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BACKGROUND: Capsular contracture is a common complication of breast augmentation surgery and many techniques to prevent and treat it have been suggested with inconsistent or variably effective results. OBJECTIVES: The aim of this paper was to describe a protocol for treating established capsular contracture after breast augmentation with a low recurrence rate. METHODS: From January 2009 to December 2012, 79 previous bilateral breast augmentation patients presented for treatment of established capsular contracture. There were 135 breasts with capsular contracture: 56 were bilateral and 23 were unilateral. Ten patients opted for no treatment; 2 patients opted for implant removal. Twenty-four were treated with the ICES (implant exchange, capsulectomy, and possible exchange of site) protocol and 43 were treated with the SPICES (Strattice placement in the reconstructive position, implant exchange, capsulectomy, and possible exchange of site) protocol. RESULTS: The 24 patients treated with the ICES protocol had a recurrent capsular contracture rate of 15%. The 43 patients treated with the SPICES protocol had a 2.7% recurrent capsular contracture incidence and an 2.7% complication rate. CONCLUSIONS: Capsular contracture after breast augmentation, whether primary or recurrent, can be successfully treated with the SPICES protocol.

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BACKGROUND: Implant-based reconstruction is currently the most common postmastectomy breast reconstruction modality with over 86,000 procedures performed in 2017. Although various methods for reconstruction techniques have been described, partial subpectoral implant placement with or without acellular dermal matrix coverage remains the most popular approach. Recently, prepectoral implant placement has gained increased recognition as a method that avoids some of the potential morbidities of submuscular implant placement. Currently, few studies have examined the outcomes of performing this approach. The purpose of this study was to evaluate and compare the outcomes of prepectoral and subpectoral direct to implant (DTI) immediate breast reconstruction. METHODS: Data from a prospective cohort of consecutive patients undergoing prepectoral DTI immediate breast reconstructions at our institution from February 2016 to November 2017 were collected. The incidence of complications such as mastectomy skin flap necrosis, seroma, hematoma, infection, implant loss, and unexpected reoperation were recorded and compared with a cohort of consecutive patients who underwent subpectoral DTI immediate breast reconstruction from May 2014 to July 2015. RESULTS: One hundred twelve prepectoral DTI immediate breast reconstructions were performed on 62 patients. Four breasts (4.4%) were diagnosed with infection. There were 8 breasts (7.1%) that suffered from mastectomy skin flap necrosis (5 partial thickness necrosis, 3 full thickness necrosis). There was 1 implant loss related to full thickness necrosis that required salvage with autologous tissue reconstruction. Prepectoral breast reconstruction had less esthetic revisions and comparable complications when compared with the historical subpectoral cohort. CONCLUSIONS: When compared with the subpectoral DTI approach, prepectoral DTI breast reconstruction grants favorable complication rates and improved esthetic outcomes. Prepectoral DTI breast reconstruction is a safe modality that should be considered in any patient who is a candidate for immediate breast reconstruction.

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BACKGROUND: Laser-assisted indocyanine green angiography (LAIGA) has been proven to accurately detect mastectomy skin flap necrosis (MSFN) intraoperatively and prevent postoperative complications in breast reconstruction. The purpose of this study was to examine the cost-effectiveness of the routine use of LAIGA in immediate breast reconstruction and to perform a break-even point analysis. METHODS: This is a retrospective review of prospectively gathered data from all patients who underwent immediate breast reconstruction from January 2014 to January 2015. LAIGA was routinely used in all cases. Patients were followed for at least 90 days to capture postoperative complications. Costs were calculated by reviewing itemized bills and Medicare Reimbursement Current Procedural Terminology codes to assess surgeon fees. Outcomes and costs were compared with a historical cohort of patients who underwent breast reconstruction before the implementation of LAIGA. RESULTS: Two-hundred-and-six immediate breast reconstructions (126 patients) were performed using LAIGA for a total cost of $210,700. The average cost of MSFN in our LAIGA cohort was $30,496. The routine use of LAIGA decreased the MSFN rate from 12.4% to 6.3% and prevented MSFN on 13 breasts resulting in a gross cost savings of $396,453, and net savings of $185,753. Break-even point analysis demonstrated that number of cases needed to break even decreases as the average MSFN cost and MSFN reduction rate increase. CONCLUSION: The routine use of LAIGA in immediate breast reconstruction is cost-effective in reducing the incidence of MSFN, implant loss, and overall unexpected reoperation rate.

