Steven T. Lanier

The effect of acellular dermal matrix use on complication rates in tissue expander/implant breast reconstruction.

Tissue expander/implant breast reconstructions by 5 surgeons at a single institution from 2005 to 2008 were retrospectively identified and divided into 2 cohorts: use of acellular dermal matrix (ADM, n = 75) versus standard submuscular placement (n = 52). The ADM group had a statistically significant higher rate of infection (28.9% vs. 12.0%, P = 0.022), reoperation (25.0% vs. 8.0%, P = 0.011), expander explantation (19.2% vs. 5.3%, P = 0.020), and overall complications (46.2% vs. 22.7%, P = 0.007). When stratifying by breast size, a higher complication rate was not observed with the use of ADM in breasts less than 600 g, whereas ADM use in breasts larger than 600 g was associated with a statistically significant higher rate of infection when controlling for the occurrence of skin necrosis. The ADM cohort had a significantly higher mean initial tissue expander fill volume (256 mL vs. 74 mL, P < 0.001) and a significantly higher mean initial tissue expander fill ratio (49% vs. 17%, P < 0.001). Further work is needed to define the ideal patient population for ADM use in tissue expander/implant breast reconstruction.

Intraoperative perfusion techniques can accurately predict mastectomy skin flap necrosis in breast reconstruction: results of a prospective trial.

Background: Intraoperative vascular imaging can assist assessment of mastectomy skin flap perfusion to predict areas of necrosis. No head-to-head study has compared modalities such as laser-assisted indocyanine green dye angiography and fluorescein dye angiography with clinical assessment. Methods: The authors conducted a prospective clinical trial of tissue expander–implant breast reconstruction with intraoperative evaluation of mastectomy skin flaps by clinical assessment, laser-assisted indocyanine green dye angiography, and fluorescein dye angiography. Intraoperatively predicted regions of necrosis were photographically documented, and clinical assessment guided excision. Postoperative necrosis was directly compared with each prediction. The primary outcome was all-inclusive skin necrosis. Results: Fifty-one tissue expander–implant breast reconstructions (32 patients) were completed, with 21 cases of all-inclusive necrosis (41.2 percent). Laser-assisted indocyanine green dye angiography and fluorescein dye angiography correctly predicted necrosis in 19 of 21 of cases where clinical judgment had failed. Only six of 21 cases were full-thickness necrosis, and five of 21 required an intervention (9.8 percent). Risk factors such as smoking, obesity, and breast weight greater than 1000 g were statistically significant. Laser-assisted indocyanine green dye angiography and fluorescein dye angiography overpredicted areas of necrosis by 72 percent and 88 percent (p = 0.002). Quantitative analysis for laser-assisted indocyanine green dye angiography in necrotic regions showed absolute perfusion units less than 3.7, with 90 percent sensitivity and 100 percent specificity. Conclusions: Laser-assisted indocyanine green dye angiography is a better predictor of mastectomy skin flap necrosis than fluorescein dye angiography and clinical judgment. Both methods overpredict without quantitative analysis. Laser-assisted indocyanine green dye angiography is more specific and correlates better with the criterion standard diagnosis of necrosis. CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, I.

Current practice among plastic surgeons of antibiotic prophylaxis and closed-suction drains in breast reconstruction: experience, evidence, and implications for postoperative care.

Background:Despite their widespread use, there are no evidence-based guidelines on the management of closed-suction drains or antibiotics in postmastectomy breast reconstruction. The purpose of this study was to assess consensus and variation in postoperative care among plastic surgeons. Methods:The authors designed and administered a self-reported, anonymous survey to 4669 American Society of Plastic Surgeons and Canadian Society of Plastic Surgeons members in October 2009. Results:A total of 650 completed surveys were available for analysis. A majority (>81%) of respondents reported using closed-suction drains in breast reconstruction. Most surgeons (>93%) used a volume criteria for drain removal, most commonly when drain output was ≤30 mL over 24 hours (>86%). Preoperative antibiotic use was nearly universal (98%), usually consisting of intravenous cefazolin (97%). Postoperative care demonstrated less uniformity with outpatient antibiotics administered by 72% of respondents. Surgeons were divided on when to discontinue outpatient antibiotics: 46% preferred concomitant discontinuation with drains, whereas 52% preferred a specific postoperative day. No clear consensus was observed for the number (1 or 2) or type (Jackson-Pratt or Blake) of drains used. Respondents were further divided on the restriction of postoperative showering with drains and the use of acellular dermal matrix. Conclusions:These results demonstrate a consensus for drain use, drain removal, and preoperative antibiotic administration. There was no consensus for number or type of drain used, postoperative antibiotic use, shower restrictions, and use of acellular dermal matrix. Our results further emphasize the need for evidence-based postoperative-care guidelines specific to breast reconstruction.

