Donald R. Mackay

Complications in tissue expander breast reconstruction: a comparison of AlloDerm, DermaMatrix, and FlexHD acellular inferior pole dermal slings.

AbstractAcellular dermal matrix (ADM) is frequently used in tissue expander breast reconstruction (TEBR) for coverage of the inferior pole. Several published studies have suggested increased rates of complications with the use of ADM. It is unknown, however, if the type of ADM used for TEBR impacts complication rates. The aim of this study is to compare 3 different types of ADM for TEBR in regard to clinically significant complications, specifically infection. We performed a retrospective analysis of primary breast cancer-related TEBR with or without ADM. Exclusion criteria consisted of prior major breast surgery, inadequate data, or loss to follow-up. Reconstructions were grouped by dermal sling type, AlloDerm, DermaMatrix (DM), FlexHD (FHD), or no ADM. Complications included cellulitis, abscess, seroma, expander leak or puncture, skin necrosis, wound dehiscence, or hematoma. Those requiring admission to hospital or reoperation were considered significant. Of 284 breasts reconstructed, 49 used AlloDerm, 110 used DM, 62 used FHD, and 64 used no ADM. The total complication rate with AlloDerm was 22% [95% confidence interval (CI), 11–34], with DM was 15% (95% CI, 8–21), and with FHD was 18% (95% CI, 8–28) (P = 0.47). Infectious complication rates for AlloDerm, DM, and FHD were equal at 10% (P = 0.97). The total complication rate of all ADM reconstructions as a grouped cohort was 17% compared to 11% without ADM (P = 0.48). The overall incidence of infectious complications with ADM was 10% compared to 2% without ADM (P = 0.09). There is no difference in the clinically significant overall complication rate or incidence of infection between AlloDerm, DM, and FHD. Isolating infectious complications, there is a trend toward increased incidence with ADM compared to reconstructions without.

Determinants of aesthetic satisfaction following TRAM and implant breast reconstruction.

Introduction:Several studies have evaluated patient satisfaction following breast reconstruction with the transverse rectus abdominis myocutaneous (TRAM) flap and tissue expander/implant. However, the specific aesthetic determinants of patient satisfaction have not been determined Methods:Patients who had undergone tissue expander/implant or TRAM flap reconstruction were retrospectively polled on their age, type and timing of reconstruction, mastectomy type, laterality of reconstruction, adjuvant therapy, and symmetrizing and nipple-areolar procedures. Aesthetic satisfaction based on breast shape, symmetry of breast shape, breast size, symmetry of breast size, breast scarring, and breast sensation was assessed using a 5-point scale. Results:Two hundred eleven patients with 105 TRAM flaps and 160 expander/implants responded. Unilateral TRAM recipients rated their breast shape, symmetry of breast shape, and symmetry of breast volume significantly higher than did implant patients. When bilateral reconstruction patients were evaluated, no significant differences were seen. The presence of nipple-areolar reconstruction positively influenced every parameter except breast sensation. Immediate reconstruction, skin-sparing mastectomy, and age >60 years at the time of reconstruction were also associated with higher scores, while postoperative radiation therapy resulted in lower satisfaction. Free flap reconstruction produced higher satisfaction in breast shape and breast scarring when compared with pedicle flap reconstruction. Conclusions:Aesthetic satisfaction after breast reconstruction is highly influenced by the presence of nipple-areolar reconstruction and less so by age, timing of reconstruction, adjuvant therapy, or free flap procedures. The type of reconstructive procedure is a significant variable only in unilateral reconstruction.

Stretching skin : undermining is more important than intraoperative expansion

The efficacy of intraoperative expansion in reducing the tension of wound closure was tested in young pigs. The young piglet as a model for studying human skin was characterized by finding a close similarity between the modulus of elastiticy of young piglet skin and human abdominoplasty and mammaplasty skin (range 12.8 to 23.7 N/mm2 for piglet skin, 14.3 to 19 N/mm2 for human skin). The tension required to close a standardized wound was determined before undermining, after undermining, and finally after intraoperative expansion. These measurements were performed in 10 young pigs with an average weight of 11.5 kg. Undermining the wound edges resulted in a significant decrease in the force required to close the wounds (p < 0.0001). Intraoperative expansion did not significantly decrease the tension. Previous work showing the importance of site and direction of pull on the tension for wound closure was confirmed in this study. Analysis of variance demonstrated that the tension required to close a standard wound is greater high on the pigs back than near the belly and near the shoulder as opposed to the hip for midflank wounds (p < 0.0001). Increasing the extent of undermining from 62 to 136 cm2 significantly decreased the tension for wound closure (p < 0.05). Further undermining did not result in a significant decrease in wound closure tension. In this model, intraoperative expansion offers no advantage over simple undermining. We suggest that the benefit reported by clinicians using intraoperative expansion may derive from an increase in the extent of undermining required to place expanders under the wound margins.

