Increase Patient Satisfaction, Referral Rates, Income for Your Institution!

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1 Increase Patient Satisfaction, Referral Rates, Income for Your Institution! Establishment of Perforator Flap Programs for Breast Reconstruction: The New England Program Experience. Lee BT, Yueh JH, et al: Plast Reconstr Surg 2009; 124 (November): Perforator flap programs can be the key to attracting more breast reconstruction patients to your breast reconstruction practice. Background: Perforator flap programs have been created to offer the latest breast reconstruction options as well as to unify care for breast cancer patients. The experience of the New England perforator flap program is presented here, with a focus on patient satisfaction and referral patterns. Objective: To review the experience of the Beth Israel Deaconess Medical Center before and after the creation of the New England perforator flap program in Design: Retrospective chart review and administration of a validated questionnaire. Participants/Methods: 977 patients were identified as having post-mastectomy breast reconstruction at Beth Israel Deaconess Medical Center between 1999 and Data were collected to evaluate demographics, referral patterns, and outcomes. Also, a questionnaire was used to analyze patient satisfaction and quality of life. Results: After creation of the perforator flap program, an increase in "outside" referrals and "outside" patients undergoing reconstruction occurred. In those who underwent perforator reconstruction, general patient satisfaction was also higher than in those undergoing non-perforator flap reconstruction. Conclusions: By establishing a perforator flap program, an increase in the number of referrals and patient satisfaction can be expected. This article hopefully may serve as a model for the creation of other such specialized centers throughout the country to offer breast cancer patients the full spectrum of reconstructive options. Reviewer's Comments: This article served as a template for establishing a perforator flap program and benefits that one might expect from doing so. While the authors admit that the outline provided at Beth Israel Deaconess Medical Center may be challenging to other institutions, if done properly and by following guidelines in the article, an increase in overall patient satisfaction and a broadening of referral patterns specific for perforator flap reconstruction can be expected. It is pretty clear that perforator flap breast reconstruction is one of the most current and cutting edge methods for patients seeking post-mastectomy reconstruction. Surgical outcomes obtained in this study are consistent with those at other major cancer centers. It would seem that by using the authors' outline, a greater overall population of breast cancer patients in a region might be captured. Moreover, these patients' overall satisfaction from perforator reconstruction will be greater than that from other current surgical techniques. (Reviewer-Jerome D. Chao, MD). Keywords: Breast Cancer, Perforator Flap, Patient Satisfaction

2 Practice Guidelines Should Evolve With the Craft Crafting Practice Guidelines in the World of Evidence-Based Medicine. Chung KC, Shauver MJ: Plast Reconstr Surg 2009; 124 (October): Practice guidelines based on evidence-based medicine help clinicians stay current. Background: Practice guidelines are condition- and population-specific recommendations for diagnosis and treatment, offered to assist clinicians in patient care. They are ideally grounded in current evidence-based thought and may help bridge any gap between clinical care and emerging literature. Unfortunately, such guidelines risk cookbook medicine and the potential for abuse as dicta. Objective: To stress the importance of a proper developmental process in crafting practice guidelines in an enlightened and objective way, in order to maximize the potential benefit of and minimize the risk from such measures. Toward that end, the authors offer some principles and important steps toward crafting a practice guideline. Design: Literature review. Methods: This paper summarizes the process used by the American Academy of Orthopedic Surgeons (AAOS) in developing a carpal tunnel practice guideline. It offers specific organizational and procedural tips on such an effort, and a reference list of sources of the ideas. The AAOS convened a workgroup to craft the 2008 Clinical Practice Guideline on the Treatment of Carpal Tunnel Syndrome. A literature search used electronic methods supplemented by manual library searches. Publications were ranked according to the American Society of Plastic Surgeons Evidence Rating Scale. Voting on specifics with grading of agreement, as well as the Delphi technique to unify polarizing ideas, helped to resolve disagreement. Peer review of the proposed guideline ensured clarity and applicability. Results: The workgroup succeeded in designing a practice guideline for management of carpal tunnel syndrome. That guideline is now widely circulated and deemed to be valid and helpful by a wide range of hand surgeons, physiatrists, and patients. Conclusions: The development process for a practice guideline should include 7 significant steps: (1) define the topic, (2) select a workgroup, (3) review relevant literature, (4) write the guideline, (5) peer review the guideline. (6) plan and schedule interval reviews and revisions to keep the guideline up to date, and (7) disseminate the guideline. Reviewer's Comments: Practice guidelines are potentially helpful to the clinical practitioner. When carefully crafted and clearly defined as helpful reminders for thought and possible recommendations for action, they seem to offer benefit. Unfortunately, even well-designed guidelines carry the potential to be characterized as the "only proper form of treatment" by the unenlightened and avaricious. The authors stress the important elements and processes that can yield good guidelines that offer most benefit. Certainly, when poorly crafted and out of date, practice guidelines would appear to offer little benefit and only liability. (Reviewer-Norman V. Godfrey, MD). Keywords: Practice Guidelines, Evidence-Based Medicine

