Revision Breast Reconstruction With Biologic or Synthetic Mesh: An Analysis of Postoperative Capsular Contracture Rates.

Background: Both biologic and synthetic mesh have been found to reduce the risk of capsular contracture, yet there is limited data assessing the use of these scaffold materials in revision breast reconstruction. Objectives: This investigation sought to assess the ability of either biologic or synthetic mesh to prevent capsular contracture in the revision breast reconstruction population. Methods: A retrospective chart review was conducted of implant-based revision reconstructions performed by the senior author between 2008 and 2023. Patient demographics and outcomes were assessed, including the incidence of Baker Grade III or IV capsular contractures. Results were compared between biologic and synthetic mesh groups using univariate and multivariate analysis. Results: Ninety-five breasts underwent revision reconstruction with 90 (94.7%) for correction of malposition, 4 (4.2%) for size change, and 1 (1.1%) for revision after additional oncologic breast surgery. Of these breasts, 26 (27.4%) used biologic mesh and 69 (72.6%) used synthetic mesh. Capsular contracture occurred in 1 (3.8%) biologic mesh breast and 4 (5.8%) synthetic mesh breasts. There was no significant difference in the incidence of capsular contracture between the 2 groups (P = 1.000). None of the recorded demographics were risk factors for capsular contracture, including the use of biologic or synthetic mesh (P = .801). Conclusions: Both biologic and synthetic mesh are successful at preventing capsular contracture in patients undergoing implant-based revision reconstruction. This adds to the growing evidence that both scaffold materials can be used in complex revision breast reconstruction to aid in preventing capsular contracture.

Targeted Muscle Reinnervation and Regenerative Peripheral Nerve Interfaces for Prophylactic Pain Control in Neurofibromatosis Type 1 Amputees.

Neurofibromatosis type 1 (NF1) is an inherited multisystem disorder that affects one in 2500 to one in 5000 people. Neurofibromas are the second-most common benign peripheral nerve sheath tumors arising from Schwann cells and are associated with neurofibromatosis. Chronic pain and opioid use is elevated in patients with NF1 when neurofibromas are associated with sensory nerves. Surgical excision is the primary treatment of neurofibromas when they become large, malignant, or painful, but they are associated with high rates of recurrence. Targeted muscle reinnervation and regenerative peripheral nerve interfaces are two prophylactic surgical techniques that are used to prevent neuroma-associated residual limb and phantom pain in amputees. Both techniques stimulate physiologic regeneration of the nerve via trophic stimulus from denervated muscle. This case report describes two patients with NF1 who underwent targeted muscle reinnervation and/or regenerative peripheral nerve interfaces at the time of amputation. Despite the abnormality of the peripheral nerves involved, both patients had excellent postoperative outcomes with minimal pain. This experience advocates for the use of prophylactic nerve management techniques in neurofibromatosis patients despite baseline nerve pathology.

Pushing the DIEP Envelope with ERAS: 24 Hour Discharge is Safe in Appropriately Selected Patients.

Enhanced recovery after surgery protocols have become increasingly adopted for autologous breast reconstruction, demonstrating improved quality of care and reduced hospital stays. Despite this, average length of stay remains over 3 days. We have found, in appropriately selected patients, hospital length of stay can be safely reduced to less than 48 hours. Methods: Retrospective review was performed of patients who underwent microsurgical breast reconstruction by the senior author (M.H.) from April 2019 to December 2021. Demographics, operative details, length of stay, and postoperative complications are reported to assess for safety of discharge within 48 hours, with the primary outcome measure being flap loss. Results: In total, 188 flaps were performed on 107 patients. Average age was 51.4 years (SD 10.1 years) with average BMI 26.6 kg/m2 (SD 4.8 kg/m2). Average length of stay was 1.97 days (SD 0.61 days), and 96 patients (89.7%) were discharged within 48 hours. Six flaps (3.2%) required operative takebacks. Five of the six (83.3%) takebacks occurred on postoperative days zero or one, and all five of these flaps were salvaged. There were four breast hematomas (2.1%), four breast seromas (2.1%), eight breast infections (4.3%), 13 breasts (6.9%) with wound dehiscence, four flaps (2.1%) with partial flap loss, and 24 breasts (12.8%) with mastectomy flap necrosis. One hundred fifty flaps (79.8%) had no complications. Overall success rate of flap reconstruction was 99.5%. Conclusion: Hospital discharge in 24-48 hours is safe in appropriately selected patients undergoing autologous tissue breast reconstruction.

