Jaco H. Festekjian

Immediate Placement of Implants in Breast Reconstruction: Patient Selection and Outcomes

Background: With the advent of skin-sparing mastectomy techniques, it became clear that immediate placement of an implant could be utilized for breast reconstruction in select patients. The authors assessed the safety, patient selection factors, and aesthetic results with this technique. Methods: Thirty-five consecutive patients (eight unilateral and 27 bilateral) who underwent immediate implant-based breast reconstruction were analyzed. Patient data and complication rates were obtained from a retrospective chart review. Postoperative photographs were evaluated by a blinded panel and scored on a four-point scale. Results: With a mean follow-up of 15 months, complications occurred in six patients (17.1 percent). There was one episode (2.9 percent) of skin necrosis resulting in implant loss, two episodes (5.7 percent) of postoperative infection, both of which resulted in implant salvage, and three patients who developed capsular contracture (8.5 percent). A total of 13 patients (37 percent) required additional surgery for revision. Revisions were necessary significantly more commonly in patients with a history of radiotherapy (p = 0.047), D-cup breast size or greater (p = 0.018), and ptosis of grade 2 or more (p = 0.017). The mean overall aesthetic score was 3.19, and upon subgroup analysis, patients with a history of radiation treatment (2.46), D-cup breast size or greater (2.64), and ptosis or grade 2 or more (2.98) had lower mean scores. Exclusion of these subgroups resulted in a mean score 3.39. Conclusions: Immediate implant-based breast reconstruction is a safe and viable option that can provide a very good aesthetic result in appropriately selected candidates. The authors recommend caution and appropriate patient counseling in patients with a history of radiotherapy, larger breasts, and/or ptotic breasts.

Inclusion of mesh in donor-site repair of free TRAM and muscle-sparing free TRAM flaps yields rates of abdominal complications comparable to those of DIEP flap reconstruction.

Background: Pedicled and free transverse rectus abdominis musculocutaneous (TRAM) flaps remain popular for autologous breast reconstruction, but the incidence of abdominal donor-site bulge and hernia is significantly greater when compared with deep inferior epigastric artery perforator (DIEP) flap reconstruction. Mesh repair after muscle harvest, however, may reduce the complication rate to that observed with perforator flaps alone. Methods: A retrospective review of all free flap breast reconstructions at the University of California, Los Angeles Medical Center from 2002 to 2007 was performed. Abdominal bulge and hernia were noted for patients undergoing free TRAM and muscle-sparing free TRAM flap reconstructions and were compared with those observed following DIEP flap reconstructions. Results: A total of 275 free TRAM plus muscle-sparing free TRAM flaps and 200 DIEP flaps were performed. Among patients with free and muscle-sparing free TRAM flaps, 11.3 percent were found to have postoperative abdominal bulge or hernia. Only 3.5 percent of DIEP flap patients had abdominal complications. Incorporating mesh into the rectus fascia repair significantly reduced the abdominal complications reported to 5.1 percent. Of the 86 free and muscle-sparing free TRAM flaps that were bilateral, 12.8 percent had hernias/bulges. Use of mesh with bilateral free and muscle-sparing free TRAM flaps reduced the complication rate to 3.7 percent. Conclusions: Incorporating mesh into rectus fascia repair in free and muscle-sparing free TRAM flap cases significantly reduces the rate of postoperative abdominal complications to levels equivalent to those for DIEP flap reconstructions. The authors advocate deciding intraoperatively between DIEP and muscle-sparing free TRAM flap dissections based on ease of dissection and whichever offers optimal safety and flap perfusion. Routine use of mesh in donor-site repair will decrease postoperative abdominal morbidity in unilateral and bilateral cases.

Immediate Free Flap Reconstruction for Advanced-Stage Breast Cancer: Is It Safe?

