Yoon S. Chun

Implant-Based Breast Reconstruction Using Acellular Dermal Matrix and the Risk of Postoperative Complications

Background: Acellular dermal matrix has been popularized as an adjunct to tissue expander or implant breast reconstruction given its utility in providing additional coverage and support for the inferior pole. This study was performed to assess the risk of postoperative complications associated with the use of acellular dermal matrix–assisted implant-based reconstruction. Methods: The authors performed a retrospective analysis of consecutive immediate breast reconstructions performed over a 6-year period. A total of 415 implant-based reconstructions were divided into two groups: tissue expander or implant-based reconstruction with or without acellular dermal matrix. Demographic information, comorbidities, oncologic data, adjuvant therapy, and complications were collected for comparison. Results: A total of 283 patients underwent 415 immediate breast reconstructions (151 unilateral and 132 bilateral); 269 reconstructions were performed using tissue expander or implants with acellular dermal matrix, and 146 reconstructions were performed without acellular dermal matrix. The seroma and infection rates were higher in the acellular dermal matrix group (14.1 versus 2.7 percent, p = 0.0003, for seroma; 8.9 versus 2.1 percent, p = 0.0328, for infection). Multiple logistic regression analysis showed that acellular dermal matrix and body mass index were statistically significant risk factors for developing seroma and infection. The use of acellular dermal matrix increased the odds of seroma by 4.24 times (p = 0.018) and infection by 5.37 times (p = 0.006). Conclusions: Acellular dermal matrix has enhanced implant-based reconstruction and remains useful in immediate prosthetic breast reconstruction. It is associated, however, with higher rates of postoperative seroma and infection. Careful patient selection, choice of tissue expander/implant volume, and postoperative management are warranted to optimize overall reconstructive outcome.

Three Patients with Full Facial Transplantation

Unlike conventional reconstruction, facial transplantation seeks to correct severe deformities in a single operation. We report on three patients who received full-face transplants at our institution in 2011 in operations that aimed for functional restoration by coaptation of all main available motor and sensory nerves. We enumerate the technical challenges and postoperative complications and their management, including single episodes of acute rejection in two patients. At 6 months of follow-up, all facial allografts were surviving, facial appearance and function were improved, and glucocorticoids were successfully withdrawn in all patients.

Restoration of Facial Form and Function After Severe Disfigurement from Burn Injury by a Composite Facial Allograft

Composite facial allotransplantation is emerging as a treatment option for severe facial disfigurements. The technical feasibility of facial transplantation has been demonstrated, and the initial clinical outcomes have been encouraging. We report an excellent functional and anatomical restoration 1 year after face transplantation. A 59‐year‐old male with severe disfigurement from electrical burn injury was treated with a facial allograft composed of bone and soft tissues to restore midfacial form and function. An initial potent antirejection treatment was tapered to minimal dose of immunosuppression. There were no surgical complications. The patient demonstrated facial redness during the initial postoperative months. One acute rejection episode was reversed with a brief methylprednisolone bolus treatment. Pathological analysis and the donors medical history suggested that rosacea transferred from the donor caused the erythema, successfully treated with topical metronidazol. Significant restoration of nasal breathing, speech, feeding, sensation and animation was achieved. The patient was highly satisfied with the esthetic result, and regained much of his capacity for normal social life. Composite facial allotransplantation, along with minimal and well‐tolerated immunosuppression, was successfully utilized to restore facial form and function in a patient with severe disfigurement of the midface.

Comparison of morbidity, functional outcome, and satisfaction following bilateral TRAM versus bilateral DIEP flap breast reconstruction.

