Donald S. Mowlds

Inframammary approach to nipple-areola-sparing mastectomy.

Background: Different approaches have been advocated for performing nipple-areola–sparing mastectomy. The inframammary approach has been viewed as having limited applications, particularly in large breasts. The authors review their experience with nipple-areola–sparing mastectomy using the inframammary approach for different breast sizes. Methods: Between 2005 and 2012, 118 nipple-areola–sparing mastectomies with staged implant-based reconstruction were performed in 80 consecutive patients. Patients with different breast sizes underwent inframammary nipple-areola–sparing mastectomy, except those patients who had very large breasts or those who requested a breast lift. Oncologic data related to tumor size, selection criteria, and recurrences are presented. All nipple-areola–sparing mastectomies and reconstructions were performed by the same surgeons (J.K.H. and A.H.S), who operated as a team in performing the mastectomies. Results: Patients were followed up from 6 to 97 months (mean, 33.5 months). There were four recurrences (5 percent), three of which were attributed to the biological behavior of the tumor. The aesthetic outcomes of the reconstructions were analyzed based on nipple location, breast contour, and symmetry: 35 patients (44 percent) had a very good result, 28 (35 percent) had a good result, nine (11 percent) had a fair result, and eight (10 percent) had a poor result. Risk factors and complications affecting the final aesthetic outcome are discussed. Conclusions: The inframammary approach for nipple-areola–sparing mastectomy is the authors’ procedure of choice for small, medium, and large breasts. The team approach to the mastectomy facilitates the procedure, reduces skin-related complications, and results in a better aesthetic outcome. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Staged Suprapectoral Expander/Implant Reconstruction without Acellular Dermal Matrix following Nipple-Sparing Mastectomy

Background: Since the introduction of nipple-sparing mastectomy as an oncologically safe procedure for the treatment of breast cancer, reconstructive efforts for immediate staged expander/implant reconstruction have focused on submuscular implantation with or without acellular dermal matrix. Suprapectoral reconstruction without acellular dermal matrix has received little attention in the reconstructive literature of nipple-sparing mastectomy. Methods: Between 2005 and 2015, 155 patients (250 breasts) underwent nipple-sparing mastectomy with prepectoral staged expander/implant reconstruction using thick mastectomy skin flaps without acellular dermal matrix. Patients with different breast sizes, including those patients with very large breasts who required a primary mastopexy, were considered candidates for the suprapectoral reconstruction. Tumor-related data, comorbidities, and preoperative or postoperative radiation therapy were evaluated for correlation with the final outcome. Results: Patients were followed up for an average of 55.5 months (range, 138.1 to 23.6 months). The tumor recurrence rate was 2.6 percent. Adverse outcomes such as capsular contracture, implant dystopia, and rippling were studied. Aesthetic outcome, based on a three-point evaluation scale, showed 53.6 percent of patients as having a very good result, 31.6 percent showing a good result, 9 percent showing a fair result, and 5.8 percent showing a poor result. Conclusions: The suprapectoral two-stage expander/implant reconstruction without acellular dermal matrix in nipple-sparing mastectomy has certain advantages with respect to breast shape, less morbidity related to expansion, ease of reconstruction, and cost effectiveness. These advantages have to be weighed against those of subpectoral reconstruction with acellular dermal matrix to determine the method of choice. CLINCAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Capsular Contracture in Implant-Based Breast Reconstruction: Examining the Role of Acellular Dermal Matrix Fenestrations.

Background: Acellular dermal matrices have been proposed to decrease the incidence of capsular contracture in implant-based breast reconstructions. The authors have modified acellular dermal matrices with fenestrations to facilitate greater lower pole expansion and improve contour. The effect of fenestrations on the ability of matrices to suppress capsule formation, however, has not been examined. Methods: A retrospective review of all fenestrated acellular dermal matrix–assisted, implant-based breast reconstructions performed by the two senior authors, with a minimum of 1-year follow-up after permanent implant placement, was completed. Patient demographics, details of extirpative and reconstructive procedures, and complications were examined. Capsular contractures were scored according to the Baker grading scale and compared to those reported in the literature. Results: Thirty patients (50 breasts) underwent fenestrated acellular dermal matrix–assisted reconstruction, with mean follow-up times of 3.3 and 2.6 years after expander placement and implant exchange, respectively. Seven patients (23 percent) had a body mass index greater than 30 kg/m2, three (10 percent) were active smokers, and six breasts (12 percent) were irradiated. Complications included one infection (2 percent), six cases (12 percent) of incisional superficial skin necrosis, and one (2 percent) tissue expander extrusion. Zero breasts had clinically significant Baker grade III/IV capsular contracture. The average Baker grade was 1.1. Conclusions: Fenestrated acellular dermal matrices decrease capsular contracture to rates similar to what is seen with nonfenestrated matrices. Further research is necessary to determine whether this observation is a result of decreased need for inferolateral acellular dermal matrix coverage to achieve these effects or modified physical interaction of acellular dermal matrices with surrounding soft tissues. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Primary Buttonhole Mastopexy and Nipple-Sparing Mastectomy: A Preliminary Report.

