Intraoperative Expansion Research Articles

Impact of Intraoperative Expansion with Air and Outcomes in First Stage Implant-based Breast Reconstruction: A Propensity-matched Analysis

Impact of Intraoperative Expansion with Air and Outcomes in First Stage Implant-based Breast Reconstruction: A Propensity-matched Analysis

Subpectoral versus prepectoral two-stage breast reconstruction: A propensity score-matched analysis of 30-day morbidity and long-term outcomes

Approximately 80% of patients undergoing total mastectomy in the US opt for implant-based breast reconstruction (IBBR). A two-stage reconstruction with tissue expander (TE) remains the most common technique. Since the implementation of ADMs, a prepectoral approach has gained popularity and is becoming the standard of care. Herein, we compared the surgical and postoperative outcomes of prepectoral versus subpectoral two-stage IBBR. A retrospective chart review was performed between January 2011 and December 2020. We included female patients undergoing immediate two-stage IBBR. The primary outcomes of this study were to compare the 30-day morbidity and the overall rate of complications during the first and second stages of reconstruction, and to compare the time to initiate postmastectomy radiotherapy (PMRT). Propensity score matching was implemented. After matching, 154 reconstructions were analyzed, 77 in each group. The two matched groups exhibited comparable (p>0.05) characteristics for all analyzed demographic and intraoperative independent variables. Reconstructions in the prepectoral group had a shortened median time for drain removal (13-days vs. 15-days, p=0.001). The intraoperative expansion volumes were higher in the prepectoral group (300ml versus 200ml, p=0.025). The 30-day morbidity and first- and second-stage complication rates were not significantly different between groups. The time to start postmastectomy radiation therapy (PMRT) was not significantly different between groups (134-days versus 126.5-days, p=0.58). Prepectoral and subpectoral TE placement had comparable complication rates during the first and second stages of IBBR. Timing for TE-to-Implant exchange and initiation of PMRT were comparable between the two approaches.

Autologous Shuffling Lipo-Aspirated Fat Combined Mechanical Stretch in Revision Rhinoplasty for Severe Contractures in Asian Patients.

A severely contracted nose is a common occurrence. Intraoperative expansion is not sufficient to soften the severely constricted nasal envelope, which poses challenges in revision rhinoplasty. In recent years, adjuvant therapies, including nasal fat grafting and cell component injection, are applied before revision rhinoplasty to soften the nasal envelope. Herein, autologous shuffling lipo-aspirated fat and manual mechanical stretch were combined as adjuvant therapy before revision rhinoplasty. A total of 24 patients with severe nasal contracture were included in this study. Of these, 8 received autologous shuffling lipo-aspirated fat and manual mechanical stretch before revision rhinoplasty (comprehensive therapy), 8 underwent mechanical stretch and revision rhinoplasty, and 8 patients underwent only revision rhinoplasty. The objective and subjective outcome assessment was processed in the follow-up period of 6 months. Nasal length, nasal tip projection, nasofrontal angle, and nasolabial angle were measured, and potential complications were assessed. All 24 patients underwent a successful revision rhinoplasty. In the comprehensive therapy group, no patient had postoperative wound infection and defect of the nasal column mucous. The comprehensive treatment group had the most significant improvement in nasal length and nasal tip projection, and the nasolabial angle was the closest to 90°, which indicated the most effective nasal revision and aesthetic contour. The adjuvant therapy combines autologous shuffling lipo-aspirated fat and manual mechanical stretch before revision rhinoplasty could effectively improve the surgical outcome and decrease the postoperative complications regarding severe nasal contractures. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Air versus Saline: The Effect of Tissue Expander Fill on Outcomes of Prepectoral Breast Reconstruction.

