Optimal Timing of Delayed Microvascular Breast Reconstruction after Radiation Therapy.

BACKGROUND: The purpose of this study was to determine the optimal timing of delayed microvascular breast reconstruction after completion of postmastectomy radiation therapy (PMRT). The authors evaluated whether the timing of reconstruction after PMRT completion affects the development of major postoperative complications. We hypothesize that delayed microvascular breast reconstruction can be safely performed within 12 months of PMRT completion. METHODS: A retrospective chart review of microvascular, autologous breast reconstructions at Brigham and Women's Hospital from 2007 to 2019 was performed. Logistic regression analysis and marginal estimation methods were used to estimate the probability of any major complication (flap compromise requiring operative intervention, hematoma formation requiring evacuation, infection requiring readmission, and flap necrosis requiring operative debridement) occurring in 2-month intervals after PMRT. Patients were classified as having undergone reconstruction 0 to 12 months after PMRT (group 1), 12 to 18 months after PMRT (group 2), or 18 to 50 months after PMRT (group 3). RESULTS: A total of 303 patients were identified. All patients received postmastectomy radiation (n = 143 group 1, n = 57 group 2, n = 103 group 3). Mean follow-up time was 71.4 ± 38 months. Patients in group 1 were significantly younger and more likely to have undergone neoadjuvant chemotherapy (p < 0.05). Major complications occurred in 10% of patients. There was no significant difference in the development of major complications between the three groups (p = 0.57). Although not statistically significant, the probability of any major complication peaked 2 to 6 months after PMRT completion. CONCLUSION: There was no significant difference in major complications among patients who underwent delayed, microvascular breast reconstruction within versus beyond 1 year of PMRT completion. These findings suggest that delayed microvascular breast reconstruction can be safely performed beginning 6 months after PMRT completion.

Three patients with full facial transplantation.

Unlike conventional reconstruction, facial transplantation seeks to correct severe deformities in a single operation. We report on three patients who received full-face transplants at our institution in 2011 in operations that aimed for functional restoration by coaptation of all main available motor and sensory nerves. We enumerate the technical challenges and postoperative complications and their management, including single episodes of acute rejection in two patients. At 6 months of follow-up, all facial allografts were surviving, facial appearance and function were improved, and glucocorticoids were successfully withdrawn in all patients.

Left Internal Mammary Vein Size and Its Impact on Microsurgical Breast Reconstruction.

The internal mammary vessels are the preferred recipient during free-flap breast reconstruction (FFBR). Previous studies have demonstrated that the left internal mammary vein (IMV) is consistently smaller than the right, but with unclear clinical implications. This study explores the impact of IMV size difference on FFBR complication rates. Methods: Abdominal-based FFBRs were retrospectively reviewed. Venous coupler size was considered a proxy for IMV diameter. Outcomes of three patient cohorts (all, unilateral, and bilateral reconstructions) were analyzed with univariate and multivariate analysis. Results: Our cohort consisted of 582 patients who underwent 874 abdominal-based FFBR, with a similar number of unilateral (n = 290) and bilateral (n = 292), and right (n = 424) and left (n = 450) reconstructions. Mean follow-up was over 4-years. For all reconstructions, the left IMV (2.7 ± 0.4 mm) was smaller than the right (3.0 ± 0.4 mm) (P < 0.0001). Complication rates between left- and right-sided FFBR were similar, but with a trend toward increased fat necrosis on the left (n = 17, 3.8% versus n = 8, 1.9%). Further subgroup analysis showed significantly higher fat necrosis in unilateral left-sided FFBR (n = 12 versus n = 2, P = 0.02), with left-sided FFBR being an independent risk factor for fat necrosis on multivariate analysis. Conclusions: The left-side IMV is significantly smaller than the right IMV. In bilateral reconstructions, the smaller size of the left IMV did not result in a greater risk of complications; however, in unilateral FFBR, fat necrosis was significantly higher on the left side.

Metastatic breast cancer after delayed deep inferior epigastric perforator flap reconstruction.

