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Henry N, Sebag V, Safran T, Viezel-Mathieu A, Dionisopoulos T, Davison P, Vorstenbosch J. Immediate Prepectoral Tissue Expander Breast Reconstruction Without Acellular Dermal Matrix Is Equally Safe Following Skin-Sparing and Nipple-Sparing Mastectomy. Ann Plast Surg 2024; 93:172-177. [PMID: 38775386 DOI: 10.1097/sap.0000000000003945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/19/2024]
Abstract
BACKGROUND Prepectoral breast reconstruction has become increasingly popular over the last decade. There is a paucity of data surrounding the impact of mastectomy type on clinical outcomes when comparing prepectoral immediate breast reconstruction without acellular dermal matrix (ADM) using tissue expansion. The purpose of this study was to compare 90-day reconstructive surgical outcomes in immediate prepectoral tissue expander reconstruction between patients with nipple-sparing mastectomy (NSM) and skin-sparing mastectomy (SSM). METHODS A retrospective review of patient records was carried out on all patients undergoing NSM or SSM with immediate prepectoral tissue expander reconstruction without ADM, in a single institution, from June 2020 to December 2021. All complications were recorded, categorized, and statistically analyzed for significance. RESULTS Seventy-nine patients (97 breasts) were studied. The mean age was 51 years old (range, 31-77). Twenty-two patients suffered complications recorded in 22 breasts (22.7%). There was no statistically significant difference in the total complications between the NSM (25.7%) and SSM (21.0%) groups or in the incidence of all major and minor complications. CONCLUSIONS Breast reconstruction using tissue expanders without ADM has similar reconstructive outcomes in both NSM and SSM. There were no significant differences in complication rates between either groups. Breast reconstruction without ADM can confer institutional cost savings without compromising safety.
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Affiliation(s)
- Nader Henry
- From the Division of Plastic and Reconstructive Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - Victoria Sebag
- McGill University, Faculty of Medicine, Montreal, Quebec, Canada
| | - Tyler Safran
- From the Division of Plastic and Reconstructive Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - Alex Viezel-Mathieu
- Division of Plastic and Reconstructive Surgery, Jewish General Hospital, Montreal, Quebec, Canada
| | - Tassos Dionisopoulos
- Division of Plastic and Reconstructive Surgery, Jewish General Hospital, Montreal, Quebec, Canada
| | - Peter Davison
- From the Division of Plastic and Reconstructive Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - Joshua Vorstenbosch
- From the Division of Plastic and Reconstructive Surgery, McGill University Health Centre, Montreal, Quebec, Canada
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2
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Kinzer H, Lee CN, Cooksey K, Myckatyn T, Olsen MA, Foraker R, Johnson AR, Politi MC. Financial Toxicity Considerations in Breast Reconstruction: Recommendations for Research and Practice. Womens Health Issues 2024; 34:107-114. [PMID: 38413293 DOI: 10.1016/j.whi.2024.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 01/21/2024] [Accepted: 01/31/2024] [Indexed: 02/29/2024]
Affiliation(s)
- Hannah Kinzer
- Washington University in St Louis, School of Medicine, St. Louis, Missouri.
