Effect of Enhanced Recovery After Surgery in Morbidly Obese Patients Undergoing Free Flap Breast Reconstruction.

Background: Enhanced Recovery After Surgery (ERAS) pathways have been widely implemented across many surgical practices, including autologous breast reconstruction. However, the benefits of ERAS in the morbidly obese population have yet to be defined.

Methods: A retrospective chart review of patients undergoing deep inferior epigastric artery perforator (DIEP) flap breast reconstruction at our institution from 2017 to 2022 was performed.

The Financial Impact of a Co-Surgeon in Breast Microsurgery.

Introduction: Co-surgeon approaches for autologous breast reconstruction have demonstrated improvements in operative efficiency. The health system financial impact, however, warrants further investigation.

Methods: Retrospective review of consecutive autologous reconstructions between 2017-2022.

Prepectoral Breast Reconstruction Prompts Revisiting the Anatomical Boundaries of the Breast: A Radiographic and Cadaveric Study.

Background: This study aimed to determine the location of superficial fascial system condensations in relation to classic anatomical breast boundaries. Cadaveric studies have provided some understanding, but knowledge about the precise location of these condensations remains limited.

Methods: Preoperative breast magnetic resonance imaging (MRI) was conducted to assess the fascial condensations defining the breast footprint relative to landmarks such as the latissimus, clavicle, sternal border, and inframammary fold.

Effectiveness of Liposomal Bupivacaine Transversus Abdominis Plane Block in DIEP Flap Breast Reconstruction: A Randomized Controlled Trial.

Background: Transversus abdominis plane (TAP) blocks improve pain control and reduce narcotic medication requirements in various surgical procedures. Liposomal bupivacaine may provide more sustained analgesia. This study compared pain-related outcomes between standard bupivacaine and liposomal bupivacaine TAP blocks after autologous breast reconstruction.

Oncoplastic breast reduction surgery decreases rates of reoperation with no increased medical risk.

The purpose of this study is to compare the oncologic, medical, and surgical outcomes of lumpectomy versus oncoplastic breast reduction surgery (OBRS) on a national scale. A national insurance-based database was queried for patients who had a lumpectomy with or without a same-day breast reduction by Current Procedural Terminology (CPT) codes. Patients were then matched by obesity, body mass index range, age, region, neoadjuvant chemotherapy, and outcomes were compared.

Use of Acellular Biologic Matrix Envelope for Cardiac Implantable Electronic Device Placement to Correct Migration into Submuscular Breast Implant Pocket.

Breast implants whether used for cosmetic or reconstructive purposes can be placed in pockets either above or below the pectoralis major muscle, depending on clinical circumstances such as subcutaneous tissue volume, history of radiation, and patient preference. Likewise, cardiac implantable electronic devices (CIEDs) can be placed above or below the pectoralis major muscle. When a patient has both devices, knowledge of the pocket location is important for procedural planning and for durability of device placement and performance.

The State of Breast Cancer Reconstruction in Virginia: An Evidence-Based Framework for Identifying Locoregional Health Disparities.

Background: Age, race, socioeconomic status, and proximity to plastic surgeons have been shown to impact receipt of reconstruction after mastectomy in several national studies. Given that targeted outreach efforts and programs to address these discrepancies would occur locoregionally, investigation of these reconstructive trends on a state level is warranted.

Study Design: Patients diagnosed with breast cancer in Virginia between 2000 and 2018 were identified in the Virginia Department of Health Cancer Registry.

Intraoperative Fluorescence Angiography in Implant-Based Breast Reconstruction: Identifying Risk Factors and Outcomes.

Background: Intraoperative fluorescence angiography (FA) has been described as a useful adjunct to physical examination in predicting mastectomy skin flap viability for immediate breast reconstruction. Its use has been described as a screening tool for mastectomy skin flap viability as well as a test used only for patients at high risk for mastectomy skin flap loss. We performed a national database review of implant-based breast reconstruction surgeries to determine the practice patterns of FA in this patient cohort and to determine if this technology impacted clinical outcomes.

Acellular Dermal Matrix Favorably Modulates the Healing Response after Surgery.

