Nipple Reconstruction: Risk Factors and Complications after 189 Procedures.

BACKGROUND: A multitude of different approaches have been proposed for achieving optimal aesthetic results after nipple reconstruction. In contrast, however, only a few studies focus on the morbidity associated with this procedure, particularly after implant-based breast reconstruction. METHODS: Using a cross-sectional study design all patients who underwent implant-based breast reconstruction with subsequent nipple reconstruction between 2000 and 2010 at Stanford University Medical Center were identified. The aim of the study was to analyze the impact of the following parameters on the occurrence of postoperative complications: age, final implant volume, time interval from placement of final implant to nipple reconstruction, and history of radiotherapy. RESULTS: A total of 139 patients with a mean age of 47.5 years (range, 29 to 75 years) underwent 189 nipple reconstructions. The overall complication rate was 13.2 percent (N = 25 nipple reconstructions). No association was observed between age (p = 0.43) or implant volume (p = 0.47) and the occurrence of complications. A trend towards higher complication rates in patients in whom the time interval between final implant placement and nipple reconstruction was greater than 8.5 months was seen (p = 0.07). Radiotherapy was the only parameter that was associated with a statistically significant increase in postoperative complication rate (51.7 percent vs. 6.25 percent; p < 0.00001). CONCLUSION: While nipple reconstruction is a safe procedure after implant-based breast reconstruction in patients without a history of radiotherapy, the presence of an irradiated field converts it to a high-risk one with a significant increase in postoperative complication rate. Patients with a history of radiotherapy should be informed about their risk profile and as a result may choose autologous reconstruction instead. LEVEL OF EVIDENCE: IV.

Nipple reconstruction after implant-based breast reconstruction: a "matched-pair" outcome analysis focusing on the effects of radiotherapy.

BACKGROUND: The major focus of research when addressing nipple reconstruction has been on developing new techniques to provide for long-lasting nipple projection. Rarely, has the outcome of nipple reconstruction as it relates to postoperative morbidity, particularly after implant-based breast reconstruction, been analyzed. METHODS: A "matched-pair" study was designed to specifically answer the question whether a history of radiotherapy predisposes to a higher complication rate after nipple reconstruction in patients after implant-based breast reconstruction. Only patients with a history of unilateral radiotherapy who underwent bilateral mastectomy and implant-based breast reconstruction followed by bilateral nipple reconstruction were included in the study. RESULTS: A total of 17 patients (i.e. 34 nipple reconstructions) were identified who met inclusion criteria. The mean age of the study population was 43.5 years (range, 23-69). Complications were seen after a total of 8 nipple reconstructions (23.5 percent). Of these, 7 complications were seen on the irradiated side (41.2 percent) (p = 0.03). CONCLUSION: While nipple reconstruction is a safe procedure after implant-based breast reconstruction in patients without a history of radiotherapy the presence of an irradiated field converts it to a procedure with a significant increase in postoperative complication rate.

Facial bone density: effects of aging and impact on facial rejuvenation.

BACKGROUND: Facial bone aging has recently been described as primarily resulting from volume loss and morphologic changes to the orbit, midface, and mandible. OBJECTIVE: The authors demonstrate how the facial skeleton bone mineral density (BMD) changes with age in both men and women and compare these changes to those of the axial skeleton. They also explore the aesthetic implications of such changes in bone density. METHODS: Dual-energy X-ray absorptiometry (DXA) scans of the facial bones and lumbar spine were obtained from 60 white subjects, 30 women and 30 men. There were 10 men and 10 women in each of 3 age categories: young (20-40 years), middle (41-60 years), and old (61+ years). The following measurements were obtained: lumbar spine BMD (average BMD of L1-L4 vertebrae), maxilla BMD (the average BMD of the right and left maxilla), and mandible BMD (the average BMD of the right and left mandibular ramus). RESULTS: The lumbar spine BMD decreased significantly for both sexes between the middle and old age groups. There was a significant decrease in the maxilla and mandible BMD for both sexes between the young and middle age groups. CONCLUSIONS: Our results suggest that the BMD of the face changes with age, similar to the axial skeleton. This change in BMD may contribute to the appearance of the aging face and potentially affect facial rejuvenation procedures.

