Prophylactic Lymphaticovenous Anastomosis Performed with Lymphadenectomy is Oncologically Safe for Melanoma.

BACKGROUND: A major concern of lymphaticovenous anastomosis (LVA), which has not been studied, is increased risk of metastasis. Melanoma patients with macrometastatic lymph node disease represent a high-risk group for recurrence and metastasis. On the basis of a literature review, this present study is the first to evaluate the impact of prophylactic LVA on cancer survival and recurrence. METHODS: This was a comparison study of patients with cutaneous melanoma who underwent therapeutic lymphadenectomy alone (comparison group) or combined with prophylactic LVA (LVA group) between 2014 and 2020. A single surgeon performed all cancer resections, therapeutic lymphadenectomies, and LVA. Exclusion criteria included non-melanoma skin cancers, stage IV cancers before lymphadenectomy, microscopic lymphatic disease (i.e., positive sentinel node biopsy was the sole indication for lymph node dissection), or follow-up time less than 12 months unless the patient died earlier owing to melanoma-related complications. RESULTS: This study included 23 patients in the LVA group and 22 consecutive patients in the comparison group. The two groups were similar in age, sex, and cancer stages. The comparison group had longer follow-up times (median 67.62 versus 29.73 months in the LVA group; p < 0.01). Average size of largest metastatic lymph node was 45.91 ± 35.03 mm and 44.54 ± 23.32 mm in the LVA and comparison groups, respectively (p = 0.99). There were no differences in OS, DMFS, and RFS times after more than 2 years of follow-up since the index surgery. CONCLUSION: Prophylactic LVA performed for macrometastatic melanoma is not a strong risk factor for relapse and metastasis. LEVEL OF EVIDENCE: II Therapeutic.

Long-term efficacy of lymphovenous anastomosis for the treatment of retroperitoneal lymphangiectasia: A case report and a review of literature.

Lymphovenous anastomosis (LVA) represents an alternative treatment for retroperitoneal lymphangiectasia. In contrast to sclerotherapy or excision, which may risk lymphatic obstruction and subsequent lymphedema, LVA preserves existing lymphatic architecture and transit. This report shows long-term efficacy of LVA for functional decompression of a symptomatic pathologically dilatated retroperitoneal lymphatics. A 47-year-old female with retroperitoneal lymphangiectasia refractory to multiple percutaneous drainages and treatments with sclerosing agents underwent LVA with anastomosis of a dominant segment of retroperitoneal lymphangiectasia to the deep inferior epigastric vein. Postoperative serial magnetic resonance imaging with 3-dimensional volume calculation over the 27 months follow-up showed evidence of decompression of the lesion with patent bypass. There were no known immediate complications nor requirement of further interventions. The patient's subjective pain also decreased substantially. This report confirms long-term efficacy of LVA for retroperitoneal lymphangiectasia as an alternative to sclerotherapy and surgical excision in the setting of previously failed treatments.

Aesthetic, Quality-of-Life, and Clinical Outcomes after Inferior Pedicle Oncoplastic Reduction Mammoplasty.

BACKGROUND: Oncoplastic breast surgery is more likely to achieve superior aesthetic outcomes compared to lumpectomy alone. Oncoplastic reduction mammoplasty (ORM) is a volume displacement oncoplastic technique that combines lumpectomy and reduction mammoplasty. Data on aesthetic and quality-of-life (QoL) outcomes after ORM are scarce in the literature. Based on a literature review, this present study reports outcomes on the largest group of ORM patients to date. METHODS: A retrospective review was conducted of all patients who underwent ORM between 2011 and 2018 at a tertiary care centre. Patients were excluded if no pedicle information was available or did not undergo post-operative radiotherapy. All patients with available post-operative photographs were aesthetically evaluated by four blinded, independent investigators blinded based on breast symmetry, nipple symmetry, and overall appearance. The BREAST-Q (breast conserving module) was used to assess QoL outcomes. RESULTS: Two-hundred-and-sixteen consecutive patients (223 breasts) were included. Macromastia (cup size D or higher) was present in 173 patients (80.1%). Inferior pedicle ORM was utilized in 179 (80.3%) breasts. Eighty-eight patients (40.7%) were aesthetically evaluated, of whom 69 patients (78.4%) had "good", "very good", or "excellent" grades in all aesthetic categories. Seventy-five patients (85.2%) had "good" or better grades in overall appearance. Preoperative ptosis grade, cup size, presence of post-operative complications, and breast specimen weight had no significant correlations with aesthetic grades. Inferior pedicle ORM was associated with a higher "satisfaction with breast" Q-score (p=0.017) compared to other pedicle approaches. CONCLUSION: Inferior pedicle ORM achieves objectively excellent aesthetic outcomes and high patient satisfaction with the reconstruction. 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 .

