Frank P. Albino

Does mesh location matter in abdominal wall reconstruction? A systematic review of the literature and a summary of recommendations.

Background: Mesh implantation during abdominal wall reconstruction decreases rates of ventral hernia recurrence and has become the dominant method of repair. The authors provide a comprehensive comparison of surgical outcomes and complications by location of mesh placement following ventral hernia repair with onlay, interposition, retrorectus, or underlay mesh. Methods: A systematic search of the English literature published from 1996 to 2012 in the PubMed, MEDLINE, and Cochrane library databases was conducted to identify patients who underwent abdominal wall reconstruction using either prosthetic or biological mesh for ventral hernia repair. Demographic information was obtained from each study. Results: Sixty-two relevant articles were included with 5824 patients treated with mesh repair of a ventral hernia between 1996 and 2012. Mesh position included onlay (19.6 percent), underlay (60.7 percent), interposition (6.4 percent), and retrorectus (12.4 percent). Prosthetic mesh was used in 80 percent of repairs and biological mesh in 20 percent. The weighted mean incidences of early events were as follows: wound complications, 19 percent; wound infections, 8 percent; seroma or hematoma formation, 11 percent; and reoperation, 10 percent. The weighted mean incidences of late complications included 8 percent for hernia recurrence and 2 percent for mesh explantation. Recurrence rates were highest for onlay (17 percent) or interposition (17 percent) reinforcement. The infection rate was also highest in the interposition cohort (25 percent). Seroma rates were lowest following a retrorectus repair (4 percent). Conclusions: Mesh reinforcement of a ventral hernia repair is safe and efficacious, but the location of the reinforcement appears to influence outcomes. Underlay or retrorectus mesh placement is associated with lower recurrence rates.

Irradiated autologous breast reconstructions: effects of patient factors and treatment variables.

Background: Postmastectomy irradiation often negatively impacts breast reconstruction outcomes. Further investigation is necessary to recognize factors contributing to adverse results. The purpose of this study was to (1) accurately assess the impact of radiation on autologous breast reconstruction and (2) identify patient and treatment factors affecting reconstructive outcomes. Methods: One hundred twenty-six patients were considered after postmastectomy breast reconstruction and irradiation. The records of 76 patients were studied after excluding for radiation therapy before reconstruction, complications before irradiation, implant reconstruction, mastectomy for recurrent disease, and history of cancer. Patient demographics and comorbidities, operative details, adjuvant therapy, and treatment outcomes were assessed. Results: Seventy-six patients underwent autologous microsurgical breast reconstruction. Complications occurred in 53 patients (70 percent) 7.2 ± 6 months after irradiation; 36 cases (47 percent) required reoperation for postirradiation effects. Parenchymal complications (fat necrosis or parenchymal fibrosis) were noted in 19.7 percent, skin complications (tissue envelope retraction or hypertrophic scarring) were recorded in 30.3 percent, and general dissatisfaction (physician or patient dissatisfaction) arose in 27.6 percent of patients. Parenchymal complications were associated with smoking (odds ratio, 9.3; p = 0.03), type II diabetes mellitus (odds ratio, 8.5; p = 0.02), and age (odds ratio, 1.1; p = 0.02). Neoadjuvant chemotherapy increased the development of complications (odds ratio, 4.4; p = 0.04), particularly skin changes (odds ratio, 2.4; p = 0.01). Conclusions: Patient-specific factors, including diabetes mellitus and smoking, increase the risk of postirradiation parenchymal changes, and neoadjuvant chemotherapy is associated with a greater than twofold increase in skin complications. Breast reconstruction followed by irradiation can be successful, but patients with specific risks should be aware of increased complication rates.

