Steven Teitelbaum

Acellular dermal matrix for the treatment and prevention of implant-associated breast deformities.

Background: Acellular dermal matrix has been increasingly accepted in prosthetic breast reconstruction. Observed benefits include improved control and support of implant position, better implant coverage, and the suggestion of a decreased capsular contracture rate. Based on this positive experience, it is not surprising that acellular dermal matrix would be applied to other challenging implant-related problems. This study investigates the use of acellular dermal matrix for correction or prevention of implant-associated breast deformities. Methods: Patients who underwent primary aesthetic breast surgery or secondary aesthetic or reconstructive breast surgery using acellular dermal matrix and implants between November of 2003 and October of 2009 were reviewed retrospectively. Patient demographics, indications for acellular dermal matrix, and acellular dermal matrix type and inset pattern were identified. Preoperative and postoperative photographs, success or failure of the procedure, complications, and need for related or unrelated revision surgery were recorded. Results: Fifty-two patients had acellular dermal matrix placed alongside 77 breast prostheses, with a mean follow-up of 8.6 months (range, 0.4 to 30.4 months). Indications included prevention of implant bottoming-out (n = 6), treatment of malposition (n = 32), rippling (n = 20), capsular contracture (n = 16), and skin flap deficiency (n = 16). Seventy-four breasts (96.1 percent) were managed successfully with acellular dermal matrix. Three failures consisted of one breast with bottoming-out following treatment of capsular contracture, one breast with major infection requiring device explantation, and one breast with recurrent rippling. There was a 9.1 percent total complication rate, consisting of three mild infections, one major infection necessitating explantation, one hematoma, and one seroma. Conclusion: Based on this experience in 77 breasts, acellular dermal matrix has shown promise in treating and preventing capsular contracture, rippling, implant malposition, and soft-tissue thinning.

The "neosubpectoral" pocket for the correction of symmastia.

Background: Symmastia is a rare but challenging problem to correct. A number of techniques have been proposed, but each has drawbacks in terms of reliability, accuracy, and difficulty. A recently described technique to treat subpectoral symmastia is reported whereby a new pocket is created between the deep surface of the pectoralis major muscle and the anterior surface of the periprosthetic capsule, the boundaries of which are limited by the adherence between the capsule and overlying tissue. The “neosubpectoral” pocket is therefore not a “repair” of the excessively medialized symmastia pocket, but is a new pocket, limited at its perimeter by the patients own tissues rather than by sutures or a patch. Methods: A precise neosubpectoral plane is developed between the pectoralis major and the anterior implant capsule wall, with dissection limited to creating only the space necessary for proper placement of the implant. The technical details of this procedure are described. A chart review was conducted of all patients who underwent symmastia correction using this technique since December of 2003 at Georgetown University Hospital in the practices of Steven Teitelbaum, M.D., and G. Patrick Maxwell, M.D. Results: A total of 23 patients underwent symmastia correction using the neosubpectoral technique. Several of these patients presented for recurrence after failed capsulorrhaphy. There has been no recurrence of symmastia to date in this study. The average follow-up was 22 months. One postoperative hematoma and one seroma occurred. One patient had uncorrected, underdiagnosed inferior malposition from an earlier procedure requiring revision. Conclusions: The neosubpectoral technique is a method for the correction of symmastia that may offer a more efficient, accurate, and effective solution in a single stage. It is an appealing concept that allows for a site change while maintaining the subpectoral position. This procedure is technically straightforward and may offer a reliable means of correcting many other forms of implant malposition and difficult reconstructions.

Breast augmentation roundtable.

This roundtable was conducted live at the American Society of Plastic Surgeons meeting in Chicago, Illinois, in 2005. Dr. Spear was not present for the roundtable, and his comments were formulated and added after the completion of the roundtable. For this reason, his comments have been placed in italics. Adams: On behalf of my co-editor for this supplement, Dr. Spear, Plastic and Reconstructive Surgery, and myself, we would like to welcome each of you and thank you for your participation. All of you were selected because this is a roundtable on reoperations in breast augmentation. This is thought to be a significant problem currently in breast augmentation, and you all have experience and insight into potential solutions. As far as the rules of this roundtable, they are written down in front of you. Basically, there is not going to be any content added post-roundtable other than grammar. There are five questions listed at the bottom. Each question will be discussed for a total of 12.5 minutes. The initial question response, which each of you will have time to respond to, will be 1.5 minutes, and the first participant to respond will be rotated. We will have an open discussion for 5 minutes or up to the 12.5minute time limit, which Dr. Teitelbaum will facilitate. Any questions? I’d like to introduce Steve Teitelbaum, who is going to moderate this. Steve, I’ll turn it over to you.

Discussion: late seromas after breast implants: theory and practice.

T presentation of a patient with a late periprosthetic breast seroma creates a therapeutic conundrum for many plastic surgeons, frequently setting off a cavalcade of e-mails to colleagues seeking advice. The recent description of anaplastic large cell lymphoma, the most common presentation of which is a seroma, has increased surgeon concern over seroma management.1–4 In contrast to familiar approaches to capsular contracture, late seromas are often managed in a “one-off” manner. This level IV retrospective multicenter case control study followed the treatment and outcome of 28 seromas in 25 patients occurring in three surgeons’ practices. Five different therapeutic strategies were used in these patients, and all seromas were successfully treated. This is correctly described as a level IV study. But although multicenter, it is a retrospective review of three separate physicians’ practices. There was not collaboration among the institutions to prospectively define diagnostic or therapeutic criteria. There were no case– controls and no comparisons between treatments made. In some respects perhaps, this study might be more accurately described as three separate level IV studies that were combined and presented simultaneously.5 A primary finding was that all the various management strategies undertaken by the authors proved successful. But that does not mean that any strategy would work. Readers must understand that these authors used specific procedures: replacement/capsulectomy, replacement/no capsulectomy, capsulectomy/removal, drainage, and antibiotics. Some surgeons reuse implants following capsular contracture or seroma surgery, but these authors always used a new implant at surgery (and with recent evidence about the association of biofilm with capsular contracture, implants should always be replaced during capsular contracture surgery.) They were also definitive with their therapy, limiting numbers of repeated aspirations and not attempting to treat the seroma with tight dressings in the unrealistic hope that it would resolve spontaneously. In an effort to protect the implant from damage, drainage was only performed with ultrasonic guidance and not blind aspiration. It is not clear whether the various methods would be equally effective in all circumstances. Seromas can occur from multiple etiologies, and it is not known whether the underlying causes of each seroma between practices or within each practice were the same or that the choice of therapy was somehow affected by subtleties of clinical presentation not captured in the collected data. The authors defined late seroma as occurring at least 1 year after implantation, with the mean occurrence at 4.7 years. Nothing in this article should be construed to apply to breast enlargement occurring in the first year after augmentation, for which the underlying causes and treatments may be much different. There were only a few patients in some of the groups (15 by capsulectomy and placement of new implant, three by new implant but without capsulectomy, two by capsulectomy without implant replacement, five by ultrasonic aspiration, and three by antibiotics alone). These numbers are too small to determine whether the outcomes would be equivalent with each of these strategies. The study considered the resolution of the presenting seroma as a success. But avoiding subsequent contracture is important; however, contracture grade after the seroma was not evaluated. And with less than 1 year of follow-up for treatment of a disorder that took nearly a mean