Synergistic interactions with a high intraoperative expander fill volume increase the risk for mastectomy flap necrosis

Nima Khavanin,Sumanas Jordan,Francis Lovecchio,Neil A. Fine,John Kim 한국유방암학회 2013 Journal of breast cancer Vol.16 No.4

Purpose: Prosthetic-based breast reconstruction is performedwith increasing frequency in the United States. Major mastectomyskin flap necrosis is a significant complication with outcomesranging from poor aesthetic appearance to reconstructivefailure. The present study aimed to explore the interactionsbetween intraoperative fill and other risk factors on the incidenceof flap necrosis in patients undergoing mastectomy with immediateexpander/implant-based reconstruction. Methods: A retrospectivereview of 966 consecutive patients (1,409 breasts) whounderwent skin or nipple sparing mastectomy with immediatetissue expander reconstruction at a single institution was conducted. Age, body mass index, hypertension, smoking status,premastectomy and postmastectomy radiation, acellular dermalmatrix use, and application of the tumescent mastectomy techniquewere analyzed as potential predictors of flap necrosis bothindependently and as synergistic variables with high intraoperativefill. The following three measures of interaction were calculated:relative excess risk due to interaction, attributable proportionof risk due to interaction, and synergy index (SI). Results: Intraoperativetissue expander fill volume was high (≥66.7% of themaximum volume) in 40.9% (576 of 1,409 breasts) of cases. Theunadjusted flap necrosis rate was greater in the high intraoperativefill cohort than in the low fill cohort (10.4% vs. 7.1%, p=0.027). Multivariate logistic regression did not identify high intraoperativefill volume as an independent risk factor for flap necrosis(odds ratio 1.442, 95% confidence interval 0.973-2.137, p=0.068). However, four risk factors were identified that interactedsignificantly with intraoperative fill volume, namely tumescence,age, hypertension, and obesity. The SI, or the departure from additiverisks, was largest for tumescence (SI, 25.3), followed byhypertension (SI, 2.39), obesity (SI, 2.28), and age older than 50years (SI, 1.17). Conclusion: In the postmastectomy, hypovascularmilieu, multiple risk factors decreasing flap perfusion interactwith high intraoperative fill volume to cross a threshold and synergisticallyincrease the risk of flap necrosis.

A Prospective Analysis of Dynamic Loss of Breast Projection in Tissue Expander-Implant Reconstruction

Mioton, Lauren M.,Jordan, Sumanas W.,Kim, John Y.S. Korean Society of Plastic and Reconstructive Surge 2015 Archives of Plastic Surgery Vol.42 No.3

Background Breast projection is a critical element of breast reconstruction aesthetics, but little has been published regarding breast projection as the firm expander is changed to a softer implant. Quantitative data representing this loss in projection may enhance patient education and improve our management of patient expectations. Methods Female patients who were undergoing immediate tissue-expander breast reconstruction with the senior author were enrolled in this prospective study. Three-dimensional camera software was used for all patient photographs and data analysis. Projection was calculated as the distance between the chest wall and the point of maximal projection of the breast form. Values were calculated for final tissue expander expansion and at varying intervals 3, 6, and 12 months after implant placement. Results Fourteen breasts from 12 patients were included in the final analysis. Twelve of the 14 breasts had a loss of projection at three months following the implant placement or beyond. The percentage of projection lost in these 12 breasts ranged from 6.30% to 43.4%, with an average loss of projection of 21.05%. Conclusions This study is the first prospective quantitative analysis of temporal changes in breast projection after expander-implant reconstruction. By prospectively capturing projection data with three-dimensional photographic software, we reveal a loss of projection in this population by three months post-implant exchange. These findings will not only aid in managing patient expectations, but our methodology provides a foundation for future objective studies of the breast form.

The Relationship between Preoperative Wound Classification and Postoperative Infection: A Multi-Institutional Analysis of 15,289 Patients

Mioton, Lauren M.,Jordan, Sumanas W.,Hanwright, Philip J.,Bilimoria, Karl Y.,Kim, John Y.S. Korean Society of Plastic and Reconstructive Surge 2013 Archives of Plastic Surgery Vol.40 No.5

