Faculty Bibliography

As a biologic product derived from human tissue, acellular dermal matrices (ADMs) did not require pre-market approval for their initial use as a soft tissue support product. Since their first utilization in breast surgery, ADMs have allowed for numerous advances in breast reconstruction. ADMs quickly gained popularity in breast surgery and are frequently utilized in various applications. During an investigation into potential factors leading to breast implant-associated anaplastic large cell lymphoma, the United States Food and Drug Administration (FDA) made an official statement that ADMs were not approved for use in breast reconstruction and that using ADMs in breast surgery was considered off-label. This special topic article details the history of ADMs in breast surgery and describes the ongoing evolution of the relationship between the FDA and ADMs.

BACKGROUND:Despite the increased utilization of nipple-sparing mastectomies (NSM), there is limited data examining long-term cancer recurrence rates in these patients. The objective of this study was to analyze breast cancer recurrence in patients who received therapeutic NSM with a median of 10 years of follow-up. METHODS:All patients undergoing NSM at a single institution were retrospectively reviewed temporally to obtain a median of 10-years of follow up. Patient demographic factors, mastectomy specimen pathology, and oncologic outcomes were analyzed. Univariate analysis was performed to identify independent risk factors for locoregional recurrence. RESULTS:126 therapeutic NSM were performed on 120 patients. The most frequently observed tumor histology included invasive ductal carcinoma (48.4%) and ductal carcinoma in situ (38.1%). Mean tumor size was 1.62 cm. Multifocal or multicentric disease and lymphovascular invasion were present in 31.0% and 10.3% of NSM specimens, respectively. Sentinel lymph node biopsy was performed in 84.9% of NSM and 17.8% were positive. The rate of positive frozen subareolar biopsy was 7.3% (n=82) and permanent subareolar pathology was 9.5% (n=126). The most frequently observed pathologic tumor stages was stage I (44.6%) and stage 0 (33.9%). Incidence of recurrent disease was 3.17% per mastectomy and 3.33% per patient. Upon univariate analysis, no demographic, operative, or tumor-specific variables were independent risk factors for locoregional recurrence. CONCLUSIONS:Overall recurrence rates are low in patients undergoing NSM at a median follow-up of 10-years. Close surveillance should remain a goal for patients and their providers to promptly identify potential recurrence.

Currently, there is an increasing trend in women seeking aesthetic flat closure after mastectomy. To date, there is no plastic surgery literature on specific techniques to achieve an aesthetic flat closure after mastectomy. As plastic surgeons, we need to continue to innovate and to iterate new surgical techniques in our reconstructive armamentarium to address the desires of and to optimize the outcomes for our reconstructive breast surgery patients. Herein, we seek to delineate key considerations and employed techniques for reconstructive plastic surgeons performing aesthetic flat closure after mastectomy. Namely, it is crucial to listen to the patient, and to fully understand the patient's concerns, wishes, and particular aesthetic desired. From a technical perspective, the key surgical pearls include completely obliterating the inframammary fold, ensuring the same size and flap thickness bilaterally, appropriately de-fatting medially on the chest wall to allow for a smooth contour, obviating any presence of dog ears medially or laterally with precise tissue excision, and confirming that the incisions are entirely symmetric bilaterally. Intraoperatively, it is important to sit these patients up to assess soft tissue re-draping, and to confirm that there are no dog ears nor any excess tissue that could compromise the perfectly flat aesthetic chest closure. With the increasing demand for flat closures after mastectomy, plastic surgeons need to be keen on employing modified surgical techniques to best optimize the desired aesthetic flat closure reconstructions for these patients, as these reconstructions are not simply linear closures.

BACKGROUND:Implant-based breast reconstruction has evolved, with a recent resurgence of prepectoral techniques. Comparative reconstructive outcomes and complications have not been fully elucidated among the total submuscular (TSM), dual-plane (DP), and prepectoral planes of implant placement. METHODS:All immediate implant-based breast reconstructions from March 2017 through August 2019 were retrospectively reviewed. Cases were divided into TSM, DP, and prepectoral cohorts. Demographics, operative techniques, and reconstructive outcomes and complications were compared among groups. RESULTS:826 cases (510 patients) were identified and divided into TSM (n=392), DP (n=358), and prepectoral (n=76) cohorts. Average follow-up for all patients was 27 months. The prepectoral cohort had a higher average BMI and rate of prior reduction/mastopexy. Overall complications were lowest in the TSM group, though this difference was not statistically significant. Major infection occurred more frequently in the DP group compared to the TSM cohort. The prepectoral cohort had a significantly increased incidence of wound dehiscence than the TSM group, while both the dual-plane and prepectoral groups had higher rates of seroma formation and explantation compared to TSM. CONCLUSIONS:Overall reconstructive complication rates were comparable among the cohorts. Compared to those undergoing TSM reconstruction, the DP cohort was more likely to develop a major infection or require explantation, while the prepectoral group had significantly higher rates of isolated dehiscence, seroma formation, and explantation. This suggest that the absence of overlying vascularized muscle may lead to an inherent inability to tolerate wound healing complications, though further research is needed to clarify these observations.

