Biomedical subjects
Publications and source records attributed to Maurice Y Nahabedian.
The long-term affects of primary breast augmentation is a topic of controversy. This case report will highlight the long-term outcome in a woman with Ivalon sponge breast implants and the reasons for explantation. The focus of the manuscript will include mammography, capsular contracture, and late hematoma.
BACKGROUND: Subcutaneous mastectomy for women with advanced breast cancer has been historically controversial because of the increased risk for tumor recurrence. Despite this, some women remain interested in this method of treatment as a means of preserving the appearance of the breast and nipple-areola complex. Several studies have evaluated the feasibility of subcutaneous mastectomy; however, there has been no study that has critically analyzed the aesthetic outcome of the nipple-areola complex following this approach. METHODS: Over a 14-month interval, 12 women had subcutaneous mastectomy with preservation of the nipple-areola complex. The reconstruction was unilateral in 10 women and bilateral in two women, totaling 14 breasts. The mastectomy was for cancer in 11 and for prophylaxis in three breasts. Outcomes were assessed based on the sensation, appearance, and secondary procedures of the nipple-areola complex, and tumor recurrence and patient satisfaction. RESULTS: Of the five parameters, sensation was present in six breasts (42.9 percent), delayed healing was noted in four breasts (28.6 percent), symmetry with the contralateral breast was achieved in five of 10 women (50 percent) following unilateral reconstruction, tumor recurrence was noted in three of 11 breasts (27.3 percent), and secondary procedures related to the nipple-areola complex were necessary in five of the 14 breasts (35.7 percent). Outcome was graded as excellent in three, good in eight, and poor in three breasts. CONCLUSION: This study has demonstrated that aesthetic outcome of the nipple-areola complex is variable following subcutaneous mastectomy and immediate breast reconstruction. However, patient satisfaction was graded as good to excellent in 11 of 14 breasts (78.6 percent). Subcutaneous mastectomy with flap reconstruction results in fewer secondary procedures and improved aesthetic outcome when compared with implant reconstruction.
BACKGROUND: The body of literature documenting normative breast sensation and postoperative changes in sensation after reduction mammaplasty has grown considerably over the last several years. Despite this, only two studies have ever been published on the subject of postaugmentation mammaplasty sensory outcomes. The purpose of this study was to precisely measure sensory thresholds at the nipple-areola complex in women who have undergone augmentation mammaplasty by either the inframammary or periareolar approach. METHODS: Twenty women underwent primary augmentation mammaplasty by either the periareolar or inframammary approach at an average follow-up of 1.12 years. Sensory testing was performed using the Pressure-Specified Sensory Device by comparing moving and static sensory thresholds at the upper and lower areola and nipple. Nine women served as size-matched, nonoperated controls in the study. RESULTS: Primary augmentation mammaplasty was found to have a statistically significant negative effect on sensory outcomes when nonoperated controls were compared with women who had undergone augmentation mammaplasty via either the periareolar or inframammary approach. No differences in sensory outcomes were found between the two approaches used. Implant volume was found to be highly predictive of sensory outcomes, with an inverse relationship between implant size and the degree of sensitivity within the nipple-areola complex. CONCLUSIONS: Plastic surgeons should feel comfortable counseling patients that augmentation mammaplasty by either the inframammary or periareolar approach results in no discernible differences in sensory outcomes. Furthermore, women who choose very large implants relative to their breast skin envelopes should be warned about potential adverse sensory sequelae within the nipple-areola complex.
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The surgical management of melanoma continues to evolve. A large body of information serves as a foundation for the oncologic principles, surgical excisions, and reconstructive methodologies that are currently in use. This article serves as a guide for the physician considering surgical management of the melanoma patient.
Microsurgeons currently employ the internal mammary artery and vein as recipient vessels for microvascular reconstruction of the breast with increasing frequency. Recent reports have demonstrated that the perforating branches of the internal mammary artery and vein can also be used as recipient vessels. The purpose of the following cadaver study was to determine the location and diameter of these internal mammary perforators and whether they are suitable as recipient vessels. Ten fresh cadavers were obtained for this project. Using a micrometer under loupe magnification, bilateral measurements were taken of the perforators from the first five interspaces. The largest arterial perforator averaged 1.74 mm in diameter and the largest venous perforator averaged 1.78 mm in diameter. The largest perforators were most commonly found in the second interspace. Based on the results of this study, the internal mammary perforators appear to have suitable diameter for microvascular anastomosis and should be considered.
