Complications Following Tissue Expander-Based Reconstruction in Pediatric Burn Injuries: A Retrospective Analysis.

BACKGROUND: Tissue expansion has been widely used to reconstruct soft tissue defects following burn injuries in pediatric patients, allowing for satisfactory cosmetic and functional outcomes. Factors impacting the success of tissue expander (TE)-based reconstruction in these patients are poorly understood. Herein, we aim to determine the risk factors for postoperative complications following TE-based reconstruction in pediatric burn patients. METHODS: A retrospective review of pediatric patients who underwent TE placement for burn reconstruction from 2006 to 2019 was performed. Primary outcomes were major complications (TE explantation, extrusion, replacement, flap necrosis, unplanned reoperation, readmission) and wound complications (surgical site infection and wound dehiscence). Descriptive statistics were calculated. The association between primary outcomes, patient demographics, burn characteristics, and TE characteristics was assessed using the chi-squared, Fisher's exact, and Mann-Whitney U tests. RESULTS: Of 28 patients included in the study, the median [interquartile range (IQR)] age was 6.5 (3.3-11.8) years, with a follow-up of 12 (7-32) months. The majority were males [n = 20 (71%)], Black patients [n = 11 (39%)], and experienced burns due to flames [n = 78 (29%)]. Eleven (39%) patients experienced major complications, most commonly TE premature explantation [n = 6 (21%)]. Patients who experienced major complications, compared to those who did not, had a significantly greater median (IQR) % total body surface area (TBSA) [38 (27-52), 10 (5-19), P = 0.002] and number of TEs inserted [2 (2-3), 1 (1-2), P = 0.01]. Ten (36%) patients experienced wound complications, most commonly surgical site infection following TE placement [n = 6 (21%)]. Patients who experienced wound complications, compared to those who did not, had a significantly greater median (IQR) %TBSA [35 (18-45), 19 (13-24), P = 0.02]. CONCLUSION: Pediatric burn injuries involving greater than 30% TBSA and necessitating an increasing number of TEs were associated with worse postoperative complications following TE-based reconstruction.

Multivariate Analysis of Risk Factors for Complications in Pediatric Tissue Expansion.

BACKGROUND: Tissue expanders represent one of the main surgical options for skin reconstruction in cases of tumors, traumalike burn injury, scar contracture, and alopecia. However, the tissue expander device is also associated with complications such as infection and extrusion. The aim of this study was to analyze risk factors for major complications of use of tissue expanders in pediatric patients using multivariate analysis. METHODS: A retrospective, single-center observational study was performed over 10 years in pediatric patients who were treated with tissue expanders for tumors, nevus, scars, burn reconstruction, and alopecia from April 2012 to March 2022. The primary outcome was overall complications per operation and expander, including infection and extrusion. Ten predictor variables were included as risk factors based on previous studies and as new factors considered important from clinical experience. Univariate and multivariate logistic regression analyses were performed to identify risk factors for major complications such as expander infection or extrusion. RESULTS: The study included 44 patients who underwent 92 operations using 238 tissue expanders. The overall complication rate per expander was 14.3%. Univariate logistic regression analysis identified associations of younger age, number of expanders used per operation, history of infection, and tissue expander locations with a higher complication rate. In multivariate logistic regression analysis, younger age (odds ratio, 1.14; P = 0.043) was associated with a high likelihood of expander complications. CONCLUSIONS: Younger age is an independent risk factor for tissue expander complications in pediatric patients. This factor should be considered in preoperative planning and discussions with the patient's family.

Post-mastectomy Breast Reconstruction With Gas vs Saline Tissue Expanders: Does the Fill Type Matter?

