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ABSTRACT: BACKGROUND:: Human acellular dermal matrices (ADMs) have gained increasing use in immediate expander-based breast reconstruction. However, some studies suggest that these grafts may be associated with a higher incidence of infection and seroma. In order to evaluate complication rates after ADM-based breast reconstruction, the authors conducted a prospective multicenter cohort study to evaluate a sterile human ADM in immediate expander-based breast reconstruction, specifically to determine if it offered a more favorable risk profile with respect to infection and seroma. A secondary outcome was to determine whether the sterilization process affects graft incorporation. METHODS:: The authors performed 65 consecutive tissue expander-based breast reconstructions in a cohort of patients over a one-year period using a single protocol. Sterile human acellular dermal matrix was used in all cases. The patients were evaluated for early complications (infection, seroma) and graft incorporation at the time of exchange or definitive reconstruction. Biopsies were performed in the first 20 reconstructions to provide histological correlation of graft incorporation. RESULTS:: Complications occurred in three breasts (4.6 percent), including one cellulitis (1.5 percent) and two partial mastectomy flap necroses (3.0 percent) that required debridement. There were no seromas or explantations. The grafts were incorporated in all cases and verified histologically in the first 20 biopsies. CONCLUSION:: Sterile human acellular dermal matrix can offer reliable matrix incorporation and a low complication rate. Sterilization does not negatively impact the incorporation of the graft. The rates of infection and seroma in this prospective study compare favorably to previous studies with non-sterilized (aseptic) ADM. LEVEL OF EVIDENCE:: Therapeutic, II.
Plastic and reconstructive surgery 09/2012; · 2.74 Impact Factor
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ABSTRACT: The internal mammary vein (IMV) is commonly used as a recipient vessel in the direction of antegrade flow for free flap breast reconstruction. Recent reports show that the distal IMV is valveless and can accommodate retrograde flow. We sought to quantify blood velocity and flow through the distal IMV following free tissue transfer.
Ten free flap breast reconstructions were performed. The larger vena comitans of the DIEA was anastomosed to the antegrade internal mammary vein (AIMV). The smaller vena comitans was anastomosed to the retrograde internal mammary vein (RIMV) in five free flaps, and the superficial inferior epigastric vein (SIEV) was anastomosed to the RIMV in five other free flaps.
The mean diameter of the larger vena comitans (3.4 ± 0.5 mm) was significantly greater than that of the smaller vena comitans (2.4 ± 0.4 mm; P = 0.003). Mean velocity in the AIMV after anastomosis was 10.13 ± 5.21 mm/s compared with 7.01 ± 2.93 mm/s in the RIMV (P = 0.12). Mean blood flow in the AIMV and the RIMV was 81.33 ± 52.81 mm(3) /s and 57.84 ± 45.11 mm(3) /s, respectively (P = 0.30). Mean blood flow in the RIMV was not significantly affected by whether the donor vein was the smaller vena comitans (70.78 ± 61.43 mm(3) /s) or the SIEV (44.90 ± 19.70 mm(3) /s; P = 0.40).
Blood flow in the RIMV was less but not significantly different from flow in the AIMV. The difference is likely due to the smaller-sized donor vein anastomosed to the RIMV. The RIMV is a reliable, useful option when the antegrade vein is not available, or when a second recipient vein is needed.
Microsurgery 09/2011; 31(8):596-602. · 1.61 Impact Factor
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ABSTRACT: This study evaluated narcotic use after deep inferior epigastric perforator flap breast reconstruction when a local anesthetic catheter was used. A retrospective analysis was performed comparing 40 consecutive control patients (no catheter) to 40 consecutive study patients who had received a pain pump catheter. The catheter was left in the abdomen for 72 hours. Using an equianalgesic table, all narcotic doses (oral and intravenous) were converted to intravenous morphine equivalents. Initial average 24-hour morphine requirement for the control group was 42 mg compared with 33 mg for the study group (P = 0.04). Total hospitalization average morphine requirement for the control group was 71 mg compared with 55 mg for the catheter group (P = 0.03). The use of an implantable local anesthetic catheter placed in the abdomen can decrease narcotic use in the postoperative period after deep inferior epigastric perforator flap breast reconstruction.
Annals of plastic surgery 07/2009; 62(6):618-20. · 1.29 Impact Factor
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ABSTRACT: The purpose of this study was to stratify plastic surgery patients into venous thromboembolism risk categories; identify patients at highest risk for venous thromboembolism; and quantify rates of postoperative all-cause mortality, venous thromboembolism, and hematoma/bleeding on different forms of thromboprophylaxis. Furthermore, this study aimed to determine the compliance and average duration of outpatient chemoprophylaxis.
