Faculty Bibliography

BACKGROUND: Approximately 20 percent of women select autologous tissue for postmastectomy breast reconstruction, and most commonly choose the abdomen as the donor site. An increasing proportion of women are seeking muscle-sparing procedures, but the benefit remains controversial. It is therefore important to determine whether better outcomes are associated with these techniques, thereby justifying longer operative times and increased costs. METHODS: Patients from five North American centers were eligible if they underwent reconstruction by means of the deep inferior epigastric artery perforator (DIEP) flap, muscle-sparing free transverse abdominis myocutaneous (TRAM) flap, free TRAM flap, or the pedicled TRAM flap. Patients were sent the BREAST-Q. Demographics and complications were collected. RESULTS: The authors analyzed 1790 charts representing 670 DIEP, 293 muscle-sparing free TRAM, 683 pedicled TRAM, and 144 free TRAM patients with an average follow-up of 5.5 years. Flap loss did not differ by flap type. Partial flap loss was higher in pedicled TRAM compared with DIEP (p = 0.002). Fat necrosis was higher in pedicled TRAM compared with DIEP and muscle-sparing free TRAM (p < 0.001). Hernia/bulge was highest in pedicled TRAM (p < 0.001). Physical well-being (abdomen) scores were higher in DIEP compared with pedicled TRAM controlling for confounders. CONCLUSIONS: Complications and patient-reported outcomes differ when comparing abdominally based breast reconstruction techniques. The results of this study show that the DIEP flap was associated with the highest abdominal well-being and the lowest abdominal morbidity compared with the pedicled TRAM flap, but did not differ from muscle-sparing free TRAM and free TRAM flaps. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

BACKGROUND: Autologous breast reconstruction has been shown to have fewer complications and superior outcomes. In the elderly patient population, a paucity of literature on the subject may render the surgeon reluctant to recommend or perform such a procedure. The objective of this study was to compare complications and satisfaction after abdominally based breast reconstruction in patients older than versus younger than 65 years. METHODS: A retrospective study was performed with data from 5 North American centers from 2002 to 2012. Patients who underwent autologous reconstruction were identified retrospectively, and chart review was performed. The BREAST-Q questionnaire was sent to these patients via mail. Patient variables, operative outcomes and BREASTQ results were analyzed. The Pearson chi and analysis of variance tests were used. Given the number of analyses, a more conservative alpha of 0.01 was used for each comparison. RESULTS: A total of 1809 patients were included with 1751 patients younger than 65 years and 58 patients aged 65 years or older. Analysis of postoperative complications showed no significant differences between the age groups, though there was a trend toward higher seroma development (17.2% vs 8.1%; P = 0.013) and infection (19.0% vs 10.0%; P = 0.028) in the older group with statistical significance set at P less than 0.01 to account for multiple comparisons. A total of 1809 BREAST-Q surveys were sent with a response rate of 52.5%. Patient satisfaction results were equally high between the 2 age groups. CONCLUSIONS: This is the largest study to compare patients undergoing autologous breast reconstruction older than and younger than 65 years within the same cohort. Women older than 65 years represent a minority and constituted only 3% of patients in this multicenter 10-year review. We have shown that with careful patient selection, abdominally based autologous reconstruction should be considered in the elderly patient population because it is well tolerated and achieves high patient satisfaction.

BACKGROUND: The use of autologous adipose tissue harvested through liposuction techniques for soft-tissue augmentation has become commonplace among cosmetic and reconstructive surgeons alike. Despite its longstanding use in the plastic surgery community, substantial controversy remains regarding the optimal method of processing harvested lipoaspirate before grafting. This evidence-based review builds on prior examinations of the literature to evaluate both established and novel methods for lipoaspirate processing. METHODS: A comprehensive, systematic review of the literature was conducted using Ovid MEDLINE in January of 2015 to identify all relevant publications subsequent to the most recent review on this topic. Randomized controlled trials, clinical trials, and comparative studies comparing at least two of the following techniques were included: decanting, cotton gauze (Telfa) rolling, centrifugation, washing, filtration, and stromal vascular fraction isolation. RESULTS: Nine articles comparing various methods of processing human fat for autologous grafting were selected based on inclusion and exclusion criteria. Five compared established processing techniques (i.e., decanting, cotton gauze rolling, centrifugation, and washing) and four publications evaluated newer proprietary technologies, including washing, filtration, and/or methods to isolate stromal vascular fraction. CONCLUSIONS: The authors failed to find compelling evidence to advocate a single technique as the superior method for processing lipoaspirate in preparation for autologous fat grafting. A paucity of high-quality data continues to limit the clinician's ability to determine the optimal method for purifying harvested adipose tissue. Novel automated technologies hold promise, particularly for large-volume fat grafting; however, extensive additional research is required to understand their true utility and efficiency in clinical settings.

