Faculty Bibliography

INTRODUCTION: During preoperative discussions with breast reconstruction patients, questions often arise about what to expect during the recovery period. However, there is a paucity of data elucidating post-breast reconstruction pain, fatigue, and physical morbidity. This information is important to patient and physician understanding of reconstructive choices and the postoperative recovery process. We sought to evaluate how recovery may vary for patients based on the timing and type of reconstruction. MATERIALS AND METHODS: Patients were recruited as part of the Mastectomy Reconstruction Outcomes Consortium (MROC) study, which is a prospective, multicentered National Institute of Health (NIH)-funded study (1RO1CA152192). Here, patients completed the Numerical Pain Rating Scale (NPRS), McGill Pain Questionnaire, and Breast-Q preoperatively, at 1 week, and 3 months postoperatively. Pain, fatigue, and upper body morbidity were evaluated by the type and timing of reconstruction. RESULTS: A total of 2013 MROC study participants had completed a 3-month follow-up, and therefore they were included for the analysis. A total of 1583 (78.6%) and 1517 patients (75.3%) completed surveys at 1 week and 3 months, respectively, post reconstruction. Across all procedure groups, fatigue and physical well-being scores did not return to preoperative levels by 3 months. At 3 months, pain measured by the NPRS differed across procedure types (P = 0.01), with tissue expander/implant (TE/I) having more pain than direct to implant (P < 0.01). Similarly, at 3 months, chest and upper body physical morbidity, as measured by BREAST-Q, differed by procedure types (P < 0.001), with generally less morbidity for autologous reconstruction as compared with TE/Is. CONCLUSIONS: For all reconstructive procedure groups, patients did not fully recover at 3 months post surgery. In addition, postoperative pain and upper body physical morbidity vary significantly by reconstructive procedure with patients undergoing TE/I reporting the most distress.

OBJECTIVE: The treatment of head and neck cancer has varying impact on postoperative recovery and return of swallowing function. The authors aim to establish screening tools to assist in preoperatively determining the need for gastrostomy tube placement. METHODS: The authors prospectively assessed all patients undergoing complex head and neck reconstructive surgery during a 1-year study period. Only patients tolerating an oral diet, without preoperative gastrostomies, were enrolled for study. Eight parameters were assessed including: body mass index (BMI), prealbumin, albumin, smoking history, comorbidities [including coronary artery disease (CAD), chronic obstructive pulmonary disease (COPD), and diabetes mellitus (DM)], age, use of microvascular reconstruction, and type of defect. Two specific screening tools were assessed. In the first, a multivariate logistic regression model was employed to determine factor(s) that predict postoperative gastrostomy tube. In a second screening tool, the 8 parameters were scored between 0 to 1 points. The total score obtained for each patient was correlated with postoperative gastrostomy placement. RESULTS: Out of the 60 study patients enrolled in the study, 24 patients (40%) received a postoperative gastrostomy. In the logistic regression model, albumin level was the only factor that was significantly associated with need for postoperative gastrostomy (P < 0.0023). A score of 4 or greater was determined to have a sensitivity of 83% and specificity of 61% for postoperative gastrostomy. CONCLUSIONS: Patients with a score of 4 or more with this screening scoring system or those patients with an albumin level <3.5 g/dL were at high risk for postoperative feeding tube placement.

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.

Perioperative infection is the most common and dreaded complication associated with tissue expander (TE) breast reconstruction. Historically, the expansion period was thought to be the time of greatest hazard to the implant. However, recent institutional observations suggest infectious complications occur prior to expansion. This investigation, therefore, was conducted to determine the timing of infectious complications associated with two-stage TE breast reconstructions. Following IRB approval, a retrospective review of all consecutive two-stage immediate TE breast reconstructions at a single institution from November 2007 to November 2011 was conducted. Reconstructions were then divided into two cohorts: those suffering infectious complications and those that did not. Infectious complications including minor cellulitis, major cellulitis, abscess drainage, and explantation were identified. Various operative and patient variables were evaluated in comparison. Eight hundred ninety immediate two-stage TE breast reconstructions met inclusion criteria. Patients suffering infection were older (55.4 years versus 49.3 years; p < 0.001), and more likely to have therapeutic mastectomy (94% versus 61%; p < 0.0001), the use of acellular dermal matrix (ADM; 72.5% versus 54.9%; p = 0.001), and greater initial TE fill (448.6 mL versus 404.7 mL; p = 0.0078). The average time to developing of infectious symptoms was 29.6 days (range 9-142 days), with 94.6% (n = 87) of infections prior to the start of expansion. Perioperative infections in immediate two-stage TE to implant breast reconstructions are significant and occur mostly prior to the start of expansion. Thus, challenging the conventional wisdom that instrumentation during expander filling as the primary cause of implant infections. Possible etiologic factors include greater age, therapeutic mastectomy versus prophylactic mastectomy, larger initial TE fill, and the use of ADM.

