Focus on Technique

Plastic &amp Reconstructive Surgery (Impact Factor: 2.99). 11/2012; 130:89S-94S. DOI: 10.1097/PRS.0b013e3182625852


Prosthetic-based breast reconstruction commonly involves device placement in either a total submuscular pocket or a partial subpectoral position for just superior pole coverage, with various possible strategies for inferior pole coverage. Historically, the pectoralis major muscle is managed either by suturing the muscle to the inferior flap or with marionette sutures; alternatively, the device is placed under total muscle/fascia coverage (under the pectoralis major, plus the serratus anterior and rectus abdominis muscles or fascia). For many plastic surgeons, acellular dermal matrix is now used instead to function as a sling or “hammock” supporting the periprosthetic pocket and thus covering the inferior pole of the device, attached to the pectoralis major muscle above and to the inframammary fold below. In addition to its added soft-tissue support in the inferior pole, acellular dermal matrix may help to stabilize the pectoralis major muscle along its inferolateral margin, create a well-defined inframammary fold, provide the opportunity to significantly increase intraoperative fill volume of the tissue expander, and reduce the incidence or severity of significant or symptomatic capsular contracture, particularly in a patient whose breast has been treated with radiation. In addition to its indications in primary breast reconstruction, acellular dermal matrix has been increasingly used in secondary revision reconstruction cases. It can be used to buttress capsulorrhapy and capsulotomy sites and it can be used to replace periprosthetic capsule following capsulectomy. While clinical experience is accruing for these indications, acellular dermal matrix continues to be used in primary and secondary breast reconstruction.

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    ABSTRACT: BACKGROUND:: Use of acellular dermal matrix (ADM) in breast reconstruction has been associated with increased complications. However, existing studies are generally small, from single centers, and underpowered to control for confounding using regression techniques. Here, we utilized the Tracking Outcomes and Operations in Plastic Surgery (TOPS) database to examine the effect of ADM on expander/implant loss when controlling for other confounders. METHODS:: Analysis was limited to patients having tissue expander or implant-based breast reconstruction. Surgeon-reported data, ICD-9 codes, and CPT codes were used to identify independent variables. The dependent variable of interest was 30-day rates of tissue expander or implant loss. Bivariate statistics were performed. Multivariable logistic regression identified independent predictors of expander/implant loss when controlling for other confounders. RESULTS:: Data was available for 14,249 patients. The overall rate of expander/implant loss was 2.05%. Bivariate analysis demonstrated ADM was associated with an absolute increase in expander/implant loss of 0.7% (1.88% vs. 2.58%, p=0.012). 8,746 patients had complete data and were placed into the regression model. When compared to the reference group, BMI of 30-40 and ≥40 were independent predictors of expander/implant loss. Additional independent predictors included current smoker and diabetes. When controlling for all other identified confounders, use of ADM was associated with significant increase in expander/implant loss (OR 1.42, 95% CI 1.04-1.94, p=0.026). CONCLUSIONS:: 30-day risk for expander/implant loss after tissue expander or implant-based breast reconstruction was 2.05%. Use of ADM was associated with a 0.7% absolute risk increase for expander/implant loss. LEVEL OF EVIDENCE:: Risk, II.
    Plastic and Reconstructive Surgery 03/2013; 132(1). DOI:10.1097/PRS.0b013e318290f917 · 2.99 Impact Factor
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    ABSTRACT: Prosthetic-based breast reconstruction is performed with increasing frequency in the United States. Major mastectomy skin flap necrosis is a significant complication with outcomes ranging from poor aesthetic appearance to reconstructive failure. The present study aimed to explore the interactions between intraoperative fill and other risk factors on the incidence of flap necrosis in patients undergoing mastectomy with immediate expander/implant-based reconstruction. A retrospective review of 966 consecutive patients (1,409 breasts) who underwent skin or nipple sparing mastectomy with immediate tissue expander reconstruction at a single institution was conducted. Age, body mass index, hypertension, smoking status, premastectomy and postmastectomy radiation, acellular dermal matrix use, and application of the tumescent mastectomy technique were analyzed as potential predictors of flap necrosis both independently and as synergistic variables with high intraoperative fill. The following three measures of interaction were calculated: relative excess risk due to interaction, attributable proportion of risk due to interaction, and synergy index (SI). Intraoperative tissue expander fill volume was high (≥66.7% of the maximum volume) in 40.9% (576 of 1,409 breasts) of cases. The unadjusted flap necrosis rate was greater in the high intraoperative fill cohort than in the low fill cohort (10.4% vs. 7.1%, p=0.027). Multivariate logistic regression did not identify high intraoperative fill volume as an independent risk factor for flap necrosis (odds ratio 1.442, 95% confidence interval 0.973-2.137, p=0.068). However, four risk factors were identified that interacted significantly with intraoperative fill volume, namely tumescence, age, hypertension, and obesity. The SI, or the departure from additive risks, was largest for tumescence (SI, 25.3), followed by hypertension (SI, 2.39), obesity (SI, 2.28), and age older than 50 years (SI, 1.17). In the postmastectomy, hypovascular milieu, multiple risk factors decreasing flap perfusion interact with high intraoperative fill volume to cross a threshold and synergistically increase the risk of flap necrosis.
    Journal of Breast Cancer 12/2013; 16(4):426-31. DOI:10.4048/jbc.2013.16.4.426 · 1.58 Impact Factor
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    ANZ Journal of Surgery 01/2014; 84(1-2):2-3. DOI:10.1111/ans.12485 · 1.12 Impact Factor
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