BACKGROUND: Acellular dermal matrices are used in implant-based breast reconstruction. The introduction of contour fenestrated AlloDerm (Life-Cell, Branchburg, N.J.) offers sterile processing, a crescent shape, and prefabricated fenestrations. However, any evidence comparing reconstructive outcomes between this newer generation acellular dermal matrices and earlier versions is lacking. METHODS: Patients undergoing implant-based breast reconstruction from 2010 to 2014 were identified. Reconstructive outcomes were stratified by 4 types of implant coverage: aseptic AlloDerm, sterile "ready-to-use" AlloDerm, contour fenestrated AlloDerm, or total submuscular coverage. Outcomes were compared with significance set at P < 0.05. RESULTS: A total of 620 patients (1019 reconstructions) underwent immediate, implant-based breast reconstruction; patients with contour fenestrated AlloDerm were more likely to have nipple-sparing mastectomy (P = 0.0001, 0.0004, and 0.0001) and immediate permanent implant reconstructions (P = 0.0001). Those with contour fenestrated AlloDerm coverage had lower infection rates requiring oral (P = 0.0016) and intravenous antibiotics (P = 0.0012) compared with aseptic AlloDerm coverage. Compared with sterile "ready-to-use" AlloDerm coverage, those with contour fenestrated AlloDerm had similar infection outcomes but significantly more minor mastectomy flap necrosis (P = 0.0023). Compared with total submuscular coverage, those with contour fenestrated AlloDerm coverage had similar infection outcomes but significantly more explantations (P = 0.0001), major (P = 0.0130) and minor mastectomy flap necrosis (P = 0.0001). Significant independent risk factors for increased infection were also identified. CONCLUSIONS: Contour fenestrated AlloDerm reduces infections compared with aseptic AlloDerm, but infection rates are similar to those of sterile, ready-to-use AlloDerm and total submuscular coverage.

BACKGROUND: Patients undergoing autologous breast reconstruction have higher long-term satisfaction rates compared with those undergoing prosthetic reconstruction. Regardless, most patients still undergo prosthetic reconstruction. The authors compared outcomes of microsurgical reconstruction to those of prosthetic reconstruction in thin patients and evaluated the effect of reconstructive type on quality of life. METHODS: After institutional review board approval was obtained, the authors reviewed all patients undergoing breast reconstruction at a single institution from November of 2007 to May of 2012. Thin patients (body mass index <22 kg/m) were included for analysis and divided into two cohorts: microsurgical reconstruction and tissue expander/implant reconstruction. Once identified, patients were mailed a BREAST-Q survey for response; a retrospective chart review was also conducted. RESULTS: A total of 273 patients met inclusion criteria: 81.7 percent (n = 223) underwent tissue expander/implant reconstruction and 18.3 percent (n = 50) underwent microsurgical reconstruction. Of the patients undergoing microsurgical reconstruction, 50 percent (n = 25) responded to the BREAST-Q survey, whereas 48.4 percent of patients (n = 108) with implant reconstruction were responders. Microsurgical patients required more secondary revision [48 percent (n = 12) versus 25.9 percent (n = 28)] and autologous fat grafting [32 percent (n = 8) versus 16.9 percent (n = 19)] and a greater volume of fat per injection (147.85 ml versus 63.9 ml; p < 0.001). Furthermore, BREAST-Q responses showed that these patients were more satisfied with their breasts (71.1 percent versus 64.9 percent; p = 0.004), but had similar overall satisfaction with reconstruction (73.0 percent versus 74.8 percent; p = 0.54). CONCLUSIONS: Microsurgical breast reconstruction is efficacious in patients with a body mass index less than 22 kg/m and, when compared with prosthetic reconstruction, results in higher satisfaction with breasts. However, it requires more secondary revision surgery and the use of autologous fat grafting as an adjunct. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