A Spectrum of Disease: Breast Implant-Associated Anaplastic Large Cell Lymphoma, Atypicals, and Other Implant Associations.

Breast implant associated anaplastic large cell lymphoma (BIA-ALCL) is an uncommon and emerging malignancy caused by textured breast implants. The most common patient presentation is delayed seromas, other presentations include breast asymmetry, overlying skin rashes, palpable masses, lymphadenopathy, and capsular contracture. Confirmed diagnoses should receive lymphoma oncology consultation, multidisciplinary evaluation, and PET-CT or CT scan evaluation prior to surgical treatment. Disease confined to the capsule is curable in the majority of patients with complete surgical resection. BIA-ALCL is now recognized as one disease among a spectrum of inflammatory mediated malignancies which include implant-associated squamous cell carcinoma and B cell lymphoma.

Free Vascularized Fibular Flap with Bilateral Bipolar Latissimus Transfer for Upper Extremity Reconstruction: A Case Report.

CASE: A 19-year-old woman presented with bilateral mangled upper extremities after jumping in front of a moving train. After revascularization, osteocutaneous free vascularized fibula flap was performed to reconstruct the right humerus. The left forearm required transradial amputation with acute targeted muscle reinnervation. Finally, staged bilateral bipolar latissimus dorsi functional muscle flaps were performed to restore elbow flexion. CONCLUSION: Staged orthoplastic reconstruction of the upper extremities is an effective treatment approach for traumatic bone and soft-tissue defects. This patient's recovery demonstrates improved quality of life after severe upper extremity trauma.

The Palpable Nodule after Autologous Fat Grafting: Distinguishing Benign versus Malignant Lesions in Breast Reconstruction.

BACKGROUND: Nodule formation after autologous fat grafting to the breast is the most common complication. In the reconstructive population, this generates significant patient anxiety and presents a diagnostic challenge. The authors characterized palpable nodule occurrence after autologous fat grafting in breast reconstruction and compared benign versus malignant nodule characteristics. METHODS: Chart review of the senior author's experience with breast fat grafting was performed. Data extracted included demographics, intraoperative details, nodule data, radiographic characteristics, and biopsy results. Logistic regression identified risk factors for nodule formation. Unpaired t tests and Fisher exact tests compared characteristics of benign versus malignant nodules. RESULTS: In total, 775 breasts were identified that underwent 1158 fat grafting procedures, of which 67 (8.6 percent) developed palpable nodules. Sonographic characterization of nodules included presumed fat necrosis (38.2 percent), benign lesions (27.6 percent), presumed oil cysts (17.1 percent), indeterminate (8.9 percent), and concerning for malignancy (8.1 percent). Lesions concerning for malignancy were more often irregular (10.0 percent versus 0 to 2.9 percent of benign nodules) and more often larger than 0.8 cm in greatest dimension (80 percent versus 42.9 to 61.8 percent of benign nodules). Six patients developed a palpable local recurrence. Malignant nodules tended to be larger (1.45 cm versus 0.70 cm; p = 0.03), were more often vascular (50 percent versus 3.8 percent; p = 0.03), and tended to occur later (17.5 months versus 10.0 months; p = 0.60). Benign nodules occurred in the setting of larger fat graft volumes (64.2 cc versus 40.0 cc; p = 0.008). CONCLUSION: This study provides the first comparison of radiographic and clinical characteristics between benign and malignant palpable nodules after autologous fat grafting in breast reconstruction. CLINICAL QUESTION/LEVEL OE EVIDENCE: Risk, III.

An In Vivo Comparison: Novel Mesh Suture Versus Traditional Suture-Based Repair in a Rabbit Tendon Model.

