Acellular Dermal Matrix Research Articles

ThP1.9 - Seroma in Pre-pectoral Acellular Dermal Matrix-based procedures

Abstract Aims Pre-pectoral reconstruction has gained popularity in recent years and is now considered to be the preferred technique in immediate breast reconstruction. This is done with silicone implants and various synthetic, biological acellular dermal matrix (ADM). Seroma is a well-recognized issue after these IBRs with a wide range of reported incidence (iBAG study). This study reviews incidence and management after Pre-pectoral IBRs with the use of one such porcine ADM (Braxon®). Methods A retrospective audit from a single institution, single surgeon prospectively kept data. The data concerning seroma and its effective management was audited in this study. Results Over an eight-year period, a total of 74 patients with 86 procedures (12 bilateral) were analysed. The mean age was 52.6 and BMI 23.5. Reconstruction was carried out in 89.1% for malignancy, 9.4% had prophylactic surgery and 5.4% had revisions (Subpectoral to Pre-pectoral) for animation. All patients had drains in situ for a mean duration of 7 days. Seroma was seen in 15%(11 patients) of patients but only 18%(2patients) needed intervention in terms of aspiration and/or re-exploration. The authors’ indications for seroma aspiration were based on an algorithm (clinical signs of progression of seroma, skin changes along with signs of poor integration rather than US findings alone) Conclusions From the audit, we could conclude that the formation of seroma is common after ADM and pre-pectoral implant-based IBR but careful monitoring and selective use of aspiration can be practiced thereby minimizing the risk of infection and implant loss as a result of intervention.

Evaluation of Tibiofemoral Contact Mechanics After a Novel Hybrid Procedure for Femoral Osteochondral Defect Repairs With a Subchondral Implant and Dermal Matrix.

There is a lack of procedures that adequately address the subchondral bone structure and function for reconstructing osteochondral defects in the femoral condyles. To biomechanically evaluate the tibiofemoral joint contact characteristics before and after reconstruction of femoral condylar osteochondral defects using a novel hybrid reconstructive procedure, which was hypothesized to restore the contact characteristics to the intact condition. Controlled laboratory study. Tibiofemoral contact areas, contact forces, and mean contact pressures were measured in 8 cadaveric knees (mean age 52 ± 11 years; 6 women, 2 men) using a custom testing system and pressure mapping sensors. Five conditions were tested for each condyle: intact, 8-mm defect, 8-mm repair, 10-mm defect, and 10-mm repair. Medial femoral condylar defects were evaluated at 30° of knee flexion and lateral condylar defects were evaluated at 60° of knee flexion, with compressive loads of 50, 100, and 150 N. The defects were reconstructed with a titanium fenestrated threaded implant countersunk in the subchondral bone and an acellular dermal matrix allograft. Repeated-measures analysis of variance with Bonferroni correction for multiple comparisons was used to compare the results between the 5 testing conditions at each load. Medial condylar defects significantly increased mean contact pressure on the lateral side (P < .042), which was restored to the intact levels with repair. The lateral condylar defect decreased the mean contact pressure laterally while increasing the mean pressure medially. The lateral and medial mean contact pressures were restored to intact levels with the 8-mm lateral condylar defect repair. The medial mean contact pressure was restored to intact levels with the 10-mm lateral condylar defect repair. The lateral mean contact pressure decreased compared with the intact state with the lateral condylar 10-mm defect repair. Tibiofemoral joint contact pressure was restored to the intact condition after reconstruction of osteochondral defects with dermal allograft matrix and subchondral implants for the repair of both 8- and 10-mm lateral condylar defects as well as 8-mm medial condylar defects but not completely for 10-mm medial condylar defects. The novel hybrid procedure for osteochondral defect repair restored tibiofemoral joint contact characteristics to normal in a cadaveric model.