Aeromonas species isolated from medicinal leeches.

Aeromonas hydrophila infections are a recognized complication of the use of medicinal leeches. The authors performed an experiment designed to find a safe and practical way to sterilize the leech gut of pathogenic organisms. Leeches were incubated for a 12-hour period in solutions of antibiotic effective against A. hydrophila. The incubations in the antibiotic solutions failed to eradicate pathogenic bacteria from the gut of the leeches. The authors examined cultures of bacteria isolated from the guts of the commonly used Hirudo medicinalis (European leech) and found a wide variety of pathogenic organisms. A. hydrophila is widely believed to be the most common enteric pathogen, but the authors found A. sobria more frequently in their experiment. They also cultured the guts of the leech H. michaelseni recently used clinically in South Africa. A. caviae was the most common pathogen encountered in these leeches. A. caviae and A. sobria cause a spectra of disease similar to A. hydrophila. The authors endorse the current recommendation that all patients who have leech therapy for congested flaps or replants receive broad-spectrum prophylactic antibiotics. This appears to be the safest and simplest way to prevent leech-related infections.

Effects of interleukin‐8 on granulation tissue maturation

The inflammatory α‐chemokine, interleukin‐8 (IL‐8), affects the function and recruitment of various inflammatory cells, fibroblasts, and keratinocytes. Gap junctions are anatomical channels that facilitate the direct passage of small molecules between cells. The hypothesis is that IL‐8 enhances gap junctional intercellular communication (GJIC) between fibroblasts in granulation tissue, which increases the rate of granulation tissue maturation. In vitro, human dermal fibroblasts were incubated with IL‐8 prior to scrape loading, a technique that quantifies GJIC. Polyvinyl alcohol (PVA) sponges were implanted within subcutaneous pockets in rats and received local injections of either IL‐8 or saline and were harvested on day 11. In vitro, IL‐8 treated fibroblasts demonstrated an increase in GJIC by scrape loading compared to saline treated controls. In vivo, IL‐8 treated PVA sponges demonstrated a decrease in cell density and an increase in vascularization compared to saline controls by H&E staining. Polarized light viewed Sirius red‐stained specimens demonstrated greater collagen birefringence intensity, indicating thicker, more‐mature collagen fibers. IL‐8 increases GJIC in cultured fibroblasts and induces a more rapid maturation of granulation tissue.

Routine drainage is not required in reduction mammaplasty

&NA; To date, there have been no randomized trials documenting the efficacy of closed suction drainage when applied to reduction mammaplasty. Despite this, it has become the standard of care. A recent retrospective review suggests that closed suction drainage is not necessary. This study attempts to resolve this issue in a prospective, randomized fashion. The Institutional Review Board of the College of Medicine of The Pennsylvania State University approved the study. Forty‐nine consecutive patients who underwent reduction mammaplasty by the inferior pedicled techniques were enrolled. Each patient was randomized to having a drain in either the right or left breast. The other breast was undrained. Patients were followed up for rate of complications and for patient satisfaction. Their ages ranged from 17 to 62 years, with a mean of 33 years. Weight of reduction from the drained breasts ranged from 360 to 1090 g, with a mean reduction of 675 g. Weight of reduction from the undrained group ranged from 380 to 1011 g, with a mean of 620g. There were a total of 11 complications in the study. In the drained group, there were six complications out of 49 breasts (partial nipple loss in one, minor wound breakdown in two, fat necrosis in two, and hematoma in one). In the undrained group, there were five complications out of 49 breasts (partial nipple loss in none, minor wound breakdown in three, fat necrosis in one, and hematoma in one). Statistical analysis using the McNemar test revealed no significant difference between the two groups. A questionnaire revealed that the patients preferred the increased early postoperative comfort afforded by the absence of a drain. Performing reduction mammaplasty without the use of closed suction drainage is safe and is preferred by the patients. (Plast. Reconstr. Surg. 111: 113, 2003.)

Correlation of Complications of Body Contouring Surgery With Increasing Body Mass Index

