Thursday, 17 November 2016

Mastotrainer new version: realistic simulator for training in breast surgery

Mastotrainer new version: realistic simulator for training in breast surgery

Zucca-Matthes, G,Lebovic G,  Lyra M
The Breast February 2017 Volume 31, Pages 82–84 


The “Mastotrainer” was introduced as a new concept of simulators for use in surgical training. Simulators of this type are critical as the use of cadavers is limited or prohibited in some countries. The Mastotrainer has proved very useful in training various surgical techniques, with the first version of the simulator being focused on breast augmentation and reconstruction following mastectomy.This current project explores use of a new version of the surgical simulator that can facilitate a broader spectrum of procedures in the training of breast surgeons as well as plastic and reconstructive surgeons in order to achieve better outcomes.

Fully Awake Breast Reduction

Fully Awake Breast Reduction

Filson, S A. Yarhi, D. Ramon, Y.

Plastic & Reconstructive Surgery November 2016 - Volume 138 - - Issue 5 - p 978–983

Summary: The authors present 25 cases and an in-depth 4-minute video of fully awake aesthetic breast reduction, which was made possible by thoracic epidural anesthesia. There are obvious and important advantages to this technique. Not only does this allow for intraoperative patient cooperation (i.e., patient self-positioning and opinion for comparison of breasts), meaning a shorter and more efficient intraoperative time, there also is a reduction in postoperative pain, complications, recovery, and discharge times. The authors have also enjoyed great success and no complications with this technique in over 150 awake abdominoplasty/total body lift patients. The authors feel that the elimination of the need for general anesthesia by thoracic epidural sensorial–only anesthesia is a highly effective and efficient technique, with very few disadvantages/complications, providing advantages to both patients and surgeons.

Techniques and Perforator Selection in Single, Dominant DIEP Flap Breast Reconstruction: Algorithmic Approach to Maximize Efficiency and Safety

Techniques and Perforator Selection in Single, Dominant DIEP Flap Breast Reconstruction: 
Algorithmic Approach to Maximize Efficiency and Safety

Mohan, AT et al

Plastic & Reconstructive Surgery November 2016 - Volume 138 - Issue 5 - p 790e–803e

Background: Perforator selection is critical to deep inferior epigastric perforator (DIEP) flap harvest. Commitment to a single perforator has the potential benefit of a simpler dissection, but may increase fat necrosis or perfusion-related complications compared with multiple perforator harvest. 
Methods: A 3-year retrospective study was carried out of all patients who underwent DIEP flap breast reconstruction performed by the senior author (M.S.-C). Data were collected on patient demographics and surgical outcomes.
Results: One hundred eighty-three flaps were performed (105 patients) over 3 years. One hundred fifty-six bilateral (78 patients) and 24 unilateral flaps were included in the final study. Mean age was 47.8 ± 8.4 years and mean body mass index was 29.1 ± 5.3 kg/m2. Seventy-five percent of flaps were based on single dominant perforators. Single perforators were used in 33.3 percent of flaps weighing over 1000 g, 80 and 74 percent of flaps weighing 500 to 1000 g and less than 500 g, respectively (p = 0.01). There were no differences in overall complications between single- versus multiple-perforator DIEP flaps. Neither body mass index nor flap weight posed additional risk to overall complications. Conversion to a muscle-sparing flap was 9.4 percent. 
Conclusions: The authors present an algorithm for perforator selection, stepwise approach to flap harvest, and considerations for intraoperative decision-making in DIEP flap reconstruction. Single–dominant perforator flaps can be safely performed, but inclusion of the largest perforator is critical to flap perfusion. Additional perforators must be weighed against the associated tradeoff with donor-site morbidity. The threshold for conversion to a muscle-sparing flap is reduced with increased clinical experience.

