Faculty Bibliography

BACKGROUND: To decrease the rate of infectious complications, surgeons have begun to use Biopatch (Ethicon, Somerville, N.J.) disks at drain exit sites. The authors investigated whether use of a Biopatch disk could convey a reduction in perioperative infections in patients undergoing immediate tissue expander breast reconstruction. METHODS: A retrospective review was conducted of all patients undergoing tissue expander/implant breast reconstruction from November of 2010 to November of 2012 at a single institution. Breasts were divided into two cohorts: controls with traditional adhesive dressings and those with Biopatch disks at drain sites. Breasts were compared based on demographics, complications, drain duration, and antibiotic type. RESULTS: A total of 1211 breasts met inclusion criteria. The control group (November of 2010 to October of 2011) included 606 breasts. The Biopatch cohort (November of 2011 to October of 2012) included 605 breasts. When comparing breasts with disks to controls, there were no statistical differences in overall infection (6.2 versus 7.4 percent; p = 0.4235), major infection (4.0 versus 4.3 percent; p = 0.8853), need for explantation (2.2 versus 1.8 percent; p = 0.5372), and mastectomy skin flap necrosis (12.6 versus 14.6 percent; p = 0.3148). However, age greater than 50 years, diabetes mellitus, hypertension, hypercholesterolemia, obesity, history of prior breast irradiation, and mastectomy skin flap necrosis were independent predictors of infectious complications. CONCLUSIONS: Biopatch disks do not reduce the rate infectious complications in patients undergoing immediate tissue expander breast reconstruction. Other conventional risks, including medical comorbidities, obesity, and mastectomy skin flap necrosis, remain significantly associated with infectious complications. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Background The purpose of this investigation was to examine patients with low body mass index (BMI) regarding the feasibility to perform autologous breast reconstruction in such patients, as well as to determine optimal donor sites and evaluate outcomes accordingly. Patients and Methods All patients undergoing microsurgical breast reconstruction were divided into three cohorts based on BMI. Group 1 included patients with BMI greater than or equal to 22 kg/m2 and was defined "low-normal BMI." Patients with BMI 22 to 25 kg/m2 were placed in Group 2, labeled as "high-normal BMI." Group 3, defined as "overweight," included patients with BMI greater than 25 kg/m2, but less than 30 kg/m2. Patients were then analyzed based on demographics, breast cancer history, intraoperative details, complications, and revisionary surgeries. F-tests, chi-square goodness-of-fit tests, and Freeman-Halton extension of the Fisher exact tests were used for statistical analysis. Results During the study period, a total of 259 reconstructions were performed. Group 1 included 30 patients (n = 49 flaps), Group 2 included 58 patients (n = 98 flaps), and Group 3 included 69 patients (n = 112 flaps). Patients undergoing nipple-areolar sparing mastectomy were more likely to be in Groups 1 (39% [n = 19]) and 2 (37% [n = 37]) as compared with Group 3 (14.2% [n = 16]) (p < 0.001) as compared with the overweight cohort. Patients with increasing BMI were more likely to undergo abdominally based free flaps as compared with alternative donor sites (Group 1 = 2.26, Group 2 = 7.9, Group 3 = 27 [p < 0.001]). Conclusions Abdominally based free flaps are possible in the majority of patients, however alternative harvest sites have to be used more frequently in low BMI patients.

