Mihye Choi

The use of acellular dermal matrix in immediate two-stage tissue expander breast reconstruction.

Background: Acellular dermal matrix is commonly used in implant-based breast reconstruction to allow for quicker tissue expansion with better coverage and definition of the lower pole of the breast. This study was performed to analyze complications associated with its use in immediate two-stage, implant-based breast reconstruction and to subsequently develop guidelines for its use. Methods: A retrospective analysis of 628 consecutive immediate two-stage tissue expander breast reconstructions at a single institution over a 3-year period was conducted. The reconstructions were divided into two groups: reconstruction with acellular dermal matrix and reconstruction without it. Demographic information, patient characteristics, surface area of acellular dermal matrix, and complications were analyzed and compared. Results: A total of 407 patients underwent 628 immediate two-stage, implant-based breast reconstructions; 442 reconstructions (70.3 percent) used acellular dermal matrix and 186 (29.6 percent) did not. The groups had similar patient characteristics; however, major complications were significantly increased in the acellular dermal matrix group (15.3 versus 5.4 percent; p = 0.001). These complications included infection requiring intravenous antibiotics (8.6 versus 2.7 percent; p = 0.001), flap necrosis requiring excision (6.7 versus 2.7 percent; p = 0.015), and explantation of the tissue expander (7.7 versus 2.7 percent; p = 0.004). Conclusions: Use of acellular dermal matrix in immediate two-stage, implant-based breast cancer reconstruction is associated with a significant increase in major complications. Therefore, it should only be used in specific patients and in minimal amounts. Indications for its use include single-stage permanent implant reconstruction and inadequate local muscle coverage of the tissue expander. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Wise-pattern breast reconstruction: modification using AlloDerm and a vascularized dermal-subcutaneous pedicle.

Immediate implant-based breast mound reconstruction offers many advantages over staged implant reconstruction techniques. For large volume breast reconstruction, a Wise-pattern skin resection may provide very good aesthetic results; however, the submuscular implant pocket is inadequate to cover the inferior pole of the breast. In this patient population, the risk of implant exposure from T-point breakdown is significant. We present our technique of Wise-pattern breast reconstruction using AlloDerm (LifeCell, Branchburg, NJ) and a vascularized dermal-subcutaneous pedicle (DSP) to augment the volume and quality of immediate breast implant coverage, particularly in the area of the T-point suture lines. We reviewed a series of 20 consecutive patients with large breasts who were treated with an immediate implant reconstruction of greater than 400 mL volume using the Wise-pattern with DSP. Preoperative and postoperative 3-dimensional surface scan studies were performed to evaluate breast symmetry. The average volume of breast reconstruction in this study group was 458 mL. T-point breakdown occurred in 5 patients (25%). These patients were treated with local wound care and healed with an excellent aesthetic result. None of these patients required implant removal, implant exchange, or operative debridement. Pre- and postoperative 3-dimensional surface scan analysis of these patients demonstrated comparable differences between the affected and unaffected sides in women undergoing immediate breast implant reconstruction when compared with a matched group of patients undergoing 2-stage breast reconstruction with tissue expanders. Wise-pattern skin-reducing mastectomy is an excellent strategy to provide an aesthetically pleasing, immediate implant breast reconstruction. This technique provides breast symmetry that is at least comparable to that of tissue expander-based, staged implant reconstructions. The reliability of the Wise-pattern technique is significantly improved with the addition of AlloDerm to the muscular pocket and a vascularized DSP to preserve the integrity of the reconstruction in the presence of T-point breakdown.

3D analysis of breast augmentation defines operative changes and their relationship to implant dimensions.

Breast augmentation is one of the most common plastic surgery procedures performed in the United States today. Evaluation of postoperative results lacks true objective measurements. The following study reports the application of 3-dimensional (3D) photography to document changes that occur in breast morphology after breast augmentation. Patients undergoing augmentation mammaplasty with a periareolar incision were offered pre- and postoperative 3D photographs. 3D models were constructed and the following parameters were assessed: maximum anterior-posterior projection from the chest wall, angle of breast projection, total breast volume, volumetric tissue distribution in the superior and inferior poles, and surface and vector distance measurements to key landmarks. A completed series of 3D images were obtained from 14 augmentation patients (28 breasts) at an average postoperative day of 143. Saline and silicone implants were used equally (n = 14 for each). Total volume of the breast changed in correlation with the implant size (1.9% difference, P = 0.83). There were no significant changes in the volumetric distribution within the upper and lower poles of the breasts noted between pre- and postoperative scans (P = 0.81). The internal angle of breast projection was found to increase (13.6 degrees, P < 0.01), as did the sternal notch to nipple distance (11 mm, P = 0.018). Anterior-posterior projection significantly increased by 23.3 mm. However, this increase in projection was 20.9% less than expected based on implant dimensions (72.7–58.7 mm, respectively, P < 0.01). This study documents objective changes in breast morphology after augmentation mammaplasty. 3D imaging scans were able to document true changes that occur with breast augmentation including breast volume, the increase in the internal angle of the breast projection, and the sternal notch to nipple distance. 3D photography further highlighted that breast augmentation results in less than expected anterior-posterior projection, possibly due to tissue attenuation occurring anterior to the implant.

