Early Complications in Prepectoral Tissue Expander-Based Breast Reconstruction.

BACKGROUND: Prepectoral implant placement for postmastectomy breast reconstruction has increased in recent years. Benefits of prepectoral reconstruction may include lack of animation deformities and reduced postoperative pain, but its complication profile is currently unclear. This study aimed to examine the complication profile of prepectoral tissue expanders (TEs) to determine factors associated with TE loss. METHODS: A retrospective review was performed to identify all patients who underwent immediate prepectoral TE reconstruction from January 2018 to June 2021. The decision to use the prepectoral technique was based on mastectomy skin quality and patient comorbidities. Patient demographics, comorbidities, and operative details were evaluated. Outcomes of interest included TE loss, seroma, hematoma, infection/cellulitis, mastectomy skin flap necrosis requiring revision, and TE exposure. Logistic regression analysis was performed to identify factors associated with TE loss. RESULTS: The study identified 1225 TEs. The most frequent complications were seroma (8.7%, n = 106), infection/cellulitis (8.2%, n = 101), and TE loss (4.2%, n = 51). Factors associated with TE loss in the univariate analysis included ethnicity, history of smoking, body mass index, mastectomy weight, and neoadjuvant chemotherapy. In the multivariate regression analysis, only mastectomy weight had a positive association with TE loss (odds ratio, 1.001; p = 0.016). CONCLUSION: Prepectoral two-stage breast reconstruction can be performed safely with an acceptable early complication profile. The study data suggest that increasing mastectomy weight is the most significant factor associated with TE loss. Further research examining the quality of the soft tissue envelope and assessing patient-reported outcomes would prove beneficial.

The evolution of pediatric soft-tissue free flap reconstruction of the lower extremity after oncologic resection: A 30 year experience.

INTRODUCTION: Limb salvage has become the standard of care for lower extremity tumors because of improvements in adjuvant treatments and reconstructive techniques. While there is literature assessing pediatric lower extremity free flap reconstruction in the setting of trauma, there is a paucity of literature that analyzes oncologic free flap reconstruction in this patient population. We report our long-term experience and evolution of care for lower extremity oncologic free flap reconstruction in pediatric patients. METHODS: This is a retrospective case series of all patients ≤18 years of age who underwent oncologic soft-tissue microvascular reconstruction of the lower extremity, from 1992 to 2021. Data were collected for patient demographics, oncologic treatment, operative details, and post-operative outcomes. Functional outcomes were assessed by weight bearing status, ambulation, and participation in activities-of-daily-living (ADLs), and musculoskeletal tumor society (MSTS) scores. RESULTS: Over the 30-year study period, inclusion criteria were met by 19 patients (11 males, 8 females) with a mean age of 13.8 years and a mean follow-up of 5.3 years. At last follow-up, 13 patients (68.5%) were alive. The most common pathology was osteogenic sarcoma (13 patients, 68.5%). Sites of reconstruction were the hip (n = 1), thigh (n = 5), knee (n = 4), leg (n = 7), and the foot (n = 2). The most commonly used flaps were latissimus dorsi (n = 8), gracilis (n = 4), and anterolateral thigh ± vastus (n = 4). Postoperative complications occurred in nine patients (43%). Overall flap success rate was 95%. At latest follow-up, ambulation without assistive device was obtained in 11 patients (58%), full weight bearing was achieved by 13 patients (68.5%), and ADLs could be performed independently by 13 patients (68.5%). Mean MSTS score was 23.1/30. CONCLUSION: Microvascular reconstruction for oncological lower extremity defects in the pediatric population has high limb salvage rates and good functional outcomes.

Social Determinants of Health and Patient-reported Outcomes Following Autologous Breast Reconstruction, Using Insurance as a Proxy.