Aging of the facial skeleton: aesthetic implications and rejuvenation strategies.

BACKGROUND: Facial aging is a dynamic process involving the aging of soft-tissue and bony structures. In this study, the authors demonstrate how the facial skeleton changes with age in both male and female subjects and what impact these structural changes may have on overall facial aesthetics. METHODS: Facial bone computed tomographic scans were obtained from 60 female and 60 male Caucasian subjects. Twenty male and 20 female subjects were placed in three age categories (20 to 40 years, 41 to 64 years, and 65 years and older). Each computed tomographic scan underwent three-dimensional reconstruction with volume rendering. Edentulous patients were excluded. The following measurements were obtained: upper face (orbital aperture area, orbital aperture width, and curvilinear analysis of the superior and inferior orbital rims), midface (glabellar angle, pyriform angle, maxillary angle, and pyriform aperture area), and lower face (bigonial width, ramus breadth, ramus height, mandibular body height, mandibular body length, and mandibular angle). RESULTS: The orbital aperture width and orbital aperture area increased significantly with age for both sexes. There was a significant increase in orbital aperture size (increase in height of the superomedial and inferolateral orbital rim) in both sexes. The glabellar and maxillary angles decreased significantly with age for both sexes, whereas the pyriform aperture area significantly increased for both sexes with age. Mandibular length and height both decreased significantly for each sex. The mandibular angle significantly increased with age for both sexes. CONCLUSIONS: These results suggest that the skeletal morphology of the face changes with age. This change in skeletal morphology may contribute to the appearance of the aging face.

Overview of current thoughts on facial volume and aging.

Facial aging is a dynamic process involving the aging of soft tissue and bony structures. Much is known in regards to how the face loses volume as the soft tissue structures age. Epidermal thinning and the decrease in collagen cause skin to lose its elasticity. Loss of fat, coupled with gravity and muscle pull, leads to wrinkling and the formation of dynamic lines. The aging process has also been shown to affect the facial bones. Multiple studies suggest that the bony aging of the orbit and midface is a process primarily of contraction and morphologic change. This loss of bony volume and projection may contribute to the aged appearance. In this review, we will demonstrate how specific soft tissue and bony aspects of the face change with age in both genders and what impact these structural changes may have on overall facial aesthetics.

Aging of the mandible and its aesthetic implications.

BACKGROUND: Facial aging is a dynamic process involving the aging of soft-tissue and bony structures. In this study, the authors demonstrate how specific bony aspects of the mandible change with age in both genders and what impact these structural changes may have on overall facial aesthetics. METHODS: Facial bone three-dimensional computed tomographic scans were obtained from 120 Caucasian subjects (60 women and 60 men). Our study population consisted of 20 male and 20 female subjects in each of three age categories (20 to 40, 41 to 64, and > or = 65 years). Edentulous patients were excluded. The following measurements were obtained: bigonial width, ramus breadth, ramus height, mandibular body height, mandibular body length, and mandibular angle. The data were analyzed with one-way analysis of variance and two-tailed t tests, with results considered significant at a value of p < 0.05. RESULTS: There was no significant change with regard to bigonial width or ramus breadth across age groups for either gender. Ramus height, mandibular body height, and mandibular body length decreased significantly with age for both genders, whereas the mandibular angle increased significantly for both genders with increasing age. CONCLUSIONS: These results suggest that the bony elements of the mandible change significantly with age for both genders and that these changes, coupled with soft-tissue changes, lead to the appearance of the aged lower third of the face.

Periorbital skeletal augmentation to improve blepharoplasty and midfacial results.

