Prepectoral Breast Reconstruction Prompts Revisiting the Anatomic Boundaries of the Breast: A Radiographic and Cadaveric study.

BACKGROUND: This study aimed to determine the location of superficial fascial system (SFS) condensations in relation to classic anatomic breast boundaries. Cadaveric studies have provided some understanding, but knowledge about the precise location of these condensations remains limited. METHODS: Preoperative breast MRI was conducted to assess the fascial condensations defining the breast footprint relative to landmarks like the latissimus, clavicle, sternal border, and inframammary fold (IMF). Concurrently, cadaveric mastectomies were performed to measure the breast borders in relation to these landmarks for comparison. RESULTS: 290 breasts underwent preoperative MRI. Eight cadaveric breast dissections were completed. Radiographically, the lateral breast fascial condensation was 3.9 cm medial to the latissimus dorsi, while cadaveric measurements were 4.5 cm. The medial condensation was 2.1 cm lateral to the sternal border radiographically and 4.8 cm to midline in cadavers. The superior fascial condensation was 2.3 cm inferior to the clavicle radiographically and 5.5 cm by dissection. The inferior condensation was above the IMF in 82.7% of breasts by MRI and 100% of cadaveric breasts. MRI and cadaveric investigation showed similar patterns of breast tissue fascial condensations relative to standard breast boundaries. Breast skin flap thickness was greater peripherally (MRI: 11.5 mm, cadaver: 11.1 mm) than centrally (MRI: 6.6 mm, cadaver: 5.5 mm). CONCLUSIONS: MRI and cadaveric analysis demonstrated a close correlation between SFS and standard breast boundaries, although variations existed among subjects. Collaborating with breast oncologists and utilizing preoperative imaging to identify individual fascial condensations may enhance the camouflage of prepectoral implants after mastectomy.

Effectiveness of Liposomal Bupivacaine Transversus Abdominis Plane Block in DIEP Flap Breast Reconstruction: Randomized Controlled Trial.

BACKGROUND: Transversus Abdominis Plane (TAP) blocks improve pain control and reduce narcotic medication requirements in various surgical procedures. Liposomal bupivacaine may provide more sustained analgesia. This study compares pain related outcomes between standard bupivacaine and liposomal bupivacaine TAP blocks after autologous breast reconstruction. METHODS: Prospective single-center, single-blinded, randomized controlled trial between March 2021 and December 2022. DIEP flap breast reconstruction patients in a standardized Enhanced Recovery After Surgery (ERAS) pathway were randomized to receive intraoperative TAPs with either bupivacaine / epinephrine (control) or liposomal bupivacaine / bupivacaine / epinephrine (experimental). Primary outcome was postoperative narcotic medication requirements, with secondary outcomes of pain scores, length of stay (LOS), and narcotic medication refills. RESULTS: 117 patients met inclusion criteria (59 control, 58 experimental). Patient demographics, comorbidities, breast pathologic variables, surgery laterality and immediate versus delayed reconstruction status were equivalent between groups. Control group had significantly higher average pain scores postoperatively (4.3 vs. 3.6, p=0.004). However, there were no significant differences in mean narcotic use (66.9 MME vs 60.2 MME, p=0.47). Both LOS and postoperative narcotic prescription refills were equivalent between groups (2.1 vs 2.2 days, p = 0.55, 22% vs 17.2%, p=0.52). CONCLUSION: Addition of liposomal bupivacaine to standard bupivacaine TAP block mixture in a standardized ERAS protocol did not demonstrate a significant reduction in postoperative narcotic requirements after DIEP flap breast reconstruction compared to standard bupivacaine alone. Patient-reported pain scores, however, were lower among liposomal bupivacaine patients after the initial 24 hours postoperatively and consistent with a longer duration of analgesia.

Oncoplastic breast reduction surgery decreases rates of reoperation with no increased medical risk.

