A Systematic Review of Outcomes After Genital Lymphedema Surgery: Microsurgical Reconstruction Versus Excisional Procedures.

INTRODUCTION: Genital lymphedema (GL) surgery can be either palliative or functional. Palliative procedures involve excision of the affected tissue and reconstruction by either local flaps or skin grafts. Reconstructive procedures aim to restore lymphatic flow through microsurgical lymphaticovenous anastomoses (LVAs). This systematic analysis of outcomes and complication rates aims to compare outcomes between these surgical treatment options for GL. METHODS: A systematic review of the PubMed database was performed with the following search algorithm: (lymphorrhea or lymphedema) and (genital or scrotal or vulvar) and (microsurgery or "surgical treatment"), evaluating outcomes, and complications after surgical treatment of GL. RESULTS: Twenty studies published between 1980 and 2016 met the inclusion criteria (total, 151 patients). Three main surgical treatments for GL were identified. Surgical resection and primary closure or skin graft was the most common procedure (46.4%) with a total complication rate of 10%. Surgical resection and flap reconstruction accounted for 39.1% of the procedures with an overall complication rate of 54.2%. Lympho venous shunt (LVA) procedures (14.5%) had a total complication rate of 9%. CONCLUSIONS: This review demonstrates a lack of consensus in both the preoperative assessment and surgical management of GL. Patients receiving excisional procedures tended to be later stage lymphedema. Patients in the excision and flap reconstruction group seemed to have the highest complication rates. Microsurgical LVAs may represent an alternative approach to GL, either alone or in combination with traditional procedures.

Long-term evaluation of Nipple-Areolar complex changes in inferior versus superomedial pedicle reduction mammoplasty: A comparative study.

BACKGROUND: In breast reduction, traditionally the inferior pedicle (IFP) technique is considered the most performed by plastic surgeons. A growing interest for the superomedial pedicle (SMP) mammoplasty technique has been documented in literature and clinical practice. Sensory recovery of the nipple-areolar complex (NAC), final areolar shape and scarring may also have a significant impact on patient satisfaction. OBJECTIVE: This study represents a retrospective multimodal analysis comparing NAC sensation and appearance outcomes in IFP and SMP wise pattern breast reductions with 2-year follow-up. METHODS: From 2013 to 2017, all performed reduction mammoplasty were included and divided in two groups (IFP or SMP technique). Testing included pressure perception (Semmes-Weinstein monofilaments), NAC measurement (diameters ratio and circumference) and circumareolar scar hypertrophy assessment. Measurements were repeated at 2 weeks, 6 and 24 months postoperatively. RESULTS: amongst the 73 patients, 42 (58%) had SMP technique and 31 (42%) had IFP technique. Values at 6-months showed better sensory return in the SMP (p < 0.01**). NAC enlargement, showed no difference between groups. However, there was a statistically significant increase in both the SMP (p < 0.001***) and the IFP (p < 0.01**) groups when comparing the 2-week and 24-month follow-up visits measured ratios confirming a more oval appearance over time with both techniques. Scar hypertrophy showed statistically significant reduction in both the SMP (p < 0.001***) and the IFP (p < 0.01**) groups over time. CONCLUSION: This 2-year follow-up study showed little difference in outcomes between the two techniques, but some advantages in NAC sensory recovery with the SMP.

Dermal Triangular Flaps to Prevent Pseudoptosis in Mastopexy Surgery: The Hammock Technique.

