Obesity Portends Increasing Rates of Superficial Surgical Site Infection Following Pediatric Reduction Mammoplasty: A National Surgical Database Analysis.

INTRODUCTION: Pediatric reduction mammoplasty has become increasingly common due to the obesity epidemic. While obesity remains the leading cause of macromastia leading to surgery, it may also be a risk factor for postoperative complications. This study examines the safety of pediatric reduction mammoplasty and the risk of obesity for complications following this procedure. METHODS: The American College of Surgeons National Surgical Quality Improvement Program Pediatrics was queried to obtain all reduction mammoplasty cases from 2012 to 2020. Univariate and multivariate logistic regression analyses controlling for confounders were carried out to assess the relationship between body mass index (BMI) and rates of complication. RESULTS: One thousand five hundred eighty-nine patients with the primary Current Procedural Terminology code 19318 were included in the final analysis. The mean age was 16.6 (SD, 1.1) years, and the mean BMI was 30.5 (SD, 6.2) lb/in2. Notably, 49% of the patients were obese, and 31% were overweight, while only 0.4% were underweight. Forty-three patients (2.7%) sustained a superficial surgical site infection (SSI) postoperatively. Other complications were less prevalent, including deep SSI (4 patients, 0.3%), dehiscence (11, 0.7%), reoperation (21, 1%), and readmission (26, 1.6%).Independent variables analyzed included age, sex, BMI, diabetes mellitus, American Society of Anesthesiologists (ASA) class, and operative time, of which only BMI and ASA class were found to be significantly associated with SSI on univariate analysis. On multivariate logistic regression while controlling for ASA class and the false discovery rate, there was a strong association between increasing rates of superficial SSI and increasing BMI (unit odds ratio, 1.05; 95% confidence interval, [1.01, 1.09]; P = 0.02). The OR indicates that for each 1-unit increase in BMI, the odds of SSI increase by 5%. CONCLUSIONS: Complications following pediatric reduction mammoplasty are uncommon, demonstrating the safety of this procedure. High BMI was found to have a significantly higher risk for superficial SSI. Increased caution and infection prophylaxis should be taken when performing this operation on obese patients.

Alpha Defensin-1 Biomarker Outperforms Culture in Diagnosing Breast Implant-Related Infection: Results from a Multicenter Prospective Study.

BACKGROUND: Prompt diagnosis of breast implant infection is critical to reducing morbidity. A high incidence of false-negative microbial culture mandates superior testing modalities. Alpha defensin-1 (AD-1), an infection biomarker, has outperformed culture in diagnosing periprosthetic joint infection with sensitivity/specificity of 97%. After previously demonstrating its feasibility in breast implant-related infection (BIRI), this case-control study compares the accuracy of AD-1 to microbial culture in suspected BIRI. METHODS: An institutional review board-approved, prospective, multicenter study was conducted of adults with prior breast implant reconstruction undergoing surgery for suspected infection (cases) or prosthetic exchange/revision (controls). Demographics, perioperative characteristics, antibiotic exposure, and implant pocket fluid were collected. Fluid samples underwent microbial culture, AD-1 assay, and adjunctive markers (C-reactive protein, lactate, cell differential); diagnostic performance was assessed by means of sensitivity, specificity, and accuracy from receiver operating characteristic curve analysis, with values of P < 0.05 considered significant. RESULTS: Fifty-three implant pocket samples were included (cases, n = 20; controls, n = 33). All 20 patients with suspected BIRI exhibited cellulitis, 65% had abnormal drainage, and 55% were febrile. All suspected BIRIs were AD-1 positive (sensitivity, 100%). Microbial culture failed to grow any microorganisms in four BIRIs (sensitivity, 80%; P = 0.046); Gram stain was least accurate (sensitivity, 25%; P < 0.001). All tests demonstrated 100% specificity. Receiver operating characteristic curve analyses yielded the following areas under the curve: AD-1, 1.0; microbial culture, 0.90 ( P = 0.029); and Gram stain, 0.62 ( P < 0.001). Adjunctive markers were significantly higher among infections versus controls ( P < 0.001). CONCLUSIONS: Study findings confirm the accuracy of AD-1 in diagnosing BIRI and indicate superiority to microbial culture. Although further study is warranted, AD-1 may facilitate perioperative decision-making in BIRI management in a resource-efficient manner. CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, II.

