Minimizing Nipple-Areolar Complex Complications in Prepectoral Breast Reconstruction After Nipple-Sparing Mastectomy.

PURPOSE: Nipple-areolar complex (NAC) viability remains a significant concern following prepectoral tissue expander (TE) reconstruction after nipple-sparing mastectomy (NSM). This study assesses the impact of intraoperative TE fill on NAC necrosis and identifies strategies for mitigating this risk. METHODS: A chart review of all consecutive, prepectoral TEs placed immediately after NSM was performed between March 2017 and December 2022 at a single center. Demographics, mastectomy weight, intraoperative TE fill, and complications were extracted for all patients. Partial NAC necrosis was defined as any thickness of skin loss including part of the NAC, whereas total NAC necrosis was defined as full-thickness skin loss involving the entirety of the NAC. P < 0.05 was considered statistically significant. RESULTS: Forty-six patients (83 breasts) with an average follow-up of 22 months were included. Women were on average 46 years old, nonsmoker (98%), and nondiabetic (100%) and had a body mass index of 23 kg/m2. All reconstructions were performed immediately following prophylactic mastectomies in 49% and therapeutic mastectomies in 51% of cases. Three breasts (4%) were radiated, and 15 patients (33%) received chemotherapy. Mean mastectomy weight was 346 ± 274 g, median intraoperative TE fill was 150 ± 225 mL, and median final TE fill was 350 ± 170 mL. Partial NAC necrosis occurred in 7 breasts (8%), and there were zero instances of complete NAC necrosis. On univariate analysis, partial NAC necrosis was not associated with any patient demographic or operative characteristics, including intraoperative TE fill. In multivariable models controlling for age, body mass index, mastectomy weight, prior breast surgery, and intraoperative TE fill, partial NAC necrosis was associated with lower body mass index (odds ratio, 0.53; confidence interval [CI], 0.29-0.98; P < 0.05) and higher mastectomy weight (odds ratio, 1.1; CI, 1.01-1.20; P < 0.05). Prior breast surgery approached significance, as those breasts had a 19.4 times higher odds of partial NAC necrosis (95% CI, 0.88-427.6; P = 0.06). CONCLUSIONS: Nipple-areolar complex necrosis following prepectoral TE reconstruction is a rare but serious complication. In this study of 83 breasts, 7 (8%) developed partial NAC necrosis, and all but one were able to be salvaged.

Breast Implant Illness as a Clinical Entity: A Systematic Review of the Literature.

BACKGROUND: Breast implant illness (BII) has become a contentious subject in recent years. While some studies have reported associations between breast implants and autoimmune diseases, others have failed to establish a definitive link. OBJECTIVES: The objective of this study is to provide a comprehensive, up-to-date evaluation of the literature surrounding BII, with an emphasis on identifying patient-related factors that may be associated with BII. METHODS: A systematic review was performed following PRISMA guidelines using Pubmed (MEDLINE), EMBASE, and Cochrane databases to search for relevant studies published in the last twenty years. RESULTS: Thirty-one studies were included with a total of 39,505 implant patients and mean age of 44.2 ± 9.30 years. Fifteen studies reported implant explantation status with 72.4% patients choosing to remove their implants. Among these, nine studies reported symptom improvement in 83.5% patients. Fifty-three percent of patients undergoing explantation had total capsulectomy. Twenty-eight studies documented total numbers of patients experiencing symptoms related to BII, with 31.3% patients reporting such symptoms. Among these, sixteen studies of 4,109 BII patients distinguished whether the reason for implantation was cosmetic augmentation or reconstruction. When specified, more patients experiencing BII-related symptoms received implants for "cosmetic" versus "reconstructive" reasons (Cosmetic: 3,864/4,109; 94.0% vs. Reconstruction: 245/4,109; 5.96%, p < 0.001). CONCLUSIONS: This review provides an overview of the current state of knowledge regarding BII. Our study highlights a potential relationship between BII and indication for implants (cosmetic vs. reconstructive) among other variables, offering valuable insight on factors associated with BII and directions for future research.

Post-surgical pyoderma gangrenosum in otherwise healthy patient with history of COVID-19.