Mastopexy is one of the most performed cosmetic surgery procedures in the United States. Despite the numerous mastopexy techniques that were published in the past decades, preventing pseudoptosis to ensure longer lasting results remains the principal challenge. OBJECTIVES: This paper describes a new mastopexy technique developed for moderate to severe ptosis/pseudoptosis associated with upper pole deflation. Considering some of the commonest risk factors generally considered predictive of worse outcomes (massive weight loss, multiple pregnancies, skin quality, smoking, age), we aimed to assess whether this technique could be beneficial in the support of the desired breast shape over time. METHODS: Twelve patients, all featuring 1 or more of the abovementioned preoperative risk factors, were operated on by the same senior surgeon with the hammock mastopexy technique using dermal flaps as a support for the glandular reshaping (6 bilateral mastopexies and 6 unilateral mastopexies for contralateral symmetrization after breast reconstruction). Patients' characteristics, such as smoking, weight loss, or multiparity with consequent inelastic skin, age, and lengthy nipple-areola complex lift, were considered as independent risk factors for ptosis recurrence and bottoming out. Patients were divided into 3 subgroups according to the number of their risk factors. Aesthetic results were assessed at 12 months postoperatively. Changes in postoperative were assessed for each patient by breast measurements and a superposition of the standardized breast photographs. Long-term outcomes were compared with a control group of 6 patients who benefited from mastopexy without "hammock technique." RESULTS: Satisfactory maintenance of shape and stable nipple-areola complex position was seen at 12 months regardless of the number of risk factors. However, a statistically significant difference was found in lower pole lengthening between patients with more than 3 risk factors compared to other groups. Aesthetic measurement results were consistent between the patient and surgeon reporting a satisfying cosmetic result, regardless of the number of risk factors. In the control group, we found a significant increase in breast lower pole measurements at 12 months when compared with the hammock group. CONCLUSIONS: This mastopexy technique improves projection and reinforces the lower pole support with lateral and medial dermal flaps. The technique is safe and reliable and provides easily reproducible results for patients with risk factors for postoperative pseudoptosis.

A single-centre, retrospective proof-of-concept review of salvage of infected or exposed implant breast reconstructions with explantation and one-stage free flap replacement.

INTRODUCTION: Implant-based breast reconstruction has relatively high complication rates. Removal of infected implants and immediate autologous reconstruction is a safe single-stage procedure that preserves the native breast skin envelope. METHODS: A single-centre, retrospective proof-of-concept review of all salvage procedures performed for acute/chronic infected or exposed implant-based reconstructions by a single surgeon over a 6-year period. RESULTS: We present 13 cases of a particularly difficult subgroup of acute/chronic infection/extrusion over a 6-year period. All were successfully salvaged in a single procedure by implant removal and immediate free flap reconstruction with no significant complications. All patients had a change of pocket from subpectoral to subcutaneous and partial capsulectomies. Four patients had unilateral DIEP flaps for unilateral reconstruction, 3 bi-pedicle DIEP flaps for unilateral reconstruction, 2 bilateral TUG flaps for unilateral reconstruction, 3 bilateral DIEP flaps for bilateral reconstruction and 1 unilateral DIEP and implant for unilateral reconstruction. CONCLUSIONS: These patients are often slim with limited donor sites and pose technical challenges, often requiring double free flap reconstructions. Single-stage implant removal and autologous reconstruction preserves the breast skin envelope to maximise cosmesis in a single procedure. The introduction of healthy, well-vascularised tissue may also help treat the infection.

Perforator mapping reduces the operative time of DIEP flap breast reconstruction: A systematic review and meta-analysis of preoperative ultrasound, computed tomography and magnetic resonance angiography.