The advantages of breast reconstruction using the deep inferior epigastric perforator (DIEP) flap and the muscle-sparing free transverse rectus abdominis musculocutaneous (TRAM) flap (MS-2) are well recognized. Both techniques optimize abdominal function by maintaining the vascularity, innervation, and continuity of the rectus abdominis muscle. The purpose of this study was to compare these two methods of breast reconstruction and determine whether there is a difference in outcome. The study considered 177 women who have had breast reconstruction using muscle-sparing flaps over a 4-year period. This includes 89 women who had an MS-2 free TRAM flap procedure, of which 65 were unilateral and 24 were bilateral, and 88 women who had a DIEP flap procedure, of which 66 were unilateral and 22 were bilateral. The total number of flaps was 223. Mean follow-up was 23 months (range, 3 to 49 months). For all MS-2 free TRAM flaps (n = 113), outcome included fat necrosis in eight (7.1 percent), venous congestion in three (2.7 percent), and total necrosis in two (1.8 percent). For the women who had an MS-2 free TRAM flap, an abdominal bulge occurred in three women (4.6 percent) after unilateral reconstruction and in five women (21 percent) after bilateral reconstruction. The ability to perform sit-ups was noted in 63 women (97 percent) after unilateral reconstruction and 20 women (83 percent) after bilateral reconstruction. For all DIEP flaps (n = 110), outcome included fat necrosis in seven (6.4 percent), venous congestion in five (4.5 percent), and total necrosis in three (2.7 percent) patients. For the women who had DIEP flap reconstruction, an abdominal bulge occurred in one woman (1.5 percent) after unilateral reconstruction and in one woman (4.5 percent) after bilateral reconstruction. The ability to perform sit-ups was noted in all women after unilateral reconstruction and in 21 women (95 percent) after bilateral reconstruction. These results demonstrate that there are no significant differences in fat necrosis, venous congestion, or flap necrosis after DIEP or MS-2 free TRAM flap reconstruction. The percentage of women who are able to perform sit-ups and the percentage of women who did not develop a postoperative abdominal bulge is increased after DIEP flap reconstruction; however, this difference is not statistically significant.
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The etiology of lower abdominal bulge following breast reconstruction with the DIEP flap is uncertain. Most studies report an incidence that ranges from 0.7% to 5%. The purpose of this study was to review a set of factors that may predispose to a lower abdominal bulge. This was a retrospective review of 123 women who had breast reconstruction with the DIEP flap over a 4-year period. The reconstruction was unilateral in 93 women and bilateral in 30 women, totaling 153 flaps. Etiologic factors that were evaluated included patient age, diabetes mellitus, tobacco use, previous abdominal operations, unilateral or bilateral reconstruction, previous childbirth, aponeurotic plication to improve the natural abdominal contour, and use of Marlex mesh. A lower abdominal bulge occurred in 5 of the 123 women (4%), 2 following 30 bilateral reconstructions (6.6%) and 3 following 93 unilateral reconstructions (3.2%). Analysis of the factors for all women demonstrated diabetes mellitus in 1 (0.8%), tobacco use in 9 (7.3%), a prior abdominal operation in 55 (44.7%), previous childbirth in 95 (77%), aponeurotic plication in 49 (40%), and use of Marlex mesh in 4 (3.3%). Statistical analysis did not show any significant association between the explanatory factors and the occurrence of a lower abdominal bulge, except for a weak trend in women who had not been pregnant (P = 0.08). The results of this study demonstrate that the occurrence of a lower abdominal bulge following the DIEP flap is a random event that can occur in anyone. Pregnancy may confer a preventative effect as the collagen fibers strengthen to overcome the stretching forces. Techniques for prevention and treatment include intraoperative assessment of the anterior rectus sheath, use of an adjuvant material for reinforcement if unstable, and vertical plication for bulge repair.
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The prevalence of anastomotic failure resulting in return to the operating room and flap necrosis after microvascular breast reconstruction ranges from 1 to 5 percent. The purpose of this study was to review a set of factors that may be associated with this occurrence. Microvascular reconstruction of the breast was performed in 198 women from January of 1998 to July of 2002. The mean age for all women was 47.7 years. There were 158 unilateral and 41 bilateral reconstructions, for a total of 240 flaps. The specific flaps included the free transverse rectus abdominis musculocutaneous flap (n = 176), the deep inferior epigastric perforator flap (n = 58), and the superior gluteal artery perforator flap (n = 6). Upon recognition of anastomotic failure, women were immediately returned to the operating room. Factors that were considered relevant to anastomotic failure included the choice of recipient vessel, timing of reconstruction, previous chest wall radiation therapy, previous axillary lymph node dissection, tobacco use, diabetes mellitus, patient age, and hematoma. Patient follow-up ranged from 5 to 59 months. Descriptive statistics, Fisher's exact test, and exact logistic regression were used for analyses and to summarize data. Of the 240 flaps, return to the operating room was necessary for 20 (8.3 percent), total necrosis occurred in nine (3.8 percent), and the rate of flap salvage was 55 percent (11 of 20 flaps). Venous occlusion was responsible for 16 of the 20 returns and eight of the nine failures. Statistical analysis demonstrated that both return to the operating room and flap necrosis were significantly associated with venous occlusion, delayed reconstruction, and hematoma. Previous lymph node dissection and previous radiation therapy had only a weak association with return to the operating room. The results of this study demonstrate that venous occlusion is responsible for return to the operating room and flap necrosis in the majority of cases. Age, tobacco use, choice of recipient vessel, and diabetes mellitus were not associated with anastomotic failure. The significance of delayed reconstruction may be related to its frequent association with previous lymph node dissection and/or radiation therapy resulting in perivascular fibrosis.
