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Background The purpose of this study was to determine the optimal timing of delayed microvascular breast reconstruction after completion of postmastectomy radiation therapy (PMRT). The authors evaluated whether the timing of reconstruction after PMRT completion affects the development of major postoperative complications. We hypothesize that delayed microvascular breast reconstruction can be safely performed within 12 months of PMRT completion. Methods A retrospective chart review of microvascular, autologous breast reconstructions at Brigham and Women's Hospital from 2007 to 2019 was performed. Logistic regression analysis and marginal estimation methods were used to estimate the probability of any major complication (flap compromise requiring operative intervention, hematoma formation requiring evacuation, infection requiring readmission, and flap necrosis requiring operative debridement) occurring in 2-month intervals after PMRT. Patients were classified as having undergone reconstruction 0 to 12 months after PMRT (group 1), 12 to 18 months after PMRT (group 2), or 18 to 50 months after PMRT (group 3). Results A total of 303 patients were identified. All patients received postmastectomy radiation (n = 143 group 1, n = 57 group 2, n = 103 group 3). Mean follow-up time was 71.4 ± 38 months. Patients in group 1 were significantly younger and more likely to have undergone neoadjuvant chemotherapy (p Conclusion There was no significant difference in major complications among patients who underwent delayed, microvascular breast reconstruction within versus beyond 1 year of PMRT completion. These findings suggest that delayed microvascular breast reconstruction can be safely performed beginning 6 months after PMRT completion.

Inflammatory breast cancer (IBC) exhibits dermal lymphatic involvement at presentation, and thus, the standard surgical approach is a nonskin-sparing modified radical mastectomy (MRM) without breast reconstruction (BR). In this study, we evaluated immediate and delayed BR receipt and its outcomes in IBC. Using an IRB-approved database, we retrospectively evaluated stage III IBC patients who received trimodality therapy (preoperative systemic therapy, followed by MRM and postmastectomy chest wall/regional nodal radiation). Patients with an insufficient response to preoperative systemic therapy and/or who required preoperative radiotherapy were excluded. BR receipt, timing, and morbidity were evaluated. Among 240 stage III IBC patients diagnosed between 1997 and 2016, 40 (17%) underwent BR. Thirteen (33%) had immediate, and 27 (67%) had delayed BR. Four patients had complications (1 [8%] immediate BR and 3 [11%] delayed BR); only 1 BR (delayed) was unsuccessful. From the MRM date, the median time to recurrence was 35 months (

Introduction Nipple sparing mastectomy (NSM) is oncologically safe and provides excellent cosmetic outcomes. Complications after surgery may impact patient reported outcomes (PROs). We assessed the impact of complications on PROs after NSM. Methods We enrolled 63 patients (pts) who met eligibility criteria for NSM from September 2011 until August 2014. PROs were administered before surgery and at 1 year. Clinical data were collected from the electronic health record. Analyses were performed in SPSS Statistics for Windows (version 21.0). Pts with and without complications were compared using a one-way ANOVA. Data Sixty-three women were enrolled with a median age of 46. Postoperative complications requiring surgical treatment were seen in 10 patients (15.9%). Two patients required nipple excision due to necrosis (3.1%). No statistically significant differences in BREAST-Q scores were seen between pts with and without complications. Conclusion Experiencing a complication after initial NSM surgery is not associated with decrease in PROs.

Guidelines for venous thromboembolism (VTE) prophylaxis are not well-established for breast surgery patients. An individualized VTE prophylaxis protocol using the Caprini score was adopted at our institution for patients undergoing mastectomy ± implant-based reconstruction. In this study, we report our experience during the first year of implementation. In August 2016, we adopted a VTE prophylaxis protocol for patients undergoing mastectomy ± implant-based reconstruction. We used the Caprini score, a validated risk assessment tool for VTE, to determine each patient’s perioperative prophylaxis regimen. Detailed chart review was performed to record patient and treatment details, the Caprini score, pharmacologic VTE prophylaxis administration, and 30-day incidence of VTE and bleeding complications. We performed univariate analysis to identify factors associated with protocol compliance. Overall, 522 patients met the inclusion criteria. Median age was 51 years, 486 (93.1%) patients had malignancy, 234 (44.8%) underwent bilateral mastectomy, and 350 (67.0%) underwent reconstruction. Caprini scores ranged from 2 to 11, with 431 (82.6%) patients having a score from 5 to 7. Overall protocol compliance was 60.5%, and was associated with bilateral mastectomy (p = 0.02), reconstruction (p = 0.03), and longer procedures (p

The American Society of Plastic Surgeons commissioned a multistakeholder Work Group to develop recommendations for autologous breast reconstruction with abdominal flaps. A systematic literature review was performed and a stringent appraisal process was used to rate the quality of relevant scientific research. The Work Group assigned to draft this guideline was unable to find evidence of superiority of one technique over the other (deep inferior epigastric perforator versus pedicled transverse rectus abdominis musculocutaneous flap) in autologous tissue reconstruction of the breast after mastectomy. Presently, based on the evidence reported here, the Work Group recommends that surgeons contemplating breast reconstruction on their next patient consider the following: the patient's preferences and risk factors, the setting in which the surgeon works (academic versus community practice), resources available, the evidence shown in this guideline, and, equally important, the surgeon's technical expertise. Although theoretical superiority of one technique may exist, this remains to be reported in the literature, and future methodologically robust studies are needed.