An Innovative Three-dimensional Approach to Defining the Anatomical Changes Occurring after Short Scar-medial Pedicle Reduction Mammaplasty

Background: Three-dimensional photography of the breast offers new opportunities to advance the fields of aesthetic and reconstructive breast surgery. The following study investigates the use of three-dimensional imaging to assess changes in breast surface anatomy, volume, tissue distribution, and projection following medial pedicle reduction mammaplasty. Methods: Preoperative and postoperative three-dimensional scans were obtained from patients undergoing short-scar medial pedicle breast reduction. Three-dimensional models were analyzed by topographical color maps, changes in the lowest point of the breast, surface measurements, and the point of maximal projection. Total breast volume and percentage volumetric tissue distribution in the upper and lower poles were also determined. Results: Thirty patients underwent reduction mammaplasty (mean postoperative scan, 80 ± 5 days). Color maps highlighted the majority of spatial changes in the central, upper poles. Reduction mammaplasty resulted in a significant decrease in the anteroposterior projection of the breast (6.3 ± 0.2 postoperatively compared with 8.1 ± 0.2 cm preoperatively; p < 0.01). The point of maximal breast projection was elevated in the cranial-caudal direction (4.8 ± 0.4 cm; p < 0.01), with a corresponding elevation in the lowest point of the breast (4.8 ± 0.5 cm; p < 0.01). Volumetric three-dimensional measurements identified a significant change in percentage tissue distribution after reduction mammaplasty (45 ± 2 percent above the inframammary fold preoperatively versus 76 ± 2 percent postoperatively; p < 0.01). Conclusions: This study is the first to demonstrate the technical feasibility and clinical utility of three-dimensional geometric data in medial pedicle breast reduction surgery. This novel approach suggests new opportunities to define long-term operative changes following various breast procedures.

Three-Dimensional Imaging Provides Valuable Clinical Data to Aid in Unilateral Tissue Expander-Implant Breast Reconstruction

Abstract:  The current approach to breast reconstruction remains largely subjective and is based on physical examination and visual‐estimates of breast size. Thus, the overall success of breast reconstruction is limited by the inability of plastic surgeons to objectively assess breast volume and shape, which may result in suboptimal outcomes. A potential solution to this obstacle may be three‐dimensional (3D) imaging, which can provide unique clinical data that was previously unattainable to plastic surgeons. The following study represents a prospective analysis of patient volunteers undergoing unilateral tissue expander (TE)‐implant reconstruction by one of the two senior authors (MC, NSK). All patients underwent unilateral mastectomy with immediate or delayed insertion of a TE, followed by an exchange for a permanent silicone or saline implant. 3D scans were obtained during routine pre‐ and postoperative office visits. The 3D breast‐volume calculations served as a guide for surgical management. Twelve patients have completed 3D‐assisted unilateral breast reconstruction to date. These patients represent a wide range of body habitus and breast size/shape; 3D volume range from 136 to 518 cm3. The mean baseline breast asymmetry in this group was 12.0 ± 10.8%. Contralateral symmetry procedures were performed in eleven patients, consisting of the following: mastopexy (n = 6), augmentation (n = 1), mastopexy/augmentation (n = 2), and reduction mammoplasty (n = 2). Reconstruction was completed in a total number of 2 (n = 10) or 3 (n = 2) operations. Overall breast symmetry improved at the completion of reconstruction in the majority of patients, with an average postoperative symmetry of 95.1 ± 4.4% (relative to 88% preoperatively). 3D imaging serves a valuable adjunct to TE‐implant breast reconstruction. This technology provides volumetric data that can help guide breast reconstruction, such as in choosing the initial TE size, total volume of expansion, and final implant size/shape. 3D imaging technology also provides benefit as a method for assessing tissue expansion, the need for symmetry or revision procedures, and critically analyzing the final reconstructive outcome.

