Goo-Hyun Mun

Updated Evidence of Acellular Dermal Matrix Use for Implant-Based Breast Reconstruction: A Meta-analysis.

AbstractBackgroundAlthough the use of acellular dermal matrix (ADM) has increased nexponentially, debates regarding its safety are still ongoing. There have been several meta-analyses; however, potential learning curve effects of using ADM might affect their outcomes. The present meta-analysis reappraised the potential benefits and risks of ADM on the outcome of implant-based breast reconstruction using recent publications.MethodsElectronic databases were searched to identify relevant studies comparing the outcome of ADM use with traditional submuscular technique, which were published from 2011 to 2014. The relative risks of postoperative complications and mean difference of expander dynamics between the two groups were computed.ResultsA total of 23 studies representing 6199 cases were analyzed. There was one randomized controlled study and three prospective cohort studies. The use of ADM significantly elevated the risks of infection, seroma, and mastectomy flap necrosis, but did not affect the risks of implant loss, unplanned reoperation, and total complications. The risks of capsular contracture and implant malposition were significantly reduced by the application of ADM. The ADM allows for significantly greater intraoperative expansion and reduced frequency of injection to complete expansion.ConclusionsAccording to this meta-analysis, the increasing risks for serious complication and overall morbidity related to ADM use might not be remarkable, while its benefits for preventing late complications and improving expander dynamics might be appreciable. Although future well-controlled studies would be required, the implant-based breast reconstruction using ADM may be reliable and advantageous.

Is Late Seroma a Phenomenon Related to Textured Implants? A Report of Rare Complications and a Literature Review

BackgroundLate seroma is an infrequent complication that manifests as fluid collection in the periprosthetic space at least 1xa0year after breast enlargement surgery. Interest in late seroma has grown with the potential connection between breast implants and anaplastic large cell lymphoma (ALCL), which presents with clinical symptoms similar to those of late seroma. This report presents a case of late seroma experienced by a patient with a history of multiple implant ruptures and a review of the relevant literature.MethodsDetails are reported for a patient who presented with sudden swelling of an augmented breast that was initially suspected to be symptomatic of ALCL. A literature search of PubMed regarding this phenomenon also was conducted.ResultsThe literature review identified 14 articles on late seroma involving 60 patients, including the reported case. Analyses included epidemiology, etiology, and management strategy. Although a detailed statistical analysis was not performed, 55 cases (92xa0%) of late seroma occurred that involved patients with textured implants. No evidence-based guideline for the management of late seroma has been established, although the patients were managed successfully in all cases using various strategies.ConclusionsThe reported case and data from the literature provide evidence of a relationship between textured implant use and late seroma. Based on their review, the authors offer “sequential treatment steps,” from conservative treatment to surgical management, which will be helpful for successful management of future late seroma cases. However, further study is needed to clarify the relationship, if any, between a particular type of textured implant and the development of late seroma.Level of Evidence VThis 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 Contents or the online Instructions to Authors www.springer.com/00266.

Fibrin Sealants and Quilting Suture for Prevention of Seroma Formation Following Latissimus Dorsi Muscle Harvest: A Systematic Review and Meta-analysis.

PurposeDespite popular use of fibrin sealants and quilting sutures for prevention of seroma formation at the donor site of the latissimus dorsi (LD) muscle flap, there is still no consensus regarding their efficacy. The present review estimates the potential benefits of fibrin and quilting suture for reducing seroma-related morbidity following LD muscle harvest.MethodsUsing Medline, Ovid, and Cochrane databases, two-arm studies evaluating the efficacy of fibrin sealants, quilting suture, or their combination for prevention of seroma formation following LD muscle transfer were searched. The outcome measure was the incidence of seroma, total drainage volume from the back, periods of drainage in situ, volume of seroma, and frequency of aspiration for treatment of seroma. The efficacy on reducing the seroma-related morbidity for each procedure was estimated by meta-analytic methodology.ResultsFourteen studies were analyzed. Fibrin alone failed to reduce seroma-related morbidities compared with no intervention, while fibrin instillation combined with quilting suture halved the risk of seroma formation (relative risk (RR): 0.51, 95xa0% CI 0.12–2.16) and significantly reduced total drainage volume (mean difference (MD); −320.80, 95xa0% CI −389.92 to −251.68) and drain indwelling periods (MD −1.62, 95xa0% CI −2.91 to −0.33) compared with quilting suture alone. Quilting suture had significant protective effects on reducing the risk of seroma formation (RR 0.38, 95xa0% CI 0.19–0.75), total drainage volume (MD −284.10, 95xa0% CI −474.61 to −93.60), and drain indwelling periods (MD −3.65, 95xa0% CI −5.43 to −1.87), and its efficacy was enhanced by combining with fibrin.ConclusionsAccording to this review, both fibrin and quilting sutures contributed in varying degrees to reducing seroma-related morbidity following LD muscle transfer, and their combination can have a synergistic effect. Although large-scaled, randomized studies are needed, the combination of both procedures may be considered an effective option for minimizing the risk of seroma.No Level AssignedThis journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Risk Factors for Complications in Immediate Expander–Implant Breast Reconstruction for Non-obese Patients: Impact of Breast Size on Complications