BACKGROUND: Insurance type can serve as a surrogate marker for social determinants of health and can influence many aspects of the breast reconstruction experience. We aimed to examine the impact of insurance coverage on patients reported outcomes with the BREAST-Q (patient reported outcome measure for breast reconstruction patients, in patients receiving) in patients receiving deep inferior epigastric artery perforator (DIEP) flap breast reconstruction. METHODS: We retrospectively examined patients who received DIEP flaps at our institution from 2010 to 2019. Patients were divided into categories by insurance: commercial, Medicaid, or Medicare. Demographic factors, surgical factors, and complication data were recorded. Descriptive statistics, Fisher's exact, Kruskal-Wallis rank sum tests, and generalized estimating equations were performed to identify associations between insurance status and five domains of the BREAST-Q Reconstructive module. RESULTS: A total of 1,285 patients were included, of which 1,011 (78.7%) had commercial, 89 (6.9%) had Medicaid, and 185 (14.4%) had Medicare insurances. Total flap loss rates were significantly higher in the Medicare and Medicaid patients as compared to commercial patients; however, commercial patients had a higher rate of wound dehiscence as compared to Medicare patients. With all other factors controlled for, patients with Medicare had lower Physical Well-being of the Chest (PWBC) than patients with commercial insurance (ß = - 3.1, 95% confidence interval (CI): -5.0, -1.2, p = 0.002). There were no significant associations between insurance classification and other domains of the BREAST-Q. CONCLUSION: Patients with government-issued insurance had lower success rates of autologous breast reconstruction. Further, patients with Medicare had lower PWBC than patients with commercial insurance regardless of other factors, while other BREAST-Q metrics did not differ. Further investigation as to the causes of such variation is warranted in larger, more diverse cohorts.

An updated systematic review of esthetic grading tools in postmastectomy breast reconstruction.

BACKGROUND AND OBJECTIVES: We ascertained whether a validated esthetic grading tool for breast reconstruction had been developed and widely adopted since the last published systematic review on the topic from 2015. METHODS: We performed a systematic review identifying all studies using a grading tool to assess breast reconstruction, using search terms associated with all types of breast surgery and outcomes research. Articles were assessed for patient number, validated scale use, assessor type and training, assessor blinding, assessment method, scoring system type, type and timing of reconstruction, and usage of corroborating scales. RESULTS: Of 2809 articles screened, 148 met the criteria. Only 3 used a validated tool, the Esthetic Items Scale. Most used study-only tools (n = 111) or unvalidated tools (n = 28). The most used unvalidated tool was the Garbay/Lowery 5-subscale rubric. Unanchored Likert scales were the most common subjective tool; two-dimensional images were the most used medium. Surgeons, patients, and nurses were the most common assessors. Twenty percent of studies used corroborating scales. CONCLUSIONS: In the absence of a validated esthetic grading tool for breast reconstruction, researchers continue to rely on unvalidated scales. The only validated scale available is used infrequently and only validated among physicians. A validated, reliable, simple grading tool with clinical and scholastic relevance is needed.

Increasing rates of general anesthesia use in lumpectomy procedures: A 15-year trends analysis.

BACKGROUND: Anesthesia methods in oncologic breast surgery have evolved with less invasive practices. The aims of this study were primarily to examine trends in anesthesia type used during lumpectomy. METHODS: We analyzed lumpectomy procedures from 2005 to 2019 using the NSQIP database. Upon defining the nadir in general anesthesia (GA) and peak in monitored anesthesia care (MAC) use as 2007, we compared patient characteristics and complications in the 2007 versus 2019 GA and MAC cohorts. Multivariable logistic regression was used to examine associations with receipt of GA. RESULTS: Of 253 545 lumpectomy patients, 191 773 (75.6%) received GA and 61 772 (24.4%) received MAC. From 2005 to 2019, GA rates increased from 66.7% to 82.5%, while MAC rates decreased from 33.3% to 17.5%. More GA patients were obese and American Society of Anesthesiologists class 3. Over time, age and body mass index (BMI) increased in both GA and MAC cohorts. Odds of receiving GA increased over time, and predictors included concurrent axillary lymph node dissection (p < 0.0001) or sentinel lymph node biopsy (p < 0.0001). CONCLUSIONS: We demonstrate increasing use of GA over time for lumpectomy, which may be related to aging lumpectomy patient population with higher BMIs. We also find a strong association between use of GA and concurrent lymph node procedures.

Decreasing length of stay in breast reconstruction patients: A national analysis of 2019-2020.