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The use of acellular dermal matrix has revolutionized implant-based breast reconstruction in the 21st century. There have been a number of different dermal matrices introduced to clinical use and their equivalence has been debated. The purpose of this study is to examine a sequential series of acellular dermal matrix assisted implant-based breast reconstructions by a single surgeon and to compare the outcomes between a freeze-dried (FD) Alloderm cohort and a sterile ready to use Alloderm cohort. METHODS: After institutional review board approval, all consecutive implant-based breast reconstructions of a single surgeon (D.S.W.) from January 2009 to June 2016 were examined. Two hundred thirty-six patients received either FD Alloderm in the first 151 breasts reconstructed or sterile ready-to-use Alloderm in the last 227 breasts. RESULTS: The FD Alloderm patients had more tissue expander reconstructions performed and were all subpectoral placement. The ready-to-use Alloderm patients had more direct-to-implant procedures and some prepectoral placements. The complication rates were similar for seroma, hematoma, skin necrosis, and dehiscence. There were more infections, implant losses, and unexpected reoperations in the FD Alloderm group. CONCLUSION: The rate of infection, explantation, and unexpected reoperation was lower in the sterile ready-to-use Alloderm group versus the FD Alloderm group.

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BACKGROUND: Complication rates following immediate breast reconstruction range from 4% to 60%. Mastectomy skin flap necrosis (MSFN) is often the sentinel event leading to secondary complications. METHODS: All patients undergoing immediate reconstruction were enrolled. Upon mastectomy completion, the surgeon visually interpreted the skin flaps, performed laser-assisted indocyanine green angiography (LAIGA), and intervened if needed. Patients were followed for 90 days, documenting skin necrosis, infection, seroma, hematoma, implant loss, and reoperation. RESULTS: There were 126 patients who had 206 immediate breast reconstructions. The complication rate was 22.3%. The incidence of MSFN was 14.1%. The reoperation rate was 8.7%. There was 1 necrosis-related implant loss. Postoperative surveys were completed on 193 breasts: 137 had visual and LAIGA interpretation of well or adequately perfused, resulting in 5.8% rate of necrosis, 2 reoperations, and no implant losses. Twenty breasts had visual and LAIGA interpretation of marginal or poor perfusion. Sixteen of these underwent intervention. The necrosis rate in this group was 35% with no implant losses. A third group with 26 breasts had adequate visual interpretation with marginal or poor perfusion on LAIGA. Ten breasts had no intervention, and 16 received intervention. The overall necrosis rate in this group was 42.3%, with 4 reoperations for necrosis and 1 implant loss. CONCLUSIONS: LAIGA can more accurately predict complications from MSFN than surgeon assessment alone. When surgeon decision making is supplemented with LAIGA, it reduces the incidence of MSFN, infection, implant loss, and overall unexpected reoperation rate. LAIGA is a valuable adjunct for intraoperative decision making.

