Using Clinical Measurements to Predict Breast Skin Necrosis: A Quantitative Analysis.

BACKGROUND: Breast skin necrosis can lead to poor healing, reoperation, and unaesthetic reconstructive outcomes after mastectomy. Furthermore, the prolonged recovery can delay adjuvant oncologic regimens. This study aims to explore the role of breast surface area as a risk factor for mastectomy skin flap necrosis and to identify predictive clinical measurements. METHODS: The authors retrospectively identified patients who underwent immediate breast reconstruction (N = 926 breasts) by 2 surgeons at a single institution between 2011 and 2021. Preoperative breast measurements such as nipple-notch (NN) distance, nipple-inframammary fold (NF) distance, chest width (CW), breast circumference (BC), and breast height (BH) were used to estimate breast surface area. Univariate analysis and receiver operating characteristic curves were used to determine predictive measurements and optimal cutoff values. RESULTS: When approximated using either a cone without base or a half ellipsoid, larger surface area was a significant risk factor for mastectomy skin flap necrosis (P = 0.027 and P = 0.022, respectively). Larger NN, NF, CW, BC, and BH measurements were significant predictors of necrosis (P < 0.05). Surface area (cone without base) greater than 212 cm2, surface area (half ellipsoid) greater than 308 cm2, NN distance greater than 27 cm, NF greater than 8.5 cm, CW greater than 15 cm, BC greater than 29 cm, and BH greater than 10.5 cm are all values shown to increase the incidence of necrosis. CONCLUSIONS: Larger breast surface area is an independent risk factor for breast skin necrosis. Preoperative breast measurements can be a useful adjunct for predicting necrosis in postmastectomy patients.

A Comparative Analysis of Risk Factors for Breast Skin Necrosis following Autologous versus Device-Based Breast Reconstruction.

BACKGROUND: Mastectomy skin flap necrosis often necessitates prolonged wound care, surgical re-excision, and it increases the risk for infection. This study aims to compare rates of skin flap necrosis between autologous and device-based reconstructions and identify risk factors. METHODS: The authors retrospectively identified patients who underwent immediate breast reconstruction using either the deep inferior epigastric perforator (DIEP) flap (n = 373 breasts, 41%) or tissue expanders (n = 529 breasts, 59%) by two surgeons at a single institution between 2011 and 2021. The rate of skin flap necrosis between autologous and device-based reconstructions was compared and multivariate regression analysis was performed to identify risk factors. RESULTS: There was no significant difference in rates of skin flap necrosis between the two cohorts (26.8 vs. 15.5%, p = 0.052). Across all patients, hypertension and body mass index >30 were significant predictors of necrosis (p = 0.024 and p <0.001, respectively). Within our DIEP cohort, mastectomy specimen weight was a significant risk factor for necrosis (p = 0.001). The DIEP flap weight itself did not confer a higher risk for necrosis (p = 0.8). CONCLUSION: Immediate autologous reconstruction does not place patients at higher risk of skin necrosis. Hypertension and obesity (body mass index >30) were independent risk factors for necrosis in all patients. Mastectomy specimen weight was a significant predictor of necrosis in DIEP flap patients while the DIEP flap weight itself did not increase the risk for necrosis.

A Comparison Between Immediate and Babysitter Deep Inferior Epigastric Perforator Flap Breast Reconstruction in Postoperative Outcomes.

