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Autologous fat grafting is a useful tool in breast reconstruction. The authors have previously demonstrated a difference in the rate of processing adipose grafts in a randomized time and motion clinical trial. The purpose of this study was to compare clinical outcomes in commonly used grafting systems.Three methods to prepare adipose grafts were compared: a passive washing filtration system (Puregraft system), an active washing filtration system (Revolve system), and centrifugation (Coleman technique). Postoperative complications, rates of fat necrosis, revision procedures, and additional imaging were recorded.Forty-six patients were included in the prospective, randomized study (15 active filtration, 15 passive filtration, and 16 centrifugation). Their mean age was 54 years and mean body mass index was 28.6 kg/m 2 . The mean length of follow-up was 16.9 ± 4 months. The overall complication rate was 12.1 percent. The probability of fat necrosis was no different between the groups (active filtration, 15 percent versus passive filtration, 14.3 percent] versus centrifugation, 8 percent; p = 0.72). Fat necrosis was highest in patients with breast conservation before grafting (60 percent; p = 0.011). There was no significant difference in contour irregularity (active filtration, 40 percent versus passive filtration, 38 percent versus centrifugation, 36 percent; p = 0.96) or additional grafting (active filtration, 40 percent versus passive filtration, 24 percent versus centrifugation, 32 percent; p = 0.34).This is the first prospective, randomized study to compare clinical outcomes of adipose graft preparation. There was no significant difference in early complications, fat necrosis, or rates of additional grafting among the study groups. There was significantly higher risk of fat necrosis in patients with previous breast conservation treatment regardless of processing technique.Therapeutic, II.

Background With the increased use of acellular dermal matrix (ADM) in breast reconstruction, the number of available materials has increased. There is a relative paucity of high-quality outcomes data for use of different ADMs. Objectives The goal of this study was to compare the outcomes between a human (HADM) and a bovine ADM (BADM) in implant-based breast reconstruction. Methods A prospective, single-blinded, randomized controlled trial was conducted to evaluate differences in outcomes between HADM and BADM for patients undergoing immediate tissue expander breast reconstruction. Patients with prior radiation to the index breast were excluded. Patient and surgical characteristics were collected and analyzed. Results From April 2011 to June 2016, a total of 90 patients were randomized to a mesh group, with 68 patients (HADM, 36 patients/55 breasts; BADM, 32 patients/48 breasts) included in the final analysis. Baseline characteristics were similar between the 2 groups. No significant differences in overall complication rates were identified between HADM (n = 14, 25%) and BADM (n = 13, 27%) (P = 0.85). Similar trends were identified for major complications and complications requiring reoperation. Tissue expander loss was identified in 7% of HADM patients (n = 4) and 17% of BADM patients (n = 8) (P = 0.14). Conclusions Similar complication and implant loss rates were found among patients undergoing immediate tissue expander breast reconstruction with HADM or BADM. Regardless of what material is used, careful patient selection and counseling, and cost consideration, help to improve outcomes and sustainability in immediate breast reconstruction. Level of Evidence: 2

Background The relationship between treatment-related, cost-associated distress “financial toxicity” (FT) and quality-of life (QOL) in breast cancer patients remains poorly characterized. This study leverages validated patient-reported outcomes measures (PROMs) to analyze the association between FT and QOL and satisfaction among women undergoing ablative breast cancer surgery. Study design This is a single-institution cross-sectional survey of all female breast cancer patients (>18 years old) who underwent lumpectomy or mastectomy between January 2018 and June 2019. FT was measured via the 11-item COmprehensive Score for financial Toxicity (COST) instrument. The BREAST-Q and SF-12 were used to asses condition-specific and global QOL, respectively. Responses were linked with demographic and clinical data. Pearson correlation coefficient and multivariable regression were used to examine associations. Results Our analytical sample consisted of 532 patients; mean age 58, mostly white (76.7%), employed (63.7%), married/committed (73.7%), with 64.3% undergoing reconstruction. Median household income was $80,000 to $120,000/year, and mean COST score was 28.0. After multivariable adjustment, a positive relationship for all outcomes was noted; lower COST (greater cost-associated distress) was associated with lower BREAST-Q and SF-12 scores. This relationship was strongest for BREAST-Q psychosocial well-being, for which we observed a 0.89 (95% CI 0.76–1.03) change per unit change in COST score. Conclusions Financial toxicity captured in this study correlates with statistically significant and clinically important differences in BREAST-Q psychosocial well-being, patient satisfaction with reconstructed breasts, and SF-12 global mental and physical quality of life. Treatment costs should be included in the shared decision-making for breast cancer surgery. Future prospective outcomes research should integrate COST.

BACKGROUND There is ongoing debate regarding the optimal timing of contralateral prophylactic mastectomy fueled by concern that performing it at the time of the mastectomy for the index breast cancer may delay adjuvant therapy. The study objective was to examine the effect of simultaneous contralateral prophylactic mastectomy with immediate breast reconstruction on the complication rate and adjuvant therapy timing. METHODS A retrospective study was conducted of consecutive patients who underwent contralateral prophylactic mastectomy with immediate breast reconstruction and received adjuvant therapy over a 6-year period. Demographic, treatment, and outcomes data were collected, and relationships between multiple variables and outcomes were evaluated. RESULTS Of 241 patients (482 breasts) included, 186 (372 breasts) underwent simultaneous index breast mastectomy and contralateral prophylactic mastectomy with immediate breast reconstruction followed by adjuvant therapy (immediate group), and 55 (110 breasts) underwent index mastectomy, then adjuvant therapy, followed by delayed contralateral prophylactic mastectomy with immediate breast reconstruction (delayed group). Demographics were similar, although breast cancer stage (p < 0.001), tumor category (p = 0.0072), and nodal category (p < 0.001) were significantly higher in the delayed group. In the immediate group, complications before adjuvant therapy occurred in 31 patients (16.7 percent), and in six patients (3.2 percent) complications occurred only in the contralateral prophylactic mastectomy breast; delay to adjuvant therapy occurred in 11 patients (5.9 percent), in four (2.2 percent) of whom the contralateral prophylactic mastectomy breast was responsible for the delay. CONCLUSIONS Contralateral prophylactic mastectomy with immediate breast reconstruction can be performed safely at the time of the index mastectomy in carefully selected patients. These findings will engage patients seeking contralateral prophylactic mastectomy in shared decision-making regarding optimal timing with respect to the risks and benefits. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.