BackgroundAlthough obesity is a well-known risk factor for complications in immediate expander–implant breast reconstruction, no studies have identified risk factors for non-obese patients. The purpose of this study was to identify risk factors for complications in non-obese patients.MethodsA retrospective analysis of prospectively collected data from 397 consecutive immediate expander–implant breast reconstructions in 367 non-obese patients at a single institution over a 5-year period was conducted. Univariable and multivariable analysis were performed to determine the influence of six patient-related and eight procedure-related characteristics on complications.ResultsMean BMI was 21.7xa0±xa02xa0kg/m2 and median mastectomy weight was 298.0xa0g (range: 40–1164xa0g). Multivariable analysis showed that neither BMI nor the use of acellular dermal matrix was a predictor for complications. Adjuvant radiation (oddsxa0=xa03.12, pxa0<xa00.001) and mastectomy weight (pxa0<xa00.001) were independent risk factors for complications. A 100xa0g increase in the mastectomy weight was significantly associated with a 23xa0% increase in the odds of overall complications (pxa0=xa00.003), major complications (pxa0=xa00.004), and skin flap complications (pxa0=xa00.007), as well as a 28xa0% increase in the odds of seroma (pxa0=xa00.044), but was not associated with reconstruction failure. Adjuvant radiation (pxa0<xa00.001) and hypertension (pxa0<xa00.001) were risk factors for reconstruction failure.ConclusionsBreast size was an independent risk factor for complications in non-obese patients while BMI was not. In the reconstruction of large breasts, greater attention and additional adjunctive procedures would be needed to prevent complications.Level of Evidence IIIThis 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 Contents or the online Instructions to Authors www.springer.com/00266.

Preoperative Magnetic Resonance Imaging-Based Breast Volumetry for Immediate Breast Reconstruction

BackgroundPreoperative breast magnetic resonance imaging (MRI) is a routine test for oncologic evaluation. However, determining breast volume using a preoperative MRI obtained as a part of oncologic evaluation has not yet been attempted for immediate breast reconstruction. The study introduces the benefit of MRI-based volumetry, not only in autologous breast reconstruction but also in implant-based breast reconstruction.MethodsForty patients preparing for autologous breast reconstruction with a deep inferior epigastric artery perforator (DIEP) flap and 30 patients for implant-based breast reconstruction from June 2011 to June 2012 were included in this study. In every DIEP case, we collected data about actual resected breast tissue weight during mastectomy and final flap weight inserted intraoperatively. Computed tomography (CT) was for preoperative CT angiography for microsurgical breast reconstruction, whereas MRI was performed for oncologic evaluation. In every implant-based reconstruction case, MRI-based breast volume was measured in the same way for DIEP patients and resected breast tissue weight was measured intraoperatively. In addition, we also added or subtracted the breast volume by any modification, such as reduction and augmentation on the ipsilateral or contralateral side. To determine the accuracy of MRI-based volumetry, Pearson correlation coefficients were calculated to quantify the correlation between CT and MRI-based volumetry data and intraoperative volume measurements.ResultsFor DIEP patients, the mean resected breast tissue weight during mastectomy was more closely related to the mean estimated breast volume using MRI than to the mean estimated breast volume using CT (Pearson coefficient 0.928 and 0.782; pxa0=xa00.001). MRI gave a closer correlation to final flap weight than CT (Pearson correlation coefficient 0.959 and 0.873; pxa0=xa00.001). For implant-based reconstruction patients, the breast volume measured by MRI correlated closely with the actual mean weight of resected breast specimens (0.937; pxa0=xa00.001). Mean net implanted volume was more closely related to mean estimated breast volume using MRI than to mean resected breast tissue weight during mastectomy (0.893 and 0.880; pxa0=xa00.001).ConclusionsReliable volumetric information can be obtained using MRI for breast implant volume and autologous tissue needed in optimizing symmetry in breast reconstruction.Level of Evidence IVThis 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 Contents or the online Instructions to Authors www.springer.com/00266.