BACKGROUND: The effects of COVID-19 on breast reconstruction included shifts toward alloplastic reconstruction methods to preserve hospital resources and minimize COVID exposures. We examined the effects of COVID-19 on breast reconstruction hospital length of stay (LOS) and subsequent early postoperative complication rates. METHODS: Using the National Surgical Quality Improvement Program, we examined female patients who underwent mastectomy with immediate breast reconstruction from 2019 to 2020. We compared postoperative complications across 2019-2020 for alloplastic and autologous reconstruction patients. We further performed subanalysis of 2020 patients based on LOS. RESULTS: Both alloplastic and autologous reconstruction patients had shorter inpatient stays. Regarding the alloplastic 2019 versus 2020 cohorts, complication rates did not differ (p > 0.05 in all cases). Alloplastic patients in 2020 with longer LOS had more unplanned reoperations (p < 0.001). Regarding autologous patients in 2019 versus 2020, the only complication increasing from 2019 to 2020 was deep surgical site infection (SSI) (2.0% vs. 3.6%, p = 0.024). Autologous patients in 2020 with longer LOS had more unplanned reoperations (p = 0.007). CONCLUSIONS: In 2020, hospital LOS decreased for all breast reconstruction patients with no complication differences in alloplastic patients and a slight increase in SSIs in autologous patients. Shorter LOS may lead to improved satisfaction and lower healthcare costs with low complication risk, and future research should examine the potential relationship between LOS and these outcomes.

A Characterization of Pediatric Craniofacial Injuries from Children's Toys.

INTRODUCTION: Playing with toys contributes significantly to the cognitive, physical, and social development of children. Certain toys, unfortunately, carry the potential for serious craniofacial injury. There is a gap in the literature regarding the comprehensive assessment of toy-related craniofacial injuries. By studying mechanisms of injury and ensuing trauma, our goal is to encourage innovative design and educate caregivers, health care workers, and the Consumer Product Safety Commission on risk mitigation and prevention. METHODS AND MATERIALS: The National Electronic Injury Surveillance System Database was queried to analyze toy-related craniofacial injuries that occurred in children (ages 0-10) between 2011 and 2020. RESULTS: Approximately 881,000 injuries occurred over a 10-year span. Children ages 1 to 5 sustained most injuries, peaking at age 2 (16.3%). Males were injured 1.95 times more frequently than females. Injured sites included the face (43.7%), head (29.7%), mouth (13.5%), ears (6.9%), and eyes (6.2%). The top diagnoses were lacerations (40.4%), foreign bodies (16.2%), internal injuries (15.8%), and contusions (15.8%). The most common causes were scooters (13%), balls (6.9%), toy vehicles excluding riding toys (6.3%), building sets (4.4%), and tricycles (3%). DISCUSSION: This study identifies toys that most frequently cause craniofacial injuries in children. These results provide new information about types of play that should be supervised, and this data helps anticipate injury profiles seen in emergency settings. Future research should study why the products identified are strongly associated with injuries, so safety features can be optimized and designs appropriately altered.

A Regional Analysis of Hospital Readmissions Following Total Hip and Knee Arthroplasty and the Impact of Medicaid Expansion.

The Hospital Readmissions Reduction Program (HRRP) works to temper nationally rising readmission rates. Total knee arthroplasty (TKA) and total hip arthroplasty (THA) have a 30-day readmission cost burden of $889,300 and $689,400, respectively. No research has compared TKA and THA readmission rates by region and Medicaid expansion status. This study compares THA and TKA readmission rates in the United States by region, Medicaid status, and performance. One-way ANOVAs were conducted to determine the regions with the highest and lowest mean excess readmission ratios (ERRs). An independent t-test compared Medicaid versus non-Medicaid expansion states. Southern hospitals have the highest mean ERR, followed by northeastern, midwestern, and then western hospitals. Although Medicaid expansion states have significantly lower ERRs compared to non-expansion states, Medicaid status alone does not account for regional differences in ERRs after THA and TKA. Regional factors likely confound Medicaid status's effect on readmission rates. (Journal of Surgical Orthopaedic Advances 32(1):005-008, 2023).

Effects of COVID-19 on mastectomy and breast reconstruction rates: A national surgical sample.

