Establishment and Feasibility of an Immediate Lymphatic Reconstruction Program in a Community Health System.

BACKGROUND: Breast cancer-related lymphedema (BCRL) remains a significant post-surgical complication of breast cancer treatment. Immediate lymphatic reconstruction (ILR) at the time of axillary lymph node dissection (ALND) has shown promise in preventing BCRL. While the primary literature supporting ILR comes from academic institutions, the majority of breast cancer care in the USA occurs in the community setting. This study evaluated a preventative lymphedema program performing ILR at a community health system. PATIENTS AND METHODS: A prospective database including all patients who underwent ALND with concurrently attempted ILR from 2019 to 2021 was retrospectively reviewed. The historical benchmark lymphedema rate was calculated through retrospective review of electronic medical records for all patients who underwent ALND without ILR from 2011 to 2021. RESULTS: Ninety patients underwent ALND with ILR, of which ILR was successful in 69 (76.7%). ILR was more likely to be aborted in smokers (p < 0.05) and those with fewer lymphatic channels (p < 0.05) or a higher body mass index (BMI) (p = 0.08). Patients with successful versus aborted ILR had lower lymphedema rates (10.9% versus 66.7%, p < 0.01) and improved Disability of the Arm, Shoulder, and Hand (DASH) scores (8.7 versus 19.8, p = 0.25), and lower lymphedema rates than the historical benchmark (10.9% versus 50.2%, p < 0.01). Among patients with successful ILR, older patients were more likely to develop lymphedema (p < 0.05). CONCLUSIONS: Successful ILR after ALND significantly reduced the lymphedema rate when compared with patients with aborted ILR and our institution's historical benchmark. Our experience supports the efficacy of ILR and highlights the feasibility of ILR within a community health system.

Bipedicle-Conjoined Deep Inferior Epigastric Perforator Flaps for Unilateral Breast Reconstruction in Overweight and Obese Patients: Do the Benefits Outweigh the Risks?

BACKGROUND: Some surgeons have advocated for the use of bipedicle-conjoined deep inferior epigastric perforator (DIEP) flaps in unilateral autologous breast reconstruction in thin patients in whom a hemiabdominal flap is deemed insufficient. There have been no studies to date, however, exploring complication rates for bipedicle-conjoined DIEP flaps for unilateral reconstruction in overweight or obese patients. METHODS: The authors performed a retrospective review of two senior authors' patients from 2013 until 2018. In this time period, 71 patients underwent unilateral breast reconstruction with bipedicle-conjoined DIEP flaps. The patients were divided into normal weight (body mass index [BMI] < 25, n = 30), and overweight/obese (BMI > 25, n = 41) groups. Outcomes were reviewed for both major and minor complications. RESULTS: The average BMI of the normal group was 23.1 ± 1.3 kg/m2, while the average BMI of the overweight/obese group was 28.9 ± 4.0 kg/m2 (p < 0.01). There were no significant differences in demographics or comorbidities between the two groups.There were no statistically significant differences in the overall incidence of major or minor complications between the two groups (major: overweight/obese = 12.1%, normal BMI = 10.0%, p = 0.39; minor: overweight/obese = 39.0%, normal BMI = 36.7%, p = 0.47). The rate of moderate fat necrosis was significantly higher in the overweight/obese group (overweight/obese = 9.8%, normal BMI = 0%, p = 0.04). CONCLUSION: Unilateral breast reconstruction with bipedicle-conjoined DIEP flaps can be performed safely in overweight and obese patients. The use of bipedicle-conjoined DIEP flaps in this population allows surgeons to provide overweight or obese patients with reconstructions that are commensurate with their body habitus and/or contralateral breast.

Unilateral Autologous Breast Reconstruction with Bi-pedicled, Conjoined Deep Inferior Epigastric Perforator Flaps.