The most common reconstruction technique following mastectomy is a 2-stage technique that involves tissue expansion followed by definitive implant-based reconstruction (IBR). Tissue expanders (TEs) have classically used saline for initial fill; however, TEs with an initial gas fill (GTE)-including the CO2-based AeroForm (AirXpanders, San Francisco, CA) TE and TEs initially filled with atmospheric air-have been increasingly used in the past decade. We aimed to compare the outcomes in breast reconstruction for tissue expanders initially filled with saline vs gas. PubMed was queried for studies comparing gas- and saline-filled tissue expanders (STEs) used in IBR. A meta-analysis was performed on major postoperative outcomes and the required expansion and definitive reconstruction time. Eleven studies were selected and included in the analysis. No significant differences existed between tissue expansion with GTEs vs STEs for 11 of the 13 postoperative outcomes investigated. Out of the complications investigated, only the risk of infection/cellulitis/abscess formation was significantly lower in the GTE cohort (odds ratio 0.62; 95% CI, 0.47 to 0.82; P = .0009). The time to definitive reconstruction was also significantly lower in the GTE cohort (mean difference [MD], 45.85 days; 95% CI, -57.80 to -33.90; P < .00001). The total time to full expansion approached significance in the GTE cohort (MD, -20.33 days; 95% CI, -41.71 to 1.04; P = .06). A cost analysis considering TE cost and infection risk determined that GTE use saved a predicted $2055.34 in overall healthcare costs. Surgical outcomes for both fill types were predominantly similar; however, GTEs were associated with a significantly decreased risk of postoperative infection compared to saline-filled TEs. GTEs could also reduce healthcare expenditures and require less time until definitive reconstruction after placement.

Seroma After Breast Reconstruction With Tissue Expanders: Outcomes and Management.

BACKGROUND: Seroma is a relatively common complication after breast reconstruction with tissue expanders. The main risk in the presence of seroma is development of periprosthetic infection, which can lead to implant loss. Our goals were to identify risk factors for seroma, and to describe our protocol for managing fluid accumulation. PATIENTS AND METHODS: An IRB approved breast reconstruction database was reviewed to identify patients who underwent tissue expander reconstruction. Patient characteristics, details of surgery, outcomes and treatment were recorded. RESULTS: Two hundred nineteen tissue expander reconstructions were performed in 138 patients. Twenty-eight reconstructions developed seroma (12.8%), and 75 were identified to have prolonged drains (34.2%). Seroma was more common in patients with lymph node surgery ( P = 0.043), delayed reconstruction ( P = 0.049), and prepectoral reconstruction ( P = 0.002). Seroma and/or prolonged drains were more commonly noted in patients with higher body mass index ( P = 0.044) and larger breast size ( P = 0.001). Aspiration was the most common intervention (85.7%), which was performed in the clinic utilizing the expander port site. There was no difference in infection or explantation rate between seroma and no-seroma patients ( P = 0.546 and 0.167), whereas patients with any fluid concern (seroma and/or prolonged drains) were more prone to developing infection and undergoing explantation ( P = 0.041 and P < 0.005). CONCLUSION: We recommend that prolonged drain placement longer than 3 weeks should be avoided, and patients should be screened for fluid accumulation after drain removal. Serial aspiration via expander port site and continuation of expansion provide a safe and effective method to manage seromas to avoid infection and expander loss.

Pediatric Tissue Expansion: Analysis of the National Surgical Quality Improvement Program-Pediatric.

INTRODUCTION: Tissue expansion (TE) in pediatric surgery provides vascularized tissue to attain functional and esthetic goals in a broad range of reconstructive procedures. Our study evaluates the demographic, operative, and short-term outcomes of TE in pediatric patients utilizing the American College of Surgeons National Surgical Quality Improvement Program-Pediatric (NSQIP-P) database and highlights factors associated with postoperative complications. MATERIALS AND METHODS: Retrospective review of a large multicenter database of 402 pediatric patients that underwent TE within the NSQIP-P database from 2013 to 2020 at freestanding general acute care children's hospitals, children's hospitals within a larger hospital, specialty children's hospitals, or general acute care hospitals with a pediatric wing. Patient demographics, clinical risk factors, operative information, and postoperative outcomes were collected with an odds ratio analysis of risk factors. RESULTS: Patients were majority female (55.5%), White (63.2%), and non-Hispanic (67.4%). The minority were born prematurely (11.9%) and had congenital malformations (16.7%). Complications occurred in 5.7%, unplanned readmission in 4.5%, and unplanned operation in 6.5% of patients. Complications lead to readmission in 2.5% and return to the operating room in 3.2% of patients. American Society of Anesthesiology (ASA) score III-IV, congenital malformations, >1-day hospital stay, and pulmonary, neurologic, and hematologic comorbidities were associated with the greatest increase in odds of complication. CONCLUSION: This study utilizes the NSQIP-P to provide a comprehensive multicenter view of pediatric patients undergoing TE. Increased understanding of risk factors for complications allows for guidance in patient selection and helps in achieving favorable surgical outcomes.

