Erin M. Taylor

Surgical treatment of nipple malposition in nipple-sparing mastectomy device-based reconstruction.

Background: This article discusses the senior author’s (M.T.) experience with nipple-areola complex malposition following nipple-sparing mastectomy, surgical options for treatment, and an analysis of risk factors. Methods: A retrospective review was conducted on a prospectively collected institutional review board–approved database of nipple-sparing mastectomy cases with immediate device-based reconstruction performed between July of 2006 and October of 2012. Malposition was graded as mild (1 cm), moderate (2 cm), or severe (>3 cm) displacement. Results: Three hundred nineteen nipple-sparing mastectomies were reviewed. Malposition occurred in 44 (13.79 percent). Significant factors were age (p < 0.0001), diabetes mellitus (p = 0.0025), body mass index (p = 0.0093), preoperative sternal notch–to-nipple distance (p = 0.015), preoperative breast base width (p = 0.0001), periareolar mastectomy incision with lateral extension (p < 0.0001), prior radiation (p = 0.0004), prior lumpectomy (p = 0.0125), unilateral nipple-sparing mastectomy (p = 0.0004), and postoperative nipple-areola complex ischemia (p = 0.0174). Smoking status, breast volume resected, implant size, ablative surgeon, acellular dermal matrix, and single-stage reconstruction were not significant. Nineteen patients were satisfied. Eight were not offered surgical correction because of an inadequate skin envelope. Eight had crescent mastopexy, three had implant exchange and pocket revision, four had free nipple grafts, and two had pedicled nipple transposition. There were no incidences of necrosis or malposition after surgical correction. Conclusions: Nipple-sparing mastectomy followed by immediate device-based reconstruction has a risk of nipple malposition. Various surgical procedures are available to correct nipple malposition based on clinical presentation and are safe in certain populations. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

The 3-4 loop of an archaeal glutamate transporter homolog experiences ligand-induced structural changes and is essential for transport

Glutamatergic synaptic transmission is terminated by members of the excitatory amino acid transporter (EAAT) family of proteins that remove glutamate from the synaptic cleft by transporting it into surrounding glial cells. Recent structures of a bacterial homolog suggest that major motions within the transmembrane domain translocate the substrate across the membrane. However, the events leading to this large structural rearrangement are much less clear. Two reentrant loops have been proposed to act as extracellular and intracellular gates, but whether other regions of these proteins play a role in the transport process is unknown. We hypothesized that transport-related conformational changes could change the solvent accessibilities of affected residues, as reflected in protease sensitivity or small-molecule reactivity. In the model system GltPh, an archaeal EAAT homologue from Pyrococcus horikoshii, limited trypsin proteolysis experiments initially identified a site in the long extracellular loop that stretches between helices 3 and 4 that becomes protected from proteolysis in the presence of a substrate, L-aspartate, or an inhibitor, DL-TBOA in the presence of Na+, the cotransported ion. Using a combination of site-directed cysteine-scanning mutagenesis and fluorescein-5-maleimide labeling we found that positions throughout the loop experience these ligand-induced conformational changes. By selectively cleaving the 3-4 loop (via introduced Factor Xa sites) we demonstrate that it plays a vital role in the transport process; though structurally intact, the cleaved proteins are unable to transport aspartate. These results inculcate the 3-4 loop as an important player in the transport process, a finding not predicted by any of the available crystal structures of GltPh.

Pectoralis Major Myocutaneous Flap versus Free Fasciocutaneous Flap for Reconstruction of Partial Hypopharyngeal Defects: What Should We Be Doing?

BACKGROUND Partial hypopharyngeal defects are most commonly reconstructed with the pectoralis major myocutaneous flap (PMMF) or free fasciocutaneous (FFC) flap. The purpose of this study is to determine the ideal method for reconstruction of partial hypopharyngeal defects by reviewing our institutional experience and the literature. METHODS A retrospective review of partial hypopharyngeal reconstructions since 2009 was performed. A National Library of Medicine search of studies on partial hypopharyngeal reconstruction since 1988 was performed. Data on complications, diet, and speech were extracted and pooled. RESULTS A total of 18 patients were studied-9 had PMMF reconstruction and 9 had FFC reconstruction. Operative time (8.75 vs. 13.0 hours, p = 0.0003) was shorter in the PMMF group. Pharyngocutaneous fistula developed in one PMMF patient (11.1%) and two FFC patients (22.2%). Late strictures occurred in three PMMF patients. Six patients in each group (66.7%) progressed to a regular diet. Three patients in each group produced tracheoesophageal speech after TEP. Literature review identified 36 relevant studies, with 301 patients reconstructed with PMMF and 605 patients with FFC. Pooled-data analysis revealed that PMMF had higher reported rates of fistula (24.7 vs. 8.9%, p < 0.0001) and requirement for second surgery (11.3 vs. 5.5%, p = 0.04). There was no difference in stricture rates or progression to regular diet. Fewer PMMF patients produced tracheoesophageal speech (17.5 vs. 52.1%, p < 0.0001). CONCLUSIONS PMMF and FFC flaps are valid approaches to reconstructing partial hypopharyngeal defects, though rates in the literature of fistula, need for revisional surgery, and tracheoesophageal speech after laryngectomy are more favorable after free flap reconstruction.

