• Archives of Plastic Surgery
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• v.45 no.1
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• pp.4-13
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• 2018

The evolution of breast reconstructive surgery keeps pace with the evolution of breast oncologic surgery. The reconstructive choice should always balance the optimal local control of disease and the best cosmetic result, reflecting an informed decision that is shared with the patient, who is always at the center of the decision-making process. Implant-based breast reconstruction following mastectomy represents a complex choice. In order to obtain optimal results, the following considerations are mandatory: thorough preoperative planning, a complete knowledge of the devices that are used, accurately performed surgery, and appropriate follow-up.

• Archives of Plastic Surgery
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• v.43 no.5
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• pp.424-429
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• 2016

Background The objective of this paper was to describe a novel technique for improving the maintenance of nipple projection in primary nipple reconstruction by using acellular dermal matrix as a strut in one of three different configurations, according to the method of prior breast reconstruction. The struts were designed to best fill the different types of dead spaces in nipple reconstruction depending on the breast reconstruction method. Methods A total of 50 primary nipple reconstructions were performed between May 2012 and May 2015. The prior breast reconstruction methods were latissimus dorsi (LD) flap (28 cases), transverse rectus abdominis myocutaneous (TRAM) flap (10 cases), or tissue expander/implant (12 cases). The nipple reconstruction technique involved the use of local flaps, including the C-V flap or star flap. A $1{\times}2-cm$ acellular dermal matrix was placed into the core with O-, I-, and L-shaped struts for prior LD, TRAM, and expander/implant methods, respectively. The projection of the reconstructed nipple was measured at the time of surgery and at 3, 6, and 9 months postoperatively. Results The nine-month average maintenance of nipple projection was $73.0%{\pm}9.67%$ for the LD flap group using an O-strut, $72.0%{\pm}11.53%$ for the TRAM flap group using an I-strut, and $69.0%{\pm}10.82%$ for the tissue expander/implant group using an L-strut. There were no cases of infection, wound dehiscence, or flap necrosis. Conclusions The application of an acellular dermal matrix with a different kind of strut for each of 3 breast reconstruction methods is an effective addition to current techniques for improving the maintenance of long-term projection in primary nipple reconstruction.

• Archives of Plastic Surgery
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• v.45 no.2
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• pp.180-184
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• 2018

Breast deformity, in post-burn patients, is a common problem leading to lower self-esteem and reclusive behavior that impairs quality of life. The authors present the course of treatment of an 18-year-old immigrant girl who suffered second- to third-degree burns over approximately 20% of her total body surface area in her early childhood. The second- to third-degree burns were located on her right trunk and abdomen, as well as her right shoulder, neck, and right groin area. Since it was not offered in her home country, reconstructive surgery, including microsurgical breast reconstruction, was sought abroad. Due to the lack of available skin and soft tissue, a bilateral breast reconstruction with free transverse myocutaneous gracilis flaps was offered. This case illustrates one method of using microsurgery to address post-burn breast deformities in order to alleviate psychological suffering and improve quality of life.

• Archives of Plastic Surgery
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• v.35 no.5
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• pp.533-538
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• 2008

Purpose: Sensory changes in the upper limb are complications of a mastectomy with immediate breast reconstruction with the treatment of breast cancer. The purpose of this study is to clarify whether immediate breast reconstruction worsens the sensory changes. Methods: From March 2004 to December 2005, 20 patients who had a mastectomy with immediate breast reconstruction(reconstruction group) were compared with 23 patients who had a mastectomy alone(control group). All patients had stage I or II breast cancer. The sensory changes were assessed in a blind manner by one examiner that used light touch sensation, static two-point discrimination, pain, vibration, hot and cold temperature perception. The sensory changes were identified along the sensory dermatome for diagnosing the damaged nerves. The following factors and their relationship with the sensory changes were analyzed : age, complications, and the mastectomy method. Results: There was no statistical difference in the static two-point discrimination, pain, vibration, hot and cold temperature perception between the two groups. However, the ability to recognize light touch was significantly better(p=0.045) in the reconstruction group than in the control group. The main site of sensory change was the proximal and medial portion of the upper limb in both groups. At these sites, the mean value of Semmes-Weinstein monofilament was $1.01g/mm^2$(reconstruction group 0.82, control group 1.17) and 2-point discrimination was 51.74(converted to perfect score of 100; reconstruction group 42.50, control group 59.78). The total rate of early complications was found to be significantly lower(p=0.006) in the reconstruction group than in the control group. Conclusion: These findings suggest that an immediate breast reconstructive procedure following a mastectomy is as safe as or safer than a mastectomy alone with respect to postoperative sensory changes of the ipsilateral upper limb.

