Arm and thigh plasty after massive weight loss.

Massive weight loss patients are often left with significant excess skin, which is associated with reduced quality of life and physical limitations due to the symptoms from the excess skin including pendulation, skin maceration, wounding, pain, and infection. The arm and thigh plasty are procedures that reduce the patient's physical symptoms and increase the quality of life by removing excess skin and shaping the remaining tissue. The aim of this review is to describe patient selection for the arm and thigh plasty, discuss indications, surgical principles, and common complications.

A cost-effectiveness analysis of delayed breast reconstruction with pedicled flaps from the back.

BACKGROUND: Variability in breast reconstruction methods provides an opportunity to investigate whether a method is superior to another with regard to cost, quality, or both. We performed a cost-effectiveness analysis (CEA) study based on tertiary endpoint data from a randomized clinical trial to compare the cost-effectiveness of delayed breast reconstruction by either a latissimus dorsi flap (LD) or a thoracodorsal artery perforator flap (TAP). MATERIAL & METHODS: A total of 50 women were included for unilateral delayed breast reconstruction and were randomized to reconstruction by either the LD flap (n = 18) or the TAP flap (n = 22). The CEA was based on differences in shoulder function after the reconstruction. Direct and indirect costs relating to the two procedures were assessed by the Danish Diagnosis-Related Groups tariffs. RESULTS: Our analysis showed a significant positive effect of introducing the TAP flap on the total shoulder score with an additional cost of $2779. The incremental cost-effectiveness ratio was $4481 and based on a willingness to pay (WTP) $500, we found an estimated net benefit of $519, which was statistically significant (p = 0.0375). The cost-effectiveness acceptability curve indicated that there is a 96.3% probability for the TAP flap being cost-effective to the LD flap at a WTP threshold of $500. CONCLUSION: From a societal perspective, our cost-effective analysis demonstrated that the TAP flap is the more cost-effective method of breast reconstruction compared to the LD flap with respect to patient-reported shoulder-related disability.

[Surgical techniques for correction of the breast in women after massive weight loss].

Massive weight loss (MWL) results in significant changes of the female breast becoming deflated, ptotic and flat in the upper pole. It may cause physical discomfort such as infections, intertrigo and psychological discomfort including reduced health-related quality of life, where subsequent corrective surgery of the breast is indicated. In this review, we outline our experiences of the most commonly used surgical techniques for correction of the breast in women after MWL. We highlight the principles of the various surgical techniques.

Abdominoplasty after massive weight loss.

Patients with excess skin after massive weight loss often experience skin maceration, infection, wounding and reduced quality of life. Abdominoplasty is a surgical procedure that removes excess skin aiming to relieve physical inconveniences and improve quality of life. The abdominoplasty can be performed with different techniques using a horizontal, vertical and/or a circumferential procedure. The purpose of this review is to describe the indications for the different surgical approaches, the surgical principles and the complications following abdominoplasty in patients after massive weight loss.

Good health-related quality-of-life and high patient-reported satisfaction after delayed breast reconstruction with pedicled flaps from the back.

BACKGROUND: This paper presents the results of a randomized controlled trial (RCT) that focus on health-related quality-of-life (QoL) and patient-reported satisfaction following breast reconstruction with pedicled flaps from the back. MATERIALS & METHODS: We included women for unilateral delayed breast reconstruction. Patients were randomized to reconstruction by either a latissimus dorsi (LD) flap or a thoracodorsal artery perforator (TAP) flap. Assessment of QoL and patient satisfaction was made using two different patient-reported outcome measures (PROMs): The EORTC QLQ-30 and the Breast-Q questionnaire for post-mastectomy breast reconstruction. RESULTS: A total of 50 women were enrolled over a two-year period and allocated to reconstruction. Forty patients completed both surgery and follow-up and were included in the analysis - 18 in the LD group and 22 in the TAP group. The EORTC QLQ-30 was administered at the baseline and at one-year follow-up. There was no significant effect of introducing the TAP flap on either the summary score, the global QoL-score or the financial impact-score when compared to the LD flap. The Breast-Q questionnaire was administered only at one-year follow-up. There was no significant difference between the two groups for the scores for satisfaction with the reconstructed breast, the overall outcome and QoL related to psycho-social, sexual and physical well-being. CONCLUSION: Women from both groups report high satisfaction and QoL following the reconstruction. The quality of the dataset and the study design are, however, insufficient to rule out any existing difference. A larger cohort, longer follow-up and different design are warranted to assess the true clinical significance these reconstructions might have on satisfaction and QoL.

