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This study aimed to compare the therapeutic effects of biplane skin dilator implantation with those of conventional skin dilator implantation in auricular reconstruction. A total of 137 patients with microtia who met the inclusion criteria from January 2020 to April 2021 were retrospectively selected. Sixty-three patients comprised the control group and were implanted with a skin expander using the conventional method. Seventy-four patients comprised the experimental group and were implanted with a skin expander using the biplane method. Non-parametric tests were used to compare the down-moving distance of the skin dilator between the experimental group and the control group. There was a statistically significant difference in the down-moving distance of the skin dilator between the experimental group and the control group (P < 0.05). The chi-square test showed no significant difference in postoperative complications between the experimental group and the control group (P > 0.05). Moreover, there was no significant difference in the satisfaction rate of patients and their families between the experimental group and the control group (P > 0.05). In this study, the treatment effect of biplane skin dilator implantation was better than that of conventional skin dilator implantation., (© 2021. The Author(s).)

Background/aim: We employed a survey to the American Society of Plastic Surgeons (ASPS) to investigate the management of breast reconstruction across the US during the COVID-19 pandemic., Patients and Methods: An electronic survey on breast reconstruction practice demographics, COVID-19-related restrictions on breast reconstruction, and pertinent dates of restrictions was employed., Results: A total of 228 responses were obtained. Demographics were balanced for geography with most respondents located in either urban or suburban settings (91.2%). The majority proceeded with mastectomy/reconstruction as originally planned (39.0%), followed by hormonal/chemotherapy only (22.6%). The most common reconstructive option was tissue expander/implant-based reconstruction (47.7%). Most institutions implemented restrictions between March 11-20 th (59%). Almost all respondents (91.8%) reported mandatory pre-operative SARS-Cov-2 testing once cases resumed., Conclusion: COVID-19 has forced the breast surgical team to adapt to new conditions to the detriment of women with breast cancer requiring reconstruction. Varying restrictions have limited access to breast reconstruction, carrying consequences yet to be determined.

Background: Within the multidisciplinary management of breast cancer, variations exist in the reconstructive options offered and care provided. The authors evaluated plastic surgeon perspectives on important issues related to breast cancer management and reconstruction and provide some insight into factors that influence these perspectives., Methods: Women diagnosed with early-stage breast cancer (stages 0 to II) between July of 2013 and September of 2014 were identified through the Georgia and Los Angeles Surveillance, Epidemiology, and End Results registries. These women were surveyed and identified their treating plastic surgeons. Surveys were sent to the identified plastic surgeons to collect data on specific reconstruction practices., Results: Responses from 134 plastic surgeons (74.4 percent response rate) were received. Immediate reconstruction (79.7 percent) was the most common approach to timing, and expander/implant reconstruction (72.6 percent) was the most common technique reported. Nearly one-third of respondents (32.1 percent) reported that reimbursement influenced the proportion of autologous reconstructions performed. Most (82.8 percent) reported that discussions about contralateral prophylactic mastectomy were initiated by patients. Most surgeons (81.3 to 84.3 percent) felt that good symmetry is achieved with unilateral autologous reconstruction with contralateral symmetry procedures in patients with small or large breasts; a less pronounced majority (62.7 percent) favored unilateral implant reconstructions in patients with large breasts. In patients requiring postmastectomy radiation therapy, one-fourth of the surgeons (27.6 percent) reported that they seldom recommend delayed reconstruction, and 64.9 percent reported recommending immediate expander/implant reconstruction., Conclusions: Reconstructive practices in a modern cohort of plastic surgeons suggest that immediate and implant reconstructions are performed preferentially. Respondents perceived a number of factors, including surgeon training, time spent in the operating room, and insurance reimbursement, to negatively influence the performance of autologous reconstruction.

Background: Rates of breast reconstruction following mastectomy continue to increase. The objective of this study was to determine the frequency of elective revision surgery and the number of procedures required to achieve a stable breast reconstruction 2 years after mastectomy., Methods: Women undergoing first-time breast reconstruction after mastectomy were enrolled and followed for 2 years, with completion of reconstruction occurring in 1996. Patients were classified based on the absence or presence of complications. Comparisons within cohorts were performed to determine factors associated with revisions and total procedures. Mixed-effects regression modeling identified factors associated with elective revisions and total operations., Results: Overall, 1534 patients (76.9 percent) had no complications, among whom 40.2 percent underwent elective revisions. The average number of elective revisions differed by modality (p < 0.001), with abdominally based free autologous reconstruction patients undergoing the greatest number of elective revisions (mean, 0.7). The mean total number of procedures also differed (p < 0.001), with tissue expander/implant reconstruction patients undergoing the greatest total number of procedures (mean, 2.4). Complications occurred in 462 patients (23.1 percent), with 67.1 percent of these patients undergoing elective revisions, which was significantly higher than among patients without complications (p < 0.001). The mean number of procedures again differed by modality (p < 0.001) and followed similar trends, but with an increased mean number of revisions and procedures overall. Mixed-effects regression modeling demonstrated that patients experiencing complications had increased odds of undergoing elective revision procedures (OR, 3.2; p < 0.001)., Conclusions: Breast reconstruction patients without complications undergo over two procedures on average to achieve satisfactory reconstruction, with 40 percent electing revisions. If a complication occurs, the number of procedures increases., Clinical Question/level of Evidence: Risk, II.

Background: Two-stage implant breast reconstruction is the most commonly performed breast reconstruction procedure. Limited data exist regarding reconstruction complication rates examined by mastectomy indication., Methods: Patients who underwent two-stage implant breast reconstruction at Yale New Haven Hospital from 2011 to 2017 were included in the study. Perioperative complications were compared. Chi-square analysis, t tests, and Fisher's exact tests were used to determine significant associations. A binary logistic regression was used to determine variables with a significant impact on the likelihood of mastectomy flap necrosis., Results: Between 2011 and 2017, complete perioperative records were available for 141 patients who underwent 226 mastectomies followed by two-stage tissue expander/permanent implant reconstruction. Of the 226 mastectomies, 134 were therapeutic and 92 were prophylactic. On regression analysis, there were no significant differences in demographics, comorbidities, or mastectomy and reconstructive details between the two breast groups except for there being more modified radical mastectomies in therapeutic breasts (p = 0.003). When comparing complications, there was a significantly higher risk of mastectomy flap necrosis in the therapeutic group (p = 0.017). Therapeutic mastectomies had a 9.5 times higher risk of mastectomy flap necrosis than prophylactic mastectomies when adjusted for confounding variables. There were no significant differences in other reconstructive complications between the two groups., Conclusions: Patients undergoing therapeutic mastectomies have a significantly higher risk of mastectomy flap necrosis than those undergoing prophylactic mastectomies. Although the underlying cause still needs to be determined, differences in technique may be related to mastectomy flap necrosis., Clinical Question/level of Evidence: Risk, II.

