A Systematic Review of Comparison of Autologous, Allogeneic, and Synthetic Augmentation Grafts in Nipple Reconstruction

A Systematic Review of Comparison of Autologous,Allogeneic, and Synthetic Augmentation Grafts in Nipple Reconstruction

Plastic & Reconstructive Surgery:

January 2016 - Volume 137 - Issue 1 - p 14e–23e

Winocour, S et al.

Background: Many techniques have been described for nipple reconstruction, with the principal limitation being excessive loss of projection. The ideal reconstructed nipple provides sustained projection, the fewest complications, and high levels of patient satisfaction. A variety of materials are available for projection augmentation, including autologous, allogeneic, and synthetic materials. To date, there has been no systematic review to study the efficacy, projection, and complication rates of different materials used in nipple reconstruction. Methods: MEDLINE, Embase, and PubMed databases were searched, from inception to August of 2014, to identify literature reporting on outcomes of autologous, allogeneic, and synthetic grafts in nipple reconstruction. Retrospective and prospective studies with controlled and uncontrolled conditions were included. Studies reporting the use of autologous flap techniques without grafts and articles lacking postoperative outcomes were excluded. Study quality was assessed using the Newcastle-Ottawa Scale. Results: Thirty-one studies met the inclusion criteria. After evidence review, one study represented two of nine stars on the Newcastle-Ottawa Scale, two studies represented three stars, six studies represented four stars, seven studies represented five stars, 11 studies represented six stars, and four studies represented seven stars. Conclusions: The results of this review revealed heterogeneity in the type of material used within each category and inconsistent methodology used in outcomes assessment in nipple reconstruction. Overall, the quality of evidence is low. Synthetic materials have higher complication rates and allogeneic grafts have nipple projection comparable to that of autologous grafts. Further investigation with high-level evidence is necessary to determine the optimal material for nipple reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

DIEAP flap for safe definitive autologous breast reconstruction

DIEAP flap for safe definitive autologous breastreconstruction
The Breast April 2016 Volume 26, Pages 59–66


Katrin Seidenstuecker, Carl van Waes, Beatrix I. Munder, Karel E.Y. Claes, Christian Witzel, Nathalie Roche, Filip Stillaert, Ajay L. Mahajan Christoph Andree, Phillip N. Blondeel


Breast cancer is the commonest form of cancer in women affecting almost a quarter of a million patients in the US annually. 30 percent of these patients and patients with genetic mutations undergo removal of the breast, as highlighted in a high profile celebrity patient. Although breast reconstruction with free microvascular transfer of a DIEAP flap from the abdomen is an ideal form of reconstruction, there have been misgivings about the complexity and potential complications. This study was aimed at clearing these misunderstandings and establishing the value of this form of breast reconstruction. 

Natrelle Silicone Breast Implant Follow-Up Study: Demographics, Lifestyle, and Surgical Characteristics of More Than 50,000 Augmentation Subjects

Natrelle Silicone Breast Implant Follow-Up Study:Demographics, Lifestyle, and Surgical Characteristics of More Than 50,000 Augmentation Subjects

Plastic & Reconstructive Surgery:

