Armando A. Davila

A meta-analysis of human acellular dermis and submuscular tissue expander breast reconstruction

Background: Human acellular dermal matrix has become an increasingly used adjunct to traditional submuscular tissue expander/implant breast reconstruction, but there is no strong consensus regarding complication outcomes. This study stratified outcomes based on a meta-analysis of complications. Methods: A query of the MEDLINE database for articles on human acellular dermal matrix and submuscular tissue expander breast reconstruction yielded 901 citations. Two levels of screening identified 48 relevant studies. The DerSimonian and Laird random-effects model was used to perform the meta-analysis. Risk ratios and pooled complication rates were calculated for each outcome of interest. Results: Nineteen studies reporting human acellular dermal matrix (n = 2037) and 35 reporting submuscular outcomes (n = 12,847) were used to estimate complication rates. Rates were generally higher in acellular dermis patients: total complications, 15.4 versus 14.0 percent; seroma, 4.8 versus 3.5 percent; infection, 5.3 versus 4.7 percent; and flap necrosis, 6.9 versus 4.9 percent. Six studies reporting both acellular dermis and submuscular outcomes were used to estimate relative risks. There was an increased risk of total complications (relative risk, 2.05; 95 percent CI, 1.55 to 2.70), seroma (relative risk, 2.73; 95 percent CI, 1.67 to 4.46), infection (relative risk, 2.47; 95 percent CI, 1.71 to 3.57), and reconstructive failure (relative risk, 2.80; 95 percent CI, 1.76 to 4.45) in acellular dermis patients. Conclusions: The meta-analysis suggests that the use of human acellular dermal matrix increases complication rates vis-à-vis submuscular expander/implant reconstruction. This must be weighed against its reported advantages in enhancing cosmesis and ameliorating contracture. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Human Acellular Dermis versus Submuscular Tissue Expander Breast Reconstruction: A Multivariate Analysis of Short-Term Complications

Background Acellular dermal matrix (ADM) allografts and their putative benefits have been increasingly described in prosthesis based breast reconstruction. There have been a myriad of analyses outlining ADM complication profiles, but few large-scale, multi-institutional studies exploring these outcomes. In this study, complication rates of acellular dermis-assisted tissue expander breast reconstruction were compared with traditional submuscular methods by evaluation of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) registry. Methods Patients who underwent immediate tissue expander breast reconstruction from 2006-2010 were identified using surgical procedure codes. Two hundred forty tracked variables from over 250 participating sites were extracted for patients undergoing acellular dermis-assisted versus submuscular tissue expander reconstruction. Thirty-day postoperative outcomes and captured risk factors for complications were compared between the two groups. Results A total of 9,159 patients underwent tissue expander breast reconstruction; 1,717 using acellular dermis and 7,442 with submuscular expander placement. Total complications and reconstruction related complications were similar in both cohorts (5.5% vs. 5.3%, P=0.68 and 4.7% vs. 4.3%, P=0.39, respectively). Multivariate logistic regression revealed body mass index and smoking as independent risk factors for reconstructive complications in both cohorts (P<0.01). Conclusions The NSQIP database provides large-scale, multi-institutional, independent outcomes for acellular dermis and submuscular breast reconstruction. Both thirty-day complication profiles and risk factors for post operative morbidity are similar between these two reconstructive approaches.

The differential effect of BMI on prosthetic versus autogenous breast reconstruction: A multivariate analysis of 12,986 patients

BACKGROUND The comparative safety of breast reconstruction in obese patients remains to be clearly defined. This study utilized multi-institutional data to characterize the effect of body mass index (BMI) on breast reconstruction outcomes. METHODS Utilizing Current Procedural Terminology (CPT) codes, patients undergoing tissue expander, pedicled transverse rectus abdominis myocutaneous (TRAM) flap, latissimus dorsi flap, and free flap breast reconstruction were identified in the National Surgical Quality Improvement Program (NSQIP) database. Patients were stratified as obese (BMI ≥ 30) and non-obese (BMI < 30). Overall postoperative morbidity, flap complications, non-flap complications, and reoperation rates were compared among the groups. RESULTS Of 12,986 patients who underwent breast reconstruction, 3636 (28.0%) were obese. Overall morbidity was significantly elevated in obese patients across all forms of reconstruction (p < 0.05). BMI was correlated with increased surgical complications for tissue expander, pedicled TRAM, and free flap reconstructions (OR = 1.09, OR = 1.05, OR = 1.10, respectively; p < 0.05). Medical complications were higher in obese patients undergoing tissue expander and pedicled TRAM reconstructions (p = 0.001 and p < 0.001), but no significant difference was observed in latissimus and free flap reconstruction patients. Compared with obese tissue expander recipients, obese patients reconstructed using autologous tissue had higher rates of reoperations (12.8% versus 9.1%), overall morbidity (18.0% versus 9.5%), surgical (12.7% versus 8.3%), and medical complications (9.0% versus 2.2%). CONCLUSIONS The NSQIP database allows for evaluation and comparison of reconstructive outcomes in the obese population. Increased BMI was associated with higher morbidity in autologous reconstruction than tissue expander reconstruction. Among autologous procedures, latissimus flaps experienced the lowest captured 30 day morbidity.