The purpose of this study is to compare the oncologic, medical, and surgical outcomes of lumpectomy versus oncoplastic breast reduction surgery (OBRS) on a national scale. A national insurance-based database was queried for patients who had a lumpectomy with or without a same-day breast reduction by Current Procedural Terminology (CPT) codes. Patients were then matched by obesity, body mass index range, age, region, neoadjuvant chemotherapy, and outcomes were compared. There were 421,455 patients in the lumpectomy group and 15,909 patients in the OBRS group. After matching, 15,134 patients were identified in each group. Repeat lumpectomy or subsequent mastectomy was more common in the lumpectomy group (15.2% vs. 12.2%, p < 0.001). OBRS patients had higher rates of 90-day surgical complications including dehiscence, infection, fat necrosis, breast abscesses, and antibiotic prescription (p < 0.001). Meanwhile, any medical complication was less common in the OBRS group (3.7% vs. 4.5%, p = 0.001). Logistic regression revealed that OBRS was associated with decreased odds of repeat lumpectomy (OR = 0.71, 95% CI 0.66-0.77, p < 0.001) with no significant increased odds of subsequent mastectomy (OR = 1.01, 95% CI 0.91-1.11, p = 0.914). OBRS was found to be associated with decreased risk for reoperation in the form of lumpectomy without increased likelihood of subsequent mastectomy. Although OBRS was associated with increased wound complications, medical complications were found to occur less frequently. This study endorses increased consideration of OBRS when lumpectomy or OBRS is appropriate.

Use of Acellular Biologic Matrix Envelope for Cardiac Implantable Electronic Device Placement to Correct Migration into Submuscular Breast Implant Pocket.

Breast implants whether used for cosmetic or reconstructive purposes can be placed in pockets either above or below the pectoralis major muscle, depending on clinical circumstances such as subcutaneous tissue volume, history of radiation, and patient preference. Likewise, cardiac implantable electronic devices (CIEDs) can be placed above or below the pectoralis major muscle. When a patient has both devices, knowledge of the pocket location is important for procedural planning and for durability of device placement and performance. Here, we report a patient who previously failed subcutaneous CIED placement due to incision manipulation with prior threatened device exposure requiring plane change to subpectoral pocket. Her course was complicated by submuscular migration of the CIED into her breast implant periprosthetic pocket. With subcutaneous plane change being inadvisable due to patient noncompliance, soft tissue support of subpectoral CIED placement with an acellular biologic matrix (ABM) was performed. Similar to soft tissue support used for breast implants, submuscular CIED neo-pocket creation with ABM was performed with durable CIED device positioning confirmed at 9 months postprocedure.

Desmoid Tumor and Implant-Based Breast Reconstruction.

Desmoid tumors are rare locally aggressive myelodysplastic tumors that are usually abdominally based. They account for 0.2% of breast tumors. Certain factors like prior surgery, familial adenomatous polyposis, pregnancy, and high estrogen states are associated with chest wall desmoid tumor occurrence. We present a patient with a history of intraductal carcinoma of the left breast who underwent mastectomy with implant-based reconstruction who had a desmoid tumor of the breast detected during workup for cardiac transplantation for chemotherapy-induced heart failure. The tumor was originally thought to be recurrent breast cancer during workup with imaging obscured by the implant. Excisional biopsy demonstrated a desmoid tumor with a positive deep margin requiring rib resection, synthetic mesh, and pectoralis major flap reconstruction. Breast desmoid tumors are reactive malignancies that have been diagnosed after prior breast implant surgery but without an established risk associated with breast implants. Excision with microscopically negative margins and chest wall reconstruction when indicated is the current established treatment protocol; however, recent paradigm shifts include "watchful waiting" and medical management among treatment strategies.

The State of Breast Cancer Reconstruction in Virginia: An Evidence-Based Framework for Identifying Locoregional Health Disparities.