BACKGROUND: Delayed-immediate, or "babysitter," deep inferior epigastric perforator (DIEP) flap reconstruction, defined as immediate tissue expander or implant placement at the time of mastectomy followed by eventual exchange for DIEP flap, is becoming increasingly popular in breast cancer patients anticipated to receive adjuvant radiotherapy. In this study, we aim to compare delayed-immediate to immediate DIEP flap patients in postoperative outcomes including major complications and surgical site morbidity. METHODS: A retrospective cohort study between immediate and delayed-immediate DIEP flap patients was performed. Patient demographics, comorbidities, and preoperative cancer treatment were compared between the 2 cohorts. Clinical outcomes of interest included dehiscence, necrosis, and infection of the breast, abdomen, and umbilicus in the 90-day postoperative period as well as breast hematoma, anastomotic failure, flap loss, and venous thromboembolism. RESULTS: Of the 248 patients (443 breasts) included in this study, 193 women (344 breasts) and 55 women (99 breasts) were in the immediate and delayed-immediate cohorts, respectively. The 2 cohorts were comparable in age, body mass index, and comorbidities (P > 0.05). Despite significantly higher rates of preoperative cancer treatment (P < 0.05), delayed-immediate patients were not at an elevated risk for major complications. The 2 cohorts were also comparable in surgical site outcomes, with the exception of breast skin necrosis, which was significantly higher in incidence in the immediate cohort (16.0% vs 2.0%, P < 0.001). CONCLUSIONS: This study is the first to directly compare delayed-immediate to immediate DIEP flap reconstruction in postoperative outcomes. Our findings show that babysitter DIEP flaps are a safe option for patients, even in those expected to undergo breast irradiation preoperatively.

Explantation in Tissue Expander and Direct-to-Implant Reconstruction with Acellular Dermal Matrix: How to Avoid Early Reconstructive Failures.

BACKGROUND: In the United States, approximately 57,000 tissue expander/implant-based breast reconstructions are performed each year. Complete submuscular tissue expander coverage affords the best protection against implant exposure but can restrict lower pole expansion. The benefits of using acellular dermal matrix are enticing, but questions remain as to whether or not its presence increases reconstructive failures. The purpose of this study was to investigate predictors of explantation in those patients with acellular dermal matrix reconstructions and to discuss salvage techniques. METHODS: An approved retrospective review was conducted of 137 patients undergoing 234 individual breast reconstructions over 4 years performed by a single plastic surgeon (J.D.) at a single institution. Patients who underwent implant-based reconstruction with either immediate placement of a tissue expander that was subsequently exchanged for a permanent implant at a second operation or immediate placement of a permanent implant when indicated were included. RESULTS: One hundred thirty-seven patients who underwent 234 implant-based breast reconstructions using acellular dermal matrix met criteria. There was an overall 23 percent complication rate, including any cellulitis, seroma, skin necrosis, and hematoma formation. Significant preoperative risk factors for any postoperative complication included body mass index greater than 25 kg/m2 and a history of radiation therapy before acellular dermal matrix placement. Radiation therapy was found to be a significant risk factor for postoperative skin necrosis. Of explantations, many fluid cultures grew Gram-negative bacteria. CONCLUSIONS: Skin necrosis is a serious risk factor for explantation in implant-based reconstruction with acellular dermal matrix. The reconstructive surgeon should consider early excision of any skin necrosis as soon as it is identified. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Muscle Flap Closure following Complex Spine Surgery: A Decade of Experience.

BACKGROUND: Advances in surgical technology and adjuvant therapies along with an aging and increasingly morbid U.S. population have led to an increase in complex spine surgery. With this increase comes an elevated risk of complications, including those related to the surgical wound, with some studies demonstrating wound complication incidences approaching 45 percent. The authors hypothesize that immediate muscle flap closure improves outcomes in high-risk patients. METHODS: Three hundred one consecutive index cases of spinal wound closure using local muscle flaps performed by the senior author at a single institution between 2006 and 2018 were reviewed. The primary outcome was major wound complication (reoperation and/or readmission because of surgical-site infection, late infection, dehiscence, seroma, or hematoma). Logistic regression analysis was performed to identify predictors of this endpoint. RESULTS: Major wound complications occurred in 6.6 percent of patients (reoperation, 3.6 percent; readmission, 3.0 percent), with a 6.0 percent infection rate and five cases requiring instrumentation removal because of infection. Risk factors identified included radiotherapy (OR, 5.9; p = 0.004), age 65 years or older (OR, 2.8; p = 0.046), and prior spine surgery (OR, 4.3; p = 0.027). The incidence of major wound complication increased dramatically with each additional risk factor. Mean drain dwell duration was 21.1 ± 10.0 days and not associated with major wound complications, including infection (OR, 1.04; p = 0.112). CONCLUSIONS: Immediate local muscle flap closure following complex spine surgery on high-risk patients is associated with an acceptable rate of wound complications and, as these data demonstrate, is safe and effective. Consideration should be given to immediate muscle flap closure in appropriately selected patients. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

The medial sural artery perforator flap: A better option in complex head and neck reconstruction?

