Caitlin M. Connor

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.

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.

Focus on technique: two-stage implant-based breast reconstruction.

Background: Acellular dermal matrix has become a frequent adjunct to traditional expander-based breast reconstruction. Its putative advantages include improved positioning of the prosthesis, better definition of the inframammary fold, amelioration of potential contracture, and overall enhancement of cosmesis. Concomitantly, there may be an increased risk of seroma, infection, and reconstructive failure. Methods: A thorough review of the techniques and outcomes of two-stage acellular dermis–assisted breast reconstruction was performed. Results: Key technical aspects of two-stage acellular dermal matrix–based reconstruction are presented. Indications, techniques of handling and inset, and select strategies to avoid and manage common complications are discussed. Evidence-based outcomes are reviewed. Conclusions: Acellular dermal matrix–based two-stage reconstruction continues to evolve as a viable option in breast reconstruction. Future studies will better delineate the risks and benefits of the technique.

Multidisciplinary approach to the management of dermatofibrosarcoma protuberans

BACKGROUND Dermatofibrosarcoma protuberans (DFSP) is the most common cutaneous sarcoma. Tentacle-like extensions of neoplastic cells create a high incidence of local recurrence and pose challenges to resection and reconstruction. OBJECTIVE Here we present a multidisciplinary approach to the management of DFSP incorporating the expertise of a Mohs micrographic surgeon, surgical oncologist, dermatopathologist, and plastic surgeon. METHODS This was a single-institution, retrospective review of a prospectively maintained database of 19 consecutive patients who underwent resection and reconstruction of a DFSP from 1998 to 2010. All patients underwent Mohs micrographic surgery for mapping of peripheral margins (stage I excision), followed by wide local excision for delineation of the deep margin (stage II excision). Procedures were performed in consultation with a dermatopathologist who confirmed tumor-free margins, and a plastic surgeon who performed immediate reconstruction after the wide local excision (stage II reconstruction). RESULTS Nineteen patients were included in this study. The average number of Mohs stages required for clearance of peripheral margins was 2.7 ± 0.7. The mean time between stage I and II procedures was 16 ± 11 days. The average defect size after the stage II operation was 87.3 cm(2) (range, 9-300 cm(2)). There were no cases of tumor recurrence. Mean follow-up time was 17 months (range, 1-53 months). LIMITATIONS This is a retrospective review of a single-institution experience. CONCLUSION A multidisciplinary approach to the management of DFSP optimizes both oncologic and reconstructive outcomes, minimizing the risk for local recurrence and limiting the functional and cosmetic morbidity associated with surgical resection.

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.

Variations in Complication Rates for Elective Non-Reconstructive Breast Surgery: An Analysis of NSQIP Data from 2006-2010

Methods: Patients in the National Surgical Quality Improvement Program (NSQIP) database who underwent elective breast surgery between 2006 and 2010 were identified using primary CPT codes. Twenty defined morbidities were compared among mastopexy (CPT 19316), reduction mammaplasty (CPT 19318), and augmentation mammaplasty (CPT 19325) procedures using ANOVA and chi-squared tests for continuous variables and categorical variables, respectively. Logistic regression modeling was employed to identify preoperative risk factors for complications.

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.