Impact of Radiation on Implant-Based Breast Reconstruction in Prepectoral Versus Submuscular Planes.

BACKGROUND: Postmastectomy implant-based breast reconstruction (IBR) in the setting of radiation (XRT) comes with a high risk of perioperative complications regardless of reconstruction method. The aim of study was to identify the effects of XRT on IBR using a prepectoral versus submuscular approach. METHODS: A retrospective chart review was performed after institutional review board approval was obtained. Patients at a single institution who had 2-stage IBR from June 2012 to August 2019 were included. Patients were separated into 4 groups: prepectoral with XRT (group 1), prepectoral without XRT (group 2), submuscular with XRT (group 3), and submuscular without XRT (group 4). Patient demographics, comorbidities, and postoperative complications were recorded and analyzed. RESULTS: Three hundred eighty-seven breasts among 213 patients underwent 2-stage IBR. The average age and body mass index were 50.10 years and 29.10 kg/m2, respectively. One hundred nine breasts underwent prepectoral reconstruction (44 in group 1, 65 in group 2), and 278 breasts underwent submuscular reconstruction (141 in group 3, 137 in group 4). Prepectoral tissue expander placement was associated with higher complication rates in the radiated group (38.6% compared with 34.0% submuscular) and lower complication rates in the nonradiated group (26.2% compared with 29.2% submuscular), although significantly less explants were performed in prepectoral group, regardless of XRT status. The 3 most common complications overall were contracture (15.1% radiated, 10.4% nonradiated), infection (18.4% radiated, 11.9% nonradiated), and seroma (15.7% radiated, 10.9% nonradiated). CONCLUSIONS: Two-stage, prepectoral tissue expander placement performs clinically better than submuscular in nonradiated patients compared with radiated patients; however, no statistical significance was identified. Prepectoral had a significantly less incidence of reconstructive failure than submuscular placement regardless of XRT status. Future larger-scale studies are needed to determine statistically significant difference in surgical approach.

Ketorolac and Hematoma Incidence in Postmastectomy Implant-Based Breast Reconstruction.

BACKGROUND: Ketorolac tromethamine (Toradol) is an effective a nonsteroidal anti-inflammatory drug and a powerful analgesic for patients undergoing breast surgery. However, the potential for postoperative bleeding has not yet been explored specifically in women undergoing implant-based breast reconstruction. There is concern that an increased risk of bleeding exists in this population due to the lack of tissue apposition as a result of implant placement. We therefore seek to assess the associated risk of bleeding complication in implant-based breast reconstruction at our academic institution. To the best of our knowledge, this represents the first case series addressing safety profile of Toradol specifically in patients undergoing nonautologous, implant-based breast reconstruction. METHODS/RESULTS: A single-center, retrospective review was performed analyzing our institutional experience with Toradol in nonautologous, implant-based breast reconstruction following mastectomy. A prospective database of 522 patients collected between 2008 and 2013 was analyzed. Within the database, 57 patients who received intraoperative ketorolac were identified among a total of 180 patients undergoing prosthetic reconstruction. No statistically significant difference was found in the incidence of clinically relevant hematoma formation between the control and Toradol groups. The frequency of hematoma formation in the control was 0.09 (11/123 patients, 95% confidence interval = 0.05-0.15) and 0.04 in the Toradol group (2/57 patients, 95% confidence interval = 0.01-0.12), resulting in a P value of 0.32. Regarding the secondary outcomes, we did not detect a statistically significant difference in the total number of complications or length of hospital stay in the Toradol and control groups. CONCLUSIONS: Review of our breast reconstruction database did not find a trend toward an elevated incidence of hematoma associated with intraoperative Toradol use in implant-based postmastectomy reconstruction.

Robotic-assisted deep inferior epigastric artery perforator flap abdominal harvest for breast reconstruction: A case report.

