Decreasing Seroma Incidence Following Abdominoplasty: A Systematic Review and Meta-Analysis of High-Quality Evidence.

Background: Seroma formation is the most common complication of abdominoplasties. Many preventive interventions have been proposed, but none have been recognized as a definitive solution, partly due to varying levels of evidence (LOE) in the literature. Objectives: We aimed to analyze seroma prevention methods supported by high-level evidence. Methods: The PubMed database was queried through August 2023. Primary articles of interest included randomized controlled trials (RCTs), prospective comparative studies, and meta-analyses of these studies. The LOE for each article was determined according to the American Society of Plastic Surgeons Rating Scale. The "seroma occurrence ratio," or ratio of seroma events in the interventional group to respective control group, was calculated to compare incidence rates between techniques. Results: Twenty articles and 9 categories of techniques were analyzed. Study designs included 10 RCTs, 2 prospective cohort studies, 7 prospective comparative studies, and 1 retrospective randomized study. The use of progressive-tension and quilting sutures had the most data supporting a statistically significant reduction in seroma (occurrence ratio 0.306, P < .001). Tissue adhesives and preservation of Scarpa's fascia were also well reinforced (0.375, P < .01 and 0.229, P < .011, respectively), while increasing the number of drains was not (P = .7576). Meta-analysis demonstrated that compared with 2 drains alone, alternative techniques were more effective at reducing seroma occurrence (pooled risk ratio 0.33, 95% CI, 0.11-0.99). Conclusions: This review highlights multiple seroma prevention techniques for abdominoplasty investigated in recent high-quality literature. We suggest future randomized comparative studies of the various seroma prevention methods to fully ascertain their efficacy following abdominoplasty.

Autologous Skin Grafts, versus Tissue-engineered Skin Constructs: A Systematic Review and Meta-analysis.

For over 100 years, autologous skin grafts have remained the gold standard for the reconstruction of wounds but are limited in availability. Acellular tissue-engineered skin constructs (acellular TCs) and cellular tissue-engineered skin constructs (cellular TCs) may address these limitations. This systematic review and meta-analysis compare outcomes between them. Methods: A systematic review was conducted using PRISMA guidelines, querying MEDLINE, Embase, Web of Science, and Cochrane to assess graft incorporation, failure, and wound healing. Case reports/series, reviews, in vitro/in vivo work, non-English articles or articles without full text were excluded. Results: Sixty-six articles encompassing 4076 patients were included. No significant differences were found between graft failure rates (P = 0.07) and mean difference of percent reepithelialization (p = 0.92) when split-thickness skin grafts were applied alone versus co-grafted with acellular TCs. Similar mean Vancouver Scar Scale was found for these two groups (p = 0.09). Twenty-one studies used at least one cellular TC. Weighted averages from pooled results did not reveal statistically significant differences in mean reepithelialization or failure rates for epidermal cellular TCs compared with split-thickness skin grafts (p = 0.55). Conclusions: This systematic review is the first to illustrate comparable functional and wound healing outcomes between split-thickness skin grafts alone and those co-grafted with acellular TCs. The use of cellular TCs seems promising from preliminary findings. However, these results are limited in clinical applicability due to the heterogeneity of study data, and further level 1 evidence is required to determine the safety and efficacy of these constructs.

Efficacy of leupeptin in treating ischemia in a rat hind limb model.