| | - Clara N Lee
- University of North Carolina-Chapel Hill, School of Medicine, Chapel Hill, North Carolina
| | - Krista Cooksey
- Washington University in St Louis, School of Medicine, St. Louis, Missouri
| | - Terence Myckatyn
- Washington University in St Louis, School of Medicine, St. Louis, Missouri
| | - Margaret A Olsen
- Washington University in St Louis, School of Medicine, St. Louis, Missouri
| | - Randi Foraker
- Washington University in St Louis, School of Medicine, St. Louis, Missouri
| | - Anna Rose Johnson
- Washington University in St Louis, School of Medicine, St. Louis, Missouri
| | - Mary C Politi
- Washington University in St Louis, School of Medicine, St. Louis, Missouri
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Little AK, Patmon DL, Sandhu H, Armstrong S, Anderson D, Sommers M. Inpatient versus Outpatient Immediate Alloplastic Breast Reconstruction: Recent Trends, Outcomes, and Safety. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e5135. [PMID: 37744774 PMCID: PMC10513287 DOI: 10.1097/gox.0000000000005135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Accepted: 06/06/2023] [Indexed: 09/26/2023]
Abstract
Background Immediate alloplastic breast reconstruction was traditionally performed as an inpatient procedure. Despite several reports in the literature demonstrating comparable safety outcomes, there remains hesitancy to accept breast reconstruction performed as an outpatient procedure. Methods A retrospective review of National Surgical Quality Improvement Program data from 2014 to 2018 was utilized to evaluate recent trends and 30-day postoperative complication rates for inpatient versus outpatient immediate prosthetic-based breast reconstruction. Propensity score matching was used to obtain comparable groups. Results During the study period, 33,587 patients underwent immediate alloplastic breast reconstruction. Of those, 67.5% of patients were discharged within 24 hours, and 32.4% of patients had a hospital stay of more than 24 hours. Immediate alloplastic reconstruction had an overall growth rate of 16.9% from 2014 to 2018. After propensity score matching, intraoperative variables that correlated with significantly increased inpatient status included increased work relative value units (16.3 ± 2.3 versus 16.2 ± 2.6; P < 0.001), longer operative times (228 ± 86 versus 206 ± 77; P < 0.001), and bilateral procedure (44.0% versus 43.5%; P < 0.001). There were higher rates of pulmonary embolism, wound dehiscence, urinary tract infection, transfusions, sepsis, readmissions, and reoperations in the group with the longer hospital stay. Conclusion Based on increased complication rates and costs in the inpatient setting, we propose outpatient reconstructive surgery as a safe and cost-effective alternative for immediate alloplastic breast reconstruction.
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Affiliation(s)
- Andrea K. Little
- From the Division of Plastic and Reconstructive Surgery, Spectrum Health Michigan State University Plastic Surgery Residency, Grand Rapids, Mich
| | - Darin L. Patmon
- Michigan State University College of Human Medicine, Grand Rapids, Mich
| | - Harminder Sandhu
- Michigan State University College of Human Medicine, Grand Rapids, Mich
| | | | - Daniella Anderson
- From the Division of Plastic and Reconstructive Surgery, Spectrum Health Michigan State University Plastic Surgery Residency, Grand Rapids, Mich
| | - Megan Sommers
- From the Division of Plastic and Reconstructive Surgery, Spectrum Health Michigan State University Plastic Surgery Residency, Grand Rapids, Mich
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Tanna N, Barnett SL, Robinson EL, Smith ML. Hybrid Microsurgical Breast Reconstruction:: HyFIL® & HyPAD™ Techniques. Clin Plast Surg 2023; 50:337-346. [PMID: 36813411 DOI: 10.1016/j.cps.2022.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
There are numerous indications for hybrid breast reconstruction, with the most common being patients who have inadequate donor site volume to achieve the desired breast volume. This article reviews all aspects of hybrid breast reconstruction, including preoperative and assessment, operative technique and considerations, and postoperative management.
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Affiliation(s)
- Neil Tanna
- Division of Plastic and Reconstructive Surgery, Northwell Health, Great Neck, NY, USA; Divsion of Plastic & Reconstructive Surgery, The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA.
| | - Sarah L Barnett
- Division of Plastic and Reconstructive Surgery, Northwell Health, Great Neck, NY, USA
| | - Emma L Robinson
- Divsion of Plastic & Reconstructive Surgery, The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Mark L Smith
- Division of Plastic and Reconstructive Surgery, Northwell Health, Great Neck, NY, USA; Divsion of Plastic & Reconstructive Surgery, The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
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Atia AN, Sergesketter AR, Morris MX, Biswas S, Zhang G, Langdell HC, Hollins AW, Phillips BT. Predicting Final Implant Volume in Two-stage Prepectoral Breast Reconstruction. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e4780. [PMID: 36699206 PMCID: PMC9857536 DOI: 10.1097/gox.0000000000004780] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 11/28/2022] [Indexed: 05/10/2023]
Abstract
UNLABELLED Two-stage implant-based breast reconstruction remains the most commonly performed reconstructive modality following mastectomy. Although prior studies have explored the relationship between tissue expander (TE) features and permanent implant (PI) size in subpectoral reconstruction, no such study exists in prepectoral reconstruction. This study aims to identify pertinent TE characteristics and evaluate their correlations with PI size for prepectoral implant-based reconstruction. METHODS This study analyzed patients who underwent two-stage prepectoral tissue expansion for breast reconstruction followed by implant placement. Patient demographics and oncologic characteristics were recorded. TE and PI features were evaluated. Significant predictors for PI volume were identified using linear and multivariate regression analyses. RESULTS We identified 177 patients and 296 breast reconstructions that met inclusion criteria. All reconstructions were performed in the prepectoral plane with the majority using acellular dermal matrix (93.8%) and primarily silicone implants (94.3%). Mean TE size was 485.4 cm3 with mean initial fill of 245.8 cm3 and mean final fill of 454.4 cm3. Mean PI size was 502.9 cm3 with a differential fill volume (PI-TE) of 11.7 cm3. Multivariate analysis identified significant features for PI size prediction, including TE size (R2 = 0.60; P < 0.0001) and TE final fill volume (R2 = 0.57; P < 0.0001). The prediction expression for TE final fill and TE size was calculated as 26.6 + 0.38*(TE final fill) + 0.61*(TE size). CONCLUSIONS TE size and final expansion volume were significant variables for implant size prediction. With prepectoral implant placement gaining popularity, the predictive formula may help optimize preoperative planning and decision-making in prepectoral reconstructions.
