Suhail K. Kanchwala

Reliable soft tissue augmentation: a clinical comparison of injectable soft-tissue fillers for facial-volume augmentation.

While injectable fillers for facial-volume augmentation have been extensively marketed, there are few published reports comparing the clinical efficacy and cost-effectiveness of multiple injectable agents for soft-tissue augmentation in the face. We present our experience in 976 patients with the use of 4 common injectable agents: autologous fat, Hylaform, Restylane, and Radiesse. We analyzed the injection characteristics of each filler, including injection volume, complication rate, revision rate, and longevity, across 3 commonly treated anatomic regions: the nasolabial fold, glabella, and lips. We subsequently performed a detailed cost-effectiveness analysis of each filler in each anatomic region. Our results demonstrate that autologous fat transplantation is ideally suited for the treatment of the nasolabial fold and glabella, particularly in combination with other procedures. Fat grafting to the lips is limited to use as an adjunct to other facial surgery due to the prolonged recovery time required. We prefer Radiesse for the isolated treatment of the nasolabial folds and glabella. However, Radiesse is not recommended in the lips due to the increased incidence of complications. Last, the hyaluronic fillers Restylane and Hylaform have an excellent safety profile and are our first choice for isolated lip augmentation procedures.

Impact of Obesity on Outcomes in Breast Reconstruction: Analysis of 15,937 Patients from the ACS-NSQIP Datasets

BACKGROUND Obesity is a growing epidemic in the United States (US) affecting more than 33% of adults. We aimed to use the World Health Organization (WHO) obesity stratification scheme to assess the overall risk of obese patients undergoing breast reconstruction using the ACS-NSQIP database from 2005 to 2010. STUDY DESIGN We reviewed the 2005 to 2010 ACS-NSQIP databases identifying encounters for Current Procedural Terminology (CPT) codes including either implant-based reconstruction (immediate, delayed, and tissue expander) or autologous reconstruction (pedicled transverse rectus abdominis myocutaneous [pTRAM], free TRAM, and latissimus dorsi flap with or without implant). Patients were classified and compared based on WHO obesity criteria: nonobese (body mass index [BMI] = 20 to 29.9 kg/m(2)), class I (BMI = 30 to 34.9 kg/m(2)), class II (BMI = 35 to 39.9 kg/m(2)), and class III (BMI > 40 kg/m(2)). RESULTS During the study period 15,937 breast reconstructions were performed. The majority of reconstructions were immediate reconstructions (85.0%) and implant-based (79.1%). The incidence of obesity was 27.1%, with 16.3% defined as class I obese, 6.9% defined as class II obese, and 4.0% defined as class III obese. The WHO-classified obese patients tended to have a progressively higher incidence of comorbid conditions, higher American Society of Anesthesiologists (ASA) physical status (p < 0.001), longer operative times (p = 0.0001), and greater lengths of hospital stay (p = 0.0001). Progressively higher BMIs were associated with higher rates of complications, including wound (p < 0.001), medical (p < 0.001), infections (p < 0.001), major surgical (p < 0.001), graft and prosthesis loss (p < 0.001), and return to the operating room (p < 0.001). CONCLUSIONS This study characterized the effect of progressive obesity on the incidence of surgical and medical complications after breast reconstruction using a large, prospective multicenter dataset. Increasing obesity is associated with increased perioperative morbidity. Data derived from this cohort study can be used to risk-stratify patients, enhance risk counseling, and advocate for institutional reimbursement in obese patients undergoing breast reconstruction.

Autologous fat grafting to the reconstructed breast: the management of acquired contour deformities.

Background: Autologous fat grafting has become a workhorse for soft-tissue augmentation throughout the body. In the reconstructed breast, autologous fat grafting is a useful tool for managing secondary contour deformities. The authors have categorized these deformities into three types: type 1 deformities are step-off deformities between the chest wall/reconstructed breast interface, type 2 deformities result from intrinsic deficiencies within a flap such as fat necrosis, and type 3 deformities are the result of extrinsic factors such as postoperative irradiation. Methods: The authors conducted a detailed retrospective review of 110 patients who have received fat grafting to the reconstructed breast for the management of contour deformities. In addition, the authors reviewed the recent literature describing the use of autologous fat grafting to the breast. Particular attention has been placed on the concerns of oncologic surveillance in reconstructed breasts that have undergone fat grafting. Results: The authors have had relative success in the treatment of patients who will require postoperative irradiation and even those who have rippling surrounding an implant. Conclusions: Autologous fat grafting represents an important tool for the management of secondary contour deformities of the reconstructed breast. Fat grafting is a simple, safe, and effective treatment option, with low morbidity.