A retrospective cohort study was carried out on a single plastic surgeon's experience. Venous thromboembolism risk stratification identified patients at highest risk. Records were reviewed for regimen of thromboprophylaxis and for occurrences of all-cause mortality, venous thromboembolism, and hematoma/bleeding. Outpatient compliance and duration of low-molecular-weight heparin chemoprophylaxis was also documented.
During the study time period, 173 operations involved 120 patients at highest risk for venous thromboembolism. Among highest risk patients, one (0.8 percent) suffered a pulmonary embolism, eight (6.7 percent) experienced a deep vein thrombosis, and 15 (12.5 percent) endured a hematoma/bleed. Thirteen of 14 outpatients (92.9 percent) were compliant with low-molecular-weight heparin and remained on chemoprophylaxis for an average of 7.4 days.
Mechanical prophylaxis plus subcutaneous heparin (unfractionated or low-molecular-weight heparin) conferred a statistically significant reduction in the rate of venous thromboembolism without a significant increase in bleeding versus mechanical prophylaxis alone. Subgroup analysis of patients placed on mechanical prophylaxis plus low-molecular-weight heparin revealed similar statistically significant findings. Outpatients placed on low-molecular-weight heparin chemoprophylaxis demonstrated excellent compliance and comfort with self-administration. Therefore, the use of mechanical prophylaxis supplemented with low-molecular-weight heparin is strongly recommended as the first-line regimen for thromboprophylaxis in plastic surgery patients at highest risk for venous thromboembolism.
Plastic and reconstructive surgery 01/2009; 122(6):1701-8. · 2.74 Impact Factor
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Plastic and reconstructive surgery 08/2008; 122(1):33e-34e. · 2.74 Impact Factor
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ABSTRACT: The purpose of this study was to evaluate both clinical outcomes and satisfaction in patients who have undergone prophylactic mastectomy and breast reconstruction.
A 5-year retrospective analysis of the senior author's (S.L.S.) experience with breast reconstruction following prophylactic mastectomy was performed. Timing, type of mastectomy and reconstruction, complications, and cancer occurrence/recurrence were examined. Patients reported their level of satisfaction and willingness to undergo the procedure again. Aesthetic outcomes were graded by an independent and blinded group of surgeons.
There were 101 breast reconstructions performed in 74 patients following prophylactic mastectomy. With a mean follow-up of 31 months, there were three breast-site complications in this group (3 percent). Forty-seven patients in the study had a unilateral prophylactic mastectomy; on the contralateral side with cancer, there were five breast-site complications in reconstructions following therapeutic mastectomy (10 percent). Aesthetic outcome ratings by surgeons were higher in the bilateral prophylactic mastectomy and reconstruction patients compared with the cancer patients who had undergone a therapeutic mastectomy and reconstruction along with a contralateral prophylactic mastectomy; however, this difference did not reach statistical significance. Patient satisfaction was higher in the bilateral prophylactic group, with all of the patients completing the survey stating they would undergo the procedure again.
Breast reconstruction following prophylactic mastectomy was as safe as or more safe than that following therapeutic mastectomy, which has been shown in other studies to result in a high percentage of patient satisfaction. Although not statistically significant, the results from reconstruction after prophylactic mastectomy trended toward improved aesthetic outcome with a lower complication rate compared with reconstruction after therapeutic mastectomy.
Plastic and reconstructive surgery 08/2008; 122(1):1-9. · 2.74 Impact Factor
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ABSTRACT: Management of head and neck melanoma has changed dramatically with the use of sentinel node biopsy for staging. Nodal dissection may now be delayed or deferred based on the results of the sentinel node biopsy. The authors suggest using a face lift incision to access the nodal basins for sentinel node biopsy in head and neck melanoma.
A face lift incision was used successfully for sentinel node biopsy in 21 patients. The diagnosis of melanoma, histologic subtype, and depth of penetration were established by biopsy with permanent sections. All patients underwent lymphoscintigraphy on the morning of their surgery. If the scan showed multiple nodes at various levels of the neck or parotid, the patient was selected for a face lift incision for biopsy.
