Faculty Bibliography

Unilateral breast reconstruction poses a special set of challenges to the reconstructive breast surgeon compared to bilateral reconstructions. No studies to date provide an objective comparison between autologous and implant based reconstructions in matching the contralateral breast. This study compares the quantitative postoperative results between unilateral implant and autologous flap reconstructions in matching the native breast in shape, size, and projection using three-dimensional (3D) imaging. Sixty-four patients who underwent unilateral mastectomy with tissue expander (TE)-implant (n = 34) or autologous microvascular free transverse rectus abdominus myocutaneous (TRAM; n = 18) or deep inferior epigastric artery perforator (DIEP; n = 12) flap (n = 30) reconstruction from 2007 to 2010 were analyzed. Key patient demographics and risk factors were collected. Using 3D scans of patients obtained during pre and postoperative visits including over 1 year follow-ups for both groups, 3D models were constructed and analyzed for total breast volume, anterior-posterior projection from the chest wall, and 3D comparison. No significant differences in mean age, body mass index, or total number of reconstructive surgeries were observed between the two groups (TE-implant: 52.2 +/- 10, 23.9 +/- 3.7, 3 +/- 0.9; autologous: 50.7 +/- 9.4, 25.4 +/- 3.9, 2.9 +/- 1.3; p > 0.05). The total volume difference between the reconstructed and contralateral breasts in the TE-implant group was insignificant: 27.1 +/- 22.2 cc, similar to the autologous group: 29.5 +/- 24.7 cc, as was the variance of breast volume from the mean. In both groups, the reconstructed breast had a larger volume. A-P projections were similar between the contralateral and the reconstructed breasts in the TE-implant group: 72.5 +/- 3.21 mm versus 71.7 +/- 3.5 mm (p > 0.05). The autologous reconstructed breast had statistically insignificant but less A-P projection compared to the contralateral breast (81.9 +/- 16.1 mm versus 61.5 +/- 9.5 mm; p > 0.05). Variance of A-P projection from the mean was additionally insignificant between the contralateral and reconstructed breasts. Both groups produced similar asymmetry scores based on global 3D comparison (TE-implant: 2.24 +/- 0.3 mm; autologous: 1.96 +/- 0.2 mm; p > 0.05). Lastly, when the autologous group was further subdivided into TRAM and DIEP cohorts, no significant differences in breast volume, A-P projection or symmetry existed. Using 3D imaging, we demonstrate that both TE-implant and autologous reconstruction can achieve symmetrical surgical results with the same number of operations. This study demonstrates that breast symmetry, while an important consideration in the breast reconstruction algorithm, should not be the sole consideration in a patient' decision to proceed with autologous versus TE-implant reconstruction.

BACKGROUND: Postoperative wound complications in patients undergoing complex spinal surgery can have devastating sequelae, including hardware exposure, meningitis, and unplanned reoperation. The literature shows that wound complication rates in this patient population approach 19 percent and, in very high-risk patients (i.e., prior spinal surgery, existing spinal wound infection, cerebrospinal fluid leak, malignancy, or history of radiation therapy), as high as 40 percent and with reoperation rates as high as 12 percent. The authors investigated whether prophylactic closure of spinal wounds with muscle flaps improves outcomes. METHODS: A retrospective review was performed of 102 reconstructions (in 96 patients) in which spinal wound closure was performed by means of paraspinous, trapezius, or latissimus muscle advancement flaps by a single plastic surgeon (J.A.S.) from 2006 to 2014. Data regarding presurgical diagnosis, patient demographics, and incidence of postoperative complications were recorded. RESULTS: One hundred two reconstructions were included, with follow-up ranging from 2 to 60 months. Eighty-eight reconstructions were classified as very high-risk for wound complications, defined as those having prior spinal surgery, existing spinal wound infection, cerebrospinal fluid leak, malignancy, or prior radiation therapy. Within the very high-risk group, there were six wound complications (6.8 percent), three of which (3.4 percent) required reoperation. CONCLUSIONS: In this study, there is a markedly lower rate (6.8 percent) of postoperative wound complications compared with historical controls after closure of spinal wounds with local muscle flaps in very high-risk patients. These data encourage safe and routine use of muscle flaps for closure in this cohort of patients undergoing spinal surgery. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

A clinical case demonstrating the use of a free fibula osteoseptocutaneous flap for reconstruction of a high-energy ballistic mandible defect is detailed. The surgical videos highlight key nuances and pearls of flap design, harvest, dissection, and execution of microsurgical anastomosis. Attention is also given to preoperative surgical planning and postoperative care. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Importance: Limited data exist on performing major oral cavity resections and reconstructions without elective tracheotomy. Objectives: To describe a group of patients who successfully underwent major microvascular mandibular reconstruction without an elective tracheotomy and to perform a literature review to identify commonalities between our group and the available literature to identify potential common factors that might contribute to the success of this approach. Design, Setting, and Participants: Case series with retrospective medical chart review of 15 patients who underwent fibula microvascular free flap reconstruction of mandibular defects without tracheotomy between 2000 and 2014 (the most common indication was osteoradionecrosis) conducted at a tertiary referral hospital center. Exposures: Mandibular reconstruction with fibula free flap without elective tracheotomy. Main Outcomes and Measures: Perioperative morbidity and mortality with a focus on airway management and perioperative complications. Results: The median age of 15 patients (11 males and 4 females) at the time of reconstruction was 42 years (range, 10-64 years). The indication for surgery was nonmalignant pathologic abnormalities in 8 patients (53%), osteosarcoma in 4 patients (27%), and oral cavity squamous cell carcinoma in 3 patients (20%). All patients were intubated endonasally and, excepting 1 pediatric case, were extubated the day following surgery. The fibula spanned the parasymphysis and/or symphysis in 2 patients, and was limited to the mandibular body in others (mean length, 7.6 cm [range, 4.0-15.0 cm]). The flap design was osteocutaneous in 3 patients and osseous in the rest. No patient required reintubation or tracheotomy. No complications due to endonasal intubation occurred. The average hospital length of stay was 11 days. Conclusions and Relevance: Major oral cavity resection and reconstruction with microvascular free flaps can be performed safely without elective tracheotomy in a select group of patients. Limited data exist on patient selection criteria. Further studies are needed to identify favorable factors and develop protocols for safe patient selection.

