Plastic Surgeons' Perspective on the FDA Breast Implant Regulatory Mandates.

BACKGROUND: In 2021, the US Food and Drug Administration (FDA) issued a new checklist, labeling and rupture screening recommendations for breast implants to improve the decision-making process. OBJECTIVES: This study aims to understand the plastic surgeon's perspective on these changes and their perceived impact on clinical practice. METHODS: In September 2023, a 27 multiple-choice cross-sectional survey was distributed to 4,352 active members of the American Society of Plastic Surgeons to evaluate attitudes on the FDA's black box warning, informed decision checklist, and updated rupture screening recommendations. RESULTS: A total of 591 responses were collected (13.6%). The majority of respondents were between the ages of 45 to 64 (58%) and had been in practice for more than 20 years (52%). Surgeons felt like some additions were appropriate, however the majority (57%) stated that the informed decision checklist did not have a positive impact on workflow; 66% were also neutral or disagreed with the reported incidence rates related to complications and cancer. Nearly half of respondents (47%) did not feel the black box warning improved their patients' understanding of the risks and benefits. Additionally, 47% of respondents also believed these requirements, in combination, did not improve the overall patient experience with implants. CONCLUSIONS: Respondents had an overall positive response towards the addition of risk information provided by the FDA issued guidance and updates to rupture screening recommendations. However, they remain divided as to whether the black box warning and patient decision checklist had an overall positive impact on clinical practice patterns.

Current Trends in Breast Reconstruction following Bilateral Prophylactic Mastectomy.

Background: Individuals with genetic susceptibility to breast cancer may pursue bilateral prophylactic mastectomy (BPM) and subsequent breast reconstruction. This study aimed to characterize immediate reconstructive trends following BPM. Methods: The ACS-NSQIP database (2010 -2019) was used to examine differences in demographics and operative outcomes based on breast reconstruction technique following BPM and factors predicting reconstruction type. Results: Of 1945 patients (mean age, 43.8 ± 11.3 years), implant-based reconstruction (IBR) was most frequently (71.8%) performed following BPM. Patients who underwent IBR (n = 1396) were younger (42.6 years, P < 0.001), more likely to be White (P < 0.05), and more likely to have a BMI less than 25 (P < 0.001). Patients who underwent autologous reconstruction (AR) (n = 186, 45.8 years) were more likely to be Black or African American and have a BMI of 25-30. Patients who underwent mastectomy only (MO) without immediate reconstruction (n = 363) were older (47.6 years), more likely to be Asian, and more likely to have a BMI greater than 35. The MO cohort had the highest frequency of diabetes or smoking history. AR was associated with longer operations, longer lengths of stay, and increased complications. Increasing age and BMI were predictive of AR or MO compared to IBR. Smoking was predictive of MO. Conclusion: This is the first large-scale study of genetically susceptible patients who underwent BPM demonstrating a significant relationship between patient demographics, operative outcomes, and immediate reconstruction technique. These results provide valuable insight for surgeons and patients during the shared decision-making process.

The Central Mound Pedicle: A Safe and Effective Technique for Reduction Mammaplasty.