Purpose: Despite advancements in surgical techniques, suture pull-though and rupture continue to limit the early range of motion and functional rehabilitation after flexor tendon repairs. The aim of this study was to evaluate a suturable mesh compared with a commonly used braided suture in an in vivo rabbit intrasynovial tendon model. Methods: Twenty-four New Zealand female rabbits (3-4 kg) were injected with 2 units/kg botulinum toxin evenly distributed into 4 sites in the left calf. After 1 week, the animals underwent surgical tenotomy of the flexor digitorum tendon and were randomized to repair with either 2-0 Duramesh suturable mesh or to 2-0 Fiberwire using a 2-strand modified Kessler and 6-0 polypropylene running epitendinous suture. Rabbits were killed at 2, 4, and 9 weeks after surgery. Results: Grouping across time points, 58.3% (7 of 12) of Duramesh repairs were found to be intact for the explant compared with 16.7% (2 of 12) of Fiberwire repairs (P = .09). At 2 weeks, the mean Duramesh repairs were significantly stronger than the Fiberwire repairs with a mean failure load of 50.7 ± 12.7 N compared to 14.8 ± 18.3 N (P = .02). The load supported by the Duramesh repairs at 2 weeks (mean 50.7 ± 12.7 N) was similar to the load supported by both Fiberwire (52.2 ± 13.6 N) and Duramesh (57.6 ± 22.3 N) at 4 weeks. The strength of repair between Fiberwire and Duramesh at 4 weeks and 9 weeks was not significantly different. Conclusions: The 2-strand tendon repair with suturable mesh achieved significantly greater strength at 2 weeks than the conventional suture material. Future studies should evaluate the strength of repair prior to 2 weeks to determine the strength curve for this novel suture material. Clinical Relevance: This study evaluates the utility of a novel suturable mesh for flexor tendon repair in an in vivo rabbit model compared with conventional suture material.

Can Breast Implants Induce Breast Cancer Immunosurveillance? An Analysis of Antibody Response to Breast Cancer Antigen following Implant Placement.

BACKGROUND: Women with cosmetic breast implants have significantly lower rates of subsequent breast cancer than the general population (relative risk, 0.63; 95 percent CI, 0.56 to 0.71). The authors hypothesize that breast implant-induced local inflammation stimulates immunosurveillance recognition of breast tumor antigen. METHODS: Sera were collected from two cohorts of healthy women: women with long-term breast implants (i.e., breast implants for >6 months) and breast implant-naive women. Antibody responses to breast tumor antigens were tested by enzyme-linked immunosorbent assay and compared between cohorts by unpaired t test. Of the implant-naive cohort, nine women underwent breast augmentation, and antibody responses before and after implant placement were compared by paired t test. RESULTS: Sera were collected from 104 women: 36 (34.6 percent) long-term breast implants and 68 (65.4 percent) implant-naive women. Women with long-term breast implants had higher antibody responses than implant-naive women to mammaglobin-A (optical density at 450 nm, 0.33 versus 0.22; p = 0.003) and mucin-1 (optical density at 450 nm, 0.42 versus 0.34; p = 0.02). There was no difference in antibody responses to breast cancer susceptibility gene 2, carcinoembryonic antigen, human epidermal growth factor receptor-2, or tetanus. Nine women with longitudinal samples preoperatively and 1 month postoperatively demonstrated significantly elevated antibody responses following implant placement to mammaglobin-A (mean difference, 0.13; p = 0.0002) and mucin-1 (mean difference 0.08; p = 0.02). There was no difference in postimplant responses to other breast tumor antigens, or tetanus. CONCLUSIONS: Women with long-term breast implants have higher antibody recognition of mammaglobin-A and mucin-1. This study provides the first evidence of implant-related immune responses to breast cancer antigens. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Targeted Muscle Reinnervation for the Treatment of Neuroma.

Targeted muscle reinnervation (TMR) is the surgical rerouting of severed nerve endings to nearby expendable motor nerve branches. These nerve transfers provide a pathway for axonal growth, limiting the amputated nerve ends' disorganized attempt at regeneration that leads to neuroma formation. In the amputee population, TMR is successful in the treatment and prevention of chronic phantom limb pain and residual limb pain. In the nonamputee population, applications of TMR are ever expanding in the treatment of chronic neuroma pain owing to trauma, compression, or surgery. This article reviews the indications for TMR, preoperative evaluation, and various surgical techniques.