There are increasing reports of autoimmune and dermatologic sequelae of COVID-19. We describe an otherwise healthy patient with recent history of serious COVID-19 infection who developed post-surgical pyoderma gangrenosum following bilateral reduction mammoplasty and was successfully treated with infliximab, mycophenolic acid, and corticosteroids. We present this case to highlight the lingering systemic proinflammatory effects of COVID-19 infection that may increase the risk of rare autoimmune complications of surgery. As a complete understanding of the long-term effects of COVID-19 is poorly understood, patients with a history of COVID-19 infection should be appropriately counseled to these possible risks when discussing surgery.

Facial Injuries Due to Cycling are Prevalent: Improved Helmet Design Offering Facial Protection is Recommended.

PURPOSE: Safety equipment for recreational cycling is commonly designed to protect the calvarium, but not the face, in the event of a crash. The purpose of this study is to identify the prevalence of facial injuries and their most common subcategories due to cycling injuries and to serve as an anatomical guide of what facial structures most need protection. METHODS: We report a cross-sectional study of consecutive patients reported to the National Electronic Injury Surveillance System from January 1, 2010 to December 31, 2019. Patients were included in our study if they were evaluated in the emergency department (ED) for an injury due to cycling trauma. Primary outcome was injury to the face. Other variables of interest include age, sex, race, ED disposition, type of facial injury, location of facial injury, and presence of additional injuries. Descriptive and univariate statistics of the primary outcome were computed with these variables. RESULTS: There were 138,078 total patients injured due to cycling trauma reported by National Electronic Injury Surveillance System -participating EDs during the study period and, of those, 14,326 patients experienced injury to the face, revealing a 10.4% prevalence of facial injury due to cycling trauma (14,326/138,078). Thirteen percent (1,987/14,326) of facial injuries were fractures, and the most involved structures were the nose (786/1987; 40%), orbit (459/1987; 23%), and mandible (405/1987; 20%). Compared to children, adults demonstrate a greater risk of facial fracture (23.5% versus 6.5%, P < .0001) and hospital admission after facial injury (8.9 vs 2.8%, P < .0001). CONCLUSIONS: The prevalence of facial injury in the setting of cycling trauma is over 10%, and 13% of these injuries were facial fractures. With this high prevalence, there is a need for cycling helmets that include facial protection or faceguards, and we outline the commonly fractured anatomical areas that need the most protection.

Alcohol and Drug Use While Cycling Significantly Increases the Likelihood of Facial Fractures.

PURPOSE: Substance use, including alcohol and drugs, has been found to amplify the risks associated with cycling. Our purpose was to determine the relationship between alcohol or drug use and facial injuries in a nationwide population of patients experiencing cycling trauma. METHODS: The authors report a cross-sectional study of patients reported to the National Electronic Injury Surveillance System from January 1, 2019 to December 31, 2019, in the United States. Patients were included in our study if they were evaluated in the emergency department for a cycling-related injury. Primary outcome was facial injury. RESULTS: There were a total of 6499 adult patients who experience an injury after cycling trauma reported by the National Electronic Injury Surveillance System-participating emergency departments during the study period. A total of 553 (553/6499; 8.5%) patients had a facial injury and 82 patients with facial injuries had alcohol/drug use recorded (82/553; 14.8%). The proportion of males with facial injuries was higher in the alcohol/drug group than the no alcohol/drug group (86.6% versus 76.4%, respectively; P = 0.04). Injured cyclists in the alcohol/drug group experienced greater odds of sustaining a facial injury (odds ratio: 2.21, 95% confidence interval: 1.71-2.84, P < 0.0001) and a facial fracture (odds ratio: 2.75, 95% confidence interval: 1.83-4.13, P < 0.0001) than injured cyclists in the no alcohol/drug group. CONCLUSIONS: Substance use while cycling is not safe and significantly increases the likelihood of a facial injury and of facial fractures. This prevalence of injuries would suggest that cycling under the influence should always be illegal, and the law strictly enforced.

Management of surgical soft tissue defects of the lower extremities.

Management of post-operative soft-tissue defects on the lower legs is challenging owing to arterial and venous insufficiency, poor skin quality including epidermal and dermal atrophy, insufficient tissue laxity, and increased risk of infection. This paper highlights the management of post-operative soft-tissue defects on the lower extremity that cannot be closed primarily or by reconstruction with a local flap. A systematic review of the literature was performed using the National Library of Medicine (NLM) PubMed online database. Articles were included if they reported the management of post-operative lower extremity soft-tissue defects with secondary intention healing, full-thickness skin graft, split-thickness skin grafts, or skin substitutes. Sixty-three articles were included for analysis. There are several options for managing surgical defects on the lower legs and the method chosen should depend on various factors, including the quality of the skin, vascularity and size of the defect, medical history of the patient, and the experience of the surgeon.

