Troy A. Pittman

A Prospective Study on Lipoaugmentation of the Breast

BACKGROUND The current standard for breast augmentation involves placement of an implant. As an alternative, surgeons have been exploring breast augmentation with autologous tissue in the form of injectable fat. OBJECTIVES The authors explore the efficacy and safety of lipoaugmentation of the breast, with specific interest in volume changes, fat retention, overall aesthetic improvement, and patient satisfaction. METHODS Direct measurements, 2- and 3-dimensional images, mammograms, and magnetic resonance imaging (MRI) were obtained preoperatively from 10 consecutive patients undergoing augmentation mammaplasty with autologous fat transfer. These measurements were repeated 1 year postoperatively. Postoperative photo imaging was conducted at 3-month intervals for 1 year. Efficacy was evaluated by determining the volume of fat retention 1 year after the procedure with 3-dimensional imaging, standard breast MRI volume measurements, and subjective aesthetic comparisons. RESULTS The average amount of fat injected was 236 cc (90-324; SD, 69.8) in the right breast and 250 cc (90-300; SD, 65.1) in the left. The mean volume change based on 3-dimensional imaging was 85.1 cc (36% retention) for the right breast and 98.1 cc (39.2% retention) for the left. The mean volume change based on MRI measurements was 30.0 cc (39.8% change) on the right and 29.3 cc (38.1% change) on the left. Blinded observers found substantial improvement in 1 patient (10%), moderate improvement in 5 patients (50%), and minimal to no improvement in 4 (40%). Overall patient satisfaction was high, as measured by the abbreviated BREAST-Q. Radiologic abnormalities and artifacts were common and required additional imaging. CONCLUSIONS Objective breast enlargement in this study was modest but yielded disproportionately high subjective patient satisfaction reports. LEVEL OF EVIDENCE 2.

Comparison of Different Acellular Dermal Matrix (ADM) in Breast Reconstruction: The 50/50 Study.

Background: Acellular dermal matrix has enjoyed extensive use in primary and secondary alloplastic breast aesthetic and reconstructive surgery. The objective of this study was to examine clinical outcomes between available acellular dermal matrix products: DermACELL (LifeNet Health, Virginia Beach, Va.) and AlloDerm Ready To Use (LifeCell Corp., Branchburg, N.J.). Methods: A retrospective chart review was performed on 58 consecutive patients (100 breasts) reconstructed with either DermACELL (n = 30 patients; 50 breasts) or AlloDerm Ready To Use (n = 28 patients; 50 breasts). The mastectomies were performed by three different breast surgeons. All reconstructions were performed by the same plastic surgeon (T.A.P.). Statistical analysis was performed by means of Fisher’s exact test. Results: Differences in the average age, body mass index, percentage having neoadjuvant/adjuvant chemotherapy or breast irradiation, and numbers of therapeutic and prophylactic mastectomies between the two groups were not statistically significant (p < 0.05). Complications in both cohorts of patients were clinically recorded for 90 days after immediate reconstruction. When comparing outcomes, patients in the DermACELL group had a significantly lower incidence of “red breast syndrome” (0 percent versus 26 percent; p = 0.0001) and fewer days before drain removal (15.8 days versus 20.6 days; p = 0.017). No significant differences were seen in terms of seroma, hematoma, delayed healing, infection, flap necrosis, or explantation. Conclusion: Patients reconstructed with DermACELL as compared with AlloDerm Ready To Use have significantly decreased number of days to drain removal and red breast syndrome and equivalent rates of other complications, including seroma, infection, flap necrosis, and explantation. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Anaplastic Large Cell Lymphoma: Emerging Consent and Management Patterns among American and International Board Certified Plastic Surgeons.