BACKGROUND: Beauty lies in the eyes of the beholder, but influenced by the individual's geographic, ethnic, and demographic background and characteristics. In plastic surgery, objective measurements are used as a foundation for aesthetic evaluations. This study assumes interdependence between variables such as country of residence, sex, age, occupation, and aesthetic perception. METHODS: Computerized images of a model's face were generated with the ability to alter nasal characteristics and the projection of the lips and chin. A survey containing these modifiable images was sent to more than 13,000 plastic surgeons and laypeople in 50 different countries, who were able to virtually create a face that they felt to be the aesthetically "ideal" and most pleasing. Demographic information about the interviewees was obtained. RESULTS: Values of various aesthetic parameters of the nose were described along with their relationship to geography, demography, and occupation of the respondents. Interregional and ethnic comparison revealed that variables of country of residence, ethnicity, occupation (general public vs surgeon), and sex correlate along a 3-way dimension with the ideal projection of the lips and the chin. Significant interaction effects were found between variables of country of residence or ethnicity with occupation and sex of the respondents. CONCLUSIONS: What are considered the "ideal" aesthetics of the face are highly dependent on the individual's cultural and ethnic background and cannot simply and solely be defined by numeric values and divine proportions. As confirmed with this study, ethnic, demographic, and occupational factors impact peoples' perception of beauty significantly.

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: Autologous microvascular breast reconstruction is an increasingly common procedure. While arterial anastomoses are traditionally being hand-sewn, venous anastomoses are often completed with a coupler device. The largest coupler size possible should be used, as determined by the smaller of either the donor or recipient vein. While its efficacy has been shown using 3.0-mm size and greater couplers, little is known about the consequences of using coupler sizes less than or equal to 2.5 mm. Methods: A retrospective chart review of patients undergoing autologous breast reconstruction was conducted at NYU Medical Center between November 2007 and November 2011. Flaps were divided into cohorts based on coupler size used: 2.0 mm, 2.5 mm, and 3.0 mm. Outcomes included incidence of arterial or venous insufficiency, hematoma, fat necrosis, partial flap loss, full flap loss, and need for future fat grafting. Results: One-hundred ninety-seven patients underwent 392 flaps during the study period. Patients were similar in age, type of flap, smoking status, and radiation history. Coupler size less than or equal to 2.0 mm was found to be a significant risk factor for venous insufficiency (P = 0.038), as well as for development of fat necrosis (P = 0.041) and future need for fat grafting (P = 0.050). In multivariate analysis, body mass index was found to be an independent risk factor for skin flap necrosis (P = 0.010) and full flap loss (P = 0.035). Conclusions: Complications were significantly increased in patients where couplers of 2.0 mm or less were used, therefore to be avoided whenever possible. When needed, more aggressive vessel exposure through rib harvest, the use of thoracodorsal vessels or hand-sewing the anastomosis should be considered in cases of internal mammary vein caliber of 2.0 mm or less. CLINICAL QUESTION: Therapeutic LEVEL OF EVIDENCE: Level III. (c) 2013 Wiley Periodicals, Inc. Microsurgery, 2013.

BACKGROUND: Infection requiring explantation remains the most devastating complication associated with implant-based breast reconstruction. There are many treatment algorithms to prevent reconstructive failure in face of infection using both oral and intravenous antibiotics. In the absence of patient-specific culture data, antibiotic selection is generally directed toward broad-spectrum coverage based on historical data. We hypothesize that reviewing our institution's microbiology data obtained from explanted implant-based breast reconstructions would provide a rational basis for antibiotic selection in the future. METHODS: A retrospective review of 902 consecutive immediate implant-based breast reconstructions at a single institution from November 2007 to May 2011 was conducted. Implant reconstructions requiring explantation or drainage by interventional radiology were identified. Patient demographics, implant characteristics, presence of skin necrosis, microbiological data, and outcomes were reviewed. RESULTS: Forty-three (4.76%) implant reconstructions requiring explantation or drainage by interventional radiology met the inclusion criteria for this study. Five patients (11.6%) had round, smooth silicone implants, and 36 (88.4%) had textured tissue expanders. Twenty-six implants were explanted because of infection; 3, because of exposure from skin necrosis; and 11, because of the combination of flap necrosis and infection; and 1, secondarily because of cancer invasion into the skin. Reconstruction was salvaged in 21 breasts (51.2%): 12 (57.1%) by implant reconstruction, 5 (23.8%) by pedicled latissimus dorsi flaps, and 4 (19.1%) with a microvascular free flap. Thirty explants had microbiology data available. The most common organism isolated was Staphylococcus epidermidis (10), followed by methicillin-sensitive Staphylococcus aureus (5), Serratia marcescens (5), Pseudomonas aeruginosa (4), enterococcus (3), Escherichia coli (2), Enterobacter (2), group B streptococcus (1), and Morganella morganii (1). Forty percent of the organisms were resistant to cefazolin; however, 86% were sensitive to gentamicin, 80% were sensitive to Levaquin, and 63% were sensitive to ciprofloxacin. CONCLUSIONS: Infection associated with implant-based breast reconstructions continues to threaten explantation and reconstructive failure. Based on our microbiological data, initial cellulitis amenable to oral antibiotics should be treated with oral fluoroquinolones as a first-line treatment. If this regimen fails, intravenous imipenem or gentamicin and vancomycin should be initiated. Obviously, clinical judgment regarding specific patient risk factors and compliance should play a role in decision making, but these data provide an evidence-based rationale for first-line oral antibiotic selection.

