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Background Skin necrosis after nipple-sparing mastectomy (NSM) and deep inferior epigastric perforator (DIEP) breast reconstruction impacts cosmesis and patient satisfaction. Skin grafting might mitigate these sequelae, but oftentimes creates a color and texture mismatch with native breast skin. In contrast, abdominal skin on the DIEP flap is an excellent match and can be banked. The purposes of this study are to review our experience with skin banking of DIEP flaps and determine the cost-benefit of skin banking compared with other reconstructive options. Methods This was a retrospective review study conducted from 2011 to 2014 to examine patients undergoing staged DIEP reconstruction immediately after NSM. Medicare reimbursement costs using Current Procedural Terminology codes, and provider and facilities fees for conventional reconstructions options versus skin banking were obtained with subsequent cost-minimization and sensitivity analyses. Results The proportion of patients who developed mastectomy skin necrosis was 12.1%, and that of those who had a positive retroareolar biopsy corresponding to an average surface area of 58.3 cm was 3.0%. Average per patient cost of skin banking was $1224, $844 more than split-thickness skin graft (STSG) without Integra, $420 more than STSG with Integra, and $839.01 more than full-thickness skin graft. Sensitivity analysis demonstrates that skin banking was less than managing mastectomy skin loss with STSG and Integra when the incidence of necrosis >10 cm exceeded 25.3%. Conclusions Skin banking maximizes aesthetic outcomes after skin loss from either positive margins or skin flap necrosis. Use of this technique should occur especially in select patients at increased risk of mastectomy skin flap/nipple-areola complex (NAC) necrosis and/or suspicion for occult NAC carcinoma. Furthermore, among reconstructive plastic surgeons whose rate of mastectomy flap/NAC necrosis >10 cm exceeds 25.3%, sensitive analysis favors undergoing a staged reconstruction after NSM.

Background Premature fusion of the metopic suture leads to a range of clinical presentations, with more severe patients presenting characteristically with trigonocephaly. Endoscopic-assisted correction of craniosynostosis is emerging as an alternative to the gold-standard open cranial vault remodeling. While there are several documented benefits of endoscopic correction, the management of craniosynostosis varies widely in the literature with little consensus as to the preferred timing and surgical technique for repair. The purpose of this study was to investigate the safety outcomes of endoscopic versus open surgery at our institution. Methods This retrospective cohort study included all patients diagnosed with metopic craniosynostosis who underwent open or closed surgical management and received at least 6 months of follow-up. Data extraction was performed via chart review and included demographic information and safety outcome variables. Results During the study period, 17 patients who met our inclusion criteria were treated by the multidisciplinary craniofacial team at our institution. Eight patients underwent endoscopic surgery and 9 underwent open surgery. The mean age at surgery was significantly higher in the open surgery group than the endoscopic surgery group (13.7 months versus 2.3 months, respectively). Estimated blood loss, percent estimated blood volume lost, transfusion volume, procedure length, hospital length of stay, and intensive care unit (ICU) length of stay were all significantly higher in the open surgery group compared with the endoscopic group. Conclusions In our patient population, endoscopic surgery for metopic craniosynostosis had an improved safety profile versus open surgery based on reduced procedure length, estimated blood loss, volume of blood transfusion, and length of stay in the ICU and hospital.

