Oncoplastic breast reconstruction: Principles, current techniques, and future directions.

Oncoplastic breast reconstruction has improved esthetic results after breast-conserving surgery with low complication rates and stable oncologic outcomes. Basic principles can be applied across different volume displacement and replacement techniques including restoration of breast shape and symmetry through esthetic incisions while eliminating dead space. Technique selection is guided by several factors including breast size, resection-to-breast ratio, and patient desires. A surgeon familiar with all techniques will allow individualization of treatment and optimization of outcomes.

Microscope-Assisted Arterial Anastomosis in Adult Living Donor Liver Transplantation: A Systematic Review and Meta-analysis of Outcomes.

BACKGROUND: Living donor liver transplantation (LDLT) has expanded the availability of liver transplant but has been associated with early technical complications including the devastating complication of hepatic artery thrombosis (HAT), which has been reported to occur in 14% to 25% of LDLT using standard anastomotic techniques. Microvascular hepatic artery reconstruction (MHAR) has been implemented in an attempt to decrease rates of HAT. The purpose of this study was to review the available literature in LDLT, specifically related to MHAR to determine its impact on rates of posttransplant complications including HAT. METHODS: A systematic review was conducted using PubMed/Medline and Web of Science. Case series and reviews describing reports of microscope-assisted hepatic artery anastomosis in adult patients were considered for meta-analysis of factors contributing to HAT. RESULTS: In all, 462 abstracts were screened, resulting in 20 studies that were included in the meta-analysis. This analysis included 2,457 patients from eight countries. The pooled rate of HAT was 2.20% with an overall effect size of 0.00906. CONCLUSION: Systematic literature review suggests that MHAR during LDLT reduces vascular complications and improves outcomes posttransplant. Microvascular surgeons and transplant surgeons should collaborate when technical challenges such as small vessel size, short donor pedicle, or dissection of the recipient vessel wall are present.

The role of neurotization in autologous breast reconstruction: Can reconstruction restore breast sensation?

As the sophistication of microsurgical breast reconstruction continues to evolve, plastic surgeons are focusing on techniques to improve functional and psychosocial outcomes for patients, including breast sensation. Interest in neurotization of breast flaps, among both patients and surgeons, has grown significantly in recent years. This study aimed to review the outcomes of neurotization across autologous flap reconstructions, to provide a comprehensive analysis of the efficacy of this technique in improving postoperative sensory recovery.

Thin Perforator Flaps for Reconstruction of the Lower Extremity.

Thin flaps, a modification of traditional flaps that minimize the need for debulking and revision, offer unique advantages in the field of lower limb reconstruction. Advances in the field of microsurgery have made this streamlined method of reconstruction a viable solution for soft tissue coverage in patients with both trauma and nonhealing wounds. Better understanding of anatomy has allowed for flap harvest above the fascia level and the Scarpal plane. These modifications allow for flap transfer with thicknesses more comparable to the native anatomy of the lower leg, ankle, and foot. Flap survival is comparable to traditional techniques with greater potential for improved patient-centered outcomes.

The Efficacy of Negative Pressure Wound Therapy and Antibiotic Beads in Lower Extremity Salvage.

BACKGROUND: Antibiotic beads and negative pressure wound therapy (NPWT) represent two methods of wound management used during staged debridement in the post-trauma limb salvage pathway. The efficacy of NPWT and antibiotic beads in preventing infection remains unclear. METHODS: This study is a retrospective review of patients with traumatic lower extremity open fractures who received NPWT and/or antibiotic beads before soft tissue reconstruction at an urban level 1 trauma center between August 2007 and December 2015. Patients with wound infections before application of NPWT and/or antibiotic beads were excluded. RESULTS: In 73 lower extremities requiring soft tissue coverage, 46 received antibiotic beads and 48 received NPWT. Overall infection rate was 15.1%. Use of antibiotic beads was associated with a decreased risk of infection (6.4% versus 30.7%; P = 0.01). Use of NPWT was associated with an increased risk of one or more complications (45.7% versus 4.2%; P = 0.001). The development of infection was associated with a greater period of time between application of antibiotic beads (22 ± 13 versus 12 ± 6 d, P = 0.01) or NPWT (23 ± 15 versus 10 ± 11 d, P = 0.004) and soft tissue coverage. Overall limb salvage rate was 95.9%; secondary amputation was associated with development of infection (P = 0.001) but not with use of NPWT or antibiotic beads. CONCLUSIONS: Antibiotic beads may prevent infections in patients awaiting soft tissue coverage of wounds. NPWT may contribute to a greater rate of complication. Limb salvage was successful in most cases regardless of method of wound management.