January 2016 - Volume 137 - Issue 1 - p 70–81

Singh, N, Picha, G, Murphy, D

Background: A large, multicenter, 10-year observational study is being conducted to compare the long-term safety and effectiveness of Natrelle silicone breast implants with saline implants or national norms. Study baseline data and surgical characteristics are reported here. Methods: Women seeking primary augmentation, revision-augmentation, primary reconstruction, or revision-reconstruction participated. Eligible subjects had completed surgery and received one implant or matching implants. Baseline demographics, health, lifestyle, and surgical characteristics were recorded. Data are presented here for subjects (≥22 years old) who underwent primary augmentation or revision-augmentation. Results: Of 50,979 subjects who underwent augmentation procedures, 35,756 received silicone implants and 15,223 received saline implants. Of these, 86.3 percent underwent primary augmentation, and 13.7 percent underwent revision-augmentation; nearly all subjects (99.3 percent) received bilateral implants. In the primary augmentation group, 67.6 percent of subjects received silicone implants versus 86.1 percent in the revision-augmentation group. Median age was lower in the primary augmentation group compared with the revision-augmentation group (33 versus 42 years old, respectively). Most subjects were white nonsmokers and had attended college. Hispanic subjects and subjects with a body mass index of 25 kg/m2 or greater were more likely to receive saline versus silicone implants. Across groups, the most common characteristics by procedure or implant type included inframammary incision site (54.6 percent), partial (58.2 percent) or complete (31.9 percent) submuscular placement, smooth surface implants (93.1 percent), and implant size of 300 to 399 cc. Incision size was larger for silicone versus saline implants. Conclusion: These data add to the body of knowledge on women undergoing augmentation procedures by providing an unprecedented look at a large number of subjects.

The Use of Autologous Fat Grafting for Treatment of Scar Tissue and Scar-Related Conditions: A Systematic Review

The Use of Autologous Fat Grafting for Treatmentof Scar Tissue and Scar-Related Conditions: A Systematic Review

Plastic & Reconstructive Surgery: January 2016 - Volume 137 - Issue 1 - p 31e–43e

Negenborn, V et al.


Background: Scar tissue can cause cosmetic impairments, functional limitations, pain, and itch. It may also cause emotional, social, and behavioral problems, especially when it is located in exposed areas. To date, no gold standard exists for the treatment of scar tissue. Autologous fat grafting has been introduced as a promising treatment option for scar tissue-related symptoms. However, the scientific evidence for its effectiveness remains unclear. This systematic review aims to evaluate the available evidence regarding the effectiveness of autologous fat grafting for the treatment of scar tissue and scar-related conditions. Methods: A systematic literature review was performed using MEDLINE, Cochrane Library, EMBASE, and Web of Science. No language restrictions were imposed. Results: Twenty-six clinical articles were included, reporting on 905 patients in total. Meta-analysis was not performed because of the heterogeneous methodology demonstrated among the articles. Main outcome measures were scar appearance and skin characteristics, restoration of volume and/or (three-dimensional) contour, itch, and pain. All publications report a beneficial effect of autologous fat grafting on scar tissue. There is statistical significant improvement of the scar appearance, skin characteristics, and pain. Itch and restoration of volume and three-dimensional contour also improved. Conclusions: Autologous fat grafting is used to improve a variety of symptoms related to scar tissue. This systematic review suggests that autologous fat grafting provides beneficial effects with limited side effects. However, the level of evidence and methodological quality are quite low. Future randomized controlled trials with a methodologically strong design are necessary to confirm the effects of autologous fat grafting on scar tissue and scar-related conditions.

Carbon Dioxide versus Saline Tissue Expanders: Does It Matter?

Carbon Dioxide versus Saline Tissue Expanders:Does It Matter?

Plastic & Reconstructive Surgery:

January 2016 - Volume 137 - Issue 1 - p 31–35

Ascherman, J et al

Background: Implant-based breast reconstruction is the most common reconstructive technique in the United States. Despite its popularity, saline-based tissue expansion still has its limitations, including lengthy expansion times, large uncomfortable bolus dosing, and frequent percutaneous injections/expansion visits. Ideally, a novel technology would eliminate frequent, percutaneous saline injections and allow patients to perform expansion at home, reducing the disruptive experience of current tissue expansion. Methods: Within the past 6 years, the AeroForm tissue expander system has used remotely activated carbon dioxide release as the fill medium instead of saline, eliminating many limitations of traditional tissue expanders. In this article, the authors first review the relevant literature concerning carbon dioxide–based tissue expansion in animal and human models. The authors then analyze the similarities and differences between two groundbreaking human trials (i.e., Patient Activated Controlled Expansion and AirXpanders Patient Activated Controlled Tissue Expander) with carbon dioxide–based expanders and discuss the risks and benefits associated with this new technology. Results: At their site, the authors have enrolled 34 patients using 36 experimental devices in total, and have found significantly shorter expansion and overall reconstruction times in the patient-controlled tissue expander group. Conclusions: The authors believe that carbon dioxide–based devices may play a significant role in the future of implant-based breast reconstruction, and may be widely applicable to other areas of plastic surgery that also involve tissue expansion.

