Implant-Based Breast Reconstruction After Nipple-Sparing and Skin-Sparing Mastectomy in Breast-Augmented Patients: Prepectoral or Submuscular Direct-to-Implant Reconstruction?

BACKGROUND: Patients with breast augmentation facing a breast cancer diagnosis pose unique challenges for both breast and plastic surgeons in terms of treatment and reconstruction. Traditional submuscular direct-to-implant (DTI) breast reconstruction is often considered the standard approach, regardless of the previous implant pocket. However, recent trends in prepectoral reconstruction provide an innovative solution for patients with previous subglandular and submuscular implants. OBJECTIVES: In this study we aimed to share our experiences with DTI breast reconstruction in patients with a history of breast augmentation, with a specific focus on the viability of prepectoral reconstruction. METHODS: A retrospective review was conducted on 38 patients with previous breast augmentation who underwent either skin-sparing mastectomy or nipple-sparing mastectomy for breast cancer followed by DTI reconstruction between January 2015 and July 2023. Our analysis considered various factors, including previous implant positioning, capsular and implant status, and mastectomy flap thickness (MFT), offering insights into the rationale behind choosing the new implant positioning. RESULTS: Patients with a history of subglandular breast augmentation and an MFT greater than 1 cm were candidates for prepectoral reconstruction. When the MFT was less than 1 cm but flap vascularity was sufficient, a prepectoral reconstruction was performed; otherwise, retropectoral reconstruction was preferred. Patients with submuscular breast augmentation were evaluated similarly, with submuscular reconstruction chosen when the MFT was less than 1 cm and prepectoral reconstruction preferred when the MFT exceeded 1 cm. CONCLUSIONS: Immediate prepectoral DTI reconstruction represents a feasible option for specific patients with a history of breast augmentation. Decisions regarding the reconstructive approach are influenced by variables such as mastectomy flap thickness, implant status, and capsular conditions.

Safe Reduction of Intermammary Distance in Implant Breast Augmentation Without Fat Grafting.

BACKGROUND: Over the latest 15 years, breast augmentation with implant has been progressively refined technically and artistically. However, little attention is usually given to the intermammary space. The aim of this article is to report author's experience and technique in the safe reduction of the intermammary space in breast augmentation with implants without fat grafting. PATIENTS AND METHODS: From July 2019 to July 2021, 62 consecutive patients undergoing cosmetic breast enhancement with implant and requesting a reduction of the intermammary space were retrospectively evaluated. Preoperatively, breast features were registered for all patients. Preoperative intermammary distance ranged from 2.3 to 7 cm (5.4 ± 0.74). RESULTS: The average follow-up time was 20 months (range 12 to 36 months). All implants were anatomical silicon-gel filled implants with micropolyurethane foam shell. No major early and late complications were experienced. The outcomes were graded as excellent in 45 breasts (72.6 %), very good in 15 (24.2%), good in the two cases (3.2%) with minor delayed wound healing (less than 1 cm) which solved conservatively within 1 month. Patients' satisfaction was high to very high. Postoperative intermammary distance was reduced in all cases and ranged from 1 to 4.5 (mean 2.6 ± 0.52 cm) CONCLUSION: The intermammary distance can be safely reduced with implant only in all cases who seek it, both via submuscular and via subfascial approach by a precise medial pocket dissection and implantation of micropolyurethane foam-coated implant, which guarantee device's stability during the healing process avoiding malposition. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

When to Consider Prepectoral Implant Conversion After Subpectoral Implant Breast Reconstruction and How to Plan It.