BACKGROUND: Age, race, socioeconomic status, and proximity to plastic surgeons have been shown to impact receipt of reconstruction after mastectomy in several national studies. Given that targeted outreach efforts and programs to address these discrepancies would occur locoregionally, investigation of these reconstructive trends on a state level is warranted. STUDY DESIGN: Patients diagnosed with breast cancer in Virginia between 2000 and 2018 were identified in the Virginia Department of Health Cancer Registry. Patients who underwent mastectomy breast conservation surgery, and/or breast reconstruction at the time of oncologic surgery were identified. Patient demographics were analyzed, and logistic regression analyses were used to determine the likelihood of receipt of mastectomy, receipt of mastectomy versus breast conservation surgery, receipt of mastectomy with reconstruction versus mastectomy alone, and receipt of mastectomy with reconstruction versus breast conservation surgery with respect to the demographic variables. Geographically weighted regression analyses were also performed to determine impact of geographic location on receipt of mastectomy and reconstruction after mastectomy. RESULTS: A total of 78,682 patients in Virginia underwent surgical treatment for breast cancer between 2000 and 2018. Living outside a metropolitan area, increased age, lower socioeconomic status, non-White race, and lower number of plastic surgeons within 50 miles were associated with decreased rates of postmastectomy reconstruction. Rural setting, lower socioeconomic status, and lower plastic surgeon supply were also associated with decreased rates of breast conservation surgery. Reconstruction after mastectomy was lowest in the northwest, central, and southwest regions of Virginia. CONCLUSIONS: Within the state of Virginia, programs to improve access to breast reconstruction for patients residing in rural regions, as well as non-White patients, older patients, and those in lower socioeconomic groups should be implemented. Future studies would implement and study the efficacy of such outreach programs, which could then be applied and tailored to other states or regions to address sociodemographic disparities in access to breast reconstruction.

Intraoperative Fluorescence Angiography in Implant-Based Breast Reconstruction: Identifying Risk Factors and Outcomes.

BACKGROUND: Intraoperative fluorescence angiography (FA) has been described as a useful adjunct to physical examination in predicting mastectomy skin flap viability for immediate breast reconstruction. Its use has been described as a screening tool for mastectomy skin flap viability as well as a test used only for patients at high risk for mastectomy skin flap loss. We performed a national database review of implant-based breast reconstruction surgeries to determine the practice patterns of FA in this patient cohort and to determine if this technology impacted clinical outcomes. METHODS: A national insurance claims database was reviewed to select patients having undergone direct-to-implant (DTI) and immediate tissue expander (TE) placement with and without intraoperative FA as well as patients who had FA at the time of mastectomy without reconstruction. Patient characteristics that prompted FA and postoperative outcomes with and without FA were evaluated to determine its clinical impact in the observed practice pattern. RESULTS: Of the 48,464 patients identified, 836 had FA. More than twice as many patients undergoing DTI had FA than patients undergoing immediate TE placement (10.4% vs 5%, P < 0.0001). Twelve percent of patients receiving FA at the time of mastectomy had reconstruction delayed. Fluorescence angiography was associated with a trend toward lower overall complication rates in DTI patients (8.0% vs 11.9% without FA) but a significantly higher overall complication rate with immediate TE placement (13.8% vs 10.5% without FA, P = 0.018) and was associated with higher reoperation (12.0% vs 8.3% without FA, P = 0.037) in the TE group. There was no difference in other individual complications, readmission, or explantation for either clinical group with and without FA. Regression analysis identified obesity (odds ratio, 1.32; P < 0.001) and younger age (odds ratio, 1.74; P < 0.001) to be associated with performing FA, whereas obesity, diabetes, and tobacco use were associated with higher complication rates. CONCLUSIONS: Younger and otherwise healthier obese patients were more likely to have FA. A greater proportion of DTI patients had FA than TE patients with improved outcomes in the former group and worse outcomes in the latter group. Obesity, tobacco use, and diabetes were associated with worse outcomes, whereas only obesity was associated with FA use.

Acellular Dermal Matrix Favorably Modulates the Healing Response after Surgery.

