Immediate Prepectoral Tissue Expander Breast Reconstruction Without Acellular Dermal Matrix Is Equally Safe Following Skin-Sparing and Nipple-Sparing Mastectomy.

BACKGROUND: Prepectoral breast reconstruction has become increasingly popular over the last decade. There is a paucity of data surrounding the impact of mastectomy type on clinical outcomes when comparing prepectoral immediate breast reconstruction without acellular dermal matrix (ADM) using tissue expansion. The purpose of this study was to compare 90-day reconstructive surgical outcomes in immediate prepectoral tissue expander reconstruction between patients with nipple-sparing mastectomy (NSM) and skin-sparing mastectomy (SSM). METHODS: A retrospective review of patient records was carried out on all patients undergoing NSM or SSM with immediate prepectoral tissue expander reconstruction without ADM, in a single institution, from June 2020 to December 2021. All complications were recorded, categorized, and statistically analyzed for significance. RESULTS: Seventy-nine patients (97 breasts) were studied. The mean age was 51 years old (range, 31-77). Twenty-two patients suffered complications recorded in 22 breasts (22.7%). There was no statistically significant difference in the total complications between the NSM (25.7%) and SSM (21.0%) groups or in the incidence of all major and minor complications. CONCLUSIONS: Breast reconstruction using tissue expanders without ADM has similar reconstructive outcomes in both NSM and SSM. There were no significant differences in complication rates between either groups. Breast reconstruction without ADM can confer institutional cost savings without compromising safety.

Breast Implant-Related Adverse Events During Mammography: An Assessment of the Food and Drug Administration Manufacturer and User Facility Device Experience Database.

BACKGROUND: Adverse events arising in patients with breast implants during mammography reported by the Food and Drug Administration include implant rupture, pain, and impaired visualization. However, data supporting these claims were collected in 2004, and since, newer implant generations have been developed with overall rate of implantation increasing by 48%. OBJECTIVES: This article aims to determine the current incidence of implant-related adverse events arising during mammography. METHODS: We analyzed reports regarding silicone and saline breast implants published in the Food and Drug Administration Manufacturer and User Facility Device Experience database between 2008 and November 2018. Search terms included "mammogram," "mammography," "radiograph," "breast cancer screening," "breast cancer test," and "x-ray." RESULTS: Of the 20 539 implant-related adverse events available in the Manufacturer and User Facility Device Experience database, 427 were retrieved using our search strategy and 41 were related to mammography. Thirty-five of identified cases (85.4%) reported implant rupture, of which 19 (54.3%) were confirmed by a healthcare professional, 9 (25.7%) were clinically confirmed by saline implant deflation, and 7 (20.0%) were unverified reports by patients. Sixteen ruptures (45.7%) occurred with silicone implants, whereas 19 ruptures (54.3%) occurred with saline. Other adverse events included pain (29.3%), change in implant appearance (14.6%), and swelling (7.3%). CONCLUSIONS: Although implant rupture, pain, change in implant appearance, and swelling may occur, minimal implant-related adverse events arise during mammography. Given the extremely low reported risk of implant rupture, this should neither prevent patients from adhering to breast cancer screening programs nor deter patients from seeking breast implants. Patients should be aware of these reported risks and discuss screening options with their breast cancer screening team.

Acellular Dermal Matrix-sparing Direct-to-implant Prepectoral Breast Reconstruction: A Comparative Study Including Cost Analysis.