PURPOSE: There is no more important decision an academic Plastic Surgery Department or Division can make than naming a chair or chief. Externally recruited leadership brings fresh perspectives and connections. Critics, however, argue that they lack the in-depth knowledge of the institution's culture and history that may be needed to succeed. The ability and skill of an internal candidate is already known and can increase the odds of that person's success in the leadership position. Finally, external recruitment can be a more costly process. Ultimately, the decision is really a litmus test for a Plastic Surgery program. The authors aim to evaluate factors influencing ascent in Plastic Surgery leadership, including training history, internal promotion, and external recruiting. METHODS: All Plastic Surgery residency programs accredited by the Accreditation Council for Graduate Medical Education were noted (n = 71). Academic departmental chairs or divisional chiefs of these residency programs were identified at the time of study design (October 1, 2011). For each chair or chief, gender, training history, and faculty appointment immediately prior to the current leadership position was recorded. RESULTS: There were 71 academic chairs or chiefs of Plastic Surgery residency programs at the time of data collection. The majority (62%) had done fellowship training following Plastic Surgery residency. Fellowships included hand (43%), craniofacial (29%), microsurgery (18%), and other types (10%). The majority (73%) of leaders were internal hires (P < 0.01), having faculty appointments at their institutions prior to promotion. However, only a fraction (22%) of these internal hires had done Plastic Surgery residency or fellowship training at that institution (P < 0.01). External recruits consisted of 27% of all 71 academic hires (P < 0.01). CONCLUSIONS: Many factors influence the decision to recruit leadership from internally or to hire an external candidate. These include the time to fill the position, program culture, candidate experience, and cost. These results support that the insider/outsider hire decision is ultimately one of duality. That dichotomy is achieved with an emphasis on internal promotion, but always with an eye towards the advantages of bringing in external talent as a valuable contribution to increase organizational success.

BACKGROUND: Autologous breast reconstruction offers higher rates of patient satisfaction, but not all patients are ideal candidates, often due to inadequate volume of donor sites. Although autologous fat grafting is frequently used to augment volume and contour abnormalities in implant-based breast reconstruction, its clear utility in microsurgical breast reconstruction has yet to be defined. Here, we examined patients undergoing autologous microsurgical breast reconstruction with and without the adjunct of autologous fat grafting to clearly define utility and indications for use. METHODS: A retrospective review of all patients undergoing autologous breast reconstruction with microvascular free flaps at a single institution between November 2007 and October 2011 was conducted. Patients were divided into 2 groups as follows: those requiring postoperative fat grafting and those not requiring fat grafting. Patient demographics, indications for surgery, history of radiation therapy, patient body mass index, mastectomy specimen weight, need for rib resection, flap weight, and complications were analyzed in comparison. RESULTS: Two hundred twenty-eight patients underwent 374 microvascular free flaps for breast reconstruction. One hundred (26.7%) reconstructed breasts underwent postoperative fat grafting, with an average of 1.12 operative sessions. Fat was most commonly injected in the medial and superior medial poles of the breast and the average volume injected was 147.8 mL per breast (22-564 mL). The average ratio of fat injected to initial flap weight was 0.59 (0.07-1.39). Patients undergoing fat grafting were more likely to have had deep inferior epigastric perforator and profunda artery perforator flaps as compared to muscle-sparing transverse rectus abdominis myocutaneous. Patients additionally were more likely to have a prophylactic indication 58% (n = 58) versus 42% (n = 117) (P = 0.0087), rib resection 68% (n = 68) versus 54% (n = 148) (P < 0.0153), and acute postoperative complications requiring operative intervention 7% (n = 7) versus 2.1% (n = 8) (P < 0.0480). Additionally, patients undergoing autologous fat grafting had smaller body mass index, mastectomy weight, and flap weight. CONCLUSIONS: Fat grafting is most commonly used in those breasts with rib harvest, deep inferior epigastric perforator flap reconstructions, and those with acute postoperative complications. It should be considered a powerful adjunct to improve aesthetic outcomes in volume-deficient autologous breast reconstructions and additionally optimize contour in volume-adequate breast reconstructions.