Early post-operative outcome of pre-pectoral implant-based immediate total breast reconstruction with Polyglactin 910 (Vicryl™) mesh – low cost solution for a low-middle income country

BackgroundThe incidence of breast cancer in Pakistan has been rising with approximately one third of these patients requiring mastectomy. Among breast reconstruction treatment options, the use of Acellular Dermal Matrix (ADM) for pre-pectoral breast implant surgery has proven effective with improved cosmetic outcome. However, due to high cost it cannot be regularly implemented in a developing country like Pakistan. An alternative to ADM, Polyglactin 910 (Vicryl™, Ethicon) mesh has been introduced in pre-pectoral breast reconstructive surgery which has shown to be almost 10 times lower in cost. We set out to determine the frequency of early postoperative complications when using Polyglactin 910 mesh for pre-pectoral implant-based breast reconstruction surgery.MethodsA single centre, retrospective, chart review was conducted, and a total 28 women were included in the study. Thirty-two pre-pectoral implant-based mastectomies with Polyglactin 910 mesh were performed. Early post-operative outcomes (within 12 months of procedure) including duration of antibiotic use, post-operative infection, implant displacement, flap necrosis, seroma formation, wound dehiscence, hematoma formation, capsular contracture and reconstruction failure, were recorded.ResultsOnly 4 (12.5%) women experienced early post-operative morbidity. One patient developed a wound dehiscence, which eventually led to reconstruction failure and removal of the implant. Another patient had seroma formation and flap necrosis. None of the patients developed postoperative implant displacement, hematoma formation or capsular contracture in the early post-operative period.ConclusionThis study reveals that early post-operative outcomes with Polyglactin 910 mesh in breast reconstructive surgery are few, thus making it a cost effective, reliable, and safe treatment option, especially in developing countries like Pakistan.

Prediction model for intraoperative implant volume using the 3D surface imaging system (VECTRA XT 3D) in direct-to-implant breast reconstructions.

In direct-to-implant breast reconstruction, accurate preoperative breast volume estimation is crucial for surgeons to select the appropriate implant volume, considering the cosmetic outcomes during surgery. We proposed the prediction model for intraoperative implant volume based on the preoperative estimated volume of the contralateral breast obtained through a three-dimensional surface imaging system (3DSI) as surgeons usually choose the implant volume on the breast which should be reconstructed considering symmetricity with the contralateral breast. We enrolled 97 patients from our single institution who underwent unilateral mastectomy with immediate breast reconstruction using smooth silicone implants between October 2021 and January 2023. Preoperatively, plastic surgeons measured the volume of the contralateral breast using the VECTRA XT 3D imaging system. Data on implant volume and the types of acellular dermal matrix used during surgery, determined by a single surgeon to ensure symmetry, were also collected. Linear regression analysis was utilized to construct the predictive model. In the multiple linear regression analysis with preoperative contralateral breast volume, age, and body mass index as variables, the coefficient of determination of the model expressed as R squared (R2) was 0.554, and except for age, the other variables were statistically significant. When replaced by mastectomy volume instead of age, R2 increased to 0.723 and all variables were significant. 3DSI can be helpful for preoperative surgical planning and postoperative outcome simulation. With our multiple linear regression model, we can predict the intraoperative implant volume using preoperative contralateral breast volume measured by the 3D scans.

Combined use of composite mesh and acellular dermal matrix graft for abdominal wall repair following tumour resection

BackgroundSurgeries for sarcomas in the abdominal wall require wide resections, often radical en bloc resections, which generate major defects involving a very complex repair. The combined use of porcine dermal xenografts, together with composite meshes, may assist in the repair of these defects with minimal complications.MethodWe present a series of 19 patients (10 males and 9 females), with a mean age of 53.2 years (range: 11–86 years) treated in the Sarcoma Unit of the Virgen de la Arrixaca University Hospital from January 2015 to December 2021. Histopathologically, there were four chondrosarcomas (21%), three Ewing sarcomas (15.7%), two desmoid tumours (10.5%), two undifferentiated pleomorphic sarcomas (10.5%), two well-differentiated liposarcomas (10.5%), two leiomyosarcomas (10.5%), one synovial sarcoma, one dermatofibrosarcoma protuberans, one fibromyxoid sarcoma (or Evans tumour), and one metastasis from an adenocarcinoma of unknown origin. All the patients were resected following surgical oncology principles and reconstructed by means of the combined use of a composite mesh acting as a neoperitoneum and a porcine dermal xenograft acting as an abdominal neofascia.ResultsThe mean size of the defects generated after surgery for tumour excision was 262.8 cm2 (range: 150–600 cm2). After a mean follow-up of 38 months, six patients (31.5%) developed complications—two cases of wound dehiscence, one case of surgical wound infection, one case of graft partial necrosis, one case of anastomotic leak and one death due to multiorgan failure secondary to massive bronchoaspiration.ConclusionSurgeries for sarcomas of the abdominal wall require wide oncological resections, which generate major abdominal wall defects. The repair of these defects by means of the combined use of synthetic and biological meshes is a technique associated with minimal complications and excellent medium-term results.

