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Browsing by Author "Ahmed, Shahnur"
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Item 177. Prophylactic Absorbable Antibiotic Beads For High Risk Implant-based Reconstruction: A Single Institution Pilot Study(Wolters Kluwer, 2023-05-19) Ahmed, Shahnur; Lee, Jason T. C.; Roth, Dylan D.; Liu, Steven; Fisher, Carla S.; Fan, Betty; Imeokparia, Folasade; Ludwig, Kandice; Lester, Mary E.; Hassanein, Aladdin H.; Surgery, School of MedicinePURPOSE: Infections are problematic in implant-based reconstruction after mastectomies. Infection rates have been reported to be as high as 31%. Strategies to reduce the risk of infection include various antibiotic irrigation solutions, “no-touch” techniques, optimizing sterility, and empiric antibiotic use for skin flora coverage. Absorbable antibiotic beads have been well described for other indications, including orthopedic and pressure sore reconstruction. The purpose of this study is to evaluate the use of prophylactic biodegradable antibiotic beads during pre-pectoral and sub-pectoral implant-based breast reconstruction following mastectomy. METHODS: A single-center retrospective review of patients who underwent implant-based breast reconstruction post-mastectomy between 2019 to 2022. Patients were divided into two groups: Group I were deemed “high risk” by the senior author and received biodegradable antibiotic beads (1 gram vancomycin, 240 mg gentamicin) during tissue expander or implant reconstruction (pre-pectoral or subpectoral) while Group II (control) had no antibiotic beads. Demographic data, diabetes, body mass index (BMI), implant plane (pre-pectoral or sub-pectoral), smoking and use of mesh were recorded. Outcome variables included postoperative cellulitis or infection requiring oral or intravenous antibiotics and tissue expander loss at 90 days. RESULTS: In our study period, 19 patients (36 total implants/expanders) received biodegradable antibiotic beads during implant-based breast reconstruction (Group I). There were 174 patients (290 total expanders) who did not receive antibiotic beads (Group II). Patients in Group I had a history of previous expander/implant infection in 73.6%. Pre-pectoral placement of implants occurred in 84.2% of patients in Group I and 74.1% in Group II. Diabetes was prevalent in 15.8% of Group I compared to 5.7% seen in Group II patients. The mean BMI in Group I was 30.5 kg/m2 compared to 27.8 kg/m2 in Group II (p-value 0.88). Implant infection rate of Group I at 90 days was 8.3% (3/36 total expanders) compared to 8.6% (25/290 total expanders) in Group II. Implant loss in Group I was 5.5% (2/26 total expanders) compared to 7.6% (22/290) in Group II. CONCLUSION: The incidence of infection in high risk patients who have absorbable antibiotic beads placed during the time of reconstruction appears to be normalized to the control group in this pilot study, suggesting that absorbable antibiotic beads may decrease postoperative infection complications. Future studies may further clarify its benefit in selected groups.Item 80. Lymphatic Preconditioning: Novel Investigation Of A “Lymphatic Delay Phenomenon”(Wolters Kluwer, 2024-04-19) Hulsman, Luci; Mohan, Ganesh; Ahmed, Shahnur; Jorge, Miguel D.; Sullivan, Steven J.; Mohammed, Imran; Sinha, Mithun; Hassanein, Aladdin H.; Surgery, School of MedicineBackground: The vascular delay phenomenon is a well-described concept of flap physiology with many clinical applications used to increase flap viability. The approach employs a staged surgical procedure with selective partial disruption of the flap’s blood supply to increase the robustness of the remaining blood supply, followed by interval flap transfer 7-10 days later. While this vascular delay phenomenon has been thoroughly studied, no investigation has been performed to determine if a similar “delay phenomenon” exists for lymphatic vessels. Lymphedema frequently occurs following injury of lymphatics during lymph node dissection. The purpose of this study was to evaluate whether lymphatic preconditioning with staged disruption of lymphatics can be protective against lymphedema. Methods: The standard murine tail lymphedema model was