Bilateral Diffuse Pseudoangiomatous Stromal Hyperplasia Necessitating Mastectomy.

Pseudoangiomatous stromal hyperplasia (PASH) is an uncommon, benign breast lesion often diagnosed incidentally and frequently mistaken for fibroadenoma given similar radiographic appearance. Histopathology classically reveals diffuse, dense fibrous stromal background with a complex network of spindle cells forming slit-like spaces, giving it the appearance of angiomatous proliferation. Surgical excision is generally not necessary. Here we present two unusual cases of PASH: an adolescent patient with bilateral rapid onset of symptoms, and a premenopausal patient with bilateral, diffuse, recurrent PASH. Both required mastectomy. We aim to highlight the variable nature of presentation and briefly review current management options.

The Triangular Dart Flap: A Reconstructive Option for Soft Tissue Defects.

INTRODUCTION: Reconstruction of soft tissue defects after skin cancer excision remains a challenge. Options for reconstruction are numerous, including primary repair, local tissue rearrangement, and skin grafts, among others. In this series, the authors present a novel technique: The triangular dart flap. This is a single-stage tissue rearrangement that uses the redundant tissue of the dog-ear to aid in the closure of these wounds. METHODS: A retrospective review was conducted of all patients undergoing local tissue rearrangements by the senior author from 2009 to 2018. Factors were collected and analyzed, including age, size and cause of defect, comorbidities, smoking history, and postoperative complications. RESULTS: Twenty-four patients underwent reconstruction with a triangular dart flap for repair of malignant defects. Mean defect size was 7.3 cm2 (0.8-20 cm2), and mean repair size was 29.7 cm2 (6-80 cm2). Initial pathology included basal cell carcinoma (45.8%), melanoma in situ (29.2%), and squamous cell carcinoma (16.7%), among others. Location varied widely among face and extremities. Anesthesia was predominantly local only (79.1%). There were no major complications, and 5 (20.8%) minor complications. CONCLUSIONS: The triangular dart flap is a novel single-stage procedure, generally performed under local anesthesia only, for correction of Mohs defects. By using the redundant tissue of dog-ears to better approximate the wound edges, a tension-free primary closure can be achieved in sensitive areas, such as the nasal tip.

Dermal Regeneration Template and Staged Skin Grafting for Extirpative Scalp Wound Reconstruction: A 14-Year Experience.

OBJECTIVE: Dermal regeneration template and staged split-thickness skin grafting may mitigate the need for flap coverage of postoncologic scalp defects. This technique has been studied previously in small case series. We examine the effect of risk factors, surgical technique, irradiation, and dressing modalities on reconstructive outcomes in a highly comorbid patient cohort. STUDY DESIGN: Retrospective review. SETTING: Academic medical center. METHODS: Full- and partial-thickness extirpative scalp wounds reconstructed with dermal regeneration template and staged skin grafting were reviewed over a 14-year period. Stage 1 consisted of template application following burr craniectomy in cases lacking periosteum. Stage 2 consisted of skin grafting. Negative pressure wound therapy (NPWT) was variably used to support adherence. RESULTS: In total, 102 patients were analyzed (average age 74, mean follow-up 18 months). Eighty-one percent were American Society of Anesthesiologists class 3 or 4. Defect size averaged 56 cm2. Average skin graft take was 94.5% in full-thickness wounds. Seven patients failed this method. Preoperative scalp irradiation was associated with major complication and delayed graft healing. Comorbidities, wound size, and burring were not associated with complication. Patients were more likely to heal with NPWT compared to bolster (hazard ratio, 1.67; 95% CI 1.01-2.77; P = .046). Time between stages was 6.6 days shorter when NPWT was applied (P < .001). CONCLUSION: Dermal template and staged skin grafting is a reliable option for postcancer scalp reconstruction in poor flap candidates. Radiotherapy is associated with adverse outcomes. Negative pressure wound therapy simplifies postoperative wound care regimens and may accelerate healing.

Aesthetic outcomes of acellular dermal matrix in tissue expander/implant-based breast reconstruction.