Optimal surgical strategy for meningiomas involving the superior sagittal sinus: a systematic review.

Involvement of the superior sagittal sinus (SSS) by meningiomas poses specific challenges, without an agreement about the degree of surgical aggressiveness when dealing with these lesions. In this systematic review and meta-analysis, we compare outcomes and complication rates, after different surgical strategies. Studies focused on meningiomas involving the SSS were collected from numerous online databases. Surgical outcome and complication data were abstracted. Comparisons were made considering complication and recurrence rates between an "aggressive" and a "non-aggressive" surgical attitude. A total of 26 studies, encompassing 1614 patients, were identified. Most of the tumors (53%) arose from the middle third of SSS and 75% of patients had a patent sinus at the time of surgery. A favorable outcome was achieved in 73% of patients treated with an "aggressive" surgical attitude compared to 78% of patients treated with a "non-aggressive" surgical attitude. Complication rates were similar between "aggressive" and "non-aggressive" attitudes, except for a higher rate of venous infarct (4% versus 2%, respectively) and worsening of preexisting motor deficits (34% versus 13%, respectively) in aggressively treated patients. Recurrence rates were not substantially different in the two groups after accounting for length of follow-up. Patients with incomplete resection (Simpson grades II-V) or with high histological grade (WHO grade III) had significantly higher recurrence rates. A complete resection achieves higher rates of tumor control, however, without nullifying the risk of recurrence. Moreover, "aggressive" tumor removal is associated with higher rates of venous complications and worsening of preexisting motor deficits.

How I do it: surgical clip reconstruction of a large, partially thrombosed, ruptured middle cerebral artery aneurysm.

BACKGROUND: Ruptured large and partially thrombosed aneurysms are challenging lesions to treat successfully. METHODS: We describe the surgical treatment of a large, ruptured partially thrombosed middle cerebral artery (MCA) aneurysm. Once the Sylvian fissure is dissected, temporary clips are placed, and the clot is evacuated with simple microsuction and ultrasonic aspiration. The aneurysm is then carefully clip reconstructed to avoid compromise of the parent vessels. CONCLUSION: In cases of surgical clipping of large, thrombosed aneurysms, it is important to be aware of a few, but critically important, pitfalls to ensure successful outcome.

Subdural hematoma from an acquired dural arteriovenous fistula following external ventricular drain placement for subarachnoid hemorrhage.

Objective: Intracranial dural arteriovenous fistulas represent pathological connections between dural arteries and dural veins, dural sinuses or meningeal veins in the absence of an intervening capillary bed. They are thought to be acquired secondary to trauma, surgery, sinus thrombosis, venous hypertension or arterial dysplasia. Methods: A 66-year-old Asian female presented with subarachnoid hemorrhage secondary to ruptured 2-mm saccular aneurysm of the left middle cerebral artery associated with fusiform dilatation. It was successfully treated with endovascular coiling. A right frontal external ventricular drain was also placed to treat her hydrocephalus. On post-bleed day 10, she became acutely unresponsive with a fixed and dilated right pupil. Head CT was obtained and revealed an acute right subdural hematoma which was emergently evacuated. Results: No obvious bleeders were identified during surgery. Patient improved and repeat catheter angiography a week later showed a new dural arteriovenous fistula fed by the anterior falcine artery and the middle meningeal artery to a cortical vein draining into the superior sagittal sinus. Conclusion: We hope that the present report will raise awareness to treating physicians to be cognizant of this unusual complication in their differential diagnosis when treating patients with an EVD in place.

Microvascular decompression with partial occipital condylectomy in a case of pediatric spasmodic torticollis.

Spasmodic torticollis is a rare, neurologic disorder that is caused by abnormal nerve compression of the 11th cranial nerve by blood vessels or bony protrusions. It is typically treated pharmacologically and, if necessary, with surgical intervention. We report a unique case of spasmodic torticollis in a 15-year-old female that involved abnormal compression of the left 11th cranial nerve (CN) by the left vertebral artery, displaced by a hypertrophic left occipital condyle. After treatment with Botox was unsuccessful, the patient was treated with microvascular decompression and occipital condylectomy that adequately relieved the abnormal compression of CN XI. Mild symptoms persisted, and the patient underwent a partial section of the sternocleidomastoid muscle 1 year later, after which torticollis symptoms resolved.

