Bradley P. Bengtson

Reduction mammaplasty : long-term efficacy, morbidity, and patient satisfaction

This retrospective study was designed to determine if reduction mammaplasty relieved preoperative symptoms in patients with macromastia. Seven-hundred and eighty women who had reduction mammaplasties between 1981 and 1992 were surveyed. Responses to questions concerning the preoperative and postoperative symptoms, breast size, complications, and satisfaction were elicited. Completed surveys were returned by 406 patients (52 percent) who had bilateral operations. The mean age at surgery was 38 years, with an average follow-up of 4.7 years. Preoperative complaints of shoulder grooving (94 percent), shoulder pains (93 percent), and back pains (81 percent) were significantly reduced following surgery (McNemar test, p < 0.0001). Cup size decreased an average of two sizes in 72 percent. There were 215 women (53 percent) with postoperative complications, and although most were minor, 20 (5 percent) required surgical correction. Self-esteem improved in 358 (88 percent), and most would have surgery again (93 percent) and would encourage others to have the same (94 percent). Reduction mammaplasty decreases breast size and significantly relieves preoperative symptoms associated with mammary hypertrophy. Relief of symptoms was the most common reason women gave for having the operation, and 87 percent were satisfied with the results despite frequent minor postoperative complications.

Influence of prior radiotherapy on the development of postoperative complications and success of free tissue transfers in head and neck cancer reconstruction

The purpose of this study was to determine whether prior radiotherapy had any effect on the development of postoperative complications in patients undergoing microvascular tissue transfers for reconstruction of head and neck cancer. A prospective database was used to review 354 consecutive patients who had a total of 368 free tissue transfers limited to the head and neck during the 4-year period from July 1988 to June 1992. Postoperative complications in 167 patients who received preoperative radiotherapy (XRT) were compared with those of 187 patients who did not undergo radiotherapy preoperatively (NR). No statistical differences in complications or flap loss between the two groups were noted using the chi 2 test or Fishers exact test (p > 0.2). Total flap loss occurred in 5.3% of the XRT group (9 of 169) and 5.0% of the NR patient group (10 of 199), and partial flap loss occurred in 4.1% of the irradiated patients and 2.5% of the nonirradiated patients. Major wound complications requiring additional surgery occurred in 16% of the XRT group and 11% of the NR group. Minor wound complications that did not require further surgery occurred in 21% of the irradiated patients and 18% of the nonirradiated patients. No significant difference in the timing or dose of preoperative radiation, previous neck dissection, or anastomotic type could be documented in failed versus successful flaps (two-tailed t-test, p > 0.80, and chi 2, p > 0.2). Our results show that, in a large group of cancer patients undergoing free tissue transfers to the head and neck, prior radiotherapy or surgery did not predispose them to a higher rate of acute flap loss or wound complications than their nonirradiated cohorts.

Natrelle style 410 form-stable silicone breast implants: core study results at 6 years.

BACKGROUND The Natrelle Style 410 shaped, form-stable silicone gel implant (Allergan, Inc; Irvine, California) has been the subject of a pivotal study that supports potential US Food and Drug Administration approval of the device. The 3-year results of this study were reported previously. OBJECTIVES The authors update the safety and effectiveness findings for the Natrelle Style 410 implants through 6 years of study. METHODS This prospective, nonrandomized, multicenter study included 941 patients (492 primary augmentations, 156 revision-augmentations, 225 primary reconstructions, and 68 revision-reconstructions). Since the original 3-year report, follow-up visits have been conducted annually. Kaplan-Meier risk rates were calculated for local complications, reoperations, and explantations. One-third of the subjects were enrolled in the magnetic resonance imaging (MRI) cohort and underwent biannual MRI rupture screening. Effectiveness was measured by subject satisfaction on a 5-point scale. RESULTS As expected after breast implantation, capsular contracture (CC) was one of the most common complications, with 6-year risk rates of 4.6% for augmentation, 6.9% for revision-augmentation, 10.7% for reconstruction, and 18.3% for revision-reconstruction. The rates for CC among augmentations and revision-augmentations were significantly lower with the Natrelle 410 implants than with other standard gel implants. The rupture rate (confirmed plus suspected) across all cohorts was 6.4% by subject and 3.8% by implant. The most common reasons for reoperation were style or size change (augmentation), implant malposition (revision-augmentation), scarring (reconstruction), and CC (revision-reconstruction). The satisfaction rate exceeded 80% in all cohorts. CONCLUSIONS These fifth-generation, form-stable implants represent another option to achieve desired aesthetic outcomes with minimal complications.

Style 410 highly cohesive silicone breast implant core study results at 3 years.