BACKGROUND: The central mound technique offers a relatively less common approach for breast reduction. This study evaluated the expected safety and efficacy outcomes using this technique in a large patient series. METHODS: A retrospective review of all patients undergoing central mound breast reduction at the authors' institution between June of 1999 and November of 2018 was performed. Both bilateral macromastia and unilateral symmetrizing reduction patients were included but evaluated separately for some outcomes. Patient demographics and comorbidities, operative details, postoperative adverse events, and BREAST-Q scores were recorded. Associations between preoperative variables and outcomes were assessed with chi-square tests, Wilcoxon tests, and Kendall tau-b correlations. RESULTS: A total of 325 patients were identified for inclusion (227 bilateral and 98 unilateral; 552 breasts). The average patient age was 46 years, and the average body mass index was 27.4 kg/m. Among the bilateral macromastia patients, the average operative time was 3 hours 34 minutes, and average breast tissue removed was 533 g (right breast) and 560 g (left breast). Among all patients, average follow-up was 169 days. On a per-breast basis for all patients, the following complication rates were observed: seroma, 0.2 percent; hematoma, 1.1 percent; dehiscence, 2.9 percent; infection, 1.5 percent; hypertrophic scar, 4.6 percent; nipple necrosis, 0.4 percent; fat necrosis, 0.9 percent; and skin flap necrosis, 1.7 percent. Using the BREAST-Q Reduction/Mastopexy questions on a Likert scale ranging from 1 to 5, restricted to the bilateral macromastia patient population, all scores improved with statistical significance. CONCLUSION: The central mound pedicle is a safe and effective approach for reduction mammaplasty for both bilateral macromastia patients and unilateral symmetrizing operations. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Overview of Host Defense Peptides and Their Applications for Plastic and Reconstructive Surgeons.

BACKGROUND: Host defense peptides are a family of endogenous short peptides that are found in all living beings and play a critical role in innate immunity against infection. METHODS: A nonsystematic review of host defense peptides was conducted with specific interest in properties and applications relevant to plastic and reconstructive surgery. RESULTS: In addition to their direct antimicrobial actions against pathogens, including multidrug-resistant bacteria, they also demonstrate important functions in immunomodulation, tumor cell lysis, and tissue regeneration. These properties have made them a topic of clinical interest for plastic surgeons because of their potential applications as novel antibiotics, wound healing medications, and cancer therapies. The rising clinical interest has led to a robust body of literature describing host defense peptides in great depth and breadth. Numerous mechanisms have been observed to explain their diverse functions, which rely on specific structural characteristics. However, these peptides remain mostly experimental, with limited translation to clinical practice because of numerous failures to achieve acceptable results in human trials. CONCLUSIONS: Despite the broad ranging potential of these peptides for use in the field of plastic and reconstructive surgery, they are rarely discussed in the literature or at scientific meetings. In this review, the authors provide a summary of the background, structure, function, bacterial resistance, and clinical applications of host defense peptides with the goal of stimulating host defense peptide-based innovation within the field of plastic and reconstructive surgery.

Systematic Review of the Impact of Acellular Dermal Matrix on Aesthetics and Patient Satisfaction in Tissue Expander-to-Implant Breast Reconstructions.

BACKGROUND: Acellular dermal matrix is used in most postmastectomy implant-based breast reconstructions in the United States. It is believed to be safe, despite a slightly increased complication rate. Although never established in a unifying study, the primary advantage of acellular dermal matrix is believed to be an enhanced aesthetic result, thus justifying the added expense. The purpose of this study was to assess the aesthetic benefits of acellular dermal matrix in expander-to-implant breast reconstruction. METHODS: A systematic review adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses methodology was performed including all original studies examining aesthetic outcomes of expander-to-implant breast reconstructions with acellular dermal matrix compared to muscular coverage. Direct-to-implant and prepectoral studies were excluded from the evaluation. The results were aggregated and reported as a summary. RESULTS: Among 883 studies identified, 49 full-text articles were reviewed and nine articles ultimately met inclusion criteria. All nine studies were not randomized. Of these, three articles (1448 total patients) evaluated reconstruction aesthetic outcomes by patient satisfaction, whereas six articles evaluated the aesthetic outcomes by external observer (504 total patients). None of the articles evaluating patient satisfaction reported a difference between acellular dermal matrix and muscular reconstruction. Five of the six articles using objective outcomes demonstrated significant improvement in aesthetic outcome in the acellular dermal matrix group. CONCLUSIONS: Although little evidence exists evaluating the aesthetic benefits of acellular dermal matrix for expander-to-implant breast reconstruction, the data suggest that objective observers consider acellular dermal matrix-assisted expander-to-implant breast reconstructions aesthetically superior to reconstruction with only muscular coverage, but patients appear to be equally satisfied with both reconstructive options.