Surgical correction of facial bone deformity and enophthalmos after tripod fracture using an acellular dermal matrix: a case report.

This paper presents a novel approach to the correction of zygomatic malposition and secondary reconstruction orbital floor fractures, highlighting the use of hydrated acellular dermal matrix (ADM), specifically CGDerm One-Step, in a case where traditional solid implants failed to maintain structural integrity and volume. A 27-year-old woman with persistent facial deformities following a traumatic incident underwent a transformative procedure that utilized ADM for volume correction and structural support, addressing significant challenges such as enophthalmos and facial contour depression. This approach was necessitated by the descent of the entire orbital floor and a previously placed implant (Medpor), leading to unsatisfactory volume correction. By integrating ADM with titanium-reinforced fan plates (Synpor), the surgery successfully restored the patient's facial symmetry and addressed her functional concerns, including diplopia and limited eye movement. Postoperative evaluations demonstrated the long-term effectiveness of this method, with significant improvements in facial contour and eye symmetry. Our findings suggest that ADM, particularly in its hydrated form, offers a reliable alternative to traditional bone grafts and implants for correcting complex craniofacial deformities, providing both aesthetic and functional benefits. This case underscores the importance of adaptable, tissue-mimicking materials in facial reconstructive surgery, offering insights into their potential for broader application in post-traumatic facial corrections.

Use of Integra dermal regeneration template in burn patients: An Italian expert consensus Delphi study

IntroductionBurn injuries pose significant challenges in healthcare, with Integra dermal regeneration template (DRT) emerging as a prominent solution to enhance wound healing and recovery. Although there is no clear consensus on its technical use and application. We convened a panel of 14 burn specialists aiming to provide consensus regarding the application and usage of Integra in managing burn wounds. MethodsPanelists employed a modified Delphi technique to assess agreement and provide feedback on 81 initial statements covering various aspects of Integra DRT application in burn wound care over three subsequent rounds. This study was endorsed by the Italian Society of Burn Surgery (SIUST). ResultsFourteen heads of burn unit departments participated in the Delphi process. At the end of the third round and subsequent discussion on the final statement list, the panel achieved consensus on 24 statements shaping recommendations for Integra application across various aspects, including wound bed preparation, acellular dermal matrix application, definitive coverage, and complication management. ConclusionThe resultant 24 finalized statements from this Italian consensus offer a comprehensive and practical framework for employing Integra DRT in burn patient care. Reflective of specific Italian expertise and practice, these recommendations supplement and refine existing literature, serving as a dynamic guide subject to periodic updates aligned with evolving evidence and experience in the field of burn surgery.

Expanded Polytetrafluoroethylene Combined with Human Acellular Dermis Matrix for the Nasal Reconstruction in Patients with Postoperative Deformities.