Background During deep inferior epigastric perforator (DIEP) flap cases, anesthesiologists commonly avoid intravenous vasopressor administration because of the theoretical concern of inducing vasospasm, thrombosis, or congestion in the vessels of the anastomosis, potentially resulting in poor flap perfusion and ischemia and necessitating revision. In the setting of hypotension, however, vasopressor administration may actually improve outcomes by augmenting flap perfusion by means of increased mean arterial pressure. Methods The authors reviewed 475 consecutive DIEP flap cases in 333 patients at a single large academic medical center over a 3-year period, addressing potential confounders using univariate analyses. Results Ephedrine administration was significantly associated with decreased risk of intraoperative flap complications (OR, 0.88), including vasospasm, thrombosis, and congestion requiring revision, compared with controls, after controlling for the severity and duration of hypotension. Phenylephrine had no significant association with complication rates. Vasopressor administration was not associated with an increased risk of reoperation in the setting of necrosis within 60 days. Conclusions Ephedrine treatment for hypotension during DIEP flap cases is associated with decreased intraoperative flap complication rates compared with controls who did not receive vasopressors, whereas phenylephrine has no significant association. The common clinical practice of complete abstinence from vasopressors out of concern for worsening DIEP flap outcomes is not supported by this study. Clinical question/level of evidence Therapeutic, III.

Background Pathogenic mutations have been identified in approximately 10 percent of patients who present with breast cancer. Notably, failure to identify deleterious genetic mutations has particular implications for patients undergoing abdominally based breast reconstruction, as the donor site can be used only once. The authors sought to determine: (1) how many patients underwent genetic testing before unilateral abdominally based free flap breast reconstruction; (2) how often deleterious mutations were detected after abdominally based free flap breast reconstruction; and (3) the cost-effectiveness of expanding genetic testing in this patient population. Methods The authors retrospectively identified all patients who underwent unilateral abdominally based free flap breast reconstruction at Brigham and Women's Hospital/Dana-Farber Cancer Institute between 2007 and 2016. Chart review was performed to collect relevant demographic and clinical data. Relevant hospital financial data were obtained. Results Of the 713 who underwent free flap breast reconstruction, 160 patients met inclusion criteria, and mean follow-up was 5.8 years. Three patients (1.9 percent of 160) underwent contralateral surgery after completing reconstruction, two of whom had BRCA2 and one with ATM mutation. One hundred eleven patients met National Comprehensive Cancer Network guidelines for genetic testing, but of those only 55.9 percent (62 patients) were tested. Financial data revealed that testing every patient in the cohort would result in a net savings of $262,000. Conclusions During a relatively short follow-up period, a small percentage of patients were diagnosed with pathogenic mutations and underwent contralateral mastectomy and reconstruction. However, because of the costliness of surgery and the decreased cost of genetic testing, it is cost-effective to test every patient before unilateral abdominally based free flap breast reconstruction.

BACKGROUND The purpose of this study was to evaluate the impact of prior unilateral chest wall radiotherapy on reconstructive outcomes among patients undergoing bilateral immediate breast reconstruction. METHODS A retrospective evaluation of patients with a history of unilateral chest wall radiotherapy was performed. In each patient, the previously irradiated and reconstructed breast was compared to the contralateral nonirradiated side, which served as an internal control. Descriptive and bivariate statistics were computed. Multiple regression statistics were computed to identify adjusted associations between chest wall radiotherapy and complications. RESULTS Seventy patients were included in the study. The mean follow-up period was 51.8 months (range, 10 to 113 months). Thirty-eight patients underwent implant-based breast reconstruction; 32 patients underwent abdominal autologous flap reconstruction. Previously irradiated breast had a significantly higher rate of overall complications (51 percent versus 27 percent; p < 0.0001), infection (13 percent versus 6 percent; p = 0.026), and major skin necrosis (9 percent versus 3 percent; p = 0.046). After adjusting for age, body mass index, reconstruction method, and medical comorbidities, prior chest wall radiotherapy was a significant risk factor for breast-related complications (OR, 2.98; p < 0.0001), infection (OR, 2.59; p = 0.027), and major skin necrosis (OR, 3.47; p = 0.0266). There were no differences between implant-based and autologous reconstructions with regard to complications (p = 0.76). CONCLUSION Prior chest wall radiotherapy is associated with a 3-fold increased risk of postoperative complications following immediate breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.

