Flap Necrosis Rate Research Articles

Radiotherapy and nipple-areolar complex necrosis after nipple-sparing mastectomy: a systematic review and meta-analysis.

To perform a meta-analysis to determine the effect of radiotherapy (RT) on nipple-areolar complex (NAC) and skin flap necrosis, and local recurrence in women who undergo nipple-sparing mastectomy (NSM) and immediate breast reconstruction. Medline, PubMed, Cochrane, and Google Scholar databases were searched until October 16, 2015. Randomized-controlled-trials, prospective, retrospective, and cohort studies were included. The primary outcome was the NAC necrosis rate, and the secondary outcomes were the skin flap necrosis and local recurrence rates. Of 186 studies identified, 2 prospective and 5 retrospective studies including a total of 3692 patients were included in the meta-analysis. Five, 3, and 2 studies reported data of NAC necrosis (3461 breasts), skin flap necrosis (2490 breasts), and local recurrence (988 breasts), respectively. Pooled results showed no difference in the odds of NAC necrosis [odds ratio (OR)=1.250, 95% confidence interval (CI) 0.481-3.247, P=0.647], or local recurrence (OR=0.564, 95% CI 0.056-5.710, P=0.627) between patients who received and did not receive RT. Patients treated with RT had a higher likelihood of skin flap necrosis (OR=2.534, 95% CI 1.720-3.735, P<0.001). Significant heterogeneity, however, was noted in the analysis of NAC and local recurrence. Because of the limitations of the small number of studies and heterogeneity in the analysis, this study does not allow drawing any definitive conclusions and highlights the need of well-controlled trials to determine the effect of RT in patients undergoing NSM.

The Effect of Sterile Acellular Dermal Matrix Use on Complication Rates in Implant-Based Immediate Breast Reconstructions.

BackgroundThe use of acellular dermal matrix (ADM) in implant-based immediate breast reconstruction has been increasing. The current ADMs available for breast reconstruction are offered as aseptic or sterile. No published studies have compared aseptic and sterile ADM in implant-based immediate breast reconstruction. The authors performed a retrospective study to evaluate the outcomes of aseptic versus sterile ADM in implant-based immediate breast reconstruction.MethodsImplant-based immediate breast reconstructions with ADM conducted between April 2013 and January 2016 were included. The patients were divided into 2 groups: the aseptic ADM (AlloDerm) group and the sterile ADM (MegaDerm) group. Archived records were reviewed for demographic data and postoperative complication types and frequencies. The complications included were infection, flap necrosis, capsular contracture, seroma, hematoma, and explantation for any cause.ResultsTwenty patients were reconstructed with aseptic ADM, and 68 patients with sterile ADM. Rates of infection (15.0% vs. 10.3%), flap necrosis (5.0% vs. 7.4%), capsular contracture (20.0% vs. 14.7%), seroma (10.0% vs. 14.7%), hematoma (0% vs. 1.5%), and explantation (10.0% vs. 8.8%) were not significantly different in the 2 groups.ConclusionsSterile ADM did not provide better results regarding infectious complications than aseptic ADM in implant-based immediate breast reconstruction.

Is It Possible to Increase Flap Viability by Hydrostatic Dilation?: An Experimental Study in the Rat Abdominal Fasciocutaneous Flap Model.

Ergun et al previously demonstrated the efficacy of hydrostatic dilation in a TRAM flap model in an experimental study. We investigated the effect of hydrostatic dilation on a fasciocutaneous flap model. Eighteen female Wistar rats were equally divided into 3 groups, of which 1 served as a control. In the second, the abdominal fasciocutaneous flap surgical delay procedure was performed by division of the left superficial inferior epigastric (SIE) vessels. In the third, hydrostatic dilation was performed on the left SIE artery and vein, with a mean pressure of 300 mm Hg, while elevating the flap on the right-sided SIE pedicle. The groups were compared by microangiography and by the survival ratio of abdominal flaps 7 days after elevation. The mean (SD) flap necrosis rates were as follows: control group, 44.75% (4.31%); delay group, 33.32% (7.11%); and hydrostatic dilation group, 32.51% (5.03%). There was a significant difference between the control group and the other 2 groups (P < 0.05). There was no difference between the delay and hydrostatic dilation groups with respect to surface area necrosis. The microangiographies showed remarkable increased vascularity in the delay and hydrostatic dilation groups. Hydrostatic dilation is a new method of enhancing flap viability that could be used in clinical cases in place of surgical delay once further studies and clinical trials are completed.