Evaluation of Xenograft Efficacy in Immediate Prosthesis-based Breast Reconstruction.

The advent of acellular dermal matrix (ADM) has revolutionized prosthesis-based breast reconstruction. However, paucity of human cadaveric tissue has resulted in limitation of supply and increased associated costs, prompting concerted effort to identify xenograft alternatives. Although studies have examined the safety of Artia, a porcine-derived ADM, few have evaluated its clinical efficacy as soft tissue reinforcement. This study uniquely evaluates the clinical efficacy of Artia in implant-based breast reconstruction. Methods: IRB-approved retrospective chart review was conducted to identify 243 consecutive TE-based procedures performed at a tertiary academic medical center between March 2017 and March 2021. Propensity matching was conducted to minimize differences between cohorts. Efficacy metrics, defined as initial tissue expander (TE) fill volume, number of TE fills, and time interval between exchange of TE for final implant, were compared between xenograft (Artia) and allograft (AlloDerm) groups. Results: Patients who underwent Artia-based breast reconstruction achieved superior initial TE fill volume relative to those who underwent AlloDerm-based breast reconstruction via univariate analysis (317.3 ± 185.8 mL versus 286.1 ± 140.4 mL, P < 0.01) when patient and operative characteristics were well-matched. However, linear regression analysis failed to demonstrate difference in efficacy metrics, such as initial TE fill volume (P = 0.31), ratio between initial TE fill volume and final implant size (P = 0.19), and number of TE fills (P = 0.76). Complication rates were comparable between groups. Conclusion: This study suggests that Artia can be used as a safe and efficacious alternative to human-derived ADM in immediate TE-based breast reconstruction.

Evaluating the Inaccuracy of the National Surgical Quality Improvement Project Surgical Risk Calculator in Plastic Surgery: A Meta-analysis of Short-Term Predicted Complications.

BACKGROUND: Preoperative surgical risk assessment is a major component of clinical decision making. The ability to provide accurate, individualized risk estimates has become critical because of growing emphasis on quality metrics benchmarks. The American College of Surgeons National Surgical Quality Improvement Project (NSQIP) Surgical Risk Calculator (SRC) was designed to quantify patient-specific risk across various surgeries. Its applicability to plastic surgery is unclear, however, with multiple studies reporting inaccuracies among certain patient populations. This study uses meta-analysis to evaluate the NSQIP SRC's ability to predict complications among patients having plastic surgery. METHODS: OVID MEDLINE and PubMed were searched for all studies evaluating the predictive accuracy of the NSQIP SRC in plastic surgery, including oncologic reconstruction, ventral hernia repair, and body contouring. Only studies directly comparing SCR predicted to observed complication rates were included. The primary measure of SRC prediction accuracy, area under the curve (AUC), was assessed for each complication via DerSimonian and Laird random-effects analytic model. The I2 statistic, indicating heterogeneity, was judged low (I2 < 50%) or borderline/unacceptably high (I2 > 50%). All analyses were conducted in StataSE 16.1 (StataCorp LP, College Station, Tex). RESULTS: Ten of the 296 studies screened met criteria for inclusion (2416 patients). Studies were classified as follows: (head and neck: n = 5, breast: n = 1, extremity: n = 1), open ventral hernia repair (n = 2), and panniculectomy (n = 1). Predictive accuracy was poor for medical and surgical complications (medical: pulmonary AUC = 0.67 [0.48-0.87], cardiac AUC = 0.66 [0.20-0.99], venous thromboembolism AUC = 0.55 [0.47-0.63]), (surgical: surgical site infection AUC = 0.55 [0.46-0.63], reoperation AUC = 0.54 [0.49-0.58], serious complication AUC = 0.58 [0.43-0.73], and any complication AUC = 0.60 [0.57-0.64]). Although mortality was accurately predicted in 2 studies (AUC = 0.87 [0.54-0.99]), heterogeneity was high with I2 = 68%. Otherwise, heterogeneity was minimal (I2 = 0%) or acceptably low (I2 < 50%) for all other outcomes. CONCLUSIONS: The NSQIP Universal SRC, aimed at offering individualized quantifiable risk estimates for surgical complications, consistently demonstrated poor risk discrimination in this plastic surgery-focused meta-analysis. The limitations of the SRC are perhaps most pronounced where complex, multidisciplinary reconstructions are needed. Future efforts should identify targets for improving SRC reliability to better counsel patients in the perioperative setting and guide appropriate healthcare resource allocation.