BACKGROUND Surgical management of breast cancer in pregnancy (BCP) requires balancing benefits of therapy with potential risks to the developing fetus. Minimal data describe outcomes after mastectomy with immediate breast reconstruction (IR) in pregnant patients. METHODS Retrospective review was performed of patients who underwent IR after mastectomy within a BCP cohort. Parameters included intra- and post-operative complications, short-term maternal/fetal outcomes, surgery duration, and delayed reconstruction in non-IR cohort. RESULTS Of 82 patients with BCP, 29 (35%) had mastectomy during pregnancy: 10 (34%) had IR, 19(66%) did not. All IR utilized tissue expander (TE) placement. Mean gestational age (GA) at IR was 16.2 weeks. Mean surgery duration was 198 min with IR versus 157 min without IR. Those with IR delivered at, or close to, term infants of normal birthweight. No fetal or major obstetrical complications were seen. Post-mastectomy radiation (PMRT) was provided after pregnancy in 2 (20%) patients in the IR cohort and 12 (63%) in the non-IR cohort. All patients in the IR cohort successfully transitioned to permanent implant. CONCLUSIONS This report represents one of the largest series describing IR during BCP. IR after mastectomy increased surgery duration, but was not associated with adverse obstetrical or fetal outcomes. IR with TE may preserve reconstructive options when PMRT is indicated. J. Surg. Oncol. 2016;114:140-143. © 2016 Wiley Periodicals, Inc.

Supplemental Digital Content is available in the text., Background: The incidence of bilateral mastectomies is increasing along with the rates of breast reconstructions. A substantial number of patients will present with abdominal scars after Cesarean section, laparoscopy, laparotomy, and so on. The aim of this study was to evaluate the impact of prior abdominal scars on complication rates in abdominal bilateral free flap breast reconstruction. Methods: All consecutive patients with autologous free flap breast reconstruction between 2007 and 2014 were eligible. The relevant demographic and clinical data were prospectively collected into a study-specific database. Complications and reoperations were prospectively registered after postoperative outpatient visits. Results: Overall, 493 patients underwent abdominally based breast reconstruction during the study period: unilateral (n = 250; 50.7%) or bilateral (n = 243; 49.3%). In the bilateral group, the abdominal scar locations were Pfannenstiel (n = 73; 30.1%), midline (n = 16; 6.6%), lower oblique (n = 17; 7.0%), upper oblique (n = 5; 2.1%), and laparoscopic (n = 69; 28.4%). Four (1.7%) flap failures (including 1 converted to a pedicled transverse rectus abdominis flap) were registered, all occurring in patients from the scar group: 3 with Pfannenstiel incision and 1 patient with prior laparoscopy. Pfannenstiel scar was associated with higher risk of hematoma at the recipient site when compared with no scar group (13.7% versus 2.2%; P = 0.006). Partial flap necrosis, infection, and seroma occurred in 14 (5.9%), 8 (3.4%), and 5 (2.1%) patients, respectively, and no differences between the scar groups were identified. Conclusion: Surgical outcomes of bilateral reconstructions in patients with abdominal scars are generally comparable with ones in patients without prior surgery; however, some problems have been identified. These procedures might have some intraoperative considerations and often require increased operative times. Apart from the traditional preoperative computed tomography angiography, intraoperative imaging (e.g., fluorescence angiography) may be advocated in patients with abdominal scars.

The 2013 Boston Marathon bombings resulted in a large and unexpected influx of patients requiring acute multidisciplinary surgical care. The authors describe the surgical management experience of these patients at Brigham & Women's Hospital and Brigham & Women's Faulkner Hospital, with a particular focus on the important role played by reconstructive plastic surgery. The authors suggest that this experience illustrates the value of reconstructive plastic surgery in the treatment of these patients specifically and of trauma patients in general, and argue for the increasing importance of promoting our identity as a specialty.

Purpose: Mastectomy with immediate reconstruction (MIR) requires coordination between breast and reconstructive surgical teams, leading to increased preoperative delays that may adversely impact patient outcomes and satisfaction. Our cancer center established a target of 28 days from initial consultation with the breast surgeon to MIR. We sought to determine if a centralized breast/reconstructive surgical coordinator (BRC) could reduce care delays. Methods: A 60-day pilot to evaluate the impact of a BRC on timeliness of care was initiated at our cancer center. All reconstructive surgery candidates were referred to the BRC, who had access to surgical clinic and operating room schedules. The BRC worked with both surgical services to identify the earliest surgery dates and facilitated operative bookings. The median time to MIR and the proportion of MIR cases that met the time-to-treatment goal was determined. These results were compared with a baseline cohort of patients undergoing MIR during the same time period (January to March) in 2013 and 2014. Results: A total of 99 patients were referred to the BRC (62% cancer, 21% neoadjuvant, 17% prophylactic) during the pilot period. Focusing exclusively on patients with a cancer diagnosis, an 18.5% increase in the percentage of cases meeting the target (P = .04) and a 7-day reduction to MIR (P = .02) were observed. Conclusion: A significant reduction in time to MIR was achieved through the implementation of the BRC. Further research is warranted to validate these findings and assess the impact the BRC has on operational efficiency and workflows.

Unlike conventional reconstruction, facial transplantation seeks to correct severe deformities in a single operation. We report on three patients who received full-face transplants at our institution in 2011 in operations that aimed for functional restoration by coaptation of all main available motor and sensory nerves. We enumerate the technical challenges and postoperative complications and their management, including single episodes of acute rejection in two patients. At 6 months of follow-up, all facial allografts were surviving, facial appearance and function were improved, and glucocorticoids were successfully withdrawn in all patients.