When first described for breast reconstruction, the presence of acellular dermal matrices was associated with increased seroma formation and infection. However, clinical safety data have gradually improved with surgeon experience to an acceptable outcomes profile of acellular dermal matrix-assisted reconstruction when compared to submuscular implant coverage. In fact, acellular dermal matrix use potentially decreases capsular contracture rates and facilitates expansion for staged prepectoral breast reconstruction.

Immunomodulation of Acellular Dermal Matrix Through Interleukin 4 Enhances Vascular Infiltration.

Background: Acellular dermal matrix (ADM) supported implant-based reconstruction remains the most commonly performed mode of reconstruction after breast cancer. Acellular dermal matrix clinical usage has reported benefits but requires rapid and efficient vascular and cellular incorporation into the recipient to have the best outcomes. Orderly transition from M1 to M2 macrophage phenotypic profile, coordinated in part by interleukin 4 (IL-4), is an important component of vascular stabilization and remodeling.

Understanding the Evidence and Improving Outcomes with Implant-Based Prepectoral Breast Reconstruction.

Learning Objectives: After studying this article, the participant should be able to: 1. Describe the risks, benefits, and safety profile of prepectoral breast reconstruction. 2.

Systemic Fibrocyte Levels and Keloid Expression of the Chemoattractant CXCL12 Are Upregulated Compared With Patients With Normal Scar.

Background: Fibrocytes are bone marrow mesenchymal precursors with a surface phenotype compatible with leukocytes, fibroblasts, and hematopoietic progenitors that have been shown to traffic to wound healing sites in response to described chemokine pathways. Keloids are focal fibrotic responses to cutaneous trauma characterized by disordered collagen, which may be associated with elevated systemic fibrocyte levels and/or wound bed chemokine expression.

Methods: Blood specimens from patients with longstanding keloids and those who form grossly normal scars were assayed by fluorescence activated cell sorting analysis for fibrocytes (CD45+, Col I+).

Safety Profile and Predictors of Aesthetic Outcomes After Prepectoral Breast Reconstruction With Meshed Acellular Dermal Matrix.

Introduction: Prepectoral acellular dermal matrix (ADM)-assisted breast reconstruction has demonstrated improved pain scores, faster return to full range of motion, and an appropriate postoperative safety profile when compared with cohorts with submuscular implant placement; however, there are limited data on aesthetic outcomes. Basic science biointegration research has previously demonstrated faster ADM incorporation with fenestrated compared with confluent ADM. We report the safety profile of anterior support meshed ADM prepectoral breast reconstruction and analyze predictive factors for aesthetic outcomes after gel implant placement.

The Biointegration of a Porcine Acellular Dermal Matrix in a Novel Radiated Breast Reconstruction Model.

Background: Ideal acellular dermal matrices (ADM) for breast reconstruction exhibit native extracellular matrix (ECM) structure to allow rapid biointegration and appropriate mechanical properties for desired clinical outcomes. In a novel in vivo model of irradiated breast reconstruction, we describe the cellular and vascular ingrowth of Artia, a porcine product chemically prepared to mimic the biomechanics of human ADM, with retained natural ECM structure to encourage cellular ingrowth.

Methods: Utilizing the murine dorsal skinfold model, Artia was implanted into 16 C57bl/6 mice.

The Performance of Patient-Worn Actigraphy Devices to Measure Recovery after Breast Reconstruction.

Introduction: Annually, over 250,000 women are diagnosed with breast cancer with over one-third undergoing mastectomy and contemplating reconstruction. Surgical breast reconstructive options vary in post-operative recovery, yet with a paucity of objective data to inform women of their expected recovery after flap or implant-based reconstruction. As a result, patient decision-making is based primarily on surgeon preference and subjective data regarding perceived invasiveness of surgical options.

Complex Reconstruction of a Pelvic Marjolin's Ulcer Arising from Hidradenitis Suppurativa.

The chronic inflammation of hidradenitis suppurativa can cause painful nodules, draining abscesses, sinus tracts, and fibrous scars. This long-term cutaneous inflammation in rare circumstances can lead to malignant transformation producing an aggressive cutaneous malignancy referred to as a Marjolin's ulcer. Particularly when a Marjolin's ulcer involves the sacral region, resection and reconstruction can be challenging.

Fenestration Improves Acellular Dermal Matrix Biointegration: An Investigation of Revascularization with Photoacoustic Microscopy.