Locoregional breast cancer recurrence is a relatively rare event, occurring more frequently in patients diagnosed with more advanced stages of cancer and those with inflammatory features. While typical signs of recurrence after reconstruction include the development of a mass in the native skin or deep chest wall, oncologic relapse may also rarely be heralded by subtle cutaneous changes. This article describes a patient with inflammatory breast cancer who underwent neoadjuvant chemotherapy, mastectomy, radiation therapy, and hormonal therapy followed by delayed reconstruction with a deep inferior epigastric artery perforator flap and subsequently presented with a recurrence manifest as a localized rash over the upper abdomen. Surgeons who perform breast reconstruction should be attuned to both common and uncommon recurrence symptoms, as they may be the first to diagnose recrudescent disease.

Pyoderma gangrenosum following bilateral deep inferior epigastric perforator flap breast reconstruction.

Pyoderma gangrenosum (PG) is a relatively rare condition of ulcerative cutaneous dermatosis. Usually seen in the setting of systemic inflammatory disease, PG can be difficult to distinguish from infection. We present a case of an otherwise healthy 37-year-old woman, a BRCA-1 gene mutation carrier, who was evaluated several months after bilateral mastectomies with deep inferior epigastric perforator (DIEP) flap breast reconstruction with open wounds on the right DIEP flap. Multiple interventions were employed without success. As the disease progressed, the patient eventually developed new open wounds on the left DIEP flap as well. Ultimately, rigorous dermatopathology evaluation revealed PG, and the patient was treated appropriately with a high-dose prednisone course. The wounds healed completely, and despite significant cutaneous scarring, the breast reconstructions were salvaged. There was no fat necrosis within the DIEP flap tissue itself. PG should be considered in the differential diagnosis of chronic nonhealing cutaneous ulcers following surgical intervention that do not respond to standard initial care.

Genetic Testing for Breast Cancer Susceptibility Should Be Offered before Unilateral Abdominally Based Free Flap Breast Reconstruction.

BACKGROUND: Pathogenic mutations have been identified in approximately 10 percent of patients who present with breast cancer. Notably, failure to identify deleterious genetic mutations has particular implications for patients undergoing abdominally based breast reconstruction, as the donor site can be used only once. The authors sought to determine: (1) how many patients underwent genetic testing before unilateral abdominally based free flap breast reconstruction; (2) how often deleterious mutations were detected after abdominally based free flap breast reconstruction; and (3) the cost-effectiveness of expanding genetic testing in this patient population. METHODS: The authors retrospectively identified all patients who underwent unilateral abdominally based free flap breast reconstruction at Brigham and Women's Hospital/Dana-Farber Cancer Institute between 2007 and 2016. Chart review was performed to collect relevant demographic and clinical data. Relevant hospital financial data were obtained. RESULTS: Of the 713 who underwent free flap breast reconstruction, 160 patients met inclusion criteria, and mean follow-up was 5.8 years. Three patients (1.9 percent of 160) underwent contralateral surgery after completing reconstruction, two of whom had BRCA2 and one with ATM mutation. One hundred eleven patients met National Comprehensive Cancer Network guidelines for genetic testing, but of those only 55.9 percent (62 patients) were tested. Financial data revealed that testing every patient in the cohort would result in a net savings of $262,000. CONCLUSIONS: During a relatively short follow-up period, a small percentage of patients were diagnosed with pathogenic mutations and underwent contralateral mastectomy and reconstruction. However, because of the costliness of surgery and the decreased cost of genetic testing, it is cost-effective to test every patient before unilateral abdominally based free flap breast reconstruction.

Regeneration in medicine: a plastic surgeons "tail" of disease, stem cells, and a possible future.

