Decreased postoperative pain and opioid use following prepectoral versus subpectoral breast reconstruction after mastectomy: A retrospective cohort study: Pain after pre- versus subpectoral reconstruction.

BACKGROUND: Prepectoral (PP) breast reconstruction is now commonly performed and minimizes dissection of the pectoralis major muscle. Data are lacking comparing the immediate postoperative recovery of these patients as compared with traditional subpectoral (SP) breast reconstruction. METHODS: From December 2015 to February 2017, 73 patients underwent PP prosthetic-based reconstruction at a single academic institution. PP cases were matched 1:1, by age and stage, to patients undergoing traditional SP reconstruction. Analysis of postoperative pain (visual analog scale) and opioid use (oral morphine equivalents, OME), was performed with both bi- and multivariate analyses. Additional outcomes explored included length of stay (LOS) and reconstructive intervention by plane of prosthetic reconstruction. RESULTS: A total of 146 patients were included in the final cohort. PP reconstruction was associated with higher rates of direct-to-implant reconstruction (84.9% vs. 34.3%, p <0.001) and higher rates of initial prosthetic fill (401.53 mL vs. 280.88 mL, p<0.001). Patients undergoing PP reconstruction had significantly reduced postoperative pain (4.29 vs. 5.44, p<0.001) and in-hospital opioid use (62.63 mg OME vs. 98.84 mg OME, p = 0.03) compared with SP patients. This result remained in multivariate analysis for both pain (3.94 vs. 5.25, p<0.001) and opioid use (17.14 mg OME vs. 63.03 mg OME, p = 0.03). Additionally, patients undergoing PP reconstruction had significantly reduced overall LOS on multivariate analysis (21.36 vs. 26.28 h, p = 0.02). CONCLUSION: Following mastectomy, PP breast reconstruction results in significantly reduced pain, opioid use, and hospital LOS compared with SP reconstruction.

A Multi-Site, Single-Blinded, Prospective Pilot Clinical Trial for Non-Invasive Fat Reduction of the Abdomen and Flanks Using a Monopolar 2 MHz Radiofrequency Device.

BACKGROUND AND OBJECTIVES: Demand for non-invasive body sculpting procedures has been steadily increasing, spurring the development of new energy-based technologies. This study assessed the safety and efficacy of a new monopolar 2 MHz radiofrequency (RF) device for fat reduction of the flanks and abdomen. STUDY DESIGN/MATERIALS AND METHODS: Nineteen subjects from two clinical sites were enrolled in this study and received a single 15-minute treatment with the 2 MHz RF device. Up to six applicators were placed on the abdomen and/or flanks during the treatment. Follow-up assessments were scheduled 12 weeks after treatment. Efficacy evaluations included live ratings and Global Aesthetic Improvement Scale (GAIS) ratings by blinded investigators, ultrasound measurements of fat thickness, and patient-reported outcomes before and after treatment. RESULTS: Investigator assessments showed more than one-point change in the GAIS scale at the 12-week follow-up visit. Ultrasound measurements revealed a significant reduction in fat thickness in both the abdomen (average 24%) and the flanks (22%). The majority of the patients were satisfied with the treatment and mild self-resolving side effects were observed. No serious adverse events were reported. CONCLUSIONS: Treatment of local adiposities with a new monopolar 2 MHz radiofrequency device leads to improvement of body contour with no downtime or side effects. Lasers Surg. Med. © 2020 Wiley Periodicals LLC.

Use of hyperbaric oxygen therapy for tissue ischemia after breast reconstruction.

INTRODUCTION: Mastectomy skin flap necrosis represents a significant complication of breast reconstructive procedures and is reported to occur in 30%-52% of patients undergoing breast reconstruction. Early identification of ischemia and early initiation of hyperbaric oxygen (HBO2) therapy can mitigate the effects of ischemia and rescue otherwise non-viable breast flap tissue. METHODS: We retrospectively examined the outcomes of HBO2 therapy in eight breasts with compromised mastectomy skin flaps between September 2015 and January 2017. Indocyanine green angiography (ICGA) was used to assess perfusion intraoperatively and post-HBO2 administration. RESULTS: Seven patients were referred for HBO2 within 24 hours of mastectomy. One patient failed to improve despite starting hyperbaric treatment within 24 hours. All other patients manifested successful healing of their mastectomy skin flaps with acceptable cosmesis after 10 HBO2 treatments. The mean relative perfusion of the at-risk area was 13.8% (±3.7%) pre-HBO2 and 101.6% (±37.3%) post-HBO2. The average area at-risk pre-HBO2 was 17.1 cm2 and reduced to zero post-HBO2. Relative perfusion values after HBO2 were found to be 6.8 (±3.4) times greater than those measured prior to HBO2. CONCLUSIONS: A short course of HBO2 may be sufficient to successfully rescue at risk post-mastectomy breast flaps. ICGA is a useful adjunct for evaluating post-mastectomy breast flap perfusion before and after HBO2 therapy.