BACKGROUND: Acellular dermal matrix is a commonly used adjunct in implant-based breast reconstruction. Several investigations have shown increased complications associated with its use. Therefore, the authors' institution placed strict limitations on its use and transitioned to sterile "ready-to-use" acellular dermal matrix. The purpose of this investigation was to compare the infectious complications associated with aseptic versus sterile acellular dermal matrix. METHODS: A prospective study of all patients undergoing immediate implant-based breast reconstruction at a single academic medical center between November of 2010 and October of 2012 was conducted. AlloDerm (Life Cell Corporation, Branchburg, N.J.) was used as the source of acellular dermal matrix. Breasts were divided into three cohorts: total submuscular coverage, aseptic acellular dermal matrix, and sterile, ready-to-use acellular dermal matrix. Breasts were then compared based on demographic information, cancer qualities, and complications. RESULTS: A total of 546 reconstructed breasts met inclusion criteria: 64.3 percent (n = 351) with no acellular dermal matrix, 16.5 percent (n = 90) with aseptic matrix, and 19.2 percent (n = 105) with ready-to-use matrix. When comparing reconstructions with ready-to-use versus aseptic acellular dermal matrix, patients had a decrease in overall infection (8.5 percent versus 20.0 percent; p = 0.0088), major infection (4.7 percent versus 12.2 percent; p = 0.069), and need for explantation (1.9 percent versus 6.6 percent; p = 0.1470). When comparing patients undergoing reconstruction with ready-to-use matrix to total submuscular coverage, patients had similar overall infectious complications (8.5 percent versus 5.7 percent; p = 0.3602). Diabetes mellitus, seroma, mastectomy skin flap necrosis, and aseptic acellular dermal matrix were independent predictors of infectious complications. CONCLUSIONS: Ready-to-use acellular dermal matrix in immediate implant-based breast reconstruction provides a useful adjunct. In addition, it mitigates the risks of infectious complications when compared with aseptic acellular dermal matrix. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

BACKGROUND: Clinical results of fat grafting have been unpredictable. In this article, the authors hypothesize that centrifugation creates "graded densities" of fat with varying characteristics that influence lipoaspirate persistence and quality. METHODS: Aliquots of human female lipoaspirate (10 cc) were centrifuged for 3 minutes at 1200 g. The bloody and oil fractions were discarded. Subsequently, 1.0 cc of the highest density and lowest density fat was separated for lipoinfiltration or analysis. Highest density or lowest density fat grafted into adult FVB mice was harvested at 2 and 10 weeks to quantify short- and long-term persistence, respectively. Progenitor cell number and expression of vascular endothelial growth factor, stromal cell-derived factor-1alpha, platelet-derived growth factor, and adiponectin were analyzed by flow cytometry and enzyme-linked immunosorbent assay, respectively. RESULTS: Greater percentages of highest density fat grafts remain at 2 and 10 weeks after injection compared with lowest density fat grafts (85.4 +/- 1.9 percent versus 62.3 +/- 0.1 percent, p = 0.05; and 60.8 +/- 4.9 versus 42.2 +/- 3.9, p < 0.05, respectively). Highest density fractions contain more progenitor cells per gram than lowest density fractions (2.0 +/- 0.2-fold increase, p < 0.01). Furthermore, concentrations of vascular endothelial growth factor, stromal vascular fraction, platelet-derived growth factor, and adiponectin are all elevated in highest density compared with lowest density fractions (34.4 percent, p < 0.01; 34.6 percent, p < 0.05; 52.2 percent, p < 0.01; and 45.7 percent, p < 0.05, respectively). CONCLUSIONS: Greater percentages of highest density fractions of lipoaspirate persist over time compared with lowest density fractions. A vasculogenic mechanism appears to contribute significantly, as highest density fractions contain more progenitor cells and increased concentrations of several vasculogenic mediators than lowest density fractions.

BACKGROUND: : Lipoaspirate centrifugation creates graded density of adipose tissue. High-density fat contains more vasculogenic cytokines and progenitor cells and has greater graft survival than low-density fat. The authors hypothesize that accelerating the bone marrow-derived progenitor cell response to injected low-density fat will improve its graft survival. METHODS: : Male 8-week-old FVB mice (n = 60) were grafted with either high-density (n = 20) or low-density (n = 40) human lipoaspirate. Half of the mice receiving low-density fat (n = 20) were treated with a stem cell mobilizer for 14 days. Grafted fat was harvested at 2 and 10 weeks for analysis. RESULTS: : Low-density fat, low-density fat plus daily AMD3100, and high-density fat had 26 +/- 3.0, 61.2 +/- 7.5, and 49.6 +/- 3.5 percent graft survival, respectively, at 2 weeks (low-density fat versus low-density fat plus daily AMD3100 and low-density fat versus high-density fat, both p < 0.01). Similar results were observed 10 weeks after grafting. Mice receiving low-density fat plus daily AMD3100 had significantly more vasculogenic progenitor cells per cubic centimeter of peripheral blood (p < 0.01) and more new blood vessels (p < 0.01). Both low-density fat plus daily AMD3100 and high-density fat contained more stromal-derived factor-1alpha and vascular endothelial growth factor mRNA/protein. CONCLUSION: : Endogenous progenitor cell mobilization enhances low-density fat neovascularization, increases vasculogenic cytokine expression, and improves graft survival to a level equal to that of high-density fat grafts.