Benefits of Using Magnetic Resonance Imaging During Breast Tissue Expansion: Literature Review and Case Series.

Breast cancer results in up to 1.6 million new candidates for yearly breast reconstruction (BR) surgery. Two-stage breast reconstruction surgery with the use of a tissue expander (TE) is a common approach to reconstructing the breast after mastectomy. However, a common disadvantage encountered with the traditional breast TE is the magnetic injection port, which has been reported to cause injuries in patients undergoing magnetic resonance (MR) imaging. Therefore this type of breast TE is labeled "MR unsafe." Recent technological advances have incorporated radio-frequency identification (RFID) technology in the TE to allow for the location of the injection port without magnetic components, resulting in an MR-conditional TE. This paper aims to review the information regarding the safety profile of TEs with magnetic ports and to gather distinct clinical scenarios in which an MR-conditional TE benefits the patient during the BR process. A literature review ranging from 2018 to 2022 was performed with the search terms: "tissue expander" OR "breast tissue expander" AND "magnetic resonance imaging" OR "MRI." Additionally, a case series was collected from each of the authors' practices. The literature search yielded 13 recent peer-reviewed papers, and 6 distinct clinical scenarios were compiled and discussed. Most clinicians find MRI examinations to be the state-of-art diagnostic imaging modality. However, due to the preexisting risks associated with TEs with magnetic ports, the MRI labeling classification should be considered when deciding which TE is the most appropriate for the patient requiring MRI examinations.

Psychosocial Experiences in Children With Congenital Melanocytic Nevus on the Face and Their Parents Throughout the Tissue Expansion Treatment.

ABSTRACT: Large congenial melanocytic nevus (LCMN) on the head and face can have negative psychological effects on children and possibly also parents. Patients and their families experience prolonged periods of stress during tissue expansion treatment. The purpose of this study was to evaluate the psychological impact of LCMN on children and parents and explore their fluctuations of psychological status during treatment. Psychosocial status was evaluated in 30 children with LCMN on the head and face and a control group of 56 sex- and age-matched children using the Child Behavior Checklist and the inventory of Subjective Life Quality for Child and Adolescents. The parents of both groups were also evaluated using the Symptom Checklist-90, the Hospital Anxiety and Depression Scale, and the Perceived Stress Scale. Psychological assessments were performed before expander implantation, before lesion resection, and after operation. Results indicated that children with LCMN were more prone to social problems, withdrawal, and aggressive behavior. Furthermore, their psychological problems increased after entering to school. Parents of children with LCMN had high levels of emotional problems and stress. Continuous expansion resulted in the psychosocial status of both children and parents to reach the worst levels during the period before lesion resection. Six months after surgery, most of these psychosocial effects reduced to levels lower than before surgery. Additionally, we identified several risk factors, namely sex, number of operations, being in education, employment status of mother, and family pressures. Large congenial melanocytic nevus on head and face have considerable psychological impact on children and their parents throughout the tissue expansion treatment. This study demonstrates the need for appropriate psychological screening and interventions.

Establishment of a Novel Mouse Model for Soft Tissue Expansion.