Background:  One aim of unilateral postmastectomy breast reconstruction (BR) is to restore symmetry with the contralateral breast. As such, unilateral prosthetic reconstruction often requires a contralateral symmetry procedure (CSP). There is sparse literature on the impact of CSPs on long-term patient-reported outcomes (PROs) such as satisfaction and health-related quality of life (HRQoL). This study aims to describe PROs following CSPs, using a validated PRO tool, BREAST-Q. The hypothesis is that CSPs are associated with greater patient-reported satisfaction and HRQoL., Methods:  This study is a single institutional analysis of prospectively collected BREAST-Q scores of patients who underwent unilateral prosthetic BR during 2011 to 2015. Women 18 years and older with BREAST-Q scores measured ≥ 9months after BR with or without CSP(s) at the time of expander replacement were included. Patients were classified into four subcohorts: augmentation, mastopexy, reduction, and no symmetry procedure (controls). Sociodemographic, clinical characteristics, and BREAST-Q scores were analyzed. Multivariable linear regression was performed., Results:  Of 553 patients, 67 (12%) underwent contralateral augmentation, 68 (12%) mastopexy, 93(17%) reduction, and 325 (59%) were controls. Mean follow-up time was 52 months. Satisfaction with breast and outcomes were higher in the augmentation compared with the control groups ( p  = 0.01). On multivariable analysis, augmentation remained an independent predictor of satisfaction with breast ( p  = 0.04). Physical well-being scores were lower for contralateral mastopexy and reduction compared with the controls with a trend toward statistical significance on multivariable models. Psychological and sexual well-being was similar across groups., Conclusion:  Prosthetic reconstruction with contralateral breast augmentation was associated with greater satisfaction with breast and reconstructive outcome. In contrast, breast reduction and mastopexy procedures demonstrated equivalent satisfaction with breasts compared with controls but may be associated with lower physical well-being. Such information can be used to improve the shared decision-making process for women who choose unilateral prosthetic BR., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Background: Flap-based breast reconstruction demands greater operative labor and offers superior patient-reported outcomes compared with implants. However, use of implants continues to outpace flaps, with some suggesting inadequate remuneration as one barrier. This study aims to characterize market variation in the ratio of implants to flaps and assess correlation with physician payments., Methods: Using the Blue Health Intelligence database from 2009 to 2013, patients were identified who underwent tissue expander (i.e., implant) or free-flap breast reconstruction. The implant-to-flap ratio and physician payments were assessed using quadratic modeling. Matched bootstrapped samples from the early and late periods generated probability distributions, approximating the odds of surgeons switching reconstructive method., Results: A total of 21,259 episodes of breast reconstruction occurred in 122 U.S. markets. The distribution of implant-to-flap ratio varied by market, ranging from the fifth percentile at 1.63 to the ninety-fifth percentile at 43.7 (median, 6.19). Modeling the implant-to-flap ratio versus implant payment showed a more elastic quadratic equation compared with the function for flap-to-implant ratio versus flap payment. Probability modeling demonstrated that switching the reconstructive method from implants to flaps with a 0.75 probability required a $1610 payment increase, whereas switching from flaps to implants at the same certainty occurred at a loss of $960., Conclusions: There was a correlation between the ratio of flaps to implants and physician reimbursement by market. Switching from implants to flaps required large surgeon payment increases. Despite a relative value unit schedule over twice as high for flaps, current flap reimbursements do not appear commensurate with physician effort.

Background: The AlloX2 Breast Tissue Expander (Sientra, Santa Barbara, Calif.) is a unique device that contains a second port to allow for transdermal communication with the pocket around the implant. The injection dome of this expander contains two ports; one is used for traditional saline injection, and a new second port facilitates fluid drainage from the periprosthetic space through an integral drain. The AlloX2 allows for the treatment of seromas and diagnostic fluid sampling to identify bacteria and hone antibiotic treatment in the setting of periprosthetic infection. This device has a significant advantage over traditional expanders, given that seromas and infections are the most common complications in implant-based breast reconstruction, with or without the use of soft-tissue support matrix., Methods: This article provides short-term case studies and surgical pearls from 3 surgeons who utilize the AlloX2 in primary breast reconstruction patients. Three surgeons implanted 40 primary reconstruction patients with AlloX2. Follow-up was approximately 6 months, per the standard of care. All patients implanted with AlloX2 underwent immediate reconstruction, with the exception of 1 delayed reconstruction., Results: The most common complications the patients experienced were seromas. In most cases, the surgeons successfully used the second port to drain periprosthetic fluid., Conclusions: The AlloX2 has been successful in treating seromas and should be considered a tool for noninvasive treatment of common complications of implant-based breast reconstruction. Three surgeons with varied backgrounds and techniques provide their surgical and postoperative management experiences and recommendations.

Background: Prosthetic breast reconstruction rates have risen in the United States, whereas autologous techniques have stagnated. Meanwhile, single-institution data demonstrate that physician payments for prosthetic reconstruction are rising, while payments for autologous techniques are unchanged. This study aims to assess payment trends and variation for tissue expander and free flap breast reconstruction., Methods: The Blue Health Intelligence database was queried from 2009 to 2013, identifying women with claims for breast reconstruction. Trends in the incidence of surgery and physician reimbursement were characterized by method and year using regression models., Results: There were 21,259 episodes of breast reconstruction, with a significant rise in tissue expander cases (incidence rate ratio, 1.09; p < 0.001) and an unchanged incidence of free flap cases (incidence rate ratio, 1.02; p = 0.222). Bilateral tissue expander cases reimbursed 1.32 times more than unilateral tissue expanders, whereas bilateral free flaps reimbursed 1.61 times more than unilateral variants. The total growth in adjusted tissue expander mean payments was 6.5 percent (from $2232 to $2378) compared with -1.8 percent (from $3858 to $3788) for free flaps. Linear modeling showed significant increases for tissue expander reimbursements only. Surgeon payments varied more for free flaps (the 25th to 75th percentile interquartile range was $2243 for free flaps versus $987 for tissue expanders)., Conclusions: The incidence of tissue expander cases and reimbursements rose over a period where the incidence of free flap cases and reimbursements plateaued. Reasons for stagnation in free flaps are unclear; however, the opportunity cost of performing this procedure may incentivize the alternative technique. Greater payment variation in autologous reconstruction suggests the opportunity for negotiation with payers.

