Evaluation of capsular contracture following immediate prepectoral versus subpectoral direct-to-implant breast reconstruction
Capsular contracture is a common adverse outcome following implant breast reconstruction, often associated with radiation treatment. The authors hypothesize that muscle fibrosis is the main contributor of breast reconstruction contracture after radiation. Retrospective chart review identified patients that underwent DTI reconstruction with pre-or post-operative breast irradiation. Signs of capsular contracture were assessed using clinic notes and independent graders reviewing two-dimensional images and anatomic landmarks. Capsular contracture rate was greater in the subpectoral vs. prepectoral group (nâ€‰=â€‰28, 51.8% vs. nâ€‰=â€‰12, 30.0%, pâ€‰=â€‰0.02). When compared to prepectoral DTI reconstruction in irradiated patients, subpectoral implant placement was nearly 4 times as likely to result in capsular contracture (pâ€‰<â€‰0.01). Rates of explantation, infection, tissue necrosis, and hematoma were comparable between groups. We also found that when subpectoral patients present with breast contracture, chemoparalysis of the muscle alone can resolve breast asymmetry, corroborating that muscle is a key contributor to breast contracture. As prepectoral breast reconstruction is gaining popularity, there have been questionsÂ regarding outcome following radiation treatment. This study suggest that prepectoral breast reconstruction is safe in an irradiated patient population, and in fact compares favorably with regard to breast contracture.
Wrist arthrodesis with the medial femoral condyle flap: Outcomes of vascularized bone grafting for osteomyelitis [Case Report]
BACKGROUND:Osteomyelitis of the wrist is rare but destructive. Subsequent bone defects often require vascularized bone for successful healing. Recent literature has pointed to the successful use of the medial femoral condylar (MFC) flap for difficult non-unions, yet it has not been specifically described for wrist fusion. We present our experience with this technique for limited and complete wrist arthrodesis. PATIENTS AND METHODS/METHODS:We reviewed 4 cases of radiocarpal bone loss from osteomyelitis. All cases utilized debridement of nonviable tissues, and at least 6 weeks of intravenous antibiotics, followed by vascularized bone grafting with a MFC flap. The flap was based on the horizontal periosteal branch of the descending geniculate artery, and utilized to directly bridge the bony defects following resection. RESULTS:Three patients healed primarily, and 1 patient required secondary cancellous bone grafting to reach union. One patient required revision of the donor site closure. None of the patients had a recurrence of infection or other complications. Average follow up was 8.5 months after reconstruction. Average time to union was 11.5 weeks. Three patients demonstrated full composite fist, and 1 patient had incomplete finger range of motion following several flexor and extensor tendon grafts. CONCLUSIONS:These cases illustrate the use of the MFC in wrist arthrodesis after osteomyelitis defects. In all cases, there was complete union in a short time, no recurrence of infection, and low donor-site morbidity.
Venous Anastomoses in Anterolateral Thigh Flaps for the Lower Extremity: Vessel Selection In Lieu of Obligatory Number
BACKGROUND:Dual venous drainage for anterolateral thigh flaps has been proposed to protect against flap-related complications in head and neck applications. Here we report our experience with single vs dual venous anastomosis during lower extremity free-tissue transfer. METHODS:All free anterolateral thigh flaps for lower extremity reconstruction from 2011 to 2017 were retrospectively reviewed. An algorithm was used to determine the type and number of venous anastomoses, emphasizing patient anatomy, venous quality, and size match. Patients were divided into single- and dual-venous-anastomosis groups. Univariate analysis determined differences between the groups. A multivariable analysis identified independent risk factors. RESULTS:Fifty patients met the inclusion criteria. Patient demographics, recipient sites, wound type, and flap characteristics were similar in 1 and 2 vein groups. Average follow-up was 9.6 months. Forty-two percent underwent single venous drainage anastomoses. Mean age was 52.7 years, 78.0% were male, and 60% had defects of the foot and ankle. Increased flap area and early dangling did not increase flap demise. Thirty-three percent of single-drainage patients and 31.0% of dual-drainage patients had a complication. A body mass index of greater than 30 kg/m was a predictor for both flap complication (P = 0.025) and partial flap loss (P = 0.031) in univariate analysis. No independent predictors were found in multivariate analysis. CONCLUSIONS:The number of venous anastomoses, area, and dangling protocol did not influence outcomes while using our lower extremity vein method. Thoughtful evaluation of venous egress should outweigh the routine use of multiple veins in perforator flap reconstructions of the lower extremity.
