Nipple-Areola Complex Reconstruction.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Understand how to determine nipple-areola complex positioning on the reconstructed breast. 2. Understand the multitude of local flap and distant graft options for nipple-areola complex reconstruction. 3. Draw at least three fundamental nipple-areola complex reconstruction patterns. 4. Understand the forces that are responsible for flattening of the reconstructed papule. 5. Understand the current techniques used in secondary nipple-areola complex reconstructions. SUMMARY: Nipple-areola complex reconstruction and tattooing represent the final two stages of breast reconstruction. Nipple-areola complex reconstruction is typically accomplished with the use of local flaps, local flaps with augmentation grafts, or a combination thereof. Regardless of the technique used, however, all nipple-areola complex reconstructions lose a degree of projection over time. Options for secondary reconstruction include the use of local tissue flaps alone or in combination with acellular biological matrices.

Comparison of Synthetic and Biologic Mesh in Ventral Hernia Repair Using Components Separation Technique.

Ventral hernia repair (VHR) for large abdominal wall defects is challenging. Prior research established that the use of mesh is superior to suture closure alone and that component separation is an effective technique to combat loss of abdominal domain. Studies comparing component separation technique (CST) outcomes utilizing synthetic versus biologic mesh are limited. A retrospective review was conducted of 72 consecutive patients who underwent VHR with CST between 2006 and 2010 at our institution. Surgeon preference and the presence of contamination guided whether synthetic mesh (27 patients) or biologic mesh (45 patients) was used. Mean follow-up interval for all comers was 13.9 months and similar in both groups (P > 0.05). Degree of contamination and severity of premorbid medical conditions were significantly higher in the biologic mesh group, as reflected in the higher Ventral Hernia Working Group (VHWG) score (2.04 versus 2.86). Clinical outcomes, as measured by both minor and major complication rates and recurrence rates, were not significantly different. Minor complication rates were 26% in the synthetic group and 37% in the biologic group and major complication rates 15% in the synthetic group and 22% in the biologic group. There was 1 recurrence (4%) in the synthetic mesh group versus 5 (11%) in the biologic mesh group. Multivariable analysis for major complications revealed no significant difference for either synthetic or biologic mesh while controlling for other variables. Subset analysis of uncontaminated cases revealed recurrence rates of 4% in the synthetic mesh group and 6% in the biologic mesh group. VHR using CST and either synthetic mesh or biologic mesh resulted in low recurrence rates with similar overall complication profiles, despite the higher average VHWG grading score in the biologic mesh group. Our results support the VHWG recommendation for biologic mesh utilization in higher VHWG grade patients. In VHWG grade 2 patients, our clinical outcomes were similar, supporting the use of either type of mesh.

Comparison of vertical and oblique rectus abdominis myocutaneous flaps for pelvic, perineal, and groin reconstruction.

BACKGROUND: Wound complications after perineal and groin obliterative procedures are a significant cause of morbidity, particularly following chemoradiation therapy. Vertical and, increasingly, oblique rectus abdominis myocutaneous flaps have been used to fill potential dead space and bring healthy, vascularized tissue into the defect. The authors compared the complications and outcomes of patients undergoing perineal or groin reconstruction with vertical or oblique rectus abdominis myocutaneous flaps. They hypothesized that the oblique flap offers outcomes similar to those of the vertical flap, without an increased risk of complications. METHODS: All patients who underwent immediate reconstruction of perineal, pelvic, or groin defects using vertical (n=49) or oblique rectus abdominis myocutaneous (n=22) flaps over the past 10 years at the University of Washington Medical Center were reviewed retrospectively. Patient, disease, and obliterative procedure characteristics and donor- and recipient-site complications were compared. Statistical analysis was performed using the t test for continuous variables and Fisher's exact test for categorical variables. RESULTS: There were no statistically significant differences in major or minor donor- or recipient-site complication rates, need for augmented fascial closure, need for additional flaps, flap loss, readmission, or reoperation rate between the two groups. CONCLUSIONS: Immediate reconstruction of perineal or groin defects with oblique rectus abdominis myocutaneous flaps results in complication rates similar to those with reconstruction using with vertical flaps. Oblique flap reconstruction is a reasonable and safe alternative, providing several distinct advantages over the vertical flap, including greater arc of rotation, thinner skin paddle, less bulk, and limited fascial harvest. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Implantable Cook-Swartz Doppler probe versus Synovis Flow Coupler for the post-operative monitoring of free flap breast reconstruction.