Background Oncologic resections involving both the spine and chest wall commonly require immediate soft tissue reconstruction to eliminate dead space and protect spinal instrumentation and vital neurovascular structures. We hypothesized that reconstructions of composite resections involving both the thoracic spine and chest wall would have a higher complication rate than reconstructions for resections limited to the thoracic spine alone. Methods We performed a retrospective analysis of all consecutive patients who underwent a thoracic vertebrectomy and soft tissue reconstruction from 2002 to 2017. Patients were divided into two groups: those whose defect was limited to the thoracic spine (TS) and those who also required chest wall resection (TS+CW). Results One hundred patients were included (TS: n=53 vs TS+CW: n=47). TS+CW patients had larger resections, as indicated by a greater incidences of multi-level vertebrectomies (70.2% vs. 17%; p=0.001) and instrumentation of more than 6 vertebral levels (76.6% vs. 26.4%; p=0.001). TS patients were older (58.2 α 10.4 vs 48.6 α 13.9 years; p 1 comorbidity (96.2% vs. 74.5%; p=0.002), and had a greater incidence of metastatic disease (88.7% versus 38.3%; p=0.001). Univariate and multivariate logistic regression analyses demonstrated that composite resections were not significantly associated with a higher rate of surgical, medical, or overall complications. Multivariate logistic regression analysis of the TS+CW subgroup demonstrated that flap separation of the spinal cord from the intrapleural space was protective against complications (odds ratio [OR]=0.22, 95% CI 0.05-0.81; p=0.03). Conclusions Despite the large defect size in TS+CW patients, there was no increase in complications compared to TS patients. In TS+CW patients, separating the exposed spinal cord from the intrapleural space with well-vascularized soft tissue was protective against complications.

Management of chest wall defects after oncologic resection is challenging due to multifactorial etiologies. Traditionally, skeletal stabilization in chest wall reconstruction (CWR) was performed with synthetic prosthetic mesh. The authors hypothesized that CWR for oncologic resection defects with acellular dermal matrix (ADM) is associated with a lower incidence of complications than synthetic mesh. Consecutive patients who underwent CWR using synthetic mesh (SM) or ADM at a single center were reviewed. Only oncologic defects involving resection of at least one rib and reconstruction with both mesh and overlying soft tissue flaps were included in this study. Patients’ demographics, treatment factors, and outcomes were prospectively documented. The primary outcome measure was surgical-site complications (SSCs). The secondary outcomes were specific wound-healing events, cardiopulmonary complications, reoperation, and mortality. This study investigated 146 patients [95 (65.1%) with SM; 51 (34.9%) with ADM] who underwent resection and CWR of oncologic defects. The mean follow-up period was 29.3 months (range 6–109 months). The mean age was 51.5 years, and the mean size of the defect area was 173.8 cm2. The SM-CWR patients had a greater number of ribs resected (2.7 vs. 2.0 ribs; p = 0.006) but a similar incidence of sternal resections (29.5% vs. 23.5%; p = 0.591) compared with the ADM-CWR patients. The SM-CWR patients experienced significantly more SSCs (32.6% vs. 15.7%; p = 0.027) than the ADM-CWR patients. The two groups had similar rates of specific wound-healing complications. No differences in mortality or reoperations were observed. The ADM-CWR patients experienced fewer SSCs than the SM-CWR patients. Surgeons should consider selectively using ADM for CWR, particularly in patients at higher risk for SSCs.

Despite significant advances in abdominal wall reconstruction, parastomal hernias remain a complex problem, with a high risk of recurrence following repair. While a number of surgical hernia repair techniques have been proposed, there is no consensus on optimal management. Several clinical variables must be considered when developing a comprehensive repair plan that minimizes the likelihood of hernia recurrence and surgical site occurrences. In this review, we describe the incidence of parastomal hernias and discuss pertinent risk factors, medical history findings, physical examination findings, supplementary diagnostic modalities, parastomal hernia classification systems, surgical indications, and repair techniques. Special consideration is given to the discussion of mesh reinforcement, including available biomaterials, anatomic plane selection, and the extent of mesh reinforcement. Although open repairs are the primary focus of this article, minimally invasive laparoscopic and robotic approaches are also briefly described. It is our hope that the provided surgical outcome data will help guide surgical management and optimize outcomes for affected patients.

Background Lateral abdominal wall (LAW) myofascial defects are a challenging reconstructive problem, and no consensus exists on their surgical management. We hypothesized that mesh repairs anchored to the nonyielding LAW boundaries (pillar-anchored repairs [PARs]) would provide more durable reconstructions, with lower hernia recurrence and bulge occurrence rates, compared with mesh repairs anchored to the surrounding oblique muscle complexes (direct repairs [DRs]). Study Design We retrospectively reviewed LAW reconstructions at a single center from 2004 to 2010. Patients were divided into 2 groups based on whether they had received a PAR or a DR. The primary outcome measure was hernia recurrence. The secondary outcome measures were surgical site occurrences (SSOs), surgical site infections (SSIs), and reoperations for complications. Results We analyzed 106 consecutive patients with LAW reconstructions (PAR, 59 DR, 47). The median follow-up time was 28.1 months (PAR, 24.5 months; DR, 34.5 months). The baseline demographics were similar in the groups. Nineteen hernia recurrences were observed (PAR, 5 [8.5%]; DR, 14 [29.8%]; p = 0.033, log-rank test). The “closure type” (bridged vs reinforced repair), “mesh type” or “defect area” were not associated with hernia recurrence or bulge occurrence. The groups did not differ significantly regarding SSOs, SSIs, or reoperations for complications. In the multivariable Cox proportional regression model, PAR provided a 3.5 times lower risk of hernia recurrence than DR (adjusted hazard ratio, 0.28; 95% CI 0.09 to 0.88; p = 0.03). Conclusions The PAR technique is superior to DR for reconstructing LAW defects in order to achieve the lowest hernia recurrence rates in this complex patient population.

Background Time and motion studies provide a reliable methodology to quantify efficiency and establish recommendations for best practices in autologous fat grafting. The purpose of this study was to compare the rate of graft processing of three frequently used systems for graft preparation. Methods The authors conducted a prospective randomized comparison of three methods to prepare adipose tissue for autologous fat grafting: an active filtration system (Revolve; LifeCell Corporation, Branchburg, N.J.), a passive filtration system (PureGraft 250; Cytori Therapeutics, San Diego, Calif.), and centrifugation. An independent observer collected data according to the study's behavioral checklist. The primary outcome measure was rate of adipose tissue processed. Results Forty-six patients (mean age, 54 years; mean body mass index, 28.6 kg/m2) were included in the study (15 per arm; one patient was included with intention to treat after a failed screening). The rate of adipose tissue preparation was greater for the active filtration system compared with the others (active filtration: 9.98 ml/min versus passive filtration: 5.66 ml/min versus centrifugation: 2.47 ml/min). Similarly, there was a significant difference in total grafting time (active: 82.7 ± 8.51 minutes versus passive: 152 ± 13.1 minutes, p = 0.0005; versus centrifugation: 209.9 ± 28.5 minutes, p = 0.0005); however, there was no difference in total operative time (p = 0.82, 0.60). Conclusions As the number of fat grafting procedures increases, there is interest in developing techniques to harvest, process, and inject fat to improve clinical outcomes and operative efficiency. The results of this study indicate that an active fat processing system is more time efficient at graft preparation than a passive system or centrifugation.