BACKGROUND: The abdomen remains the most popular and reliable donor site for autologous breast reconstruction. Some patients, however, lack sufficient tissue to recreate an aesthetic breast mound using a single-pedicle, deep inferior epigastric perforator (DIEP) flap, particularly when matching a contralateral native breast. The amount of abdominal skin and/or soft tissue reliably supplied by one vascular pedicle is frequently insufficient to adequately restore the breast skin envelope and "footprint." This study summarizes our experience with using bipedicled DIEP flaps to improve the aesthetic results of unilateral breast reconstruction in such patients. METHODS: Consecutive patients undergoing unilateral breast reconstruction with bi-pedicled, conjoined DIEP flaps over a 4-year period were retrospectively reviewed. Primary and secondary flap microvascular anastomoses were performed to the antegrade internal mammary (IM) vessels and to either the retrograde IM vessels or a primary DIEP pedicle side branch, respectively. Clinical characteristics and outcomes were recorded. RESULTS: Sixty-three patients underwent immediate (n = 29) or delayed (n = 34) reconstruction, with age and body mass index of 54.1 ± 8.4 years and 26.6 ± 4.7, respectively. Mean follow-up was 14.1 months. Twenty-eight (44.4%) patients received prereconstruction radiation therapy. All patients had preoperative abdominal imaging, including 57 (90.5%) using magnetic resonance angiography. There were no flap losses with three operative interventions for flap salvage. CONCLUSION: Unilateral breast reconstruction with bipedicled, conjoined DIEP flaps is safe and reliable. These procedures can be performed with a complication profile similar to single-pedicle DIEP flaps. The additional skin and soft tissue available with bi-pedicled flaps allows for greater flexibility in matching the shape and projection of a woman's contralateral breast, and in some cases is necessary to achieve an aesthetically acceptable reconstruction. With growing expectations among breast reconstruction patients, conjoined bi-pedicled flaps represent a tool for meeting their reconstructive needs and exceeding the status quo for aesthetic outcomes.

Modern techniques and alternative flaps in microsurgical breast reconstruction.

Breast reconstruction with autologous tissue has become an essential part of the breast cancer patient care algorithm, with the abdomen being the most common tissue donor site. However, within this field, the technology and surgical techniques available to the reconstructive breast surgeon have evolved over time. This review aims to summarize the literature surrounding current techniques in microsurgical breast reconstruction including the use of alternative, nonabdominal flaps.

Outcomes of Subfascial, Suprafascial, and Super-Thin Anterolateral Thigh Flaps: Tailoring Thickness without Added Morbidity.

BACKGROUND: Subfascial anterolateral thigh (ALT) flap thickness can be problematic with regards to bulk, oral competence, shoe-fit, or as a potential source of recurrent wound breakdown. We have utilized distinct upper thigh fascial planes to fashion thin (suprafascial) or super-thin (periscarpal) ALT flaps to improve surface topography. We compared outcomes based on ALT flap thickness to determine any significant differences in extremity coverage and reconstruction. METHODS: Analysis was completed on patients who consecutively underwent ALT free tissue transfer at a single institution from May 2012 to January 2017. Patient's operative, and postoperative characteristics were evaluated. Univariate analysis determined differences among matching as well as functional outcomes. A multivariable regression identified independent risk factors associated with patient, donor site, and flap complications. RESULTS: Fifty-one patients met inclusion criteria. Of these, 16 (31.4%) underwent traditional subfascial ALT flaps, and 35 (68.6%) underwent suprafascial (N = 23) or super-thin (N = 12) flaps. Thin flap patients were more likely to use tobacco (42.9% versus 6.3%; p < 0.01), have fewer perforators (1.20 ± 0.41 versus 1.64 ± 0.63; p < 0.009), and shorter mean operative times (425.9 ± 87.8 versus 511.9 ± 79.9; p < 0.002), but nearly identical flap sizes (163 cm2 versus 168 cm2). There were no significant differences in flap complications (18% versus 22%) or donor-site complications (6.3% versus 5.7%) between the thick and thin cohorts, respectively (p > 0.05). In subgroup analysis, diabetes mellitus was an independent risk factor for donor site morbidity (odds ratio [OR] = 1.23; p = 0.027) for all groups, whereas tobacco use and obesity (body mass index [BMI] > 30) failed to significantly alter outcomes independently. CONCLUSIONS: Tailoring ALT thickness can be performed safely without compromising flap outcomes or patient morbidity. Suprafascial and super-thin ALTs allowed for safe, precise solutions for tissue coverage.

Outcomes After Elevation of Serratus Anterior Fascia During Prosthetic Breast Reconstruction.