Microvascular free flaps are key components of reconstructive surgery, but despite their common use and usual reliability, flap failures still occur. Many pharmacological agents have been utilized to minimize risk of flap failure caused by thrombosis. However, the challenge of most antithrombotic therapy lies in providing patients with optimal antithrombotic prophylaxis without adverse bleeding effects. There is a limited but growing body of evidence suggesting that the vasoprotective and anti-inflammatory actions of statins can be beneficial for free flap survival. By inhibiting mevalonic acid, the downstream effects of statins include reduction of inflammation, reduced thrombogenicity, and improved vasodilation. This review provides a summary of the pathophysiology of thrombus formation and the current evidence of anticoagulation practices with aspirin, heparin, and dextran. In addition, the potential benefits of statins in the perioperative management of free flaps are highlighted.

Pyoderma gangrenosum (PG) is a relatively rare condition of ulcerative cutaneous dermatosis. Usually seen in the setting of systemic inflammatory disease, PG can be difficult to distinguish from infection. We present a case of an otherwise healthy 37-year-old woman, a BRCA-1 gene mutation carrier, who was evaluated several months after bilateral mastectomies with deep inferior epigastric perforator (DIEP) flap breast reconstruction with open wounds on the right DIEP flap. Multiple interventions were employed without success. As the disease progressed, the patient eventually developed new open wounds on the left DIEP flap as well. Ultimately, rigorous dermatopathology evaluation revealed PG, and the patient was treated appropriately with a high-dose prednisone course. The wounds healed completely, and despite significant cutaneous scarring, the breast reconstructions were salvaged. There was no fat necrosis within the DIEP flap tissue itself. PG should be considered in the differential diagnosis of chronic nonhealing cutaneous ulcers following surgical intervention that do not respond to standard initial care.

Regeneration in medicine is a concept that has roots dating back to the earliest known records of medical interventions. Unfortunately, its elusive promise has still yet to become a reality. In the field of plastic surgery, we use the common tools of the surgeon grounded in basic operative principles to achieve the present day equivalent of regenerative medicine. These reconstructive efforts involve a broad range of clinical deformities, both congenital and acquired. Outlined in this review are comments on clinical conditions and the current limitations to reconstruct these clinical entities in the effort to practice regenerative medicine. Cleft lip, microtia, breast reconstruction, and burn reconstruction have been selected as examples to demonstrate the incredible spectrum and diverse challenges that plastic surgeons attempt to reconstruct. However, on a molecular level, these vastly different clinical scenarios can be unified with basic understanding of development, alloplastic integration, wound healing, cell–cell, and cell-matrix interactions. The themes of current and future molecular efforts involve coalescing approaches to recapitulate normal development in clinical scenarios when reconstruction is needed. It will be a better understanding of stem cells, scaffolding, and signaling with extracellular matrix interactions that will make this future possible. Eventually, reconstructive challenge will utilize more than the current instruments of surgical steel but engage complex interventions at the molecular level to sculpt true regeneration. Immense amounts of research are still needed but there is promise in the exploding fields of tissue engineering and stem cell biology that hint at great opportunities to improve the lives of our patients. Birth Defects Research (Part C) 84:322–334, 2008. © 2008 Wiley-Liss, Inc.

Objective: Despite cleft palate repair, velopharyngeal competence is not achieved in ∼15% of patients, often necessitating secondary surgical correction. Velopharyngeal competence postrepair may require the conversion of levator veli palatini muscle fibers from injury-susceptible type 2 fibers to injury-resistant type 1 fibers. As an initial step to determining the validity of this theory, we tested the hypothesis that, in most cases, repair induces the transformation to type 1 fibers, thus diminishing susceptibility to injury. Interventions: Single permeabilized levator veli palatini muscle fibers were obtained from normal palates and nonrepaired congenitally-clefted palates of young (2 months old) and adult (14 to 15 months old) goats and from repaired palates of adult goats (8 months old). Repair was done at 2 months of age using a modified von Langenbeck technique. Main Outcome Measures: Fiber type was determined by contractile properties and susceptibility to injury was assessed by force deficit, the decrease in maximum force following a lengthening contraction protocol expressed as a percentage of initial force. Results: For normal palates and cleft palates of young goats, the majority of the fibers were type 2 with force deficits of ∼40%. Following repair, 80% of the fibers were type 1 with force deficits of 20% ± 2%; these deficits were 45% of those for nonrepaired cleft palates of adult goats (p < .0001). Conclusion: The decrease in the percentage of type 2 fibers and susceptibility to injury may be important for the development of a functional levator veli palatini muscle postrepair.

