Improved Diagnostic Accuracy of Periprosthetic Breast Infection: Novel Application of the Alpha Defensin-1 Biomarker.

Prompt, accurate diagnosis of breast implant infection is critical to minimizing patient morbidity. Bacterial culture false negative rate approaches 25%-30%, and better costeffective testing modalities are needed. Alpha defensin-1 (AD-1) is a neutrophil-mediated biomarker for microbial infection. With sensitivity/specificity of 97% and 96%, it has replaced culture as the preferred diagnostic modality for orthopedic periprosthetic infection, but has yet to be investigated in breast reconstruction. This pilot study compares the diagnostic performance of AD-1 to bacterial culture in suspected periprosthetic breast infection. METHODS: Patients with prosthetic breast reconstruction and suspected periprosthetic infection were prospectively studied. Implant pocket fluid was analyzed with gram stain and culture, AD-1 assay, and adjunctive markers. Demographics, operative history, prosthetic characteristics, and antibiotic exposure were collected, and diagnostic performance of each test was compared. RESULTS: Fifteen breasts with suspected periprosthetic breast infection were included, 10 (66.7%) of which were acutely infected. Gram stain correctly identified only 1 of 10 infections, whereas culture failed to identify 1 infection and reported equivocal/false-positives in 2 noninfected samples. AD-1, however, correctly classified all 15 samples. AD-1 exhibited 100% sensitivity and specificity, comparing favorably to culture (sensitivity: 90%, specificity: 60%), although this did not reach significance (P=0.22). Infected breasts also demonstrated significantly higher adjunctive marker levels compared to noninfected breasts. CONCLUSIONS: This study demonstrates the utility of AD-1 in diagnosing periprosthetic breast infection. Combining AD-1 with adjunctive inflammatory markers may allow more accurate, prompt detection of implant infection which may reduce morbidity and reconstructive failures.

Transabdominal Breast Augmentation: A Review of 114 Cases Performed over 14 Years.

BACKGROUND: Abdominoplasty patients are frequently candidates for breast rejuvenation as well. Transabdominal breast augmentation permits insertion of breast implants through the abdominoplasty incision. This combined procedure is preferentially performed in an outpatient setting under monitored anesthesia care and nerve blocks. METHODS: This study was a 14-year retrospective review of a single surgeon's technique and outcomes using transabdominal breast augmentation through a low transverse abdominoplasty incision in select patients requesting simultaneous abdominoplasty and bilateral breast augmentation. Patients had minimal ptosis, smoking cessation a minimum of 4 weeks before surgery and indefinitely thereafter, and a lack of superior abdominal or significant breast surgery. RESULTS: The study's 114 patients had a mean follow-up of 19.2 months. The procedure was performed under monitored anesthesia care with intercostal nerve blocks for most patients [n = 107 (93.9 percent)] and general anesthesia [n = 7 (6.1 percent)] for a few. Seventy-nine patients [n = 74 (64.9 percent)] underwent additional procedures, with most (n = 48) undergoing suction-assisted lipectomy. Many patients underwent multiple procedures. Most complications occurred predictably along the central distal abdominoplasty flap and were minor (small wound breakdown, seroma, and mild skin infection). Major complications [n = 8 (7.0 percent)] included two patients with implant malposition requiring revision and one patient with a Baker grade III capsule; notably, this patient was a half-pack-per-day smoker with a body mass index of 27 kg/m. CONCLUSIONS: Transabdominal breast augmentation is a safe, reliable procedure in the appropriately selected, healthy patient and may be used in minimally to moderately ptotic patients who request concurrent breast augmentation and abdominoplasty. Morbidity compares favorably to reported abdominoplasty series in the appropriately selected patient. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Septum-Inferior-Medial (SIM)-Based Pedicle: A Safe Pedicle with Well-Preserved Nipple Sensation for Reduction in Gigantomastia.

BACKGROUND: Reduction in breasts with well-preserved nipple sensation and a viable nipple-areola complex (NAC) is one of the basic core concepts of reduction mammoplasty. Many techniques have been described with enthusiasm advocating full achievement of the aforementioned goals. The goal of this study is to introduce a novel technique that provides an intact neurovascular source to the nipple-areola complex for reduction in gigantic breasts. PATIENTS AND METHODS: Twenty-six patients operated on from December 2010 through April 2015 were included in the study. The reduction was performed by isolating Wuringer's septum and the inferior pedicle in continuity with the medial pedicle to save the neurovascular supply to the NAC and its accompanying breast parenchyma. This pedicle is called as septum-inferior-medial-based pedicle. Inclusion criteria, marking and planning with detailed description of the surgical procedure are presented. RESULTS: The overall satisfaction rate was high. Eighty percent of the patients rated their results. The results were as follows: 81% rated as 'very satisfied'; 19% rated as 'somewhat satisfied.' NAC sensation was intact in all cases at all time intervals even immediately after surgery. CONCLUSION: The united pedicle technique provides an intact neurovascular source to the nipple-areola complex. Reduction with this pedicle is a safe procedure. Remodeling the gigantic breast can be accomplished without any restriction because of the flexibility of this pedicle. The very early results are promising, but long-term results needed to be evaluated. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Calf contouring with endoscopic fascial release, calf implant, and structural fat grafting.