An economic analysis of prophylactic lymphovenous anastomosis among breast cancer patients receiving mastectomy with axillary lymph node dissection.

BACKGROUND AND OBJECTIVES: Prophylactic lymphovenous anastomosis (LVA) has been shown to decrease the incidence of postoperative lymphedema among patients receiving mastectomy with axillary lymph node dissection (ALND). However, the economic impact of this intervention on overall healthcare costs has not been adequately studied and insurance reimbursement for lymphedema treatment is limited resulting in substantial out-of-pocket patient expenses. METHODS: We performed a cost-minimization decision analysis from the societal perspective to assess two different patient scenarios: (a) mastectomy with ALND alone, (b) mastectomy with ALND and prophylactic LVA. RESULTS: The annual cost of lymphedema-related care is estimated to be $5,691.88 ($3,160.52 direct, $2,531.36 indirect). If all patients undergoing mastectomy with ALND undergo prophylactic LVA, the average expected lifetime cost per patient in the entire population (whether or not they develop lymphedema) is approximately $6,295.61, compared to $13,942.26 if no patients in the same population receive prophylactic LVA. CONCLUSIONS: Prophylactic LVA is economically preferred over mastectomy and ALND alone from a cost minimization perspective, and results in an average of $7,646.65 (45.2%) cost saving per patient over the course of their lifetime.

Vascularized Lymph Node Transfer: A Primer for the Radiologist.

Lymphedema, the accumulation of lymphatic fluid in the tissues, is a chronic disease and a major cause of long-term morbidity and disability. Lymphedema is usually a secondary condition, often caused by prior oncologic therapy, such as surgery for cancers, radiation therapy, and chemotherapy. Treatment for lymphedema has traditionally been conservative and limited, but new surgical and microsurgical procedures have arisen in recent years. Vascularized lymph node transfer (VLNT) is one of the most promising new microsurgeries. VLNT involves the transfer of functional lymph nodes (LNs) from a healthy donor site to an area of the body with damaged or diseased lymphatic drainage. The goal of the transplant is to restore physiologic LN drainage and improve lymphedema. Donor LNs are commonly found in the groin, axilla, neck, omentum, or submental region. Imaging can be used for preoperative planning to identify donor sites with the richest number of LNs. This can help identify those patients who may be candidates for VLNT and can help identify the best anatomic site for surgical harvest in those candidates. Imaging can be performed with US, CT, or MRI. VLNT preoperative imaging often requires acquisition techniques and reconstruction parameters that differ from those used in routine diagnostic imaging. Furthermore, to properly identify target LNs, the radiologist must be aware of surgical anatomic landmarks. Online supplemental material is available for this article. ©RSNA, 2020.

Contemporary Management of Alopecia: A Systematic Review and Meta-analysis for Surgeons.

BACKGROUND: The decision of surgical approach for hair restoration often involves evaluation of the type of alopecia; however, the impact of surgical hair restoration from existing techniques in specific population subsets has not been comprehensively investigated. OBJECTIVES: The authors sought to systematically review the literature on micrografts, minigrafts, mini-micrografts, tissue grafts, tissue flaps and expanders, as well as evaluate graft survival and satisfaction within specific populations in a meta-analysis. METHODS: PubMed and Scopus literature searches between 1980 and 2018 yielded 57 articles for systematic review and 34 articles for meta-analysis. Study design, mean patient age and gender, patient alopecia type, surgical hair restoration technique, number of treatment areas, mean follow-up, graft survival rate and satisfaction rate were extracted from each study, and a meta-analysis was performed. RESULTS: The pooled rates of graft survival were 84.98% (95% CI 78.90-91.06) using micrografts and 93.11% (95% CI 91.93-94.29) using micrografts and minigrafts in nonscarring alopecia patients, as well as 88.66% (95% CI 80.12-97.20) using micrografts and 86.25% (95% CI 74.00-98.50) using micrografts and minigrafts in scarring alopecia patients. The pooled rates of satisfaction were 89.70% (95% CI 82.64-96.76) using micrografts and 97.00% (95% CI 92.48-100.0) using micrografts and minigrafts in nonscarring alopecia patients, as well as 97.80% (95% CI 94.59-100.0) using micrografts and 88.70% (95% CI 66.49-100.0) using micrografts and minigrafts in scarring alopecia patients. Dot plots depict rates of graft survival rate from micrografts and satisfaction from micrografts and minigrafts. CONCLUSION: Surgical hair restoration for nonscarring and scarring alopecia yields high graft survival and satisfaction rates. LEVEL OF EVIDENCE III: 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.