Comprehensive outcome and cost analysis of free tissue transfer for breast reconstruction: an experience with 1303 flaps.

Background: Free tissue transfer is standard for postoncologic reconstruction, yet it entails a lengthy operation and significant recovery. The authors present their longitudinal experience of free tissue breast reconstructions with an emphasis on predictors of major surgical and medical complications. Methods: The authors reviewed their prospectively maintained free flap database and identified oncologic breast reconstruction patients from 2005 to 2011. Factors associated with surgical and medical complications were identified using univariate analyses and logistic regression to determine predictors of complications. Results: Complications included major immediate surgical complications [n = 34 (4.0 percent)], major delayed surgical complications [n = 54 (6.4 percent)], minor surgical complications [n = 404 (47.6 percent)], and medical complications [n = 50 (5.9 percent)]. Obesity (p = 0.034), smoking (p = 0.06), flap type (p = 0.005), and recipient vessels (p < 0.001) were associated with immediate complications. Similarly, delayed surgical complications were associated with obesity (p < 0.001), chronic obstructive pulmonary disease (p < 0.001), hypertension (p < 0.001), and prior radiation therapy (p = 0.06). Regression analysis demonstrated that flap choice (p = 0.024) was independently associated with major immediate complications, and patient comorbidities such as chronic obstructive pulmonary disease (p = 0.001) and obesity (p < 0.0001) were associated with delayed complications. Patients who developed an immediate surgical complication experienced longer hospital stays (p < 0.0001), higher operating costs (p < 0.001), and greater hospital costs (p < 0.001). Conclusions: Early major complications are related to flap selection, whereas late major complications are associated with patient comorbidities. Overall, major surgical and medical complications are associated with increased hospital length of stay and greater cost in autologous breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

The role of autologous fat and alternative fillers in the aging face.

Summary: Soft-tissue fillers can be used successfully to restore volume loss caused by facial aging. Injectable fillers can be used in isolation or in conjunction with other facial rejuvenation procedures. To achieve a superior aesthetic result, the plastic surgeon must understand the key components of facial aging: soft-tissue atrophy, gravitational descent, and loss of skin tone. An accurate assessment of the relationship of these factors will determine the role of soft-tissue augmentation through the use of fillers. Because the majority of facial volume loss through aging is attributable to fat loss, the authors believe that autologous fat represents the ideal soft-tissue replacement. The authors describe the appropriate use of autologous fat and improvements in technique that have enhanced the predictability of facial fat grafting. When autologous fat is not an option, alternative facial fillers including calcium hydroxylapatite and hyaluronic acid may provide excellent results. The authors’ algorithm for filler selection is based on relative morbidity, recipient-site characteristics, and the physical characteristics of each filler. This algorithm is discussed in the following anatomical regions: the nasolabial folds, glabellar crease, malar region, nasojugal groove, and lips. When used appropriately, soft-tissue fillers can contribute significantly to overall facial rejuvenation.

Free tissue transfer in the obese patient: an outcome and cost analysis in 1258 consecutive abdominally based reconstructions.

