Mark T. Villa

Barbed sutures: A review of the literature

Background: Despite substantial mention in the popular press, there is little in the plastic surgery or dermatology literature regarding the safety, efficacy, longevity, or complications of barbed suture suspension procedures. The authors review the literature to estimate several clinical parameters pertaining to barbed thread suspensions. Methods: The authors performed a MEDLINE search using the keywords “barbed and suture,” “thread and suspension,” “Aptos,” “Featherlift,” and “Contour Thread.” Results: The authors identified six studies that met their criteria of addressing midface elevation with barbed thread suspension. These detected some adverse events, but most of these were minor, self-limited, and of short duration. Less clear are the data on the extent of the peak correction and the longevity of effect. Objective outcome measures and long-term follow-up data were not provided in a systematic manner in the few available studies. Conclusions: Suspension of the aging face with barbed sutures offers the promise of a minimally invasive technique with diminished adverse events. The technique is in its infancy, but it has potential to be a useful and effective clinical tool as further innovations are made in the clinic and laboratory.

Optimal timing of delayed free lower abdominal flap breast reconstruction after postmastectomy radiation therapy

Background: The purpose of this study was to determine the optimal timing of delayed abdominal free flap breast reconstruction following postmastectomy radiation therapy. The authors evaluated the association between timing of delayed abdominal free flap breast reconstruction following postmastectomy radiation therapy and postoperative complications. Methods: The authors reviewed a prospectively maintained database of delayed abdominal free flap breast reconstruction performed between July of 2005 and December of 2009. Data regarding demographics, operative variables, and clinical outcomes were collected. Patients were classified as having undergone reconstruction less than 12 months after postmastectomy radiation therapy (group I) or 12 months or more after postmastectomy radiation therapy (group II). Complications were compared between groups, including microvascular thrombosis, flap loss, reoperation, wound dehiscence, and fat necrosis. Results: One hundred eighty-nine patients were identified, 82 (43.4 percent) in group I and 107 (56.6 percent) in group II. The total flap loss rate was 2.6 percent, with all flap losses occurring in group I (p = 0.014). The reoperation rate was higher in group I (14.6 percent versus 4.7 percent; p = 0.022). In addition, group I patients trended toward a higher incidence of microvascular thrombosis, infection, and wound dehiscence. Conclusions: Patients who underwent delayed abdominal free flap breast reconstruction after 12 months from the completion of postmastectomy radiation therapy developed fewer complications, including microvascular thrombosis and total flap loss, than those who underwent delayed abdominal free flap breast reconstruction within 12 months of completing postmastectomy radiation therapy. Allowing an interval of 12 months between the completion of postmastectomy radiation therapy and delayed abdominal free flap breast reconstruction will likely minimize complications and optimize outcomes in free flap breast reconstruction in patients receiving postmastectomy radiation.

The advantages of free abdominal-based flaps over implants for breast reconstruction in obese patients

Background: The authors hypothesized that, for obese patients, delayed abdominal-based free flap (rather than implant-based and immediate) breast reconstruction would result in fewer overall complications and reconstruction losses. Methods: The authors retrospectively analyzed consecutive implant- and abdominal-based free flap breast reconstructions performed in obese patients between 2005 and 2010 by utilizing the World Health Organization obesity classifications: class I, 30.0 to 34.9 kg/m2; class II, 35.0 to 39.9 kg/m2; and class III, ≥40 kg/m2. Primary outcome measures included flap failures and overall complications. Logistic regression analysis identified associations among patient, defect, and reconstructive characteristics and surgical outcomes. Results: The analysis included 990 breast reconstructions (548 flaps versus 442 implants) in 700 patients. Mean follow-up was 17 months. Age, smoking, medical illness, and body mass index greater than 37 predicted overall complications on regression analysis. Implants demonstrated a higher failure rate (15.8 percent) than flaps (1.5 percent). Although failure rates were similar for immediate and delayed flap reconstructions overall (1.3 versus 1.9 percent) and among obesity classifications, there was a trend toward more implant failures in immediate rather than delayed reconstructions (16.8 versus 5.3 percent). Differences between immediate implant versus flap reconstruction failure rates were highest among more obese patients [class II (24.7 versus 1.3 percent) and class III (25.4 versus 0 percent) compared with class I (11.7 versus 1.4 percent)]. Conclusions: Obese patients (particularly class II and III) experience higher failure rates with implant-based breast reconstruction, particularly immediate reconstruction. Free flap techniques or delayed implant reconstruction may be warranted in this population. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Reconstructive outcomes in patients undergoing contralateral prophylactic mastectomy

