factors investigated included: age, sex, type of flap, tumor location, history of radiation, presence of previous neck dissection, tumor stage, and any underlying disease. Data related with recipient vein including the number of anastomosis, the repair technique, the type of recipient vein, and the configuration of selected venous system were examined. The impact of patient factors and parameters related with recipient vein on the venous patency and flap survival were analyzed using bivariate and multivariate analyses. RESULTS: Of 652 free flaps, 36 flaps (5.5%) were re-explored due to venous congestion and 28 flaps (77.8%) were salvaged. The overall survival rate of total free flaps was 98.8%. The type of recipient venous system was found to be an insignificant factor with respect to venous congestion and flap survival in multivariate analysis. A history of radiation treatments was the only factor associated with a higher risk of venous compromise (odds ratio [OR] = 13.138, p < 0.001) and a lower rate of flap survival (OR = 20.182, p = 0.002). CONCLUSION: The selection of recipient venous systems has no impact on venous patency and flap survival. History of radiation treatment was the only factor associated with venous congestion and flap failure. Since no single method can ensure a successful reconstructive result, selecting the optimal recipient vein should be based on individual patient factors and the surgeon's experience.

Appropriate Prophylactic Antibiotic Use in Clean Wound Surgery Under Local Anesthesia.

BACKGROUND: Although guidelines to prevent surgical site infections (SSIs) were published more than a decade ago, prophylactic antibiotics are still used subjectively in clinical practice. In this study, we evaluated the safety of single-dose preoperative intravenous antibiotics without postoperative antibiotics in the field of clean wound surgery performed under local anesthesia. We also surveyed the present clinical conditions for prophylactic antibiotic use in the plastic surgery departments of training hospitals in Korea. METHODS: A total of 360 consecutive patients who underwent clean wound surgery under local anesthesia in an outpatient clinic from March 2018 to October 2018 were reviewed. In the study group, a single surgeon administered first-generation cephalosporins intravenously within 1 hour of skin incision and did not prescribe additional antibiotics. In the control group, 2 other surgeons prescribed oral first-generation cephalosporins postoperatively for 2 to 3 days without preoperative antibiotics. A telephone survey about perioperative antibiotic regimens was conducted at the departments of plastic surgery in training hospitals. RESULTS: There were 128 patients in the study group and 232 patients in the control group. There were no significant differences between the 2 groups regarding SSIs and other surgical complications. A total of 41 training hospitals answered the survey and every hospital had protocols of prescribing postoperative oral antibiotics routinely at the time of discharge with a mean duration of 3.9 days. Only 11 hospitals (26.8%) prescribed parenteral antibiotics before surgery as well as postoperative oral antibiotics. CONCLUSION: Intravenous injection of single-dose first-generation cephalosporins 1 hour before surgery without postoperative antibiotics did not increase the incidence of SSIs compared with the usual practice of giving only postoperative antibiotics prescription for 2 to 3 days in cases of clean wound surgery performed under local anesthesia. Proper antibiotic prophylaxis should be performed by surgeons in training hospitals without hesitation.

Intraoperative Detection of Leakage Using Topical Fluorescein Following Free Flap Inset in Head and Neck Reconstruction.

In microsurgical head and neck reconstruction, a watertight closure following flap inset is essential to prevent saliva leakage and subsequent complications, such as wound dehiscence and fistulas. However, no standard method has been established to detect and localize the leakage following flap inset. The authors introduce a simple, easy, mobile, and inexpensive method to intraoperatively detect the leakage using topical fluorescein sodium mixed saline and Wood lamp. This simple procedure will allow surgeons to be confident of watertight closure.

Simultaneous Nipple-Areola Complex Reconstruction Technique: Combination Nipple Sharing and Tattooing.