Background: Numerous studies have demonstrated that immediate breast reconstruction following mastectomy is associated with improvements in quality of life and body image. However, immediate breast reconstruction for advanced-stage breast cancer remains controversial. This study evaluates its safety in patients with advanced-stage breast cancer. Methods: Over a 10-year period, patients diagnosed with stage IIB or greater breast cancer treated with mastectomy followed by immediate breast reconstruction were identified and analyzed. Complication rates and reconstructive aesthetics were determined. Results: One hundred seventy patients were identified who underwent 157 unilateral and 13 bilateral reconstructions (183 flaps) predominantly by means of free transverse rectus abdominis musculocutaneous flaps (n = 162). The average age was 47 years and the average hospital stay was 5.1 days. There were 15 major complications (8.8 percent), but adjuvant postoperative therapy was delayed in only eight patients (4.7 percent), with the maximum delay lasting 3 weeks in one patient. Although some degree of flap shrinkage was noted in 30 percent of patients treated with postoperative radiotherapy, only 10 percent of patients experienced severe breast distortion. Importantly, the overall cosmetic outcome in patients who underwent postoperative irradiation was comparable to that of those who did not. Conclusions: The authors have shown that immediate breast reconstruction in the setting of advanced-stage breast cancer is safe and well tolerated by patients, and is not associated with significant delays in adjuvant therapy. These findings make a strong argument for immediate reconstruction regardless of cancer stage. The authors found the changes caused by radiation to the reconstructed breast to be less significant than previously reported and readily addressed to complete an ultimate reconstruction that is aesthetically acceptable to both surgeon and patient. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV. Figure. No caption available.

Microvascular lifeboats: a stepwise approach to intraoperative venous congestion in DIEP flap breast reconstruction.

Summary: The deep inferior epigastric perforator (DIEP) flap is becoming a widely practiced method of autologous breast reconstruction. Although it has been shown to be a safe and reliable technique with acceptable morbidity, disadvantages include a comparatively higher incidence of venous congestion and total flap loss compared with autologous reconstruction with a pedicled or free transverse rectus abdominis myocutaneous flap. Venous congestion is reported in up to one-third of cases of breast reconstruction with a DIEP flap. If venous congestion is detected and addressed intraoperatively compared with postoperatively, outcomes are significantly improved. A wide variety of techniques have been introduced to augment venous drainage to treat congestion and prevent flap failure. Here, the authors offer a comprehensive review of techniques available to address intraoperative venous congestion in DIEP flaps for breast reconstruction. From this review, the authors propose a stepwise, algorithmic approach to diagnosing and treating this potentially devastating complication.

Staged wise-pattern skin excision for reconstruction of the large and ptotic breast.

Background: The postmastectomy reconstruction of large and/or ptotic breasts poses a more difficult aesthetic challenge than the reconstruction of small or moderately sized breasts because of an excessively large skin envelope in both horizontal and vertical dimensions. The Wise-pattern skin excision best addresses this excess skin but is associated with a high incidence of tissue necrosis with subsequent wound breakdown, primarily at the T point. To optimize the aesthetic potential and minimize complications in the setting of these large skin envelopes, the authors have deconstructed the single-stage Wise-pattern skin excision into a two-stage procedure, eliminating the need for a primary simultaneous T-point closure. Methods: In the first stage, the mastectomy and reconstruction are performed using a vertical excision, which tightens the breast skin envelope horizontally. In the second stage, the redundant skin at the inframammary fold is excised horizontally, tightening the breast skin envelope vertically. The summation of the two staged excisions recreates the Wise pattern, breaking up the T point into two straightforward primary closures. Results: Twelve patients (21 breasts) underwent successful reconstruction using the staged Wise-pattern skin excision. The breast size, shape, and projection of the patients were greatly improved without any wound complications. Conclusions: The staged Wise-pattern skin excision for breast reconstruction is a simple technique that delivers superior results for the challenging reconstruction of large and/or ptotic breasts. This method offers an aesthetically pleasing breast shape, allows for the correction of ptosis, eliminates wound complications, and results in a standard Wise-pattern scar.

Chest wall reconstruction for sternal dehiscence after open heart surgery.

BackgroundSternal dehiscence is a grave complication after open heart surgery. Sternal debridement and flap coverage are the mainstays of therapy, but no consensus exists regarding the appropriate level of debridement. More recently, the use of vacuum-assisted closure devices has been advocated as a bridge to definitive closure, but indications for use remain incompletely defined. Materials and MethodsA retrospective review of all chest wall reconstructions performed from January 2000 to December 2010 was conducted. The type of operative management was evaluated to assess morbidity, mortality, and length of hospital stay. ResultsFifty-four patients underwent chest wall reconstruction for poststernotomy mediastinitis. Of these patients, 24 underwent conservative sternal debridement with flap closure, 24 underwent radical sternectomy including resection of the costal cartilages followed by flap closure, and 6 underwent radical sternectomy with vacuum-assisted closure therapy followed by flap closure in a delayed fashion. There were 15 patients in the conservative group and 8 patients in the radical sternectomy group who developed postoperative complications (62.5% vs 33.3%, P < 0.05). The conservative sternectomy group had more serious complications requiring reoperation compared to the radical sternectomy group (86.7% vs 25.0%, P < 0.05). The most common complication in the former group was flap dehiscence (8/15, 53.3%), whereas that in the latter group was a superficial wound infection (6/8, 75.0%). There was no significant difference in mortality (25.0% vs 25.0%, P > 0.05%) or length of hospital stay. ConclusionsRadical sternectomy including the costal cartilages is associated with lower rates of surgical morbidity and reoperation, but not mortality.