Surgeon-Controlled Study and Meta-Analysis Comparing FlexHD and AlloDerm in Immediate Breast Reconstruction Outcomes

Surgeon-Controlled Study and Meta-Analysis Comparing FlexHD and AlloDerm in Immediate Breast Reconstruction Outcomes

Sobti N, Liao E C

Plastic & Reconstructive Surgery November 2016 - Volume 138 - Issue 5 - p 959–967

Background: The use of acellular dermal matrix has facilitated immediate prosthesis-based breast reconstruction. However, few studies directly compare surgical outcomes following acellular dermal matrix–based reconstruction with two of the most commonly available materials, AlloDerm and FlexHD. Those studies that are available often do not adequately control for the surgeon as a variable. The authors hypothesize that complication rates will not differ significantly between AlloDerm and FlexHD when practice and surgeon variables are properly controlled. Methods: Retrospective review was conducted to identify consecutive implant-based reconstruction procedures performed at a tertiary academic medical institution by a single plastic surgeon over 6 years. Univariate and binomial regression analyses were conducted to compare patient characteristics and clinical endpoints across acellular dermal matrix groups (AlloDerm/AlloDerm ready-to-use versus FlexHD Pliable/Perforated). Results: Of the 233 patients that underwent matrix-based breast reconstruction, 11 (4.7 percent) developed surgical-site infection. The infection rate was not statistically different between patients who received FlexHD [n = 5 (5.0 percent)] versus AlloDerm [n = 6 (4.6 percent)] on either univariate (p = 0.89) or binomial regression analysis (p = 0.56). Likewise, there were no statistical differences in rates of seroma, hematoma, explantation, or delayed wound healing. Conclusions: Clinical endpoints of interest were all equivalent between acellular dermal matrix types. This study uniquely reports a single-surgeon case series comparing outcomes between different acellular dermal matrix types. Instead of focusing on acellular dermal matrix as a predictor of outcome, other patient and surgeon factors should be addressed to improve results and innovate better alternatives.

The Profunda Artery Perforator Flap Experience for Breast Reconstruction

The Profunda Artery Perforator Flap Experience for Breast Reconstruction

Allen, R J et al

Plastic & Reconstructive Surgery November 2016 - Volume 138 - Issue 5 - p 968–975

Background: The profunda artery perforator flap was first introduced for breast reconstruction in 2010. In this article, the authors analyze the results of all profunda artery perforator flaps performed by their group to date. Methods: A retrospective review was completed of consecutive profunda artery perforator flaps performed by the senior author (R.J.A.) from 2010 to 2014. Patient demographics, indications, operative techniques, flap specifics, complications, and number of operations were recorded. Results: Ninety-six patients have undergone 164 profunda artery perforator flap operations for breast reconstruction since 2010. Reconstructions were performed following breast cancer management (59.5 percent), following prophylactic mastectomy for cancer risk reduction (35.7 percent), and for congenital breast deformity (4.8 percent). The average age of the patients was 48 years (range, 24 to 64 years) and their average body mass index was 22.5 kg/m2. Average flap weight was 367.4 g and average pedicle length was found to be 10.2 cm. The success rate of the profunda artery perforator flap was greater than 99 percent, with a 3 percent take-back rate and only one flap loss recorded. Complications included hematoma (1.9 percent), seroma (6 percent), fat necrosis (7 percent), and donor-site infection (1.9 percent). Conclusions: The profunda artery perforator flap is an excellent option for breast reconstruction. Advantages include a reliable blood supply, long pedicle, thick donor tissue, and a favorable donor site. Currently, the profunda artery perforator flap is second only to the deep inferior epigastric artery perforator among flaps used by the authors for breast reconstruction. 

Robotic nipple-sparing mastectomy for the treatment of breast cancer: Feasibility and safety study

Robotic nipple-sparing mastectomy for the treatment of breast cancer: Feasibility and safety study

Toesca A et al

The Breast February 2017 Volume 31, Pages 51–56 

We previously devised and reported on an innovative surgical technique of robotic nipple-sparing mastectomy and immediate robotic breast reconstruction. Here we describe the outcome of the first 29 such consecutive procedures performed on breast cancer patients to assess feasibility, reproducibility and safety.

