Prepectoral Versus Subpectoral Breast Reconstruction in High-Body Mass Index Patients.

BACKGROUND: The effect of body mass index (BMI) on complication rates in prepectoral implant-based breast reconstruction is not well established. The purpose of this study was to compare complication rates between different BMI groups in subpectoral and prepectoral reconstruction. METHODS: A single-surgeon, 4-year, retrospective review was performed of consecutive prosthetic breast reconstructions. During this time, the senior author's practice shifted from a subpectoral to prepectoral technique. Patients were stratified into BMI subgroups (<25, 25-35, and >35 kg/m2) and complication rates were analyzed. A survey was administered to blinded medical personnel and patients comparing esthetic results. RESULTS: Implant-based reconstructions were performed in 195 patients (103 subpectoral and 92 prepectoral). No significant difference in major complication rate was observed between techniques. Among patients with BMI greater than 35 kg/m2, implant exposure occurred at a significantly higher rate in the prepectoral group (P = 0.04). In patients with BMI greater than 25 kg/m2, minor asymmetry was more prevalent with prepectoral reconstruction (12.3% vs 0%; P = 0.02). Regardless of technique, the odds of reoperation increased by 7% per point increase in BMI, although this did not reach statistical significance (P = 0.07; odds ratio, 1.07; 95% confidence interval, 0.99-1.15).A total of 66 survey responses were received. Physicians rated esthetic results more positively than patients did. Patients with a BMI of less than 25 kg/m2 were rated better than other BMI groups in nearly all categories. The position of submuscular reconstruction was rated significantly better than prepectoral. CONCLUSIONS: There is a trend toward higher complication rates in prepectoral versus subpectoral breast reconstruction with increasing BMI. Nonetheless, the technique appears to be safe, with comparable clinical and cosmetic results.

Broadening applications and insights into the cross-paramedian forehead flap over a 19-year period.

BACKGROUND: Forehead flap reconstruction of large nasal defects can be challenging. The senior author has used a paramedian forehead flap modification using the supratrochlear artery on the contralateral side of the defect. METHODS: A 9-year retrospective review (2008-2016) was performed for patients undergoing nasal reconstruction with the cross-paramedian forehead flap. Outcomes were analyzed by comparing our previous reviews, which allows us to analyze patient outcomes for over 19 years. RESULTS: Fifty-three patients were identified. The aasal defect was most frequently due to basal cell carcinoma (n = 37, 69.8%). Twenty-three (43%) patients were smokers, and nine (17%) had diabetes. The mean defect size was 12.9 cm2, involving an average of 2.6 nasal subunits. One-third of the patients had cartilage defects (n = 18) and mucosal lining defects (n = 19). Periorbital involvement was present in five patients. Complications included partial flap loss (n = 6), donor site dehiscence (n = 4), flap dehiscence (n = 2), and postoperative infection (n = 1). Only two of the partial flap losses were considered significant, as they required additional reconstructive procedures for soft tissue coverage. Complications were 12 times as likely as those in diabetes (OR = 11.97, p = 0.007, 95% CI 1.94-72.44), six times as likely as those in cartilage defects (OR = 6.4, p = 0.007, 95% CI 1.64-24.92), and nearly five times as likely as those in mucosal lining defects (OR = 4.8, p = 1.27-18.09, 95% CI 1.27-18.09). Thirty-one patients required revisions most commonly for flap debulking (n = 16). CONCLUSION: The cross-paramedian forehead flap is a reliable option in the armamentarium of the reconstructive surgeon for large and complex defects in addition to those with periorbital extension. SUMMARY: Coverage of distal nasal defects after tumor extirpation remains a challenge to the reconstructive surgeon. Our institution uses the cross-paramedian forehead flap for these defects. This flap is based on the supratrochlear artery on the contralateral side of the defect and is oriented obliquely across the forehead for additional length and an improved donor site scar at the level of the eyebrow. The technique and outcomes were published in 2009, and this manuscript serves as an update on outcomes and applications during the past 9 years. By including all our data, we can analyze outcomes for over 19 years. During the past 9 years, 53 patients underwent the cross-paramedian forehead flap technique between 2008 and 2016. These patients were found to have an average defect size of 12.9 cm2 and an average loss of 2.6 nasal subunits. Cartilage defects were present in 34.6% (n = 18) and mucosal defects were present in 36.5% (n = 19) of patients. Five patients had periorbital reconstruction with the forehead flap, of which three patients underwent a single-stage islandized forehead flap reconstruction. Given the large defect size, additional local flaps were frequently used, including nasolabial flaps (n = 16) and cheek rearrangement (n = 11). Complications included partial flap loss (n = 6), donor site dehiscence (n = 4), and postoperative infection (n = 1). Only two of these partial flap losses were considered significant, as they required additional reconstructive procedures to address areas of soft tissue loss. Increased rates of complications were associated with the presence of diabetes and defect characteristics, which reflects increased complexity including mucosal and cartilage loss. When comparing with our prior review of this technique, the more recent population have had increasing complexity of the nasal defects with a large surface area involvement. Overall, the cross-paramedian forehead flap is a reliable option in the armamentarium of the reconstructive surgeon for large and distal nasal defects.