Background: As the rate of contralateral prophylactic mastectomy in breast cancer patients increases, more women are seeking immediate bilateral breast reconstruction. The authors evaluated complication rates in the index and prophylactic breasts in patients undergoing bilateral immediate reconstruction. Methods: The authors retrospectively reviewed the outcomes of all consecutive patients undergoing immediate postmastectomy bilateral reconstruction for an index breast cancer combined with a contralateral prophylactic mastectomy between 2005 and 2010. Patient, tumor, reconstruction, and outcome characteristics were compared between the index and prophylactic breasts in the same patient. Patients were classified by reconstruction method: implant, abdominal flap, or latissimus dorsi flap/implant. Regression models evaluated patient and reconstruction characteristics for potential predictive or protective associations with postoperative complications. Results: Of 497 patients included, 334 (67.2 percent) underwent implant reconstruction, 142 (28.6 percent) had abdominal flap reconstruction, and 21 (4.2 percent) had latissimus dorsi flap/implant reconstruction. Index reconstructions had a complication rate (22.5 percent) equivalent to that of contralateral prophylactic mastectomy reconstructions (19.1 percent; p = 0.090). Overall, 101 patients (20.3 percent) developed a complication in one reconstructed breast, and 53 (10.7 percent) developed complications in both breasts. Of the 154 patients who developed complications, 42 (27.3 percent) developed a complication in the prophylactic breast. Conclusions: Immediate index and contralateral prophylactic breast reconstructions appear to have equivalent outcomes, both overall and across reconstruction classifications. Together, patients, reconstructive surgeons, and extirpative surgeons should carefully consider the oncologic benefits of a contralateral prophylactic mastectomy in light of the risk of increased surgical morbidity of this type of mastectomy and reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Muscle and Omental Flaps for Chest Wall Reconstruction

Reconstruction of the chest wall represents an important part of a patients treatment following resection of various thoracic tumors. Many different types of flaps, including both pedicled and free flaps, have been described for use in chest wall reconstruction. These reconstructions are most effectively managed with a multidisciplinary approach involving plastic and cardiothoracic surgery. The pectoralis major, latissimus dorsi, rectus abdominis, trapezius, and external oblique muscles and the omentum are all local options that can play an important role in the reconstruction of the chest wall.

Obese Women Experience Fewer Complications after Oncoplastic Breast Repair following Partial Mastectomy Than after Immediate Total Breast Reconstruction

Background: The authors hypothesized that obese patients would experience fewer complications after oncoplastic breast reconstruction following partial mastectomy than after immediate breast reconstruction following total mastectomy. Methods: Complication rates were compared for oncoplastic breast reconstruction versus immediate breast reconstruction (with either implants or autologous tissue) in consecutive obese patients (body mass index ≥30 kg/m2) treated at a single center between January of 2005 and April of 2013. Logistic regression was used to analyze the associations between patient and surgical characteristics and postoperative outcomes. Results: The study included 408 patients: 131 oncoplastic breast reconstruction and 277 immediate breast reconstruction patients. Presenting breast cancer stage was similar between the two groups. Oncoplastic breast reconstruction patients were older (55 years versus 53 years; p = 0.029), more obese (average body mass index, 37 kg/m2 versus 35 kg/m2; p < 0.001), and had more comorbidities. Nevertheless, the oncoplastic breast reconstruction group experienced fewer major complications requiring operative management (3.8 percent versus 28.5 percent; p < 0.001), fewer complications delaying adjuvant therapy (0.8 percent versus 14.4 percent; p < 0.001), and fewer incidences of hematoma/seroma formation (3.1 percent versus 11.6 percent; p < 0.004) than the immediate total breast reconstruction group. Univariate analysis found oncoplastic breast reconstruction to be an independent protector against major complications (OR, 0.1; p < 0.001) and complications that delayed adjuvant therapy (OR, 0.05; p = 0.002). Conclusion: Oncoplastic breast reconstruction likely represents a safer option than immediate total breast reconstruction following mastectomy for obese patients, particularly for patients who are superobese or present with preexisting medical comorbidities. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Reconstructive outcomes in patients with sarcoma of the breast

Background: Primary soft-tissue sarcomas account for less than 1 percent of all breast malignancies. Many of these are associated with prior radiation therapy. Few studies have evaluated this patient population. The purpose of this study was to examine reconstruction techniques and outcomes in a cohort of patients with breast sarcoma to elucidate the optimal type and timing of reconstruction. Methods: The authors conducted a retrospective review of all patients diagnosed and treated for soft-tissue breast sarcomas between July 1, 1988, and December 9, 2009, at a tertiary cancer center. Data collected included demographics, histology, oncologic and reconstructive treatment, and clinical outcomes. Results: Twenty-three breast sarcoma patients underwent 24 reconstructions. The mean age at diagnosis was 42 years (range, 17 to 78 years). The most common histologic finding was angiosarcoma; six of the 11 angiosarcomas developed following irradiation for either breast carcinoma or lymphoma. The median follow-up was 44 months. Twenty patients were alive through the follow-up period. Reconstruction was immediate in 20 cases and delayed in four. The reconstruction used autologous tissue in 16 cases, implants in five, and both in three. All patients who underwent irradiation during treatment underwent autologous tissue reconstruction. Surgical complications included implant displacement, tissue expander displacement, total flap loss, seroma, implant exposure, and partial skin graft loss. Conclusions: Soft-tissue breast sarcomas are uncommon and demand aggressive, multimodal treatment and well-planned reconstruction. Most sarcoma patients receive radiotherapy; to minimize complications, we recommend delayed autologous reconstruction after completion of radiotherapy.