Uncovering Lymphatic Transport Abnormalities in Patients with Primary Lipedema.

BACKGROUND: Although lipedema is often clinically distinguished from lymphedema, there is considerable overlap between the two entities. The purpose of this study was to evaluate lymphoscintigraphic findings in patients with lipedema to better characterize lymphatic flow in this patient population. METHODS: Patients with lipedema receiving lymphoscintigraphy between January 2015 and October 2017 were included. Patient demographics, clinical characteristics, and lymphoscintigraphic findings were extracted. Klienhan's transport index (TI) was utilized to assess lymphatic flow in patient's lower extremities (LEs).Scores ranged from 0 to 45, with values > 10 denoting pathologic lymphatic transport. RESULTS: A total of 19 total patients with lipedema underwent lymphoscintigraphic evaluation. Mean age was 54.8 years and mean body mass index was 35.9 kg/m2. Severity of lipedema was classified as stage 1 in five patients (26.3%), stage 2 in four patients (21.1%), stage 3 in four patients (21.1%), and stage 4 in six patients (31.6%). The mean TI for all extremities was 12.5; 24 (63.2%) LEs had a pathologic TI, including 7 LEs with stage 1 (29.2%), 3 LEs with stage 2 (12.5%), 6 LEs with stage 3 (25.0%), and 8 LEs with stage 4 lipedema (33.3%). The mean TI was significantly greater for extremities with severe (stage 3/4) lipedema than those with mild or moderate (stage 1/2) lipedema (15.1 vs. 9.7, p = 0.049). Mean difference in TI scores between each LE for individual patients was 6.43 (standard deviation +7.96). CONCLUSION: Our results suggest that patients with lipedema have impaired lymphatic transport, and more severe lipedema may be associated with greater lymphatic transport abnormalities.

Breast implant-associated anaplastic large cell lymphoma, a systematic review and in-depth evaluation of the current understanding.

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is a T-cell neoplasm that arises in the capsule around breast implants. While an association with implants has been proposed, no causal link has been identified and the pathophysiology and natural history of BIA-ALCL remain unknown. A literature review of 391 articles was performed to assess the current understanding of BIA-ALCL and to provide a balanced and unbiased view of the current controversy surrounding the disease.

Penile Reinnervation Surgery: A Comprehensive Review of the Literature.

BACKGROUND: Modern approaches to erectile dysfunction (ED) often entail the use of multimodal medical therapy and surgery; however, with recent advances in microsurgery, new options may exist for patients suffering from ED. This comprehensive review of the literature serves to reevaluate anatomical and physiological principles that mediate erection to improve understanding for reconstructive surgeons hoping to offer new interventions. METHODS: A search strategy for this review was agreed upon by all authors. Articles were divided into 2 categories - primary and secondary. Primary articles were defined as those in which the anatomy of the pelvis and/or perineum was the primary focus of the article, whereas secondary did not directly focus on anatomic considerations. Select historical texts and textbook chapters were also included to provide well established and critical anatomical evidence for this review. RESULTS: Several approaches may be used to restore nerve function to treat neurogenic and vasculogenic ED. Somatic sensory loss can be treated by either direct neurorrhaphy or neuroplasty in the location of disruption. Microvascular techniques also exist to improve flow or to repair small vessels injured in the pelvis. Classical approaches to impotence include vein stripping to reduce venous outflow or direct vascularization to improve inflow. CONCLUSIONS: Postradical prostatectomy ED has been demonstrated to improve with microsurgical interventions. In the coming years, innovation will continue and collaboration between plastic surgeons and urologists will allow us to tackle this common and difficult problem.

Cost-Utility Analysis of Surgical Decompression Relative to Injection Therapy for Chronic Migraine Headaches.