BACKGROUND: Narrow palpebral fissures, short lower lids, and full cheeks are hallmarks of youthful periorbita. The presence of these features is predicated on a convex upper midface skeleton. Faces whose midface skeletons are flat or concave do not manifest these youthful attributes, tend to age prematurely, and are prone to lower lid malposition after blepharoplasty. METHODS: Augmentation of the infraorbital rim with alloplastic implants can provide convexity to the deficient upper midface skeleton. Suspension of the cheek soft tissues (subperiosteal midface lift) on this now supportive framework narrows the palpebral fissure, shortens the lower lid, and gives fullness to the cheek. The addition of lateral canthopexy to skeletal augmentation and subperiosteal midface lift can restore lower lid position when previous blepharoplasty has resulted in lower lid malposition in patients with deficient midface skeletons. RESULTS: This concept has been utilized in 87 patients (65 female, 22 male) over the last 7 years. Of these 87 patients, four patients (5 percent) required revision surgery to correct implant malposition or prominence. Three patients (3 percent) required implant removal to treat infection. Implants were later replaced in two of these three patients. CONCLUSIONS: Augmentation of the infraorbital rim with alloplastic implants provides convexity to the upper midface skeleton. Together with lower lid and midface soft-tissue suspension, it creates or restores youthful periorbital aesthetics.

Aging of the bony orbit: a three-dimensional computed tomographic study.

BACKGROUND: Facial aging is a dynamic process involving the aging of soft tissue and bony structures. The shape, size, and volume of the bony orbit have all been shown to change with increasing age. OBJECTIVE: In this study, we demonstrate how specific bony aspects of the orbit change with age in both male and female subjects and what impact this may have on the techniques used in facial cosmetic surgery. METHODS: Facial bone computed tomography (CT) scans were obtained from 60 white subjects (30 female, 30 male). Our study population consisted of 10 male and 10 female subjects in each of 3 age categories. Each CT scan underwent three-dimensional (3-D) reconstruction with volume rendering. Orbital aperture width was measured as a line drawn from the posterior lacrimal crest to the frontozygomatic suture. This line was then used as the x-axis from which the distance to the superior and inferior orbital rim at nine equal increments (labeled 10 to 90) was obtained. The orbital aperture area was also measured on each 3-D model. The Student t test was used to identify any trends between age groups. RESULTS: The orbital aperture width and area in both our male and female subjects showed a significant increase with increasing age. There was a significant increase in height of the superior orbital rim medially in both genders, suggesting that the superior orbital rim receded with age in this region. The inferior orbital rim receded significantly laterally in our female population, while our male subjects had a recession of the entire inferior orbital rim. CONCLUSIONS: These results suggest that the bony elements of the orbit change dramatically with age, and this, coupled with soft tissue changes, can lead to the appearance of the aged eye and orbit.

The timing of implant exchange in the development of capsular contracture after breast reconstruction.

OBJECTIVE: Capsular contracture is a common complication associated with reconstructive breast surgery. The optimal time interval between the completion of tissue expansion and placement of the permanent implant is arbitrary and incompletely studied in the literature. The aim of the study was to determine whether the time interval between completion of expansion and placement of the permanent implant would affect the incidence of capsular contracture. METHODS: We conducted a retrospective study of 112 patients with breast cancer, including 140 breasts, who underwent postmastectomy tissue expander placement between 1997 and 2004. All patients underwent replacement of tissue expander with a permanent prosthesis. Data were collected retrospectively, including whether the patient smoked, underwent radiation therapy, had saline or silicone implant reconstruction, required reoperation after tissue expander placement or after permanent implant placement, Baker classification, and the interval between completion of expansion and placement of permanent implant. RESULTS: We used a logistic regression model to incorporate the predictors of capsular contracture. Keeping all other predictors constant, we found that the time interval between implant exchange had no effect on capsular contracture. The only significant predictor of capsular contracture was whether the patient required a reoperation after the permanent implant was placed (P = .0001). CONCLUSIONS: Allowing the capsule around a tissue expander to mature does not significantly affect development of capsular contracture. However, a complication that necessitates disrupting the periprosthetic capsule of the permanent implant with an operation significantly increases odds of developing contracture.

Internal maxillary distraction with a new bimalar device.

