Plastic and Reconstructive Surgery – Global Open

Evaluation of Lipofilling Safety in Elderly Patients with Breast Cancer Background: Lipofilling is widely used in breast reconstruction after mastectomy with reconstruction or breast conserving surgery in patients with breast cancer. The aim of this study is focused on complications associated with lipofilling in elderly breast cancer patients with breast defects after breast conserving surgery or reconstruction. Methods: A total of 137 patients older than 60 years who underwent 153 lipofilling procedures were included. All patients had undergone breast lipofilling using Coleman's technique. Estimated breast defect volume, lipofilling volume, and complications after lipofilling were obtained for analysis. Results: Most patients (67%) had only 1 lipofilling procedure. The median lipofilling volume to breast defect volume ratio was 1.5. No severe complications were found after treatment. Liponecrosis was detected in 10 of 153 breasts (7%) or 9 of 137 patients within 2 weeks after lipofilling and required surgical drainage in 2. No local recurrences were noted. Conclusions: The incidence of liponecrosis after lipofilling in elderly patients was relatively high, requiring surgical drainage in some cases. As a rough guide, the lipofilling volume should not exceed 1.5 times the defect volume, and close postoperative follow-up within the first 2 weeks is suggested for these patients.

Mastectomy Weight and Tissue Expander Volume Predict Necrosis and Increased Costs Associated with Breast Reconstruction Introduction: Impaired vascular perfusion in tissue expander (TE) breast reconstruction leads to mastectomy skin necrosis. We investigated factors and costs associated with skin necrosis in postmastectomy breast reconstruction. Methods: Retrospective review of 169 women with immediate TE placement following mastectomy between May 1, 2009 and May 31, 2013 was performed. Patient demographics, comorbidities, intraoperative, and postoperative outcomes were collected. Logistic regression analysis on individual variables was performed to determine the effects of tissue expander fill volume and mastectomy specimen weight on skin necrosis. Billing data was obtained to determine the financial burden associated with necrosis. Results: This study included 253 breast reconstructions with immediate TE placement from 169 women. Skin necrosis occurred in 20 flaps for 15 patients (8.9%). Patients with hypertension had 8 times higher odds of skin necrosis [odd ratio (OR), 8.10, P < 0.001]. Patients with TE intraoperative fill volumes >300 cm3 had 10 times higher odds of skin necrosis (OR, 10.66, P =0.010). Volumes >400 cm3 had 15 times higher odds of skin necrosis (OR, 15.56, P = 0.002). Mastectomy specimen weight was correlated with skin necrosis. Specimens >500 g had 10 times higher odds of necrosis and specimens >1000 g had 18 times higher odds of necrosis (OR, 10.03 and OR, 18.43; P =0.003 and P <0.001, respectively). Mastectomy skin necrosis was associated with a 50% increased inpatient charge. Conclusion: Mastectomy flap necrosis is associated with HTN, larger TE volumes and mastectomy specimen weights, resulting in increased inpatient charges. Conservative TE volumes should be considered for patients with hypertension and larger mastectomy specimens.

Deep Inferior Epigastric Artery Perforator Flap Breast Reconstruction without Microsurgery Fellowship Training Background: Deep inferior epigastric artery perforator (DIEP) flap breast reconstruction requires complex microsurgical skills. Herein, we examine whether DIEP flap breast reconstruction can be performed safely without microsurgical fellowship training. Methods: A total of 28 patients and 34 DIEP flaps were included in the study. We reviewed the medical records of patients for donor site and flap-related complications and analyzed the correlation between the complications and preoperative risk factors. We also performed a literature review to compare complication rates in our series with the literature. Results: We observed total flap necrosis in 1 patient (2.9%), partial flap necrosis in 5 patients (14.7%), infection in 1 patient (2.9%), hematoma/seroma in 3 patients (8.8%), donor site complications in 5 patients (18.5%), venous occlusion in 4 patients (11.7%), and arterial occlusion in 1 patient (2.9%). We did not observe any correlation between complications and preoperative risk factors. Literature review yielded 18 papers that met our inclusion criteria. Partial flap necrosis rate was significantly higher in our series compared with literature (14.7% vs 1.6%, P = 0.003). Venous complication rate was marginally higher in our series compared with literature (11.7% vs 3.3%, P = 0.057). However, total flap loss rate in our series was comparable with the literature (2.9% vs 2.2%, P = 0.759). Conclusion: With proper training during plastic surgery residency, DIEP flap can be performed with acceptable morbidity.