Pulsed Electromagnetic Fields Reduce Postoperative Interleukin-1β, Pain, and Inflammation: A Double-Blind, Placebo-Controlled Study in TRAM Flap Breast Reconstruction Patients.

Background: Pulsed electromagnetic fields have been shown to reduce postoperative pain, inflammation, and narcotic requirements after breast reduction and augmentation surgical procedures. This study examined whether pulsed electromagnetic field therapy could produce similar results in patients undergoing unilateral transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction, a significantly more complex and painful surgical procedure. Methods: In this double-blind, placebo-controlled, randomized study, 32 patients undergoing unilateral TRAM flap breast reconstruction received active or sham pulsed electromagnetic field therapy. Pain levels were measured by using a visual analogue scale; narcotic use and wound exudate volume were recorded starting 1 hour postoperatively. Wound exudates were analyzed for interleukin-1&bgr;. Results: Mean visual analogue scale pain scores were 2-fold higher in the sham cohort at 5 hours and 4-fold higher at 72 hours (p < 0.01), along with a concomitant 2-fold increase in narcotic use in sham patients (p < 0.01). Wound exudate volume was 2-fold higher in the sham cohort at 24 hours (p < 0.01), and mean interleukin-1&bgr; concentration in wound exudates of sham patients was 5-fold higher at 24 hours (p < 0.001). Conclusions: Pulsed electromagnetic field therapy significantly reduced postoperative pain, inflammation, and narcotic use following TRAM flap breast reconstruction, paralleling its effect in breast reduction patients. Both studies also report a significant reduction of interleukin-1&bgr; in the wound exudate, supporting a mechanism involving a pulsed electromagnetic field effect on nitric oxide/cyclic guanosine monophosphate signaling, which modulates the body’s antiinflammatory pathways. Adjunctive pulsed electromagnetic field therapy could impact the speed and quality of wound repair in many surgical procedures. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, I.

Surgeon-Based 3D Printing for Microvascular Bone Flaps

Background Three‐dimensional (3D) printing has developed as a revolutionary technology with the capacity to design accurate physical models in preoperative planning. We present our experience in surgeon‐based design of 3D models, using home 3D software and printing technology for use as an adjunct in vascularized bone transfer. Methods Home 3D printing techniques were used in the design and execution of vascularized bone flap transfers to the upper extremity. Open source imaging software was used to convert preoperative computed tomography scans and create 3D models. These were printed in the surgeons office as 3D models for the planned reconstruction. Vascularized bone flaps were designed intraoperatively based on the 3D printed models. Results Three‐dimensional models were created for intraoperative use in vascularized bone flaps, including (1) medial femoral trochlea (MFT) flap for scaphoid avascular necrosis and nonunion, (2) MFT flap for lunate avascular necrosis and nonunion, (3) medial femoral condyle (MFC) flap for wrist arthrodesis, and (4) free fibula osteocutaneous flap for distal radius septic nonunion. Templates based on the 3D models allowed for the precise and rapid contouring of well‐vascularized bone flaps in situ, prior to ligating the donor pedicle. Conclusions Surgeon‐based 3D printing is a feasible, innovative technology that allows for the precise and rapid contouring of models that can be created in various configurations for pre‐ and intraoperative planning. The technology is easy to use, convenient, and highly economical as compared with traditional send‐out manufacturing. Surgeon‐based 3D printing is a useful adjunct in vascularized bone transfer. Level of Evidence Level IV.

Clear to Cloudy: Silicone Breast Implants In Vivo

Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of

Serratus branch as recipient vessel for microvascular tissue transfer in breast reconstruction