The study comprised 14 men and seven women between the ages of 26 and 82 years (mean age, 55 years). The sites of melanoma included the temple in six patients, cheek in five, neck in four, and ear and scalp in two patients each. The average Clark's level and Breslow depth were 3.67 and 1.76 mm, respectively. The average number of basins involved was 2.14; the average number of nodes was 3.33, with an average of 1.56 nodes per basin. Follow-up ranged from 2 to 53 months (average, 26 months). Only two patients had sentinel nodes that were positive for metastatic melanoma. One complication, a transient paresis of the right marginal mandibular nerve, was observed.
Using a face lift incision for sentinel node biopsy in head and neck melanoma is a safe, reliable technique. It provides excellent access to multiple nodal basins, well-concealed incisions, wide exposure for delayed therapeutic nodal dissection, and local and regional flap options for reconstructing the excision site.
Plastic and reconstructive surgery 12/2007; 120(6):1533-9. · 2.74 Impact Factor
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ABSTRACT: LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Understand the different variables that are inherent to breast augmentation. 2. Identify certain breast shape characteristics that make one approach more advantageous than others. 3. Take into account certain patient characteristics to develop a logical surgical plan for breast augmentation. SUMMARY: The optimal technique for breast augmentation has always been debated, and numerous variables fit the needs of the variously shaped patients in our population. The purpose of this article is to present the advantages and disadvantages of the various techniques available in breast augmentation so that, in conjunction with the patient's physical examination, a sound surgical plan can be developed for aesthetic augmentation of the breast.
Plastic and reconstructive surgery 01/2007; 118(7 Suppl):188S-196S; discussion 197S-198S. · 2.74 Impact Factor
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ABSTRACT: The use of sub-atmospheric pressure dressings, available commercially as the vacuum-assisted closure (VAC) device, has been shown to be an effective way to accelerate healing of various wounds. The optimal sub-atmospheric pressure for wound healing appears to be approximately 125 mm Hg utilizing an alternating pressure cycle of 5 minutes of suction followed by 2 minutes off suction. Animal studies have demonstrated that this technique optimizes blood flow, decreases local tissue edema, and removes excessive fluid from the wound bed. These physiologic changes facilitate the removal of bacteria from the wound. Additionally, the cyclical application of sub-atmospheric pressure alters the cytoskeleton of the cells in the wound bed, triggering a cascade of intracellular signals that increases the rate of cell division and subsequent formation of granulation tissue. The combination of these mechanisms makes the VAC device an extremely versatile tool in the armamentarium of wound healing. This is evident in the VAC device's wide range of clinical applications, including treatment of infected surgical wounds, traumatic wounds, pressure ulcers, wounds with exposed bone and hardware, diabetic foot ulcers, and venous stasis ulcers. VAC has also proven useful in reconstruction of wounds by allowing elective planning of the definitive reconstructive surgery without jeopardizing the wound or outcome. Furthermore, VAC has significantly increased the skin graft success rate when used as a bolster over the freshly skin-grafted wound. VAC is generally well tolerated and, with few contraindications or complications, is fast becoming a mainstay of current wound care.
American Journal of Clinical Dermatology 02/2005; 6(3):185-94. · 1.71 Impact Factor
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ABSTRACT: The term venous thromboembolism refers to a spectrum of disease that includes deep venous thrombosis and pulmonary embolism. Both deep venous thrombosis and pulmonary embolism are often clinically silent and thus difficult to diagnose, which leads to a substantial delay in treatment that results in high rates of morbidity and mortality. The purposes of this article are to help physicians determine the proper venous thromboembolism prophylaxis and to simplify the complex problem of treating venous thromboembolism. The tools provided in this article will help expedite and clarify the decision-making process.
Plastic and reconstructive surgery 10/2004; 114(3):43E-51E. · 2.74 Impact Factor
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ABSTRACT: Over the last five years, there has been a groundswell of interest in the prevention of venous thromboembolism (VTE). An increased level of understanding of the disease process coupled with data documenting the alarmingly high incidence of VTE has prompted a global awareness of the disease. Consequently, prevention of VTE has been targeted by hospitals, both in the United States and abroad, as a top priority to improve patient care. VTE refers to a continuum of disease that begins with deep venous thrombosis (DVT) and can progress to pulmonary embolism (PE). DVT is the more common form of VTE and is often silent, with only 33% of patients presenting with symptoms. As a result, VTE often goes undetected and, if allowed, can progress to PE. This typically delays treatment and results in high rates of morbidity and mortality. The combination of VTE being both difficult to detect and deadly if untreated makes it a disease that is best addressed with preventive rather than therapeutic measures.
Aesthetic surgery journal / the American Society for Aesthetic Plastic surgery 29(5):421-8.