A Comparative Analysis and Systematic Review of the Wound-Healing Milieu: Implications for Body Contouring after Massive Weight Loss

Background: Wound-healing complications following body contouring for massive weight loss patients are significant, with rates exceeding 40 percent. To better understand aberrant healing in this population, the authors have performed a comparative analysis of the wound milieu literature for patient populations with similar complication rates. Methods: PubMed and Ovid databases were reviewed from January of 1985 to January of 2009 for key terms, including wound healing, obesity, cancer, burn, transplant, and body contouring. Serum and wound levels of multiple factors, including matrix metalloproteinases (MMPs) and cytokines, were assessed. Results: Complication rates in body contouring surgery range from 31 to 66 percent. Sixty-five studies were reviewed, and wound-healing complication rates were identified for cancer (45.8 percent), burn (30.4 percent), posttransplant (36 percent), and obese (43 percent) populations. In these groups, matrix metalloproteinases and tissue inhibitors of metalloproteinase (TIMPs) help regulate wound repair. Matrix metalloproteinase levels were elevated in cancer (4-fold increase in MMP-2), burn (20- to 30-fold increase in MMP-9), transplant (1.4-fold increase in MMP-2), and obese/chronic (79-fold increase) populations. TIMPs were increased in cancer (1.9-fold increase in TIMP-2) and burn (1.4-fold increase in TIMP-1) patients but decreased in chronic wound (55-fold decrease in TIMP-1) populations. Alterations to these regulatory proteins lead to prolonged matrix degradation, up-regulation of inflammatory mediators, and decreased growth factors, delaying the wound-healing process. Conclusions: Complications after body contouring surgery are likely multifactorial; however, molecular imbalances to the massive weight loss wound milieu may contribute to poor surgical outcomes. Examining wound regulatory proteins including transforming growth factor-β, vascular endothelial growth factor, and matrix metalloproteinases could aid in understanding the healing difficulties observed clinically.

A Patient-centered Appraisal of Outcomes following Abdominal Wall Reconstruction: A Systematic Review of the Current Literature

Background: Published assessment tools have attempted to investigate patient-centered outcomes after abdominal wall defect repairs, including quality-of-life measures, functional outcomes, pain assessment, and overall satisfaction scores; however, health-related quality of life following hernia repair remains unclear. Methods: The MEDLINE, PubMed, and Cochrane databases were queried and 880 articles were identified. Of these, 22 met inclusion/exclusion criteria. Analysis included health-related quality-of-life metrics focusing on quality of life, pain, physical function, overall satisfaction with surgery, impact of component separation, use of synthetic or biologic mesh, and emotional sequelae of an abdominal wall defect and repair. Results: Twenty-two studies were reviewed; the mean study size was 117.7 patients (range, 14 to 402 patients). Mean and median ventral hernia defect sizes were 104.5 cm2 and 71.5 cm2, respectively. All studies reported open repairs using synthetic mesh. The Short Form-36 was used most often (11 of 22) in comparison to other assessment methods. Patients had global improvement in quality of life, functionality, impact on social function, and patient satisfaction. Hernia recurrence was found to have a major negative impact on quality of life. Midline repair improved overall pain and abdominal wall functionality in both presurgical patients and those with hernia recurrence. Component separation techniques appear to have a positive impact on global health-related quality of life. Conclusions: Adopting an abdominal wall procedure–specific quality-of-life assessment tool as the standard is strongly recommended to gain a comprehensive understanding of abdominal wall defects and repairs. The available literature in open abdominal wall repair suggests an improved quality of life. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Use of intraoperative indocyanin-green angiography to minimize wound healing complications in abdominal wall reconstruction

Abstract Complication rates following abdominal wall reconstruction (AWR) remain high. Early complications are related to skin necrosis and delayed healing, whereas late complications are related to recurrence. When concomitant body contouring procedures are performed, complication rates can be further increased. It is hypothesised that fluorescent angiography using indocyanin green (ICG) can identify poorly perfused tissues and thus reduce the incidence of delayed healing. A retrospective review was conducted of all patients who underwent AWR with concomitant panniculectomy from 2007–2012. Intraoperative ICG angiography with the SPY system (LifeCell Corp.) was used to determine the amount of resection for body contouring in patients who underwent reconstruction in a cohort of patients. SPY-Q was used to assess relative perfusion of analysed areas. Preoperative, postoperative, and operative details were analyzed. Seventeen patients met inclusion criteria, 12 patients were included in the non-ICG cohort, while five patients were included in the ICG cohorts. Wound-healing complications occurred in 5/12 (42%) patients in the non-ICG cohort vs 1/5 (20%) of the ICG cohorts. A description of the sole patient with complications in the ICG cohort is illustrated. Operative debridement and wound infection development occurred more frequently in the non-ICG cohort compared with the ICG cohort (17%, 17% vs 0%, 0%, respectively). Average time to wound healing was 41.1 days. Intraoperative ICG angiography can accurately detect perfusion abnormalities and can decrease wound healing related complications in complex hernia repair with concomitant panniculectomy. Assessing and ensuring skin viability can decrease the need for operative debridement.