BACKGROUND: Achieving optimal inferolateral coverage is critical to successful prosthetic breast reconstruction. Serratus anterior fascia (SF) elevation, a promising alternative to muscle flaps and acellular dermis (ADM), has not been rigorously studied. This study evaluates complication rates after mastectomy and immediate tissue expander (TE) coverage using SF, relative to other existing methods of reconstruction. METHODS: Retrospective review of consecutive patients undergoing mastectomy with immediate TE reconstruction over 10 years at 1 institution was performed. Patients with serratus muscle (SM) or SF elevation were analyzed. ADM reconstructions were used for comparative analysis only. Relevant demographic and clinical data were recorded. Complications were categorized by type and end outcome, including nonoperative (no further surgery), operative (surgery except explantation), and explantation. RESULTS: The SM and SF elevation was performed in 375 (487 breasts) and 177 (255 breasts) patients, respectively. Mean follow-up was 43.8 months. The SM and SF patients were demographically similar, but SF had higher intraoperative fill volumes (P < 0.0001) and required fewer postoperative expansions (P < 0.0001). There were no differences in complications between SM and SF patients. Regression analysis, adjusted for several variables, revealed that SF was not an independent risk factor for complications. The ADM- and SF-assisted reconstruction also showed no differences in outcomes. CONCLUSIONS: Our review demonstrates that SF elevation is a safe, feasible alternative for achieving inferolateral coverage during prosthetic breast reconstruction. Furthermore, this technique allows for greater fill volumes and less expansions than SM. As a readily available alternative to muscle flaps and ADM, SF elevation should be considered integral to any prosthetic breast reconstruction algorithm.

Super-Thin and Suprafascial Anterolateral Thigh Perforator Flaps for Extremity Reconstruction.

Background The anterolateral thigh (ALT) flap remains a workhorse for soft tissue reconstruction. However, the traditional ALT flap is often too bulky for resurfacing shallow, distal extremity defects, prohibiting adequate function, or well-fitted orthotics. This study evaluates extremity reconstruction using ALT flaps elevated in the suprafascial or super-thin plane. Methods Retrospective review of ALT free flap reconstruction from October 2014 to July 2016 was performed. Suprafascial and super-thin flaps were those elevated just above the crural fascia and within the superficial scarpal plane, respectively. Adjunct operative procedures, demographics, and complications were recorded. Results A total of 25 patients underwent suprafascial (n = 14) or super-thin (n = 11) ALT flap reconstruction for primarily lower extremity wounds (n = 19), with an average age and body mass index of 53.8 years and 26.3 kg/m2, respectively. Follow-up was 6.3 months. Comorbidities included smoking (n = 7), diabetes (n = 8), peripheral vascular disease (n = 6), and hypertension (n = 8). The presence of hardware (n = 9), trauma (n = 10), and chronic infection (n = 12) were common risk factors. Average flap size was 8.2 × 21.5 cm, with 64% (n = 16) taken on one perforator. Forty-eight percent (n = 12) were end-to-side anastomoses and 62% (n = 13) utilized one venous anastomosis. Mean hospital stay was 7.8 days with a 24% (n = 6) complication rate. There were no partial or complete flap losses. Conclusion The ALT flap, elevated in a suprafascial or super-thin plane, is a safe, effective option for extremity soft tissue reconstruction. The decreased flap volume and bulk provides the improved contour and pliability necessary for appropriate distal extremity function. The potential versatility of super-thin flaps reinforces the importance of continued innovation by reconstructive microsurgeons.

The use of desiccation to treat Staphylococcus aureus biofilm-infected wounds.

