Original research

Vol. 26, No. 2 February 2014 37

Abstract: Background. Lower T-junction wound dehiscence following breast reduction surgery or mastopexy constitutes a vexing and griev-ous complication both to the surgeon and the patient. Treatment mo-dalities that can expedite wound healing and reepithelialization rates are highly craved. The objective of this study was to assess wound healing and epithelialization rates of open wounds following breast reduction and mastopexy wound dehiscence treated with charged polystyrene microspheres (CPM). Materials and Methods. Five female patients with wound dehiscence and subsequent open wounds follow-ing breast reduction and mastopexy were treated with daily with CPM-soaked dressings. Wound closure rates were documented. Results. The wounds showed both accelerated granulation tissue formation as well as swift epithelialization rates. No complications or side effects were encountered. Conclusions. Charged polystyrene microspheres may of-fer a new and efficacious way to heal open wounds due to wound dehis-cence following aesthetic breast surgery. Further research with a larger patient population is still needed to verify these findings.

Key words: breast reduction, mastopexy, surgical complications, charged polystyrene microspheres, open wound

WOUNDS 2014;26(2):37-42

From the 1Department of Plastic and Reconstructive Surgery, Sheba Medical Center, Tel Hashomer, Affiliated to Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel; 2Department of Plastic and Burns Surgery, Montpellier University, Montpellier, France; 3Section of Plastic and Reconstructive Surgery, Department of Surgery, University of Chicago Medical Center, Chicago, IL

Address correspondence to:Oren Weissman, MD2 Bodenheimer StreetTel-Aviv, Israelorenweissman@gmail.com

Disclosure: Josef Haik, MD, acts as a medical consultant to Polyheal Ltd (Yavneh, Israel).

Breast reduction surgery is one of the most commonly performed pro-cedures in plastic surgery. According to the American Society of Plastic Surgeons (ASPS), in 2009, 78,427 breast reduction procedures were

performed in the United States alone.1 The benefits of this procedure are well-documented with studies demonstrating long-term improvements in physical and psychological well being.2-4 One of the most commonly prac-ticed techniques for breast reduction relies on an inferiorly based pedicle for the nipple areolar complex introduced between 1975 and 1977 by Ribeiro,5

Robbins,6 and Courtiss and Goldwyn.7 In this technique, the skin is usually removed in the Wise pattern which results in an inverted T scar in the infra-mammary fold. Even when using other techniques, such as the supero-medial

Treatment of Wounds Following Breast Reduction and Mastopexy With Subsequent Wound Dehiscence With Charged Polystyrene Microspheres

Oren Weissman, MD1; Eyal Winkler, MD1; Luc Teot, MD, PhD2; Eric Remer, MD1; Nimrod Farber, MD1; Jonathan Bank, MD3; Gabriel Hundeshagen, BMedSc1; Isaac Zilinsky, MD1; Josef Haik, MD, MPH1

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pedicle with a keyhole shaped skin incision, an inverted T scar is sometimes needed to remove excess skin and manage the resulting “dog ears,” the skin and subcutane-ous fat excess that is usually the result of flap rotation or advancement, frequently necessitating its excision, result-ing in an additional scar.

Common complications of this procedure include wound dehiscence, hematoma or seroma formation, wound infection, fat necrosis, stitch abscesses, diminished nipple sensation, hypertrophic scarring, and sometimes skin and/or nipple-areola necrosis.8-13 From all the afore-mentioned complications, delayed wound healing and wound dehiscence are the most common, with a reported incidence for the latter of approximately 10%.13-15 This aforementioned dehiscence usually occurs in the conver-gence of the flaps in the inverted T skin scar, where the tension on the skin flaps is usually the highest. Wound dehiscence constitutes a vexing complication to both the patient and the surgeon, thus swift resolution of these open wounds is in the best interest of both sides. Existing literature regarding the management of the consequent open wound following wound dehiscence includes heal-ing by secondary intention, local antibiotic preparations, moist dressings, hydrofiber dressings, and the application of topical negative pressure dressings.13,16-19 Still, even with the abundance of existing wound dressing solutions, the authors have yet to encounter a product or dressing regime that clearly accelerates epithelization rates.