INTRODUCTION: Refined mastectomy techniques, the advent of new technologies and materials such as acellular dermal matrix (ADM), cohesive gel silicone implants, and intraoperative tissue perfusion analysis, have fueled a resurgence in prepectoral breast reconstruction. This article aims to compare an immediate direct-to-implant prepectoral ADM-sparing approach with the traditional subpectoral 2-stage immediate reconstruction. A cost analysis within a Canadian-run single-payer system is also presented. METHODS: A retrospective 2-group comparative chart review study was performed (June 2015-January 2017) to identify all patients who underwent prepectoral direct-to-implant breast reconstruction using an ADM-sparing technique. The comparison group consisted of patients having undergone traditional 2-stage subpectoral reconstruction with ADM. All countable variables were included in the cost analysis, which was performed in Canadian dollars. RESULTS: A total of 77 patients (116 reconstructed breasts) were included. Both the prepectoral and subpectoral groups were comparable in size, demographics including age, diabetic and smoking status, and receiving neoadjuvant chemotherapy and postmastectomy radiotherapy. Patients having undergone direct-to-implant prepectoral reconstruction benefited from fewer follow-up visits (3.8 vs 5.4, respectively) and from less complications (24.7% vs 35.6%, respectively) including animation deformity. In addition, direct-to-implant prepectoral reconstruction costs 25% less than the 2-stage subpectoral reconstruction when all associated costs were considered. CONCLUSION: Prepectoral implant placement avoids many of the disadvantages of the traditional 2 stage subpectoral reconstruction, including pectoralis muscle dissection, animation deformity, and multiple surgeries. As the first comparative cost analysis study on the subject, our ADM-sparing direct-to-implant prepectoral reconstruction method costs 25% less than the traditional 2-stage subpectoral reconstruction with a comparable complication profile.

The Potential Role of Corticosteroid Prophylaxis for the Prevention of Microscopic Fat Embolism Syndrome in Gluteal Augmentations.

BACKGROUND: Microscopic fat embolism syndrome (micro-FES) has been recently identified as a potentially fatal complication following gluteal augmentation utilizing autologous fat grafts; safety recommendations advocating for subcutaneous lipo-injections may be insufficient for its prevention. OBJECTIVES: The authors of this systematic review evaluated the potential role of corticosteroid prophylaxis for the prevention of micro-FES in gluteal augmentation procedures. METHODS: The authors performed a systematic search employing the National Library of Medicine (PubMed), Medline, and Embase databases. Search terms were those pertaining to studies reporting the efficacy of prophylactic corticosteroid administration on micro-FES incidence in a high-risk surrogate population. RESULTS: Thirteen articles met the inclusion criteria for review, comprising 2 studies reporting on the efficacy of a single intravenous (IV) corticosteroid dose for the prophylaxis of micro-FES, 9 studies reporting on multiple prophylactic IV doses, and 2 additional studies reporting on the efficacy of inhaled corticosteroids in this context. All studies were identified from the orthopedic literature given that none were available directly from within plastic surgery. The prophylactic efficacy of multiple IV doses of methylprednisolone, or a single larger dose, was established, whereas the efficacy of inhaled corticosteroids remains elusive. CONCLUSIONS: A single perioperative IV dose of methylprednisolone may be most appropriate for utilization by plastic surgeons; the safety and implication of this therapy on wound healing and fat graft survival are discussed. Further studies directly evaluating the efficacy of corticosteroid prophylaxis in the gluteal augmentation population are indicated. Finally, recommendations pertaining to the prevention, timely recognition, and effective management of micro-FES are discussed.

Step-Specific Simulation: The Utility of 3D Printing for the Fabrication of a Low-Cost, Learning Needs-Based Rhinoplasty Simulator.

BACKGROUND: Rhinoplasty is a complex procedure that requires meticulous planning and precise execution. Plastic surgeons involved in teaching residents must balance a trainee's hands-on experience while ensuring appropriate execution of difficult maneuvers. Surgical simulation, a field of growing importance with the shift towards competency-based education, may aid in trainee skill development. Through the concept of deliberate practice, the authors looked to explore the utility and economics of 3-dimensional (3D) printing technology to develop a step-specific rhinoplasty simulator. OBJECTIVES: The main objective of this study was to address rhinoplasty skills previously identified as "learning areas of weakness" and develop a low-cost, step-specific simulator to help rhinoplasty teaching. METHODS: A patient's facial bones, upper and lower lateral cartilages, and septum were segmented from a computed tomography scan and rendered in 3D format. This was 3D printed utilizing Ultimaker Polylactic filament with a polyvinyl acetate dissolvable support for bone, a mixture of Rigur 450 and Tango plus polyjet material for cartilage, and Smooth-On Dragon Skin for skin. RESULTS: A modular simulator was developed with 3 separate, interchangeable components with a perfect fit design. The simulator allowed for deliberate practice of the 5 rhinoplasty learning areas of weakness, with a maximal recurring cost of $75 CAD. CONCLUSIONS: Through the employment of 3D printing, a low-cost, maneuver-specific rhinoplasty simulator reinforcing deliberate practice was developed. This concept of simulation-based deliberate practice may be of increasing interest when considering the implementation of competency-based curricular standards in plastic surgery education.