Surgical treatment of previously embolized craniocervical junction dural arteriovenous fistula.

Craniocervical junction dural arteriovenous fistulas (dAVFs) are rare vascular lesions with a potentially dangerous natural history due to the onset of neurological deficit secondary to intracranial hemorrhage or myelopathy due to venous congestion. Despite advances in endovascular techniques, many dAVFs located in this area continue to require surgical treatment as embolization is often not feasible or safe. In this video, the authors illustrate a patient with a symptomatic craniocervical junction dAVF who had undergone attempted Onyx embolization at another institution. Because of persistent filling of the fistula and worsening myelopathy after the previous attempt, the patient was referred to the authors' clinic for definitive surgical treatment. The video illustrates the typical location of the early draining vein in most craniocervical junction dAVFs immediately below the emergence of the vertebral artery from the dura. The patient underwent successful definitive clip ligation of the fistula, which was exposed through a lateral suboccipital craniotomy.The video can be found here: https://youtu.be/Bvg6VKLgwO0.

Nuances of carotid artery stenting under flow arrest with dual-balloon guide catheter.

Cerebral protection device utilization during carotid artery stenting (CAS) has been demonstrated to decrease the risk of perioperative stroke. The ProximAl Protection with the MO.MA Device During CaRotid Stenting (ARMOUR) Trial had the lowest event rates of any independently adjudicated study. In this video of two cases of severe carotid artery stenosis, the authors present the nuances of the CAS procedure utilizing a dual-balloon guide catheter device (MO.MA). This device has the benefit of being in place before the lesion is crossed with any device, being able to arrest flow while the atherosclerotic lesion is crossed, and aiding in protection from distal emboli and stroke.The video can be found here: https://youtu.be/0o8DlC1n6_M.

Unruptured intracranial aneurysms in patients over 80 years: natural history and management implications.

PURPOSE: Patients over the age of 80 years when diagnosed with an unruptured intracranial aneurysm (UIA) pose unique decision-making challenges due to shortened life-expectancy and increased risk of treatment. Thus, we investigated the risk of rupture and survival of a consecutive series of patients who were diagnosed with an UIA after the age of 80 years. METHODS: Data of consecutive patients with an UIA were reviewed, and patients were included in our study if they were first evaluated for a UIA by the senior author during their ninth decade of life. Outcomes were aneurysm rupture and overall survival after diagnosis. Survival was estimated from a Kaplan-Meier survival curve. Incidence of risk factors was compared to a population of patients less than 65 years who were seen by the senior author over the same time period. RESULTS: Eighty-three patients who were over 80 years when diagnosed with a UIA were included in this study. In our population, there is a risk of rupture of 3.2% per patient-year. One-, three-, and five-year survival rates for our population were estimated to be 92, 64, and 35%, respectively. When compared to patients under 65 years diagnosed with a UIA, "over 80" patients had a significantly higher incidence of hypertension, and a significantly lower incidence of smoking history and familial aneurysm history. CONCLUSIONS: In our study population, UIAs greater than 7 mm carry a non-negligible risk of rupture of 3.2% per patient-year, and further studies investigating the risk-to-benefit ratio of treatment in this population are warranted.

Surgical ligation of spinal dural arteriovenous fistula.

BACKGROUND: Spinal dural arteriovenous fistulas (SDAVFs) are abnormal arteriovenous shunts between a radicular artery and the radicular vein, located in the dorsal surface of the dura sleeve, which drains in a retrograde manner into the coronal venous plexus of the spinal cord without an interposed capillary network. This result is a venous hypertension that reduces spinal cord perfusion and leads to ischemia and edema. Spontaneous resolution is extremely rare and, once symptomatic, the typical course is further progression with increased neurological impairment. Therefore, once a fistula is diagnosed, treatment is recommended. METHOD: The fistula is placed at the level of intervertebral foramen and surgical ligation is performed through a laminectomy. After dural opening, the area is inspected, and the arterialized vein is identified and ligated. CONCLUSIONS: Laminectomy and arteriovenous fistula ligation is a safe and reliable approach for accessing and treating spinal dural arteriovenous fistulas.

Risk factors for growth of conservatively managed unruptured intracranial aneurysms.