A rare case of staphylococcal toxic shock syndrome after abdominoplasty.

Toxic shock syndrome (TSS) is a serious, potentially life-threatening condition resulting from an overwhelming immunological response to an exotoxin released by Staphylococcus aureus. TSS has rarely been described as a complication after elective aesthetic plastic surgery. We present here the case of a patient who underwent abdominoplasty after massive weight loss and had a near-fatal case of TSS 6 weeks after surgery. Prolonged use of closed suction drains may have been the ultimate source of virulent bacterial growth leading to systemic toxicity. To our knowledge, TSS has not been reported as a complication after abdominoplasty, nor has a case with such a delayed presentation of the disease been described.

Abstract 27. The Use of Liposomal Bupivacaine in Patients Undergoing Abdominally-Based Autologous and Implant-Based Breast Reconstruction

CONCLUSION: Despite their similarities in clinical and radiographic presentation, pediatric JE phalangeal fractures are a distinct entity from SH2 fractures. Presenting with significantly more radiographic angulation and clinical instability, JE fractures more frequently required operative fixation compared to SH2 fractures. This distinction is important when determining the treatment strategy employed (operative fixation versus nonoperative management) as well as potential length and degree of immobilization/stabilization for nonoperative management to increase the success of treatment.

Impact of Prior Tissue Expander/Implant on Postmastectomy Free Flap Breast Reconstruction.

Background: Implant-based breast reconstructions can result in unsatisfactory results requiring surgical revision or salvage reconstructive surgery with autologous tissue. This study compares the outcomes and complications of salvage (tertiary) flap reconstruction after failed prosthesis placement to those of primary/secondary flap reconstruction. Methods: All patients undergoing free flap breast reconstruction after failed prosthesis between July 1, 2005, and June 30, 2014, were identified. A matched number of patients who underwent a de novo free flap breast reconstruction were selected randomly for review. The indication for prosthesis removal, demographic and operative data, flap type and inset, and complication rates were evaluated. Results: Eighty-nine women with a history of failed implant-based reconstruction required free flap reconstruction for salvage in 121 breasts. Capsular contracture was the most common indication for prosthesis removal (62.0 percent). Recipient vessel scarring was 5.23 times more likely to occur in the prior prosthesis group (p < 0.001). Alternate flap types other than deep inferior epigastric perforator and transverse rectus abdominis myocutaneous flaps were more frequently used in this cohort. Major complications requiring operative management were more common in the experimental group (17.4 percent versus 8.1 percent; p = 0.035). No difference was noted in flap loss rates, operative take back, or operative time. Conclusions: Salvage breast reconstruction with autologous tissue after failed prosthesis can be safely performed, with success rates similar to those of primary free flap breast reconstruction. However, these procedures may have increased complexity because of recipient vessel scarring, higher rates of prior radiation therapy, and major complications, which may warrant appropriate preoperative planning and patient counseling. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Comparison of Immediate Implant-Based Breast Reconstruction with and without Acellular Dermal Matrix in the Setting of Post-Mastectomy Radiation

RESULTS: A total of 67 immediate TE-based breast reconstructions were included [ADM group n=47 (70.1%) nonADM group n=20 (29.9%)]. Patient characteristics including age at time of reconstruction (mean 48 ±11 vs. 47±10 years) and BMI (mean 24.4±5 vs. 22±3 kg/m2) were similar between groups (P>0.05). In univariate analyses, capsular contracture, inframammary fold (IMF) problems, infection, and wound problems were similar between both groups (P>0.05). After adjusting for clinical characteristics and postoperative complications with multivariate logistic regression, these trends remained. ADM use was not associated with less capsular contracture, IMF problems, wound problems, reoperations, or implant failure requiring fl ap salvage in the setting of post mastectomy radiation.