Mastectomy technique using a self-designed self-retaining retractor system.

Mastectomy is one of the most common procedures for treating breast cancer. It is often performed by a breast surgeon with an assistant holding the retractor to provide adequate tension for dissection of the skin flap. However, the technique is highly dependent on the retraction from the assistant. We herein describe a novel technique using a self-retained retractor system with a specially designed retractor ring and elastic stay hooks to allow adequate and constant tension of retraction throughout the entire mastectomy procedure. This new technique was introduced at our breast center in 2008, and the skin flap necrosis rate and time required for skin flap dissection remain comparable to those in other regions. The retractor ring costs less than $200 USD, and the disposable elastic hooks cost around $50 USD. In conclusion, this new technique is simple, versatile, and effective.

Oncological and Surgical Outcomes After Nipple-Sparing Mastectomy: Do Incisions Matter?

While nipple-sparing mastectomy (NSM) for the treatment of breast cancer is becoming more accepted, technical aspects are still evolving. Data regarding risk factors contributing to complications after NSM are limited. This study evaluated technical aspects on outcomes of NSM. Review of our database identified 201 patients who had NSM during the period from January 2012 to June 2015. We compared the effect of operative techniques on surgical outcomes. A total of 351 NSM were performed in 201 patients. Mean patient age was 47years. Inframammary (47%) or periareolar (35%) incisions were most frequent. Tumescence was used in 203 (58%) NSM. Skin flaps were created using sharp dissection in 213 (61%) and electrocautery in 138 (39%) breasts. Nipple areola complex (NAC) necrosis was seen in 56 (16%) breasts, of which 7 were severe (2%). A higher rate of NAC complications was seen with periareolar incisions (p=0.02). Sharp dissection did not result in significant rates of flap necrosis compared with electrocautery. Ten patients (3%) had a positive anterior/deep margin, of which 7 (64%) had an inframammary approach. Twenty-two (11%) patients had an infection that required intravenous antibiotics. Fourteen (7%) patients had implant loss. Dissection technique was not associated with implant loss (p=1.0) or infection (p=0.84). Forty-two (12%) patients had radiation and seven (16%) required implant removal. NSM has an acceptable complication rate. NAC necrosis requiring excision or implant loss is rare. Postmastectomy radiation is a significant risk factor for implant loss. Inframammary incisions have fewer ischemic complications but may result in tumor-involved margins.

Nasoseptal Flap Elevation in Patients with History of Septal Surgery: Does It Increase Flap Failure or Cerebrospinal Fluid Leakage?

The nasoseptal flap (NSF) has been shown to be a mainstay in the reconstruction of skull base defects. We evaluated the efficacy and complications of NSF in patients with a history of septal surgery who had the potential risk of tearing and poor vascularity. We performed a retrospective chart and video review of patients who underwent NSF for skull base reconstruction between February 2012 and May 2015. Comparison was made between 18 patients (revision group) who had a history of septoplasty and/or transseptal transsphenoidal approach and 88 patients (primary group) without a history of septal surgery. Laceration when raising the flap, vascularity on postoperative magnetic resonance imaging, viability on postoperative endoscopy, and cerebrospinal fluid (CSF) leakage were compared between the revision and primary groups. Laceration of the flap occurred during NSF elevation in 2 patients (11.1%) in the revision group and 4 patients (4.5%) in the primary group (P= 0.269). Poor flap vascularity on magnetic resonance imaging was observed in 2 patients (11.1%) in the revision group and 8 patients (9.1%) in the primary group (P= 0.674). The rate of flap necrosis on endoscopy was 5.6% in the revision group and 1.1% in the primary group (P= 0.312). There was no significant difference in CSF leakage rate between the 2 groups (revision 5.6% and primary 10.2%). There was no difference in rate of CSF leakage or flap integrity between the 2 groups. Therefore, NSF for skull base reconstruction is feasible in patients with a history of septal surgery.