Reconstruction Outcomes of Oncologic Foot Defect Using Well-Contoured Free Perforator Flaps

BackgroundReconstruction of foot defects following oncologic resection is a crucial element in the treatment of soft tissue malignancy of the foot.ObjectiveThe present study aimed to comprehensively evaluate outcomes of oncologic foot reconstruction using free perforator flaps.MethodsOutcomes of patients with soft tissue malignancy of the foot who underwent reconstruction using a free perforator flap following ablative surgery were reviewed, and perioperative and delayed complications (secondary debulking operation and flap instability) were documented. The Foot Function Index (FFI) questionnaire was surveyed to assess functional status.ResultsOverall, 72 patients were analyzed, with a median follow-up period of 28xa0months. Malignant melanoma was a predominant etiology. Three kinds of perforator flaps were used, with the thoracodorsal artery perforator flap being the most common. Flaps with skin dimensions matching the defect size were inset and the thickness of the flaps was controlled with primary defatting. Flap re-exploration was conducted in 11 (15.2%) cases and total flap loss occurred in 3 (4.2%) cases. Delayed complications developed in an additional 12 cases, therefore 23 (31.9%) cases required a return to the operating room. The average FFI score was 8.86 at postoperative month 36, on average (range 11–128xa0months). All respondents reported being independently ambulatory and had minimal difficulty in their daily lives. Reconstruction of defects on weight-bearing regions showed a significantly higher FFI score than that on nonweight-bearing regions (mean 11.96 vs. 4.79, pxa0=xa00.029), although the scores remained very low for both instances.ConclusionsOncologic foot defects can be reliably reconstructed using well-contoured free perforator flaps with minimal functional morbidity.

Minimizing Surgical Skin Incision Scars with a Latex Surgical Glove

BackgroundThe current trend in minimally invasive surgery is to make a small surgical incision. However, the excessive tensile stress applied by the retractors to the skin surrounding the incision often results in a long wound healing time and extensive scarring. To minimize these types of wound problems, the authors evaluated a simple and cost-effective method to minimize surgical incision scars based on the use of a latex surgical glove.MethodsThe tunnel-shaped part of a powder-free latex surgical glove was applied to the incision and the dissection plane. It was fixed to the full layer of the dissection plane with sutures. The glove on the skin surface then was sealed with Ioban (3 M Health Care, St. Paul, MN, USA) to prevent movement. The operation proceeded as usual, with the retractor running through the tunnel of the latex glove.ResultsIt was possible to complete the operation without any disturbance of the visual field by the surgical glove, and the glove was neither torn nor separated by the retractors. The retractors caused traction and friction during the operation, but the extent of damage to the postoperative skin incision margin was remarkably less than when the operation was performed without a glove.ConclusionThis simple and cost-effective method is based on the use of a latex surgical glove to protect the surgical skin incision site and improve the appearance of the postoperative scar.Level of Evidence VThis 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 Contents or the online Instructions to Authors www.springer.com/00266.

Optimal Sequencing of Postmastectomy Radiotherapy and Two Stages of Prosthetic Reconstruction: A Meta-analysis

BackgroundDespite an expanding role of adjuvant radiotherapy and the popularity of two-stage prosthesis-based reconstruction in the treatment of breast cancer, there is no consensus on the proper timing of postmastectomy radiotherapy (PMRT) in relation to the two stages of the reconstruction procedure. The present meta-analysis investigated the optimum timing of PMRT by comparing the outcomes of the following two sequences: radiation on tissue expander followed by the exchange, and radiation on the permanent implant after the exchange.MethodsThe Medline, Ovid, and Google Scholar databases were searched to identify relevant studies presenting complication rates of the two sequencings. The relative risks of the adverse outcomes between the groups were calculated.ResultsA total of eight studies were analyzed, representing 899 cases. There were no prospective randomized controlled trials, and all but one were retrospective cohorts in nature. The risks for reconstruction failure and major complication requiring reoperation tended to be higher in the group with PMRT to tissue expanders compared to that with PMRT to implants; however, the differences were not significant. The group with PMRT to tissue expanders had a significantly lower risk of severe capsular contracture (relative risk, 0.44; Pxa0<xa00.001).ConclusionsDelivering PMRT to tissue expanders can reduce the risk of severe capsular contracture compared to delivering to implants. No significant differences in the risks of other complications, including reconstruction failure between the two sequencings, were detected; however, as a result of low level of evidence and insufficient sample sizes, further studies are needed to support evidence-based decision making.

Postoperative leucocytoclastic vasculitis in free flap mimicking venous insufficiency

A 29-year-old man, who had been diagnosed with myelodysplastic syndrome 1 year before, developed a wound on his thigh and knee due to necrotising fasciitis. Forty h after a free thoracodorsal artery perforator flap transfer, the colour of the flap changed from pink to purple, starting from the peripheral margin and epitheliolysis proceeded. Within a week, the colour returned to normal spontaneously and the flap survived completely. On punch biopsy, the lesion was confirmed as leucocytoclastic vasculitis, necrotising inflammatory disease of the small vessels in the dermis. This case demonstrates that leucocytoclastic vasculitis mimics postoperative venous insufficiency of a free flap; hence, differential diagnosis by careful judgement of vascular status is required. This rare occurrence needs to be considered in free-flap monitoring, especially in immunosuppressed patients.

Method of breast reconstruction and the development of lymphoedema

Several studies have demonstrated an association between immediate autologous or implant‐based breast reconstruction and a reduced incidence of lymphoedema. However, few of these have ocused specifically on whether the reconstruction method affects the development of lymphoedema. The study evaluated the potential impact of breast reconstruction modality on the incidence of lymphoedema.