Over Troubled Water: An Outbreak of Infection Due to a New Species of Mycobacterium following Implant-Based Breast Surgery

Over Troubled Water: An Outbreak of Infection Due toa New Species of Mycobacterium following Implant-Based Breast Surgery

Plastic & Reconstructive Surgery: January 2016 - Volume 137 - Issue 1 - p 97–105

Scheflan, M, Wixtrom, R


Summary: Mycobacterial infection is a rare complication associated with breast surgery using implants. Over the course of 5 months, one center experienced 12 such cases, 10 of which were linked to a single surgeon. Most presented 3 to 6 weeks postoperatively with clear serous drainage from the incision, minimal local redness, no fever or other systemic signs of infection, and negative standard bacterial cultures. Patients were given empiric broad-spectrum oral antibiotic therapy. In eight cases, implants were removed and exchanged for new devices after irrigation of the pocket with antibiotics; these patients nonetheless experienced recurrent infection, which led to explantation (without immediate exchange for new implants). The last two patients proceeded straight to explantation. Because mycobacteria grow in water, the water supply and air-conditioning system were initially suspected as the source, and both were disinfected. However, this did not stop the outbreak. Eventually, the source was traced to a new species of mycobacteria isolated from a garden hot tub. These bacteria had then been unwittingly transferred to patients during surgery. A Triclosan-containing shampoo effectively ended the outbreak. This series is unique in several respects: the novelty of the pathogen, the heavy colonization of the surgeon, and the mechanism of transmission (the first occurrence of human-to-human mycobacterial transfer published in the plastic surgery literature). Surgeons who perform breast surgery with implants should be aware of the possibility of mycobacterial infection. Proactive culturing of the organism, use of antibiotics, and reoperation are essential to good outcomes.

Information requirements of young women with breast cancer treated with mastectomy or breast conserving surgery: A systematic review

Information requirements of young women with breast cancer treated with mastectomy or breast conserving surgery: A systematic review
Recio-Saucedo A, Gerty S et al.
Online Publication (February 2016Volume 25, Pages 1–13)


Young women with breast cancer have poorer prognosis, greater lifetime risk of local recurrence, contralateral recurrence, and distant disease, regardless of surgery received. Here we systematically review published evidence relating to the information requirements and preferences of young women diagnosed with early-stage breast cancer offered a choice between mastectomy and Breast Conservation Surgery (BCS). Findings will inform the development of a surgical decision aid for young women.

The Profunda Artery Perforator Flap: Investigating the Perforasome Using Three-Dimensional Computed Tomographic Angiography

The Profunda Artery Perforator Flap: Investigating the Perforasome Using Three-Dimensional Computed Tomographic Angiography
Wong, C et al
Plastic & Reconstructive Surgery: November 2015 - Volume 136 - Issue 5 - p 915–919


Background: The profunda artery perforator flap has been emerging as an alternative method of autologous breast reconstruction. This flap uses upper posterior thigh tissue. The profunda artery perforator perforasome is investigated using three-dimensional computed tomographic angiography.
Methods: Ten cadaveric thighs were dissected centered over the profunda artery perforator. The perforator was injected with contrast medium and the flap was then subjected to computed tomographic scanning using a GE Lightspeed 16-slice scanner. The three-dimensional images were viewed, and measurements were obtained using Aquarius software, including horizontal and vertical extensions of the flap and areas of perfusion. Clinical examples are presented.
 Results: A profunda artery perforator (occasionally two) was consistently found in the upper medial thigh region, posterior to the gracilis muscle. The area of vascularity shown by the spread of contrast extends inferiorly beyond the usual lower border of the profunda artery perforator flap, which is usually 7 cm wide. In injected cadaveric flaps, the mean horizontal dimension was 16.7 cm and the mean vertical dimension was 16.5 cm. The mean area perfused was 8812 cm2. Conclusions: The profunda artery perforator flap is a vascularly sound flap, and is a good option for autologous breast reconstruction. Advantages include a reliable pedicle, no position changes required, and possibly an improved donor-site contour from a thigh lift. It is an excellent alternative to abdominally based free flaps and can also be used in conjunction with other flaps for further volume enhancement.

