Faculty Bibliography

BACKGROUND: : Fat grafting has emerged as a useful method for breast contouring in aesthetic and reconstructive patients. Advancements have been made in fat graft harvest and delivery, but the ability to judge the overall success of fat grafting remains limited. The authors applied three-dimensional imaging technology to assess volumetric fat graft survival following autologous fat transfer to the breast. METHODS: : Fat grafting surgery was performed using a modified Coleman technique in breast reconstruction. Patients undergoing the procedure were entered into the study prospectively and followed. Three-dimensional imaging was performed using the Canfield Vectra system and analyzed using Geomagic software. Breasts were isolated as closed objects, and total breast volume was calculated on every scan. RESULTS: : The data stratified patients into three groups with statistically significant parameters based on the volume of fat injected. The largest injected group (average volume, 151 cc) retained a volume of 86.9 percent (7 days postoperatively), 81.1 percent (16 days), 57.5 percent (49 days), and 52.3 percent (140 days). The smallest group (average, 51 cc) retained a volume of 87.9 percent (7 days postoperatively), 75.8 percent (16 days), 56.6 percent (49 days), and 27.1 percent (140 days). The intermediate group (average, 93 cc) retained 90.3 percent (7 days postoperatively), 74 percent (16 days), 45.7 percent (49 days), and 38.1 percent (140 days). Of note, irradiation or prior breast procedure type did not seem to affect the volume retention rate. CONCLUSIONS: : The authors' data suggest that fat retention is volume and time dependent. Patients receiving higher volumes of injected fat had slower volume loss and greater total volume retention.

BACKGROUND: : Nipple-sparing mastectomy warrants thorough preoperative evaluation to effectively achieve risk reduction, high patient satisfaction, and improved aesthetic outcome. To the authors' knowledge, this review represents the largest series of microsurgical breast reconstructions following nipple-sparing mastectomies. METHODS: : All patients undergoing nipple-sparing mastectomy with microsurgical immediate breast reconstruction treated at New York University Medical Center (2007-2011) were identified. Patient demographics, breast cancer history, intraoperative details, complications, and revision operations were examined. Descriptive statistical analysis, including t test or regression analysis, was performed. RESULTS: : In 51 patients, 85 free flap breast reconstructions (n = 85) were performed. The majority of flaps were performed for prophylactic indications [n = 55 (64.7 percent)], mostly through vertical incisions [n = 40 (47.0 percent)]. Donor sites included abdominally based [n = 66 (77.6 percent)], profunda artery perforator [n = 12 (14.1 percent)], transverse upper gracilis [n = 6 (7.0 percent)], and superior gluteal artery perforator [n = 1 (1.2 percent)] flaps. The most common complications were mastectomy skin flap necrosis [n = 11 (12.7 percent)] and nipple necrosis [n = 11 (12.7 percent)]. There was no correlation between mastectomy skin flap or nipple necrosis and choice of incision, mastectomy specimen weight, body mass index, or age (p > 0.05). However, smoking history was associated with nipple necrosis (p < 0.01). CONCLUSIONS: : This series represents a high-volume experience with nipple-sparing mastectomy followed by immediate microsurgical reconstruction. When appropriately executed, it can deliver low complication rates. CLINICAL QUESTION/LEVEL OF EVIDENCE: : Therapeutic, IV.