Prolonged tourniquet use can lead to tissue ischemia and can cause progressive muscle and nerve injuries. Such injuries are accompanied by calpain activation and subsequent Wallerian-like degeneration. Several known inhibitors, including leupeptin, are known to impede the activity of calpain and associated tissue damage. We hypothesize that employment of leupeptin in a rat model of prolonged hind limb ischemia can mitigate muscle and nerve injuries. Sprague-Dawley rats (n = 10) weighing between 300-400 g were employed in this study. Their left hind limbs were subjected to blood flow occlusion for a period of 2-h using a neonatal blood pressure cuff. Five rats were given twice weekly intramuscular leupeptin injections, while the other five received saline. After 2 weeks, the animals were euthanized, their sciatic nerves and gastrocnemius muscles were harvested, fixed, stained, and analyzed using NIH Image J software. The administration of leupeptin resulted in larger gastrocnemius muscle fiber cross-sectional areas for the right (non-tourniquet applied) hindlimb as compared to that treated with the saline (p = 0.0110). However, no statistically significant differences were found between these two groups for the injured left hindlimb (p = 0.1440). With regards to the sciatic nerve cross-sectional areas and sciatic functional index, no differences were detected between the leupeptin and control treated groups for both the healthy and injured hindlimbs. This research provides new insights on how to employ leupeptin to inhibit the degenerative effects of calpain and preserve tissues following ischemia resulting from orthopedic or plastic surgery procedures.

Negative-Pressure Wound Therapy versus Standard Surgical Dressings after Malignant Tumor Resection: A Systematic Review and Meta-Analysis.

BACKGROUND: Negative-pressure wound therapy offers many advantages over standard surgical dressings in the treatment of open wounds, including accelerated wound healing, cost savings, and reduced complication rates. Although contraindicated by device manufacturers in malignancy-resected wounds because of hypothesized risk of tumor recurrence, negative-pressure wound therapy is still applied postoperatively because of limited clinical support. The authors performed a systematic review with meta-analysis to compare negative-pressure wound therapy outcomes with those of standard surgical dressings on open wounds, with their null hypothesis stating there would be no outcome differences. METHODS: A systematic review of the literature on negative-pressure wound therapy and standard surgical dressings on malignancy-resected wounds was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines using PubMed, Embase, CINAHL, and Cochrane Central databases. Meta-analysis compared group outcomes, including malignancy recurrence, wound complication, and surgical site infection rates, with a random effects model. RESULTS: A total of 1634 studies were identified and 27 met eligibility criteria, including four randomized controlled trials, four prospective cohort studies, and 19 retrospective reviews. Eighty-one percent of articles ( n = 22) recommended negative-pressure wound therapy in malignancy-resected wounds. Meta-analysis determined that the treatment yielded significantly lower overall surgical site infection ( p = 0.004) and wound complication ( p = 0.01) rates than standard surgical dressings; however, there were no statistically significant differences found for other outcomes between the two groups. CONCLUSIONS: This review demonstrates favorable outcomes of negative-pressure wound therapy over standard surgical dressings for malignancy-resected wounds without an increased risk of malignancy recurrence. However, because limited randomized controlled trials (detailing only incisional wounds for limited malignancies and anatomic regions) are available, additional high-power randomized controlled trials are recommended.

Reconstructive Trends After Tissue-Expander Loss in Breast Reconstruction.

PURPOSE: Tissue-expander breast reconstruction (TEBR) is a common method of reconstruction after mastectomy but may result in complications that may necessitate removal. Although complications in TEBR have been well studied, there is a paucity of data regarding outcomes after tissue-expander loss. In this study, we examine the eventual reconstructive pathways and associated factors of patients who required tissue-expander removal after infection. METHODS: This retrospective study examines patients undergoing breast reconstruction at a single institution. Patients included underwent mastectomy, immediate TEBR, and subsequent tissue-expander loss. Patients who underwent autologous reconstruction after mastectomy or had successful TEBR were excluded. Patients were followed for an average of 7 years, with a minimum of 2 years and a maximum of 13 years. RESULTS: A total of 674 TEBR patients were initially screened, of which 60 patients (8.9%) required tissue-expander removal because of infection or skin necrosis. Thirty-one of these patients (group 1) did not complete reconstruction after initial tissue-expander loss, whereas the remaining 29 patients (group 2) underwent either TEBR or autologous reconstruction after tissue-expander loss. Group 1 had a significantly higher mean body mass index than group 2 (32.61 ± 8.88 vs 28.69 ± 5.84; P = 0.049) and also lived further away from our institution than group 2 (P = 0.052), which trended toward significance. There were otherwise no significant differences in demographics between the 2 groups.Among the 29 patients in group 2, 18 patients underwent a second TEBR (group 2a), and 11 patients underwent autologous reconstruction (group 2b). Patients in group 2b had a significantly greater mean number of complication related admissions (1.11 ± 0.323 vs 1.55 ± 0.688; P = 0.029) and also had higher occurrence of postmastectomy radiation therapy (16.7% vs 45.5%; P = 0.092), although this was not significant. There were otherwise no differences between the 2 groups. CONCLUSION: Our data demonstrate the trends in breast reconstruction decision making after initial tissue-expander loss. This study elucidates the factors associated with patients who undergo different reconstructive options. Further work is needed to delineate the specific reasons between the decision to pursue different reconstructive pathways among a larger cohort of patients.

