Stelios C. Wilson

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.

The role of autologous fat grafting in secondary microsurgical breast reconstruction.

BackgroundAutologous breast reconstruction offers higher rates of patient satisfaction, but not all patients are ideal candidates, often due to inadequate volume of donor sites. Although autologous fat grafting is frequently used to augment volume and contour abnormalities in implant-based breast reconstruction, its clear utility in microsurgical breast reconstruction has yet to be defined. Here, we examined patients undergoing autologous microsurgical breast reconstruction with and without the adjunct of autologous fat grafting to clearly define utility and indications for use. MethodsA retrospective review of all patients undergoing autologous breast reconstruction with microvascular free flaps at a single institution between November 2007 and October 2011 was conducted. Patients were divided into 2 groups as follows: those requiring postoperative fat grafting and those not requiring fat grafting. Patient demographics, indications for surgery, history of radiation therapy, patient body mass index, mastectomy specimen weight, need for rib resection, flap weight, and complications were analyzed in comparison. ResultsTwo hundred twenty-eight patients underwent 374 microvascular free flaps for breast reconstruction. One hundred (26.7%) reconstructed breasts underwent postoperative fat grafting, with an average of 1.12 operative sessions. Fat was most commonly injected in the medial and superior medial poles of the breast and the average volume injected was 147.8 mL per breast (22–564 mL). The average ratio of fat injected to initial flap weight was 0.59 (0.07–1.39). Patients undergoing fat grafting were more likely to have had deep inferior epigastric perforator and profunda artery perforator flaps as compared to muscle-sparing transverse rectus abdominis myocutaneous. Patients additionally were more likely to have a prophylactic indication 58% (n = 58) versus 42% (n = 117) (P = 0.0087), rib resection 68% (n = 68) versus 54% (n = 148) (P < 0.0153), and acute postoperative complications requiring operative intervention 7% (n = 7) versus 2.1% (n = 8) (P < 0.0480). Additionally, patients undergoing autologous fat grafting had smaller body mass index, mastectomy weight, and flap weight. ConclusionsFat grafting is most commonly used in those breasts with rib harvest, deep inferior epigastric perforator flap reconstructions, and those with acute postoperative complications. It should be considered a powerful adjunct to improve aesthetic outcomes in volume-deficient autologous breast reconstructions and additionally optimize contour in volume-adequate breast reconstructions.

Antibiotic selection for the treatment of infectious complications of implant-based breast reconstruction

BackgroundInfection requiring explantation remains the most devastating complication associated with implant-based breast reconstruction. There are many treatment algorithms to prevent reconstructive failure in face of infection using both oral and intravenous antibiotics. In the absence of patient-specific culture data, antibiotic selection is generally directed toward broad-spectrum coverage based on historical data. We hypothesize that reviewing our institution’s microbiology data obtained from explanted implant-based breast reconstructions would provide a rational basis for antibiotic selection in the future. MethodsA retrospective review of 902 consecutive immediate implant-based breast reconstructions at a single institution from November 2007 to May 2011 was conducted. Implant reconstructions requiring explantation or drainage by interventional radiology were identified. Patient demographics, implant characteristics, presence of skin necrosis, microbiological data, and outcomes were reviewed. ResultsForty-three (4.76%) implant reconstructions requiring explantation or drainage by interventional radiology met the inclusion criteria for this study. Five patients (11.6%) had round, smooth silicone implants, and 36 (88.4%) had textured tissue expanders. Twenty-six implants were explanted because of infection; 3, because of exposure from skin necrosis; and 11, because of the combination of flap necrosis and infection; and 1, secondarily because of cancer invasion into the skin. Reconstruction was salvaged in 21 breasts (51.2%): 12 (57.1%) by implant reconstruction, 5 (23.8%) by pedicled latissimus dorsi flaps, and 4 (19.1%) with a microvascular free flap. Thirty explants had microbiology data available. The most common organism isolated was Staphylococcus epidermidis (10), followed by methicillin-sensitive Staphylococcus aureus (5), Serratia marcescens (5), Pseudomonas aeruginosa (4), enterococcus (3), Escherichia coli (2), Enterobacter (2), group B streptococcus (1), and Morganella morganii (1). Forty percent of the organisms were resistant to cefazolin; however, 86% were sensitive to gentamicin, 80% were sensitive to Levaquin, and 63% were sensitive to ciprofloxacin. ConclusionsInfection associated with implant-based breast reconstructions continues to threaten explantation and reconstructive failure. Based on our microbiological data, initial cellulitis amenable to oral antibiotics should be treated with oral fluoroquinolones as a first-line treatment. If this regimen fails, intravenous imipenem or gentamicin and vancomycin should be initiated. Obviously, clinical judgment regarding specific patient risk factors and compliance should play a role in decision making, but these data provide an evidence-based rationale for first-line oral antibiotic selection.

