Brett T. Phillips

Intraoperative perfusion techniques can accurately predict mastectomy skin flap necrosis in breast reconstruction: results of a prospective trial.

Background: Intraoperative vascular imaging can assist assessment of mastectomy skin flap perfusion to predict areas of necrosis. No head-to-head study has compared modalities such as laser-assisted indocyanine green dye angiography and fluorescein dye angiography with clinical assessment. Methods: The authors conducted a prospective clinical trial of tissue expander–implant breast reconstruction with intraoperative evaluation of mastectomy skin flaps by clinical assessment, laser-assisted indocyanine green dye angiography, and fluorescein dye angiography. Intraoperatively predicted regions of necrosis were photographically documented, and clinical assessment guided excision. Postoperative necrosis was directly compared with each prediction. The primary outcome was all-inclusive skin necrosis. Results: Fifty-one tissue expander–implant breast reconstructions (32 patients) were completed, with 21 cases of all-inclusive necrosis (41.2 percent). Laser-assisted indocyanine green dye angiography and fluorescein dye angiography correctly predicted necrosis in 19 of 21 of cases where clinical judgment had failed. Only six of 21 cases were full-thickness necrosis, and five of 21 required an intervention (9.8 percent). Risk factors such as smoking, obesity, and breast weight greater than 1000 g were statistically significant. Laser-assisted indocyanine green dye angiography and fluorescein dye angiography overpredicted areas of necrosis by 72 percent and 88 percent (p = 0.002). Quantitative analysis for laser-assisted indocyanine green dye angiography in necrotic regions showed absolute perfusion units less than 3.7, with 90 percent sensitivity and 100 percent specificity. Conclusions: Laser-assisted indocyanine green dye angiography is a better predictor of mastectomy skin flap necrosis than fluorescein dye angiography and clinical judgment. Both methods overpredict without quantitative analysis. Laser-assisted indocyanine green dye angiography is more specific and correlates better with the criterion standard diagnosis of necrosis. CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, I.

Current practice among plastic surgeons of antibiotic prophylaxis and closed-suction drains in breast reconstruction: experience, evidence, and implications for postoperative care.

Background:Despite their widespread use, there are no evidence-based guidelines on the management of closed-suction drains or antibiotics in postmastectomy breast reconstruction. The purpose of this study was to assess consensus and variation in postoperative care among plastic surgeons. Methods:The authors designed and administered a self-reported, anonymous survey to 4669 American Society of Plastic Surgeons and Canadian Society of Plastic Surgeons members in October 2009. Results:A total of 650 completed surveys were available for analysis. A majority (>81%) of respondents reported using closed-suction drains in breast reconstruction. Most surgeons (>93%) used a volume criteria for drain removal, most commonly when drain output was ≤30 mL over 24 hours (>86%). Preoperative antibiotic use was nearly universal (98%), usually consisting of intravenous cefazolin (97%). Postoperative care demonstrated less uniformity with outpatient antibiotics administered by 72% of respondents. Surgeons were divided on when to discontinue outpatient antibiotics: 46% preferred concomitant discontinuation with drains, whereas 52% preferred a specific postoperative day. No clear consensus was observed for the number (1 or 2) or type (Jackson-Pratt or Blake) of drains used. Respondents were further divided on the restriction of postoperative showering with drains and the use of acellular dermal matrix. Conclusions:These results demonstrate a consensus for drain use, drain removal, and preoperative antibiotic administration. There was no consensus for number or type of drain used, postoperative antibiotic use, shower restrictions, and use of acellular dermal matrix. Our results further emphasize the need for evidence-based postoperative-care guidelines specific to breast reconstruction.

A systematic review of antibiotic use and infection in breast reconstruction: what is the evidence?