BACKGROUND: Common treatments for chronic migraine headaches include injection of corticosteroid and anesthetic agents at local trigger sites. However, the effects of therapy are short term, and lifelong treatment is often necessary. In contrast, surgical decompression of migraine trigger sites accomplishes the same goal yet demonstrates successful long-term elimination of chronic migraines. OBJECTIVES: Our primary objective was to perform a cost-utility analysis to determine which patients would benefit most from available treatment options in a cost-conscious model. METHODS: A cost-utility analysis was performed, taking into consideration costs, probabilities, and health state utility scores of various interventions. RESULTS: Injection therapy offered a minor improvement in quality-adjusted life-years (QALYs) compared with surgical decompression (QALY Δ = 0.6). However, long-term injection therapy was significantly costlier to society than surgical decompression: injection treatment was estimated to cost $106,887.96 more than surgery. The results of our cost-utility analysis thus conferred a positive incremental cost-utility ratio of $178,163.27 in favor of surgical decompression. CONCLUSIONS: Surgery provides a durable intervention and has been shown in this study to be extremely cost effective despite a very minor QALY deficit compared with injection therapy. If patients are identified who require treatment in the form of injections for less than 8.25 years, they may fall into a group that should not be offered surgery.

Microtexture and the Cell/Biomaterial Interface: A Systematic Review and Meta-Analysis of Capsular Contracture and Prosthetic Breast Implants.

BACKGROUND: The use of textured breast implants over smooth implants has been widely shown to have a lower incidence of capsular contracture. However, the impact of micropatterning techniques on the incidence of postoperative patient morbidity has not been comprehensively investigated. OBJECTIVES: The authors sought to examine the incidence of capsular contracture, seroma, and implant rippling among the 3 major micropatterning techniques applied in the manufacturing of textured breast implants. METHODS: Literature searches of PubMed/Medline and Embase between 1995 and 2017 were performed, and 19 studies were selected for analysis. Data from each study were extracted into a form including mean age, study design, population size, mean follow-up, number of capsular contracture cases, number of seroma cases, and number of rippling cases. Meta-analysis was performed separately for studies that included capsular contracture rates for foam textured implants, imprinted textured implants, and salt-loss textured implants. RESULTS: The pooled rate of capsular contracture rates in primary augmentation patients was 3.80% (95% CI, 2.19-5.40) for imprinted textured implants, 4.90% (95% CI, 3.16-6.64) for foam textured implants, 5.27% (95% CI, 3.22-7.31) for salt-loss textured implants, and 15.56% (95% CI, 13.31-18.16) for smooth implants. The results of each meta-analysis were summarized on a forest plot depicting the distribution of capsular contracture rates from each study. CONCLUSIONS: Micropatterning of prosthetic implants could drastically reduce postoperative patient morbidity given the advent of recent technologies that allow for more detailed texturing of implant surfaces.

The Public's Perception on Breast and Nipple Reconstruction: A Crowdsourcing-Based Assessment.

BACKGROUND: Breast reconstruction outcomes have traditionally been measured by evaluating the opinions of patients and surgeons. OBJECTIVES: Our goal was to assess the views of the general public. METHODS: A survey was designed and distributed through a crowdsourcing website called Amazon Mechanical Turk. Questions assessed participant demographics, personal experience with breast reconstruction, perceptions on breast reconstruction, and opinions regarding aesthetics results. Responses were analyzed using chi-square test. RESULTS: A total of 992 responses were collected. Most participants were female (56.1%), white (32.1%), aged 30 to 39 years (40.4%), and had a bachelor's degree (42.0%). A total of 44.2% had personal experience with breast reconstruction and 25.8% with nipple reconstruction. Several aesthetic and reconstructive factors were significantly favored over others across sex, ethnicity, age group, education level, and personal experience with breast reconstruction. For instance, women were more likely to prefer reconstructed nipples (P < 0.0001), view a breast without a nipple as complete (P = 0.024) and place less importance on nipple shape (P = 0.002). Additionally, those who personally experienced nipple reconstruction were willing to undergo more procedures for a complete nipple-areola complex (P < 0.0001), to increase aesthetic results (P = 0.018), and to increase chances of nipple survival (P = 0.002). CONCLUSIONS: Crowdsourcing can be useful in plastic surgery and has helped identify several key findings. The importance of the nipple in reconstruction has been validated; almost three-quarters of respondents did not view a breast without a nipple as complete. The aesthetic preferences seem to support bilateral nipple-sparing reconstruction when possible. Most importantly, the respondents helped elucidate key differences in perception of aesthetic outcomes.

The First Reported Case of Gluteal Implant-Associated Anaplastic Large Cell Lymphoma (ALCL).