Many deformities occur after subpectoral implant-based breast reconstruction. Today, immediate prepectoral reconstruction with implants shows a significant increase in popularity because it has many advantages over subpectoral positioning: absence of muscle deficit and breast animation deformity, reduced implant dislocation, and less postoperative pain and easy recovery. Implant pocket conversion from the submuscular to prepectoral plane has become our preferred strategy for solving most problems related to the submuscular implant position. The authors performed a retrospective review (from June 2018 to December 2022) of patients who underwent prepectoral implant conversion for correction of animation deformity, dysfunctional chronic pain, or to ameliorate poor cosmetic results. Acellular dermal matrix (ADM) was utilized in the first 7 cases; in the remaining 56 patients polyurethane-covered implants were placed. Resolution of animation deformity and chronic pain were evaluated, as were cosmetic results and any postoperative complications. Sixty-three patients (87 breasts) underwent prepectoral implant conversion with complete resolution of animation deformity and chronic pain as well as improved cosmetic results. Preventive lipofilling was done in 18 patients. Complication rate included 3 periprosthetic seromas in ADM group. All resolved after ultrasound-guided aspiration. Rippling was noted in 3 patients, and edge visibility was documented in 1 patient. There were no incidences of grade 3 or 4 capsular contracture. The prepectoral implant conversion improves functional and aesthetic results, reaching excellent outcomes. Preparation for this surgery with fat grafting is considered a complementary procedure that increases the indications for prepectoral implant conversion.

An Innovative Scoring System to Select the Optimal Surgery in Breast Cancer after Neoadjuvant Chemotherapy.

INTRODUCTION: The selection of surgery post-neoadjuvant chemotherapy (NACT) is difficult and based on surgeons' expertise. The aim of this study was to create a post-NEoadjuvant Score System (pNESSy) to choose surgery, optimizing oncological and aesthetical outcomes. METHODS: Patients (stage I-III) underwent surgery post-NACT (breast-conserving surgery (BCS), oncoplastic surgery (OPS), and conservative mastectomy (CMR) were included. Data selected were BRCA mutation, ptosis, breast volume, radiological response, MRI, and mammography pre- and post-NACT prediction of excised breast area. pNESSy was created using the association between these data and surgery. Area under the curve (AUC) was assessed. Patients were divided into groups according to correspondence (G1) or discrepancy (G2) between score and surgery; oncological and aesthetic outcomes were analyzed. RESULTS: A total of 255 patients were included (118 BCS, 49 OPS, 88 CMR). pNESSy between 6.896-8.724 was predictive for BCS, 8.725-9.375 for OPS, and 9.376-14.245 for CMR; AUC was, respectively, 0.835, 0.766, and 0.825. G1 presented a lower incidence of involved margins (5-14.7%; p = 0.010), a better locoregional disease-free survival (98.8-88.9%; p < 0.001) and a better overall survival (96.1-86.5%; p = 0.017), and a better satisfaction with breasts (39.8-27.5%; p = 0.017) and physical wellbeing (93.5-73.6%; p = 0.001). CONCLUSION: A score system based on clinical and radiological features was created to select the optimal surgery post-NACT and improve oncological and aesthetic outcomes.

Preventing Soft Tissue Complications in Secondary Aesthetic Breast Surgery Using Indocyanin Green Angiography.

BACKGROUND: Secondary cosmetic breast surgery after primary augmentation with implant can be associated with an increased risk of adverse events. Partial/complete nipple-areola complex necrosis is particularly feared. In this preliminary study, the authors propose the utilization of indocyanine green (ICG) angiography to assess the blood supply of breast tissue after implant removal. OBJECTIVES: The main objective was to prevent skin and gland necrosis in revision breast surgery. METHODS: The authors performed a retrospective comparative analysis of 33 patients who underwent secondary breast surgery between 2018 and 2021 by a single surgeon (M.S.). Breast tissue perfusion was assessed in 16 patients by intraoperative ICG angiography at the end of implant removal and possible capsulectomy. Non-stained/non-fluorescent areas were judged to be low perfusion areas and were excised with short scar mastopexy. RESULTS: In the ICG angiography group, 7 patients (44%) showed an area of poor perfusion along the inferior pole; all of these patients underwent subglandular breast augmentation. Resection of the poor perfusion areas allowed an uneventful postoperative course. In the non--- ICG angiography group (17 patients), 5 patients experienced vertical-scar dehiscence/necrosis. We found a statistically significant association between the non-ICG angiography group and vertical scar dehiscence/necrosis, and also between vertical scar dehiscence/necrosis and subglandular implant placement (P = 0.04). CONCLUSIONS: Safer secondary surgery can be offered to patients undergoing secondary aesthetic breast procedures, especially when the first augmentation surgery is unknown-for example, implant plane, type of pedicle employed, if the implant is large and subglandular, and if capsulectomy is performed.