Chronic wounds colonized with biofilm present a major burden to our healthcare system. While the current paradigm for wound healing is to maintain a moist environment, we sought to evaluate the effects of desiccation, and the ability of honey to desiccate wounds, on wound healing characteristics in Staphylococcus aureus biofilm wounds. In vivo biofilm wound healing after exposure to open-air desiccation, honey, molasses, and saline was analyzed using a rabbit ear model of S. aureus biofilm wounds previously developed by our group. Wound morphology was examined using scanning electron microscopy and granulation tissue deposition was measured using light microscopy with hematoxylin and eosin staining. Viable bacterial counts in rabbit ear biofilm wounds and scabs were measured using a drop dilution method. In vitro S. aureus growth curves were established using tryptic soy broth containing honey and glycerol. Gene expression analysis of rabbit ear wounds was performed using reverse transcription quantitative PCR. Rabbit ear S. aureus biofilm wounds exposed to open-air desiccation, honey, and molasses developed a dry scab, which displaced the majority of biofilm bacteria off of the wound bed. Wounds treated with open-air desiccation, honey, and molasses expressed lower levels of the inflammatory markers tumor necrosis factor-α and interleukin-1ß at postoperative day 12 compared with wounds treated with saline, and had increased levels of granulation tissue formation. In vitro growth of S. aureus in tryptic soy broth was inhibited by the presence of honey to a greater extent than by the presence of osmolality-matched glycerol. Desiccation of chronic wounds colonized with biofilm via exposure to open air or honey leads to improved wound healing by decreasing bacterial burden and inflammation, and increasing granulation tissue formation. The ability of honey to help heal chronic wounds is at least in part due to its ability to desiccate bacterial biofilm, but other factors clearly contribute.

Comparison of Delayed and Immediate Tissue Expander Breast Reconstruction in the Setting of Postmastectomy Radiation Therapy.

BACKGROUND: Despite the continued demand for immediate prosthetic breast reconstruction, some suggest that delayed reconstruction may reduce complications. However, with limited comparative data available, the extent of this benefit is unclear, particularly in the setting of postmastectomy radiation therapy (PMRT). This study evaluates outcomes after mastectomy and delayed tissue expander reconstruction (DTER) or immediate tissue expander reconstruction (ITER). METHODS: A retrospective review of 893 consecutive patients (1201 breasts) who underwent mastectomy with DTER or ITER at one institution during a 10-year period was performed. Relevant patient factors, including the use of PMRT and complication rates, were recorded. Complications were categorized by type and end-outcome, including nonoperative (no further surgery), operative (further surgery except explantation), and explantation. Statistics were done using Student t test and Fisher exact test. RESULTS: There were no differences in clinical risk factors between ITER (n = 1127 breasts) and DTER (n = 74 breasts) patients. Delayed tissue expander reconstruction breasts had lower rates of mastectomy flap necrosis (P = 0.003), and nonoperative (P = 0.01) and operative (P = 0.001) complications relative to ITER. In ITER breasts, PMRT increased operative complications (P = 0.02) and explantation (P = 0.0005), resulting in a decrease in overall, 2-stage success rate (P < 0.0001). In contrast, there were no differences in outcomes between PMRT and non-PMRT DTER breasts. CONCLUSIONS: This comparative study, the largest to date, suggests that DTER is a viable reconstructive alternative that may minimize certain complications over ITER, including in patients needing PMRT. However, unlike with ITER, surgeons can evaluate patients' potential for success with DTER based on skin flap appearance after both mastectomy and PMRT (when present). As a result, the benefits of DTER may also be due to a careful patient selection process preoperatively. The choice of DTER should, therefore, be balanced against both individual patient risk factors and the psychological appeal of immediate reconstruction.

Activity of imipenem against Klebsiella pneumoniae biofilms in vitro and in vivo.

Encapsulated Klebsiella pneumoniae has emerged as one of the most clinically relevant and more frequently encountered opportunistic pathogens in combat wounds as the result of nosocomial infection. In this report, we show that imipenem displayed potent activity against established K. pneumoniae biofilms under both static and flow conditions in vitro. Using a rabbit ear model, we also demonstrated that imipenem was highly effective against preformed K. pneumoniae biofilms in wounds.

Impact of a novel, antimicrobial dressing on in vivo, Pseudomonas aeruginosa wound biofilm: quantitative comparative analysis using a rabbit ear model.