The Evolution from Subcutaneous to Prepectoral Prosthetic Breast Reconstruction.

Prosthetic breast reconstruction is the most common method of reconstruction offered to women following mastectomy. Prepectoral breast reconstruction has recently reemerged as an alternative technique to the partial and total muscle coverage methods. Though this technique has been demonstrated to be safe and effective in the recent published literature, many surgeons have been hesitant to adopt it out of fear of incurring the same complications associated with subcutaneous reconstructions of the past. However, recent advancements in plastic surgery including the use of acellular dermal matrices, autologous fat grafting, and improved breast implants and improved mastectomy techniques have enabled plastic surgeons to revisit the prepectoral space. In this review, the authors describe the evolution of prosthetic-based breast reconstruction from subcutaneous to prepectoral and review outcomes.

Nerve Repair with Nerve Conduits: Problems, Solutions, and Future Directions.

Nerve conduits are becoming increasingly popular for the repair of peripheral nerve injuries. Their ease of application and lack of donor site morbidity make them an attractive option for nerve repair in many situations. Today, there are many different conduits to choose in different sizes and materials, giving the reconstructive surgeon many options for any given clinical problem. However, to properly utilize these unique reconstructive tools, the peripheral nerve surgeon must be familiar not only with their standard indications but also with their functional limitations. In this review, the authors identify the common applications of nerve conduits, expected results, and shortcomings of current techniques. Furthermore, future directions for nerve conduit use are identified.

A case of Tannerite(®) target mixture causing severe blast injury.

Tannerite(®) is a proprietary blend of an oxidizer, ammonium nitrate, and aluminum powder catalyst used to make homemade exploding targets. While it is currently approved for unrestricted sale in the United States, it can be used to form devices capable of inflicting major blast injury. We present here a case of close proximity exposure to detonation of the mixed Tannerite(®) blend. In our patient, the exposure lead to injuries typical of blast injury, such as tympanic membrane rupture, globe injury, and severe burns. We review here the sequelae of blast injuries that one must consider when treating a patient with close proximity exposure to Tannerite, with considerations unique to this product.

KIF3a promotes proliferation and invasion via Wnt signaling in advanced prostate cancer.

UNLABELLED: Aberrant activation of the Wnt/ß-catenin signaling pathway is a critical event in advanced prostate cancer, but the genetic alterations that activate the Wnt signaling pathway in many other cancers are rarely observed in prostate cancer. Other molecular mechanisms that regulate the Wnt signaling pathway in prostate cancer remain to be identified. Here, it is demonstrated that KIF3a, a subunit of kinesin-II motor protein, functions as an agonist of the Wnt signaling pathway in prostate cancer. KIF3a is upregulated in the majority of human prostate cancer cell lines and primary tumor biopsies. The expression levels of KIF3a correlate with a higher Gleason score, tumor-node-metastasis stage, and metastatic status of prostate cancer. Moreover, exogenous expression of KIF3a promoted cell growth in the benign prostate cells, whereas silencing KIF3a in cancer cells decreased cell proliferation, anchorage-independent cell growth, and cell migration/invasion. Mechanistically, KIF3a increases CK1-dependent DVL2 phosphorylation and ß-catenin activation in prostate cancer cells, leading to transactivation of the Wnt-signaling target genes such as cyclin D1, HEF1, and MMP9. These findings support the notion that upregulation of KIF3a is causal of aberrant activation of Wnt signaling in advanced prostate cancer through the KIF3a-DVL2-ß-catenin axis. IMPLICATIONS: Inactivation of KIF3a may improve survival of patients with advanced prostate cancer in which Wnt signaling is activated.

Localization of the dominant deep inferior epigastric artery perforator by computed tomography angiogram: does the standard deep inferior epigastric artery perforator flap design include the dominant perforator?

BACKGROUND: The deep inferior epigastric artery perforator (DIEP) free flap is the optimal autogenous reconstructive technique in many patients undergoing postmastectomy. Our aim was to evaluate the standard DIEP free flap design in relation to the dominant perforating vessels using computed tomography angiography (CTA). METHODS: We retrospectively reviewed CTAs from 75 patients who had undergone perforator flap reconstruction within the past year. Locations of the largest perforator with a minimum diameter of 2.0 mm piercing the anterior rectus fascia were recorded. RESULTS: Of 150 hemiabdomens reviewed, 146 (97.3%) had a dominant perforator. The median location for the dominant perforator was 3.3 cm lateral and 0.9 cm below the umbilicus. One hundred twenty-one (83%) of the dominant perforators arose within 3 cm of the umbilicus. One hundred one (69%) arose at or below the level of the umbilicus. Forty-five (31%) arose above the level of the umbilicus. Thirteen (9%) arose more than 2 cm above the umbilicus. CONCLUSIONS: The standard DIEP flap design incorporates most of the dominant perforating vessels. However, a significant number of perforators arise at or above the umbilicus, which would be near the edge or out of the standard design of the DIEP. Our findings support the use of preoperative CTA in the evaluation of patients undergoing DIEP free flap reconstruction. Modification of flap design to include the dominant perforating vessels should be considered when the dominant vessel is outside the standard design of the DIEP.