Background/Purpose: Craniofacial microsomia (CFM) is the second most common congenital facial anomaly, yet its genetic etiology remains unknown. Methods/Description: We perform whole-exome or genome sequencing of 146 kindreds with sporadic (n=138) or familial (n=8) CFM.
Result(s): We identify a highly significant burden of loss of function variants in SF3B2 (P=3.8 x 10-10), a component of the U2 small nuclear ribonucleoprotein complex, in probands. We describe twenty individuals from seven kindreds harboring de novo or transmitted haploinsufficient variants in SF3B2. Probands display mandibular hypoplasia, microtia, facial and preauricular tags, epibulbar dermoids, lateral oral clefts in addition to skeletal and cardiac abnormalities. Targeted morpholino knockdown of SF3B2 in Xenopus results in disruption of cranial neural crest precursor formation and subsequent craniofacial cartilage defects, supporting a link between spliceosome mutations and impaired neural crest development in congenital craniofacial disease.
Conclusion(s): The results establish haploinsufficient variants in SF3B2 as the most prevalent genetic cause of CFM, explaining ~3% of sporadic and ~25% of familial cases

BACKGROUND:Social media has altered the mechanisms by which published research is disseminated and accessed. The objective of this study was to measure the effect of promotion on research article dissemination, influence, and impact in Plastic and Reconstructive Surgery. METHODS:All articles published in Plastic and Reconstructive Surgery from January 1, 2016-December 31, 2018 were obtained and reviewed to determine inclusion/exclusion and for the Altmetric Attention Score (AAS), citations, relative citation rate (RCR), and 16 unique promotional tags (journal club, editor's pick, press release, patient safety, etc.) as indexed on the Plastic and Reconstructive Surgery website. 1,502 articles were included in the analysis. Statistical analysis was completed using descriptive statistics, Pearson's correlations, and Student t-tests where appropriate with a predetermined level of significance of p≤0.05. RESULTS:A total of 637 articles (42.4%) had a promotional tag, while 252 (16.8%) had multiple tags. Articles with promotional tags had higher AAS (30.35 vs 8.22; p<0.001), more citations (11.96 vs 8.47; p<0.001), and a higher RCR (2.97 vs 2.06; p<0.001) compared to articles without a tag. Articles with multiple tags had higher AAS (50.17 vs 17.39; p<0.001), more citations (15.78 vs 9.47; p<0.001), and a higher RCR (3.67 vs 2.51; p<0.001) compared to articles with only one tag. As the number of tags increased for an article, AAS (p<0.001), citation count (p<0.001), and RCR (p<0.001) likewise increased. CONCLUSIONS:This analysis strongly suggests that promotion of research articles is associated with significantly wider dissemination, broader visibility, and more subsequent citations in the literature.

INTRODUCTION/BACKGROUND:The coronavirus disease-19 (COVID-19) pandemic dramatically changed the delivery of breast cancer care. The objective of this study was to quantify the effect of the pandemic on breast cancer screening, treatment, and reconstruction at a single institution in New York City. METHODS:A retrospective chart review was conducted to determine the number of mammograms, lumpectomies, mastectomies, and breast reconstruction operations performed between January 1, 2019 and June 30, 2021. Outcomes analyzed included changes in mammography, oncologic surgery, and breast reconstruction surgery volume before, during and after the start of the pandemic. RESULTS:Mammography volume declined by 11% in March-May of 2020. Oncologic breast surgeries and reconstructive surgeries similarly declined by 6.8% and 11%, respectively, in 2020 compared with 2019, reaching their lowest levels in April 2020. The volume of all procedures increased during the summer of 2020. Mammography volumes in June and July 2020 were found to be at pre-COVID levels, and in October-December 2020 were 15% higher than in 2019. Oncologic breast surgeries saw a similar rebound in May 2020, with 24.6% more cases performed compared with May 2019. Breast reconstruction volumes increased, though changes in the types of reconstruction were noted. Oncoplastic closures were more common during the pandemic, while two-stage implant reconstruction and immediate autologous reconstruction decreased by 27% and 43%, respectively. All procedures are on track to increase in volume in 2021 compared to that in 2020. CONCLUSION/CONCLUSIONS:The COVID-19 pandemic reduced the volume of breast cancer surveillance, surgical treatment, and reconstruction procedures. While it is reassuring that volumes have rebounded in 2021, efforts must be made to emphasize screening and treatment procedures in the face of subsequent surges, such as that recently attributable to the Delta and Omicron variants.