Background: The literature reports overall complication rates in breast reconstruction to be as high as 60 percent. Infection rates can exceed 20 percent, much higher than anticipated in clean elective surgery. There is no consensus among surgeons regarding the necessary duration of antibiotic prophylaxis, although the Centers for Disease Control and Prevention guidelines suggest only 24 hours. This systematic review examines antibiotic regimens and associated infection rates in breast reconstruction. Methods: Systematic electronic searches were performed in the PubMed, Ovid, and Cochrane databases using Medical Subject Headings terms for studies reporting antibiotic use and infection in all forms of breast reconstruction. Studies between 1970 and 2011 were reviewed. Included publications were required to report an antibiotic protocol and infection rate. Results: A total of 834 abstracts were identified, 81 of which met inclusion criteria and were included in the review. The overall reported infection rates in the included studies varied between 0 and 29 percent (average, 5.8 percent). When comparing combined patient cohorts receiving no antibiotics, less than 24 hours, and greater than 24 hours, the average infection rates were 14.4, 5.8, and 5.8 percent, respectively. Conclusions: There is no consensus on the necessary duration of antibiotic prophylaxis following breast reconstruction. No benefit was found in patients who received more than 24 hours of postoperative antibiotics. Standardized definitions for antibiotic regimens, unit of analysis reporting, and a new breast reconstruction surgical-site infection grading system are offered to improve standardized outcome documentation. Randomized controlled trials are warranted to best determine an optimal antibiotic regimen. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Modeling fade patterns of nipple areola complex tattoos following breast reconstruction.

BackgroundNipple-areolar complex (NAC) tattoos are an effective cosmetic solution for creating a finished look following breast reconstruction procedures. NAC tattoos are prone to significant fading, leading patients to seek revisions. This study was designed to quantify changes in NAC tattoo appearance over time. MethodsA total of 71 images of 39 patients were analyzed for NAC tattoo color and shape by 5 blinded medical student graders using a customized scoring system. Subsequently, each image was analyzed using ColorPic software (Iconico, New York, NY). Red/green/blue and hue/saturation/value color parameters were collected. Color quantities were normalized to the individual patient’s skin tone to control for variability in lighting. Spearman correlations and nonlinear regressions were calculated utilizing GraphPad Prism 6.0 (GraphPad, La Jolla, CA). ResultsThe length of time after tattoo placement inversely correlated with color score (P < 0.0001) and shape score (P = 0.0007). The time following tattoo placement was also inversely correlated with all quantitative color parameters. Each color parameter fit a 1-phase exponential decay model. ConclusionsThe decline in qualitative color and shape score agrees with clinical experience of tattoo quality declining over time. The color qualities of the tattoo approach those of the patient’s skin over time, ultimately reaching a plateau. This can be modeled using a 1-phase decay equation. In practice, tattoo colors may be selected that compensate for the predictable changes that will occur. The results of this study will help optimize tattoo color and may alleviate the need for NAC tattoo revisions.

Sentinel lymph node detection using laser-assisted indocyanine green dye lymphangiography in patients with melanoma.

Introduction. Sentinel lymph node (SLN) biopsy is a vital component of staging and management of multiple cancers. The current gold standard utilizes technetium 99 (tech99) and a blue dye to detect regional nodes. While the success rate is typically over 90%, these two methods can be inconclusive or inconvenient for both patient and surgeon. We evaluated a new technique using laser-assisted ICG dye lymphangiography to identify SLN. Methods. In this retrospective analysis, we identified patients with melanoma who were candidates for SLN biopsy. In addition to tech99 and methylene blue, patients received a dermal injection of indocyanine green (ICG). The infrared signal was detected with the SPY machine (Novadaq), and nodes positive by any method were excised. Results. A total of 15 patients were evaluated, with 40 SLNs removed. Four patients were found to have nodal metastases on final pathology. 100% of these 4 nodes were identified by ICG, while only 75% (3/4) were positive for tech99 and/or methylene blue. Furthermore, none of the nodes missed by ICG (4/40) had malignant cells. Conclusion. ICG dye lymphangiography is a reasonable alternative for locating SLNs in patients with melanoma. Prospective studies are needed to better ascertain the full functionality of this technique.

Subjective rating of cosmetic treatment with botulinum toxin type A: do existing measures demonstrate interobserver validity?