Traditionally, saline is used for intraoperative/postoperative expansion in two-stage alloplastic breast reconstruction. Recently, intraoperative expansion with air has been proposed, to reduce pressure on the mastectomy skin flap in the immediate postoperative setting. The authors examined whether the intraoperative tissue expansion medium (i.e., air versus saline) affected postmastectomy complications in two-stage prepectoral reconstruction. This was a retrospective cohort study of 87 patients (144 breasts) undergoing prepectoral breast reconstruction at the authors' institution. Patient data were abstracted from medical records. Stepwise, multivariable-adjusted logistic regression using robust variances was used to identify predictors of postmastectomy complications. Statistical and power analyses were completed. Of the 87 study patients, 29 (33.3 percent) received intraoperative saline fill and 58 (66.7 percent) received air fill. Demographic/clinical data were well-matched between cohorts. Median follow-up was 165 days, and average patient age was 46.7 years. Initial tissue expander fill volumes were similar between study cohorts ( p = 0.2). The crude association between air versus saline fill on overall complication rates suggested that air-filled tissue expanders may be protective (OR = 0.4; p = 0.03), and the suggested protective effect was maintained with borderline significance even after potential confounders (i.e., American Society of Anesthesiologists class III or higher, body mass index, diabetes, mastectomy specimen weight, smoking status) were added to the model (OR = 0.4; p = 0.05). In addition, fewer complications requiring salvage reoperation were observed with air-filled tissue expanders (adjusted OR = 0.3; p = 0.02). The medium used for immediate intraoperative tissue expansion impacted postmastectomy outcomes in patients undergoing two-stage prepectoral breast reconstruction. The results demonstrated that air-filled tissue expanders were associated with fewer postoperative complications/salvage reoperations relative to saline-filled tissue expanders. Therapeutic, III.

Indications and Limitations of the Use of Intraoperative Expansion for Treatment of Scalp Defects

Indications and Limitations of the Use of Intraoperative Expansion for Treatment of Scalp Defects

Surgical outcome of empyema thoracis patients with special correlation to pre-operative contrast-enhanced computerized tomography (CECT) thorax morphometry.

Empyema thoracis is a very common disease. The surgical outcome of empyema patients depends upon various factors. To the best of our knowledge, there is no study in literature describing the surgical outcome of patients in relation to the contrast-enhanced computerized tomography (CECT) thorax morphometric findings. In this study, we examined the surgical outcome of empyema thoracis patients in relation to both clinical and radiological findings. It is a prospective hospital-based study conducted between October 2016 and August 2018. A total of 30 patients, who underwent decortication during the study period, were included. They were divided into three performance groups (excellent performance, average performance and poor performance groups) according to the outcome. The surgical outcome was correlated with the pre-operative clinical, radiological, intra-operative and post-operative parameters. Intra-operative ability to complete decortication, intra-operative expansion of the lungs and presence of broncho-pleural fistula were significantly different between the three performance groups. Duration of the disease, pre-operative duration of antitubercular therapy (ATT) intake and duration of pre-operative intercostal drain (ICD) were statistically insignificant between groups. In computed tomography (CT) morphometry, residual lung volume of the involved lung and volume of empyema were found to be significantly different between the performance groups. The residual volume of the involved lung (expressed in terms of the percentage of lung volume of the normal opposite lung) can predict the complete expansion of the lung with sensitivity of 71% and specificity of 70%. The pre-operative residual lung volume of the involved lung, empyema volume, completeness of decortication, intra-operative expansion of the lung and presence or absence of broncho-pleural fistula can determine the surgical outcome in empyema thoracis patients.

Air Versus Saline: The Effect of Tissue Expander Fill Prepectoral Breast Reconstruction Postoperative Complications

