Sharaf, Basel

Background: Intrathoracic fistulas pose unique challenges for thoracic and reconstructive surgeons. To decrease the incidence of fistula recurrence, pedicled flaps have been suggested to buttress the repair site. The authors aimed to report their experience with muscle flap transposition for the management of intrathoracic fistulas. Methods: A retrospective review of all patients who underwent intrathoracic muscle flap transposition for the management of intrathoracic fistulas from 1990 to 2010 was conducted. Patient demographics, surgical characteristics, and complication rates were abstracted and analyzed. Results: A total of 198 patients were identified. Bronchopleural fistula was present in 156 of the patients (79 percent), and 48 had esophageal fistula (24 percent). A total of 238 flaps were used, constituting an average of 1.2 flaps per patient. After the initial fistula repair, bronchopleural fistula complicated the course of 34 patients (17 percent), and esophageal fistula occurred in 13 patients (7 percent). Partial flap loss was identified in 11 flaps (6 percent), and total flap loss occurred in four flaps (2 percent). Median follow-up was 27 months. At the last follow-up, 182 of the patients (92 percent) had no evidence of fistula, 175 (89 percent) achieved successful chest closure, and 164 (83 percent) had successful treatment. Preoperative radiation therapy and American Society of Anesthesiologists score of 4 or greater were identified as risk factors for unsuccessful treatment. Conclusions: Intrathoracic fistulas remain a source of major morbidity and mortality. Reinforcement of the fistula closure with vascularized muscle flaps is a viable option for preventing dehiscence of the repair site and can be potentially life-saving. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Background: Prepectoral implant-based reconstruction reemerged as a viable approach following recent advances in reconstructive techniques and technology. To achieve successful outcomes, careful patient selection is critical. Obesity increases the risk of complications and has been suggested as a relative contraindication for prepectoral breast reconstruction. Methods: Retrospective chart review of patients who underwent immediate two-stage implant-based reconstruction at the authors’ institution was performed. Only women having a body mass index of 30 kg/m2 or greater were included. Patient demographics, operative details, and surgical outcomes of prepectoral and subpectoral reconstruction were compared. Results: One hundred ten patients (189 breasts) who underwent prepectoral and 83 (147 breasts) who underwent subpectoral reconstruction were included. Complications were comparable between the two groups. Twelve devices (6.4 percent), including implants and tissue expanders, required explantation in the prepectoral group, and 12 devices (8.2 percent) required explantation in the subpectoral group (p =0.522). Final implant-based reconstruction was achieved in 180 breasts (95.2 percent) in the prepectoral group and 141 breasts (95.9 percent) in the subpectoral group. Regardless of type of reconstruction (prepectoral or subpectoral), for each point increase in body mass index, the odds of complications and device explantation increased by 3.4 percent and 8.6 percent, respectively; and the optimal cutoff to predict higher complications and explantation rates was a body mass index of 34.8 kg/m2 and 34.1 kg/m2, respectively. Conclusions: Obesity increases complications and failure rates in a positive correlation; however, complications and final reconstruction rates are comparable between the prepectoral and subpectoral groups. The authors believe that obesity should not be a contraindication for prepectoral breast reconstruction but that care should be taken in patients with a body mass index above 35 kg/m2. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Background Implant-based breast reconstruction (IBR) accounts for 70% of postmastectomy reconstructions in the United States. Improving the quality of surgical care in IBR patients through accurate measurements of outcomes is necessary. The purpose of this study is to compare the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) data from our institution to our complete institutional health records database. Methods Data were collected and recorded for all patients undergoing IBR at our institution from 2015 to 2017. The data were completely identified and compared with our institutional NSQIP database for demographics and complications. Results The electronic health records data search identified 768 IBR patients in 3 years and NSQIP reported on 229 (30%) patients. Demographics were reported similarly among the 2 databases. Rates of tissue expander/implant infections (5.9% vs 1.8%; P = 0.003) and wound dehiscence (3.5% vs 0.4%; P = 0.003) were not reported similarly between our database and NSQIP. However, the rates of hematoma (2.7% vs 1.8%) and skin flap necrosis (2.5% vs 1.8%) were comparable between the two databases. In our database, 43% of all complications presented after 30 days of surgery, beyond NSQIP's capture period. Conclusions Databases built on partial sampling, such as the NSQIP, may be useful for demographic analyses, but fall short of providing data for complications after IBR, such as infections and wound dehiscence. These results highlight the utility and importance of complete databases. National comparisons of clinical outcomes for IBR should be interpreted with caution when using partial databases.