Hip disarticulation with pedicled total leg fillet flap for recurrent fungating sarcoma.

Soft tissue sarcomas may be treated with limb-sparing procedures in the majority of cases; however, certain cases involving significant tumor spread and fungation may call for amputation. In the thigh, hip disarticulation typically involves a pedicled gluteus maximus flap or a pedicled anterior quadriceps flap. In this case report, we describe a rare situation in which the anterior flap, posterior flap, and adductor flap musculature were contaminated with tumor; therefore, a hip disarticulation was performed applying a pedicled total leg fillet flap for closure. Eighteen months after treatment, the patient continues to have no local recurrence of disease, a stable flap site, and ambulates with a walker. We present this amputation and closure method as a potentially effective modality in treating extensive oncologic disease of the proximal lower extremity.

Acellular Dermal Matrix Sterility: Does It Affect Microbial and Clinical Outcomes Following Implantation?

The use of acellular dermal matrices (ADMs) in breast reconstruction is a controversial topic. Recent literature has investigated the effects of ADM sterilization on infectious complications, although with varying conclusions. Previous work by our group showed no difference between aseptic and sterilized products immediately out of the package. In this study, we investigate the microbiologic profiles of these agents after implantation. METHODS: In this prospective study, we cultured samples of ADM previously implanted during the first stage of tissue expander-based immediate breast reconstruction. A 1 cm2 sample was excised during the stage II expander-implant exchange procedure, and samples were incubated for 48 hours in tryptic soy broth. Samples with growth were further cultured on tryptic soy broth and blood agar plates. Patient records were also analyzed, to determine if ADM sterilization and microbial growth were correlated with infectious complications. RESULTS: In total, 51 samples of ADM were collected from 32 patients. Six samples were from aseptic ADM (AlloDerm), 27 samples were from ADM sterilized to 10-3 (AlloDerm Ready-to-Use), and 18 samples were from products sterilized to 10-6 (AlloMax). No samples demonstrated bacterial growth. Only 5 patients experienced postoperative complications, of whom only 1 patient was infectious in nature. We failed to demonstrate a statistically significant correlation between sterility and postoperative complications. CONCLUSIONS: Our findings showed no difference in microbial presence and clinical outcomes when comparing ADM sterility. Furthermore, no samples demonstrated growth in culture. Our study brings into question the necessity for terminal sterilization in these products.

The Effect of Axillary Lymph Node Sampling during Mastectomy on Immediate Alloplastic Breast Reconstruction Complications.