BackgroundPatients undergoing nipple-sparing mastectomy and immediate-implant based reconstruction occasionally require a mastopexy based on their breast size and degree of ptosis. Previous reports have shown the feasibility of mastopexy-nipple-sparing mastectomy in selected patients to raise the nipple up to 5 cm. Major mastopexy with nipple transposition more than 6 cm in conjunction with nipple-sparing mastectomy for therapeutic indications has not been described. The authors review their experience with primary buttonhole mastopexy performed in conjunction with nipple-sparing mastectomy. MethodsBetween 2008 and 2014, 16 patients (32 breasts) underwent bilateral primary mastopexy and nipple-sparing mastectomy with immediate staged implant-based reconstruction. The Passot buttonhole technique was used for the mastopexy in all patients, raising the nipple from 7 to 12 cm. Tumor-related data, risk factors, breast size, degree of ptosis, expander size, fill volume, selection criteria, and complications are discussed. ResultsThe average follow-up period was 33 months (range, 14 to 80 months). There were no tumor recurrences, and all patients completed their reconstruction. Two patients required removal of the expander and delayed reconstruction because of infection and implant exposure due to nipple-areola loss. The reasons for nipple-areola loss and technical modifications to enhance skin viability by retaining a thin layer of subareolar breast tissue for removal during the second-stage implant exchange are discussed. ConclusionsPrimary mastopexy using the buttonhole technique performed together with nipple-sparing mastectomy is a safe procedure with predictable results in patients with very large or ptotic breasts requiring lifts greater than 6 cm. The success of the combined procedure depends on preserving a thin layer of subareolar breast tissue and removing it at the time of implant exchange.

Comparison of perioperative outcomes of autologous breast reconstruction surgeries

Since the introduction of ADM in breast reconstruction its use has significantly grown. Several advantages including better pocket control, reduced implant visibility and improved implant coverage have been attributed to its use. In our experience combination of serratus fascia and strattice provides an improved lateral pocket control. The serratus fascia has been successfully used in breast augmentation and reconstructive surgery for expander implant and as an autologous conjoint fascial flap to cover implants in breast reconstruction however, it’s use in combination with strattice has not been described before. Anatomically, the serratus fascia is the continuation of pectoralis fascia superomedially, rectus fascia inferomedially and axillary fascias superiorly. The serratus fascia offers several advantages. It is readily available and provides well vascularised autologous tissue which can be used for inferolateral coverage of an implant. It is robust, yet more expandable than Strattice therefore yielding a more aesthetically pleasing breast contour (Figures 1e2). Since the dissection is straightforward it does not add any significant time to the surgery or morbidity as the underlying Serratus muscle is left untouched. In patients with small to medium size breasts incorporation of serratus fascia also reduces the amount of strattice required for implant coverage, potentially curtailing the cost especially in patients undergoing bilateral immediate breast reconstructions since one piece can be halved and used for both breast. The senior author has used the Serratus fascia in 42 breast reconstructions in 31 patients (since 2011) without complication. In summary the Serratus fascia provides good pocket control and aesthetically pleasing contour in immediate implant and strattice breast reconstruction with minimal additional dissection or morbidity.

Acellular dermal matrix fenestrations and their effect on breast shape

BackgroundAcellular dermal matrices (ADMs) are increasingly being utilized in primary and secondary breast reconstruction as they confer several advantages, including soft tissue enhancement at the inferolateral pole of the breast. The senior authors have added fenestrations to ADMs to allow for more rapid expansion and improved breast aesthetics. The purpose of this study is to describe the benefits of ADM fenestration using a mathematical formula as a proof of concept for the effects of these modifications on breast shape.MethodsThe aggregate effect of symmetrically arranged fenestrations on the ADM’s mechanical properties is explained by a uniform reduction in the effective Young’s modulus of the graft in a direction perpendicular to the chest wall in the area of graft fenestration. Asymmetric reduction of the Young’s modulus is achieved by concentration of the fenestrations at either the cephalic or caudal ends of the ADM.ResultsThe relaxed Young’s modulus facilitates an increased deflection of the ADM from its resting, unaltered state under the weight of the implant or tissue expander and is modeled using a one-dimensional boundary equation. The reduced inferior pole tension allows for enhanced expansion under the weight of the implant or tissue expander. The effects of asymmetrically arranged fenestrations are similarly modeled and appear to afford the surgeon greater precision in controlling inferior pole characteristics.ConclusionsAcellular dermal matrix fenestration improves aesthetic outcome by facilitating greater inferior pole expansion. Mathematical models are provided to describe the modifications and elucidate the mechanism behind their effect on breast shape.Level of Evidence: Not ratable

Pyoderma gangrenosum: A case report of bilateral dorsal hand lesions and literature review of management.