Oncologic safety of axillary lymph node dissection with immediate lymphatic reconstruction.

PURPOSE: Immediate lymphatic reconstruction (ILR) at the time of axillary lymph node dissection (ALND) can reduce the incidence of lymphedema in patients with breast cancer. The oncologic safety of ILR is unknown and has not been reported. The purpose of this study was to evaluate if ILR is associated with increased breast cancer recurrence rates. METHODS: Patients with breast cancer who underwent ALND with ILR from September 2016 to December 2020 were identified from a prospective institutional database. Patient demographics, tumor characteristics, and operative details were recorded. Follow-up included the development of local recurrence as well as distant metastasis. Oncologic outcomes were analyzed. RESULTS: A total of 137 patients underwent ALND with ILR. At cancer presentation, 122 patients (89%) had clinically node positive primary breast cancer, 10 patients (7.3%) had recurrent breast cancer involving the axillary lymph nodes, 3 patients (2.2%) had recurrent breast cancer involving both the breast and axillary nodes, and 2 patients (1.5%) presented with axillary disease/occult breast cancer. For surgical management, 103 patients (75.2%) underwent a mastectomy, 22 patients (16%) underwent lumpectomy and 12 patients (8.8%) had axillary surgery only. The ALND procedure, yielded a median of 15 lymph nodes pathologically identified (range 3-41). At a median follow-up of 32.9 months (range 6-63 months), 17 patients (12.4%) developed a local (n = 1) or distant recurrence (n = 16), however, no axillary recurrences were identified. CONCLUSION: Immediate lymphatic reconstruction in patients with breast cancer undergoing ALND is not associated with short term axillary recurrence and appears oncologically safe.

Lymphedema Prevention Surgery: Improved Operating Efficiency Over Time.

BACKGROUND: Lymphedema prevention surgery (LPS), which identifies, preserves, and restores lymphatic flow via lymphaticovenous bypasses (LVB), has demonstrated potential to decrease lymphedema in breast cancer patients requiring axillary lymph node dissection. Implementing this new operating technique requires additional operating room (OR) time and coordination. This study sought to evaluate the improvement of LPS technique and OR duration over time. METHODS: A prospective database of patients who underwent LPS at our institution from 2016 to 2019 was queried. Type of breast and reconstruction surgery, number of LVB performed, and OR times were collected. LPS details were compared by surgical group and year performed. RESULTS: Ninety-four patients underwent LPS, and 88 had complete OR time data available for analysis. Average age was 51 years, body mass index of 28, with an average of 15 lymph nodes removed. Reconstructive treatment groups included prosthetic reconstruction 56% (49), oncoplastic reduction 10% (9), and no reconstruction 34% (30). The number of patients undergoing LPS increased significantly from 2016 to 2019, and average number of LVB per patient doubled. In patients without reconstruction, the average time for LPS improved significantly from 212 to 87 min from 2016 to 2019 (p = 0.015) and similarly in patients undergoing LPS with prosthetic reconstruction from 238 to 160 min (p = 0.022). CONCLUSIONS: LVB is an emerging surgical lymphedema prevention technique. While requiring additional surgical time, our results show that with refinement of technique, over 4 years, we were able to perform double the number of LVB per patient in half the OR time.