Total scalp avulsion with severe cervical spine injury is a contraindication for emergency replantation of the scalp to its anatomical site. We describe a case involving the ectopic implantation of an avulsed scalp on the forearm. A 41-year-old woman presented with severe total scalp avulsion and tears in the intervertebral discs at the C4/5 and C5/6 levels. The avulsed scalp was ectopically implanted on the left forearm with a tissue expander to provide support. Two-stage replantation of the scalp at its anatomical site was performed 19 and 40 days later. Replantation was successful, and the avulsed tissue exhibited excellent viability. In conclusion, this case shows that the ectopic implantation of the avulsed scalp on the forearm may be an option for total scalp avulsion with cervical spine injury., (© 2016 Wiley Periodicals, Inc.)

Soft tissue coverage and tension-free closure can often be challenging in patients with ankle arthropathy being considered for total ankle arthroplasty. We present 2 patients with severe posttraumatic ankle arthropathy who underwent placement of a soft tissue expander to assist with soft tissue coverage prior to total ankle arthroplasty., Levels of Evidence: Level IV.

The landscape of breast reconstruction has changed significantly. This study assesses trends in type of reconstruction performed after mastectomy and impact on immediate postoperative complications., Methods: Data for 67,450 patients undergoing mastectomy for breast cancer were analyzed using the National Surgical Quality Improvement Program (NSQIP) database for years 2005-2014. Primary outcomes were wound, nonwound related infections, and bleeding complications. Data were analyzed by univariate and multivariate analysis., Results: The percentage of patients that underwent reconstruction after breast cancer increased from 26.94% in 2005 to 43.30% in 2014 (p < 0.01). There was increased wound (5.59%), bleeding (6.82%), and infection (1.80%) complications after flap-based reconstruction (p < 0.01). There was no difference in wound, infection, and bleeding complications between immediate implant reconstruction and tissue expander (TE) at 4.38 vs. 3.89% (p = 0.18), 0.82 vs. 0.7%, p = 0.46), and 0.76 vs. 0.64% (p = 0.45), respectively. Several independent factors were associated with increased wound complications in patients undergoing all or any forms of reconstruction after mastectomy such as being overweight (OR 1.38, CI 1.23-1.55), obese (OR 2.11, CI 1.89-2.35), morbidly obese (OR 3.84, CI 3.34-4.43), ASA Class III (OR 1.35, CI 1.08-1.69), ASA Class IV (OR 1.49, 1.06-2.10), diabetic (OR 1.28 , CI 1.14-1.43), and smokers (OR 1.76, CI 1.59-1.94). TRAM flap was associated with increased risk of wound complication (OR 1.87, CI 1.28-2.75)., Conclusion: More women are undergoing reconstruction as utilization of TE increases drastically. Immediate implant placement has only seen moderate increase likely due to surgeon preference., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Objective: To introduce a postoperative protocol to optimize the final size of the penis in patients undergoing metoidioplasty., Patients and Methods: Fourteen patients with the mean age of 29.3 years (8-40 ± 11.7), ten female transsexuals (46 xx karyotype) and four with 5-alpha-reductase deficiency syndrome (5ARDS) who had undergone extensive metoidioplasty entered a penile improvement protocol (PIP) between 2007 and 2015 at a specialized clinic in a general hospital in Tehran, Iran. Subjects were thoroughly instructed, rehearsed on the protocol and closely followed for 24 weeks. Written informed consent was obtained from all participants. We adapted a popular device, the so-called penile traction device, to accommodate the size of the neo-penis., Results: All patients achieved an increase in their penile length with a mean of 28.42 mm (21-47 ± 6.86). Two subjects developed penile bruises and edema during the protocol implementation. No significant procedural complications were detected in the remaining 12 participants., Conclusions: PIP can be an effective step in increasing the size of the neo-penis in patients who have undergone metoidioplasty. We suggest this procedure to be seriously considered in postoperative management of well-informed and motivated patients to improve the final penile length and function in this population. Larger studies are needed to further validate this protocol., Level of Evidence Ii: This journal requires that the authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Background: Tissue expansion has evolved reconstruction surgery by providing a great source of additional tissue for large skin defects. Nevertheless, wide application of tissue expander reconstruction is challenging due to high complication rates and uncertainty about final outcomes. Recently, endoscopy has shown promise in reconstructive surgeries using tissue expander placement., Aims: This study aimed to compare outcomes between open and endoscopic-assisted neck tissue expander placement in reconstruction of post-burn facial scar deformities., Methods: Through a randomized clinical trial, 63 patients with facial burn scars were assigned to an open group or endoscopic group for placement of 81 tissue expanders. The complication rate, operative time, length of hospital stay, and time to full expansion were compared between the two groups., Results: Thirty-one patients were assigned to the open group and 32 patients to the endoscopic group. The average operative time was significantly reduced in the endoscopic group compared with the open group (42.2 ± 3.6, 56.5 ± 4.5 min, p < 0.05). The complication rate was significantly lower in the endoscopic group than the open group (6 vs. 16, p < 0.05). Hospital stay was also significantly diminished from 26.3 ± 7.7 h in open group to 7.4 ± 4.5 h in endoscopic group (p < 0.0001). There was a significant reduction in time to full expansion in the endoscopic group as compared with the open group (93.5 ± 10.2 vs. 112.1 ± 14.2 days, p = 0.002)., Conclusion: Endoscopic neck tissue expander placement significantly reduced operative time, the postoperative complication rate, length of hospital stay, and time to achieve full expansion and allowed early initiation of expansion and remote placement of the port in relation to the expander pocket., Level of Evidence I: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Background: Therapeutic or prophylactic mastectomy is often indicated for women with breast cancer, or for those at a high risk of developing cancer due to familial history or genetic mutations. Favorable aesthetic and psychological results make prosthetic reconstruction of the breast with placement of tissue expanders followed by permanent implant a popular choice for women diagnosed with breast cancer. This study describes the results of the ASPIRE trial, the objective of which was to provide supportive data to demonstrate the performance and safety of the AeroForm™ System in a population with broader selection criteria than previous studies. Results of the earlier PACE clinical studies (PACE 1 and 2) demonstrated that the AeroForm™ System could be used safely and effectively to achieve the desired expansion necessary for successful breast reconstruction. In the current ASPIRE trial described in the paper, performance of the device was evaluated by successful tissue expansion and exchange to breast implant(s) unless precluded by a non-device related event. Safety data was evaluated based on reported adverse events., Methods: A prospective, single center, open-label study in which subjects who met the inclusion criteria and agreed to participate were enrolled and implanted