BACKGROUND: Despite its increasing use, not much is known about tissue expansion, and its complication rates are significantly high. Thus, there is an urgent need to establish a stable animal model to overcome the limitations and complications of tissue expansion. Although the mouse model has shown several advantages in the in-depth studies, an appropriate mouse expansion model has rarely been reported, likely because of its loose skin. MATERIALS AND METHODS: A micro expander was designed and implanted under the scalp of a mouse (expanded group); sterilized saline was regularly injected into the expander. In sham-operated mice (control group), a silicone sheet was implanted under the scalp. Skin samples were collected 5 wk after surgery. Histologic changes including epidermal and dermal thickness and collagen fiber arrangement were analyzed. In addition, vascular density and cell proliferation ratio were determined. An ultrastructural analysis was also performed. RESULTS: With the application of the expansion device, the skin became tight and showed area enlargement. The epidermal thickness of the expanded skin increased significantly (P < 0.01), whereas the thickness of the dermis decreased significantly (P < 0.05) as compared with the control skin. Masson staining demonstrated that collagen bundles were arranged more compactly in the expanded skin (P < 0.05) than in the controls. Furthermore, more proliferating cells (P < 0.05) and blood vessels (P < 0.01) were observed. Transmission electron microscopy showed that the fibers of expanded skin were stretched and broken into bundles of various diameters, with abundant active fibroblasts. CONCLUSIONS: A reliable mouse model of scalp skin expansion was successfully established, which may be a promising tool for in-depth studies on skin soft tissue expansion.

Safety and Efficacy of Smooth Surface Tissue Expander Breast Reconstruction.

BACKGROUND: Traditional 2-stage breast reconstruction involves placement of a textured-surface tissue expander (TTE). Recent studies have demonstrated textured surface devices have higher propensity for bacterial contamination and biofilm formation. OBJECTIVES: The purpose of this study was to evaluate the safety and efficacy of smooth surface tissue expanders (STE) in immediate breast reconstruction. METHODS: The authors retrospectively reviewed consecutive women who underwent STE breast reconstruction from 2016 to 2017 at 3 institutions. Indications and outcomes were evaluated. RESULTS: A total 112 patients underwent STE reconstruction (75 subpectoral, 37 prepectoral placement), receiving 173 devices and monitored for a mean follow-up of 14.1 months. Demographics of patients included average age of 53 years and average BMI of 27.2 kg/m2, and 18.6% received postmastectomy radiation therapy. Overall complication rates were 15.6% and included mastectomy skin flap necrosis (10.4%), seroma (5.2%), expander malposition (2.9%), and infection requiring intravenous antibiotic therapy (3.5%). Six (3.5%) unplanned reoperations with explantation were reported for 3 infections and 3 patients requesting change of plan with no reconstruction. CONCLUSIONS: STEs represent a safe and efficacious alternative to TTE breast reconstruction with at least equitable outcomes. Technique modification including tab fixation, strict pocket control, postoperative bra support, and suture choice may contribute to observed favorable outcomes and are reviewed. Early results for infection control and explantation rate are encouraging and warrant comparative evaluation for potential superiority over TTEs in a prospective randomized trial.

Long-term complications and reconstruction failures in previously radiated breast cancer patients receiving salvage mastectomy with autologous reconstruction or tissue expander/implant-based reconstruction.

Salvage mastectomy (SM) is the standard of care for patients with local recurrence (LR) after breast conservation therapy (BCT), often with immediate reconstruction. Complications of reconstruction are a concern for these patients, and long-term data are limited. We sought to compare rates of complications requiring re-operation (CRR) and reconstruction failure (RF) between autologous reconstruction (AR) and tissue expander/implant reconstruction (TE/I). Patients with locally recurrent breast cancer after BCT, treated with SM and immediate AR or TE/I between 2000 and 2008, were identified. CRR was defined as unplanned return to operating room for wound infection, dehiscence, necrosis (including flap, skin, or fat), hematoma, or hernia (for AR) and extrusion, leak, or capsular contracture (for TE/I). RF was defined as conversion to another reconstruction technique or to flat chest wall. This study included 103 patients with 107 reconstructions. Median follow-up was 6.6 years. CRR and RF were significantly higher with TE/I (n = 34) compared to AR (n = 73) at 5 years (50.9% vs 25.5%; P = 0.02) and (42.1% vs 5.8%; P < 0.001). On univariate analysis (UVA), TE/I (HR = 2.14; P = 0.02) and diabetes (HR = 5.10; P = 0.007) were significant predictors for CRR. On UVA, TE/I (HR = 7.30; P < 0.001) and older age at reconstruction (HR = 1.03; P = 0.003) were significant predictors for RF. In this population of previously irradiated patients, TE/I was associated with significantly higher CRR and RF. Complications continue to occur up to 10 years after TE/I. AR should be considered in appropriately selected patients, though TE/I may remain a reasonable option in patients without high-risk factors for surgical complications.