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PURPOSE: Postoperative infection is the most common complications after implant-based immediate breast reconstruction (IBR), with reported rates ranging from less than 1% to 43%. This heterogeneity among the literature may be explained by a lack of consensus on the definition of postoperative infection. The purpose of this study was to review the prevalence of infection and how it is defined in studies involving prosthetic-based IBR. It is necessary to establish a clear definition of infection to standardize the reporting of complications. METHODS: A comprehensive literature review was performed to identify infection rates among implant/tissue expander-based IBR performed between 1996 and 2017. A PubMed search using the keywords "immediate breast reconstruction" matched with "infection" and "tissue expanders" or "implant" was performed. Reconstructive modality, infection rates, and definitions were recorded and reviewed. RESULTS: An initial search provided 196 articles; 138 articles met inclusion criteria and were reviewed. Eighty-five (61%) articles failed to define infection and reported an infection rate ranging from 0% to 22%. The studies that characterized infection had highly variable definitions. Whereas some authors chose to define infection based on Centers for Disease Control guidelines, others used more subjective findings such as clinical signs of infection. CONCLUSIONS: Currently, there is no consensus on the definition of infection after implant-based IBR. We propose that the definition should include the administration of antibiotics beyond the surgeon's standard perioperative period with or without the presence of localized clinical signs of infection (erythema, pain, increased temperature, etc). A universal definition of postoperative infection after implant-based IBR that accurately captures the incidence of infection will allow better comparisons between future studies.

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BACKGROUND: Current literature comparing outcomes of immediate breast reconstruction using direct-to-implant (DTI) single-stage and 2-stage tissue expanders (TEs) is conflicting. This study compared overall outcomes and determined predictive patient factors associated with higher complication rates. METHODS: After institutional review board approval, a retrospective cohort study of consecutive patients who underwent immediate breast reconstruction from 2010 to 2014 at a single hospital was performed. Demographic data and complications were recorded and compared using univariate analysis. Infection was defined as any patient receiving antibiotics beyond the expected postoperative course or restarting antibiotics for a suspected infection. RESULTS: Seventy-nine breasts (50 patients) underwent immediate breast reconstruction using tissue expansion, and 117 breasts (69 patients) underwent immediate breast reconstruction using the DTI technique. Overall complications, infection rate, and rate of aesthetic revisions were higher in the TE group compared with the DTI group. There was no difference in rates of seroma, hematoma, and mastectomy skin flap necrosis between the 2 groups. Infectious complications were significantly higher in patients with body mass index of greater than 30 who underwent TE-based reconstruction than those who underwent DTI-based reconstruction. CONCLUSIONS: Single-stage DTI immediate breast reconstruction has less overall complications than 2-stage TE-based immediate reconstruction. Direct-to-implant immediate breast reconstruction may provide favorable outcomes in patients with body mass index of greater than 30.

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BACKGROUND: Venous thromboembolism (VTE) risk models including the Davison risk score and the 2005 Caprini risk assessment model have been validated in plastic surgery patients. However, their utility and predictive value in breast reconstruction has not been well described. We sought to determine the utility of current VTE risk models in this population and the VTE rate observed in various methods of breast reconstruction. METHODS: A retrospective review of breast reconstructions by a single surgeon was performed. One hundred consecutive transverse rectus abdominis myocutaneous (TRAM) patients, 100 consecutive implant patients, and 100 consecutive latissimus dorsi patients were identified over a 10-year period. Patient demographics and presence of symptomatic VTE were collected. 2005 Caprini risk scores and Davison risk scores were calculated for each patient. RESULTS: The TRAM reconstruction group was found to have a higher VTE rate (6%) than the implant (0%) and latissimus (0%) reconstruction groups (P < 0.01). Mean Davison risk scores and 2005 Caprini scores were similar across all reconstruction groups (P > 0.1). The vast majority of patients were stratified as high risk (87.3%) by the VTE risk models. However, only TRAM reconstruction patients demonstrated significant VTE risk. CONCLUSIONS: TRAM reconstruction appears to have a significantly higher risk of VTE than both implant and latissimus reconstruction. Current risk models do not effectively stratify breast reconstruction patients at risk for VTE. The method of breast reconstruction appears to have a significant role in patients' VTE risk.