with the AeroForm expander either at the time of mastectomy (immediate) or sometime after mastectomy (delayed). In the event of a bilateral procedure, the expander was implanted in each side. Subjects were followed until the explant of the tissue expander(s) and exchange for silicone or saline breast implant(s)., Results: Thirty-four expanders were placed in 21 subjects in the clinical trial; the average age of subjects was 49.7 ± 8.6 years with average BMI of 26.1 ± 4.7. Bilateral procedures accounted for 62% of the total and 88% of the reconstructions were completed with a latissimus dorsi flap (anterior approach) per the investigators standard procedure. Four (12%) of the cases (12%) were completed in two subjects using an inferior dermal flap. Overall success rate was 94% (32/34 breasts) with no device related reconstruction failures. Two subjects failed reconstruction, one due to infection and one due to wound healing issues, both requiring unilateral expander removal and revision surgery. However, successful second stage reconstruction was completed in both subjects in a delayed procedure., Conclusion: The ASPIRE trial reports confirmatory data in a more inclusive patient population than the previous PACE 1 and 2 trials, indicating that the AeroForm Expander, provides a time-saving, needle-free, safe and effective method of tissue expansion for breast reconstruction. There were no device related complications that precluded the subjects from achieving the study goal of a permanent implant exchange. Reported complications are similar to those reported in the literature for tissue expansion procedures. Further development may enable a single dose controller to operate both expanders in a bilateral patient and increase the size range offered with this promising technology., (Copyright © 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Background: The expectation for improved results by women undergoing postmastectomy reconstruction has steadily risen. A majority of these operations are tissue expander/implant-based breast reconstructions. Acellular dermal matrix (ADM) offers numerous advantages in these procedures. Thus far, the evidence to justify improved aesthetic outcome has solely been based on surgeon opinion. The purpose of this study was to assess aesthetic outcome following ADM use in tissue expander/implant-based breast reconstruction by a panel of blinded plastic surgeons., Methods: Mean aesthetic results of patients who underwent tissue expander/implant-based breast reconstruction with (n = 18) or without ADM (n = 20) were assessed with objective grading of preoperative and postoperative photographs by five independent blinded plastic surgeons. Absolute observed agreement as well as weighted Fleiss Kappa (κ) test statistics were calculated to assess inter-rater variability., Results: When ADM was incorporated, the overall aesthetic score was improved by an average of 12.1 %. In addition, subscale analyses revealed improvements in breast contour (35.2 %), implant placement (20.7 %), lower pole projection (16.7 %), and inframammary fold definition (13.8 %). Contour (p = 0.039), implant placement (p = 0.021), and overall aesthetic score (p = 0.022) reached statistical significance. Inter-rater reliability showed mostly moderate agreement., Conclusions: Mean aesthetic scores were higher in the ADM-assisted breast reconstruction cohort including the total aesthetic score which was statistically significant. Aesthetic outcome alone may justify the added expense of incorporating biologic mesh. Moreover, ADM has other benefits which may render it cost-effective. Larger prospective studies are needed to provide plastic surgeons with more definitive guidelines for ADM use., Level of Evidence Iv: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Background: With increasing rates of postmastectomy breast reconstruction, it has been suggested that there is an insufficient supply of services that meet patient demands. This study aimed to identify potential disparities in, and variables associated with, postmastectomy reconstruction in Japan., Methods: Using 20,257 Japanese breast cancer discharge data from 2010, the authors identified 1616 breast cancer patients, with tumor-node-metastasis classification of malignant tumors T1~4 and N0M0, between 20 and 59 years of age. Factors influencing the use of immediate breast reconstruction of either autogenous tissue or tissue expander placement were analyzed using multinomial logistic regression comparing no reconstruction to either autogenous tissue or tissue expander placement., Results: The immediate breast reconstruction rate was 11.2 percent among the study patients. The rate of autogenous method use was 49 percent and the rate of tissue expander use was 51 percent. Tissue expander placement was performed primarily in patients who resided in cities (OR, 2.4; 95 percent confidence interval, 1.5 to 4.1) and was performed at city hospitals. Patients who lived in rural areas primarily underwent autogenous tissue reconstruction, traveled to city hospitals to undergo surgery (OR, 2.0; 95 percent confidence interval, 1.0 to 4.0), and had normal body mass index (OR, 1.9; 95 percent confidence interval, 1.1 to 3.1)., Conclusions: The authors identified potential disparities associated with breast reconstruction. These disparities might be due to limited surgery methods and might have excluded some patients because of their age, physical, and economic status. Uneven distribution of plastic surgeons might have required patients to travel for breast reconstruction., Clinical Question/level of Evidence: Therapeutic, III.

Background: Choosing a breast reconstructive modality after mastectomy is a critical step involving complex decisions. The authors provide outcomes data comparing two common reconstructive modalities to assist patients and surgeons in preoperative counseling and discussions., Methods: A prospectively maintained database was queried identifying select patients undergoing expander/implant and abdominally based free flaps for breast reconstruction between 2005 and 2008. Variables evaluated included comorbidities, operations, time to reconstruction, complications, overall outcome, clinic visits, revisions, and costs., Results: One hundred forty-two patients received free flaps and 60 received expander/implants. Expander/implant patients required more procedures (p < 0.001) but had shorter overall hospital lengths of stay (p < 0.001). The two cohorts experienced a similar rate of revision (p = 0.17). Free flap patients elected to undergo nipple-areola reconstruction more frequently (p = 0.01) and were able to sooner (p < 0.0001). Patients undergoing expander/implant reconstruction had a higher rate of failure (7.3 versus 1.3 percent, p = 0.008). Free flap patients achieved a stable reconstruction significantly faster (p = 0.0005), with fewer visits (p = 0.02). Cost analysis demonstrated total cost trended toward significantly lower in the free flap cohort (p = 0.15). Reconstructive modality was the only independent factor associated with time to stable reconstruction and reconstructive failure (p < 0.001 and p = 0.05, respectively)., Conclusions: The authors' analysis revealed that free flap reconstructions required fewer procedures, had lower rates of complications and failures, had fewer clinic visits, and achieved a final, complete reconstruction faster than expander/implant reconstructions. Although autologous reconstruction is still not ideal for every patient, these findings can be used to enhance preoperative discussions when choosing a reconstructive modality., Clinical Question/level of Evidence: : Therapeutic, III.

