Faculty Bibliography

BACKGROUND:Few studies in the literature examine outcomes of immediate breast reconstruction after mastectomy with nipple preservation and radiation therapy. METHODS:Retrospective analysis of multisurgeon consecutive implant-based reconstructions after nipple-sparing mastectomy from June of 2007 to December of 2012 was conducted at a single institution. RESULTS:Six hundred five immediate breast reconstructions were performed following nipple-sparing mastectomy, of which 88 were treated with radiation therapy. There was a trend toward more complications in patients with radiation (19.3 percent versus 12.8 percent; p = 0.099) associated with a higher rate of implant loss (6.8 percent versus 1.0 percent; p = 0.001). Preoperative radiotherapy had a higher risk of total complications (p = 0.04; OR, 2.225; 95 percent CI, 1.040 to 4.758) and postoperative radiotherapy had a higher risk of explantation (p = 0.015; OR, 5.634; 95 percent CI, 1.405 to 22.603). There were no significant differences in nipple removal secondary to malposition or positive oncologic margins in patients with radiation compared to those without radiation. Patients with radiation did have a higher incidence of secondary procedures for capsular contracture (12.5 percent versus 2.3 percent; p < 0.001) and fat grafting (13.6 percent versus 3.9 percent; p < 0.001). The total nipple retention rate in patients with radiation therapy was 90 percent (79 of 88), and the reconstruction failure rate was 8 percent. CONCLUSIONS:Nipple-sparing mastectomy and immediate reconstruction in patients who had or will receive radiation therapy is associated with a higher incidence of complications and operative revisions compared with patients without radiation. However, most patients have successful reconstructions with nipple retention and no recurrences.

BACKGROUND:There is an intense push to decrease overall healthcare costs in the United States. Although the use of acellular dermal matrix in implant-based reconstruction has grown significantly over the past decade, potential drawbacks remain a source of debate. Matrices are costly and not universally available across institutions, whereas Vicryl mesh is widely available, relatively inexpensive, and resistant to bacteria biofilm formation. With the intent of maximizing the reconstructive and economic advantages of direct-to-implant breast reconstruction, the authors report the first experience in the literature using an absorbable mesh as an inferolateral sling. METHODS:A retrospective review was performed of the first 50 consecutive patients (76 reconstructions) who underwent implant-based breast reconstruction with Vicryl mesh from August of 2011 until June of 2012. RESULTS:Fifty patients underwent 76 direct-to-implant reconstructions with Vicryl mesh between August of 2011 and June of 2012 (mean follow-up, 1.2 years). Five breasts (6.6 percent) had complications, with only one complication resulting in implant loss (1.3 percent). Implant positioning and contour were excellent, with only two patients [three breasts (3.9 percent)] undergoing revision procedures, for size enlargement. Using costs available at the authors' institution, use of Vicryl mesh instead of acellular dermal matrix resulted in a direct material cost savings of $172,112 in 10 months. CONCLUSIONS:Results to date have been encouraging, with a low complication rate (6.6 percent) and excellent aesthetic results. The technique has resulted in $172,112 in direct material cost savings over 10 months. Continued follow-up is planned to evaluate long-term results. CLINICAL QUESTION/LEVEL OF EVIDENCE/METHODS:Therapeutic, IV.

BACKGROUND:Few studies address salvage rates for infection in implant-based breast reconstruction. An understanding of success rates and clinical predictors of failure may help guide management. METHOD/METHODS:A retrospective analysis of multisurgeon consecutive implant reconstructions from 2004 to 2010 was performed. RESULTS:Immediate implant-based reconstructions (n=1952) were performed in 1241 patients. Ninety-nine reconstruction patients (5.1 percent) were admitted for breast erythema and had a higher incidence of smoking (p=0.007), chemotherapy (p=0.007), radiation therapy (p=0.001), and mastectomy skin necrosis (p<0.0001). There was no difference in age, body mass index, or acellular dermal matrix usage. With intravenous antibiotics, 25 (25.3 percent) reconstruction patients cleared the infection, whereas 74 (74.7 percent) underwent attempted operative salvage (n=18) or explantation (n=56). Patients who failed to clear infection had a higher mean white blood cell count at admission (p<0.0001). Of the attempted operative salvage group, 12 cleared the infection with immediate implant exchange and six eventually lost the implant. Patients who failed implant salvage were more likely to have methicillin-resistant Staphylococcus aureus (p=0.004). The total explantation rate was 3.2 percent. Following explantation, 32 patients underwent attempted secondary tissue expander insertion. Twenty-six were successful and six had recurrent infection and implant loss. There were no differences in time interval to tissue expander insertion between successful and unsuccessful secondary operations. CONCLUSIONS:Salvage with intravenous antibiotics and implant exchange was successful in 37.3 percent of patients. Smoking, irradiation, chemotherapy, and mastectomy skin necrosis were predictors for developing infection. Patients with a higher white blood cell count at admission and methicillin-resistant S. aureus were more likely to fail implant salvage. There was no association with time interval to tissue expander insertion and secondary explantation. CLINICAL QUESTION/LEVEL OF EVIDENCE/METHODS:Therapeutic, IV.

