Head and Neck Medicine by Alexandros G.Sfakianakis: Plastic and Reconstructive Surgery

Background: Fat grafting is a powerful and increasingly used technique in breast reconstruction. However, fat necrosis can lead to palpable postoperative changes that can induce anxiety and lead to unplanned diagnostic studies. The authors' aim in this study was to evaluate the incidence, type, and timing of these unanticipated studies; the specialty of the ordering provider; and the factors that trigger the ordering process. Methods: A retrospective chart review was conducted for patients from 2006 to 2015 who underwent fat grafting as part of implant-based breast cancer reconstruction and had at least 1-year follow-up after fat grafting. Results: From 2006 to 2015, 166 patients underwent fat grafting as part of implant-based breast reconstruction. Forty-four women (26.5 percent) underwent at least one imaging procedure. Thirteen women (7.8 percent) underwent 17 biopsies. For a palpable mass, the initial imaging test most commonly ordered was ultrasound, followed by mammography/ultrasound. The percentage of patients with a diagnosis of fat necrosis on mammography, ultrasound, and biopsy was 4.2, 12.7, and 5.4 percent, respectively. Seven patients (4.2 percent) had distant metastases. Tissue diagnosis of local recurrence was never identified. Mean follow-up was 2.4 years. Conclusions: Fat-grafting sequelae may lead to early unplanned invasive and noninvasive procedures initiated by a variety of providers. In this study, fat grafting had no impact on local recurrence rate. As use of fat grafting grows, communication among breast cancer care providers and enhanced patient and caregiver education will be increasingly important in optimizing the multidisciplinary evaluation and monitoring of palpable breast lesions. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Reducing Expansion Visits in Immediate Implant-Based Breast Reconstruction: A Comparative Study of Prepectoral and Subpectoral Expander Placement

Background: The numerous office visits required to complete expansion in implant-based breast reconstruction impact patient satisfaction, office resources, and time to complete reconstruction. This study aimed to determine whether prepectoral compared to subpectoral immediate implant-based breast reconstruction offers expedited tissue expansion without affecting complication rates. Methods: Consecutive patients who underwent immediate implant-based breast reconstruction with tissue expanders from January of 2016 to July of 2017 by a single surgeon were grouped into subpectoral (partial submuscular/partial acellular dermal matrix) or prepectoral (complete acellular dermal matrix coverage), and reviewed. The primary outcomes were total days and number of visits to complete expansion. Groups were compared by univariate analysis with significance set at p < 0.05. Results: In total, 101 patients (subpectoral, n = 69; prepectoral, n = 32) underwent 184 immediate implant-based breast reconstructions (subpectoral, n = 124; prepectoral, n = 60). There was no difference in age, body mass index, smoking, or diabetes between the groups (all p > 0.05). Follow-up was similar between groups (179.3 ± 98.2 days versus 218.3 ± 119.8 days; p = 0.115). Prepectoral patients took fewer days to complete expansion (40.4 ± 37.8 days versus 62.5 ± 50.2 days; p < 0.001) and fewer office visits to complete expansion (2.3 ± 1 .7 versus 3.9 ± 1.8; p < 0.001), and were expanded to greater final volumes than subpectoral patients (543.7 ± 122.9 ml versus 477.5 ± 159.6 ml; p = 0.017). Between prepectoral and subpectoral reconstructions, there were similar rates of minor complications (25 percent versus 18.5 percent; p = 0.311), readmissions (5 percent versus 2.4 percent; p = 0.393), seromas (8.3 percent versus 5.6 percent; p = 0.489), reoperations for hematoma (3.3 percent versus 1.6 percent; p = 0.597), and explantations (5 percent versus 2.4 percent; p = 0.393). Conclusion: This novel analysis demonstrates that prepectoral immediate implant-based breast reconstruction can facilitate expansion to higher total volumes in nearly half the office visits compared to subpectoral placement in similar populations without increasing complication rates. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Discussion: Reducing Expansion Visits in Immediate Implant-Based Breast Reconstruction: A Comparative Study of Prepectoral and Subpectoral Expander Placement
No abstract available

Increases in Postmastectomy Reconstruction in New York State Are Not Related to Changes in State Law

Background: Postmastectomy reconstruction remains underused. In 2011, new legislation in New York State mandated discussion of reconstructive options before mastectomy. This study assesses the impact of this policy on immediate breast reconstruction rates. Methods: The Statewide Planning and Research Cooperative System database was queried to identify women undergoing mastectomy from January of 2005 to October of 2015 and follow them for at least 1 year postoperatively to determine the incidence and timing of reconstruction. Demographic and socioeconomic characteristics were collected. Chi-square test and multivariable logistic regression were used to compare periods before (2005 to 2010) and after (2011 to 2015) the legislative change. Results: Of 52,837 records, there were 24,340 patients (46 percent) who underwent immediate breast reconstruction. The incidence of immediate breast reconstruction increased over the study period, most significantly in 2008 to 2009. Rates of immediate breast reconstruction continued to increase, although at a slower rate, after 2011 compared with before 2011 across all subgroups. Both implant and autologous reconstructive techniques increased over time. Implant-based reconstruction increased steadily, whereas autologous reconstruction increased most significantly between 2008 and 2009. Conclusions: Despite an overall increase in immediate breast reconstruction, there was an overall lack of effect on post-2011 reconstructive rates attributable to the legislative changes. Reconstructive rates have increased significantly in New York State over the past decade, and these changes appear to be largely independent of the 2011 New York State Breast Reconstruction Act. There are likely nonlegislative drivers of breast reconstruction use.