Background: Postmastectomy breast reconstruction is offered to women with breast cancer regardless of body habitus and breast size. The decision regarding technique for breast reconstruction includes patient preference, risk factors, and physical characteristics. The purpose of this study was to determine whether there is a relationship between preoperative breast size and choice of reconstruction, choice of contralateral breast symmetry procedure, and incidence of complications., Methods: A retrospective review of 355 patients who underwent unilateral breast reconstruction at Emory University from 2005 to 2009 was performed. Patients were stratified into 3 groups based on mastectomy specimen weight with small breasts defined as less than 500 g, medium breasts as 500 to 1000 g, and large breasts as more than 1000 g. Patient demographics were queried including age and risk factors. Additional data points included type of reconstruction, contralateral procedure, and complications., Results: There were 144 patients with small breasts (40.5%), 150 with medium breasts (42.1%), and 62 with large breasts (17.4%). Women with small breasts were equally likely to undergo tissue expander (34%), latissimus dorsi flap (32%), or TRAM/DIEP flap (34%) reconstruction. Women with medium breasts were most likely to undergo TRAM/DIEP reconstruction (47%), whereas women with large breasts were most likely to undergo latissimus dorsi reconstruction (37%; P = 0.134). Small-breasted women were more likely to undergo contralateral augmentation (P < 0.0001), which varied based on the type of reconstruction. Women with medium-sized breasts were more likely to undergo mastopexy (P = 0.033), and large-breasted women were more likely to undergo reduction (P < 0.0001). Women with complications had a greater mean mastectomy weight than women without complications (744 g compared with 620 g, P = 0.0062), and there was an increasing incidence of postoperative wound infections with increasing breast size (18% of large breasts, 7% of medium breasts, and 3% of small breasts; P = 0.0003)., Conclusions: Preoperative breast size does play a role when choosing the most appropriate reconstructive option and symmetry procedure. Being able to adjust the contralateral breast, however, brings the extremes of breast size toward the middle, making most options available regardless of initial size and shape. There are noticeable trends in technique and outcome when stratified by breast size.

Purpose: The goal of this study was to explore the perspectives and practice of radiation oncologists who treat breast cancer patients who have had breast reconstruction., Methods: In 2010, an original electronic survey was sent to all physician members of the American Society of Radiation Oncology, National Cancer Research Institute-Breast Cancer Studies Group in the United Kingdom, Thai Society of Therapeutic Radiology and Oncology, Swiss Society of Radiation Oncology, and Turkish Radiation Oncology Society. We identified factors associated with radiation oncologists who treat breast cancer patients with reconstruction performed prior to radiation and obtained information regarding radiation management of the breast reconstruction., Results: 358 radiation oncologists responded, and 60% of the physicians were from the United States. While 64% of participants agree or strongly agree that breast image affects a woman's quality of life during radiation, 57% feel that reconstruction challenges their ability to deliver effective breast radiation. Compared with other countries, treatment within the United States was associated with a high reconstruction rate (>/= 50% of mastectomy patients) prior to radiation (p < 0.05). Delayed-immediate reconstruction with a temporary tissue expander was more common in the United States than in other countries (52% vs. 23%, p = 0.01). Among physicians who treat patients with tissue expanders, the majority (60%) prefer a moderately inflated implant with 150-250 cc of fluid rather than a completely deflated (13%) or inflated expander (28%) during radiation. Among radiation oncologists who treat reconstructions, 49% never use bolus and 40% never boost a breast reconstruction. United States physicians were more likely than physicians from other countries to boost or bolus the reconstruction irrespective of the type of reconstruction seen in their clinic patients (p < 0.01)., Conclusions: Great variation in practice is evident from our study of radiation treatment for breast cancer patients with reconstruction. Further research on the impact and delivery of radiation to a reconstructed breast may validate some of the observed practices, highlight the variability in treatment practice, and help create a treatment consensus.

Objectives: The repair of skin defects in the head and neck region still poses a significant problem for many clinicians. Tissue expansion is described as a treatment option providing good color, texture, and thickness match of the expanded skin. Unfortunately, the complication rates for tissue expansion range from 0 to 48 %. Therefore, the purpose of this study was to investigate risk factors for the use of tissue expanders in head and neck reconstructions., Materials and Methods: Forty-nine patients with skin deficits in the head and neck area underwent tissue expansion. Sixty-two implanted expanders were analyzed regarding the various complications and the success rate., Results: The success rate of treated patients was 37 (75.5 %) of all 49 included patients. The most frequent cause for the skin deficit was a tumor resection near the tip of the nose followed by skin deficits resulting after craniectomy. Interestingly, a higher number of expanders and a larger volume were significantly associated with a worse outcome. There was a trend of association between larger defect size and failure, too., Conclusions: The internal tissue expansion is a suitable technique for skin reconstruction in the head and face area. Compared to distant or free flaps, it often offers a better cosmetic outcome. In very large defects (>100 cm(2)) or when more than two expanders are needed, the failure rate increases. In these cases, other treatment options are recommended., Clinical Relevance: The internal tissue expansion is a suitable technique for skin reconstruction in the head and face area.