Peroxisome Proliferator-Activated Receptor-γ Knockdown Impairs Bone Morphogenetic Protein-2-Induced Critical-Size Bone Defect Repair.

The Food and Drug Administration-approved clinical dose (1.5 mg/mL) of bone morphogenetic protein-2 (BMP2) has been reported to induce significant adverse effects, including cyst-like adipose-infiltrated abnormal bone formation. These undesirable complications occur because of increased adipogenesis, at the expense of osteogenesis, through BMP2-mediated increases in the master regulatory gene for adipogenesis, peroxisome proliferator-activated receptor-γ (PPARγ). Inhibiting PPARγ during osteogenesis has been suggested to drive the differentiation of bone marrow stromal/stem cells toward an osteogenic, rather than an adipogenic, lineage. We demonstrate that knocking down PPARγ while concurrently administering BMP2 can reduce adipogenesis, but we found that it also impairs BMP2-induced osteogenesis and leads to bone nonunion in a mouse femoral segmental defect model. In addition, in vitro studies using the mouse bone marrow stromal cell line M2-10B4 and mouse primary bone marrow stromal cells confirmed that PPARγ knockdown inhibits BMP2-induced adipogenesis; attenuates BMP2-induced cell proliferation, migration, invasion, and osteogenesis; and escalates BMP2-induced cell apoptosis. More important, BMP receptor 2 and 1B expression was also significantly inhibited by the combined BMP2 and PPARγ knockdown treatment. These findings indicate that PPARγ is critical for BMP2-mediated osteogenesis during bone repair. Thus, uncoupling BMP2-mediated osteogenesis and adipogenesis using PPARγ inhibition to combat BMP2's adverse effects may not be feasible.

Latissimus Dorsi Flap Breast Reconstruction-A Nationwide Inpatient Sample Review.

INTRODUCTION: The latissimus dorsi (LD) myocutaneous flap has been a long term standard for breast reconstruction. The variable indications for the LD flap have not been statistically examined because of the relative infrequency of its use by any single surgeon or institution. METHODS: The Nationwide Inpatient Sample data set was queried for all patient encounters involving a LD myocutaneous flap procedure. The study population was further restricted to female patients with a history of breast cancer or previous mastectomy. Demographics, Charlson Comorbidity Index scores, previous radiation history, and additional simultaneous procedures were extracted. Analysis was performed using nonparametric correlation coefficients and linear regression models. RESULTS: In total, 2304 LD breast reconstruction hospitalizations were identified between 2008 and 2010. Average patient age was 52.1 years, average hospital length of stay (LOS) was 2.8 days, bilateral latissimus reconstruction was performed in 252 (10.9%) patients, and 1414 patients (61.4%) were delayed reconstruction. Previous irradiation was present in 389 (16.9%) patients and was correlated with delayed reconstruction (P < 0.001).Younger age was associated with bilateral latissimus reconstructions (P < 0.05), contralateral free flap reconstruction (P < 0.0001), and combination with implants or tissue expanders (both P < 0.0001).After adjustment for age and Charlson Comorbidity Index, increased LOS was observed in patients undergoing contralateral free flap reconstruction (+1.29 days, P < 0.05) and immediate reconstruction (mastectomy, +0.39 days unilateral, P < 0.05; +0.64 days, bilateral, P < 0.001). The use of tissue expanders and implants were found to decrease hospital LOS (bilateral implant, -0.65 days, P < 0.001; bilateral expander, -0.72 days, P < 0.001), likely from confounding comorbidities. Charlson Comorbidity Index was strongly related to LOS (+0.08 days per point, P < 0.005), whereas age was not statistically significant when considered with comorbidity. CONCLUSIONS: The LD is most commonly used for delayed or salvage breast reconstruction, with particular utility in irradiated patients. Younger patients tend to undergo more involved LD variants with bilateral reconstructions and expanders or implants. After adjusting for comorbidity, age and the use of bilateral latissimus flaps with implants or expanders have no adverse impact on LOS.

