Elliot M. Hirsch

One-stage mastopexy with breast augmentation : A review of 321 patients

Background: One-stage mastopexy with breast augmentation is an increasingly popular procedure among patients. In the past 9 years, there has been a 506 percent increase in mastopexy procedures alone. Although some recommend a staged mastopexy and breast augmentation, there are currently no large studies evaluating the safety and efficacy of a one-stage procedure. Methods: A retrospective chart review was conducted of 321 consecutive patients who underwent one-stage mastopexy and breast augmentation. Data collected included the following: patient characteristics, implant information, operative technique, and postoperative results. Complication and revision rates were calculated to evaluate the safety and efficacy of the one-stage procedure. Results: No severe complications were recorded over an average of 40 months’ follow-up. The most common complication was deflation of a saline implant (3.7 percent), followed by poor scarring (2.5 percent), recurrent ptosis (2.2 percent), and areola asymmetry (2.2 percent). Forty-seven patients (14.6 percent) underwent some form of revision surgery following the one-stage procedure. Thirty-five (10.9 percent) of these were for an implant-related issue, whereas 12 patients (3.7 percent) underwent a tissue-related revision. This 10.9 percent implant-related revision rate is less than a previously documented 13.2 percent 3-year reoperation rate for breast augmentation alone. The authors’ 3.7 percent tissue-related revision rate also compares favorably to an 8.6 percent revision surgery rate in patients who underwent mastopexy alone. Conclusions: Although it has been stated that the risks of a one-stage procedure are more than additive, the results of our review suggest otherwise. Although a revision rate of 14.6 percent is significant, it is far from the 100 percent reoperation rate required for a staged procedure.

Outcomes of tissue expander/implant breast reconstruction in the setting of prereconstruction radiation.

Background: Although the effects of postoperative radiation on tissue expander breast reconstruction are well documented, few data exist regarding the effects of prereconstruction radiation. This study evaluates the outcomes of tissue expander breast reconstruction in women with prereconstruction radiation. Methods: This study retrospectively evaluated two treatments: (1) mastectomy without reconstruction followed by postoperative radiation and delayed reconstruction (10 patients) and (2) failed breast-conserving therapy (lumpectomy plus radiotherapy) necessitating mastectomy and immediate reconstruction (66 patients). Procedures were performed at Northwestern Memorial Hospital between August of 1999 and July of 2008. Average follow-up was 35 months. Results: In both groups, approximately 60 percent of patients successfully completed two stages of reconstruction. Overall complication rates, including major and minor complications, were 70 percent per reconstruction (37 percent first stage, 45 percent second stage) for immediate reconstruction and 50 percent per reconstruction (20 percent first stage, 38 percent second stage) for delayed reconstruction. No differences in complication rates were observed based on age, smoking status, body mass index, or timing between radiation and surgery (p > 0.05). Conclusions: When discussing expander/implant reconstruction with patients who have a history of prior breast radiotherapy, a frank discussion of the risks, benefits, and alternatives should occur. If a 40 percent total explantation or conversion to flap rate is truly understood by the patient, and if immediate autologous breast reconstruction is to be avoided, then the patient may proceed with tissue expander breast reconstruction. For patients who wish to avoid additional scars or more invasive procedures, however, this study demonstrates that they have a 60 percent chance of success. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Utility of acellular dermis-assisted breast reconstruction in the setting of radiation: a comparative analysis.