Improved Diagnostic Accuracy of Periprosthetic Breast Infection: Novel Application of the Alpha Defensin-1 Biomarker.

Prompt, accurate diagnosis of breast implant infection is critical to minimizing patient morbidity. Bacterial culture false negative rate approaches 25%-30%, and better costeffective testing modalities are needed. Alpha defensin-1 (AD-1) is a neutrophil-mediated biomarker for microbial infection. With sensitivity/specificity of 97% and 96%, it has replaced culture as the preferred diagnostic modality for orthopedic periprosthetic infection, but has yet to be investigated in breast reconstruction. This pilot study compares the diagnostic performance of AD-1 to bacterial culture in suspected periprosthetic breast infection. METHODS: Patients with prosthetic breast reconstruction and suspected periprosthetic infection were prospectively studied. Implant pocket fluid was analyzed with gram stain and culture, AD-1 assay, and adjunctive markers. Demographics, operative history, prosthetic characteristics, and antibiotic exposure were collected, and diagnostic performance of each test was compared. RESULTS: Fifteen breasts with suspected periprosthetic breast infection were included, 10 (66.7%) of which were acutely infected. Gram stain correctly identified only 1 of 10 infections, whereas culture failed to identify 1 infection and reported equivocal/false-positives in 2 noninfected samples. AD-1, however, correctly classified all 15 samples. AD-1 exhibited 100% sensitivity and specificity, comparing favorably to culture (sensitivity: 90%, specificity: 60%), although this did not reach significance (P=0.22). Infected breasts also demonstrated significantly higher adjunctive marker levels compared to noninfected breasts. CONCLUSIONS: This study demonstrates the utility of AD-1 in diagnosing periprosthetic breast infection. Combining AD-1 with adjunctive inflammatory markers may allow more accurate, prompt detection of implant infection which may reduce morbidity and reconstructive failures.

Severe burn injuries caused by bioethanol-design fireplaces-an overview on recreational fire threats.

Commercially available bioethanol-fueled fireplaces have become increasingly popular additions for interior home decoration in Europe and more recently in the United States. These fireplaces are advertised as smokeless, ecologically friendly, and do not require professional installation, formal gas lines, or venting. Although manufacturers and businesses promote their safety, recent presentations of injuries have alerted the authors to the relevant danger bioethanol fireplaces can pose for the incautious user. Are bioethanol fireplaces going to become the future threat in domestic burn accidents beside common barbeque burns? A Medline literature search on barbeque and domestic fireplace accidents was performed to compare and stratify the injury patterns reported and to identify a risk profile for contemporary bioethanol-fueled fireplaces. To exemplify, two representative clinical cases of severe burn accidents caused by bioethanol-fueled fireplaces, both treated in the burn unit of the authors, are being presented. Design fireplaces are being recognized as an increasing source of fuel and fire-related danger in the home. This risk may be underestimated by the uninformed customer, resulting in severe burn injuries. Because bioethanol-fueled fireplaces have become more commonplace, they may overtake barbecue-related injury as the most common domestic burn injury.

Immediate breast tissue expander-implant reconstruction with inferolateral AlloDerm hammock and postoperative radiation: a preliminary report.