Intravenous Hyaluronidase with Urokinase as Treatment for Arterial Hyaluronic Acid Embolism.

Although injection of hyaluronidase into surrounding tissues was proposed to treat arterial hyaluronic acid embolism, its application is still rather limited. The authors' goal was to investigate whether intravenous use of hyaluronidase can help resolve hyaluronic acid-induced arterial embolism. Inferior epigastric arteries, nourishing inferior abdominal skin of rats, were injected with 0.02 ml of hyaluronic acid to create the animal model. The rats were divided randomly into four groups and given different solutions intravenously: hyaluronidase plus urokinase (group A), hyaluronidase (group B), urokinase (group C), or saline (group D). Progression of tissue necrosis in all groups was recorded for 1 week. The flap survival rate and mean percentage of surviving flap area were analyzed. The animal model closely imitated actual hyaluronic acid arterial obstruction cases. Flap necrosis occurrence rates of each group were 10 percent in group A, 70 percent in group B, 80 percent in group C, and 90 percent in group D. The mean surviving flap areas of each group were 92.45 percent (group A), 47.67 percent (group B), 41.41 percent (group C), and 33.19 percent (group D). When hyaluronidase and urokinase were used together, the flap necrosis rate decreased significantly compared with that of the control group (p < 0.05). Even in cases of necrosis, group A had a higher average surviving flap area than did the other groups. Combined use of hyaluronidase and urokinase can help increase the flap survival rate when administered intravenously in intraarterial hyaluronic acid occlusion cases. Both red thrombus and hyaluronic acid emboli must be dissolved for flap reperfusion. This method shows a promising effect for future application.

Assessment of Fibula Flap Skin Perfusion in Patients Undergoing Oromandibular Reconstruction

Complications of partial flap necrosis contribute substantially to morbidity in patients who undergo head and neck reconstructive surgery. To assess the usefulness of clinical findings, intraoperative fluorescein angiography, and intraoperative indocyanine green angiography (ICGA) for evaluation of flap skin paddle perfusion in patients undergoing oromandibular reconstruction who are at high risk of partial skin paddle necrosis. Retrospective medical record review from May 21, 1996, to May 27, 2015, at a tertiary care academic medical center. Participants were 73 patients who underwent reconstruction of through-and-through defects of the mucosa, mandible, and skin using fibula free flaps that contained large bilobed skin paddles. The rates of partial skin paddle necrosis and revision reconstructive surgery. The rates of partial flap necrosis were 8% (n = 2) among 25 patients in whom the skin paddle was trimmed based on ICGA and 33% (n = 16) among 48 patients in whom the skin paddle was trimmed according to clinical findings (P = .02). The rates of revision reconstructive surgery were 20% (5 of 25) when flap skin paddles were trimmed using ICGA and 42% (20 of 48) when trimmed per clinical findings (P = .06). The use of ICGA may reduce the risk of partial skin flap necrosis in free flaps used in patients undergoing head and neck reconstruction who are at high risk of developing flap necrosis. Indocyanine green angiography imaging should be considered in any flap in which skin paddle viability is uncertain based on clinical findings and in patients in whom the skin paddle extends beyond the primary and adjacent angiosomes. 3.

Skin Flap Necrosis After Mastectomy With Reconstruction: A Prospective Study.

Rates of mastectomy with immediate reconstruction are rising. Skin flap necrosis after this procedure is a recognized complication that can have an impact on cosmetic outcomes and patient satisfaction, and in worst cases can potentially delay adjuvant therapies. Many retrospective studies of this complication have identified variable event rates and inconsistent associated factors. A prospective study was designed to capture the rate of skin flap necrosis as well as pre-, intra-, and postoperative variables, with follow-up assessment to 8 weeks postoperatively. Uni- and multivariate analyses were performed for factors associated with skin flap necrosis. Of 606 consecutive procedures, 85 (14 %) had some level of skin flap necrosis: 46 mild (8 %), 6 moderate (1 %), 31 severe (5 %), and 2 uncategorized (0.3 %). Univariate analysis for any necrosis showed smoking, history of breast augmentation, nipple-sparing mastectomy, and time from incision to specimen removal to be significant. In multivariate models, nipple-sparing, time from incision to specimen removal, sharp dissection, and previous breast reduction were significant for any necrosis. Univariate analysis of only moderate or severe necrosis showed body mass index, diabetes, nipple-sparing mastectomy, specimen size, and expander size to be significant. Multivariate analysis showed nipple-sparing mastectomy and specimen size to be significant. Nipple-sparing mastectomy was associated with higher rates of necrosis at every level of severity. Rates of skin flap necrosis are likely higher than reported in retrospective series. Modifiable technical variables have limited the impact on rates of necrosis. Patients with multiple risk factors should be counseled about the risks, especially if they are contemplating nipple-sparing mastectomy.