BACKGROUND: The COVID-19 pandemic profoundly impacted breast cancer treatment in 2020. Guidelines initially halted elective procedures, subsequently encouraging less invasive surgeries and restricting breast reconstruction options. We examined the effects of COVID-19 on oncologic breast surgery and reconstruction rates during the first year of the pandemic. METHODS: Using the National Surgical Quality Improvement Program, we performed an observational examination of female surgical breast cancer patients from 2017 to 2020. We analyzed annual rates of lumpectomy, mastectomy (unilateral/contralateral prophylactic/bilateral prophylactic), and breast reconstruction (alloplastic/autologous) and compared 2019 and 2020 reconstruction cohorts to evaluate the effect of COVID-19. RESULTS: From 2017 to 2020, 175 949 patients underwent lumpectomy or mastectomy with or without reconstruction. From 2019 to 2020, patient volume declined by 10.7%, unilateral mastectomy rates increased (70.5% to 71.9%, p = 0.003), and contralateral prophylactic mastectomy rates decreased. While overall reconstruction rates were unchanged, tissue expander reconstruction increased (64.0% to 68.4%, p < 0.001) and direct-to-implant and autologous reconstruction decreased. Outpatient alloplastic reconstruction increased (65.7% to 73.8%, p < 0.0001), and length of hospital stay decreased for all reconstruction patients (p < 0.0001). CONCLUSIONS: In 2020, there was a nearly 11% decline in breast cancer surgeries, comparable mastectomy and reconstruction rates, increased use of outpatient alloplastic reconstruction, and significantly reduced in-hospital time across all reconstruction types.

Revisiting the Pericranial Flap for Scalp Reconstruction.

ABSTRACT: Soft tissue deficits of the scalp due to trauma, infection, or tumor resection present a unique challenge to the reconstructive surgeon whose goal is to achieve excellent cosmesis in a hair bearing area without compromising coverage. While extensive undermining for large rotation flaps or free tissue transfer can provide necessary coverage, the pericranial flap is an excellent alternative for less ideal surgical candidates who cannot tolerate more extensive interventions or for patients who require long-term cancer surveillance. Elevation of the pericranial flap limits the need for back cuts through the skin and uses blunt dissection to preserve overlying hair follicles. Here we present a review of the anatomy and historical use of the pericranial flap for scalp coverage and we present 4 cases to demonstrate its current utility.

Craniofacial Injuries From Personal Watercraft Accidents.

ABSTRACT: Personal watercraft (PWC) use is a popular leisure activity. Although injuries associated with PWCs have been examined broadly, there is a lack of investigation into craniofacial injuries within this setting. This paper reviews the literature discussing PWC incidents and PWC-related craniofacial injuries. A comprehensive literature search of the MEDLINE, EMBASE, Google Scholar, and National Library of Medicine databases was conducted for studies published through January 2021. Articles were selected if they contained information on PWC accidents and related craniofacial injuries. We also examined 3 patient cases of PWC-related craniofacial injuries. Overall, our review suggests that over the past 20 years, injuries and accidents have decreased significantly whereas fatalities have decreased to a lesser extent. Most PWC-related craniofacial injuries result from blunt trauma and a notable number of deaths and traumatic brain injuries occur in adolescents. Given the increasing number of PWC sales, PWC-related craniofacial injuries may be more prevalent, which prompts improved regulations and protective gears. Existing state laws on PWCs vary dramatically. As of now, there is no uniform policy that requires protective equipment use like helmets or instruction before PWC use. There also should be limitations on alcohol consumption as well as age of the riders. Overall, our review indicates that more research is needed to reduce the number of craniofacial injuries among PWC riders.

Telemedicine for Sports-Related Injuries.

BACKGROUND: Telemedicine use has expanded rapidly since the COVID-19 pandemic in order to adhere to social distancing protocols and has been met with much enthusiasm. However, less is known about the use of telemedicine in sports and exercise medicine (teleSEM) and its utility to treat emergent craniofacial injuries. Given how common facial trauma is among athletes and its possible complications, incorporation of telemedicine in sports-related injuries may prove to be quintessential for athletes and coaches. METHODS: A comprehensive literature search of the MEDLINE, PubMed, Google Scholar, EMBASE, and Cochrane Central Register of Controlled Trials was conducted for studies published through December 2020 with multiple search terms related to telemedicine in sports and trauma care. RESULTS: Overall, teleSEM is appreciated by both patients and physicians alike. Studies show that the satisfaction rate among patients and physicians are high. Sports-related telemedicine visits can help improve resource utilization and total costs. Facial trauma studies also reveal that the level of concurrency of treatment options between telemedicine visits and in-person consultations is almost perfect. Further, there are many additional ways that teleSEM can be implemented in treating injured athletes, including possible collaboration between athletic coaches and physicians as well as mobile device applications. Telemedicine may be particularly useful in treating acute injuries in low-resourced areas with limited equipment and training. CONCLUSION: Telemedicine has been widely employed for sports-related injuries and in traumatic care. Patients and providers alike have noted its utility over other methods of communication with physicians. Our findings suggest that telemedicine has a significant potential in treating sports-related injuries and improving the efficiency of diagnoses and treatments. It may enhance outcomes for participants in athletic events. This may become a key aspect of determining whether a player can return to immediate competition.