Lymphaticovenous Bypass for Immediate Lymphatic Reconstruction in Locoregional Advanced Melanoma Patients.

BACKGROUND: Extremity lymphedema is a dreaded complication of ilioinguinal or axillary lymphadenectomy. In conventional lymph node dissection, no effort is performed to maintain or reestablish extremity lymphatic circulation. We hypothesized that immediate lymphatic reconstruction (ILR) could be a reproducible procedure to maintain functional lymphatic flow after ilioinguinal and axillary lymphadenectomy in patients with malignant melanoma. This is the first report describing prophylactic ILR in patients with melanoma who underwent complete lymph node dissection for gross nodal disease. PATIENTS AND METHODS: We report a case series of 22 malignant melanoma patients who had axillary or ilioinguinal lymph node dissection for bulky locoregional invasion with immediate lymphatic reconstruction. A novel method to identify and select lymphatics with high flow using fluorescent lymphangiogram with indocyanine green dye gradient software is described. Surgical details, common difficulties, as well as indications are discussed. Instructional videos are also provided. RESULTS: Our technique is reproducible, since we have successfully completed immediate lymphatic reconstruction in 22 cases consecutively. Intradermal indocyanine green injections allowed for visualization of 1 to 3 transected lymphatics after lymphadenectomy. An average of 1.8 lymphaticovenous bypass (range 1-3) was performed per patient. CONCLUSION: Reestablishment of lymphatic circulation after ilioinguinal or axillary lymphadenectomy in patients with melanoma characterizes a novel method that may reduce the problem of upper and lower extremity iatrogenic lymphedema. This is particularly important given the emergence of new adjuvant treatment modalities that considerably improve patients' survival after lymphadenectomy.

Facelift Part I: History, Anatomy, and Clinical Assessment.

In this article, the authors aim to thoroughly describe the critical surgical anatomy of the facial layers, the retaining ligamentous attachments of the face, and the complex three-dimensional course of the pertinent nerves. This is supplemented with clarifying anatomic dissections and artwork figures whenever possible to enable easy, sound, and safe navigation during surgery. The historic milestones that led the evolution of cervicofacial rejuvenation to the art we know today are summarized at the beginning, and the pearls of the relevant facial analysis that permit accurate clinical judgment and hence individualized treatment strategies are highlighted at the end. The facelift operation remains the cornerstone of face and neck rejuvenation. Despite the emergence of numerous less invasive modalities, surgery continues to be the most powerful and more durable technique to modify facial appearance. All other procedures designed to ameliorate facial aging are either built around or serve as adjuncts to this formidable craft.

Indocyanine Green Fluorescence Imaging with Lymphoscintigraphy for Sentinel Node Biopsy in Melanoma: Increasing the Sentinel Lymph Node-Positive Rate.

INTRODUCTION: The goal of this study was to analyze patients who underwent a sentinel lymph node biopsy (SLNB) in melanoma with the combination of radioisotope lymphoscintigraphy and indocyanine green (ICG) fluorescence imaging to compare our true positive (TP) rate, a means to perform immediate analysis of the SLNB, with that of the literature. METHODS: Consecutive cutaneous melanoma patients who underwent SLNB with lymphoscintigraphy and ICG-based fluorescence imaging by the senior author (BG) from 2012 to 2018 were prospectively enrolled. The average expected SLN-positive rate per T stage was calculated based on three studies and compared with our SLN-positive rate. RESULTS: Overall, 574 consecutive patients were analyzed. Average Breslow thickness was 1.9 mm. A total of 1754 sentinel nodes were sampled; 1497 were identified by gamma probe signaling and ICG, 241 were identified by gamma probe signaling only, and 16 were identified by ICG only. There were 123 (21.4%) patients with at least one positive SLN; 113 (91.9%) had at least one positive node identified with both gamma probe signaling and ICG, 8 (6.5%) had positive node(s) identified with gamma probe signaling only, and 2 (1.6%) had positive node(s) identified with ICG only. There was an overall 21.4% SLN-positive rate, with 8% T1, 18.5% T2, 41.1% T3, and 52.4% T4, which is higher than the predicted rates for each stage. CONCLUSIONS: With the largest cohort of patients reported who underwent a melanoma SLNB with lymphoscintigraphy and ICG, we demonstrated that this technique results in higher SLN-positive rates than predicted. Patients are being followed but, given the TP data, knowledge of our results may foster the use of this modality to improve staging and treatment options.