INTRODUCTION: Tissue expander and implant-based breast reconstruction after mastectomy is the most common method of breast reconstruction. Modifications of the traditional total submuscular reconstruction (TSR) have been made using acellular dermal matrix (ADM) to create an inferolateral sling and a more natural implant pocket for superior aesthetic results. The objective of this study was to assess aesthetic outcomes when using ADM in breast reconstruction. METHODS: A retrospective chart review identified all patients who underwent implant-based breast reconstruction from 2005 to 2009 at our institution. Demographic information, complications, reoperations, and aesthetic outcome data were collected for all patients meeting inclusion criteria related to adequate follow-up and postoperative photographs. Five aesthetic outcomes were evaluated for all study patients by 18 blinded evaluators using postoperative photographs. Outcomes were scored on a scale of 1 to 5, with 5 representing the best possible aesthetic score. RESULTS: A total of 122 patients underwent 183 tissue expander-based reconstructions (ADM, n = 58; TSR, n = 125). The infection rate in patients with ADM was 16.2% compared to 5.9% in TSR patients, but this was not statistically significant (P = 0.09). Capsular contracture was more common in TSR patients (23.5%), compared to those with ADM (8.1%), P = 0.048. Aesthetic scores from the attending plastic surgeons were as follows: natural contour (ADM, 3.36; TSR, 3.02; P = 0.0001), symmetry of shape (ADM, 3.57; TSR, 3.27; P = 0.005), symmetry of size (ADM, 3.68; TSR, 3.42; P = 0.002), position on chest wall (ADM, 3.75; TSR, 3.45; P = 0.004), and overall aesthetic appearance (ADM, 3.56; TSR, 3.20; P = 0.0001). CONCLUSIONS: For all 5 aesthetic parameters evaluated, the ADM group scored significantly higher than the TSR group by 18 blinded evaluators. These consistent findings suggest that the use of ADM in breast reconstruction does confer a significant advantage in aesthetic outcomes for breast reconstruction. This is likely at the cost of a higher infection rate when using ADM; however, that may be offset by the advantage of a lower rate of capsular contracture in patients with ADM.

The effect of reusable versus disposable draping material on infection rates in implant-based breast reconstruction: a prospective randomized trial.

BACKGROUND: Clinical infection remains a significant problem in implant-based breast reconstruction and is a physical and emotional strain to the breast reconstruction patient. Bacterial strikethrough of draping and gown material is a likely source of infection. Strategies to reduce infection in implant-based breast reconstruction are essential to improve patient outcomes. OBJECTIVE: The aim of this study is to determine if a disposable draping system is superior to reusable draping materials in the prevention of implant-based breast reconstruction infection. METHODS: This single-institution, prospective, randomized, single-blinded, IRB-approved study enrolled women with breast cancer who were eligible for implant-based breast reconstruction. The primary endpoint was clinical infection by postoperative day 30. Secondary endpoints included all other complications encountered throughout the follow-up period and culture data. Demographic data recorded included patient age, body mass index, diabetes, smoking, chemotherapy, radiation, and follow-up. Procedural data recorded included procedure type, procedure length, estimated blood loss, use of acellular dermal matrix, use of muscle flap, and inpatient versus outpatient setting. RESULTS: From March 2010 through January 2012, 107 women were randomized and 102 completed the study. Five patients were determined not to be candidates for reconstruction after randomization. There were 43 patients in the Reusable Group and 59 patients in the Disposable Group. There were no significant differences in patient demographic data, procedural data, or the type of procedure performed between groups. In the Reusable Group, there were 5 infections (12%) within 30 days compared to 0 (0%) infections in the Disposable Group (P = 0.012). There was no significant difference in secondary complications. There was a trend for positive wound cultures (11% vs. 3%, P = 0.10) and positive drape cultures (17% vs.4%, P = 0.08) in patients with clinical infection. There were no differences in the number of colony-forming units or positive cultures between groups. CONCLUSIONS: Disposable draping material is superior to a reusable draping system in the prevention of clinical infection within the immediate postoperative period. This study did not demonstrate a clear link between intraoperative culture data and the development of clinical infection. A completely disposable gown and draping system is recommended during implant-based breast reconstruction.

Outcome study of the surgical management of panniculitis.