Craniofacial Injuries in Lacrosse: A Novel Algorithm for Injury Assessment.

INTRODUCTION: Lacrosse is played widely across the United States, as evidenced by growing participation in the sport. The rapid increase in participation suggests that many of the new players are inexperienced. Many coaches might be ill-equipped to deal with player trauma. There are several crucial differences in the way the sports are played between males and females, altering the experience of the game and the injury profiles that may arise. METHODS: A query of the National Electronic Injury Surveillance System database was performed to study the types of craniofacial injuries incurred from lacrosse. RESULTS: Concussions were the most common injury type, and players between 10 and 14 years old were found to be at greater risk of contusions relative to older players. Players between 15 and 19 years old were at a greater risk of sustaining lacerations. In terms of gender, females were more likely to experience concussions than males, and were at increased risk of head injuries relative to face injuries. DISCUSSION: The finding that females are at increased risk of concussion might be subsequent to a lack of adequate training by coaches. Female athletes tend to experience worse outcomes following concussions incurred secondary to playing sports. Recent work has suggested that this may be a consequence of female anatomy; women tend to have shorter neck dimensions, which predisposes them to more deleterious head-neck accelerations, and thus concussions. These results may inform a layperson-friendly algorithm for the workup of craniofacial injuries sustained from lacrosse.

Biomaterials in Craniomaxillofacial Reconstruction: Past, Present, and Future.

ABSTRACT: Deformity and tissue loss involving the craniomaxillofacial region occurs frequently as a result of trauma, oncologic resection, or a congenital malformation. In order to maximize the patient's quality of life, reconstruction of the craniomaxillofacial skeleton must seek to restore aesthetics as well as function. Advances in diagnostic technology, surgical technique, instrumentation, and innovative biomaterials used have transformed the way reconstructive surgeons approach their patients' needs. From the advent of alloplastic reconstruction, surgeons have sought the ideal material for use in craniomaxillofacial surgery. Substances such as metals, ceramics, glasses, and more recently resorbable polymers and bioactive materials have all been utilized.While autologous bone has remained widely-favored and the gold standard, synthetic alternatives remain a necessity when autologous reconstruction is not readily available. Today, alloplastic material, autografting via microvascular tissue transfer, hormone and growth factor-induced bone formation, and computer-aided design and manufacturing of biocompatible implants represent only a fraction of a wide range of options used in the reconstruction of the craniomaxillofacial skeleton. We present a brief review of the materials used in the repair of deformities of the craniomaxillofacial skeleton as well as a look into the potential future direction of the field.

Rolling With the Punches: A National Electronic Injury Surveillance System Database Study of Craniofacial Injuries in Boxing.

INTRODUCTION: Boxing is a popular combat sport in which competitors may sustain high impact blows to the face. For this reason, they are at high risk for craniofacial injuries; however, data on facial injuries specific to boxing remains sparse. Studies on safety measures, such as headgear, to prevent such injuries in boxing have been inconclusive. Boxing is popular with a wide audience. However, there is no consensus on safety measures across different populations involved in boxing due to lack of data. The objective of this study is to characterize the demography and incidence of injury types of patients presenting to emergency departments with boxing-related craniofacial injuries on a national scale in order to facilitate the establishment of evidence-based safety guidelines for prevention of boxing-related injuries. METHODS: The National Electronic Injury Surveillance System database was searched for boxing-related craniofacial injuries from the last 10 years (2010-2019). Injuries involving boxing were isolated and organized into 5-year age groups. Information on demographics and injury type was extracted from the National Electronic Injury Surveillance System database. Statistical analysis was performed between different age and gender groups. RESULTS: A total of 749 boxing-related craniofacial injuries treated in US emergency departments between 2010 and 2019 were recorded. The 19 to 34-year-old age group had the highest number of cases (54%), followed by the 12 to 18-year-old age group (31%). The most common injury types within both of these age groups were concussions and lacerations. This difference was found to be significant when compared to other craniofacial injury types (P < 0.05). The majority of athletes in these age groups were male (93% and 91%, respectively). Analysis of sex differences demonstrated concussions were more common in females compared to other injury types, whereas lacerations in males were more common compared to other injury types; these differences were found to be significant (P < 0.05). CONCLUSIONS: The high incidence of boxing-related craniofacial injuries such as concussions and lacerations incurred in young adults (19-34 years) and adolescents (12-18 years) indicate that protective measures such as community-based safety interventions and revised guidelines for protective equipment may be indicated in these groups to protect against craniofacial injuries such as lacerations and concussions. Further studies are required to develop algorithms for management of boxing-related craniofacial injuries and to evaluate the safety and efficacy of protective equipment such as boxing headgear on concussions.