Supplemental Digital Content is available in the text., Summary: Rhinoplasty in middle-aged and elderly patients comes with its own set of challenges. There is relative lengthening of the nose with drooping of the nasal tip. With aging, the skin loses its elasticity, and the combination of nasal skeletal reduction along with overlying inelastic skin provides a setup for skin redundancy and poor postoperative outcome. We describe a surgical technique involving lenticular skin excision as a part of rhinoplasty in 12 patients older than 50 years to improve the aesthetic outcome. Skin width up to 1.6 cm was excised. Included is a literature review of skin excision in rhinoplasty. In elderly patients with thin, inelastic skin and long nose with a drooping tip, a reduction rhinoplasty technique might result in skin redundancy. Lenticular skin excision along the radix of the nose in these 12 patients improved the aesthetic outcome by decreasing the redundancy and preventing nasal tip ptosis. The wound from the skin resection healed in all the patients with minimal scar, and no complication was noted after at least 1 year of follow-up for each patient.

Bilateral mastectomies (BM) are traditionally performed by single surgeons (SS); a co-surgeon (CS) technique, where each surgeon concurrently performs a unilateral mastectomy, offers an alternative approach. We examined differences in general surgery time (GST), overall surgery time (OST), and patient complications for BM performed by CS and SS.Patients undergoing BM with tissue expander reconstruction (BMTR) between January 2010 and May 2014 at our center were identified through operative case logs. GST (incision to end of BM procedure), reconstruction duration (RST) (plastic surgery start to end of reconstruction) and OST (OST = GST + RST) was calculated. Patient age, presence/stage of cancer, breast weight, axillary procedure performed, and 30-day postoperative complications were extracted from medical records. Differences in GST and OST between CS and SS cases were assessed with a t test. A multivariate linear regression was fit to identify factors associated with GST.A total of 116 BMTR cases were performed [CS, n = 67 (57.8 %); SS, n = 49 (42.2 %)]. Demographic characteristics did not differ between groups. GST and OST were significantly shorter for CS cases, 75.8 versus 116.8 min, p .0001, and 255.2 versus 278.3 min, p = .005, respectively. Presence of a CS significantly reduces BMTR time (β = -38.82, p .0001). Breast weight (β = 0.0093, p = .03) and axillary dissection (β = 28.69, p = .0003) also impacted GST.The CS approach to BMTR reduced both GST and OST; however, the degree of time savings (35.1 and 8.3 %, respectively) was less than hypothesized. A larger study is warranted to better characterize time, cost, and outcomes of the CS-approach for BM.

The healthcare budget has outpaced the economic growth for multiple decades.1,2 The percentage of Gross Domestic Product allocated to healthcare has been increasing at an alarming rate and is expected to exceed 20% of US Gross Domestic Product by 2018.3 Medicine is faced with the challenge of controlling increasing costs while being able to maintain safe and high-quality standards of care. To achieve this balance while avoiding other alternatives such as reimbursement reduction, it becomes imperative to ensure that care delivered is appropriate and unnecessary care is avoided. One way to achieve these goals is to have well-established practice guidelines, backed by objective data, for different clinical situations. Standardized practice guidelines (SPGs) may also help in effective communication between the patient and the healthcare providers and may be the key to provide high-quality care while maintaining financial viability. However, clear and objective data—the lynchpin of most SPGs—is often lacking. In a study where 10 cardiologists at Boston Children’s Hospital were shadowed, every clinical decision was recorded and classified by a team of independent observers (Table ​(Table11).4 Surprisingly, 37.1% (441 of 1188) of the decisions were made solely on experience or anecdotal evidence, whereas another 14.7% of the decisions were made arbitrarily or based on instincts. Less than 20% of decisions were made based on the data from research studies. The authors of this study made clear that the physicians studied were academically accomplished and very knowledgeable about the evidence base for pediatric cardiology. This lack of evidence base makes establishing standardized guidelines difficult and could result in significant variability in treatment protocols between different healthcare providers. Table 1. Analysis of Clinical Decision Making among 10 Pediatric Cardiologists at Boston Children’s Hospital (N = 1188) Most SPGs that have been developed focus on common medical conditions such as chronic wounds. It is difficult to obtain strong evidence for uncommon medical situations due to lack of powered data.5–8 Furthermore, SPGs may be difficult to create even in more common conditions or procedures, as high-quality evidence is often lacking or studies may conflict. An example is hypertension (cited in JNC 8) in which 5 of 9 recommendations in a recent guideline revision are based on expert consensus, not high-quality evidence. Specialities such as plastic surgery or congenital heart surgery include a plethora of rare and diverse medical situations. These situations are characterized by both institutional and individual practice discrepancies.9–12 Similarly, even though there are SPGs from American Society of Plastic Surgeons (ASPS) about the broad topic of breast reconstruction with expanders and implants, there is limited high-quality evidence, making it difficult to produce strong recommendations.13,14 Based on the ASPS guidelines, only level III evidence is available for the use of acellular dermal matrix (ADM) during reconstruction and surgeons are expected to evaluate each case individually.13,14 Also, there is variable evidence regarding the association between postoperative complications and timing of postmastectomy implant breast reconstruction. Absence of strong evidence and lack of society recommendations allows for not only practice variation, but also vulnerability to poor quality of care. The Standardized Clinical Assessment and Management Plan (SCAMP) model was developed to provide standardized care for such medical conditions where evidence was not conclusive.15,16 Because the SCAMP method is a relatively new concept and has not been implemented in the field of plastic and reconstructive surgery, the goal of this study was to determine the feasibility of SCAMPs. In this manuscript, we investigate the development and implementation of a SCAMP concept in the field of plastic surgery, specifically in immediate breast reconstruction utilizing implants or tissue expanders.