Comparison of immediate postoperative pain in implant-based breast reconstructions.

BACKGROUND: Implant-based techniques represent the most common form of breast reconstruction. However, substantial postoperative pain has been associated with implant-based breast reconstruction. OBJECTIVE: The objective of this study is to evaluate immediate postoperative pain in implant-based breast reconstruction. METHODS: We reviewed 378 patients who underwent implant-based reconstruction between January 2004 and December 2012. Each patient's visual analog scale (VAS) score, pain medication, and patient-controlled analgesia (PCA) attempts were used to assess in-hospital postoperative pain. We evaluated timing of reconstruction post mastectomy, tissue expander (TE) designed fill volume, TE initial fill volume, and single-stage immediate implant (II) versus TE reconstruction. RESULTS: No significant differences in pain parameters were noted between the immediate and delayed postmastectomy reconstruction cohorts. TEs with larger (>300 cc) designed volumes required significantly more narcotic use (p = 0.02) and PCA attempts (p < 0.01). Narcotic use was higher in the larger (>250-cc) TE initial fill group starting on postoperative day 2, but overall differences in VAS score and PCA attempts were not significant. Morphine equivalence (p < 0.01) and non-opioid oral analgesic use (average p = 0.03) of the TE cohort were significantly higher than those of the II cohort. CONCLUSION: Patients undergoing TE-based implant reconstruction show greater analgesic use than those with single-stage II-based reconstruction. This may indicate a higher immediate postoperative pain in TE procedures than in II procedures. Furthermore, higher initial fill and designed volume of TE require more morphine equivalence postoperatively. These findings may warrant further preoperative discussion for better pain management and patient satisfaction.

Implant-based immediate breast reconstruction in the previously augmented patient.

BACKGROUND: Millions of women have undergone augmentation mammaplasty with implants and breast cancer continuing to be the most common non-cutaneous malignancy in female patients. Reconstructive surgeons will inevitably encounter breast cancer patients with prior augmentation. Implant-based techniques represent the most common form of breast reconstruction overall and remains a common option among those who were previously augmented. OBJECTIVE: The purpose of this study is to evaluate outcomes of implant-based reconstruction in previously augmented women. METHODS: A retrospective review from September 2004 to December 2009 was performed. 38 women (63 breasts) with a history of prior augmentation (PA) who underwent implant-based reconstruction were identified and compared to a non-prior augmented (NPA) control group (77 patients; 138 breasts). Normative data, augmentation details, reconstruction method, complication rates, and revision rates were evaluated. RESULTS: The total complication rate was significantly different between the two groups with 18 complications (28.6%) occurring in 9 PA breasts and 20 complications (14.5%) in 19 NPA breasts (p-value 0.037). When analyzed by specific complication subtypes, capsular contracture was the only complication that bordered significance between the two cohorts (p-value 0.057). Complication rates were otherwise similar regardless of augmentation or reconstruction type. CONCLUSION: Implant-based reconstruction is a safe option for previously augmented patients that is able to provide outcomes similar to non-augmented patients. Results are not affected by the location of previous implants or the implant-based reconstruction method. There may be a higher incidence of capsular contracture in the previously augmented patient that warrants further investigation and preoperative discussion.

Comparison of postoperative pain control in autologous abdominal free flap versus implant-based breast reconstructions.