Background Ventral hernia repair(VHR) is one of the most commonly performed procedures in the United States, but studies assessing the long-term outcomes of VHR using biologic mesh are scarce. Objective We sought to determine the rates of hernia recurrence(HR) and surgical site occurrences(SSOs) in a large cohort of patients who underwent AWR with biologic mesh. Methods We conducted a retrospective cohort study of patients who underwent AWR using either porcine ADM(PADM) or bovine ADM(BADM) from 2005 to 2019. We analyzed the full cohort and a subset of our population with minimum long-term follow-up(LTF) of 5 years. The primary outcome measure was HR. Secondary outcomes were SSOs. Results We identified a total of 725 AWRs (49.5% PADM, 50.5% BADM). Mean age was 69 ± 11.5 years and mean body mass index was 31 ± 7 kg/m. Forty-two percent of the defects were clean at the time of AWR, 44% were clean-contaminated, and 14% were contaminated/infected. Mean defect size was 180 ± 174 cm, mean mesh size was 414 ± 203 cm. Hernia recurred in 93 patients(13%), with cumulative HR rates of 4.9%, 13.5%, 17.3%, and 18.8% at 1, 3, 5, and 7 years, respectively. There were no differences in HR(p = 0.83) and SSO(p = 0.87) between the two mesh types. SSOs were identified in 27% of patients. In our LTF group (n = 162), the HR rate was 16%. Obesity, bridged repair, and concurrent stoma presence/creation were independent predictors of HR; component separation was protective against HR. Conclusions Despite its use in complex AWR, ADM provides durable long-term outcomes with relatively low recurrence rates.

Background:. The requirement for postmastectomy radiation therapy (PMRT) at the time of mastectomy is often unknown. Autologous reconstruction is preferred in the setting of radiotherapy by providing healthy vascularized tissue to the chest. To maximize mastectomy skin preservation, tissue expander (TE) placement maintains the breast pocket until definitive reconstruction. This study aims to compare outcomes of skin-preserving delayed versus standard delayed autologous breast reconstruction in the setting of PMRT. Methods:. A retrospective review of a prospective database was performed of two patient cohorts at a single center between 2006 and 2016. Inclusion criteria were locally advanced breast cancer patients who completed PMRT and free autologous reconstruction. Primary outcomes were major intraoperative and postoperative TE and flap complications. Results:. Over 10 years, 241 patients underwent mastectomy and PMRT. Standard delayed autologous breast reconstruction was performed in 131 breasts (non-TE group). Skin-preserving delayed autologous reconstruction was performed in 113 breasts (TE group). The TE group was associated with a higher incidence of intraoperative complications during flap reconstruction (P = 0.002) and had a higher venous thrombosis incidence than the non-TE cohort (P = 0.007). Other major postoperative complications were not significantly different between the two groups. TE patients had 7.5 times higher risk of intraoperative complications and an 18.6% TE loss rate. Conclusions:. We identified higher intraoperative flap complications and a high rate of TE loss in patients who underwent skin-preserving delayed autologous breast reconstruction. The benefit of mastectomy skin preservation needs to be weighed against the increased risk of TE loss and higher rates of flap thrombosis.

Background Oncoplastic breast-conserving surgery expands the indications for breast conservation. When performed using modified mastopexy/breast reduction techniques, the optimal timing of the contralateral symmetrizing mastopexy/breast reduction remains unclear. This study examined the effect of the timing of symmetrizing mastopexy/breast reduction on oncoplastic breast-conserving surgery outcomes. Methods A retrospective study was conducted of all patients who underwent oncoplastic breast-conserving surgery using mastopexy/breast reduction techniques at a single center from 2010 to 2016. Patients who received synchronous (immediate) contralateral breast symmetrizing mastopexy were compared with those who underwent a delayed symmetrizing mastopexy procedure. Demographic, treatment, and outcome data were collected. Descriptive statistics were used and multivariate analysis was performed to evaluate the various relationships. Results There were 429 patients (713 breasts) included in the study; of these, 284 patients (568 breasts) underwent oncoplastic breast-conserving surgery involving mastopexy/breast reduction techniques and immediate symmetrizing mastopexy, and 145 patients underwent delayed contralateral symmetrizing mastopexy. The overall complication rate was similar between the immediate and delayed groups (25.4 percent versus 26.9 percent, respectively; p = 0.82), as was the major complication rate (10.6 percent versus 6.2 percent; p = 0.16). Complications resulted in a delay in adjuvant therapy in 18 patients (4.2 percent); in two patients (0.7 percent), this delay resulted from a complication in the contralateral symmetrizing mastopexy breast. Immediate contralateral symmetrizing mastopexy was not associated with increased risk of complications per breast (p = 0.82) or delay to adjuvant therapy (p = 0.6). Conclusion Contralateral mastopexy/breast reduction for symmetry can be performed at the time of oncoplastic breast-conserving surgery in carefully selected patients without significantly increasing the risk of complications or delay to adjuvant radiation therapy. Clinical question/level of evidence Therapeutic, III.

Background Oncoplastic breast-conserving surgery (OBCS) is most commonly performed using established or modified mastopexy/breast reduction techniques. Although the comparative complication profiles of Wise-pattern mastopexy/breast reduction techniques compared with vertical scar techniques are well understood, outcomes in the setting of OBCS are unknown. Methods A retrospective study was conducted of all patients that underwent OBCS using mastopexy/breast reduction techniques at a single center over a 6-year period. Patients who underwent Wise-pattern techniques were compared with those who underwent vertical scar techniques. Demographic, treatment, and outcomes data were collected. Descriptive statistics were used, and multivariate analysis was performed to evaluate the relationship between these multiple variables and complications. Results Of 413 eligible patients, 278 patients (67.3%) received a Wise-pattern technique and 135 (32.7%) underwent a vertical scar technique. The overall complication rate was significantly higher in the Wise-pattern than in the vertical scar group (30.6% vs 18.5%, respectively; P = 0.012), as was the major complication rate (11.9% vs 4.4%; P = 0.011) including need for additional surgery for complications (6.8% vs 1.5%; P = 0.029). Complications resulted in a delay to any adjuvant therapy in 20 patients (4.8%); however, the difference between the groups was not significant (6.1% for Wise pattern vs 2.2% for vertical scar; P = 0.098). In a multivariable logistic model, use of a Wise-pattern technique (odds ratio, 0.37 [95% confidence interval, 0.14-0.99]; P = 0.049) was a significant predictor of major complications. Conclusions The Wise-pattern mastopexy/breast reduction OBCS technique was associated with a significantly higher complication and major complication rate than vertical scar techniques. The findings should be considered during choice of surgical technique in oncoplastic breast conservation.