Spatiotemporal progression of cell death in the zone of ischemia surrounding burns

Burns are dynamic injuries, characterized by progressive death of surrounding tissue over time. Although central to an understanding of burn injury progression, the spatiotemporal degrees and rates of cellular necrosis and apoptosis in the zone of ischemia surrounding burns are not well characterized. Using a validated porcine hot comb model, we probed periburn tissue at 1, 4, and 24 hours after injury for high‐mobility group box 1 as a marker of necrosis and activated cleaved caspase‐3 as a marker of apoptosis, followed by spatiotemporal morphometric analysis. We found that necrosis was the most prominent mechanism of cell death in burn injury progression, with significant progression between 1 and 4 hours postburn. Apoptosis appeared not to play a role in early burn injury progression but was observed in cells at the interface of necrotic and viable tissue at 24 hours postburn. Our findings imply that intervention within the first 4 hours following injury is likely necessary to limit burn injury progression. Additionally, based on high‐mobility group box 1 staining patterns, we define distinct early, intermediate, and late pathological signs of cell necrosis that may facilitate delineation of causal mechanistic relationships of burn injury progression in vivo.

Factors associated with poor healing and recurrence of venous ulceration.

Background: Plastic surgeons are often approached for wound management and closure of chronic venous ulcers that fail to heal despite multimodal management. The authors present a retrospective analysis of a large series of venous ulcers to determine factors predicting nonhealing and recurrence. Methods: Consecutive patients with chronic venous ulcers (≥2-cm diameter) were examined for the presence of superficial, perforating, or deep venous disease, including reflux and/or obstruction. Treatment included compression, venous ligation, stripping, thermal ablation, sclerotherapy, and local wound care. Ulcers refractory to 6 months of treatment were defined as nonhealing ulcers. Data were analyzed for differences in baseline patient and ulcer characteristics and clinical course of nonhealing ulcers. Data were compared using Wilcoxon rank sum, chi-square, and Fishers exact tests using Sigma Stat and SPSS, with &agr; set at p < 0.05. Results: The authors identified 153 ulcers in 127 patients. Factors associated with ulcer nonhealing included advanced age, increased body mass index, history of deep venous thrombosis, noncompliance with compression therapy, and large ulcer area. One hundred thirty-one of the ulcers (85.6 percent) healed within 6 months and 147 (96 percent) of the ulcers ultimately healed without the need for operative plastic surgical intervention. Conclusions: A thorough understanding of risks and expected clinical course is required for assessment of the nonhealing venous ulcer. The authors recommend identification and correction of underlying venous abnormality and a minimum of at least 6 months of compression and local wound care followed by reassessment of venous function before operative plastic surgical intervention should be considered. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Impact of Postoperative Antibiotic Prophylaxis Duration on Surgical Site Infections in Autologous Breast Reconstruction.

BackgroundAlthough some surgeons prescribe prolonged postoperative antibiotics after autologous breast reconstruction, evidence is lacking to support this practice. We used the Tracking Operations and Outcomes for Plastic Surgeons database to evaluate the association between postoperative antibiotic duration and the rate of surgical site infection (SSI) in autologous breast reconstruction. Study DesignThe intervention of interest for this study was postoperative duration of antibiotic prophylaxis: either discontinued 24 hours after surgery or continued beyond 24 hours. The primary outcome variable of interest for this study was the presence of SSI within 30 days of autologous breast reconstruction. Cohort characteristics and 30-day outcomes were compared using &khgr;2 and Fischer exact tests for categorical variables and Student t tests for continuous variables. Multivariate logistic regression was used to control for confounders. ResultsA total of 1036 patients met inclusion criteria for our study. Six hundred fifty-nine patients (63.6%) received antibiotics for 24 hours postoperatively, and 377 patients (36.4%) received antibiotics for greater than 24 hours. The rate of SSI did not differ significantly between patients given antibiotics for only 24 hours and those continued on antibiotics beyond the 24-hour postoperative time period (5.01% vs 2.92%, P = 0.109). Furthermore, antibiotic duration was not predictive of SSI in multivariate regression modeling. ConclusionsWe did not find a statistically significant difference in the rate of SSI in patients who received 24 hours of postoperative antibiotics compared to those that received antibiotics for greater than 24 hours. These findings held for both purely autologous reconstruction as well as latissimus dorsi reconstruction in conjunction with an implant. Thus, our study does not support continuation of postoperative antibiotics beyond 24 hours after autologous breast reconstruction.

Mesh Sutured Repairs of Abdominal Wall Defects.

Background: A new closure technique is introduced, which uses strips of macroporous polypropylene mesh as a suture for closure of abdominal wall defects due to failures of standard sutures and difficulties with planar meshes. Methods: Strips of macroporous polypropylene mesh of 2 cm width were passed through the abdominal wall and tied as simple interrupted sutures. The surgical technique and surgical outcomes are presented. Results: One hundred and seven patients underwent a mesh sutured abdominal wall closure. Seventy-six patients had preoperative hernias, and the mean hernia width by CT scan for those with scans was 9.1 cm. Forty-nine surgical fields were clean-contaminated, contaminated, or dirty. Five patients had infections within the first 30 days. Only one knot was removed as an office procedure. Mean follow-up at 234 days revealed 4 recurrent hernias. Conclusions: Mesh sutured repairs reliably appose tissue under tension using concepts of force distribution and resistance to suture pull-through. The technique reduces the amount of foreign material required in comparison to sheet meshes, and avoids the shortcomings of monofilament sutures. Mesh sutured closures seem to be tolerant of bacterial contamination with low hernia recurrence rates and have replaced our routine use of mesh sheets and bioprosthetic grafts.