BACKGROUND: Tissue expander-based immediate breast reconstruction is currently the most common technique used for postmastectomy breast reconstruction. During mastectomy, axillary lymph nodes are biopsied to stage patients. The purpose of this study is to investigate postoperative complications with respect to extent of lymph node dissection. METHODS: A retrospective review of all patients undergoing tissue expander-based immediate breast reconstruction at our institution from 2010 to 2012 was conducted. Charts were analyzed to determine the association between the absolute number of axillary lymph nodes removed and postreconstructive incidence of skin necrosis, cellulitis, seroma, and expander removal. Independent sample t test and linear regression were used to analyze data. RESULTS: In total, 282 patients with 467 reconstructions were included. Overall incidence of all postoperative complications per breast was 23.8%. Breasts in which a complication occurred had a mean of 6 nodes removed versus 4 nodes in uncomplicated breasts (P = 0.018). Complications were noted at a significantly higher rate in patients who underwent axillary lymph node dissection compared with sentinel lymph node biopsy (P = 0.008). Expander removal and seroma occurred more frequently in breasts that had a greater number of nodes removed (P = 0.006 and P = 0.015, respectively). Preoperative radiation resulted in higher incidence of cellulitis and skin necrosis. Postoperative radiation and chemotherapy did not adversely affect reconstruction. CONCLUSIONS: Axillary lymph node removal of >4 nodes confers a greater risk of postreconstructive seroma formation and tissue expander loss in patients undergoing immediate reconstruction following mastectomy. Axillary lymph node dissection has a higher incidence of breast reconstruction complications compared with sentinel lymph node biopsy. Therefore, we encourage plastic surgeons to consider degree of lymphadenectomy when discussing reconstructive options with patients, as this may significantly impact their reconstructive outcome.

Development of In Vitro Bioengineered Vascular Grafts for Microsurgery and Vascular Surgery Applications.

INTRODUCTION: The use of vascular grafts is continuing to rise due to the increasing prevalence of coronary artery bypass grafting and microvascular flap-based tissue reconstructions. The current options of using native vessels (saphenous vein) or the synthetic grafts (Dacron) have been unable to manage current needs. In this study, we employed an original tissue engineering approach to develop a multi-layered vascular graft that has the potential to address some of the limitations of the existing grafts. MATERIALS AND METHODS: Biomaterials, gelatin and fibrin, were used to develop a two-layered vascular graft. The graft was seeded with endothelial cells and imaged using confocal microscopy. The graft's architecture and its mechanical properties were also characterized using histology, Scanning Electron Microscopy and rheological studies. RESULTS: Our methodology resulted in the development of a vascular graft with precise spatial localization of the two layers. The endothelial cells fully covered the lumen of the developed vascular graft, thus providing a non-thrombogenic surface. The elastic modulus of the biomaterials employed in this graft was found to be 5.186 KPa, paralleling that of internal mammary artery. The burst pressure of this graft was also measured and was found close to that of the saphenous vein (~2000 mm Hg). CONCLUSIONS: We were successfully able to employ a unique method to synthesize a multi-layered vascularized graft having adequate biological and mechanical properties. Studies are ongoing involving implantation of this developed vascular graft in the rat femoral artery and characterization of parameters such as vascular remodeling and patency.

Digital Image Speckle Correlation to Optimize Botulinum Toxin Type A Injection: A Prospective, Randomized, Crossover Trial.

BACKGROUND: Historically, physicians have relied on their subjective measures when determining the site and dosages for botulinum toxin type A injections. Digital image speckle correlation is a technology that tracks pore movement from rest to maximal exertion, allowing for the determination of the optimal sites of injection. In this prospective, randomized, crossover trial, the efficacy of using digital image speckle correlation was compared to physician assessment in choosing botulinum toxin type A injection sites. METHODS: Ten female patients were analyzed in this blinded crossover study. Subjects were randomized to either injections based on digital image speckle correlation analysis or injections based on the 2004 facial aesthetics consensus recommendations. All patients received 20 U of botulinum toxin type A in the glabellar region and were crossed over and reinjected after 6 months. Follow-up was completed with the Facial Line Outcomes 11-item survey and repeated imaging with digital image speckle correlation, to measure patient satisfaction and degree of paralysis, respectively. Statistical comparison was completed by means of matched sample t test. RESULTS: On average, the digital image speckle correlation analysis provided 4.8 injection sites, whereas the practitioner chose five injections sites. Patients receiving digital image-directed injections had higher rates of satisfaction on the Facial Line Outcomes instrument (p = 0.0003) and a larger degree of paralysis (p = 0.003). Furthermore, muscle function returned to normal later in patients injected with digital image speckle correlation (17.9 weeks versus 20 weeks; p = 0.03). CONCLUSIONS: This study demonstrates the benefits of using digital image speckle correlation in determining optimal botulinum toxin type A injection location. Digital analysis allows practitioners to better treat facial rhytides by eliminating subjective decisions regarding dose and site of injection. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

The Delay Phenomenon: Is One Surgical Delay Technique Superior?