Background: In February of 2001, Allergan (formerly Inamed) began an Investigational Device Exemption study of a shaped breast implant: the Style 410 highly cohesive silicone-filled breast implant. Methods: Forty-eight plastic surgeons across the United States performed implantation on 941 subjects enrolled in a 10-year study. This prospective, nonrandomized study provided 3-year follow-up data, clinical outcomes, and satisfaction rates from this cohort of 492 primary augmentation, 225 breast reconstruction, and 224 breast revision subjects. Complications were reported and compared with those from current standard gel and saline implant studies. Results: With greater than 85 percent follow-up compliance at 3 years, complication rates were low among augmentation subjects, with implant malposition being the most common (2.6 percent) and all other complications occurring in less than 2 percent of subjects. In the revision-augmentation group, the most common complications were capsular contracture (4.8 percent) and implant malposition (4.7 percent), with all other complications occurring in less than 4 percent. Asymmetry (8.7 percent) and capsular contracture (5.9 percent) were the only complications that occurred in more than 5 percent of reconstruction subjects. The overall risk of rupture across all cohorts was 1.0 percent by subject and 0.8 percent by implant. Subject satisfaction with implants was 98 percent for augmentation and 90 percent or higher for all other cohorts. Conclusions: The Style 410 highly cohesive silicone implant has low complication rates and high satisfaction rates through 3 years after implantation. These results are significant in introducing more evidence-based medicine that will allow plastic surgeons and patients to make better informed decisions regarding implant options.

Anticoagulants and hematomas in free flap surgery

A review of systemic anticoagulant use in 517 free flap procedures was performed to determine the associated risk of hematoma formation. Patients were divided retrospectively (not randomly) into five groups: no anticoagulation (227 flaps, 5.3 percent hematomas), low-dose heparin bolus of 2000 to 3000 units and postoperative infusion at a rate of 100 to 400 units/hr for 5 to 7 days (192 flaps, 6.7 percent hematomas), intraoperative bolus of 5000 units of heparin without postoperative anticoagulation (46 flaps, 6.5 percent hematomas), high-dose heparin infusion at a rate of 500 to 1200 units/hr (30 flaps, 20 percent hematomas), and dextran 40 infusion at a rate of 25 ml/hr (22 flaps, 9.1 percent hematomas). Intraoperative blood loss was similar for all groups. The flap loss rate was lower in the bolus (1.0 percent) and low-dose (1.0 percent) heparin groups than in the no-anticoagulation group (4.4 percent), but this difference was not statistically significant. The pedicle thrombosis rate also was lower in the bolus (2.2 percent) and low-dose (2.1 percent) heparin groups than in the no-anticoagulation group (6.2 percent). A cause-and-effect relationship between the use of anticoagulants and flap loss or prevention of thrombosis could not be established. We can conclude, however, that the use of low-dose heparin does not increase significantly the risk of hematoma or intraoperative bleeding.

Ten-year results from the Natrelle 410 anatomical form-stable silicone breast implant core study.

Background Silicone breast implants have long been used for breast augmentation and reconstruction. During this time, these medical devices have gone through a number of modifications to improve their safety, quality, and clinical outcome performance. Objectives The authors conducted a 10-year study to determine the safety and effectiveness of Natrelle 410 silicone breast implants. Methods This prospective, multicenter study enrolled 941 subjects who were undergoing either augmentation, augmentation revision, reconstruction, or reconstruction revision. Data on complications, reoperations, explantations, and subject satisfaction were collected at annual clinic visits, and one-third of subjects underwent biennial magnetic resonance imaging (MRI) to screen for implant rupture. The authors used the Kaplan-Meier estimator to calculate risk rates for local complications, reoperations, and explantations. Results Capsular contracture rates increased approximately 1% per year from the previously reported 6-year rates. The rates were significantly lower than those from the Natrelle round gel core study. The overall rate of confirmed ruptured implants in subjects who underwent MRI was 5.7%. Eleven late seromas were reported. The most common reason for explantation was a subject requesting a size or style change. Satisfaction rates remained high through 10 years, with most subjects saying they were somewhat or definitely satisfied with their implants. Conclusions This 10-year prospective trial demonstrated the long-term safety and effectiveness of Natrelle 410 anatomical form-stable implants. The complication rates were low and the satisfaction rates were high. Level of Evidence: 1 Therapeutic

Managing late periprosthetic fluid collections (seroma) in patients with breast implants: a consensus panel recommendation and review of the literature.

