Hani Sbitany

Acellular dermis-assisted prosthetic breast reconstruction versus complete submuscular coverage: a head-to-head comparison of outcomes.

Background: Complete submuscular tissue expander coverage affords the best protection against implant exposure but restricts lower pole expansion. Techniques using acellular dermis as a pectoralis muscle extension can allow for more rapid fill of the expander and better control of the inframammary fold. This study compares both techniques with regard to relevant outcomes. Methods: Results of 100 consecutive breast expander reconstructions performed by two surgeons between 2004 and 2007 were retrospectively reviewed. Patient demographics, expander coverage type, adjuvant treatment, length and characteristics of the expansion, and incidence and types of complications were analyzed. Results: One hundred women underwent breast reconstruction with 172 expanders, in 50 using complete submuscular placement and in 50 using partial subpectoral placement with acellular dermis. The patient groups were similar in terms of demographic data. Mean number of fills to complete reconstruction was 4.31 in the submuscular group and 1.72 in the acellular dermis group (p = 0.0001). Mean intraoperative fill volume was 130 cc in the submuscular group, compared with 412 cc per expander in the acellular dermis group (p = 0.0001). Fishers exact test demonstrated no significant difference in total complication rate between the two groups (14 percent versus 18 percent; p = 0.79). Conclusions: Acellular dermis allowed for a greater initial fill of saline. This potentially improves cosmetic outcome, as it better capitalizes on preserved mastectomy skin for reconstruction. The authors conclude that acellular dermis–assisted implant breast reconstruction has a safety profile no worse than that of complete submuscular coverage but offers the benefit of fewer expansions and the potential for more predictable secondary revisions.

Acellular dermis-assisted prosthetic breast reconstruction: a systematic and critical review of efficacy and associated morbidity.

Background: The use of acellular dermal matrix to assist in two-stage expander/implant breast reconstruction has increased over recent years. However, there are questions regarding the potential for increased morbidity when using these techniques relative to standard submuscular coverage techniques. This systematic review combines published data comparing the techniques, to compare morbidity and advantages of acellular dermal matrix relative to standard submuscular coverage techniques. Methods: An English language literature search was performed to find articles reporting outcomes of two-stage expander/implant reconstruction using acellular dermal matrix. The outcome categories analyzed were patient/treatment demographics, tissue expander characteristics, and complications. Results: Nine articles met inclusion criteria for this analysis. Six of these were matched cohort studies comparing outcomes of acellular dermal matrix techniques to standard submuscular techniques. The remaining three were case series of acellular dermal matrix techniques. The only difference found in complications was a higher rate of seroma for the acellular dermal matrix group (4.3 percent versus 8.4 percent, p = 0.03). Despite this, both groups illustrated similar rates of infection leading to explantation (3.2 percent for submuscular and 3.4 percent for acellular dermal matrix, p = 0.18). In addition, acellular dermal matrix techniques illustrated greater intraoperative fill volumes and consistently fewer fills required to reach expander capacity. Conclusions: The use of acellular dermal matrix in two-stage expander/implant reconstruction offers a safety profile similar to that of standard submuscular techniques. Both techniques have shown similar rates of infection ultimately requiring explantation. In addition, acellular dermal matrix offers the advantage of a more rapid reconstruction with less need for manipulation of the prosthetic through filling. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Human Satellite Cell Transplantation and Regeneration from Diverse Skeletal Muscles

Summary Identification of human satellite cells that fulfill muscle stem cell criteria is an unmet need in regenerative medicine. This hurdle limits understanding how closely muscle stem cell properties are conserved among mice and humans and hampers translational efforts in muscle regeneration. Here, we report that PAX7 satellite cells exist at a consistent frequency of 2–4 cells/mm of fiber in muscles of the human trunk, limbs, and head. Xenotransplantation into mice of 50–70 fiber-associated, or 1,000–5,000 FACS-enriched CD56+/CD29+ human satellite cells led to stable engraftment and formation of human-derived myofibers. Human cells with characteristic PAX7, CD56, and CD29 expression patterns populated the satellite cell niche beneath the basal lamina on the periphery of regenerated fibers. After additional injury, transplanted satellite cells robustly regenerated to form hundreds of human-derived fibers. Together, these findings conclusively delineate a source of bona-fide endogenous human muscle stem cells that will aid development of clinical applications.