PURPOSE: Unruptured intracranial aneurysms (UIAs) occur in 2-3% of the adult population, but, once discovered, do not always require treatment. Untreated patients are usually followed with serial imaging to identify interval growth. In this study, we assessed the risk and risk factors for growth in a homogenous series of patients with conservatively managed UIAs. METHODS: Data from consecutive patients without history of subarachnoid hemorrhage and a conservatively managed UIA were retrospectively reviewed and only patients with at least 2 years of radiological follow-up were included in our study. We evaluated patients for the incidence of UIA growth, as well as analyzed risk factors for UIA growth. RESULTS: In 349 patients and 385 conservatively managed UIAs with 2210 patient-years of radiological follow-up, the risk of growth was 2.9% per aneurysm-year. Size (diameter greater than 5 mm), location (basilar artery apex), and weight loss (decrease in BMI over follow-up period) were all significantly associated with increased risk of UIA growth. There was a greater risk of UIA growth during the first 3 years of follow-up (7.5% per aneurysm-year) compared to the remaining years (2.7% per aneurysm-year). CONCLUSIONS: Conservatively managed UIAs in patients without prior history of SAH have a 2.9% risk of growth per aneurysm-year. UIAs greater than 5 mm in diameter, those located at the basilar artery apex, or patients who experience a decrease in BMI are more likely to grow and warrant closer follow-up. The risk of aneurysm growth is increased in the few years after diagnosis and decreases afterward.

The paramedian supracerebellar infratentorial approach.

BACKGROUND: Lesions of the superior cerebellar surface, pineal region, lateral and dorsal midbrain and mesial temporal lobe are challenging to treat and often require neurosurgical intervention. METHODS: The paramedian variation of the supracerebellar infratentorial approach utilizes the downward slope of the cerebellum to facilitate exposure and the lower density of cerebellar bridging veins away from the midline decreases the need to sacrifice larger venous channels. We also discuss our experiences with the approach, and some of the drawbacks and nuances that we have encountered as it has evolved over the years. CONCLUSIONS: This approach is versatile and effective and the authors' surgical approach of choice for resecting these challenging lesions.

How I do it: surgical ligation of craniocervical junction dural AV fistulas.

BACKGROUND: Dural arteriovenous fistulas (DAVFs) of the craniocervical junction are uncommon vascular lesions, which often require surgical treatment even in the endovascular era. METHODS: Most commonly, the fistula is placed laterally, and surgical ligation is performed through a lateral suboccipital craniotomy. After dural opening, the area is inspected, and the arterialized vein is identified emerging from the dura, often adjacent to the entry point of the vertebral artery, and ligated. CONCLUSIONS: A far lateral craniotomy is the authors' preferred surgical approach for accessing and treating dural arteriovenous fistulas of the craniocervical junction that cannot be reached endovascularly.

"The GalaFLEX 'Empanada' for Direct to Implant Prepectoral Breast Reconstruction".

CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Differential preferences in breast aesthetics by self-identified demographics assessed on a national survey.

There is a paucity of literature examining how preferences differ amongst various demographic groups. This study aimed to assess how perceptions of the ideal breast differ between respondents stratified by self-identified demographic factors. A cohort of 25 patients from the senior surgeon's practice presenting for breast surgery was assembled. Pre-operative anteroposterior photographs of these patients were distributed via Qualtrics (Seattle, WA) to a large sample designed to be representative of the demographics of the United States. Survey questions aimed to measure respondents' impressions of 'breast attractiveness'. Respondents were asked to rate breasts on a Likert scale. Survey responses were analysed for differences in breast aesthetic preferences by sex, gender, sexual orientation, and race. Males rated all breasts higher on the Likert scale for attractiveness than females (2.8 vs 2.5, p < 0.001). Despite this discrepancy, ratings amongst male and female respondents were highly correlated with one another (R = 0.940; p < 0.0001). Considering sexual orientation, individuals attracted to women provided significantly higher attractiveness ratings to all breasts compared to individuals attracted to men only (2.8 vs 2.5, p < 0.001). White or Caucasian individuals ascribed significantly higher breast attractiveness ratings than Asian individuals (2.7 vs 2.2, p < 0.001), but not Black or African American individuals (2.7 vs 2.4, p = 0.23). Despite these racial discrepancies in mean breast attractiveness, ratings amongst the three groups were highly correlated. In a sample representative of the United States, a difference in breast aesthetic appraisal was observed by demographic factors. These findings merit further investigation to understand these trends and observations.

Correction: A Review of Medical Student First-Author Publications in Plastic Surgery.

[This corrects the article DOI: 10.7759/cureus.43025.].