The Ultrasound Evolution of Lateral Thoracic Perforator Flaps Design and Harvest for Partial and Total Breast Reconstruction.

BACKGROUND: The lateral thoracic area is a known source for perforator flaps for partial breast reconstruction. In this paper, we report our experience in designing and harvesting lateral thoracic perforator flaps for partial and total breast reconstruction with the introduction of the "propuller" concept. PATIENTS AND METHODS: Between September 2013 and August 2021, 95 flaps were performed for immediate, partial and total breast reconstruction. On a total of 95 flaps, 30 (19 thoracodorsal artery perforator(TDAP) flaps, 10 lateral intercostal artery perforator(LICAP) flaps and 1 lateral thoracic artery perforator(LTAP) flap) were harvested in the traditional fashion (control group) and 65 (57 LICAP, 2 LTAP and 6 TDAP flaps) according to the propeller concept (study group). All cases were preoperatively planned with Color-Coded Duplex Ultrasound. RESULTS: No flap losses were experienced in both groups. The mean operative time was 156 minutes (range 118-234) for the control group and 75 minutes (range 53-125) for the study group (p < 0.0001). A significantly higher number of LICAP flaps were chosen in the study group compared to control group. None of the patients had donor site complications. Patients' and Surgeons' satisfaction was high to very high. CONCLUSION: The ultrasound preoperative planning led to the development of an easier and safer method of local perforator flap harvesting, that we named as propuller design. Its novelty lies in that perforator intraoperative selection and fully skeletonization are not needed and a more efficient flap movement (propeller plus advancement) which transfers more tissue into the new breast can be achieved safely, faster and easier.

Rest/Stress Intradermal Lymphoscintigraphy for the Functional Imaging of the Lymphatic System.

PURPOSE: Lymphoscintigraphy is the criterion-standard method for diagnosing lymphedema, and there is no universally standardized imaging modality. In our center, we use a new approach: rest/stress intradermal lymphoscintigraphy. METHODS: We tested 231 consecutive patients with suspected lymphedema. All patients were studied after a complex physical therapy program to reduce edema. Two doses of 99m Tc-nanocolloid were injected intradermally. Two static planar scans were taken at rest following tracer injection. Next, patients performed an isotonic muscular exercise for 2 minutes followed by postexercise scans. Subsequently, a prolonged exercise was performed for 30 to 40 minutes, after which delayed scans were taken. Abnormal patterns were distinguished into minor or major findings, according to severity. RESULTS: We identified superficial lymphatic vessels and regional lymph nodes in approximately 80% of limbs. Deep vessels were visualized in 26% of limbs. Minor findings were reported in 22.7% of limbs examined, whereas major findings were reported in 53.2% of limbs. CONCLUSION: We observed major findings including lymph stagnation, extravasation, or dermal backflow in a significantly higher percentage of limbs with secondary lymphedema than in primary. We also observed the deep lymphatic pathways in a significantly higher percentage of limbs with primary lymphedema. Intradermal radiotracer injection, combined with isotonic muscular exercise, may offer a better and faster imaging of lymphatic pathways, evaluating the effects of muscular exercise on lymphatic drainage. Based on the in-depth information of the lymphatic pathways provided by rest/stress intradermal lymphoscintigraphy, microsurgeons can obtain important functional information to perform supermicrosurgical lymphatic-venous anastomosis or vascularized lymph node transfer.

Prepectoral vs. Submuscular Immediate Breast Reconstruction in Patients Undergoing Mastectomy after Neoadjuvant Chemotherapy: Our Early Experience.