Matching the Implant to the Breast: A Systematic Review of Implant Size Selection Systems for Breast Augmentation

Matching the Implant to the Breast: A Systematic Review of Implant Size Selection Systems for Breast Augmentation

Adams, WP. Mckee, D

Plastic & Reconstructive Surgery November 2016 - Volume 138 - Issue 5 - p 987–994

Background: For primary breast augmentation, several implant selection systems have been described to guide the surgeon with choosing from a variety of manufactured implant dimensions and properties. Controversy exists regarding the most efficacious method of selecting an appropriate implant size that best matches the patient’s breast. 
Methods: The goal of this systematic review was to provide a comprehensive list of documented implant size selection systems, and to critically evaluate them. Implant size selection systems were grouped into categories based on selection principles. Articles were evaluated based on reported outcome measures and methodologic quality. 
Results: Thirty-three implant size selection systems were included in the final analysis. Only 12 percent of articles (four of 33) reported clinical outcomes that could be compared to accepted literature values or industry standards. Articles that described tissue-based planning systems, which use clinical guidelines to determine the optimal patient-specific implant dimensions, were of highest methodologic quality using the Methodological Index for Non-Randomised Studies scale, when compared to systems that used breast “dimensional” analyses that stress tissues to the desire of the patient and/or surgeon, and compared to systems that did not use breast measurement (means ± SD, 6.0 ± 1.4, 1.4 ± 2.3, and 0.0 ± 0.0, respectively). 
Conclusions: There is some evidence to support tissue-based planning as a superior approach to implant size selection planning; studies that used tissue-based planning reported lower reoperation rates compared with industry standards and accepted literature values. The authors offer several suggestions on how to improve the methodologic quality of future studies describing new implant selection systems.

Contemporary social media engagement by breast surgeons

Contemporary social media engagement by breast surgeons

Ekatah GE et al


The Breast December 2016 Volume 30, Pages 172–174


There continues to be a steady rise in the use of social media among healthcare professionals. We present an overview of social media use among breast surgeons within the United Kingdom including demographic variations and some of the factors that underpin these trends. The benefits and drawbacks of open social media platforms are also considered.

Negative-Pressure Wound Therapy: A Comprehensive Review of the Evidence

Negative-Pressure Wound Therapy: A Comprehensive Review of the Evidence


Anghel, EL, Kim, PJ.

Plastic & Reconstructive Surgery September 2016 - Volume 138 - Issue 3S - p 129S–137S

Background: Negative-pressure wound therapy (NPWT) and its variations are an established adjunctive modality for the treatment of wounds. Since its introduction, there have been an increasing number of publications with periods of rapid increases in the number of publications after innovations to the technology. Its application in different wound types and varying clinical scenarios has also contributed to the growing number of publications. 
Methods: A comprehensive literature review (1998–2016) was performed using key words most relevant to NPWT using PubMed/Medline and OVID. Eligibility criteria included higher level evidence studies. 
Results: One thousand three hundred and forty-seven publications were identified. A total of 26 publications are included in this review: 16 comparing NPWT with standard wound dressing, 6 comparing variations of NPWT, and 4 for NPWT with instillation. The level of evidence, wound type studied, reported outcomes and impact, and key findings are tabulated and discussed. 
Conclusions: The number of publications has grown significantly since the inception of NPWT. In part, this reflects the variations of NPWT that have developed. However, a greater number of robust, randomized, prospective studies are needed to support its wide spread use.

Tuesday, 18 October 2016

Finding the balance between over- and under-treatment of ductal carcinoma in situ (DCIS)

Finding the balance between over- and under-treatment of ductal carcinoma in situ (DCIS)

Groen EJ et al

The Breast: Article in Press

With the widespread adoption of population-based breast cancer screening, ductal carcinoma in situ (DCIS) has come to represent 20–25% of all breast neoplastic lesions diagnosed. Current treatment aims at preventing invasive breast cancer, but the majority of DCIS lesions will never progress to invasive disease. Still, DCIS is treated by surgical excision, followed by radiotherapy as part of breast conserving treatment, and/or endocrine therapy. This implies over-treatment of the majority of DCIS, as less than 1% of DCIS patients will go on to develop invasive breast cancer annually.

A comparison of patient-centered economic and clinical outcomes of post-mastectomy breast reconstruction between obese and non-obese patients

A comparison of patient-centered economic and clinical outcomes of post-mastectomy breast reconstruction between obese and non-obese patients

Huo J et al

The Breast December 2016Volume 30, Pages 118–124

The objectives of this study were to compare, by patient obesity status, the contemporary utilization patterns of different reconstruction surgery types, understand postoperative complication profiles in the community setting, and analyze the financial impact on health care payers and patients.