The importance of bacterial biofilms to chronic wound pathogenesis is well established. Different treatment modalities, including topical dressings, have yet to show consistent efficacy against wound biofilm. This study evaluates the impact of a novel, antimicrobial Test Dressing on Pseudomonas aeruginosa biofilm-infected wounds. Six-mm dermal punch wounds in rabbit ears were inoculated with 10(6) colony-forming units of P. aeruginosa. Biofilm was established in vivo using our published model. Dressing changes were performed every other day with either Active Control or Test Dressings. Treated and untreated wounds were harvested for several quantitative endpoints. Confirmatory studies were performed to measure treatment impact on in vitro P. aeruginosa and in vivo polybacterial wounds containing P. aeruginosa and Staphylococcus aureus. The Test Dressing consistently decreased P. aeruginosa bacterial counts, and improved wound healing relative to Inactive Vehicle and Active Control wounds (p < 0.05). In vitro bacterial counts were also significantly reduced following Test Dressing therapy (p < 0.05). Similarly, improvements in bacterial burden and wound healing were also achieved in polybacterial wounds (p < 0.05). This study represents the first quantifiable and consistent in vivo evidence of a topical antimicrobial dressing's impact against established wound biofilm. The development of clinically applicable therapies against biofilm such as this is critical to improving chronic wound care.

Dermal wound transcriptomic responses to Infection with Pseudomonas aeruginosa versus Klebsiella pneumoniae in a rabbit ear wound model.

BACKGROUND: Bacterial infections of wounds impair healing and worsen scarring. We hypothesized that transcriptome analysis of wounds infected with Klebsiella pneumoniae (K.p.) or Pseudomonas aeruginosa (P.a.) would indicate host-responses associated with the worse healing of P.a.- than K.p.-infected wounds. METHODS: Wounds created on post-operative day (POD) 0 were infected during the inflammatory phase of healing on POD3 and were harvested on POD4 for microarray and transcriptome analysis. Other wounds received topical antibiotic after infection for 24 hours to promote biofilm development, and were harvested on POD6 or POD12. RESULTS: Wounds infected for 24 hours, relative to uninfected wounds, elevated transcripts of immune-response functions characteristic of infiltrating leukocytes. But P.a.-infected wounds elevated many more transcripts and to higher levels than K.p.-infected wounds. Coincidently, suppressed transcripts of both wounds enriched into stress-response pathways, including EIF2 signaling; however, this was more extensive for P.a.-infected wounds, including many-fold more transcripts enriching in the 'cell death' annotation, suggesting resident cutaneous cell toxicity in response to a more damaging P.a. inflammatory milieu. The POD6 wounds were colonized with biofilm but expressed magnitudes fewer immune-response transcripts with no stress-response enrichments. However, elevated transcripts of P.a.-infected wounds were inferred to be regulated by type I interferons, similar to a network unique to P.a.-infected wounds on POD4. On POD12, transcripts that were more elevated in K.p.-infected wounds suggested healing, while transcripts more elevated in P.a.-infected wounds indicated inflammation. CONCLUSIONS: An extensive inflammatory response of wounds was evident from upregulated transcripts 24 hours after infection with either bacterium, but the response was more intense for P.a.- than K.p.-infected wounds. Coincidently, more extensive down-regulated transcripts of P.a.-infected wounds indicated a stronger "integrated stress response" to the inflammatory milieu that tipped more toward cutaneous cell death. Unique to P.a.-infected wounds on POD4 and POD6 were networks inferred to be regulated by interferons, which may result from intracellular replication of P.a. These data point to specific downregulated transcripts of cells resident to the wound as well as upregulated transcripts characteristic of infiltrating leukocytes that could be useful markers of poorly healing wounds and indicators of wound-specific treatments for improving outcomes.

Reconstruction of the inframammary fold using barbed suture.

Achieving accurate inframammary fold (IMF) position and definition during breast reconstruction is a critical step toward obtaining optimal aesthetic outcomes. This article presents a simple technique for IMF reconstruction after implant-based breast reconstruction with an internal running, barbed suture. The results of this technique are retrospectively reviewed in 45 patients, with only 2 patients requiring additional procedures to adjust IMF position for a total revision rate of 4.4%. There have been neither instances of permanent contour deformity due to suture placement nor any instances of suture extrusion through the skin. Thus, this technique appears to be safe and effective and should be considered when surgeons are faced with an IMF asymmetry.

Body mass index as a continuous predictor of outcomes after expander-implant breast reconstruction.