Mandibular fractures are rare, most commonly occurring in young male patients who present with facial trauma. The etiology, incidence, and presentation vary among previous publications depending on cultural and socioeconomic factors of the region of origin. This multi-institutional study aims to present demographic characteristics, surgical treatment, and clinical outcomes of surgical repair of mandible fractures in the United States. An analysis of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) adult databases of the years 2006 through 2014 was performed identifying 940 patients with an International Classification of Diseases, version 9 (ICD-9) diagnosis of either closed or open fracture of the mandible. Preoperative, perioperative, and postoperative details were categorized and evaluated for these two cohorts. Multivariate analysis was performed to detect risk factors related to any complications. Patients were predominantly male (85.7%), young with a mean age of 34.0 ± 14.8 years, and relatively healthy with body mass index of 23.6 ± 8.2 and an American Society of Anesthesiologists (ASA) class of 1 or 2 (84.4%). However, more than half were regular smokers (51.1%). The top five most frequent procedures performed for mandibular repair were exclusively open surgical approaches with internal, external, or interdental fixation in both cohorts. Patients with open fractures were more often admitted as emergencies, treated inpatient, required longer operative times, and presented with more contaminated wounds ( p < 0.05). Overall, medical (1.7%) and surgical complications (3.7%) were low. A high ASA class 3 or above and emergency operations were identified as risk factors for medical adverse events. Despite frequent concomitant injuries after trauma and a diverse array of mandibular injury types, our patient sample demonstrated favorable outcomes and low complication rates. Open surgical techniques were the most common procedures in this study representing the American population.

Granular cell tumors (GCT) are generally benign soft tissue tumors. When located in the breast, they may be misdiagnosed as more typical tumors, such as invasive ductal carcinoma, based on misleading clinical or radiologic features. GCTs are frequently found in the setting of a known malignancy. We report the case of a patient with a large infra-mammary fold GCT, the management of which required a multidisciplinary operative approach due to extensive chest wall invasion.

Although mastectomy skin flap necrosis is a common complication after breast reconstruction, current methods for assessing the likelihood of necrosis rely almost exclusively on clinician judgment. Indocyanine green (ICG) angiography is a technology, however, that uses near-infrared imaging to visualize perfusion in superficial tissues in real time. In breast reconstruction, studies have shown that ICG angiography independently predicts post-operative outcomes and, when used in conjunction with clinical judgment, decreases rates of mastectomy skin flap necrosis. The goal of this chapter is to introduce the technology of ICG angiography and provide an overview from the recent literature of how the technology can be instrumental in predicting post-operative complications after breast reconstruction.

Granular cell tumors (GCT) are generally benign soft tissue tumors. When located in the breast, they may be misdiagnosed as more typical tumors, such as invasive ductal carcinoma, based on misleading clinical or radiologic features. GCTs are frequently found in the setting of a known malignancy. We report the case of a patient with a large infra-mammary fold GCT, the management of which required a multidisciplinary operative approach due to extensive chest wall invasion.

Mastectomy skin flap ischaemia leading to necrosis is a common occurrence. Laser-assisted indocyanine green (ICG) angiography can assist to locate these poorly perfused areas intra-operatively. Our study aims to identify specific perfusion values produced by ICG angiography that accurately predict mastectomy flap necrosis. A total of 42 patients undergoing autologous or implant-based breast reconstruction had mastectomy flaps imaged using laser-assisted ICG angiography at the completion of reconstruction. Intra-operative perfusion values were correlated with postoperative skin flap outcomes. Risk factors for abnormal perfusion were recorded and analysed. A total of 62 breast reconstructions were imaged, including 48 tissue expander reconstructions, six transverse rectus abdominis myocutaneous (TRAM) flaps, six deep inferior epigastric perforator (DIEP) flaps and two direct-to-implant reconstructions. Eight cases (13%) of full-thickness skin necrosis were identified postoperatively. A SPY Elite(®) value of ≤ 7 accurately predicted the development of flap necrosis at 88% sensitivity and 83% specificity. False-positive cases (those with perfusion values ≤ 7 which did not develop necrosis) were more likely to have a smoking history and/or to have had an epinephrine-containing tumescent solution used during mastectomy. Excluding patients with smoking or epinephrine use, a SPY value of ≤ 7 predicted flap necrosis with a sensitivity of 83% and specificity of 97%. Thus, these data suggest that laser-assisted ICG angiography predicts postoperative outcomes with high accuracy. In our series, a SPY value of ≤ 7 correlated well with mastectomy flap necrosis. Furthermore, smoking and intra-operative injections containing epinephrine should be considered when evaluating low perfusion values as they can lead to false-positive test results.