BACKGROUND: Curved lower legs cause psychological stress for women. In evaluating the shape, if thickness is the main contributing factor of leg aesthetic, then lipoplasty or calf reducing procedures will be the option. If the legs are slender and have no muscle hypertrophy but still have some indentation or bulges on both sides and lack an aesthetic shape what will be the options? The answer to the question is discussed in detail in this article. METHODS: Twenty-two patients, operated over a period of 5 years from 2007 to 2012, were included in the study. A novel technique has been introduced. This method requires release of fascia covering muscles of the inner leg bulge via endoscopic approach and simultaneous calf augmentation with calf implant, liposuction, and structural fat grafting to optimize the results. RESULTS: Patients were followed on a regular basis with a mean follow-up of 31 months. The procedure was well tolerated with minimal discomfort during the postoperative period. Increase in diameter of proximal and distal lower legs was measured at least 6 months after surgery. Mean diameter change of proximal lower legs was 2.16 cm and 1.77 cm in distal lower legs. CONCLUSIONS: A novel endoscopic approach for lower leg contouring is discussed. Endoscopic fasciotomy technique with calf implant and structural fat grafting for improved lower leg aesthetics is a simple, effective, reliable, and predictable technique for calf contouring.

Augmentation mammaplasty by reverse abdominoplasty (AMBRA).

BACKGROUND: The purpose of this article is to describe a novel technique of providing autologous tissues for breast augmentation and simultaneously rejuvenating the abdomen. METHODS: Thirty-seven patients underwent augmentation mammaplasty by reverse abdominoplasty (AMBRA) between 1997 and 2006. The upper abdominal pannus present in women whose lower abdomen was typically less aesthetically compromised was harvested as deepithelialized adipofascial flaps, maintaining their connection to and thus blood supply from the attached breast parenchyma. These flaps are transposed subglandularly, creating autologous tissue breast implants, and reverse abdominoplasty accomplishes donor-site closure and aesthetic improvement. If previous surgery or inadequate inframammary fold tissue thickness renders the superior circulation unfavorable, the upper abdominal tissues can be used as advancement flaps vascularly supplied by their attachment to the abdominal skin apron. RESULTS: Twenty-three patients (62 percent) had simultaneous mastopexy and 16 (43 percent) had simultaneous panniculectomy. Complications in the superior pedicle group were minimal. In the inferior pedicle group, complications were more extensive because of the premorbidity of this group of patients and the limitations of this technique, where the resuspension of the abdominal wall apron is less facile and generally weaker than closure with superiorly based flaps. CONCLUSIONS: Augmentation mammaplasty by reverse abdominoplasty is a versatile procedure that in the carefully selected patient can successfully address two aesthetic concerns simultaneously, providing durable autologous tissue that can obviate or enhance the outcome provided by prosthetic implants and rejuvenating the abdomen. It also shows promise as a significant adjunct to the techniques available to the breast reconstructive surgeon.

Implant-based breast reconstruction with allograft.

BACKGROUND: Reconstructive breast surgeons often prefer autologous tissue for those patients who can tolerate it. However, reconstruction with implants is technically easier, quicker, less traumatic, and less costly. Nevertheless, inherent problems associated with implants present some limitations to their use in reconstruction. In this study, a multipurpose application of allogenic dermal grafts to solve the problems seen in immediate breast reconstruction with implants was examined. METHODS: After skin-sparing mastectomy, a subpectoral pocket is created for the implant. After the origins of the pectoralis major muscle are released, AlloDerm is sewn to the lower pole of the released muscle. Grafts are tailored according to the dimensions of the defect. AlloDerm, an allogenic dermal graft, is fixed to the pectoralis major superiorly, to the chest wall inferiorly and inferomedially, and to the serratus anterior flap laterally. A postoperative adjustable implant is placed into the pocket that has bene created. RESULT: Allografts were used to reconstruct 30 breasts in 24 patients immediately after skin- or nipple-sparing mastectomy. There was no complication related to simultaneous allograft application. No rippling, symmastia, or bottoming-out deformity was seen. CONCLUSIONS: Breast reconstruction with implant and AlloDerm enables the surgeon to create a submuscular pocket large enough to place a fully inflated breast implant. Interposition of a lower-pole internal sling, to increase the capacity of the pectoralis major pocket while providing immediate ability to achieve full or subtotal prosthetic fill and optimal aesthetic breast contouring and to maintain thicker muscle coverage in the upper and medial pole areas and stronger lower pole support, would obviate many of the current disadvantages to implant reconstruction.