Skating on Thin Ice: Craniofacial Injuries in Amateur Ice Hockey.

INTRODUCTION: Hockey is a sport of high speeds, projectiles, and slick surfaces. A scenario is ripe for craniofacial injuries. Annually, over 1 million Americans, with many more abroad participate in organized hockey. This number continues to grow at youth, amateur and professional levels. Following the characterization of groups with the highest incidence of hockey-related craniofacial injuries, our goal is to propose guidelines for the acute management of hockey-related craniofacial injuries in amateur settings. METHODS: This study follows a 10-year retrospective cohort design, examining hockey-related craniofacial injury data derived from the National Electronic Injury Surveillance System database. Within the NEISS data, patients were stratified by age, gender, and ethnicity to allow for analysis and comparison between groups. RESULTS: Sample data consisted of 2,544 hockey-related craniofacial injuries treated in US emergency departments between 2010 and 2019. Majority of the injuries included in this analysis involved patients within the 12-18-year-old age group (53.8%). Of the diagnoses, concussion was the most frequent hockey-related craniofacial injury (39.9%). Dental injuries represented the least (1%). In the 12 to 18 age group, the diagnoses concussion, fracture, and laceration differed significantly from the null hypothesis of equality of proportions across all injury types (P < 0.05). Similarly, within the 19 to 34 age group, the diagnoses of concussion, fracture, laceration, and internal injury differed significantly from the null hypothesis of assumed equality of proportion (P < 0.05). CONCLUSIONS: High incidence of hockey-related craniofacial injury among patients 12 to 18 years of age signals a need for continued interventions targeted towards this age group. Increased sideline personnel training and education, as well as promoting a stricter adherence to established guidelines are integral parts of a greater strategy towards reducing injury incidence. Working towards reducing injuries and making participation in hockey safer, should be a goal as the sport continues to experience a historic rise in interest and participation.

Kick Start to an Epidemiological Report of Soccer-Related Craniofacial Trauma Analysis.

INTRODUCTION: Soccer is a global sport played by millions annually with an increasing popularity in the United States. Game is played by a wide range of participants from all ages and levels of competition. This scenario leads to a potential disparity in the injury profile based on quantifiable demographics. As the game continues to grow, injury detection and side-line assessment must change as well. METHODS: Utilizing a national injury database, a retrospective cohort study was conducted using 10 years of data collected from randomly selected emergency departments across the United States. Patient demographics, injury sites, and diagnosis were recorded. Diagnoses examined included concussion, contusion or abrasion, dental injury, fracture, hematoma, hemorrhage, internal injury, and laceration. RESULTS: Highest percentage of craniofacial injuries was observed in soccer players between the ages of 12 and 18. In ages 6 to 11 the most common injuries were contusions and dental injuries, with a significantly low number of fractures. Within the age group of 12 to 18 the highest percentage of injuries was concussions. Finally, the highest percentage of injury in the ages of 19 to 34 were fractures and lacerations. DISCUSSION: There is a shift in injury profile as the age of soccer players increases and the level of play becomes faster-paced. In youth players, there is a higher percentage of soft tissue injury. Older players are more likely to suffer a higher degree of injury including fractures, concussions, and lacerations. This suggests a great utility for a layperson-friendly educational intervention initiative applicable to all demographics for the sport of soccer.

National Trends in Acellular Dermal Matrix Utilization in Immediate Breast Reconstruction.