BACKGROUND: Conservative mastectomy with immediate prosthetic breast reconstruction (IPBR) is an oncologically accepted technique that offers improved esthetic results and patient quality of life. Traditionally, implants have been placed in a submuscular (SM) plane beneath the pectoralis major muscle (PMM). Recently, prepectoral (PP) placement of the prosthesis has been increasingly used in order to avoid morbidities related to manipulation of the PMM. The aim of this study was to compare outcomes of SM vs. PP IPBR after conservative mastectomy in patients with histologically proven breast cancer treated with neoadjuvant chemotherapy (NAC). METHODS: In this retrospective observational study, we analyzed two cohorts of patients that underwent mastectomy with IPBR after NAC in our institution from January 2018 to December 2021. Conservative mastectomy was performed in 146 of the 400 patients that underwent NAC during the study period. Patients were divided into two groups based on the positioning of implants: 56 SM versus 90 PP. RESULTS: The two cohorts were similar for age (mean age 42 and 44 years in the SM and PP group respectively) and follow-up (33 and 20 months, respectively). Mean operative time was 56 min shorter in the PP group (300 and 244 min in the SM and PP group). No significant differences were observed in overall major complication rates. Implant loss was observed in 1.78% of patients (1/56) in the SM group and 1.11% of patients (1/90) in PP group. No differences were observed between the two groups in local or regional recurrence. CONCLUSIONS: Our preliminary experience, which represents one of the largest series of patients undergoing PP-IPBR after NAC at a single institution documented in the literature, seems to confirm that PP-IPBR after NAC is a safe, reliable and effective alternative to traditional SM-IPBR with excellent esthetic and oncological outcomes; it is easy to perform, reduces operative time and minimizes complications related to manipulation of PPM. However, this promising results need to be confirmed in prospective trials with longer follow-up.

Lymphatic Tissue Transfer: Ultrasound-Guided Description and Preoperative Planning of Vascularised Lymph Nodes, Lymphatic Units, and Lymphatic Vessels Transfers.

BACKGROUND: The modern concept of lymphatic transfer includes vascularised lymph node transfer (VLNT), lymphatic vessels transfer (lymph interpositional flap transfer, LIFT) and lymphatic system transfer (vascularised lymph nodes and afferent lymphatics, LYST). The aim of this paper was to report our experience with different types of lymphatic transfer. PATIENTS AND METHOD: From June 2016 to June 2020, 30 consecutive patients affected by extremity lymphedema and 15 patients affected by post-traumatic lower extremity soft tissue defects, underwent lymphatic transfer (VLNT, LYST or LIFT). All cases were preoperatively evaluated by both high frequency and ultra-high frequency ultrasound. Flap features were recorded, as well as qualitative and quantitative outcomes at 1 year postoperative. RESULTS: The mean postoperative lymphedema index reduction was 7.2 ± 5.7 for upper extremity and 20.7 ± 7.1 for lower extremity. No dismission of compression garments occurred, 12 patients (26%) referred more stable results of physical treatment and 1 case showed a 1-class compression reduction. All the LIFTs aimed as preventive did not develop post-traumatic lymphedema. In all cases of distal placement of VLNT and/or LYST, patients were dissatisfied with the aesthetic appearance of reconstruction, while no donor site scar disappointment was referred. CONCLUSION: When LVA is not feasible, LTT may represent a valid treatment option. This report was aimed at comprehensively describing and assessing how different lymphatic tissue transfer modalities may fulfil the different reconstructive needs of lymphedema patients.

Impact of retrograde anastomosis during supermicrosurgical lymphaticovenous anastomosis for cancer-related lower limb lymphedema: A retrospective cohort propensity-score-matched outcome analysis.