Recently, a new product emerged claiming to expedite wound healing. This product (Polyheal-1, Polyheal Ltd, Yavneh, Israel) is a water-based sterile 0.025% suspension of charged polystyrene microspheres (CPM) with a size of 5 microns in a nutritional medium. Evidence suggests it is the size and surface properties of the charged beads that contribute to the provision of a supportive, healing microenvironment on the wound surface by serving as an additional surface for the attachment and migration

of epithelial, endothelial, and inflammatory cells, includ-ing mast cells.20,21 Polystyrene microspheres have been shown to induce a pulmonary inflammatory process in rabbits, through enhancement of the release of inflam-matory mediators such as substance P and histamine.22 Charged polystyrene microspheres have been shown to accelerate the healing rates of chronic wounds of differ-ent etiologies as well as to promote accelerated granu-lation tissue appearance.23 The company claims that in

vitro and in vivo testing demonstrated the charged micro-spheres activate different types of cells in the wound bed (eg, inflammatory cells, fibroblasts, and keratinocytes), hence promoting the initiation of granulation tissue growth and remodeling of damaged skin tissue.

The objective of this study was to assess the feasibil-ity of using CPM for open wounds, resulting from post-breast reduction and post-mastopexy wound dehiscence in terms of wound healing and epithelization rates.

Material and MethodsInclusion criteria consisted of patients that presented

to the Department of Plastic and Reconstructive Surgery at the Sheba Medical Center, Tel-Aviv, Israel, with wound dehiscence following breast reduction or mastopexy (with or without implants) and subsequent open wounds. The wounds were surgically debrided, if necessary, until a clean wound bed was achieved (ie, no necrotic tissue was present) and then treatment with CPM was commenced. In accordance with the manufacturer’s instructions, the CPM suspension was applied directly over the clean open wounds once daily, and then covered with sterile gauze that was soaked with the rest of the suspension. Dressings were left in place for 12 hours, after which the remain-ing suspension in the bottle (15 CC) was applied over the same gauze without changing it. No systemic or lo-cal antibiotic regimens were administered. Wounds were evaluated and documented via digital photography daily. Wound closure rates were measured manually (in milli-meters) and any adverse reactions (ie, local infection or allergic response) were documented. Following wound closure, the patients were discharged and follow-up con-tinued periodically in the outpatient clinic.

ResultsFrom 2009 to 2011, 5 female patients who had un-

dergone breast reduction or mastopexy augmentation procedures presented to the Department of Plastic and Reconstructive Surgery at the Sheba Medical Center, Tel-Aviv, Israel, with wound dehiscence of their surgical scar.

Keypoints

•In2009,78,427breastreductionprocedureswereperformed in the United States alone.1

•Delayedwoundhealingandwounddehiscencearethe most frequently occurring of common compli-cations, with a reported incidence for the latter of approximately 10%.13-15

•Theobjectiveof thisstudywas toassess the fea-sibility of using charged polystyrene microspheres (CPM) for open wounds, resulting from post breast reduction and mastopexy wound dehiscence.

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They were subsequently hospitalized and treated daily with CPM-soaked dressings as previously described. Table 1 shows patients ages and surgical procedure; duration of open wounds prior to the CPM regimen and previously attempted dressing regimens; CPM treatment duration; and average epithelialization rates calculated from daily wound dimension measurements. This Table also shows reported local pain before and during the CPM dressing regimen (graded by patients on a scale of 1 (no pain) to 10 (extreme pain), and patients’ satisfaction from the CPM dressing regimen (graded by patients on a scale of 1 (not at all satisfied) to 10 (extremely satisfied).

Average patient age was 41.4 years (range 28-53). Three patients were heavy smokers while the other 2 did not smoke. Patient 5 received a long-term oral ste-roid regimen due to persistent asthma with subsequent diabetes mellitus. She underwent a bilateral facelift and a revision of a mastopexy augmentation, and presented with dehiscence of wounds in both breasts and postau-ricular suture lines. This patient was advised to take vita-

min A supplements to negate the negative effect of the oral steroid regimen. Clinically, patients 1, 2, 3, and 5 had a marked response to the treatment regimen, while pa-tient 4’s wound failed to respond in such a swift manner, and required about 22 weeks of treatment to achieve complete closure (Table 1). It should be noted that pa-tient 4 was a heavy smoker and that her wound was open for almost thrice the average duration of the other patient’s wounds (70 days vs 24.7 days). Average wound duration prior to the CPM therapy for all 5 patients was 33.8 days (range 14-70 days). Average CPM treatment du-ration was 50.4 days including patient 4, and 24 days not including (range 17-156 days). Average wound epitheli-alization rate was 1.9 mm per day including patient 4, and 2.25 mm per day not including (range 0.5-2.6 mil-limeters). Figure 1 and Figure 2 demonstrate the typical clinical response and epithelialization rate related to the CPM dressing regimen. There were no documented ad-verse reactions, wound infections, or allergic reactions during the treatment. Patients did not report pain in the

Table 2. Patient’s demographic and treatment-related data.