"No-Touch" Enhancement Significantly Reduces the Risk of Infection-Related Failure in Immediate Breast Reconstruction.

PURPOSE: Infection rates in prosthetic breast reconstruction after mastectomy vary widely, ranging from 1% to 35%, with meta-analyses reporting average infection rates of greater than 5%. This infection rate of greater than 5% is unfortunate for one of today's most commonly performed plastic surgical procedures. In an attempt to reduce infectious events, the author developed a "no-touch" protocol for performing breast reconstruction with tissue expanders and acellular dermis (ADM). This approach utilizes a transparent barrier drape and self-retaining retractor system patterned after similar orthopedic and urologic techniques that have proven to significantly reduce infection of implanted prostheses. Our preliminary results published in 2015 showed a significant improvement in infection rates. With this study, we assess the impact of the no-touch technique on a much larger number of patients. METHODS: Institutional review board approval was granted for a retrospective study of patients who underwent immediate breast reconstruction with tissue expanders and ADM from 2010 to 2017 by the author. Reconstructions prior to the institution of a no-touch protocol in 2014 were compared with those after the enhancement was instituted. A minimum of 60 days' follow-up was used to assess surgical complications. Demographic and outcome data were analyzed. RESULTS: Immediate breast reconstruction with tissue expanders and ADM was performed on 133 patients (217 breasts) from 2010 to 2017. Sixty-nine patients (113 breasts) underwent reconstruction from 2010 to 2014 utilizing the traditional technique, and 64 patients (104 breasts) underwent reconstruction from 2014 to 2017 using the new no-touch enhancement applied by the author. Patients in both groups had similar demographics and comorbidity profiles. The only other technique variable besides the addition of no-touch was the trend toward the use of larger sizes of ADM in the later group (164 vs 108 cm). The rate of infection-related reconstructive failure dropped from 11.5% (13/113) to 1.9% (2/104) (P = 0.0054) after institution of the no-touch protocol. CONCLUSIONS: Institution of a specific no-touch protocol to immediate breast reconstruction with tissue expanders and ADM lowered the risk of reconstructive failure due to infection 6-fold-11.5% to 1.9%. Comparative studies from other surgeons are encouraged.

Hemodynamic Assessment with SPY-Indocyanine Green Angiography in Expansion Period: A Study for Expansion Capsule Pressure Optimization.

Tissue expansion-related severe complication exists, and the poor blood supply is one of the causes. After decades of negative correlation between capsule pressure and blood flow was verified, the widely recognized expansion capsule pressure is still absent. A prospective randomized controlled trial was performed to explore the optimal expanding capsule pressure. Thirty subjects were randomly divided into 5 groups, received a weekly expanding on 60-, 70-, 80-, 90-, and 100-mm Hg capsule pressure, respectively. All patients achieved 8-week follow-up; hemodynamic assessment by SPY-indocyanine green (ICG) angiography was taken every 2 weeks. Standardized indexes from SPY-ICG angiography were used to assess the blood supply, in which the ratio of ingress rate and the ingress rate of normal skin (IR/NIR) reflects the arterial perfusion level, and the ratio of Engress Rate and IR (ER/IR) indicates the venous reflux level. The expansion-related adverse events during the trial were recorded. The IR/NIR and the ER/IR are both obviously negatively correlated to the capsule pressure of tissue expander (P ≤ 0.05, the ER/IR's correlation coefficient = -0.453; the IR/NIR's correlation coefficient = -0.482). The post-expansion IR/NIR increased significantly after 8 weeks of expansion (P ≤ 0.05) in 90-mm Hg group. And the post-expansion ER/IR was significantly elevated (P ≤ 0.05) in 80 and 90-mmHg groups. There were 2 expansion-related complications reported in 100-mm Hg group, whereas no complication occurred in 4 other lower groups. SPY-ICG angiography is an objective measurement for tissue expansion hemodynamic monitoring. The expanding capsule pressure of 80 to 90 mm Hg is a reasonable upper limit.