3 Implant vs Flap -- What a Female Plastic Surgeon Would Choose for Herself Preferences in Choosing Between Breast Reconstruction Options: A Survey of Female Plastic Surgeons. Sbitany H, Amalfi, AN, Langstein HN: Plast Reconstr Surg 2009; 124 (December): In a survey of female plastic surgeons, 66% of respondents stated that they would choose implant-based breast reconstruction for themselves. Background: There are many options for breast reconstruction after mastectomy, and debate continues as to which options are better for patients. Female plastic surgeons have the knowledge and experience to make a well-informed decision for themselves. Objective: To survey female plastic surgeons about their views on various types of breast reconstruction and which option they would choose for themselves. Design: Survey via . Participants/Methods: The authors surveyed all board-certified female plastic surgeons in the U.S. and Canada via regarding hypothetical breast reconstruction choices for themselves and the reasons for their decisions. Results: Of 435 surveys sent, there was a 41% response rate. Of surgeons who responded, 66% chose implant-based reconstruction, while 25% stated that they would want autologous reconstruction for themselves; 9% stated that they would choose no reconstruction. Age did not significantly influence the decision to have reconstruction or the decision to have autologous or implant-based reconstruction. Mean body mass index was higher for surgeons opting for autologous rather than implant-based reconstruction (25.1 vs 21.9), as was subjective breast size. Of surgeons choosing autologous reconstruction, 47% did so because of the perceived better cosmetic result, whereas 14% of those who chose implant-based reconstruction did so for the same reason. Removal of tissue from other parts of the body was a primary reason given for 31% of those who chose autologous reconstruction. Of respondents who chose implant-based reconstruction, 24% did so because of the primary importance of recovery time, and 27% did so because of the lower invasiveness. Conclusions: Among female plastic surgeons, there is a strong preference for implant-based breast reconstruction for themselves, most commonly because it is less invasive with a faster recovery time. Reviewer's Comments: The decision on whether to have breast reconstruction after mastectomy, and what technique to choose, is personal and depends on multiple patient and surgeon factors. This survey provides some information on how female plastic surgeons would decide. It is not surprising that the majority would choose implant-based reconstruction, since recovery time and overall effect on the body are probably important factors for practicing surgeons. However, that does not mean that our choice would be what we recommend to our patients. The appearance of reconstructed breasts, the "added benefit" of a "tummy tuck," or fear of implants can all play a role in a patient's decision. I have been asked many times by my patients what I would choose for myself, and I always answer with the caveat that the best decision for me is not necessarily the best decision for someone else. These survey results do, however, argue against those who claim that autologous reconstruction is always superior, since a majority of female plastic surgeons would disagree with that for their own situations. (Reviewer-Christine H. Rohde, MD). Keywords: Reconstruction Options, Preferences, Surgeon Survey

4 Does AlloDerm Lead to Improved Cosmetic Outcomes? Acellular Dermis Assisted Prosthetic Breast Reconstruction Versus Complete Submuscular Coverage: A Head-to-Head Comparison of Outcomes. Sbitany H, Sandeen SN, et al: Plast Reconstr Surg 2009; 124 (December): Acellular dermis-assisted and complete submuscular coverage tissue expander breast reconstruction can both be achieved with low complication rates. Background: Implant-based reconstruction remains the most common type of breast reconstruction following mastectomy. Classically, this has involved initial tissue expansion with an expander covered by the pectoralis major and serratus anterior muscles. More recently, some surgeons have used an acellular dermal matrix to cover inferior and lateral portions of the expander and to avoid elevation of the serratus muscle. Objective: To compare complete submuscular coverage of expanders to acellular dermis-assisted tissue expander breast reconstruction. Design: Retrospective review. Participants: 50 consecutive patients undergoing breast reconstructions performed by 1 surgeon using complete muscular coverage of expanders were compared to 50 consecutive women undergoing reconstructions performed by a different surgeon using partial subpectoral placement with AlloDerm, an acellular dermal matrix. All 100 patients underwent reconstruction between 2004 and 2007 by 1 of 2 senior surgeons affiliated with the Division of Plastic Surgery at the University of Rochester. Methods: Complete submuscular coverage was obtained in 50 patients by splitting the fibers of the pectoralis major muscle in its midportion and creating a pocket beneath the pectoralis major and serratus anterior muscles. The other surgeon elevated the pectoralis major off the chest wall along its inferior and lower medial borders, and then sutured a 6 x 16-cm piece of AlloDerm to the inferior and medial margins of the pectoralis major. The medial and inferior AlloDerm margins were then sutured to the chest wall, and laterally the AlloDerm was sutured to the serratus anterior fascia. Results: The groups were similar in terms of demographic data and complication rates. Mean intraoperative fill volume was 130 cc in the submuscular group and 412 cc in the acellular dermis cohort (P =0.0001). Mean number of fills to complete reconstruction was 4.3 in the submuscular group and 1.7 in the acellular dermis group (P =0.0001). Mean time to complete reconstruction was 135 days in the submuscular group and 159 days in the acellular dermis group, with 220 days being the mean for the first 25 acellular dermis patients and 98 days being the mean for the second 25 acellular dermis patients. Conclusions: Use of AlloDerm does not increase the complication rate of tissue expander reconstruction, but it does enable increased initial expander fill and a decreased number of postoperative expansions. Additionally, AlloDerm may lead to improved cosmetic outcomes. Reviewer's Comments: This useful study shows that very good results can be obtained with either complete muscular coverage or AlloDerm-assisted tissue expander reconstruction. However, because 2 different surgeons performed the 2 types of expansion, it is difficult to make any firm conclusions when comparing the 2 study groups. (Reviewer-Jeffrey A. Ascherman, MD). Keywords: Acellular Dermis, AlloDerm, Tissue Expander Reconstruction