BACKGROUND: Surgical delay remains a common method for improving flap survival. However, the optimal surgical technique has not been determined. In this article, we compare flap perfusion, viable surface area, and flap contraction of 2 surgical delay techniques. METHODS: Male Sprague-Dawley rats were divided into 3 groups. In the incisional surgical delay group (n = 9), a 9 × 3 cm dorsal flap was incised on 3 sides without undermining, leaving a cranial pedicle. In the bipedicle surgical delay group (BSD, n = 9), a 9 × 3 cm dorsal flap was incised laterally and undermined, leaving cranial and caudal pedicles. Control group (n = 16) animals did not undergo a delay procedure. Ten days following surgical delay, all flaps for all groups were raised, leaving a cranial pedicle. A silicone sheet separated the flap and the wound bed. On postoperative day (POD) 7, viable surface area was determined clinically. Contraction compared to POD 0 was measured with ImageJ software. Perfusion was measured with Laser Doppler Imaging. The Kruskal-Wallis with Dunn's multiple comparisons test was performed for group comparisons. RESULTS: BSD preserved significantly more viable surface area on POD 7 (13.7 ± 4.5 cm2) than Control (8.7 ± 1.8 cm2; P = 0.01). BSD also showed significantly less contraction (21.0% ± 13.5%) than Control (45.9% ± 19.7%; P = 0.0045). BSD and incisional surgical delay showed significantly increased perfusion compared with Control on POD 0 (P = 0.02 and 0.049, respectively), which persisted on POD 3. This trend resolved by POD 7. CONCLUSION: BSD showed improved early perfusion, increased viable surface area, and reduced contraction compared to control, suggesting that BSD is the superior flap design for preclinical modeling.

Infectious Loss of Tissue Expanders in Breast Reconstruction: Are We Treating the Right Organisms?

BACKGROUND: Postoperative infections following tissue expander-based breast reconstruction represent a significant threat to the reconstructive process. Studies have found the incidence to be as high as 29%. There has been abundant research into the risk factors associated with these infections, although very few studies have focused on the causative organisms. The purpose of this study was to investigate the bacterial flora associated with tissue expander infections after breast reconstruction. METHODS: A retrospective analysis of all patients who underwent tissue expander-based breast reconstruction at our institution between February 2010 and April 2013 was conducted. The medical records were reviewed for demographic information, medical history, operative technique, postoperative course, and culture results. Descriptive data analysis was then performed. RESULTS: A total of 56 tissue expander infections were identified in 49 patients during the study period. 41.1% of the cultures grew gram-positive organisms, whereas 28.6% grew gram-negative species. The 2 most common organisms were Staphylococcus aureus (17.9%) and Staphylococcus epidermidis (14.3%). Pseudomonas aeruginosa was the most frequent gram-negative species and was also the third most frequent organism cultured (10.9%). DISCUSSION: Due to the high rate of infection in breast reconstruction patients, adequate perioperative prophylaxis is necessary. The surgeon must also be prepared to treat patients who may return with infection postoperatively. Although the majority of our infections were secondary to normal skin flora, a significant proportion were caused by gram-negative species. Given these results, the empiric antibiotic of choice for postoperative infections should be reconsidered to cover for these various organisms.

Is Sterile Better Than Aseptic? Comparing the Microbiology of Acellular Dermal Matrices.