Comparison of Allergan, Mentor, and Sientra Contoured Cohesive Gel Breast Implants: A Single Surgeon’s 10-Year Experience

Comparison of Allergan, Mentor, and Sientra Contoured Cohesive Gel Breast Implants: A Single Surgeon’s 10-Year Experience


Plastic & Reconstructive Surgery: November 2015 - Volume 136 - Issue 5 - p 957–966


Doren, Erin L.


Background: Contoured cohesive gel breast implants have been recently approved in the United States. These implants have been available for premarket approval studies for selected surgeons. The purpose of this study was to assess a single surgeon’s outcomes in three specific clinical situations—breast augmentation, secondary augmentation, and breast reconstruction—using implants of all three contoured cohesive gel implant manufacturers (Allergan, Mentor, and Sientra) over a 10-year period.
Methods: The authors performed a prospective study of contoured cohesive silicone gel breast implants. Demographic and outcomes data were recorded. Complication rates were compared among the three implant manufacturers.
Results: From 2001 to 2013, 695 patients were included from U.S. Food and Drug Administration clinical trials......................

Breast Implant–Associated Infections: The Role of the National Surgical Quality Improvement Program and the Local Microbiome

Breast Implant–Associated Infections: The Role of the National Surgical Quality Improvement Program and the Local Microbiome

Plastic & Reconstructive Surgery: November 2015 - Volume 136 - Issue 5 - p 921–929


Cohen, Justin B. et al

Background: The most common cause of surgical readmission after breast implant surgery remains infection. Six causative organisms are principally involved: Staphylococcus epidermidis and S. aureus, Escherichia, Pseudomonas, Propionibacterium, and Corynebacterium. The authors investigated the infection patterns and antibiotic sensitivities to characterize their local microbiome and determine ideal antibiotic selection.
Methods: A retrospective review of 2285 consecutive implant-based breast procedures was performed. Included surgical procedures were immediate and delayed breast reconstruction, tissue expander exchange, and cosmetic augmentation. Patient demographics, chemotherapy and/or irradiation status, implant characteristics, explantation reason, time to infection, microbiological data, and antibiotic sensitivities were reviewed.
Results: Forty-seven patients (2.1 percent) required inpatient admission for antibiotics, operative explantation, or drainage by interventional radiology. The infection rate varied depending on surgical procedure, with the highest rate seen in mastectomy and immediate tissue expander reconstruction (6.1 percent). The mean time to explantation was 41 days. Only 50 percent of infections occurred within 30 days of the indexed National Surgical Quality Improvement Program operation. The most commonly isolated organisms were coagulase-negative Staphylococcus (27 percent), methicillin-sensitive S. aureus (25 percent), methicillin-resistant S. aureus (7 percent), Pseudomonas (7 percent), and Peptostreptococcus (7 percent). All Gram-positive organisms were sensitive to vancomycin, linezolid, tetracycline, and doxycycline; all Gram-negative organisms were sensitive to gentamicin and cefepime.
Conclusions: Empiric antibiotics should be vancomycin (with the possible inclusion of gentamicin) based on their broad effectiveness against the authors’ unique microbiome. Minor infections should be treated with tetracycline or doxycycline as a second-line agent. National Surgical Quality Improvement Program data are adequate for monitoring and comparing breast infections but certainly not comprehensive. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV. 

Discussion: Use of Acellular Dermal Matrix in Postmastectomy Breast Reconstruction: Are All Acellular Dermal Matrices Created Equal?

Discussion:  Use of Acellular Dermal Matrix in Postmastectomy Breast Reconstruction: Are All Acellular Dermal Matrices CreatedEqual?



