John Shuck

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.

Autologous fat grafting and injectable dermal fillers for human immunodeficiency virus-associated facial lipodystrophy: a comparison of safety, efficacy, and long-term treatment outcomes.

Background: Facial lipoatrophy is a common side effect of human immunodeficiency virus treatment with highly active antiretroviral therapy. To identify the most clinically durable and efficient way of addressing facial lipoatrophy, the authors reviewed all available evidence for the use of injectable dermal fillers and autologous fat transfers as treatment modalities, focusing on safety, outcomes, and long-term durability. Methods: A systematic review of the Cochrane and MEDLINE databases for autologous fat transfer and injectable dermal fillers for the treatment of human immunodeficiency virus–associated lipodystrophy was performed. Based on U.S. Food and Drug Administration approval in human immunodeficiency virus lipoatrophy, studies were limited to the use of hyaluronic acid and/or poly-L-lactic acid. Facial volume, subjective patient satisfaction, standardized outcome scales, reinjection rates, and complications were recorded. Results: Nineteen studies were included representing 724 patients, with 549 patients in the hyaluronic acid/poly-L-lactic acid cohort and 175 in the autologous fat transfer cohort. Improvements in facial volume and durability of treatment were similar between dermal fillers and fat transfer, as measured by both objective means and subjective patient outcomes. However, poly-L-lactic acid was reinjected at a rate three times that of autologous fat, and was associated with a relatively high rate of subcutaneous papule formation at 22 percent (range, 3 to 44 percent). Conclusions: Dermal fillers and autologous fat transfer are effective treatment modalities for human immunodeficiency virus–associated facial lipoatrophy, with high rates of facial volume restoration and patient satisfaction. Autologous fat transfer may offer similar to superior long-term durability but with less of a financial burden compared with injectable fillers.

Analyzing implant movement with tabbed and nontabbed expanders through the process of two-stage breast reconstruction.

Background: Tabbed tissue expanders have the potential benefit of less migration during the expansion process, which may allow for more predictable outcomes. Despite this theoretical benefit, no study has critically evaluated the proposed advantage as compared with traditional nontabbed expanders. Therefore, the authors photographically analyzed the migration and movement of tabbed and nontabbed expanders throughout the reconstructive process. Methods: The authors performed a retrospective review of patients who underwent two-stage expander-to-implant reconstruction from 2010 to 2012. Standardized frontal photographs were used for analysis. Adobe Photoshop was used to measure the relative movement of each patient’s expander from insertion until immediately before implant exchange and after implant exchange. Results: Forty-four breasts were analyzed. Migration was reduced significantly in all four directions for both the tissue expander and permanent implant stages of reconstruction. Medial, lateral, superior, and inferior migration of the tissue expander in the tabbed cohort was reduced by 59.5 percent (p = 0.001), 48.3 percent (p = 0.004), 53.4 percent (p = 0.0005), and 73.4 percent (p < 0.0001), respectively, compared with the nontabbed cohort. Likewise, medial, lateral, superior, and inferior migration of the permanent implant in the tabbed cohort was reduced by 44.3 percent (p = 0.049), 73.7 percent (p < 0.0001), 67.7 percent (p = 0.0008), and 61.0 percent (p = 0.003), respectively. Conclusions: Two-stage implant reconstruction allows for precision in implant placement after an appropriately placed expander. Tabbed expanders appear to maintain better positioning on the chest wall compared with nontabbed expanders during the expansion process, and may allow for more precise mound creation with the permanent implant. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Reinforcement of the abdominal wall following breast reconstruction with abdominal flaps: a comparison of synthetic and biological mesh.

Background: Breast reconstruction using muscle-preserving abdominal flaps occasionally results in an abdominal bulge or hernia. The authors analyzed outcomes and complications following use of a synthetic or biological mesh for abdominal reinforcement following initial harvest or secondary repair of a bulge or hernia. Methods: A retrospective review was conducted of all patients (n = 818) who had abdominal flap–based breast reconstruction between 1995 and 2011. Ninety-seven patients met inclusion criteria; 61 had synthetic mesh and 36 had biological mesh (porcine acellular dermal matrix). Complications and outcomes were reviewed. Statistical analysis was performed to determine contributing factors and differences between cohorts. Results: Overall complication rates for the synthetic and biological cohorts were 6.5 and 5.5 percent (p = 0.61), respectively, with slightly higher bulge rates in patients with synthetic compared with biological mesh (18 percent versus 8.3 percent; p = 0.25). Complication rates in primary and secondary placement of synthetic mesh were 5 and 7.3 percent, respectively; bulge rates were 15 and 19.5 percent, respectively. Complication rates in primary and secondary placement of biological mesh were 6.3 and 0 percent, respectively; bulge rates were 9.4 and 0 percent, respectively. Conclusions: Synthetic and biological mesh reconstruction for primary abdominal repair and secondary contouring have similar, low complication rates. Postoperative abdominal wall laxity and bulge occurred in an equal distribution following unilateral or bilateral flap reconstruction. Early investigation demonstrates that porcine acellular dermal matrix is as effective as synthetic mesh for abdominal wall reinforcement and repair, with limited morbidity associated with each. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

The Effect of Positive Post-Debridement Cultures on Local Muscle Flap Reconstruction of the Lower Extremity.