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Affiliation(s)
- Andrew N. Atia
- From the Division of Plastic, Maxillofacial, and Oral Surgery, Department of Surgery, Duke University Medical Center, Durham, N.C
| | - Amanda R. Sergesketter
- From the Division of Plastic, Maxillofacial, and Oral Surgery, Department of Surgery, Duke University Medical Center, Durham, N.C
| | | | | | | | - Hannah C. Langdell
- From the Division of Plastic, Maxillofacial, and Oral Surgery, Department of Surgery, Duke University Medical Center, Durham, N.C
| | - Andrew W. Hollins
- From the Division of Plastic, Maxillofacial, and Oral Surgery, Department of Surgery, Duke University Medical Center, Durham, N.C
| | - Brett T. Phillips
- From the Division of Plastic, Maxillofacial, and Oral Surgery, Department of Surgery, Duke University Medical Center, Durham, N.C
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Characterization of host-pathogen-device interactions in Pseudomonas aeruginosa infection of breast implants. Plast Reconstr Surg 2022; 150:260e-271e. [PMID: 35653545 DOI: 10.1097/prs.0000000000009315] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Pseudomonas aeruginosa (PA) accounts for 7%-22% of breast implant-associated infections (BIAIs), which can result in reconstructive failures and explantation. Investigating host-pathogen-device interactions in mice and patient samples will improve our understanding of colonization mechanisms, for targeted treatments and clinical guidelines. METHODS Mice with and without implants (Mentor®) were infected with PAO1 lab strain or BIP2 or BIP16 clinical strains and sacrificed at 1 day or 7 days post-infection (dpi) to evaluate for colonization of implants and underlying tissues via colony-forming unit (CFU) enumeration. Immunostaining was performed on mouse implants, human tissue expanders (TE) colonized by BIP2, and acellular dermal matrix (ADM) colonized by BIP16. RESULTS Colonization of tissues and smooth implants by P. aeruginosa was strain-dependent: at 1dpi, all strains acutely infected tissues with and without implants with colonization levels reflecting growth rates of individual strains. At 7dpi, PAO1 caused colonization of ~105 CFUs/100mg of tissue but required implant presence, while in mice infected with BIP2/BIP16, CFUs were below the limit of detection with or without implants. Immunofluorescence staining of mouse implants, however, demonstrated continued presence of BIP2 and BIP16. Staining showed co-localization of all strains with fibrinogen, collagen I and collagen III on mouse and human samples. CONCLUSIONS The trajectory of P. aeruginosa in BIAIs was strain-dependent and strains could exhibit acute symptomatic or chronic asymptomatic colonization. With strains causing clinical symptoms, the presence of an implant significantly worsened infection. For asymptomatic colonizers, further studies investigating their long-term impacts, especially during periods of immunosuppression in hosts, are needed.
