A Multicenter Analysis Examining Patients Undergoing Conversion of Implant-based Breast Reconstruction to Abdominally based Free Tissue Transfer.

BACKGROUND: Breast implant placement is the most common method for postmastectomy reconstruction. For patients who develop complications associated with implant-based reconstruction, additional surgeries may be challenging. This study examined implant-based reconstruction failure in patients undergoing salvage with abdominal free tissue transfer. METHODS: We conducted an Institutional Review Board approved, multicenter retrospective study of patients with implant-based primary breast reconstruction followed by implant removal and subsequent abdominal free tissue transfer between 2006 and 2016. Patient demographics, treatment details, and complications were evaluated. Severity of implant failure was graded as either (1) not severe (delayed salvage reconstruction) or (2) severe (immediate salvage reconstruction). RESULTS: Between 2006 and 2016, 115 patients with 180 mastectomy defects underwent primary implant-based reconstruction with subsequent implant removal and abdominally based free tissue reconstruction. Of these, 68 were delayed and 47 were immediate salvage reconstruction. Factors leading to elective removal were capsular contracture, asymmetry, and implant malposition. Factors leading to obligatory removal were infection, delayed wound healing, and implant extrusion. Postmastectomy radiation was significantly associated with immediate salvage reconstruction (p < 0.001, odds ratio = 3.9) as were large volume implants (p = 0.06). Deep inferior epigastric perforator flaps comprised 78.3% of all abdominally based free tissue reconstructions, while muscle-sparing transverse rectus abdominus myocutaneous flaps comprised 18.3%. Overall flap failure rate was 2.6% (2.94% delayed and 2.13% immediate salvage reconstruction; p = 1.0). CONCLUSION: Our findings suggest that abdominal free tissue transfer remains a safe and effective salvage modality for implant-based breast reconstruction failure. Patients with severe implant failure were more likely to have received radiation. Surgeons should remain cognizant of this during care of patients.

An outcomes analysis of 2142 breast reduction procedures.

BACKGROUND: Breast reduction alleviates macromastia symptoms and facilitates symmetrical breast reconstruction after cancer treatment. We investigated a large series of consecutive breast reductions to study important factors that impact outcomes. METHODS: An institutional review board-approved, retrospective review of all breast reductions from 1999 to 2009 in a single institution was performed using the medical record for demographics, medical history, physical examination, intraoperative data, and postoperative complications. Multivariate statistical analysis was performed using Stata 1.0. P ≤ 0.05 defined significance. RESULTS: Seventeen surgeons performed 2152 consecutive breast reductions on 1148 patients using inferior pedicle/Wise pattern (56.4%), medial pedicle/Wise pattern (16.8%), superior pedicle/nipple graft/Wise pattern (15.1%), superior pedicle/vertical pattern (11.6%), and liposuction (0.1%) techniques. Complications included discernible scars (14.5%), nonsurgical wounds (13.5%), fat necrosis (8.2%), infection (7.3%), wounds requiring negative pressure wound therapy or reoperation (1.4%), and seroma (1.2%). Reoperation rates were 6.7% for scars, 1.4% for fat necrosis, and 1% for wounds.Body mass index greater than or equal to 35 kg/m increased risk of infections [odds ratio (OR), 2.3, P = 0.000], seromas (OR, 2.9, P = 0.03), fat necrosis (OR, 2.0, P = 0.002), and minor wounds (OR, 1.7, P = 0.001). Cardiac disease increased reoperation for scar (OR, 3.0, P = 0.04) and fat necrosis (OR, 5.3, P = 0.03). Tobacco use increased infection rate (OR, 2.1, P = 0.008). Secondary surgery increased seromas (OR, 12.0, P = 0.001). Previous hysterectomy/oophorectomy increased risk of wound reoperations (OR, 3.4, P = 0.02), and exogenous hormone supplementation trended toward decreasing infections (OR, 0.5, P = 0.08). χ analysis revealed 7.8% infection risk without exogenous hormone versus 3.8% risk with hormone supplementation (P = 0.02). CONCLUSIONS: Morbid obesity, tobacco, cardiac history, and secondary surgery negatively impacted breast reduction outcomes. Hormonal status impacted reoperations and infections.

Near-infrared lymphography as a minimally invasive modality for imaging lymphatic reconstitution in a rat orthotopic hind limb transplantation model.

