Single-stage direct-to-implant reconstruction using a prepectoral approach appears to be a safe and effective means of breast reconstruction in many patients, assuming adequate skin perfusion is present.

Background: A signifcant disadvantage of subpectoral breast reconstruction procedures is animation deformity during pectoralis major contraction. In this study, we discuss one surgeon’s experience with elective subpectoral to prepectoral implant site conversion as a definitive solution to animation deformity.. Methods: Authors performed a retrospective review of pre-pectoral and sub-pectoral breast reconstructions performed by a single surgeon. Implants placed in the prepectoral plane were supported with total anterior AlloDerm coverage. Results: One hundred forty-two breasts in 90 patients who had underwent elective subpectoral to prepectoral implant site conversion. Postoperative resolution of animation deformity was 100%. Overall, complications are minimal with rates at 4.2% for infection, 2.1% for seroma, and 0.7% for hematoma, dehiscence, partial thickness necrosis, and explantation. One patient requested reoperation for reduction in implant volume. Baker grades II–IV capsular contractures are 0% at 43 months. Conclusion: Breast implant site conversion from the subpectoral to the prepectoral plane is a safe and definitive solution for animation deformity.

BackgroundInfratentorial siderosis (iSS) is a progressive degenerative disorder targeting primarily the cerebellum and cranial nerve eighth; therefore, progressive ataxia and its neuro-otological findings are common. Toxicity from hemosiderin involves selectively vulnerable neurons and glia in these posterior fossa structures. Other neurologic findings may be present, though our focus relates to the cochlea-vestibular cerebellar involvement. Radiographic evidence of siderosis may be the result of recurrent, albeit covert bleeding in the subarachnoid space, or the consequence of an overt post-traumatic or aneurysmal subarachnoid hemorrhage (SAH). The radiographic iSS appearance is identical regardless of the SAH cause. A recent study provides compelling evidence to search and correct possible hemorrhage sources in the spinal canal. The removal of residual existing hemosiderin deposits that may potentially cause clinical symptoms remains as a major therapeutic challenge.MethodsWe reviewed large data sources and identified salient papers that describe the pathogenesis, clinical and neurotologic manifestations, and the radiographic features of iSS.ResultsThe epidemiology of iSS is unknown. In a recent series, clinically evident iSS was associated with recurrent SAH; by contrast, in a follow-up period ranging from weeks up to 11 years after a monophasic episode of SAH, radiographic siderosis was clinically silent. However, the post-aneurysmal or post-trauma SAH sample size in this single study was small and their observation period relatively short; moreover, the burden of intraneuronal hemosiderin is likely greater with recurrent SAH. There are a few reports of late iSS, several decades after traumatic SAH. A recent report found subjective hearing loss in aneurysmal SAH individuals with radiographic siderosis. Only in recent years, it is safe to perform magnetic resonance imaging (MRI) in post-aneurysmal SAH, because of the introduction of titanium, MRI-compatible aneurysm clips.ConclusioniSS can be associated with significant neurotologic and cerebellar morbidity; the recurrent SAH variant is frequently clinically symptomatic, has a shorter latency and greater neurotologic disability. In these cases, a thorough search and management of a covert source of bleeding may stop clinical progression. The frequency and clinical course of radiographic iSS after traumatic and post-aneurysmal SAH is largely unknown. Detection of radiographic iSS after trauma or aneurysm bleeding suggests that the slower clinical course could benefit from an effective intervention if it became available. The use of cochlear implants is a valid alternative with advanced hearing impairment.

Background: The deep inferior epigastric perforator flap (DIEP) is a widely known reliable option for autologous breast reconstruction. One common complication of DIEP procedures is fat necrosis. Consequences of fat necrosis include wound healing complications, pain, infection, and the psychological distress of possible cancerous recurrence. Clinical judgment alone is an imperfect method to detect at-risk segments of adipose tissue. Objective methods to assess perfusion may improve fat necrosis complication rates, reducing additional surgeries to exclude cancer and improve cosmesis for patients. Methods: The authors performed a retrospective review of patients who underwent analysis of DIEP flap vascularity with or without intraoperative indocyanine green angiography (ICGA). Flap perfusion was assessed using intravenous ICGA and was quantified with both relative and absolute value units of fluorescence. Tissue with observed values less than 25% to 30% relative value units was resected. Postoperative outcomes and fat necrosis incidence were collected. Results: Three hundred fifty-five DIEP flaps were included in the study, 187 (52.7%) of which were assessed intraoperatively with ICGA. Thirty-nine patients (10.9%) experienced operable fat necrosis. No statistically significant difference in incidence of postoperative fat necrosis was found between the 2 groups ( P = 0.732). However, a statistically significant relationship was found between fat necrosis incidence and body mass index as both a continuum ( P = 0.001) and when categorized as greater than 35 ( P = 0.038). Conclusions: Although ICGA is useful for a variety of plastic surgery procedures, our retrospective review did not show a reduction in operable fat necrosis when using this technology.

Background: Objective assessment of tissue viability is critical to improve outcomes of cosmetic and reconstructive procedures. A widely used method to predict tissue viability is indocyanine green angiography. The authors present an alternative method that determines the relative proportions of oxyhemoglobin to deoxyhemoglobin through multispectral reflectance imaging. This affordable, hand-held device is noninvasive and may be used in clinic settings. The authors hypothesize that multispectral reflectance imaging is not inferior to indocyanine green angiography in predicting flap necrosis in the murine model. Methods: Reverse McFarlane skin flaps measuring 10 × 3 cm were raised on 300- to 400-g male Sprague-Dawley rats. Indocyanine green angiography and multispectral reflectance imaging was performed before surgery, immediately after surgery, and 30 minutes after surgery. Clinical outcome images acquired 72 hours after surgery were evaluated by three independent plastic surgeons. Objective data obtained immediately after surgery were compared to postsurgical clinical outcomes to determine which method more accurately predicted flap necrosis. Results: Nine reverse McFarlane skin flaps were evaluated 72 hours after flap elevation. Data analysis demonstrated that the 95 percent confidence intervals for the sensitivity of postoperative multispectral reflectance imaging and indocyanine green angiography imaging to predict 72-hour tissue viability at a fixed specificity of 90 percent for predicting tissue necrosis were 86.3 to 91.0 and 79.1 to 86.9, respectively. Conclusions: In this experimental animal model, multispectral reflectance imaging does not appear to be inferior to indocyanine green angiography in detecting compromised tissue viability. With the advantages of noninvasiveness, portability, affordability, and lack of disposables, multispectral reflectance imaging has an exciting potential for widespread use in cosmetic and reconstructive procedures.