Strategies for Recognizing and Managing Intraoperative Venous Congestion in Abdominally Based Autologous Breast Reconstruction

Background: Despite common superficial venous system dominance of the abdominal wall, the majority of transverse rectus abdominis musculocutaneous (TRAM)/deep inferior epigastric perforator (DIEP) flaps drain adequately, due to communicating veins with the deep system. In cases where such connections are inadequate, it is necessary for the surgeon to correctly recognize resultant congestion as an intrinsic flap issue, and treat it intraoperatively. Methods: A retrospective analysis of 1201 consecutive TRAM/DIEP free flaps over a 5-year period was performed. All cases of inadequate venous outflow not due to technical anastomotic problems or venous thrombosis were identified and analyzed. Results: From a cohort of 1201 patients undergoing free TRAM and DIEP flap breast reconstruction, 11 (0.9 percent) exhibited intraoperative congestion due to persistent superficial venous system dominance, despite patent deep vein anastomosis. Most commonly (five flaps), anastomosis of the superficial inferior epigastric vein (SIEV) to a proximally dissected vena comitans of the flap deep inferior epigastric vein system (DIEV) was performed; thus, a superficial to deep venous loop was created within the flap. Intraoperative salvage rate was 100 percent. Conclusions: In this series, intraoperative congestion is most commonly due to a superficially dominant flap. In such flaps, the deep venous anastomosis is patent, and yet adequate venous drainage cannot be achieved due to the lack of communicating vessels between the two systems, or due to inadequate perforator selection. Anastomosis of the SIEV to a proximally dissected vena comitans of the DIEV on the flap was performed most commonly in our series. This allows anastomosis of two veins in close proximity, and avoidance of using a second recipient vein. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

CT contrast extravasation in the upper extremity: Strategies for management

INTRODUCTION Extravasation of CT scan contrast media into upper extremity subcutaneous tissue is a relatively frequent complication of injection. Potential sequelae of extravasation include compartment syndrome, skin sloughing, and necrosis. Many institutions institute protocols requiring inpatient plastic surgery consultations immediately following extravasation injury to the upper extremity. We hypothesize that conversion to non-ionic contrast media for contrast CT studies has greatly reduced the incidence of severe extravasation injuries, and may alleviate the need for routine hand surgery consultations. METHODS Records from 102 consecutive CT contrast media extravasation injuries were identified. Data acquired from a single institution included type and amount of contrast extravasated, anatomic location, post-procedural clinical symptoms, whether consult was obtained, and final recommendations and outcome. RESULTS In 102 consecutive cases, immediate surgical therapy was necessary in 0. Non-ionic medium was used in 94% of these cases, and ionic dye was used in 6%. Extravasation of less than 100 cc occurred in 90%, and only 10% were greater. Plastic surgery consultation was immediately obtained in 42% of cases. Factors prompting consultation included extravasation >30 cc, and the presence of erythema or induration. Trends for consultation remained without discernable pattern when patients were stratified by age, amount of extravasate, or anatomic location. Conservative management was recommended in all cases. This included elevation of the extremity, frequent pulse and sensation exams, local message, and temporary splinting. There were no secondary complications requiring surgical intervention. CONCLUSIONS Extravasation of non-ionic CT contrast media appears to be innocuous and can be treated with conservative therapy. Plastic surgery consultation should be obtained when there are obvious signs of skin and soft tissue compromise or symptoms of compartment syndrome.

Patient-reported outcomes and satisfaction after total skin-sparing mastectomy and immediate expander-implant reconstruction.

BackgroundTotal skin-sparing mastectomy (TSSM) with preservation of the nipple-areolar complex skin has become more widely accepted. Few studies looking at outcomes after TSSM and immediate reconstruction have focused on patient-reported outcomes and trends in satisfaction over time. MethodsProspective evaluation of patients undergoing TSSM and immediate expander-implant reconstruction was performed. Patients completed the BREAST-Q questionnaire preoperatively and again at 1 month, 6 months, and 1 year postoperatively. Mean scores in each BREAST-Q domain were assessed at each time point. Domains were scored on a 0- to 100-point scale. ResultsSurvey completion rate was 55%; BREAST-Q scores were calculated from responses from 28 patients. Mean overall satisfaction with breasts declined at 1 month (69.8 to 46.1, P < 0.001), but then returned to baseline by 1 year. Mean scores also declined at 1 month in the psychosocial (75.7–67.4, P = 0.2) and sexual (58.3–46.7, P = 0.06) domains, but returned to baseline by 1 year. Mean nipple satisfaction score was 76.4 at 1 year, with 89% of patients reporting satisfaction with nipple appearance. Satisfaction with nipple position and sensation was lower, with only 56% of patients reporting satisfaction with nipple position and 40% with nipple sensation. ConclusionsAfter TSSM and immediate reconstruction, patient satisfaction with their breasts, as well as psychosocial and sexual well-being, returns to baseline by 1 year. Although overall nipple satisfaction is high, patients often report dissatisfaction with nipple position and sensation; appropriate preoperative counseling is important to set realistic expectations.