Mammometrics: The standardization of aesthetic and reconstructive breast surgery

The goal of cosmetic and reconstructive breast surgery is to create symmetric and aesthetically pleasing results in a reproducible manner. Although continued progress is dependent on the ability of plastic surgeons to accurately assess surgical outcomes, available methods to objectively evaluate aesthetic and reconstructive breast surgery are limited. This is quite different from other areas of plastic surgery, such as craniomaxillofacial surgery, that often use precise skeletal measurements to provide a platform for preoperative and postoperative analysis. In comparison, systematic evaluation of breast surgery has yet to be standardized. With the advent of three-dimensional photography, objective soft-tissue analysis of the breast is now possible. Recent work from our group and others has validated the use of three-dimensional breast photography in various clinical arenas, including autologous breast reconstruction, prosthetic breast reconstruction, reduction mammaplasty, and augmentation mammaplasty.1–7 Enthusiasm toward three-dimensional imaging technology has stemmed from the ability to not only obtain well-established breast measurements in an accurate manner, but also to generate measurements that were not previously possible with conventional tools, such as total breast volume, volumetric distribution, and breast projection. This article provides an overview of three-dimensional breast photography, with particular emphasis on its potential role to establish a standardized system for breast analysis. We introduce a new concept termed “mammometrics,” in which three-dimensional–based breast measurements can be used to help guide operative planning, objectively analyze surgical results, and document postoperative changes that occur over time.

The lateral inframammary fold incision for nipple-sparing mastectomy: outcomes from over 50 immediate implant-based breast reconstructions.

Nipple‐sparing mastectomy (NSM) as a therapeutic or prophylactic procedure for breast cancer is rapidly gaining popularity as the literature continues to support it safety. The lateral inframammary fold (IMF) approach provides adequate exposure and eliminates visible scars on the anterior surface of the breast, making this incision cosmetically superior to radial or periareolar approaches. We reviewed 55 consecutive NSMs performed through a lateral IMF incision with immediate implant‐based reconstruction, with or without tissue expansion, between June 2008 and June 2011. Prior to incision, breasts were lightly infiltrated with dilute anesthetic solution with epinephrine. Sharp dissection, rather than electrocautery, was used as much as possible to minimize thermal injury to the mastectomy flap. When indicated, acellular dermal matrix was placed as an inferolateral sling. Subsequent fat grafting to correct contour deformities was performed in select patients. Three‐dimensional (3D) photographs assessed changes in volume, antero‐posterior projection, and ptosis. Mean patient age was 46 years, and mean follow‐up time was 12 months. Twelve mastectomies (22%) were therapeutic, and the remaining 43 (78%) were prophylactic. Seven of the nine sentinel lymph node biopsies (including one axillary dissection) (78%) were performed through the lateral IMF incision without the need for a counter‐incision. Acellular dermal matrix was used in 34 (62%) breasts. Average permanent implant volume was 416 cc (range 176–750 cc), and average fat grafting volume was 86 cc (range 10–177 cc). In one patient a positive intraoperative subareolar biopsy necessitated resection of the nipple‐areola complex (NAC), and in two other patients NAC resection was performed at a subsequent procedure based on the final pathology report. Mastectomy flap necrosis, requiring operative debridement, occurred in two breasts (4%), both in the same patient. One of these breasts required a salvage latissimus dorsi myocutaneous flap to complete the reconstruction. Three nipples (6%) required office debridement for partial necrosis and operative reconstruction later. No patient had complete nipple necrosis. No statistically significant differences existed between therapeutic and prophylactic mastectomies for developing partial skin and/or nipple necrosis (p = 0.35). Three episodes (5%) of cellulitis occurred, which responded to antibiotics without the need for explantation. Morphological outcomes using 3D scan measurements showed reconstructed breasts were larger, more projected, and less ptotic than the preoperative breasts (196 versus 248 cc, 80 versus 90 mm, 146 versus 134 mm, p < 0.01 for each parameter). Excellent results can be achieved with immediate implant‐based reconstruction of NSM through a lateral IMF incision. NAC survival is reliable, and complication rates are low.