Making Augmented and Virtual Reality Work for the Plastic Surgeon.

Augmented and virtual reality is an evolving technology at the forefront of medicine. It can provide physicians with hands-free, real-time access to the vast resources of the Internet and electronic medical records, allowing simultaneously recording of clinical encounters or procedures. Mixed reality platforms can be applied as a clinical tool, educational resource, or as an aid in enhancing communication in health care. This article will explore how various augmented and virtual reality platforms have enabled real-time visualization of patient information, recording of surgical cases, point-of-view photography, and intraoperative consults-all while remaining sterile in the operating room. Although this technology is of potential value to a number of different surgical and medical specialties, plastic surgery is ideally suited to lead this charge.

Vascularized Tissue Reconstruction in Previously Irradiated Sarcoma Defects.

INTRODUCTION: Radiation therapy (RT) is recommended for appropriately selected sarcoma patients to minimize the risk of local recurrence and to maximize outcomes of disease-free survival and function. The purpose of this study was to confirm the safety of vascularized tissue reconstruction in recently irradiated sarcoma defects. METHODS: A retrospective review of all patients treated by the senior author for sarcoma reconstruction from January 2005 to July 2017 was performed. Two independent reviewers collected data from both electronic and paper medical records. Patients were included if they underwent flap reconstruction (pedicled or free) following sarcoma resection. The safety of neoadjuvant RT was compared with a control group with no previous irradiation using χ(2) analysis. RESULTS: Fifty-seven patients were included in the study; 35 patients were included in the preoperative RT group, and 22 patients were included in the control group (no previous irradiation). There was no significant difference in wound complications between the 2 groups (infection, dehiscence, hematoma, and seroma). Microvascular complications (arterial thrombosis, venous thrombosis, partial/total flap loss) were also comparable in the free tissue transfer subgroup. CONCLUSIONS: The current study demonstrates the safety of both pedicled and free flap reconstruction in previously irradiated sarcoma defects. Judicious selection of reconstructive technique and recipient vessels is crucial in obtaining optimal outcomes given the devastating effects of RT on native tissues.

A Novel Mohs Precision Tool.

BACKGROUND: Effective treatment by Mohs micrographic surgery requires preparation of high-quality slides. OBJECTIVE: To examine a novel tissue alignment device designed to address variability in tissue processing because of excessive sample trimming. MATERIALS AND METHODS: A device was designed to account for angular errors and unparalleled tissue embedding. A retrospective chart review was performed both with and without the use of the device over the course of a 4-year period (2012-2015). RESULTS: Between January 1, 2012, and June 10, 2014, before device implementation, mean number of stages per case was 1.65 (n = 3,680) and mean number of surgeries per day was 6.34 (n = 640). Between June 11, 2014, and October 02, 2015, with device implemented, the average number of stages per case between decreased to 1.58 (n = 2,562) and the number of daily surgeries increased to 7.05 (n = 358). This represents a significant decrease in number of stages per case by 0.07 stages (95% CI: -0.01 to -0.13, p = .02), as well as an increase in the number of cases per day by 0.71 cases (95% CI: 0.12-1.3, p < .01). CONCLUSION: Slide preparation using the novel alignment device may result in less tissue waste and more cases being performed daily.

The State of Technology in Craniosynostosis.