Patient Number Age Smoking

statusOperation

type

Duration of open wound

before Polyheal treatment

(days)

Attempted local

treatment modalities

before polyheal

Polyheal treatment duration

until wound closure(days)

Averageepithe-lization

rate

Pain before vs during

treatment*

Average patient

satisfaction score*

1 52 Smoker Bilateral breast re-duction

21 2 (Silver sulfa – diazine,Silvercel)

17 2.6 mm per day

6/10 vs 3/10

10/10

2 28 Smoker of medical cannabis

Bilateral breast re-duction

42 2 (Prontosan, Silvercel,** Mafenide – acetate)

24 2.5 mm per day

1/10 vs 1/10

10/10

3 46 Non-smoker

Bilateral breast re-duction

22 2 (Polymem,*** Silvercel)

30 2.1 mm per day

1/10 vs 1/10

9/10

4 53 Smoker Bilateral mastopexy with bilat-eral silicone implant exchange

70 2 (Milton solution, Silvercel)

156 0.5 mm per day

1/10 vs 1/10

10/10

5 28 Non-smoker

Bilateral breast re-duction

14 1 (Silvercel)

25 1.8mmper day

3/10 vs 1/10

10/10

*Scales 1-10: 1 = none/minimal; 10 = maximal.**Silvercel (Systagenix, Gatwick UK), Prontosan (B. Braun Medical Ltd, Sheffield UK), ***Polymem (Ferris Mfg. Corp, Chicago, IL), Milton Solution – sodium hypochlorite.

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wound area during dressing changes. When comparing local pain symptoms with the CPM treatment regimen compared to previously attempted modalities, 3 patients had no local pain before the CPM regimen or during it, while the other 2 patients had some local pain before the CPM regimen that had markedly improved during the CPM treatment regimen. This finding, while encour-aging, is obviously not significant due to the temporal nature of subsequent treatment regimens. All patients reported extreme satisfaction from the CPM treatment

and its results. Average follow-up was 23 months (range 14-45 months).

DiscussionWound dehiscence, defined as significant wound

breakdown which results in delayed healing (greater than 2 weeks),16 remains one of the most common complica-tions after a breast reduction procedure. It constitutes a grievous complication for the patient and the surgeon. The patient, who has made a venerable financial invest-ment, anticipates quick and aesthetically pleasing results and instead has to deal with an open wound in her breast. Based on the accumulative experience of the authors as aesthetic and reconstructive surgeons, this is usually ac-companied by psychological stress, affecting both the patient and the surgeon. A treatment modality that can precipitate the healing of the wound, both in terms of filling the depressed wound, as well as expediting reepi-thelialization, is paramount.

Wound dehiscence, especially at the inverted T junc-tion, depends on various factors, the most important be-

Figure 2. Left to right: Patient 2 before treatment with charged polystyrene microspheres; day 5; day 12; and day 24 of treatment.

Keypoints

•From 2009 to 2011, 5 female patients who hadundergone breast reduction or mastopexy augmen-tation procedures presented with wound dehiscence of their surgical scar.

•Averagewounddurationpriortothechargedpoly-styrene microspheres (CPM) therapy for all 5 pa-tientswas33.8days(range14-70days).

•AverageCPMtreatmentdurationwas50.4daysin-cluding patient 4 (a heavy smoker), and 24 days excluding patient 4 (range 17-156 days).

Figure 1. Left to right: Patient 1 before treatment with charged polystyrene microspheres; day 5; day 10; and day 17 of treatment.

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ing wound infection and tension of the wound edges.14 These factors interfere with normal wound healing by disturbing the physiological cellular continuity of events and the tension-induced arterial and venous vascular compromise. Risk factors for wound dehiscence include smoking, obesity,13 increased resection weights, and lengthened anesthetic times.24

Current literature on the management of wound dehiscence is limited at best and prospective manage-ment options are intensively sought by plastic surgeons encountering these common complications. Healing by secondary intention is mostly suitable for small ar-eas of dehiscence along the flap edge. These are termed partial dehiscence, (ie, T-junction breakdown), and gen-erally heal without complication.13,17 Other reported modalities include application of certain antibiotic prep-arations, in case of a precipitating infection, and moist wound dressings16 and conservative surgical debride-ment of the small amounts of devitalized tissue.17 Other reported options for the management of acute open wounds utilize other dressing regimens including silver-hydrofiber dressing (eg, Aquacel Ag, ConvaTec,Skillman, NJ),18 and the use of negative pressure therapy.19 When total dehiscence occurs, (ie, dehiscence involving larger areas than the T-junction) further operative procedures are sometimes required.16 A surgical intervention in these instances is undesirable due to the tension needed to primarily close the wound edges and a high recur-rence rate of wound dehiscence.