Plastic & Reconstructive Surgery: October 2015 - Volume 136 - Issue 4 - p 654–656


A discussion article about the use of acellular dermal matrix.

A Comparison of Elliptical Mastectomy to Inverted-T Pattern Mastectomy in Two-Stage Prosthetic Breast Reconstruction

A Comparison of Elliptical Mastectomy to Inverted-T Pattern Mastectomy in Two-Stage Prosthetic Breast Reconstruction

Plastic & Reconstructive Surgery: October 2015 - Volume 136 - Issue 4 - p 426e–433e

Kilgo, Matthew S et al.

Background: Patients with large or ptotic breasts undergoing mastectomy followed by tissue expander/implant-based reconstruction may benefit from a Wise (inverted-T) pattern reduction mammaplasty incision compared with the traditional horizontal elliptical incision. The authors compared these two groups of patients with regard to complication rates and outcomes.
Methods: Sixty-nine patients (117 breasts) were identified who underwent Wise pattern mastectomy and two-stage reconstruction. A control group of 89 patients (136 breasts) who underwent reconstruction after horizontal elliptical mastectomy were selected over the same period. Patient demographics, clinical characteristics, and complication rates were recorded and analyzed statistically.
Results: Patient demographics (age, body mass index, diabetes, smoking, and irradiation history) and clinical characteristics (laterality, expander size and fill volume, and time to expansion) were similar, with the exception of body mass index (control, 26.7 kg/m2; inverted-T, 28.7 kg/m2; p = 0.04) and mean intraoperative fill volume (control, 158.7 cc; inverted-T, 196.9 cc; p = 0.02). Of all complications (infection, seroma, flap necrosis, expander loss, and salvage), only the rate of mastectomy flap necrosis was significantly greater (p = 0.002) in patients undergoing inverted-T mastectomy (25.6 percent versus 11.0 percent). This difference did not result in a significantly higher rate of expander loss or need for salvage surgery.
Conclusions: The inverted-T mastectomy approach can be performed safely with acceptable complication rates. When compared with an internal control group, complication rates were similar, with the exception of mastectomy flap necrosis. Despite a higher rate of flap necrosis, 91 percent of inverted-T patients successfully completed the expansion process. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Breast conservative surgery and local recurrence

The Breast Published Online: September 29, 2015

 Mahdi Rezai, Stefan Kraemer, Rainer Kimmig, Peter Kern

Breast conservation is a legacy of Umberto Veronesi who laid the groundwork for the preservation of the body image of women affected by breast cancer (BC) with the Milan I study in the late 70ies of the last millennium. Breast conservative surgery (BCS) has two aspects: oncological safety of tumour resection with free margins and aesthetic preservation of the breast. Determinants of local control used to be T-size, nodal status and receptor status until biologically driven concepts defined risk of recurrence on the basis of molecular portraits. We explored whether these concepts of intrinsic subtypes prove at a large scale in the context of BCS and which surgical techniques procure best oncological and aesthetic outcomes, avoiding re-excision and necessity of conversion to mastectomy.

Optimal surgical management for high-risk populations

The Breast Published Online: September 29, 2015

Tari A. King, Melissa Pilewskie, Monica Morrow

The recognition that breast cancer is a group of genetically distinct diseases with differing responses to treatment and varying patterns of both local and systemic failure has led to many questions regarding optimal therapy for those considered to be high risk. Young patients, patients with triple-negative breast cancer (TNBC), and those who harbor a deleterious mutation in BRCA1 or BRCA2 are frequently considered to be at highest risk of local failure, leading to speculation that more-aggressive surgical treatment is warranted in these patients.

Exploring information provision in reconstructive breast surgery: A qualitative study

The Breast Published Online: September 29, 2015

Shelley Potter, Nicola Mills, Simon Cawthorn, Sherif Wilson, Jane Blazeby

Women considering reconstructive breast surgery (RBS) require adequate information to make informed treatment decisions. This study explored patients' and health professionals' (HPs) perceptions of the adequacy of information provided for decision-making in RBS.

