Tiffany A. Chen

Clinical outcomes in breast cancer expander-implant reconstructive patients with radiation therapy

Immediate expander-implant breast reconstruction (EIBR) with external beam radiation therapy (XRT) is pursued by many breast cancer patients; however, there is still a lack of consensus on the expected clinical outcomes. We performed a critical analysis of postoperative outcomes in EIBR patients with XRT exposure through a retrospective review from January 2007 to December 2013. Patients were stratified into three groups: exposure to preoperative XRT (XRT-pre), postoperative XRT (XRT-post), or no XRT (control). A subset of XRT patients with bilateral EIBR was assessed using a matched-pair analysis with the patients serving as their own controls. A total of 76 patients were included in the study. Major complications were observed in 6 of 8, 26 of 38, and 14 of 30 patients in the XRT-pre, XRT-post, and control groups, respectively, and were not statistically different (p > 0.05). EIBR failure rates were 13.3% in the control group compared to 50.0% in the XRT-pre group (p = 0.044) and 26.3% in the XRT-post group (p > 0.05). In the matched-pair analysis, 16 of 26 irradiated breasts developed complications compared to only 7 of 26 contralateral non-irradiated breasts (p = 0.043). In conclusion, we detected a significantly increased risk of complications in patients with pre-mastectomy radiotherapy. Patients with this history of XRT should strongly consider autologous reconstruction instead of EIBR to avoid the high risk of developing complications and subsequently losing their implant. Increased complications in irradiated breasts when compared to the contralateral non-irradiated breasts in bilateral EIBR patients confirmed the detrimental role of XRT in the setting of EIBR.

Bioengineered dermal substitutes for the management of traumatic periocular tissue loss

ABSTRACT Purpose: Traumatic periocular injuries occasionally result in significant soft tissue loss, for which there are limited management options that provide satisfactory cosmetic and functional outcomes. The authors describe the use of a bioengineered dermal substitute (Integra® Dermal Regeneration Template [DRT], Integra LifeSciences, Plainsboro, NJ) as an alternative to immediate flap reconstruction or skin grafting. Methods: Retrospective interventional case series of patients who underwent DRT placement for periocular tissue loss at the time of trauma. In each case, primary closure or immediate flap reconstruction was deemed impractical or undesirable due to the size and location of the primary and associated secondary defects. One to four weeks later, the outer silicone layer was removed and healing assessed. Additional reconstructive techniques were performed as needed. Results: Three patients were treated at Bascom Palmer Eye Institute and one at Byers Eye Institute at Stanford. The defects healed completely in two patients, and by 79.2% in a third, with no need for additional reconstructive surgery. In the remaining patient, the defect was significantly downsized by 56.1%, allowing for a simpler flap reconstruction. Conclusions: Bioengineered dermal substitutes should be considered as a viable alternative to traditional reconstructive techniques for large periocular defects resulting from trauma. The outer silicone layer prevents desiccation and serves as a protective barrier, while the inner collagen matrix organizes the growth of neo-dermis and minimizes wound contraction. The dimensions of cutaneous defects can therefore be reduced dramatically, potentially eliminating the need for skin grafting and/or reducing the ultimate complexity of flap reconstruction.

Outcomes of Intravitreal Bevacizumab and Diode Laser Photocoagulation for Treatment-Warranted Retinopathy of Prematurity

BACKGROUND AND OBJECTIVE To investigate the outcomes of infants with treatment-warranted retinopathy of prematurity (TW-ROP) who received intravitreal bevacizumab (Avastin; Genentech, South San Francisco, CA) (IVB) injections as compared to diode laser photocoagulation (DLP). PATIENTS AND METHODS Data from the Stanford University Network for Diagnosis of Retinopathy of Prematurity database and inpatients at Stanford Childrens Hospital were retrospectively reviewed for premature newborns with TW-ROP treated with DLP or 0.625 mg of IVB. Patient characteristics, hospital course, and neurodevelopmental outcomes were compared. RESULTS In all, 49 eyes from 25 patients were included; 10 infants (20 eyes) received DLP and 15 infants (29 eyes) received IVB. The IVB infants had significantly fewer diagnoses at the time of discharge and fewer readmissions after initial hospital discharge than the DLP infants (four versus six diagnoses, P = .004; zero versus one readmission, P = .038). At an average of 20 months corrected age, there was no significant difference in neurodevelopmental delay (adjusted odds ratio = 0.87; 95% CI, 0.08-9.46). CONCLUSION Systemic morbidity may be similar among infants treated initially with bevacizumab compared to DLP. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:126-131.].