BackgroundThroughout the literature, investigators have assessed the cosmetic efficacy of botulinum toxin (BT) treatment by using various subjective, qualitative measures, including the Facial Wrinkle Scale (FWS) and Subject Global Assessment (SGA). The widely used FWS and SGA attempt to quantify both the magnitude and duration of cosmetic outcomes as assessed by physician and patient. We sought to determine the interobserver validity of these scales relative to the level of observer experience. MethodsBotulinum toxin injections were performed to cosmetic effect in 6 patients recruited as part of an institutional review board-approved investigation. Subjects were photographed at rest and during animation (raising eyebrows, frowning, and blinking) before treatment and at 1, 2, 4 weeks, and monthly with follow-up to 6 months. Standardized digital 8″ × 10″ prints were scored using the FWS by board-certified plastic surgeons (n = 5), general surgery residents (n = 3), and medical students (n = 4). Photographs at each time point were then compared to baseline using the SGA. Statistical analysis of observer data was performed using SPSS v19. Cohen &kgr; (FWS) and Spearman &rgr; (SGA) were calculated for each pairwise comparison of observer data, with a conservative &agr; of 0.01. ResultsThe FWS observer scores for the upper face overall were generally in agreement, with no negative &kgr; values. The distribution, even among members of a single group, was highly variable. Agreement among plastic surgeons was the greatest (&kgr;, 0.194–0.609). Resident concordance was moderate, and medical students displayed the most variable agreement. Spearman &rgr; for SGA scores was much higher, with surgeons approaching excellent agreement (&kgr;, 0.443–0.992). In comparisons between members of different groups, agreement was unpredictable for both the FWS and SGA. Comparisons using scores from individual areas of the face were least concordant. ConclusionsThe FWS and SGA represent the current standard of cosmetic outcomes measures; however, when subjected to scrutiny they display relatively unpredictable agreement even among plastic surgeons. Compared to the FWS, the SGA has a more acceptable user concordance, especially among plastic surgeons accustomed to using such scales. The interobserver variability of FWS and SGA scoring underlines the need to explore objective, quantitative cosmetic outcomes measures.

Antibiotic Prophylaxis following Implant-based Breast Reconstruction: What Is the Evidence?

Background: Although data from other surgical disciplines do not support the use of prolonged postoperative prophylactic antibiotics, implant-based breast reconstruction is one area of plastic surgery where this may be warranted. The purpose of this study was to review the literature on antibiotic prophylaxis in prosthetic breast reconstruction, summarize findings, and provide recommendations. Methods: A literature review was performed to identify studies that compared different perioperative prophylactic antibiotic regimens with respect to infectious outcomes in prosthetic breast reconstruction. Results: Five studies and five systematic reviews were identified. One prospective randomized trial showed that a single preoperative dose was better than placebo, and another showed no difference between 24 hours versus until drain removal. Three studies were retrospective, one showing no difference between a single preoperative dose and prolonged antibiotic use, and two showing significant reduction in infectious complications with prolonged antibiotic use. One systematic review suggested an increased rate of infection with prolonged antibiotic use, and the other showed no difference between less than 24 hours and greater than 24 hours, but showed a reduction in infections compared to no treatment. Conclusions: The literature contains conflicting data regarding the optimal duration for perioperative antibiotic prophylaxis following prosthetic breast reconstruction. The authors’ opinion is that 24 hours of antibiotic prophylaxis is warranted. Further studies are needed. Patient-centered antibiotic prophylaxis based on a risk-assessment model may be a more effective alternative to the current indiscriminate model of surgical-site infection control.

Utilizing Indocyanine Green Dye Angiography to Detect Simulated Flap Venous Congestion in a Novel Experimental Rat Model.