Re-defining pseudoptosis from a 3D perspective after short scar-medial pedicle reduction mammaplasty

BACKGROUND Bottoming out is a well-known phenomenon described with reduction mammaplasty (RM). To date, the evaluation of post-operative bottoming out remains an imprecise science. The following study reports the application of three-dimensional (3D) photography to objectively investigate changes in breast morphology. METHODS Patients undergoing medial pedicle RM had 3D photographs (Konica Minolta V910) taken during the early and late post-operative period (early=60-120 days; late=400-500 days). 3D images were compared and bottoming out was assessed with 3D parameters and vectors including total breast volume, volumetric tissue distribution above and below the Central (C) plane, distance of the C-plane to the lowest point of the breast, and maximum anterior-posterior projection from the chest wall. RESULTS Post-operative images from 15 consecutive RM patients showed an average volume of 556+/-144 cm3 (early) and 441+/-183 cm3 (late). The percent of tissue in the upper pole of the breast changed from the early to late post-operative period (76% vs. 69%, respectively; p<0.01). The distance from a fixed C-plane to the inferior pole significantly increased (42+/-15 mm early vs. 51+/-18 mm late; p<0.01). AP projection decreased by an average of 6.23 mm (p<0.01). The lateral border of the IMF significantly dropped by 6.27 mm. CONCLUSIONS This study objectively describes both the occurrence of bottoming out and the quantitative amount in terms of changes in volumetric distribution, surface topography and breast projection. With 3D photography, plastic surgeons can perform objective evaluation of breast transformation over time, which ultimately will aid in planning to allow for better surgical outcomes.

Reply: Three-Dimensional Surface Imaging in Plastic Surgery: Foundation, Practical Applications, and Beyond.

Summary: Three-dimensional surface imaging has gained clinical acceptance in plastic and reconstructive surgery. In contrast to computed tomography/magnetic resonance imaging, three-dimensional surface imaging relies on triangulation in stereophotography to measure surface x, y, and z coordinates. This study reviews the past, present, and future directions of three-dimensional topographic imaging in plastic surgery. Historically, three-dimensional imaging technology was first used in a clinical setting in 1944 to diagnose orthodontologic conditions. Karlan established its use in the field of plastic surgery in 1979, analyzing contours and documenting facial asymmetries. Present use of three-dimensional surface imaging has focused on standardizing patient topographic measurements to enhance preoperative planning and to improve postoperative outcomes. Various measurements (e.g., volume, surface area, vector distance, curvature) have been applied to breast, body, and facial topography to augment patient analysis. Despite the rapid progression of the clinical applications of three-dimensional imaging, current use of this technology is focused on the surgeon’s perspective and secondarily the patient’s perspective. Advancements in patient simulation may improve patient-physician communication, education, and satisfaction. However, a communal database of three-dimensional surface images integrated with emerging three-dimensional printing and portable information technology will validate measurements and strengthen preoperative planning and postoperative outcomes. Three-dimensional surface imaging is a useful adjunct to plastic and reconstructive surgery practices and standardizes measurements to create objectivity in a subjective field. Key improvements in three-dimensional imaging technology may significantly enhance the quality of plastic and reconstructive surgery in the near future.

Nipple-sparing mastectomy in patients with a history of reduction mammaplasty or mastopexy: how safe is it?

Background: Nipple-sparing mastectomy has gained popularity, but the question remains of whether it can be offered safely to women with a history of reduction mammaplasty or mastopexy. The authors present their experience with nipple-sparing mastectomy in this patient population. Methods: Patients at the authors’ institution who had reduction mammaplasty or mastopexy before nipple-sparing mastectomy were identified. Outcomes measured include nipple-areola complex viability, mastectomy flap necrosis, infection, presence of cancer in the nipple-areola complex, and breast cancer recurrence. Results: The records of the nipple-sparing mastectomy patients at the authors’ institution from 2006 through 2012 were reviewed. The authors identified 13 breasts in eight patients that had nipple-sparing mastectomy following reduction mammaplasty or mastopexy. Within this subset of patients, the mean age was 46.6 years and the mean body mass index was 25.1. Nine of 13 breasts had therapeutic resections, whereas the remaining four were for prophylactic indications. Average time elapsed between reduction mammaplasty or mastopexy and nipple-sparing mastectomy was 51.8 months (range, 33 days to 11 years). In all cases, prior reduction mammaplasty/mastopexy incisions were used for nipple-sparing mastectomy. Ten breasts underwent reconstruction immediately with tissue expanders, one with a latissimus dorsi flap with immediate implant and two with immediate abdominally based free flaps. Complications included one hematoma requiring evacuation and one displaced implant requiring revision. There were no positive subareolar biopsy results, and the nipple viability was 100 percent. Mean follow-up time was 10.5 months. Conclusions: The authors’ experience demonstrates that nipple-sparing mastectomy can be offered to patients with a history of reduction mammaplasty or mastopexy with reconstructive outcomes comparable to those of nipple-sparing mastectomy alone. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.