Background: Although literature and case reports regarding anaplastic large cell lymphoma (ALCL) continue to increase, changes in plastic surgery practice patterns have not been assessed. Methods: A 19-question survey was sent electronically to U.S. and international board-certified plastic surgeons. Data were analyzed using chi-square test and logistic regression analysis. Results: A total of 1383 surgeons (U.S., 715; international, 668) responded, at a rate of 13.5 percent, and 36.2 percent of U.S. physicians aspirate late seromas and send for cytologic analysis and 9.5 percent had personal experience with ALCL, equating to at least 193 self-reported cases. Overall, 26.9 percent discuss ALCL risk at the initial consultation every time, and 36.4 percent include ALCL in the informed consent. Compared to U.S. counterparts, Australian, French, and German physicians were five times as likely to include ALCL in consent. Physicians in an academic practice and those frequently (>40 percent) using textured implants were more likely to discuss ALCL in the preoperative consultation. Physicians with personal or colleague experience with ALCL were twice as likely to include ALCL in the consent process. Conclusions: Only one-third of surgeons are managing late seroma according to U.S. Food and Drug Administration guidelines. ALCL cases are likely being underreported. Collectively, plastic surgeons remain hesitant to change consent pattern. However, specific countries have adapted their consenting processes. Working in academia and frequent textured implant use makes one more likely to discuss ALCL in consultation. Personal or colleague experience makes one twice as likely to include ALCL in the consent.

Delayed Recurrent and Bilateral Breast Cancer in Patients With Partial Poland's Anomaly: Report of 2 Rare Cases and Review of the Literature

Patients with Poland’s anomaly are at risk for developing cancer in the ipsilateral hypoplastic/normal, contralateral, and reconstructed breasts. To date, however, only 16 cases of concurrent breast cancer in patients with Poland’s anomaly have been described. We report the first cases of (1) recurrent ipsilateral and (2) bilateral breast cancer in 2 patients with mild variants of partial Poland’s sequence. In both cases, localized, hormone-sensitive, ductal-based carcinoma was identified and effectively treated with mastectomy, direct lymph node assessment, and autologous reconstruction with regional pedicled flaps. No adjuvant therapies were administered in either case, and both patients remained disease-free at long-term follow-up. Recommendations regarding diagnostic screening for breast cancer in patients with Poland’s anomaly should follow those of the general population. Underlying anatomical abnormalities in these patients require special consideration, as skeletal and/or soft tissue derangements may influence decisions regarding appropriate diagnostic imaging, surgical treatment planning, adjunct oncologic therapies, and strategies for breast/chest wall reconstruction.

Midclavicular to inframammary fold measurement, a method of evaluation for nipple sparing mastectomy

Background: Preoperative assessment is vital to properly select patients for nipple sparing mastectomies (NSM). The objective of this paper is to describe a novel method, measuring from mid-clavicle to inframammary fold (IMF), to determine tissue envelope characteristics when evaluating a patient for a single stage, IMF incision NSM. Methods: The authors conducted a retrospective review of all IMF incision NSM between October 2010 to July 2016 that had IMF to mid-clavicle measurements. Patient characteristics, mastectomy weight, complications, and the association between measurement were analyzed. Results: Of a total 36 patients, 67 breasts were included for analysis. Increasing IMF to midclavicular measurements were found to be significantly related to increasing breast weight (P Conclusions: The authors demonstrated that midclavicular to IMF measurement approaching 34 cm had significantly increased complication rates, thus making this a potential tool for assessing tissue envelope characteristics in the evaluation for NSM. We propose 34 cm being a relative cut-off for single staged NSM.

Endoscopic Thoracodorsal Neurectomy for Correction of Animation Deformity following Latissimus Dorsi-Based Breast Reconstruction.

Endoscopic Thoracodorsal Neurectomy for Correction of Animation Deformity following Latissimus Dorsi–Based Breast Reconstruction Sir: P muscular contractions, involuntary twitching, tightness, and/or dynamic displacement of the breast affect a high percentage of patients (41 percent) undergoing innervated latissimus dorsi–based breast reconstruction.1 These sequelae can limit physical activity, jeopardize satisfaction, and diminish quality of life for individuals who have otherwise achieved a favorable aesthetic result. Studies evaluating the impact of surgical denervation of the latissimus dorsi muscle demonstrate significantly reduced pain and animation; comparable preservation of volume, shape, and symmetry; and improved satisfaction following thoracodorsal neurectomy.2,3 It is therefore our preference to perform primary nerve resection during immediate or delayed breast reconstruction, which is readily accomplished through an open axillary or dorsal approach and eliminates the need for a second-stage procedure. Nevertheless, plastic surgeons must also be familiar with treatment strategies for patients who present with secondary contractile deformities. In such cases, chemical denervation with botulinum toxin type A offers a temporary solution; however, results with this approach are unpredictable, and the need for repeated injections over time increases the risk of implant leakage and/or rupture.4 Alternatively, delayed proximal resection of the thoracodorsal nerve may offer the best available option for symptomatic relief. Although high success rates have been reported