A comparative analysis of cryopreserved versus prehydrated human acellular dermal matrices in tissue expander breast reconstruction

BackgroundThe use of human acellular dermal matrices (HADMs) in breast reconstruction has become routine practice for many reconstructive surgeons. Comparative studies between 2 more common iterations of human acellular dermis are scarce. Our study evaluated reconstructive outcomes of cryopreserved and prehydrated HADMs in comparative fashion. MethodsThis study is a retrospective review of 369 consecutive tissue expander breast reconstructions performed by 2 board-certified plastic surgeons whose practice focuses on breast reconstruction. Data were collected independently by 2 reviewers, and a comparative analysis for statistical significance of outcomes was performed using the Fisher exact test, 2-tailed independent t tests, and regression analysis where appropriate. ResultsOver a 5-year period, 255 patients (369 breasts) underwent breast reconstruction utilizing either cryopreserved or prehydrated HADM. Of the total, 136 breasts received cryopreserved and 233 breasts received prehydrated HADMs. The total complication rates for cryopreserved and prehydrated HADMs were 19.1% and 19.3% (P = 1.0), respectively. Additional complication rates were calculated for flap necrosis (8.1% vs 9.0%, P = 0.849), infection requiring intravenous antibiotics (10.3% vs 5.2%, P = 0.09), hematoma (2.9% vs 1.3%, P = 0.431), seroma (2.2% vs 1.0%, P = 1.0), expander exposure/dehiscence (5.9% vs 6.4%, P = 1.0), and number of breasts requiring autologous reconstruction after a complication (4.4% vs 6.4%, P = 0.491). On regression analysis, HADM type was not an independent risk factor for any complication subtype. ConclusionsThe results of this study suggest that there are no significant differences in complication rates between cryopreserved and prehydrated HADMs.

Immediate two-stage tissue expander breast reconstruction compared with one-stage permanent implant breast reconstruction: A multi-institutional comparison of short-term complications

Abstract Prosthesis-based techniques are the predominant form of breast reconstruction worldwide, with two-stage tissue expander procedures being the most popular. In the past decade, there has been increasing interest in performing single-stage implant reconstruction immediately following mastectomy as an attempt to simplify the reconstructive course and improve psychosocial morbidity. However, there is a paucity of large-scale, multi-institutional data comparing the outcomes of these two reconstructive strategies. Patients who underwent immediate tissue expander or implant reconstruction following mastectomy from 2006–2010 were identified using standardised operation codes. Demographic information for patients, 30-day outcomes, and adverse events for each type of reconstruction were analysed and compared between groups. A total of 10,561 patients underwent immediate breast reconstruction. There were 9033 patients who underwent tissue expander placement (2752 bilateral), and 1528 patients who underwent immediate implant placement (485 bilateral). Patients who had implant placement demonstrated increased rates of overall complications (6.8% compared with 5.4%, p = 0.02) and prosthesis failure (1.4% compared with 0.8%, p = 0.04). There was no difference in the rate of any surgical site infections (3.9% compared with 3.4%, p = 0.39), reoperation (7.5% compared with 6.9%, p = 0.40), or major medical complications (1.8% compared with 1.6%, p = 0.57). Both immediate one-stage, direct-to-implant, and two-stage tissue expander reconstructions result in low rates of morbidity. One-stage reconstruction suggests a slightly higher complication rate related to prosthesis failure.

A predictive model of risk and outcomes in tissue expander reconstruction: A multivariate analysis of 9786 patients

Abstract Outcomes of tissue expander breast reconstruction show variability based on presurgical risk factors. Few comprehensive, multi-institutional risk analyses exist. Patients who underwent tissue expander reconstruction were identified in a multi-institutional registry that spans over 240 institutions with over 200 variables per patient. Bivariate analysis of preoperative variables was performed across outcomes. Multivariate logistic regression was used to adjust for confounders and identify risk factors for complications. In 9786 total tissue expander patients, 526 (5.38%) patients experienced one or more complications. Wound infection and reoperations occurred in 3.45% and 6.76% of patients, respectively. Body mass index (BMI) was found to be a significant independent risk factor for overall morbidity, reoperation, prosthesis failure, and wound infection. Overweight, obese, and morbidly obese patients were at 1.7-, 2.6-, and 5.1-times greater risk of morbidity, respectively (p < 0.001 for all). Reconstructive timing, combined surgical procedures, and neoadjuvant chemotherapy were not found to be significant predictors of morbidity. The odds of developing complications were 1.5- and 1.3-times greater in smokers and patients over the age of 50, respectively (p = 0.001 and p = 0.015). For each additional hour of surgery, the odds of morbidity increased 1.26-times (p < 0.001). Precise risk profiles garnered from multi-institutional studies can help improve patient selection and education. Overall, tissue expander reconstruction was found to be safe, with relatively few complications. Operative time, BMI, and smoking were consistently found to be independent risk factors for postoperative morbidity.