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Petrie K, Cox CT, Becker BC, MacKay BJ. Clinical applications of acellular dermal matrices: A review. Scars Burn Heal 2022; 8:20595131211038313. [PMID: 35083065 PMCID: PMC8785275 DOI: 10.1177/20595131211038313] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION The extracellular matrix (ECM) plays an integral role in wound healing. It provides both structure and growth factors that allow for the organised cell proliferation. Large or complex tissue defects may compromise host ECM, creating an environment that is unfavourable for the recovery of anatomical function and appearance. Acellular dermal matrices (ADMs) have been developed from a variety of sources, including human (HADM), porcine (PADM) and bovine (BADM), with multiple different processing protocols. The objective of this report is to provide an overview of current literature assessing the clinical utility of ADMs across a broad spectrum of applications. METHODS PubMed, MEDLINE, EMBASE, Scopus, Cochrane and Web of Science were searched using keywords 'acellular dermal matrix', 'acellular dermal matrices' and brand names for commercially available ADMs. Our search was limited to English language articles published from 1999 to 2020 and focused on clinical data. RESULTS A total of 2443 records underwent screening. After removing non-clinical studies and correspondence, 222 were assessed for eligibility. Of these, 170 were included in our synthesis of the literature. While the earliest ADMs were used in severe burn injuries, usage has expanded to a number of surgical subspecialties and procedures, including orthopaedic surgery (e.g. tendon and ligament reconstructions), otolaryngology, oral surgery (e.g. treating gingival recession), abdominal wall surgery (e.g. hernia repair), plastic surgery (e.g. breast reconstruction and penile augmentation), and chronic wounds (e.g. diabetic ulcers). CONCLUSION Our understanding of ADM's clinical utility continues to evolve. More research is needed to determine which ADM has the best outcomes for each clinical scenario. LAY SUMMARY Large or complex wounds present unique reconstructive and healing challenges. In normal healing, the extracellular matrix (ECM) provides both structural and growth factors that allow tissue to regenerate in an organised fashion to close the wound. In difficult or large soft-tissue defects, however, the ECM is often compromised. Acellular dermal matrix (ADM) products have been developed to mimic the benefits of host ECM, allowing for improved outcomes in a variety of clinical scenarios. This review summarises the current clinical evidence regarding commercially available ADMs in a wide variety of clinical contexts.
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Affiliation(s)
- Kyla Petrie
- Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Cameron T Cox
- Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | | | - Brendan J MacKay
- Texas Tech University Health Sciences Center, Lubbock, TX, USA.,University Medical Center, Lubbock, TX, USA
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8
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Dimovska EOF, Chen C, Chou HH, Lin YL, Cheng MH. Outcomes and quality of life in immediate one-stage versus two-stage breast reconstructions without an acellular dermal matrix: 17- years of experience. J Surg Oncol 2021; 124:510-520. [PMID: 34133023 DOI: 10.1002/jso.26568] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 05/30/2021] [Accepted: 06/01/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND Advantages of one-stage implant-based reconstructions include expedited surgery and recovery. This study aimed to investigate clinical and patient-reported outcomes in one-stage implant-based breast reconstructions without acellular dermal matrix (ADM). METHODS A prospectively collected database from 2002 to 2018 was retrospectively reviewed. One-stage and two-stage groups were compared for demographics, implant properties, early complications (hematoma, seroma, poor wound healing, implant removal), late complications (skin necrosis, capsular contracture, implant exposure, implant rupture), revision procedures, and Breast-Q questionnaire outcomes. RESULTS A total of 223 patients, 187 one-stage (84%) and 36 two-stage (16%) patients were recruited. At a mean follow-up of 124.9 and 92.5 months, respectively (p < .01), there were no differences in early (p = .85) or late (p = .23) complications or revision procedures (p = .12). Eighty patients (36%) returned the Breast-Q questionnaire (60 one-stage, 20 two-stage patients). There were no statistical differences in patient reported outcomes in breast well-being (p = .07), psychosocial well-being (p = .84), or sexual well-being (p = .78). CONCLUSIONS One-stage implant-based breast reconstruction without an ADM is a viable reconstruction providing comparable outcomes to two-stage procedures, with the benefit of minimal complications, a shorter reconstructive journey, and satisfactory quality of life.