Postmastectomy Radiation Therapy and Two-Stage Implant-Based Breast Reconstruction: Is There a Better Time to Irradiate?

Postmastectomy Radiation Therapy and Two-Stage Implant-Based Breast Reconstruction: Is There a Better Time to Irradiate?

Santosa, K et al,

Plastic & Reconstructive Surgery:October 2016 - Volume 138 - Issue 4 - p 761–769

Background: The ideal timing of postmastectomy radiation therapy (PMRT) in the setting of two-stage implant-based breast reconstruction remains unclear. In this cohort study, the authors sought to determine whether complication rates differed between patients who received PMRT following tissue expander placement (TE-XRT) and those who received PMRT after exchange for permanent implants (Implant-XRT) utilizing using prospective, multicenter data. 
Methods: Eligible patients in the Mastectomy Reconstruction Outcomes Consortium study from 11 institutions across North America were included in the analysis. All patients had at least 6-month follow-up after their last intervention (i.e., implant exchange for TE-XRT patients, and radiation for Implant-XRT patients). Complications including seroma, hematoma, infection, wound dehiscence, capsular contracture, and implant loss were recorded. 
Results: The authors identified a total of 150 patients who underwent immediate, two-stage implant-based breast reconstruction and received PMRT. Of these, there were TE-XRT 104 patients (69.3 percent) and 46 (30.7 percent) Implant-XRT patients. There were no differences in the incidence of any complications or complications leading to reconstructive failure between the two cohorts. After adjusting for patient characteristics and site effect, the timing of PMRT (i.e., TE-XRT versus Implant-XRT) was not a significant predictor in the development of any complication, a major complication, or reconstructive failure. 
Conclusion: In the setting of PMRT and two-stage implant-based reconstruction, patients who received PMRT after expander placement (TE-XRT) did not have a higher incidence or increased odds of developing complications than those who received PMRT after exchange for a permanent implant (Implant-XRT).

Antibiotic Prophylaxis following Implant-Based Breast Reconstruction: What Is the Evidence?

Antibiotic Prophylaxis following Implant-Based Breast Reconstruction: What Is the Evidence?

Phillips, BT, Halvorson, EG.

Plastic & Reconstructive Surgery:October 2016 - Volume 138 - Issue 4 - p 751–757

Background: Although data from other surgical disciplines do not support the use of prolonged postoperative prophylactic antibiotics, implant-based breast reconstruction is one area of plastic surgery where this may be warranted. The purpose of this study was to review the literature on antibiotic prophylaxis in prosthetic breast reconstruction, summarize findings, and provide recommendations. 
Methods: A literature review was performed to identify studies that compared different perioperative prophylactic antibiotic regimens with respect to infectious outcomes in prosthetic breast reconstruction. 
Results: Five studies and five systematic reviews were identified. One prospective randomized trial showed that a single preoperative dose was better than placebo, and another showed no difference between 24 hours versus until drain removal. Three studies were retrospective, one showing no difference between a single preoperative dose and prolonged antibiotic use, and two showing significant reduction in infectious complications with prolonged antibiotic use. One systematic review suggested an increased rate of infection with prolonged antibiotic use, and the other showed no difference between less than 24 hours and greater than 24 hours, but showed a reduction in infections compared to no treatment. 
Conclusions: The literature contains conflicting data regarding the optimal duration for perioperative antibiotic prophylaxis following prosthetic breast reconstruction. The authors’ opinion is that 24 hours of antibiotic prophylaxis is warranted. Further studies are needed. Patient-centered antibiotic prophylaxis based on a risk-assessment model may be a more effective alternative to the current indiscriminate model of surgical-site infection control.