5 Increased Sampling May Lead to Increased Cancer Detection Carcinoma and Atypical Hyperplasia in Reduction Mammaplasty: Increased Sampling Leads to Increased Detection. A Prospective Study. Ambaye AB, MacLennan SE, et al: Plast Reconstr Surg 2009; 124 (November): Increased pathological sampling of breast tissue in reduction mammaplasty patients aged 40 years leads to improved detection of significant pathology. Background: Reduction mammaplasty is one of the most common plastic surgery procedures performed. The authors prospectively evaluated the incidence of occult carcinoma and atypical hyperplasia in their patient population and compared that to known standards. Objective: To determine whether increased tissue sampling in reduction mammaplasty leads to an increased finding of significant pathology. Design: Prospective, case-based pathologic specimen study. Methods: Specimens were examined from all patients who underwent reduction mammaplasty over a 20- month period, totaling 202 cases and 383 reduction specimens. All specimens underwent standard gross and microscopic pathological evaluation, followed by further "systematic" sampling. Data, including preoperative mammogram, age, and history of previous pathological abnormality, were noted. Results: A significantly higher number of pathological findings was obtained overall (12.4%), as compared to findings in the current literature, with the majority occurring in patients aged 40 years. Preoperative mammogram was not sensitive in detecting any of these lesions. Conclusions: Increased (ie, more thorough) pathological sampling of reduction mammaplasty specimens is warranted in patients aged 40 years. Reviewer's Comments: The authors should be complimented for the prospective nature of their study. While many studies have been performed evaluating occult breast cancer in breast reduction specimens, the authors have added additional pathological sampling to their cases, resulting in an increased detection of significant pathology, which they defined as occult cancer or atypical hyperplasia. Additionally, significant findings were found in greater numbers in those aged 40 years. None of these lesions were identified on preoperative mammograms, suggesting that current cancer guidelines may miss significant breast pathology in the older population and do not support performing them in patients aged <40 years without significant family histories. I believe the authors have presented an excellent preliminary study that may end up altering cancer screening guidelines in the future as well as pathological sampling guidelines. (Reviewer-Jerome D. Chao, MD). Keywords: Breast Cancer, Atypical Hyperplasia, Sampling

6 Ultrasound Can Identify Fat Necrosis Not Noted by Physical Exam Alone Fat Necrosis in Deep Inferior Epigastric Perforator Flaps: An Ultrasound-Based Review of 202 Cases. Peeters WJ, Nanhekhan L, et al: Plast Reconstr Surg 2009; 124 (December): Although the incidence of fat necrosis in deep inferior epigastric perforator flaps is high, the need for secondary corrective surgery for these areas of fat necrosis is low. Background: Fat necrosis is a common complication after autologous breast reconstruction, and it can lead to secondary surgeries. Fat necrosis is generally determined by physical examination, and reports of fat necrosis rates use diverse definitions. These differences can lead to unreliable published fat necrosis rates for different techniques. Objective: To retrospectively review the incidence of fat necrosis in deep inferior epigastric perforator (DIEP) flaps for breast reconstruction and the correlation to several risk factors. Design: Retrospective study. Methods: Physical examination and ultrasound imaging were used to determine the incidence of fat necrosis in 202 DIEP flap breast reconstructions. Age, smoking, timing of reconstruction, radiation, and body mass index were correlated to findings. Results: 202 DIEP flaps in 182 patients over 6 years were studied. Positive ultrasound findings for fat necrosis were considered in cases of a lesion with or without well-defined margins with a diameter of 5 mm. According to the authors, "Clinical fat necrosis was defined as any palpable nodule or focal area of firmness in the reconstructed breast." Of flaps, 14% had fat necrosis by physical examination, and another 21% had positive findings on ultrasound exam. Overall, the ultrasound incidence of fat necrosis was 35%, but only 7% of total flaps (21% of flaps with fat necrosis) had to undergo a secondary procedure for surgical correction of the fat necrosis. Fat necrosis rates were not different for patients who had undergone pre- or post-reconstruction radiotherapy. The other risk factors studied were also not statistically significant. Conclusions: The overall incidence of fat necrosis in DIEP flaps is higher than previously thought, when evaluated by ultrasound, but the need for additional surgery is limited. Reviewer's Comments: Fat necrosis is important for several reasons. It is a marker for the vascularity of a flap, and it is useful as one measure of comparison between breast reconstruction techniques. It can also become clinically significant if it leads to biopsies or secondary corrective surgery. There is still no generally accepted way to measure or define fat necrosis, which contributes to highly variable rates of fat necrosis reported in the literature. Use of ultrasound is one way to achieve more unified quantification of fat necrosis rates. However, ultrasound will also identify areas of no clinical significance. This paper does provide objective evidence that the rate of fat necrosis in DIEP flaps is higher than previously reported. I agree with the authors that ultrasound can be a useful tool in assessing fat necrosis. Pedicled transverse rectus abdominis myocutaneous (TRAM) flaps and muscle-sparing free TRAM flaps should also be evaluated for rates of fat necrosis using ultrasound, in order to obtain a more uniform assessment of actual rates for these procedures, and to provide a more uniform point of comparison. (Reviewer-Christine H. Rohde, MD). Keywords: Deep Inferior Epigastric Perforator Flaps, Fat Necrosis, Ultrasound