BACKGROUND: A common practice in breast reconstruction is 2-stage implant reconstruction with initial tissue expander placement. Traditionally, saline is added to the tissue expander intraoperatively, followed by continued expansion with saline postoperatively. Recently, intraoperative expansion with air rather than saline has been proposed to reduce the pressure applied to the mastectomy skin flap and incisions in the immediate postoperative setting. The aim of our study was to determine if tissue expansion fill (air versus saline) affects postoperative complications in the setting of prepectoral delayed immediate reconstruction. METHODS: A retrospective cohort study of 144 breasts (86 patients) who underwent immediate prepectoral breast reconstruction with full anterior coverage with ADM over a 2-year period was performed. Patient demographics, intraoperative tissue expander fill medium, and the occurrence of postsurgical complications were analyzed. Crude and multivariable-adjusted logistic regression estimated odds ratios were used to identify predictors of postsurgical complications. To account for the potential clustering of 144 breast interventions from 86 women, regressions used robust variances. Statistical analyses were performed using SAS software v9.4. RESULTS: The demographic and clinical data were well matched between study cohorts. The mean follow-up time is 196 days (range, 85–633 days), and the average age is 46.7 years old. Initial tissue expander fill volume was similar (P = 0.2). ASA III+, body mass index, diabetes, and smoking status were added in a step-wise fashion as potential confounding variables in the model. The crude association between air and saline fill on overall complication suggests a protective effect when the tissue expander is filled with air (odds ratio [OR], 0.5; P = 0.04), and the suggested protective effect is maintained as potential confounding variables are added to the model (OR, 0.4; P = 0.05). Fewer complications requiring salvage reoperation were observed when tissue expanders were filled with air (OR, 0.3; P = 0.02). Additionally, there is a suggested protective effect regarding skin flap necrosis if the tissue expander is air-filled (OR, 0.7; P = 0.6). CONCLUSION: The medium used in immediate intraoperative tissue expansion affects postoperative outcomes of patients undergoing delayed immediate prepectoral breast reconstruction. Here, we demonstrate that air-filled tissue expanders were associated with significantly less postoperative complications following breast reconstruction relative to saline-filled tissue expanders.

Poly-4-Hydroxybutyric Acid Mesh Compares Favorably With Acellular Dermal Matrix in Tissue Expander-Based Breast Reconstruction.

Acellular dermal matrix (ADM) is commonly used during immediate expander-based breast reconstruction, with potential advantages of greater intraoperative expansion, decreased time to complete expansion, and decreased rates of capsular contracture. However, ADM is associated with increased infection rate, seroma, and subsequent reconstructive failure. Poly-4-hydroxybutyric acid (P4HB) mesh is a large pore, biosynthetic scaffold shown to fully resorb and incorporate host tissues within 18 months. We sought to compare outcomes between the use of P4HB and ADM in immediate retropectoral expander-based reconstruction. One hundred ninety-two consecutive cases (107 patients) of breast reconstruction using ADM were compared with a subsequent cohort of 112 cases (62 patients) using P4HB mesh. In all patients, reconstruction was performed immediately after mastectomy by a single surgeon, and outcomes were compared between groups. Baseline characteristics were similar between the P4HB and ADM groups. Overall infection rates were lower, but not significantly with P4HB (11% vs 17%, P = 0.18). Time to drain removal was significantly lower with P4HB (15 vs 18 days, P = 0.008), although there was no difference in rates of seroma (0.9% vs 3%, P = 0.43). Similar numbers of patients underwent external beam radiation (22% vs 24%) and received chemotherapy in each group (48% vs 45%). By univariate analysis, all odds ratios were decreased with use of P4HB, including risk of major complications (0.55), seroma (0.17), infection (0.59), need for reoperation (0.78), and skin necrosis (0.77). Initial findings suggest P4HB mesh to be a safe alternative to ADM in expander-based breast reconstruction, with trends toward decreased rates of infection, seroma, and need for device removal using P4HB mesh. Although our results are limited to a small series of initial patients, P4HB mesh may be a promising novel technique to decrease complications inherent to use of ADM at a reduced material cost.

New economical and simple device for intraoperative expansion on small and medium sized soft tissue defects.