Background: The authors’ institution has seen an increase in obese and morbidly obese patients seeking autologous breast reconstruction. The authors provide a comprehensive outcome analysis of patients undergoing abdominally based autologous breast reconstruction. Methods: The authors identified obese patients receiving free tissue transfer for breast reconstruction. World Health Organization body mass index criteria were used: nonobese (body mass index, 20 to 29.9 kg/m2), class I (30 to 34.9 kg/m2), class II (35 to 39.9 kg/m2), and class III (>40 kg/m2). Patient comorbidities, body mass index, complications (medical and surgical), and hospital resource use were examined. Results: Eight-hundred twelve patients undergoing 1258 free tissue transfers for breast reconstruction were included. Overall, 66.5 percent (n = 540) were considered nonobese, 22.9 percent (n = 186) had class I obesity, 5.0 percent (n = 41) had class II, and 5.7 percent (n = 45) had class III. Obesity was associated with a significant increase in minor (p = 0.001) and major (p = 0.013) complications. Morbidly obese patients had significantly higher rates of total flap loss (p = 0.006) and longer operative times (p = 0.0002). Complications translated into greater cost and resource consumption (p < 0.001). Muscle-sparing transverse rectus abdominis myocutaneous flap experienced a significantly higher rate of hernia compared with other flaps (p = 0.02), without a difference in flap loss rate (p = 0.61). Conclusions: Increasing obesity is associated with increased perioperative risk in free abdominally based autologous breast reconstruction, which translated into greater perioperative morbidity, higher hospital cost, and increased health care resource consumption. Higher body mass index is directly related to intraoperative technical difficulty, flap loss, donor-site morbidity, and cost use. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Breast reconstruction modality outcome study: a comparison of expander/implants and free flaps in select patients.

Background: Choosing a breast reconstructive modality after mastectomy is a critical step involving complex decisions. The authors provide outcomes data comparing two common reconstructive modalities to assist patients and surgeons in preoperative counseling and discussions. Methods: A prospectively maintained database was queried identifying select patients undergoing expander/implant and abdominally based free flaps for breast reconstruction between 2005 and 2008. Variables evaluated included comorbidities, operations, time to reconstruction, complications, overall outcome, clinic visits, revisions, and costs. Results: One hundred forty-two patients received free flaps and 60 received expander/implants. Expander/implant patients required more procedures (p < 0.001) but had shorter overall hospital lengths of stay (p < 0.001). The two cohorts experienced a similar rate of revision (p = 0.17). Free flap patients elected to undergo nipple-areola reconstruction more frequently (p = 0.01) and were able to sooner (p < 0.0001). Patients undergoing expander/implant reconstruction had a higher rate of failure (7.3 versus 1.3 percent, p = 0.008). Free flap patients achieved a stable reconstruction significantly faster (p = 0.0005), with fewer visits (p = 0.02). Cost analysis demonstrated total cost trended toward significantly lower in the free flap cohort (p = 0.15). Reconstructive modality was the only independent factor associated with time to stable reconstruction and reconstructive failure (p < 0.001 and p = 0.05, respectively). Conclusions: The authors’ analysis revealed that free flap reconstructions required fewer procedures, had lower rates of complications and failures, had fewer clinic visits, and achieved a final, complete reconstruction faster than expander/implant reconstructions. Although autologous reconstruction is still not ideal for every patient, these findings can be used to enhance preoperative discussions when choosing a reconstructive modality. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Breast reconstruction in the morbidly obese patient: assessment of 30-day complications using the 2005 to 2010 national surgical quality improvement program data sets.

Background: The authors assess the risk and safety profiles of both implant and autologous breast reconstructions in the morbidly obese population using the National Surgical Quality Improvement Program data sets. Methods: The authors reviewed the 2005 to 2010 National Surgical Quality Improvement Program databases, identifying encounters for Current Procedural Terminology codes including either implant-based reconstruction or autologous reconstruction. Patients were classified and compared based on World Health Organization obesity criteria. Complications were divided into three categories: major surgical complications, wound complications, and medical complications. Results: During the study period, 15,937 breast reconstructions were identified. The incidence of obesity was 27.1 percent, with 4.0 percent defined as class III (morbidly) obese. Morbidly obese patients had significantly higher rates of almost all complications compared with nonobese patients, including major surgical complications (p < 0.001), medical complications (p < 0.001), respiratory complications (p = 0.015), venous thromboembolism (p = 0.001), and wound complications (p < 0.001). These patients also were more likely to require a return to the operating room both for any reason (p < 0.001) and specifically for prosthesis/flap failure (p < 0.001). Morbid obesity was found to be an independent predictor of wound complications (OR, 2.1; p < 0.001), surgical complications (OR, 1.6; p < 0.001), medical complications (OR, 1.6; p = 0.01), and return to the operating room (OR, 1.5; p < 0.001). There was no significant difference in the 30-day surgical complication rates between implant and autologous reconstructions in the morbidly obese (p = 0.23). Conclusion: Morbid obesity is associated with a significantly increased risk of perioperative complications that translates into progressive, higher rates of overall morbidity, regardless of reconstructive modality. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Prophylactic muscle flaps in vascular surgery