7 Skip Donor Site Morbidity -- Consider Freeze-Dried Allograft Bone Nasal Dorsal Augmentation With Freeze-Dried Allograft Bone. Clark RP, Wong G, et al: Plast Reconstr Surg 2009; 124 (October): Freeze-dried allograft cortical bone appears to perform well in the nasal dorsum as it has in other realms of bone-graft surgery. Background: Dorsal augmentation of the nose requires structural material of significant dimension and volume. Autograft suffers limitations of donor-site morbidity and availability, while alloplast suffers from potential infection, extrusion, and lack of suitability. This paper explores use of freeze-dried allograft bone in nasal applications. Objective: To attempt to characterize the clinical performance of freeze-dried allograft bone placed in the nasal dorsum and, moreover, to define the biologic behavior of the allograft toward a greater understanding of its strengths and limitations. Design: Retrospective review. Participants: 18 consecutive patients in whom freeze-dried allograft cortical bone was used for nasal dorsal augmentation. Clinical performance was judged by cephalometric radiography of postoperative dimensions. Biological performance was assessed with positron emission tomographic (PET) CT scanning. Methods: After eliminating 5 patients lost to follow-up, 18 operated patients were included for study. They were followed with postoperative cephalograms at 10 to 12 weeks, and at 6-month intervals thereafter out to 2 years. In addition, 5 patients underwent fluorine-18 sodium fluoride PET scan fused with CT scan to accurately define and localize post-procedure vascularization of allografts. Results: Based on cephalometrics, the average patient preserved 87% of dorsal height at 6 months compared to 10 weeks postoperatively. Thereafter, all patients maintained that height out to 24 to 36 months. Radionuclide PET scanning fused with CT images was performed in 5 patients. Four of these 5 patients had clearcut evidence of revascularization of the allografts. In the fifth patient, the allograft had been placed in a heavily scarred recipient bed. While dorsal height was preserved in this patient also, PET scan indicated that the allograft had not revascularized. Subsequent biopsy of the allograft showed no osteoblastic activity or inflammation, implying that the graft remained as an inert alloimplant. Conclusions: These early results indicate that freeze-dried allograft cortical bone performs well in the nasal dorsum as it has in other realms of bone-graft surgery. When placed in a well-vascularized bed, the implant ultimately revascularizes and endures through the process of osteoinduction from inducible precursor cells in adjacent perivascular tissue. In addition, in a case of poorly vascularized recipient bed, the freeze-dried bone appeared to endure as an inert alloimplant. Reviewer's Comments: This is an interesting piece of clinical research. If the promised follow-up cephalograms demonstrate long-term persistence of the clinical correction, freeze-dried bone may dramatically broaden our reconstructive options for the nose. Limitations of the method include potential for disease transmission, cost of the allograft, and patient and surgeon acceptance. Nonetheless, if the positive orthopedic and maxillofacial experience with freeze-dried allograft is reproduced here, it will be good news for nasal surgeons. (Reviewer-Norman V. Godfrey, MD). Keywords: Nasal Dorsal Augmentation, Bone Grafts, Freeze-Dried Allograft

8 Preserve -- Don t Resect -- Alar Cartilage! Sliding Alar Cartilage (SAC) Flap: A New Technique for Nasal Tip Surgery. Ozmen S, Eryilmaz T, et al: Ann Plast Surg 2009; 63 (November): Cephalic alar cartilage trim can be slid beneath the intact rim strip to support it. Background: Alar cartilages are the intrinsic structural support of the nasal tip. Deformity and/or weakness of these cartilages can compromise tip esthetics and function. Unfortunately, surgical maneuvers undertaken to refine the nasal tip can also compromise alar cartilage integrity. Objective: To present the authors' surgical approach to potentially conflicting objectives of reducing nasal tip fullness while preserving strength and support. They offer technical details of their tip plasty and a brief review of their clinical results. Design: Literature review. Methods: Naming the technique the sliding alar cartilage (SAC) flap, the authors describe, diagram, and photograph specifics of surgical steps involved in this specific tip modification technique. In addition, they offer a retrospective review of 160 consecutive patients treated over a 17-month period using their specific tip modification technique. They present photographic documentation of nasal appearance before and after to illustrate the results. Cases for this review were limited to rhinoplasties that had not had previous alar cartilage excision. All cases were performed via an open approach. Typically, 6 mm of caudal lateral crus was preserved in continuity with the medial and intermediate cartilage, and the remaining cephalic lateral crus was completely divided from the caudal portion. The vestibular soft tissue was dissected from the deep surface of the caudal cartilage, and the cephalic segment of cartilage was slid deep to the caudal. One or 2 mattress sutures fixed the 2 together. Results: 160 procedures were performed during the review period. No indication of operative complications (if any) is offered. With follow-up ranging from 4 to 18 months, there were no revisions related to the tip plasty technique. Patients available for late follow-up at 1 year were uniformly judged to have strong, stable, and esthetically pleasing nasal tips. Conclusions: Advantages of the SAC flap technique include (1) enhancing tip esthetics, (2) protecting tip support, (3) correcting pinched tips, (4) avoiding remote cartilage graft donor sites, (5) minimizing resorption, and (6) minimizing graft visibility. Reviewer's Comments: The technique of relocating cartilage that was discarded in older methods is enjoying wider acceptance and offers many benefits. In this reviewer's opinion, the trend toward less ablation and more reshaping is welcome, if overdue. The method offered in this paper is yet another variation on that theme. Caveats are 2. First, since the technique includes a reduction in vertical height of the lateral crus, concern remains that this will not avoid risks of alar retraction or rim notching. Second, the authors warn that such reinforced alar cartilages may appear unnatural in thin-skinned noses. (Reviewer-Norman V. Godfrey, MD). Keywords: Nasal Tip Surgery, Sliding Alar Cartilage, Lower Lateral Cartilage, Nasal Valve