OBJECTIVES: The medial sural artery perforator (MSAP) free flap is an uncommonly utilized soft tissue flap in head and neck reconstruction. It is a thin, pliable, fasciocutaneous flap that provides significant pedicle length. The donor site can be closed primarily, and its location is more aesthetically pleasing to patients. We aim to describe the MSAP flap and compare it to other commonly used free flaps in the head and neck. STUDY DESIGN: Retrospective case series. METHODS: A retrospective review of all MSAP cases performed at New York University Langone Health was performed from July 2016 to November 2017. We examined the patients' age, diagnosis, history of prior radiation therapy, and comorbidities, as well as flap-specific information and recipient site. RESULTS: Twenty-one patients underwent a variety of different head and neck procedures with coverage using an MSAP flap. Recipient sites included tongue, cheek, soft and hard palate, cervical esophagus, and pharynx. Pedicle length ranged from 8 cm to 12 cm. The smallest surface area harvested was 24 cm2 (6 cm × 4 cm), and the largest was 120 cm2 (15 cm × 8 cm). The flaps ranged from 5 to 12 mm in thickness. Venous coupler size ranged from 2.0 to 3.5 mm. Primary closure of the donor site was achieved in 18 of 21 flaps. Twenty of 21 flaps were transferred successfully. CONCLUSION: The MSAP flap is a highly versatile and reliable option for a thin, pliable soft tissue flap with a donor site that may be preferable over the radial forearm free flap and anterolateral thigh flap in complex head and neck reconstruction. LEVEL OF EVIDENCE: 4 Laryngoscope, 129:1330-1336, 2019.

Local muscle flaps minimize post-operative wound morbidity in patients with neoplastic disease of the spine.

OBJECTIVES: Patients with neoplastic disease involving the spine either from primary or metastatic disease present a unique challenge given these patients' frequent poor nutritional status at the time of surgery, the delivery of early post-operative chemotherapy or radiation, and placement of large amounts of hardware and avascular bone graft into a wound bed that is atrophic, previously operated or irradiated. As a result, wound morbidity has traditionally been high in this cohort of patients. Herein we review the outcomes of patients at our institution who underwent local muscle flap closure following spinal tumor extirpation. PATIENTS AND METHODS: Between 2007 and 2017, 55 patients with oncologic disease of the spine underwent 60 spine surgeries and concomitant muscle flap reconstruction. Charts were retrospectively reviewed for diagnosis and indications for surgery, as well as risk factors for poor wound healing including diabetes, steroid use, body mass index (BMI), history of pre-operative chemo and or radiation therapy, preoperative albumin and hemoglobin levels. Outcomes were postoperative wound related complications including surgical site infection, wound dehiscence and/or need for reoperation. RESULTS: 60 reconstructions were included in 55 patients. Median follow up was 253 days. Paraspinous muscle flaps were used in all cases. There were 2 major complications (3.3%) related to wound infections which required reoperation and 10 minor wound complications (16.7%), of which 9 were subcutaneous seromas aspirated in the office, that did not require return to the operating room. Median postoperative stay in the hospital was 10 days. Closed suction drains placed at the end of the reconstruction were removed at a median of 17.5 days. Regression analysis found patient BMI to be a significant risk predictor for wound related post-operative complications. CONCLUSIONS: Post-operative wound specific complications that required return to the operating room were uncommon despite the high-risk profile of this subset of patients. These data indicate that muscle flap closure should be routinely practiced in this high-risk cohort of patients.

Functional and Aesthetic Outcomes in Free Flap Reconstruction of Intraoral Defects With Lip-Split Versus Non-Lip-Split Incisions.

