Faculty Bibliography

BACKGROUND:Use of biological implants such as acellular dermal matrices in tissue expander breast reconstruction is a common adjunct to submuscular implant placement. There is a paucity of published prospective studies involving acellular matrices. The authors sought to evaluate a porcine-derived acellular peritoneal matrix product for immediate breast reconstruction. METHODS:A prospective, single-arm trial was designed to analyze safety and outcomes of immediate tissue expander-based breast reconstruction with a novel porcine-derived acellular peritoneal matrix surgical mesh implant. Twenty-five patients were enrolled in this industry-sponsored trial. Patient demographics, surgical information, complications, histologic characteristics, and satisfaction (assessed by means of the BREAST-Q questionnaire) were evaluated. RESULTS:Twenty-five patients (44 breasts) underwent mastectomy with immediate breast reconstruction using tissue expanders with acellular peritoneal matrix. Sixteen reconstructed breasts experienced at least one complication (36 percent). Seroma and hematoma occurred in one of 44 (2.3 percent) and two of 44 breasts (4.6 percent), respectively. Wound dehiscence occurred in four of 44 breasts (9.1 percent). Three subjects experienced reconstruction failure resulting in expander and/or acellular peritoneal matrix removal (6.8 percent); all failures were preceded by wound dehiscence. Histologic analysis showed cellular infiltration and product resorption. Results of the BREAST-Q demonstrated a level of postoperative patient satisfaction consistent with results in the available literature. CONCLUSIONS:Prepared porcine-derived acellular peritoneal matrix is a safe adjunct in immediate two-stage tissue expander-based breast reconstruction. Further studies are required to determine efficacy compared to current commercially available acellular matrices. CLINICAL QUESTION/LEVEL OF EVIDENCE/METHODS:Therapeutic, IV.

BACKGROUND:Patients with large or ptotic breasts undergoing mastectomy followed by tissue expander/implant-based reconstruction may benefit from a Wise (inverted-T) pattern reduction mammaplasty incision compared with the traditional horizontal elliptical incision. The authors compared these two groups of patients with regard to complication rates and outcomes. METHODS:Sixty-nine patients (117 breasts) were identified who underwent Wise pattern mastectomy and two-stage reconstruction. A control group of 89 patients (136 breasts) who underwent reconstruction after horizontal elliptical mastectomy were selected over the same period. Patient demographics, clinical characteristics, and complication rates were recorded and analyzed statistically. RESULTS:Patient demographics (age, body mass index, diabetes, smoking, and irradiation history) and clinical characteristics (laterality, expander size and fill volume, and time to expansion) were similar, with the exception of body mass index (control, 26.7 kg/m; inverted-T, 28.7 kg/m; p = 0.04) and mean intraoperative fill volume (control, 158.7 cc; inverted-T, 196.9 cc; p = 0.02). Of all complications (infection, seroma, flap necrosis, expander loss, and salvage), only the rate of mastectomy flap necrosis was significantly greater (p = 0.002) in patients undergoing inverted-T mastectomy (25.6 percent versus 11.0 percent). This difference did not result in a significantly higher rate of expander loss or need for salvage surgery. CONCLUSIONS:The inverted-T mastectomy approach can be performed safely with acceptable complication rates. When compared with an internal control group, complication rates were similar, with the exception of mastectomy flap necrosis. Despite a higher rate of flap necrosis, 91 percent of inverted-T patients successfully completed the expansion process. CLINICAL QUESTION/LEVEL OF EVIDENCE/METHODS:Therapeutic, III.

Reconstruction of bony defects in the surgical management of vertebral osteomyelitis is a challenging endeavor. Our objective is to report the use of intra-abdominal vessels as the recipient vessels for microanastomosis of vascularized bone graft and the use of a spinal cage for fixation. Three patients failed conservative treatment for vertebral osteomyelitis and suffered pathologic fracture. Their treatment consisted of staged posterior irrigation and debridement with segmental fixation, followed by a thoracoabdominal approach multiple-level corpectomy. Reconstruction was performed with a free vascularized fibular graft placed within a custom, expandable cage. The vascularized fibular graft was anastomosed to an intra-abdominal recipient vessel. All patients improved clinically with no neurologic deficits noted. All showed evidence of successful fusion. Free vascularized bone grafts continue to be an excellent option for multi-level spinal defects related to osteomyelitis. Intra-abdominal recipient vessels are appropriate recipient vessels, as their diameter, length, and accessibility allow vascularized bone graft reconstruction of vertebral column defects of the thoracolumbar region. These vessels are also easily accessible and the anastomoses can be performed in the superficial operating incision.