9 Irradiated Homograft Cartilage May Not Resorb as Critics Say Give It Another Look! Long-Term Use and Follow-Up of Irradiated Homologous Costal Cartilage Grafts in the Nose. Kridel RW, Ashoori F, et al: Arch Facial Plast Surg 2009; 11 (November-December): The antigenicity of cartilage grafts resides in the perichondrium. Irradiation or removal of the perichondrium may minimize or eliminate this as a problem. Background: Ideal nasal augmentation material should be easily obtainable in adequate quantity and be welltolerated, strong, and enduring, with little tendency to distort or extrude. Irradiated homograft cartilage may meet these criteria. Objective: To describe the long-term performance of irradiated homograft costal cartilage in rhinoplasty. Design: Retrospective review. Methods: This paper reports a single-surgeon case series of primary and secondary rhinoplasties utilizing irradiated homograft costal cartilage. Most rhinoplasties in the series were performed open. Most dorsal grafts were "fixed" by precise pocket dissection, but many others were sutured with braided polyglycolic acid or monofilament polypropylene or polydioxanone. In many cases, autografts and alloplasts were used in addition to the homografts. Patient satisfaction was polled with a questionnaire. However, only 42 (12%) of 357 patients were polled. Results: Mean follow-up period for this series was 13 years with a range of 4 days to 24 years. Overall complication rates were quite low. Approximate rates of warping, infection, and resorption were 1% per graft and 3% per patient. There were no extrusions noted and no allergic reactions or systemic diseases encountered. Patient satisfaction was 90%. Conclusions: Irradiated homograft costal cartilage performs well in the nose. It is free of autograft donor site morbidity and incurs little risk of alloplast-type extrusion. Reviewer's Comments: This paper is extremely long (17 pages with 20 additional pages of e-supplement offered online) and is difficult to read. The editors suggest that, as an effort to define the nasal role of irradiated homograft, it stands as a scientific benchmark. Unfortunately, while the effort was a good one, this paper fails in that attempt because the clinical material does not suffice. It is a retrospective case series review. The variability of patients, indications, incisional approach, graft types, operative techniques, and combination with other grafts and alloplasts among these 357 cases is so great as to preclude any specific differential conclusions. Patient satisfaction, a potentially meaningful finding, was not polled in 88% of patients. The series is described as case-controlled with the preoperative state as the control. On that basis, the performance of irradiated homograft is judged relative to no treatment. Accordingly, with regard to homograft performance relative to other treatment options, no meaningful data are generated. These criticisms aside, the paper has merit. The experience of a single skilled surgeon, with the largest series of irradiated homografts of which I am aware, has been overwhelmingly positive. The material is versatile and easy to work with. Complication rates of warping, infection, resorption, and revision are impressively low. The paper includes numerous photos, diagrams, and case details to assist the reader to perform such surgery. (Reviewer-Norman V. Godfrey, MD). Keywords: Cartilage Graft, Homograft, Augmentation Rhinoplasty, Saddle Nose

10 New Technique May Be Effective in Reducing Fat Cryolipolysis for Noninvasive Fat Cell Destruction. Zelickson B, Egbert BM, et al: Dermatol Surg 2009; 35 (October): Cryolipolysis is worthy of further study because it has been shown to significantly decrease subcutaneous fat and change body contour without causing damage to the overlying skin and surrounding structures or deleterious changes in blood lipids. Background: Liposuction is the most common cosmetic surgical operation over the last 20 years. Complications from liposuction are rare, but the possibility of a nonoperative approach to fat removal is exciting. Focused ultrasound is the leading noninvasive technology, but an emerging technology involves chilling fat to destroy it. Objective: To determine whether noninvasive controlled and selective destruction of fat cells (Cryolipolysis) can selectively damage subcutaneous fat without causing damage to the overlying skin or rise in lipid levels. Design: Prospective nonrandomized animal study. Methods: 4 pigs were used in this study. Each pig had a different protocol used. A cooling apparatus produced by Zeltiq Aesthetics (Pleasanton, CA) was used. Cooling was reported as a "cooling intensity factor," as opposed to a temperature. The device was applied to the skin and held in place for a variable amount of time. The cooling device vibrated for 5 minutes during the treatments. Three pigs were treated once and sacrificed 90 days later. The fourth pig was treated 90, 60, 30, 14, 7, and 3 days and immediately before sacrifice. The pigs were assessed for visible contour changes as well as ultrasound measurements and gross pathology. One pig was examined histologically. Results: Visual inspection revealed a depression in the skin where the procedure was performed. This was confirmed with ultrasound, where 2 pigs had a 33% reduction in the fat layer. Gross pathology in 1 pig showed about a 50% decrease in the fat layer. Fat was analyzed histologically over time. Inflammation was followed by phagocytosis of lipids and ultimately removal of fat cells. There was no damage to the dermis or epidermis. In the short term, only erythema was seen. Lipids were assessed and did not change. Conclusions: Cold exposure resulted in death of pig fat cells, which are more susceptible to cold injury than the skin. The paper suggests that this might be a method of destroying fat in humans. Reviewer's Comments: The finder of a viable technique that does not injure non-fat tissue will undoubtedly become extremely wealthy. The Zeltiq technique here may be such a technique. One must remember that this was a very small, and not well designed, study. There were just 4 pigs, and each was treated differently. Statistics were not presented. For scientific validity, at least 10 pigs, treated and analyzed identically, should have been performed. Nowhere in the paper was the temperature of the cooling apparatus discussed. Standardization of the cooling temperature would be critically important in analyzing this procedure. The next step would be to perform a larger, more scientifically rigid study. If visual and histological end points are confirmed, then a study could be conducted in humans. After independent studies confirm the efficacy and safety of the device, then FDA approval could be sought. As is so typical in plastic surgery, this device has already been described on television programs as the next big answer in noninvasive fat removal. (Reviewer- Arthur W. Perry, MD). Keywords: Fat Removal, Cryolipolysis

