Subareolar Sealant Reduces Minor Complications and Surgery for Necrosis in Prosthetic Reconstruction after Nipple-sparing Mastectomy.

Nipple-sparing mastectomy (NSM) is aesthetically superior to skin-sparing only mastectomy or reconstructed nipples. However, nipple-sparing mastectomy partially preserves nipple ducts, which are remaining communications between the environment and breast pocket that can potentially allow bacteria transfer and compromise the prosthesis. Previous methods to create a subareolar "barrier" to reduce through-duct bacteria penetration involve subpectoral implant placement, adjunct meshes or acellular dermal matrix, and external nipple adhesives. To further protect the implant from nipple-derived contamination, we propose subareolar sealant (SAS). SAS involves the application of a synthetic sealant on the nipple undersurface before implant placement. In our study, we analyzed 77 breasts that received prepectoral prosthetic breast reconstruction. SAS was used in 70 of 77 breasts. All breasts received adjunctive acellular dermal matrix. Comparing SAS versus no-SAS, we found that no-SAS was associated with 10.4-fold more infections (P = 0.032) and 17.3-fold more re-hospitalizations (P = 0.017). No-SAS also resulted in more "at least one major complication" (P < 0.001), capsular contracture (P < 0.001), and necrosis requiring surgery (P < 0.001). Due to the small no-SAS sample size, goodness-of-fit (Quasi-likelihood independence model) criteria was applied, and a post hoc power analysis was calculated. Erythema, all minor complications, dehiscence, and necrosis requiring surgery remained significant (all P < 0.0001). This innovative technique markedly reduces overall minor complications and necrosis requiring surgery. A larger no-SAS sample size is required to adequately determine whether SAS reduces infection and hospitalization rates. Nonetheless, SAS reduces complications and is cost effective compared with other adjunct materials.

Knot Security 101: A Comprehensive Practical Review to Optimal Knot Configuration, Pulling Direction, Throw Count, and Tail Length.

Background: Knots are the weakest structural point in a suture line and inevitably weaken almost all suture materials. This practical review critically evaluates the factors, such as suture material properties, gauge, configuration, throw count, and tail length, that affect knot security. Methods: A PubMed search between the years 1934 and 2023 identified relevant studies that addressed factors relating to knot security. Studies that investigated knots and sutures solely used in laparoscopic and arthroscopic surgery were excluded. Knot configurations assessed were the Aberdeen, sliding, square, and surgeon's. Results: Eighty-six articles were included in this review article and demonstrated that knot security varies greatly between suture materials and gauge. Knot security also varies by configuration, throw count, conditions, tail length, and stitch type. Throw count differs by knot configuration, with the Aberdeen knot being most secure with three throws and one to two turns compared with three to five throws for surgeon's and square knots. The optimal tail length was 3 mm. Conclusions: This practical review demonstrates that there are significant differences in knot security based on a variety of factors. It is challenging to propose an ideal knot because most studies did not evaluate knot security using a broad variety of suture materials, gauges, and throws for each of the most common knots. Although this review article demonstrated several applicable findings, additional robust studies are needed to simplify proposals.

To acellular dermal matrix or not to acellular dermal matrix?-outcomes of pre-pectoral prosthetic reconstruction after nipple-sparing mastectomy with and without acellular dermal matrix.

Background: Acellular dermal matrix (ADM) has been the go-to biomaterial in post-mastectomy breast reconstruction, particularly in pre-pectoral reconstruction. ADM is thought to decrease capsular contracture, control the pocket, and increase soft tissue, but may yield more complications. This study evaluated whether ADM is even needed. Methods: All patients undergoing immediate breast reconstruction with pre-pectoral tissue expander (TE) or direct-to-implant (DTI) after nipple-sparing mastectomy (NSM) by the senior author between April 2013 and January 2021, were included in this study. Cohorts were stratified into breasts with ADM or no-ADM. Complications within 30 days post-operatively were analyzed. Results: A total of 115 pre-pectoral reconstructions were performed in 66 patients. ADM was applied to 75 breasts. TEs were used in 80 breasts and DTI in 35 breasts. Controlling for implant type, breasts with ADM exhibited more nipple necrosis (28.0% vs. 10.0%, P=0.02). Controlling for ADM status, DTI compared to TE was associated with less necrosis of the nipple (11.4% vs. 26.3%, P=0.04), implant loss (5.7% vs. 38.8%, P=0.004), and surgery for any complication (14.3% vs. 27.5%, P=0.04). Conclusions: Outcomes of prosthetic reconstructions with ADM and no-ADM were similar. DTI reconstruction was associated with less complications, which was likely due to intraoperative bias and placement of TEs more often in breasts with perceived poorer vascularity.

