Due to the high rate of infection in breast reconstruction patients, adequate perioperative prophylaxis is necessary. The surgeon must also be prepared to treat patients who may return with infection postoperatively. Although the majority of our infections were secondary to normal skin flora, a significant proportion were caused by gram-negative species. Given these results, the empiric antibiotic of choice for postoperative infections should be reconsidered to cover for these various organisms.

Background Venous thromboembolism (VTE) chemoprophylaxis warrants individualized, risk-stratified approach, and constitutes a relatively controversial topic in plastic surgery. Objectives To determine the safety of a seven-day postoperative enoxaparin regimen for VTE prophylaxis compared to a single preoperative dose of heparin in abdominal body contouring surgery. Methods This single-institution pre-post study compared the safety of a seven-day enoxaparin postoperative regimen to a single preoperative dose of heparin in abdominal body contouring procedures performed by a single surgeon from 2007 to 2018. Four procedures were included: traditional panniculectomy, abdominoplasty, fleur-de-lis panniculectomy, and body contouring liposuction. Group I patients received a single dose of 5000 units subcutaneous heparin in the preoperative period, and no postoperative chemical prophylaxis was administered. Group II patients received 40 mg subcutaneous enoxaparin in the immediate preoperative period, then once-daily for seven days postoperatively. Results A total of 195 patients were included in the study, 66 in Group I and 129 in Group II. The groups demonstrated statistically similar VTE risk profiles, based on the 2005 Caprini risk assessment model. There were no statistically significant differences in the two primary outcomes: postoperative bleeding and VTE events. Group I patients had higher reoperation rates (22.7 percent versus 10.1 percent, p = 0.029), which was secondary to higher rates of revision procedures. Conclusions A seven-day postoperative course of once-daily enoxaparin for VTE risk reduction in abdominal body contouring surgery does not significantly increase the risk of bleeding. Implementation of this regimen for post-discharge chemoprophylaxis, when indicated following individualized risk stratification, is appropriate.

Background: Tissue expander-based immediate breast reconstruction is currently the most common technique used for postmastectomy breast reconstruction. During mastectomy, axillary lymph nodes are biopsied to stage patients. The purpose of this study is to investigate postoperative complications with respect to extent of lymph node dissection. Methods: A retrospective review of all patients undergoing tissue expander-based immediate breast reconstruction at our institution from 2010 to 2012 was conducted. Charts were analyzed to determine the association between the absolute number of axillary lymph nodes removed and postreconstructive incidence of skin necrosis, cellulitis, seroma, and expander removal. Independent sample t test and linear regression were used to analyze data. Results: In total, 282 patients with 467 reconstructions were included. Overall incidence of all postoperative complications per breast was 23.8%. Breasts in which a complication occurred had a mean of 6 nodes removed versus 4 nodes in uncomplicated breasts ( P = 0.018). Complications were noted at a significantly higher rate in patients who underwent axillary lymph node dissection compared with sentinel lymph node biopsy ( P = 0.008). Expander removal and seroma occurred more frequently in breasts that had a greater number of nodes removed ( P = 0.006 and P = 0.015, respectively). Preoperative radiation resulted in higher incidence of cellulitis and skin necrosis. Postoperative radiation and chemotherapy did not adversely affect reconstruction. Conclusions: Axillary lymph node removal of >4 nodes confers a greater risk of postreconstructive seroma formation and tissue expander loss in patients undergoing immediate reconstruction following mastectomy. Axillary lymph node dissection has a higher incidence of breast reconstruction complications compared with sentinel lymph node biopsy. Therefore, we encourage plastic surgeons to consider degree of lymphadenectomy when discussing reconstructive options with patients, as this may significantly impact their reconstructive outcome.