Radiation and depression associated with complications of tissue expander reconstruction.

PURPOSE: Rates of implant failure, wound healing delay, and infection are higher in patients having radiation therapy (RT) after tissue expander (TE) and permanent implant reconstruction. We investigated pretreatment risk factors for TE implant complications. PATIENTS AND METHODS: 127 breast cancer patients had TE reconstruction and radiation. For 85 cases of bilateral TE reconstruction, the non-irradiated breast provided an internal control. Comparison of differences in means for continuous variables used analysis of variance, then multiple pairwise comparisons with Bonferroni correction of p value. RESULTS: Mean age was 53 ± 10.1 years with 14.6% African-American. Twelve (9.4%) were BRCA positive (9 BRCA1, 4 BRCA2, 1 Both). Complications were: Grade 0 (no complication; 43.9%), Grade 1 (tightness and/or drifting of implant or Baker Grade II capsular contracture; 30.9%), Grade 2 (infection, hypertrophic scarring, or incisional necrosis; 9.8%), Grade 3 (Baker Grade III capsular contracture, wound dehiscence, or impending exposure of implant; 5.7%), Grade 4 (implant failure, exchange of implant, or Baker Grade IV capsular contracture; 9.8%). 15.3% (19 cases) experienced Grade 3 or 4 complication and 9.8% (12 cases) had Grade 4 complication. Considering non-irradiated breasts, there were two (1.6%) Grade 3-4 complications. For BMI, there was no significant difference by category as defined by the CDC (p = 0.91). Patients with depression were more likely to experience Grade 3 or 4 complication (29.4 vs 13.2%; p = 0.01). Using multiple logistic regression to predict the probability of a Grade 3 or 4 complications in patients with depression were found to be 4.2 times more likely to have a Grade 3 or 4 complication (OR = 4.2, p = 0.03). CONCLUSIONS: Higher rates of TE reconstruction complications are expected in patients receiving radiotherapy. An unexpected finding was that patients reporting medical history of depression showed statistically significant increase in complication rates.

Effect of Drain Placement on Infection, Seroma, and Return to Operating Room in Expander-Based Breast Reconstruction.

INTRODUCTION: There is significant variability in the location and management of drains in breast reconstruction, with most surgeons attempting to shorten the duration of drains while preventing complications possibly related to early removal. The aim of this work was to compare our experiences with placement of 1 versus 2 drains in tissue expander breast reconstruction. METHODS: This is a retrospective cohort study comparing 2 groups of patients after breast tissue expander placement in a complete submuscular pocket and without the use of acellular dermal matrix. In the first group, a single subcutaneous drain was placed; in the second group, both a subcutaneous and a submuscular drain were placed. These groups were evaluated on their relative duration of drain placement, incidence of seroma formation, incidence of infection, and rates of complication necessitating return to operating room (OR). RESULTS: The single-drain group was found to have a significantly shorter duration of drain placement (14.58 vs 22.84 days, P = < 0.01) as well as lower incidence of return to OR for complications after expander placement (8.3% vs 17.6%, P = 0.040), with no difference in rate of seroma formation (6.9% vs 14.7%, P = 0.114) or infection (1.4% in the single-drain group vs 8.8% in the 2-drain group, P = 0.054). CONCLUSIONS: Compared with a two-drain approach, a single subcutaneous drain yields shorter total duration of drain placement and lower rate of complications requiring return to OR while not resulting in higher rates of seroma or infection. It has become our standard approach to use a single subcutaneous drain in patients having a breast tissue expander placed in a submuscular pocket.

Complications of Post-Burn Tissue Expansion Reconstruction: 9 Years Experience with 42 Pediatric and 26 Adult Patients.