Judging an Expander by Its Cover: A Propensity-Matched Analysis of the Impact of Tissue Expander Surface Texture on First-Stage Breast Reconstruction Outcomes.

BACKGROUND: There is increased scrutiny of texturing on implants and a paucity of data looking at texturing on expanders. Because of the difficulty in controlling potential confounders with these comparative studies, the authors performed propensity matching between smooth and textured tissue expander cohorts to provide definitive insight into the impact of expander texture on breast reconstruction outcomes. METHODS: A single-surgeon experience with immediate two-stage breast reconstruction was reviewed for 90-day postoperative complications after mastectomy and expander placement. Variables extracted included demographics, comorbidities, tissue expander texturing, mastectomy type, infection, seroma, skin flap necrosis, dehiscence, explantation, and overall complication rates. Subjects were 1:1 propensity matched using the nearest neighbor matching algorithm with caliper (maximum propensity score difference) of 0.2, and chi-square test was performed for statistical analysis. RESULTS: After 1:1 propensity matching, 282 reconstructed breasts were analyzed (141 textured versus 141 smooth expanders). Textured expanders had higher minor infection rates than smooth expanders (5.0 percent versus 0 percent; p = 0.024). Smooth expanders had higher seroma rates than textured expanders (5.0 percent versus 0.7 percent; p = 0.031). Smooth expanders also had longer drain retention (20.4 days versus 16.8 days; p = 0.001). There was no difference in other complications, including major infection, explantation, or any complication, between textured and smooth expanders. CONCLUSIONS: Textured expanders are associated with increased minor infection risk, whereas smooth expanders are associated with increased seroma formation. However, these differing complication profiles coalesce to equal explantation rates. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Lateral and Inferior Implant Malposition in Prosthetic Breast Reconstruction: Incidence and Risk Factors.

Implant malposition is one of the most common causes for revision after prosthetic breast reconstruction. There is a paucity of research on the incidence, etiology and risk factors for implant malposition in this setting. METHODS: Retrospective review of a single surgeon's prosthetic breast reconstructions was performed. Variables collected included age, BMI, radiation, chemotherapy, implant characteristics and malposition location (inferior or lateral). Binary logistic regression identified risk factors for malposition. Chi-square test assessed malposition rate as a function of implant volume to BMI subgroups. RESULTS: Of 836 breasts, 82 (9.8%) exhibited implant malposition. Risk factors for any malposition were older age (OR 1.05, 95% CI 1.02-1.07), BMI<25 (OR 1.64, 95% CI 1.00-2.70) and bilateral reconstruction (OR 13.41, 95% CI 8.50-21.16). Risk factors for inferior malposition were older age (OR 1.04, 95% CI 1.01-1.06), BMI<25 (OR 3.43, 95% CI 1.88-6.26) and bilateral reconstructions (OR 11.50, 95% CI 6.79-19.49), while risk factors for lateral malposition were only older age (OR 1.05, 95% CI 1.02-1.08) and bilateral reconstructions (OR 7.08, 95% CI 4.09-12.26). Post-mastectomy radiation was protective against lateral malposition (OR 0.30, 95% CI 0.10-0.88). Stratification by implant volume and BMI demonstrated patient subgroups with distinct patterns of malposition (incidence 0.0% versus 10.9%, P = 0.001). CONCLUSIONS: This is the first study to identify risk factors for implant malposition after prosthetic breast reconstruction. Different risk factors contributed to malposition in different directions. The effect of implant size on malposition was mediated through BMI, highlighting the interplay of implant and patient characteristics with respect to malposition.

Benchmarking Residual Limb Pain and Phantom Limb Pain in Amputees through a Patient-reported Outcomes Survey.