BACKGROUND: In addition to antegrade anastomosis, retrograde anastomosis has been thought to offer further improvements after lymphaticovenous anastomosis (LVA) by bypassing the retrograde lymphatic flow. However, this concept has yet to be validated. The aim of this study was to determine the impacts on outcomes of performing both retrograde and antegrade anastomosis, as compared to antegrade-only anastomosis for treating lower limb lymphedema. STUDY DESIGN: This was a retrospective cohort propensity score-matched study. Eighty-seven patients with gynecologic cancer-related lower limb lymphedema were enrolled, including 58 patients who had received both antegrade and retrograde anastomoses (Group I) and 29 patients who had received antegrade-only anastomoses (Group II) as the control group. LVA was the primary treatment. Patients who had previous LVA, liposuction, or excisional therapy were excluded. Patient characteristics, intraoperative findings, and functional parameters including the ratio of indocyanine green-enhanced and flow-positive lymphatic vessels were recorded. Magnetic resonance volumetry was used for outcome assessments. The primary endpoint was the volume change at 6 months after LVA. RESULTS: After matching, a total of 26 patients have remained in each group. All parameters were matched except that Group I still had significantly more median LVA performed compared to Group II (8 [IQR: 5.3-10.0] vs. 5.5 [4.3-6.0], p = 0.001, respectively). Group II showed more post-LVA improvements at six-month and one-year follow-up compared to Group I but without statistically significant differences. CONCLUSION: The use of supplementary retrograde anastomoses is discouraged since it may lead to inferior post-LVA outcome compared to antegrade-only anastomoses.

Lymphaticovenular Anastomosis for Advanced-Stage Peripheral Lymphedema: Expanding Indication and Introducing the Hand/Foot Sign.

BACKGROUND: Effective lymphaticovenular anastomosis (LVA) requires identification of functioning lymphatics, which are not always visible with contrast-based imaging in advanced-stage lymphedema patients. Ultrasound (US) allows to identify preoperatively functioning lymphatic vessels even in limbs severely affected by lymphedema. Moreover, in our experience, we observed an interesting clinical sentry in advanced-stage lymphedema patients, the hand/foot sign that is analyzed in this paper. PATIENTS AND METHODS: From January 2016 to January 2019, 76 consecutive advanced-stage secondary lymphedema patients underwent LVA. Preoperative planning included lymphoscintigraphy, indocyanine-green lymphography (ICG-L) and US. Patients' features, the hand/foot sign (preservation of more normal skin on the dorsum of the hand or foot), lymphatic degeneration, quantitative, qualitative, and composite outcomes at 1-year follow-up were evaluated. RESULTS: An average number of 3±0.1 LVA was performed in upper limb lymphedema (ULL) (range 2-5, 47 patients) and of 4±1.08 LVAs in lower limb lymphedema (LLL) cases (range 4-7, 29 patients). The composite outcome was positive in 45 cases (59.7%). The "negative" hand /foot sign was significantly associated with presence of functioning lymphatic channels. The incidence of adverse outcomes was significantly higher in patients with positive hand/foot sign. CONCLUSION: Patients with no functioning lymphatic vessels detectable by lymphoscintigraphy and ICG-L may still have functioning lymphatic channels that can be identified preoperatively by ultra-high-frequency ultrasound and salvaged by LVA. The "hand/foot sign" is a simple clinical sentry that appears to be correlated with higher probability of being able to localize functional lymphatics for potential lymphovenous bypass surgery.

Level II Oncoplastic Surgery as an Alternative Option to Mastectomy with Immediate Breast Reconstruction in the Neoadjuvant Setting: A Multidisciplinary Single Center Experience.

Oncoplastic surgery level II techniques (OPSII) are used in patients with operable breast cancer. There is no evidence regarding their safety and efficacy after neoadjuvant chemotherapy (NAC). The aim of this study was to compare the oncological and aesthetic outcomes of this technique compared with those observed in mastectomy with immediate breast reconstruction (MIBR), in post-NAC patients undergoing surgery between January 2016 and March 2021. Local disease-free survival (L-DFS), regional disease-free survival (R-DFS), distant disease-free survival (D-DFS), and overall survival (OS) were compared; the aesthetic results and quality of life (QoL) were evaluated using BREAST-Q. A total of 297 patients were included, 87 of whom underwent OPSII and 210 of whom underwent MIBR. After a median follow-up of 39.5 months, local recurrence had occurred in 3 patients in the OPSII group (3.4%), and in 13 patients in the MIBR group (6.1%) (p = 0.408). The three-year L-DFS rates were 95.1% for OPSII and 96.2% for MIBR (p = 0.286). The three-year R-DFS rates were 100% and 96.4%, respectively (p = 0.559). The three-year D-DFS rate were 90.7% and 89.7% (p = 0.849). The three-year OS rates were 95.7% and 95% (p = 0.394). BREAST-Q highlighted significant advantages in physical well-being for OPSII. No difference was shown for satisfaction with breasts (p = 0.656) or psychosocial well-being (p = 0.444). OPSII is safe and effective after NAC. It allows oncological and aesthetic outcomes with a high QoL, and is a safe alternative for locally advanced tumors which are partial responders to NAC.