BACKGROUND: Studies show that obesity is a risk factor for complications after expander/implant breast reconstructions. However, reports vary on the precise threshold of body mass index (BMI) as a predictor of heightened risk. We endeavored to link BMI as a continuous variable to overall complications in a single-surgeon series of expander-implant reconstructions. METHODS: From 399 patients undergoing expander-implant reconstruction, 551 breasts were stratified to normal weight, overweight, and obese groups for analysis and comparison with previous studies. Logistic regression was performed to predict changes to risk profile per increment of BMI. RESULTS: Complication rates for obese and overweight patients were significantly greater than for normal weight patients, that is, 21.1% and 24.0% versus 10.4%, respectively (P < 0.005). A unit increase in BMI predicted a 5.9% increase in the odds of a complication occurring, and 7.9% increase in the odds of reconstruction ending in failure. CONCLUSIONS: By expanding the analysis of BMI to include patients who do not meet the traditional definition of obesity (BMI ≥ 30 kg/m), we demonstrated that simply overweight patients (25 ≤ BMI < 30 kg/m) had an elevated complication rate. Moreover, through regression analysis, we established that BMI as a continuous variable predicts outcomes from expander-based breast reconstruction.

Outcomes of immediate tissue expander breast reconstruction followed by reconstruction of choice in the setting of postmastectomy radiation therapy.

A common sequence for performing staged tissue expander breast reconstruction is to immediately insert a tissue expander, complete expansion before radiotherapy, and then perform the definitive reconstruction after radiotherapy is complete. This study evaluates the outcomes of this treatment regimen in 237 patients over a 10-year period at Northwestern Memorial Hospital. Overall, 62% of the patients successfully completed tissue expander/implant reconstruction, 22.3% experienced major complications leading to explantations or conversions to flap, and 13.5% completed tissue expander/elective autologous reconstruction. Of the patients who underwent second-stage tissue expander to implant exchange, 87.5% successfully completed reconstruction without experiencing complications leading to explantation or conversion to autologous reconstruction. Thus, this study indicates that immediate tissue expander followed by reconstruction of choice breast reconstruction in the setting of postmastectomy radiation therapy can be successfully performed in most of the patients.

Wise-Pattern Mastectomy with an Inferior Dermal Sling: A Viable Alternative to Elliptical Mastectomy in Prosthetic-Based Breast Reconstruction.

BACKGROUND: Prosthetic-based postmastectomy breast reconstruction in patients with large or pendulous breasts remains challenging because of inelastic and redundant skin, with various approaches to skin reduction at the time of mastectomy. This study describes the authors' experience with a Wise-pattern inferior dermal sling approach to skin-sparing mastectomy. METHODS: Retrospective chart review was performed on patients who underwent immediate prosthetic-based breast reconstruction after mastectomy from 2009 to 2021. A total of 240 patients who underwent Wise-pattern skin-sparing mastectomy (WSSM) were compared with a cohort of patients who had traditional elliptical skin-sparing mastectomy (ESSM), matched for mastectomy weight, prior radiation therapy, and smoking. Ninety-day postsurgical outcomes were examined. RESULTS: The WSSM cohort had a significantly higher body mass index (30.3 kg/m 2 versus 26.9 kg/m 2 ; P < 0.0001) and mastectomy weight (831 g versus 607 g; P < 0.0001). After propensity score matching, there was no significant difference in complication or treatment rates between WSSM and ESSM breasts except for mastectomy flap necrosis (11.6% versus 5.0%; P = 0.0082). WSSM patients who had mastectomy flap necrosis did not have significantly different treatment rates of admission, return to the operating room, or explantation compared with ESSM patients. CONCLUSIONS: In the largest reported series to date, WSSM was associated with a higher rate of mastectomy flap necrosis, but this did not translate into statistically significant differences in treatment. The inferior dermal flap likely acts as a protective layer of vascularized tissue, which appears to prevent evolution of mastectomy skin flap necrosis into more serious adverse outcomes. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Noncontact, low-frequency ultrasound as an effective therapy against Pseudomonas aeruginosa-infected biofilm wounds.

