Surgical Outcomes Following Partial Breast Reconstruction with Chest Wall Perforator Flaps

Introduction: In the last two decades, chest wall perforator flaps (CWPF) have become a versatile tissue replacement technique for partial breast reconstruction following breast-conserving surgery (BCS) in well-selected cases. We present the surgical outcome of 81 patients with chest wall perforator flaps used for breast-conserving surgery. Methods: We recorded the outcomes of three oncoplastic breast surgeons who performed partial breast reconstruction with chest wall perforator flaps from 1st January 2018 to 30th June 2022 at Sherwood Forest Hospitals NHS Foundation Trust. Data were collected on patient demographics, including age, BMI, smoking status, bra size, previous treatments, type of CWPF procedure, tumor size (measured clinically, via imaging and histologically), biopsy results, specimen weight, margins involvement, re-operation rate, surgical site infection (SSI), flap loss, flap shrinkage, hematoma, and seroma rates. Results: A total of 81 patients were included in this study, with an average age of 55.7 years and a body mass index (BMI) of 26.7 kg/m2. The bra size varied between A to FF with A (7.4%), B (28.3%), C (38.2%), D (13.6%), DD (11.1%), and FF (1.2%). 14.8% of the patients had neoadjuvant chemotherapy (NACT). For 45 patients, LICAP (lateral intercostal artery perforator), 16 AICAP (anterior intercostal artery perforator), 13 MICAP (medial intercostal artery perforator), and for seven patients, LTAP (lateral thoracic artery perforator) flaps were used. The average tumor was measured at 15.75 mm clinically, 19.1 mm via imaging, and 19.6 mm histologically. Biopsy showed that 16% of the tumors were ductal carcinoma in situ (DCIS), and 84% were invasive. 16% of patients had involved margins, and re-excision was required in 10 patients, and completion mastectomy was performed in 2 patients. A thirty-day SSI rate was 6.2%, with flap-related complications, including flap loss and shrinkage, at 3.7% and 4.9%, respectively. In addition, 3.7% had a hematoma, and 17.3% had other complications. Conclusion: Partial breast reconstruction with perforator flaps is an excellent volume replacement technique in breast-conserving surgery with acceptable complications in well-selected cases.

Rapid printing of 3D porous scaffolds for breast reconstruction

Prosthesis implantation and fat transplantation are common breast reconstructionmethods.In general,prosthesis implantation alone does not achieve a realistic enough appearance,and fat transplantation alone is difficult to achieve in the correct capacity.To date,no reports have focused on methods of combining fat with implanted prostheses for breast reconstruction.Using a newly designed bionic ink(i.e.,polyether F127 diacrylate(F127DA)&poly(ethylene glycol)diacrylate(PEGDA))and projection-based three-dimensional bioprinting(PBP),we report the development of a new method for printing porous prostheses.PEGDA was used to improve the printing precision of the prosthesis by increasing the gel point of F127DA and reducing the impact of external temperature.The compression modulus of the printed prosthesis was very close to that of prostheses currently used in clinical practice and to that of natural breasts.Finally,stromal vascular fraction gel(SVF-gel),a human fat extract,was injected into the pores of the synthesized prostheses to prepare a prosthesis mixed with adipose tissue.These were implanted subcutaneously in nude mice to observe their biological performance.After 14 and 28 days of observation,the prosthesis showed good biocompatibility,and adipose tissues grew well in and around the prosthesis.This result shows that a porous prosthesis containing pre-placed adipose tissues is a promising breast reconstruction material.

Breast reconstruction:Review of current autologous and implantbased techniques and long-term oncologic outcome

Implant-based reconstruction is the most common method of breast reconstruction.Autologous breast reconstruction is an indispensable option for breast reconstruction demanding keen microsurgical skills and robust anatomical understanding.The reconstructive choice is made by the patient after a discussion with the plastic surgeon covering all the available options.Advantages and disadvantages of each technique along with long-term oncologic outcome are reviewed.

