The FALD-V: A predictive formula for preoperative volume assessment of adipose tissue transplantation in FALD flap.

BACKGROUND: The fat-augmented latissimus dorsi (FALD) flap is an evolution of the traditional latissimus dorsi (LD) flap, which allows to obtain a total autologous breast reconstruction (BR) avoiding the use of breast implants. The aim of this study was to develop a predictive preoperative formula in order to estimate and optimize the amount of fat to be transferred during FALD flap BR, using only anthropometric measurements. METHODS: We conducted a prospective clinical study between September 2020 and April 2023. All patients underwent back pre-operative ultrasound scan to assess the subcutaneous skin paddle thickness (SPT) and a regression analysis was performed to evaluate which anthropometric variable had a better correlation with this thickness. RESULTS: Data from 66 FALD flaps were collected. The mean SPT was 11.95 mm (SD 4.56). A significant correlation between SPT and body mass index (BMI) was found (r = 0.640, p < 0.0001). Using the fat-to-capacity ratio (113%), the following formula (the FALD-V) was developed to predict the needed fat transfer into FALD flap: [-509 + 12.32 × BMI + 11.71 × skin paddle width + 17.43 × skin paddle height] × 1.13. The considered variables (BMI, skin paddle width and skin paddle height) were statistically significant (p < 0.001, p = 0.0483, p = 0.0154, respectively). The cross-validation confirmed the accuracy of the formula (r = 0.810). CONCLUSION: The FALD-V can be used as an innovative complimentary device in the planning of FALD flap one-stage total autologous BR. To enhance its application, a 3.0 WebApp at www.braflap.com (and www.breast-v.com) is available free of charge for both iOS and Android devices. LEVEL OF EVIDENCE: II.

International consensus recommendations on face transplantation: A 2-step Delphi study.

Face transplantation is a viable reconstructive approach for severe craniofacial defects. Despite the evolution witnessed in the field, ethical aspects, clinical and psychosocial implications, public perception, and economic sustainability remain the subject of debate and unanswered questions. Furthermore, poor data reporting and sharing, the absence of standardized metrics for outcome evaluation, and the lack of consensus definitions of success and failure have hampered the development of a "transplantation culture" on a global scale. We completed a 2-round online modified Delphi process with 35 international face transplant stakeholders, including surgeons, clinicians, psychologists, psychiatrists, ethicists, policymakers, and researchers, with a representation of 10 of the 19 face transplant teams that had already performed the procedure and 73% of face transplants. Themes addressed included patient assessment and selection, indications, social support networks, clinical framework, surgical considerations, data on patient progress and outcomes, definitions of success and failure, public image and perception, and financial sustainability. The presented recommendations are the product of a shared commitment of face transplant teams to foster the development of face transplantation and are aimed at providing a gold standard of practice and policy.

The Ergonomic FALD Flap for One-stage Total Breast Reconstruction.

Background: The fat-augmented latissimus dorsi (FALD) flap combines this pedicled flap with immediate intraoperative fat transfer. Very little is described concerning its inset at the mammary site. Our efforts have concentrated on seeking the best flap orientation and skin-adipose paddle shaping, to improve the aesthetic outcome and to obtain a complete breast reconstruction (BR) in one stage. Methods: A prospective clinical study was performed in patients who underwent BR with FALD flaps, between December 2020 and March 2022. Patients were randomly enrolled into two groups: ergonomic inset of the FALD flap with vertical orientation of the skin-adipose paddle (group A) and FALD flap with traditional horizontal paddle orientation (group B). The study's endpoints were the evaluation of the aesthetic outcomes (from patients' and surgeon's perspectives) and complications. Results: Thirty-two FALD flaps (23 patients) were performed for group A, and 31 FALD flaps (25 patients) for group B. The two groups were homogeneous in terms of demographic and surgical data (P > 0.05). The overall complication rate was homogeneous among the groups, without statistically significant differences (P = 1.00). The surgeon's assessments showed a statistically significant superior aesthetic outcome in group A regarding volume, symmetry, and shape (P < 0.05). Higher satisfaction was observed in group A patients, in terms of breast size (P < 0.00001), shape (P = 0.0049), and overall satisfaction (P = 0.00061). Conclusions: The ergonomic vertical FALD flap technique enables surgeons to perform one-stage total BR, with excellent breast projection and upper pole fullness. These refinements in flap shaping and molding reduced the need for further autologous fat transfer, obtaining a brilliant totally autologous BR without the need for microsurgical experience.