Background: The role of acellular dermis in immediate prosthetic breast reconstruction remains unclear, particularly within a radiated field. The authors evaluated and compare outcomes following reconstruction with and without acellular dermis, and analyzed patients exposed to radiation therapy. Methods: Retrospective review of 417 consecutive patients (592 breasts) treated from January of 2006 to October of 2008 at one institution was performed. Relevant patient characteristics and follow-up were recorded. Complications were categorized by type and end outcome, including nonoperative, operative, or explantation. Both groups had comparable follow-up (acellular dermis, 23.2 ± 8.9 months; no acellular dermis, 24.4 ± 12.7 months; p = 0.23). Appropriate statistical analyses, including multiple regression, were performed. Results: Acellular dermis patients (n = 199 breasts) had larger body mass indexes (p = 0.0001) and more nipple-sparing mastectomies (p = 0.04) than non–acellular dermis patients (n = 393 breasts). Breasts with acellular dermis had larger intraoperative fill volumes (p < 0.0001) and decreased postoperative expansions (p = 0.02), but no decrease in time to implant exchange. There were no significant differences in complication profiles between acellular dermis and non–acellular dermis breasts, after adjusting for other relevant patient variables on regression analysis. After stratifying patients by exposure to radiation, acellular dermis breasts had a decreased risk of all complications related to radiation as compared with non–acellular dermis breasts. Conclusions: This study suggests that acellular dermis does not adversely affect complication rates following prosthetic breast reconstruction. It may be advantageous, however, in select patients, particularly those undergoing postoperative radiation therapy. Therefore, the choice to use acellular dermis does not compromise outcomes but should be individualized to each patient. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Is one-stage breast augmentation with mastopexy safe and effective? a review of 186 primary cases

BACKGROUND Although some authors have reported that 1-stage breast augmentation with mastopexy does not increase the risks of surgery, recent literature has raised the question of whether better results might be achieved by staging the procedures. OBJECTIVE The authors evaluated the safety and efficacy of 1-stage breast augmentation with mastopexy in their own patients by analyzing long-term complication and revision rates. METHODS A retrospective chart review was performed of 186 consecutive patients who underwent primary 1-stage breast augmentation with mastopexy at a single outpatient facility. Patient data recorded included age, body mass index, smoking status, degree of breast ptosis, and any preoperative asymmetry. Operation-related data recorded included type of mastopexy performed, operating surgeon, length of surgery, American Society of Anesthesiologists level, and concomitant procedures. Data on implant type, volume, and position were also collected. Complication and revision rates were recorded and calculated. RESULTS Ninety-six patients (44%) received saline implants; 104 (56%) received silicone implants. In most cases, textured implants were placed in submuscular pockets. The mean implant volume was 320 cc. Inverted T mastopexy was performed in 60% of cases, circumareolar in 24% of cases, and vertical or crescent accounted for most of the remainder. No severe complications occurred, although 1 patient developed a late infection that required removal of the breast implant. The most common complication was saline implant deflation (5.9%), although saline implants were used in less than half of cases. Thirty-one patients (16.7%) underwent some form of revision surgery within the average 42-month follow-up period. CONCLUSIONS Our review of 1-stage breast augmentation with mastopexy procedures revealed no severe complications. Although the overall revision rate of 16.7% is significant, it is comparable to rates for breast augmentation alone and is significantly lower than the 100% reoperation rate required for a staged procedure. In our experience, it is a safe and effective procedure, although one that is not easy to perform. Patients should be advised of the possibility that a second procedure may be necessary.

Cancer risk among Los Angeles women with cosmetic breast implants

Background: As the first generation of women who received cosmetic breast implants ages, questions remain about cancer risk. This study is an update of the Los Angeles Augmentation Mammaplasty Study and examines cancer risk among women with long-term exposure to breast implants. Methods: The authors conducted a record linkage cohort study of patients with cosmetic breast implants by abstracting from records of the private practices of 35 board-certified plastic surgeons in Los Angeles County, California. They included 3139 Caucasian women who received cosmetic breast implants between 1953 and 1980. Spanish-surnamed women, nonresidents of Los Angeles County, and patients with prior subcutaneous mastectomy or breast cancer were excluded. Cancer outcomes through 1994 were ascertained through record linkage with the Los Angeles County Cancer Surveillance Program. Results: With a mean follow-up period of 15.5 years, 43 cases of breast cancer were observed, compared with 62.6 expected, based on Los Angeles County population-based incidence rates (standardized incidence ratio, 0.69; 95% CI, 0.50 to 0.93). Significant increases were observed for cancer of the lung and bronchus (standardized incidence ratio, 2.14; 95% CI, 1.42 to 3.09) and vulvar cancer (standardized incidence ratio, 3.47; 95% CI, 1.39 to 7.16). Conclusions: The breast cancer results of this study are consistent with the previous reports of the Los Angeles study as well as with several other long-term cohort studies. Lung cancer has previously been found to be increased in this cohort and also in some, but not most, other studies. The increased risk of vulva cancer has previously been observed in this cohort and just one other.