BACKGROUND Vascular surgery-related groin complications can lead to catastrophic outcomes and pose a significant healthcare burden. We have taken steps to reduce potential complications at the time of initial surgery by performing prophylactic muscle flaps. The purpose of this study is to evaluate the efficacy and benefit of prophylactic flaps in high-risk patients. METHODS A retrospective cohort study was performed on patients undergoing open vascular surgery involving the femoral vessels through a groin incision between 2005 and 2010. Patients receiving prophylactic muscle flaps at their initial surgery were compared with those patients not receiving a flap (control). RESULTS Sixty-eight prophylactic flaps in 53 patients were compared with 195 open vascular procedures without flaps in 178 patients. The most frequent indication was reoperative bypass surgery with prosthetic reconstruction (63%). The prophylactic patient group exhibited significantly higher rates of comorbidities, including chronic obstructive pulmonary disease (25.0% vs 12.6%; P = .018) and hyperlipidemia (80.9% vs 59.1%; P = .002). Patients receiving prophylactic flaps had lower rates of overall complications (16.2% vs 50.3%; P < .001), infections (1.5% vs 38.5%; P < .001), seroma (0% vs 7.2%; P = .023), and lymphocele (1.5% vs 15.4%; P = .002). Multivariate regression demonstrated that obesity (odds ratio [OR], 2.1 [1.001-4.49]; P = .05), smoking (OR, 2.7 [1.37-5.16]; P = .004), reoperation (OR, 3.5 [1.41-8.63]; P = .007), and prosthetic graft reconstruction (OR, 2.0 [1.03-3.78]; P = .04) were associated with postoperative complications. Additionally, in analyzing all groin complications in all patients, we found that patients who received a prophylactic flap experienced significantly less groin wound complications (OR, 0.17; P < .001). CONCLUSIONS Complications following open groin surgery are common, lead to significant morbidity, and are very costly. Performing prophylactic muscle flaps at the initial surgery to cover the femoral vessels and reduce dead space can significantly reduce complications in select high-risk patients. Prophylactic flaps are safe, effective, and should be considered in patients with multiple comorbidities undergoing high-risk groin surgery, such as reoperative prosthetic bypass surgery.

Wound healing complications after autologous breast reconstruction: A model to predict risk

INTRODUCTION Delayed wound healing is costly to the breast reconstruction patient and the health care infrastructure. The purpose of this study is to identify potentially modifiable risk factors and to create a model to assess patient risk of these complications. METHODS We performed a retrospective study of all free autologous reconstructions at a single institution (2005-2011). Patients with delayed wound healing (operative wounds requiring dressing changes for longer than 3 weeks) were compared to patients with normal healing with respect to history and case characteristics. A risk model was developed to stratify patients based on the multivariate logistic regression results. RESULTS Delayed wound healing impacted 297 (44%) of 682 patients. These patients were older (p = 0.02), with higher BMI(p < 0.0001), and higher rates of medical comorbidities (p < 0.001), active smoking (p = 0.02) and bilateral reconstruction (p = 0.02). They received a lower rate/kg of fluid resuscitation intraoperatively (p = 0.001) and more commonly received vasopressors (p = 0.004), with a greater total reconstructive cost (p = 0.003). A regression demonstrated that progressive obesity, smoking, bilateral reconstruction, and utilization of vasopressors were associated with delayed healing (p < 0.05). The final model, with three risk groups (low, intermediate and high) demonstrated that high risk patients have an 86% risk of wound healing complications, compared to a 33% risk in patients with few risk factors. CONCLUSIONS While patient disease remains a major predictor of wound complications, potentially modifiable variables including smoking and vasopressor administration impacted this complication. Utilizing the simple model to preoperatively assess patient risk, targeted measures can be undertaken with the goal of ultimately reducing wound healing complications and cost.