INTRODUCTION: Postoperative infections are a major complication associated with tissue-expander-based breast reconstruction. The use of acellular dermal matrix (ADM) in this surgery has been identified as a potential reservoir of infection, prompting the development of sterile ADM. Although aseptic and sterile ADMs have been investigated, no study has focused on the occurrence and clinical outcome of bacterial colonization before implantation. METHODS: Samples of aseptic AlloDerm, sterile Ready-To-Use AlloDerm, and AlloMax were taken before implantation. These samples were incubated in Tryptic soy broth overnight before being streaked on Trypticase soy agar, MacConkey agar, and 5% blood agar plates for culture and incubated for 48 hours. Culture results were cross-referenced with patient outcomes for 1 year postoperatively. RESULTS: A total of 92 samples of ADM were collected from 63 patients. There were 15 cases of postoperative surgical site infection (16.3%). Only 1 sample of ADM (AlloMax) showed growth of Escherichia coli, which was likely a result of contamination. That patient did not develop any infectious sequelae. Patient outcomes showed no difference in the incidence of seroma or infection between sterile and aseptic ADMs. CONCLUSIONS: This study evaluates the microbiology of acellular dermal matrices before use in breast reconstruction. No difference was found in the preoperative bacterial load of either aseptic or sterile ADM. No significant difference was noted in infection or seroma formation. Given these results, we believe aseptic processing used on ADMs is equivalent to sterile processing in our patient cohort in terms of clinical infection and seroma occurrence postoperatively.

Are Prophylactic Postoperative Antibiotics Necessary for Immediate Breast Reconstruction? Results of a Prospective Randomized Clinical Trial.

BACKGROUND: Closed-suction drains, implants, and acellular dermal matrix (ADM) are routinely used in tissue expander-based immediate breast reconstruction (TE-IBR). Each of these factors is thought to increase the potential for surgical site infection (SSI). Although CDC guidelines recommend only 24 hours of antibiotic prophylaxis after TE-IBR, current clinical practices vary significantly. This study evaluated the difference in SSI between 2 different prophylactic antibiotic durations. STUDY DESIGN: A noninferiority randomized controlled trial was designed in which TE-IBR patients received antibiotics either 24 hours postoperatively or until drain removal. The primary outcome was SSI, as defined by CDC criteria. Operative and postoperative protocols were standardized. Secondary endpoints included clinical outcomes up to 1 year and all implant loss, or reoperation. RESULTS: There were 112 TE-IBR patients (180 breasts) using ADM who were randomized into 2 study arms, with 62 patients in the 24-hour group and 50 in the extended group. Surgical site infection was diagnosed in 12 patients in the 24-hour group and 11 in the extended group (19.4% vs 22.0%, p = 0.82). The extended group had 7 patients who required IV antibiotics and an overall implant loss in 7 patients (14.0%). The 24-hour group had 4 patients who required IV antibiotics, with 3 requiring removal (4.8%). Patients with diabetes, postoperative seroma, or wound dehiscence were all more likely to develop SSI (p < 0.02). CONCLUSIONS: In a randomized controlled noninferiority trial, 24 hours of antibiotics is equivalent to extended oral antibiotics for SSI in TE-IBR patients. Additional multicenter trials will further assess this important aspect of TE-IBR postoperative care.

AdVEGF-All6A+ Preconditioning of Murine Ischemic Skin Flaps Is Comparable to Surgical Delay.