Preparing for Facial Feminization Surgery: Timing.

Facial feminization surgery may be a part of a treatment plan for gender dysphoria. Initial mental health assessment must occur. Referrals for hormonal therapy may then be made if appropriate. No guidelines exist for timing of facial feminization surgery. Generally, recommendations are for individuals to undergo hormonal therapy and live in a gender-congruent role for at least 12 months before surgical intervention. Referral letters meeting World Professional Association of Transgender Health guidelines must be made regarding the treatment course and goals. Informed consent must be obtained; patient should understand how surgical alteration fits into their overall treatment goals.

Expanded Algorithm and Updated Experience with Breast Reconstruction Using a Staged Nipple-Sparing Mastectomy following Mastopexy or Reduction Mammaplasty in the Large or Ptotic Breast.

BACKGROUND: Staged nipple-sparing mastectomy following mastopexy or reduction mammaplasty was first described in 2011 by Spear et al. to expand the indications for nipple-sparing mastectomy to women with large or ptotic breasts. Since that time, the authors have revised their treatment algorithm and technique to enhance oncologic safety and improve wound healing complications. METHODS: An institutional review board-approved retrospective review was undertaken of all patients undergoing staged nipple-sparing mastectomy following mastopexy or reduction mammaplasty at a single institution from July of 2011 through July of 2016. Management followed an updated treatment protocol to improve surgical and oncologic outcomes. RESULTS: Twenty-six patients (50 breasts) were identified who underwent staged nipple-sparing mastectomy. Five breasts (10 percent) required reoperation for a complication such as infection or tissue necrosis. Two devices (4 percent), both in the therapeutic cohort, required explantation because of infection. Skin flap necrosis and nipple-areola complex necrosis were each seen in two breasts (4 percent). Infection was seen in four breasts (8 percent), and wound healing complications were seen in only two breasts (4 percent). CONCLUSIONS: The authors offer their updated treatment algorithm for a staged approach to nipple-sparing mastectomy for patients with macromastia or grade II or III ptosis. Their results build on previously published reports demonstrating the safety and efficacy of this approach for nipple preservation and oncologic management in this patient population. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

An Analysis of Plastic Surgeons' Social Media Use and Perceptions.

BACKGROUND: Social media have become ubiquitous in society with an increasing number of active daily users across multiple platforms. Social media use has grown within the field of plastic surgery; many surgeons have created a professional account to gain exposure. OBJECTIVES: This study investigates the patterns of use and perceptions of social media in plastic surgery. METHODS: A 16-item questionnaire was sent electronically to board-certified plastic surgeons to investigate professional social media use and perceptions. A literature review of all studies pertaining to social media and plastic surgery was also undertaken. RESULTS: An online survey was sent to 6136 ASPS members with 454 responses (7.4%). Of the respondents, 61.9% reported having an active professional social media account. Respondents whose practice primarily consisted of aesthetic/cosmetic surgery were the most likely to have an active professional social media account (79.4%). Nonacademic surgeons were most likely to maintain an active professional social media account (71.9%) compared with university-affiliated community surgeons (41.4%) and academic surgeons (29.5%). Nonacademic surgeons were more likely to believe social media is positive for the field (48.9%) compared with the other 2 cohorts (27.6% and 35.1%, respectively). Academic surgeons are more likely to believe social media worsens the image of the field (49.3%) vs the other cohorts (35.4% and 37.2%). CONCLUSIONS: Professional social media use is rising within plastic surgery. However, a dichotomy exists in acceptance. Private practice, younger surgeons are more likely to view social media as an acceptable method of reaching patients.

Positive Nipple Margin After Nipple-Sparing Mastectomy: An Alternative and Oncologically Safe Approach to Preserving the Nipple-Areolar Complex.

BACKGROUND: The aim of this study is to describe a less aggressive approach to management of positive nipple margin following nipple-sparing mastectomy (NSM), allowing for preservation of the nipple-areolar complex (NAC). STUDY DESIGN: A single-institution retrospective chart review was performed for patients undergoing NSM from 1989 to 2017. Positive nipple margin was defined as any residual invasive carcinoma or ductal carcinoma in situ (DCIS) within the additional nipple margin. Management included complete NAC removal, subareolar shave biopsy, or observation alone. Primary outcomes included rates of positive nipple margin and local recurrence. RESULTS: A total of 819 breasts underwent NSM, yielding a total of 32 breasts (3.9%) with positive nipple margin. Management included 11 (34.4%) subareolar shave biopsies, 15 (46.9%) complete NAC excisions, and 5 (15.6%) with observation alone, plus 1 (3.1%) lost to follow-up. Final pathology after subareolar shave biopsy did not reveal any residual disease, and no patients developed NAC necrosis or required NAC removal. Final pathology after NAC excision revealed 3 of 15 with additional disease (1 invasive ductal carcinoma, 2 DCIS). Of the five patients who had no subsequent intervention, tumor pathology was DCIS in all cases. One patient received adjuvant radiation therapy. Mean time to intervention was 3.7 ± 1.9 with mean follow-up of 2.9 years. CONCLUSIONS: Management of positive nipple margin after NSM with subareolar shave biopsy is a safe alternative to preserve the NAC.