BACKGROUND: The Cook-Swartz Doppler has long been a trusted tool for close monitoring of blood flow after microvascular reconstruction; however, device implantation requires additional operating time. Synovis Life Technologies, Inc. received FDA approval in 2010 for the Flow Coupler, which combines an end-to-end anastomotic coupler with a removable 20 MHz Doppler, allowing both procedures to be performed simultaneously. However, its short history of widespread use necessitates further evaluation in the clinical setting. The authors studied the Synovis Flow Coupler in comparison to the more well-established Cook-Swartz Doppler for effectiveness and reliability in detection of vascular compromise. METHODS: The authors reviewed 220 free flap breast reconstructions in 150 patients over a three-year period in which either the Cook-Swartz Doppler or the Synovis Flow Coupler was implanted to monitor blood flow. Outcomes measured include false-positive or false-negative rates (FPR, FNR); rates of OR take-back and salvage; and flap survival. RESULTS: FPR was 1.0% for the Cook-Swartz Doppler and 1.9% for the Synovis Flow Coupler (p>0.05). FNR was 0.0% for both groups. Take-back rates were 10.1% for the Cook-Swartz, and 4.5% for Synovis (p>0.05). Flap failure rates were 1.8% and 0.9% for the Cook-Swartz and Synovis devices, respectively (p>0.05). CONCLUSIONS: Our study reveals no statistically significant differences in outcomes for free flap breast reconstruction where either the Cook-Swartz Doppler or the Synovis Flow Coupler was used to monitor blood flow to the perforator flap. LEVEL OF EVIDENCE: III.

Comparison of outcomes using AlloDerm versus FlexHD for implant-based breast reconstruction.

BACKGROUND: Prosthetic reconstruction using human acellular dermis (ADM) is a common practice in breast reconstruction. AlloDerm and FlexHD are two different forms of ADM, each with unique characteristics. No studies have directly compared the postoperative complications of these 2 products. METHODS: The outcomes of 547 consecutive implant-based breast reconstructions were reviewed. RESULTS: Reconstruction was performed in 382 consecutive women (547 total breasts), employing mostly immediate reconstruction (81%). Mean follow-up was 6.4 months. Among immediate reconstructions, 165 used AlloDerm and 97 used FlexHD. Complications were similar by univariate analysis. In multivariate analysis, smoking and higher initial implant fill were risk factors for delayed healing. The use of FlexHD, single-stage reconstruction, and smoking were independent risk factors for implant loss. CONCLUSIONS: There is no significant difference in the complication rates between AlloDerm and FlexHD in immediate breast reconstruction. Multivariate analysis suggests that FlexHD may be a risk factor for implant loss.

Clinical utility of CT angiography in DIEP breast reconstruction.

BACKGROUND: CT angiography has become the gold-standard imaging modality prior to DIEP flap breast reconstructions. Recent studies show excellent correlation between CTA and operative perforator location, but not their clinical significance. This study seeks to specifically evaluate the clinical utility of CTA in DIEP free flaps. METHODS: Preoperative CT angiography of the deep inferior epigastric system was obtained in 52 sequential DIEP free flaps involving 37 patients with dominant perforators marked by radiologist. Planned and used perforators were documented by the surgeon before and after the operation. RESULTS: A total of 62 out of 76 planned perforators were ultimately used (82%). Of those not used, 71% were abandoned due to inadequacy of preoperative CT. An additional 38 perforators were used that were not part of the initial preoperative plan, 60% of which were added due to inadequacy of the preoperative CT for planning. In total 23/52 flaps (44%) involved intraoperative changes due to features not appreciated on preoperative CT. CONCLUSION: CTA mapping of perforators prior to DIEP flap surgery increases surgeon confidence and reduces operative time; however, there are still a significant number of changes made based on clinical judgment. This study highlights the importance of surgeon review of CTA images. Caution is warranted in reliance on CTA mapping, and significant perforators should not be sacrificed until the anticipated perforator(s) have been exposed and evaluated. LEVEL OF EVIDENCE: Level 3.

Duration of antibiotics after microsurgical breast reconstruction does not change surgical infection rate.

