Search

Acellular dermal matrices have been proposed to decrease the incidence of capsular contracture in implant-based breast reconstructions. The authors have modified acellular dermal matrices with fenestrations to facilitate greater lower pole expansion and improve contour. The effect of fenestrations on the ability of matrices to suppress capsule formation, however, has not been examined.A retrospective review of all fenestrated acellular dermal matrix-assisted, implant-based breast reconstructions performed by the two senior authors, with a minimum of 1-year follow-up after permanent implant placement, was completed. Patient demographics, details of extirpative and reconstructive procedures, and complications were examined. Capsular contractures were scored according to the Baker grading scale and compared to those reported in the literature.Thirty patients (50 breasts) underwent fenestrated acellular dermal matrix-assisted reconstruction, with mean follow-up times of 3.3 and 2.6 years after expander placement and implant exchange, respectively. Seven patients (23 percent) had a body mass index greater than 30 kg/m, three (10 percent) were active smokers, and six breasts (12 percent) were irradiated. Complications included one infection (2 percent), six cases (12 percent) of incisional superficial skin necrosis, and one (2 percent) tissue expander extrusion. Zero breasts had clinically significant Baker grade III/IV capsular contracture. The average Baker grade was 1.1.Fenestrated acellular dermal matrices decrease capsular contracture to rates similar to what is seen with nonfenestrated matrices. Further research is necessary to determine whether this observation is a result of decreased need for inferolateral acellular dermal matrix coverage to achieve these effects or modified physical interaction of acellular dermal matrices with surrounding soft tissues.Therapeutic, IV.

BACKGROUND There are limited data regarding blood transfusion following abdominoplasty, especially in post-bariatric surgery patients. The purpose of this study was to evaluate (1) the frequency and outcomes of blood transfusion in post-bariatric surgery patients undergoing abdominoplasty and (2) the predictive risk factors of blood transfusion in this patient population. METHODS Using the Nationwide Inpatient Sample database, the authors examined the clinical data of patients with a history of bariatric surgery who underwent abdominoplasty from 2007 to 2011 in the United States. RESULTS A total of 20,130 post-bariatric surgery patients underwent abdominoplasty during this period. Overall, 1871 patients (9.3 percent) received blood transfusion. Chronic anemia patients had the highest rate of blood transfusion (25.6 percent). Post-bariatric surgery patients who received blood transfusion experienced a significantly higher complication rate (10.1 percent versus 4.8 percent; p < 0.01), longer mean hospital stay (4.0 days versus 2.4 days; p < 0.01), and higher mean total hospital charges ($49,116 versus $33,927; p < 0.01). Multivariate regression analysis showed that deficiency anemia (adjusted OR, 3.8), congestive heart failure (adjusted OR, 2.4), concurrent breast reduction (adjusted OR, 1.5), diabetes mellitus (adjusted OR, 1.4), coronary artery disease (adjusted OR, 1.4), African American race (adjusted OR, 1.4), Hispanic race (adjusted OR, 1.4), and female sex (adjusted OR, 1.3) were all independent risk factors for blood transfusion. CONCLUSIONS The blood transfusion rate in post-bariatric surgery abdominoplasty patients is not insignificant. Chronic anemia and congestive heart failure are the two major predictors of transfusion. Modifying risk factors such as anemia before abdominoplasty might significantly decrease the possibility of blood transfusion. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, III.