utilized which involves creating a 3 mm circumferential skin excision by the base of the tail and surgically clipping two lymphatics. This standard model was used for a control (Group 1, Control A, n=6). A second control (Group 2, Control B, n=5) had 3 mm circumferential skin excision, one tail lymphatic clipped at that level, and an immediate second hemi-circumferential skin excision on the more proximal tail with disruption of the other remaining lymphatic. Group 3 (experimental lymphatic preconditioning, n=6), had a 3 mm full thickness skin excision by the base of the tail, disruption of one tail lymphatic at that level (leaving one lymphatic vessel intact) followed by staged hemi-circumferential skin excision with disruption of the remaining lymphatic vessel 7 days later. Tail volume was assessed with tail measurements using the truncated cone equation. Immunohistochemistry and histology was sent. Results: Group 3 (experimental lymphatic preconditioning) had a change in tail volume of 79.1 mm3 compared to Group 1 (Control A) 154.6 mm3 (p=0.03) and Group 2 (Control B) 126.6 mm3 (p=0.05) at 28 days post-lymphatic injury. Conclusion: Mice that underwent lymphatic preconditioning with partial lymphatic injury followed by staged completion of lymphatic disruption 7 days later exhibited less tail swelling. This study demonstrates evidence for a novel concept of “lymphatic delay phenomenon” parallel to the well-known vascular delay phenomenon. Lymphatic preconditioning has potential translational clinical applications for protective effects to minimize lymphatic dysfunction.Item Prophylactic Absorbable Antibiotic Beads for High-risk, Implant-based Prepectoral Reconstruction(Wolters Kluwer, 2023-10-16) Ahmed, Shahnur; Lee, Jason T. C.; Roth, Dylan; Sinha, Mithun; Fisher, Carla; Fan, Betty; Imeokparia, Folasade; Ludwig, Kandice; Lester, Mary E.; Hassanein, Aladdin H.; Surgery, School of MedicineInfections are problematic in postmastectomy implant-based reconstruction with infection rates as high as 30%. Strategies to reduce the risk of infection have demonstrated various efficacies. A prolonged course of systemic, oral antibiotics has not shown evidence-based benefit. Although absorbable antibiotic beads have been described for orthopedic procedures and pressure wounds, their use has not been well studied during breast reconstruction, particularly for prepectoral implant placement. The purpose of this study was to evaluate the selective use of prophylactic absorbable calcium sulfate antibiotic beads during high-risk implant-based, prepectoral breast reconstruction after mastectomy. Patients who underwent implant-based, prepectoral breast reconstruction between 2019 and 2022 were reviewed. Groups were divided into those who received antibiotic beads and those who did not. Outcome variables included postoperative infection at 90 days. A total of 148 patients (256 implants) were included: 15 patients (31 implants) who received biodegradable antibiotic beads and 133 patients (225 implants) in the control group. Patients who received antibiotic beads were more likely to have a history of infection (66.7%) compared with the control group (0%) (P < 0.01). Surgical site infection occurred in 3.2% of implants in the antibiotic bead group compared with 7.6%, but this did not reach statistical significance. The incidence of infection in high-risk patients who have absorbable antibiotic beads placed during the time of reconstruction seems to be normalized to the control group in this pilot study. We present a novel use of prophylactic absorbable antibiotic beads in prepectoral breast implant reconstruction.Item The Lymphedematous Limb as a Donor Site for Breast Fat Grafting(Wolters Kluwer, 2024-05-17) Ahmed, Shahnur; Mohan, Ganesh; Hulsman, Luci; Greene, Arin K.; Shaheen, Muhammad; Sinha, Mithun; Hassanein, Aladdin H.; Surgery, School of MedicineBreast cancer-related lymphedema results in chronic upper limb swelling with subcutaneous deposition of fluid and fibroadipose tissue. Morbidity includes psychosocial distress, infection, and difficulty using the extremity. Operative management includes excisional procedures such as suction-assisted lipectomy to reduce abnormal