My Papers

Should We Stick With Surgical Glues? The Incidence of Dermatitis after 2-Octyl Cyanoacrylate Exposure in 102 Consecutive Breast Cases

Summary: Skin adhesives have become standard in wound closure as alternatives to traditional sutures or as sterile occlusive dressings after surgery of all types. The literature is replete with case reports of contact dermatitis following exposure to cyanoacrylate-based adhesives, such as 2-octyl cyanoacrylate. Nonetheless, it has been the impression of the senior author and others that the incidence of allergic and/or contact dermatitis is much higher than commonly considered. The authors prospectively studied 102 consecutive patients who underwent breast surgery performed by the senior author with 2-octyl cyanoacrylate placed over incisions as an occlusive dressing. Two patients with a known glue allergy did not receive cyanoacrylate at surgery but were scratch tested to confirm the diagnosis. All patients were followed postoperatively. Twelve patients went on to develop significant dermatitis postoperatively after glue placement. Cyanoacrylate was confirmed as the cause of all rashes by allergy scratch testing for a total incidence of 14 percent (14 patients). Given the popularity of cyanoacrylate products across emergency rooms, clinics, and operating rooms, awareness of the true incidence of these reactions may caution against their use in the future.

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Accurate Nipple Areolar Positioning in Nipple-sparing Mastectomy Reconstruction

Summary: Nipple-sparing mastectomy continues to grow in popularity as oncologic indications for preserving the nipple areolar complex have become less stringent and more patients with genetic predispositions to breast cancer seek aesthetically superior prophylactic mastectomy reconstructions. Nonetheless, nipple malposition remains a common and disturbing complication. This article proposes several anatomic variations that predispose to nipple malposition and a strategy to avoid it through a reliable, easily reproducible method of preoperative marking and intraoperative stabilization.

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Burn in an Irradiated Prepectoral Breast Reconstruction: A Cautionary Tale

Summary: Burns to breast reconstructions, both autologous and implant-based, are well described in the plastic surgery literature. The mechanism has often been contact; however, burns secondary to sun exposure have also been reported. With the increasing number of prepectoral breast reconstructions, including irradiated prepectoral reconstructions, we would like to highlight the increased susceptibility of these reconstructions to thermal and ultraviolet injury. We present the case of a patient who underwent prepectoral implant-based breast reconstruction years after irradiation, who subsequently developed full-thickness injury to her mastectomy flap after minor sun exposure. After weeks of daily wound care and hyperbaric oxygen treatments, the patient eventually reepithelialized over her exposed acellular dermal matrix tissue layer, allowing for implant salvage. Postmastectomy flaps overlying implants in the prepectoral plane are delicate; major burns can develop from minor thermal injury, even months after surgery. Irradiated prepectoral reconstruction patients should be educated about the susceptibility of their breast flaps to even minor burn injury and should maintain vigilance beyond the immediate postoperative period. It remains to be seen whether prepectoral reconstruction in an irradiated breast can be a viable, long-term option.

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BFACE: A Framework for Evaluating Breast Aesthetics

Summary: Although much has been written about breast aesthetics, the literature lacks a simple yet systematic and comprehensive approach for pre-operative breast assessment. With use of the mnemonic BFACE, the breast surgeon will analyze the bony skeleton and the breast footprint, areola, conus, and envelope. The authors present a thorough review of the important parameters that define the ideal breast, and several techniques for perceiving asymmetries more clearly. Strategic surgical planning is enabled by accurate perception.

(Plast. Reconstr. Surg. 140: 287e, 2017.)