BACKGROUND: Traditional free flap reconstruction of complex intraoral defects often uses large lip-splitting incisions. To reduce morbidity and preserve aesthetics, we have adopted a more technically demanding visor technique obviating an incision through the lower lip through which the resection and reconstruction are performed. METHODS: A retrospective review was performed of patients who underwent free flap reconstruction of intraoral defects over 7 years by a single plastic surgeon (C.H.R.) at a single institution. Patients were included if they underwent a resection from the mandible, tongue, or floor of mouth followed by free tissue transfer as a reconstructive approach. Patients were excluded if they underwent reconstruction of an area that does not traditionally require a lip incision, such as a maxillectomy or laryngeal defect. An ablative approach was taken via a lip-split technique or visor technique. Wound complications, margins of resection, and functional outcomes were assessed. Two standardized questionnaires (Derriford Appearance Scale Short Form and Quality of Life Questionnaire for Head and Neck Cancer) were used to assess psychological distress and dysfunction from disfigurement, speech quality, and oral function. Preoperative and postoperative patient photos were evaluated. RESULTS: Of 27 patients (mean ± SD age, 58.33 ± 13.02 years), 52% (14) had visor reconstructions whereas 48% (13) had lip-splitting reconstructions. About 78.6% of visor patients had widely-free margins compared with 46.2% of the lip-split patients. No differences in surgical-site complications between the lip-split and visor group (38.5% vs 28.6%) or in operative times were observed. Ninety-three percent of visor patients versus 54% of lip-split patients tolerated oral feeds at 1 year. Lip-split patients rated their quality of eating and speech worse than the visor patients (Quality of Life Questionnaire for Head and Neck Cancer mean score, 2.2 vs 1.56). Patients and clinical staff deemed visor reconstructions resulted in less visible sequelae. CONCLUSIONS: A visor technique with no lip-split incision for intraoral free flap reconstruction is an oncologically safe technique to consider that may improve cosmetic and functional outcomes for head and neck reconstruction patients.

Comparison of Antibiotic-Coated versus Uncoated Porcine Dermal Matrix.

BACKGROUND: The objective of this study was to evaluate the antimicrobial performance of a rifampin/minocycline-coated, non-cross-linked, acellular porcine dermal matrix (XenMatrix AB) compared to an uncoated, non-cross-linked, acellular porcine dermal matrix (Strattice) after implantation/inoculation with methicillin-resistant Staphylococcus aureus or Escherichia coli in a dorsal rabbit model. METHODS: Forty male New Zealand White rabbits were bilaterally implanted with XenMatrix AB or Strattice grafts and inoculated with clinically isolated methicillin-resistant S. aureus (5 × 10 colony-forming units/ml) or E. coli (1 × 10 colony-forming units/ml). At 2 and 8 weeks, sites were analyzed for viable methicillin-resistant S. aureus/E. coli colony-forming units, abscess formation, and histologic response (n = 5 rabbits per group per bacterium per time point). RESULTS: XenMatrix AB completely inhibited bacterial colonization of the graft, inhibited abscess formation, reduced inflammation and encapsulation, and improved neovascularization compared with Strattice. XenMatrix AB implants exhibited significantly fewer colony-forming units compared with Strattice implants at 2 weeks (methicillin-resistant S. aureus) (p < 0.01) and at 2 and 8 weeks (E. coli) (p < 0.05). In addition, XenMatrix AB implants demonstrated a significantly lower abscess score at 2 weeks (methicillin-resistant S. aureus) and 8 weeks (E. coli) (p < 0.01 in both cases). For both types of bacteria and both time points evaluated, XenMatrix AB implants exhibited minimal inflammation and encapsulation and a lack of neutrophils. In contrast, Strattice implants displayed marked inflammatory and neutrophilic responses and moderate encapsulation. CONCLUSIONS: This study demonstrated the antimicrobial performance of a rifampin/minocycline-coated bioprosthetic (XenMatrix AB) in a rabbit inoculation model. XenMatrix AB completely inhibited bacterial colonization of the graft, with minimal host inflammation and encapsulation, and improved neovascularization compared with Strattice.