SUMMARY: When first described for breast reconstruction, the presence of acellular dermal matrices was associated with increased seroma formation and infection. However, clinical safety data have gradually improved with surgeon experience to an acceptable outcomes profile of acellular dermal matrix-assisted reconstruction when compared to submuscular implant coverage. In fact, acellular dermal matrix use potentially decreases capsular contracture rates and facilitates expansion for staged prepectoral breast reconstruction. Because of new regulatory requirements, the collection of unbiased, well-powered premarket approval data summarizing long-term clinical outcomes will be essential over the coming years to understand the clinical performance of acellular dermal matrix use in breast reconstruction. Currently, the authors can highlight the physiologic benefits of acellular dermal matrix use in breast reconstruction by evaluating the components of surgical wound healing that are favorably augmented by the implanted collagen substrate. Acellular dermal matrix takes advantage of the wound healing cascade to incorporate into the patient's tissues-a process that requires a coordinated inflammatory infiltrate and angiogenesis. The presence of acellular dermal matrix augments and modulates the wound healing process to its advantage by simultaneously increasing the invasion of appropriate cellular constituents to facilitate expeditious healing and accelerate angiogenesis. In this article, the authors summarize the wound healing literature to demonstrate the mechanisms acellular dermal matrices use to biointegrate and the literature in which cellular constituents and soluble growth factors are up-regulated in the presence of acellular dermal matrix. Lastly, the authors use their experimental observations of acellular dermal matrix incorporation to corroborate the literature.

Immunomodulation of Acellular Dermal Matrix Through Interleukin 4 Enhances Vascular Infiltration.

BACKGROUND: Acellular dermal matrix (ADM) supported implant-based reconstruction remains the most commonly performed mode of reconstruction after breast cancer. Acellular dermal matrix clinical usage has reported benefits but requires rapid and efficient vascular and cellular incorporation into the recipient to have the best outcomes. Orderly transition from M1 to M2 macrophage phenotypic profile, coordinated in part by interleukin 4 (IL-4), is an important component of vascular stabilization and remodeling. Using the ADM substrate as a delivery device for immunomodulation of macrophage phenotype holds the potential to improve integration. METHODS: Interleukin 4 was adsorbed onto ADM samples and drug elution curves were measured. Next, experimental groups of 8 C57BL/6 mice had 5-mm ADM discs surgically placed in a dorsal window chamber with a vascularized skin flap on one side and a plastic cover slip on the other in a model of implant-based breast reconstruction. Group 1 consisted of IL-4 (5 µg) adsorbed into the ADM preoperatively and group 2 consisted of an untreated ADM control. Serial gross examinations were performed with histology at day 21 for markers of vascularization, mesenchymal cell infiltration, and macrophage lineage. RESULTS: Drug elution curves showed sustained IL-4 release for 10 days after adsorption. Serial gross examination showed similar rates of superficial vascular investment of the ADM beginning at the periphery by day 14 and increasing through day 21. Interleukin-4 treatment led to significantly increased CD31 staining of vascular endothelial cells within the ADM over the control group (P < 0.05) at 21 days. Although vimentin staining did not indicate a significant increase in fibroblasts overall, IL-4 did result in a significant increase in expression of α-smooth muscle actin. The expression of macrophage phenotype markers Arginase1 and iNOS present within the ADM were not significantly affected by IL-4 treatment at the day 21 time point. CONCLUSIONS: Acellular dermal matrix has the potential to be used for immunomodulatory cytokine delivery during the timeframe of healing. Using implanted ADM as a delivery vehicle to drive IL-4 mediated angiogenesis and vascular remodeling significantly enhanced vascularity within the ADM substrate.

Understanding the Evidence and Improving Outcomes with Implant-Based Prepectoral Breast Reconstruction.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Describe the risks, benefits, and safety profile of prepectoral breast reconstruction. 2. Have knowledge of primary immediate and delayed prepectoral breast reconstruction techniques and secondary procedures required. 3. Describe data on outcomes of prepectoral breast reconstruction. SUMMARY: Once considered to have an unacceptable complication profile, prepectoral breast reconstruction is increasing in popularity because of decreased surgical invasiveness and postoperative pain and the absence of animation deformity. Short-term outcomes studies comparing prepectoral breast reconstruction to partially submuscular techniques demonstrate similarly acceptable rates of postoperative complications. Aesthetic outcomes demonstrate similar rates of capsular contracture but increased rippling and implant palpability of the upper pole. Postoperative functional data are limited but overall show decreased pain and more rapid return of function but equivalent satisfaction on the BREAST-Q. Long-term aesthetic data and rates of revision are lacking.

Systemic Fibrocyte Levels and Keloid Expression of the Chemoattractant CXCL12 Are Upregulated Compared With Patients With Normal Scar.