More than 75% of major limb amputees experience chronic pain; however, data on severity and experience of pain are inconsistent. Without a benchmark using quantitative patient-reported outcomes, it is difficult to critically assess the efficacy of novel treatment strategies. Our primary objective is to report quantitative pain parameters for a large sample of amputees using the validated Patient-reported Outcomes Measurement System (PROMIS). Secondarily, we hypothesize that certain patient factors will be associated with worse pain. METHODS: PROMIS and Numerical Rating Scales for residual limb pain (RLP) and phantom limb pain (PLP) were obtained from a cross-sectional survey of upper and lower extremity amputees recruited throughout North America via amputee clinics and websites. Demographics (gender, age, race, and education) and clinical information (cause, amputation level, and time since amputation) were collected. Regression modeling identified factors associated with worse pain scores (P < 0.05). RESULTS: Seven hundred twenty-seven surveys were analyzed, in which 73.4% reported RLP and 70.4% reported PLP. Median residual PROMIS scores were 46.6 [interquartile range (IQR), 41-52] for RLP Intensity, 56.7 (IQR, 51-61) for RLP Behavior, and 55.9 (IQR, 41-63) for RLP Interference. Similar scores were calculated for PLP parameters: 46.8 (IQR, 41-54) for PLP Intensity, 56.2 (IQR, 50-61) for PLP Behavior, and 54.6 (IQR, 41-62) for PLP Interference. Female sex, lower education, trauma-related amputation, more proximal amputation, and closer to time of amputation increased odds of PLP. Female sex, lower education, and infection/ischemia-related amputation increased odds of RLP. CONCLUSION: This survey-based analysis provides quantitative benchmark data regarding RLP and PLP in amputees with more granularity than has previously been reported.

Management of Unreconstructable Saphenous Nerve Injury with Targeted Muscle Reinnervation.

Neuroma pain significantly impacts patient quality of life and is associated with unemployment, chronic opioid dependence, and depression. Targeted muscle reinnervation (TMR), a surgical technique that coapts proximal stumps of cut nerves to distal motor nerves of adjacent muscles, has demonstrated efficacy in the treatment and prevention of neuroma pain. The objective of this study was to describe the surgical technique for TMR of the saphenous nerve, while providing a retrospective review. Between January 2015 and December 2018, 18 patients underwent TMR of the saphenous nerve: 1 nonamputee patient with chronic pain after ankle surgery and 17 amputee patients (10 for relief of chronic postamputation neuroma pain and phantom pain and 7 at the time of amputation for prevention of these symptoms). Six patients were lost to follow up; 2 patients had recurrent pain; and 10 patients had reduced or no pain after TMR surgery. TMR is a successful technique for the management of traumatic neuroma pain in both the amputee and nonamputee populations, and in this study, we describe the technique for saphenous nerve TMR.

Management of Sural Nerve Neuromas with Targeted Muscle Reinnervation.

Neuromas are a debilitating peripheral nerve problem due to aberrant axon sprouting and inflammation after nerve injury. The surgical management of neuromas has for a long time been up for debate, largely due to lack of consistent, reliable outcomes with any one technique. We have found success utilizing targeted muscle reinnervation, a technique originally described in amputees that re-routes the proximal ends of cut sensory nerve stumps into the distal ends of motor nerves to nearby muscles. In doing so, the sensory nerve ending can regenerate along the length of the motor nerve, giving it a place to go and something to do. In this report, we describe our technique specifically for targeted muscle reinnervation of sural nerve neuromas that is applicable to both amputees and to patients with intact limbs. Sural nerve neuromas can occur after sural nerve harvest for reconstructive procedures and particularly after lateral malleolar incisions for orthopedic access to the calcaneus. By re-routing the sural nerve into a motor nerve of the lateral gastrocnemius muscle, we are able to manage a variety of sural nerve neuromas presenting anywhere along the course of the sural nerve and in a variety of clinical settings.

Utilization of Intraparotid Segments of Superficial Temporal Vessels for Head and Scalp Free Flap Microanastomosis: A Clinical, Histological, and Cadaveric Study.