BACKGROUND: Women who undergo mastectomy and breast reconstruction are shown to express more pain than those who undergo mastectomy alone. The authors evaluated postoperative pain outcomes following breast reconstruction. METHODS: Patients undergoing primary implant-based (n = 1038) or flap-based (n = 837) reconstructions from 2004 to 2012 at the University of California, Los Angeles, were evaluated. Postoperative pain was measured using the visual analogue scale, total narcotic use, and number of patient-controlled analgesia attempts. Narcotic dosage was standardized to morphine equivalents per kilogram. The authors modeled postoperative narcotic use, patient-controlled analgesia attempts, and visual analogue scale scores over time using spline graphs for comparison between the two reconstruction methods. RESULTS: Both total narcotic use and patient-controlled analgesia attempts were higher in the implant-based group throughout the immediate postoperative period. Implant-based reconstruction patients had significantly higher visual analogue scale scores (p < 0.0001) and total narcotic use (p < 0.0001) through postoperative day 3 compared with autologous tissue-based reconstruction patients. When controlling for reconstruction method, bilateral procedures were more painful (visual analogue scale score and patient-controlled analgesia attempts, both p < 0.001). When controlling for laterality, unilateral implant-based and autologous reconstructions had comparable visual analogue scale scores (p = 0.38) and patient-controlled analgesia attempts. However, unilateral implant-based procedures required more narcotic use than unilateral autologous tissue-based procedures (p = 0.0012). CONCLUSION: Although commonly perceived as a less distressing operation, implant-based breast reconstruction may be more painful during the immediate postoperative hospitalization than abdominally based free tissue transfer. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

The effect of prior abdominal surgery on abdominally based free flaps in breast reconstruction.

BACKGROUND: The abdomen has long remained the preferred donor site in breast reconstruction. Over time, the flap has evolved to limit morbidity with reduced muscular harvest. Previous abdominal operations, however, may limit the ability to perform a muscle- or fascia-sparing flap. The purpose of this study was to evaluate outcomes in women who had prior abdominal operations and underwent abdominally based autologous breast reconstruction. METHODS: All patients who underwent abdominally based breast free flap reconstruction between 2004 and 2009 were reviewed. A study group of patients with previous open abdominal surgery were compared to patients with no prior abdominal surgery. Patient demographics, operative details, and flap and donor-site complications were analyzed. RESULTS: A total of 539 patients underwent abdominally based breast free flap reconstruction. The study group consisted of 268 patients (341 flaps) and the control group consisted of 271 patients (351 flaps). Prior abdominal surgery led to greater muscular harvest, as 19.9 percent in the study group versus 12.0 percent required muscle-sparing 1-type harvest (p < 0.01). Both groups presented similar overall complications, with the exception of lower partial flap loss and increased wound healing complications in the study group (p < 0.05). Abdominal wall laxity became less frequent with increasing number of prior abdominal operations. CONCLUSIONS: Abdominally based flaps for breast reconstruction, including muscle-sparing 3 (deep inferior epigastric perforator) flaps, can be performed safely in patients with prior abdominal surgery. These patients should be informed, however, of an increased chance of muscular harvest and wound healing complications. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Surgical management of silicone mastitis: case series and review of the literature.

BACKGROUND: Free silicone injection for breast augmentation, which became widespread in the 1960s and continues illicitly to this day, has well-known adverse effects. In this retrospective chart review of 14 patients treated for silicone mastitis from 1990 to 2002, we present our experience with the surgical management of patients with silicone mastitis. METHODS: All the patients were women, ranging in age from 49 to 76 years old (mean age = 58.8). Patients presented to us a mean of 29.9 years after their free silicone breast injection. Treatment modalities were analyzed, and, specifically, methods of breast reconstruction involving autologous tissue transfers, implants, or a combination were evaluated. RESULTS: The majority of patients (12 of 14) required mastectomies for extensive silicone-infiltrated tissues. The remaining two patients had focal areas of disease and were successfully treated with excision and local breast parenchyma flaps. Autologous reconstruction was performed with a total of 20 flaps, including 12 free transverse rectus abdominis myocutaneous flaps, 4 free superior gluteal artery perforator (SGAP) flaps, and 4 pedicled latissimus dorsi (LD) flaps. Two patients had bilateral implant-based breast reconstruction. CONCLUSION: A variety of reconstructive options are available for patients presenting with silicone mastitis. Once an appropriate breast cancer workup has been performed, the surgical goal is to excise as much of the silicone-infiltrated tissues as possible before reconstruction. To our knowledge, this is the first reported series that incorporates the use of SGAP and LD flaps as a means of autologous tissue reconstruction for silicone-infiltrated breasts. 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 .