11 Who Can Benefit Most From Nipple-, Areola-Sparing Mastectomy? Nipple-Sparing Mastectomy and Immediate Tissue Expander/Implant Breast Reconstruction. Chen CM, Disa JJ: Plast Reconstr Surg 2009; 124 (December): The ideal patient for nipple- and areola-sparing mastectomy with immediate expander/implant reconstruction is a relatively small-breasted woman with little or no ptosis who is undergoing bilateral riskreducing mastectomy. Background: Decades of breast cancer treatment have proven that the nipple is an uncommon site for development and recurrence; however, the nipple-areola complex is routinely excised in breast cancer treatment. Objective: To evaluate risks and benefits of nipple- or areola-sparing mastectomy with immediate autologous breast reconstruction. Design: Retrospective review. Methods: Data were pulled on 115 breasts that had consecutively undergone nipple- or areola-sparing mastectomies and immediate tissue expander breast reconstruction. There were 66 patients from 1998 to Indications included prophylaxis in 75 breasts and treatment of disease in 40 breasts. Results: Average patient age was 45 years and mean follow-up time was 22 months. Of mastectomies, 48 were bilateral and 19 unilateral. There were 111 nipple-sparing and 4 areola-sparing mastectomies. On final pathology of the breasts, 20 had ductal carcinoma in situ, 20 had invasive cancer, 11 had lobular carcinoma in situ, 1 had phyllodes tumor, 1 had mucinous carcinoma, and 62 were disease free. Incisions included periareolar and radial (n=61), inframammary (n=25), omega type (n=14), customized to include a previous scar (n=10), and transareolar (n=5). Six nipples were excised secondary to occult disease (5.2%), and 4 nipples were lost due to wound-healing problems (3.5%). Conclusions: In this series of nipple- and areola-sparing mastectomies, there was a low incidence of occult disease (5.2%). Nipple- and areola-sparing mastectomy is a feasible option in carefully selected and well informed patients. It merits additional investigation. Reviewer's Comments: This is a well written and comprehensive article that shares the Memorial Sloan- Kettering Cancer Center s experience with nipple- and areola-sparing mastectomies over the past decade. The authors describe in detail their indications for operation, which is a controversial topic, as well as incision placement and then explain types of complications and how they were handled. All reconstruction in this series was autologous. The rate of nipple necrosis in this paper was within the previously published range. The authors interestingly noted that full- and partial-thickness loss of the nipple-areola complex was not related to initial expander fill volume, but was more common in thin mastectomy skin flaps and larger, more ptotic breasts. This paper adds to the growing literature in nipple- and areola-sparing mastectomies demonstrating that this is a reasonable technique that can result in a high level of patient satisfaction without sacrificing oncologic safety. It is a ripe topic for additional investigation. (Reviewer-Robert T. Grant, MD). Keywords: Nipple Sparing Mastectomy, Areola Sparing Mastectomy, Nipple Necrosis, Recurrence

12 Is Pocket Change Technique for Implant Revisions Successful? Difficulties With Subpectoral Augmentation Mammaplasty and Its Correction: The Role of Subglandular Site Change in Revision Aesthetic Breast Surgery. Lesavoy MA, Trussler AP, Dickinson BP, et al: Plast Reconstr Surg 2010; 125 (January): Change of pocket procedure can safely correct problems of unwanted implant movement, symmastia implant malposition, and capsular contraction. Background: Subpectoral breast augmentation can be associated with particular postoperative complications not encountered when the implants are placed in subglandular pockets. Subpectoral implant placement leads to some degree of implant motion with chest wall contraction. However, there is a group of patients who have other concomitant issues such as implant malpositioning and improper superior contouring who desire correction. Objective: To describe a technique to correct the adverse effects of contraction-induced deformities following subpectoral implant placement. The technique was also applied to those patients with implant malposition, capsular contracture, and symmastia. Design: Retrospective review. Methods: Over a 12-year period, the authors performed 36 procedures using their technique of removal of the subpectoral implant, limited capsulectomy, pectoralis resuspension, and implant replacement in a subglandular pocket. Regardless of prior incisions, all procedures were performed via inframammary access incisions. The previously placed subpectoral implants were removed and a "modified" capsulectomy was performed, leaving the posterior aspect of the capsule on the chest wall and the anterior capsule on the undersurface of the pectoralis muscle. This anterior capsule was used to secure the attenuated muscle down to the underlying rib perichondrium and/or sternum. A subglandular pocket was then dissected for new implant placement. For cases of symmastia, medial capsulodesis was carried out with sutures followed by placement of Prolene "U" sutures medially along the lateral borders of the sternum down to the periosteum. These sutures were tied down over bolsters and removed after 3 weeks. Results: All patients were dissatisfied with abnormal breast movement prior to revision, while 62% had additional malposition, 53% with capsular contracture, and 10% with symmastia. The average number of prior breast augmentations was 2 (range, 1 to 5). In total, 81% of patients received smooth silicone implants of smaller volume than they had previously had. Three patients opted to not have new implants replaced. Postoperatively, implant malposition, movement, and symmastia were corrected in 100% of cases. Revision rate was 2.8% at 6 months. Conclusions: This procedure can be performed to successfully correct a variety of problems associated with subpectoral breast augmentation. Reviewer's Comments: Revision breast augmentation can be a challenging procedure. When a subpectoral pocket is overdissected at the initial or even secondary procedure, the patient may be left with a less than esthetic appearing result. Contraction-induced implant issues are not uncommon when the implant is placed in a submuscular pocket. The authors describe their experience with a technique (similar to others before) where they create a virgin plane in which to "re-pocket" a new implant. There is very little new technique described here. (Reviewer-Robert T. Grant, MD). Keywords: Revision Breast Augmentation, Contraction-Induced Deformities