Wider application of vascularized composite allotransplantation (VCA) is limited by the need for chronic immunosuppression. Recent data suggest that the lymphatic system plays an important role in mediating rejection. This study used near-infrared (NIR) lymphography to describe lymphatic reconstitution in a rat VCA model. Syngeneic (Lewis-Lewis) and allogeneic (Brown Norway-Lewis) rat orthotopic hind limb transplants were performed without immunosuppression. Animals were imaged pre- and postoperatively using indocyanine green (ICG) lymphography. Images were collected using an NIR imaging system. Co-localization was achieved through use of an acrylic paint/hydrogen peroxide mixture. In all transplants, ICG first crossed graft suture lines on postoperative day (POD) 5. Clinical signs of rejection also appeared on POD 5 in allogeneic transplants, with most exhibiting Grade 3 rejection by POD 6. Injection of an acrylic paint/hydrogen peroxide mixture on POD 5 confirmed the existence of continuous lymphatic vessels crossing the suture line and draining into the inguinal lymph node. NIR lymphography is a minimally invasive imaging modality that can be used to study lymphatic vessels in a rat VCA model. In allogeneic transplants, lymphatic reconstitution correlated with clinical rejection. Lymphatic reconstitution may represent an early target for immunomodulation.

Residents as Mentors: The Development of Resident Mentorship Milestones.

BACKGROUND: Mentorship of residents by more senior colleagues has been identified as important for stress management and creating an ideal learning environment. OBJECTIVE: We set out to define the attributes of an ideal resident mentor and explore ways to develop these attributes during residency training. METHODS: A 28-member, multi-specialty counsel of residents and fellows used 2 phases of a small group exercise. In the first phase, the group developed desirable attributes of resident mentors and explored means of developing these attributes. In the second phase, the group identified trends in the results, and in a second small group exercise with participants at a major national conference, refined these trends into Resident Mentorship Milestones. RESULTS: The exercises identified 3 common themes: availability, competence, and support of the mentee. We defined milestones for mentorship in each of these areas. CONCLUSIONS: The Resident Mentorship Milestones, developed by a national panel of residents, describe 3 key dimensions of mentorship: availability, defined as making time for mentorship; competence for and success in mentoring; and support of the mentee. These milestones may serve as a novel tool to develop and assess successful resident mentorship models.

Assessing the effort associated with teaching residents.

BACKGROUND: Intraoperative resident education is an integral mission of academic medical centers and serves as the basis for training the next generation of surgeons. The actual effort associated with teaching residents is unknown as it pertains to additional operative time. Using a large validated multi-institutional dataset, this study aims to quantify the effect of having a resident present in common plastic surgery procedures on operative time. Future directions for developing standardized methods to record and report teaching time are proposed, which can help inform prospective studies. STUDY DESIGN: The 2006-2012 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried to identify seven isolated plastic surgical procedures that were categorized based on resident involvement and supervision. Linear regression models were used to calculate the difference in operative time with respect to resident participation while controlling for patient and operative factors. RESULTS: Resident involvement was associated with longer operative times for muscle flap trunk procedures (53 min, 95% CI = [25, 80], p-value = 0.0002) and breast reconstruction procedures with a latissimus dorsi flap (55 min, 95% CI = [22, 88], p-value = 0.001). For six of the seven surgeries evaluated, resident involvement was associated with longer operative times, as compared to no resident involvement. CONCLUSION: Resident involvement is associated with an increase in operative time for certain plastic surgery procedures. This finding underscores the need for a mechanism to quantify the time and effort that the attending surgeons allocate toward intraoperative resident education. Further study is also necessary to determine the causal impact on patient care.

Can Vascular Patterns on Preoperative Magnetic Resonance Imaging Help Predict Skin Necrosis after Nipple-Sparing Mastectomy?