Regeneration in medicine is a concept that has roots dating back to the earliest known records of medical interventions. Unfortunately, its elusive promise has still yet to become a reality. In the field of plastic surgery, we use the common tools of the surgeon grounded in basic operative principles to achieve the present day equivalent of regenerative medicine. These reconstructive efforts involve a broad range of clinical deformities, both congenital and acquired. Outlined in this review are comments on clinical conditions and the current limitations to reconstruct these clinical entities in the effort to practice regenerative medicine. Cleft lip, microtia, breast reconstruction, and burn reconstruction have been selected as examples to demonstrate the incredible spectrum and diverse challenges that plastic surgeons attempt to reconstruct. However, on a molecular level, these vastly different clinical scenarios can be unified with basic understanding of development, alloplastic integration, wound healing, cell-cell, and cell-matrix interactions. The themes of current and future molecular efforts involve coalescing approaches to recapitulate normal development in clinical scenarios when reconstruction is needed. It will be a better understanding of stem cells, scaffolding, and signaling with extracellular matrix interactions that will make this future possible. Eventually, reconstructive challenge will utilize more than the current instruments of surgical steel but engage complex interventions at the molecular level to sculpt true regeneration. Immense amounts of research are still needed but there is promise in the exploding fields of tissue engineering and stem cell biology that hint at great opportunities to improve the lives of our patients.

Ultrasound-assisted liposuction as a treatment of fat necrosis after deep inferior epigastric perforator flap breast reconstruction: a case report.

A single case is reported utilizing ultrasound-assisted liposuction (UAL) to treat fat necrosis after deep inferior epigastric artery perforator flap breast reconstruction. UAL treatment resulted in softening of the fibrous fat necrotic areas, while maintaining acceptable breast contour. UAL is safer and less invasive than traditional treatments for fat necrosis including direct excision and suction-assisted liposuction.

Selective Intraoperative Vasopressor Use Is Not Associated with Increased Risk of DIEP Flap Complications.

BACKGROUND: During deep inferior epigastric perforator (DIEP) flap cases, anesthesiologists commonly avoid intravenous vasopressor administration because of the theoretical concern of inducing vasospasm, thrombosis, or congestion in the vessels of the anastomosis, potentially resulting in poor flap perfusion and ischemia and necessitating revision. In the setting of hypotension, however, vasopressor administration may actually improve outcomes by augmenting flap perfusion by means of increased mean arterial pressure. METHODS: The authors reviewed 475 consecutive DIEP flap cases in 333 patients at a single large academic medical center over a 3-year period, addressing potential confounders using univariate analyses. RESULTS: Ephedrine administration was significantly associated with decreased risk of intraoperative flap complications (OR, 0.88), including vasospasm, thrombosis, and congestion requiring revision, compared with controls, after controlling for the severity and duration of hypotension. Phenylephrine had no significant association with complication rates. Vasopressor administration was not associated with an increased risk of reoperation in the setting of necrosis within 60 days. CONCLUSIONS: Ephedrine treatment for hypotension during DIEP flap cases is associated with decreased intraoperative flap complication rates compared with controls who did not receive vasopressors, whereas phenylephrine has no significant association. The common clinical practice of complete abstinence from vasopressors out of concern for worsening DIEP flap outcomes is not supported by this study. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Bilateral Free Flap Breast Reconstruction Outcomes: Do Abdominal Scars Affect Bilateral Flaps?

BACKGROUND: The incidence of bilateral mastectomies is increasing along with the rates of breast reconstructions. A substantial number of patients will present with abdominal scars after Cesarean section, laparoscopy, laparotomy, and so on. The aim of this study was to evaluate the impact of prior abdominal scars on complication rates in abdominal bilateral free flap breast reconstruction. METHODS: All consecutive patients with autologous free flap breast reconstruction between 2007 and 2014 were eligible. The relevant demographic and clinical data were prospectively collected into a study-specific database. Complications and reoperations were prospectively registered after postoperative outpatient visits. RESULTS: Overall, 493 patients underwent abdominally based breast reconstruction during the study period: unilateral (n = 250; 50.7%) or bilateral (n = 243; 49.3%). In the bilateral group, the abdominal scar locations were Pfannenstiel (n = 73; 30.1%), midline (n = 16; 6.6%), lower oblique (n = 17; 7.0%), upper oblique (n = 5; 2.1%), and laparoscopic (n = 69; 28.4%). Four (1.7%) flap failures (including 1 converted to a pedicled transverse rectus abdominis flap) were registered, all occurring in patients from the scar group: 3 with Pfannenstiel incision and 1 patient with prior laparoscopy. Pfannenstiel scar was associated with higher risk of hematoma at the recipient site when compared with no scar group (13.7% versus 2.2%; P = 0.006). Partial flap necrosis, infection, and seroma occurred in 14 (5.9%), 8 (3.4%), and 5 (2.1%) patients, respectively, and no differences between the scar groups were identified. CONCLUSION: Surgical outcomes of bilateral reconstructions in patients with abdominal scars are generally comparable with ones in patients without prior surgery; however, some problems have been identified. These procedures might have some intraoperative considerations and often require increased operative times. Apart from the traditional preoperative computed tomography angiography, intraoperative imaging (e.g., fluorescence angiography) may be advocated in patients with abdominal scars.