Intraoperative expansion has been used to cover small to large defects without disadvantages of the conventional tissue expanders. Various materials, for example, expanders and Foley catheters are being used. We introduce a new, convenient and economical device immediately available in the operating room, according to the defect size for intraoperative expansion, with latex gloves or balloons. The retrospective study was done with 20 patients who presented with skin and soft tissue defects. During the operation, expansion was done with latex gloves or balloons inflated with saline through an intravenous line and a three-way stopcock. After the inflation, the glove was removed and skin was covered with expanded tissue. A careful decision was made regarding the inflation volume and placement of the expander according to the defect size. There were no postoperative complications. The skin contracture and tension was minimal with a texture similar to the adjacent tissue. The new intraoperative expansion devices with latex gloves and balloons were cheap and made easily right in the operation room. The reconstruction of small to large sized skin defects can be done successfully, functionally and aesthetically without using expensive commercial materials.

Endoscopic Delayed Breast Reconstruction With Expanders and Implants via the Axillary Incision Made for Sentinel Lymph Node Biopsy or Lymphadenectomy.

Classic techniques of delayed prosthetic breast reconstruction use the mastectomy scar as an access route. As a result, the filling of the expander must be postponed until the wounds have healed. This creates an asymmetry between the breasts with the volume changes caused by the filling of the expander, which may occur over several weeks and cause considerable discomfort. Delayed breast reconstruction was performed via the axillary incision made for sentinel lymph node biopsy or lymphadenectomy with endoscopic assistance and detachment of the pectoralis major muscle. The filling of the expander and symmetrization with the contralateral breast was performed in the first stage.The expander was replaced with the definitive prosthesis 3 months later, after endoscopic capsulotomy. Fat grafting was performed to create a lipobed around the implant and to improve tissue quality. Sixty-two patients underwent surgery. Mean follow-up was 19 months. There were no major complications in the reconstructed breast. One case of hematoma in a contralateral breast reduction and an oil cystic mass secondary to fat grafting were recorded. In all cases, the filling of the expander with the definitive volume was possible during the first stage. Endoscopic delayed breast reconstruction with insertion of implants through the axillary incision for sentinel node biopsy or lymphadenectomy is safe and feasible. It achieves complete intraoperative expansion, symmetry between the volumes of the breasts during the first stage, and avoids problems with the scar and the risk of extrusion, as the scar is placed remotely in the axilla.

Adjuvant Therapy for Revision Rhinoplasty of Contracted Nose Using Polydeoxyribonucleotide and Invasive Bipolar Radiofrequency.

Most cases of severely contracted nose require revision rhinoplasty and septoplasty, wherein preoperative and/or intraoperative expansion of nasal soft tissue is necessary for tension-free revision surgery. The present study aimed to evaluate the efficacy and safety of pre- and postoperative adjuvant therapy using polydeoxyribonucleotide (PDRN) and invasive, pulsed-type, bipolar, alternating current radiofrequency (RF) for revision surgery of a contracted nose. In total, 30 patients were treated with 16 sessions (8 preoperative sessions and 8 postoperative sessions) of intralesional injection of PDRN and invasive RF treatment using microneedle electrodes at 1-week intervals. One week after the final combined pretreatment using PDRN and invasive bipolar RF, the skin of contracted noses was sufficiently softened, and nasal skin mobility was notably improved in all the patients. During revision rhinoplasty and septoplasty, the contracted nasal skin in each patient was adequately released for proper covering of the nasal tip without tension. Postoperatively, 8 sessions of adjuvant therapy elicited marked clinical improvements in persistent nasal tip dimpling and contracture, septal deviation, and warping from the incomplete recovery of nasal contracture after revision surgery. In conclusion, our pre- and postoperative adjuvant therapies using PDRN and invasive bipolar RF remarkably improved the therapeutic outcomes of revision rhinoplasty and septoplasty for contracted skin of the nose without major side effects.