Background: Nipple–areolar complex creation is the last step in the breast reconstruction process and plays a significant role in patients’ overall satisfaction. Although numerous surgical techniques have been described to create the nipple, very few procedures address the natural contour of the areola. Methods: We describe a surgical technique using a purse-string suture for improved areolar projection. After creation of nipple–areolar complex using a CV flap, evenly spaced stab incisions are made in a circular pattern, approximately 5 mm outside of the boundary of the proposed areola. Using these incisions, a nonabsorbable purse-string suture is placed in the deep dermis. The diameter is cinched down to the desired measurement, providing areolar projection. Results: Our experience using this technique has provided a satisfactory and stable projection of the areola in 10 patients with at least 1 year follow-up for each patient. There was no spitting of purse-string sutures in any of these patients, and there was no late areolar widening after at least 1 year follow-up. This provides a means for symmetry with an unreconstructed contralateral side. Conclusions: Improving aesthetic outcomes for areola reconstruction may further refine our goals of an ideal breast reconstruction.

In summary, if the abdomen cannot be used for a donor site, alternative flap selection is based on individual patient anatomy and body habitus, targeting the buttocks and upper thigh. Intraoperative repositioning may be required for ease in flap harvest and donor site closure, adding time to the procedure. Flap dissection is performed in the subfascial plane to avoid injury to the perforator vessels. Deep suspension sutures may be required to maintain the gluteal fold location.

Background: Allergan’s Natrelle round silicone-filled breast implants were approved by the U.S. Food and Drug Administration in 2006 based on interim results from the Core Study; final 10-year study results are now available. Methods: Seven hundred fifteen subjects were implanted with smooth and Biocell textured Natrelle round silicone implants and attended clinic visits at 0 to 4 weeks, 6 months, 1 year, and annually through 10 years. Approximately one-third of subjects underwent magnetic resonance imaging at years 1, 3, 5, 7, and 9 to assess rupture. Results: Complication rates showed modest increases over the previously published 6-year rates. The Kaplan-Meier capsular contracture rate was 18.9 percent for augmentation, 28.7 percent for revision-augmentation, and 24.6 percent for reconstruction. Among augmentation subjects, capsular contracture was significantly lower (p = 0.023) for submuscular (15.7 percent) versus subglandular (26.3 percent) placement. The overall rupture rate in the magnetic resonance imaging cohort was 13.0 percent for subjects and 7.7 percent for implants. By the end of the study, 81.8 percent of augmentation subjects still had an original implant in place. Using a five-point scale, 94.2 percent of augmentation, 83.8 percent of revision-augmentation, and 90.7 percent of reconstruction subjects reported being satisfied or definitely satisfied with their implants. Significant improvement over baseline was also seen in overall breast satisfaction and satisfaction with breast size, shape, feel, and how well they matched. Conclusion: The 10-year data from the Natrelle Core Study, which can guide surgeons and patients in decision-making, demonstrate safety and high levels of patient satisfaction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

The internal mammary vessels are frequently used for free flap breast reconstruction and are typically dissected via resection of an entire rib cartilage. Resection of rib cartilage may cause increased postoperative pain or a depressed thoracic contour deformity. We have used a new, less invasive technique that does not resect rib cartilage and exposes the vessels within the rib interspace. Over a 3-year period, all breast free flaps performed with the rib-sparing technique were reviewed and compared with a group of flaps performed with the standard rib resection technique. The rib-sparing technique was performed for 74 flaps, with no significant increase in complications, including revision of anastomosis (3%), fat necrosis (11%), or flap loss (1%), when compared with a group of 125 flaps undergoing rib resection. This less invasive technique is reviewed in detail and may prove beneficial in regard to postoperative pain and incidence of chest wall deformities.

In the September 2015 article by Caterson et al, Development of Standardized Clinical Assessment and Management Plans (SCAMPs) in Plastic and Reconstructive Surgery, Elizabeth Han should have been included as an author. The corrected byline appears below

Composite facial allotransplantation is emerging as a treatment option for severe facial disfigurements. The technical feasibility of facial transplantation has been demonstrated, and the initial clinical outcomes have been encouraging. We report an excellent functional and anatomical restoration 1 year after face transplantation. A 59-year-old male with severe disfigurement from electrical burn injury was treated with a facial allograft composed of bone and soft tissues to restore midfacial form and function. An initial potent antirejection treatment was tapered to minimal dose of immunosuppression. There were no surgical complications. The patient demonstrated facial redness during the initial postoperative months. One acute rejection episode was reversed with a brief methylprednisolone bolus treatment. Pathological analysis and the donor's medical history suggested that rosacea transferred from the donor caused the erythema, successfully treated with topical metronidazol. Significant restoration of nasal breathing, speech, feeding, sensation and animation was achieved. The patient was highly satisfied with the esthetic result, and regained much of his capacity for normal social life. Composite facial allotransplantation, along with minimal and well-tolerated immunosuppression, was successfully utilized to restore facial form and function in a patient with severe disfigurement of the midface.