INTRODUCTION: Craniosynostosis, the premature fusion of ≥1 cranial sutures, is the leading cause of pediatric skull deformities, affecting 1 of every 2000 to 2500 live births worldwide. Technologies used for the management of craniofacial conditions, specifically in craniosynostosis, have been advancing dramatically. This article highlights the most recent technological advances in craniosynostosis surgery through a systematic review of the literature. METHODS: A systematic electronic search was performed using the PubMed database. Search terms used were "craniosynostosis" AND "technology" OR "innovation" OR "novel.' Two independent reviewers subsequently reviewed the resultant articles based on strict inclusion and exclusion criteria. Selected manuscripts deemed novel by the senior authors were grouped by procedure categories. RESULTS: Following review of the PubMed database, 28 of 536 articles were retained. Of the 28 articles, 20 articles consisting of 21 technologies were deemed as being novel by the senior authors. The technologies were categorized as diagnostic imaging (n = 6), surgical planning (n = 4), cranial vault evaluation (n = 4), machine learning (n = 3), ultrasound pinning (n = 3), and near-infrared spectroscopy (n = 1). CONCLUSION: Multiple technological advances have impacted the treatment of craniosynostosis. These innovations include improvement in diagnosis and objective measurement of craniosynostosis, preoperative planning, intraoperative procedures, communication between both surgeons and patients, and surgical education.

A Systematic Review of the Effectiveness of Tongue Lip Adhesion in Improving Airway Obstruction in Children With Pierre Robin Sequence.

BACKGROUND: Tongue-lip adhesion (TLA) involves surgically tethering the tongue forward to the lower lip and is a technique to relieve airway obstruction caused by glossoptosis and retrognathia. The purpose of the present study was to evaluate the effectiveness of TLA for the treatment of airway compromise in patients with Pierre Robin sequence (PRS). METHODS: A comprehensive literature review was performed. Inclusion criteria consisted of patients having undergone isolated tongue lip adhesion and results that included airway outcome. Selected manuscripts were analyzed with regards to patient demographics, principle diagnosis, pre and postintervention airway status, and complications. RESULTS: Thirteen manuscripts met inclusion criteria, yielding 268 patients with PRS who underwent TLA. The mean age at the time of procedure was 30.5 days. Tongue lip adhesion proved to be successful in relieving airway obstruction caused by PRS in 81.3% (n = 218) of patients. Nonsyndromic patients benefited from a higher success rate as compared with the syndromic cohort (91.5% and 79.8% respectively, P = 0.0361). Eight patients who were initially successfully managed with TLA required a repeat procedure due to dehiscence. CONCLUSIONS: Tongue-lip adhesion is a safe and effective technique and is associated with lower morbidity and mortality as compared with mandibular distraction osteogenesis and tracheostomy and should be considered in patients with PRS who fail conservative management. The greater success and lower complication rates in nonsyndromic patients reinforce the importance of proper patient selection and consideration of other techniques such as mandibular distraction osteogenesis should be given in patients with associated syndromic diagnoses.

Altered Foreign Body Response at the Posterior Surface Compared to the Anterior Surface of Human Silicone Breast Implants.

Soft implantable devices are crucial to optimizing form and function for many patients. However, periprosthetic capsule fibrosis is one of the major challenges limiting the use of implants. Currently, little is understood about how spatial and temporal factors influence capsule physiology and how the local capsule environment affects the implant structure. In this work, we analyzed breast implant capsule specimens with staining, immunohistochemistry, and real-time polymerase chain reaction to investigate spatiotemporal differences in inflammation and fibrosis. We demonstrated that in comparison to the anterior capsule against the convex surface of breast implants, the posterior capsule against the flat surface of the breast implant displays several features of a dysregulated foreign body reaction including increased capsule thickness, abnormal extracellular remodeling, and infiltration of macrophages. Furthermore, the expression of pro-inflammatory cytokines increased in the posterior capsule across the lifespan of the device, but not in the anterior capsule. We also analyzed the surface oxidation of breast explant samples with XPS analysis. No significant differences in surface oxidation were identified either spatially or temporally. Collectively, our results support spatiotemporal heterogeneity in inflammation and fibrosis within the breast implant capsule. These findings presented here provide a more detailed picture of the complexity of the foreign body reaction surrounding implants destined for human use and could lead to key research avenues and clinical applications to treat periprosthetic fibrosis and improve device longevity.

The cellular and molecular properties of capsule surrounding silicone implants in humans vary uniquely according to the tissue type adjacent to the implant.