Augmentation rhinoplasty is one of five aesthetic surgeries in the world. Expanded polytetrafluoroethylene (ePTFE) has been reported as a rational choice to augment the nasal dorsum and tip. However, its application for nasal tip augmentation has some debates. This study presented a technique using ePTFE grafts combined with human acellular dermis matrix (HADM) to reconstruct a deformed nose caused by previous rhinoplasties. 50 female patients who came to the hospital from 08/2022 to 09/2022 for surgical revision of their nasal deformity. ePTFE was applied to reconstruct the nasal dorsum, tip, and columella strut. HADM grafts were utilized to reinforce the reconstructed framework. Patients were evaluated for at least 12 months for both aesthetic and functional results. Postoperatively, the nasal dorsal length increased from 38.9 ± 1.32 to 43.4 ± 1.22 mm; while, the projection of the nasal tip also raised from 19.8 ± 1.16 to 23.9 ± 1.05 mm. 38 patients (76%) reported that their breathing and smelling were improved compared to preoperatively. No cases had implant reactions, extrusion, or warping columella strut. Most of the patients (84%) were satisfied with the surgical outcomes. Three patients (6%) had redness at the nasal tip. The nasal tip of ten patients (20%) was hardened for 3 months postoperatively. There were 6% of patients who developed an infection and 2% of patients had asymmetric soft tissues of the tip 3 postoperative months. This technique brought satisfactory aesthetic and functional results to patients, with no extrusion or rejection observed 12 months postoperatively. Infection was a prominent complication that should be considered and strictly monitored. 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 Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Immediate Prepectoral Tissue Expander Breast Reconstruction Without Acellular Dermal Matrix Is Equally Safe Following Skin-Sparing and Nipple-Sparing Mastectomy.

Prepectoral breast reconstruction has become increasingly popular over the last decade. There is a paucity of data surrounding the impact of mastectomy type on clinical outcomes when comparing prepectoral immediate breast reconstruction without acellular dermal matrix (ADM) using tissue expansion. The purpose of this study was to compare 90-day reconstructive surgical outcomes in immediate prepectoral tissue expander reconstruction between patients with nipple-sparing mastectomy (NSM) and skin-sparing mastectomy (SSM). A retrospective review of patient records was carried out on all patients undergoing NSM or SSM with immediate prepectoral tissue expander reconstruction without ADM, in a single institution, from June 2020 to December 2021. All complications were recorded, categorized, and statistically analyzed for significance. Seventy-nine patients (97 breasts) were studied. The mean age was 51 years old (range, 31-77). Twenty-two patients suffered complications recorded in 22 breasts (22.7%). There was no statistically significant difference in the total complications between the NSM (25.7%) and SSM (21.0%) groups or in the incidence of all major and minor complications. Breast reconstruction using tissue expanders without ADM has similar reconstructive outcomes in both NSM and SSM. There were no significant differences in complication rates between either groups. Breast reconstruction without ADM can confer institutional cost savings without compromising safety.

Tannic acid-modified acellular dermal matrix dressings for promoting full-thickness wound healing

Wound healing is a significant clinical and public health concern, and wound dressings are currently the primary method for addressing it. This study aimed to develop a multifunctional, all-natural wound dressing with antibacterial and anti-inflammatory properties using porcine acellular dermal matrix (PADM), a bioderived material that closely resembles the structure of human skin. The cells were decellularized using hypertonic salt and strong alkaline to remove immunogenicity while retaining the extracellular matrix. Subsequently, the wound dressing was prepared through tannic acid modification. In vitro cytotoxicity, scratch, anti-inflammatory, and antibacterial tests were used to assess the multifunctionality of the biomaterials. A full-thickness skin defect wound was created in rats, and the wound healing was analyzed using gross and histological staining. The results indicated that tannic acid-modified acellular dermal matrix exhibits favorable mechanical properties and biocompatibility. In vitro experiments demonstrated its effective inhibition of the growth of Gram-negative Escherichia coli and Gram-positive Staphylococcus aureus. It can downregulate nitric oxide (NO) production and the expression levels of pro-inflammatory factors in macrophages stimulated by lipopolysaccharide. In vitro experiments demonstrated that the dressing can enhance wound healing. Therefore, tannic acid-modified acellular dermal matrix accelerates wound healing through anti-inflammatory and antibacterial effects. Its excellent properties make it a potential biological material for promoting wound healing.

Safety Profile Comparison of 2 Smooth Tissue Expander Types: Artoura and CPX4.