Surgical Complications in Breast Reconstruction: Assessment and Associations

Introduction: Breast cancer represents a pathology that generates catastrophic impact and has recently increased its incidence and survival due to timely diagnosis and treatment. Therefore, improving the quality of life of cancer survivors has become a priority, offering reconstructive procedures that reduce complications, costs, hospital stay, and optimize resources. Material and methods: 264 patients reconstructed with autologous tissue (TRAM flap and latissimus dorsi) and alloplastic (breast tissue expander—breast implant and direct breast implant) were included. Variables such as demographic, anthropometric, and histologic type were collected. Results: 62% were reconstructed through the use of alloplastics and 38% with autologous tissue. The risk factors related to a greater probability of immediate postoperative complications (surgical site infection, surgical wound dehiscence and reconstruction failure) were obesity (OR: 2.1, CI: 1.5 - 2.7), preoperative radiation (OR: 1.89, CI: 1.75 - 1.92), arterial hypertension (OR: 1.2), Diabetes Mellitus (OR: 1.78) and smoking (OR: 1.31). Conclusions: The reconstructive process is complex and influenced by patient factors, surgeon experience and the hospital center. However, when choosing the reconstructive strategy, risk factors present in each patient must be considered, since radiation and obesity present a greater probability of postoperative complications.

Lessons Learned from Three Different Acellular Dermal Matrices in Direct-to-Implant Breast Reconstruction

The aim of the study was to show significant differences regarding postoperative complications and outcomes using three different Acellular Dermal Matrices (ADM), namely Epiflex®, Strattice® and Braxon®, in immediate implant-based subpectoral breast reconstruction cases. Background: The use of Acellular Dermal Matrices for implant-based breast reconstruction cases continues to evolve. There is a wide variety of products which differ significantly in their biological features. It remains unclear if and how these differences manifest in clinical practice. Methods: 82 cases of primary breast reconstruction in the Department of Plastic and Aesthetic Surgery of HELIOS Clinics Schwerin, Germany between 2010 and 2018 were analyzed. 25 patients received Strattice® acellular dermal matrix (SADM), 22 cases Epiflex® acellular dermal matrix (EADM) and the remaining 35 cases Braxon® acellular dermal matrix (BADM). The mean follow-up was 1.8 years. Cases were analyzed regarding minor or major complications and rate of capsular contracture grade III or IV (Baker Classification). Results: The overall complication rate was 34.1% for all groups (SADM = 40%, EADM = 50%, BADM = 20%, p-value = 0.051). Of all cases, 6 patients underwent implant exchange or secondary autologous reconstruction due to capsular contracture (7.3%). The mean time between revision due to capsular contracture and reconstruction was 35.8 ± 14.4 months. 50% of patients, who developed capsular contracture, received postoperative radiation. Mean hospitalization time was 8.2 ± 3 days (SADM = 8 ± 3.2 days, EADM = 10 ± 2.8 days, BADM = 6 ± 1.3 days). There were no significant differences between all three groups for demographics, overall complication rate or capsular contracture. However, patients receiving Braxon® matrix showed significantly fewer minor complications (p-value = 0.01). Moreover, patients receiving Braxon® ADM showed a significantly lower time of hospitalization (p < 0.001). Conclusion: No significant differences regarding the overall complication rate were found between the three groups. Different biological features of ADM showed a weak influence on overall results. However, patients receiving Braxon® ADM showed significantly lower minor complication rates and hospitalization time. In addition, these matrices showed a trend towards lower capsular contracture rates. The low rate of capsular contracture hints at possible advantages of ADM-use in direct-to-implant cases.

Multi-center investigation of breast reconstruction after mastectomy from Chinese Society of Breast Surgery:A survey based on 31 tertiary hospitals(CSBrS-004)