Direct-to-Implant Extracellular Matrix Hammock-based Breast Reconstruction; Prepectoral or Subpectoral?

BACKGROUND: Skin-sparing mastectomy followed by immediate implant-based breast reconstruction is a commonly used treatment for breast cancer. However, when placing the implant in a subpectoral pocket, a high incidence of breast animation deformity (BAD) has been reported. Besides the nuisance that BAD can cause, lifting of the pectoralis major muscle (PMM) can result in a more extended postoperative recovery period. When placing the implant solely prepectorally leaving the PMM undisturbed, the incidence and severity of BAD might be mitigated. However, new challenges may occur because of thinner skin cover. METHODS/DESIGN: A prospective, multi-centre, randomised controlled trial will be carried out with the primary aim of assessing and comparing the incidence and degree of BAD in women having a direct-to-implant breast reconstruction with either a prepectorally or a subpectorally placed implant. The secondary outcomes are shoulder and arm function, quality of life, aesthetic evaluation, length of stay, complications, need for surgical corrections, and development of capsular contracture. A total of 70 included patients will be followed under admittance and at clinical check-ups 3 months and 1 year after surgery. DISCUSSION: To our knowledge, this trial is the first randomised controlled trial evaluating and comparing subpectoral and prepectoral implant placement when performing direct-to-implant breast reconstruction following skin-sparing mastectomy. The results will hopefully provide us with a broader knowledge of the outcomes of immediate breast reconstruction, making better preoperative planning possible in the future by providing our patients with a more objective information. TRIAL REGISTRATION: ClinicalTrials.gov, ID: NCT03143335. Prospectively registered on 8 May 2017.

Visualized pre- and subpectoral implant placement for immediate breast reconstruction.

The use of mesh for immediate breast reconstruction was introduced almost two decades ago. Lately, the number of prepectoral direct to implant breast reconstructions has increased as this technique seems to leave an unimpaired muscle function and may lead to less or no breast animation deformity (BAD) and quicker recovery. However, challenges still remain as there is a risk of thin tissue coverage, visible implant edges and secondary ptosis. In this visualized surgery paper, we visualize the technical disparities between the sub- and prepectoral direct to implant breast reconstruction.

Shoulder-related donor site morbidity after delayed breast reconstruction with pedicled flaps from the back: An open label randomized controlled clinical trial.

BACKGROUND: This randomized controlled trial (RCT) investigates differences in shoulder-related morbidity after delayed breast reconstruction by either a latissimus dorsi (LD) flap or a thoracodorsal artery perforater (TAP) flap. MATERIAL AND METHODS: In accordance with the CONSORT guidelines, we included women for unilateral delayed breast reconstruction. Patients were randomized to reconstruction by either of the two flaps. Shoulder-function was assessed at baseline and at 3, 6 and 12 months after surgery. The primary endpoint was patient-reported shoulder-related pain. A further objective assessment by the Constant Shoulder Score (CSS) was included as secondary endpoints. RESULTS: A total of 50 women were enrolled over a two-year period and allocated to reconstruction, with 25 patients in each group. Patient-reported shoulder-related pain was significantly lower in the TAP group at 12 months after surgery when adjusting for pain at baseline: OR = 0.05 95%CI(0.005-0.51), p-value = 0.011. The estimated effect on the total CSS at 12 months, when applying the TAP flap instead of the LD flap and adjusting for the baseline score, was 6.2 points with 95%CI(0.5-12.0), p-value 0.033. The TAP flap seems to have a statistically significant positive effect on pain and activity in daily life (ADL), while there were no significant effect on range of motion and strength after one year. CONCLUSION: Patient reconstructed by the TAP flap are less likely to experience shoulder-related pain and have a better shoulder-function one year after the reconstruction. Harvest of the LD flap carries a higher risk of shoulder-function impairment, chronic pain and reduced ADL.

Prepectoral Hammock and Direct-to-implant Breast Reconstruction in 10 Minutes: A Focus on Technique.