Patients with panniculus morbidus have an abdominal panniculus that becomes a pathologic entity, associated with the development of candidal intertrigo, dermatitis, lymphedema, and ischemic panniculitis. Panniculectomy is a standard treatment for this problem. The objective of this study was to determine risk factors for complications associated with panniculectomy surgery to lower the complication rate. We performed a retrospective chart review of patients who underwent panniculectomy between 1999 and 2007 by looking at data related to surgical complications, comorbidities, age, and gender. In 563 patients, we recorded the incidence of the following complications: wound-related (infection, dehiscence, and/or necrosis), hematoma/seroma, respiratory distress, blood transfusions, deep venous thrombosis or pulmonary embolism, and death. Overall, 34.3% of patients suffered at least 1 complication. In patients with wound complications specifically, there was a significantly higher body mass index versus those with no wound complications (43.7% vs. 30.7%, P < 0.0001). Smokers also had a higher rate of wound complications (40.5% vs. 19.5%, P < 0.0001).

Outcomes of immediate breast reconstruction in patients undergoing single-stage sentinel lymph node biopsy and mastectomy.

The ability to more definitively plan breast reconstruction after obtaining final histologic analysis of the sentinel lymph node biopsy (SLNB) has led several groups to advocate a staged approach to SLNB and mastectomy. Certain disadvantages are inherent in that approach, including increased patient morbidity, financial expense, and inconvenience. A retrospective review was conducted 195 procedures in which mastectomy and SLNB were performed in a single stage with immediate breast reconstruction (IBR) over a 10-year period. Long-term outcomes were analyzed within the context of patient characteristics and SLNB results. Intraoperative SLNB analysis was found to be a reliable method for planning IBR, as there were no patients noted to have untoward sequelae as a result of a false-negative SLNB, and the probability of postmastectomy radiation therapy was predictable based on the intraoperative SLNB results. We advocate that SLNB be performed in a single stage with mastectomy and IBR.

Outcomes analysis of a resident cosmetic clinic: safety and feasibility after 7 years.

Cosmetic patients have many options when seeking out their surgeons. In midsize and larger cities, these options span not only different specialties but also different levels of experience. Because surgical experience can best be gained first hand, there exists a special and symbiotic relationship between a surgeon-in-training and his or her patient. Benefits stem from the opportunity for a surgeon to gain independent experience while offering cost effective benefits to patients who may or may not otherwise have access to cosmetic surgery. To meet the needs of both patients and the surgeons-in-training, the Wake Forest University Plastic and Reconstructive Surgery Training Program has set up and maintained a chief resident run cosmetic surgery clinic for 17 years. Each chief resident serves as primary surgeon 1 day a week during the chief year. We present a 7-year retrospective outcome analysis of this experience. The authors performed an Institutional Review Board approved retrospective chart review of all patients who received major cosmetic procedures performed in the WFU chief resident clinic over a 7-year span from 2000 to 2007. A total of 210 charts were reviewed. Fourteen charts were excluded because of inadequate records or non esthetic procedures performed concomitantly. All procedures were viewed as independent events. A total of 196 patients underwent 272 procedures. All procedures were evaluated for major and minor complications and revisions. A total number of 272 initial cosmetic procedures were performed in a 7-year span. Adverse events were divided into major and minor complications. There were no major complications for any of the procedures. Overall minor complication rate was 8.0%. Overall revision rate was 14.4%. Procedures with greatest probability of revision were abdominoplasty and reduction mammaplasty. Chief resident clinics provide a unique experience wherein surgeons-in-training are allowed to hone previously developed surgical acumen while providing a safe and expectedly desirable result for their patients. Because many cosmetic patients desire secondary touch up procedures, a rate of 14.4% in this cohort is neither unexpected nor unacceptable. In addition, the postoperative evaluation and the decision to pursue secondary procedures provides a unique perspective to the chief residents. A chief resident run clinic can be an effective and safe learning tool, providing benefit to patient and the surgeon in training.

Impact of sentinel lymph node biopsy on immediate breast reconstruction after mastectomy.

Traditionally, sentinel lymph node biopsy (SLNB) is performed at the time of mastectomy and reconstruction. However, several groups have advocated SLNB as a separate outpatient procedure before mastectomy, when immediate reconstruction is planned, to allow for complete pathologic evaluation. The purpose of this study was to determine the impact of intraoperative analysis of SLNB on the reconstructive plan when performed at the same time as definitive surgery. A retrospective review was conducted of all mastectomy cases performed at a single institution between September 1998 and November 2007. Of the 747 mastectomy cases reviewed, SLNB was conducted in 344 cases, and there was immediate breast reconstruction in 193 of those cases. There were 27 (7.8%) false negative and three (0.9%) false positive intraoperative analysis of SLNB. Touch preparation analysis from the SLNB changed the reconstructive plan in four (2.1%) cases. In our experience, SLNB can be performed at the time of mastectomy with minimal impact on the reconstructive plan. A staged approach incurs significant additional expense, increases the delay in initiation of systemic therapy and the propensity of procedure-related morbidity; therefore, SLNB should not be performed as a separate procedure before definitive surgery with immediate breast reconstruction.