Classification and management of the postoperative, high-riding nipple.

Background: Postoperative nipple malposition can be an aesthetically devastating problem for patients and a formidable challenge for surgeons. The authors’ aim was to identify the common antecedent events leading to high-riding nipples, provide a classification system for these problems, and discuss management. Methods: A retrospective review of medical records was conducted for patients who presented to the senior surgeon (S.L.S.) for management of a postoperative, excessively high nipple-areola complex over an 8-year period from January of 2004 to March of 2012. Demographic information, medical histories, operative details, and office records were reviewed for each patient. The high nipple-areola complex was classified as mild, moderate, or severe depending on the distance from the superior breast border to the top of the nipple-areola complex in relation to the vertical breast height. Results: Twenty-five women met study criteria, with 41 breasts determined to have an excessively high nipple-areola complex. The average patient was aged 44.3 years and had undergone 2.5 ± 1.3 operations before the development of a notably high nipple-areola complex, including nipple-sparing mastectomy (32 percent), augmentation/mastopexy (29 percent), augmentation (27 percent), mastopexy (10 percent), and skin-sparing mastectomy with nipple reconstruction (2 percent). Patients were classified as having mild (27 percent), moderate (56 percent), or severe (17 percent) nipple-areola complex displacement; surgical correction was attempted in 54 percent of cases. Conclusions: A high-riding nipple-areola complex can develop following aesthetic or reconstructive surgery. Although many patients may not need or choose correction, there are surgical options that may be helpful in improving the nipple-areola complex position.

Evaluating long-term outcomes following nipple-sparing mastectomy and reconstruction in the irradiated breast.

Background: Although it is well established that reconstruction of the irradiated breast is associated with diminished cosmetic results and more frequent complications, little is known about the specific effects of radiation therapy on the reconstructive outcomes after nipple-sparing mastectomy. Methods: Patients who had nipple-sparing mastectomy and had either previous radiation therapy for breast-conservation therapy or postmastectomy radiation therapy were reviewed. Patient demographics, reconstructive details, and postoperative outcomes were analyzed. Patient photographs were used to evaluate aesthetic parameters. Fisher’s exact and t tests were used for comparison of groups, with a value of p < 0.05 considered significant. Results: Eighteen patients were identified as having nipple-sparing mastectomy either after breast-conservation therapy (72.2 percent) or before postmastectomy radiation therapy (27.8 percent), with an average follow-up of 3 years. First-stage complications occurred in six patients (33.3 percent). Nipple position was classified as high-riding in 55.6 percent of patients. Average time to revision was 13.3 months. Most common revisions were for correction of malposition (27.8 percent), capsular contracture (16.7 percent), and high-riding nipple (22.4 percent). Capsular contracture occurred more commonly in patients who needed postmastectomy radiation therapy compared with those who had previously undergone breast-conservation therapy (40 percent versus 7.8 percent). Maintenance of reconstruction occurred in 88.9 percent patients, with eventual implant loss occurring in two patients (11.1 percent). Conclusions: Nipple-sparing mastectomy and implant reconstruction should be approached cautiously in the setting of radiation therapy. When early complications are present, significant morbidity may occur. Late revision surgery is common in this subset of patients. Implant malposition and a high-riding nipple occur most frequently. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Microvascular autologous breast reconstruction in the context of radiation therapy: comparing two reconstructive algorithms.