Effects of radiation therapy for breast cancer based on type of free flap reconstruction.

BACKGROUND: Adjuvant radiation therapy for locally advanced breast cancer decreases local recurrence and improves survival. Immediate autologous breast reconstruction before postmastectomy irradiation is highly controversial. However, it is presently unknown whether there exist differences in the durability of various autologous flaps (myocutaneous or fasciocutaneous) to the effects of radiation. METHODS: All patients who underwent autologous breast reconstruction at the authors' institution between July of 2002 and July of 2005 were evaluated retrospectively. Patients who did not complete all stages of their reconstruction at the authors' institution were excluded. Free flap types were analyzed based on postoperative radiation exposure versus no radiation exposure. The authors also analyzed patients who underwent reconstruction in a delayed fashion with prior radiation exposure and assessed overall outcomes for early and late complications and secondary breast procedures. RESULTS: Three hundred sixty-three of 446 flaps (81 percent) were included in the analysis, with the three most common flaps being the free transverse rectus abdominis myocutaneous (TRAM) flap (7.4 percent), the muscle-sparing free TRAM flap (44 percent), and the deep inferior epigastric perforator flap (41 percent). There were no significant differences in early or late complications among the different flap types or radiation categories. Flaps with prior radiation exposure were associated with higher percentages of contralateral symmetry procedures, whereas flaps with postoperative radiation exposure had a lower incidence of ipsilateral revisions. CONCLUSIONS: Autologous breast reconstruction can be performed safely regardless of preoperative or postoperative radiation therapy. There are no significant differences in complication rates or number of revisions based on the type of free flap. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Salvage rates of compromised free flap breast reconstruction after recurrent thrombosis.

BACKGROUND: Microvascular complications after free flap breast reconstruction are devastating problems that increase patient morbidity and potentially lead to flap loss. Yet, there is a dearth of literature about rates of free flap salvage after recurrent vascular thromboses. METHODS: A retrospective review of all patients undergoing microvascular breast reconstruction at UCLA Medical Center from January 1991 to June 2010 was conducted. The incidence of microvascular thrombosis was evaluated and rates of flap salvage and complications were specifically analyzed after a single microvascular revision (Single Event), 2 or more revisions (Multiple Event), and delayed presentation (>2 days) with attempted salvage (Delayed Event). RESULTS: During the study period, 2094 free flap breast reconstructions were evaluated. Of these, 75 (3.6%) flaps suffered a microvascular complication and 16 (0.76%) flaps were lost. The overall salvage rate was 78.7% (59/75) with the highest salvage rate of 95.9% (47/49) for Single Events. Multiple Events had a salvage rate of 53.3% (8/15), whereas Delayed Events had a salvage rate of 27.3% (3/11). The salvage rate decreased with repeated microvascular events (P < 0.01). In the Multiple Event group, vascular conversion (alternate recipient vessel) correlated with improved flap salvage (87.5%), whereas the lack thereof was associated with flap loss (P < 0.001). CONCLUSIONS: The salvage rate of free flap breast reconstruction diminishes dramatically with recurrent microvascular complications, but can be improved with vascular conversion. The salvage rate in cases of delayed presentation is even worse confirming the need for vigilant postoperative monitoring and aggressive intervention in the setting of flap compromise.

Reconstructive surgery training: increased operative volume in plastic surgery residency programs.