This study presents 5 patients with wound dehiscence following a breast reduction procedure that was suc-cessfully treated with CPM in the Department of Plastic and Reconstructive Surgery at the Sheba Medical Center, Tel-Aviv, Israel. Albeit a feasibility study with no control cases or cost analysis, the results were clinically apparent. Except for 1 patient, wound closure was clinically and visibly expedited with the use of CPM. The application of CPM was rather simple, painless, and had no appar-ent complications, thus rendering it as an appealing treat-ment option. The authors have witnessed marked promo-tion of granulation tissue formation in wound beds and swift epithelization rates with CPM treatment. The pro-motion of granulation tissue formation in wound beds aided in filling the depressed wound beds and leveled out the scar formation plane with adjacent flaps. The fact that these effects were visible, coupled with daily improve-ment witnessed by both physicians and patients, aided in alleviating the psychological stress of these patients. Even though in all cases the resulting scars became pro-

gressively smaller due to scar contracture, they remained as a visible remnant of the complication. The treatment with CPM did not, in the authors minds, help achieve cos-metically appealing scars, even though it prevented the development of depressed scars. The resulting scars were, in the authors’ opinion, quite similar in appearance to postoperative scars that would have been achieved with skin grafting. While skin grafting could, arguably, have pro-moted slightly faster results, avoiding additional surgery with its accompanying donor site scarring/pigmentation changes is paramount in this patient population (ie, the elective aesthetic patient). The patients were happy with the resulting scars and did not wish for further scar revi-sion; but it is plausible that some of these scars will re-quire further management later on. As there is no perfect solution for any wound, patient 4, being a heavy smoker, had no marked clinical response to the CPM treatment. That patient’s wound epithelialization rate was less than a quarter of the average epithelialization rate of the other 4 patients (0.5 mm compared to 2.25 mm per day).

Conclusion These preliminary findings suggest CPM might play a

significant role in the future management of postopera-tive open wounds, and, more specifically, in open wounds after wound dehiscence following breast reductions. However, from the very nature of this case series, there is no control of confounders and bias. Because there is no control for bias, there is also the possibility that the treat-ment effect observed might be overestimated.25,26

The lack of homogeneity of the patients’ wounds in this study appears to add to the strength of the observa-tions, because while prognostic healing factors differed between patients, a comparable effect was demonstrated. The possible benefit of presenting this case series is that it helps form the basis of the evidence hierarchy required for any therapeutic intervention, and induces upcoming randomized controlled trials to further evaluate the im-pact of CPM on wounds. It should be noted that several

Keypoints

•This studypresents5patientswithwounddehis-cence following a breast reduction procedure that was successfully treated with CPM.•Exceptfor1patient,woundclosurewasclinicallyand visibly expedited with the use of CPM.•ThesepreliminaryfindingssuggestCPMmightplaya significant role in the future management of postop-erative open wounds.

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other case studies are being conducted in the author’s department, examining the use of CPM in other types of wounds, and are yielding promising results.

References1. American Society of Plastic Surgeons, 2010 report of the

2009 statistics, National Clearinghouse of plastic surgery

statistics. Available from: http://www.plasticsurgery.org/

2. Spector JA, Karp NS. Reduction mammaplasty: a sig-

nificant improvement at any size. Plast Reconstr Surg.

2007;120(4):845-850.

3. Blomqvist L, Brandberg Y. Three-year follow-up on clinical

symptoms and health-related quality of life after reduc-

tion mammaplasty. Plast Reconstr Surg. 2004;114(1):49-

54.

4. Thoma A, Sprague S, Veltri K, Duku E, Furlong W. A pro-

spective study of patients undergoing breast reduction

surgery: health-related quality of life and clinical out-

comes. Plast Reconstr Surg. 2007;120(1):13-26.

5. Ribeiro L. A new technique for reduction mammaplasty.

Plast Reconstr Surg. 1975;55(3):330-334.

6. Robbins TH. A reduction mammaplasty with the areola-

nipple based on an inferior dermal pedicle. Plast Recontr

Surg. 1977;59(1):64-67.