With the recent transition to smooth tissue expanders (TEs), functional differences between TE subtypes have not been fully elucidated. This study evaluated the differences in TE characteristics and complications between 2 commonly used Mentor smooth TE models, Artoura and CPX4. A retrospective review of patients who received either smooth Mentor Artoura or CPX4 TE from 2012 to 2022 was conducted. Demographic data, perioperative information, pain scores, TE variables, cancer characteristics, and complications were collected. A multivariate analysis was used to evaluate the relationship between TE subtype and complications while controlling for demographic, TE characteristics, radiation, and chemotherapy exposure. During the study period, 62 smooth Artoura TEs and 79 smooth CPX4 TEs were used. Patients who received CPX4 smooth implants tended to be older (51.09 vs 46.18 years old, P = 0.02) and have a higher body mass index (28.66 vs 23.50 kg/m 2 , P < 0.001). There were no differences among patient comorbidities. CPX4 required on average a greater total fill volume (422.23 vs 348.07 mL, P = 0.01) and had a greater drain duration (16.91 vs 14.33 days, P = 0.05). There were no differences in TE plane placement between Artoura and CPX4. Additionally, there were no differences in complication rates, including infection, hematomas, seromas, wound breakdown, TE replacement, and capsular contracture. When controlling for body mass index, diabetes, TE plane placement, acellular dermal matrix use, radiation exposure, and chemotherapy, there was no association between TE subtype and any individual complication. Differences in total fill volume and drain duration were significantly different between Mentor Artoura and CPX4 implants, which may influence TE subtype selection. However, Artoura and CPX4 have excellent and equivalent safety profiles with similar complication rates, even when controlling for demographic and TE characteristics.

Subareolar Sealant Reduces Minor Complications and Surgery for Necrosis in Prosthetic Reconstruction after Nipple-sparing Mastectomy.

Nipple-sparing mastectomy (NSM) is aesthetically superior to skin-sparing only mastectomy or reconstructed nipples. However, nipple-sparing mastectomy partially preserves nipple ducts, which are remaining communications between the environment and breast pocket that can potentially allow bacteria transfer and compromise the prosthesis. Previous methods to create a subareolar "barrier" to reduce through-duct bacteria penetration involve subpectoral implant placement, adjunct meshes or acellular dermal matrix, and external nipple adhesives. To further protect the implant from nipple-derived contamination, we propose subareolar sealant (SAS). SAS involves the application of a synthetic sealant on the nipple undersurface before implant placement. In our study, we analyzed 77 breasts that received prepectoral prosthetic breast reconstruction. SAS was used in 70 of 77 breasts. All breasts received adjunctive acellular dermal matrix. Comparing SAS versus no-SAS, we found that no-SAS was associated with 10.4-fold more infections (P = 0.032) and 17.3-fold more re-hospitalizations (P = 0.017). No-SAS also resulted in more "at least one major complication" (P < 0.001), capsular contracture (P < 0.001), and necrosis requiring surgery (P < 0.001). Due to the small no-SAS sample size, goodness-of-fit (Quasi-likelihood independence model) criteria was applied, and a post hoc power analysis was calculated. Erythema, all minor complications, dehiscence, and necrosis requiring surgery remained significant (all P < 0.0001). This innovative technique markedly reduces overall minor complications and necrosis requiring surgery. A larger no-SAS sample size is required to adequately determine whether SAS reduces infection and hospitalization rates. Nonetheless, SAS reduces complications and is cost effective compared with other adjunct materials.

Heterogeneous acellular dermal matrix for wound repair after endoscopic Type-Ⅴa cordectomy

Objective:To observe the clinical effect of placing heterogeneous acellular dermal matrix membrane for laryngeal cavity wound healing after CO2 laser Type-Ⅴa cordectomy for glottic carcinoma. Methods:Thirty-five patients with bilateral vocal cord laryngeal cancer who underwent endoscopic CO2 laser surgery at the Department of Otorhinolaryngology Head and Neck Surgery, the Second Xiangya Hospital of Central South University from March 2018 to December 2019 were selected and divided into 2 groups, including 18 patients in the study group and 17 patients in the control group. The control group was simply placed silicone tube stent, while in the study group, heterogeneous acellular dermal matrix membrane was coated with silicone tube stent. The postoperative laryngeal wound repair and clinical manifestations were observed and compared between the two groups. Results:Compared postoperative laryngeal wound after 6 months: no patients in the study group had granulation tissue, whereas 4 patients in the control group had granulation tissue; 3 patients in the study group developed moderate to severe tissue adhesion, while 9 patients in the control group; 10 patients in the control group developed 2nd to 4th degree laryngeal obstruction, compared with only 4 patients in the study group. Conclusion:The primary placement of ADM can reduce laryngeal granulation tissue and tissue adhesion after CO2 laser Type-Ⅴa cordectomy for laryngeal cancer, and may reduce the occurrence of postoperative laryngeal obstruction.