Introduction:Postoperative infections are a major complication associated with tissue-expander-based breast reconstruction. The use of acellular dermal matrix (ADM) in this surgery has been identified as a potential reservoir of infection, prompting the development of sterile ADM. Although aseptic and sterile ADMs have been investigated, no study has focused on the occurrence and clinical outcome of bacterial colonization before implantation.Methods:Samples of aseptic AlloDerm, sterile Ready-To-Use AlloDerm, and AlloMax were taken before implantation. These samples were incubated in Tryptic soy broth overnight before being streaked on Trypticase soy agar, MacConkey agar, and 5% blood agar plates for culture and incubated for 48 hours. Culture results were cross-referenced with patient outcomes for 1 year postoperatively.Results:A total of 92 samples of ADM were collected from 63 patients. There were 15 cases of postoperative surgical site infection (16.3%). Only 1 sample of ADM (AlloMax) showed growth of Escherichia coli, which was likely a result of contamination. That patient did not develop any infectious sequelae. Patient outcomes showed no difference in the incidence of seroma or infection between sterile and aseptic ADMs.Conclusions:This study evaluates the microbiology of acellular dermal matrices before use in breast reconstruction. No difference was found in the preoperative bacterial load of either aseptic or sterile ADM. No significant difference was noted in infection or seroma formation. Given these results, we believe aseptic processing used on ADMs is equivalent to sterile processing in our patient cohort in terms of clinical infection and seroma occurrence postoperatively.

Introduction Nasal reconstruction after oncologic resection often constitutes a technically demanding task. The aim of this study was to investigate our experience with nasal reconstruction after Mohs micrographic surgery using the following 3 well-established, versatile, and reliable techniques: the bilobed flap, nasolabial flap, and forehead flap. Methods A single-surgeon retrospective chart review of all patients undergone a bilobed, nasolabial, or forehead flap for nasal reconstruction after Mohs micrographic surgery from 2003 to 2017 was conducted. Data collected for analysis included demographics and defect characteristics. Revisions and complications were analyzed. Results A total of 83 patients were included in the study; 52 patients underwent bilobed, 17 patients nasolabial, and 14 patients forehead flaps. All defects involved the middle and lower nasal zones. There was a significant difference in the defect size between the 3 groups (P < 0.001). The mean diameters were as follows: 1.37 cm for the bilobed, 2.22 cm for the nasolabial, and 3.46 cm for the forehead flap groups. Liberal utilization of the bilobed and nasolabial flaps achieved reconstruction of defects larger than typically described in the literature. Reconstruction of all defects, including support for successful restoration of mucosal lining and cartilage when indicated, was achieved. An algorithm dealing with defects larger than 0.5 cm in the middle and distal nasal zones was devised. Conclusions In this study, the liberal application of the 3 flaps was described based on an individualized treatment approach. The algorithm provides a simplified approach for larger nasal defects in the middle and lower thirds.

Introduction:The use of acellular dermal matrices (ADMs) in breast reconstruction is a controversial topic. Recent literature has investigated the effects of ADM sterilization on infectious complications, although with varying conclusions. Previous work by our group showed no difference between aseptic and sterilized products immediately out of the package. In this study, we investigate the microbiologic profiles of these agents after implantation.Methods:In this prospective study, we cultured samples of ADM previously implanted during the first stage of tissue expander-based immediate breast reconstruction. A 1 cm2 sample was excised during the stage II expander–implant exchange procedure, and samples were incubated for 48 hours in tryptic soy broth. Samples with growth were further cultured on tryptic soy broth and blood agar plates. Patient records were also analyzed, to determine if ADM sterilization and microbial growth were correlated with infectious complications.Results:In total, 51 samples of ADM were collected from 32 patients. Six samples were from aseptic ADM (AlloDerm), 27 samples were from ADM sterilized to 10–3 (AlloDerm Ready-to-Use), and 18 samples were from products sterilized to 10–6 (AlloMax). No samples demonstrated bacterial growth. Only 5 patients experienced postoperative complications, of whom only 1 patient was infectious in nature. We failed to demonstrate a statistically significant correlation between sterility and postoperative complications.Conclusions:Our findings showed no difference in microbial presence and clinical outcomes when comparing ADM sterility. Furthermore, no samples demonstrated growth in culture. Our study brings into question the necessity for terminal sterilization in these products.