Background: This study reports the rate of breast reconstruction failure and cosmetic outcomes after postmastectomy radiation therapy (PMRT) with temporary tissue expanders (TEs) or implants in place., Patients and Methods: Ninety-four patients underwent mastectomy (93 unilateral, 1 bilateral; 95 cases total) and immediate TE reconstruction followed by PMRT. Ninety TEs and 5 permanent implants were irradiated. All patients received a dose of 5400 cGy given in 180-cGy fractions to the reconstructed breast. Twenty-one patients (22%) received tangents alone and 74 patients (78%) were treated with tangents and a supraclavicular field using a monoisocentric technique. Bolus was used in 91 patients (96%). Eighty-eight patients (93%) received chemotherapy and 78 patients (82%) received endocrine therapy., Results: With a median follow-up of 24.1 months, 19 patients (20%) experienced failure of reconstruction. The 1-, 2-, and 3-year actuarial rate of reconstruction failure was 9.7%, 19.3%, and 25.5%, respectively. Infection was the most common cause of failure. Of the 19 failures, 8 patients underwent salvage procedures with flap reconstruction. Univariate analysis was performed examining age, chemotherapy use, hormone therapy use, use of a supraclavicular field, smoking status, diabetes, hypertension, and menopausal status. No risk factors were found to be associated with reconstruction failure. In patients who did not experience reconstruction failure, good/excellent cosmesis was observed in 75% of patients., Conclusion: In the current series of women with a high risk of locoregional recurrence, PMRT with a TE/implant in place provides good cosmesis in the majority of women, with an acceptable risk of expander or implant loss., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Purpose: This study is designed to ascertain whether a regional bias exists, as well as provide a reference to those seeking the various modalities used in pre-surgical intervention for cleft lip and palate either for their own patients or educational purposes., Methods: A survey was constructed using Survey Monkey and distributed via e-mail to American Academy of Pediatric Dentistry members. Approximately 3689 surveys were delivered consisting of 12 questions asking whether they provide pre-surgical intervention to cleft lip and palate patients, and what type of interventions they use., Results: A total of 572 members responded. Of the respondents, 480 reported they treat children affected by cleft lip and/or cleft palate. Of these, only 102 reported that they provide pre-surgical treatment. Pre-surgical nasoalveolar molding (PNAM) represented 29.2 percent of the interventions used and was most heavily concentrated in Texas. Other modalities used included the Latham appliance, lip adhesion/tacking, the passive appliance, and a category 'other' was included. Those checking 'other' most often described alveolar grafting prior to later surgical procedures than were of interest in this study. The University of Texas Health Science Center San Antonio had the largest number of respondents using the PNAM., Conclusions: A very small proportion of pediatric dentists are providing pre-surgical intervention of any kind to patients with cleft lip and palate. However, those that are providing the service are spread around the country enough to consider PNAM as the standard of care for pre-surgical infant cleft treatment.

Purpose: Operative treatment of giant omphalocele (OC) is still a challenge for pediatric surgeons. We were interested to ascertain whether published operative techniques for giant OC once advocated by their authors were still being used by these authors and whether the techniques had been modified or even abandoned for other techniques., Methods: Relevant studies concerning the treatment of giant OC were identified by an electronic search. Publication date of the articles was from 1967 to 2009. A questionnaire was sent to the first author or coauthor, unless contact details were unavailable. The described surgical techniques were categorized into primary closure, staged closure, and delayed closure., Results: Almost half of the authors (42%), independent of the initial technique used (primary, staged, or delayed closure), changed or stopped using their technique after the publication of the article. The change was not to one particular proven better technique. Herniation rate was lower in delayed closure (9% delayed vs 18% staged vs 58% primary)., Conclusions: The results of the questionnaire did not show a generally accepted method of treatment after more than 30 years of innovations in managing patients with a giant OC. There are generally 2 main treatment modalities: staged closure and delayed closure. Because of the lack of large patient numbers and late follow-up, long-term results of the published techniques are needed, and randomized multicenter trials based on these outcomes are recommended. Until then, we remain dependent on expert opinions., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Background: The use of human acellular dermal matrix (HADM) materials in prosthetic-based breast reconstruction has gained popularity in recent years. Questions remain, however, regarding the nature and incidence of postoperative complications associated with this technique. The results reported in the available literature vary widely. This meta-analysis examines this question further with a broad review of the available literature in an effort to better define the true nature and incidence of near-term complications associated with the use of HADM in prosthetic-based breast reconstruction. It does not aim to compare this method of reconstruction to others., Methods: A review of the available literature was performed in July 2009. The goal was to identify all previous works describing the placement of HADM at prosthetic-based breast reconstruction. Included were studies that documented the use of HADM for coverage of tissue expanders or permanent implants following therapeutic or prophylactic mastectomy. Excluded were studies that reported on the use of HADM in cosmetic breast surgery or studies that included the use of xenografts. Data collected included demographics as well as the nature and incidence of complications, with separate categories assigned for seroma, infection, flap necrosis, and "other." Data were analyzed using Comprehensive Meta-Analysis(®) software (Biostat, Englewood, NJ). Raw proportions, fixed-effect models, and random-effect models were used to assess the complication rates across studies., Results: Eleven published articles and one abstract that was later published as an article were identified. Within these 12 studies, a total of 789 breasts were identified that had undergone reconstruction with HADM. The mean follow-up was 13.7 months. Under the random-effects model, the total complication rate was 12.0%. The most common complications were flap necrosis (3.3%), seroma (3.3%), and infection (5.6%). All complications not included in these categories were set apart in a separate category, "Other," and totaled 3.0%, Conclusion: The true incidence of postoperative complications in the near term utilizing HADM in prosthetic-based breast reconstruction appears to be approximately 12%. The incidence of long-term complications such as capsular contracture remains unknown. However, as surgical experience with HADM grows, operative techniques designed at reducing risks will mature, strategies for managing complications will advance, and more advanced products designed to reduce the incidence of complications are likely to become available.

Background/purpose: Closure of abdominal wall defects in children poses a challenge for pediatric surgeons. We describe a technique using tissue expanders placed either intraperitoneally or in the abdominal wall to aid in the reconstruction of a variety of complex abdominal wall defects., Methods: The tissue expanders are inserted under general anesthesia. Initial expansion is done in the operating room with attention to peak airway pressure, urine output, and end-tidal carbon dioxide. The expanders are inflated in the outpatient setting via percutaneous access until the calculated inflation volume is achieved. They are then removed; and definitive closure is accomplished using a combination of native tissue flaps, abdominal component separation techniques, biomaterials, and synthetic material., Results: Six children underwent tissue expansion for treatment of abdominal wall defects (omphalocele, n = 3), trauma (n = 1), and thoracopagus twins (n = 1 pair). One to 4 expanders were used per patient, with all having a successful reconstruction of their abdominal walls. Two to 3 operations were required to restore abdominal domain and consisted of expander insertion, removal with reconstruction, and possible revision of the reconstruction., Conclusions: Tissue expanders possess a broad range of applications for abdominal wall reconstruction and can be used in patients of all ages., (Copyright © 2011 Elsevier Inc. All rights reserved.)