Background Local muscle flaps are a reconstructive option for wound coverage in the distal lower extremity, particularly in high-risk patients who are poor candidates for free tissue transfer. At our institution, chronic and infected wounds are managed with serial debridement before definitive reconstruction. There is a paucity of data on optimal timing for reconstruction in this patient population. This study investigates the relationship of positive postdebridement cultures (PDC) and wound closure rates at 90 days. Methods A retrospective review of patients undergoing local muscle flap coverage of chronic distal lower extremity wounds between 2006 and 2012 was performed. All patients were managed with serial debridement until negative PDC were obtained. In some cases, PDC remained positive or exhibit delayed culture growth in the day(s) following closure. Data recorded include demographics, flap type/location, culture data, and wound closure at 90-day follow-up. Results Of 76 patients, 60 met inclusion criteria with minimum 90-day follow-up. Despite 100% flap survival, 17 patients (28.3%) had failure of wound closure at 90 days and 22 patients (36%) had positive PDC. Multivariate analysis identified positive PDC (odds ratio, 29.6; 95% CI, 3.6-246.4; P = 0.002) and smoking (odds ratio, 8.9; 95% CI, 1.4-57.6; P = 0.02) as independent predictors of nonclosure at 90 days. Conclusions In this series of local muscle flap coverage of distal lower extremity wounds, positive PDC were a strong independent predictor of failure of wound closure at 90 days. This study demonstrates the importance of serial debridement to negative cultures before definitive coverage in this patient population.

Options for Revascularization: Artery Versus Vein : Technical Considerations

Vascular grafts, as either interpositional conduits or bypass grafts, can be used for revascularization procedures in the upper extremity. Vein grafts are more readily available and can be easier to harvest. Arterial grafts may provide superior patency rates compared with vein grafts. Arterial grafts can be located and harvested with consistent and reliable anatomy throughout the body.

Abstract QS26: A Prospective Pilot Study of Robotic-Assisted Harvest of the Latissmus Dorsi Muscle for FDA 510(K) Approval

BACKGROUND: Delayed immediate autologous breast reconstruction consists of immediate post mastectomy tissue expander placement, followed by radiation therapy and subsequent autologous reconstruction. The decision between delayed versus delayed immediate autologous breast reconstruction in patients anticipating post mastectomy radiotherapy is challenging and remains to be elucidated. The purpose of this investigation was to evaluate the effects of delayed versus delayed immediate autologous breast reconstruction in patients undergoing post mastectomy radiotherapy on patient reported outcomes and quality of life in predominantly minority patients.

A critical look at the effect of hyperbaric oxygen on the ischemic nipple following nipple sparing mastectomy and implant based reconstruction: a case series

Background Nipple preservation provides superior aesthetic results as well as patient satisfaction in patients treated with both therapeutic and prophylactic mastectomy. Post-operative nipple ischemia and necrosis presents a unique clinical challenge that may be treated with hyperbaric oxygen therapy or conservative measures alone. To date, the efficacy of hyperbaric oxygen on post-operative nipple ischemia has yet to be evaluated. Methods A retrospective review of patients treated with either hyperbaric oxygen or conservative management was performed. Post-operative photographs were evaluated using a novel imaging data pathway to in both groups to determine rates of healing. Results Although patients treated with hyperbaric oxygen experienced rates of healing nearly twice those of patients treated with conservative measures alone, no statistical significance was found between groups in this series. Conclusions No significance difference was found between groups treated with hyperbaric oxygen or conservative management in this series. Further large scale, multi-center studies are warranted to further determine clinical utility and cost-effectiveness of hyperbaric oxygen for nipple ischemia following nipple sparing mastectomy (NSM) and implant based reconstruction.

Near-complete Humerus Reconstruction in the Pediatric Patient with Vascularized Free Fibula Transfer.

Summary: Vascularized free fibula transfer remains the gold standard for reconstruction of large segmental diaphyseal defects of the upper extremity. In the pediatric patient, before skeletal maturity, free fibula transfer with the fibular head provides an active physis for growth and an articular interface for glenohumeral joint reconstruction. Clinical and cadaveric studies have demonstrated that the vascular supply to the fibular head originates, in most cases, from the anterior tibial system. However, anatomical variation exists, and we report a case in which a vascularized fibula autograft including the physis was transferred on the peroneal artery in a 5-year-old patient with Ewing’s sarcoma. At 15-month follow-up, the patient has functional range of motion of the shoulder.

Impact of Connective Tissue Disease on Oncologic Breast Surgery and Reconstruction.

BackgroundThe impact of connective tissue disease (CTD) on outcomes following breast surgery and reconstruction is unknown. The purpose of this study was to evaluate the effect of both CTDs and systemic immunomodulatory therapy on outcomes following breast surgery and reconstruction. MethodsA retrospective review was performed of all patients from 2005 to 2010 with an active CTD who underwent breast surgery with or without reconstruction. Surgical events were assigned to 1 of 4 groups: ablative surgery alone, autologous reconstruction, implant reconstruction, and revision surgery. Logistic regression was utilized to examine the relationship between complications and type of surgery, CTD diagnosis, and immunomodulatory therapy. Four non-CTD control groups were then compiled for outcome comparison. The a priori P-value was set at P < 0.05, and all tests were 2 sided. ResultsThirty-three patients with CTD underwent112 procedures. Diagnoses included psoriasis/psoriatic arthritis (n = 12), rheumatoid arthritis (n = 10), lupus (n = 4), scleroderma (n = 3), Sjogren syndrome (n = 2), mixed CTD (n = 1), and seronegative polyarthritis (n = 1). Nineteen of 33 (58%) patients who received systemic treatment for CTD in the perioperative period were less likely to experience a minor complication compared with those without treatment (odds ratio= 0.69; P = 0.019). There were no differences in postoperative complications in patients with CTD compared with control groups. ConclusionsAblative breast surgery and reconstruction among patients with CTDs can be performed safely with low perioperative complication rates. Patients receiving systemic therapy, and continuing their regimens perioperatively, experience complication rates similar to those not requiring therapy.