Deep Inferior Epigastric Artery Perforator Flap Breast Reconstruction without Microsurgery Fellowship Training.

Background:Deep inferior epigastric artery perforator (DIEP) flap breast reconstruction requires complex microsurgical skills. Herein, we examine whether DIEP flap breast reconstruction can be performed safely without microsurgical fellowship training.Methods:A total of 28 patients and 34 DIEP flaps were included in the study. We reviewed the medical records of patients for donor site and flap-related complications and analyzed the correlation between the complications and preoperative risk factors. We also performed a literature review to compare complication rates in our series with the literature.Results:We observed total flap necrosis in 1 patient (2.9%), partial flap necrosis in 5 patients (14.7%), infection in 1 patient (2.9%), hematoma/seroma in 3 patients (8.8%), donor site complications in 5 patients (18.5%), venous occlusion in 4 patients (11.7%), and arterial occlusion in 1 patient (2.9%). We did not observe any correlation between complications and preoperative risk factors. Literature review yielded 18 papers that met our inclusion criteria. Partial flap necrosis rate was significantly higher in our series compared with literature (14.7% vs 1.6%, P = 0.003). Venous complication rate was marginally higher in our series compared with literature (11.7% vs 3.3%, P = 0.057). However, total flap loss rate in our series was comparable with the literature (2.9% vs 2.2%, P = 0.759).Conclusion:With proper training during plastic surgery residency, DIEP flap can be performed with acceptable morbidity.

Is It Possible To Increase Flap Viability by Hydrostatic Dilation? An Experimental Study in the Rat Abdominal Fasciocutaneous Flap Model

INTRODUCTION Ergun et al previously demonstrated the efficacy of hydrostatic dilation in a TRAM flap model in an experimental study. We investigated the effect of hydrostatic dilation on a fasciocutaneous flap model. METHODS Eighteen female Wistar rats were equally divided into 3 groups, of which 1 served as a control. In the second, the abdominal fasciocutaneous flap surgical delay procedure was performed by division of the left superficial inferior epigastric (SIE) vessels. In the third, hydrostatic dilation was performed on the left SIE artery and vein, with a mean pressure of 300 mm Hg, while elevating the flap on the right-sided SIE pedicle. The groups were compared by microangiography and by the survival ratio of abdominal flaps 7 days after elevation. RESULTS The mean (SD) flap necrosis rates were as follows: control group, 44.75% (4.31%); delay group, 33.32% (7.11%); and hydrostatic dilation group, 32.51% (5.03%). There was a significant difference between the control group and the other 2 groups (P < 0.05). There was no difference between the delay and hydrostatic dilation groups with respect to surface area necrosis. The microangiographies showed remarkable increased vascularity in the delay and hydrostatic dilation groups. CONCLUSIONS Hydrostatic dilation is a new method of enhancing flap viability that could be used in clinical cases in place of surgical delay once further studies and clinical trials are completed.