Bacterial biofilms, a critical chronic wound mediator, remain difficult to treat. Energy-based devices may potentially improve healing, but with no evidence of efficacy against biofilms. This study evaluates noncontact, low-frequency ultrasound (NLFU) in the treatment of biofilm-infected wounds. Six-millimeter dermal punch wounds in rabbit ears were inoculated with 10(7) colony-forming units of Pseudomonas aeruginosa or left as sterile controls. A biofilm was established in vivo using our published model. NLFU treatment was carried out every other day or every day, with contralateral ear wounds acting as internal, untreated controls. Wounds were harvested for several quantitative endpoints and scanning electron microscopy to evaluate the biofilm structure. The P. aeruginosa biofilm consistently impaired wound epithelialization and granulation. NLFU, both every other day and every day, improved healing and reduced bacterial counts relative to untreated controls (p < 0.05). Scanning electron microscopy confirmed a qualitative decrease in bacteria after both treatments. NLFU also reduced inflammatory cytokine expression (p < 0.05). Our study suggests that NLFU is an effective therapy against P. aeruginosa wound biofilm. This represents the first in vivo evidence of energy-based modalities' impact on wound biofilm, setting the foundation for future mechanistic studies. Continued wound care technology research is essential to improving our understanding, and treatment, of biofilm-infected chronic wounds.

Deficient cytokine expression and neutrophil oxidative burst contribute to impaired cutaneous wound healing in diabetic, biofilm-containing chronic wounds.

Diabetic patients exhibit dysregulated inflammatory and immune responses that predispose them to chronic wound infections and the threat of limb loss. The molecular underpinnings responsible for this have not been well elucidated, particularly in the setting of wound biofilms. This study evaluates host responses in biofilm-impaired wounds using the TallyHo mouse, a clinically relevant polygenic model of type 2 diabetes. No differences in cytokine or Toll-like receptor (TLR) expression were noted in unwounded skin or noninoculated wounds of diabetic and wild-type mice. However, diabetic biofilm-containing wounds had significantly less TLR 2, TLR 4, interleukin-1ß, and tumor necrosis factor-α expression than wild-type wounds with biofilm (all p < 0.001). Both groups had similar bacterial burden and neutrophil infiltration after development of biofilms at 3 days postwounding, but diabetic wounds had significantly less neutrophil oxidative burst activity. This translated into a log-fold greater bacterial burden and significant delay of wound epithelization for biofilm-impaired diabetic wounds at 10 days postwounding. These results suggest that impaired recognition of bacterial infection via the TLR pathway leading to inadequate cytokine stimulation of antimicrobial host responses may represent a potential mechanism underlying diabetic susceptibility to wound infection and ulceration.

Hematoma after mastectomy with immediate reconstruction: an analysis of risk factors in 883 patients.

BACKGROUND: Mastectomy followed by breast reconstruction presents unique circumstances, such as 2 operating teams, that may affect the likelihood of postoperative bleeding. This study evaluates risk factors for hematoma formation in patients undergoing mastectomy with immediate implant reconstruction. METHODS: The charts of 883 patients (1199 breasts) who underwent mastectomy and immediate tissue expander reconstruction between April 1998 and August 2008 at a single institution were retrospectively reviewed. Demographic and operative factors and information on hematoma location were recorded. Fisher exact test, Student t test, and multiple linear regression were used for statistical analysis. RESULTS: There were no differences in preoperative, operative, and oncologic characteristics between hematoma (n = 28 breasts) and nonhematoma (n = 1171 breasts) groups. Multiple linear regression analysis revealed no independent risk factors for hematoma formation, except an individual mastectomy and reconstructive surgeon (odds ratio, 3.58; 95% confidence interval, 1.03-12.37; P = 0.03; odds ratio, 2.54; 95% confidence interval, 1.06-6.08; P = 0.03, respectively). Most hematomas were diagnosed on postoperative day 0 or 1 (23/28, 82.1%) and found to originate from the pectoralis muscle (14/28, 50.0%) or axillary region (6/28, 21.4%). CONCLUSIONS: The risk of postoperative hematoma after mastectomy with immediate reconstruction is not affected by any measurable preoperative, operative, or oncologic factors. With no definitive risk factor for bleeding, surgeons should remain meticulous and vigilant throughout the operation. In particular, hemostasis should be focused on the chest wall musculature given its propensity for being the primary source of hematoma formation.