Does sustained epinephrine release trigger a hypoxia-neovascularization cascade?

BACKGROUND: Recent data regarding the long-term local administration of epinephrine to soft tissues for the purpose of inducing prolonged vasoconstriction have yielded promising results. These studies postulated that long-term release of epinephrine by a microsphere/drug delivery system caused continuous vasoconstriction and subsequent vascular augmentation. The goal of this study was to test the hypothesis that epinephrine induces a hypoxia-neovascularization cascade and plays a primary role in vascular proliferation within soft tissues. METHODS: Thirty male New Zealand White rabbits were randomly grouped as follows: group I, control (n = 10); group II, saline-loaded microsphere/drug delivery system injection (n = 10); and group III, epinephrine-loaded microsphere/drug delivery system injection (n = 10). A 2 x 1-cm rectangle was marked on the dorsal surface of the left ear of each rabbit. No solutions were injected in the control group, whereas 1 ml of saline-loaded and epinephrine-loaded microspheres was injected into groups II and III, respectively. A laser Doppler device was used to measure tissue blood volume and tissue blood flow. RESULTS: Laser Doppler monitoring in tissue blood flow yielded a distinct difference between the epinephrine-loaded microsphere-injected group and the other two groups (p < 0.05). CONCLUSIONS: The ability of epinephrine-loaded microspheres to augment the vascular network in vivo is the result of sustained vasoconstriction with consequent tissue hypoxia and subsequent neovascularization. Data extracted from the present study, first, might be applied to improve hemostasis for operations typically plagued by serious intraoperative blood loss. Second, the ability to intentionally augment the vascularity of certain flaps before elevation should result in their increased survival. Radiation-injured tissues may also derive great benefit from this treatment.

Effect of long-term application of epinephrine on rat skin vasculature: experimental study.

As a potent vasoconstrictor, epinephrine is used ubiquitously in plastic surgery. It is typically delivered subcutaneously in very low concentrations over a brief time interval. We are aware of no reports describing the long-term release of epinephrine as an independent agent to the soft tissues for the purpose of causing prolonged local vasoconstriction. This study was designed to address two goals: first, to investigate the effect of long-term local release of epinephrine from a drug delivery system on rat abdominal skin vasculature; secondly, to evaluate the pharmacological properties of this drug delivery system (DDS). Thirty male Sprague-Dawley rats, weighing 300-400 g, were included in the study. Animals were subdivided into two groups of 15 each. Group A (control group) and Group B (experimental group) were treated with saline and epinephrine-loaded microspheres (msps), respectively. The manufacturing process and formulation studies of the DDS are described. In vivo assays revealed a 7-day sustained release of epinephrine. After 7 days, neither residual nor supraphysiologic release of epinephrine was shown with high-performance liquid chromatography (HPLC). Histological studies with hematoxylin-eosin and periodic acid Schiff revealed a statistically significant increase in number of vessels as well as their diameter and wall thickness (P <0.05). Epinephrine release via this msp/DDS predictably induces local vasoconstriction over a time sequence known to be optimally associated with hypoxia and promotion of vascular augmentation. This model can be valuable in sustaining hemostasis during long-lasting (more than a few hours) surgical procedures by its long-acting vasoconstructive effect. The system's ability to intentionally cause vascular augmentation also bodes great potential in flap and graft surgery.

Chemical delay: an alternative to surgical delay experimental study.

The delay phenomenon has long been recognized as a powerful adjunct to flap surgery. Currently, delay procedures remain a reliable method of maximizing flap survival. Although delay yields successful results, the necessity of an additional surgical procedure is a persistent disadvantage from both clinical and economic perspectives. The authors' purpose is to demonstrate the usefulness of a novel chemical delay technique that obviates the need for a surgical delay procedure. This technique contains an epinephrine-loaded microsphere delivery system. In this study, 30 rats were subdivided into three groups of 10 animals. In group I, transverse rectus abdominis musculocutaneous (TRAM) flaps were delayed surgically 1 week before formal elevation. Group II (sham chemical delay) animals were injected with saline-loaded microspheres into the entire undersurface of the proposed TRAM flaps, which were elevated 1 week later. In group III rats, epinephrine-loaded microspheres were injected into the undersurface of the TRAM flaps to initiate a chemical delay 1 week before surgical elevation. Groups were compared via TRAM flaps 1 week after elevation. There was a significant difference between groups I and III in favor of surface area viability and angiographic assessment (p < 0.05). Surgical delay has traditionally been accepted to be the most reliable method of enhancing flap viability. Statistically similar results were obtained by chemical delay initiated by epinephrine-loaded microspheres. Chemical delay is less invasive, less time-consuming, and far more cost-effective compared with its surgical alternative. The chemical delay model lends further support to the role of relative hypoxia as the primary promoter of the delay phenomenon.