BACKGROUND: Surgical flap delay is commonly used in preconditioning reconstructive flaps to prevent necrosis. However, staged procedures are not ideal. Pharmacologic up-regulation of angiogenic and arteriogenic factors before flap elevation poses a nonsurgical approach to improve flap survival. METHODS: Male Sprague Dawley rats were divided into control (n = 16), surgical delay (Delay), AdNull, AdEgr-1, and AdVEGF (n ≥ 9/group) groups. Delay rats had a 9 cm × 3 cm cranial based pedicle skin flap incised 10 days prior to elevation. Adenoviral groups received 28 intradermal injections (10(9) pu/animal total) throughout the distal two thirds of the flap 1 week prior to elevation. At postoperative day (POD) 0 flaps were elevated and silicone sheeting was placed between flap and wound bed. Perfusion analysis in arbitrary perfusion units of the ischemic middle third of the flap using laser Doppler imaging was conducted preoperatively and on POD 0, 3, and 7. Clinical and histopathologic assessments of the skin flaps were performed on POD 7. RESULTS: AdVEGF (50.8 ± 10.9 APU) and AdEgr-1 (39.3 ± 10.6 APU) perfusion levels were significantly higher than controls (16.5 ± 4.2 APU) on POD 7. Delay models were equivalent to controls (25.9 ± 6.8 APU). AdVEGF and Delay animals showed significantly more viable surface area on POD 7 (14.4 ± 1.3 cm(2), P < 0.01 and 12.4 ± 1.2 cm(2), P < 0.05, respectively) compared with Controls (8.7 ± 0.7 cm(2)). CONCLUSIONS: AdVEGF preconditioning resulted in flap survival comparable to surgical delay. Adenoviral preconditioning maintained perfusion levels postoperatively while surgical delay did not.

Comparison of Laser Doppler and Laser-Assisted Indocyanine Green Angiography Prediction of Flap Survival in a Novel Modification of the McFarlane Flap.

BACKGROUND: The McFarlane rat ischemic dorsal skin flap model has been commonly used for clinical vector studies, as well as the testing of noninvasive diagnostics. However, variability of this model secondary to flap contact with the wound bed has led many to question its validity. Here we present a novel modification to the McFarlane skin flap using sterile silicone. We also use this model to test the prognostic efficacy of laser-assisted indocyanine green (ICG) angiography and laser Doppler imaging (LDI). METHODOLOGY: A 3 × 9-cm dorsal skin flap with a cranially based pedicle was created, centered 1 cm distal to the scapulae. The flap was undermined, and in one of the 2 groups, a sterile silicone sheet was placed onto the wound bed. All flaps were then reapproximated with sutures 1-cm intervals. Clinical assessment and perfusion imaging was performed immediately postoperative, and at 24, 48, and 72 hours postsurgery. Postoperative day 7 clinical assessment was obtained before euthanasia. RESULTS: A comparative study using silicone blocked versus unblocked models (n = 6 per group) showed that, clinically, both models had equivalent flap survival [8.5 (0.913) vs 9.5 (1.01) cm]. However, a statistically significant increase in perfusion in the mid-third of unblocked models was observed on POD3 [20.28% (2.7%) vs blocked 13.45% (2.5%), P < 0.05], with a similar increase in the distal third on POD7 [18.73% (2.064%) vs 10.91% (4.19%), P < 0.05]. A prognostic study comparing LDI and ICG angiography prediction of POD7 survival at early time points (n = 10) found that LDI underpredicted flap survival at early time points [84.2% (12.03%) on POD0, 87.35% (16.11%) on POD1]. In contrast, ICG was more proficient [100.1% (10.1%) on POD0]. CONCLUSIONS: We present a modification of the McFarlane skin flap model that results in similar clinical results, but with a noted reduction in perfusion inconsistencies noted in unblocked models. The ICG angiography is superior to LDI in predicting POD7 flap necrosis within the first 48 hours postinjury. Future work will focus on histologic validation of our model, and vector efficacy testing.

Comparing quantitative values of two generations of laser-assisted indocyanine green dye angiography systems: can we predict necrosis?