Extended vertical rectus abdominis myocutaneous flap for pelvic reconstruction: Three-dimensional and four-dimensional computed tomography angiographic perfusion study and clinical outcome analysis

Background: The extended vertical rectus abdominis myocutaneous (eVRAM) flap includes skin and subcutaneous fat extending from the costal margin to the anterior axillary line. The reliability and vascularity of this distal extension have been questioned. The authors hypothesized that the eVRAM flap would have adequate perfusion throughout the extended portion and be reliable for pelvic reconstruction. To evaluate this, the authors conducted a perfusion study on eVRAM flaps from cadavers and a retrospective clinical study of outcomes in patients. Methods: In the perfusion study, seven eVRAM flaps were harvested from fresh cadavers. Iodinated contrast material was injected into the deep inferior epigastric artery of each flap, and three- and four-dimensional computed tomography (three-dimensional and four-dimensional computed tomography) angiography was performed. In the clinical study, the surgical outcomes of all patients who underwent repair of pelvic defects with a pedicled eVRAM flap between 2004 and 2008 were retrospectively evaluated. Results: Three-dimensional and four-dimensional computed tomography demonstrated connections between adjacent intercostal and superior epigastric artery vascular territories that provided a robust blood supply to the flap extension. In the eight patients included in the clinical study, all flaps demonstrated excellent vascularity and survived completely. Two minor complications occurred: a lateral perineal dehiscence and hypertrophic scarring of the abdomen. Conclusions: Four-dimensional computed tomography angiography demonstrated vascular perfusion throughout the eVRAM flaps. Low rates of donor-site and recipient-site complications and good distal flap perfusion were observed when a pedicled eVRAM flap was used for pelvic reconstruction. The eVRAM flap is a reliable option for pelvic reconstruction requiring large tissue volume and/or additional flap reach.

Salvaging the infected breast tissue expander: A standardized multidisciplinary approach

Background: Infections of breast tissue expander (TE) are complex, often requiring TE removal and hospitalization, which can delay further adjuvant therapy and add to the overall costs of breast reconstruction. Therefore, to reduce the rate of TE removal, hospitalization, and costs, we created a standardized same-day multidisciplinary outpatient quality improvement protocol for diagnosing and treating patients with early signs of TE infection. Methods: We prospectively evaluated 26 consecutive patients who developed a surgical site infection between February 2013 and April 2014. On the same day, patients were seen in the Plastic Surgery and Infectious Diseases clinics, underwent breast ultrasonography with or without periprosthetic fluid aspiration, and were prescribed a standardized empiric oral or intravenous antimicrobial regimen active against biofilm-embedded microorganisms. All patients were managed as per our established treatment algorithm and were followed up for a minimum of 1 year. Results: TEs were salvaged in 19 of 26 patients (73%). Compared with TE-salvaged patients, TE-explanted patients had a shorter median time to infection (20 vs 40 days; P = 0.09), a significantly higher median temperature at initial presentation [99.8°F; interquartile range (IQR) = 2.1 vs 98.3°F; IQR = 0.4°F; P = 0.01], and a significantly longer median antimicrobial treatment duration (28 days; IQR = 27 vs 21 days; IQR = 14 days; P = 0.05). The TE salvage rates of patients whose specimen cultures yielded no microbial growth, Staphylococcus species, and Pseudomonas were 92%, 75%, and 0%, respectively. Patients who had developed a deep-seated pocket infection were significantly more likely than those with superficial cellulitis to undergo TE explantation (P = 0.021). Conclusions: Our same-day multidisciplinary diagnostic and treatment algorithm not only yielded a TE salvage rate higher than those previously reported but also decreased the rate of hospitalization, decreased overall costs, and identified several clinical scenarios in which TE explantation was likely.

Plastic surgeon expertise in predicting breast reconstruction outcomes for patient decision analysis

Background: Decision analysis offers a framework that may help breast cancer patients make good breast reconstruction decisions. A requirement for this type of analysis is information about the possibility of outcomes occurring in the form of probabilities. The purpose of this study was to determine if plastic surgeons are good sources of probability information, both individually and as a group, when data are limited. Methods: Seven plastic surgeons were provided with pertinent medical information and preoperative photographs of patients and were asked to assign probabilities to predict number of revisions, complications, and final aesthetic outcome using a questionnaire designed for the study. Logarithmic strictly proper scoring was used to evaluate the surgeons’ abilities to predict breast reconstruction outcomes. Surgeons’ responses were analyzed for calibration and confidence in their answers. Results: As individuals, there was variation in surgeons’ ability to predict outcomes. For each prediction category, a different surgeon was more accurate. As a group, surgeons possessed knowledge of future events despite not being well calibrated in their probability assessments. Prediction accuracy for the group was up to 6-fold greater than that of the best individual. Conclusions: The use of individual plastic surgeon–elicited probability information is not encouraged unless the individual’s prediction skill has been evaluated. In the absence of this information, a group consensus on the probability of outcomes is preferred. Without a large evidence base for calculating probabilities, estimates assessed from a group of plastic surgeons may be acceptable for purposes of breast reconstruction decision analysis.