Body contouring has a higher rate of thromboembolism than traditional plastic surgery procedures. Although risk stratification protocols exist, few offer specific therapeutic guidelines for deep venous thrombosis prevention. This single surgeon series classifies 105 consecutive patients into low, moderate, high, and highest risk groups. The respective thromboembolism prevention treatment included pneumatic compression devices alone, postoperative low-dose unfractionated heparin (LDUH), preoperative and 2 doses of postoperative LDUH, and preoperative and postoperative LDUH/low-dose molecular weight heparin for 7 days. Complications included 1 reoperation for bleeding. There were no clinically detected deep venous thromboses. In conclusion, this treatment algorithm for thromboembolism prevention results in a low rate of bleeding and thrombosis. Further studies are warranted to determine optimal timing and duration of chemoprophylaxis in plastic surgery patients.

One of the most serious complications in plastic surgery is a thromboembolic event. However, little physiologic evidence exists to support the observed hypercoagulable state seen in contouring procedures. Twenty-one consecutive patients were enrolled prospectively to assess thrombin generation, which measures activity of the coagulation cascade, at baseline, intraoperative, and 24 hours after surgery. Compared with preoperative values, total thrombin generation increased by a mean of 997 nM intraoperatively (1.3-fold, P<0.004) and 1406 nM postoperatively (1.4-fold, P<0.001) in 9 patients undergoing abdominoplasty without deep venous thrombosis (DVT) chemoprophylaxis. The mean thrombin generation did not significantly change during or after surgery in 12 patients who received heparin for DVT prophylaxis (P=0.3). Thrombin generation was significantly less in patients receiving chemoprophylaxis compared with those who received no prophylaxis (P<0.01). This suggests abdominal contouring procedures induce a significant increase in the activity of the coagulation cascade that can be prevented by DVT chemoprophylaxis.

BACKGROUND:Noninvasive procedures for facial rejuvenation are becoming an increasingly popular component of a comprehensive skin care regimen. Concurrently, many new treatment methods are now available to both the plastic surgeon and the aesthetician. Because these techniques have become an integral part of many cosmetic practices, this study aimed to assess the existing evidence-based literature as to their clinical efficacy; to provide an objective overview of some of the most popular noninvasive rejuvenation strategies such as dermaplaning, oxygen therapy, and light therapy; to discuss recent pertinent scientific evidence-based literature; and to provide treatment recommendations based on these findings. METHODS:A systematic review was performed in August 2009 using PubMed and the following keywords: "dermaplaning," "oxygen therapy," and "light therapy." All peer-reviewed articles then were screened independently by three plastic surgeons. RESULTS:The search identified 42 English-written, peer-reviewed manuscripts. The overall amount of scientific data supporting these methods was found to be scarce, anecdotal, and not well documented. Nevertheless, all three noninvasive therapies have become increasingly popular in the cosmetic market because many patients and physicians or surgeons report being pleased with their results. CONCLUSION/CONCLUSIONS:Although the evidence supporting these nonsurgical methods is suboptimal, their uses continue to expand. As with any plastic surgery procedure, providing patients with realistic expectations is essential to achieving optimal outcomes and patient satisfaction. Therefore, critical investigation is warranted. In addition, these methods are most effective when included within a comprehensive skin care regimen consisting of sunscreen, vitamin therapy, and lifestyle modification.

BACKGROUND:Acellular dermal matrix has become a common adjunct in prosthesis-based breast reconstruction. The authors' aim was to determine whether acellular dermal matrix use in immediate prosthesis-based breast reconstruction is associated with higher rate of complications. METHODS:Over a 5½-year period at the Brigham and Women's Hospital, 470 postmastectomy defects were reconstructed immediately using tissue expanders or implants. These were divided into two groups: reconstructions with or without acellular dermal matrix. Data were collected on patient comorbidities, radiation, intraoperative tumescent solution use, prosthesis size, initial fill volume, and complications. RESULTS:The risk for major infections that required prosthesis removal was elevated in the acellular dermal matrix group (4.9 versus 2.5 percent), but this increase did not reach statistical significance (p = 0.172). There was a statistically significant increase in overall wound infection rate in the acellular dermal matrix group (6.8 versus 2.5 percent, p = 0.031), but in a multivariate analysis, the use of acellular dermal matrix did not materialize as a significant risk factor for overall wound infection. Overall surgical complication rate was significantly higher in the acellular dermal matrix group at 19.5 percent, compared with the non-acellular dermal matrix group at 12.3 percent (p < 0.001). Other significant risk factors for overall surgical complication included smoking, higher body mass index, higher initial volume, and larger implant size. CONCLUSIONS:Patient selection for prosthesis reconstruction involving acellular dermal matrix should be judicious, especially among smokers and patients with elevated body mass index. Even though the use of acellular dermal matrix allows higher initial volumes and reduced number of expansions, one should be careful about putting in too high of an initial volume.