Introduction: Nipple-sparing mastectomy (NSM) is the latest advancement in the treatment of breast cancer. Long-term oncologic outcomes in nipple-sparing mastectomy (NSM) continue to be defined. Rates of locoregional recurrence for skin-sparing mastectomy (SSM) and NSM in the literature range from 0 to 14.3%. We investigated the outcomes of NSM at our institution. Methods: Patients undergoing NSM at our institution from 2006 to 2014 were identified. Patient demographics, tumor characteristics, and outcomes were collected. Locoregional recurrence was compared to previously published NSM and SSM results compiled from 14 and 11 studies in the literature. Institutional review board approval was obtained prior to the initiation of this study. Results: From 2006 to 2014, 319 patients (555 breasts) underwent NSM. 149 patients (248 breasts) had long-term follow-up available. Average patient age and BMI were 47.4 and 24.28. Eighty-five percent of patients underwent mastectomy primarily for a therapeutic indication. Average tumor size was 1.41 centimeters with the most common histologic type being invasive ductal carcinoma (66.7%) followed by DCIS (23.8%). Nodal disease was present in 14.8% of patients. Average patient follow-up was 30.72 months. There was one (0.7%) incidence of ipsilateral chest-wall recurrence in a 44 year-old (p<0.0001, compared to aggregate NSM and SSM data). There were 0.36 complications per patient. There were 3 incidences of nipple-areola complex (NAC) necrosis: 2 partial thickness necrosis and 1 full thickness necrosis. (Table Presented) Conclusions: We examined our institutional outcomes with NSM and found a locoregional recurrence rate of 0.7% with no nipple-areolar complex recurrence. This rate is significantly lower than aggregate published rates for both NSM and SSM

Functional analysis of a clinical microbiome facilitates the elucidation of mechanisms by which microbiome perturbation can cause a phenotypic change in the patient. The direct approach for the analysis of the functional capacity of the microbiome is via shotgun metagenomics. An inexpensive method to estimate the functional capacity of a microbial community is through collecting 16S rRNA gene profiles then indirectly inferring the abundance of functional genes. This inference approach has been implemented in the PICRUSt and Tax4Fun software tools. However, those tools have important limitations since they rely on outdated functional databases and uncertain phylogenetic trees and require very specific data pre-processing protocols. Here we introduce Piphillin, a straightforward algorithm independent of any proposed phylogenetic tree, leveraging contemporary functional databases and not obliged to any singular data pre-processing protocol. When all three inference tools were evaluated against actual shotgun metagenomics, Piphillin was superior in predicting gene composition in human clinical samples compared to both PICRUSt and Tax4Fun (p<0.01 and p<0.001, respectively) and Piphillin's ability to predict disease associations with specific gene orthologs exhibited a 15% increase in balanced accuracy compared to PICRUSt. From laboratory animal samples, no performance advantage was observed for any one of the tools over the others and for environmental samples all produced unsatisfactory predictions. Our results demonstrate that functional inference using the direct method implemented in Piphillin is preferable for clinical biospecimens. Piphillin is publicly available for academic use at http://secondgenome.com/Piphillin.

Aims. This study evaluated the effects of L-PRF presence and implant surface texture on bone healing around immediately placed implants. Methods. The first mandibular molars of 8 beagle dogs were bilaterally extracted, and implants (Blossom, Intra-Lock International, Boca Raton, FL) were placed in the mesial or distal extraction sockets in an interpolated fashion per animal. Two implant surfaces were distributed per sockets: (1) dual acid-etched (DAE, micrometer scale textured) and (2) micrometer/nanometer scale textured (Ossean surface). L-PRF (Intraspin system, Intra-Lock International) was placed in a split-mouth design to fill the macrogap between implant and socket walls on one side of the mandible. The contralateral side received implants without L-PRF. A mixed-model ANOVA (at alpha = 0.05) evaluated the effect of implant surface, presence of L-PRF, and socket position (mesial or distal), individually or in combination on bone area fraction occupancy (BAFO). Results. BAFO values were significantly higher for the Ossean relative to the DAE surface on the larger mesial socket. The presence of L-PRF resulted in higher BAFO. The Ossean surface and L-PRF presence resulted in significantly higher BAFO. Conclusion. L-PRF and the micro-/nanometer scale textured surface resulted in increased bone formation around immediately placed implants.