Discussion: Increases in Postmastectomy Reconstruction in New York State Are Not Related to Changes in State Law
No abstract available

Survival and Disease Recurrence Rates among Breast Cancer Patients following Mastectomy with or without Breast Reconstruction

Background: Concerns have been expressed about the oncologic safety of breast reconstruction following mastectomy for breast cancer. This study aimed to evaluate the association of breast reconstruction with breast cancer recurrence, and 5-year survival among breast cancer patients. Methods: The authors analyzed data from The Johns Hopkins Hospital comprehensive cancer registry, comparing mastectomy-only to postmastectomy breast reconstruction in breast cancer patients to evaluate differences in breast cancer recurrence and 5-year survival. Kaplan-Meier curves were used to compare unadjusted estimates of survival or disease recurrence. Data were modeled through Cox proportional hazards regression, using as outcomes time to death from any cause or time to cancer recurrence. Results: The authors analyzed data on 1517 women who underwent mastectomy for breast cancer at The Johns Hopkins hospital between 2003 and 2015. Of these, 504 (33.2 percent) underwent mastectomy only and 1013 (66.8 percent) underwent mastectomy plus immediate breast reconstruction. Women were followed up for a median of 5.1 years after diagnosis. There were 132 deaths and 100 breast cancer recurrences. A comparison of Kaplan-Meier survival estimates demonstrated a survival benefit among patients undergoing mastectomy plus reconstruction. After adjusting for various clinical and socioeconomic variables, there was still an overall survival benefit associated with breast reconstruction which, however, was not statistically significant (hazard ratio, 0.78; 95 percent CI, 0.53 to 1.13). Patients who underwent reconstruction had a similar rate of recurrence compared to mastectomy-only patients (hazard ratio, 1.08; 95 percent CI, 0.69 to 1.69). Conclusion: This study suggests that breast reconstruction does not have a negative impact on either overall survival or breast cancer recurrence rates. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

A Quantitative Analysis of Animation Deformity in Prosthetic Breast Reconstruction

Background: Animation deformity is characterized by implant deformity with pectoralis contraction after subpectoral implant-based breast reconstruction. Extant methods to measure and analyze animation deformity are hampered by the paucity of objective, quantitative data. The authors endeavored to supplement subjective measures with an in-depth quantitative analysis. Methods: Patients undergoing subpectoral implant-based breast reconstruction were followed prospectively with video analysis of animation deformity. Nipple displacement and surface area of contour deformity in resting and contracted states were quantified using imaging software. Degree of animation was compared to breast size, body mass index, division of pectoralis muscle, complications, and radiation therapy. Results: One hundred forty-five reconstructed breasts (88 patients) were analyzed. Mean nipple displacement was 2.12 ± 1.04 cm, mean vector of nipple displacement was 62.5 ± 20.6 degrees, and mean area of skin contour irregularity was 16.4 ± 15.41 percent. Intraoperative pectoralis division, smooth/round implants, and bilateral reconstructions were associated with greater deformity. A three-tiered grading system based on thresholds of 2-cm net nipple displacement and 25 percent skin contour irregularity placed 41.4 percent of breasts in grade 1, 35.9 percent in grade 2, and 22.8 percent in grade 3. Interrater variability testing demonstrated 89.5 percent overall agreement (kappa = 0.84). Conclusions: This study presents the first quantitative analysis of animation deformity in prosthetic breast reconstruction. Geometric analysis of nipple displacement vector and increasing animation with pectoralis division both implicate the inferior pectoralis myotome as a primary driver of animation deformity. A concomitant grading schema was developed to provide a standardized framework for discussing animation from patient to patient and from study to study.