A Comparison of Psychological Response, Body Image, Sexuality, and Quality of Life between Immediate and Delayed Autologous Tissue Breast Reconstruction: A Prospective Long-Term Outcome Study

A Comparison of Psychological Response, Body Image, Sexuality, and Quality of Life between Immediate and Delayed Autologous Tissue Breast Reconstruction: A Prospective Long-Term Outcome Study

Zhong T et al

Plastic & Reconstructive Surgery:October 2016 - Volume 138 - Issue 4 - p 772–780


Background: This is the first study to use generic distress, cancer-specific, and procedure-specific measures to prospectively evaluate psychological responses, body image, sexuality, and health-related quality of life in immediate compared with delayed breast reconstruction. Methods: Consecutive patients undergoing autologous immediate and delayed breast reconstruction (June of 2009 to December of 2010) completed the Hospital Anxiety and Depression Scale, Body Image Scale, Sexuality Scale, and BREAST-Q preoperatively and postoperatively (6, 12, and 18 months). Linear mixed-effects analyses between each outcome and time point were performed. Results: One hundred six women underwent mastectomy with immediate (n = 30) and delayed breast reconstruction (n = 76). Before reconstruction, 26 percent of patients had abnormal anxiety scores and 9 percent had abnormal depression scores, with no significant differences between groups. Patients awaiting delayed breast reconstruction had significantly impaired prereconstruction body image (p = 0.01) and sexuality (p = 0.01) and worse satisfaction with breast (p < 0.01), psychological (p < 0.01), and sexual well-being (p < 0.01). At 18 months after immediate and delayed breast reconstruction, there was significant improvement in anxiety, depression, body image, sexuality, and health-related quality of life. Conclusions: This single-center study shows that mastectomy with immediate breast reconstruction may protect breast cancer patients from a period of psychosocial distress, poor body image, and diminished sexual well-being compared with those waiting for delayed breast reconstruction. In patients who are oncologically eligible and strongly interested in breast reconstruction, efforts should be made to provide immediate breast reconstruction to decrease the interval of psychosocial distress, poor body image, and impaired sexuality.

Current Concepts in Debridement: Science and Strategies

Current Concepts in Debridement: Science and Strategies

Anghel, E et al


Plastic & Reconstructive Surgery September 2016 - Volume 138 - Issue 3S - p 82S–93S

Background: The establishment of a healthy wound bed through adequate debridement of infected, senescent, and/or devitalized tissue is central to the progression of normal wound healing. Although a variety of surgical and nonsurgical strategies have been proposed, none have proven completely effective in all settings. This review focuses on the principles and techniques of modern debridement practices employed in the management of complex wounds. 
Methods: A comprehensive review of the PubMed/Medline and Ovid databases was performed to identify basic science and clinical studies using key words most relevant to biofilm, debridement, and wound healing. English language articles that were peer reviewed and that met the standard of evidence-based medicine were included. Level of evidence for various debridement approaches was rated utilizing the American Society of Plastic Surgeons Rating Levels of Evidence and Grading Recommendations. 
Results: The value of both operative and nonoperative debridement techniques, their indications, and limitations are described. With an emphasis placed on surgical debridement, this review highlights technical adjuncts that can be used to optimize wound bed preparation, including preoperative topical staining of the wound, as well as the use of color-guided endpoints to prevent removal of excess healthy tissue. The indications for using temporizing measures for wound control such as negative pressure wound therapy with and without installation are also discussed. 
Conclusion: Optimal management requires a multimodal approach that centers around operative debridement and incorporates the use of adjunctive measures to facilitate the removal of infected tissue, biofilm, and/or senescent cells that impede the progression of normal wound healing.

Allergan Style 410 Implants for Breast Reconstruction: A Prospective Study in Efficacy, Safety, and Symmetry


Allergan Style 410 Implants for Breast Reconstruction: A Prospective Study in Efficacy, Safety, and Symmetry

Unger J et al

Plastic & Reconstructive Surgery September 2016 - Volume 138 - Issue 3 - p 548–555