Objective: Deep inferior epigastric artery perforator (DIEP) flap is an excellent option for breast reconstruction in young and active patients who have a history of chest wall radiation. One drawback, however, is that the entire capacity of abdominal pannus cannot be reliably transferred on a single pedicle. The purpose of this case report is to demonstrate a method of maximizing the volume of reconstruction with a dual-pedicled DIEP flap. Methods: A case is reported in which both antegrade and retrograde internal mammary vessels were used as recipient sites for a dual-pedicled, folded, stacked DIEP flap. Results: Good flows were observed in both sets of recipient vessels intraoperatively. Postoperative imaging revealed patent vascular anastomoses of both pedicles. At 1-year follow-up, there was no evidence of fat necrosis and a satisfactory aesthetic outcome was achieved. Conclusion: To maximize the volume of the reconstructed breast, the entire abdominal pannus can be utilized. The retrograde limb of internal mammary vessels can act as the recipient site for the second pedicle, minimizing donor site morbidity.

A single case is reported utilizing ultrasound-assisted liposuction (UAL) to treat fat necrosis after deep inferior epigastric artery perforator flap breast reconstruction. UAL treatment resulted in softening of the fibrous fat necrotic areas, while maintaining acceptable breast contour. UAL is safer and less invasive than traditional treatments for fat necrosis including direct excision and suction-assisted liposuction.

BACKGROUND: Previous abdominal surgery may affect perforator anatomy and complication rates in patients undergoing deep inferior epigastric perforator (DIEP) flap breast reconstruction. The purpose of this study was to determine whether abdominal scars in DIEP breast reconstruction have an effect on flap and donor-site complications. METHODS: Over a 3-year period, 168 DIEP flap patients were retrospectively divided into a control group with no previous abdominal operations and a scar group with previous abdominal procedures. Flap and abdominal wound complications were compared between the two groups. RESULTS: Ninety patients (54 percent) underwent 114 flaps in the control group and 78 patients (46 percent) underwent 104 flaps in the scar group. The most common previous incisions were Pfannenstiel, laparoscopic, and midline. There was no significant difference between the groups in age, body mass index (mean 27 kg/m2 in both groups), smoking history, or radiation status. There were no significant differences between the control and scar groups in DIEP flap loss (1.8 percent versus 2.9 percent), partial flap loss (1.8 percent versus 1.0 percent), or fat necrosis (15 percent versus 14 percent, respectively). However, the scar group had a significantly higher rate of abdominal donor-site complications (24 percent) compared with the control group (6.7 percent; p = 0.003). The most common complications were abdominal wound breakdown (12 percent), seroma requiring operative drainage (6.4 percent), and abdominal laxity or bulge (5.1 percent). CONCLUSIONS: With minor technical modifications, DIEP flaps can be performed successfully without increased flap complications in patients with preexisting abdominal incisions. Despite these design modifications, patients should be informed of an increased risk for donor-site complications.

Breast reconstruction utilizing the latissimus dorsi musculocutaneous flap with an underlying breast implant is a well-established technique. Postoperative shoulder limitation is usually limited if at all noticeable. The muscle itself may, however, remain active in the new anterior position. Many patients find the muscle twitches with extension of the humerus, despite the anterior translocation of the muscle. This leads to a disturbing contraction, superolaterally, of the entire reconstruction. In addition, the resting tone can lead to a sense of tightness, despite a lack of clinically obvious capsular contracture. Division of the thoracodorsal nerve during initial flap elevation can prevent this problem. When raising the routine flap however, the pedicle itself is often not visualized and there is anxiety related to dividing the nerve and accidentally injuring the vascular pedicle. In addition, many of the transferred muscles atrophy, thereby avoiding this potential problem. When the muscle remains active, delayed division of the thoracodorsal nerve via a 2.5-cm axillary incision will stop the active twitching, decrease the resting tone of the muscle, and in most patients offer significant relief from symptoms of tightness. During the past 2 1/2 years, 100 latissimus dorsi flap breast reconstructions in 80 patients were performed. Forty-one nerves in 28 patients have been divided, with successful denervation in 37 of the 41 reconstructions, for a success rate of 90%. Delayed division of the thoracodorsal nerve can offer relief to patients complaining of tightness and muscle activity post-latissimus flap breast reconstruction.