Sensory Recovery of the Breast following Innervated and Noninnervated DIEP Flap Breast Reconstruction

Background: The sensory recovery of the breast remains an undervalued aspect of autologous breast reconstruction. The aim of this study was to evaluate the effect of nerve coaptation on the sensory recovery of the breast following DIEP flap breast reconstruction and to assess the associations of length of follow-up and timing of the reconstruction. Methods: A prospective comparative study was conducted of all patients who underwent either innervated or noninnervated DIEP flap breast reconstruction and returned for follow-up between September of 2015 and July of 2017. Nerve coaptation was performed to the anterior cutaneous branch of the third intercostal nerve. Semmes-Weinstein monofilaments were used for sensory testing of the native skin and flap skin. Results: A total of 48 innervated DIEP flaps in 36 patients and 61 noninnervated DIEP flaps in 45 patients were tested at different follow-up time points. Nerve coaptation was significantly associated with lower monofilament values in all areas of the reconstructed breast (adjusted difference, −1.2; p < 0.001), which indicated that sensory recovery of the breast was significantly better in innervated compared with noninnervated DIEP flaps. For every month of follow-up, the mean monofilament value decreased by 0.083 in innervated flaps (p < 0.001) and 0.012 in noninnervated flaps (p < 0.001). Nerve coaptation significantly improved sensation in both immediate and delayed reconstructions. Conclusions: This study demonstrated that nerve coaptation in DIEP flap breast reconstruction is associated with a significantly better sensory recovery in all areas of the reconstructed breast compared with noninnervated flaps. The length of follow-up was significantly associated with the sensory recovery.

Patterns and Correlates of Knowledge, Communication, and Receipt of Breast Reconstruction in a Modern Population-Based Cohort of Patients with Breast Cancer

Background: Disparities persist in the receipt of breast reconstruction after mastectomy, and little is known about the nature of communication received by patients and potential variations that may exist. Methods: Women with early-stage breast cancer (stages 0 to II) diagnosed between July of 2013 and September of 2014 were identified through the Georgia and Los Angeles Surveillance, Epidemiology, and End Results registries and surveyed to collect additional data on demographics, treatment, and decision-making experiences. Treating general/oncologic surgeons were also surveyed. Primary outcomes measures included self-reported communication-related measures on receipt of information on breast reconstruction and on the receipt of breast reconstruction. Results: The authors analyzed 936 women who underwent mastectomy for unilateral breast cancer. Four hundred eighty-four (51.7 percent) underwent mastectomy with reconstruction. Women who were older and for whom English was not their primary spoken language had lower odds of being informed by a doctor about breast reconstruction. Ultimately, women who were older, were Asian, had invasive disease, had bronchitis/emphysema, and had lower income were less likely to undergo breast reconstruction. Breast reconstruction was performed more often in patients undergoing bilateral mastectomies (OR, 3.27; 95 percent CI, 2.26 to 4.75). Women cared for by surgeons with higher volumes of breast cancer patients (≥51 patients per year) were more likely to undergo breast reconstruction (OR, 2.43; 95 percent CI, 1.40 to 4.20). Conclusion: To eliminate existing disparities, increased efforts should be made in consultations for surgical management of breast cancer to provide information to all patients regarding the option of breast reconstruction, the possibility of immediate reconstruction, and insurance coverage of all stages of reconstruction.

Assessing Retrobulbar Hyaluronidase as a Treatment for Filler-Induced Blindness in a Cadaver Model

Background: Retrobulbar injection of hyaluronidase is a proposed but unproven treatment for blindness induced by hyaluronic acid gel fillers. This study examines the viability of this treatment by determining whether hyaluronidase can diffuse through the dural sheath of the optic nerve to clear a filler-mediated occlusion of the central retinal artery. Methods: Six human cadaveric optic nerves were studied in vitro. One optic nerve was selected as a control and maintained at physiologic temperature, without any exposure to hyaluronic acid gel or hyaluronidase. Another optic nerve was randomly selected to simulate the filler-induced central retinal artery occlusion with subsequent retrobulbar hyaluronidase injection. To simulate a central retinal artery occlusion, this experimental nerve and additional controls were injected with hyaluronic acid gel. These hyaluronic acid gel–injected nerves were then either injected directly with hyaluronidase to establish a control for intraneural hyaluronidase exposure, or immersed in undiluted hyaluronidase to simulate retrobulbar hyaluronidase injection. To control for passive diffusion of hyaluronic acid gel from neural parenchyma, one nerve was immersed in saline. Following fixation, the nerves were grossly and microscopically assessed for the quantity and distribution of hyaluronic acid. Results: Intact hyaluronic acid gel was observed grossly and microscopically in the control optic nerves injected directly with filler and not with hyaluronidase. The control optic nerve injected with intraneural hyaluronidase exhibited partial digestion of the filler. Immersion in undiluted hyaluronidase led to no apparent gross or microscopic digestion of injected intraneural hyaluronic acid gel. Conclusion: Hyaluronidase does not demonstrate the ability to cross the dural sheath of the optic nerve, suggesting that retrobulbar hyaluronidase injection is unlikely to alleviate hyaluronic acid gel–mediated central retinal artery occlusion and blindness.

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com

Head and Neck Medicine by Alexandros G.Sfakianakis

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Πέμπτη 25 Ιουλίου 2019

Plastic and Reconstructive Surgery

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