The Impact of Obesity on Success of Immediate Lymphatic Reconstruction for Prevention of Breast Cancer-Related Lymphedema.

BACKGROUND: Breast cancer-related lymphedema (BRCL) is a potential sequela of high-risk breast cancer treatment. Preventive treatment with immediate lymphatic reconstruction (ILR) at the time of axillary lymph node dissection (ALND) has emerged as the standard of care; however, there is relatively little known about factors that may contribute to procedural failure. METHODS: A retrospectively maintained, institutional review board-approved study followed patients who underwent ILR at the time of ALND at our tertiary care center between May 2018 and May 2023. Patients who presented for at least one follow-up visit in our multidisciplinary lymphedema clinic met the criteria for inclusion. Patients who developed lymphedema despite ILR and potential contributing factors were further explored. RESULTS: 349 patients underwent ILR at our institution between May 2018 and May 2023. 341 of these patients have presented for follow-up in our multidisciplinary lymphedema clinic. 32 (9.4%) patients developed lymphedema despite ILR. This cohort was significantly more likely to be obese (56% vs 35%, P = 0.04). Multivariate logistic regression demonstrates increased odds of procedural failure in patients with a body mass index (BMI) ≥30 kg/m2 (odds ratio 2.6 [1.2-5.5], P = 0.01). CONCLUSION: These data comment upon our institutions outcomes following ILR. Patients who develop lymphedema despite ILR tend to have a higher BMI, with a significantly increased risk in patients with a BMI of 30 or greater. Consideration of these data is critical for preprocedural counseling and may support a BMI cutoff when considering candidacy for ILR going forward, as well as when optimizing failures for secondary lymphedema procedures.

Immediate Lymphatic Reconstruction in 77 Consecutive Breast Cancer Patients: 2-year Follow-up.

BACKGROUND: Breast cancer-related lymphedema (BCRL) is a cyclical, progressive disease that begins at the time of axillary dissection and worsens in the setting of adjuvant oncologic therapies. The paradigm of lymphedema management in these patients is shifting from therapeutic surgeries and decongestive therapy to preventative surgery with immediate lymphatic reconstruction (ILR). METHODS: After institutional review board approval, a prospective database was maintained of all patients undergoing ILR. Patients were excluded if they had preoperative lymphedema or expired during the study period. All ILR were performed by the senior author. A control group was established with standardized physician delivered phone surveys of patients who had axillary dissection for breast cancer (same oncologic surgeon cohort) prior to the implementation of ILR at the same institution. The study and control groups were matched based on history of adjuvant radiation and body mass index. RESULTS: A cohort of patients between 2016 and 2019 with 2 years of follow-up after undergoing ILR (77 patients) were matched with those who did not undergo lymphatic reconstruction (94 patients). The incidence of lymphedema in the study group undergoing ILR was 10% (N = 8). In comparison, the incidence in the cohort who did not undergo lymphatic reconstruction was 38% (N = 36; p < 0.01). Patients with ILR had 92% lower odds of developing lymphedema (p < 0.01). CONCLUSION: ILR can significantly reduce the risk of developing BRCL in high-risk patients at 2 years of follow-up. Patients receiving adjuvant radiation therapy are more likely to develop BCRL after ILR compared with those who do not. Ongoing studies include investigation aimed at identifying patients most at risk for the development of BRCL to help target intervention as well as elucidate factors that contribute to the success of ILR.

The Use of Acellular Tissue Matrices in Gender-Affirming Surgery: Review of the Literature and Institutional Experience.

Wound healing complications are not uncommon after genital gender-affirming surgery and can pose significant challenges for the reconstructive surgeon. Acellular tissue matrices are products that contain extracellular matrix compounds without living cells and are used to expedite and improve wound healing. Some of these products have been described for a variety of different indications in gender-affirming surgery.  In this paper, the authors present a review of the current literature on the use of acellular tissue matrices in gender-affirming surgery as well as the authors' institutional experience in using these products.

Reliable Location of Upper Extremity Lymphatic Channels for Use in Immediate Lymphatic Reconstruction.