Outpatient reconstruction using integra* and subatmospheric pressure.

Integra (Integra Lifesciences Corporation, Plainsboro, NJ) has been used in a variety of reconstructive surgical procedures. The application of Integra using subatmospheric pressure (V.A.C., Kinetic Concepts, Inc, San Antonio, TX) has been suggested to be easier, faster, and more consistent than previous dressings, allowing grafting as soon as 1 week after Integra placement. Ten patients were chosen for outpatient reconstructive surgery with Integra and subatmospheric pressure with skin grafting 7-10 days (mean = 8 days) post-Integra. Skin graft take was 75% to 100% (mean = 91.5%). No patients required additional grafting or reconstruction. Integra may be successfully used for reconstruction of difficult areas as an outpatient in combination with subatmospheric pressure (V.A.C.). This allows for expedited treatment, decreased morbidity, and lower cost versus standard Integra application.

Vacuum-assisted closure for defects of the abdominal wall.

BACKGROUND: Reconstruction of the abdominal wall poses a problem common to many surgical specialties. Abdominal wall defects may be caused by trauma and/or prior surgery, with dehiscence or infection. Several options to repair the structural integrity of the abdominal wall exist, including primary closure, flaps, mesh, and skin grafts. Complications of these procedures include recurrent infection of the abdominal wall, infection of mesh, dehiscence, flap death, and poor skin graft take. Risk factors predisposing to these complications include tissue edema, preoperative tissue infection, and patient debilitation, with poor wound healing potential. Ideally, reconstruction should be performed on a nonedematous, clean tissue bed with bacterial levels less than 10 bacteria/cm in a well-nourished patient. METHODS: Vacuum-assisted closure was used in a series of patients in an attempt to prepare the abdominal wall for reconstruction and reduce the risk of complications. Charts were reviewed for 100 patients who underwent abdominal wall reconstruction after vacuum-assisted closure therapy. Their wound cause, reconstruction technique, complications, and number of days on the vacuum-assisted closure device are reported. RESULTS: The ability of vacuum-assisted closure to reduce edema, increase blood flow, potentially decrease bacterial colonization, and reduce wound size greatly facilitated abdominal wall reconstruction. The vacuum-assisted closure device served as a temporary dressing with which to control dehiscence and to maintain abdominal wall integrity when bowel wall edema prevented abdominal closure. CONCLUSION: Vacuum-assisted closure therapy frequently shortened time to abdominal wall reconstruction and simplified the method of reconstruction.

Negative pressure wound therapy.

Negative pressure wound therapy has become an increasingly important part of wound management. Over the last decade, numerous uses for this method of wound management have been reported, ranging from acute and chronic wounds, to closure of open sternal and abdominal wounds, to assistance with skin grafts. The biophysics behind the success of this treatment largely have focused on increased wound blood flow, increased granulation tissue formation, decreased bacterial counts, and stimulation of wound healing pathways through shear stress mechanisms. The overall success of negative pressure wound therapy has led to a multitude of clinical applications, which are discussed in this article.

Vacuum-assisted closure: state of clinic art.

Treatment of wounds has been the cornerstone of plastic surgery since its inception. Vacuum-assisted closure provides a new paradigm that can be used in concert with a wide variety of standard existing plastic surgery techniques. It was originally developed as an alternative treatment for debilitated patients with chronic wounds. It has rapidly evolved into a widely accepted treatment of chronic and acute wounds, contaminated wounds, burns, envenomations, infiltrations, and wound complications from failed operations. The ease of technique and a high rate of success have encouraged its adaptation by thoracic, general, trauma, burn, orthopedic, urologic, as well as plastic surgeons. This article discusses multidisciplinary advances in the use of the vacuum-assisted closure technique over the past 10 years and its status as of 2006. Creative surgeons continue to regularly adapt the system to difficult problems. This technique in trained surgical hands greatly enhances the scope and safety of wound treatment.