Background: Acellular dermal matrices have revolutionized alloplastic breast reconstruction. Furthering our knowledge of their biointegration will allow for improved design of these biomaterials. The ideal acellular dermal matrix for breast reconstruction would provide durable soft-tissue augmentation while undergoing rapid biointegration to promote physiologic elasticity and reduced infectious complications.

Prepectoral Wise-Pattern Staged Implant-Based Breast Reconstruction for Obese or Ptotic Patients.

Introduction: The obese or ptotic breast demonstrates significant difficulty in breast reconstruction after mastectomy with increased rates of perioperative complications compared with the general population, regardless of reconstruction type. Implant-based reconstruction in this patient population with the traditional horizontal elliptical skin-sparing mastectomy tends to have aesthetically displeasing qualities secondary to skin flap redundancy and blunting of the breast contour. Wise-pattern closures have been described with submuscular direct-to-implant and 2-stage reconstructions, with more favorable complication profile when staged.

Early Functional Outcomes After Prepectoral Breast Reconstruction: A Case-Matched Cohort Study.

Introduction: Staged, tissue expander-based implant reconstruction continues to be the most common mode of breast reconstruction after mastectomy and has evolved significantly for the past 60 years. Prepectoral acellular dermal matrix (ADM)-assisted breast reconstruction is gaining popularity with complication rates similar to total submuscular and ADM-assisted partially submuscular reconstruction. Ours is among the first reports comparing postoperative pain and early functional outcomes between 2-stage ADM-assisted prepectoral and partial submuscular breast reconstruction.

The Role of Triple-Antibiotic Saline Irrigation in Breast Implant Surgery.

Implant-based breast reconstruction accounts for more than 70% of all breast reconstructions, and breast augmentation is the most commonly performed cosmetic operation annually. The clinically significant impact of infection and capsular contracture after breast implant surgery has brought clinicians to create infection reduction protocols for both oncologic and cosmetic operations alike. The use of triple-antibiotic saline irrigation has become a recommended intraoperative maneuver within these protocols to minimize surgical site infections, but the constituents of the irrigation, its individual efficacy, and the acceptability of including povidone-iodine within irrigation recipes have been debated.

Combined Gluteus and Pudendal Thigh Flap Reconstruction of Vaginal Defects following Robotic Abdominoperineal Resection.

Low-lying rectal cancers are being treated more frequently with robotic-assisted abdominoperineal resection, obviating the need for laparotomy and the ability to raise vertical rectus abdominis musculocutaneous flaps. For female patients, posterior vaginectomy often accompanies the resection. Combined pudendal thigh flaps as an extension of bilateral gluteus advancement flaps allow for posterior vaginal resurfacing with thin pliable fasciocutaneous flaps, which rest on the gluteal flap soft-tissue bulk that obliterates the pelvic dead space.

Arteriogenesis in murine adipose tissue is contingent on CD68 /CD206 macrophages.

Objective: The surgical transfer of skin, fat, and/or muscle from a donor site to a recipient site within the same patient is a widely performed procedure in reconstructive surgeries. A surgical pretreatment strategy that is intended to increase perfusion in the flap, termed "flap delay," is a commonly employed technique by plastic surgeons prior to flap transplantation. Here, we explored whether CD68 /CD206 macrophages are required for arteriogenesis within the flap by performing gain-of-function and loss-of-function studies in a previously published flap delay murine model.

Tissue Monitoring with Three-Wavelength Light Emitting Diode-Based Near-Infrared Spectroscopy.

 Flap monitoring with near-infrared spectroscopy (NIRS) facilitates early detection of vascular compromise. However, standard NIRS devices that employ two wavelengths of light to assess tissue oxygenation (StO) are susceptible to artifact from background noise and demonstrate significant variability in the clinical setting. As the number of wavelengths detected by a NIRS device is increased, the precision of StO measurements can be improved and additional chromophores other than oxyhemoglobin and deoxyhemoglobin can be measured.

Reducing Infectious Complications in Implant Based Breast Reconstruction: Impact of Early Expansion and Prolonged Drain Use.

Introduction: The most common modality of breast reconstruction continues to be implant based, with infection being the most significant complication. Risk factors including radiation, obesity, and smoking have been associated with infection and other surgical complications. We hypothesized that prolonged drain use may likewise be associated with postoperative complications, particularly infection, and that early postoperative expansion may allow for earlier drain removal and improved outcomes.