Reconstructive Approach for Patients With Augmentation Mammaplasty Undergoing Nipple-Sparing Mastectomy

Nipple-sparing mastectomy (NSM) is a recent advance in the therapeutic and prophylactic management of breast cancer; however, the procedure is associated with increased reconstructive complications. Data on NSM after previous breast augmentation are limited. The authors compared reconstructive complications after NSM between patients with previously augmented breasts and a larger cohort that had not undergone prior augmentation. An approach to NSM that involves 2-stage reconstruction in augmented patients is also described. Medical records of NSMs performed at New York University Langone Medical Center from 2006 to 2013 were reviewed. Data points evaluated included patient characteristics, comorbidities, breast implant plane, and reconstructive complications. Fisher's exact and t tests were used for the comparisons. During the study period, NSMs were performed in 17 augmented breasts at this institution. After NSM, 15 of these breasts underwent implant-based reconstruction and 2 breasts underwent microvascular free flaps. Reconstructive complications included 1 hematoma managed nonoperatively (5.9%) and 1 partial necrosis of the nipple-areola complex (NAC) (5.9%). Compared with the larger nonaugmented cohort (n=332), patients with previously augmented breasts had fewer complications, and there were no statistically significant differences in the rates of mastectomy flap necrosis, partial NAC necrosis, complete NAC necrosis, hematoma, capsular contracture, explantation, implant displacement, seroma, or breast cellulitis. The results indicate that NSM reconstruction is associated with minimal complications in patients with previous augmentation mammaplasty. 4.

Comparison of outcomes of pressure sore reconstructions among perforator flaps, perforator‐based rotation fasciocutaneous flaps, and musculocutaneous flaps

Pressure sore reconstruction remains a significant challenge for plastic surgeons due to its high postoperative complication and recurrence rates. Free-style perforator flap, fasciocutaeous flap, and musculocutaneous flap are the most common options in pressure sore reconstructions. Our study compared the postoperative complications among these three flaps at Kaohsiung Chang Gung Memorial Hospital. From 2003 to 2012, 99 patients (54 men and 45 women) with grade III or IV pressure sores received regional flap reconstruction, consisting of three cohorts: group A, 35 free-style perforator-based flaps; group B, 37 gluteal rotation fasciocutaneous flaps; and group C, 27 musculocutaneous or muscle combined with fasciocutaneous flap. Wound complications such as wound infection, dehiscence, seroma formation of the donor site, partial or complete flap loss, and recurrence were reviewed. The mean follow-up period for group A was 24.2 months, 20.8 months in group B, and 19.0 months for group C. The overall complication rate was 22.9%, 32.4%, and 22.2% in groups A, B, and C, respectively. The flap necrosis rate was 11.4%, 13.5%, and 0% in groups A, B, and C, respectively. There was no statistical significance regarding complication rate and flap necrosis rate among different groups. In our study, the differences of complication rates and flap necrosis rate between these groups were not statistically significant. Further investigations should be conducted.

Retrospective Review of Pilonidal Sinus Patients With Early Discharge After Limberg Flap Procedure

The aim of this study was to evaluate the results of cases with pilonidal sinus (PS) disease that underwent Limberg flap (LF) transposition and to compare the short and long-term results of early discharge cases with those in the literature. A total of 345 patients who underwent rhomboid excision and LF transposition for PS were evaluated retrospectively. No major anesthetic or surgical complications occurred. Partial wound dehiscence, localized flap necrosis, hematoma, wound infection, and seroma rates were determined as 4.0, 2.1, 1.5, 3.3, and 3.7% respectively. All patients other than those with a hematoma or localized necrosis were discharged with a drain in place 24 hours after the operation. The recurrence rate was 3.9% after a mean 33.1-month follow-up (range, 6-72 months). As a result, we found that short and long-term results of patients who underwent LF and were discharged 24 hours after the operation were similar to those in the literature. We suggest that patients without postoperative complications, such as hematoma or flap necrosis, can be discharged early.

Une plateforme de suivi chirurgical pour réduire les complications en reconstruction par lambeau libre

In 2007, the WHO adopted surgical safety as the theme for the 2nd global patient safety challenge. Measurement of surgical services was identified as a surgical care area in need of major improvements. Aware of this recommendation, a preliminary study was conducted in our hospital and showed that the incidence of complete necrosis in free flap surgery was 10.0 %, a rate among the highest found in medical literature. In that context, an interactive surgical follow-up platform (PICS) was implemented to monitor outcomes in free flap surgery. The hypothesis was to reduce the short-term failure of microsurgical reconstructions. In Summer 2010, the tool for capturing and analyzing data (PICS) was implemented. All patients who underwent free flap reconstruction were prospectively registered in the platform. The primary endpoints to evaluate the effectiveness of the tool are the rates of surgical re-exploration and complete necrosis of the flap. From May 2010 to December 2011, 129 cases of free flap reconstruction were recorded. The rate of total flap necrosis was 10.0 % before database introduction and declined to 3.1 % afterwards (P<0.05). Take-backs occurred in 27.0 % of free flap reconstructions at baseline and in 10.1 % after implementation (P<0.01). The implementation of PICS is associated with a significant improvement of postoperative short-term outcomes in free flap surgery. This tool is effective to evaluate care services and provides an increased surgical safety for patients. Surgical teams are encouraged to implement a data collection tool in order evaluate operative care on a routine basis.