Abstract Objective Implant-based breast reconstruction after mastectomy remains the most common reconstructive modality worldwide. Infection is a frequent complication that negatively affects the reconstructive outcome and increases health-care costs. The aim of this study is to evaluate the accuracy of ultrasonography in identifying fluid collections in patients with breast implant infection. Methods After receiving institutional review board approval, a retrospective chart review was performed on patients who presented with breast implant infection after breast reconstruction, during the period 2009–2017. To estimate the sensitivity and specificity of ultrasound (US) in detecting fluid collections, only patients with US evaluation and surgery during the same admission were included. Results In total, 64 patients with 64 infected implants met the inclusion criteria. Infected devices included 44 (69%) tissue expanders, and 20 (31%) implants, of which 40 (62%) were placed in the subpectoral and 24 (38%) prepectoral positions. Periprosthetic fluid was identified by US preoperatively in 45 (70%) of the patients, and a fluid collection was found in 61 (95%) of the patients during surgery. Sensitivity and specificity of US were 74% and 100%, respectively. Inaccurate US results were more likely in patients with silicone implants than patients with saline expander implants. Conclusion Caution should be exercised in interpreting negative US findings in patients with silicone implants in the setting of infection. Other imaging modalities should be explored if US results are negative in cases with high clinical suspicion.

Background: The eyebrows play an important role in emotional facial expressions, nonverbal communication, and facial esthetics. A comprehensive understanding of the mechanisms underlying eyebrow aging is vital in allowing plastic surgeons to appropriately address these age-related changes and to recreate an aesthetically desirable outcome for patients seeking brow rejuvenation. The aim of this study is to summarize the current literature on eyebrow height changes with aging. Methods: A comprehensive search was conducted across several databases to identify all published studies that reported changes of eyebrow position or height with aging, from 1946 to January 2019. Studies that reported eyebrow position at the level of medial canthus, mid-pupil, and lateral canthus were included in a meta-analysis. Results: A total of 346 articles were initially identified, of which 19 met our inclusion criteria. Of 3,634 patients who were identified, 2,237 (64%) were females and 1,274 (36%) were males. Eyebrow height showed significant increase with aging at the level of medial canthus (mean difference 1.4 mm; 95% CI: 0.22–2.59; P = 0.02), and the level of mid-pupil (mean difference 1.17 mm; 95% CI: 0.54–1.8; P = 0.0002). However, no significant difference was found at the level of lateral canthus (mean difference 0.19 mm; 95% CI: −0.87 to 1.25; P = 0.72). Conclusions: Based on the reviewed literature to date, the medial eyebrow height increases with age, whereas it remains stable at the level of the lateral canthus. These results should be considered when considering eyebrow rejuvenation.

Background Postsurgical complications have been an increasing concern for hospitals, particularly in light of payment reform. The costs to the health care system are increasing in light of Medicare penalties for readmissions for certain conditions. Surgical site infection following implant-based breast reconstruction (IBR) remains challenging. The rates of positive cultures and isolated microorganisms in IBR are unknown. This systematic review summarizes the reported microorganisms and positive culture rates in the existing literature. Methods A systematic review was performed using the guidelines outlined in Preferred Reporting Items for Systematic Reviews and Meta-analyses. Articles were included if breast implant infection rates and culture results were reported. Further subgroup analysis of culture positive infections was performed. Results A total of 25 studies were included, encompassing 25,177 IBR. Implant infections were reported in 1356 reconstructions (5.4%). Cultures were positive in 74.5% of infections. Gram-positive bacteria were the most common (68.6%), of which Staphylococcus species (51%) was the most isolated pathogen, followed by Pseudomonas. A subgroup analysis showed that early infections (63% vs 88%), radiotherapy (82% vs 93%), and acellular dermal matrix use (90% vs 100%) were associated with lower positive culture rates than their respective counterparts. Patients who received chemotherapy had higher positive culture results (94% vs 83%). Isolated microorganisms also varied among the subgroups. Conclusions This systematic review outlines reported microorganisms in IBR. Staphylococcus species and Pseudomonas were the most frequently reported microorganism. Negative cultures were reported in up to 25.5% of infections. Patients with early infections, radiotherapy, and acellular dermal matrix demonstrated higher negative culture rates. This review can help guide the use of empirical antimicrobial therapy in IBR.