Background: The potential for donor-site morbidity associated with bilateral pedicled transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction has led to the popularization of deep inferior epigastric artery perforator (DIEP) flap reconstruction. This study compares postoperative morbidity and satisfaction following bilateral pedicled TRAM and DIEP flap reconstruction. Methods: One hundred five women with bilateral pedicled TRAM flaps were compared with 58 women with bilateral DIEP flap reconstruction. Medical records were reviewed for complications and demographic data. Postoperative follow-up data were obtained through Short Form-36, Functional Assessment of Cancer Therapy-Breast, Michigan Breast Satisfaction, and Qualitative Assessment of Back Pain surveys. Results: The mean follow-up interval was 6.2 years in the bilateral TRAM group and 2.3 years in the bilateral DIEP group (p < 0.001). Demographic data were otherwise similar. Abdominal hernias occurred in three TRAM patients (2.9 percent) and in no DIEP patients, whereas abdominal bulges occurred in three TRAM patients (2.9 percent) and four DIEP patients (6.9 percent); these differences were not statistically significant. Fat necrosis occurred less frequently in the TRAM group (p = 0.04). Postoperative survey results revealed no significant difference in patient satisfaction, incidence of back pain, or physical function. The TRAM group scored higher in the Medical Outcome Study Short Form-36 subjective energy category (p = 0.01) and mean Functional Assessment of Cancer Therapy-Breast score (p = 0.01). Conclusions: This study suggests no significant differences in donor-site morbidity, survey-based functional outcome, or patient satisfaction between bilateral TRAM and DIEP flap breast reconstruction. Although perforator flaps represent an important technological advancement, bilateral pedicled TRAM flap reconstruction still represents a good option for autologous breast reconstruction.

Minimizing Complications With the Use of Acellular Dermal Matrix for Immediate Implant-based Breast Reconstruction

BackgroundAcellular dermal matrix (ADM) use in implant-based breast reconstruction has been associated with higher rates of postoperative seroma and infection. This follow-up study was performed to determine whether specific modifications in technique are associated with a reduction in the rate of complications. MethodsThe authors performed a retrospective analysis of immediate ADM-assisted implant-based breast reconstructions performed by the lead author (Y.C.) during an 18-month period after instituting specific modifications to prevent seroma. These included draining both the submastectomy and sub-ADM planes, lowering the threshold for drain removal, and addition of postoperative soft compression dressings and surgical bras. A total of 179 implant-based reconstructions were evaluated for rates of complications, including infection, hematoma, seroma, and skin flap necrosis. These were compared to results of a series of 150 similar procedures performed by the lead author before institution of the procedural modifications described. ResultsSeroma rate decreased from 18.6% to 4.7% (P = 0.0022), and major infection rate decreased from 7% to 1.9% (0.0250). ConclusionsAlthough implant-based breast reconstruction using ADM has been associated with increased seroma and possible infection rates, the use of specific clinical practices designed to prevent seroma has minimized our rate of these postoperative complications.

Use of tumescent mastectomy technique as a risk factor for native breast skin flap necrosis following immediate breast reconstruction

BACKGROUND Native breast skin flap necrosis is a complication that can result from ischemic injury following mastectomy and can compromise immediate breast reconstruction. The tumescent mastectomy technique has been advocated as a method of allowing sharp dissection with decreased blood loss and perioperative analgesia. This study was performed to determine whether the technique increases the risk for skin flap necrosis in an immediate breast reconstruction setting. METHODS Three hundred eighty consecutive mastectomies with immediate reconstruction over a 6-year period were reviewed and divided into 2 cohorts for comparison: 100 tumescent and 280 nontumescent mastectomy cases. The incidence of minor and major skin flap necrosis was evaluated. RESULTS The use of tumescent mastectomy (odds ratio [OR], 3.93; P < .001), prior radiation (OR, 3.19; P = .011), patient age (OR, 1.59; P = .006), and body mass index (OR, 1.11; P = .004) were significant risk factors for developing postoperative major native skin flap necrosis. CONCLUSIONS The use of the tumescent mastectomy technique appears to be associated with a substantial increase in the risk for postoperative major skin flap necrosis in an immediate breast reconstruction setting.

Outcomes and patient satisfaction following breast reconstruction with bilateral pedicled TRAM flaps in 105 consecutive patients.

Background: Breast reconstruction using pedicled transverse rectus abdominis musculocutaneous (TRAM) flaps has come under increasing scrutiny secondary to presumed abdominal wall morbidity. This study analyzes morbidity and patient satisfaction in a consecutive series of breast reconstructions performed using bilateral pedicled TRAM flaps. Methods: Between 1991 and 2007, 105 women underwent bilateral pedicled TRAM flap breast reconstruction performed by the senior author (J.J.P.). Charts were reviewed for postoperative complications and demographic data. Minimum 11-month follow-up survey data were obtained through the Michigan Breast Satisfaction Questionnaire, the Qualitative Assessment of Back Pain Questionnaire, and the Short Form-36 questionnaire. Results: The mean follow-up interval was 6 years. Abdominal wall complications included three abdominal hernias (2.9 percent), three abdominal wall bulges (2.9 percent), and four partial donor-site skin dehiscences (3.8 percent). Fat necrosis was the most common flap complication, present in 24 flaps (11.4 percent). The survey response rate was 61.9 percent. Short Form-36 data demonstrated no significant difference from a mean age-matched female population in general well-being, although patients with a body mass index greater than or equal to 30 reported significantly lower emotional well-being (p = 0.01), social functioning (p = 0.03), and overall energy scores (p = 0.03) in comparison with patients with a body mass index less than 30. Thirteen of the 65 patients who completed the survey (20 percent) complained of postoperative back pain, although most of these patients reported their symptoms to be mild in nature. Conclusions: Low complication rates were demonstrated and patients were generally satisfied in this series of 105 consecutive bilateral pedicled TRAM flaps. This suggests that the bilateral pedicled TRAM flap remains a viable option for breast reconstruction.