BACKGROUND: Practitioners in other surgical specialties have increasingly advanced their volume of reconstructive procedures traditionally served by plastic surgeons. Because there has not been a previous specialty training comparison, the average operative reconstructive volume of graduating plastic surgery residents was formally compared with that of other specialties. METHODS: The authors review the case log statistical reports of the Accreditation Council for Graduate Medical Education. For each specialty, this annual report highlights the average number of cases performed for all graduating residents. The national case log reports were reviewed for orthopedic surgery, otolaryngology, and plastic surgery. Six procedures were compared for residents graduating in the 2006 to 2010 academic years and are reviewed. A two-sample Welch-Satterthwaite t test for independent samples with heterogeneous variance was conducted to compare the average number of procedures performed per graduating resident. RESULTS: Graduates of plastic surgery residencies compared with graduates of other specialties performed more cleft lip and palate repairs, hand amputation, hand fracture, and nasal fracture procedures. This difference showed statistical significance for all years examined (2006 to 2010). For repair of mandible fractures, plastic surgery trainees had significantly more cases for 2006 to 2009 but not 2010. CONCLUSIONS: The quantitative operative experience of graduating plastic surgery residents for selected reconstructive cases is above that of the average graduating trainee outside of plastic surgery. Given the exposure and strength of plastic surgery training, plastic surgeons should remain at the forefront of reconstructive surgery.

Vascular complications and microvascular free flap salvage: the role of thrombolytic agents.

BACKGROUND: Vascular thrombosis with flap loss is the most dreaded complication of microvascular free tissue transfer. Thrombolytic agents such as tissue plasminogen activator have been used clinically for free flap salvage in cases of pedicle thrombosis. Yet, there is a paucity of data in the literature validating the benefit of their use. METHODS: A retrospective review of the breast reconstruction free flap database was performed at a single institution between the years of 1991-2010. The incidence of vascular complications (arterial and/or venous thrombosis) was examined to determine the role of adjuvant thrombolytic therapy in flap salvage. Pathologic examination was used to determine the incidence of fat necrosis after secondary revision procedures. RESULTS: Seventy-four cases were identified during the study period. In 41 cases, revision of the anastamoses was performed alone without thrombolytics with 38 cases of successful flap salvage (92.7%). In 33 cases, anastamotic revision was performed with adjuvant thrombolytic therapy, and successful flap salvage occurred in 28 of these cases (84.8%). Thrombolysis did not appear to significantly affect flap salvage. Interestingly, only two of the salvaged flaps that had received thrombolysis developed fat necrosis, whereas 11 of the nonthrombolysed flaps developed some amount fat necrosis (7.1% vs. 28.9%, P < 0.05). CONCLUSIONS: The decreased incidence of fat necrosis may be attributable to dissolution of thrombi in the microvasculature with the administration of thrombolytics. Although the use of adjuvant thrombolytic therapy does not appear to impact the rate of flap salvage, their use may have secondary benefits on overall flap outcomes.

Immediate free flap reconstruction for advanced-stage breast cancer: is it safe?

BACKGROUND: Numerous studies have demonstrated that immediate breast reconstruction following mastectomy is associated with improvements in quality of life and body image. However, immediate breast reconstruction for advanced-stage breast cancer remains controversial. This study evaluates its safety in patients with advanced-stage breast cancer. METHODS: Over a 10-year period, patients diagnosed with stage IIB or greater breast cancer treated with mastectomy followed by immediate breast reconstruction were identified and analyzed. Complication rates and reconstructive aesthetics were determined. RESULTS: One hundred seventy patients were identified who underwent 157 unilateral and 13 bilateral reconstructions (183 flaps) predominantly by means of free transverse rectus abdominis musculocutaneous flaps (n = 162). The average age was 47 years and the average hospital stay was 5.1 days. There were 15 major complications (8.8 percent), but adjuvant postoperative therapy was delayed in only eight patients (4.7 percent), with the maximum delay lasting 3 weeks in one patient. Although some degree of flap shrinkage was noted in 30 percent of patients treated with postoperative radiotherapy, only 10 percent of patients experienced severe breast distortion. Importantly, the overall cosmetic outcome in patients who underwent postoperative irradiation was comparable to that of those who did not. CONCLUSIONS: The authors have shown that immediate breast reconstruction in the setting of advanced-stage breast cancer is safe and well tolerated by patients, and is not associated with significant delays in adjuvant therapy. These findings make a strong argument for immediate reconstruction regardless of cancer stage. The authors found the changes caused by radiation to the reconstructed breast to be less significant than previously reported and readily addressed to complete an ultimate reconstruction that is aesthetically acceptable to both surgeon and patient. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.(Figure is included in full-text article.).