BACKGROUND The aims of this study were (1) to evaluate the frequency of various reconstructive techniques for autologous breast reconstruction and (2) to compare perioperative outcomes of autologous breast reconstruction in teaching versus nonteaching hospitals. MATERIALS The authors analyzed clinical data of patients who underwent autologous breast reconstructive surgery from 2009 to 2010 using the Nationwide Inpatient Sample database. Autologous breast reconstruction operations included latissimus dorsi myocutaneous, pedicled transverse rectus abdominis myocutaneous (TRAM), free TRAM, free deep inferior epigastric artery perforator (DIEP), free superficial inferior epigastric artery, and free gluteal artery perforator flaps. RESULTS A total of 35,883 patients underwent autologous breast reconstructive surgery in that period. Most reconstructions were performed in teaching hospitals (74 percent). The two most common breast reconstruction types in teaching hospitals were latissimus dorsi myocutaneous (26 percent) and DIEP flaps (26 percent), compared with latissimus dorsi myocutaneous (39 percent) and pedicled TRAM flaps (22 percent) in nonteaching hospitals. In addition, the rate of free flap breast reconstruction was significantly higher in teaching hospitals (46 percent) compared with nonteaching hospitals (31 percent) (p < 0.01). There was no statistically significant difference for total in-hospital complication rate (teaching, 6.9 percent; nonteaching, 7.1 percent; p = 0.54) or total in-hospital mortality rate (teaching, 0.04 percent; nonteaching, 0.05 percent; p = 0.56). CONCLUSIONS Three-fourths of autologous breast reconstructions performed from 2009 to 2010 were performed in teaching hospitals, with free flaps also more likely to be performed in teaching hospitals. Despite more complex free flap breast reconstructions being performed in teaching hospitals, there was no statistically significant difference in perioperative outcomes (morbidity and mortality) between teaching and nonteaching hospitals. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.

BACKGROUND Venous thromboembolism (VTE) can be a significant cause of morbidity and mortality in autologous breast reconstruction surgery. The aim of this study was to evaluate the effect of patient characteristics, comorbidities, payer type, reconstruction type, reconstruction timing, radiation, chemotherapy, and teaching status of hospital on VTE (deep venous thrombosis and/or pulmonary embolism) in autologous breast reconstructive surgery. METHODS Using the Nationwide Inpatient Sample (NIS) database, we examined the clinical data of patients who underwent autologous breast reconstructive surgery in 2009 to 2010 in the United States. Univariate and multivariate regression analyses were performed to identify factors predictive of in-hospital VTE. RESULTS A total of 35,883 patients underwent autologous breast reconstructive surgery during this period. Overall rate of VTE was 0.13%. The highest rate of VTE (0.26%) was observed in pedicled transverse rectus abdominis myocutaneous flap. Patients who experienced VTE had significantly longer mean hospital stay (11.6 vs 3.9 days; P < 0.001) and higher mean total hospital charges ($146,432 vs $61,794; P < 0.001) compared with non-VTE patients; however, there was no significant difference observed in mortality rate (VTE, 0.0% vs non-VTE, 0.04%; P = 0.886). Using multivariate regression analysis, immediate reconstruction after mastectomy (adjusted odds ratio [AOR], 5.4), older than 65 years (AOR, 4.2), obesity (AOR, 3.7), history of chemotherapy (AOR, 3.5), and chronic lung disease (AOR, 2.5) were associated with higher risk of VTE. There was no association between race, payer type, diabetes, hypertension, liver disease, congestive heart failure, peripheral vascular disease, chronic kidney disease, smoking, reconstruction type, radiation, or teaching status of hospital on VTE. CONCLUSIONS In patients undergoing autologous breast reconstruction surgery, immediate reconstruction, older than 65 years, obesity, history of chemotherapy, and chronic lung disease are all independent predictors of higher VTE. Surgeons should consider these factors and use appropriate prophylaxis to minimize the risk of VTE development.

PURPOSE Although most patients with implants have an uneventful course, some will require explantation. Moreover, women's breasts and their perception of their body habitus change with time. This study covering greater than a 32-year period will address the reconstruction options available after breast implant explantation. METHODS Augmentation mammoplasty was performed on 42 patients who subsequently underwent explantation. The following data were recorded: age at time of implantation and explantation, length of implant, type, reason for explantation, and decision after explantation. Recommendations were made based on patient preferences, degree of ptosis, clinical history, opinions regarding scars, and breast contour. Reconstruction options were categorized into none, mastopexy, capsulectomy and reaugmentation with saline implants, and mastopexy with immediate or delayed augmentation. RESULTS The average age of patients at implantation was 32.3 years, 46.8 years at explantation, with a length of implantation of 14.4 years. Thirty-six (86%) of 42 patients received explantation for capsular contracture, 7 (17%) for negative publicity of silicone implants, 7 (17%) for change in body habitus and perception of implants, 6 (14%) for rupture, 5 (12%) for ptosis, and 1 (2.4%) each for synmastia, breast cancer, and painful implants. Sixteen (38%) patients underwent mastopexy after explantation, 15 (36%) underwent no reconstruction after explantation, 6 (14%) with mastopexy and reaugmentation (2 immediate and 4 delayed), 4 (9.5%) with implant exchange, and 1 (2.4%) with mastectomy and reconstruction. All patients demonstrated satisfactory to excellent results. CONCLUSIONS This study provides long-term results of augmentation mammoplasty by a single surgeon (G.P.G.) evaluating available options and reasonable expectations after explantation. Although most of the augmentation patients have a good outcome, some require removal of implants for a variety of reasons and long-term satisfactory options do exist after explantation.