Anaplastic large-cell lymphoma (ALCL) is a very rare but life-threatening complication that has largely been demonstrated to be associated with breast implants (BIA-ALCL). Patients are at risk of BIA-ALCL with the placement of breast implants for either cosmetic or reconstructive purposes, with the highest risks associated with textured breast implants. In the past decade, an increasing number of publications have focused on BIA-ALCL, but there has yet to be a reported case outside of the breast. Here, we describe a unique instance of gluteal implant-associated ALCL (GIA-ALCL) in a middle-aged woman. The patient received bilateral textured silicone gluteal implants only a year prior to her diagnosis of GIA-ALCL. The patient later presented to the Plastic and Reconstructive Surgery Department at our institution with ulceration at the site of her gluteal implants. Unfortunately, her condition deteriorated before explanation could be performed. Biopsy of a left lung mass demonstrated "hallmark" cells of ALCL ("horseshoe"-shaped nuclei). The diagnosis was verified by immunohistochemical testing that revealed expression of CD30, CD4, CD43, BCL6, Perforin, and Ki67 in a population of abnormal cells. The goals of this case report are thus to demonstrate that all patients undergoing implantation of textured silicone implants are at risk of developing ALCL and to provide evidence for the possible new diagnosis of GIA-ALCL. Level of Evidence: 5.

Ultrathin Free Flaps to the Foot and Ankle: New Options for Optimal Soft Tissue Coverage and Functional Contour.

Soft tissue defects and chronic wounds around the foot and ankle can prove difficult to reconstruct using conventional techniques. Traditional flaps used for coverage in this region can result in the need for future debulking, shoe gear modifications, donor site morbidity, decreased function, and scarring. Successful reports of ultrathin free flaps harvested along suprafascial planes have yet to be described in the foot and ankle literature. We present 2 cases of ultrathin flaps used for foot and ankle defects that provide optimal contour while not limiting anatomic function. The resultant functional outcomes and contour shown by both flaps underscore the benefit of a thin and pliable flap in this region.

Introducing the subdermal free flap: Preserving the ultrathin-free skin flap option in morbidly obese patients.

In the morbidly obese population (BMI > 35), distal extremity defects are difficult to reconstruct. Traditional skin flaps are several centimeters in thickness in obese patients; however, a new plane superficial to the scarpal plane has demonstrated success in these patients. In this report, we present a 62-year-old female (BMI = 44.81) with a chronic lower extremity wound. A suprascarpal thin flap (approximately 1 cm in thickness) was harvested from the thigh and transferred successfully with no wound-healing issues.

Primary tumors of the hand: Functional and restorative management.

Primary malignant tumors of the hand are rare. Most cases present to clinics unaffiliated with cancer centers, making it incumbent on all hand surgeons to understand the pathology indicative of malignancy and the proper course of treatment of hand neoplasms. In this review, we report, based on tumor type, the anatomical considerations, proper management, staging, surgical approaches, reconstructive considerations, and long-term surveillance of primary malignant tumors of the hand.

Free vascularized fibula grafting in the operative treatment of malignant bone tumors of the upper extremity: A systematic review of outcomes and complications.

BACKGROUND AND OBJECTIVES: Vascularized bone grafting after tumor resection can be an important component in the treatment of bony neoplasms of the upper extremity. The purpose of this study was to determine the outcomes of free vascularized fibula grafting (FVFG) in the treatment of upper extremity sarcomas. METHODS: A systematic review of the literature of FVFG used in the treatment of upper extremity sarcomas was performed. RESULTS: A total of 56 studies were included in final analysis. The most common diagnosis was osteosarcoma (35.1%) and the most common recipient site was the humerus (57.3%). FVFG had a median union rate of 93.3%, with the median time to union being 5.0 months. The most common complications were fracture (11.7%), nerve injury (7.5%), infection (5.7%), and hammer toe deformity (3.3%). The reoperation rate was 34.5%. The most commonly reported standardized assessment of clinical outcomes following treatment was the Musculoskeletal Tumor Society Score, which had a median of 80% postoperatively. CONCLUSIONS: FVFG in the treatment of malignant bony neoplasms of the upper extremity has a high rate of union and good overall outcomes; however, postoperative complication rates are high. A greater degree of standardization is needed in the reporting of patient-centered outcomes to facilitate future comparative studies.

Lymph node transplantation for the treatment of lymphedema.

Lymphedema is a complex disease process with deranged lymphatic transport, fluid accumulation and secondary lipedema and fibrosis. This is a challenging disease to treat with a surgical focus on debulking and physiologic strategies. One strategy is the use of vascularized lymph node transplant (VLNT) to improve physiologic lymph clearance. In this article, VLNT is discussed in detail, including mechanisms, combined strategies, and outcomes.