Abstract: Adipofascial Flap Versus ADM: An Intraoperative Selection Algorithm for Implant Coverage in Immediate Breast Reconstruction

PURPOSE: Acellular dermal matrix (ADM) has gained popularity1 to enhance lower pole coverage in immediate implant or expander reconstruction. Advantages of ADM include improved rapid reconstruction, postoperative expander filling and lower capsular contracture. Potential trade-offs include higher seroma, infection2,3 and cost. Alternatives for implant coverage include local fascial flaps and inferior dermal flaps as autologous options in select patients.4,5 Given the controversy about the use of ADM, this study provides an intraoperative algorithm for its selective use and review of clinical outcomes in two-stage immediate breast reconstruction. METHODS: A 2 year retrospective chart review of women who underwent the first-stage of two-stage immediate tissue expander reconstruction following skin-sparing mastectomy by two senior surgeons. Patients who had an inferior dermal flap were excluded. Patients were divided into two groups: Group 1 was reconstructed with ADM as an adjunct, and group 2 had a local adipofascial flap. Primary outcomes measures included intraoperative and first visit expander-fill volume, time to reach final fill volume, expansion ratios and clinic visits. Secondary outcome measures included the size of expander, pain during inpatient stay, and complications. RESULTS: 84 patients (148 expanders) were included: group 1 (ADM) had 41 patients (72 breasts) and group 2 (No ADM) had 43 patients (76 breasts). There were no statistical differences in patient demographics, mastectomy weight (P=0.10), and expander placement plane. There were no significant differences between the two groups of tissue expanders for intraoperative expansion volume (P=0.15), total expansion volume (P=0.28), and number of inflations required (P=0.18). Multivariate models adjusted for expander placement and postoperative radiation demonstrated that ADM patients had 0.13 higher expansion ratio intra-operatively (P=0.02) and at the first postoperative fill (P=0.001), but this did not differ significantly for final expansion volumes (P=0.58). There were 10 complications, 6 in the ADM and 4 in the no ADM groups. Complications were treated conservatively except two patients who had previous radiotherapy and requiring explantation for infection (ADM, N=1) and mastectomy skin flap necrosis (No ADM, N=1). CONCLUSION: We provide an anatomical and simple surgical approach to successfully assess and perform adipofascial flaps for implant coverage. Autologous adipofascial tissue, if present, can provide reliable comparable coverage to the inferior pole of the implant with no increased morbidity, complications, and comparable outcomes and can have a beneficial cost reduction. REFERENCES: 1. Gurunluoglu R, Gurunluoglu A, Williams SA, Tebockhorst S. Current trends in breast reconstruction: survey of American Society of Plastic Surgeons 2010. Ann Plast Surg. 2013;70(1):103–10. 2. Antony AK, McCarthy CM, Cordeiro PG, et al. Acellular human dermis implantation in 153 immediate two-stage tissue expander breast reconstructions: determining the incidence and significant predictors of complications. Plast Reconstr Surg. 2010;125(6):1606–14. 3. Berry T, Brooks S, Sydow N, et al. Complication rates of radiation on tissue expander and autologous tissue breast reconstruction. Ann Surg Oncol. 2010;17 Suppl 3:202–10. 4. Saint-Cyr M, Dauwe P, Wong C, Thakar H, Nagarkar P, Rohrich RJ. Use of the serratus anterior fascia flap for expander coverage in breast reconstruction. Plast Reconstr Surg. 2010;125(4):1057–64. 5. Kijima Y, Yoshinaka H, Owaki T, Funasako Y, Aikou T. Immediate reconstruction using inframammary adipofascial flap of the anterior rectus sheath after partial mastectomy. Am J Surg. 2007;193(6):789–91.

Abstract P2-13-06: Acellular dermal allograft fenestrations decrease outpatient expander fills and increase direct to implant incidence in implant-based immediate breast reconstruction