Neoadjuvant chemotherapy is not a contraindication for nipple sparing mastectomy

The Breast, October 2015 Volume 24, Issue 5, Pages 661–666

Stefano Santoro, Andrea Loreti, Francesco Cavaliere, Leopoldo Costarelli, Massimo La Pinta, Elena Manna, Maria Mauri, Paola Scavina, Elena Santini, Ugo De Paula, Vito Toto, Lucio Fortunato

Nipple-sparing mastectomy (NSM) has been recently implemented to improve cosmetic outcome after mastectomy, but it is rarely considered today after neoadjuvant chemotherapy (NCH).

Shifting Autologous Breast Reconstruction into an Ambulatory Setting: Patient-Reported Quality of Recovery

Plastic and Reconstructive Surgery October 2015 - Volume 136 - Issue 4 - p 657–665

Davidge, Kristen et al

As bundled payment models gain popularity, it is imperative that providers use patient outcomes and patient experience to define evidence-based pathways of care. The purpose of this study was to evaluate the quality of recovery experienced by women undergoing early discharge (less than 24 hours) after autologous breast reconstruction with a pedicled flap and determine predictors of postoperative quality of recovery. Methods: A prospective cohort study was performed on all women undergoing autologous breast reconstruction at Women’s College Hospital between September of 2011 and July of 2013 that met study inclusion criteria. 

Use of Acellular Dermal Matrix in Postmastectomy Breast Reconstruction: Are All Acellular Dermal Matrices Created Equal?

Plastic and Reconstructive Surgery October 2015 - Volume 136 - Issue 4 - p 647–653

Ranganathan, Kavitha et al

AlloDerm and FlexHD are two types of acellular dermal matrices commonly used in implant-based reconstruction. Although the use of acellular dermal matrix has revolutionized immediate breast reconstruction in the setting of breast cancer, it remains unclear which type of acellular dermal matrix is best. The purpose of this retrospective cohort study was to compare postoperative complication rates between these two types of acellular dermal matrix. The authors reviewed the records of all patients who underwent implant-based breast reconstruction at their institution between 1998 and 2013. Dependent variables of seroma, hematoma, infection, delayed wound healing, implant exposure, and return to the operating room for management of complications were recorded.

Natrelle410 Extra-Full Projection Silicone Breast Implants: 2-Year Results from Two Prospective Studies

Plastic and Reconstructive Surgery October 2015 - Volume 136 - Issue 4 - p 638–646

Cordeiro, Peter G.; McGuire, Patricia; Murphy, Diane K.  

The safety and effectiveness of the Natrelle Style 410 highly cohesive silicone gel breast implant (Allergan, Inc., Irvine, Calif.) in full or moderate height and projection have been shown in a 10-year study. Extra-full projection implants may be an appropriate option for some women undergoing breast reconstruction. A total of 2795 women received at least one Natrelle 410 extra-full projection implant (X-style) for breast reconstruction in two similarly designed, prospective, multicenter studies…………..

TUGs into VUGs and Friendly BUGs: Transforming the Gracilis Territory into the Best Secondary Breast Reconstructive Option

TUGsinto VUGs and Friendly BUGs: Transforming the Gracilis Territory into the Best Secondary Breast Reconstructive Option

Plastic and Reconstructive Surgery 136(3):447-454, September 2015.

Park, Julie E.; Alkureishi, Lee W. T.; Song, David H.

The best secondary option for autologous breast reconstruction remains controversial. Limitations of the gracilis myocutaneous flap, including volume, skin paddle reliability, and donor morbidity, have been addressed by several modifications, hereby expanding its role in the decision tree for autologous breast reconstruction. This report documents the authors’ experience with gracilis flap breast reconstruction. This is a retrospective case series of a prospectively maintained database of patients undergoing breast reconstruction with the free gracilis myocutaneous flap, including the transverse upper gracilis, vertical upper gracilis, and bilateral stacked vertical upper gracilis.