Use of the tabbed expander in latissimus dorsi breast reconstruction

Abstract Latissimus dorsi (LD) myocutaneous flap breast reconstruction with a tissue expander/implant is a post-mastectomy option often used as a salvage procedure for a failed tissue expander (TE). The patient is traditionally placed in the lateral decubitus position for flap dissection and is re-prepped and re-draped in the supine position for placement of the tissue expander. A new generation of anatomically-shaped, tabbed tissue expanders are increasingly being used in place of traditional untabbed expanders. The innovative suture tabs allow for more predictable and controlled expander placement while the patient is in the lateral decubitus position, eliminating the need to reposition the patient intraoperatively. The objective of this study was to evaluate the use of tabbed tissue expanders in latissimus dorsi breast reconstruction, with respect to total operative time, complication rates, and aesthetic outcomes. The outcomes of 34 LD breast reconstruction procedures with tissue expanders were evaluated. Eight patients received tabbed tissue expanders with no position change, while 26 patients underwent an intraoperative position change. Demographic information, total operative time, and follow-up complication data were collected. Aesthetic outcomes were evaluated by three blinded individuals using a validated scoring scale. The mean operative time for procedures with no position change was 107 minutes. The mean operative time for position change cohort was 207 minutes. There was no statistical difference in complication rates or aesthetic outcomes between the two groups. In conclusion, tabbed tissue expanders decrease operative time by eliminating the need for an intraoperative position change without influencing complication rates while maintaining equivalent aesthetic outcomes.

The weave technique for nipple reconstruction.

Abstract Traditional nipple reconstruction relies on local flap techniques. However, there are several problems associated with local flap reconstruction including loss of projection, widening of the base width, and difficulty working around the mastectomy scar. This study presents a variation of traditional local flap nipple reconstruction, which is termed the weave technique. Rather than using two flaps to create base width, the weave technique uses one. By controlling the base width, this may serve to sustain long-term projection. Second, filling the inside of the nipple with the second flap may contribute to longer term projection. Because there is no third flap, it is easier to orient the nipple with respect to the mastectomy scar. To date, the senior author has used this method to reconstruct 55 nipples in 40 patients, with 415 days (range 191–733) mean follow-up time. This includes 45 (82%) nipple reconstructions after tissue expander-implant reconstruction. The use of this technique has produced excellent aesthetic results with nipple projection and site healing. The majority of patients have been satisfied with their nipple reconstruction. Three patients had wound healing difficulties, including two (3.6%) that healed with conservative wound care and one (1.8%) in a radiated patient requiring surgical revision. There were no other revisions necessary and no infections. In summary, the weave technique is a suitable modification to the popular C-V technique that maintains the benefits and simplicity of the aforementioned flap while potentially reducing projection loss, conserving base width, and allowing greater flexibility for nipple placement.

Abstract 46: The BRA Score: Creating a General Risk Calculator for Breast Reconstruction Outcomes.

ConClusions: Broadening indications has lead to increasing immediate breast reconstruction rates in high-risk patients at a major academic medical center. The majority of patients with unfavorable clinical characteristics undergo immediate implant-based reconstruction, relative to autologous tissue, as an efficient less invasive means of recreating the breast mound. Moving forward, the long-term safety and reliability of implant use in this patient group needs to be determined. 46 the Bra Score: creating a General risk calculator for Breast reconstruction outcomes

A novel prospective three-dimensional analysis of nasolabial fold augmentation.

BACKGROUND There are many products approved for aesthetic soft tissue augmentation. Despite this abundance, there is limited objective data regarding safety, longevity, and complication rates. Instead, most reports rely on subjective measures to report volume changes and outcomes, making product comparison difficult. OBJECTIVES The authors developed and validated a mathematical model to prospectively calculate and analyze three-dimensional (3D) volumetric changes associated with nasolabial fold augmentation based on human acellular dermis. METHODS Seven consecutive patients were included in this prospective review. The patients underwent nasolabial fold treatment with BellaDerm (Musculoskeletal Transplant Foundation, Edison, NJ), administered by a single surgeon. 3D photographs were obtained and analyzed with a novel mathematical model to determine absolute volumetric changes and objective longevity. RESULTS Mean preoperative nasolabial fold volume was 0.17 mL. The mean one-, three-, and six-month postoperative fill volumes were 0.35, 0.19, and 0.07 mL, respectively. Fill volumes and contour changes returned to baseline by 24 weeks postoperatively in the majority of patients. CONCLUSIONS The mathematical model utilized in this study provided prospective and objective data regarding longevity and volumetric changes associated with nasolabial fold augmentation. The analysis demonstrated minimal objective filler permanence beyond six months, with peak volume enhancement between one and three months. Adoption of objective 3D mathematical metrics into the assessment of soft tissue filler outcomes is critical to obtaining more accurate product-to-product comparisons.