Timing of radiation therapy in nipple-sparing mastectomy influences outcomes and patient-reported quality of life.

The aim of this study is to assess the complication profile and impact on patient-reported quality of life in those undergoing nipple-sparing mastectomy (NSM) with immediate breast reconstruction and subsequent prosthetic reconstruction in patients with prior breast radiation therapy (pRT) vs those receiving adjuvant post-mastectomy radiation therapy (PMRT). An IRB-approved, retrospective analysis was performed from 2002 to 2014 to identify NSM patients that underwent pRT or PMRT. A 22-item Likert scale questionnaire was administered by a third party to register patient-reported quality of life. Forty patients met criteria for outcomes analysis, and 30 patients answered the questionnaire. Mean age was 45.6 years old and mean follow-up was 3.8 years. Complication rates for the PMRT cohort were 61.9% vs 31.6% in the pRT cohort, P = .067, and those requiring operative intervention were PMRT 38.1% vs pRT 5.3%, P = .021. Nipple-areolar complex survival was 100% in the pRT vs 85.7% in the PMRT, P = .233. Breast-related quality of life scores were superior in the pRT group within multiple domains. Patients are more likely to develop complications requiring an operative intervention and have decreased breast-related quality of life when undergoing NSM with PMRT compared to patients undergoing NSM having received pRT.

Sientra AlloX2 Short-Term Case Study, Surgical Pearls, and Roundtable Discussion.

BACKGROUND: The AlloX2 Breast Tissue Expander (Sientra, Santa Barbara, Calif.) is a unique device that contains a second port to allow for transdermal communication with the pocket around the implant. The injection dome of this expander contains two ports; one is used for traditional saline injection, and a new second port facilitates fluid drainage from the periprosthetic space through an integral drain. The AlloX2 allows for the treatment of seromas and diagnostic fluid sampling to identify bacteria and hone antibiotic treatment in the setting of periprosthetic infection. This device has a significant advantage over traditional expanders, given that seromas and infections are the most common complications in implant-based breast reconstruction, with or without the use of soft-tissue support matrix. METHODS: This article provides short-term case studies and surgical pearls from 3 surgeons who utilize the AlloX2 in primary breast reconstruction patients. Three surgeons implanted 40 primary reconstruction patients with AlloX2. Follow-up was approximately 6 months, per the standard of care. All patients implanted with AlloX2 underwent immediate reconstruction, with the exception of 1 delayed reconstruction. RESULTS: The most common complications the patients experienced were seromas. In most cases, the surgeons successfully used the second port to drain periprosthetic fluid. CONCLUSIONS: The AlloX2 has been successful in treating seromas and should be considered a tool for noninvasive treatment of common complications of implant-based breast reconstruction. Three surgeons with varied backgrounds and techniques provide their surgical and postoperative management experiences and recommendations.

The P1 Method: Prepectoral Breast Reconstruction to Minimize the Palpable Implant Edge and Upper Pole Rippling.

BACKGROUND: Prepectoral prosthetic-based breast reconstruction has become increasingly popular as an alternative to the partial or total submuscular approach. Potential issues with the prepectoral approach include a noticeable superior implant edge and implant rippling. These concerns are particularly apparent in thin patients. We introduce a novel muscle-sparing technique in which a partial-thickness slip of pectoralis muscle is created in an otherwise prepectoral plane to mask these upper pole defects, mask superior implant rippling, and provide greater implant support (The P1 Method). METHODS: A retrospective review of all patients undergoing modified prepectoral (P1) breast reconstruction at a single institution over 2 years was undertaken. Data pertaining to patient demographics, mastectomy type/weight, reconstruction type, and esthetic and surgical outcomes were collected. Outcomes were analyzed using Fisher exact and Student t tests. RESULTS: Fifty patients (93 breasts) were identified during the study period. Mean final follow-up was 63 weeks (range, 53-85 weeks). Patients undergoing P1 reconstructions achieved improved esthetic results with less implant rippling and complete elimination of animation deformity seen on postoperative clinical images or at final follow-up. CONCLUSIONS: As prepectoral prosthetic-based breast reconstruction becomes more popular, architectural adaptations will be made to improve surgical and patient-centered outcomes. The P1 Method is effective in improving the superomedial contour in thin patients, minimizes upper pole rippling, and provides greater overall implant support.