Objective:Multi-center data on the current status and trends of breast reconstruction after mastectomy in China are lacking.Herein,we conducted a cross-sectional survey to investigate the current clinical practice pattern of postmastectomy breast reconstruction among Chinese female patients with breast cancer.Methods:A standardized questionnaire used to collect information on breast reconstruction among females diagnosed with breast cancer was distributed by 31 members of the Chinese Society of Breast Surgery between January 1,2018 and December 31,2018.Information was collected on tumor characteristics,treatment,mesh application,nipple-areola complex(NAC)preservation,postoperative complications,bilateral reconstruction,patient satisfaction and local recurrence.The overall rate of breast reconstruction was assessed,and the characteristics were compared across patient groups with different reconstruction approaches.Results:A total of 1,554 patients underwent breast reconstruction after total mastectomy,with a reconstruction rate of 9.6%.Among them,1,190 were implant-based,and 262 underwent autologous reconstructions,while 102 cases underwent a combination of both.Patients who underwent implant-based reconstruction were younger than those who received autologous reconstruction(40.1±4.6 vs.45.0±5.9,P=0.004).Compared to patients with autologous reconstruction,mesh application(25.5%vs.6.5%),NAC preservation(51.8%vs.40.5%)and reconstruction failure(1.8%vs.0)were more frequently reported among those with implant-based reconstruction.There was no significant difference in general satisfaction across three reconstruction approaches,though patients with autologous reconstruction reported the highest aesthetic satisfaction among the three groups(P=0.044).Conclusions:Implant-based breast reconstruction remains the dominant choice among patients,while autologous reconstruction was associated with higher aesthetic satisfaction.Our multi-center investigation based on the findings of the tertiary hospitals of Chinese Society of Breast Surgery may guide a future series of clinical studies on breast reconstruction in China.

Patient Satisfaction Index and Quality of Life Measurement with Breast-Q after Breast Reconstruction in a Plastic Surgery Center in Mexico

Introduction: Cancer is one of the most devastating pathologies to affect the breast. Mastectomy stigmas are associated with depression, body image dysmorphia, and decreasing quality of life. BREAST-Q is a PROM (Patient Reported Outcome Measures) that has proven useful in measuring satisfaction with breast reconstruction results from the patient’s point of view. Objectives: To measure the satisfaction index and improvement in quality of life after breast reconstruction for breast cancer sequelae in our hospital in the last 5 years. Materials and Methods: Descriptive Study that includes patients with Breast cancer diagnosis that underwent mastectomy and breast reconstruction (prosthesis or autologous tissue) in “Hospital Central Sur de Petroleos Mexicanos” (January 2015 to January 2020), whose satisfaction index was measured with BREAST-Q one year after reconstruction. Results: 153 patients were included in the analysis. Mean global satisfaction was 74 points. We observed a tendency towards higher psychosocial, sexual and appearance satisfaction in patients who underwent reconstruction with autologous tissue. The mean satisfaction with provided information was 64 points and with the medical team > 90 points. Conclusion: Breast reconstruction is associated to a high satisfaction index and quality of life improvement regardless of the technique. BREAST-Q proved to be useful in evaluating patient experience and it helped us identify areas of opportunity to improve our care.

Breast Reconstruction: Does It Worth to Start If the Patient Is Not Sure to Take All the Process Along?

Introduction: Breast cancer is the most common cancer in women worldwide, representing a major public health problem. There is still little information comparing the satisfaction of the patients who finished their process against the ones who start it but did not finish it. The aim of our retrospective study was to analyze the results in terms of satisfaction after one year of undergoing to complete breast reconstruction (CBR) vs incomplete breast reconstruction (IBR). Materials and Methods: Retrospective study of patients that underwent breast reconstruction (BR) surgery after mastectomy for breast cancer treatment. Performed at Hospital Central Sur de Alta Especialidad PEMEX in Mexico City, including patients from January 1, 2015 to January 01, 2020. Demographic baseline variables were included. BREAST-Q satisfaction questionnaires one year after the last reconstructive procedure were analyzed. Results: A total of 44 patients fulfilled the inclusion criteria. Of these 44 patients, 11 were included in the IBR group, and 33 patients in the CBR group. There were no statistically significant differences between the two groups in terms of age (IBR 56.09 vs CBR 53.06 years, p = 0.321);BMI (IBR 27.94 vs CBR 26.40, p = 0.253), time from mastectomy to first reconstructive procedure (IBR 22.8 vs CBR 31 months, p = 0.957), history of chemotherapy (IBR 27.3% vs CBR 33.3%, p = 0.709) and radiotherapy (IBR 54.5% vs CBR 42.4%, p = 0.484), additionally type of reconstruction, affected side or complication rate were not significantly different. Regarding postoperative satisfaction, only the second module of satisfaction with breasts displayed statistically significant differences, with a higher score in the CBR group (46.27 vs 52.27, p = 0.019). Other items explored didn’t show significant differences. Discussion: The data reported in this study suggest that regardless of whether the last stage of a BR is reached, the results in these settings can be very similar in terms of psychosocial well-being, sexual well-being, physical well-being regarding the chest area, with some degree of better perception of her breasts. Conclusion: This study suggests that the results in terms of satisfaction in BR after mastectomy for breast cancer are quite similar for patients who decide to take only the first reconstructive stage, compared with those that finished all the process along, this may be a valuable tool for decision making.