BACKGROUND: Breast cancer-related lymphedema (BCRL) is a limiting sequelae of breast cancer treatment that may negatively impact 30% to 50% of high-risk breast cancer survivors. Risk factors for development of BCRL include axillary lymph node dissection (ALND), and recently, axillary reverse lymphatic mapping and immediate lymphovenous reconstruction (ILR) at time of ALND have been implemented to prevent BCRL. Reliable anatomy of neighboring venules has been commented on in the literature; however, little information exists about anatomical location of local lymphatic channels amenable for bypass. METHODS: After institutional review board approval, patients who underwent ALND with axillary reverse lymphatic mapping and ILR at a tertiary cancer center from November 2021 to August 2022 were applicable for this study. The location and number of lymphatic channels used for ILR were identified and measured intraoperatively with the arm abducted to 90 degrees and soft tissue under no tension. Four measurements were taken to localize each lymphatic and were based on relationship with reliable anatomic landmarks including 4th rib, anterior axillary line, and lower border of the pectoralis major muscle. Demographics, oncologic treatments, intraoperative factors, and outcomes were prospectively maintained. RESULTS: Twenty-seven patients met inclusion for this study by August 2022 with a total of 86 lymphatic channels identified. Patients were on average 50 ± 12 years old with a body mass index of 30 ± 6 and had an average of 1 vein and 3 identifiable lymphatic channels amenable to bypass. Seventy percent of lymphatic channels were found in a cluster of 2 or more channels. The average horizontal location was 4.5 ± 1.4 cm lateral to the 4th rib. The average vertical location was 1.3 ± 0.9 cm from the superior border of the 4th rib. CONCLUSIONS: These data comment upon intraoperatively identified and consistent location of upper extremity lymphatic channels used for ILR. These lymphatic channels are often found in clusters with 2 or more lymphatic channels at the same location. Such insight may aid in easier intraoperative identification of amenable vessels for the unexperienced surgeon, decrease in intraoperative time, and higher success of ILR.

Gender Facial Affirmation Surgery: Cheek Augmentation.

Cheek augmentation is frequently used in facial feminization surgery. Options for augmentation include both surgical and nonsurgical techniques, such as autologous and non-autologous injections, implants, and osteotomies. Cheek augmentation can be combined with other facial procedures. Complications of cheek augmentation include malposition, resorption, asymmetry, and unfavorable cosmetic results. Cheek augmentation should be considered as part of an overall facial feminizing plan.

Efficacy of Immediate Lymphatic Reconstruction in Prevention of Breast Cancer-Related Lymphedema.

INTRODUCTION: Breast cancer-related lymphedema (BCRL) is a chronic condition that can negatively affect the quality of life of breast cancer survivors. Immediate lymphatic reconstruction (ILR) at the time of axillary lymph node dissection is emerging as a technique for the prevention of BCRL. This study compared the incidence of BRCL in patients who received ILR and those who were not amenable to ILR. METHODS: Patients were identified through a prospectively maintained database between 2016 and 2021. Some patients were deemed nonamenable to ILR due to a lack of visualized lymphatics or anatomic variability (eg, spatial relationships or size discrepancies). Descriptive statistics, independent t test, and Pearson χ 2 test were used. Multivariable logistic regression models were created to assess the association between lymphedema and ILR. A loose age-matched subsample was created for subanalysis. RESULTS: Two hundred eighty-one patients were included in this study (252 patients who underwent ILR and 29 patients who did not). The patients had a mean age of 53 ± 12 years and body mass index of 28.6 ± 6.8 kg/m 2 . The incidence of developing lymphedema in patients with ILR was 4.8% compared with 24.1% in patients who underwent attempted ILR without lymphatic reconstruction ( P = 0.001). Patients who did not undergo ILR had significantly higher odds of developing lymphedema compared with those who had ILR (odds ratio, 10.7 [3.2-36.3], P < 0.001; matched OR, 14.2 [2.6-77.9], P < 0.001). CONCLUSIONS: Our study showed that ILR was associated with lower rates of BCRL. Further studies are needed to determine which factors place patients at highest risk of developing BCRL.

Wound healing complications in gender-affirming surgery.

AIMS: Gender-affirming surgery consists of a group of surgical procedures for patients presenting with gender incongruence. Patients may seek treatment of anatomic areas including the face, chest, breast, and genitalia. The aim of this scoping review is to provide a general understanding of wound healing to optimize outcomes and manage complications. METHODS: A scoping review was performed to include wound healing principles, outcomes related to gender-affirming surgery, and management of postsurgical wounds. RESULTS: Based on the review performed and clinical experience, strategies to manage complications are recommended. These include an understanding of wound healing principles, patient optimization, and postoperative management. CONCLUSIONS: A comprehensive understanding of wound healing principles, perioperative optimization, and postoperative management of wounds assists the provider in mitigating and managing complications.