BACKGROUND: : Prior breast irradiation increases the rate of postoperative complications, including capsular contracture, in tissue expander/implant reconstruction. Acellular dermal matrix is heralded to decrease capsular contracture, but recent evidence suggests a possible increase in postoperative complications. The authors evaluated outcomes in patients undergoing bilateral tissue expander/implant reconstruction with acellular dermal matrix in the setting of prior unilateral irradiation. METHODS: : A case-control study was conducted on all patients undergoing bilateral, acellular dermal matrix-assisted, tissue expander/implant reconstruction with a history of previous unilateral irradiation at Memorial Sloan-Kettering Cancer Center. Complication rates were compared. RESULTS: : Twenty-three patients met inclusion criteria and had an average follow-up of 19 months (range, 4 to 60 months). The perioperative infection rate was 21.7 percent (n = 5) in irradiated breasts and 4.3 percent (n = 1) in control breasts (p = 0.079). Mastectomy skin flap necrosis, explantation, hematoma, and seroma rates were not significantly different between the groups. Sixty percent of patients had irradiated breast contracture that was one Baker grade greater than that in the nonirradiated breast. Body mass index greater than 25 and smoking history were significant independent risk factors for early postoperative complications in univariate analysis (p = 0.01). CONCLUSIONS: : Previous irradiation does not appear to increase the risk of early postoperative complications associated with acellular dermal matrix use in tissue expander/implant breast reconstruction. However, body mass index greater than 25 and smoking history are cause for caution. In addition, acellular dermal matrix does not appear to affect the degree of capsular contracture formation in the setting of prior irradiation. CLINICAL QUESTION/LEVEL OF EVIDENCE: : Therapeutic, III.

BACKGROUND: Access to the frontal sinus remains a challenging problem for the craniofacial surgeon. A wide array of techniques including minimally invasive endoscopic approaches have been described. Here we present our technique using medical modeling to gain fast and safe access for multiple indications. METHODS: Computer-aided surgery involves several distinct phases: planning, modeling, surgery, and evaluation. Computer-aided, precise cutting guides are designed preoperatively and allowed to perfectly outline and then cut the anterior table of the frontal sinus at its junction to the surrounding frontal bone. The outcomes are evaluated by postoperative three-dimensional computed tomography scan. RESULTS: Eight patients sustaining frontal sinus fractures were treated with the aid of medical modeling. Three patients (37.5%) had isolated anterior table fractures, and 4 (50%) had combined anterior and posterior table fractures, whereas 1 patient (12.5%) sustained isolated posterior table fractures. Operative times were significantly shorter using the cutting guides, and fracture reduction was more precise. There was no statistically significant difference in complication rates or overall patient satisfaction. CONCLUSIONS: The surgical approach to the frontal sinus can be made more efficient, safe, and precise when using computer-aided medical modeling to create customized cutting guides.