OBJECTIVE: To preserve the mastectomy skin envelope in select patients destined to receive radiation following mastectomy, we performed immediate tissue expander-implant reconstruction with a subpectoral tissue expander and an inferolateral AlloDerm hammock for complete implant coverage. We hypothesized that the AlloDerm hammock may allow greater intraoperative volume expansion and potentially avoid the need for an autologous construct. METHODS: Tissue expanders were filled to 75%-85% capacity intraoperatively and 85%-100% prior to radiation therapy. This allowed for maximum preservation of the mastectomy skin envelope prior to radiation therapy and provided a sizable breast mound immediately following mastectomy. Histology of irradiated and nonirradiated capsules was compared. RESULTS: Five patients aged 29-51 years had immediate implant (1) or expander-implant (4) breast reconstruction followed by postreconstruction radiation 2-6 months following the procedure. Patients were followed for 2.5-5.5 years following implant reconstruction and 2-5 years following radiation. No capsular contracture or implant loss was observed in any patient. No patients required or requested autologous reconstruction following radiation and all currently have silicone implants. Capsular biopsies from radiated and nonradiated implants showed identical collagen architecture on histology, confirming clinical observations. CONCLUSION: Tissue expander-implant breast reconstruction following mastectomy preserves the skin envelope in patients who receive postmastectomy radiation. Further investigation is warranted to determine whether complete implant coverage with the pectoralis muscle and AlloDerm hammock mitigates the deleterious effects of radiation.

Mastopexy techniques after massive weight loss: an algorithmic approach and review of the literature.

Mastopexy after massive weight loss (MWL) poses unique challenges that may not be successfully addressed with traditional mastopexy procedures. Several novel techniques have been proposed to improve esthetic outcomes; however, little data exists to guide the plastic surgeon on choice of technique for individual patients. A literature review revealed 10 articles with specific emphasis on mastopexy techniques in MWL patients. These articles focused on ways to improve shape, projection, and long-term results, using autologous tissue alone or combined with breast implants. Key concepts include increasing volume of the breast by utilizing excess axillary tissue (lateral thoracic/spiral/intercostal artery perforator flap), modification of existing superomedial pedicle techniques to maximize breast volume, and increasing breast parenchymal support with suture fixation and dermal suspension. This article offers an algorithmic approach to treat breast ptosis in the MWL patient based on breast volume, axillary tissue, desired scar location, and preferred surgical technique.

Improving shape and symmetry in mastopexy with autologous or cadaveric dermal slings.

Mastopexy and reduction mammaplasty reshape breast parenchyma and restore youthful contour in women with ptotic breasts. However, recurrent ptosis and breast base widening are common. We have been using internal autologous or cadaveric (AlloDerm) dermal slings to circumferentially support and shape the breasts for symmetry or rejuvenation. Ten patients underwent unilateral mastopexy (3), unilateral reduction-mastopexy (1), bilateral mastopexy (5), or bilateral reduction-mastopexy (1) with an internal dermal sling to correct breast reconstruction asymmetry (2), congenital asymmetry (2), or acquired ptosis (6). Three of 6 patients acquired breast ptosis after massive weight loss. Autologous dermis was used in 5 patients, and 5 patients were reconstructed with AlloDerm. Patients have maintained projection and breast base width after 6 months to 3 years. In conclusion, internal dermal slings improve shape, breast projection, and base width in select patients undergoing mastopexy. An algorithm based on quantity and quality of native skin is provided.

Inferolateral AlloDerm hammock for implant coverage in breast reconstruction.

PURPOSE: Implant reconstruction is commonly performed to reconstruct mastectomy defects or to correct breast hypoplasia. We have been using an inferolateral AlloDerm hammock as an inferior extension of the pectoralis major muscle to provide a mechanical barrier between the implant and skin and to control implant position. METHODS: The inferior border of the AlloDerm hammock is attached inferiorly to the rectus abdominis fascia and laterally to the serratus anterior fascia to create the borders of the implant pocket. The AlloDerm is then sewn to the pectoralis major muscle to enclose the implant. RESULTS: The AlloDerm hammock was used in 43 patients and 67 breasts for immediate expander-implant reconstruction (10), immediate silicone implant reconstruction (30), delayed expander-implant reconstruction (4), and revisional implant reconstruction for capsular contracture following capsulectomy (23). The AlloDerm hammock allowed complete coverage of the implant and symmetric positioning of the inframammary fold. In delayed reconstructions with existing skin redundancy at the mastectomy site, inferior epigastric tissue was recruited and tissue expanders filled over 75% of the desired volume, thus decreasing the need for subsequent filling. Patients were overall satisfied with their results and had few complications. No capsular contracture, hematoma, or seroma was observed in 6 months to 3 years of follow-up. CONCLUSION: Implant reconstruction with an inferolateral AlloDerm hammock facilitates positioning of the implant in immediate or revisional breast reconstruction and simplifies expander-implant reconstruction. This safe technique is easy to learn and should be considered a viable option for breast reconstruction.

