Splitting the Difference: Using Synthetic and Biologic Mesh to Decrease Cost in Prepectoral Immediate Implant Breast Reconstruction.

SUMMARY: Prepectoral breast reconstruction has minimized morbidity and dynamic deformities associated with submuscular implant-based breast reconstruction. However, reliance on implant coverage with acellular dermal matrix in immediate implant reconstruction remains limited by high material costs. The authors describe a technique in which anterior implant coverage in prepectoral reconstruction is split into acellular dermal matrix inferolaterally and synthetic, absorbable mesh superiorly. Use of acellular dermal matrix inferiorly provides coverage and reinforces the inframammary fold, whereas the absorbable mesh is trimmed and sutured to the acellular dermal matrix at the appropriate tension to support the implant and relieve pressure on mastectomy flaps. A retrospective review was performed on all consecutive prepectoral one-stage breast reconstructions using this technique at a single institution. Patient demographics, mastectomy and reconstruction characteristics, reconstructive outcomes, and cost of support materials were queried and analyzed. Eleven patients (21 breasts) underwent prepectoral immediate implant reconstruction with Vicryl and acellular dermal matrix anterior coverage. Average mastectomy weight was 775.8 g. Smooth, round cohesive implants were used in all cases and average implant size was 514.5 ml. Overall complication rates were low and included one minor infection (4.8 percent) and one case of minor mastectomy flap and partial nipple necrosis each (4.8 percent). Calculated cost savings of Vicryl and acellular dermal matrix anterior coverage was up to $3415 in unilateral and $6830 in bilateral cases. Prepectoral breast reconstruction using acellular dermal matrix inferiorly and Vicryl mesh superiorly is a safe technique that decreases material costs associated with support materials and allows the surgeon to precisely control the implant pocket and position. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

A prospective study of two methods of closing surgical scalp wounds.

BACKGROUND AND OBJECTIVE: Scalp wounds are commonly closed in two layers, although single layer closure is feasible. This study prospectively compared the two methods of closing scalp wounds. METHODOLOGY: Patients with non-traumatic scalp wounds were allocated to either the single layer closure group or the multilayer closure group. We obtained relevant data from the patients. The primary outcome measures were wound edge related complications, rate of suturing and cost of sutures used for suturing. RESULTS: Thirty-one wounds were in the single layer closure group and 30 were in the multilayer closure group. Age range was 1-80 years. The most common indication for making a scalp incision was subdural hematoma, representing 27.8% of all the indications. The most common surgery was burr hole drainage of subdural hematoma. Polyglactin acid suture was used for the inner layer and polyamide -00- for the final layer in the multilayer closure group. Only the latter suture was used for the single layer closure method. Total cost of suturing per wound in the single layer closure group was N= 100 (0.70USD) and N= 800 (5.30USD) in the multilayer group. The mean rate of closure was 0.39 ± 1.89 mm/sec for single layer closure and 0.23 ± 0.89 mm/sec in multilayer closure. The difference was statistically significant. Wound edge related complication rate was 19.35% in the single layer closure group and 16.67% in the multilayer closure method group. The difference was not statistically significant (z: 0.00, p value: 1.000; Pearson chi-squared (DF = 1)= 0.0075, p = 0.0785). CONCLUSION: The study shows that closing the scalp in one layer is much faster and more cost effective compared to the multilayer closure method. We did not observe significant difference in the complication rates in the two methods of closure. Long-term outcome, especially cosmetic outcome, remains to be determined in this preliminary study.

Randomized controlled trial of barbed polyglyconate versus polyglactin suture for robot-assisted laparoscopic prostatectomy anastomosis: technique and outcomes.

BACKGROUND: Transperitoneal robot-assisted laparoscopic prostatectomy (RALP) urethrovesical anastomosis is a critical step. Although the prevalence of urine leaks ranges from 4.5% to 7.5% at high-volume RALP centers, urine leaks prolong catheterization and may lead to ileus, peritonitis, and require intervention. Barbed polyglyconate sutures maintain running suture line tension and may be advantageous in RALP anastomosis for reducing this complication. OBJECTIVE: To compare barbed polyglyconate and polyglactin 910 (Vicryl, Ethicon, Somerville, NJ, USA) running sutures for RALP anastomosis. DESIGN, SETTING, AND PARTICIPANTS: This was a prospective, randomized, controlled, single-surgeon study comparing RALP anastomosis using either barbed polyglyconate (n = 45) or polyglactin 910 (n = 36) sutures. SURGICAL PROCEDURE: RALP anastomosis using either barbed polyglyconate or polyglactin 910 sutures was studied. MEASUREMENTS: Operative time, cost differential, perioperative complications, and cystogram contrast extravasation by anastomosis suture type were measured. RESULTS AND LIMITATIONS: Although baseline characteristics and overall operative times were similar, barbed polyglyconate sutures were associated with shorter mean anastomosis times of 9.7 min versus 9.8 min (p = 0.014). In addition, anastomosis with barbed polyglyconate rather than polyglactin 910 sutures was associated with more frequent cystogram extravasation 8 d postoperatively (20.0% vs 2.8%; p = 0.019), longer mean catheterization times (11.1 d vs 8.3 d; p = 0.048), and greater suture costs per case ($51.52 vs $8.44; p < 0.001). After 8 of 29 (27.6%) barbed polyglyconate anastomosis sites demonstrated postoperative day 8 cystogram extravasation, we modified our technique to avoid overtightening, reducing cystogram extravasation to 1 (6.3%) of 16 subsequent barbed polyglyconate anastomosis sites. Potential limitations include small sample size and the single-surgeon study design. CONCLUSIONS: Compared to traditional sutures, barbed polyglyconate is more costly and requires technical modification to avoid overtightening, delayed healing, and longer catheterization time following RALP.