Evidence-Based Clinical Practice Guideline: Autologous Breast Reconstruction with DIEP or Pedicled TRAM Abdominal Flaps.

The American Society of Plastic Surgeons commissioned a multistakeholder Work Group to develop recommendations for autologous breast reconstruction with abdominal flaps. A systematic literature review was performed and a stringent appraisal process was used to rate the quality of relevant scientific research. The Work Group assigned to draft this guideline was unable to find evidence of superiority of one technique over the other (deep inferior epigastric perforator versus pedicled transverse rectus abdominis musculocutaneous flap) in autologous tissue reconstruction of the breast after mastectomy. Presently, based on the evidence reported here, the Work Group recommends that surgeons contemplating breast reconstruction on their next patient consider the following: the patient's preferences and risk factors, the setting in which the surgeon works (academic versus community practice), resources available, the evidence shown in this guideline, and, equally important, the surgeon's technical expertise. Although theoretical superiority of one technique may exist, this remains to be reported in the literature, and future methodologically robust studies are needed.

Anticoagulants and Statins As Pharmacological Agents in Free Flap Surgery: Current Rationale.

Microvascular free flaps are key components of reconstructive surgery, but despite their common use and usual reliability, flap failures still occur. Many pharmacological agents have been utilized to minimize risk of flap failure caused by thrombosis. However, the challenge of most antithrombotic therapy lies in providing patients with optimal antithrombotic prophylaxis without adverse bleeding effects. There is a limited but growing body of evidence suggesting that the vasoprotective and anti-inflammatory actions of statins can be beneficial for free flap survival. By inhibiting mevalonic acid, the downstream effects of statins include reduction of inflammation, reduced thrombogenicity, and improved vasodilation. This review provides a summary of the pathophysiology of thrombus formation and the current evidence of anticoagulation practices with aspirin, heparin, and dextran. In addition, the potential benefits of statins in the perioperative management of free flaps are highlighted.

Reconstruction of Areolar Projection Using a Purse-String Suture Technique.

BACKGROUND: Nipple-areolar complex creation is the last step in the breast reconstruction process and plays a significant role in patients' overall satisfaction. Although numerous surgical techniques have been described to create the nipple, very few procedures address the natural contour of the areola. METHODS: We describe a surgical technique using a purse-string suture for improved areolar projection. After creation of nipple-areolar complex using a CV flap, evenly spaced stab incisions are made in a circular pattern, approximately 5 mm outside of the boundary of the proposed areola. Using these incisions, a nonabsorbable purse-string suture is placed in the deep dermis. The diameter is cinched down to the desired measurement, providing areolar projection. RESULTS: Our experience using this technique has provided a satisfactory and stable projection of the areola in 10 patients with at least 1 year follow-up for each patient. There was no spitting of purse-string sutures in any of these patients, and there was no late areolar widening after at least 1 year follow-up. This provides a means for symmetry with an unreconstructed contralateral side. CONCLUSIONS: Improving aesthetic outcomes for areola reconstruction may further refine our goals of an ideal breast reconstruction.

Saved by De-epithelialization: DIEP Flap Dermal Skin Regeneration Salvage after Mastectomy Skin Flap Loss.