13 One Surgeon's Experience With Bilateral Pedicled TRAM Flaps Outcomes and Patient Satisfaction Following Breast Reconstruction With Bilateral Pedicled TRAM Flaps in 105 Consecutive Patients. Chun YS, Sinha I, et al: Plast Reconstr Surg 2010; 125 (January): 1-9 Breast reconstruction with bilateral pedicled TRAM flaps has a low complication rate and good patient satisfaction similar to previously published series. Background: Pedicled transverse rectus abdominis musculocutaneous (TRAM) flap breast reconstruction has long been a safe and reliable method of breast reduction, but has been criticized for possible problems with abdominal wall laxity. Reports of rates of abdominal complications such as hernia, bulge, and wound dehiscence have varied. Objective: To evaluate abdominal wall complication rates and patient satisfaction in a series of patients undergoing bilateral pedicled TRAM. Design: Retrospective review. Participants/Methods: 105 patients underwent bilateral pedicled TRAM flaps for breast reconstruction by a single surgeon over a 10-year period. Medical records were retrospectively reviewed to determine complication rates and analyzed for risk factors for these complications. A questionnaire was sent to all patients with markers of patient satisfaction (Michigan Breast Satisfaction Questionnaire), incidence of back pain, and functional outcome (Short Form-36). If the form was not returned, 2 further attempts were made to contact the patient. There was a minimum of 11 months follow-up. Results: Average follow-up was 6.0 years with an operative time of 5.7 hours, average age of 47.8 years, and body mass index (BMI) of Of 105 patients, 3 had an abdominal hernia and 3 had an abdominal bulge (2.9% each). Four patients (3.8%) had abdominal wound complications and 2 patients (1.9%) had skin infection. Four patients had seroma, and fat necrosis occurred in 21 patients (24 flaps) for a total of 11.4% and no flaps were lost. Overall survey response rate was 61.9% (65 of 105). In total, 20% of patients had newonset back pain (mostly mild), 80% of patients were satisfied with their overall reconstruction, and 70% would choose to have the same reconstruction again. Short-Form 36 analysis showed that bilateral pedicled TRAM patients did not have any lower emotional well-being scores than the general population, but those patients with BMI >30 were more likely to have lower scores for energy, social functioning, and emotional well-being. Conclusions: In this series of patients, bilateral pedicled TRAM breast reconstruction is a well-tolerated procedure with good patient satisfaction and low abdominal wall complication rates comparable to those of other surgeons. Reviewer's Comments: This article demonstrates that there is not a much higher abdominal wall complication rate for pedicled TRAM than published rates for free TRAM, and the rate is low overall. The author did use a mesh inlay for closure, which may help with the rates of bulging. Also, it should be noted that there was only a 65% response rate and this may have skewed results if unsatisfied patients did not respond. There was no difference in rates of complications for responders versus nonresponders, however. It would have been nice for the author to explain why he chose pedicled TRAM versus microsurgical TRAM since the senior author is a well-known microsurgeon. (Reviewer-Robert T. Grant, MD). Keywords: Autologous Breast Reconstruction, TRAM Flap, Hernia, Bulge, Pedicled Flap

14 PEAK PlasmaBlade Causes Less Tissue Damage, Scarring Than Electrocautery Comparative Healing of Surgical Incisions Created by the PEAK PlasmaBlade, Conventional Electrosurgery, and a Scalpel. Loh SA, Carlson GA, et al: Plast Reconstr Surg 2009; 124 (December): The PEAK PlasmaBlade provides scalpel-like cutting that minimizes thermal damage with hemostasis comparable to traditional electrocautery. Background: The pulsed electron avalanche knife (PEAK) PlasmaBlade provides an alternative to traditional electrocautery that operates with cyclic bursts and in theory uses less total energy and reduces collateral thermal damage. Objective: To compare blood loss, wound tensile strength, coagulation necrosis, inflammation, and scarring between traditional electrocautery, the PEAK, and a scalpel. Design: Prospective comparative trial in animal model. Methods: 6 pigs underwent sterile surgical wounding on days 0, 21, 28, 35, and 42. At each procedure, 4 fullthickness 3-cm incisions were made using a No. 10 blade, the PEAK, a Bovie on cut 40 Blend, and a Bovie on coagulation 40 Spray. During surgery, operative temperature was recorded by infrared camera and blood loss was measured by surface area on filter paper placed over the incision for 60 seconds. Incisions were closed with a 3-0 nylon suture. Animals were killed on day 42 and scars were photographed, harvested, tested for wound strength using a digital force tester, and stained with H&E and for immunohistochemical markers of inflammation (T-cells, macrophages, myofibroblasts). Results: Temperature of the PEAK was 45 C versus 241 C for Bovie on cut and 180 C on coagulation. PEAK showed 59% less bleeding than a scalpel and did have slightly more bleeding than cautery, but the difference was not statistically significant. PEAK had a smaller histologic zone of necrosis than cautery (66 μm vs 456 for cut and 615 for coagulation). T-cell and macrophage counts for PEAK incisions were lower than both scalpel and cautery consistently over 6 weeks. PEAK and scalpel scars were 22% to 24% the width of cautery scars, and wound burst strength for scalpel and PEAK incisions was also greater at all time points. Conclusions: The PEAK PlasmaBlade provides a wound-healing profile with minimal tissue damage similar to the scalpel with significantly less bleeding. Reviewer's Comments: This is a solid animal study showing that the PEAK PlasmaBlade definitely causes less tissue damage and leads to less scarring than electrocautery when used on skin. It is unclear why the PlasmaBlade leads to lower T-cell counts (marker of inflammation) than even the scalpel and the authors did not touch on this. Although it seems that the PlasmaBlade might be a great way to cut skin, this study does not show if it is capable of hemostasis in active bleeding and whether it would be appropriate for cutting through muscle or fatty tissue. Also, no statistical difference in bleeding between cut and coag modes of the cautery is surprising. If it should be used for skin only but with a regular Bovie for any major cutting through breast tissue, for example, one may have to decide if it is worth the cost to have on the field. (Reviewer-Robert T. Grant, MD). Keywords: Wound Healing, Cutting, Electrocautery, PlasmaBlade