• Archives of Plastic Surgery
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• v.47 no.5
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• pp.419-427
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• 2020

Background This study evaluated the Blossom system, an innovative self-filling, rate-controlled, pressure-responsive saline tissue expander (TE) system. We investigated the feasibility of utilizing this technology to facilitate implant-based and combined flap with implant-based breast reconstruction in comparison to conventional tissue expansion. Methods In this prospective, single-center, single-surgeon pilot study, participants underwent either implant-based breast reconstruction or a combination of autologous flap and implantbased breast reconstruction. Outcome measures included time to full expansion, complications, total expansion volume, and pain scores. Results Fourteen patients (TEs; n=22), were included in this study. The mean time to full expansion was 13.4 days (standard error of the mean [SEM], 1.3 days) in the combination group and 11.7 days (SEM, 1.4 days) in the implant group (P=0.78). The overall major complication rate was 4.5% (n=1). No statistically significant differences were found in the complication rate between the combination group and the implant group. The maximum patient-reported pain scores during the expansion process were low, but were significantly higher in the combination group (mean, 2.00±0.09) than in the implant group (mean, 0.29±0.25; P=0.005). Conclusions The reported average duration for conventional subcutaneous TE expansion is 79.4 days, but this pilot study using the Blossom system achieved an average expansion duration of less than 14 days in both groups. The Blossom system may accommodate single-stage breast reconstruction. The overall complication rate of this study was 4.5%, which is promising compared to the reported complication rates of two-stage breast reconstruction with TEs (20%-45%).

• Archives of Plastic Surgery
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• v.38 no.6
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• pp.803-807
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• 2011

Purpose: The safety of radiation therapy after breast reconstruction using transverse rectus abdominis myocutaneous (TRAM) flap is still being debated, and few studies exist on the outcome of irradiation after immediate TRAM breast reconstruction. Some authors presented satisfactory outcomes after adjuvant radiation therapy on reconstructed breast with pedicled TRAM flap, while others reported significant post radiation changes of the flap. Effect of radiation therapy on TRAM flap was evaluated to see whether adjuvant radiation therapy was tolerable. Methods: 1000 immediate TRAM breast reconstruction was done by a single surgeon from July, 2001 to December, 2009. Among them 105 patients required adjuvant radiation therapy because of advanced disease or locoregional recurrence. Fat necrosis, radiation fibrosis, mastectomy skin flap necrosis, need for secondary touch up procedures, patient satisfaction were evaluated. Results: The incidence of fat necrosis was 10.5% and significant radiation fibrosis occurred in only one patient. Delayed wound problem did not occur during or after irradiation. Secondary touch-up procedures were performed in 12.3%, the most common being fat graft (8.6%). Average patient satisfaction score was 8.62/10, which was not significantly different from the authors' previous report involving all the TRAM patients (8.50). Conclusion: Radiation therapy did not increase the complication rate significantly. Aesthetic result was affected but was tolerated in most cases. The fear of adjuvant radiation is not a negative factor in selecting immediate breast reconstruction with TRAM flap.

• Archives of Plastic Surgery
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• v.42 no.5
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• pp.601-607
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• 2015

Background Autologous or implant-based breast reconstruction after nipple-sparing mastectomy is increasingly preferred worldwide as a breast cancer treatment option. However, postoperative nipple-areola complex (NAC) necrosis is the most significant complication of nipple-sparing mastectomy. The purpose of our study was to identify the risk factors for NAC necrosis, and to describe the use of our skin-banking technique as a solution. Methods We reviewed cases of immediate autologous breast reconstruction after nipple-sparing mastectomy at our institution between June 2005 and January 2014. The patients' data were reviewed and the risk of NAC necrosis was analyzed based on correlations between patient variables and NAC necrosis. Moreover, data pertaining to five high-risk patients who underwent the donor skin-banking procedure were included in the analysis. Results Eighty-five patients underwent immediate autologous breast reconstruction after nipple-sparing mastectomy during the study period. Partial or total NAC necrosis occurred in 36 patients (43.4%). Univariate analysis and binary regression modeling found that body mass index, smoking history, radiation therapy, and mastectomy volume were significantly associated with NAC necrosis. Of the 36 cases of NAC necrosis, 31 were resolved with dressing changes, debridement, or skin grafting. The other five high-risk patients underwent our prophylactic skin-banking technique during breast reconstruction surgery. Conclusions NAC necrosis is common in patients with multiple risk factors. The use of the skin-banking technique in immediate autologous breast reconstruction is an attractive option for high-risk patients. Banked skin can be used in such cases without requiring additional donor tissue, with good results in terms of aesthetic and reconstructive outcomes.