Minimizing Complications With the Use of Acellular Dermal Matrix for Immediate Implant-Based Breast Reconstruction

Acellular dermal matrix (ADM) use in implant-based breast reconstruction has been associated with higher rates of postoperative seroma and infection. This follow-up study was performed to determine whether specific modifications in technique are associated with a reduction in the rate of complications. The authors performed a retrospective analysis of immediate ADM-assisted implant-based breast reconstructions performed by the lead author (Y.C.) during an 18-month period after instituting specific modifications to prevent seroma. These included draining both the submastectomy and sub-ADM planes, lowering the threshold for drain removal, and addition of postoperative soft compression dressings and surgical bras. A total of 179 implant-based reconstructions were evaluated for rates of complications, including infection, hematoma, seroma, and skin flap necrosis. These were compared to results of a series of 150 similar procedures performed by the lead author before institution of the procedural modifications described. Seroma rate decreased from 18.6% to 4.7% (P = 0.0022), and major infection rate decreased from 7% to 1.9% (0.0250). Although implant-based breast reconstruction using ADM has been associated with increased seroma and possible infection rates, the use of specific clinical practices designed to prevent seroma has minimized our rate of these postoperative complications.

The effect of harmonic scalpel, electrocautery, and scalpel use on early wound complications after modified radical mastectomy

Mastectomy when performed with scalpel and electrocautery is associated with some blood loss and morbidity in the form of prolonged drainage, seroma, wound infection, flap necrosis, and hematoma. A total of 120 patients operated with mastectomy enrolled for the study. The groups were defined by the instruments used for flap preparation: 41 patients operated with electrocautery, 40 patients operated with scalpel, and 39 patients operated with harmonic scalpel formed three groups. The need for closed suction drains, the amount and duration of seroma, surgical site infection, hematoma, and flap ischemia and necrosis were evaluated. The amounts of intraoperative blood loss in electrocautery and harmonic scalpel groups were 560 and 500 mL, respectively, and it was increased to 750 mL in scalpel group (p = 0.001). Total drainage amounts of scalpel and harmonic scalpel groups were 894 and 908 mL, respectively, and it was increased to 1,113 mL in electrocautery group (p = 0.0033). Seroma incidence rates in scalpel, electrocautery, and harmonic scalpel groups were 45, 65 and 28 %, respectively (p = 0.003). The differences between groups in relation to the duration of surgery, breast volume and weight, the areas of flap dissection, the duration of closed suction drainage, and the amount of early drainage were not statistically significant. There was also no difference between groups with regard to hematoma, flap necrosis, and ecchymosis and infection rates. Although the use of harmonic scalpel reduces the risk of seroma formation and intraoperative blood loss, further studies are needed to verify the real impact of such technique.

Unilateral Preoperative Chest Wall Irradiation in Bilateral Tissue Expander Breast Reconstruction with Acellular Dermal Matrix