Relationship of Adjuvant Radiation and the Lymphedema Index: A Valuable Trend to Follow Subclinical Lymphedema in Patients After Immediate Lymphatic Reconstruction.

BACKGROUND: Immediate lymphaticovenular bypass (immediate lymphatic reconstruction [ILR]) at the time of axillary lymph node dissection has emerged as a preventative paradigm to decrease the incidence of breast cancer-related lymphedema in high-risk patients. These patients are often treated with adjuvant therapies, including radiation. Bioimpedance spectroscopy is a validated tool for trending breast cancer-related lymphedema and identifying subclinical disease. Lymphedema Index (LDEX) values are commonly obtained in ILR patients; however, postoperative trends and relationships with adjuvant treatments are yet to be reported in the literature. METHODS: After International Review Board approval, 100 consecutive patients underwent axillary lymph node dissection with axillary reverse lymphatic mapping and ILR at a tertiary cancer center. These patients were then followed prospectively in a multidisciplinary lymphedema clinic at 3-month intervals with clinical examination, circumferential limb girth measurements and bioimpedance spectroscopy (LDEX). RESULTS: Seventy-two patients met inclusion for analysis at 3 months, 60 at 6 months, 51 at 9 months, 45 at 12 months, 41 at 15 months, and 22 at 18 months. A majority of the patients included underwent adjuvant radiation. Average LDEX score for patients who developed lymphedema was 3.02 at 3 months, at 29.1 months, 17.8 at 9 months, 15.05 at 12 months, 18.75 at 15 months, and 7.7 at 18 months. Patients who went on to develop lymphedema had a higher LDEX score at 6 months (29.1 vs 3.20, P = 0.1329), which reached a significant difference beginning at 9 months (17.8 vs 3.19, P = 0.0004). All patients who went on to develop lymphedema received adjuvant radiation. CONCLUSIONS: These data provide valuable insight guiding follow-up after ILR. Six-month LDEX is much higher in patients who developed lymphedema, all of which underwent adjuvant radiation therapy, which correlates with the time of completion of their treatment. Average LDEX value after this remains significantly higher in this population. Patients who demonstrate this increase in LDEX and received adjuvant radiation are at highest risk to develop lymphedema despite ILR. All patients who developed lymphedema despite ILR had adjuvant radiation, and this is likely a contributing factor. Injury from adjuvant radiation and its impact after ILR is not insignificant and warrants further studies.

Reverse Lymphatic Mapping and Immediate Microsurgical Lymphatic Reconstruction Reduces Early Risk of Breast Cancer-Related Lymphedema.

BACKGROUND: Breast cancer-related lymphedema is a progressive disease that poses tremendous physical, psychosocial, and financial burden on patients. Immediate lymphaticovenular anastomosis at the time of axillary lymph node dissection is emerging as a potential therapeutic paradigm to decrease the incidence of breast cancer-related lymphedema in high-risk patients. METHODS: Eighty-one consecutive patients underwent reverse lymphatic mapping and, when feasible, supermicrosurgical immediate lymphaticovenular anastomosis at the time of axillary lymph node dissection at a tertiary care cancer center. Patients were followed prospectively in a multidisciplinary lymphedema clinic (plastic surgery, certified lymphatic therapy, dietary, case management) at 3-month intervals with clinical examination, circumferential limb girth measurements, and bioimpedance spectroscopy. An institutional control cohort was assessed for the presence of objectively diagnosed and treated breast cancer-related lymphedema. Data were analyzed by a university statistician. RESULTS: Seventy-eight patients met inclusion, and 66 underwent immediate lymphaticovenular anastomosis. Mean follow-up was 250 days. When compared to a retrospective control group, the rate of lymphedema in patients who underwent immediate lymphaticovenular anastomosis was significantly lower (6 percent versus 44 percent; p < 0.0001). Patients with 6-month follow-up treated with combined adjuvant radiation therapy and chemotherapy had significantly greater risk of developing breast cancer-related lymphedema (p = 0.04) compared to those without combined adjuvant therapy. Arborized anastomotic technique had a statistically shorter operative time than end-to-end anastomosis (p = 0.005). CONCLUSIONS: This series of consecutive patients demonstrate a 6 percent incidence of early-onset breast cancer-related lymphedema with immediate lymphaticovenular anastomosis and an increased risk in those undergoing combined adjuvant treatment. These early data represent an encouraging and substantial decrease of breast cancer-related lymphedema in high-risk patients. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

The Learning Curve: Trends in the First 100 Immediate Lymphatic Reconstructions Performed at a Single Institution.