Background We evaluated the incidence of and the risk factors for readmission in patients who underwent abdominal wall reconstruction (AWR) using acellular dermal matrix (ADM) and assess whether readmission affects AWR long-term outcomes. Methods A retrospective, single-center study of patients underwent AWR with ADM was conducted. The primary outcome was the incidence of unplanned readmission within 30 days after the initial discharge post-AWR. Secondary outcomes were surgical site occurrence (SSO) and hernia recurrence at follow-up. Results Of 452 patients (mean age, 59 years; mean follow-up, 35 months), 29 (6.4%) were readmitted within 30 days. Most readmissions were due to SSO (44.8%) or wound infections (12.8%). The hernia recurrence rate was significantly higher in readmitted patients (17.2% vs 9.9%; P = 0.044). Wider defects, prolonged operative time, and coronary artery disease were independent predictors of readmission. Conclusions Readmission is associated with hernia recurrence on long-term follow-up. SSO is the most common cause for readmission.

Background Although multiple acellular dermal matrix sources exist, it is unclear how its processing impacts complication rates. The authors compared complications between two preparations of human cadaveric acellular dermal matrix (freeze dried and ready-to-use) in immediate tissue expander breast reconstruction to analyze the effect of processing on complications. Methods The authors retrospectively reviewed all alloplastic breast reconstructions with freeze-dried or ready-to-use human acellular dermal matrices between 2006 and 2016. The primary outcome measure was surgical-site occurrence defined as seroma, skin dehiscence, surgical-site infection, or reconstruction failure. The two groups were compared before and after propensity score matching. Results The authors included 988 reconstructions (freeze-dried, 53.8 percent; ready-to-use, 46.2 percent). Analysis of 384 propensity score-matched pairs demonstrated a slightly higher rate of surgical-site occurrence (21.4 percent versus 16.7 percent; p = 0.10) and surgical-site infection (9.6 percent versus 7.8 percent; p = 0.13) in the freeze-dried group than in the ready-to-use group, but the difference was not significant. However, failure was significantly higher for the freeze-dried versus ready-to-use group (7.8 percent versus 4.4 percent; p = 0.050). Conclusions This is the largest study comparing the outcomes of alloplastic breast reconstruction using human acellular dermal matrix materials prepared by different methods. The authors demonstrated higher early complications with aseptic, freeze-dried matrix than with sterile ready-to-use matrix; reconstructive failure was the only outcome to achieve statistical significance. The authors conclude that acellular dermal matrix preparation has an independent impact on patient outcomes in their comparison of one company's product. Clinical question/level of evidence Therapeutic, III.

Lateral abdominal wall (LAW) defects are defined as hernias, bulges, or surgical wounds that occur within the anatomic region bounded by the linea semilunaris, costal margin, iliac crest, and paraspinous musculature. Reconstruction of the LAW is complicated by the relatively complex anatomy, asymmetric biomechanical forces on the repair, and progressive nature of concomitant denervation injuries. Furthermore, the relative rarity and varied nature of these defects have complicated comparative analysis and the development of consensus regarding optimal surgical management. Although mesh reinforcement of LAW defects is a universal component of available repair techniques, significant variation exists regarding mesh material selection, anatomic plane utilization, and extent of mesh reinforcement. Special consideration must be given to extirpative defects that extend beyond the aforementioned boundaries of the LAW. In this review, we outline the incidence of LAW defects, pertinent risk factors, common history and physical examination findings, supplementary diagnostic modalities, defect classification systems, surgical indications, and available repair techniques. The outcomes data in this review are presented to help guide surgical management and optimize outcomes for affected patients.

Background Extensive flap salvage attempts are routinely performed in patients with late-onset flap vascular crisis despite low flap survival rates. A knowledge gap exists in management of compromised free flaps in patients who present with perfusion-related complications after hospital discharge. Methods A retrospective review of 7443 free flaps used in 7128 cancer patients at a single institution from January of 2001 to March of 2015 was performed. Results Of 7443 free flap reconstructions, 856 patients (12 percent) were taken back to the operating room. Also, 261 patients (4 percent) suffered from microvascular compromise, of whom 110 (1 percent) experienced total flap loss. The authors identified 17 patients (10 breast cancer patients and seven head and neck cancer patients) who had vascular flap compromise and underwent reoperation after hospital discharge (median, 10 days; range, 4 to 107 days) after free flap reconstruction. Of these 17 patients, nine breast cancer patients and two head and neck cancer patients underwent flap salvage attempts. Salvage procedures included thrombectomy, thrombolytic and heparin injections, and reanastomoses (11 patients); vein grafting (four patients); vein supercharging with cephalic turndown (two patients); and change of recipient vessels (two patients). Sixteen of the 17 patients (94 percent) experienced total flap loss, and one patient (6 percent) had partial flap loss requiring long-lasting wound treatment. Conclusions Outpatient free flap salvage has a low success rate regardless of flap type, recipient site, or patient population. The authors' study suggests that immediate second-line reconstruction is more effective for late-onset flap vascular crisis than extensive flap salvage procedures. Clinical question/level of evidence Therapeutic, V.

Background:. “Time burden” (time required during treatment) is relevant when choosing a local therapy option for early-stage breast cancer but has not been rigorously studied. We compared the time burden for three common local therapies for breast cancer: (1) lumpectomy plus whole-breast irradiation (Lump+WBI), (2) mastectomy without radiation or reconstruction (Mast alone), and (3) mastectomy without radiation but with reconstruction (Mast+Recon). Methods:. Using the MarketScan database, we identified 35,406 breast cancer patients treated from 2000 to 2011 with these local therapies. We quantified the total time burden as the sum of inpatient days (inpatient-days), outpatient days excluding radiation fractions (outpatient-days), and radiation fractions (radiation-days) in the first two years postdiagnosis. Multivariable regression evaluated the effect of local therapy on inpatient-days and outpatient-days adjusted for patient and treatment covariates. Results:. Adjusted mean number of inpatient-days was 1.0 for Lump+WBI, 2.0 for Mast alone, and 3.1 for Mast+Recon (P < 0.001). Adjusted mean number of outpatient-days was 42.9 for Lump+WBI, 42.2 for Mast alone, and 45.8 for Mast+Recon (P < 0.001). The mean number of radiation-days for Lump+WBI was 32.4. Compared with Mast+Recon (48.9 days), total adjusted time burden was 4.7 days shorter for Mast alone (44.2 days) and 27.4 days longer for Lump+WBI (76.3 days). However, use of a 15 fraction WBI regimen would reduce the time burden differential between Lump+WBI and Mast+Recon to just 10.0 days. Conclusions:. Although Mast+Recon confers the highest inpatient and outpatient time burden, Lump+WBI carries the highest total time burden. Increased use of hypofractionation will reduce the total time burden for Lump+WBI.