Risk factors for residual fibroglandular breast tissue following a mastectomy - an overview and retrospective cohort study

BackgroundResidual fibroglandular breast tissue (RFGT) following a mastectomy is associated with the remaining of occult breast cancer at the time of mastectomy as well as an increased local recurrence risk thereafter. Despite its oncologic implications, data on measures to prevent RFGT are lacking. Therefore, in a first step knowledge of risk factors for RFGT is of uttermost importance in order to allow identification of patients at risk and subsequently adaption of the surgical treatment and potentially prevention of RFGT a priori.MethodsWe performed a systematic literature review in PubMed using the MESH terms [residual fibroglandular breast tissue], [residual breast tissue], [mastectomy] and [risk factor] followed by a retrospective data analysis including all patients with a mastectomy treated at the Department of Obstetrics and Gynecology of the Medical University of Vienna, Austria, between 01.01.2015 and 26.02.2020 in order to identify risk factors of RFGT following a mastectomy. The primary aim of the study was to assess a potential difference in RFGT volume between the different types of mastectomy. The secondary objectives of the study were to identify other potential risk factors for RFGT as well as to compare the skin and subcutaneous fat tissue thickness pre- to postoperatively.ResultsSignificantly higher RFGT volumes were observed following a nipple-sparing mastectomy (NSM) compared to a skin-sparing mastectomy (SSM) and radical mastectomy (RME) (p < .001). Furthermore, RFGT volume was significantly associated with the variables: reconstruction (p = .012), acellular dermal matrix (ADM) or mesh (p = .031), patient age (p = .022), preoperative fibroglandular tissue (FGT) volume (p = .012) and preoperative whole breast volume (including the skin envelope and nipple-areola-complex) (p = .030). The reduction in the postoperative compared to preoperative skin envelope thickness measured medially and laterally reached statistical significance in the NSM-cohort (medial p < .001, lateral p = .001) and showed a numerical difference in the RME and SSM-cohort.ConclusionMastectomy type, reconstruction, ADM or mesh, patient age, preoperative FGT volume and whole breast volume were identified as risk factors for RFGT in univariable analysis. The observed reduction in the post- compared to preoperative skin envelope thickness should be avoided considering the known associated increase in risk for ischemic complications.

Use of acellular matrices as scaffolds in cartilage regeneration - a systematic review.

Cartilage regeneration remains a significant challenge in the field of regenerative medicine. Acellular matrix-based cartilage tissue regeneration offers an innovative approach to repairing cartilage defects by providing a scaffold for new tissue growth. Its significance lies in its potential to restore joint function, mitigate pain, and improve the quality of life for patients suffering from cartilage-related injuries and conditions. Recent advances in acellular matrix-based cartilage regeneration have focused on enhancing scaffold properties for improved cell adhesion, proliferation, and differentiation. Moreover, several scaffold techniques such as combining ADM and ACM with cartilage tissue, as well as biphasic scaffolding enjoy rising research activity. Incorporating bioactive factors and advanced manufacturing techniques holds promise for producing more biomimetic scaffolds, advancing efficient cartilage repair and regeneration. Obstacles in acellular matrix-based cartilage regeneration include achieving proper integration with surrounding tissue and ensuring long-term durability of the regenerated cartilage. Further, issues such as high costs and limited availability of suitable cells for scaffold seeding must be considered. The heterogeneity and limited regenerative capabilities of cartilage need to be addressed for successful clinical translation. Research should focus on exploring advanced biomaterials and developing new techniques, regarding easily reproductible scaffolds, ideally constructed from clinically validated and readily available commercial products. Findings underline the potential of AM-based approaches, especially rising exploration of tissue-derived ADM and ACM. In future, the primary objective should not only be the regeneration of small cartilage defects, but rather focus on fully regenerating a joint or larger cartilage defect.