BACKGROUND: Breast animation deformity has sparked a reappraisal of the prepectoral implant placement in breast reconstruction. Our approach for direct-to-implant breast reconstruction (DIR) has evolved from a dual plane muscle/mesh coverage to a simple prepectoral hammock covering just the inferolateral part of the implant without the muscle. The aim of this study was to test the procedure in a prospective case series with emphasis on reconstructive outcome. METHODS: Twenty-seven patients undergoing nipple- or skin-sparing mastectomy without subsequent radiation therapy requesting a primary implant-based reconstruction were included from May 2016 to April 2017. Median age was 46 years (25-67). We registered comorbidities, complications, and long-term results of successful or failed reconstruction. RESULTS: Forty-seven DIR in 27 women, 20 bilateral, 7 unilateral. The median body mass index was 24 (17-31). The median time for mastectomy and DIR was 103 minutes (60-150). The inferolateral hammock consisted of Meso Biomatrix (34), Strattice (11), and Vicryl (2). The median implant size was 260 cc (140-345). Four complications (14%), 2 hematomas, 1 seroma, and 1 infection with partial nipple necrosis were all salvaged and reconstruction completed successfully. The median follow-up was 11 months (7-17). CONCLUSION: The prepectoral inferolateral hammock, a swift one-stage procedure with a quick recovery, creates promising results in the presence of an adequate skin flap. The simplicity of the method has made it the authors first choice for DIR.

Shoulder-related donor site morbidity and patient-reported satisfaction after delayed breast reconstruction with pedicled flaps from the back: A comparative analysis.

BACKGROUND: We report a study evaluating and comparing shoulder-related morbidity associated with delayed breast reconstruction using either the conventional latissimus dorsi (LD) flap or the thoracodorsal artery perforator (TAP) flap. MATERIAL & METHODS: We conducted a retrospective cohort study of women over 18 years of age who had a unilateral, delayed breast reconstruction by either an LD or TAP flap at one center over a 56-month period. Shoulder function was assessed using the Constant Shoulder Score (CSS), which evaluated pain, activity of daily life (ADL), range of motion (ROM), and strength. A number of secondary outcomes were also examined. RESULTS: Forty-nine women were included. Demographic and breast treatment data were comparable between the groups. The mean total CSS score for the reconstructed side of the TAP flap was statistically significantly better than that of the LD flap, with a difference of 10.9 points (95% confidence interval [CI] = 2.6-19.2, p-value 0.01). The mean total CSS score for the nonreconstructed side was not statistically significant between groups, with a difference of 0.1 points (95% CI = -6.1-6.2, p-value 0.98). The subscore analysis revealed that women reconstructed using the TAP flap had a difference of 3.2 points for pain (p-value 0.003) and 5.5 points for ROM (p-value 0.011). The factors ADL and strength were of equal magnitude in both groups. CONCLUSIONS: Patients who undergo delayed breast reconstruction by the TAP flap seem less prone to suffer from postoperative pain and restricted ROM, thereby suggesting that this flap should be considered an advantageous alternative to the conventional LD flap. A randomized clinical trial is warranted to provide sufficient evidence to this statement.

Complications following Nipple-Sparing Mastectomy and Immediate Acellular Dermal Matrix Implant-based Breast Reconstruction-A Systematic Review and Meta-analysis.

BACKGROUND: Acellular dermal matrix was introduced in breast reconstruction in 2001 and is gradually becoming a standard component for immediate breast reconstruction and nipple-sparing mastectomy. The reconstructive technique allows for improved aesthetic outcomes. However, there seems to be uncertainty regarding complication rates. The aim of this review was to systematically evaluate complication rates related to this method. METHODS: This systematic review was conducted according to the recommendations outlined in the Cochrane Handbook for reviews and reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Relevant databases were searched for in the literature concerning the use of acellular dermal matrix in implant-based nipple-sparing mastectomy and immediate breast reconstruction. All studies underwent detailed quality assessment. Summarized outcome rates were computed using meta-analysis. RESULTS: Nine of 1,039 studies were eligible for inclusion yielding 778 procedures. The quality was acceptable for all included studies. The meta-analysis found the rate of skin necrosis to be 11%, nipple necrosis 5%, infection in 12%, hematoma in 1%, treated seroma in 5%, explantation 4%, and unplanned return to the operating room in 9%. CONCLUSION: The use of acellular dermal matrix in nipple-sparing mastectomy and implant-based breast reconstruction can be done with acceptable complication rates in selected patients. We recommend future studies to include specific definitions when reporting complication rates. Furthermore, future studies should elaborate on demographic characteristics of the included study samples and include predictor analysis to enhance knowledge of high risk patients.

Prophylactic Nipple-Sparing Mastectomy and Direct-to-Implant Reconstruction of the Large and Ptotic Breast: Is Preshaping of the Challenging Breast a Key to Success?