The differential effect of BMI on prosthetic versus autogenous breast reconstruction: A multivariate analysis of 12,986 patients

BACKGROUND The comparative safety of breast reconstruction in obese patients remains to be clearly defined. This study utilized multi-institutional data to characterize the effect of body mass index (BMI) on breast reconstruction outcomes. METHODS Utilizing Current Procedural Terminology (CPT) codes, patients undergoing tissue expander, pedicled transverse rectus abdominis myocutaneous (TRAM) flap, latissimus dorsi flap, and free flap breast reconstruction were identified in the National Surgical Quality Improvement Program (NSQIP) database. Patients were stratified as obese (BMI ≥ 30) and non-obese (BMI < 30). Overall postoperative morbidity, flap complications, non-flap complications, and reoperation rates were compared among the groups. RESULTS Of 12,986 patients who underwent breast reconstruction, 3636 (28.0%) were obese. Overall morbidity was significantly elevated in obese patients across all forms of reconstruction (p < 0.05). BMI was correlated with increased surgical complications for tissue expander, pedicled TRAM, and free flap reconstructions (OR = 1.09, OR = 1.05, OR = 1.10, respectively; p < 0.05). Medical complications were higher in obese patients undergoing tissue expander and pedicled TRAM reconstructions (p = 0.001 and p < 0.001), but no significant difference was observed in latissimus and free flap reconstruction patients. Compared with obese tissue expander recipients, obese patients reconstructed using autologous tissue had higher rates of reoperations (12.8% versus 9.1%), overall morbidity (18.0% versus 9.5%), surgical (12.7% versus 8.3%), and medical complications (9.0% versus 2.2%). CONCLUSIONS The NSQIP database allows for evaluation and comparison of reconstructive outcomes in the obese population. Increased BMI was associated with higher morbidity in autologous reconstruction than tissue expander reconstruction. Among autologous procedures, latissimus flaps experienced the lowest captured 30 day morbidity.

Long-term outcomes following fat grafting in prosthetic breast reconstruction: A comparative analysis

Background: Autologous fat grafting has become a common technique for optimizing aesthetic outcomes following breast reconstruction. Its long-term oncologic implications, however, remain unclear. The authors evaluated long-term outcomes following tissue expander breast reconstruction with and without fat grafting. Methods: A retrospective review was performed of consecutive patients undergoing mastectomy with immediate tissue expander reconstruction from April of 1998 to August of 2008. Demographic, operative, oncologic, and postoperative factors were recorded, including the use of fat grafting. Mean follow-up was 42.1 ± 28.8 and 43.6 ± 27.2 months for non–fat-grafting and fat-grafting patients, respectively (p = 0.63), including 24.8 ± 5.9 months after the first fat-grafting procedure. Fishers exact test, t test, and regression analysis were used for statistics. Results: A review of 886 patients (n = 1202 breasts) revealed no significant differences in demographics, operative characteristics, tumor staging, or radiation therapy exposure between fat-grafting (n = 90 breasts) and non–fat-grafting (n = 1112 breasts) patients. Ninety-nine fat-grafting procedures were performed an average of 18.3 months after reconstruction, with one complication (fat necrosis). Grafting did not affect local tumor recurrence or survival when compared with non–fat-grafted breasts. Complication following reconstruction, including a poor cosmetic result, was an independent predictor of undergoing subsequent fat grafting (p < 0.0001). Conclusions: The analysis suggests that fat grafting after breast reconstruction does not adversely affect local tumor recurrence or survival on long-term follow-up. Autologous fat grafting can be used as an aesthetic adjunct to prosthetic reconstruction with minimal complications. These results also indicate the need for multi-institutional, prospective studies to definitively establish its oncologic safety. 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.