15 Are There Adverse Effects to AlloDerm Use in Prosthetic Breast Reconstruction? AlloDerm Performance in the Setting of Prosthetic Breast Surgery, Irradiation and Infection. Nahabedian MY: Plast Reconstr Surg 2009; 124 (December): The risk of infection in prosthetic breast reconstruction with AlloDerm is not increased compared to traditional methods, even in the setting of radiation. Background: There is current debate about whether AlloDerm increases the rate of infection when used in prosthetic breast reconstruction. Also, previous studies have demonstrated that radiation to the breast may increase infection rates. Objective: To compare rates of infection in one surgeon's experience with prosthetic breast reconstruction with and without AlloDerm and whether radiation affects the rates of infections and complications in those patients. Design: Retrospective review. Methods: One surgeon completed breast reconstruction with tissue expanders (later exchanged to implants) in 361 women from July 1997 to September 2008 at 2 institutions. In total, 285 women (324 breasts) had reconstruction without AlloDerm and 76 women (100 breasts) had reconstruction with AlloDerm. The AlloDerm cases were only from 2006 to Patients were followed for 17 months. Within the AlloDerm group, 23 women underwent radiation either before (9), after (13), or both before and after AlloDerm placement. The incidences of infection, seroma, skin necrosis, and incisional dehiscence were measured. Results: When no AlloDerm was used, incidence of infection was 5.85% compared to 5.0% with AlloDerm. Within the AlloDerm group, infection occurred in 3.9% of nonradiated breasts, 7.7% of breasts that received post-alloderm radiation, and 11.1% of breasts that received pre-alloderm radiation. Seroma rate was 5.0% in breasts with AlloDerm and 2.4% in breasts without AlloDerm. Rates of skin necrosis and incisional dehiscence were measured only within the AlloDerm group. Necrosis occurred only in nonradiated breasts (3.9%) and incisional dehiscence occurred in 1 nonradiated patient, 2 patients with preop radiation, and 1 patient with both preop/postop radiation. Conclusions: There is no increased risk of infection in breast reconstruction with use of AlloDerm compared to traditional methods.there is a small incidence of skin necrosis and dehiscence both with and without use of radiation. Reviewer's Comments: This is a reasonable analysis of one surgeon's experience that shows comparable infection rates with and without AlloDerm. However, there is no statistical analysis anywhere in the paper and although rates of complications, etc are presented, there are no P values to state whether differences are significant. Also, rates of skin necrosis and dehiscence were measured only within the AlloDerm group, and it would have been good knowledge as to whether there is an increased rate of these complications with AlloDerm. The author asserts that patients had complications in the setting of radiation, but did not comment on whether this had any significance. Also, the series without AlloDerm was done at 2 institutions; whereas based on the timing of the AlloDerm cases, they would have been done only at Georgetown. This may have contributed to difference in infection rate. (Reviewer-Robert T. Grant, MD). Keywords: AlloDerm, Radiation, Infection, Breast Implants

16 Capsular Contracture--Why It Happens, What to Do About It Capsular Contractures: A Systematic Review. Araco A, Caruso R, et al: Plast Reconstr Surg 2009; 124 (December): Although a great deal of progress has been made over the past few decades, a definitive cause and effective treatments for capsular contracture have not yet been described. Background: Reported rates of capsular contracture after both cosmetic and reconstructive breast implant surgery vary widely. Optimal means to prevent and treat this complication have not yet been described. Objective: To discuss risk factors, hypotheses for the etiology of the disorder, and known treatment modalities for capsular contract. Design: Literature review. Methods: A literature search was performed of all published data regarding breast implants, their complications, and the management of capsular contracture. Results: Most of the data that exist today represent small sample sizes, retrospective chart reviews, and limited follow-up time. There are many theories of the mechanism of capsular contracture, but none have been explicitly delineated. Associated use of radiation therapy, presence of infection, smooth implant shell surface, and subglandular implant placement are described by the authors as risk factors associated with higher rates of capsular contracture. Limited implant handling and pocket irrigation with antibiotics are associated with decreased rates of contracture. The effect of chemotherapy as an independent variable remains unclear. The treatment of capsular contracture invariably involves re-operation, and there are as of yet no proven methods of prevention. Conclusions: Further study is necessary to better understand the mechanism of capsular contracture in order to help prevent it and allow for more effective and less invasive treatment of the problem. Reviewer's Comments: This article represents a basic review of the evidence on the mechanism of capsular contracture. However, there are several issues that are not explored. There is no discussion of the impact of hematoma formation on eventual contracture, nor on the effect of irritants such as powdered gloves. There is also limited discussion of the many studies on microbiological analyses of capsulectomy specimens. While the authors state that one of the most implicated factors in the development of capsular contracture remains subclinical infection, they have a limited discussion of the evidence supporting this. Furthermore, while they do cite the Argenta article on endogenous breast bacteria, they do not discuss the evidence of bacteria in capsulectomy specimens that differ from normal skin flora. Overall, this paper offers a basic understanding of the main mechanisms of capsular contracture, but it is incomplete and it fails to sufficiently suggest effective methods of future study on the subject. (Reviewer-Robert T. Grant, MD). Keywords: Capsular Contracture, Breast Implants