PURPOSE: Distraction osteogenesis of the Le Fort I segment is advocated for patients who require significant advancement of the maxilla or who have a soft tissue envelope compromised by scar tissue. We present a technique for maxillary distraction using an interconnecting intraoral device anchored to the malar prominences above the osteotomy and either the maxilla and/or the dentition below the level of the osteotomy. MATERIALS AND METHODS: Ten patients with nonsyndromic cleft lip and palate, mean age of 18, underwent Le Fort I maxillary distraction osteogenesis for management of maxillary hypoplasia. A Le Fort I osteotomy is performed and a Spectrum Intraoral Midface Multi-Vector Distractor (OsteoMed, Addison, TX) is placed leaving a 1 mm to 2 mm distraction gap. After a 2 to 4 day latency period, distraction begins at a rate of 1 mm a day. Once the desired occlusion is achieved the device is left in place for a minimum of 2 months for consolidation. RESULTS: Preoperative Sella-Nasion-A point measurements from lateral cephalograms averaged 74 degrees (range, 70-76 degrees). Postoperative Sella-Nasion-A point averaged 81 degrees (range, 75-89 degrees). Preoperative overjet averaged -7.4 mm (range, -3 to -13 mm). Postoperative overjet averaged 2.6 mm (range, 1-3 mm). Average distraction was 9 mm (range, 6-16 mm). The average vertical movement was 7.2 mm in an inferior direction (range, 0-15 mm). The results remained stable at a follow-up of 30 months. CONCLUSIONS: We report on distraction of the Le Fort I segment using an internal device. The device design allows the forces of distraction to be shared across a larger surface area delivering a uniform and reliable vector of distraction with increased stability.

Aging of the midface bony elements: a three-dimensional computed tomographic study.

BACKGROUND: The face loses volume as the soft-tissue structures age. In this study, the authors demonstrate how specific bony aspects of the face change with age in both men and women and what impact this may have on the techniques used in facial cosmetic surgery. METHODS: Facial bone computed tomographic scans were obtained from 60 Caucasian patients (30 women and 30 men). The authors' study population consisted of 10 male and 10 female subjects in each of three age categories. Each computed tomographic scan underwent three-dimensional reconstruction with volume rendering, and the following measurements were obtained: glabellar angle (maximal prominence of glabella to nasofrontal suture), pyriform angle (nasal bone to lateral inferior pyriform aperture), and maxillary angle (superior to inferior maxilla at the articulation of the inferior maxillary wing and alveolar arch). The pyriform aperture area was also obtained. The t test was used to identify any trends between age groups. RESULTS: The glabellar and maxillary angle in both the male and female subjects showed a significant decrease with increasing age. The pyriform angle did not show a significant change between age groups for either sex. There was a significant increase in pyriform aperture area from the young to the middle age group for both sexes. CONCLUSIONS: These results suggest that the bony elements of the midface change dramatically with age and, coupled with soft-tissue changes, lead to the appearance of the aged face.

Laparoscopic repair for recurrent abdominal wall hernia after TRAM flap breast reconstruction: case report of 2 patients.

BACKGROUND: The transverse rectus abdominis musculocutaneous (TRAM) flap is an appealing option for women choosing between various breast reconstructive techniques as it results in an autologous reconstructed breast that is soft and mimics a natural breast. Despite these benefits, there are complications with this procedure, such as pain at the donor site, longer scars, and most frequently the occurrence of abdominal wall hernia or bulge, which has been reported in up to 20%-40% of patients. METHODS: In this case report, we share our experience with 2 patients who had multiple open hernia repairs, 5 between the 2 of them, after their TRAM flap surgery. Each of these 5 repairs was performed with a Prolene mesh overlay, but not one lasted for more than 6 months. After reviewing our patients' records and our surgical options, we decided to proceed with laparoscopic repair of their recurrent hernias. RESULTS: The patients are now at postoperative follow-up of 12 months and 15 months, with no evidence of recurrence. DISCUSSION: Laparoscopic surgery has many benefits, such as shorter hospitalization and decreased pain. For our patients, it also resulted in a more beneficial and longer-lasting repair. We believe that this is partly due to the mechanics of the repair, which allows the abdominal contents to buttress the mesh against the abdominal wall. In addition, we believe that this technique reinforces the posterior sheath, which may not be accomplished in an open repair. This is important as most hernias after TRAM flap surgery occur below the arcuate line. From our experience with these 2 patients, we now advocate the use of laparoscopic repair as a treatment option for those who present with recurrent abdominal wall hernia or bulge after their TRAM flap surgery and believe with more experience it will become a first-line treatment.