Background Venous thromboembolic events result in significant morbidity, mortality, and costly therapeutic interventions. As medical resource allocation strategies are becoming more pervasive, appropriate risk stratification and prophylactic regimens are essential. Previous studies have shown a decreased incidence of perioperative venous thromboembolism in the chronic spinal cord injury population. The question remains of whether chronic spinal cord injury is protective against venous thromboembolism. Methods A retrospective review of all cases involving chronic spinal cord injury patients who underwent plastic and reconstructive surgery operations (n = 424) and general surgery patients (n = 777) with a primary outcome of deep venous thrombosis or pulmonary embolism within 90 days of surgery was performed. Results The incidence of postoperative deep venous thrombosis in the control and spinal cord injury groups was 1.7 percent and 0.2 percent, respectively (p = 0.027). However, such significance was not observed with regard to postoperative pulmonary embolism incidence (p = 0.070). Collectively, the incidence of postoperative venous thromboembolism-specifically, deep venous thrombosis or pulmonary embolism-was significantly greater in the general surgery population (p = 0.014). A nearly 10-fold increased risk of venous thromboembolism was seen among the control group (1.9 percent versus 0.2 percent) despite administration of optimal prophylaxis. Conclusions This study demonstrates a profoundly low incidence of venous thromboembolism among chronic spinal cord injury patients compared with general surgery patients. Future efforts to elucidate how chronic spinal cord injury confers a protective mechanism may potentially influence the evolution of venous thromboembolism prevention guidelines, and spark the development of alternative prophylactic agents or customized application of prevention efforts.

Background The purpose of this study was to investigate the incidence of postoperative venous thromboembolism in chronic spinal cord injury patients undergoing plastic and reconstructive surgery. Previous studies show a venous thromboembolism incidence of 9.3 percent; however, based on anecdotal evidence, the authors hypothesize that the incidence is actually much lower. As postoperative venous thromboembolism prophylaxis is becoming mandated by the Surgical Care Improvement Project, more data are necessary so that recommendations for chronic spinal cord injury patients can be given. Methods A retrospective chart review was undertaken using electronic medical records from a Veterans Affairs hospital from 2004 through 2009 in which the perioperative course of the chronic spinal cord injury cohort was evaluated for the primary endpoint of venous thromboembolism evolution. The Pearson correlation was used for statistical analysis. Results Of the 415 operative cases evaluated, 155 cases were excluded secondary to operative time under 1 hour, use of mechanical or chemical venous thromboembolism prophylaxis, unknown operative time, or unknown prophylaxis use. Of the 260 cases evaluated without venous thromboembolism prophylaxis, there were no cases where venous thromboembolism developed within a 2-month postoperative time period. Conclusions Postoperative venous thromboembolism is a common surgical complication with significant morbidity and mortality. This study demonstrates that in the chronic spinal cord injury patient cohort, the incidence of postoperative venous thromboembolism evolution is extremely low and that a benefit from perioperative mechanical or chemical prophylaxis is not evidence based. Further prospective studies are required to fully elucidate the true venous thromboembolism incidence in these patients and give recommendations on this issue. Clinical question/level of evidence Therapeutic, IV.