BACKGROUND: Cancer-related lymphedema will affect 10% to 50% of breast cancer survivors. Early data show that immediate lymphatic reconstruction may help prevent breast cancer lymphedema; however, the details have not been fully elucidated. The purpose of this study was to evaluate the cohort of our first 100 patients for trends in demographics, treatment, and technique. METHODS: At a tertiary care cancer center, high-risk breast cancer-related lymphedema patients underwent axillary reverse lymphatic mapping and immediate lymphatic reconstruction. After institutional review board approval, demographics, technique, and outcomes were recorded. The first 100 patients were analyzed to compare the differences between the first 50 versus the second 50 patient cohorts. RESULTS: Of the first 100 axillary reverse lymphatic mapping performed, there was a significant difference in neoadjuvant chemotherapy with 81% in the earlier cohort versus 98% in the later cohort (P = 0.01). An arborized technique was used more frequently in the second cohort (82% vs 54%, P = 0.01). The incidence of lymphedema was lower in the latter cohort (7 patients vs 1 patient, P = 0.03). The first cohort was 12.2 times more likely to develop lymphedema despite lymphatic reconstruction than the second cohort (P = 0.03). CONCLUSIONS: The data demonstrate multiple trends in the learning curve associated with immediate lymphatic reconstruction at a single institution including improvements in identifying and dissecting lymphatic structures, performing more anastomoses per patient, using the arborized technique more frequently, performing the operation with shorter operative times, and reducing the incidence of lymphedema.

The Ethical Triage and Management Guidelines of the Entrapped and Mangled Extremity in Resource Scarce Environments: A Systematic Literature Review.

OBJECTIVE: A systematic literature review (SLR) was performed to elucidate the current triage and treatment of an entrapped or mangled extremity in resource scarce environments (RSEs). METHODS: A lead researcher followed the search strategy following inclusion and exclusion criteria. A first reviewer (FR) was randomly assigned sources. One of the 2 lead researchers was the second reviewer (SR). Each determined the level of evidence (LOE) and quality of evidence (QE) from each source. Any differing opinions between the FR and SR were discussed between them, and if differing opinions remained, then a third reviewer (the other lead researcher) discussed the article until a consensus was reached. The final opinion of each article was entered for analysis. RESULTS: Fifty-eight (58) articles were entered into the final study. There was 1 study determined to be LOE 1, 29 LOE 2, and 28 LOE 3, with 15 determined to achieve QE 1, 37 QE 2, and 6 QE 3. CONCLUSION: This SLR showed that there is a lack of studies producing strong evidence to support the triage and treatment of the mangled extremity in RSE. Therefore, a Delphi process is suggested to adapt and modify current civilian and military triage and treatment guidelines to the RSE.

Millennial-Assisted Liposuction: The Next-Generation/Future Technique.

Over the past 6 decades through innovation, creativity, ingenuity, and hard work, liposuction is now one of the most popular cosmetic procedures around the world. Several different liposuction technologies now exist, which include suction-assisted lipectomy, power-assisted liposuction, and so on. We have devised a new technique geared toward the incoming Generation Y surgeon called millennial-assisted liposuction. With such great advances in current liposuction techniques, one might ponder the need to introduce a new technique. This may become more common as the "Me Generation" sets forth in the working community and takes over for the prior generation of plastic surgeons. This article was written and developed by a millennial and the senior author, a nonmillennial, to help conform to the changing dynamic of incoming plastic surgeons. The technique was developed to solve the problem regarding millennials requiring constant reinforcement, around-the-clock assistance, immediate feedback, work-hour limits, frequent breaks, and lack of trophies.

Bilobed Gracilis Flap: A Novel Alternative for Pelvic and Perineal Reconstruction.

Perineal reconstruction historically has been guided by the vertical rectus abdominis myocutaneous flap. In oncologic patients, because of prior surgical intervention, this donor site is often unavailable, the pelvis has been irradiated, and defects can be deep or irregularly contoured. Using plastic surgery principles of perforators, geometrically defined local tissue rearrangement, and flap inset, the authors have developed a modification of the gracilis flap to include a second soft-tissue arm similar to a bilobed flap. The authors performed five bilobed gracilis/medial circumflex femoral vascular pedicle myocutaneous flaps for perineal reconstruction secondary to oncologic defects and one secondary to Fournier gangrene at a tertiary care center. Oncologic patients had undergone adjuvant chemotherapy and radiation therapy and had compromised abdominal donor sites. Given their results, the authors recommend that a bilobed gracilis flap be used in patients with moderate to large defects, defects that require ample soft-tissue bulk, or in patients with limited abdominal donor sites. CLINICAL QUESTION/LEVEL OF EVIDENCE:: Therapeutic, IV.