Rates of Reconstruction Failure in Patients Undergoing Immediate Reconstruction With Tissue Expanders and/or Implants and Postmastectomy Radiation Therapy

OBJECTIVES Mastectomy rates for breast cancer have increased, with a parallel increase in immediate reconstruction. For some women, tissue expander and implant (TE/I) reconstruction is the preferred or sole option. This retrospective study examined the rate of TE/I reconstruction failure (ie, removal of the TE or I with the inability to replace it resulting in no final reconstruction or autologous tissue reconstruction) in patients receiving postmastectomy radiation therapy (PMRT). METHODS AND MATERIALS Between 2004 and 2012, 99 women had skin-sparing mastectomies (SSM) or total nipple/areolar skin-sparing mastectomies (TSSM) with immediate TE/I reconstruction and PMRT for pathologic stage II to III breast cancer. Ninety-seven percent had chemotherapy (doxorubicin and taxane-based), 22% underwent targeted therapies, and 78% had endocrine therapy. Radiation consisted of 5000 cGy given in 180 to 200 cGy to the reconstructed breast with or without treatment to the supraclavicular nodes. Median follow-up was 3.8 years. RESULTS Total TE/I failure was 18% (12% without final reconstruction, 6% converted to autologous reconstruction). In univariate analysis, the strongest predictor of reconstruction failure (RF) was absence of total TE/I coverage (acellular dermal matrix and/or serratus muscle) at the time of radiation. RF occurred in 32.5% of patients without total coverage compared to 9% with coverage (P=.0069). For women with total coverage, the location of the mastectomy scar in the inframammary fold region was associated with higher RF (19% vs 0%, P=.0189). In multivariate analysis, weight was a significant factor for RF, with lower weight associated with a higher RF. Weight appeared to be a surrogate for the interaction of total coverage, thin skin flaps, interval to exchange, and location of the mastectomy scar. CONCLUSIONS RFs in patients receiving PMRT were lowered with total TE/I coverage at the time of radiation by avoiding inframammary fold incisions and with a preferred interval of 6 months to exchange.

Acellular Dermal Matrix in Primary Breast Reconstruction

The use of acellular dermal matrix (ADM) in many plastic surgery procedures, including breast reconstruction, has increased dramatically in recent years. While expander/implant reconstruction can be performed successfully with standard techniques, the introduction of ADM has added a new tool with which to achieve lasting, predictable results. This article is a summary of existing literature on ADM for primary implant reconstruction, to provide a more thorough understanding of the benefits of ADM in single- and to two-stage breast reconstruction and to identify the areas where further investigation is needed.

Preferences in choosing between breast reconstruction options: a survey of female plastic surgeons.

Background: Female plastic surgeons are well suited to make a personal choice regarding breast reconstruction options, based on their knowledge of the actual procedures and first-hand experience with results. The authors surveyed this group to elicit their personal views on various modalities of breast reconstruction and to ascertain which types of reconstruction they would choose if faced with such a decision. Methods: All board-certified female plastic surgeons in the United States and Canada were surveyed by means of e-mail. This survey included questions regarding basic demographic and practice data. Respondents were requested to rank desired methods of reconstruction for themselves and to cite reasons for these choices. Results: A total of 435 surveys were sent: 350 were delivered (85 had invalid e-mail addresses), and 143 were returned (response rate, 41 percent). Overall, 66 percent of respondents chose implant-based reconstruction, 25 percent chose autologous reconstruction, and 9 percent chose no reconstruction. Respondents selecting autologous reconstruction cited cosmetic outcome as the most important factor considered in 47 percent of cases, compared with 14 percent of those choosing implant-based breast reconstruction (p = 0.0001). Invasiveness of the procedure/recovery time was cited as the most important factor by 83 percent of those surgeons opting for no breast reconstruction and by 51 percent of those choosing implant-based breast reconstruction (p = 0.0175). Conclusions: Board-certified female plastic surgeons exhibit a strong desire to pursue implant-based breast reconstruction over autologous reconstruction. When it was chosen, autologous reconstruction was felt to offer improved aesthetic outcomes. When making such a decision, patients can use female plastic surgeons as a resource for information, thus helping them to make an informed decision.

Free Tissue Transfer: Comparison of Outcomes between University Hospitals and Community Hospitals

Background: In university hospitals, free tissue transfer has become a standard method of reconstruction for a broad spectrum of defects. Because of its complexity, free tissue transfer has not been routinely performed in a community hospital setting. This study reports the outcomes of two equal groups of free tissue transfer performed by the same surgeons, comparing the university versus the community hospital setting. Methods: A total of 735 free tissue transfers were performed at one university hospital and six community hospitals in our region over a 10-year study period. Outcome parameters used in this study included wound complications such as infection, dehiscence, delayed healing, hematoma, and fat necrosis. Results: A total of 674 operations were performed using 735 free tissue transfers: 386 free tissue transfers were performed at the university hospital (53 percent) and 349 (47 percent) were performed at the community hospital. Categories of free tissue transfer reconstruction included breast, lower extremity, head and neck, and upper extremity reconstructions. Most of the breast reconstructions were performed in the community hospital, whereas most of the lower extremity and head and neck reconstructions were performed at the university hospital. Fifty-one major postoperative complications occurred in the university hospital (14 percent), while 31 (10 percent) occurred in the community hospital. Complication rates did not differ significantly between settings; however, there was a trend toward more wound infections in the university hospital and more cases of fat necrosis in the community hospital, most likely reflected in the differing case mix between hospital settings. Conclusion: Free tissue transfer is an effective and practical method of reconstruction that has been safely performed in both university and community hospital settings.