BACKGROUND: Fibrocytes are bone marrow mesenchymal precursors with a surface phenotype compatible with leukocytes, fibroblasts, and hematopoietic progenitors that have been shown to traffic to wound healing sites in response to described chemokine pathways. Keloids are focal fibrotic responses to cutaneous trauma characterized by disordered collagen, which may be associated with elevated systemic fibrocyte levels and/or wound bed chemokine expression. METHODS: Blood specimens from patients with longstanding keloids and those who form grossly normal scars were assayed by fluorescence activated cell sorting analysis for fibrocytes (CD45+, Col I+). The expression of the fibrocyte chemotactic cell surface marker CXCR4, intracellular markers of fibroblast differentiation (pSMAD2/3), and plasma levels of the CXCR4 cognate CXCL12 were compared. Keloid specimens and grossly normal scars were excised, and local expression of CXCL12 was assayed. RESULTS: Keloid-forming patients demonstrated a significantly greater number of circulating fibrocytes (17.4 × 105 cells/mL) than control patients (1.01 × 105 cells/mL, P = 0.004). The absolute number of fibrocytes expressing CXCR4 was significantly greater (P = 0.012) in keloid-forming patients. Systemic CXCL12 levels were insignificantly greater in keloid-forming patients than controls. Keloid specimens had significantly greater CXCL12 expression (529.3 pg/mL) than normal scar (undetectable). CONCLUSIONS: Systemic fibrocyte levels and the CXCR4/CXCL12 biologic axis responsible for fibrocyte trafficking to areas of regional fibrosis were both upregulated in patients who form keloids compared with controls. Keloids persistently expressed CXLC12, which serves both as the main chemoattractant for fibrocytes and a downstream mediator for local inflammation, suggesting a role for this biologic axis in keloid formation and possibly recurrence.

Safety Profile and Predictors of Aesthetic Outcomes After Prepectoral Breast Reconstruction With Meshed Acellular Dermal Matrix.

INTRODUCTION: Prepectoral acellular dermal matrix (ADM)-assisted breast reconstruction has demonstrated improved pain scores, faster return to full range of motion, and an appropriate postoperative safety profile when compared with cohorts with submuscular implant placement; however, there are limited data on aesthetic outcomes. Basic science biointegration research has previously demonstrated faster ADM incorporation with fenestrated compared with confluent ADM. We report the safety profile of anterior support meshed ADM prepectoral breast reconstruction and analyze predictive factors for aesthetic outcomes after gel implant placement. METHODS: All consecutive immediate staged prepectoral expander-to-implant breast reconstructions with more than 6 months of follow-up were compared with a partially submuscular cohort for demographics, comorbidities, and postoperative complications. All patients 1 to 3.5 years after gel implant placement were evaluated for the impact of clinical characteristics on aesthetic outcomes. RESULTS: Two hundred twenty-four prepectoral tissue expander placements were compared with 535 partially submuscular tissue expanders with no significant differences in demographics. There was increased wound dehiscence repaired in clinic and insignificantly decreased seromas with prepectoral expander placement. One hundred sixty breasts were reconstructed with gel implants, and 12 underwent autologous reconstruction during the conduct of the study. The remaining 21 patients were continuing expansion, and 3 succumbed to disease progression. Regression analysis of 86 breast reconstructions showed that a body mass index of greater than 30, fat grafting, and highly cohesive anatomic implants decreased rippling, whereas radiation increased capsular contracture (P < 0.05). CONCLUSIONS: Prepectoral meshed ADM breast reconstruction has an equivalent safety profile to partially submuscular ADM-assisted reconstruction and early aesthetic ratings comparable with other published accounts of implant-based reconstruction. Radiated skin envelopes carry higher capsular contracture rates. Thin patients have a higher risk of visible rippling, whereas fat grafting and higher cohesivity implants are associated with less rippling.

The Biointegration of a Porcine Acellular Dermal Matrix in a Novel Radiated Breast Reconstruction Model.