BACKGROUND: Infection rates for breast surgery are 3 to 15 percent, higher than average for a clean surgical procedure. Preoperative and postoperative antibiotics have lowered infection rates in other surgical groups, yet there is no consensus on postoperative prophylactic antibiotic use in microsurgical breast reconstruction. METHODS: A retrospective review of consecutive patients who underwent autologous breast reconstruction between 2006 and 2009 was performed. Specific risk factors for autologous reconstruction were reviewed, including medical comorbidities, irradiation, and chemotherapy history. Data were collected on type and duration of prophylactic antibiotics. A prospective cohort of patients who received only 24 hours of postoperative antibiotics was identified. The incidence of surgical-site infections was measured using Centers for Disease Control and Prevention criteria. RESULTS: A total of 256 patients with 360 microvascular breast reconstructions who received both preoperative and postoperative prophylactic antibiotics were analyzed. The overall surgical-site infection rate was 17.2 percent (44 of 256 patients). Surgical-site infection was correlated with increased age, tobacco use, and prior radiation. Duration of postoperative antibiotic use did not differ in those patients who developed surgical-site infections (6.2 versus 7.7 days; p = 0.19). Eighty-two patients (32 percent) received only 24 hours of postoperative antibiotics, while 174 (68 percent) received more than 24 hours of antibiotics for a median duration of 10 days. There was no difference in the overall surgical-site infection rate in those who received more than 24 hours of antibiotics (19.5 versus 15.5 percent; p = 0.47). CONCLUSION: There was no reduction in the overall surgical-site infection rate among autologous breast reconstruction patients who received postoperative antibiotic prophylaxis for more than 24 hours. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Quantifying tissue level ischemia: hypoxia response element-luciferase transfection in a rabbit ear model.

Ischemia is a common underlying factor in a number of pathologic conditions ranging from cardiac dysfunction to delayed wound healing. Previous efforts have shown the resulting hypoxia activates the hypoxia inducible factor, a transcription factor with signaling effects through an intranuclear hypoxia response element (HRE). We hypothesized that ischemic conditions should activate these hypoxic signaling pathways in a measurable manner. We tested our hypothesis using variations of an established rabbit ear ischemic wound model and an HRE-luciferase-reporter gene construct. This plasmid construct was transfected into the ears of young, female New Zealand White rabbits, harvested at day 7 and processed to yield a reactive solution. Luminometry was used to quantify luciferase expression in each solution as a marker for HRE activation in each wound. Quantitative readings of hypoxic signaling as measured by luminescence yielded profound and statistically significant differences between the various ischemic models. Our results suggest that the biologic systems for hypoxic signaling can be used to detect local ischemia. HRE-luciferase transfection is an effective tool for quantifying the degree of tissue hypoxia. The caudal ischemic rabbit ear model showed significantly higher levels of hypoxia. Use of a validated model that produces sufficient tissue levels of hypoxia is recommended for meaningful study of ischemic wound healing.

Reconstruction of the pelvic floor and perineum with human acellular dermal matrix and thigh flaps following pelvic exenteration.

BACKGROUND: Patients who undergo pelvic floor resection as treatment for recurrent cancer following radiation therapy have increased rates of complications, particularly if permanent prosthetic mesh is used for reconstruction. Human acellular dermal matrix (HADM), commonly used for reconstruction in other torso locations, is associated with lower rates of complications (including infection, adhesions and cutaneous exposure) than synthetic mesh. We describe an effective technique to reconstruct the pelvic floor and perineum with HADM and thigh-based flaps following pelvic exenteration and radical vulvectomy. CASE: A 75-year-old woman underwent radical resection of the pelvic floor and perineum to treat recurrent vulvar squamous cell carcinoma and osteoradionecrosis. The pelvic floor and perineal soft tissue defect were reconstructed with HADM (AlloDerm; LifeCell Corporation, Branchburg, NJ) and bilateral, thigh-based tissue flaps, respectively. Despite a large resection, previous irradiation therapy and bacterial contamination the wounds healed without complications. CONCLUSION: Reconstruction of pelvic floor defects using HADM is an option when wound conditions are unfavorable for the use of permanent prosthetic meshes.

Anterior thoracic spine reconstruction using a titanium mesh cage and pedicled rib flap.

STUDY DESIGN: A retrospective clinical study. OBJECTIVES: To evaluate the safety and efficacy of using an integrated titanium mesh cage and pedicled rib flap for thoracic spine reconstruction in patients at high risk of pseudarthrosis. SUMMARY OF BACKGROUND DATA: A variety of materials are available for interbody thoracic reconstruction; however, the optimal treatment of patients at high risk of pseudarthrosis remains a challenging problem. Free or pedicled bone flaps have been shown to be highly effective in terms of promoting fusion and titanium mesh cages provide excellent structural support. METHODS: Eleven patients who underwent anterior thoracic corpectomy and spinal reconstruction using an integrated titanium mesh cage and pedicled rib flap were analyzed with a mean follow-up of 37 months (range, 25-55 months). The etiology of spinal disease was infection in 7 (64%) patients and tumor in the remaining 4 (36%) patients. Seven (64%) patients were treated with only an anterior approach while the remaining 4 (36%) patients underwent circumferential spinal reconstruction. RESULTS: All patients demonstrated clinical and radiographic evidence of spinal fusion at the time of follow-up. All patients had stable or improved Frankel grades after surgery. There was a mean kyphosis correction of 7 degrees for both the focal and regional thoracic kyphosis. There were three significant postoperative complications: bilateral pleural effusion, gram-negative bacteremia, and transient right lower extremity weakness requiring reoperation and pedicle screw revision. Two patients died after surgery: one from aneurysmal subarachnoid hemorrhage and the other from complications of breast cancer. CONCLUSIONS: The use of an integrated rib flap and titanium mesh cage construct appears to be a safe and effective means of providing immediate and substantial anterior column support as well as achieving arthrodesis in challenging fusion candidates.