BACKGROUND: Wound re-epithelialization has been traditionally described to occur from the dermal appendages of the wound edges. As such, the role of the dermal wound bed in re-epithelialization has been questioned. In a patient undergoing breast reconstruction with free tissue transfer, the buried portions of the free flap skin paddle could be either de-epithelialized or deskinned. In case of mastectomy skin flap loss, the role of de-epithelialized skin in wound healing has not been described before. METHODS: We report a patient with bilateral mastectomies and bilateral deep inferior epigastric perforator flaps whose postoperative course was complicated by bilateral full-thickness mastectomy skin flap loss. Multiple debridements of nonviable skin resulted in exposure of previously buried de-epithelialized skin paddle of the deep inferior epigastric perforator flap. RESULTS: Our study demonstrates self re-epithelialization of the dermal wound bed from the dermal appendages. We noticed multiple noncontiguous neoepidermal islands in the dermal wound bed, which did not communicate with the wound edges. CONCLUSIONS: In case of full-thickness mastectomy skin flap loss, deep vascular plexus present in the dermal bed of the underlying de-epithelialized skin paddle of the free flap converts an otherwise full-thickness wound to a partial-thickness wound. Our study demonstrates the self-epithelialization potential of the de-epithelialized dermal wound bed from the dermal appendages when exposed to air and in the presence of wound healing elements.

Use of Tumescence for Outpatient Abdominoplasty and Other Concurrent Body Contouring Procedures: A Review of 65 Consecutive Patients.

INTRODUCTION: Abdominoplasty is being increasingly performed as an outpatient procedure. The role of tumescent technique in decreasing postoperative pain and hospital stay has not been extensively studied. METHODS: We reviewed 65 consecutive patients who underwent tumescent abdominoplasty over 20 months by a single surgeon. All the patients were followed up for at least 1 year. The outcomes were evaluated in terms of systemic complications such as deep vein thrombosis and pulmonary embolism and local complications such as seroma, wound infection, and skin necrosis. RESULTS: Of the 65 patient records analyzed, 61 were of females and 4 of males. Average age for the patient population was 45.2 years. Mean follow-up was at least 1 year for all the patients. Ninety-five percent of patients could be discharged the same day with tumescent abdominoplasty, whereas 71% of the patients who underwent concurrent procedures with abdominoplasty were also able to go home the same day. All the patients reported excellent postoperative pain control. There was no report of deep vein thrombosis or pulmonary embolism in any of these patients. Wound complications occurred in 14 patients (21.6%), of which 12 patients had seroma (18.5%) and 2 had wound infection (3.1%). The seromas were treated with repeated aspirations or Jackson-Pratt drain placement, whereas the wound infections resolved with outpatient antibiotics. CONCLUSIONS: The safety and efficiency of outpatient abdominoplasty can be further facilitated by utilizing tumescence. Tumescence helps the patients be discharged sooner, usually the same day, mobilize sooner, and rely less on oral narcotics at home.

Skin Excision as an Adjunctive Technique to Rhinoplasty in Middle-Aged and Elderly Patients.

Rhinoplasty in middle-aged and elderly patients comes with its own set of challenges. There is relative lengthening of the nose with drooping of the nasal tip. With aging, the skin loses its elasticity, and the combination of nasal skeletal reduction along with overlying inelastic skin provides a setup for skin redundancy and poor postoperative outcome. We describe a surgical technique involving lenticular skin excision as a part of rhinoplasty in 12 patients older than 50 years to improve the aesthetic outcome. Skin width up to 1.6 cm was excised. Included is a literature review of skin excision in rhinoplasty. In elderly patients with thin, inelastic skin and long nose with a drooping tip, a reduction rhinoplasty technique might result in skin redundancy. Lenticular skin excision along the radix of the nose in these 12 patients improved the aesthetic outcome by decreasing the redundancy and preventing nasal tip ptosis. The wound from the skin resection healed in all the patients with minimal scar, and no complication was noted after at least 1 year of follow-up for each patient.

Development of Standardized Clinical Assessment and Management Plans (SCAMPs) in Plastic and Reconstructive Surgery.