A Multi-institutional Analysis of Insurance Status as a Predictor of Morbidity Following Breast Reconstruction

Background: Although recent literature suggests that patients with Medicaid and Medicare are more likely than those with private insurance to experience complications following a variety of procedures, there has been limited evaluation of insurance-based disparities in reconstructive surgery outcomes. Using a large, multi-institutional database, we sought to evaluate the potential impact of insurance status on complications following breast reconstruction. Methods: We identified all breast reconstructive cases in the 2008 to 2011 Tracking Operations and Outcomes for Plastic Surgeons clinical registry. Propensity scores were calculated for each case, and insurance cohorts were matched with regard to demographic and clinical characteristics. Outcomes of interest included 15 medical and 13 surgical complications. Results: Propensity-score matching yielded 493 matched patients for evaluation of Medicaid and 670 matched patients for evaluation of Medicare. Overall complication rates did not significantly differ between patients with Medicaid or Medicare and those with private insurance (P = 0.167 and P = 0.861, respectively). Risk-adjusted multivariate regressions corroborated this finding, demonstrating that Medicaid and Medicare insurance status does not independently predict surgical site infection, seroma, hematoma, explantation, or wound dehiscence (all P > 0.05). Medicaid insurance status significantly predicted flap failure (odds ratio = 3.315, P = 0.027). Conclusions: This study is the first to investigate the differential effects of payer status on outcomes following breast reconstruction. Our results suggest that Medicaid and Medicare insurance status does not independently predict increased overall complication rates following breast reconstruction. This finding underscores the commitment of the plastic surgery community to providing consistent care for patients, irrespective of insurance status.

Acellular Dermal Matrix in Tissue Expander Breast Reconstruction Predicts Increased Infection and Seroma in a Multivariate Regression Model

INTRODUCTION: Acellular dermal matrix (ADM) is a popular adjunct to two-stage tissue expander/implant (TE/I) breast reconstruction following mastectomy. Touted benefits include the ability to rapidly expand the breast mound and improved aesthetic results. Recent comparative studies as well as our preliminary results have raised the possibility of higher complication rates associated with ADM use (1-4). However, existing knowledge is limited due to an inability to account for existing predisposing patient conditions. Our study assessed relative risks for complications in a large series of TE/I breast reconstructions using a robust multivariate regression model.

Statistical process control charts for ophthalmology

Dear Editor,In this era of evidence-based medicine, ophthalmologistscontinually strive to integrate the most advanced medicaland surgical knowledge into routine clinical practice.However, do we have any real-time methods to statisticallymonitor processes of care in our practices and revealavenues for improvement? Over the past several years, theuse of statistical process control (SPC) charts, a toolkitdeveloped in engineering for process improvement, hasgained popularity in healthcare. Though SPC charts aretypically used in primary care settings, specialties includingcardiology and pulmonology have begun to utilize thesetools to assess both patient outcomes and the effectivenessof quality improvement interventions into clinical processes[1, 2].There are several types of SPC charts. XmR charts andp-charts are frequently used in the healthcare setting [2].These charts characterize the incidence of disease longitu-dinally over a given period of time. They can be used inconjunction with g-charts, which are designed to monitorthe number of days between incidence of disease. Interpre-tation of a g-chart enables the user to predetermine howmuch variation (i.e., the interval days between cases) ispermissible before case frequency becomes excessive, thuscreating a goal to guide quality improvement measures.SPC charts not only monitor incidence over time but canalso be used to calculate points of statistically significantvariation—‘special cause’—in the clinical process [2].Initially, physicians must determine the normal clinicaloutcome variation for a given procedure. Benchmarks fornormal variation can be foundintheliterature.Forexample, assume that at a particular clinic there have beenapproximately 3–4 cases of endophthalmitis each year forthe past 10 years, and that 6,000–8,000 surgeries have beenperformed each year. If one were to track this data over adecade, it would most likely be the case that the data wouldbe in normal (‘common cause’) variation. Normal variationis stable and predictable. However, if there is a ‘specialcause’ signal, it denotes that there has been a change to theprocess or system either above the upper control limit(UCL) or below the lower control limit (LCL). Specialcause indicates that the incidence of cases has exceedednormal variation in a given time (e.g., seven cases peryear). In the case of endophthalmitis occurrence, if thespecial cause signal occurs below the LCL, this lets oneknow that there is something positive occurring in theclinical process and that one must continue to do it in orderto continue such progress. As one can discern, qualitativejudgment must be used to decide on a clinically acceptablelevel of complications when trying to determine if a processis to be continued or if changes to the process arewarranted.There have been only two reports in the ophthalmologicliterature exploring the use of control charts [3, 4]. Both