Research Progress of Titanium Polypropylene Mesh in Breast Reconstruction

To investigate the application of titanium polypropylene mesh in breast reconstruction.In this study,we selected the literature data in recent 4 years to analyze the application of titanium polypropylene mesh in breast reconstruction.Using the keywords of"breast reconstruction,""titanium polypropylene mesh,^^"application"and"research progress,we analyzed and summarized the related research progress of titanium polypropylene mesh in breast reconstruction.The research was conducted using the analysis of titanium polypropylene mesh,titanium polypropylene mesh in breast reconstruction surgery advantages,adverse complications related to titanium polypropylene mesh in breast reconstruction surgery and preventive measures.By constantly improving these aspects in the research process,the current study has certain value,and may guide the research work of titanium mesh in breast reconstruction.

A network data-based survey and analysis of attention towards breast reconstruction after breast cancer surgery in Chinese and American populations

Background:Breast reconstruction is an effective technique to rebuild the appearance of the breasts in patients after mastectomy and improves the prognosis.The current study aimed to compare and analyze willingness for breast reconstruction after breast cancer between populations in China and the United States,from the perspective of social concern,using big data analysis.We also aimed to explore factors affecting surgical selection and to identify methods that can improve social cognition and acceptance of breast reconstruction.Methods:Using Baidu and Google,two representative Internet search engines in China and the United States as research tools,and using big data search volume as the benchmark,we compared and analyzed breast reconstruction willingness and attention characteristics between Chinese and American people,based on search heat,geographical distribution,age and sex,keyword distribution,ethnic group,and social development degree.Results:In both the long-term and short-term,Chinese people paid more attention towards searching about breast cancer,but less attention to breast reconstruction after breast cancer surgery.However,in both the short-term and long-term,people from the United States paid more attention towards breast cancer and breast reconstruction with the help of the Internet,showing a synchronous change relationship.There was a large regional difference in the search volume for breast cancer among the Chinese population,while no significant regional differences were noted in the search volume for breast cancer in the United States.However,a large regional difference was observed in the search volume for breast reconstruction between the two countries;people in the coastal and economically developed areas paid more attention to it.Most people who paid attention to breast reconstruction in China were women aged 20–39 years,while the attention among men was low.Search keywords were also limited to breast cancer-related information.However,between Asians and European Americans,Americans paid more attention to breast cancer and were affected by regional development,religious beliefs,and health facilities.Conclusion:Attention towards breast reconstruction after breast cancer was lower in the Chinese population than in the American population,and this difference was closely related to the level of regional development.There is insufficient information on breast reconstruction after breast cancer in recent Internet media.In addition to strengthening communication in clinics,media education is important to improve the cognitive level and social awareness of patients and their families,which is conducive to breast reconstruction.

Progress in Implant-Based Breast Reconstruction:What Do We Know?

Breast cancer is the most common malignancy and the most frequently diagnosed cancer in women worldwide.In China,the incidence rate of breast cancer among women has been showing an upward trend and is higher in urban areas.Decades of clinical research have made considerable progress,which is attributable to improved mastectomy and mainte­nance of a well-perfused skin flap after mastectomy.An in-depth insight into the nature of breast cancer will contribute to reduced overall mortality and prolonged survival.In China,there is an increasing awareness of the importance of breast reconstruction in improving quality of life(QoL)and life expectancy.There has been progress in breast reconstruction surgical procedures due to demand from women.Clinicians should be aware that breast reconstruction is not only a medical problem but also a surgical problem.In the following sections,we present the epitome of advances in implant-based breast reconstruction.