BACKGROUND:The sural nerve is commonly used as a donor site for cavernous nerve grafting. However, the genitofemoral nerve is accessible and easily dissected and may represent an improved donor site for this procedure. METHODS:Fourteen patients underwent radical prostatectomy followed by cavernous nerve grafting using the genitofemoral nerve. Seventeen donor sites (3 patients underwent bilateral grafts) were assessed by questionnaires (including the McGill Pain Scale) and focused neurologic examination. RESULTS:Residual numbness in the genitofemoral nerve distribution was noted in 9 of 17 donor sites (53%). No patients reported that the deficits interfered with normal daily activities. All patients denied the presence of burning, cold sensitivity, or pain. All patients scored 0 on each of the 3 pain rating components of the short form McGill Pain questionnaire (sensory, affective, or total). Furthermore, no patients documented pain on either the PPI or VAS portions of the questionnaire. On examination, patients were unable to discriminate between sharp versus dull stimuli in 3 donor sites (17.6%), while 7 donor sites (41.2%) showed decreased light-touch sensation. The Semmes-Weinstein testing demonstrated that 8 (47.1%) were found to have distinct areas with sensory deficit ranging in size from 23 to 63 cm (mean, 16.6 cm). The highest-pressure thresholds for each of the 17 donor sites ranged from 3.61 to 6.45 g/mm (mean, 4.91 g/mm). The mean pressure threshold for the control regions (n=11) was 3.35 g/mm (range, 2.38--4.71 g/mm, P=0.014). Only 50% of the sensory deficits documented by the Semmes-Weinstein test were clinically apparent to the patients. CONCLUSIONS:Due to its low donor site morbidity, the genitofemoral nerve is an excellent donor source for cavernous nerve grafting during radical prostatectomy. In the majority of the patients, the sensory deficit produced by resection of this nerve is minimal and caused no other adverse symptoms. Harvest of this nerve prevents the additional morbidity associated with a donor site located elsewhere on the body (ie, sural nerve).

Breast cancer patients will occasionally need to undergo mastectomy after previous reduction mammaplasty or mastopexy. The presence of the "inverted-T" scar presents a unique reconstructive dilemma: Do mastectomy flaps that are traversed by surgical scars still allow for adequate tissue expansion and a good aesthetic result? The objective of this study was to evaluate the authors' experience with tissue expansion/implant reconstruction in patients with an inverted-T scar. All patients who underwent tissue expansion and implant reconstruction after inverted-T mammaplasty were reviewed retrospectively to determine aesthetic results, patient satisfaction, and complication rates associated with this reconstructive technique. During a 6-year period (1995-2001), 11 patients (12 breasts) underwent breast reconstruction with tissue expansion and implant placement after either reduction mammaplasty (N = 8) or mastopexy (N = 4). All patients reached target expansion volumes. After successful tissue expansion, exchange to either saline (N = 7) or silicone (N = 5) implants was performed. The mean follow-up period after implant exchange was 18.5 months (range, 2-72 months). Complications were minimal and included partial flap necrosis (N = 1). Aesthetic appearance and symmetry were judged to be good or excellent in the majority of patients. Overall patient satisfaction was high. Tissue expansion with implant exchange is an effective reconstructive technique for mastectomy defects after previous inverted-T mammaplasty. In this series, good to excellent aesthetic results were achieved in the majority of patients with minimal associated complications.

The aim of this clinical study was to evaluate the effectiveness and safety of using computer-generated alloplastic (hard-tissue replacement) implants for the reconstruction of large defects of the upper craniofacial region. Fourteen patients who had large (> 150 cm2) preexisting defects of the cranium or cranio-orbital region underwent surgical reconstruction. Preoperatively, a three-dimensional computed tomographic scan was obtained from which an anatomic model was fabricated. The defect in the model was then used to create an alloplastic (hard tissue-replacement polymer) implant for reconstruction and surgical placement. At the time of surgery, the implant was secured into position with either metal or resorbable fixation. In cases where the frontal sinus was in proximity to the implant, the frontal sinus was either cranialized and covered with a pericranial flap or obliterated with hydroxyapatite cement. In cases that had been previously irradiated or infected, wide bony debridement and coverage with a vascularized muscle was initially performed, followed by implant reconstruction 6 months later. All implants fit easily into the bone defects, and only four (29 percent) required some minor adjustments to complete the fit. All patients healed uneventfully. With a minimum of 1 year follow-up (average, 3 years) in all cases, excellent contours have been maintained and all patients have remained infection-free. In large cranial defects, custom implants fabricated from porous, hydrophilic hard-tissue replacement polymer provide an exacting anatomic fit and a solid stable reconstruction. This method of reconstruction in these defects is rapid and exact, and significantly reduces operative time. Critical attention must be paid, however, to management of the frontal sinus and preexisting bone infection and the quality of the overlying soft-tissue cover.