The use of tissue expanders and implants is the simplest option for breast reconstruction following mastectomy. In the 1980s, Hilton Becker introduced a round, inflatable breast implant that could be used as a permanent implant. Since then, the original implant has been improved in both design and architecture. The new Becker device consists of an anatomical implant composed of 35% cohesive silicone gel in the outer chamber and 65% normal saline in the inner chamber. This multicenter study describes our experience with the new anatomical Becker implants in a large series of patients, in both immediate and delayed breast reconstruction. We reviewed the clinical records of 204 patients who underwent a breast reconstruction with an anatomical Becker-type implant in the sub-muscular position between November 2004 and December 2006. Data on the patients' characteristics, indications for reconstruction, operative technique, device size used, complications, and need for further operations were collected and analyzed. A total of 248 breast reconstructions were performed in 204 patients. One hundred forty-three patients (70%) underwent an immediate reconstruction; in the remaining 61 cases (30%), the breast reconstruction was performed later. The patients' age ranged from 26 to 66 years, with a median age of 47.5 years. The implant was placed unilaterally in 160 women (78.5%) and bilaterally in the remaining 44 (21.5%). Complications occurred in 85 cases (34.2%), in both the immediate and delayed reconstruction groups, and were related to wound healing, bleeding, seroma, and problems with the inflatable expanders. Iatrogenic implant rupture was documented in one case (0.4%). Inflation was impossible in 7 cases (2.8%) as a result of valve obstruction (3 cases, 1.2%) and valve displacement (4 cases, 1.6%). Implant malposition was the most troublesome complication; indeed, 34 patients (13.7%) complained of device malposition. Capsular contracture was assessed in all the patients. Significant capsular contracture (Baker grade III and IV) was detected in 6 cases (2.4%) at the follow-up approximately 1 year after surgery. Breast reconstruction with permanent inflatable expanders is widely acknowledged as a useful technique for breast cancer patients undergoing simple or modified radical mastectomy. The use of this device eliminates the need to replace a temporary tissue expander with a breast implant, thus avoiding a second operation. Although we believe autologous tissues afford the best method of reconstruction in the majority of patients, the results of our study show that expander implant placement may yield a reasonable reconstruction.

Purpose: Prior studies demonstrating the ability to lengthen intestinal segments with mechanical force required devices with extracorporeal components. The feasibility of using a completely implantable device for in vivo intestinal lengthening was evaluated in this study., Methods: Biocompatible Nitinol springs capable of 5-fold expansions were compressed using absorbable sutures and were implanted into isolated segments of proximal jejunum in rats. Springs compressed with nonabsorbable sutures served as controls. The animals were observed with serial abdominal x-rays until the springs became fully expanded. Intestinal segments were then retrieved for histologic analysis. Two-tailed and paired Student's t tests were used for statistical analysis., Results: Intestinal segments were successfully lengthened in the experimental group from 1.3 +/- 0.3 cm to 4.4 +/- 0.5 cm (P < .001). Maximum spring length was achieved on postoperative day 36 (range, 16-50 days). In the control group, there was also an increase in intestinal lengths, from 1.6 +/- 0.04 cm to 2.9 +/- 0.4 cm (P < .001) (Fig. 4). In percentages, a 250% increase in length was observed in the experimental group vs an 85% increase in the control group (P < .001). Microscopic evaluation of both control and experimental segments revealed gross preservation of intestinal architecture; however, muscular layer hypertrophy and villous atrophy were noted., Conclusions: Continuous mechanical force with an implantable spring successfully lengthened isolated segments of small bowel in an animal model. Although similar results have been demonstrated using other devices, the current device is totally implantable and may be deployed endoscopically., (Copyright 2010 Elsevier Inc. All rights reserved.)

The current approach to breast reconstruction remains largely subjective and is based on physical examination and visual-estimates of breast size. Thus, the overall success of breast reconstruction is limited by the inability of plastic surgeons to objectively assess breast volume and shape, which may result in suboptimal outcomes. A potential solution to this obstacle may be three-dimensional (3D) imaging, which can provide unique clinical data that was previously unattainable to plastic surgeons. The following study represents a prospective analysis of patient volunteers undergoing unilateral tissue expander (TE)-implant reconstruction by one of the two senior authors (MC, NSK). All patients underwent unilateral mastectomy with immediate or delayed insertion of a TE, followed by an exchange for a permanent silicone or saline implant. 3D scans were obtained during routine pre- and postoperative office visits. The 3D breast-volume calculations served as a guide for surgical management. Twelve patients have completed 3D-assisted unilateral breast reconstruction to date. These patients represent a wide range of body habitus and breast size/shape; 3D volume range from 136 to 518 cm(3). The mean baseline breast asymmetry in this group was 12.0 +/- 10.8%. Contralateral symmetry procedures were performed in eleven patients, consisting of the following: mastopexy (n = 6), augmentation (n = 1), mastopexy/augmentation (n = 2), and reduction mammoplasty (n = 2). Reconstruction was completed in a total number of 2 (n = 10) or 3 (n = 2) operations. Overall breast symmetry improved at the completion of reconstruction in the majority of patients, with an average postoperative symmetry of 95.1 +/- 4.4% (relative to 88% preoperatively). 3D imaging serves a valuable adjunct to TE-implant breast reconstruction. This technology provides volumetric data that can help guide breast reconstruction, such as in choosing the initial TE size, total volume of expansion, and final implant size/shape. 3D imaging technology also provides benefit as a method for assessing tissue expansion, the need for symmetry or revision procedures, and critically analyzing the final reconstructive outcome.

Tissue expander or permanent implant coverage in postmastectomy breast reconstruction is often challenging. Multiple authors have demonstrated the use of acellular cadaveric dermis (ACD) in nonexpansive, single-stage breast reconstruction. The literature also suggests that tissue expansion may be accomplished with ACD as well for stage reconstructions. In many cases tissue expansion is necessary to create a submuscular and subACD pocket to accommodate a subsequent permanent prosthesis. In this study we report the outcomes and complication rates of using ACD in staged breast reconstruction. We reviewed the charts of 41 patients (65 breasts) in whom ACD was used in staged reconstructions. We analysed the patients' charts and operative records to determine postoperative complication rates and results. Complication rates for wound infection, expander removal, haematoma, and seroma were: 3.1% (two of 65), 1.5% (one of 65), 1.5% (one of 65), and 4.6% (three of 65), respectively. The use of ACD in expansive postmastectomy breast reconstruction has an extremely low complication rate, results in good cosmetic outcome, and should be in the repertoire of plastic surgeons. Further follow up is needed to evaluate the long term outcomes of ACD use in postmastectomy breast reconstruction.