Background: When postmastectomy radiation therapy is anticipated, delaying autologous reconstruction prevents radiation delivery issues and radiation-induced contour irregularities. Delayed-immediate autologous breast reconstruction may allow for maintenance of the breast skin envelope as compared with delayed reconstruction with the temporary insertion of a tissue expander. The authors compared perioperative complications and revision surgery rates of comparative cohorts to determine which method is preferable. Methods: Delayed-immediate reconstruction was defined as placement of a temporary tissue expander in the first stage at the time of mastectomy before flap reconstruction, which occurred following postmastectomy radiation therapy. Delayed reconstruction was categorized as mastectomy with primary closure in the first stage followed by flap reconstruction. Results: One hundred fifty-two patients and 192 breasts met the study criteria for this retrospective review (delayed reconstruction, 118 breasts; delayed-immediate autologous breast reconstruction, 74 breasts). Patient age and body mass index were similar between groups (p > 0.05). Perioperative first-stage complication rates were 8.5 percent in the delayed group and 10.8 percent in the delayed-immediate cohort (p = 0.81). Total flap loss (2.5 versus 4.1 percent; p = 0.68) and arterial (1.7 versus 1.4 percent; p = 0.82) and venous (4.3 versus 5.4 percent; p = 0.73) anastomotic revision rates were similar between the cohorts, respectively. Reoperative surgery occurred in 11.9 percent versus 9.6 percent in the delayed and delayed-immediate cohorts, respectively (p = 0.69). Conclusions: In comparing two treatment algorithms, flap-related complication rates are comparable. First-stage surgery results in a slightly increased complication rate in the delayed-immediate cohort. Improved overall results with delayed-immediate reconstruction are implied, given significantly decreased rates of revision surgery following flap reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

The use of porcine acellular dermal matrix in a bridge technique for complex abdominal wall reconstruction: an outcome analysis

BACKGROUND Outcomes using the porcine acellular dermal matrix (PADM) in abdominal wall reconstruction (AWR) have been reported when used for midline reinforcement; however, there have been no reports focused on outcomes when used as a bridging mesh. METHODS A retrospective review was conducted of all patients who underwent AWR with a non-cross-linked PADM as a bridged repair without midline fascial approximation. RESULTS Nine patients were identified with an average follow-up of 546 days. The average preoperative hernia defect diameter was 22.4 cm. After PADM placement, the average defect diameter was 9.8 cm. Complications occurred in 55.6% of patients, with PADM exposure occurring in all of these patients. No PADM was explanted, and all patients eventually healed. Abdominal wall eventration and/or recurrence occurred in 8 of 9 (88.9%) patients. CONCLUSIONS When fascial approximation cannot be achieved, PADM bridging may be the best option to avoid complications associated with synthetic mesh. However, there is a high potential for abdominal wall eventration and/or recurrence.

Repairing the high-riding nipple with reciprocal transposition flaps.

Summary: The high-riding nipple-areola complex is a clinical problem that can be encountered following cosmetic and reconstructive breast surgery. Because of the desire to avoid scars on the superior aspect of the breast and the limited availability of superior breast skin, it can be technically challenging to place the nipple-areola complex in a lower position. Multiple surgical strategies have attempted to lower it, and each has its advantages and disadvantages. Reciprocal rotation flaps have been used by the authors with success. They describe the surgical technique and outcomes in five breasts. The medical records of all patients who had reciprocal rotation flaps for high-riding nipple-areola complexes performed by the senior author (S.L.S.) were reviewed. The institutional review board–approved review included preoperative history and examination, surgical findings, surgical technique, and postoperative course. Five reciprocal rotation flap procedures were performed on four patients between 2005 and 2012 for high-riding nipple-areola complexes. The high-riding nipple-areola complexes were all iatrogenic, following reconstruction for nipple-sparing mastectomy or mastopexy. All nipple-areola complexes were successfully lowered with an average follow-up duration of 2.1 years. One breast that had undergone previous radiation therapy had a nipple-areola complex flap that appeared ischemic; the patient underwent hyperbaric oxygen therapy and the flap fully survived. Reciprocal rotation flaps are an effective strategy for management of the high-riding nipple-areola complex and can be safely performed with thoughtful planning and careful surgical technique. This technique is riskier in the irradiated breast but may be facilitated with hyperbaric oxygen therapy. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.