Background: Wound re-epithelialization has been traditionally described to occur from the dermal appendages of the wound edges. As such, the role of the dermal wound bed in re-epithelialization has been questioned. In a patient undergoing breast reconstruction with free tissue transfer, the buried portions of the free flap skin paddle could be either de-epithelialized or deskinned. In case of mastectomy skin flap loss, the role of de-epithelialized skin in wound healing has not been described before. Methods: We report a patient with bilateral mastectomies and bilateral deep inferior epigastric perforator flaps whose postoperative course was complicated by bilateral full-thickness mastectomy skin flap loss. Multiple debridements of nonviable skin resulted in exposure of previously buried de-epithelialized skin paddle of the deep inferior epigastric perforator flap. Results: Our study demonstrates self re-epithelialization of the dermal wound bed from the dermal appendages. We noticed multiple noncontiguous neoepidermal islands in the dermal wound bed, which did not communicate with the wound edges. Conclusions: In case of full-thickness mastectomy skin flap loss, deep vascular plexus present in the dermal bed of the underlying de-epithelialized skin paddle of the free flap converts an otherwise full-thickness wound to a partial-thickness wound. Our study demonstrates the self-epithelialization potential of the de-epithelialized dermal wound bed from the dermal appendages when exposed to air and in the presence of wound healing elements.

Locoregional breast cancer recurrence is a relatively rare event, occurring more frequently in patients diagnosed with more advanced stages of cancer and those with inflammatory features. While typical signs of recurrence after reconstruction include the development of a mass in the native skin or deep chest wall, oncologic relapse may also rarely be heralded by subtle cutaneous changes. This article describes a patient with inflammatory breast cancer who underwent neoadjuvant chemotherapy, mastectomy, radiation therapy, and hormonal therapy followed by delayed reconstruction with a deep inferior epigastric artery perforator flap and subsequently presented with a recurrence manifest as a localized rash over the upper abdomen. Surgeons who perform breast reconstruction should be attuned to both common and uncommon recurrence symptoms, as they may be the first to diagnose recrudescent disease.

1133 Background: Management of pregnancy-associated breast cancer (PABC) requires balancing benefits of therapy with potential risks to the developing fetus. Surgical management can be influenced by gestational age of fetus and tumor stage. Minimal data describe surgical and obstetrical outcomes after mastectomy with immediate breast reconstruction (IR) in a pregnant patient (pt). Methods: Pts who underwent IR after mastectomy were identified within a multi-institutional PABC cohort. Retrospective chart review was performed for outcomes including adverse intraoperative events, immediate postoperative complications, gestational age at delivery and fetal weight. Other parameters evaluated included stage at presentation, duration of surgery, and use of delayed reconstruction in pts who did not receive IR. Results: Within a cohort of 79 PABC pts, 25 (32%) had mastectomy while pregnant, 8 (32%) of whom had IC; 17 (68%) did not undergo IR. Mean gestational age at time of IR was 16.6 weeks (range 10-30) and all IR utilized tissue expander (TE) placement followed by permanent implant placement in 7 pts. In the IR cohort, 1 (12.5%) pt was stage 0, 3 (37.5%) stage I and 4 (50%) stage IIB. There were no intraoperative or immediate postoperative surgical complications. The mean duration of surgery was 198 min with IR (7 pts) vs. 157 min without IR (available for 12 pts). All women who underwent IR delivered at, or close to, term infants of normal birthweight. One pt had pre-term labor after surgery at 29 weeks which resolved with tocolysis. Mean gestational age at delivery was 37.3 weeks in the IR cohort vs. 36.3 weeks in the non-IR cohort. No fetal abnormalities or major obstetrical complications were seen after IR. Post-mastectomy radiation (PMRT) was provided after pregnancy in 2 pts (25%) in the IR cohort and cosmetic outcome was not adversely affected. Conclusions: This report represents one of the largest series describing IR after mastectomy in PABC. Results suggest immediate tissue expander placement after mastectomy may increase duration of surgery but does not lead to adverse obstetrical or fetal outcomes. IR with tissue expanders may preserve reconstructive options when PMRT is indicated.

Background: Breast reconstruction is associated with high levels of patient satisfaction. Previous patient satisfaction studies have been subjective. This study utilizes functional magnetic resonance imaging (fMRI) to objectively evaluate ‘‘sense of self’’ following deep inferior epigastric perforator (DIEP) flap breast reconstruction in an attempt to better understand patient perception. Methods: Prospective fMRI analysis was performed on four patients before and after delayed unilateral DIEP flap breast reconstruction, and on four patients after immediate unilateral DIEP flap breast reconstruction. Patients were randomly cued to palpate their natural breast, mastectomy site or breast reconstruction, and external silicone models. Three regions of interest (ROIs) associated with self-recognition were examined using a general linear model, and compared using a fixed effects and random effects ANOVA, respectively. Results: In the delayed reconstruction group, activation of the ROIs was significantly lower at the mastectomy site compared to the natural breast (p,0.01). Ten months following reconstruction, activation of the ROIs in the reconstructed breast was not significantly different from that observed with natural breast palpation. In the immediate reconstruction group, palpation of the reconstructed breast was also similar to the natural breast. This activity was greater than that observed during palpation of external artificial models (p,0.01). Conclusions: Similar activation patterns were observed during palpation of the reconstructed and natural breasts as compared to the non-reconstructed mastectomy site and artificial models. The cognitive process represented by this pattern may be a mechanism by which breast reconstruction improves self-perception, and thus patient satisfaction following mastectomy.