Axillary reverse mapping and lymphaticovenous bypass: Lymphedema prevention through enhanced lymphatic visualization and restoration of flow.

BACKGROUND: A lymphedema (LE) prevention surgery (LPS) paradigm for patients undergoing axillary lymphadenectomy (ALND) was developed to protect against LE through enhanced lymphatic visualization during axillary reverse mapping (ARM) and refinement in decision making during lymphaticovenous bypass (LVB). METHODS: A retrospective analysis of a prospective database was performed evaluating patients with breast cancer who underwent ALND, ARM, and LVB from September 2016 to December 2018. Patient and tumor characteristics, oncologic and reconstructive operative details, complications and LE development were analyzed. RESULTS: LPS was completed in 58 patients with a mean age of 51.7 years. An average of 14 lymph nodes (LN) were removed during ALND. An average of 2.1 blue lymphatic channels were visualized with an average of 1.4 LVBs performed per patient. End to end anastomosis was performed in 37 patients and a multiple lymphatic intussusception technique in 21. Patency was confirmed 96.5% of patients. Adjuvant radiation was administered to 89% of patients. Two patients developed LE with a median follow-up of 11.8 months. CONCLUSION: We report on our experience using a unique LPS technique. Refinements in ARM and a systematic approach to LVB allows for maximal preservation of lymphatic continuity, identification of transected lymphatics, and reestablishment of upper extremity lymphatic drainage pathways.

Developing a protocol for normothermic ex-situ limb perfusion.

BACKGROUND: Ischemia time represents a significant limitation for successful extremity transplantation because of the rapid deterioration of ischemic muscle. Normothermic ex-situ preservation is an emergent method to prolong the organ viability following procurement, by replicating the physiologic conditions. The aim of this study was to develop an ex-situ normothermic limb perfusion system to preserve the viability and function of porcine limbs for 12 hours following procurement. METHODS: A total of 18 swine limbs were perfused. Thirteen limbs were used to develop the perfusion protocol. Five limbs were perfused according to the optimized protocol. These limbs were perfused at 39°C for twelve hours using an oxygenated colloid solution containing red blood cells. Glucose and electrolytes were kept within physiologic range by partial perfusate exchange. Limb specific perfusion quality was assessed by muscle contractility upon electrical nerve stimulation, compartment pressure, creatine kinase (CK) and myoglobin concentrations, tissue oxygen saturation (near infrared spectroscopy), indocyanine green angiography, and infrared radiation by thermographic imaging. RESULTS: The last five limbs reached the 12 hours' perfusion target maintaining normal compartment pressure (16.4 ± 8.20 mmHg), minimal weight increase (0.54 ± 7.35%), and mean muscle temperature of 33.6 ± 1.67°C. Myoglobin and CK concentrations were 875 ± 291.4 ng/mL, and 53344 ± 14850.34 U/L, respectively, at the end of perfusion. Muscle contraction was present in all limbs until cessation of perfusion. Differences in uniformity and quality of distal perfusion were identified with thermography and angiography imaging at 12 hours of perfusion. CONCLUSIONS: Ex-situ normothermic limb perfusion preserves swine limb physiology and function for at least 12 hours.

The Effect of Smoking on Facial Fat Grafting Surgery.