subcutaneous fibroadipose tissue to improve limb volume. Patients who have had postmastectomy breast reconstruction often benefit from fat grafting. This report introduces the concept of fat grafting the breast using the lymphedematous arm as a donor site. This technique improves the volume of the limb by removing the excess subcutaneous adipose, and at the same time reconstructs the breast without adding a donor site not related to the breast cancer-related lymphedema.Item Topical tissue nanotransfection of Prox1 is effective in the prophylactic management of lymphedema(Elsevier, 2024-01-18) Mohan, Ganesh; Khan, Imran; Neumann, Colby R.; Jorge, Miguel D.; Ahmed, Shahnur; Hulsman, Luci; Sinha, Mithun; Gordillo, Gayle M.; Sen, Chandan K.; Hassanein, Aladdin H.; Surgery, School of MedicineLymphedema is chronic limb swelling resulting from lymphatic dysfunction. There is no cure for the disease. Clinically, a preventive surgical approach called immediate lymphatic reconstruction (ILR) has gained traction. Experimental gene-based therapeutic approaches (e.g., using viral vectors) have had limited translational applicability. Tissue nanotransfection (TNT) technology uses a direct, transcutaneous nonviral vector, gene delivery using a chip with nanochannel poration in response to a rapid (<100 ms) focused electric field. The purpose of this study was to experimentally prevent lymphedema using focal delivery of a specific gene Prox1 (a master regulator of lymphangiogenesis). TNT was applied to the previously optimized lymphedematous mice tail (day 0) directly at the surgical site with genetic cargo loaded into the TNT reservoir: group I (sham) was given pCMV6 (expression vector backbone alone) and group II was treated with pCMV6-Prox1. Group II mice had decreased tail volume (47.8%) compared to sham and greater lymphatic clearance on lymphangiography. Immunohistochemistry showed greater lymphatic vessel density and RNA sequencing exhibited reduced inflammatory markers in group II compared to group I. Prox1 prophylactically delivered using TNT to the surgical site on the day of injury decreased the manifestations of lymphedema in the murine tail model compared to control.Item Trends in Immediate Lymphatic Reconstruction(Springer Nature, 2024-04-28) Ahmed, Shahnur; Hassanein, Aladdin H.; Lester, Mary E.; Manghelli, Joshua; Fisher, Carla; Imeokparia, Folosade; Ludwig, Kandice; Fan, Betty; Surgery, School of MedicineBackground and objective: Immediate lymphatic reconstruction (ILR) is emerging as a useful adjunct after axillary lymph node dissection (ALND), leading to a decrease in lymphedema rates from 30 to 3-13% in breast cancer patients. ILR requires coordination between two surgical specialties for oncologic ALND and microsurgical axillary lymphatic anastomosis. This study aimed to assess the trends in the frequency of ILR performed after ALND at our institution. Methods: This study involved a retrospective review of breast cancer patients undergoing ALND with and without ILR at our institution (2017-2022). Data on patient demographics, tumor characteristics, and treatments received were gathered and analyzed. Results: A total of 316 patients underwent ALND at our institution and 30.7% (97/316) of them received ILR. There was no significant difference in clinical breast cancer stages between patients who underwent ALND with or without ILR (p>0.05). Neoadjuvant chemotherapy was given to 51.1% (112/219) of patients with ALND only compared to 60.8% (59/97) of patients who underwent ALND with ILR (p=0.09). All patients received adjuvant radiation therapy. ILR was performed after ALND in 4.2% (2/47) in 2017, 25.8% (3/58) in 2018, 17.6% (12/68) in 2019, 35% (21/60) in 2020, 56.9% (41/72) in 2021, and 54.5% (6/11) in 2022. When comparing the first year of the ILR program with the last year of the study period, the odds ratio of receiving ILR after ALND was 1.8 (p=0.04). Conclusions: The frequency of performing ILR after ALND in breast cancer patients at our institution witnessed a substantial increase during the study period. The implementation of an established ILR program at an institution can increase procedure uptake accompanied by continued growth in utilization.