BACKGROUND: The superficial temporal vessels (STV) are an underutilized target for head and neck microvascular reconstruction. Most surgeons regard the dissection as difficult, unreliable, and the anastomosis prone to vasospasm. The intraparotid course of the STV may provide more reliable flow without accompanying morbidity. METHODS: A retrospective review of patients who underwent head and scalp free flap reconstruction utilizing STV intraparotid segment was performed. Demographic factors such as intraoperative and postoperative complications are reported. Five bilateral cadaver heads were dissected to describe the relationship to the facial nerve. STV histology was performed on four of the cadavers, noting intraluminal diameter and vessel wall thickness. RESULTS: Thirty-nine patients underwent free flap reconstruction with anastomosis to intraparotid STVs. Defect etiology included tumor resection (71.8%), traumatic brain injury (10.3%), intracranial bleed (12.8%), and acute trauma (5.1%). Flaps transferred included anterolateral thigh (51.3%), latissimus (33.3%), thoracodorsal artery perforator (7.7%), radial forearm (2.8%), and vastus lateralis (5.1%). Two flaps (5.1%) required takeback for arterial thrombosis, with one incidence of total flap loss (2.8%). There were no instances of transient or permanent facial nerve damage nor sialocele. On cadaver dissection, three distinct vessel segments were identified. Segments 1 and 2 represented the STVs superior to the upper tragal border. Segment 3 (intraparotid segment) began at the upper tragal border and STVs enlarged with a targeted anastomosis point at an average of 16.3 mm medial and 4.5 mm inferior to the upper border of the tragus. The frontal branch coursed 11.7 mm inferior and 11.5 mm anterior to this point. On histology, the intraluminal diameter of segment 3 was significantly larger than segment 2 (1.2 vs. 0.9 mm, p = 0.007). CONCLUSION: Head and neck free flap reconstruction with microanastomosis to the intraparotid segment of STVs can be safely and reliably performed.

Gluteal Vein Anatomy: Location, Caliber, Impact of Patient Positioning, and Implications for Fat Grafting.

BACKGROUND: Deaths in gluteal autografting occur due to gluteal vein injuries, but data are lacking on the precise location and caliber of these veins. OBJECTIVES: The authors sought to present the first in vivo study of gluteal vein anatomy utilizing magnetic resonance imaging. METHODS: Magnetic resonance imaging venography of 16 volunteer hemi-sections was conducted in the supine, prone, prone with a bump (jack-knife), and left and right decubitus positions in 1 session after a single contrast administration. Caliber and course of the superior and inferior gluteal veins (SGV/IGV) were analyzed vs bony landmarks and position changes. RESULTS: The SGV has a very short submuscular course before splitting into 2 smaller branches superolaterally. The IGV runs immediately deep to the gluteus maximus in the center of the buttock as a single large trunk, on average 56 mm deep (mean 27 mm of muscle belly and 30 mm subcutaneous fat). No intramuscular or subcutaneous branches greater than 2 mm were found. In the prone position, the IGV and SGV have an average caliber of 5.96 mm and 5.63 mm. Vessel caliber decreased by 21% and 27%, respectively, in the jack-knife position and by 14% and 15% in lateral decubitus. CONCLUSIONS: The SGV and IGV are immediately deep to gluteus maximus approximately 6 cm deep with a caliber on the order of 6 mm in the prone position. The distribution of these vessels suggests there is no "safe zone" in the intramuscular or submuscular planes. The jackknife or lateral decubitus positions can decrease vein caliber by up to 27%, possibly reducing the risk of injury due to either traction or direct cannula impact.

The Relationship between Animation Deformity and Patient-Reported Outcomes: Application of the BREAST-Q to a Quantitative Stratification of Animation Severity.

BACKGROUND: Animation deformity can occur following subpectoral breast reconstruction and is an oft-touted rationale for prepectoral reconstruction. Despite increasing recognition, there is a paucity of patient-reported outcome studies in women with animation deformity. METHODS: Women presenting after subpectoral implant-based breast reconstruction were evaluated for animation deformity. Video analysis and quantitative deformity assessment were performed in conjunction with BREAST-Q surveys. BREAST-Q data were compared to our quantitative animation grading scale to assess the relationship between animation severity and patient-reported outcomes. RESULTS: One hundred forty-one subpectoral breast reconstructions met inclusion criteria. Average scores were 67.8 ± 17.9 of 100 for satisfaction with breasts and 78.3 ± 14.1 of 100 for physical well-being. Animation deformity severity did not correlate with satisfaction with breasts (p = 0.44). Physical well-being, particularly pain-related questions, increased with increasing animation (p = 0.01); specifically, patients reported significantly less pulling, nagging, and aching in the breast (p = 0.01, p = 0.001, and p = 0.004, respectively). Patients with the least and most severe animation deformity had significantly higher numbers of revision procedures (0.89 and 1.03 procedures, respectively) compared with patients with intermediate deformity (0.49 procedures; p = 0.01 and p = 0.009, respectively). CONCLUSIONS: Although pectoralis release creates a more mobile-and more animating-reconstruction, this same release may lead to less pain because muscle is no longer contracting against a fixed space. This may lead to two distinct origins of subpectoral revision: (1) patients in pain (but low animation) and (2) patients with visibly distorted animation (but low pain). CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