Pedicled or Free Flap from Contralateral Breast for Autologous Breast Reconstruction

Background Through precise understanding of the vascular anatomy of the breast,the lower segment of the breast could be harvested as a pedicled or free flap for contralateral breast reconstruction.Case presentation In case 1,based on the 4th internal thoracic artery perforator,the pedicled flap from the breast was transferred to the contralateral side for immediate breast reconstruction.In case 2,with the thoracoacromial vascular pedicle,the free flap from the healthy breast was harvested for delayed breast reconstruction on the contralateral side.Results Both flaps survived well postoperatively.A certain degree of asymmetry was observed in both cases,but the patients were satisfied with the overall results.At the end of follow-up,no tumor recurred in either breast.Conclusion In patients with a large healthy breast,the lower segment could be harvested as a pedicled or free flap for contralateral breast reconstruction.

Postmastectomy radiotherapy in breast reconstruction:Current controversies and trends

Breast cancer is the most common cancer among women worldwide.Postmastectomy radiotherapy(PMRT)is an essential component of combined therapy for early-stage,high-risk breast cancer.Breast reconstruction(BR)is often considered for patients with breast cancer who have undergone mastectomy.There has been a considerable amount of discussion about the optimal approach to combining PMRT with BR in the treatment of breast cancer.PMRT may increase the risk of complications and prevent good aesthetic results after BR,while BR may increase the complexity of PMRT and the radiation dose to surrounding normal tissues.The purpose of this review is to give a broad overview and summary of the current controversies and trends in PMRT and BR in the context of the most recent literature available.

Study on the Impact of Post-Mastectomy Radiotherapy on Immediate Breast Reconstruction and Complications: A Meta-Analysis

Background and objective:Immediate breast reconstruction not only reduces the number of surgeries for patients after mastectomy but also decreases psychological and physical trauma,making it increasingly popular.However,there is currently no consensus on the integration of post-mastectomy radiotherapy(PMRT)with reconstruction techniques.This review evaluates the impact of PMRT on complications following immediate breast reconstruction,providing guidance for clinical treatment decisions.Methods:PubMed,Web of Science,Embase,and other databases were searched for studies published in the past 15 years on outcomes of implant-based breast reconstruction in the context of radiotherapy to identify articles for analysis.RevMan 5.4 software was used to analyze the risks of seroma,infection,wound dehiscence,flap necrosis,implant exposure,capsule contracture,and reconstruction failure.Results:A total of 1l relevant studies were included,comprising 6323 cases of immediate breast reconstruction.It was found that breasts receiving postoperative irradiation had a significantly increased risk of complications,with statistically significant differences in seroma(P=0.004),infection(P<0.00001),wound dehiscence(P=0.04),implant exposure(P<0.00001),capsule contracture(P<0.00001),and reconstruction failure(P<0.00001).There was no statistically significant difference in flap necrosis(P=0.88).Conclusion:The results indicate that postoperative radiotherapy significantly increases the risk of complications for patients undergoing immediate implant-based reconstruction.Preventive measures may be taken in advance with the assistance of healthcare providers if necessary.

Natural History of Seroma Following the Immediate Latissimus Dorsi Flap Method of Breast Reconstruction

Background： The latissimus dorsi （LD） flap procedure remains a popular and useful breast reconstrtlction tool in China and Western countries, and donor site seroma formation is the main complication. This study was conducted in Chinese patients to determine whether stable cases of seromas would resolve without treatment. Methods： A retrospective review of 45 consecutive cases of immediate breast reconstruction with LD flap from April 2012 to February 2017 was conducted. The scope of the seroma was demarcated with a marker pen, and cases that remained stable over time （i.e. the size of the seroma did not increase） were observed without treatment. The measured outcomes included the incidence ofseromas, the volume and duration of postoperative wound drainage, and other demographic characteristics. Results： Twenty-four patients （53.3%） developed a seroma at the donor site. Of these, 21 patients （87.5%） did not require treatment, and the seroma resolved over time. The mean duration of a sustained serol-na was 6.8 ± 1.4 weeks （range： 4-9 weeks）. Conclusions： This study observed the scope and progression of the seromas and found that seromas at the LD donor sites resolved over time without treatnlent.