Additional Lymphaticovenular Anastomosis on the Posterior Side for Treatment of Primary Lower Extremity Lymphedema.

The efficacy of lymphaticovenular anastomosis (LVA) for the treatment of primary lymphedema has been reported. Previous research suggested the efficacy of LVA on the anterior side of the lower limb, but no research has yet underlined the effectiveness of LVA on the posterior side. In the present study, we aimed to investigate the efficacy of LVA on the posterior side of the lower leg for treatment of primary lymphedema, i.e., whether further improvement of primary lower extremity lymphedema could be expected by performing LVA on the posterior side of the lower limb in addition to the LVA on the anterior side, which is usually performed. Forty-five patients with primary lower extremity lymphedema who underwent LVA twice between March 2018 and September 2020 were retrospectively investigated. Patients were classified into two groups: those who underwent LVA on the posterior side in the second operation (PoLVA group) and those who underwent LVA on the medial and anterior sides again in the second operation (MeLVA group). All patients underwent LVA on the medial and anterior sides in the first operation, but no sufficient improvement was observed. The following factors in the second operation were compared between the two groups: skin incision length, the number of anastomoses, the diameters of the lymphatic vessels, the time required for the dissection of the lymphatic vessels and veins and the reduction in volume. LVA resulted in 227 anastomoses (106 anastomoses in the PoLVA group and 121 anastomoses in the MeLVA group) in 26 patients with primary lymphedema of the lower extremities in two surgeries. The reduction in lower extremity lymphedema index was significantly greater in the PoLVA group than that in the MeLVA group (10.5 ± 4.5 vs. 5.5 ± 3.6; p = 0.008), and the number of anastomoses in the PoLVA group was significantly lower than that in the MeLVA group (3.5 ± 0.6 vs. 4.6 ± 1.0; p = 0.038). LVA on the posterior side subsequent to LVA on the medial and anterior sides resulted in the further improvement of primary lower extremity lymphedema with fewer numbers of anastomoses.

Recipient Venule Selection and Anastomosis Configuration for Lymphaticovenular Anastomosis in Extremity Lymphedema: Algorithm Based on 1,000 Lymphaticovenular Anastomosis.

BACKGROUND: The lymphaticovenular anastomosis (LVA) has three components, lymphatics, venules, and anastomosis, and all of them influence the anastomotic pressure gradient. Although it has been demonstrated that venule flow dynamics has an independent impact on the outcomes regardless the degeneration status of lymphatic vessels, recipient venules (RV) have been mainly neglected in literature. METHODS: From January 2016 to February 2020, 232 nonconsecutive patients affected by extremity lymphedema underwent LVA, for a total of 1,000 LVAs. Only patients with normal-to-ectasic lymphatic collectors were included to focus the evaluation on the RV only. The preoperative collected data included the location, diameter, and continence of the selected venules, the expected number, the anastomoses configuration, and their flow dynamics according to BSO classification. RESULTS: The 232 patients included 117 upper limb lymphedema (ULL) and 115 lower limb lymphedema (LLL). The average size of RV was 0.81 ± 0.32 mm in end-to-end (E-E), 114 ± 0.17 mm in end-to-side (E-S), 0.39 ± 0.22 mm in side-to-end (S-E), and 0.76 ± 0.38 mm in side-to-side (S-S) anastomoses. According to the BSO classification, on a total of 732 RV, 105(14%) were backflow venules, 136 (19%) were slack, and 491 (67%) were outlet venules. Also, 824 (82%) were E-E, 107 (11%) were E-S, 51 (5%) were S-E, and 18 (2%) were S-S anastomoses. CONCLUSION: Based on 1,000 LVAs with similar lymphatic characteristics, we propose our algorithm that may aid the lymphatic microsurgeon in the selection of RV and the consequent anastomosis configuration, in order of obtain the best flow dynamic through the LVA. This therapeutic study reflects level of evidence IV.