The foreign body reaction (FBR) to biomaterials results in fibrous encapsulation. Excessive capsule fibrosis (capsular contracture) is a major challenge to the long-term stability of implants. Clinical data suggests that the tissue type in contact with silicone breast implants alters susceptibility to developing capsular contracture; however, the tissue-specific inflammatory and fibrotic characteristics of capsule have not been well characterized at the cellular and molecular level. In this study, 60 breast implant capsule samples are collected from patients and stratified by the adjacent tissue type including subcutaneous tissue, glandular breast tissue, or muscle tissue. Capsule thickness, collagen organization, immune and fibrotic cellular populations, and expression of inflammatory and fibrotic markers is quantified with histological staining, immunohistochemistry, and real-time PCR. The findings suggest there are significant differences in M1-like macrophages, CD4+ T cells, CD26+ fibroblasts, and expression of IL-1ß, IL-6, TGF-ß, and collagen type 1 depending on the tissue type abutting the implant. Subglandular breast implant capsule displays a significant increase in inflammatory and fibrotic markers. These findings suggest that the tissue microenvironment contributes uniquely to the FBR. This data could provide new avenues for research and clinical applications to improve the site-specific biocompatibility and longevity of implantable devices.

The Radiographic "Air Sign" in Neonatal Mandibular Distraction Osteogenesis.

Timing of extubation on post-mandibular distraction osteogenesis (MDO) surgery is critical, given that at baseline these infants have difficult airways and failed extubation requires either re-intubation of an already complex airway with a fragile, recently osteotomized mandible, or adjunctive airway measures such as CPAP that may apply unwanted pressure to the surgical site. Thus, the goal is to plan extubation when the risk of failure is minimal. Currently, there is a void in the literature addressing the timing of extubation post-MDO and no objective sign of extubation readiness has been elucidated. This study describes a simple clinical pearl to assist in the evaluation of extubation readiness in these patients. Postoperatively, we obtain weekly radiographs to assess distractor stability and advancement, and to assess for the "Air Sign". The Air Sign describes a radiolucent space (air) visualized in the oropharynx on lateral radiographs, likely indicating that the tongue based airway obstruction has been relieved by mandibular advancement.

Le moment de l'extubation est très important après une opération de l'ostéogenèse par distraction mandibulaire, car ces nourrissons ont des voies respiratoires difficiles d'accès au départ, et une extubation malavisée entraîne soit la réintubation de voies respiratoires déjà difficiles à traverser alors que l'ostéotomie récente a fragilisé la mandibule, soit des interventions respiratoires d'appoint comme la CPAP, qui peuvent exercer une pression indésirable sur la zone opératoire. Ainsi, il faut planifier l'extubation au moment où le risque d'échec est minimal. À l'heure actuelle, les publications ne précisent pas le moment de l'extubation après l'ostéogenèse par distraction mandibulaire, et aucun signe objectif n'est fixé pour établir quand le patient y est prêt. La présente étude décrit une perle clinique simple pour contribuer à évaluer si ces patients sont prêts à être extubés. Après l'opération, les chercheurs ont obtenu des radiographies hebdomadaires pour évaluer la stabilité et l'avancement du distracteur, de même que le " signe de l'air ". Celui-ci décrit un espace translucide (air) visualisé dans l'oropharynx aux radiographies latérales, probablement indicateur du soulagement de l'obstruction des voies respiratoires par la langue grâce à l'avancement de la mandibule.

Breast Implanted-Associated Anaplastic Large Cell Lymphoma: A Case of Advanced Disease with Flow Cytometric Findings.

Breast implant-associated anaplastic large cell lymphoma (breast implant-associated ALCL) is a recently described, distinct clinicopathological entity associated with macrotextured breast implants. The diagnostic workup of a patient suspected to have breast implant-associated ALCL includes cytological assessment of effusions and tissue biopsies of any masses or enlarged lymph nodes, with morphologic and immunophenotypic evaluation and possible flow cytometric and molecular testing. We report the case of a woman found to have breast implant-associated ALCL on fine needle aspirate and core biopsy, who on surgical resection, had extensive local disease with involvement of the resection margins and lymph nodes, requiring systemic treatment. We focus on the flow cytometric findings that identified a population of large cells on the CD30/side scatter dot plot and whose immunophenotype was consistent with breast implant-associated ALCL, highlighting the value of flow cytometry as an adjunct to morphological and immunophenotypic evaluation.