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Affiliation(s)
- Eleonora O F Dimovska
- Division of Plastic & Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden.,Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Courtney Chen
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Hsu-Huan Chou
- Department of General Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Yi-Ling Lin
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Ming-Huei Cheng
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Center for Tissue Engineering, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,Section of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
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Aliotta RE, Duraes EFR, Scomacao I, Morisada M, Orra S, Moreira A, Bernard S, Schwarz G, Djohan R. A controlled cost and outcomes analysis of acellular dermal matrix and implant-based reconstruction. J Plast Reconstr Aesthet Surg 2020; 74:1229-1238. [PMID: 33526361 DOI: 10.1016/j.bjps.2020.10.079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 08/29/2020] [Accepted: 10/22/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION The use of acellular dermal matrix (ADM) for breast reconstruction continues to change in both single- and two-stage reconstruction. Determining optimal outcomes clinically, aesthetically, financially as well as for the patient's quality of life has become a priority. METHODS A retrospective review of implant-based reconstructions was performed at a single center from 2010 to 2016, with patients blindly matched 1:1:1 into three cohorts based on reconstruction type: 1) single stage direct to implant with ADM, 2) two-stage tissue expander to implant (TE/I) without ADM, and 3) two-stage TE/I with ADM. Relative cost between groups, esthetic outcomes, and quality of life within each group was analyzed. RESULTS Group 1 was more likely to be older and use intraoperative angiography, but with fewer overall surgeries and postoperative visits (p<0.001). There was no statistically significant difference in reconstructive success among all three groups (p = 0.85). Cost was significantly higher for group 3 relative to groups 1 and 2. Overall appearance was higher in groups 1 and 3 relative to group 2, with radiation therapy the only independent factor. Group 1 had higher scores using Breast-Q for the physical well-being domain (p = 0.01). CONCLUSION This is the first study to incorporate clinical outcomes, esthetic visual grading, and patient-reported quality within the same cohort of individuals, considering both use of ADM and staging. Despite the added ADM cost, it is proven safe, eliminates time and cost associated with tissue expanders, decreases post-operative visits and can lead to equally as functional and aesthetically pleasing outcomes in single- and two-stage breast reconstructions.
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Affiliation(s)
- Rachel E Aliotta
- Department of Plastic & Reconstructive Surgery, Cleveland Clinic Foundation, A60 Crile Building, 9500 Euclid Avenue, Cleveland, OH 44195, United States
| | - Eliana F R Duraes
- Department of Plastic & Reconstructive Surgery, Cleveland Clinic Foundation, A60 Crile Building, 9500 Euclid Avenue, Cleveland, OH 44195, United States
| | - Isis Scomacao
- Department of Plastic & Reconstructive Surgery, Cleveland Clinic Foundation, A60 Crile Building, 9500 Euclid Avenue, Cleveland, OH 44195, United States
| | - Megan Morisada
- Department of Plastic & Reconstructive Surgery, Cleveland Clinic Foundation, A60 Crile Building, 9500 Euclid Avenue, Cleveland, OH 44195, United States
| | - Susan Orra
- Department of Plastic & Reconstructive Surgery, Cleveland Clinic Foundation, A60 Crile Building, 9500 Euclid Avenue, Cleveland, OH 44195, United States
| | - Andrea Moreira
- Department of Plastic & Reconstructive Surgery, Cleveland Clinic Foundation, A60 Crile Building, 9500 Euclid Avenue, Cleveland, OH 44195, United States
| | - Steven Bernard
- Department of Plastic & Reconstructive Surgery, Cleveland Clinic Foundation, A60 Crile Building, 9500 Euclid Avenue, Cleveland, OH 44195, United States
| | - Graham Schwarz
- Department of Plastic & Reconstructive Surgery, Cleveland Clinic Foundation, A60 Crile Building, 9500 Euclid Avenue, Cleveland, OH 44195, United States
| | - Risal Djohan
- Department of Plastic & Reconstructive Surgery, Cleveland Clinic Foundation, A60 Crile Building, 9500 Euclid Avenue, Cleveland, OH 44195, United States.