BACKGROUND: Nipple-sparing mastectomy with simultaneous hammock technique direct-to-implant reconstruction is increasingly offered to patients opting for risk-reducing mastectomy. Despite this promising method, patients with macromastia and ptotic breasts remain a challenging group to treat satisfactorily and more often end up undergoing a difficult corrective procedure and experience an unacceptably high rate of failed reconstruction. The authors examined whether targeted preshaping mastopexy/reduction could prepare these patients for a successful nipple-sparing mastectomy/direct-to-implant reconstruction. METHODS: Patients seeking risk-reducing nipple-sparing mastectomy/direct-to-implant reconstruction at the authors' institutions deemed unfit for a one-stage procedure based on their previous experience were offered a targeted two-stage, risk-reducing mastopexy/reduction followed by a delayed secondary nipple-sparing mastectomy and direct-to-implant reconstruction. Patients were followed up at 3 weeks and 6 or 12 months. RESULTS: Forty-four reconstructions were performed in 22 patients aged 43 years (range, 26 to 57 years). All 44 procedures were completed successfully without any failure or nipple-areola complex losses. Patients' median body mass index was 30 kg/m (range, 22 to 44 kg/m). Six patients were smokers and one had hypertension. Two patients underwent reoperation because of hematoma and fat necrosis. CONCLUSIONS: The authors' results demonstrate that a targeted preshaping mastopexy/reduction followed by nipple-sparing mastectomy/direct-to-implant reconstruction can be safely planned in women who opt for a risk-reducing mastectomy and can be performed successfully with a 3- to 4-month time span between operations. On the basis of these results and the superior cosmetic outcome, the two-stage approach has become the authors' standard of care in all such settings. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Thermal injury in TAPIA breast reconstruction-thermal injury to thoracodorsal artery perforator flap.

This paper presents two case reports on thermal injury to a breast reconstructed by the TAPIA method. In both cases the injuries were caused by excessive sun exposure. Thermal injury to flaps used in breast reconstruction has previously been described but most commonly in abdominal flaps, which may be due to the relative high frequency of this type of reconstructions. Reports of thermal injury to reconstructions using the Latissimus Dorsi flap are rare. The injuries previously described are most often caused by severe heat exposure. The thoracodorsal artery perforator (TAP)-flap can be used as an alternative to the Latissimus Dorsi flap but it may be more susceptible to thermal insult due to the total denervation, the restricted blood supply and the limited thickness of the flap. Precautions are recommended to avoid this type of injury.

Complete Lower Lip Reconstruction with a Large Lip Switch Flap and a Composite Modiolus Advancement Flap.

Total loss of the lower lip is debilitating and poses a reconstructive challenge. Aiming to restore oral continence and function and also cosmetic appearance, a successful reconstruction has a huge impact on the quality of life for the individual patient. Early sources of local tissue rearrangement for lip reconstruction date back 3000 years, with earliest reports of lip switch procedures more than 2 centuries ago in Europe, when noma was still endemic in Europe, indicating that the anatomy was better understood by the barber surgeons of the past than we like to acknowledge. We are still faced with such challenging cases all over the world where resources are limited. Our current understanding of perforator anatomy and blood supply makes more frequent revisits to flaps of the past with modern advances. Innovative solutions are imperative for salvage, and old ideas tend to reappear when they prove to be useful. Herein, we describe in open access a new reconstructive method where we combined a large lip switch flap together with a composite advancement modiolus flap to reconstruct a whole lower lip and the donor defect of the upper lip all at once, a procedure that is simple to perform and works in settings where it is greatly needed.

Fast and simple fat grafting of the breast.

Fat grafting (FG) is being used at an escalating rate for correction of shape and volume of all types of breast surgery in order to optimize the aesthetic result in spite of an ongoing debate of the oncologic safety. In this paper we demonstrate our simple and fast sedimentation based FG technique in the attached video as visualized surgery. We have used this simple approach for 348 procedures in 176 women to optimize and correct the aesthetic result following all types of breast surgery. We prefer this simple technique as no technique has been shown to be superior to other more costly techniques and furthermore there are still questions about the oncologic safety in using adipose derived stem cells (ADSC). Simple fat harvesting using low vacuum and preparation by sedimentation is a fast and effective method to perform FG successfully for correction of shape and volume deficits of the breast following both ablative surgery as well as benign conditions with a high margin of safety.

Bilateral Breast Reconstruction with Extended Thoracodorsal Artery Perforator Propeller Flaps and Implants.

We present our experience of bilateral total breast reconstruction using a double-sided extended thoracodorsal artery perforator propeller flap in a case series of 10 patients. Reconstruction was successfully achieved in all cases with few complications. The median time for surgery was 275 minutes (200-330), and the average implant size used was 350 cm(3) (195-650). We demonstrate how the extended thoracodorsal artery perforator propeller flap allows for a swift and reliable direct to implant bilateral total breast reconstruction in a simple setting and is a valuable adjunct to our armamentarium of techniques for single-stage bilateral breast reconstruction.