7. Courtiss EH, Goldwyn RM. Reduction mammaplasty by

the inferior pedicle technique. An alternative to free nip-

ple and areola grafting for severe macromastia or extreme

ptosis. Plast Reconstr Surg. 1977;59(4):500-507.

8. Strombeck JO. Macromastia in women and its surgical

treatment. A clinical study based on 1,042 cases. Acta

Chir Scand Suppl. 1964;341:Suppl.

9. Dabbah A, Lehman JA Jr, Parker MG, Tantri D, Wagner DS.

Reduction mammaplasty: an outcome analysis. Ann Plast

Surg. 1995;35(4):337-341.

10. Menke H, Eisenmann-Klein M, Olbrisch RR, Exner K. Con-

tinuous quality management of breast hypertrophy by the

German Association of Plastic Surgeons: a preliminary re-

port. Ann Plast Surg. 2001;46(6):594-598.

11. Zubowski R, Zins JE, Foray-Kaplon A, et al. Relationship of

obesity and specimen weight to complications in reduc-

tion mammaplasty. Plast Reconstr Surg. 2000;106(5):998-

1003.

12. Lejour M. Vertical mammaplasty: early complications af-

ter 250 personal consecutive cases. Plast Reconstr Surg.

1999;104(3):764-770.

13. Mandrekas AD, Zambacos GJ, Anastasopoulos A, Haspsas

DA. Reduction mammaplasty with the inferior pedicle

technique: early and late complications in 371 patients.

Br J Plast Surg. 1996;49(7):442-446.

14. Zambacos GJ, Mandrekas AD. Complication rates in infe-

rior pedicle reduction mammaplasty. Plast Reconstr Surg.

2006;118(1):274-276.

15. Nassab R, Hamnett N, Barrett M, Dhital S, Juma A. Letter:

Obesity and complications in breast reduction surgery. J

Plast Reconstr Aesthet Surg. 2010;63(2):e168.

16. Shah R, Al-Ajam Y, Stott D, Kang N. Obesity in mammaplas-

ty: A study of complications following breast reduction. J

Plast Reconstr Aesthet Surg. 2011;64(4):508-514.

17. Modolin M, Cintra W Jr, Silva MM, Ribeiro L, Gemperli R,

Ferreira MC. Mammaplasty with inferior pedicle flap after

massive weight loss. Aesthetic Plast Surg. 2010;34(5):596-

602.

18. Jurczak F, Dugré T, Johnstone A, Offori T, Vujovic Z, Hol-

lander D; AQUACEL Ag Surgical/Trauma Wound Study

Group. Randomised clinical trial of hydrofiber dressing

with silver versus povidone-iodine gauze in the manage-

ment of open surgical and traumatic wounds. Int Wound

J. 2007;4(1):66-76.

19. Dustagheer S, Tohill M, Khan K. Vacuum-assisted closure

dressing as an aid to salvage breast following severe post-

operative infection. Breast J. 2009;15(2):214-215.

20. Wu L, Mockros NE, Casperson ME, et al. Effects of elec-

trically charged particles in enhancement of rat wound

healing. J Surg Res. 1999:85(1):43-50.

21. Sasaki A, Mueller RV, Xi G, Sipe R, Buck D, Hollinger J. Mast

cells: an unexpected finding in the modulation of cutane-

ous wound repair by charged beads. Plast Reconstr Surg.

2003;111(4):1446-1453.

22. Nemmar A, Delaunois A, Nemery B, et al. Inflammatory ef-

fect of intratracheal instillation of ultrafine particles in the

rabbit: role of C-fiber and mast cells. Toxicol Appl Phar-

macol. 1999;160(3):250-261.

23. Govrin J, Kogan L, Luger E, Tamir J, Zeilig J, Shafir R. New

method for treating hard-to-heal wounds: clinical experi-

ence with charged polystyrene microspheres. Wounds

UK. 2010;6(4):52-61.

24. Cunningham BL, Gear AJ, Kerrigan CL, Collins ED. Analysis

of breast reduction complications derived from the BRA-

VO study. Plast Reconstr Surg. 2005;115(6):1597-1604.

25. Guyatt GH, Sackett DL, Cook DJ. Users’ guides to the medi-

cal literature, II: how to use an article about therapy or

prevention. A. Are the results of the study valid? JAMA.

1993;270(21):2598-2601.

26. Levine M, Walter S, Lee H, Haines T, Holbrook A, Moyer V.

Users’ guides to the medical literature. IV. How to use an

article about harm. Evidence-Based Medicine Working

Group. JAMA. 1994;271(20):1615-1619.

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