My Papers

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

Lauren C. Nigro, M.D.; Jamie Parkerson, B.F.A., M.S.; Julia Nunley, M.D.; Nadia Blanchet, M.D.

Plastic and Reconstructive Surgery – 2020;145(1):32-37

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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Omega Lift after Total Capsulectomy in Prior Breast Augmentation

Miller, Jonathan E. M.D.; Goodreau, Adam M. M.D.; Blanchet, Nadia P. M.D.

Plastic and Reconstructive Surgery: December 2020 – Volume 146 – Issue 6 – p 835e-836e

Breast augmentation remains one of the most popular cosmetic procedures today, with over 300,000 performed in 2018. In this same year, almost 30,000 patients underwent implant removal, a roughly 40 percent increase from 2008.1 This trend echoes growing public concerns regarding breast implant–related illnesses as recently outlined in a special topic review by Rohrich et al.2 There is undoubtedly a growing population in both reconstructive and cosmetic settings seeking consultation for breast implant removal, often with specific request for capsulectomy.

In the cosmetic patient presenting for explantation, the challenge of preserving breast aesthetics following total capsulectomy is uniquely linked to implant position. Subglandular implant placement is potentially the most perilous variation because of an amalgamation of effects exerted by the prosthesis on the surrounding tissues. Implant placement above the pectoralis results in glandular atrophy.3 Similarly, the absence of muscular support leads to ptosis of the skin envelope. Following capsulectomy, these skin flaps frequently resemble nipple-sparing mastectomy flaps with blood supply primarily through the subdermal plexus.

Previous literature has revealed the pitfalls associated with lifting the breast following nipple-sparing mastectomy. Davies et al. found that Wise and vertical patterns had increased wound healing complications versus periareolar incisions.4 Variations of an omega incision have been described in this context. Santanelli di Pompeo et al. used a double-mirrored omega pattern after skin-sparing mastectomy with decreased rates of skin necrosis versus a Wise-pattern incision.5

The omega lift can be performed alone [see Figure, Supplemental Digital Content 1, which shows preoperative (left) and postoperative (right) photographs of a patient undergoing subglandular implant removal and capsulectomy with an omega lift without new implant placement, http://links.lww.com/PRS/E275] or over a new implant [see Figure, Supplemental Digital Content 2, which shows preoperative (left) and postoperative (right) photographs of a patient who underwent removal of subglandular implant with capsulectomy and an omega lift over new implant in the subglandular plane, http://links.lww.com/PRS/E276], and in conjunction with fat grafting. It is designed along a horizontal axis centered on a superior periareolar incision (Fig. 1left). Following total capsulectomy, tailor tacking is performed and skin excess resected superior to the nipple-areola complex such that the breast envelope and nipple-areola complex are appropriately positioned on the chest wall. The skin between the superior and inferior limbs of the omega pattern can be deepithelialized for autoaugmentation of the upper (Fig. 1center) or lower poles. We advocate placement of quilting sutures between the breast envelope and the chest wall to prevent migration of the nipple-areola complex, to control postoperative ptosis, and to minimize risk of seroma formation.

Fig. 1.
Fig. 1

Fig. 1.: (Left) Breast augmentation with Regnault grade II ptosis with markings for omega lift (blue line). (Center) After removal of breast implants by means of incision along the superior limb of the omega pattern. Removal of the breast implant reveals more severe ptosis and thinned soft-tissue envelopes similar to mastectomy flaps. Here, the skin inferior to the incision is deepithelialized and used to autoaugment the upper pole. Alternatively, the incision could be made along the inferior limb of the omega pattern (not shown) to allow the deepithelialized tissue to augment the nipple-areola complex. The nipple-areola complex will be repositioned with the skin closure, as shown by the arrow. (Right) Final closure with correction of ptosis and an omega-shaped scar.

Implant removal by means of total capsulectomy in the subglandular augmentation patient presents a technical challenge because of the profound effects of the implant on both the gland and overlying skin envelope. A complication of skin flap necrosis is devastating in any patient but can be distinctly so in the cosmetic patient population. The omega lift has been validated in the setting of breast reconstruction in high-risk patients. Although the debate over the safety of breast implants continues, so will the high incidence of patients seeking explantation after cosmetic breast augmentation. For those patients with prior subglandular augmentation with atrophic glandular tissue and thin ptotic skin envelopes, it is our experience that the omega lift yields a safe and aesthetic result.

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Resolution of Thumb Pain following Adoption of Mathieu Needle Holder: An Ergonomic Analysis

Schuth, Olga MD; Powers, Jeremy MD; Merritt, Wyndell MD; Blanchet, Nadia MD

Plastic and Reconstructive Surgery: April 2020 – Volume 8 – Issue 4 – p e2768

Abstract

Background: 

As surveys reveal the prevalence of musculoskeletal pain among surgeons, it is important to have an appreciation and understanding of surgical ergonomics to protect against long-term injuries and mitigate the symptoms of existing conditions. Surgeons diagnosed with thumb carpometacarpal (CMC) joint osteoarthritis, a progressive and debilitating condition, can be especially vulnerable to the pain caused by the repetitive manual tasks of operating.

Methods: 

In this article, the authors describe a case of occupational thumb CMC arthritis in a right-hand dominant plastic surgeon and provide an ergonomic analysis of the different needle holders.

Results: 

Following diagnosis, the simple switch from the traditional Hegar needle holder to the Mathieu needle driver with its palm grip and rotating ratchet lock mechanism stalled the progression of the disease, allowing the surgeon to continue operating pain free.

Conclusions: 

This is the first report of utilization of an alternative needle holder leading to the resolution of thumb pain. In sharing this case, the authors hope to bring awareness to the importance of hand ergonomics in the operating room and offer a practical tip to surgeons with CMC arthritis.

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

Lauren C. Nigro, M.D.; Jamie Parkerson, B.F.A., M.S.; Julia Nunley, M.D.; Nadia Blanchet, M.D.

Plastic and Reconstructive Surgery 2020;145(1):32-37

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.

Click Here to read the full article.

Accurate Nipple Areolar Positioning in Nipple-sparing Mastectomy Reconstruction

Mayer, Alexander P. MD; Goodreau, Adam M. MD; Blanchet, Nadia P. MD

Plastic and Reconstructive Surgery – Global Open: January 2019 – Volume 7 – Issue 1 – p e2064

SummaryNipple-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

Nigro, Lauren C. MD; Feldman, Michael J. MD; Blanchet, Nadia P. MD

Plastic and Reconstructive Surgery – Global Open: August 2018 – Volume 6 – Issue 8 – p e1874

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

Maryann E. Martinovic, M.D. Nadia P. Blanchet, M.D

Plastic Reconstructive Surgery 140: 287e, 2017

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

Shuhao Zhang, MD; Nadia P. Blanchet, MD

Plastic Reconstructive Surgery Global Open 2017;5:e1426;

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

Lauren C. Nigro, MD; Nadia P. Blanchet, MD

Plastic Reconstr Surgery Global Open 2017;5:e1407;

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

Shuhao Zhang, M.D.; Nadia P. Blanchet, M.D.

Plastic and Reconstructive Surgery 2016 pg 1067e

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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