• Archives of Plastic Surgery
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• v.44 no.6
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• pp.509-515
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• 2017

Background Skin flap necrosis is a common complication after mastectomy and breast reconstruction. It has been proven that nitroglycerin ointment, as a topical vasodilator, can decrease the rate of skin flap necrosis after mastectomy and breast reconstruction. However, nitroglycerin can cause several side effects, including headache, dizziness, and hypotension. The purpose of this study was to evaluate whether the application of a low dose of nitroglycerin ointment reduced the rate of skin flap necrosis in breast reconstruction after skin-sparing or nipple-sparing mastectomy. Methods A total of 73 cases of breast reconstruction after nipple-sparing and skin-sparing mastectomy at our institution from March 2012 to January 2017 were retrospectively studied. Of these patients, 52 received nitroglycerin ointment (4.5 mg) application to the skin around the nipple-areolar complex from August 2015 to January 2017, while 21 received fusidic acid ointment from March 2012 to August 2015. The number of patients who experienced necrosis of the breast skin flap was counted in both groups. Results Skin flap necrosis developed in 2 (3.8%) patients who were treated with nitroglycerin ointment and 5 (23.8%) patients who did not receive nitroglycerin ointment treatment. Patients who did not receive nitroglycerin ointment treatment had a significantly higher risk of mastectomy skin flap necrosis than patients who did (odds ratio=7.81; 95% confidence interval, 1.38 to 44.23; P=0.02). Conclusions Low-dose nitroglycerin ointment administration significantly decreased the rate of skin flap necrosis in patients who underwent breast reconstruction after skin-sparing or nipple-sparing mastectomy, without increasing the incidence of the side effects of nitroglycerin.

• Archives of Plastic Surgery
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• v.49 no.2
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• pp.158-165
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• 2022

Background Implant-based breast reconstruction has evolved tremendously in the last decades, mainly due to the development of new products and techniques that make the procedure safer and more reliable. The purpose of this study was to compare the outcomes in immediate one-stage breast reconstruction between acellular dermal matrix (ADM) and inferior dermal flap (IDF). Methods We conducted a retrospective comparative study of patients submitted to immediate breast reconstructions with an anatomical implant and ADM or IDF in a single center between 2016 and 2018. Outcomes evaluated included major complications, early complications, reinterventions, readmissions, and reconstruction failure. Simple descriptive statistics and univariate analysis were performed. Results A total of 118 breast reconstructions (85 patients) were included in the analysis. Patients in the IDF group had a higher body mass index (median = 27.0) than patients in the ADM group (median = 24). There were no statistically significant differences among both groups regarding immediate major complication, early complications, readmissions, and reinterventions. Conclusion There are no significant differences in complications between the ADM and IDF approach to immediate implant breast reconstruction. In patients with higher body mass index and large, ptotic breasts, we recommend an immediate implant reconstruction with IDF.

• Archives of Plastic Surgery
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• v.47 no.1
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• pp.33-41
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• 2020

Background Closed-suction drains are widely used in expander-based breast reconstruction. These drains are typically removed using a volume-based criterion. The drainage volume affects the hospital stay length and the recovery time. However, few studies have analyzed the factors that influence drainage volume after expander-based breast reconstruction. Methods We retrospectively analyzed data regarding daily drainage from patients who underwent expander-based breast reconstruction between April 2014 and January 2018 (159 patients, 176 expanders). Patient and operative factors were analyzed regarding their influence on total drainage volume and drain placement duration using univariate and multivariate analyses and analysis of variance. Results The mean total drainage volume was 1,210.77±611.44 mL. Univariate analysis showed correlations between total drainage volume and age (B=19.825, P<0.001), body weight (B=17.758, P<0.001), body mass index (B=51.817, P<0.001), and specimen weight (B=1.590, P<0.001). Diabetes history (P<0.001), expander type (P<0.001), and the surgical instrument used (P<0.001) also strongly influenced total drainage. The acellular dermal matrix type used did not affect total drainage (P=0.626). In the multivariate analysis, age (B=11.907, P=0.004), specimen weight (B=0.927, P<0.001), and expander type (B=593.728, P<0.001) were significant predictors of total drainage. Conclusions Our findings suggest that the total drainage and the duration of drain placement needed after expander-based breast reconstruction can be predicted using preoperative and intraoperative data. Patient age, specimen weight, and expander type are important predictors of drainage volume. Older patients, heavier specimens, and use of the Mentor rather than the Allergan expander corresponded to a greater total drainage volume and a longer duration of drain placement.