A New Approach to Minimize Acellular Dermal Matrix Use in Prosthesis-based Breast Reconstruction Background: Acellular dermal matrices (ADMs) are often used to improve lower-pole contour, as well as allow for single-stage reconstruction, but numerous studies have shown an increased complication rate using ADM. As such, our group has developed a minimal-ADM-use technique to lower complications while effectively recreating lower-pole contour. Methods: A total of 380 postmastectomy prosthesis-based breast reconstructions were performed in 265 patients by a single surgeon. One hundred eight reconstructions were performed using the traditional ADM technique, with a large piece of ADM along the entire inferior and lateral borders. Two hundred twenty-five reconstructions were performed with the minimal-use technique, patching only the lateral area of the reconstruction. Thirty-five reconstructions were performed without the use of any ADM for high-risk reconstructions, most often in morbidly obese patients. Results: Comparing the traditional technique with the minimal-use technique, the seroma rate dropped from 3% to 0%. The rate of infection and reconstruction loss fell from 9% to 1%. Upon greatly reducing or eliminating the use of ADM use in obese patients, the seroma rate decreased from 15.4% to 5.7%, and the reconstruction loss rate decreased from 38% to 9%. Conclusions: This article describes a new surgical approach to minimize the amount of ADM necessary to create an aesthetically pleasing breast reconstruction. We believe that this approach helps avoid the complications of seroma, infection, and loss of the reconstruction. In certain obese patients, total avoidance of ADM may be the better choice.

Can an Immediate 2-stage Breast Reconstruction Be Performed After Previous Conservative Surgery and Radiotherapy? Background: Prosthetic breast reconstruction is generally considered contraindicated after previous breast irradiation. As a result, patients undergoing a salvage mastectomy for recurrent breast cancer or "risk-reducing" mastectomies after previous conservative surgery and radiotherapy (CS + RT) are usually offered autologous breast reconstruction. However, not all such patients are suitable candidates for a major flap reconstruction. The purpose of this study is to review our results of immediate 2-stage prosthetic breast reconstruction after CS + RT. Methods: A retrospective review was undertaken for 671 consecutive patients with prosthetic-only breast reconstruction performed by a single surgeon over a 12.5-year period. Twenty-two patients who qualified for the criteria were audited. Outcomes examined include complications, loss of tissue expander or implant, revisional surgery, and aesthetic result. Results: Twenty-two patients underwent 33 mastectomies and immediate 2-stage breast reconstructions after previous CS + RT (15 for recurrent cancer and seven "risk-reduction") and 11 contralateral risk-reducing mastectomies. One patient died due to extensive metastatic disease. There was no reconstruction failure. The average breast implant size was 491.7 g (range 220 -685g). Seroma was the most common complication and occurred in 3 of 22 patients (13.6%) after stage 1 and 3 of 21 patients (14.3%) after stage 2 reconstruction. The revisional surgery rate was 28.6%. Aesthetic result was rated as excellent in 9.5%, good in 76.2%, and fair in 14.3%. Conclusions: For selected patients, immediate 2-stage prosthetic breast reconstruction can be performed successfully after a salvage mastectomy subsequent to a recurrence after CS + RT.

Radiofrequency-Assisted Liposuction Compared with Aggressive Superficial, Subdermal Liposuction of the Arms: A Bilateral Quantitative Comparison Background: Liposuction of the arms alone may be inadequate for aesthetic improvement because of skin laxity. Radiofrequency-assisted liposuction (RFAL) and aggressive superficial liposuction (SupL) have been described to stimulate soft tissue retraction to improve results. We compare the techniques and describe a classification scheme that factors skin laxity, skin quality, and Fitzpatrick type to provide treatment recommendations. Methods: Ten consecutive female patients underwent RFAL of 1 arm and SupL on the contralateral arm. All patients had Fitzpatrick skin types of III, IV, or V with an average body mass index of 26.0. Using fluorescent tattooing, key points on the arm skin were measured preoperatively and postoperatively to indicate changes in surface area. Results: There were no complications in the group, and all patients reported satisfaction with the aesthetic results. All patients showed reduction of measured skin surface areas and skin distances postoperatively. At 1 year, the measured surface area reductions on the anterior arms averaged 15.0% for RFAL and 10.9% for SupL on the anterior arm skin. Posteriorly, RFAL showed 13.1% reduction and SupL 8.1% reduction in the surface areas at 1 year. Linear reduction for RFAL averaged 22.6% and 17.8% for SupL 1 year postoperatively anteriorly. Conclusion: Both RFAL and SupL of the arms showed quantifiable and sustained reductions in skin surface. Good contour and soft tissue contraction were achieved with both techniques but RFAL with its safety features presents an alternative to SupL, which has a higher complication rate, risk for contour deformities, and steeper learning curve.