Titanium-coated polypropylene mesh as innovative bioactive material in conservatives mastectomies and pre-pectoral breast reconstruction

Breast reconstruction is rapidly evolving,thanks to the growing acceptance of synthetic meshes as innovative biomaterials.276 patients undergoing mastectomy(total of 328 mastectomies)were analyzed in a retrospective observational study to evaluate the pre-pectoral immediate breast reconstruction(IBR)using an implant wrapped with Titanium-Coated Polypropylene Mesh(TCPM)vs.patients treated with tissue expander(TE),equally placed pre-pectorally(and wrapped with the same TCPM in 74.3%of the control group’breasts).163 patients,of the study group(SG),underwent mastectomy and pre-pectoral IBR with implant wrapped with TCPM,in a one-step surgery,called direct-to-implant technique(DTI),while 113 patients control group(CG)underwent mastectomy and TE.DTI technique has been performed in 192 breasts of the SG while TE procedure in 136 breasts of the CG.The BREAST-Q questionnaire has been provided before the treatment and 2 years later.Baker scale has been used to evaluate capsular contracture.Oncologic,surgical,and aesthetic outcomes along with BREAST-Q scores were analyzed.Additionally,a histologic evaluation was conducted in 11 capsules’samples randomly chosen(6 derived from SG patients and 5 derived from CG).Complications were recorded in 43 cases(29SG-14CG):8 skin-nipple necrosis(5SG-3CG),8 wound dehiscence(6SG-2CG),3 hematomas(1SG-2CG),and 24 infections(8SG-16CG).Grade IV capsular contracture was detected in 9 breasts(1SG-8CG),whereas 254 breasts were grade I(110SG-144CG),33(10SG-23CG)grade II,and 32(4SG-28CG)grade III.Implant wrinkling was detected in 18 cases(10SG-8CG)after 30 months.The local tumor recurrence rate was 5.8%.Three recurrences were on the nipple-areola complex(1.9%).SG patients showed significantly higher rates in the BREAST-Q overall Satisfaction with Outcome(74.1),overall Satisfaction with Breasts(69.1),Psychosocial Well-being(81.9),and Sexual Well-being(63.1),versus CG’s patients(p<0.05).Histological analysis showed a process of normal tissue repair with a complete mesh integration and normal healing.Conservative mastectomies with pre-pectoral IBR assisted by TCPM proved themselves oncologically safe,biologically integrated into native tissues,and highly accepted in terms of quality of life guaranteeing a more natural and aesthetic breast appearance.Core tip:This retrospective observational study provided clinical and histological outcomes of the pre-pectoral IBR using an implant wrapped with TCPM vs.patients treated with TE,equally placed pre-pectorally.The efficacy of IBR using an implant wrapped with TCPM was confirmed by the cosmetic results obtained and by a rate of side effects comparable to TE.All the histological analyses performed confirmed the TCPM mesh complete integration with the physiological aspects of healing:The Collagen 1 and 3 expressions did not differ,between TCPM and NO TCPM samples to confirm a process of healing overlapping to perfect device incorporation and normal healing.

Cost-effectiveness of one-stage versus two-stage breast reconstruction in the United Kingdom

Aim:Permanent expanders allow for breast reconstruction as a single stage.These prostheses are more expensive than conventional tissue expanders,but this excess cost is markedly offset as only one operation is required.However,if the revision rate is sufficiently high,then this effect is negated.We aim to compare costs of one-stage vs.two-stage reconstruction at a single center,taking into account explantation and unexpected admissions following complications.Methods:A retrospective review was carried out on all patients who underwent one-stage and two-stage reconstruction over a 5-year period by a single surgeon.A cost analysis was performed taking into account,explantation and additional admissions.Results:One hundred and forty-three one-stage and 45 two-stage procedures were included.The explantation rate for one-stage procedures is 36%,at a mean of 12.9 months postimplantation,the majority of which were exchanged for silicone implants to improve cosmesis.Four(9%)of the two-stage procedures were explanted a mean of 18 months postreconstruction.Overall,one-stage reconstructions were significantly more expensive than the two-stage group(P=0.016).Conclusion:There are many benefits of one-stage breast reconstruction.However,it does not appear to be cost-effective when additional admissions for explantation surgery are taken into account.