Background: Historically, physicians have relied on their subjective measures when determining the site and dosages for botulinum toxin type A injections. Digital image speckle correlation is a technology that tracks pore movement from rest to maximal exertion, allowing for the determination of the optimal sites of injection. In this prospective, randomized, crossover trial, the efficacy of using digital image speckle correlation was compared to physician assessment in choosing botulinum toxin type A injection sites. Methods: Ten female patients were analyzed in this blinded crossover study. Subjects were randomized to either injections based on digital image speckle correlation analysis or injections based on the 2004 facial aesthetics consensus recommendations. All patients received 20 U of botulinum toxin type A in the glabellar region and were crossed over and reinjected after 6 months. Follow-up was completed with the Facial Line Outcomes 11-item survey and repeated imaging with digital image speckle correlation, to measure patient satisfaction and degree of paralysis, respectively. Statistical comparison was completed by means of matched sample t test. Results: On average, the digital image speckle correlation analysis provided 4.8 injection sites, whereas the practitioner chose five injections sites. Patients receiving digital image–directed injections had higher rates of satisfaction on the Facial Line Outcomes instrument (p = 0.0003) and a larger degree of paralysis (p = 0.003). Furthermore, muscle function returned to normal later in patients injected with digital image speckle correlation (17.9 weeks versus 20 weeks; p = 0.03). Conclusions: This study demonstrates the benefits of using digital image speckle correlation in determining optimal botulinum toxin type A injection location. Digital analysis allows practitioners to better treat facial rhytides by eliminating subjective decisions regarding dose and site of injection. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Background Hematomas after tissue expander immediate breast reconstruction (TE-IBR) pose a significant challenge during the recovery period. In this study, we aim to evaluate whether hematoma formation leads to subsequent complications and how management can impact final reconstructive goals. Methods A single-institution retrospective review of TE-IBRs from 2001 to 2018 was performed using an established breast reconstruction database. Demographics, medications, comorbidities, and complications were identified. Implant loss was defined as removal of the tissue expander/implant without immediate reimplantation during that operation. Hematoma size, management, transfusion requirement, reoperations, and final outcome were recorded. Reconstructive failure was defined as an implant loss that was not replaced with another implant or required secondary autologous reconstruction. Results Six hundred twenty-seven TE-IBR patients were analyzed. Postoperative hematoma (group 1) occurred in 4.1% (n = 26) of TE-IBRs and did not develop in 95.9% (group 2: n = 601). Group 2 had a higher mean body mass index (24.5 vs 27.3 kg/m2, P = 0.018); however, there were no significant differences in smoking status, preoperative/postoperative radiation/chemotherapy, or other comorbidities. Group 1 was found to have increased rates of implant loss (15.4% vs 3.7%, P = 0.0033) and reconstructive failure (11.5% vs 2.8%, P = 0.0133) compared with group 2. Eighteen hematomas (69.2%) underwent surgical intervention (group 1a) compared with 30.8% (n = 8) that were clinically managed (group 1b). Group 1a had statistically significant lower rates of subsequent complications (22.2% vs 62.5%, P = 0.046) and reoperations (5.6% vs 27.5%, P = 0.037) than did group 1b, respectively. Lastly, 23.1% (n = 6) of patients who developed a hematoma were on home antithrombotics (group 1c) compared with 76.9% (n = 20) of patients with no antithrombotics (group 1d). There were statistically significant differences in transfusion rates (50% vs 0%, P = 0.001) between groups 1c and 1d, respectively. Differences in hematoma volume (330 vs 169.3 mL, P = 0.078) and reconstructive failure (33.3% vs 5%, P = 0.057) approached significance between both groups. Conclusions Hematoma after TE-IBR should be monitored closely, as it may play a role in jeopardizing reconstruction success. Patients on home antithrombotic medication may be at increased risk of larger-volume hematomas and reconstruction failure. Plastic surgeons should consider aggressive surgical evacuation of postoperative TE-IBR hematomas to reduce subsequent complications and reoperations, thus optimizing reconstructive outcomes.