Free flap success depends on rapid identification and subsequent salvage of failing flaps. Conventional free flap monitoring techniques require an external component, whereas an implantable monitor readily indicates changes in free flap perfusion, especially in buried flaps used in head and neck reconstruction.This is a retrospective review of 169 consecutive head and neck free flaps reconstructed mostly for oncologic surgical defects in 155 patients from April of 2000 to December of 2006, all of which were monitored by an implantable venous Doppler device.There were 25 buried flaps, representing 14.8 percent of 169 flaps. Flap ischemia caused by thrombosis (n = 16), hematoma (n = 2), or tight closure (n = 1) occurred in 11.2 percent of the cases. The Doppler probe detected all of the failing free flaps, and we were able to salvage 18 of 19 ischemic flaps (94.7 percent). All Doppler-detected ischemic nonburied flaps (100 percent) and three of the four buried free flaps were salvaged (75 percent). There were 33 total complications (19.5 percent), with thrombosis occurring in 9.5 percent of the flaps, whereas 12 flaps required reoperation for vascular revision (7.1 percent). The mortality rate was less than 1 percent (0.6 percent). The overall success rate using the implantable Doppler probe was 98.2 percent, which was similar to that of the most recent reported cases of all free flaps in the literature, with significant improvement in the salvage rate for both buried and nonburied head and neck free flaps.The implantable Doppler probe is a useful monitoring device in buried free flaps and should be considered for use in head and neck reconstruction.

The objectives of this study were to evaluate 1) the rate of immediate breast reconstruction; 2) the frequency of immediate tissue expander placement; and 3) to compare perioperative outcomes in patients who underwent breast reconstruction after mastectomy for breast cancer with immediate tissue expander placement (TE) with those with no reconstruction (NR). Using the Nationwide Inpatient Sample database, we examined the clinical data of patients with breast cancer who underwent mastectomy with or without immediate TE from 2006 to 2010 in the United States. A total of 344,253 patients with breast cancer underwent mastectomy in this period in the United States. Of these patients, 31 per cent had immediate breast reconstruction. We only included patients with mastectomy and no reconstruction (NR: 237,825 patients) and patients who underwent only TE placement with no other reconstruction combination (TE: 61,178 patients) to this study. Patients in the TE group had a lower overall postoperative complication rate (2.6 vs 5.5%; P0.01) and lower in-hospital mortality rate (0.01 vs 0.09%; P0.01) compared with the NR group. Fifty-three per cent of patients in the NR group were discharged the day of surgery compared with 36 per cent of patients in the TE group. Using multivariate regression analyses and adjusting patient characteristics and comorbidities, patients in the TE group had a significantly lower overall complication rate (adjusted odds ratio [AOR], 0.6) and lower in-hospital mortality (AOR, 0.2) compared with the NR group. The rate of immediate reconstruction is 31 per cent. TE alone is the most common type of immediate reconstruction (57%). There is a lower complication rate for the patients who underwent immediate TE versus the no-reconstruction cohort.

Hypothesis Many soft tissue infections treated with surgical drainage resolve even when treated with antibiotics not active against the organism isolated from the infection. Design Retrospective. Setting Integrated Soft Tissue Infection Services clinic. Patients All patients treated from July 19, 2000, to August 1, 2001, who underwent surgical drainage of a soft tissue infection and had microbiological culture results. Main Outcome Measures Documented resolution of the infection with drainage of the abscess and antibiotic therapy alone was deemed a cure. An infection resulting in death or other surgical therapy was deemed a failure. Therapy was appropriate when the organism was sensitive to prescribed antibiotics and was inappropriate when the organism was insensitive. Results The study included 376 patients with 450 infections. Staphylococcus aureus as the primary organism was isolated from 441 of the cultures. Methicillin sodium–sensitive S aureus and methicillin-resistant S aureus were found in 157 and 284 of these isolates, respectively. Appropriate antibiotics were prescribed in 153 infections with methicillin-sensitive S aureus and in 25 with methicillin-resistant S aureus . Of 441 episodes, 408 were clinically evaluated for cure. Three patients failed treatment, 2 in the appropriately treated group (resulting in death and amputation) and 1 patient with osteomyelitis in the inappropriately treated group. The cure rate for infections treated appropriately or inappropriately was the same. Conclusions Treatment of soft tissue infections after surgical drainage, even with inappropriate antibiotics, has a high cure rate. Further studies to evaluate the efficacy of treating these infections without antibiotics are needed.