Body mass index as a predictor of postoperative complications in reduction mammaplasty.

Background: Obesity, determined by body mass index, is known to be associated with surgical complications. This study was performed to evaluate a correlation between body mass index and postoperative complications in reduction mammaplasty. Methods: The authors performed a retrospective analysis of consecutive reduction mammaplasties performed at the Brigham and Womens Hospital by eight surgeons between 1995 and 2007. Data regarding demographics, comorbidities, body mass index, reduction specimen weight, reduction technique, and complications were collected. Univariate and multivariate analyses were used to assess the association between body mass index and complication rates. Multivariate logistic regression analysis was used to determine the threshold body mass index value at which differential complication rates were maximal. Results: A total of 675 bilateral reduction mammaplasties were analyzed; 75 complications (11 percent) were observed, including hematoma, infection, necrosis, and reoperation. Mean body mass index was 31.0 ± 6.2. A significant association was noted between body mass index and complication rate on the basis of both univariate (p = 0.036) and multivariate (p = 0.037) analyses. Trend analysis of body mass index as a categorical variable relative to complication rate was also statistically significant (p = 0.01). A cutoff point was suggested whereby patients with a body mass index of more than 35.6 experienced a significantly higher complication rate than did patients below this threshold (odds ratio = 2.002; p = 0.004). Conclusions: Body mass index is significantly associated with increased complications following reduction mammaplasty. An index value greater than 35.6 is associated with a twofold-higher risk of complications. Patients with a body mass index of 36 or above should be cautioned regarding a potential increased risk of complications. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, IV.

Impact of neoadjuvant chemotherapy on breast reconstruction

With advances in oncologic treatment, cosmesis after mastectomy has assumed a pivotal role in patient and provider decision making. Multiple studies have confirmed the safety of both chemotherapy before breast surgery and immediate reconstruction. Little has been written about the effect of neoadjuvant chemotherapy on decisions about reconstruction.

Comparison of clinical outcomes and patient satisfaction in immediate single-stage versus two-stage implant-based breast reconstruction.

Background: The purpose of this study was to assess the outcomes of immediate, single-stage, implant-based reconstruction compared with traditional, two-stage reconstruction (i.e., tissue expander placement followed by exchange to implant). Methods: A retrospective review of consecutive patients who underwent immediate unilateral or bilateral breast reconstruction over an 8-year period was performed. The primary predictor variable was method of reconstruction (single-stage versus two-stage). Outcome measures were postoperative complication rates, revision rates, and BREAST-Q patient satisfaction scores. Descriptive, bivariate, and multiple regression statistics were computed. Results: The study sample consisted of 346 subjects who underwent reconstruction of 582 breasts (166 single-stage and 416 two-stage reconstructions). Complication rates between the single-stage and two-stage groups were similar for minor infections, major infections, hematoma formation, seroma formation, minor necrosis, and major necrosis (p ≥ 0.20). In a multiple logistic regression model, subjects undergoing single-stage reconstruction were found to be 87 percent more likely to require revision necessitating an additional operation (p = 0.005). In an adjusted regression model, subjects undergoing two-stage reconstruction had higher BREAST-Q scores for satisfaction with medical and office staff (p ⩽ 0.02). Subjects undergoing single-stage reconstruction had higher sexual well-being satisfaction scores. Conclusions: There is no significant difference in complication rates between single-stage versus two-stage implant-based breast reconstructions. Although single-stage reconstruction is associated with higher sexual well-being satisfaction, it is more than 80 percent more likely to require additional operative revisions. Two-stage reconstruction is associated with significantly higher satisfaction with the medical and office staff. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.