Staged wise-pattern skin excision for reconstruction of the large and ptotic breast.

BACKGROUND: The postmastectomy reconstruction of large and/or ptotic breasts poses a more difficult aesthetic challenge than the reconstruction of small or moderately sized breasts because of an excessively large skin envelope in both horizontal and vertical dimensions. The Wise-pattern skin excision best addresses this excess skin but is associated with a high incidence of tissue necrosis with subsequent wound breakdown, primarily at the T point. To optimize the aesthetic potential and minimize complications in the setting of these large skin envelopes, the authors have deconstructed the single-stage Wise-pattern skin excision into a two-stage procedure, eliminating the need for a primary simultaneous T-point closure. METHODS: In the first stage, the mastectomy and reconstruction are performed using a vertical excision, which tightens the breast skin envelope horizontally. In the second stage, the redundant skin at the inframammary fold is excised horizontally, tightening the breast skin envelope vertically. The summation of the two staged excisions recreates the Wise pattern, breaking up the T point into two straightforward primary closures. RESULTS: Twelve patients (21 breasts) underwent successful reconstruction using the staged Wise-pattern skin excision. The breast size, shape, and projection of the patients were greatly improved without any wound complications. CONCLUSIONS: The staged Wise-pattern skin excision for breast reconstruction is a simple technique that delivers superior results for the challenging reconstruction of large and/or ptotic breasts. This method offers an aesthetically pleasing breast shape, allows for the correction of ptosis, eliminates wound complications, and results in a standard Wise-pattern scar.

Predictive factors in identifying subspecialty fellowship applicants who will have academic practices.

BACKGROUND: The challenge of subspecialty fellowship directors is to recruit surgeons who are motivated to continue the tradition of teaching by entering academic medicine. The authors looked for predictive factors to help with more accurate selection of applicants. METHODS: Application and follow-up data from plastic surgery subspecialty fellows in craniofacial surgery, hand surgery, and microsurgery from the University of California, Los Angeles were reviewed for the years 1987 through 2002 (n = 62). Fellows were divided into three groups as follows: group 1, full-time academic; group 2, part-time clinical faculty; and group 3, private practice at 1 year and 5 years after fellowship. Common factors of fellows within the three groups were listed. RESULTS: Although a majority of applicants (95 percent) indicated an aspiration to practice academic medicine, only one-third remained in full-time academics 5 years after their subspecialty training. There was a trend toward leaving academic practice: the rates at 1 year were 74 percent for group 1 (academic) and 5 percent for group 3 (private practice), but by 5 years this had equalized (group 1, 34 percent; group 3, 32 percent). Group 1 (academic) showed more academic productivity publications per year, academic titles, editorial boards, and active participation in medical societies compared with group 3 (private practice). The factors that were more common to group 1 were married or married with children, five or more publications, one or more years of research, and 7 or more years of training. CONCLUSION: Plastic surgery fellowship directors may look at the following predictive factors of applicants if they would like their graduates to carry on the tradition of teaching future plastic surgeons: (1) previous dedicated research training, (2) more years of clinical training, and (3) more scientific publications.