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Reelevating the Mastectomy Flap: A Safe Technique for Improving Nipple-Areolar Complex Malposition after Nipple-Sparing Mastectomy

Summary: Nipple-areolar complex (NAC) malposition is one of the most common complications following nipple-sparing mastectomy with implant-based reconstruction. To maximize perfusion to the NAC, traditional methods of correcting NAC malposition limit undermining below the NAC. We demonstrate a series of cases in which improvement of NAC malposition was safely performed by reelevating the NAC and mastectomy flap to allow redraping of the soft tissue envelope over the implant and the overlying capsule. Thirty-four patients were identified in a span over 4 years where 44 NACs were repositioned using this method. There was zero incidence of postoperative ischemia or necrosis of the NAC or mastectomy flaps. There was noticeable improvement in the NAC position on the breast mound. Reelevation of the mastectomy skin flap to correct malposition of the NAC after nipple-sparing mastectomy is a safe and effective option, avoids additional scars, and can be performed more than once to further improve positioning of the NAC.

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Animation Deformity in Postmastectomy Implant-Based Reconstruction

Animation deformity (AD), including its prevalence and effect on patients, has been studied in the context of subpectoral augmentation mammaplasty.1 However, to our knowledge, only 1 other study has defined the prevalence and effect of AD in the subpectoral implant-based breast reconstruction patient population.2 Given the recent rise in prepectoral, implant-based reconstruction, an assessment of patient experience with AD in the partial subpectoral implant-based reconstruction population is timely and relevant.

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Bioengineered Breast: Concept, Technique, and Preliminary Results

We read with interest the article titled Bioengineered Breast: Concept, Technique, and Preliminary Results by Maxwell and Gabriel. The concept of bioengineering the breast using acellular dermal matrix and fat grafting has revolutionized prosthetic-based reconstruction; the authors contribution to the literature in this field is significant. The authors detail their method using acellular dermal matrix and fat grafting to augment the soft-tissue envelope in breast reconstruction during the second stage of breast reconstruction.

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Surgical Delay of the Nipple-Areolar Complex in High-risk Nipple-sparing Mastectomy Reconstruction

SUMMARY: As nipple-sparing mastectomy gains increasing popularity, minimizing the risk of nipple necrosis continues to be of critical importance to patients and surgeons. Patients with large or ptotic breasts, scars from previous cosmetic and/or oncologic breast surgery, or previous irradiation have often been denied nipple-sparing mastectomy (NSM) because of increased risk of nipple necrosis. A variety of interventions have been suggested to minimize the ischemic insult to the nipple areolar complex (NAC). This article presents our experience in 26 high-risk patients with surgical delay of the NAC.

(Plast Reconstr Surg Glob Open 2016;4:e760; doi: 10.1097/GOX.0000000000000716; Published online 28 June 2016.)

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An Easy and Cost-Effective Method to Perform the “No-Touch” Technique in Saline Breast Augmentation

The no-touch technique of breast implant insertion is a well-described method to minimize skin contamination, which is thought to be a significant cause of capsular contracture
after implant-based breast augmentation. Studies have detected bacterial growth in 76% to 89% of contracted implants, and the presence of biofilms has also been shown to increase the risk of capsular contracture in a porcine model. The original no-touch technique was described by Mladick in 1993. In the original iteration, several assistants held retractors to keep the skin incision open and avoid skin contact while the implant was inserted. Here, we describe the simple modification of a disposable, sterile light-handle glove into a sleeve for insertion of a saline prosthesis….

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Angiographic delay: a viable alternative to surgical delay

Since its description by Hartrampf et al in 1982, the transverse rectus abdominis musculocutaneous (TRAM) flap has been the most frequently used autologous flap procedure for breast reconstruction. To improve the vascularity of the pedicled TRAM flap, a preoperative delay procedure can be performed. Both surgical delay (ligation of both artery and vein) and delay by selective embolization of the inferior epigastric arteries have been described. Scheufler et al first introduced the concept of delay by selective embolization in 2000.

We reviewed a series of 88 consecutive endovascularly delayed unipedicled TRAM flap breast reconstructions by the senior author (N.B.). The purpose of this study was twofold: (1) to determine whether delay by selective arterial embolization is comparable to surgically delayed pedicled TRAM flaps as reported in the literature, in terms of skin and fat necrosis, and (2) to examine whether certain risk factors play a role in TRAM flap fat necrosis despite arterial angiographic delay.

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