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Discussion: Cost-Effectiveness Analysis of Silicone versus Saline Implant-Based Breast Reconstruction Using the BREAST-Q. Plast Reconstr Surg 2019; 143:285e-286e. [PMID: 30688879 DOI: 10.1097/prs.0000000000005222] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Kedar D, Inbal A, Arad E, Gur E, Barnea Y. Immediate breast reconstruction in high-risk cases using an anatomically shaped permanent expandable implant. J Plast Reconstr Aesthet Surg 2018; 72:401-409. [PMID: 30528287 DOI: 10.1016/j.bjps.2018.10.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2018] [Accepted: 10/28/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND Anatomically shaped permanent expandable implants are dual-chambered devices, which allow their postoperative expansion for the adjustment of volume. Their use is optional when 1-stage immediate breast reconstruction (IBR) direct to permanent implant is not feasible. The aim of this study is to present one center's long-term experience with the anatomical Becker expandable implant in a large series of patients who underwent either IBR or a salvage procedure for IBR with the device. METHODS The records of 141 patients (a total of 161 breasts) who underwent IBR with the Becker implant were retrospectively reviewed. Patient demographics and surgical outcomes were analyzed. Indications for this procedure included reduced skin envelopes, compromised skin flaps, salvage procedures, and single-stage procedures in patients with major comorbidities. RESULTS One hundred twenty-three devices (76%) involved IBR and 38 devices (24%) were salvage cases after direct-to-implant IBR. The device was used in a previously radiated breast in 36 cases (22%). Long-term follow-up demonstrated that 99 devices (61.5%) had been exchanged or removed and that only 62 devices (38.5%) remained as permanent implants. Removal of the device was associated with prior breast radiation and advanced age. CONCLUSIONS The use of the Becker device in high-risk IBR cases had a low retention rate as a permanent implant. Favorable indications for the use of this device in IBR cases include contralateral breast augmentation and patients with major comorbidities, which demonstrated a higher retention rate. Other indications for high-risk IBR cases could probably benefit using a 2-stage tissue-expander and implant technique.
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Affiliation(s)
- Daniel Kedar
- Plastic and Reconstructive Breast Surgery Unit, Department of Plastic Surgery, Tel-Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, 6 Weizmann St., Tel-Aviv 6423906, Israel
| | - Amir Inbal
- Plastic and Reconstructive Breast Surgery Unit, Department of Plastic Surgery, Tel-Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, 6 Weizmann St., Tel-Aviv 6423906, Israel
| | - Ehud Arad
- Plastic and Reconstructive Breast Surgery Unit, Department of Plastic Surgery, Tel-Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, 6 Weizmann St., Tel-Aviv 6423906, Israel
| | - Eyal Gur
- Plastic and Reconstructive Breast Surgery Unit, Department of Plastic Surgery, Tel-Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, 6 Weizmann St., Tel-Aviv 6423906, Israel
| | - Yoav Barnea
- Plastic and Reconstructive Breast Surgery Unit, Department of Plastic Surgery, Tel-Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, 6 Weizmann St., Tel-Aviv 6423906, Israel.
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Cortiva Versus AlloDerm Ready-to-use in Prepectoral and Submuscular Breast Reconstruction: Prospective Randomized Clinical Trial Study Design and Early Findings. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2018; 6:e2013. [PMID: 30881804 PMCID: PMC6414118 DOI: 10.1097/gox.0000000000002013] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Accepted: 09/19/2018] [Indexed: 11/26/2022]
Abstract
Background: Several acellular dermal matrices (ADMs) can be used to provide soft-tissue support for post- and prepectoral prosthetic breast reconstructions. Yet, several recent meta-analysis suggest that due to a lack of rigorous evaluation in the setting of head-to-head prospective randomized control trials, few reliable conclusions regarding performance outcomes can be drawn. We compare Cortiva 1 mm to AlloDerm RTU in the setting of submuscular reconstruction in one study, and prepectoral in the second. Moreover, we present the findings from the interim analysis in our submuscular study. Methods: Using a single-blinded prospective randomized control trial design, we compare outcomes in 180 patients undergoing submuscular breast reconstruction with 16 × 8 cm ADM support (either Cortiva 1 mm or AlloDerm RTU). A parallel study evaluates 16 × 20 cm sheets of these ADMs in 180 patients undergoing prepectoral reconstructions. Time to drain removal, complications, fill volumes, patient-reported outcomes, and narcotic consumption are prospectively evaluated. Results: Interim analysis of 59 breasts in the submuscular study arm (Cortiva n = 31; AlloDerm n = 28) revealed no statistically significant differences with respect to outcome. At the time of interim analysis, the AlloDerm RTU group contained a higher proportion of never-smokers (P = 0.009), while patients implanted with Cortiva 1 mm received a larger tissue expander (P = 0.02). Conclusion: We present a protocol for a robust randomized control trial to evaluate outcomes in both submuscular and prepectoral prosthetic breast reconstruction assisted by 2 distinct types of ADM. Our interim analysis reveals no evidence of inferiority of outcomes in a comparison of AlloDerm to Cortiva.
