Samir S. Rao

Two-stage prosthetic breast reconstruction using AlloDerm including outcomes of different timings of radiotherapy.

Background: The authors compared the outcomes of two-stage, acellular dermal matrix (AlloDerm)-assisted prosthetic breast reconstruction including different timings of radiotherapy. Methods: A review of two-stage, AlloDerm-assisted, prosthetic breast reconstructions from 2004 to 2010 was performed. All data were recorded prospectively and the study population was stratified by the timing of radiotherapy. Complications were analyzed following first- and second-stage reconstruction. The Spear-Baker classification of capsular contracture was modified for irradiated devices. Reconstructive failure was defined as nonelective removal of a breast prosthesis. Results: AlloDerm-assisted prosthetic reconstruction was performed in 289 women (428 breasts). After first-stage reconstruction, clinically significant capsular contracture rates (grade III/IV) were higher in the radiation therapy during expansion group and in the radiation therapy before mastectomy group compared with the no–radiation therapy group. Three hundred fifty-three breasts (85.9 percent) successfully underwent second-stage reconstruction, with a median follow-up of 15.2 months. Of those 353 breasts, clinically significant capsular contracture (grade III/IV) was highest in the radiation therapy during expansion group. More often than in the other groups, the radiation therapy during expansion group failed two-stage reconstruction and required flaps in addition or as replacement. Conclusions: In AlloDerm-assisted prosthetic breast reconstruction, irradiated devices demonstrated higher rates of clinically significant capsular contracture following the first stage. These rates declined considerably on completion of reconstruction, with prostheses irradiated during expansion still having the highest frequency of clinically significant capsular contracture. With the follow-up reported, irradiated devices failed breast reconstruction less frequently and required autologous tissue less often than has been historically reported without acellular dermal matrix. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

A multiple logistic regression analysis of complications following microsurgical breast reconstruction

BACKGROUND Although we practice in an era of high flap success rates following microsurgical breast reconstruction, complications can still occur. Several studies have evaluated the impact of risk factors on microvascular outcomes in the setting of a particular type of patient or with a particular type of flap. However, few studies that have evaluated a consecutive series of high-risk patients will all types of microvascular breast reconstruction. Our goal was to gain a better understanding of the relationship between risk factors and complications in order to provide useful information for patients and surgeons considering free flap breast reconstruction in high-risk patients. METHODS We performed a retrospective review of all patients who underwent microsurgical breast reconstruction by the senior author (M.Y.N) from July 2005 July 2010. Patient records were analyzed for risk factors (age, BMI, smoking history, medical history, adjunct therapies, timing of reconstruction, type of reconstruction), and complications (hematoma, seroma, infection, wound dehiscence, pulmonary embolism (PE), deep venous thrombosis (DVT), pneumonia, fat necrosis, leech use, partial flap loss, total flap loss). Statistical methods were employed to determine statistically significant relationships. RESULTS A total of 352 patients underwent 490 microvascular breast reconstructions during the study period. Active smoking was found to be a statistically significant risk factor for seroma [P<0.0001; odds ratio (OR) =36; 95% confidence interval (CI), 5.9-193.9], infection (P=0.0081; OR =4.3; 95% CI, 1.3-14.1), and pneumonia (P<0.0001; OR =17.1; 95% CI, 3.3-89.9). Unilateral reconstruction was found to be a statistically significant factor for fat necrosis (P=0.0083; OR =4; 95% CI, 1.4-11.4). Additionally, BMI was found to be a statistically significant risk factor for infection (P<0.00001). CONCLUSIONS This study corroborates findings from previous studies. Tobacco use was demonstrated to be a significant risk factor for infection, seroma, and pneumonia. Obesity was demonstrated to be a significant risk factor for infection. Unilateral reconstruction was demonstrated to pose additional risk for fat necrosis compared to bilateral reconstruction. Patients who choose to have microsurgical breast reconstruction should be informed of the complication profile associated with certain risk factors.

Rapid awakening protocol in complex head and neck reconstruction

Patients undergoing complex head and neck free flap reconstructions are commonly maintained on mechanical ventilation in an intensive care unit (ICU). This study reviews indications and outcomes of such patients undergoing a rapid awakening protocol (RAP).

Long-term outcomes of failed prosthetic breast reconstruction.