BACKGROUND: With rising cost of healthcare, there is an urgent need for developing effective and economical streamlined care. In clinical situations with limited data or conflicting evidence-based data, there is significant institutional and individual practice variation. Quality improvement with the use of Standardized Clinical Assessment and Management Plans (SCAMPs) might be beneficial in such scenarios. The SCAMPs method has never before been reported to be utilized in plastic surgery. METHODS: The topic of immediate breast reconstruction was identified as a possible SCAMPs project. The initial stages of SCAMPs development, including planning and implementation, were entered. The SCAMP Champion, along with the SCAMPs support team, developed targeted data statements. The SCAMP was then written and a decision-tree algorithm was built. Buy-in was obtained from the Division of Plastic Surgery and a SCAMPs data form was generated to collect data. RESULTS: Decisions pertaining to "immediate implant-based breast reconstruction" were approved as an acceptable topic for SCAMPs development. Nine targeted data statements were made based on the clinical decision points within the SCAMP. The SCAMP algorithm, and the SDF, required multiple revisions. Ultimately, the SCAMP was effectively implemented with multiple iterations in data collection. CONCLUSIONS: Full execution of the SCAMP may allow better-defined selection criteria for this complex patient population. Deviations from the SCAMP may allow for improvement of the SCAMP and facilitate consensus within the Division. Iterative and adaptive quality improvement utilizing SCAMPs creates an opportunity to reduce cost by improving knowledge about best practice.

Evolving options for breast reconstruction.

In summary, if the abdomen cannot be used for a donor site, alternative flap selection is based on individual patient anatomy and body habitus, targeting the buttocks and upper thigh. Intraoperative repositioning may be required for ease in flap harvest and donor site closure, adding time to the procedure. Flap dissection is performed in the subfascial plane to avoid injury to the perforator vessels. Deep suspension sutures may be required to maintain the gluteal fold location.

Why we are here: early reflections on the role of reconstructive plastic surgery in the 2013 Boston marathon bombings.

The 2013 Boston Marathon bombings resulted in a large and unexpected influx of patients requiring acute multidisciplinary surgical care. The authors describe the surgical management experience of these patients at Brigham & Women's Hospital and Brigham & Women's Faulkner Hospital, with a particular focus on the important role played by reconstructive plastic surgery. The authors suggest that this experience illustrates the value of reconstructive plastic surgery in the treatment of these patients specifically and of trauma patients in general, and argue for the increasing importance of promoting our identity as a specialty.

Functional MRI to evaluate "sense of self" following perforator flap breast reconstruction.

BACKGROUND: Breast reconstruction is associated with high levels of patient satisfaction. Previous patient satisfaction studies have been subjective. This study utilizes functional magnetic resonance imaging (fMRI) to objectively evaluate "sense of self" following deep inferior epigastric perforator (DIEP) flap breast reconstruction in an attempt to better understand patient perception. METHODS: Prospective fMRI analysis was performed on four patients before and after delayed unilateral DIEP flap breast reconstruction, and on four patients after immediate unilateral DIEP flap breast reconstruction. Patients were randomly cued to palpate their natural breast, mastectomy site or breast reconstruction, and external silicone models. Three regions of interest (ROIs) associated with self-recognition were examined using a general linear model, and compared using a fixed effects and random effects ANOVA, respectively. RESULTS: In the delayed reconstruction group, activation of the ROIs was significantly lower at the mastectomy site compared to the natural breast (p<0.01). Ten months following reconstruction, activation of the ROIs in the reconstructed breast was not significantly different from that observed with natural breast palpation. In the immediate reconstruction group, palpation of the reconstructed breast was also similar to the natural breast. This activity was greater than that observed during palpation of external artificial models (p<0.01). CONCLUSIONS: Similar activation patterns were observed during palpation of the reconstructed and natural breasts as compared to the non-reconstructed mastectomy site and artificial models. The cognitive process represented by this pattern may be a mechanism by which breast reconstruction improves self-perception, and thus patient satisfaction following mastectomy.