Pyoderma gangrenosum is a great masquerader in wound diagnosis and management. Frequently misdiagnosed as a necrotizing infection, the elusive nature of its etiology and pathogenesis has thwarted the establishment of a standardized management algorithm, leaving immunosuppressant therapies as the mainstay of treatment. The present report describes a 61-year-old woman presenting with temporally discrete bilateral dorsal hand lesions successfully managed with distinctive multimodality therapies. The initial lesion was managed under the auspices of a necrotizing process using a combination of hyperbaric oxygen therapy and skin grafting with a negative-pressure dressing, both individually demonstrated to be effective for prompt wound stabilization and coverage. A subsequent contralateral hand lesion was similarly managed as a necrotizing infection before a diagnosis of pyoderma gangrenosum was considered. Stabilization and eventual resolution was achieved using intravenous and topical steroids followed by hyperbaric oxygen therapy, again highlighting the benefits of multimodality therapy in the setting of pyoderma gangrenosum.

Nipple-Sparing Mastectomy in the Community Setting

The majority of the surgical literature describing institutional experience with nipple-sparing mastectomy (NSM) has come from academic institutions. Little has been published by community-based surgeons who are responsible for more than 80 % of breast cancer surgical treatment in the United States. This chapter describes the experience of a single breast surgeon (JKH) over the past 11 years in the community setting as a member of a comprehensive multidisciplinary breast program. Early on, a more assertive approach was taken to include patients that others felt were not candidates for NSM. Overall, 374 areolar or nipple-areolar sparing mastectomies were performed in 237 patients. The loco-regional recurrence rates and complication profile were comparable to what is reported in the peer-reviewed literature. We hope that this will inspire other community programs to publish their experiences as a means of reinforcing the safety of NSM in the community setting.

Invasive squamous cell bladder cancer of the ureterovesical junction in a renal transplant patient: a case report

Abstract It is well established in the literature that the incidence of malignancy is higher in transplant patients than in the general population. Risk factors and screening guidelines for transplant patients have been proposed, but are far from standardized. In this case report, we discuss the treatment course of a 73-year-old female with a history of renal tuberculosis, who developed squamous cell carcinoma at the transplant ureterovesical junction 6 years following graft placement. To our knowledge, this is the second reported case in a patient with a history of renal tuberculosis.

Abstract P2-13-06: Acellular dermal allograft fenestrations decrease outpatient expander fills and increase direct to implant incidence in implant-based immediate breast reconstruction

Introduction: The innovation of fenestrated allograft (acellular dermal matrix, ADM) has improved patient outcomes in two-stage tissue expander/implant breast reconstruction. This technical alteration utilizes optimal fenestration overlap and has enhanced the efficiency of the reconstructive experience. We present a follow-up study of one- and two-stage breast reconstruction with a more refined, standardized method of surgeon-designed fenestration of ADM. Methods: We conducted a retrospective review of 52 patients (91 breasts) having undergone one- and two-stage breast reconstruction using fenestrated ADM at our institution from 2013 to 2014. Results: Mean intra-operative fill volume (IOFV) measured 402cc (SD=118cc), and IOFV as a percent of tissue expander size averaged 79.1% (SD=16.7%). Ten breasts were expanded to 100% and completed reconstruction in one stage with implant placement. IOFV as a percentage of total fill volume at completion of expansion averaged 73.6% (SD=16.6%). Two-stage reconstruction patients underwent 1.8 post-operative expansions on average (range 0-4) and averaged 81.2cc (SD=29.3cc) per in-office expansion. Days to full expansion averaged 45.1 days, while days to exchange averaged 137.8 days (Table 1). Mean days to exchange between our first 24 breasts to complete reconstruction vs. our last 23 breasts to complete reconstruction differed significantly, with 205 ± 43.8 days vs. 137.7 ± 138.1 days, respectively (p=0.03). The major complication rate requiring re-operation within 30 days post-operatively was 11.0%. Four breasts experienced partial mastectomy flap necrosis requiring re-operation with implant salvage (4.4%). Six breasts (6.6%) underwent explantation due to: infection (three), flap necrosis (two), and patient preference (one) (Table 2). Conclusion: Our fenestrated technique is demonstrated to increase intra-operative fill volume, decrease number of post-operative expansions and time to full expansion, and improve expansion rate with subjectively less pain. We believe our patients benefited from improved cosmetic outcomes with better shape, maintenance of breast footprint, and enhanced comfort due to the decreased number of intra-office fills and increased intra-operative expansion. Citation Format: Daar DA, Bourgeois JM, Mowlds DS, Wirth GA, Paydar KZ. Acellular dermal allograft fenestrations decrease outpatient expander fills and increase direct to implant incidence in implant-based immediate breast reconstruction. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P2-13-06.