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13
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A Predictive Model for Determining Permanent Implant Size During 2-Stage Implant Breast Reconstruction. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2018; 6:e1790. [PMID: 29922567 PMCID: PMC5999420 DOI: 10.1097/gox.0000000000001790] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Accepted: 03/29/2018] [Indexed: 11/26/2022]
Abstract
Background: Two-stage tissue expander (TE)/permanent implant (PI) breast reconstruction remains the most commonly performed technique in breast reconstruction. Predictions for the PI size preoperatively impact on the number and range of implants made available at TE exchange. This study aims to identify critical preoperative variables and create a predictive model for PI size. Methods: Patients who underwent 2-stage implant breast reconstruction from 2011 to 2017 were included in the study. Linear and multivariate regression analyses were used to identify significant preoperative variables for PI volume. Results: During the study period, 826 patients underwent 2-stage TE/PI breast reconstruction. Complete records were available for 226 breasts. Initial TE fill ranged from 0% to 102% with a mean final fill of 100.6% of TE volume. The majority of PIs were smooth round (98.2%), silicone (90%) implants. In a multivariate analysis, significant variables for predicting PI size were TE final fill volume (P < 0.0001), TE size (P = 0.03), and a history of preoperative radiation (P = 0.001). Relationships between these 3 variables were utilized to form a predictive model with a regression coefficient of R2 = 0.914. Conclusions: Significant variables for predicting PI volume were TE final fill volume, TE size, and a history of preoperative radiation. The ability to more accurately predict the PI volume can improve surgical planning, reduce consignment inventory, and simplify operating room workflow.
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Benz KS, Jayman J, Maruf M, Joice G, Kasprenski M, Sopko N, Di Carlo H, Gearhart JP. The Role of Human Acellular Dermis in Preventing Fistulas After Bladder Neck Transection in the Exstrophy-epispadias Complex. Urology 2018; 117:137-141. [PMID: 29704585 DOI: 10.1016/j.urology.2018.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Revised: 02/26/2018] [Accepted: 04/10/2018] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To evaluate human acellular dermis (HAD) as an adjunct during bladder neck transection (BNT) by comparing surgical outcomes with other types of tissue interposition. METHODS A prospectively maintained institutional database of exstrophy-epispadias complex (EEC) patients was reviewed for those who underwent a BNT with at least 6 months follow-up. The primary outcome was the occurrence of BNT-related fistulas. RESULTS In total, 147 EEC patients underwent a BNT with a mean follow-up time of 6.9 years (range 0.52-23.35 years). There were 124 (84.4%) classic exstrophy patients, 22 (15.0%) cloacal exstrophy patients, and 1 (0.7%) penopubic epispadias patient. A total of 12 (8.2%) BNTs resulted in fistulization, including 4 vesicoperineal fistulas, 7 vesicourethral fistulas, and 1 vesicovaginal fistula. There were 5 (22.7%) fistulas in the cloacal exstrophy cohort and 7 (5.6%) fistulas in the classic bladder exstrophy cohort (P = .019). Using either HAD or native tissue flaps resulted in a lower fistulization rate than using no interposed layers (5.8% vs 20.8%; P = .039). Of those with HAD, the use of a fibrin sealant did not decrease fistulization rates when compared to HAD alone (6.5% vs 8.8%, P = .695). There was no statistical difference in surgical complications between the use of HAD and native flaps (8.6% vs 5%, P = .716). CONCLUSION Use of soft tissue flaps and HAD is associated with decreased fistulization rates after BNT. HAD is a simple option and an effective adjunct that does not require harvesting of tissues in patients where a native flap is not feasible.