Reply: Lifetime Costs of Prophylactic Mastectomies and Reconstruction versus Surveillance [Comment]
Occult Histopathology and Its Predictors in Contralateral and Bilateral Prophylactic Mastectomies
BACKGROUND:The last decade has seen an increasing prevalence of prophylactic mastectomies with decreasing age of patients treated for breast cancer. Data are limited on the prevalence of histopathologic abnormalities in this population. This study aimed to measure the prevalence of histopathologic findings in contralateral prophylactic mastectomy (CPM) and bilateral prophylactic mastectomy (BPM) patients and identify predictors of findings. METHODS:Our institution's prophylactic mastectomies from 2004 to 2011 were reviewed. Breast specimens with prior malignancies were excluded. Patient factors and pathology reports were collected. Independent predictive factors were identified with univariate and multivariate logistic analysis. RESULTS:A total of 524 specimens in 454 patients were identified. Malignancy was found in 7.0% of CPM and 5.7% of BPM specimens. In CPM patients, ipsilateral lobular carcinoma-in situ [odds ratio (OR) 4.0] and mammogram risk group (OR 2.0) were predictive of malignancy. Age group (OR 1.5), ipsilateral lobular carcinoma-in situ (OR 2.3), and prior bilateral salpingo-oophorectomy (OR 0.3) were predictive of moderate- to high-risk histopathology. Only increasing age group was predictive of increased moderate- to high-risk histopathology in BPM patients (OR 2.3). There were no independent predictors of malignancy in BPM. BRCA status was not predictive in either CPM or BPM. CONCLUSIONS:Patients with lobular carcinoma-in situ in the index breast or high-risk mammograms have a higher prevalence of malignancies. Although BRCA patients may benefit from prophylactic mastectomy, the genetic diagnosis does not increase the prevalence of detecting occult pathology. BPM patients can be counseled about relative risk, where occult pathology increases with age.
Lifetime Costs of Prophylactic Mastectomies and Reconstruction versus Surveillance
BACKGROUND:The past decade has seen an increasing prevalence of prophylactic mastectomy with decreasing ages of patients treated for breast cancer. Data are limited on the fiscal impacts of contralateral prophylactic mastectomy trends, and no study has compared bilateral prophylactic mastectomy with reconstruction to surveillance in high-risk patients. METHODS:Lifetime third-party payer costs over 30 years were estimated with 2013 Medicare reimbursement rates. Costs were estimated for patients choosing contralateral or bilateral prophylactic mastectomy versus surveillance, with immediate reconstructions using a single-stage implant, tissue expander, or perforator-based free flap approach. Published cancer incidence rates predicted the percentage of surveillance patients that would require mastectomies. Sensitivity analyses were conducted that varied cost growth, discount rate, cancer incidence rate, and other variables. Lifetime costs and present values (3 percent discount rate) were estimated. RESULTS:Lifetime prophylactic mastectomy costs were lower than surveillance costs, $1292 to $1993 lower for contralateral prophylactic mastectomy and $15,668 to $21,342 lower for bilateral prophylactic mastectomy, depending on the reconstruction. Present value estimates were slightly higher for contralateral prophylactic mastectomy over contralateral surveillance but still cost saving for bilateral prophylactic mastectomy compared with bilateral surveillance. Present value estimates are also cost saving for contralateral prophylactic mastectomy when the modeled contralateral breast cancer incidence rate is increased to at least 0.6 percent per year. CONCLUSIONS:These findings are consistent with contralateral and bilateral prophylactic mastectomy being cost saving in many scenarios, regardless of the reconstructive option chosen. They suggest that physicians and patients should continue to receive flexibility in deciding how best to proceed clinically in each case.