OBJECTIVE: Several devices exist today to assist the intraoperative determination of skin flap perfusion. Laser-Assisted Indocyanine Green Dye Angiography (LAICGA) has been shown to accurately predict mastectomy skin flap necrosis using quantitative perfusion values. The laser properties of the latest LAICGA device (SPY Elite) differ significantly from its predecessor system (SPY 2001), preventing direct translation of previous published data. The purpose of this study was to establish a mathematical relationship of perfusion values between these 2 devices. METHODS: Breast reconstruction patients were prospectively enrolled into a clinical trial where skin flap evaluation and excision was based on quantitative SPY Q values previously established in the literature. Initial study patients underwent mastectomy skin flap evaluation using both SPY systems simultaneously. Absolute perfusion unit (APU) values at identical locations on the breast were then compared graphically. RESULTS: 210 data points were identified on the same patients (n = 4) using both SPY systems. A linear relationship (y = 2.9883x + 12.726) was identified with a high level or correlation (R(2) = 0.744). Previously published values using SPY 2001 (APU 3.7) provided a value of 23.8 APU on the SPY Elite. In addition, postoperative necrosis in these patients correlated to regions of skin identified with the SPY Elite with APU less than 23.8. CONCLUSION: Intraoperative comparison of LAICGA systems has provided direct correlation of perfusion values predictive of necrosis that were previously established in the literature. An APU value of 3.7 from the SPY 2001 correlates to a SPY Elite APU value of 23.8.

Modeling fade patterns of nipple areola complex tattoos following breast reconstruction.

BACKGROUND: Nipple-areolar complex (NAC) tattoos are an effective cosmetic solution for creating a finished look following breast reconstruction procedures. NAC tattoos are prone to significant fading, leading patients to seek revisions. This study was designed to quantify changes in NAC tattoo appearance over time. METHODS: A total of 71 images of 39 patients were analyzed for NAC tattoo color and shape by 5 blinded medical student graders using a customized scoring system. Subsequently, each image was analyzed using ColorPic software (Iconico, New York, NY). Red/green/blue and hue/saturation/value color parameters were collected. Color quantities were normalized to the individual patient's skin tone to control for variability in lighting. Spearman correlations and nonlinear regressions were calculated utilizing GraphPad Prism 6.0 (GraphPad, La Jolla, CA). RESULTS: The length of time after tattoo placement inversely correlated with color score (P < 0.0001) and shape score (P = 0.0007). The time following tattoo placement was also inversely correlated with all quantitative color parameters. Each color parameter fit a 1-phase exponential decay model. CONCLUSIONS: The decline in qualitative color and shape score agrees with clinical experience of tattoo quality declining over time. The color qualities of the tattoo approach those of the patient's skin over time, ultimately reaching a plateau. This can be modeled using a 1-phase decay equation. In practice, tattoo colors may be selected that compensate for the predictable changes that will occur. The results of this study will help optimize tattoo color and may alleviate the need for NAC tattoo revisions.

A systematic review of antibiotic use and infection in breast reconstruction: what is the evidence?

BACKGROUND: The literature reports overall complication rates in breast reconstruction to be as high as 60 percent. Infection rates can exceed 20 percent, much higher than anticipated in clean elective surgery. There is no consensus among surgeons regarding the necessary duration of antibiotic prophylaxis, although the Centers for Disease Control and Prevention guidelines suggest only 24 hours. This systematic review examines antibiotic regimens and associated infection rates in breast reconstruction. METHODS: Systematic electronic searches were performed in the PubMed, Ovid, and Cochrane databases using Medical Subject Headings terms for studies reporting antibiotic use and infection in all forms of breast reconstruction. Studies between 1970 and 2011 were reviewed. Included publications were required to report an antibiotic protocol and infection rate. RESULTS: A total of 834 abstracts were identified, 81 of which met inclusion criteria and were included in the review. The overall reported infection rates in the included studies varied between 0 and 29 percent (average, 5.8 percent). When comparing combined patient cohorts receiving no antibiotics, less than 24 hours, and greater than 24 hours, the average infection rates were 14.4, 5.8, and 5.8 percent, respectively. CONCLUSIONS: There is no consensus on the necessary duration of antibiotic prophylaxis following breast reconstruction. No benefit was found in patients who received more than 24 hours of postoperative antibiotics. Standardized definitions for antibiotic regimens, unit of analysis reporting, and a new breast reconstruction surgical-site infection grading system are offered to improve standardized outcome documentation. Randomized controlled trials are warranted to best determine an optimal antibiotic regimen. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.