Long-Term Safety of Textured and Smooth Breast Implants.

In this review, the authors provide a 20-year review and comparison of implant options and describe the evolution of breast implant surface textures; compare available implant surfaces; present long-term safety data from the 10-year US-based Core clinical studies; list the key benefits and risks associated with smooth and textured implants; and provide perspectives on breast implant-associated anaplastic large cell lymphoma (BIA-ALCL). The authors explore the key benefits and risks associated with all available devices so that optimal and safe patient outcomes can be achieved.

The 4-flap Jester's Hat Technique for Nipple Reduction.

Macrothelia, or nipple hypertrophy, is a condition that may cause severe psychological distress to those who suffer from it. Although effective in their primary goal of reducing nipple diameter and projection, previously reported techniques in nipple reduction suffer from imperfect aesthetic outcomes with noticeable scarring patterns, anatomically anomalous shape, and a smoothing of the natural ruffles of the nipple. We propose a simple technique to nipple reduction that improves upon previous techniques and creates a more naturally appearing nipple. A 4-flap technique resembling a jester's hat is described whereby suture lines are concealed within the central nipple to recreate the naturally ruffled appearance of a native nipple. Four patients have undergone this technique at a single institution with 100% patient satisfaction and no postoperative complications. Nipple sensation was maintained in all patients postoperatively. A 4-flap nipple reduction technique is a viable alternative to previously described techniques, which may offer more anatomically congruent results.

Comparison of Different Acellular Dermal Matrices in Breast Reconstruction: The 50/50 Study.

BACKGROUND: Acellular dermal matrix has enjoyed extensive use in primary and secondary alloplastic breast aesthetic and reconstructive surgery. The objective of this study was to examine clinical outcomes between available acellular dermal matrix products: DermACELL (LifeNet Health, Virginia Beach, Va.) and AlloDerm Ready To Use (LifeCell Corp., Branchburg, N.J.). METHODS: A retrospective chart review was performed on 58 consecutive patients (100 breasts) reconstructed with either DermACELL (n = 30 patients; 50 breasts) or AlloDerm Ready To Use (n = 28 patients; 50 breasts). The mastectomies were performed by three different breast surgeons. All reconstructions were performed by the same plastic surgeon (T.A.P.). Statistical analysis was performed by means of Fisher's exact test. RESULTS: Differences in the average age, body mass index, percentage having neoadjuvant/adjuvant chemotherapy or breast irradiation, and numbers of therapeutic and prophylactic mastectomies between the two groups were not statistically significant (p < 0.05). Complications in both cohorts of patients were clinically recorded for 90 days after immediate reconstruction. When comparing outcomes, patients in the DermACELL group had a significantly lower incidence of "red breast syndrome" (0 percent versus 26 percent; p = 0.0001) and fewer days before drain removal (15.8 days versus 20.6 days; p = 0.017). No significant differences were seen in terms of seroma, hematoma, delayed healing, infection, flap necrosis, or explantation. CONCLUSION: Patients reconstructed with DermACELL as compared with AlloDerm Ready To Use have significantly decreased number of days to drain removal and red breast syndrome and equivalent rates of other complications, including seroma, infection, flap necrosis, and explantation. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Anaplastic Large Cell Lymphoma: Emerging Consent and Management Patterns among American and International Board Certified Plastic Surgeons.

BACKGROUND: Although literature and case reports regarding anaplastic large cell lymphoma (ALCL) continue to increase, changes in plastic surgery practice patterns have not been assessed. METHODS: A 19-question survey was sent electronically to U.S. and international board-certified plastic surgeons. Data were analyzed using chi-square test and logistic regression analysis. RESULTS: A total of 1383 surgeons (U.S., 715; international, 668) responded, at a rate of 13.5 percent, and 36.2 percent of U.S. physicians aspirate late seromas and send for cytologic analysis and 9.5 percent had personal experience with ALCL, equating to at least 193 self-reported cases. Overall, 26.9 percent discuss ALCL risk at the initial consultation every time, and 36.4 percent include ALCL in the informed consent. Compared to U.S. counterparts, Australian, French, and German physicians were five times as likely to include ALCL in consent. Physicians in an academic practice and those frequently (>40 percent) using textured implants were more likely to discuss ALCL in the preoperative consultation. Physicians with personal or colleague experience with ALCL were twice as likely to include ALCL in the consent process. CONCLUSIONS: Only one-third of surgeons are managing late seroma according to U.S. Food and Drug Administration guidelines. ALCL cases are likely being underreported. Collectively, plastic surgeons remain hesitant to change consent pattern. However, specific countries have adapted their consenting processes. Working in academia and frequent textured implant use makes one more likely to discuss ALCL in consultation. Personal or colleague experience makes one twice as likely to include ALCL in the consent.