The selection of recipient vessels that are suitable for microvascular anastomosis in the head and neck region is one of many components that is essential for successful free tissue transfer. The purpose of this study was to evaluate a set of factors that are related to the recipient artery and vein and to determine how these factors influence flap survival. A retrospective review of 102 patients over a 5-year consecutive period was completed. Indications for microvascular reconstruction included tumor ablation (n = 76), trauma (n = 13), and chronic wounds or facial paralysis (n = 13). The most frequently used recipient artery and vein included the facial, superficial temporal, superior thyroid, carotid, and jugular. Various factors that were related to the recipient vessels were analyzed and included patient age, recipient artery and vein, diabetes mellitus, tobacco use, the timing of reconstruction, the method of anastomosis, previous radiation therapy, creation of an arteriovenous loop, and use of an interposition vein graft. Successful free tissue transfer was obtained in 97 of 102 flaps (95%). Flap failure was the result of venous thrombosis in 4 and arterial thrombosis in 1. Statistical analysis demonstrated that anastomotic failure was associated with an arteriovenous loop (2 of 5, P = 0.03) and tobacco use (3 of 5, P = 0.03). Flap failure was not related to patient age, choice of recipient vessel, diabetes mellitus, previous irradiation, the method of arterial or venous anastomosis, use of an interposition vein graft, or the timing of reconstruction.
Clinical applications for the internal mammary artery include use as an arterial conduit for coronary revascularization and as a recipient artery for microvascular reconstruction of the breast. This study was completed in an attempt to resolve the controversy over which indication should have priority. Five hundred twenty women with breast cancer who underwent breast reconstruction were reviewed. Of these, 240 were 50 years of age or more and were evaluated for cardiac disease. Three components were studied that included analysis of factors related to cardiac function (prior cardiac surgery, specific cardiac disorders, and cardiac medications), analysis of risk factors related to cardiac disease (hypertension, diabetes mellitus, and tobacco use), and analysis of factors related to the reconstruction (selection of recipient vessels, type of reconstruction). The women were stratified based on age-50 to 59 years, 60 to 69 years, and older than 70 years-to analyze trends based on advancing age. Results demonstrated that the incidence of coronary artery disease was 2 in 240 women (0.8%) and that the incidence of factors related to cardiac function and the incidence of risk factors related to cardiac disease appear to increase with advancing age. The internal mammary vessels were used in 35 of 114 free tissue transfers with no adverse sequelae. No woman in whom the internal mammary artery was used has developed coronary artery disease. The 2 women with coronary artery disease were reconstructed with implants. Based on the results of this study, the author thinks that use of the internal mammary artery as a recipient vessel for microvascular reconstruction of the breast is justified. Options for future coronary revascularization would include the opposite internal mammary artery when available, a saphenous vein graft, or angioplasty.
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The incidence of infection following breast reconstruction with expanders and implants ranges from 1 to 24 percent. Numerous factors associated with infection have been described; however, a one-variable at time setting and multifactorial analysis have not been performed. The purpose of this study was to analyze a set of factors that may predispose women to infection of the expander or implant. Between 1997 and 2000, a total of 168 implant reconstructions were performed in 130 women at a single institution. The mean age for all women was 48.2 years (range, 25 to 77 years). The factors that were analyzed included axillary lymph node dissection, chemotherapy, radiation therapy, tumor stage, timing of implant insertion, number of sides (unilateral versus bilateral), tobacco use, and presence or absence of diabetes mellitus. Statistical analysis was performed with stepwise logistic regression. Mean time to follow-up for all patients was 29 months (range, 12 to 47 months). Infectious complications occurred in 10 women (7.7 percent) and in 10 expanders or implants (5.9 percent). Infected implants were removed an average of 116 days following insertion (range, 14 to 333 days). Cultured bacteria included Staphylococcus aureus and Serratia marcescens. A significant association (p < 0.04) was detected between implant infection and radiation therapy. The chance for implant infection was 4.88 times greater for implants that were exposed to radiation therapy compared with those that were not. In addition, there was suggestive (p < 0.09) evidence that the chance of implant infection following lymph node dissection was 6.29 times higher than when no lymph nodes were removed. No significant association between implant infection and age, diabetes, tobacco use, tumor stage, timing of implant insertion, or chemotherapy was found.