A Multi-Center Retrospective Observational Analysis of Three-Year Experience of Our Protocol for Prevention and Monitoring of Surgical Site Infections in Implant-Based Breast Reconstruction.

With the rise in the mastectomy rate, the number of patients who choose to undergo postmastectomy reconstruction has been increasing, and implant-based procedures are the most performed methods for postmastectomy breast reconstruction. Among the possible complications, the most feared is the loss of reconstruction. It can be related to several reasons, but one of the most common is infection of the implant, which can lead to prolonged antibiotic treatment, undesired additional surgical procedures, increased incidence of capsular contracture, and unsatisfactory aesthetics results, with a huge psychological impact on patients. The primary intent of this study is to analyze the status of infection rates at our institution and evaluate the effectiveness of our prevention protocol since its introduction. Secondly, we compared data of the surgical site infections (SSIs) after implant-based breast reconstruction at Trieste Hospital, where the protocol has been employed since 2020, and in another center, where plastic surgeons of our team are involved, with different prevention procedures. We enrolled 396 female patients, who underwent implant-based breast reconstruction, using definitive mammary implants or breast tissue expanders, with or without ADM (acellular dermal matrix), both for breast cancer and risk-reducing surgery in BRCA1/2 patients. Patients treated at the Hospital of Trieste, with the use of the prevention protocol, were considered the experimental group (group 1), while patients treated in Gorizia by the same breast team with standardized best-practice rules, but without the use of the prevention protocol, were considered the control group (group 2). Infected patients were 5 in the first group (1.7%) and 8 in the second one (7.9%), with a global infection rate of 3.2%. After the introduction of our prevention protocol, we faced a lower incidence of infection after breast surgery with implants or tissue expanders.

The Effect of Bowel Anastomosis on Outcomes in Complex Abdominal Wall Reconstruction: A 10-Year Retrospective Cohort Study.

In patients who require complex abdominal wall reconstruction (CAWR), the need for a bowel anastomosis could impact procedure choice and outcome. In this retrospective cohort study, we examine the effect of bowel anastomosis on complications and hernia recurrence. All patients who underwent CAWR between 2011 and 2021 by the senior author were reviewed in a retrospective cohort analysis. Patients were included if they met the above criteria. Patients were excluded if they did not undergo the above procedure or if they underwent a different procedure simultaneously. Univariate analysis was performed for patients who underwent bowel anastomosis, and multiple variable logistic regression analysis was performed with respect to overall complications. A total of 264 patients underwent CAWR over a 10-year interval. A total of 41 patients underwent bowel anastomosis (16%), and 223 patients (84%) underwent CAWR without bowel anastomosis. Mean patient age was 55.50 ± 11.55 years. Mean patient body mass index was 32.36 ± 7.31 kg/m 2 . Mean follow-up time was 10.20 months. There was a significant difference in hernia repair etiology, with higher rates of recurrent hernia repair among patients receiving bowel anastomosis (odds ratio, 2.98; 95% confidence interval, 1.49-5.95; P = 0.0018). Acellular dermal matrix was used more frequently in patients who required a bowel anastomosis (odds ratio, 3.74; 95% confidence interval, 1.75-8.00; P = 0.0018). Major and minor complications were also significantly higher in this cohort. Regression analysis for overall complications revealed the presence of bowel anastomosis, fascial repair technique, and follow-up time as independent predictors of overall complications. Bowel anastomosis performed at the time of CAWR significantly increased the rate of overall and major complications but did not predict hernia recurrence. Plastic surgeons should utilize this information in counseling patients and in deciding the most appropriate hernia repair technique.