Educational Exposure to Transgender Patient Care in Plastic Surgery Training.

Background: Gender dysphoria is estimated to occur in up to 0.9 percent of the U.S. population. With increasing awareness and decreasing stigma surrounding transgender issues, it is predicted that more patients will begin to seek medical and surgical transition. This study aims to determine the current state of transgender-related education in U.S. plastic surgery residency programs and to evaluate trainee perceptions regarding the importance of such training. Methods: Plastic surgery trainees from a representative sample of 21 U.S. training programs were asked to complete a cross-sectional eight-question survey between November of 2015 and January of 2016. Respondents were queried regarding demographics, transgender curricular exposure (didactic versus clinical), and perceived importance of training opportunities in transgender patient care. Results: A total of 322 residents or fellows responded to the survey (80 percent response rate) from four U.S. Census regions. Sixty-four percent of respondents had education on or direct exposure to transgender patient care during residency. Among those with experiences in gender-confirming surgery, more than half were exposed to chest and genital surgery. Overall, the majority of respondents believed that training in gender-confirming surgery is important, and 72 percent endorsed the necessity for gender-confirming surgery fellowship training opportunities. Conclusions: A significant number of plastic surgery trainees are exposed to transgender patient care, although exposure type is variable. The majority of trainees endorsed the importance of residency and fellowship training in gender-confirming surgery. To better serve the transgender population, formal fellowship training in gender-confirming surgery should be offered.

Current Thoughts on Fat Grafting: Using the Evidence to Determine Fact or Fiction.

Background: Autologous fat grafting is an increasingly popular procedure used for facial rejuvenation and body contouring. The purpose of this article is to perform an evidence-based review to determine fact from fiction for the hot topics in autologous fat grafting. Methods: A comprehensive literature search was performed. The following key words were then searched: “fat grafting,” “autologous fat grafting,” “autologous fat transfer,” “lipotransfer,” “liposculping,” and “lipofilling.” The authors then assessed each modality individually for the level of evidence that exists and whether the majority of evidence supports or refutes it. Results: A review of the literature demonstrated that there is no standard test for determining fat viability or volume augmentation after grafting. Furthermore, there is no difference in cell viability seen between syringe aspiration and liposuction pump aspiration harvest techniques (Level II). The decision to wash or centrifuge the fat plays very little role in fat graft survival (Level III). There is no difference between cell viability as a function of harvest location (Level IV). Nearly all studies show no significant effect of local anesthesia on adipocyte cells (Level IV). There are excellent data that support the fact that low-shear devices maintain fat structural integrity (Level IV). There is quality evidence that supports longevity of fat grafted to the breast (Level III). Two studies support large-volume fat grafting longevity but fail to prove their results using objective measures or with sufficiently large sample sizes (Level IV). External preexpansion devices improve total graft survival rate (Level IV). There is quality evidence to support that fat should be injected soon after harvesting, as properties of fat begin to change after processing (Level IV). Microneedling (preconditioning) before fat grafting has been demonstrated to improve fat survival (Level III). Conclusions: Currently, the highest levels of evidence derive from human studies of clinical trials and animal studies using human fat. The evidence presented here helps to address the need for accurate and quantitative viability assays. These assays would facilitate a systematic evaluation of each procedural step during fat graft harvest, processing, and grafting to improve the overall viability and predictability of fat grafts.

Treatment and outcomes of fingertip injuries at a large metropolitan public hospital.