Topical Tranexamic Acid in Breast Reconstruction: A Double-Blind Randomized Controlled Trial.

BACKGROUND: Excess fluid accumulation (seroma/hematoma) around the breast implant after reconstruction can lead to significant complications. Topical administration of tranexamic acid (TXA) may reduce fluid accumulation and reduce postoperative complications. This trial aims to investigate whether TXA-treated mastectomy pockets will exhibit less postoperative fluid production and complications. METHODS: This paired, double-blind, randomized, controlled trial enrolled patients undergoing bilateral mastectomies with immediate direct-to-implant reconstruction. In each patient, one breast was randomized to receive 3 g of TXA (100 cc), and the other received 100 cc of normal saline. The blinded solutions were soaked in the mastectomy pocket for 5 minutes before implant placement. Postoperatively, daily drain outputs, complications, and baseline demographics were recorded. RESULTS: Fifty-three eligible patients, representing 106 breasts, were enrolled. All patients underwent bilateral nipple-sparing mastectomies. After randomization, TXA was placed in the right breast in 30 patients (56.6%). The use of topical TXA resulted in a mean drain output reduction of 30.5% (range, -83.6% to 26.6%). Drains on the TXA-treated breast were eligible for removal 1.4 days (range, 0 to 4 days) sooner than the control side. The TXA-treated group had three complications (5.67%) versus 15 (28.3%) in the control group (OR, 0.1920; P = 0.0129). Specifically, for operative hematomas, the TXA group had none (0%), versus three in the control group (5.7%) (OR, 0.1348; P = 0.18). CONCLUSIONS: Soaking the mastectomy bed with 3% topical TXA before implant insertion leads to a decrease in drain output and a decrease in complications. Topical administration of TXA represents an option to decrease complications in alloplastic breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, I.

Direct-to-Implant, Prepectoral Breast Reconstruction: Geometric Breast Measurements and Changes at 2-Year Follow-Up.

BACKGROUND: Prepectoral breast reconstruction has recently experienced a resurgence in popularity. However, in direct-to-implant (DTI) reconstruction, there is no opportunity for capsular modifications before final implant insertion. Implant pocket and breast shape are thus maintained, initially, solely by the mastectomy skin flaps, and eventually, by attachments of the periprosthetic capsule. The present study aims to quantify changes in breast geometric measurements over time following DTI prepectoral breast reconstruction. METHODS: A retrospective chart review was performed for patients who underwent bilateral prepectoral DTI reconstruction performed by a single surgeon from June of 2016 to January of 2018. Patients followed for more than 2 years were included. Yearly standardized frontal photographs were analyzed, and nipple-to-midline, sternal notch-to-nipple, and midclavicle-to-lower pole measurements were obtained. Patient demographics, operative details, and complications were documented. RESULTS: A total of 72 breasts (38 women) undergoing direct-to-implant, prepectoral breast reconstruction were included in the final analysis. Acellular dermal matrix was used in 56 breasts only (78.9%) for anterior coverage. The average change in nipple-to-midline distance after 2 years decreased by 0.41 cm (range, -2.00 to 2.97 cm), sternal notch-to-nipple distance decreased by 0.62 cm (range, -4.98 to 5.4 cm), and midclavicle-to-lower pole distance decreased 0.10 cm superiorly (range, -6.07 to 3.6 cm). In breasts that underwent postmastectomy radiation therapy, the average changes were -0.08, -0.43, and -0.56 cm, respectively. No patient in this cohort had severe malposition requiring further surgery. CONCLUSIONS: The present study provides insight into geometric breast measurements following prepectoral breast reconstruction at 2-year follow-up. The minimal breast shape changes observed demonstrate the feasibility of prepectoral DTI reconstruction with or without the use of acellular dermal matrix. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.