The Ray Method: Aesthetic and Simple Technique for Prosthesis Coverage in Prepectoral Breast Reconstruction

Summary: In prepectoral breast reconstruction, the acellular dermal matrix (ADM) is commonly used to envelop breast implants. Various wrapping methods have been proposed. We present a simple but aesthetic method (ie, the ray method) for wrapping in prepectoral breast reconstruction. Without any complicated design, we folded the four corners of one large ADM and sewed them together to completely envelop the implant. Then, the 6 o’clock corner of the ADM envelope was folded up and sutured to make a pentagonal shape. The other corners of the ADM envelope were quilted to determine the position and movement of the internal implant. Additional sutures were placed on the ADM envelope to separate the implant from the host tissue. The folded 6 o’clock corner was cut to a convex contour and had a diagonal gap to prevent the collection of fluid in the ADM envelope. Finally, the wrapped implant was inserted in the postmastectomy space, and the ADM envelope was spread widely to support soft tissue effectively. This simple design is straightforward for inexperienced surgeons and reduces operation time. The position and movement of the breast implant in the ADM envelope can be easily controlled by using quilted sutures. Subclavian depression and step-off deformities can be minimized by this wide-stretched ADM. By total coverage with a large ADM, the breast implant is separated from the surrounding tissue, and foreign body reactions are reduced. This method is reliable for maximizing the aesthetic advantages of prepectoral direct-to-implant breast reconstruction.

Chyle Leak Management in the Setting of Tissue Expander Breast Reconstruction with Acellular Dermal Matrix: Case Series and Literature Review.

Chylous leakage is a rare surgical complication most frequently encountered following operations involving the neck and thorax. Even more rare are axillary chyle leaks secondary to breast cancer involving the axillary lymph nodes. Anatomic variability in the termination of the thoracic duct may play a role in the susceptibility some individuals may have to this type of leakage. There is no consensus on the definitive management of these complications, especially in the context of breast reconstruction. Here, we report our experience in the management of chylous leakage in three patients who underwent left axillary lymph node dissection and immediate breast reconstruction with the use of tissue expanders and acellular dermal matrix. Descriptions of each case are followed by a review of the relevant literature. We also present an original treatment algorithm. Two of three patients with suspected chylous leakage secondary to intraoperative injury to the axillary region underwent definitive diagnosis by clinical examination and drain fluid triglyceride analysis, followed by conservative management with a low-fat diet. The third patient was diagnosed clinically with no fluid analysis. All leakages resolved through conservative means, with no need to return to the operating room for surgical exploration and repair. Based on our experience, we believe that patients with suspected chylous leakage secondary to axillary lymph node dissection in the context of breast reconstruction can be safely and effectively managed by conservative management in the acute postoperative period. If these measures are insufficient, surgical management may be necessary.

What did we catch? Predictors of infection after tissue expander–based breast reconstruction in a safety-net system

BackgroundInfection is a common complication following tissue expander (TE)–based breast reconstruction. Few studies have examined risk factors specifically in the unique populations encountered at safety-net hospitals. The purpose of this study was to identify predictors of TE infection at Harris Health safety-net hospitals, which serve the third most populous county in the United States. MethodsA retrospective review was performed to evaluate women over the age of 18 years who underwent TE placement at two safety-net hospitals from October 2015 to November 2022. Demographic information, medical history, operative details, and postoperative course were recorded for each individual TE. The primary outcome was TE infection, for which univariate and multivariate analysis was conducted. The secondary outcome was the time to onset of TE infection, for which a Kaplan-Meier analysis was undertaken. ResultsThere were 279 patients, totaling 372 breasts, meeting the inclusion criteria. The TE infection rate was 23%. Increased body mass index (BMI), diabetes, use of acellular dermal matrix (ADM), and prolonged surgical drain use were all significantly associated with TE infection in univariate and multivariate analysis. Similarly, BMI ≥30 kg/m2, diabetes, and ADM use were also associated with earlier onset of TE infection. ConclusionsThis study demonstrated similar TE infection rates at our safety-net hospitals compared with previously reported literature. To optimize the quality of care for patients in safety-net institutions, these risk factors must be addressed in the context of the unique challenges encountered in these settings.