Prior breast irradiation increases the rate of postoperative complications, including capsular contracture, in tissue expander/implant reconstruction. Acellular dermal matrix is heralded to decrease capsular contracture, but recent evidence suggests a possible increase in postoperative complications. The authors evaluated outcomes in patients undergoing bilateral tissue expander/implant reconstruction with acellular dermal matrix in the setting of prior unilateral irradiation. A case-control study was conducted on all patients undergoing bilateral, acellular dermal matrix-assisted, tissue expander/implant reconstruction with a history of previous unilateral irradiation at Memorial Sloan-Kettering Cancer Center. Complication rates were compared. Twenty-three patients met inclusion criteria and had an average follow-up of 19 months (range, 4 to 60 months). The perioperative infection rate was 21.7 percent (n = 5) in irradiated breasts and 4.3 percent (n = 1) in control breasts (p = 0.079). Mastectomy skin flap necrosis, explantation, hematoma, and seroma rates were not significantly different between the groups. Sixty percent of patients had irradiated breast contracture that was one Baker grade greater than that in the nonirradiated breast. Body mass index greater than 25 and smoking history were significant independent risk factors for early postoperative complications in univariate analysis (p = 0.01). Previous irradiation does not appear to increase the risk of early postoperative complications associated with acellular dermal matrix use in tissue expander/implant breast reconstruction. However, body mass index greater than 25 and smoking history are cause for caution. In addition, acellular dermal matrix does not appear to affect the degree of capsular contracture formation in the setting of prior irradiation. : Therapeutic, III.

Botulinum toxin A and B raise blood flow and increase survival of critically ischemic skin flaps

BackgroundBotulinum toxin (BTX) A and B are commonly used for aesthetic indications and in neuromuscular disorders. New concepts seek to prove efficacy of BTX for critical tissue perfusion. Our aim was to evaluate BTX A and B in a mouse model of critical flap ischemia for preoperative and intraoperative application. MethodsBTX A and B were applied on the vascular pedicle of an axial pattern flap in mice preoperatively or intraoperatively. Blood flow, tissue oxygenation, tissue metabolism, flap necrosis rate, apoptosis assay, and RhoA and eNOS expression were endpoints. ResultsBlood-flow measurements 1 d after the flap operation revealed a significant reduction to 53% in the control group, while flow was maintained or increased in all BTX groups (103%–129%). Over 5 d all BTX groups showed significant increase in blood flow to 166-187% (P < 0.01). Microdialysis revealed an increase of glucose and reduced lactate/pyruvate ratio and glycerol levels in the flap tissue of all BTX groups. This resulted in significantly improved tissue survival in all BTX groups compared with the control group (62% ± 10%; all P < 0.01): BTX A preconditioning (84% ± 5%), BTX A application intraoperatively (88% ± 4%), BTX B preconditioning (91% ± 4%), and intraoperative BTX B treatment (92% ± 5%). This was confirmed by TUNEL assay. Immunofluorescence demonstrated RhoA and eNOS expression in BTX groups. All BTX applications were similarly effective, despite pharmacologic dissimilarities and different timing. ConclusionsIn conclusion, we were able to show on a vascular, tissue, cell, and molecular level that BTX injection to the feeding arteries supports flap survival through ameliorated blood flow and oxygen delivery.

Total Skin-Sparing Mastectomy

Despite the potential aesthetic and psychological benefits of total skin-sparing mastectomy (TSSM) with preservation of the nipple-areolar complex (NAC) skin, there is still reluctance to use the technique due to concern for increased recurrence rates or higher postoperative complication rates. The rapidly expanding literature describing outcomes after TSSM enables a comprehensive review of recurrence rates and surgical complications. Studies describing nipple-sparing or TSSM were identified from the MEDLINE and Cochrane databases. Studies that reported oncologic outcomes and/or data on postoperative complications were included. Twenty-seven studies were identified that met inclusion criteria, representing a total of 3331 mastectomies. Review of oncologic outcomes in the 10 studies (representing 1148 mastectomies) with documented mean/median follow-up of 2 years demonstrated an overall local-regional recurrence rate of 2.8%. Ischemic complications involving the NAC were reported in 24 studies (representing 3091 mastectomies), with 9.1% of cases reported to have some degree of NAC necrosis and 2.0% of cases complicated by complete necrosis leading to NAC loss. Sixteen studies (representing 2213 mastectomies) reported rates of skin flap necrosis, which occurred in 9.5% of cases. Eighty-one percent of the total cases reviewed involved expander-implant reconstruction; in the 16 studies (representing 2343 reconstructions) that reported outcomes after expander-implant reconstruction, overall expander-implant loss was 3.4%. There is now a significant body of literature demonstrating low rates of early local-regional recurrence and postoperative complications after TSSM. These data support the use of TSSM techniques, which improve psychological and aesthetic outcomes without compromising therapeutic efficacy.