BACKGROUND: Ideal acellular dermal matrices (ADM) for breast reconstruction exhibit native extracellular matrix (ECM) structure to allow rapid biointegration and appropriate mechanical properties for desired clinical outcomes. In a novel in vivo model of irradiated breast reconstruction, we describe the cellular and vascular ingrowth of Artia, a porcine product chemically prepared to mimic the biomechanics of human ADM, with retained natural ECM structure to encourage cellular ingrowth. METHODS: Utilizing the murine dorsal skinfold model, Artia was implanted into 16 C57bl/6 mice. Eight of the mice received a single dose 35 Gy radiation to the skin, followed by 12 weeks to produce radiation fibrosis and 8 mice served as nonradiated controls. Real-time photoacoustic microscopy of vascular integration and oxygen saturation within the ADM were made over 14 days. At 21 days, vascular ingrowth (CD31), fibroblast scar tissue formation (alpha smooth-muscle actin α-SMA, vimentin), and macrophage function (M2/M1 ratio) were evaluated. Scanning electron microscopy images of Artia were produced to help interpret the potential orientation of cellular and vascular ingrowth. RESULTS: Repeated photoacoustic microscopy imaging demonstrated vascular ingrowth increasing over 14 days, with a commensurate increase in oxygen saturation within both radiated and nonradiated ADM-albeit at an insignificantly lower rate in the radiated group. By day 21, robust CD31 staining was seen that was insignificantly greater in the nonradiated group. Of the fibroblast markers, vimentin expression was significantly greater in the radiated group (P < 0.05). Macrophage lineage phenotype was consistent with remodeling physiology in both radiated and nonradiated groups. Scanning electron microscopy demonstrated transversely organized collagen fibrils with natural porous ECM structure to allow cellular ingrowth. CONCLUSIONS: Artia demonstrates appropriate biointegration, with increased oxygen saturation by 14 days, consistent with the performance of other collagen substrates in this model. Radiation fibrosis resulted in higher vimentin expression yet did not impact macrophage phenotype while only modestly decreasing Artia biointegration suggesting that ADM may have a role in reconstructive efforts in a radiated setting. Taken together with its enhanced biomechanics, this porcine ADM product is well poised to be clinically applicable to breast reconstruction.

The Performance of Patient-Worn Actigraphy Devices to Measure Recovery after Breast Reconstruction.

INTRODUCTION: Annually, over 250,000 women are diagnosed with breast cancer with over one-third undergoing mastectomy and contemplating reconstruction. Surgical breast reconstructive options vary in post-operative recovery, yet with a paucity of objective data to inform women of their expected recovery after flap or implant-based reconstruction. As a result, patient decision-making is based primarily on surgeon preference and subjective data regarding perceived invasiveness of surgical options. This study aims to identify recovery outcomes of interest to breast cancer patients and to determine the feasibility of objectively measuring patient recovery after mastectomy and reconstruction using patient-worn actigraphy devices. METHODS: Three survivorship focus groups for patients after mastectomy with and without reconstruction were used to identify recovery outcomes they considered relevant. Cloud storage systems and actigraphy devices were piloted to determine performance. Actigraphy devices were worn by patients peri-operatively to measure post-operative sleep quality and steps taken, normalized to individual patient pre-operative control data. RESULTS: Focus groups identified sleep quality, return to activity (measurable with actigraphy), and driving as variables impacting surgical decision-making. We prospectively measured outcomes for four women undergoing immediate pre-pectoral tissue expander placement and four women undergoing immediate free flap reconstruction. Actigraphy data demonstrated an initial decrease in activity, increase in sleep variability and increased heart rate that approached the patients' pre-operative normalized data as they recovered over time. CONCLUSIONS: These data demonstrate that actigraphy data would be of interest to patients making breast reconstruction decisions and that the data can be successfully collected to inform decision-making.

Complex Reconstruction of a Pelvic Marjolin's Ulcer Arising from Hidradenitis Suppurativa.