Background: Lymphedema is a debilitating clinical condition predominantly affecting survivors of cancer. It adversely affects patients' quality of life and results in substantial cost burdens to both patients and the healthcare system. Specialist lymphedema care is optimally provided within integrated clinical programs that align the necessary specialties to provide patient-focused, multidisciplinary, structured, and coordinated care. This article examines our experience building a specialist lymphedema academic program. Methods: We describe the critical components necessary for constructing a multidisciplinary comprehensive academic lymphedema program. Furthermore, lessons learned from our experience building a successful lymphedema program are discussed. Results: Building a comprehensive academic lymphedema program requires institutional support and engagement of stakeholders to establish the necessary infrastructure for comprehensive patient care. This includes the infrastructure for outpatient clinical assessment, diagnostic investigations, radiological imaging, collection of outcomes metrics, non-surgical treatment delivered by lymphedema-specialist therapists, surgical procedures using specialized equipment, and integration of an outpatient framework for comprehensive patient evaluation during follow-up at standardized time intervals. Conclusions: This article examines our experience building a multidisciplinary comprehensive academic lymphedema program and provides a structured roadmap to benefit others that are embarking on this mission.

Management of chest wall defects after oncologic resection is challenging due to multifactorial etiologies. Traditionally, skeletal stabilization in chest wall reconstruction (CWR) was performed with synthetic prosthetic mesh. The authors hypothesized that CWR for oncologic resection defects with acellular dermal matrix (ADM) is associated with a lower incidence of complications than synthetic mesh.Consecutive patients who underwent CWR using synthetic mesh (SM) or ADM at a single center were reviewed. Only oncologic defects involving resection of at least one rib and reconstruction with both mesh and overlying soft tissue flaps were included in this study. Patients' demographics, treatment factors, and outcomes were prospectively documented. The primary outcome measure was surgical-site complications (SSCs). The secondary outcomes were specific wound-healing events, cardiopulmonary complications, reoperation, and mortality.This study investigated 146 patients [95 (65.1%) with SM; 51 (34.9%) with ADM] who underwent resection and CWR of oncologic defects. The mean follow-up period was 29.3 months (range 6-109 months). The mean age was 51.5 years, and the mean size of the defect area was 173.8 cmThe ADM-CWR patients experienced fewer SSCs than the SM-CWR patients. Surgeons should consider selectively using ADM for CWR, particularly in patients at higher risk for SSCs.

Background Reconstruction of partial breast defects in low-volume, nonptotic breasts can be challenging. The authors hypothesized that use of the latissimus dorsi flap in partial breast reconstruction is safe and associated with low complication and high patient satisfaction rates. Methods All patients who underwent breast-conserving therapy and latissimus dorsi flap reconstruction from January 1, 2006, to December 31, 2016, were identified in a prospectively maintained database. Patient demographics, tumor characteristics, and complications were recorded. Patient-reported outcomes were assessed with the BREAST-Q breast-conserving therapy module. A group of plastic surgeons and laypersons used a five-point Likert scale to evaluate aesthetic outcomes in representative patients. Results Forty-seven patients met the inclusion criteria. Median follow-up was 5.4 years. Most patients (93.6 percent) underwent immediate reconstruction. The mean resection volume was 219.5 cc (range, 70 to 877 cc). The overall complication rate was 8.5 percent. Grade 2 or 3 ptosis (OR, 1.21; 95 percent CI, 1.0 to 1.46; p = 0.03), smoking (OR, 13.1; 95 percent CI, 1.2 to 143.2; p = 0.03), and multicentric tumor (OR, 1.23; 95 percent CI, 1.04 to 1.64; p = 0.02) were associated with a higher complication rate. Ductal carcinoma in situ was associated with reoperation for positive margins (OR, 14.4; 95 percent CI, 2.1 to 100; p = 0.009). Of particular interest, patient-reported outcomes were favorable, with the highest rated domains being Satisfaction with Breasts (61; interquartile range, 37 to 77), Psychosocial Well-being (87; interquartile range, 63 to 100), and Physical Well-being (87; interquartile range, 81 to 100). The median aesthetic score was 4 (of 5). Conclusions This is the first study to date using the BREAST-Q to assess patient-reported outcomes associated with the latissimus dorsi flap for partial breast reconstruction. The flap is safe and effective for reconstruction in the setting of breast-conserving therapy, providing aesthetically pleasing results with high patient satisfaction. Clinical question/level of evidence Therapeutic, IV.

Previous studies suggest that bridged mesh repair for abdominal wall reconstruction may result in worse outcomes than mesh-reinforced, primary fascial closure, particularly when acellular dermal matrix is used. We compared our outcomes of bridged versus reinforced repair using ADM in abdominal wall reconstruction procedures.This retrospective study included 535 consecutive patients at our cancer center who underwent abdominal wall reconstruction either for an incisional hernia or for abdominal wall defects left after excision of malignancies involving the abdominal wall with underlay mesh. A total of 484 (90%) patients underwent mesh-reinforced abdominal wall reconstruction and 51 (10%) underwent bridged repair abdominal wall reconstruction. Acellular dermal matrix was used, respectively, in 98% of bridged and 96% of reinforced repairs. We compared outcomes between these 2 groups using propensity score analysis for risk-adjustment in multivariate analysis and for 1-to-1 matching.Bridged repairs had a greater hernia recurrence rate (33.3% vs 6.2%, P .001), a greater overall complication rate (59% vs 30%, P = .001), and worse freedom from hernia recurrence (log-rank P .001) than reinforced repairs. Bridged repairs also had a greater rate of wound dehiscence (26% vs 14%, P = .034) and mesh exposure (10% vs 1%, P = .003) than mesh-reinforced abdominal wall reconstruction. When the treatment method was adjusted for propensity score in the propensity-score-matched pairs (n = 100), we found that the rates of hernia recurrence (32% vs 6%, P = .002), overall complications (32% vs 6%, P = .002), and freedom from hernia recurrence (68% vs 32%, P = .001) rates were worse after bridged repair. We did not observe differences in wound healing and mesh complications between the 2 groups.In our population of primarily cancer patients at MD Anderson Cancer Center bridged repair for abdominal wall reconstruction is associated with worse outcomes than mesh-reinforced abdominal wall reconstruction. Particularly when employing acellular dermal matrix, reinforced repairs should be used for abdominal wall reconstruction whenever possible.