BACKGROUND: Nipple-areola complex (NAC) reconstruction is the final critical process used to achieve breast symmetry, patient satisfaction, and overall reconstruction completeness. Here, we introduce our simplified simultaneous NAC reconstruction approach with nipple sharing and tattooing that resulted in minimal morbidity, high patient satisfaction, and a shortened total reconstructive period. METHODS: Patients who underwent simultaneous nipple sharing and tattooing between July 2012 and December 2017 after the final operative procedure or adjuvant therapy were included. We retrospectively evaluated breast reconstruction type, interval between breast and NAC reconstruction, mean operation time for simultaneous nipple sharing and tattooing, and postoperative complications. Overall patient satisfaction and willingness to undergo simultaneous NAC reconstruction again were assessed. RESULTS: The mean interval between the final operative procedure or adjuvant therapy and NAC reconstruction was 4.4, 4.4, and 6.7 months in non-adjuvant patients, those who underwent chemotherapy, and those who underwent radiotherapy, respectively. The mean operation time for simultaneous NAC reconstruction was 46 min. No major complications such as infection or total nipple loss were observed regardless of breast reconstruction type at least 6 months postoperatively. The average overall satisfaction was 8.0 on a 10-point scale, and 96.9% of patients indicated that they would undergo this simultaneous NAC reconstruction again. CONCLUSIONS: Our simplified technique of simultaneous nipple sharing and tattooing is safe and reliable and features high patient satisfaction rates. Additionally, it can be performed in the clinical setting and is convenient for patients and surgeons alike since it features a decreased total reconstruction period. 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 .

Use of Strict Patient Selection Criteria to Achieve Significant Surgical Outcomes from a Low DIEP Flap Breast Reconstruction.

BACKGROUND: The low deep inferior epigastric perforator (DIEP) flap was first introduced in 2016 as it had aesthetic advantages over the conventional DIEP flap. With our experience of over 100 low DIEP flap procedures to date, we have conspicuously lowered complication rates and established more definitive criteria to select proper candidates. METHODS: We analyzed 103 patients who underwent breast reconstruction with the low DIEP flap at our hospital between May 2014 and June 2018. Demographics, patient selection criteria, flap specifics, surgical outcomes including postoperative complications, and the location of the abdominal scar and umbilicus were reviewed retrospectively. RESULTS: The mean patient age was 46.7 years, and the average body mass index was 23.7 kg/m2. A low DIEP with an average weight of 377 g was utilized within 6 hours 17 minutes in this cohort. There was no significant difference in the rate of venous congestion or fat necrosis compared with the conventional DIEP flap. The average distance from the pubic hairline to the abdominal scar was 0.6 cm and from the anterior superior iliac spine to the abdominal scar was -0.4 cm. The postoperative location of the umbilicus was 7.0 cm above the pubic hairline. CONCLUSION: The low DIEP flap is not only a reliable option for a breast reconstruction but is an aesthetically superior approach with a lower abdominal scar and natural umbilicus. Patients may benefit from this technique if prudently selected by computed tomography (CT) angiography. A perforator that is larger than 1 mm in diameter and well enhanced on CT angiography from the division of the external iliac artery to the abdominal skin particularly in the intramuscular course should be selected.

Use of a Vertical Muscle-Sparing Latissimus Dorsi Flap in Implant-Based Breast Reconstruction Without Position Change.

BACKGROUND: The use of various latissimus dorsi (LD) flap types in combination with implants is a safe and reliable 1-stage breast reconstruction method. However, 1 or more positional changes are generally required during the procedure. We designed a vertical skin paddle that was centered along the midaxillary line and harvested the required LD muscle amount based on the thoracodorsal artery descending branch, thereby completing flap elevation, inset, and donor-site closure in the supine position following skin-sparing mastectomy. METHODS: Between July 2017 and September 2017, we enrolled patients who underwent breast reconstruction using the vertical muscle-sparing LD (ms-LD) flap with an implant. The vertical ms-LD flap was selected when the nipple-areolar complex could not be spared or when adjuvant radiation therapy was anticipated. RESULTS: Eleven patients were enrolled in the study. All patients underwent skin-sparing mastectomy (with excision of the nipple-areolar complex for oncological reason). The mean mastectomy specimen weight was 402.3 g. The average flap length and width were 15.2 and 5.5 cm, respectively. The mean implant size was 290 mL. The average operative time was 112 minutes. All surgical procedures were performed in the supine position, and the flap reached the most medial part of the breast without any tension in all cases. The mean follow-up length was 87 days, and no complications such as infection, partial flap loss, or donor-site seroma were observed. CONCLUSIONS: Vertical ms-LD flaps can be harvested and utilized in direct-to-implant reconstructions when a skin paddle (or banking) is required, or when acellular dermal matrix use is precluded, or when additional soft tissue coverage is mandatory in high-risk patients not requiring intraoperative position changes. This technique can shorten the operation time and may reduce donor-site morbidity and associated complications.