Background: Surgical-site infection after implant-based breast reconstruction adversely affects surgical outcomes and increases health care costs. This 11-year case-control study examines risk factors specific for surgical-site infection after immediate tissue expander/implant-based breast reconstruction. Methods: The authors performed a retrospective review to identify all consecutive patients with breast implant infections between 2006 and 2016. Patients who developed surgical-site infection after immediate tissue expander/implant-based breast reconstruction were included. Surgical-site infection was defined using the Centers for Disease Control and Prevention criteria; specifically, infections requiring hospital admission, intravenous antibiotics, or surgical intervention were included. The authors matched a control patient to each infection case by patient age and date of surgery. Patient demographics, medical comorbidities, and perioperative surgical variables were examined. Univariate and multivariable conditional logistic regression models were constructed. Results: A total of 270 breasts in 252 patients were evaluated. On multivariate analysis, patients with a higher body mass index (OR, 1.1 per 1 body mass index point increase; 95 percent CI, 1.0 to 1.2; p = 0.02), hypertension (OR, 6.5; 95 percent CI, 1.9 to 22.3; p = 0.002), neoadjuvant chemotherapy (OR, 2.6; 95 percent CI, 1.0 to 6.3; p = 0.04), axillary lymph node dissection (OR, 7.1; 95 percent CI, 1.7 to 29.2; p = 0.006), seroma formation (OR, 15.34; 95 percent CI, 3.7 to 62.5; p = 0.0001), and wound healing complications (OR, 23.91; 95 percent CI, 6.1 to 93.4; p < 0.0001) were significantly associated with surgical-site infection. Conclusions: Women with obesity, women with hypertension, and those treated with neoadjuvant chemotherapy are at increased risk of surgical-site infection. Further risks are also associated with postoperative seroma and wound complications. This may help patient selection and counseling, adjusted based on risk factors regarding complications of immediate implant-based breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Background: Pediatric calvarial reconstruction is challenging because of the unique anatomical and growth considerations in this population. Comparative studies evaluating current cranioplasty materials are lacking. This review addresses the knowledge gap in pediatric cranioplasty outcomes with emphasis on current materials used. Methods: A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Outcome data comparing fresh bone, banked bone, titanium, poly(methyl methacrylate), and polyetheretherketone were abstracted. Results: Twenty studies met the authors’ selection criteria. The mean patient age ranged from 4 to 17.4 years. Autologous cranioplasty was performed in 439 patients, and 201 patients underwent alloplastic reconstruction. Fresh bone grafts and titanium mesh were associated with the lowest infection rates (0.4 percent and 3.3 percent, respectively; p < 0.001), graft failures (2.9 percent and 3.3 percent, respectively; p < 0.001), and surgical-site occurrence rates (8.8 percent and 6.7 percent, respectively; p < 0.001). Banked bone flaps had the highest overall complication rates (51 percent; p < 0.001), bone resorption (39.7 percent; p < 0.001), and failure rates (40.2 percent; p < 0.001), whereas polyetherether ketone had the highest rates of infection (16.1 percent; p < 0.001). Conclusions: Based on the available evidence to date, fresh bone grafts and titanium mesh demonstrated the lowest surgical-site infection, surgical-site occurrence, and graft failure rates. Banked bone flaps had the highest overall surgical-site complications and graft failures. Pediatric cranioplasty outcomes studies are needed to evaluate current and novel cranioplasty materials.

Background and objectives: Differences in patient anatomy and physiology exist between young and older patients undergoing breast reconstruction after mastectomy. Breast cancer has been described as being more aggressive, more likely to receive radiation, contralateral mastectomy, as well as bilateral reconstruction in young patients. Our purpose is to report long-term experience on two-staged implant-based breast reconstruction (IBR) in young females, with complication sub-analysis based on obesity and adjuvant radiation. Materials and Methods: Retrospective chart review of all consecutive young patients who underwent two-staged IBR at our institution, between 2000 and 2016, was performed. Patients between 15 and 40 years old with least 1-year follow-up were included. Univariate logistic regression models and receiver operating characteristic (ROC) curves were created. Results: Overall 594 breasts met our inclusion criteria. The mean age was 34 years, and the median follow-up was 29.6 months. Final IBR was achieved in 98% of breasts. Overall, 12% of breasts had complications, leading to explantations of 5% of the devices. Adjuvant radiation was followed by higher rates of total device explantations (p = 0.003), while obese patients had higher rates of total complications (p < 0.001). For each point increase in BMI, the odds of developing complications increased 8.1% (p < 0.001); the cutoff BMI to predict higher complications was 24.81 kg/m2. Conclusions: This population demonstrates high successful IBR completion and low explantation rates. These data suggest that obese women and those with planned adjuvant radiation deserve special counseling about their higher risk of complications.

Background: Oncologic sternectomy results in complex defects where preoperative planning is paramount to achieve best reconstructive outcomes. Although pectoralis major muscle flap (PMF) is the workhorse for sternal soft tissue coverage, additional flaps can be required. Our purpose is to evaluate defects in which other flaps beside PMF were required to achieve optimal reconstruction. Methods: A retrospective review of consecutive patients at our institution who underwent reconstruction after sternal tumor resection was performed. Demographics, surgical characteristics, and outcomes were evaluated. Further analysis was performed to identify defect characteristics where additional flaps to PMF were needed to complete reconstruction. Results: In 11 years, 60 consecutive patients were identified. Mean age was 58 (28–81) years old, with a mean follow-up of 40.6 (12–64) months. The majority were primary sternal tumors (67%) and the mean defect size was 148 cm2 (±81). Fourteen (23%) patients presented with postoperative complications, and the 30-day mortality rate was 1.6%. In 19 (32%) cases, additional flaps were required; the most common being the rectus abdominis muscle flaps. Larger thoracic defects (P = 0.011) and resections involving the inferior sternum (P = 0.021) or the skin (P = 0.011) were more likely to require additional flaps. Conclusions: Reconstruction of oncologic sternal defects requires a multidisciplinary team approach. Larger thoracic defects, particularly those that involve the skin and the inferior sternum, are more likely to require additional flaps for optimal reconstruction.