IntroductionFor patients undergoing prosthetic breast reconstruction whose device was removed because of infection or exposure, there is no published information examining long-term outcomes. Despite initial failure, many patients want to pursue breast reconstruction. MethodsA retrospective review was performed of immediate prosthetic breast reconstruction failures during a 5-year period. ResultsA total of 26 patients (29 breasts) were identified who failed primary prosthetic 2-stage reconstruction. On average, the device was removed 262 days from the initial expander placement. Of these breasts, 19 were removed for infection, 7 for exposure, and 3 for a combination of both. Of these 29 failures, secondary reconstruction was attempted in 20 (69%). Among secondary reconstructions, 13 were with a device and 7 with autologous tissue. Of the 13 (92.3%) secondary device reconstructions, 12 were successful.Those in whom secondary reconstruction was attempted were younger at initial reconstruction (48 vs 57 years; P = 0.038), had lower body mass indexes (BMIs) (26.0 vs 29.4; P = 0.27), and smaller breasts (650 vs 979 g; P = 0.23) than those who did not attempt secondary reconstruction.Of the nipple-sparing mastectomy patients, 100% underwent secondary reconstruction, whereas only 61% of skin-sparing mastectomy patients underwent secondary reconstruction (P = 0.14).For patients undergoing secondary reconstruction, those receiving a second device reconstruction had lower BMIs (24.7 vs 28.5; P = 0.18) and smaller breasts (489 vs 946 g; P = 0.08) than those with autologous reconstructions; 15% of secondary implant reconstructions underwent irradiation versus 43% of the secondary autologous reconstructions (P = 0.29). ConclusionsAfter failed prosthetic breast reconstruction, a second attempt with an implant in properly selected patients has a high success rate (92.3%).

Reduction mammaplasty and mastopexy in previously irradiated breasts.

BACKGROUND Little data exist on the safety of elective breast surgery following breast conservation therapy. OBJECTIVES The authors evaluate their experience performing reduction mammaplasties and mastopexies in previously irradiated breasts. METHODS A retrospective chart review was conducted of all reduction mammaplasties and mastopexies in previously irradiated breasts performed by the 2 senior authors (MYN and SLS) from 1995 to 2012 (n = 18). Patient records were analyzed for demographics, perioperative and postoperative details, and complications. RESULTS During the study period, 12 reduction mammaplasties and 6 mastopexies were performed on breasts previously treated with breast conservation therapy. The average study participant age was 49.5 years, and average body mass index was 29. Average preoperative bra cup size was D/DD. One patient was a former smoker; 17 were nonsmokers. Eleven of the 18 patients had been previously treated with chemotherapy; average time between radiation therapy and surgery was 2.5 years. Average specimen weight in the 12 reduction mammaplasties was 623 g. Twenty-two percent (n = 4) of patients experienced a total of 5 minor complications; none required a return to the operating room. One patient (6%) experienced a major complication resulting in approximately 50% loss of breast tissue, which was reconstructed with a latissimus dorsi musculocutaneous flap. Seventeen patients (94%) had successful outcomes with preoperative goals achieved. CONCLUSIONS In the previously irradiated breast, reduction mammaplasty and mastopexy should be approached with extra caution, but the surgeries may still be safely and successfully performed. LEVEL OF EVIDENCE 4.

The acellular dermal matrix onlay graft for areolar reconstruction.

BackgroundAcellular dermal matrix (ADM) has been well described for use in breast reconstruction. The purpose of this study was to describe a novel use for ADM in areolar reconstruction. MethodsA total of 19 patients and 24 nipple-areolar complexes of breast cancer or BRCA-positive patients status postmastectomy were treated. After nipple flap reconstruction was completed, the areolar complex was marked at 40–45 mm and de-epithelialized. ADM was reconstituted and cut to size. This was sewn into place as an areolar onlay graft using 5-0 chromic running sutures and a vaseline gauze bolster. ResultsAll 24 areola re-epithelialized in an average of 8.1 weeks. Graft take was 100% in 23 areolas, while 1 areola had only 75% graft take. Two patients underwent subsequent nipple projection procedures. Sixteen areolas were tattooed for color, with plans to tattoo the others. All patients had satisfactory transition from native skin to nipple-areolar complex. All surveyed patients stated they would undergo the procedure again. Average follow-up was 15.7 months. ConclusionThe ADM onlay graft for areolar reconstruction is a feasible addition to the plastic surgeon’s armamentarium. The primary benefits of this technique are grafting the donor bed of nipple reconstruction, avoidance of a skin graft donor site wound, and prevention of flattening of the breast dome, as seen with primary closure after nipple flap reconstruction. The cost of ADM must be taken into account (

Unilateral Failures in Bilateral Microvascular Breast Reconstruction

31 per square centimeter), which could be offset by banking excess ADM at the time of breast reconstruction.