Silver-impregnated vacuum-assisted closure in the treatment of recalcitrant venous stasis ulcers.

Vacuum-assisted closure (VAC) has made a significant contribution to the treatment of acute and chronic wounds. Microdeformational forces from the VAC device accelerate granulation tissue formation when compared with moist saline dressing changes. We present 2 patients with multiple comorbid conditions and complex venous stasis ulcers that had persistent purulent drainage after conventional treatment modalities. Only after utilizing silver-impregnated VAC therapy (GranuFoam Silver), combining the antimicrobial benefits of silver with the advantages of VAC technology, were the wound beds adequately prepared for substantial split-thickness skin grafts. Based on these cases, the silver-impregnated VAC device may be a useful adjunct in wound bed preparation when standard therapies have failed to clear infected wounds. This may lead to improved healing rates and overall decreased wound burden in these complex patients.

Immediate bilateral breast reconstruction with implants and inferolateral AlloDerm slings.

To shorten the reconstructive process, improve results, and provide additional options for women seeking mastectomy, we used an acellular cryopreserved dermal matrix (AlloDerm) sling to reestablish the lower pole of the pectoralis major muscle. This technique creates a subpectoral-sub-AlloDerm pocket that completely encloses the breast implant. By tailoring the width of the AlloDerm, we can precisely control the degree of lower-pole fullness. This technique shortens or eliminates the need for tissue expansion and provides an additional option for single-stage breast reconstruction with implants. We have selectively used this technique as a reconstructive option for 10 women undergoing bilateral mastectomy (20 breasts).

Early experience using low-frequency ultrasound in chronic wounds.

Periodic wound debridement promotes healing in chronic wounds. Low-frequency ultrasonic debridement (LFUD) is a promising adjunct to wound care, which offers relatively painless debridement and bacterial biofilm destruction. We performed LFUD on 17 patients over 8 months, with a minimum follow-up of 3 months. Nine of the wounds (53%) healed primarily or with the aid of a skin graft. Six additional patients (35%) experienced a wound-size reduction of at least 50%. The remaining 2 patients (12%), one with sickle cell anemia and one with a venous stasis ulcer, had reductions in wound area of 20%-30%. None of the patients required initiation of antibiotic treatment after starting LFUD. LFUD has had an early favorable experience in our institution. Further randomized clinical studies are required to better define the mechanism of action and the patient populations most appropriate for this modality.

Occult breast carcinoma in reduction mammaplasty specimens: 14-year experience.

Reduction mammaplasty is commonly performed for bilateral macromastia, congenital asymmetry, or as a contralateral symmetry procedure in breast reconstruction following mastectomy for cancer. Occult carcinoma has been detected in 0.06 percent to 0.4 percent of breast reduction specimens. The purpose of this study was to examine the incidence of breast cancer in breast reductions performed in one institution over a 14-year period. The authors reviewed their experience with 800 reduction mammaplasties performed between 1988 and 2001. Six cancers were detected (0.8 percent). Of these cancers, three were invasive (0.4 percent) and three were ductal carcinoma in situ (0.4 percent). Stratified by indication for surgery, there was a trend toward higher detection rates in the reconstruction group (1.2 percent) compared with the macromastia (0.7 percent) or congenital asymmetry (0 percent) groups. Mammography was performed preoperatively in these patients and all results were negative for masses or suspicious microcalcification. Pathological diagnosis was guided by gross specimen evaluation in two patients and specimen radiography in one patient. Reduction mammaplasty has a small but definite risk of finding cancer in the resection specimen.