Background Despite advances in surgical techniques, sterile protocols, and perioperative antibiotic regimens, surgical site infections (SSIs) remain a significant problem. We investigated the relationship between wound classification (i.e., clean, clean/contaminated, contaminated, dirty) and SSI rates in plastic surgery. Methods We performed a retrospective review of a multi-institutional, surgical outcomes database for all patients undergoing plastic surgery procedures from 2006-2010. Patient demographics, wound classification, and 30-day outcomes were recorded and analyzed by multivariate logistic regression. Results A total of 15,289 plastic surgery cases were analyzed. The overall SSI rate was 3.00%, with superficial SSIs occurring at comparable rates across wound classes. There were similar rates of deep SSIs in the clean and clean/contaminated groups (0.64%), while rates reached over 2% in contaminated and dirty cases. Organ/space SSIs occurred in less than 1% of each wound classification. Contaminated and dirty cases were at an increased risk for deep SSIs (odds ratios, 2.81 and 2.74, respectively); however, wound classification did not appear to be a significant predictor of superficial or organ/space SSIs. Clean/contaminated, contaminated, and dirty cases were at increased risk for a postoperative complication, and contaminated and dirty cases also had higher odds of reoperation and 30-day mortality. Conclusions Analyzing a multi-center database, we found that wound classification was a significant predictor of overall complications, reoperation, and mortality, but not an adequate predictor of surgical site infections. When comparing infections for a given wound classification, plastic surgery had lower overall rates than the surgical population at large.

A Prospective Analysis of Dynamic Loss of Breast Projection in Tissue Expander-Implant Reconstruction

Lauren M Mioton,Sumanas W Jordan,John YS Kim 대한성형외과학회 2015 Archives of Plastic Surgery Vol.42 No.3

Background Breast projection is a critical element of breast reconstruction aesthetics, but little has been published regarding breast projection as the firm expander is changed to a softer implant. Quantitative data representing this loss in projection may enhance patient education and improve our management of patient expectations. Methods Female patients who were undergoing immediate tissue-expander breast reconstruction with the senior author were enrolled in this prospective study. Three-dimensional camera software was used for all patient photographs and data analysis. Projection was calculated as the distance between the chest wall and the point of maximal projection of the breast form. Values were calculated for final tissue expander expansion and at varying intervals 3, 6, and 12 months after implant placement. Results Fourteen breasts from 12 patients were included in the final analysis. Twelve of the 14 breasts had a loss of projection at three months following the implant placement or beyond. The percentage of projection lost in these 12 breasts ranged from 6.30% to 43.4%, with an average loss of projection of 21.05%. Conclusions This study is the first prospective quantitative analysis of temporal changes in breast projection after expander-implant reconstruction. By prospectively capturing projection data with three-dimensional photographic software, we reveal a loss of projection in this population by three months post-implant exchange. These findings will not only aid in managing patient expectations, but our methodology provides a foundation for future objective studies of the breast form.

The Relationship between Preoperative Wound Classification and Postoperative Infection: A Multi-Institutional Analysis of 15,289 Patients

Lauren M Mioton,Sumanas W Jordan,Philip J Hanwright,Karl Y Bilimoria,John YS Kim 대한성형외과학회 2013 Archives of Plastic Surgery Vol.40 No.5

Background Despite advances in surgical techniques, sterile protocols, and perioperative antibiotic regimens, surgical site infections (SSIs) remain a significant problem. We investigated the relationship between wound classification (i.e., clean, clean/contaminated, contaminated,dirty) and SSI rates in plastic surgery. Methods We performed a retrospective review of a multi-institutional, surgical outcomes database for all patients undergoing plastic surgery procedures from 2006-2010. Patient demographics, wound classification, and 30-day outcomes were recorded and analyzed by multivariate logistic regression. Results A total of 15,289 plastic surgery cases were analyzed. The overall SSI rate was 3.00%,with superficial SSIs occurring at comparable rates across wound classes. There were similar rates of deep SSIs in the clean and clean/contaminated groups (0.64%), while rates reached over 2% in contaminated and dirty cases. Organ/space SSIs occurred in less than 1% of each wound classification. Contaminated and dirty cases were at an increased risk for deep SSIs (odds ratios, 2.81 and 2.74, respectively); however, wound classification did not appear to be a significant predictor of superficial or organ/space SSIs. Clean/contaminated, contaminated,and dirty cases were at increased risk for a postoperative complication, and contaminated and dirty cases also had higher odds of reoperation and 30-day mortality. Conclusions Analyzing a multi-center database, we found that wound classification was a significant predictor of overall complications, reoperation, and mortality, but not an adequate predictor of surgical site infections. When comparing infections for a given wound classification,plastic surgery had lower overall rates than the surgical population at large.