BACKGROUND: Implant-based reconstruction is the most common method of immediate breast reconstruction in the United States, with acellular dermal matrices (ADMs) playing a significant role in implant support and coverage. This study evaluated recent national trends in ADM use in immediate breast reconstruction and assessed patient characteristics and 30-day complication rates. METHODS: The authors queried the American College of Surgeons National Surgical Quality Improvement Program database for all patients undergoing immediate breast reconstruction from 2015 to 2020. Primary outcomes were major surgical and medical complications, as well as ADM use per year. Subset analysis was performed to compare patients undergoing immediate breast reconstruction with ADM in 2015 versus 2020. RESULTS: In 39,800 immediate breast reconstructions, ADMs were used in 55.5% of cases ( n = 22,087). ADM usage increased annually from 2015 through 2020. Direct-to-implant reconstruction was significantly associated with ADM use ( P < 0.001). Compared with the no-ADM cohort, there was a significantly increased rate of return to the operating room for any reason ( P < 0.001). When comparing the 2015 and 2020 ADM cohorts, the 2020 ADM cohort had a significantly higher rate of superficial infections. Obesity, smoking history, and insulin-dependent diabetes were independent risk factors for superficial wounds in patients receiving ADM. CONCLUSIONS: ADM use in immediate breast reconstruction increased significantly from 2015 to 2020, likely reflecting national trends in increasing direct-to-implant and prepectoral breast reconstruction. Obesity, smoking history, and insulin-dependent diabetes were independent risk factors for superficial wound infections in the ADM cohort. Patients with ADM had a slight increased incidence of return to the operating room. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Early Complications in Prepectoral Breast Reconstructions with and without Acellular Dermal Matrix: A Preliminary Analysis of Outcomes.

BACKGROUND: Prepectoral tissue expander (TE) placement for two-stage postmastectomy reconstruction is usually performed in conjunction with insertion of acellular dermal matrix (ADM). However, the effects of ADM use on TE loss or other early complications remain unknown. Therefore, the aim of this study was to compare early postoperative complications in patients who underwent prepectoral breast implant reconstruction with or without ADM use. METHODS: The authors performed a retrospective cohort study of all patients at their institution who underwent prepectoral breast reconstruction from January of 2018 to June of 2021. The primary outcome was TE loss within 90 days of surgery; secondary outcomes included other complications such as infection, TE exposure, mastectomy skin flap necrosis requiring revision, and seroma. RESULTS: Data on 714 patients with 1225 TEs (1060 with ADM and 165 without) were analyzed. Baseline demographics did not differ by ADM use, although mastectomy breast tissue weight was higher in patients without ADM (750.3 g versus 540.8 g; P < 0.001). Rates of TE loss were similar in reconstructions with (3.8%) ADM and without (6.7%; P = 0.09). We also did not find differences in the rates of secondary outcomes between cohorts. CONCLUSIONS: ADM use had no statistically significant effect on early complication rates among patients undergoing breast reconstruction with prepectoral TEs. Still, this study was underpowered, and data trended toward statistical significance; thus, larger studies are required in the future. Additional research and randomized studies should focus on larger cohorts and examine long-term complications such as capsular contracture and implant malposition. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Three-Dimensional Surface Analysis for Preoperative Prediction of Breast Volume: A Validation Study.

BACKGROUND: Few studies have examined whether preoperative three-dimensional surface imaging can accurately predict breast volume. Reliably predicting breast volume preoperatively can assist with breast reconstruction planning, patient education, and perioperative risk stratification. METHODS: The authors conducted a review of patients who underwent mastectomy from 2020 to 2021 and included all patients who had preoperative VECTRA XT three-dimensional imaging. VECTRA Analysis Module (VAM) and VECTRA Body Sculptor (VBS) were used for volumetric analysis using standard anatomical breast borders. Breast weights were obtained intraoperatively. Predictive accuracy was defined as VAM estimates ±10% of mastectomy specimen weight or ±100 g of mastectomy weight. RESULTS: The study included 179 patients (266 breasts). There was no significant difference ( P = 0.22) between mean mastectomy weight of 620.8 ± 360.3 g and mean VAM estimate of 609.5 ± 361.9 g. Mean VBS estimate was 498.9 ± 337.6 g, which differed from mean mastectomy weight ( P < 0.001). When defining predictive accuracy as ±100 g, 58.7% of VAM and 44.4% of VBS estimates were accurate. Body mass index, body surface area, and ptosis grade significantly affected VAM and VBS breast volume predictions. CONCLUSIONS: VAM is more accurate at predicting mastectomy weight than VBS, likely because of VAM's analysis of surface topography rather than discrete surface landmarks. Discrepancies between VECTRA estimates and mastectomy weight were likely attributable to differences between surgical mastectomy borders and breast borders used in volumetric analysis. Surgeons should consider the physical characteristics of patients when using three-dimensional imaging. CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, I.