The deep inferior epigastric perforator (DIEP) flap is a mainstay of autologous breast reconstruction. The da Vinci robot has recently been adapted for an increasing number of reconstructive surgeries. The literature has yet to describe its use for the intra-abdominal harvest of the deep inferior epigastric vessels (DIEV) during DIEP flap breast reconstruction. We show the use of the da Vinci robotic surgical system for the intra-abdominal dissection of DIEV during delayed breast reconstruction with a DIEP flap in a 51-year-old female who had undergone a right modified radical mastectomy. After dissecting the flap from the anterior abdominal wall leaving only the targeted perforating vessels intact, a 1.5 cm fascial incision was made adjacent to the perforator and the vessels were dissected to below the level of the fascia. The intra-abdominal robotic-assisted dissection of the DIEV up to the perforator was then completed. The DIEV were divided at their origin using the robot and the flap removed from the abdomen for subsequent reconstruction. This technique enabled improved precision of flap harvest while also decreasing the donor-site morbidity by minimizing the incision length of the anterior rectus sheath. The patient had an uneventful postoperative course and, at 9-month follow-up, exhibited no evidence of flap or donor-site complications, specifically hernia or bulge. This novel approach for the harvest of a DIEP flap introduces an alternative technique to the conventional DIEP flap procedure in the appropriate patient population. Risks inherent to this technique as well as additional costs must be considered.

Aberrant cell adhesion molecule expression in human bronchopulmonary sequestration and congenital cystic adenomatoid malformation.

In many organs, integrins and cadherins are partly regulated by Hox genes, but their interactions in airway morphogenesis and congenital lung diseases are unknown. We previously showed that the Hox protein HoxB5 is abnormally increased in bronchopulmonary sequestration (BPS) and congenital cystic adenomatoid malformation (CCAM), congenital lung lesions with abnormal airway branching. We now report on alpha(2)-, alpha(3)-, and beta(1)-integrin and E-cadherin expression in normal human lung and in BPS and CCAM tissue previously shown to have abnormal HoxB5 expression and on the relationship of cell adhesion molecule expression to Hoxb5 regulation. alpha(2)-, alpha(3)-, and beta(1)-integrins and E-cadherin expression in normal human lung and BPS and CCAM were evaluated using Western blot and immunohistochemistry. Fetal mouse lung fibroblasts with Hoxb5-specific siRNA downregulation were evaluated for alpha(2)-integrin protein levels by Western blot. Compared with normal human lung, a previously undetected alpha(2)-integrin isoform potentially lacking essential cytoplasmic sequences was significantly increased in BPS and CCAM, and alpha(2)-integrin spatial and cellular expression was more intense. E-cadherin protein levels were also significantly increased, whereas alpha(3) increased in CCAM compared with canalicular, but not with alveolar, stage lung. beta(1)-integrin levels were unchanged. We conclude that in BPS and CCAM, altered alpha(2)-integrin cytoplasmic signaling contributes to abnormal cellular behavior in these lung lesions. Aberrant cell adhesion molecule and Hox protein regulation are likely part of the mechanism involved in the development of BPS and CCAM.

Comparison of wound irrigation and tangential hydrodissection in bacterial clearance of contaminated wounds: results of a randomized, controlled clinical study.

Thorough irrigation of contaminated or infected traumatic and open surgical wounds is considered standard practice. High-power pulse lavage is frequently used to facilitate the removal of surface contaminants and bacteria but studies to compare the results of various irrigation techniques are limited. The purpose of this randomized, controlled clinical study was to compare the ability of a high-pressure parallel waterjet (pressure range 5,025 to 7,360 psi) to pulse lavage (pressure 40 psi) in reducing wound bacterial counts. The higher velocity instrument utilizes a waterjet oriented parallel to the surface of the wound and can be used to cut and remove necrotic tissues. After obtaining informed consent, 21 patients who presented with open surgical and traumatic wounds were randomly assigned to high-pressure parallel waterjet (n = 12) or pulse lavage (n = 9). Pre- and post irrigation tissue culture results showed an average decrease in absolute bacterial counts of 90.8% in the high-pressure parallel waterjet and 86.9% in the pulse lavage group. The difference between the two treatment groups was not statistically significant. The results of this study confirm that cleansing contaminated or infected acute wounds using high pressure (at least 15 psi) reduces wound bacterial counts. Studies to compare the clinical outcomes of various irrigation techniques and pressure ranges are warranted and the potential benefit of selective debridement using the high-pressure parallel waterjet should be investigated.