The effect of incision choice on outcomes of nipple-sparing mastectomy reconstruction

INTRODUCTION The indications for nipple-sparing mastectomy (NSM) are broadening as more breast surgeons appreciate the utility of preserving the nipple-areolar complex. A number of incision locations are available to the mastectomy surgeon, including inframammary, lateral and periareolar approaches. The present study investigated the effect of these three incisions on reconstructive outcomes; specifically, nipple necrosis. METHODS A single-centre, retrospective review of 37 breast NSM reconstructions treated with immediate tissue expander reconstruction with acellular dermis between 2007 and 2008 was performed. The primary outcome was the incidence of nipple necrosis associated with periareolar, lateral and inframammary incisions. Secondary outcomes were the effects of radiation, chemotherapy and breast size on nipple necrosis. RESULTS Thirty-seven breast procedures performed on 20 patients were included in the present study. Periareolar incisions were used in 21 cases, lateral incisions in 14 and inframammary incisions in two. The periareolar incision was associated with a significantly higher incidence of nipple necrosis compared with lateral or inframammary incisions (38.1% versus 6.3%, P=0.028). Patients receiving breast radiation (45.5% versus 15.4%, P=0.066) and those with larger breast size (540.4 g versus 425.7 g, P=0.130) also demonstrated a modest trend toward an increased rate of nipple necrosis. CONCLUSION The periareolar incision results in a higher rate of nipple necrosis following NSM and immediate tissue expander breast reconstruction. Using the lateral or inframammary incision reduces the incidence of nipple necrosis and may help improve overall reconstructive and cosmetic outcomes.

Is It Safe to Combine Abdominoplasty with Elective Breast Surgery? A Review of 151 Consecutive Cases

Background: This study was designed to evaluate and compare the complication rates of patients having abdominoplasty without breast surgery with the rates of those having abdominoplasty with various types of elective breast surgery, including breast augmentation, breast reduction, mastopexy, and mastopexy combined with simultaneous augmentation. Methods: The data collected represent a retrospective chart review of consecutive abdominoplasty procedures performed at a single outpatient facility by the senior surgeon (W.G.S.) over a 15-year period (1989 to 2004). Two groups were compared: patients who underwent abdominoplasty without breast surgery and those who had abdominoplasty with breast surgery. The second group was subdivided by the various types of breast procedures noted above. The minor complications assessed included seromas, hematomas, infections, and small (<5 cm) wound breakdowns. Major complications evaluated included large (>5 cm) flap necrosis, need for blood transfusion, deep vein thrombosis, pulmonary embolus, myocardial infarction, and death. Additional data compiled included age, sex, tobacco use, body mass index, past medical history, American Society of Anesthesiologists physical status level, and operative times. Results: Of the 415 abdominoplasty procedures, 264 (group 1) did not include simultaneous breast surgery. One hundred fifty-one procedures (group 2) involved simultaneous breast surgery, representing 36 percent of the total. Group 2 was further subdivided into those who had breast augmentation surgery (group 2A, n = 50), those who had breast reduction surgery (group 2B, n = 31), those who had mastopexy surgery (group 2C, n = 28), and those who had simultaneous mastopexy and breast augmentation surgery (group 2D, n = 42). Removal and replacement of implants and capsulectomy/capsulotomy procedures were included in the augmentation group (group 2A). There were no major complications, including flap necrosis (open wound >5 cm), blood transfusions, deep vein thrombosis, pulmonary embolus, myocardial infarction, or death. No patients required hospitalization. No statistically significant associations with complications were noted between groups 1 and 2 (chi-square, 0.0045; p > 0.95, not significant). Furthermore, when subdivided by type of breast surgery, no statistically significant associations were noted among subgroups: group 1 versus 2A (chi-square, 0.96; p > 0.05, not significant), group 1 versus 2B (chi-square, 0.032; p > 0.9, not significant), group 1 versus 2C (chi-square, 0.003; p > 0.975, not significant), and group 1 versus 2D (chi-square, 0.83; p > 0.5, not significant). Conclusion: The results of this retrospective review indicate that combining elective breast surgery with abdominoplasty does not appear to significantly increase the number of major or minor complications.