Sensory reinnervation of free flaps in reconstruction of the breast and the upper and lower extremities

There is long-standing debate about sensate versus non-sensate free microvascular flaps among microsurgeons. The principle of connecting not only the vascular supply, but also sensitive nerves, in free tissue transfer is attractive. However, increased operating time and partial spontaneous innervation led to the common decision to restrict microsurgical tissue transfer to the vascular anastomosis and to leave the nerves ＂untreated＂. Nevertheless, in special cases such as breast reconstruction or extremity reconstruction, the question about sensory nerve coaptation of the flaps remains open. We present our experience with free microvascular tissue transfer for breast and extremity reconstruction and compare the data with previous literature and conclude that most free flap surgeries do not benefit from nerve coaptation.

Application of acellular dermal matrix in breast reconstruction

In the past 10 years, acellular dermal matrix （ADM） has .been widely used in various fields of surgery, includingcleft palate repair, abdominal wall repair, tendon repair, hernia repair, facial and eyelid soft tissue augmentation surgery, ulcer repair, and vaginal sling repair, among others.1-3 ADM not only provides initial structural strength and bulk, but also allows relatively rapid vascular growth and serves as a scaffold for ＂new＂ tissue formation.4 These properties have led to its application to resolving surgical problems where tissue deficiency remains an issue. Many surgeons have begun to use ADM-assisted breast reconstruction techniques. Compared with ADM, the traditional method of implant-based breast reconstruction is more straightforward but is more prone to postoperative complications. Generally speaking, breast revision surgery procedures are complex, challenging, and unpredictable as the potential for the development of serious complications, such as capsular contracture （CC）, must be addressed. CC has plagued plastic surgeons as the most common complication of reconstructive breast surgery for many yearsY The application of ADM addresses these problems, and as a result, its popularity is growing： in the United States 73% of surgeons have some experience in the use of xenogeneic or allogeneic ADM in breast reconstruction.8 Furthermore, the use of ADM in nipple and areola reconstruction can achieve a more natural appearance and avoids complications of other more traditional techniques.~ In cases of breast reconstruction, techniques that incorporate the use of ADM have been used to treat and reduce the incidence of CC, determine the position of the inframammary fold and final breast contour, enhance the use of available mastectomy skin, and increase the thickness of the soft tissue to reduce implant visibility or palpability. These goals can be achieved by replacing or extending the tissue with ADM or using ADM as a supplement. In addition to the advantages afforded by the use of ADM, the safety and efficacy of these techniques have been widely reported.1-1 Tissue expander breast reconstruction consists of three major surgical steps： placement of the expander after mastectomy, exchange of the expander for an implant, and nipple-areola complex reconstruction. This article summarizes the main methods and different aspects of ADM-assisted breast reconstruction.

An analysis of underweight status on 30-day outcomes after breast reconstruction

Aim:To examine the impact of underweight body mass index(BMI)values on breast reconstruction outcomes.Methods:The American College of Surgeons National Surgical Quality Improvement Program(ACS-NSQIP)database was retrospectively reviewed for all patients who underwent breast reconstruction between 2006 and 2011.Patients were first stratified by breast reconstruction modality into prosthetic or autologous cohorts,and second by BMI values into underweight(BMI<18.5),normal to overweight(reference,BMI 18.5-29.99),moderate obesity(BMI 30-34.99),severe obesity(BMI 35-39.99),and morbid obesity cohorts.Multivariate logistic regression models were used to determine independent predictors of complications.Results:With regard to prosthetic breast reconstruction patients,obese patients demonstrated increased rates of surgical complications,while underweight patients did not have any differences on multivariable analysis.With respect to autologous reconstruction,risk-adjusted multivariate regression models showed a dose dependent response between obesity and risk for surgical complications and reoperation,but not for underweight patients.Conclusion:On multivariable analysis of over 4,600 patients,there were no significant differences in the rates of adverse events between underweight patients(BMI<18.5)and their reference-weight counterparts,in spite of a significant increase in surgical and medical complication rates in underweight patients on univariate analysis.