Abstract Introduction: The innovation of fenestrated allograft (acellular dermal matrix, ADM) has improved patient outcomes in two-stage tissue expander/implant breast reconstruction. This technical alteration utilizes optimal fenestration overlap and has enhanced the efficiency of the reconstructive experience. We present a follow-up study of one- and two-stage breast reconstruction with a more refined, standardized method of surgeon-designed fenestration of ADM. Methods: We conducted a retrospective review of 52 patients (91 breasts) having undergone one- and two-stage breast reconstruction using fenestrated ADM at our institution from 2013 to 2014. Results: Mean intra-operative fill volume (IOFV) measured 402cc (SD=118cc), and IOFV as a percent of tissue expander size averaged 79.1% (SD=16.7%). Ten breasts were expanded to 100% and completed reconstruction in one stage with implant placement. IOFV as a percentage of total fill volume at completion of expansion averaged 73.6% (SD=16.6%). Two-stage reconstruction patients underwent 1.8 post-operative expansions on average (range 0-4) and averaged 81.2cc (SD=29.3cc) per in-office expansion. Days to full expansion averaged 45.1 days, while days to exchange averaged 137.8 days (Table 1). Mean days to exchange between our first 24 breasts to complete reconstruction vs. our last 23 breasts to complete reconstruction differed significantly, with 205 ± 43.8 days vs. 137.7 ± 138.1 days, respectively (p=0.03). Table 1. Fill volume characteristics for 91 breasts after immediate reconstruction with fenestrated ADM. Data on tissue expander size was excluded.CharacteristicMinimumMaximumMeanSDTE size300700512.6108.3Intra-op fill (cc)150650402.1118Intra-op/TE size (%)44.1108.379.116.7Total fill (cc)31082537.6120.3Intra-op/Total fill (%)34.110073.616.6Total fill/TE size (%)76.9141.310813.2# of post-op expansions041.81.1Office fill per expansion (cc)31.322581.229.3Days to full expansion020445.141.8Days to exchange0554142117.9Implant size (cc)335800547.3126.9 The major complication rate requiring re-operation within 30 days post-operatively was 11.0%. Four breasts experienced partial mastectomy flap necrosis requiring re-operation with implant salvage (4.4%). Six breasts (6.6%) underwent explantation due to: infection (three), flap necrosis (two), and patient preference (one) (Table 2). Table 2. Complication rates in 91 breasts after immediate reconstruction with fenestrated ADM.Complicationsn%Minor 30-day complication22.2Major 30-day complication1011.030-Day take back for necrosis with salvage44.430-Day explant66.6Explant due to infection33.2Explant due to necrosis22.2Explant due to patient preference11.1Total 30-day complication1213.2 Conclusion: Our fenestrated technique is demonstrated to increase intra-operative fill volume, decrease number of post-operative expansions and time to full expansion, and improve expansion rate with subjectively less pain. We believe our patients benefited from improved cosmetic outcomes with better shape, maintenance of breast footprint, and enhanced comfort due to the decreased number of intra-office fills and increased intra-operative expansion. Citation Format: Daar DA, Bourgeois JM, Mowlds DS, Wirth GA, Paydar KZ. Acellular dermal allograft fenestrations decrease outpatient expander fills and increase direct to implant incidence in implant-based immediate breast reconstruction. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P2-13-06.

Comparison of subcutaneous versus submuscular expander placement in the first stage of immediate breast reconstruction

Tissue expander-based two-stage reconstruction remains the most commonly used technique in immediate breast reconstruction. This study compares the subcutaneous expander placement to the traditional submuscular placement and describes our early experience with the expander insertion plane-choosing algorithm. A retrospective study of patients who underwent two-stage immediate breast reconstruction from May 2012 to October 2014 was conducted. All expander insertion planes were chosen using the same algorithm. Expansion, pain, and complications were compared between two groups. The study included 88 patients (158 expanders; 50 subcutaneous and 108 submuscular). The subcutaneous group had a higher intraoperative expansion ratio (p<0.001), high first postoperative expansion ratio (p<0.001), shorter duration of expansion (p=0.02), less number of expansion visits (p=0.002), and less average pain during admission (p=0.004). Significant differences in the intraoperative and first postoperative expansion ratios in patients with postmastectomy radiation therapy were also found between the two groups (p=0.005 and 0.01, respectively). Complications during expansion and after second-stage autologous flap reconstruction were comparable between two groups. The subcutaneous expander placement was associated with greater intraoperative and first postoperative expansion, shorter expansion duration, less expansion visits, and less pain. With the expander insertion plane-choosing algorithm, subcutaneous expander placement could be performed with comparable complications rates with the submuscular placement during expansion and after second-stage autologous flap reconstruction. Further studies can be performed due to the lack of long-term complications following second-stage implant reconstruction in the subcutaneous approach.