BACKGROUND: Burn scar reconstruction is extremely challenging, even for the most proficient reconstructive surgeon. Within the arsenal of tools at the plastic surgeon's disposal, tissue expansion provides an efficient modality for reconstruction despite the reported complication rates. OBJECTIVES: To critically review our experience with tissue expansion for burn scar reconstruction, comparing particularly the adult and pediatric populations. METHODS: We conducted a retrospective study of the outcomes of patients who underwent burn scar reconstruction with tissue expansion at Hadassah Medical Center between January 2003 and July 2012. The data included patient age, anatomical site of expansion, number of procedures, and associated complications. The outcomes of the above-mentioned populations were also compared with those in a control group of patients undergoing reconstruction with tissue expansion for indications other than burn scars. RESULTS: Sixty-seven tissue expansion procedures were carried out in 50 patients, 42 in the pediatric population (< 16 years of age) and 25 in the adult population. Complications were observed in 10 of the 42 pediatric procedures (23.8%) and in 3 of the 25 adult procedures (12%). This difference was found to be statistically significant. When the complication rate for each population was compared to its control group (tissue expansion for indications other than burn scar reconstruction, such as reconstruction for motor vehicle accident scarring, congenital nevi, or vascular malformations), no statistically significant difference was found between them (complication rates 19.8% and 12.5%, respectively). Furthermore, there was no statistically significant difference in complication rates between the different anatomical areas of expansion within both populations undergoing burn scar reconstruction. Most of the complicated cases completed successful reconstruction. CONCLUSIONS: Tissue expansion is a useful surgical tool in post-burn scar reconstruction, both in the adult and pediatric populations and in all anatomic sites, despite consistently high complication rates, especially in the pediatric population. This complication rate is not higher than in patients undergoing tissue expansion for indications other than burn scar reconstruction.

Transition from Round to Shaped Implants in Immediate Breast Reconstruction: Our Preferred Approach and Clinical Outcomes.

BACKGROUND: Smooth, round, silicone implants predominate device-based breast reconstruction in the USA; despite their prevalence, complications can include bottoming out, superior contour deformity, rippling, and/or lateral malposition. This complication profile increases the need for revision surgery and subsequent patient dissatisfaction. With the resurgence of shaped, textured, silicone implants in the USA, we report the senior author's success with these devices and outline a strategy to optimize outcomes in breast reconstruction surgery. METHODS: A retrospective chart review was conducted on a prospectively collected IRB-approved database of nipple-sparing mastectomies (NSMs) with immediate breast reconstruction with smooth, round, silicone implants (Group A) in 2011 in comparison to textured, shaped, silicone implants (Group B) in 2012. Changes in operative technique were highlighted and extrapolated. Outcomes were reviewed. RESULTS: In Group A, 128 NSMs were performed in 76 patients. In Group B, 109 NSMs were performed in 59 patients. Thirteen percent of patients in Group A had direct to implant reconstruction as compared with 21% in Group B. Patients with textured, shaped implants were more likely to have acellular dermal matrix (61 vs 34%, p < 0.0001) than those with smooth, round implants. Patients who had smooth, round implants were more likely to have postoperative nipple malposition (18 vs 0%, p < 0.0001,) and rippling (29 vs 0%, p < 0.0001.) Patients with textured, shaped implants had fewer operative revision reconstructions as compared with those with smooth, round implants (36.71 vs 12.8%, p < 0.0001) Based on these results, our technique has evolved and has eight key technical modifications. CONCLUSION: With a few adaptations in surgical technique, the transition to textured, shaped, silicone devices for breast reconstruction can be seamless with superior breast contour and reduced complications/revision rates. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Impact of Acellular Dermal Matrix (ADM) Use Under Mastectomy Flap Necrosis on Perioperative Outcomes of Prosthetic Breast Reconstruction.