BACKGROUND Venous congestion is a leading cause for free flap failure and still relies on clinical observation as the diagnostic gold standard. We sought to characterize blood flow in a variable venous congestion murine hind limb model using indocyanine green (ICG, SPY Pack, LifeCell, Branchburg, NJ) angiography. METHODS Male Sprague-Dawley rats (Charles River, Hudson, NY) underwent bilateral partial amputation at the inguinal ligament, leaving only the femoral vessels and femur intact. Complete unilateral venous occlusion was achieved via suture ligation, while partial occlusion was achieved by surrounding the femoral vein with a synthetic microtube to achieve 25, 75, 85, or 92% occlusion. Relative blood flow of occluded and control limbs was tracked with ICG angiography throughout a 90-minute time course. RESULTS ICG angiography detected statistically significant (p < 0.05) reductions in limb blood flow 1 and 2 minutes following ICG injection in the 100, 92, and 85% occluded limbs when compared with contralateral control limbs. Dynamic tracking using the slope of ICG inflow for 45 seconds postinjection reflected this same significant difference. No statistically significant change in limb blood flow or dye influx rate was observed in the 25 and 75% occlusion groups. CONCLUSIONS ICG angiography can detect venous congestion in a rat lower extremity model reliably at occlusion rates ≥ 85%. This method may offer surgeons an intraoperative diagnostic tool to identify venous congestion at extremely early time points, allowing for immediate intervention. Further investigation and characterization is warranted in a larger animal model before clinical adaptation.

Comparison of Laser Doppler and Laser-Assisted Indocyanine Green Angiography Prediction of Flap Survival in a Novel Modification of the McFarlane Flap.

BackgroundThe McFarlane rat ischemic dorsal skin flap model has been commonly used for clinical vector studies, as well as the testing of noninvasive diagnostics. However, variability of this model secondary to flap contact with the wound bed has led many to question its validity. Here we present a novel modification to the McFarlane skin flap using sterile silicone. We also use this model to test the prognostic efficacy of laser-assisted indocyanine green (ICG) angiography and laser Doppler imaging (LDI). MethodologyA 3 × 9-cm dorsal skin flap with a cranially based pedicle was created, centered 1 cm distal to the scapulae. The flap was undermined, and in one of the 2 groups, a sterile silicone sheet was placed onto the wound bed. All flaps were then reapproximated with sutures 1-cm intervals. Clinical assessment and perfusion imaging was performed immediately postoperative, and at 24, 48, and 72 hours postsurgery. Postoperative day 7 clinical assessment was obtained before euthanasia. ResultsA comparative study using silicone blocked versus unblocked models (n = 6 per group) showed that, clinically, both models had equivalent flap survival [8.5 (0.913) vs 9.5 (1.01) cm2]. However, a statistically significant increase in perfusion in the mid-third of unblocked models was observed on POD3 [20.28% (2.7%) vs blocked 13.45% (2.5%), P < 0.05], with a similar increase in the distal third on POD7 [18.73% (2.064%) vs 10.91% (4.19%), P < 0.05]. A prognostic study comparing LDI and ICG angiography prediction of POD7 survival at early time points (n = 10) found that LDI underpredicted flap survival at early time points [84.2% (12.03%) on POD0, 87.35% (16.11%) on POD1]. In contrast, ICG was more proficient [100.1% (10.1%) on POD0]. ConclusionsWe present a modification of the McFarlane skin flap model that results in similar clinical results, but with a noted reduction in perfusion inconsistencies noted in unblocked models. The ICG angiography is superior to LDI in predicting POD7 flap necrosis within the first 48 hours postinjury. Future work will focus on histologic validation of our model, and vector efficacy testing.

The Role of Intraoperative Perfusion Assessment: What Is the Current State and How Can I Use It in My Practice?

Summary: Evolving intraoperative technology has an increased presence and usefulness in aiding surgeon clinical judgment. Many surgical devices are readily available as an adjunct to this gold standard assessment of adequate tissue perfusion. Intraoperative perfusion monitoring provides surgeons with the ability to interpret additional information that enhances surgical decision-making in real-time. Technologies include various dye-based and non–dye-based near-infrared angiography, tissue oximetry measurements, and ultrasound-based tools. This review summarizes the available intraoperative technologies for planning and assessment of tissue perfusion in plastic and reconstructive surgery. The authors discuss the available literature for the individual devices and supporting evidence for their use. The authors recommend the evidence-based use of these tools in indicated surgical cases to improve clinical outcomes.