Background: The goal of this consensus is to establish an algorithm for the management of patients who develop a late or delayed periprosthetic fluid collection. A work group of practicing plastic surgeons and device industry physicians met periodically by teleconference and discussed issues pertinent to the diagnosis and management of late periprosthetic fluid collections in patients with breast implants. Based on these meetings, treatment recommendations and a treatment algorithm were prepared in association with an editorial assistant. Method: The work group participants discussed optimal care approaches developed in their private practices and from evidence in the literature. Results: The consensus algorithm and treatment and management recommendations represent the consensus of the group. Conclusions: The group concluded that late periprosthetic fluid collection (arbitrarily defined as occurring ≥1 year after implant) is an infrequently reported occurrence (0.1 percent) after breast implant surgery and that, at a minimum, management should include clinically indicated ultrasound-guided aspiration of fluid, with appropriate cultures and cytologic testing. Further evaluation and additional treatment is recommended for recurrence of periprosthetic fluid collection after aspiration, or clinical suspicion of infection or neoplasia.

Capsular tissue: a new local flap.

Capsular tissue, the interface that forms between an implanted device and the bodys own soft tissues, has recently been shown to develop its own unique blood supply. This capsular tissue with its extensive vascular plexus has not been described previously as an isolated flap. The purpose of our study was to determine whether an isolated flap of capsular tissue would survive as a local pedicle flap and provide enough inherent vascularity to support a skin graft. Isolated expanded and nonex-panded capsular flaps were compared by using 20 expanders (10 expanded and 10 nonexpanded) in two mixed-breed female pigs. Expanded and nonexpanded capsular flaps were elevated 8 weeks following expander placement. These flaps were raised on their capsular bases alone, and skin grafts were placed onto the capsular surfaces. All the expanded capsular flaps and their skin grafts had 100 percent survival. Skin grafts on the non-expanded flaps survived an average of 28 percent, with graft survival corresponding to flap survival. This study confirms that flaps of isolated expanded capsular tissue survive and provide enough inherent vascularity to support a split-thickness skin graft.

Reduction mammaplasty : A safe and effective outpatient procedure

Traditionally, reduction mammaplasty has been performed on an inpatient basis with a one to two day hospitalization. Many procedures once commonly performed on an inpatient basis have been shown to be safe and effective when performed in an outpatient setting. The purpose of this study was to determine if reduction mammaplasty could be performed safely on an outpatient basis and to compare findings between inpatient and outpatient groups. An outcome based retrospective review of patients who had bilateral reduction mammaplasty from 1989 to 1993 was performed at two centers. Minimum follow-up was nine months. Of 331 patients, 161 were outpatients and 170 were inpatients. Seventy-six percent of the surgeries were performed in the hospital and 24 percent at a free-standing surgical facility. There were no statistical differences between the two groups when comparing age, marital status, preoperative health status, operative technique, and resection weight. Evaluation of patient body weights, use of antibiotics, and complications did reveal statistical differences between the two groups. The inpatients were heavier, more likely to experience a complication, and less likely to receive antibiotics. There was, however, no difference between the two groups for incidence of rehospitalization, return to the emergency department, or reoperation.A patient satisfaction survey was conducted with both out-patient and inpatient groups reporting high satisfaction with their results. Over 95 percent of patients in both groups felt the experience was a positive one. The survey indicated high patient acceptance of breast reduction on an outpatient basis for the outpatient population. The data confirms that reduction mammaplasty is a safe and effective procedure when performed on an outpatient basis. The cost savings associated with outpatient surgery is significant and an important consideration in this era of health care reform.

Breast augmentation roundtable.

This roundtable was conducted live at the American Society of Plastic Surgeons meeting in Chicago, Illinois, in 2005. Dr. Spear was not present for the roundtable, and his comments were formulated and added after the completion of the roundtable. For this reason, his comments have been placed in italics. Adams: On behalf of my co-editor for this supplement, Dr. Spear, Plastic and Reconstructive Surgery, and myself, we would like to welcome each of you and thank you for your participation. All of you were selected because this is a roundtable on reoperations in breast augmentation. This is thought to be a significant problem currently in breast augmentation, and you all have experience and insight into potential solutions. As far as the rules of this roundtable, they are written down in front of you. Basically, there is not going to be any content added post-roundtable other than grammar. There are five questions listed at the bottom. Each question will be discussed for a total of 12.5 minutes. The initial question response, which each of you will have time to respond to, will be 1.5 minutes, and the first participant to respond will be rotated. We will have an open discussion for 5 minutes or up to the 12.5minute time limit, which Dr. Teitelbaum will facilitate. Any questions? I’d like to introduce Steve Teitelbaum, who is going to moderate this. Steve, I’ll turn it over to you.