A Quantitative Analysis of Animation Deformity in Prosthetic Breast Reconstruction.

BACKGROUND: Animation deformity is characterized by implant deformity with pectoralis contraction after subpectoral implant-based breast reconstruction. Extant methods to measure and analyze animation deformity are hampered by the paucity of objective, quantitative data. The authors endeavored to supplement subjective measures with an in-depth quantitative analysis. METHODS: Patients undergoing subpectoral implant-based breast reconstruction were followed prospectively with video analysis of animation deformity. Nipple displacement and surface area of contour deformity in resting and contracted states were quantified using imaging software. Degree of animation was compared to breast size, body mass index, division of pectoralis muscle, complications, and radiation therapy. RESULTS: One hundred forty-five reconstructed breasts (88 patients) were analyzed. Mean nipple displacement was 2.12 ± 1.04 cm, mean vector of nipple displacement was 62.5 ± 20.6 degrees, and mean area of skin contour irregularity was 16.4 ± 15.41 percent. Intraoperative pectoralis division, smooth/round implants, and bilateral reconstructions were associated with greater deformity. A three-tiered grading system based on thresholds of 2-cm net nipple displacement and 25 percent skin contour irregularity placed 41.4 percent of breasts in grade 1, 35.9 percent in grade 2, and 22.8 percent in grade 3. Interrater variability testing demonstrated 89.5 percent overall agreement (kappa = 0.84). CONCLUSIONS: This study presents the first quantitative analysis of animation deformity in prosthetic breast reconstruction. Geometric analysis of nipple displacement vector and increasing animation with pectoralis division both implicate the inferior pectoralis myotome as a primary driver of animation deformity. A concomitant grading schema was developed to provide a standardized framework for discussing animation from patient to patient and from study to study.

Appreciation of Postpartum Changes of the Rectus Muscles in Primary and Repeated Abdominoplasty.

BACKGROUND: Abdominoplasty is one of the top five most commonly performed cosmetic procedures. Whereas widening of the linea alba is a well-accepted consequence of pregnancy, the changes to the rectus abdominis muscles are less well known and thus unappreciated and undertreated. METHODS: After institutional review board approval, the Northwestern Enterprise Data Warehouse identified nulliparous and multiparous women, aged 18 to 45 years, who underwent abdominal computed tomography between 2000 and the present. Measurements included the width and cross-sectional area of each rectus muscle, width of the linea alba, and circumference of the abdominal cavity at the level of the L3 vertebra. In addition, two case reports addressing these anatomical changes with muscle modification and mesh reinforcement are presented. RESULTS: Sixty women were identified that met our inclusion criteria: 15 nulliparous, 15 after one pregnancy (para 1), 15 after two pregnancies (para 2), and 15 after three or more pregnancies (para ≥ 3). The linea alba was significantly widened after one pregnancy from 1.14 cm to 2.29 cm, but did not significantly widen further with each subsequent pregnancy. The width of each rectus muscle was significantly widened from 6.00 ± 0.60 cm in nulliparous to 6.61 ± 0.58 cm in para 1, significantly widened again to 7.03 ± 0.46 cm in para 2, but not significantly widened after that (6.97 ± 1.00 cm in para 3). CONCLUSIONS: In addition to widening of the linea alba, pregnancy alters the shape of the rectus abdominis muscle. Correction of muscle width during abdominoplasty may be a necessary adjunct to achieve the proper tension in both primary and revision procedures. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.