Prior abdominal wall radiotherapy (XRT) adversely affects wound healing, but data are limited on how prior XRT may affect abdominal wall reconstruction (AWR) outcomes. The purpose of this study was to determine whether prior abdominal wall radiotherapy is associated with a higher incidence of complications following AWR for a hernia or oncologic resection defect. We performed a retrospective study of consecutive patients who underwent complex AWR using acellular dermal matrix (ADM) at a single center. We compared outcomes between patients who underwent prior XRT that directly involved the abdominal wall and those who did not receive XRT. Propensity score match-paired and multivariate analyses were performed. A total of 511 patients (130 [25.4 %] with prior XRT; 381 [74.6 %] without prior XRT) underwent AWR with ADM for repair of a complex hernia or oncologic resection defect. Mean follow-up was 31.4 months, mean XRT dose was 48.9 Gy, and mean time between XRT and reconstruction was 19.2 months. XRT AWR patients underwent more flap reconstructions (14.6 vs. 5.0 %, P

Oncoplastic reconstruction is an approach that enables patients with locally advanced or adversely located tumors to undergo breast conserving surgery (BCS). The objectives were to identify the use of BCS with oncoplastic reconstruction (BCS + R) and determine the operative and oncologic outcomes compared with other breast surgical procedures for breast cancer. This retrospective cohort study interrogated a single institution’s prospectively maintained databases to identify patients who underwent surgery for breast cancer between 2007 and 2014. Surgeries were categorized as BCS, BCS + R, total mastectomy (TM), or TM with immediate reconstruction (TM + R). Demographic and clinicopathologic characteristics and postoperative complications were analyzed. There were 10,607 operations performed for 9861 patients. Median follow-up was 3.4 years (range, 0–9.1 years). The use of BCS + R had a nearly fourfold increase in the percentage of all breast cancer surgeries during the study period; 75 % of patients who underwent BCS + R had a T1 or T2 tumor. There was no difference in the use of BCS + R compared with BCS for any quadrant of the breast except the lower outer quadrant (11.1 vs. 6.8 %; p

Oncoplastic breast-conserving surgery (OBCS) broadens the indications for breast conservation. Neoadjuvant systemic chemotherapy (NAC) is used increasingly in the treatment of patients with early-stage and locally advanced breast cancer. This study aimed to evaluate the outcomes for patients who received NAC followed by OBCS. A retrospective chart review was performed for all patients who underwent OBCS involving the mastopexy/breast-reduction technique, including synchronous mastopexy/breast reduction for symmetry, at the University of Texas MD Anderson Cancer Center between January 2010 and January 2016. Patients who had received NAC were compared with those who had undergone surgery first. Demographic, treatment, and outcomes data were collected. The study included 429 patients, corresponding to 713 breasts. Of these patients, 122, corresponding to 199 breasts, received NAC. The patients who received NAC were younger (p

Compared with conventional ventral hernia repair, there are several additional considerations germane to the oncologic abdominal wall reconstruction, including the management of radiation soft-tissue injury, the management of bacterial contamination, and the location and extent of the defect. Herein, we review some of the unique challenges associated with oncologic abdominal wall reconstruction and introduce a new classification schema to assist the reconstructive surgeon in performing these complex cases.

Due to the abundant and lax tissue of the abdominal wall, most ventral trunk defects are amenable to local soft tissue closure. However, when abdominal defects are accompanied by a lack of soft tissue, the surgeon faces a more complex subset of reconstructions. Three important principles guide the reconstruction of these wounds: timing of closure, careful assessment of the true extent of the wound, and the components of the defect. This article focuses on these three guiding principles and suggests the authors' preferred technique for these difficult defects.

Background:. Several steps to reduce the rate of postoperative surgical site infections (SSIs) have been implemented. The use of prophylactic antimicrobials targeting patient’s microbial flora has been associated with a decrease in postoperative infections. We evaluated the relationship between perioperative antimicrobials, baseline microbial flora, and occurrence of SSIs. Methods:. We prospectively enrolled 241 patients scheduled to receive a postmastectomy implant-based reconstructive procedure between September 2015 and January 2018. Axillary swab cultures were obtained preoperatively, and all recovered bacteria were identified. Surgeons were blinded to these results. The use of prophylactic perioperative antimicrobials was defined as concordant if the baseline axillary flora were susceptible to the given antibiotic and discordant if not. As Staphylococcus species are the most common pathogen causative for breast implant-related infections, patients colonized with these organisms were analyzed in detail. All patients were followed up for at least 6 months postoperatively and evaluated for SSIs. Results:. A total of 238 patients (99%) received both perioperative and postoperative oral antimicrobials. The most common preoperative staphylococci axillary flora recovered were methicillin-sensitive coagulase-negative Staphylococcus (67%), methicillin-resistant coagulase-negative Staphylococcus (35%), with only 1 case of methicillin-sensitive Staphylococcus aureus (0.4%). Thirty-three patients (14%) developed an SSI. Of those with a positive Staphylococcus culture, only 54% received a concordant antimicrobial regimen, but this was not associated with an increased risk for infection (P > 0.72). Conclusions:. The use of perioperative antimicrobials whether concordant or discordant with the preoperative axillary microbial flora, specifically Staphylococci species, did not provide a significant impact on the risk of SSI.

Body image is a multidimensional construct involving perceptions, thoughts, and feelings about the entire body and its functioning.1 It is recognized as a critical psychosocial issue for cancer patients undergoing reconstructive surgery because they are at high risk of experiencing disfigurement and functional impairment. The process of adjusting to bodily changes during reconstructive treatment is ongoing, as multi-staged procedures are often required. Interim outcomes may be particularly bothersome to patients when cosmetic form and function have not been fully restored. Among the adverse psychosocial difficulties linked with body image disturbance in cancer patients include depression and anxiety2–6, sexual functioning difficulties7–10, and impairments in overall quality of life11–13. High rates of body image concerns have been documented for head and neck and breast cancer patients, two groups who most often undergo reconstructive surgery. Body image disturbance is among the most common psychosocial concern reported by women with breast cancer.14 Moreover, up to 75% of patients with head and neck cancer have been found to endorse concerns or embarrassment about bodily changes following diagnosis.15,16 It is difficult to estimate rates of body image concerns among cancer patients undergoing reconstructive surgery as most research on body image and cancer has either been conducted with disease-specific samples or with a particular subgroup receiving reconstruction (i.e., breast reconstruction). The vast literature reviewing patient-reported outcomes in breast reconstruction identifies various demographic (e.g., age, marital status)17 psychological (e.g., depression, anxiety)5,18, medical (e.g., body mass index)19 and disease/treatment related factors (e.g., cancer type, type and timing of reconstruction, complications)20–22 associated with body image and quality of life. Increasing attention is being given to delivering psychosocial care to cancer patients which specifically targets body image difficulties. Much of this work is based on cognitive-behavioral models of body image disturbance which highlight the importance of addressing maladaptive thoughts, behaviors, and emotions related to one’s appearance.23–25 For a patient struggling with body image concerns, emphasis is placed on acceptance of body image changes and increasing self-confidence in social situations. Key treatment strategies for mental health specialists to manage body image issues in the oncology setting have been described elsewhere,26–29 and it is recognized that treatment should be tailored based upon the distinct phase of the cancer journey. A significant source of distress for cancer patients undergoing reconstructive surgery is related to body image changes they experience during treatment. Unfortunately, much research suggests that physicians are not adept or comfortable with evaluating or managing patient distress. Lack of time is the most frequently reported barrier for medical professionals in being able to identify and manage patient distress.30 Moreover, patients are reluctant to bring up their distress with their oncologists31,32 and this may especially be true for those experiencing body image concerns. It is not uncommon for a cancer patient to worry about being seen as “vain” and experience shame and embarrassment about having body image concerns.26 For these reasons, it is critical to develop a useful screening tool that will facilitate the identification and treatment of patients with body image difficulties in the oncology setting. Validated tools assessing body image in cancer patients are lacking, and we are not aware of any tools developed for the purpose of screening patients for body image. A systematic review by Annunziata et al., found only six questionnaires dedicated to body image assessment for cancer patients. Only one tool was applicable to patients with diverse disease sites, while remaining tools were specific to breast or gastrointestinal cancer.33 None of these tools were identified as offering a gold standard for evaluating body image in the oncology setting, nor were any specifically developed as a screening tool. More recent advancements have been made with the development of assessment tools for breast cancer patients undergoing reconstructive surgery, focused on satisfaction with outcomes and quality of life. Tools such as the Breast Reconstruction Satisfaction Questionnaire (BRECON-31)34 and Breast-Q35 have gained more widespread use, and have undergone extensive validation. However, these tools focus on a specific subset of patients undergoing reconstruction, and again are not intended for use as a screening measure of body image distress. Our goals were to design and evaluate a brief body image screening tool for cancer patients undergoing reconstructive surgery that has the potential to be used as part of routine clinical practice. This tool is needed to assist medical professionals in identifying patients with body image distress who may benefit from a referral for specialized psychosocial care.