Nipple-sparing mastectomy (NSM) as a therapeutic or prophylactic procedure for breast cancer is rapidly gaining popularity as the literature continues to support it safety. The lateral inframammary fold (IMF) approach provides adequate exposure and eliminates visible scars on the anterior surface of the breast, making this incision cosmetically superior to radial or periareolar approaches. We reviewed 55 consecutive NSMs performed through a lateral IMF incision with immediate implant-based reconstruction, with or without tissue expansion, between June 2008 and June 2011. Prior to incision, breasts were lightly infiltrated with dilute anesthetic solution with epinephrine. Sharp dissection, rather than electrocautery, was used as much as possible to minimize thermal injury to the mastectomy flap. When indicated, acellular dermal matrix was placed as an inferolateral sling. Subsequent fat grafting to correct contour deformities was performed in select patients. Three-dimensional (3D) photographs assessed changes in volume, antero-posterior projection, and ptosis. Mean patient age was 46 years, and mean follow-up time was 12 months. Twelve mastectomies (22%) were therapeutic, and the remaining 43 (78%) were prophylactic. Seven of the nine sentinel lymph node biopsies (including one axillary dissection) (78%) were performed through the lateral IMF incision without the need for a counter-incision. Acellular dermal matrix was used in 34 (62%) breasts. Average permanent implant volume was 416 cc (range 176-750 cc), and average fat grafting volume was 86 cc (range 10-177 cc). In one patient a positive intraoperative subareolar biopsy necessitated resection of the nipple-areola complex (NAC), and in two other patients NAC resection was performed at a subsequent procedure based on the final pathology report. Mastectomy flap necrosis, requiring operative debridement, occurred in two breasts (4%), both in the same patient. One of these breasts required a salvage latissimus dorsi myocutaneous flap to complete the reconstruction. Three nipples (6%) required office debridement for partial necrosis and operative reconstruction later. No patient had complete nipple necrosis. No statistically significant differences existed between therapeutic and prophylactic mastectomies for developing partial skin and/or nipple necrosis (p = 0.35). Three episodes (5%) of cellulitis occurred, which responded to antibiotics without the need for explantation. Morphological outcomes using 3D scan measurements showed reconstructed breasts were larger, more projected, and less ptotic than the preoperative breasts (196 versus 248 cc, 80 versus 90 mm, 146 versus 134 mm, p < 0.01 for each parameter). Excellent results can be achieved with immediate implant-based reconstruction of NSM through a lateral IMF incision. NAC survival is reliable, and complication rates are low.

BACKGROUND: : Acellular dermal matrix is commonly used in implant-based breast reconstruction to allow for quicker tissue expansion with better coverage and definition of the lower pole of the breast. This study was performed to analyze complications associated with its use in immediate two-stage, implant-based breast reconstruction and to subsequently develop guidelines for its use. METHODS: : A retrospective analysis of 628 consecutive immediate two-stage tissue expander breast reconstructions at a single institution over a 3-year period was conducted. The reconstructions were divided into two groups: reconstruction with acellular dermal matrix and reconstruction without it. Demographic information, patient characteristics, surface area of acellular dermal matrix, and complications were analyzed and compared. RESULTS: : A total of 407 patients underwent 628 immediate two-stage, implant-based breast reconstructions; 442 reconstructions (70.3 percent) used acellular dermal matrix and 186 (29.6 percent) did not. The groups had similar patient characteristics; however, major complications were significantly increased in the acellular dermal matrix group (15.3 versus 5.4 percent; p = 0.001). These complications included infection requiring intravenous antibiotics (8.6 versus 2.7 percent; p = 0.001), flap necrosis requiring excision (6.7 versus 2.7 percent; p = 0.015), and explantation of the tissue expander (7.7 versus 2.7 percent; p = 0.004). CONCLUSIONS: : Use of acellular dermal matrix in immediate two-stage, implant-based breast cancer reconstruction is associated with a significant increase in major complications. Therefore, it should only be used in specific patients and in minimal amounts. Indications for its use include single-stage permanent implant reconstruction and inadequate local muscle coverage of the tissue expander. CLINICAL QUESTION/LEVEL OF EVIDENCE:: Therapeutic, III.