BACKGROUND: Prior to DIEP flap breast reconstruction, mapping the perforators of the lower abdominal wall using ultrasound, computed tomography angiography (CTA) or magnetic resonance angiography (MRA) reduces the risk of flap failure. This review aimed to investigate the additional potential benefit of a reduction in operating time. METHODS: We systematically searched the literature for studies concerning adult women undergoing DIEP flap breast reconstruction, which directly compared the operating times and adverse outcomes for those with and without preoperative perforator mapping by ultrasound, CTA or MRA. Outcomes were extracted, data meta-analysed and the quality of the evidence appraised. RESULTS: Fourteen articles were included. Preoperative perforator mapping by CTA or MRA significantly reduced operating time (mean reduction of 54 minutes [95% CI 3, 105], p = 0.04), when directly compared to DIEP flap breast reconstruction with no perforator mapping. Further, perforator mapping by CTA was superior to ultrasound, as CTA saved more time in theatre (mean reduction of 58 minutes [95% CI 25, 91], p < 0.001) and was associated with a lower risk of partial flap failure (RR 0.15 [95% CI 0.04, 0.6], p = 0.007). All studies were at risk of methodological bias and the quality of the evidence was very low. CONCLUSIONS: The quality of research regarding perforator mapping prior to DIEP flap breast reconstruction is poor and although preoperative angiography appears to save operative time, reduce morbidity and confer cost savings, higher quality research is needed. REGISTRATION: PROSPERO ID CRD42017065012.

Use of acellular dermal matrix (ADM) in nipple reconstruction: the 'central-pillar technique'.

Nipple reconstructions are prone to a variable and unpredictable degree of flattening, which in some cases lead to secondary reconstruction. The use of an acellular dermal matrix (ADM) augmentation may be appropriate in cases with very thin dermis that are particularly prone to flattening or in revision cases where the first procedure has already failed. The authors present a series of 13 nipple reconstructions in ten cases. Average projection at 12 months was 51% in primary cases and 46% in secondary revision cases. This represents a better than expected long term result in a difficult cohort of patients.

Central round block repair of large breast resection defects: oncologic and aesthetic outcomes.

BACKGROUND: The central round block repair is a volume displacement technique to reconstruct large wide local excision (WLE) defects in breasts with moderate ptosis or hypertrophy. There are limited published data on the outcomes of this technique. METHODS: Data were collected prospectively for 57 consecutive patients and follow up information obtained from patient records. The volume of breast resection was estimated geometrically from mammography. Aesthetic outcomes were assessed from clinical measurements and panel review of patient photographs. RESULTS: The median age was 51 [22-86] years and follow-up 5 (1.9-8.4) years. The median specimen resection weight was 50 [25-361] g and tumour size 25 [10-75] mm. Estimated volume of breast excised was 17.8% (6-31%). In total, 12/57 patients had incomplete margins: five patients had re-excision to achieve clear margins and seven required mastectomy. Two patients had local recurrence during the follow-up period, five developed distant metastases. Aesthetic data were completed for 35/50 patients. Twelve (34%) had no measurable asymmetry and 31 (89%) had a nipple position within 2 cm of the original height. Only two patients requested symmetrising surgery. CONCLUSIONS: Central round block reconstruction of large defects after WLE is a safe technique with good aesthetic outcomes. Contralateral symmetrising surgery is not usually required.

A review of 58 patients with periorbital haemangiomas to determine appropriate cases for intervention.

BACKGROUND: Periorbital haemangiomas cause severe effects on visual development. They can be treated with some success, but there is currently no literature on the selection of patients for intervention. Our study aims to review all periorbital haemangioma cases in Edinburgh over the past 20 years, to set more stringent guidelines regarding the appropriate selection of patients for treatment and determine prognostic indicators of visual outcome. METHODS: A review of 58 patients since 1980 with significant lesions, seen by ophthalmologists and/or plastic surgeons. RESULTS: 82% of those presenting were female. The mean age of presentation was 4 months and 2 months in more serious cases. Mean follow up was for 5.6 (range 0-15) years. Loss of visual field was the most sensitive prediction of the development of visual complications (67%), but least specific (76%). Pressure on the globe and pupillary obstruction were more specific (77-100%), but less sensitive (33-50%). CONCLUSIONS: Loss of visual field, partial/complete pupillary obstruction and pressure exerted on the globe are all valuable prognostic indicators. The size and position of the lesion are also relevant, but are probably due to these factors. Based on these results we recommend specific guidelines for the selection of patients for intervention.