Many surgeons believe that primary fascial closure with mesh reinforcement should be the goal of abdominal wall reconstruction (AWR), yet others have reported acceptable outcomes when mesh is used to bridge the fascial edges. It has not been clearly shown how the outcomes for these techniques differ. We hypothesized that bridged repairs result in higher hernia recurrence rates than mesh-reinforced repairs that achieve fascial coaptation.We retrospectively reviewed prospectively collected data from consecutive patients with 1 year or more of follow-up, who underwent midline AWR between 2000 and 2011 at a single center. We compared surgical outcomes between patients with bridged and mesh-reinforced fascial repairs. The primary outcomes measure was hernia recurrence. Multivariate logistic regression analysis was used to identify factors predictive of or protective for complications.We included 222 patients (195 mesh-reinforced and 27 bridged repairs) with a mean follow-up of 31.1 ± 14.2 months. The bridged repairs were associated with a significantly higher risk of hernia recurrence (56% vs 8%; hazard ratio [HR] 9.5; p0.001) and a higher overall complication rate (74% vs 32%; odds ratio [OR] 3.9; p0.001). The interval to recurrence was more than 9 times shorter in the bridged group (HR 9.5; p0.001). Multivariate Cox proportional hazard regression analysis identified bridged repair and defect width15 cm to be independent predictors of hernia recurrence (HR 7.3; p0.001 and HR 2.5; p = 0.028, respectively).Mesh-reinforced AWRs with primary fascial coaptation resulted in fewer hernia recurrences and fewer overall complications than bridged repairs. Surgeons should make every effort to achieve primary fascial coaptation to reduce complications.

The optimal strategy for abdominal wall reconstruction in the presence of a stomal-site hernia is unclear. We hypothesized that the rate of ventral hernia recurrence in patients undergoing a combined ventral hernia repair and stomal-site herniorraphy would not differ clinically from the ventral hernia recurrence rate in patients undergoing an isolated ventral hernia repair. We also hypothesized that bridged ventral hernia repairs result in worse outcomes compared with reinforced repairs, regardless of stomal hernia.We retrospectively reviewed prospectively collected data from consecutive abdominal wall reconstructions performed with acellular dermal matrix (ADM) at a single center between 2000 and 2015. We compared patients who underwent a ventral hernia repair alone (AWR) and those who underwent both a ventral hernia repair and ostomy-associated herniorraphy (AWR+O). We conducted a propensity score matched analysis to compare the outcomes between the 2 groups. Multivariable Cox proportional hazards and logistic regression models were used to study associations between potential predictive or protective reconstructive strategies and surgical outcomes.We included 499 patients (median follow-up 27.2 months; interquartile range [IQR] 12.4 to 46.6 months), 118 AWR+O and 381 AWR. After propensity score matching, 91 pairs were obtained. Ventral hernia recurrence was not statistically associated with ostomy-associated herniorraphy (adjusted hazard ratio [HR] 0.7; 95% CI 0.3 to 1.5; p = 0.34). However, the AWR+O group experienced a significantly higher percentage of surgical site occurrences (34.1%) than the AWR group (18.7%; adjusted odds ratio 2.3; 95% CI 1.4 to 3.7; p0.001). In the AWR group, there were significantly fewer ventral hernia recurrences when the repair was reinforced compared with bridged (5.3% vs 38.5%; p0.001).There was no statistically significant difference in ventral hernia recurrence between the AWR and AWR+O groups. Bridging was associated with an increased rate of hernia recurrence and should be avoided if possible.

Background Long-term outcomes data for hernia recurrence rates after abdominal wall reconstruction (AWR) with acellular dermal matrix (ADM) are lacking. The aim of this study was to assess the long-term durability of AWR using ADM. Study Design We studied patients who underwent AWR with ADM at a single center in 2005 to 2015 with a minimum follow-up of 36 months. Hernia recurrence was the primary end point and surgical site occurrence (SSO) was a secondary end point. The recurrence-free survival curves were estimated by Kaplan-Meier product limit method. Univariate and multivariable Cox proportional hazards regression models and logistic regression models were used to evaluate the associations of risk factors at surgery with subsequent risks for hernia recurrence and SSO, respectively. Results A total of 512 patients underwent AWR with ADM. After excluding those with follow-up less than 36 months, 191 patients were included, with a median follow-up of 52.9 months (range 36 to 104 months). Twenty-six of 191 patients had a hernia recurrence documented in the study. The cumulative recurrence rates were 11.5% at 3 years and 14.6% by 5 years. Factors significantly predictive of hernia recurrence developing included bridged repair, wound skin dehiscence, use of human cadaveric ADM, and coronary disease; component separation was protective. In a subset analysis excluding bridged repairs and human cadaveric ADM patients, cumulative hernia recurrence rates were 6.4% by 3 years and 8.3% by 5 years. The crude rate of SSO was 25.1% (48 of 191). Factors significantly predictive of the incidence of SSO included at least 1 comorbidity, BMI ≥30 kg/m 2 , and defect width >15 cm. Conclusions Use of ADM for AWR was associated with 11.5% and 14.6% hernia recurrence rates at 3- and 5-years follow-up, respectively. Avoiding bridged repairs and human cadaveric ADM can improve long-term AWR outcomes using ADM.