BACKGROUND: Pseudoptosis (bottoming out) is a well-observed phenomenon occurring after all types of breast reduction surgery. The authors' team previously reported the use of three-dimensional (3D) imaging to demonstrate that significant morphologic changes occur in the breast during the first year after short-scar medial pedicle breast reduction. This study extended this evaluation to postoperative year 3. METHODS: Patients undergoing short-scar medial pedicle breast reduction had 3D photographs taken using the Canfield Vectra 3-pod system or the Konica Minolta V910 during postoperative follow-up visits at 1 month, 1 year, 2 years, and 3 years. Patients were assessed for pseudoptosis and breast morphologic changes using the 3D-based measurements. RESULTS: During the 3 year period, 10 patients completed the study. The total breast volume decreased significantly during the first postoperative year by 20.6% (P < 0.05). No change in volume occurred during postoperative years 2 and 3 (P > 0.05). Pseudoptosis was documented in the first postoperative year by a 6% migration of breast tissue from the upper pole to the lower pole of the breast (P < 0.05), without significant change noted during the next 2 postoperative years (P > 0.05). This redistribution of the breast parenchyma correlated with a decrease in breast anteroposterior projection of 10.6 mm (P < 0.05) during the same period, with an insignificant change during postoperative years 2 and 3. During the first postoperative year, 3D comparative analysis recorded a 4.4-mm difference in the 3D topography (P < 0.05) and no further changes thereafter. The angle of breast projection showed a significant decrease of 17% (P < 0.05) in the first postoperative year and no change in subsequent years. CONCLUSION: Three-dimensional photography is a useful tool enabling the plastic surgeon to monitor the postoperative changes in breast morphology objectively. This study provides quantifiable data demonstrating that pseudoptosis and tissue redistribution are limited to the initial postoperative year for patients undergoing short-scar medial pedicle breast reduction. The kinetic change in the breasts during postoperative years 2 and 3 appears to be minimal. Studies comparing the changes in morphology over time with different techniques of breast reduction are underway

BACKGROUND: Bottoming out is a well-known phenomenon described with reduction mammaplasty (RM). To date, the evaluation of post-operative bottoming out remains an imprecise science. The following study reports the application of three-dimensional (3D) photography to objectively investigate changes in breast morphology. METHODS: Patients undergoing medial pedicle RM had 3D photographs (Konica Minolta V910) taken during the early and late post-operative period (early=60-120 days; late=400-500 days). 3D images were compared and bottoming out was assessed with 3D parameters and vectors including total breast volume, volumetric tissue distribution above and below the Central (C) plane, distance of the C-plane to the lowest point of the breast, and maximum anterior-posterior projection from the chest wall. RESULTS: Post-operative images from 15 consecutive RM patients showed an average volume of 556+/-144cm3 (early) and 441+/-183cm3 (late). The percent of tissue in the upper pole of the breast changed from the early to late post-operative period (76% vs. 69%, respectively; p<0.01). The distance from a fixed C-plane to the inferior pole significantly increased (42+/-15mm early vs. 51+/-18mm late; p<0.01). AP projection decreased by an average of 6.23mm (p<0.01). The lateral border of the IMF significantly dropped by 6.27mm. CONCLUSIONS: This study objectively describes both the occurrence of bottoming out and the quantitative amount in terms of changes in volumetric distribution, surface topography and breast projection. With 3D photography, plastic surgeons can perform objective evaluation of breast transformation over time, which ultimately will aid in planning to allow for better surgical outcomes

Peripheral nerve defects are common. The surgeon faced with these problems must provide the best functional recovery for the patient with the tools provided. The ideal nerve reconstruction would create a tensionless repair with direct coaptation. However, this is not always possible and other techniques must be employed. The alternatives to direct coaptation include nerve autografts, nerve conduits, and tissue-engineered constructs. This article reviews commonly used autogenous nerve grafts and conduits. Autogenous nerve grafts have been utilized in various techniques which include the trunk graft, cable graft, interfascicular graft, and vascularized graft. The nerve conduits reviewed fall into the category of autogenous biological conduits, nonautogenous biological conduits, and nonbiological conduits. New technologies are being developed to enhance peripheral nerve regeneration with the concept that conduits can be enriched and manipulated in the laboratory to promote regeneration of the peripheral nerve. Further clinical studies hold the promise of successful alternatives for treating peripheral nerve injuries