Malignant Eccrine Spiradenoma of the Face [Case Report]
Malignant eccrine spiradenoma, or spiradenocarcinoma, is an exceedingly rare sweat-gland tumor, with only 102 reported cases. Low-grade carcinomas are especially rare with only a few cases reported. Because of the limited number of case reports, the biologic behavior of low-grade malignant eccrine spiradenoma is poorly understood and no evidence-based therapeutic approach is established. Here, the authors report a 29-year-old woman who presented with a history of left-sided facial lesions present since the age of 2 months. Histopathologic examination revealed multiple benign spiradenomas, several of which showed foci of low-grade malignant transformation evidenced by loss of the characteristic 2-cell population seen in the benign tumor component. Included are the clinical presentation, histopathologic description, and surgical decision making in an effort to guide recognition of this rare entity.
Assessment of patient factors, surgeons, and surgeon teams in immediate implant-based breast reconstruction outcomes
BACKGROUND: Outcome studies of immediate implant-based breast reconstruction have focused largely on patient factors, whereas the relative impact of the surgeon as a contributing variable is not known. As the procedure requires collaboration of both a surgical oncologist and a plastic surgeon, the effect of the surgeon team interaction can have a significant impact on outcome. This study examines outcomes in implant-based breast reconstruction and the association with patient characteristics, surgeon, and surgeon team familiarity. METHODS: A retrospective review of 3142 consecutive implant-based breast reconstruction mastectomy procedures at one institution was performed. Infection and skin necrosis rates were measured. Predictors of outcomes were identified by unadjusted logistic regression followed by multivariate logistic regression. Surgeon teams were grouped according to number of cases performed together. RESULTS: Patient characteristics remain the most important predictors for outcomes in implant-based breast reconstruction, with odds ratios above those of surgeon variables. The authors observed significant differences in the rate of skin necrosis between surgical oncologists with an approximately two-fold difference between surgeons with the highest and lowest rates. Surgeon teams that worked together on fewer than 150 procedures had higher rates of infection. CONCLUSIONS: Patient characteristics are the most important predictors for surgical outcomes in implant-based breast reconstruction, but surgeons and surgeon teams are also important variables. High-volume surgeon teams achieve lower rates of infection. This study highlights the need to examine modifiable risk factors associated with optimum implant-based breast reconstruction outcomes, which include patient and provider characteristics and the surgical team treating the patient. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.
Impact of surgeon and surgical team on outcomes in immediate implant based breast reconstruction (IBR) [Meeting Abstract]
A methodological analysis of the plastic surgery cost-utility literature using established guidelines
BACKGROUND:Cost-utility studies, common in medicine, are rare within plastic surgery despite their capability of measuring the value of procedures by considering the societal costs of improving quality of life. The objectives of this study were to analyze the design quality of the plastic surgery cost-utility literature and to identify areas of needed improvement for future studies. METHODS:A scoring tool was constructed based on the Recommendations of the Panel on Cost-Effectiveness in Health and Medicine. A PubMed search through October of 2012 was conducted for English-language plastic surgery utility studies. Articles were selected using two inclusion criteria and evaluated using the scoring tool. RESULTS:A 9-point scoring tool was created, and 37 publications were selected. Their average score was 3 out of 9 points. Thirty studies (81 percent) used population preferences in utility measurements. Fifteen studies (41 percent) measured costs, but only four (11 percent) included indirect costs and only five (14 percent) applied discount rates to calculate the value of treatments over time. Three studies (8 percent) earned zero points. The highest scoring study earned 8 points. CONCLUSIONS:The identified studies manifest the potential of cost-utility analyses in plastic surgery. Nonetheless, they are inconsistent in applying established cost-utility guidelines, especially in measuring costs and conducting recommended sensitivity analysis. Following this simple scoring tool can help future studies achieve some necessary improvements.