BACKGROUND: There is conflicting data on the potential necrotic complications of acellular dermal matrix (ADM) use in breast reconstruction, and most studies focus on mastectomy flap necrosis as an outcome measure associated with ADM use. The aim of this study was to examine cases with necrotic complications with and without the use of ADM and to investigate whether ADM affected perioperative outcomes in cases with necrotic complications. METHODS: Patients who experienced mastectomy flap necrosis following mastectomy with tissue expander placement between January 2009 and March 2015 were retrospectively reviewed. The primary outcome was explantation of the expander, and other associated outcomes such as seroma or infection were also recorded. RESULTS: A total of 57 breasts with mastectomy flap necrosis were identified: 32 of which were in the non-ADM group and 25 in the ADM group. The rate of explantation was 28% (7/25) in the ADM group versus 6.3% (2/32) in the non-ADM group, which was significantly different (P = 0.034). The ADM group had a significantly higher rate of "major" infection requiring surgical debridement than the non-ADM group (P = 0.016). Multivariate analysis showed that the use of ADM was trending toward an increasing expander rate with borderline significance (P = 0.05). CONCLUSION: This study demonstrated that ADM use under mastectomy flap necrosis was a potential risk for explantation of the expander and major infection. Surgeons should be cautious with the use of ADM with devascularized mastectomy skin flaps prone to necrosis. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Becker Expander-Based Breast Reconstruction Following Wise Pattern Skin-Reducing Mastectomy: Complication Rates and Risk Factors.

Our aim is to analyze the results of immediate breast reconstruction in women with macromastia after skin-reducing mastectomy (SRM), with an emphasis on complications and risk factors. Between 2008 and 2013, fifty women with hypertrophic breasts, aged 21-74 years, underwent immediate expander-based breast reconstruction after Wise pattern SRM. An inferiorly based de-epithelialized skin flap was sutured to the inferolateral border of the pectoralis major muscle and covered the expander. Thirty-five women had a unilateral and fifteen a bilateral procedure (total 65 breasts). In all cases, Becker-35 expanders of volume ranging from 365 to 685 cc were used. Risk factors (BMI, smoking, expander's size, preoperative irradiation, chemotherapy) and complications were recorded. Follow-up up to 60 months was compiled. In all cases, the myodermal pouch provided safe coverage and support of the expander. Postoperative complications occurred in 18 out of 65 breasts (27.6%) and included skin ischemia in 11 breasts (16.9%), late infection in two (3%), seroma and expander rotation in four and one, respectively (6.1 and 1.5%), and severe peri-prosthetical contraction in five breasts (7.6%). Statistical analysis showed that complications were significantly related to preoperative radiotherapy and smoking; no significant correlation was documented between complication rates and chemotherapy, BMI, age or expander's size. We suggest that the inverted-T SRM, creating a combined "myodermal" flap for the coverage of a Becker expander, is a useful single-stage reconstructive option for patients with macromastia. Preoperative radiotherapy is significantly related to higher postoperative complication rates, and may result in a less optimal reconstructive outcome. Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Tissue Expansion Using Hyaluronic Acid Filler for Single-Stage Ear Reconstruction: A Novel Concept for Difficult Areas.

BACKGROUND: Auricular reconstruction is one of the most challenging procedures in plastic surgery. An adequate skin envelope is essential for cartilage framework coverage, yet few good options exist without additional surgery. We propose a novel method for minimally invasive tissue expansion, using hyaluronic acid (HA) filler to allow for single-stage ear reconstruction. OBJECTIVES: To introduce the novel concept of HA filler for tissue expansion in ear reconstruction, and as an alternative to traditional expansion techniques. METHODS: Macrolane is a large particle HA gel developed for large volume restoration. Expansion of the non-hair-bearing mastoid skin was performed in our clinic weekly or every other week. Final expansion was completed one week prior to reconstructive surgery. Tissue from one patient's expanded pocket was sent for histological analysis. RESULTS: Ten patients underwent single-stage auricular reconstruction with preoperative expansion. Injection sessions ranged from 7 to 13 (mean, 9.7). Mean injected volume per session was 2.03 mL per patient, for an average total of 19.8 mL (range, 14.5-30 mL). There were no major complications. One minor complication required removal of exposed wire from the antihelix in the office. Hematoxylin and eosin stain revealed similar histology to that seen with traditional expanders. CONCLUSIONS: This novel expansion technique using serial HA injections allowed for optimized skin coverage in single-stage ear reconstruction. The concept of tissue expansion using HA filler is a new frontier for research that may be applicable to other arenas of reconstruction. LEVEL OF EVIDENCE: 4.