BACKGROUND: Lower extremity reconstruction following resection of long bone tumors is challenging because of the unique functional demands and growth potential of the lower extremity in children. The use of a free fibula flap inside a massive bone allograft provides a reliable reconstructive option. The authors evaluate the surgical and functional outcomes of using this technique. METHODS: This is a retrospective review of 12 consecutive patients who underwent reconstruction of segmental femur or tibia defects using a free fibula flap inside a massive bone allograft from 2003 to 2011. Complications and functional outcomes are reported. RESULTS: Twelve patients with a mean age of 15.8 years (range 3 to 49 years) were included in the study. Eight femur defects and four tibia defects were reconstructed. The mean follow up time was 41.4 months. Two constructs were removed because of infection, three patients required bone grafting for nonunion, one patient required an additional operation to excise a skin paddle, and one patient experienced a lower extremity DVT. The mean time to achieve full weight bearing was 14.3 months. CONCLUSIONS: The use of a free fibula flap inside a massive bone allograft following bone tumor resection provides an option for lower extremity reconstruction. The allograft component increases the initial strength of the reconstruction while the vascularized fibula component is thought to increase the biologic potential for osteosynthesis and ultimately provide a potentially life-long durable reconstruction. Patients who achieve oncologic control are likely to enjoy a high functional long-term outcome. LEVEL OF EVIDENCE: IV.

Background Prolonged operative time has been associated with increased postoperative complications and higher costs. Many academic centers have a designated day for didactics that cause cases to start 1 hour later. The purpose of this study is to analyze the late-start effect of microvascular breast reconstructions on operative duration. Methods A retrospective review was performed on all patients who underwent abdomina-based free flap breast reconstruction from 2007 to 2011 and analyzed by those who had surgery on late-start versus normal-start days. Patient demographics, average operative time, postoperative complications, and individual surgeon effects were analyzed. A Student t-test was used to compare operative times with statistical significance set at p < 0.05. A multivariate regression analysis was performed to control for potential confounders. Results A total of 272 patients underwent 461 free flap breast reconstructions. Twenty-one cases were performed on late-start days and 251 cases were performed on normal-start days. Patient demographics and complications were not statistically different between the groups. The average operative time for all reconstructions was 434.3 minutes. The average operative times were significantly longer for late-start days, 517.6 versus 427.3 minutes (p = 0.002). This was true for both unilateral and bilateral reconstructions (432.8 vs. 350.9 minutes, p = 0.05; 551.5 vs. 461.2 minutes, p = 0.007). There were no differences in perioperative complications and multivariate regression showed no statistically significant relationship of confounders to duration of surgery. Conclusion Starting cases 1 hour later can increase operative times. Although outcomes were not affected, we recommend avoiding lengthy procedures on late-start days.

BACKGROUND: Breast reduction in patients with a history of lumpectomy and irradiation is controversial because of a heightened risk of infection and wound healing complications. Persistent macromastia or asymmetry remains a problem in this patient population that is commonly not addressed. The authors studied the safety and efficacy of a central mound technique with minimal dissection for breast reduction or mastopexy in patients with a history of breast irradiation. METHODS: A case-control study of all patients undergoing bilateral breast reduction mammaplasty between 2008 and 2013 at Memorial Sloan Kettering Cancer Center was conducted. Patients who had unilateral breast irradiation and bilateral reduction using the central mound technique were included. Each patient had a control breast and an irradiated breast. Complications and outcomes were analyzed. RESULTS: Thirteen patients were included for analysis. Their average age was 50.23 +/- 9.9 years, and average time from irradiation to breast reduction mammaplasty was 41.3 +/- 48.5 months (range, 9 to 132 months). The average specimen weight of irradiated breasts was less than that of control breasts; however, this failed to reach statistical significance (254.2 +/- 173.5 g versus 386.9 +/- 218.5 g; p = 0.099). One patient developed fat necrosis in the previously irradiated breast and underwent biopsy. There was no incidence of nipple necrosis or breast cancer in either irradiated or nonirradiated breasts. CONCLUSIONS: Breast reduction mammaplasty in patients who have had irradiation is feasible and can be performed safely in select cases. The central mound technique provides reliable and reproducible results and should be considered in patients with macromastia/asymmetry and a history of irradiation. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.