Introduction: Tissue expanders have long been used for reconstructing large cutaneous and fascio-cutaneous defects in children. Previous studies have examined tissue expansion for all body regions, touching upon the head and neck regions. We present a focused review of our experience with cervicofacial tissue expansion in the pediatric population., Materials and Methods: We retrospectively reviewed 89 children who underwent tissue expansion of the head and neck regions at Children's Hospital of Los Angeles. Most patients underwent multiple expander placements bringing the total expander number to 182. Indications for expansion included congenital nevus [N=39], burn scar [N=14], hemangioma/lymphangioma/arteriovenous malformation [N=11], scar due to trauma [N=10], congenital anomaly [N=5], sebaceous nevus [N=3], cutis aplasia [N=2], tumor [N=2], infection [N=2] and scleroderma [N=1]., Results: Of the 182 expanders placed, 56 had an associated complication (30.8%). The most frequent complications included exposure, infection, leakage, migration, flap necrosis, wound separation, and skull bone remodeling. Expanders placed in the neck appeared to have the highest complication rate., Conclusions: This retrospective review identified a high complication rate in pediatric cervicofacial tissue expansion, which is similar to previously published studies. Despite these findings, tissue expansion in pediatric patients should continue to remain a viable reconstructive option, however, proper patient selection; patient education and informed consent involving a discussion of the expected treatment course and risk profile should be undertaken.

The effects of chronic pressure on the mandible during skin expansion procedures have been investigated. In 19 Göttingen miniature pigs with an average age of 3 months, tissue expanders were placed s.c. in close proximity to the growing ascending ramus of the mandible on the surface of the masseter muscle. After complete filling of the expanders (100 cc) after 6 weeks, a significant transverse discrepancy could be observed compared with the contralateral side. Additionally, severe medial dislocation of the molars were noticed. Ten weeks after the removal of the implant, the occlusal disturbance still existed, deviation of the transverse mandibular diameter still reached up to -13.6 +/- 2.1%. Because only four animals were measured based on a CT investigation, further statistical analysis was not possible. Histological examination showed osteoclastic activity of the expander with consequent bone resorption and remodelling. Strict indications should be agreed for tissue expansion in the vicinity of growing bone, as, for example, when tissue expansion is applied in children.

Tissue expansion has enjoyed a wide range of applications since the technique was popularized by Radovan in 1978. A useful application of tissue expansion is in the reconstruction of the head and neck following burn injury. From July 1986 to March 1990, 25 patients underwent head and neck reconstruction for burn injury using tissue expanders. A retrospective chart review was undertaken. The average age was 24 years, and the age range was 9 months to 46 years. Fourteen males and 11 females were treated. A total of 51 expanders were placed, and the most common locations of the expanders were the cheeks, neck, and scalp. The time period from burn injury to reconstruction averaged 22.7 months. Operative time for placement of the expanders ranged from 40 to 180 minutes. The average time for full expansion was 86 days. Major complications were those that required an additional operative procedure, and included one dehiscence, one infection, and one port failure. The major complication rate was 12%. Minor complications were those that did not interrupt the expansion process or require any operative intervention. The minor complication rate was 32%, and included three cases of exposure, three cases of wound dehiscence, one seroma, and one ruptured implant. Minor complications were frequent, although when managed conservatively they did not compromise the overall outcome. Despite a major complication rate of 12%, final reconstruction was achieved in all patients. This retrospective review demonstrates that tissue expansion is a versatile adjunct in the treatment of burn injuries to the head and neck, and reconstruction in this area can be accomplished with excellent cosmetic results.

Radovan's 1982 landmark work on the clinical use of tissue expanders was felt to be a panacea for multiple reconstructive problems. We have used and probably overused tissue expanders for reconstruction of many complicated pediatric facial burn problems. This has enlightened us to some of the limitations of their use, and we have, therefore, reassessed our indications for their use. From 1984 through 1990, 52 tissue expanders were used in 37 pediatric patients for face and anterior neck burn scar resurfacing. This experience, combined with the unique problems encountered with face and neck tissue expansion, provided the groundwork for operative guidelines. The long-term effects of gravity, growth, and scarring on facial features adjacent to expanded skin led to the following principles. (1) Caution should be used in advancing expanded neck skin beyond the border of the mandible. The risk of scar widening or possible lip or eyelid ectropion needs to be considered when planning these flaps. Extreme overexpansion is necessary to advance unburned neck flaps over the mandibular border to avoid these problems. (2) After advancement or rotational flaps neck flaps to the face, vertically directed suture lines in the neck may need redirection to prevent linear contracture. This correction may be performed during the primary operation or during revisions. (3) Expanded cheek or neck skin should preferably replace burned areas, but at the same time, not violate unburned facial aesthetic units. (4) To counteract the affects of gravity, expanded cheek skin in conjunction with expanded neck skin, if unburned, may be the best choice for face or mandibular border scar replacement.(ABSTRACT TRUNCATED AT 250 WORDS)

The collaboration between oncological and plastic surgeons proved to be essential in the multifaceted treatment of the neoplasms and high-risk lesions of the breast. It guarantees psychological advantages, and improves the quality of life of the patient, who is a candidate for demolition surgery. The authors analyse the results obtained over a 7-year period, through their experiences of 98 immediate breast reconstructions performed after subcutaneous simplex, Patey or Halsted mastectomies. They assessed the validity of this approach due to the brilliant esthetic results obtained, the minimal surgical time, and the low morbidity.

We review our experience in tissue expansion in twenty-four pediatric patients. The most frequent indications for the use of tissue expanders included congenital nevi and burn scars, they were also used with success in alopecia, congenital abdominal wall defects, mammary hypoplasia and microtia. Tissue expanders were always placed subcutaneously. Both, surgery and body deformity during expansion, were well tolerated. We found complications in five cases, but only in one patient treatment was interrupted. Results were considered excellent in nineteen cases.

Breast reconstruction after mastectomy has evolved rapidly in recent years because of public awareness, patient demand, and technical advances. Various methods involving tissue expansion and flap procedures with and without prostheses are currently available. Management of the opposite breast and nipple-areola reconstruction are also options. Patients need to be in good general health to have reconstructive surgery.