Background: Fingertip injuries are the most common hand injuries presenting for acute care. Treatment algorithms have been described based on defect size, bone exposure, and injury geometry. The authors hypothesized that despite accepted algorithms, many fingertip injuries can be treated conservatively. Methods: A prospectively collected retrospective review of all fingertip injuries presenting to Bellevue Hospital between January and May of 2011 was conducted. Patients were entered into an electronic database on presentation. Follow-up care was tracked through the electronic medical record. Patients lost to follow-up were questioned by means of telephone. Patients were analyzed based on age, mechanism of injury, handedness, occupation, wound geometry, defect size, bone exposure, emergency room procedures performed, need for surgical intervention, and outcome. Results: One hundred fingertips were injured. Injuries occurred by crush (46 percent), laceration (30 percent), and avulsion (24 percent). Sixty-four percent of patients healed without surgery, 18 percent required operative intervention, and 18 percent were lost to follow-up. Patients requiring operative intervention were more likely to have a larger defect (3.28 cm2 versus 1.75 cm2, p < 0.005), volar oblique injury (50 percent versus 8.8 percent, p < 0.005), exposed bone (81.3 percent versus 35.3 percent, p < 0.005), and an associated distal phalanx fracture (81.3 percent versus 47.1 percent, p < 0.05). Patients requiring surgical intervention had a longer average return to work time when compared with those not requiring surgical intervention (4.33 weeks versus 2.98 weeks, p < 0.001). Conclusion: Despite current accepted algorithms, many fingertip injuries can be treated nonoperatively to achieve optimal sensation, fine motor control, and earlier return to work. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Techniques and Outcomes in Fat Grafting: Using Evidence to Determine Fact or Fiction.

METHODS: A comprehensive literature search was performed using the following databases: the Cochrane Central Registrar of Controlled Trials (CEN-TRAL), Ovid MEDLINE, Ovid EMBASE , Ovid CINAHL and Google Scholar. The following key words were then searched: “fat grafting”, “autologous fat grafting”, “autologous fat transfer.” We then assessed each modality individually, from relevant articles, for the level of evidence that exists and whether the majority of evidence supports or refutes it.

Venous coupler size in autologous breast reconstruction - Does it matter?

Autologous microvascular breast reconstruction is an increasingly common procedure. While arterial anastomoses are traditionally being hand‐sewn, venous anastomoses are often completed with a coupler device. The largest coupler size possible should be used, as determined by the smaller of either the donor or recipient vein. While its efficacy has been shown using 3.0‐mm size and greater couplers, little is known about the consequences of using coupler sizes less than or equal to 2.5 mm. Methods: A retrospective chart review of patients undergoing autologous breast reconstruction was conducted at NYU Medical Center between November 2007 and November 2011. Flaps were divided into cohorts based on coupler size used: 2.0 mm, 2.5 mm, and 3.0 mm. Outcomes included incidence of arterial or venous insufficiency, hematoma, fat necrosis, partial flap loss, full flap loss, and need for future fat grafting. Results: One‐hundred ninety‐seven patients underwent 392 flaps during the study period. Patients were similar in age, type of flap, smoking status, and radiation history. Coupler size less than or equal to 2.0 mm was found to be a significant risk factor for venous insufficiency (P = 0.038), as well as for development of fat necrosis (P = 0.041) and future need for fat grafting (P = 0.050). In multivariate analysis, body mass index was found to be an independent risk factor for skin flap necrosis (P = 0.010) and full flap loss (P = 0.035). Conclusions: Complications were significantly increased in patients where couplers of 2.0 mm or less were used, therefore to be avoided whenever possible. When needed, more aggressive vessel exposure through rib harvest, the use of thoracodorsal vessels or hand‐sewing the anastomosis should be considered in cases of internal mammary vein caliber of 2.0 mm or less.

Trends and drivers of the aesthetic market during a turbulent economy.

Background: Aesthetic procedures are significant sources of revenue for plastic surgeons. With the popularity of nonsurgical aesthetic procedures, many plastic surgeons question how to best tailor their aesthetic practice. Methods: Revenue generated from surgical and minimally invasive aesthetic procedures performed in the United States between 2000 and 2011 was calculated from the American Society of Plastic Surgeons’ annual reports. Regression analysis was performed against six commonly cited economic indicators. Results: In 2011, revenue from minimally invasive procedures increased from

The Impact of Two Operating Surgeons on Microsurgical Breast Reconstruction.

3.0 billion to