The chronic inflammation of hidradenitis suppurativa can cause painful nodules, draining abscesses, sinus tracts, and fibrous scars. This long-term cutaneous inflammation in rare circumstances can lead to malignant transformation producing an aggressive cutaneous malignancy referred to as a Marjolin's ulcer. Particularly when a Marjolin's ulcer involves the sacral region, resection and reconstruction can be challenging. We present the case of a patient with a recurrent Marjolin's ulcer originating from a hidradenitis wound bed overlying and involving the sacrum. Previous radiation, large defect size, and sacral and perianal involvement necessitated the use of a multiflap approach. An extended transpelvic vertical rectus abdominis myocutaneous flap, bilateral gluteal advancement flaps, and a delayed transverse back flap were used to reconstruct the defect after abdominoperineal resection and nerve-sparing partial sacrectomy. Flap choice was derived by dividing the defect into anatomic subunits and considering intrapelvic defect volume, creating a systematic approach that led to successful reconstruction and functional restoration.

Fenestration Improves Acellular Dermal Matrix Biointegration: An Investigation of Revascularization with Photoacoustic Microscopy.

BACKGROUND: Acellular dermal matrices have revolutionized alloplastic breast reconstruction. Furthering our knowledge of their biointegration will allow for improved design of these biomaterials. The ideal acellular dermal matrix for breast reconstruction would provide durable soft-tissue augmentation while undergoing rapid biointegration to promote physiologic elasticity and reduced infectious complications. The inclusion of fenestrations in their design is thought to promote the process of biointegration; however, the mechanisms underlying this theory have not been evaluated. METHODS: Biointegration of standard and fenestrated acellular dermal matrices was assessed with serial photoacoustic microscopic imaging, in a murine dorsal skinfold window chamber model specifically designed to recapitulate the microenvironment of acellular dermal matrix-assisted alloplastic breast reconstruction. Photoacoustic microscopy allows for a serial, real-time, noninvasive assessment of hemoglobin content and oxygen saturation in living tissues, generating high-resolution, three-dimensional maps of the nascent microvasculature within acellular dermal matrices. Confirmatory histologic and immunohistochemical assessments were performed at the terminal time point. RESULTS: Fenestrated acellular dermal matrices demonstrated increased fibroblast and macrophage lineage host cell infiltration, greater mean percentage surface area vascular penetration (21 percent versus 11 percent; p = 0.08), and greater mean oxygen saturation (13.5 percent versus 6.9 percent; p < 0.05) than nonfenestrated matrices by 2 weeks after implantation. By 21 days, host cells had progressed nearly 1 mm within the acellular dermal matrix fenestrations, resulting in significantly more vascularity across the top of the fenestrated matrix (3.8 vessels per high-power field versus 0.07 vessels per high-power field; p < 0.05). CONCLUSIONS: Inclusion of fenestrations in acellular dermal matrices improves the recellularization and revascularization that are crucial to biointegration of these materials. Future studies will investigate the optimal distance between fenestrations.

Prepectoral Wise-Pattern Staged Implant-Based Breast Reconstruction for Obese or Ptotic Patients.

INTRODUCTION: The obese or ptotic breast demonstrates significant difficulty in breast reconstruction after mastectomy with increased rates of perioperative complications compared with the general population, regardless of reconstruction type. Implant-based reconstruction in this patient population with the traditional horizontal elliptical skin-sparing mastectomy tends to have aesthetically displeasing qualities secondary to skin flap redundancy and blunting of the breast contour. Wise-pattern closures have been described with submuscular direct-to-implant and 2-stage reconstructions, with more favorable complication profile when staged. Our study aims to report outcomes and safety of a prepectoral 2-stage wise-pattern closure technique in the obese and/or ptotic population. METHODS: A retrospective chart review was performed to identify all overweight, obese, and/or grade III ptotic patients who have undergone a 2-stage, wise-pattern skin closure with prepectoral placement of tissue expander by a single surgeon. Patient demographics, comorbidities, and perioperative descriptors were reported. Delayed wound healing, infection, seroma formation, and explantation or reoperation were recorded for each patient involved in the study. RESULTS: Thirty-seven obese and/or ptotic breasts among 21 patients underwent immediate prepectoral tissue expander placement with wise-pattern skin reduction closure with mean body mass index of 35.3 kg/m, and 25% of patients were diabetic The most common complication rates by breast were seroma formation (50%) and wound/dehiscence at T-point (28.6%), which all ultimately healed with intervention as described. One major (2.7%) and 1 minor (2.7%) infection were successfully treated with antibiotics. There were no cases of implant exposure. Two operative complex repairs and 1 elective explantation were performed. Diabetes and increasing body mass index were statistically associated with an increased overall perioperative complication rate. CONCLUSIONS: Prepectoral, 2-stage breast reconstruction with wise-pattern skin reduction performs well in obese and/or ptotic patients with favorable rates of perioperative complications. Wound dehiscence was prevalent but managed with wound care when complex repair was not required to expedite adjuvant chemotherapy. Infection rates and reoperation rates were low, and all patients reported positive aesthetic results at the completion of reconstruction.