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BACKGROUND: Indications for breast reduction surgery include neck pain, back pain, shoulder pain, and an intertriginous rash. Previous studies have established that bilateral breast reduction surgery is highly effective in relieving these symptoms. Third-party payers may refuse to cover breast reduction surgery for obese patients. In addition, some surgeons turn down obese breast reduction candidates, perhaps fearing that they will not achieve symptom relief or that the complication rate will be prohibitive. It is common for insurers to require an arbitrary minimum volume to be resected in order for them to reimburse for the procedure. This study was conducted to see whether patients with varying levels of obesity had any difference in surgical outcomes compared with nonobese patients with regard to symptom relief and complication rate. The authors also studied the relationship between volume of tissue resected and symptom relief and complication rate. METHODS: One hundred eighty-six consecutive patients underwent bilateral breast reduction surgery performed by a single surgeon using the inferior pedicle Wise pattern technique or the free nipple graft technique. Body mass index was calculated for each patient. RESULTS: Significant postoperative symptom relief occurred in 97 percent of patients. Statistical analysis demonstrated no difference among the various body mass index groups in terms of symptom relief or development of complications, nor was there any correlation between volume of tissue resected and relief of symptoms or complications. CONCLUSIONS: The authors conclude that there is no justification for discriminating against obese patients in either the performance of breast reduction surgery or the provision of insurance coverage for the same. The authors find no justification for denial of insurance coverage for patients in whom lesser tissue volumes are to be resected.

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BACKGROUND: Gynecomastia refers to the presence of femalelike mammary glands in a male. This disorder can lead to significant psychologic stress and self-consciousness. This study consists of a chart review of 174 patients treated surgically between July 1, 1976, and February 27, 2001. RESULTS: Operative procedures were excision, excision with suction-assisted lipectomy (SAL), SAL, skin excision (skin) and skin excision with SAL. Overall complication rate was 20%. No significant difference in complication rates was found between grades or procedures. Revision rates between grades were I = 10.3%, II = 14.5% and III = 34.8% (P < 0.001). In grade III, gynecomastia revision rates for excision +/- SAL was 29% and skin +/- SAL was 38.1% (P = 0.644). Of the 8 revisions in the skin-sparing procedures, 6 were revised with a scar-forming procedure. Therefore, 77% of patients with grade III gynecomastia were adequately treated with a skin-sparing procedure. CONCLUSION: Skin-sparing operations should be the initial procedure chosen for most grade III gynecomastia patients.

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Bilateral reduction mammoplasty in adolescent patients can be a controversial procedure because of the significance of possible long-term complications and the permanence of the results. There are no current criteria specifically for adolescent candidates for reduction surgery, although many of these young women may have severe physical symptoms. Therefore, the demographics and outcomes of these patients are of particular interest in determining the risks and benefits particular to this surgery for younger patients. Seventy-three patients who had undergone bilateral reduction mammoplasty between 1981 and 2000 were identified in the hospital and office records of four midwestern plastic surgeons. Patient ages ranged between 12.5 and 18.9 years, with a mean age of 16.1 years. A two-pronged investigation involved examination of demographics of the adolescent population and short- and long-term outcomes and satisfaction. Demographic survey included age, weight, height, BMI, breast size, and amount of tissue removed. Indications for surgery and postoperative complications were surveyed in office records and via questionnaire. Seventeen patients (23%) were successfully contacted and returned a detailed questionnaire evaluating indications for surgery, preoperative and postoperative complications, and overall satisfaction. Eighty-two percent of patients reported resolution of their physical symptoms, including back, shoulder, and neck pain. Self-esteem, however, was cited most commonly as a reason to recommend this procedure to other adolescent women. Nearly 65% of respondents would repeat their adolescent surgical experience, and 82.4% would recommend this procedure to a teenaged friend in a similar situation. The authors' data suggest that adolescent patients benefit significantly from reduction mammoplasty and that long-term satisfaction remains high, despite the age of the patients at surgery.

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