Background Minimally invasive component separation (CS) with inlay bioprosthetic mesh (MICSIB) is a recently developed technique for abdominal wall reconstruction that preserves the rectus abdominis perforators and minimizes subcutaneous dead space using limited-access tunneled incisions. We hypothesized that MICSIB would result in better surgical outcomes than conventional open CS. Study Design All consecutive patients who underwent CS (open or minimally invasive) with inlay bioprosthetic mesh for ventral hernia repair from 2005 to 2010 were included in a retrospective analysis of prospectively collected data. Surgical outcomes, including wound-healing complications, hernia recurrences, and abdominal bulge/laxity rates, were compared between patient groups based on the type of CS repair, either MICSIB or open. Results Fifty-seven patients who underwent MICSIB and 50 who underwent open CS were included. Mean follow-ups were 15.2 ± 7.7 months and 20.7 ± 14.3 months, respectively. Mean fascial defect size was significantly larger in the MICSIB group (405.4 ± 193.6 cm 2 vs 273.8 ± 186.8 cm 2 ; p=0.002). The incidences of skin dehiscence (11% vs 28%; p=0.011), all wound-healing complications (14% vs 32%; p=0.026), abdominal wall laxity/bulge (4% vs 14%; p=0.056), and hernia recurrence (4% vs 8%; p=0.3) were lower in the MICSIB group than in the open CS group. Conclusions MICSIB resulted in fewer wound-healing complications than did open CS used for complex abdominal wall reconstructions. These findings are likely attributable to the preservation of paramedian skin vascularity and reduction in subcutaneous dead space with MICSIB. MICSIB should be considered for complex abdominal wall reconstructions, particularly in patients at increased risk of wound-healing complications.

Lateral abdominal wall (LAW) defects can manifest as a flank hernias, myofascial laxity/bulges, or full-thickness defects. These defects are quite different from those in the anterior abdominal wall defects and the complexity and limited surgical options make repairing the LAW a challenge for the reconstructive surgeon. LAW reconstruction requires an understanding of the anatomy, physiologic forces, and the impact of deinnervation injury to design and perform successful reconstructions of hernia, bulge, and full-thickness defects. Reconstructive strategies must be tailored to address the inguinal ligament, retroperitoneum, chest wall, and diaphragm. Operative technique must focus on stabilization of the LAW to nonyielding points of fixation at the anatomic borders of the LAW far beyond the musculofascial borders of the defect itself. Thus, hernias, bulges, and full-thickness defects are approached in a similar fashion. Mesh reinforcement is uniformly required in lateral abdominal wall reconstruction. Inlay mesh placement with overlying myofascial coverage is preferred as a first-line option as is the case in anterior abdominal wall reconstruction. However, interposition bridging repairs are often performed as the surrounding myofascial tissue precludes a dual layered closure. The decision to place bioprosthetic or prosthetic mesh depends on surgeon preference, patient comorbidities, and clinical factors of the repair. Regardless of mesh type, the overlying soft tissue must provide stable cutaneous coverage and obliteration of dead space. In cases where the fasciocutaneous flaps surrounding the defect are inadequate for closure, regional pedicled flaps or free flaps are recruited to achieve stable soft tissue coverage.

Background Component separation (CS) is an effective technique for reconstructing complex abdominal wall defects. Violation of the rectus abdominis complex is considered a contraindication for CS, but we hypothesized that patients have similar outcomes with or without rectus complex violation. Study Design We retrospectively studied all consecutive patients who underwent CS for abdominal wall reconstruction during 8 years and compared outcomes of patients with and without rectus violation. Primary outcomes measures included complications and hernia recurrence . Logistic regression analysis identified potential associations between patient, defect, and reconstructive characteristics and surgical outcomes. Results One hundred sixty-nine patients were included: 115 (68%) with and 54 (32%) without rectus violation. Mean follow-up was 21.3 ± 14.5 months. Patient and defect characteristics were similar, except for the rectus violation group having a higher body mass index. Overall complication rates were similar in the violation (24.3%) and nonviolation (24.0%) groups, as were the respective rates of recurrent hernia (7.8% vs 9.2%; p=0.79), abdominal bulge (3.5% vs 5.6%; p=0.71), skin dehiscence (20.0% vs 22.2%; p=0.74), skin necrosis (6.1% vs 3.7%; p=0.72), cellulitis (7.8% vs 9.2%; p=0.75), and abscess (12.3% vs 9.2%; p=0.58). Regression analysis demonstrated body mass index to be the only factor predictive of complications. Conclusions CS surgical outcomes were similar whether or not the rectus complex was violated. To our knowledge, this study is the first to evaluate the effects of rectus violation on surgical outcomes in CS patients. Surgeons should not routinely avoid CS when the rectus complex is violated.

Background As the rate of contralateral prophylactic mastectomy in breast cancer patients increases, more women are seeking immediate bilateral breast reconstruction. The authors evaluated complication rates in the index and prophylactic breasts in patients undergoing bilateral immediate reconstruction. Methods The authors retrospectively reviewed the outcomes of all consecutive patients undergoing immediate postmastectomy bilateral reconstruction for an index breast cancer combined with a contralateral prophylactic mastectomy between 2005 and 2010. Patient, tumor, reconstruction, and outcome characteristics were compared between the index and prophylactic breasts in the same patient. Patients were classified by reconstruction method: implant, abdominal flap, or latissimus dorsi flap/implant. Regression models evaluated patient and reconstruction characteristics for potential predictive or protective associations with postoperative complications. Results Of 497 patients included, 334 (67.2 percent) underwent implant reconstruction, 142 (28.6 percent) had abdominal flap reconstruction, and 21 (4.2 percent) had latissimus dorsi flap/implant reconstruction. Index reconstructions had a complication rate (22.5 percent) equivalent to that of contralateral prophylactic mastectomy reconstructions (19.1 percent; p=0.090). Overall, 101 patients (20.3 percent) developed a complication in one reconstructed breast, and 53 (10.7 percent) developed complications in both breasts. Of the 154 patients who developed complications, 42 (27.3 percent) developed a complication in the prophylactic breast. Conclusions Immediate index and contralateral prophylactic breast reconstructions appear to have equivalent outcomes, both overall and across reconstruction classifications. Together, patients, reconstructive surgeons, and extirpative surgeons should carefully consider the oncologic benefits of a contralateral prophylactic mastectomy in light of the risk of increased surgical morbidity of this type of mastectomy and reconstruction. Clinical question/level of evidence Therapeutic, III.