Background: Implant-based breast reconstruction is performed with both saline and silicone. In 2001, a study was conducted in which a novel implant made of highly cohesive silicone gel in anatomical shape was used. It differs from others because it holds its anatomical shape and forces tissue to conform to the implant. 
Methods: Two hundred twelve consecutive patients who underwent reconstruction with Allergan 410 cohesive gel anatomical implants were enrolled prospectively over a 12-year period. Complications and satisfaction rates were recorded.
Results: Average age of the patients was 48.5 years and average body mass index was 24.1 kg/m2. Bilateral reconstruction was performed in 83 percent of patients. Long-term follow-up was achieved in all patients and averaged 3.3 years (range, 0.5 to 10.2 years). The overall complication rate was 19.8 percent; most were minor complications, such as rippling (9.4 percent) and asymmetry (4.2 percent). Major complications included infection (2.4 percent), malposition (1.4 percent), capsular contracture (0.9 percent), seroma (0.5 percent), extrusion (0.5 percent), and implant rupture (0.5 percent). The rate of implant-related reoperation, excluding cancer recurrence, was 9.0 percent, consisting of implant replacement (5.7 percent), implant removal (1.9 percent), and implant repositioning (1.4 percent). Patient satisfaction averaged 4.83 (range, 2 to 5) on a five-point scale. Surgeon satisfaction averaged 4.9 (range, 2 to 5). 
Conclusions: Allergan 410 cohesive gel anatomical implants have a favorable risk profile in reconstruction, with excellent patient and surgeon satisfaction. This novel implant allows for a paradigm shift in implant-based breast reconstruction. Surgeons can now use an implant to help shape the final contour of the breast mound rather than rely on mastectomy flaps and suture techniques to create aesthetic contours needed to create an attractive breast reconstruction. 

Friday, 16 September 2016

The Telemark Breast Score: A Reliable Method for the Evaluation of Results after Breast Surgery

The Telemark Breast Score: A Reliable Method for the Evaluation of Results after Breast Surgery

Plastic & Reconstructive Surgery:
September 2016 - Volume 138 - Issue 3 - p 390e–400e

Begic, A; Stark, B

Background: Validated instruments for assessing results after breast surgery are sparse. The authors present here a method used for the past 10 years at their institution for evaluation of outcome after breast-conserving surgery and microsurgical breast reconstruction. Methods: The Telemark Breast Score is a method based on standard two-dimensional photographs assessing the outcome after breast surgery in terms of volume, shape, and symmetry. Three panels comprising two plastic surgeons, two breast surgeons, and two nurses tested the Telemark Breast Score on 346 patients who underwent breast-conserving surgery for cancer and 31 other patients who underwent deep inferior epigastric perforator flap reconstruction. All patients were assessed at least 1 year after their operation. Consistency of agreement between and within the panels was studied. Results: Interobserver and intraobserver reliability was good after consensus discussion. Good rating stability was shown using test-retest measurements. Conclusion: The Telemark Breast Score is an inexpensive, statistically reliable method and can be applied for quality control after breast surgery.

Is Single-Stage Prosthetic Reconstruction Cost Effective? A Cost-Utility Analysis for the Use of Direct-to-Implant Breast Reconstruction Relative to Expander-Implant Reconstruction in Postmastectomy Patients

Is Single-Stage Prosthetic Reconstruction Cost Effective? A Cost-Utility Analysis for the Use of Direct-to-Implant Breast Reconstruction Relative to Expander-Implant Reconstruction in Postmastectomy Patients

Plastic & Reconstructive Surgery:
September 2016 - Volume 138 - Issue 3 - p 537–547

Krishnan NM et al

Background: Prosthetic breast reconstruction is most commonly performed using the two-stage (expander-implant) technique. However, with the advent of skin-sparing mastectomy and the use of acellular dermal matrices, one-stage prosthetic reconstruction has become more feasible. Prior studies have suggested that one-stage reconstruction has economic advantages relative to two-stage reconstruction despite a higher revision rate. This is the first cost-utility analysis to compare the cost and quality of life of both procedures to guide patient care. Methods: A comprehensive literature review was conducted using the MEDLINE, EMBASE, and Cochrane databases to include studies directly comparing matched patient cohorts undergoing single-stage or staged prosthetic reconstruction. Six studies were selected examining 791 direct-to-implant reconstructions and 1142 expander-implant reconstructions. Costs were derived adopting both patient and third-party payer perspectives. Utilities were derived by surveying an expert panel. Probabilities of clinically relevant complications were combined with cost and utility estimates to fit into a decision tree analysis. Results: The overall complication rate was 35 percent for single-stage reconstruction and 34 percent for expander-implant reconstruction. The authors’ baseline analysis using Medicare reimbursement revealed a cost decrease of $525.25 and a clinical benefit of 0.89 quality-adjusted life-year when performing single-stage reconstructions, yielding a negative incremental cost-utility ratio. When using national billing, the incremental cost-utility further decreased, indicating that direct-to-implant breast reconstruction was the dominant strategy. Sensitivity analysis confirmed the robustness of the authors’ conclusions. Conclusions: Direct-to-implant breast reconstruction is the dominant strategy when used appropriately. Surgeons are encouraged to consider single-stage reconstruction when feasible in properly selected patients.