Lipobrachiopexy: Cosmetic Outcomes and Limb Lymphatic Function of a Novel Brachioplasty Technique in Massive Weight Loss Patients.

BACKGROUND: Many types of brachioplasty techniques have been described in the literature, and the main focus has been scar aesthetics, reproducibility and safety. Little attention has been given to other two aspects of the procedure: overall aesthetic with a focus on the torso-brachial angle and on the lymphatic distress related to the procedure. In this paper, we described a novel technique of brachioplasty called lipobrachiopexy, a lymph-sparing procedure which includes tendon suspension suture to improve cosmetics . PATIENTS AND METHODS: Over 18 months, 22 consecutive patients underwent bilateral lipobrachioplasty with circumferential liposuction sparing brachial artery perforators, J-scar dermolipectomy and superficial fascia suspension to the pectoralis major tendon. Aesthetic outcomes, lymphatic function, sensory function and patient's satisfaction were evaluated at 1-year follow-up. The correction of the bat wing deformity and the shape of the transition of the upper arm to the chest was evaluated by quantifying the torso-brachial angle using Photoshop. Lymphatic function was analysed pre-operatively at 1, 6 and 12 months after surgery by indocyanine green lymphography (PDE, Hamamatsu Photonics, Japan). RESULTS: An average of 447.5 cc (range, 350-550 cc) of fat was aspirated for each side. No major complications were experienced. Patients' and surgeons' satisfaction was high to very high in all cases. The lymphatic function was found preserved, with the same physiological linear patterns and tracer progression pre-operatively and 1 year after surgery. The torso-brachial angles showed significant improvements (86.7 ± 14.7-100.7 ± 10.2 right side and 85.4 ± 16.3-101.5 ± 9.9 left side). CONCLUSION: Lipobrachiopexy is a safe and effective technique that adds to the recent trends in brachioplasty, a reestablishment of the brachial fascial systems and addressing the anatomical etiological factor of the bat wing deformity. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Designing Lateral Thoracic Wall Perforator Flaps for Breast Reconstruction Using Ultrasound.

BACKGROUND: Lateral thoracic flaps represent a precious source for partial and total breast reconstruction, in some cases as first option and in other cases as alternative of free flaps. This article describes the ultrasound (US)-based planning of the lateral thoracic wall perforator adipocutaneous flaps and it reports our experience on 52 consecutive flaps. METHODS: From November 2018 to May 2021, 52 consecutive lateral thoracic wall perforator flaps were performed using the US-based method for reconstruction of partial breast defects and total breast reconstruction. High-frequency US was performed in all cases prior to surgery to select the best perforator and design the flap. RESULTS: Of the 52 cases, 41 were lateral intercostal artery perforator flaps (78.8%), and 11 were thoracodorsal artery perforator (TDAP) flaps. Of the 11 TDAP flaps, 2 cases were based on the direct cutaneous branch. Moreover, in two other cases clinically scheduled for lateral thoracic perforator flaps due to the presence of an appropriate axillary roll, no suitable local/regional perforators were detected with the preoperative US examination and the latissimus dorsi myocutaneous flap was performed. CONCLUSION: Preoperative planning of these flaps using US speeds the surgery and makes it easier and more efficient. Therefore, it is reasonable that the color duplex ultrasound is the operative surgeon's tool for mapping the lateral thoracic wall perforators and to appropriately plan each flap.