BACKGROUND: Nipple-areola complex (NAC) and skin flap ischemia and necrosis can occur after nipple-sparing mastectomy (NSM). The purpose of this study was to correlate vascular findings on MRI with outcomes in patients who underwent NSM. STUDY DESIGN: Female patients at a single institution who underwent NSM and had a preoperative breast MRI between 2010 and 2014 were identified. Medical records were reviewed for patient demographics, surgical factors, and complications. Magnetic resonance images were reviewed by 2 radiologists, blinded to outcomes, for the presence of dual vs single blood supply to the breast. The association between blood supply on MRI with ischemic and necrotic complications after NSM was analyzed. RESULTS: One hundred and sixty-four NSM procedures were performed in 105 patients (mean age 45.5 years, range 25 to 69 years) who had a preoperative MRI. The majority of procedures were performed for malignancy (89 of 164 [54.3%]) or prophylaxis (73 of 164 [44.5%]). Nipple-areola complex or skin flap ischemia or necrosis occurred in 40 (24.4%) breasts. Ischemia or necrosis after NSM was less likely to occur in breasts with dual compared with single blood supply (20.8% vs 38.2%; p = 0.03). There was no association between surgical complications and age, BMI, smoking history, previous radiation therapy, indication for NSM, surgical specimen weight, surgical incision type, reconstruction approach, or operating surgeon on univariate analysis. CONCLUSIONS: Preoperative MRI characterization of breast vascularity can be considered when planning NSM. The presence of a dual blood supply to the breast on MRI is associated with a decreased risk of nipple-areola complex and skin flap ischemia and necrosis after NSM.

Initial experience with the use of foetal/neonatal bovine acellular dermal collagen matrix (SurgiMend™) for tissue-expander breast reconstruction.

BACKGROUND: Acellular dermal matrix (ADM) is commonly used in staged breast reconstruction using tissue expanders (TEs). The literature on human ADM has reported variable outcomes, and there is a paucity of data for xenogenic sources of ADM. The aim of this study is to evaluate the early complications, risk factors and outcomes using SurgiMend™ in staged breast reconstruction. METHODS: An Institutional Review Board (IRB)-approved, retrospective analysis of a single surgeon's experience was performed. From August 2009 to May 2011, 65 patients underwent staged breast reconstruction using 95 sheets of SurgiMend™. The nominal TE fill volume was 383 ± 83 cc (range 250-550), mean intra-operative fill volume was 148 ± 86 cc (range 0-350) and mean final fill volume was 413 ± 176 cc (range 100-800). The mean clinic follow-up time was 16.9 ± 8.7 months; mean age was 50.9 ± 11.7 years; and average body mass index (BMI) was 26.0 ± 5.5 kg m(-2). Correlation with risk factors and clinical outcomes were analysed. RESULTS: The incidences of postoperative complications were: haematoma 3.2%, seroma 7.5% and re-operation due to infection 2.1%. Age, diabetes mellitus, and hypertension had a significant correlation with an increased overall complication rate. With respect to early complications, such as infection requiring re-operation, diabetes demonstrated a trend with an odds ratio of 11.69. CONCLUSION: This study demonstrates that the use of SurgiMend™ is associated with low early complication rates and is well tolerated in staged breast reconstruction.

Monocytes loaded with indocyanine green as active homing contrast agents permit optical differentiation of infectious and non-infectious inflammation.

Distinguishing cutaneous infection from sterile inflammation is a diagnostic challenge and currently relies upon subjective interpretation of clinical parameters, microbiological data, and nonspecific imaging. Assessing characteristic variations in leukocytic infiltration may provide more specific information. In this study, we demonstrate that homing of systemically administered monocytes tagged using indocyanine green (ICG), an FDA-approved near infrared dye, may be assessed non-invasively using clinically-applicable laser angiography systems to investigate cutaneous inflammatory processes. RAW 264.7 mouse monocytes co-incubated with ICG fluoresce brightly in the near infrared range. In vitro, the loaded cells retained the ability to chemotax toward monocyte chemotactic protein-1. Following intravascular injection of loaded cells into BALB/c mice with induced sterile inflammation (Complete Freund's Adjuvant inoculation) or infection (Group A Streptococcus inoculation) of the hind limb, non-invasive whole animal imaging revealed local fluorescence at the inoculation site. There was significantly higher fluorescence of the inoculation site in the infection model than in the inflammation model as early as 2 hours after injection (p<0.05). Microscopic examination of bacterial inoculation site tissue revealed points of near infrared fluorescence, suggesting the presence of ICG-loaded cells. Development of a non-invasive technique to rapidly image inflammatory states without radiation may lead to new tools to distinguish infectious conditions from sterile inflammatory conditions at the bedside.