Timing of Alveolar Bone Graft and Barriers to Care.

OBJECTIVE: The current standard timing for alveolar bone grafting (ABG) occurs during mixed dentition, typically between the ages of six and twelve. A delay in receiving this operation is associated with an increase in graft loss and an overall thinner maxilla. This study aims to determine whether socioeconomic barriers are associated with a delay in timely ABG. DESIGN: A retrospective analysis of patients who received ABG at our institution since 2012. Patient demographics, cleft classifications, operative details, and surgical dates were examined. A logistic regression model was created using socioeconomic variables to predict patients receiving delayed ABG. Significant variables were then included in a backwards selection logistic regression, followed by a final analysis of maximum likelihood estimates. SETTING: Single-institution, primary cleft care center. PATIENTS: 202 patients with cleft palates who underwent ABG. INTERVENTIONS: ABG. MAIN OUTCOME MEASURES: Timing in which patients received ABG: standard (6-12 years) and delayed (>12 years). RESULTS: Female sex was a protective factor in the timing of ABG in our initial univariate analysis (OR = 0.44; p = .015). Socioeconomic factors resulting in delayed presentation for ABG include median income (OR = 1.0; p = .018) and public insurance status (OR = 3.75; p < .001). Median income, sex, and driving distance to the cleft clinic were not significant following backward elimination, however, private insurance status remained significant (OR = 3.71; p = .0001). CONCLUSION: Patients with public insurance are approximately 3.75 times more likely to receive ABG during permanent dentition. Multidisciplinary teams should work closely with patients on public insurance to ensure timely delivery of ABG.Level of Evidence III, Retrospective.

Correction of Breast Ptosis in Immediate Breast Reconstruction.

Nipple-sparing mastectomy is psychologically advantageous and can result in superior cosmetic outcomes. However, nipple position adjustment is challenging, and ischemic complications may arise. For patients who require timely mastectomies and reconstructions, concurrent mastopexy may prevent nipple malposition and reduce the risk for future corrections. Methods: A retrospective chart review of all patients undergoing immediate prosthetic reconstruction after nipple-sparing mastectomy were analyzed. Data regarding patient characteristics; surgical indications; reconstructive modality, including presence or absence of simultaneous nipple lift; and early and late complications were examined. Results: In total, 142 patients underwent 228 nipple-sparing mastectomies and prosthetic reconstructions. Correction of ptosis (lift) was performed in 22 patients and 34 breasts. The remaining 122 patients and 194 breasts did not receive mastopexy (no-lift). Two patients received bilateral reconstructions involving both lift and no-lift. Comparing the lift and no-lift cohorts demonstrated no differences in major complications (47.1% versus 57.7%; P = 0.25) and minor complications (76.5% versus 74.7%; P = 0.83). Control for plane of implant placement also did not show differences in major (P = 0.31) or minor (P = 0.97) complications. Similarly, control of application of acellular dermal matrix found major (P = 0.25) and minor (P = 0.83) complications uniform and not affected by lift status. Nipple lift distance was not associated with increased major (P = 0.10) complications. Conclusion: Simultaneous correction of nipple position in immediate prosthetic breast reconstruction seem safe with uniform complications rates that are unaffected by acellular dermal matrix use or plane of implant placement.

Immediate Ear Lobule Reconstruction After Melanoma Resection.

EAR LOBULE RECONSTRUCTION: Cancer removal from aesthetically vulnerable areas of the face strikes a delicate balance between oncologically appropriate excision and preservation of a unique structure. A 72-year-old male presented with melanoma of the right earlobe requiring complete excision. Partial or complete absence of an ear causes a deformity and is difficult to conceal. Thus, lobule reconstruction postmelanoma excision eliminates deformity and aids in psychological recovery. In this case report, we describe our novel technique of a 2-stage lobule reconstruction immediately after melanoma resection using a direct template of the excised lobule. This template allowed us to sculpt its identical size and shape using harvested contralateral conchal cartilage graft. After the cartilage was banked in a subcutaneous pocket for 8.5 weeks, the second stage liberated the reconstructed lobule. This immediate 2-stage technique eliminated a period of soft tissue contracture and presented a rare surgical opportunity to recreate a structure using its direct template. LEVEL OF EVIDENCE: Level IV-case report.