Revisiting upper eyelid anatomy: introduction of the septal extension.

BACKGROUND: The current trend in plastic surgery of the eyelid has taken on increased dependence on anatomical considerations in the marriage of aesthetic and functional ideals. Often, the plastic surgeon performs ptosis and/or septal surgery in conjunction with blepharoplasty. The relationship between eyelid adnexal structures and upper eyelid function is a delicate but critical one. Current anatomical description states that the septum does not reach the superior tarsal border and inserts at a variable level on the levator aponeurosis. Conflicting observations in clinical practice stimulated this study to delineate the septal relationship to surrounding structures. In addition, this study may help to explain the increased rate of recurrence in ptosis repairs that incorporate plication techniques. METHODS: Dissection of four fresh cadaveric upper lid specimens in situ along with hematoxylin and eosin and trichrome stains of harvested eyelid tissue were used to redefine septal anatomy. Clinical case correlations are made to illustrate the significance of the histologic findings. RESULTS: A distinct septal extension was demonstrated arising from the orbital septum and covering preaponeurotic fat and tarsus completely. Histology of the anterior lamellae confirmed the presence of this thin fibrous sheet. In vivo assessment of this structure verifies its dynamic role in upper lid function. The clinical ramifications of this anatomical nuance are realized. CONCLUSIONS: A septal extension to the ciliary margin of the upper eyelid is established. Suture plication of the septal extension can induce lid elevation, with potential postoperative lid retraction. Intraoperative failure to recognize and distinguish this extension from the aponeurosis proper may lead to the high reported rates of unsuccessful ptosis correction. This refinement of septal anatomy should increase precision and help surgeons avoid complications in advanced blepharoplasty and ptosis surgery.

Transdermal sustained-delivery oxygen improves epithelial healing in a rabbit ear wound model.

HYPOTHESIS: Transdermal sustained-delivery oxygen therapy improves wound healing. DESIGN: Experimental study using a well-established rabbit ear model for acute wound healing. SETTING: Wound-healing research laboratory in a university center. METHODS: Four full-thickness 7-mm punch wounds were created on each ear of young, female New Zealand white rabbits. Treated ears received transdermal sustained delivery of oxygen via silicone tubing tunneled subcutaneously to a pocket under a semiocclusive dressing. Oxygen production (100% oxygen at 3 mL/h continuously) relied on a small, self-contained device connected to the silicone tubing and secured to the rabbit's back for the duration of the experiment using a body harness. Ears were harvested at each of 2 time points: day 5 and day 8. RESULTS: Histologic analysis of the wounds showed significantly greater healing at both day 5 and day 8 in response to oxygen therapy. Most significantly, epithelial wound coverage was almost doubled in treated ear wounds when compared with controls. CONCLUSION: Our results suggest that epithelial wound healing is improved by transdermal sustained-delivery treatment with 100% oxygen.

The future of wound healing: pursuing surgical models in transgenic and knockout mice.

BACKGROUND: Transgenic and knockout technologies have made determination of the molecular basis of wound healing possible. But there is no comprehensive or standardized approach to the investigation of wound healing in the mouse. A convention is proposed for assessing the multiple dimensions of wound healing. An approach to phenotyping a transgenic or knockout animal in a reproducible fashion is presented using this convention. STUDY DESIGN: Age- and gender-matched wildtype and knockout mice were characterized using six parameters of wound healing: epithelialization, granulation tissue formation, contraction, tensile strength, angiogenesis, and response to ischemia. Six surgical (four standard and two impaired) models were designed and used to quantitate these parameters. These models can be combined to efficiently maximize the data from any given subject. RESULTS: Each model leads to a rapid yield of results, with an average turnover of 4.9 days (range 3 to 7 days), and morbidity and mortality were minimal. A combinatorial approach elucidates the precise wound repair deficit of any subject. A case example is presented. CONCLUSIONS: Six surgical models investigating pertinent wound healing parameters are available. A factorial approach of quantitative wound healing assays maximizes data gathered from any one animal, minimizing the number of transgenic and knockout subjects needed; finely dissects molecular pathways of wound healing; and rapidly phenotypes a particular genetically altered mouse. We propose a standardized approach to wound healing assays that will elucidate critical cellular and molecular mechanisms and potential therapies.