Facial fat grafting has been increasingly performed to create a more youthful face. Cigarette smoking might have potential harmful effects on fat graft survival. The aim of this study was to evaluate the effects of cigarette smoking on facial lipofilling.Eighteen smoker patients (13 females and 5 males) with a mean age of 37.4 years (range: 21-53 years) who underwent facial lipofilling were enrolled in this retrospective study. The patients were followed up for an average of 19.3 months (range: 14-32 months). The fat-graft survival rate, degree of skin improvement, and presence and severity of surgical complications (fat necrosis, oil cysts, and infection) were evaluated. A 10-point Likert scale was used to assess patient satisfaction with facial fat grafting surgery.The mean injected fat volume was 42 mL (range: 30-80 mL). Clinical and photographic evaluation by the surgical team led to an estimation of 40% for the mean fat survival rate. Four instances of fat necrosis, 2 oil cysts, and 1 infection were diagnosed and treated conservatively. Five patients underwent a second fat grafting surgical procedure; 3 of these had a third fat grafting surgery to obtain the desired facial fullness. Improvement of skin quality was better during the first months after surgery, but not long standing. Overall patient satisfaction in terms of aesthetic appearance, facial fullness, and rejuvenation was 74%.Although cigarette smoking causes low fat survival rates and impairs the improvement of skin quality, successful results can be obtained with facial lipofilling in the smokers.

Current Evidence for Clinical Efficacy of Platelet Rich Plasma in Aesthetic Surgery: A Systematic Review.

Background: Platelet rich plasma (PRP) has attracted attention in a number of surgical fields due to a wide variety of potential clinical benefits. Yet PRP has not gained wide popularity in aesthetic surgery as a result of uncertainty surrounding objective clinical evidence. Objectives: We aim to describe the current applications, define preparation and activation, explore effectiveness, and propose a classification system to facilitate comparisons across studies. Methods: A comprehensive review of the literature regarding the use of platelet rich plasma in aesthetic surgery was performed. Data gathered included: PRP application, study type, subject number, centrifugation, anticoagulation, activation, PRP composition, and outcomes. Results: Thirty-eight reports were identified. Applications included injection into aging skin (29%), scalp alopecia (26%), lipofilling (21%), fractional laser (13%), and facial surgery (11%). The majority of studies (53%) were case series without controls. Leucocytes were sparsely defined (32%). The concentration of injected and/or baseline platelets was rarely clarified (18%). The mechanism of activation was described in 27 studies (71%), while anticoagulation was uncommonly elucidated (47%). While most studies (95%) claim effectiveness, objective measures were only utilized in 17 studies (47%). Conclusions: Current studies produce context-dependent results with a lack of consistent reporting of PRP preparation, composition, and activation in aesthetic applications, making meaningful meta-analysis unrealistic. Thus the method of PRP preparation warrants increased attention. We recommend a set of descriptors, FIT PAAW (described below), to produce scientifically grounded conclusions, facilitating a clearer understanding of the situations in which PRP is effective. Level of Evidence: 4

Resident and Program Director Perceptions of Aesthetic Training in Plastic Surgery Residency: An Update.

Background: This is the third survey exploring the quality of cosmetic training in plastic surgery residency. We focused on determining: (1) the applied modalities and extent of resident exposure; and (2) resident confidence in performing variable cosmetic procedures. Objectives: To analyze trends in resident exposure and confidence in aesthetic plastic surgery procedures from the standpoint of program directors (PDs) and residents. Methods: The survey was developed and e-mailed to 424 residents enrolled in the ASAPS Residents Program and 95 PDs. Both independent and integrated programs were included. The questions were posed in a five-point ranking format. Univariate statistical analysis was used to examine all aspects. The results were analyzed in relation to our previous surveys in 2008 and 2011. Results: Thirty-three PDs (34.7%) and 224 (52.8%) residents responded. Residents felt most confident with abdominoplasty, breast reduction, and augmentation-mammaplasty. Facial aesthetic procedures, especially rhinoplasty and facelift, were perceived as "challenging." The three most preferred modalities of aesthetic education were, in descending order, residents' clinic, staff cosmetic patients, and cadaver dissections. Both residents and PDs felt a need for more training especially in facial procedures. Only 31.5% of residents who planned to focus on cosmetic surgery felt ideally prepared integrating cosmetic surgery into their practice (compared to 50% in previous surveys). Conclusions: Despite improvements observed from 2008 to 2011 published surveys, there are still challenges to be met especially in facial cosmetic procedures. It is suggested that resident clinics and cadaver courses be universally adopted by all training programs.