Deconstructing a Leader: An In-Depth Analysis of the Commonalities between Plastic Surgery Chiefs and Chairmen.

BACKGROUND: The authors sought to identify factors associated with current chiefs and chairpersons in academic plastic surgery to encourage and shape future leaders of tomorrow. METHODS: Academic chairpersons in plastic surgery (n = 94) were identified through an Internet-based search of all Accreditation Council for Graduate Medical Education-accredited residency training programs during the year 2015. Sex, ethnicity, academic rank, board certification, time since certification, medical school attended, residency program attended, fellowships training, advanced degrees, obtaining leadership roles at trainee's institution, and h-index were analyzed. RESULTS: Of the 94 chiefs and chairpersons, 96 percent were male and 81 percent obtained full professor status, and 98 percent were certified by the American Board of Plastic Surgery. Mean time since certification was 22 years (range, 7 to 45 years). Fifty-one percent graduated from 20 medical schools, whereas 42 percent graduated from only nine plastic surgery training programs. Fifty-six percent had pursued fellowship beyond their primary plastic surgery training. Eighteen percent had obtained advanced degrees. Twenty-nine percent of chiefs and chairpersons obtained leadership roles at the institution where they had completed plastic surgery training. The mean h-index was 17.6 (range, 1 to 63). Graduates of the nine most represented residency programs had a mean h-index of 21 versus 15 when compared with the remaining chief/chairpersons (p < 0.0062). CONCLUSION: Leaders in plastic surgery are more likely to be male, hold academic rank of professor, and have completed a fellowship after residency.

Digital-Facial Translocation in Amniotic Band Sequence: Evidence of the Intrinsic Theory.

Amniotic band sequence is a complex congenital anomaly in which infants with typically no known genetic mutation have bands of maternal amniotic tissue wrapped around body parts, most commonly the limbs and digits. The authors report a novel variation on this presentation in 3 patients from 2 centers with complex craniofacial clefting and amniotic band sequence. They presented with hypertelorism, different forms of complex craniofacial clefting, and bands connecting ipsilateral hands to facial clefts, with digital-facial translocation in 2 cases. These findings support a model in which complex craniofacial clefts result in areas of exposed, sticky, and temporally and spatially coincident mesenchyme within the embryo that are susceptible to adherence of ipsilateral fetal hands. This strongly supports the intrinsic and adhesion theories of the etiology of amniotic band syndrome.

Ketorolac and Hematoma Incidence in Postmastectomy Implant-Based Breast Reconstruction.

BACKGROUND: Ketorolac tromethamine (Toradol) is an effective a nonsteroidal anti-inflammatory drug and a powerful analgesic for patients undergoing breast surgery. However, the potential for postoperative bleeding has not yet been explored specifically in women undergoing implant-based breast reconstruction. There is concern that an increased risk of bleeding exists in this population due to the lack of tissue apposition as a result of implant placement. We therefore seek to assess the associated risk of bleeding complication in implant-based breast reconstruction at our academic institution. To the best of our knowledge, this represents the first case series addressing safety profile of Toradol specifically in patients undergoing nonautologous, implant-based breast reconstruction. METHODS/RESULTS: A single-center, retrospective review was performed analyzing our institutional experience with Toradol in nonautologous, implant-based breast reconstruction following mastectomy. A prospective database of 522 patients collected between 2008 and 2013 was analyzed. Within the database, 57 patients who received intraoperative ketorolac were identified among a total of 180 patients undergoing prosthetic reconstruction. No statistically significant difference was found in the incidence of clinically relevant hematoma formation between the control and Toradol groups. The frequency of hematoma formation in the control was 0.09 (11/123 patients, 95% confidence interval = 0.05-0.15) and 0.04 in the Toradol group (2/57 patients, 95% confidence interval = 0.01-0.12), resulting in a P value of 0.32. Regarding the secondary outcomes, we did not detect a statistically significant difference in the total number of complications or length of hospital stay in the Toradol and control groups. CONCLUSIONS: Review of our breast reconstruction database did not find a trend toward an elevated incidence of hematoma associated with intraoperative Toradol use in implant-based postmastectomy reconstruction.