Does the Use of Incisional Negative-Pressure Wound Therapy Prevent Mastectomy Flap Necrosis in Immediate Expander-Based Breast Reconstruction?

Does the Use of Incisional Negative-Pressure Wound Therapy Prevent Mastectomy Flap Necrosis in Immediate Expander-Based Breast Reconstruction?

Plastic & Reconstructive Surgery:
September 2016 - Volume 138 - Issue 3 - p 558–566

Kim, DY et al

Background: Mastectomy flap necrosis is one of the most common and significant complications in immediate expander-based breast reconstruction. Negative-pressure wound therapy is widely used for open wounds but is not commonly used for closed incisional wounds. However, the postoperative use of incisional negative-pressure wound therapy is demonstrated to reduce complication rates. The authors evaluate the incidence of mastectomy flap necrosis in patients with incisional negative-pressure wound therapy after immediate expander-based breast reconstruction compared with the incidence in patients with conventional dressing. Methods: A retrospective review was conducted to identify patients who underwent immediate expander-based breast reconstruction between January of 2010 and February of 2015 at a single institution. Patients were divided into a conventional dressing group and an incisional negative-pressure wound therapy group. Patient demographics, intraoperative findings, and complications were compared between the two groups. Results: A total of 228 breasts (206 patients) were included in this study. Of these, the incisional negative-pressure wound therapy group included 45 breasts (44 patients) and the conventional dressing group included 183 breasts (162 patients). The incisional negative-pressure wound therapy group had a lower overall complication rate (11.1 percent versus 27.9 percent; p = 0.019), overall mastectomy flap necrosis rate (8.9 percent versus 23.5 percent; p = 0.030), and major mastectomy flap necrosis rate (2.2 percent versus 13.7 percent; p = 0.031) compared with the conventional dressing group. Conclusions: Incisional negative-pressure wound therapy reduced the incidence of mastectomy flap necrosis. This simple and reliable dressing technique can be effective in preventing mastectomy flap necrosis in immediate expander-based breast reconstruction. 

The Subtleties of Success in Simultaneous Augmentation-Mastopexy

 The Subtleties of Success in Simultaneous Augmentation-Mastopexy

Plastic & Reconstructive Surgery:
September 2016 - Volume 138 - Issue 3 - p 585–592

Doshier, Laura J et al

Background: Many have challenged the safety of performing breast augmentation and mastopexy simultaneously. However, staging these procedures incurs the increased risk and inconvenience of two periods of anesthesia and recuperation. The authors set out to evaluate the occurrence of complications across the populations of patients undergoing (1) combined augmentation-mastopexy, (2) isolated augmentation, and (3) isolated mastopexy. Methods: A retrospective analysis of one surgeon’s consecutive series of each of these procedures from 2000 to 2009 was conducted. Preoperative risk factors were characterized. Sixteen different complications were examined, and those necessitating operative revision were tracked. Statistical analysis was performed looking for significant differences between the surgical groups. Results: No instances of infection, tissue loss, or implant exposure occurred among the 297 patients over an average follow-up period of 15.5 months. The isolated mastopexy group did not provide sufficient data for statistical comparison. Tissue-related complications were most common in the combined procedure group. The operative revision rate for isolated augmentation was 7.97 percent compared with a combined procedure revision rate of 12.4 percent (p = 0.28). Conclusions: The majority of complications in this series comparing simultaneous augmentation-mastopexy to isolated augmentation were minor. Complications requiring operative revision were not found to be significantly different between the two groups. There was a much lower reoperation rate (12.4 percent) with the combined procedure compared with a 100 percent reoperation rate when the procedure is staged. Thus, the authors feel the combined procedure can safely be part of every plastic surgeon’s practice.