Sir: Although the internal mammary vessels remain the recipient vessels of choice in free flap breast reconstruction, the thoracodorsal vessels are still chosen for a variety of reasons. The use of the internal mammary artery as a recipient vessel is justified despite concern for future coronary revascularization.1 The thoracodorsal vessels continue to be used because of surgeon preference and cases of suboptimal internal mammary vessels upon dissection. The potential disadvantages of the thoracodorsal artery and vein as recipient vessels include difficultly in achieving medial fullness in the final breast mound and the inability to use the latissimus flap for future breast reconstruction. We present a case in which the serratus branch is used as recipient vessels for microvascular tissue transfer, with the advantage of preserving the thoracodorsal vessels for future flap reconstruction. The patient is a 44-year-old woman with history of left breast cancer status post mastectomy, who presented for delayed autologous free flap reconstruction. After excision of the previous mastectomy scar, the prepectoral pocket was created. It was noted that the previous mastectomy scar went quite lateral, and therefore, the decision was made to dissect the thoracodorsal vessels. During the dissection, the serratus branch of the thoracodorsal vessels was noted to be quite large and suitable for microvascular anastomosis (Fig. 1). We chose to use the serratus branch as recipient vessels to spare the thoracodorsal vessels. This would allow for future use of her latissimus muscle for breast or general reconstruction. Fig. 1. Dissection of the thoracodorsal vessels. The serratus branch of the thoracodorsal vessels was found large and suitable for microvascular anastomosis. Few studies have described the use of the serratus branch as recipient vessels for microvascular transfer. Arnez et al2 describe a case of a patient who underwent a free transverse rectus abdominis myocutaneous flap reconstruction with the serratus anterior branch as a recipient vessel, thus conserving the remainder of the thoracodorsal vessels in case they were needed in a secondary salvage surgery. In a study describing their experience with 50 free TRAM flap reconstructions, Arnez et al3 describe 1 of 2 reconstructions using the serratus branch, citing the superior back flow of the serratus branch in comparison with the flow of the proximal pedicle. Another group describes their use of the serratus branch as recipient vessels in 4 patients undergoing partial breast reconstruction with mini-superficial inferior epigastric artery and mini-deep inferior epigastric artery perforator flaps to achieve the proper anatomic placement of miniflaps.4 Most cases describe the use of the serratus branch and other distal branches of the thoracodorsal artery as a means to successfully salvage a deep inferior epigastric artery perforator flap through retrograde flow anastomosis.5 In conclusion, the serratus branch of the thoracodorsal vessels provides a viable recipient site for microvascular tissue transfer with the advantages of sparing the thoracodorsal vessels for future latissimus flap reconstruction.

Abstract 47: surgical treatment of nipple malposition in nipple sparing mastectomy device-based reconstruction.

Sarday, M arch 8, 2014 results: The overall infection rate was 3.75 (603 out of 16,469 patients). The infection rate was greatest within the pedicled TRAM cohort (5.97%), followed by the free flap cohort (5.52%), prosthetic cohort (3.44%), and finally the latissimus cohort (2.80%). In addition to reconstructive modality, 5 predictors of infection were selected for inclusion within the model: BMI, age, ASA class, bleeding disorder, and history of percutaneous cardiac intervention or cardiac surgery. The model c-statistic was 0.682 and the optimism-corrected c-statistic 0.678. The model was well calibrated (HL p-value = 0.371) and the brier score was 0.036. Across all reconstructive modalities, patients with an infection experienced higher rates of reoperation (range of 38.1%-45.9% vs. 4.8%-13.5%) and readmission (50.9%-61.1% vs. 2.8%-5.3%) (all p < 0.001).

Optimizing Nipple Position following Nipple-Sparing Mastectomy

Background: The best treatment for nipple malposition following nipple-sparing mastectomy is prevention. This article reviews basic elements for success in nipple-sparing mastectomy and offers an option to patients with grade 2–3 breast ptosis who strongly desire to preserve the nipple. Methods: Retrospective review identified patients undergoing nipple-sparing mastectomy and immediate reconstruction. Results: Patient selection centered on realistic goals for postoperative breast size, nipple position, and when not to save the nipple. The choice of device considered projection and nipple centralization as equal components and led to wider, lower profile devices selectively for the first stage of reconstruction. In severe grade 2–3 nipple ptosis, an inferior vertical incision or wedge excision was used to enhance nipple position postoperatively. Eighteen consecutive patients underwent 32 implant-based breast reconstructions following nipple-sparing mastectomy with the vertical incision. The average age was 45 years old, and the average body mass index was 26.7. Direct-to-implant reconstruction was performed in 25%, whereas 75% had tissue expander-implant reconstruction. Overall complications included infection (3%) and nipple necrosis (3%) leading to explant in 1 reconstruction. Conclusions: The final nipple position following nipple-sparing mastectomy can be optimized with preoperative planning. The vertical incision, combined with proper patient selection and choice of device, may increase eligibility for nipple-sparing procedures in patients with grade 2–3 ptosis who desire nipple preservation.

Reconstruction of quadriceps function with composite free tissue transfers following sarcoma resection

BACKGROUND AND OBJECTIVES Wide margin resection of a soft tissue sarcoma (STS) may require extensive removal of quadriceps muscle with or without the knee extensor mechanism. The objective of this study is to present present the use of a combined functional muscle transfer and soft tissue coverage through the use of chimeric anterolateral thigh flaps.