Disseminated silicone granulomatosis in the face and orbit

Purpose To report a case of disseminated silicone granulomatosis presenting with ptosis, proptosis and vision loss. Observations A 56-year-old female presented with ptosis, proptosis, and vision loss and was noted to have palpable, erythematous masses involving the orbit, face, trunk, and body. She had a history of bilateral silicone breast implants and cosmetic facial filler injections. Orbital biopsy demonstrated non-caseating granulomas with foreign-body giant cells and vacuoles containing material consistent with silicone. Removal of the patients breast implants and systemic immunosuppression led to dramatic granuloma regression. Conclusions Silicone can induce a severe, systemic inflammatory response and should be considered in the differential for facial and periorbital granulomas in patients with a history of silicone breast implants. Management of disseminated silicone granulomatosis is challenging and requires multimodal treatment with silicone removal and systemic immunomodulation.

Porcine Collagen Transconjunctival Wound Closure System for Microincisional Vitrectomy Surgery

BACKGROUND AND OBJECTIVE Microincisional vitrectomy surgery has improved outcomes for vitrectomies; however, wound closure complications remain an important concern. The authors introduce a technique to improve transconjunctival wound closure in vitrectomy surgery. PATIENTS AND METHODS The authors evaluated the efficacy of porcine collagen plugs on stopping leakage from sclerotomy test sites in vitro and in vivo and assessed wound site healing with histology samples. RESULTS The porcine collagen plugs successfully prevented leakage of trypan blue dye in enucleated rabbit eyes and of fluid flow in the rabbit model. Histology showed excellent wound reconstruction and healing, with essentially no inflammation for either angled or straight incisions with a 23-gauge system. CONCLUSIONS The authors describe a simple and effective novel approach to wound closure in any-gauge vitrectomy surgery using porcine collagen plugs. This method can help reduce complications related to wound leakage. The authors plan to conduct human studies to demonstrate the safety of the approach in the future. [ Ophthalmic Surg Lasers Imaging Retina. 2017;48:576-579.].

Should We Excise Native Breast Skin Envelope to Achieve Symmetric Scars in Bilateral Autologous Breast Reconstruction?--A Survey of Surgeon and Patient Preference.

BackgroundGiven the multiple possible scar patterns in autologous breast reconstruction and combinations of such patterns in bilateral reconstruction, the present study aimed to determine the importance of scar symmetry in achieving aesthetically pleasing results. MethodsA survey was administered to 128 participants including plastic surgeons and female breast reconstruction patients. In part A of the survey, participants were provided with photos of bilateral autologous breast reconstructions, and scar placement was varied to represent bilateral (1) immediate, (2) delayed symmetric, (3) delayed asymmetric, and (4) a mixture of immediate and delayed free flap reconstructions. Participants were asked to rank the photos in order of best to worst aesthetic outcome. In part B, pairs of the same reconstruction before and after nipple-areolar complex (NAC) reconstruction were presented, and participants were asked to assign a score to each photo according to aesthetic outcome. ResultsIn part A, immediate reconstructions that included the smallest flap skin paddles ranked best among 52.5% ± 30% of participants, followed by delayed symmetric reconstructions that ranked best in 46.7% ± 29.6%. Mixed reconstructions ranked worst among 53.6% ± 37.6% of participants, followed by delayed asymmetric reconstructions (42.5% ± 37.9%). When NAC reconstruction was added to 1 set of the photos in part A, the same immediate reconstruction was ranked best, a significantly higher proportion of the time (36.3% increase, P < 0.001). This was accompanied by a significant decrease in top ranking for the delayed symmetric reconstruction (37.9% decrease, P < 0.001). In part B, addition of NAC increased each reconstructions score by an average of 1.36 points on a 5-point scale with patients citing less improvement between the conditions (0.93 ± 0.03) than plastic surgeons (1.13 ± 0.49) (P = 0.03). ConclusionsMore symmetric breast scars led to higher aesthetic ranking of bilateral autologous breast reconstructions. Participants in our survey preferred symmetric scars, even if achieving such a scar pattern would require excision of native breast skin and inclusion of more flap skin. Furthermore, NAC reconstruction alone improves aesthetic outcome, and improvement was most notable among immediate reconstructions.