Dislocation of Mandibular Condyle Into Middle Cranial Fossa: Two Alternative Methods for Two Patients.

Dislocation of the mandibular condyle into the middle cranial fossa is rare, and the number of cases discussed in published studies is limited. Various treatment routes have been suggested, and the entire published data are based on the presentations of single cases. The present report presents 2 cases of dislocation of the mandibular condyle into the middle cranial fossa. The first case was treated with closed reduction in the early stage; however, the second case, which was treated in the late stage, required open reduction. Both the methods of reduction and the key aspects of diagnosis are discussed.

Idiopathic sixth nerve palsy after bimaxillary surgery: a complication or a sequential pathology independent from surgery?

This was a case of a 21-year-old female patient with a very rare and unexpected symptom "diplopia occurring due to the idiopathic sixth nerve palsy" encountered after 2 weeks following bimaxillary surgery performed for the correction of class III malocclusion deformity.

An underestimated "ghost" foreign body as an unusual cause of mandibular osseocutaneous fistula formation: impacted spike of a soccer cleat.

In this article, the case of a patient with osteocutaneous fistula at the left malar region secondary to impacted spike of a soccer cleat to the mandible is presented. Both the clinical and radiologic diagnoses failed because of an obscure anamnesis of the patient and the unavailability of viewing the spike in orthopantomogram and computed tomography. Surgical extirpation was performed to the 41-year-old man who was injured in a football match 3 months before the presentation and had a swooning history after an accidental booting. There were no early or late complications after the surgery at the end of 9 months. This study shows the importance of both obtaining a definite history of patients and sequential radiologic imaging to make a differential diagnosis between the foreign bodies and cystic or noncystic tumors and inflammatory lesions of the mandible.

An Algorithm for Control of Excessive Perioperative Bleeding and Ecchymosis in Rhinoplasty Patients Based on 4 Decades of Experience.

BACKGROUND: Persistent intraoperative bleeding, excessive post-operative ecchymosis, epistaxis, or blood collection in the supratip area increases the complexity of rhinoplasty, causing suboptimal outcomes. We present an intraoperative bleeding management algorithm developed by the senior author (B.G.) based on 43 years of experience and assess its efficacy in achieving hemostatic control through 103 consecutive cases. METHODS: A retrospective chart review was conducted on 103 consecutive patients who had undergone septorhinoplasty by a single surgeon. Patient demographics, coagulopathies, medications, diet, intraoperative use of tranexamic acid (TXA), desmopressin (DDAVP), Vitamin K, and post-operative complications were reviewed. RESULTS: Twenty-six (25.2%) patients did not receive intraoperative hemostatic agents. Twenty-six (25.2%) patients required TXA only, three (2.91%) patients were given DDAVP only, one (0.97%) patient received Vitamin K only, and forty-six (44.7%) patients required both TXA and DDAVP. One (0.97%) patient needed TXA, DDAVP, and vitamin K. Intraoperative bleeding was controlled in all patients. One patient with known factor 11 deficiency received both TXA and DDAVP intraoperatively but did not require fresh frozen plasma. Intraoperative bleeding was controlled by first administering 10 mg/kg of TXA intravenously, followed by DDAVP with a maximum dose of 0.3 mcg if needed, and 10 mg of Vitamin K if bleeding persisted. Patients with known type I or IIa Von Willebrand disease received DDAVP preoperatively. No patient experienced post-operative epistaxis, thromboembolism, or other associated complications. CONCLUSION: The algorithm of TXA, DDAVP, and Vitamin K is effective in controlling excessive intraoperative bleeding, post-operative ecchymosis, and epistaxis. LEVEL OF EVIDENCE: IV.