Sun Protection: Current Management Strategies Addressing UV Exposure.

The use of sunscreen is essential for protection against photoaging and skin cancer. There is no global consensus on rating systems for sunscreens but it is essential to understand what makes a product broad-spectrum. In addition, physicians should have a general understanding that high-quality successful sunscreens should not only provide broad-spectrum ultraviolet A/B protection but should also be formulated so that they are easy to apply, are water resistant, and are photostable in order to increase user compliance.

Perioperative Antibiotics in the Setting of Oropharyngeal Reconstruction: Less Is More.

BACKGROUND: Recipient-site infection after oropharyngeal reconstruction is a potentially disastrous complication. Although studies suggest that perioperative antibiotics reduces infection rates in these patients from 87% to 20%, there is no consensus regarding what constitutes the most appropriate antibiotic regimen and duration of treatment. METHODS: A retrospective review of perioperative antibiotic administration was performed of all patients who underwent local, pedicled, or free flap oropharyngeal reconstruction after oncologic resection by a single surgeon at a single institution between 2007 and 2013 to assess for recipient-site complications. RESULTS: Ninety-seven patients underwent 100 reconstructions (61 free flap reconstructions, 39 pedicled/local flap reconstructions) and all received a combination of intravenous (IV) antibiotic agents designed to cover oral flora. There were 23 (23%) recipient-site complications, which included cellulitis (9%), mucocutaneous fistula (5%), abscess (5%), and wound dehiscence (4%). Duration of antibiotic prophylaxis, defined as less than 48 hours (short-course) or greater than 48 hours (long-course), was not a significant predictor of recipient-site complication. Significant risk factors for recipient-site complications were clindamycin prophylaxis (P < 0.008), increased duration of surgery (P < 0.047), and advanced age (P < 0.034). Recipient-site complication was found to be a significant predictor of both increased length of hospital stay (P < 0.001) and increased time to the resumption of enteral feeds (P < 0.035). CONCLUSIONS: These data suggest that extended courses of perioperative antibiotics do not confer additional benefits in patients undergoing oropharyngeal reconstruction. We recommend a limited 48-hour course of prophylactic antibiotics with sufficient aerobic and anaerobic coverage to help minimize the incidence of antibiotic-related morbidities.

Optimizing Successful Outcomes in Complex Spine Reconstruction Using Local Muscle Flaps.

BACKGROUND: Postoperative wound complications in patients undergoing complex spinal surgery can have devastating sequelae, including hardware exposure, meningitis, and unplanned reoperation. The literature shows that wound complication rates in this patient population approach 19 percent and, in very high-risk patients (i.e., prior spinal surgery, existing spinal wound infection, cerebrospinal fluid leak, malignancy, or history of radiation therapy), as high as 40 percent and with reoperation rates as high as 12 percent. The authors investigated whether prophylactic closure of spinal wounds with muscle flaps improves outcomes. METHODS: A retrospective review was performed of 102 reconstructions (in 96 patients) in which spinal wound closure was performed by means of paraspinous, trapezius, or latissimus muscle advancement flaps by a single plastic surgeon (J.A.S.) from 2006 to 2014. Data regarding presurgical diagnosis, patient demographics, and incidence of postoperative complications were recorded. RESULTS: One hundred two reconstructions were included, with follow-up ranging from 2 to 60 months. Eighty-eight reconstructions were classified as very high-risk for wound complications, defined as those having prior spinal surgery, existing spinal wound infection, cerebrospinal fluid leak, malignancy, or prior radiation therapy. Within the very high-risk group, there were six wound complications (6.8 percent), three of which (3.4 percent) required reoperation. CONCLUSIONS: In this study, there is a markedly lower rate (6.8 percent) of postoperative wound complications compared with historical controls after closure of spinal wounds with local muscle flaps in very high-risk patients. These data encourage safe and routine use of muscle flaps for closure in this cohort of patients undergoing spinal surgery. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.