Early Functional Outcomes After Prepectoral Breast Reconstruction: A Case-Matched Cohort Study.

INTRODUCTION: Staged, tissue expander-based implant reconstruction continues to be the most common mode of breast reconstruction after mastectomy and has evolved significantly for the past 60 years. Prepectoral acellular dermal matrix (ADM)-assisted breast reconstruction is gaining popularity with complication rates similar to total submuscular and ADM-assisted partially submuscular reconstruction. Ours is among the first reports comparing postoperative pain and early functional outcomes between 2-stage ADM-assisted prepectoral and partial submuscular breast reconstruction. METHODS: Patients reconstructed with a 2-stage, ADM-assisted prepectoral approach were case matched with patients who had undergone ADM-assisted, partial submuscular reconstruction. Demographics and complication rates were compared. Primary outcomes included postoperative pain, number of days until full active shoulder range of motion was achieved, and postoperative days until drain removal. RESULTS: Forty-five breasts among 24 patients were reconstructed with ADM-assisted prepectoral tissue expanders after mastectomy and 90 breasts among 48 patients were reconstructed with ADM-assisted partial submuscular placement. There was a similarly acceptable complication profile between the 2 groups. The prepectoral group had significantly lower inpatient pain scores, required significantly less intravenous opioids and less oral opioids as outpatients. The prepectoral group saw a return to full active range of shoulder motion in half the number days of the partial submuscular group. Drain duration was similar between groups. CONCLUSIONS: Prepectoral ADM-assisted breast reconstruction can be performed safely and with significantly less pain and earlier return to function than partial submuscular expander placement. Expander placement exclusively in the prepectoral pocket did not result in increased drain duration while affording patients the benefits of avoiding surgical elevation of the pectoralis muscle.

The Role of Triple-Antibiotic Saline Irrigation in Breast Implant Surgery.

Implant-based breast reconstruction accounts for more than 70% of all breast reconstructions, and breast augmentation is the most commonly performed cosmetic operation annually. The clinically significant impact of infection and capsular contracture after breast implant surgery has brought clinicians to create infection reduction protocols for both oncologic and cosmetic operations alike. The use of triple-antibiotic saline irrigation has become a recommended intraoperative maneuver within these protocols to minimize surgical site infections, but the constituents of the irrigation, its individual efficacy, and the acceptability of including povidone-iodine within irrigation recipes have been debated. This review will investigate the microbiological data behind the selection of the constituents of triple-antibiotic saline. In vitro testing of the effectiveness of topical antibiotics used in saline irrigation against microorganisms responsible for breast implant infection is reviewed. Clinical data are presented describing the impact of triple-antibiotic saline on implant infection and capsular contracture after cosmetic and reconstructive surgery.

Combined Gluteus and Pudendal Thigh Flap Reconstruction of Vaginal Defects following Robotic Abdominoperineal Resection.

Low-lying rectal cancers are being treated more frequently with robotic-assisted abdominoperineal resection, obviating the need for laparotomy and the ability to raise vertical rectus abdominis musculocutaneous flaps. For female patients, posterior vaginectomy often accompanies the resection. Combined pudendal thigh flaps as an extension of bilateral gluteus advancement flaps allow for posterior vaginal resurfacing with thin pliable fasciocutaneous flaps, which rest on the gluteal flap soft-tissue bulk that obliterates the pelvic dead space. For patients with advanced cancers who have had neoadjuvant chemoradiation, the pudendal skin paddle can be planned more laterally to bring in healthier medial thigh skin. The donor incisions lie within the gluteal cleft and crease and groin creases recapitulating normal perineal anatomy and aesthetics.