BACKGROUND There have been conflicting reports regarding the incidence of postoperative complications in body contouring procedures in obese and morbidly obese patients. Our subjective impression has been that the complication rate is significantly higher for these patients than it is for other weight groups. OBJECTIVE The purpose of our study was to conduct a retrospective chart review to delineate our institutions complication rate in body contouring operations across all weight groups and to identify predictors of poor outcomes/complications that would help guide patient selection. METHODS The records of 129 patients who underwent a single body contouring procedure at The Penn State Hershey Medical Center from 1993 to 2002 were reviewed. Patients were categorized based on their body mass index into the following weight groups: ideal, overweight, obese, morbidly obese, and severely morbidly obese. The complications were grouped into minor, major, or combined (minor or major). Patients who underwent combined procedures were excluded from the study. RESULTS There was a statistically significant association between minor (P = .0006), major (P = .0098), and combined (P < .0001) complications and weight group. More specifically, the percentage of complications increased as weight category increased. The percentage of minor complications increased from 3.3% in the ideal weight group to 46.9% in the severely morbidly obese group. Similarly, the percentage of major complications increased from 6.6% in the ideal weight group to 43.7% in the severely morbidly obese group. Both major and minor complications saw the largest increase in complication rates between the morbidly obese and severely morbidly obese groups. Furthermore, those in the obese (odds ratio [OR] = 6.43; P = .0115), morbidly obese (OR = 5.54; P = .0237), and severely morbidly obese (OR = 19.80; P < .0001) weight groups were more likely to experience minor or major complications than those in the ideal weight group. CONCLUSIONS This study demonstrates two points: (1) it confirms that there is a significant increase in the occurrence of complications among morbidly obese and severely morbidly obese patients undergoing a single body contouring procedure, and (2) it shows there is an increase in the occurrence of complications with worsening degree of obesity. The (post-weight loss) body mass index at the time of body contouring surgery is a predictor for postoperative complications.

Analysis of clinically significant seroma formation in breast reconstruction using acellular dermal grafts.

AbstractWith a rise in tissue expander-based breast reconstructions (TEBRs) using acellular dermal matrix (ADM), we have seen an increase in ADM-specific complications. In this study, we aimed to evaluate clinically significant seroma (CSS) formation—defined by the need for a drainage procedure—to determine if there was a difference in incidence between product types: AlloDerm (AL), DermaMatrix (DM), and FlexHD (FHD). This was a retrospective review of consecutive patients who underwent TEBR at a single institution. The total number of reconstructed breasts was separated into the following 4 groups according to the product type: AL, DM, FHD, or no ADM. We identified the total number of CSSs and compared these data between product types. A logistic regression was performed in an attempt to identify independent risk factors associated with seroma formation. In total, we identified 284 consecutive TEBRs. Overall, there were 17 (7.7%) seromas in 220 breast reconstructions in which ADM was used. When comparing the number of CSS between groups—AL (n = 2, 4.0%), DM (n = 6, 5.4%), FHD (n = 9, 14.75%), and no ADM (n = 1, 1.5%)—we found a significant difference in seroma incidence between product types (P = 0.016). Multivariate analysis identified a strong trend toward FHD as an independent predictor of seroma formation (P = 0.061). Our review suggests that there is strong trend in CSS formation with the use of FHD as compared to other product types and reconstructions in which no ADM was used.

Vanadate ingestion increases the gain in wound breaking strength and leads to better organized collagen fibers in rats during healing.

Repair of incision wounds closed by suturing is evaluated by the progressive gain in wound breaking strength. Previously the closure of open wounds in rats ingesting vanadate, an inhibitor of tyrosine phosphate phosphatases, was shown to occur with deposition of more uniformly organized collagen fiber bundles. The hypothesis of this study was that deposition of more uniformly organized collagen fibers would enhance the gain in wound breaking strength of incisional wounds. Six adult rats received vanadate-supplemented saline drinking water for 1 week before placement of two 6-cm, parallel, suture-closed wounds on their backs. Six control rats received identical wounds and were given saline drinking water. The drinking water regimen was continued for 1 week after wounding, and then wound strength was tested with a tensiometer and tissue samples were obtained for histologic evaluation. Wound breaking strength doubled in vanadate-treated rats compared with controls. Bright-field and polarized light microscopy showed that the connective tissue matrix of granulation tissue from control rats was oriented perpendicular to the surface of the skin. In contrast, the connective tissue matrix of granulation tissue from vanadate-treated rats was oriented parallel to the skin surface. The gap in granulation tissue between the edges of the wounds in the vanadate-treated rats was greater than that in controls. Electron microscopy showed that wounds in the vanadate-treated contained uniform collagen fibers that were 20 percent greater in diameter and more evenly spaced than they were in controls. It is proposed that these changes in the organization of collagen fibers within incisional wounds were responsible for the increased wound breaking strength observed in rats ingesting vanadate.

Incidence of operative procedures on cleft lip and palate patients.

The incidence of operative procedures in a group of 374 cleft lip and palate patients was determined by a chart review. These patients were part of a long term study funded by the National Institute of Dental Research at the Lancaster Cleft Palate Clinic. The chart review provided a breakdown of the primary and secondary procedures performed on the patients. Although the secondary procedures carried out were underestimated in this study, it is clear that these operations comprise a major component of the successful treatment of these patients. The results of the study and the implications in todays managed care environment are discussed.