Does Liposuction Improve Body Image and Symptoms of Eating Disorders? Background: Unpleasant attention to unfavorable fat may have harmful psychological effects in terms of body dissatisfaction. As a consequence, this may cause abnormal eating regulation. It has been noted that women interested in liposuction self-report more eating problems. As far as we know, there are no prospective studies with standardized instruments providing sufficient data regarding the effects of aesthetic liposuction on various aspects of quality of life. Nevertheless, publications on the effects of eating habits are lacking. Methods: Sixty-one consecutive women underwent aesthetic liposuction. Three outcome measures were applied at baseline and at follow-up: the eating disorder inventory, Raitasalo's modification of the Beck depression inventory, and the 15-dimensional general quality of life questionnaire. Results: The mean age at baseline was 44 years, and the mean body mass index was 26.0. Thirty-six (59%) women completed all outcome measures with a mean follow-up time of 7 months. A significant improvement from baseline to follow-up was noted in women's body satisfaction, and their overall risk for developing an eating disorder decreased significantly. Conclusion: Aesthetic liposuction results in a significantly reduced overall risk for an eating disorder in combination with improved body satisfaction.

The Americleft Project: Burden of Care from Secondary Surgery Background: The burden of care for children with cleft lip and palate extends beyond primary repair. Children may undergo multiple secondary surgeries to improve appearance or speech. The purpose of this study was to compare the use of secondary surgery between cleft centers. Methods: This retrospective cohort study included 130 children with complete unilateral cleft lip and palate treated consecutively at 4 cleft centers in North America. Data were collected on all lip, palate, and nasal surgeries. Nasolabial appearance was rated by a panel of judges using the Asher-McDade scale. Risk of secondary surgery was compared between centers using the log-rank test, and hazard ratios estimated with a Cox proportional hazards model. Results: Median follow-up was 18 years (interquartile range, 15–19). There were significant differences among centers in the risks of secondary lip surgery (P < 0.001) and secondary rhinoplasty (P < 0.001). The cumulative risk of secondary lip surgery by 10 years of age ranged from 5% to 60% among centers. The cumulative risk of secondary rhinoplasty by 20 years of age ranged from 47% to 79% among centers. No significant differences in nasolabial appearance were found between children who underwent secondary lip or nasal surgery and children who underwent only primary surgery (P > 0.10). Conclusions: Although some cleft centers were significantly more likely to perform secondary surgery, the use of secondary surgery did not achieve significantly better nasolabial appearance than what was achieved by children who underwent only primary surgery.

Three-Dimensional Changes of Maxilla after Secondary Alveolar Cleft Repair: Differences Between rhBMP-2 and Autologous Iliac Crest Bone Grafting Background: Recombinant human bone morphogenetic protein (rhBMP)-2 has been used as an alternative to autologous bone transferring, a standard method of treatment. However, its potential adverse effect on anterior maxillary arch is unknown. Thus, the purpose of this study was to quantify sagittal and transversal changes of anterior maxilla after secondary alveolar cleft repair using traditional iliac crest bone grafting versus rhBMP-2. Methods: Twelve unilateral complete cleft lip and palate patients were randomly divided into 2 groups. In group 1, patients underwent traditional iliac crest bone grafting transferring (n = 4), and in group 2, patients underwent alveolar cleft reconstruction using collagen matrix with lyophilized rhBMP-2 (n = 8). Computed tomography (CT) imaging was performed preoperatively and at 1 year postoperatively, using a previously standardized protocol. A three-dimensional (3D) CT cephalometric analysis of the linear and angular measurements of the sagittal and transverse maxilla planes was performed to assess intra- and intergroup maxillary changes. Results: Intra- and intergroup comparisons of the pre- and postoperative 3D CT cephalometric linear and angular measurements of the sagittal and transverse maxilla planes showed no significant (all P > 0.05) differences among all studied variables. Conclusions: There were no significant anterior maxilla changes after maxillary cleft repair either using iliac crest bone grafting or rhBMP-2.

A Simple, Easy, and Reliable Technique of Phalangeal Corrective Osteotomy for Overlapping Fingers Background: The theory that malrotation is best assessed by making a fist and looking for digital overlap was the basis for devising a simple, easy, and reliable technique for phalangeal corrective osteotomy. Methods: This study assessed the phalangeal corrective osteotomy technique in 7 digits, involving 7 cases in 6 patients; 1 patient required treatment bilaterally. This technique required the use of a small hologram 2-row plate and screws to maintain stable fixation during aggressive postoperative therapy. Evaluation of the clinical results was based on the total range of active motion (%TAM), the grading of results according to Büchler, and the severity of pain reported by patients using the visual analog scale. The disability of the arm, shoulder, and hand questionnaire was completed preoperatively and at final follow-up by patients. Results: Corrective osteotomy corrected the overlapping of digits in all of the patients. There were no perioperative complications. Bone union was obtained in all cases, on average 13.4 weeks after surgery. Two osteotomies required secondary tenocapsulolysis concomitant with implant removal surgery. In light of total range of active motion and Büchler's grade, all the patients had excellent to good results for both criteria at final follow-up. No patient complained about pain. Mean disability of the arm, shoulder, and hand scores significantly decreased from 16.9 (range, 11.3–26.5) preoperatively to 3.9 (range, 0–7.6) postoperatively. Conclusions: Phalangeal corrective osteotomy was performed using a simple, easy, and reliable technique.