Updated Evidence of Acellular Dermal Matrix Use for Implant-Based Breast Reconstruction: A Meta-analysis

Although the use of acellular dermal matrix (ADM) has increased exponentially, debates regarding its safety are still ongoing. There have been several meta-analyses; however, potential learning curve effects of using ADM might affect their outcomes. The present meta-analysis reappraised the potential benefits and risks of ADM on the outcome of implant-based breast reconstruction using recent publications. Electronic databases were searched to identify relevant studies comparing the outcome of ADM use with traditional submuscular technique, which were published from 2011 to 2014. The relative risks of postoperative complications and mean difference of expander dynamics between the two groups were computed. A total of 23 studies representing 6199 cases were analyzed. There was one randomized controlled study and three prospective cohort studies. The use of ADM significantly elevated the risks of infection, seroma, and mastectomy flap necrosis, but did not affect the risks of implant loss, unplanned reoperation, and total complications. The risks of capsular contracture and implant malposition were significantly reduced by the application of ADM. The ADM allows for significantly greater intraoperative expansion and reduced frequency of injection to complete expansion. According to this meta-analysis, the increasing risks for serious complication and overall morbidity related to ADM use might not be remarkable, while its benefits for preventing late complications and improving expander dynamics might be appreciable. Although future well-controlled studies would be required, the implant-based breast reconstruction using ADM may be reliable and advantageous.

Endoscopic-Assisted Neck Tissue Expansion in Reconstruction of Facial Burn Injuries

Endoscopic-assisted tissue expansion has been recently used in plastic surgery. However, there is limited evidence regarding its efficacy in reconstruction of facial burn injuries. Our study aimed to evaluate the utility of endoscopic-assisted neck tissue expansion in reconstruction of facial burn deformities. Through a prospective study, 42 consecutive patients with facial burn injuries attending a major referral center of plastic and reconstructive surgery in Iran underwent reconstruction of facial defects with endoscopic-assisted neck tissue expansion. Intraoperative events, expansion process, and postoperative outcomes were measured for this group of patients. The mean ± SD injected volume for intraoperative expansion was 66 ± 3.7 mL (range, 35-80 mL). The mean ± SD operative time was 45.6 ± 3.5 minutes. Moreover, the mean ± SD distance between the main access incision and the expander pocket was 5.6 ± 1.2 cm. Time to achieve full expansion ranged between 12 and 16 weeks, and the expanded volume at the time of reconstruction ranged from 400 to 800 mL. All the patients had less than 24 hours of hospital stay after placement of tissue expanders. There were only 2 minor complications during the postoperative follow-up including 1 case of seroma and 1 case of severe pain, which were treated conservatively. Endoscopic-assisted neck tissue expansion is associated with lower complication rate, shorter duration of hospitalization, reduced operative time, earlier initiation of expansion, and faster expansion process. It could be a feasible alternative to open technique in reconstructing facial burns, allowing smaller incision at port site, far placement of tissue expander, and excellent visualization of operation site.

Clinical application of intraoperative sustained skin and soft-tissue expansion in augmentation mammaplasty using transaxillary approach with endoscopic assistance

Objective To evaluate the results of prosthesis augmentation,relieve suffering patient experience,improve shape and touch of breast.Methods According to design,in dual-plane mammaplasty transaxillary approach with endoscopic assistance,we used soft-tissue expansion before prosthesis,saline volume in expander was the same as prosthesis size at beginning; adjusting expander volume and position,then determined prosthesis size according to expander volume lastly.after intraoperative sustained expansion for 30 to 60 minutes twice prosthes volume,replace expander with prosthesis.Results This method was applied in 120 patients,showing that pain significantly reduced after expansive without use of analgesia pump; complications included that 3 patients appeared seroma and absorbed soon; 2 patients had poor prosthese location,which was adjusted in reoperation; one capsular contracture was repaired later.After 6-months to 2-years follow-up,the results showed that breast was nature and dynamic; satisfactory rate reached to 95 ％.Conclusions In augmentation mammaplastic operation,pre-adoption of an expander can make it easy to adjust the location of prosthesis,to avoid being injured and to determine prosthesis volume by expander injection of saline volume,especially for patient with different size of both breasts. Key words: Skin and soft-tissue expansion; Intraoperative sustained expansion; Endoscopy; Augmentation mammaplasty