Direct-to-Implant as a Frontline Option for Immediate Breast Reconstruction: A Comparative Study With 2-Stage Reconstruction.

BACKGROUND: Immediate single-stage direct-to-implant breast reconstruction requires caution owing to the possibility of skin necrosis and implant failure. Nevertheless, this method has been performed widely for breast reconstruction. This study aimed to analyze the safety of single-stage implant reconstruction by comparing it with 2-stage reconstruction (TSR). METHODS: Immediate single-stage reconstructions (SSRs) and TSRs with a tissue expander, performed from January 2011 to December 2016, were retrospectively reviewed. Acellular dermal matrix was used in both groups to maintain similar pocket conditions. Risk factors were not considered in patient selection. RESULTS: We enrolled 290 patients including 8 who received bilateral breast reconstruction. A total of 298 breasts were operated, including 233 SSR cases (78%) and 65 TSR cases (22%). The surgical success (ie, the implant was maintained without explantation) rate was higher in SSR (97%) than in TSR (90.2%) (P = 0.03). Two-stage reconstruction had a significantly higher rate of hematoma (12.3% vs 3.4%, P = 0.005), seroma (41.5% vs 20.6%, P = 0.001), and implant failure (9.8% vs 3.0%, P = 0.03). However, the rate of skin necrosis was lower in TSR (7.7% vs 10.3%) with a trend toward significance (P = 0.053). The implant salvage rate was higher in SSR (61.1%) than in TSR (12.5%) even after revision operation (P = 0.013). CONCLUSIONS: Single-stage reconstruction yielded a lower complication rate than TSR. Moreover, the high salvage rate of SSR causes less concern about implant failure despite the possibility of revision operation. Therefore, SSR may be considered a frontline method for breast reconstruction without any patient selection interference.

Reconstruction of Temporal Bone Defect Using a Vertically-Oriented Free Muscle-Sparing Rectus Abdominis Musculocutaneous Flap.

Reconstruction of a temporal bone defect after tumor ablation should provide watertight filling and adequate resurfacing. A muscle-sparing rectus abdominis musculocutaneous (ms-RAMC) flap with de-epithelized skin paddle has been used and early experience was reported. Case series enrolled 7 patients who underwent free ms-RAMC flap after tumor ablation for external auditory canal cancer. Vertically oriented flap was harvested with central strip of muscle. Distal skin paddle was de-epithelized to fill the bony defect. Immediate facial nerve reconstruction was performed whenever indicated. The average operation time for reconstruction was 280 minutes. No early complication was reported. An ms-RAMC flap with de-epithelized skin paddle can be used for temporal bone defect reconstruction with its anatomic consistency and technical simplicity. It can provide sufficient bulk for water tight packing that lasts after irradiation. The 11th intercostal nerve can be harvested during pedicle dissection. Muscle sparing technique could minimize donor-site morbidity.

Does the Sequence of Tattooing and Nipple Reconstruction Affect Nipple Projection?

BACKGROUND: In nipple reconstruction, the maintenance of adequate projection is one of the most important and challenging aspects. However, no reports have evaluated whether tattooing after nipple reconstruction affects nipple projection. This study aimed to test our hypothesis that tattooing after reconstruction adversely affects nipple projection. METHOD: Between September 2001 and July 2009, 384 nipples were reconstructed using the modified top hat technique after breast reconstruction with a transverse rectus abdominis musculocutaneous flap. Of these, 320 were reconstructed before tattooing, and 64 were reconstructed after tattooing. Projection at 6 months and 1 year was compared with that measured immediately after the operation, and projection was compared between the nipples reconstructed after tattooing and those reconstructed before tattooing. RESULTS: After 6 months, the mean loss of projection was 52.5% in the tattoo-after group and 55.1% in the tattoo-before group. After 1 year, it was 59.2% in the tattoo-after group and 58.6% in the tattoo-before group. There were no significant differences between the groups regarding the sequence of the procedures. The additional tattoo and retattoo rate was 20% in the tattoo-before group and 1% in the tattoo-after group. CONCLUSIONS: These findings showed that the sequence of nipple reconstruction and tattooing had no significant effect on the projection of the reconstructed nipple. It is easier to tattoo homogeneously before nipple reconstruction because of the flat surface but more difficult to make a smooth areolar peripheral margin and circular areolar shape when reconstructing the nipple. The sequence of tattooing and nipple reconstruction can be determined according to esthetic and clinical considerations.