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Affiliation(s)
- Karl S Benz
- Robert D. Jeffs Division of Pediatric Urology, James Buchanan Brady Urological Institute, Johns Hopkins Hospital, Baltimore, MD
| | - John Jayman
- Robert D. Jeffs Division of Pediatric Urology, James Buchanan Brady Urological Institute, Johns Hopkins Hospital, Baltimore, MD
| | - Mahir Maruf
- Robert D. Jeffs Division of Pediatric Urology, James Buchanan Brady Urological Institute, Johns Hopkins Hospital, Baltimore, MD
| | - Gregory Joice
- Robert D. Jeffs Division of Pediatric Urology, James Buchanan Brady Urological Institute, Johns Hopkins Hospital, Baltimore, MD
| | - Matthew Kasprenski
- Robert D. Jeffs Division of Pediatric Urology, James Buchanan Brady Urological Institute, Johns Hopkins Hospital, Baltimore, MD
| | - Nikolai Sopko
- Robert D. Jeffs Division of Pediatric Urology, James Buchanan Brady Urological Institute, Johns Hopkins Hospital, Baltimore, MD
| | - Heather Di Carlo
- Robert D. Jeffs Division of Pediatric Urology, James Buchanan Brady Urological Institute, Johns Hopkins Hospital, Baltimore, MD
| | - John P Gearhart
- Robert D. Jeffs Division of Pediatric Urology, James Buchanan Brady Urological Institute, Johns Hopkins Hospital, Baltimore, MD.
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Moffitt Cancer Center Experience of Tissue Expander Breast Reconstruction: Does Acellular Dermal Matrix Increase Return to the Operating Room? Ann Plast Surg 2018; 80:S377-S380. [PMID: 29369110 DOI: 10.1097/sap.0000000000001322] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Tissue expander and implant remains the most common technique for breast reconstruction. A controversial topic within this method is routine use of acellular dermal matrix (ADM). Acellular dermal matrices have increased risks of infection, seroma, hematoma, skin flap necrosis, and total complications. METHODS After an institutional review board approval, a retrospective chart review was conducted of 756 tissue expander with implant cases from November 2010 to November 2016 at Moffitt Cancer Center with 2 breast reconstruction surgeons. Patients were grouped in 2 groups: tissue expander alone reconstruction (TE) and tissue expander with ADM (TE + ADM). Complications were defined by return visits to the operating room for irrigation and debridement as well as for subsequent tissue expander placement. RESULTS There were 703 patients in the TE group and 53 in the TE + ADM group. Patients undergoing TE + ADM reconstruction were 3 times more likely to experience return to operating room compared with patients undergoing TE alone (7.5% vs 2.4%). Patients were significantly more likely to undergo 3 or more subsequent tissue expander placement procedures with TE + ADM (54.7%) compared with TE alone (4.8%) (P < 0.0001). CONCLUSIONS Although ADM may be appropriate for specific patients, its use in tissue expander breast reconstruction should be judiciously selected, because there is an observed increase in complications needing return to the operating room.
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Zenn MR. Indications and Controversies for Implant-Based Breast Reconstruction Utilizing Biological Meshes. Clin Plast Surg 2018; 45:55-63. [DOI: 10.1016/j.cps.2017.08.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Zenn M, Venturi M, Pittman T, Spear S, Gurtner G, Robb G, Mesbahi A, Dayan J. Optimizing Outcomes of Postmastectomy Breast Reconstruction With Acellular Dermal Matrix: A Review of Recent Clinical Data. EPLASTY 2017; 17:e18. [PMID: 28663773 PMCID: PMC5475305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background: This article reports on the current use of acellular dermal matrix in breast reconstruction. Methods: A literature review of articles on acellular dermal matrix in breast reconstruction from January 1, 2010, through December 20, 2016, was performed and analyzed for trends in acellular dermal matrix use and differences between commonly used acellular dermal matrixes. Findings: Clinical findings varied but include improved cosmesis and more 1-stage reconstructions using acellular dermal matrix. Superiority of sterile versus aseptic acellular dermal matrixes was noted, and the increased incidence of red breast syndrome with AlloDerm was significant. The cost-effectiveness of acellular dermal matrix use despite increased upfront costs was also highlighted. Finally, the article emphasizes the importance of well-vascularized mastectomy flaps and the use of indocyanine green angiography as an adjunct in immediate reconstruction with acellular dermal matrix.
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Affiliation(s)
| | - Mark Venturi
- Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington, DC
| | - Troy Pittman
- Plastic and Reconstructive Surgery, Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington, DC
| | - Scott Spear
- Private Practice Plastic Surgery, Chevy Chase, MD
| | - Geoffrey Gurtner
- Department of Plastic Surgery, Stanford University, Palo Alto, Calif
| | - Geoffrey Robb
- Department of Plastic Surgery, MD Anderson Cancer Center, Houston, Tex
| | - Alex Mesbahi
- Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington, DC
| | - Joseph Dayan
- Department of Plastic Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY
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