意外に役立つ intraoperative expansion － 頭皮･耳介部30症例の検討

意外に役立つ intraoperative expansion － 頭皮･耳介部30症例の検討

Pain Control in Augmentation Mammaplasty Using Indwelling Catheters in 687 Consecutive Patients: Data Analysis

Postoperative pain following augmentation mammaplasty can cause significant disability. In the authors' previously published prospective study of 644 consecutive augmentation mammaplasty patients, it was shown that the use of indwelling catheters for the postoperative instillation of bupivacaine is both safe and effective in postoperative pain management. This study analyzes a large population of augmentation mammaplasty patients to not only compare the effectiveness of catheter control with systemic analgesics but also to delineate sites of pain and determine if any of a variety of factors influence postoperative pain. Questionnaires were given to all patients to record the extent of pain reduction following the instillation of local anesthesia, patient preference for a variety of analgesics, and the locations of postoperative pain. Potential correlations to pain-including the number of children, age, handedness, preoperative fear, pain tolerance, and length of narcotic use-were investigated using statistical analysis. Operative aspects, such as the size of implants, use of asymmetrical implants, intraoperative expansion, duration of surgery, and sharp versus blunt dissection were also studied to determine if these factors influenced postoperative pain. Self-administration of bupivacaine the evening after surgery achieved pain reduction in 89% of patients. Patients gave high preference scores for the instillation of local anesthesia, comparable to rates achieved with the systemic narcotics Vicodin (Abbott Laboratories, Abbott Park, IL) and Percocet (Endo Pharmaceuticals, Chadds Ford, PA). Lower patient ratings were given to ibuprofen and methocarbamol. Patients identified multiple sites of postoperative pain, including the sternum, armpits, outer ribs, top of the breast (infraclavicular), interscapular region, and shoulders. Older patients experienced less pain. Patients who reported more pain, higher levels of fear, and sternal pain used narcotics for a longer period of time. Duration of surgery, blunt versus sharp dissection, and intraoperative expansion were not significantly related to pain. Combined implant size did not correlate with pain, though in the case of asymmetrical implants, greater pain (not statistically significant) on the larger side was reported. Postoperative pain following augmentation mammaplasty may be influenced by several factors, but these appear unrelated to implant size, specific operative techniques (blunt versus sharp dissection), or duration of surgery. Pain may involve not only the breasts, but also the sternum, sides of the chest, armpits, and infraclavicular and interscapular areas. The use of indwelling catheters for the instillation of a long-acting anesthetic is rated comparable in efficacy to the systemic narcotics Vicodin and Percocet. Sternal pain can be severe and may require narcotics for effective pain control.

Endoscopic Breast Reconstruction With Intraoperative Complete Tissue Expansion and Partial Detachment of the Pectoralis Muscle

We present the surgical technique for mammary reconstruction using tissue expander with endoscopic approach, associated to partial detachment of the pectoralis muscle at the fourth rib and complete or nearly complete intraoperative expansion. Tissue expansion for breast reconstruction is a well-honored technique that provides satisfying esthetic outcomes, with minimal morbidity for the patient. Nevertheless, this technique has some potential problems: (1) wound dehiscence with extrusion of the expander; (2) the patient discomfort during the expansion process (weekly visits for the refill of the expander); (3) the poor definition of the lower pole of the breast and cranial migration of the expander with excessive roundness of the upper pole. By using intraoperative tissue expansion, these drawbacks can be avoided. We report herein our experience with this technique in 53 consecutive patients (56 breasts) undergoing a secondary breast reconstruction since December 2001.