Narrow inferior-central septum-based pedicle: A safe technique to improve aesthetic outcomes in breast reduction.

BACKGROUND: Inferior-central pedicle has some aesthetic drawbacks, including hypertrophic scar along the inframammary fold (IMF), squaring of the breast contours, and propensity to develop long-term 'bottoming-out.' This study aimed to verify if the narrow inferior-central (NIC) septum-based pedicle can allow the surgeon to improve aesthetic outcomes compared with the traditional inferior-central pedicle approach. METHODS: Forty breasts underwent NIC-based breast reduction (group A), and 37 underwent traditional inferior-central pedicles (group B). The NIC pedicle was drawn with a width of 3.5-4.5 cm. The recorded measurements were sternal notch to nipple distance (S-N) and nipple to IMF distance (N-IMF) at the time of preoperative markings and follow-up 1, 6, and 18 months after the procedure. RESULTS: The two groups were homogeneous regarding demographics, operative data, and preoperative S-N and N-IMF distances. Both groups showed no total or partial nipple-areola necrosis. At the 18-month follow-up, S-N (p < 0.00001) and N-IMF (p = 0.00039) distances were statistically different between the two groups, in favour of NIC group A. Changes in N-IMF distances between the 1- and 18-month visits were statistically different among groups (p < 0.0001), with a length variation of + 17.51% and + 28.46%, respectively. Patient satisfaction rate regarding "breast shape" (p = 0.021), "lower pole appearance" (p = 0.00017), and "scar" (p = 0.047) were higher in group A. CONCLUSION: NIC-based pedicle proved to be a safe procedure and allowed us to overcome limitations that typically characterise the inferior pedicle, i.e., 'bottoming-out' deformity, hypertrophic scar of the lower pole, and squaring of the breast contours. LEVEL OF EVIDENCE: II.

Fat-Augmented Latissimus Dorsi Flap for Secondary Breast Reconstruction in Small to Medium-Sized Irradiated Breasts.

BACKGROUND: Secondary breast reconstruction (BR) is recognized as a challenging procedure, particularly when radiotherapy (RT) has previously been performed. The aim of this study was to compare operative data and aesthetic outcomes between secondary irradiated and immediate BR using the fat-augmented latissimus dorsi (FALD) flap. METHODS: The authors conducted a prospective clinical study between September of 2020 and September of 2021. Patients were divided into two groups: group A included secondary BR using the FALD flap in previously irradiated breasts, and group B included immediate BR with the FALD flap. Demographics and surgical data were compared, and an aesthetic analysis was performed. Chi-square and t tests were performed for categorical and continuous variables, respectively. RESULTS: Twenty cases of FALD flap-based BR for each group were included. The two groups were found to be homogeneous for the demographic variables. The difference in mean operative time (263.1 minutes versus 265.1 minutes; P = 0.467) and complications ( P = 0.633) between the two groups were not significant. There was statistically significant difference in term of immediate fat grafting volume in favor of group A (218.2 cc versus 133.0 cc; P < 0.0001). Regarding aesthetic outcomes, the mean global score evaluation showed no statistically significant differences between groups (17.86 versus 18.21; P = 0.209). CONCLUSIONS: The authors' study states that the FALD flap can be considered a reliable procedure for secondary reconstruction in previously irradiated breasts, although it is not indicated for patients with larger breasts. This surgical technique allowed us to achieve a totally autologous BR with good aesthetic results and low complication rates, even in secondary irradiated cases. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Free-style technique versus computed tomographic angiography-guided perforator selection in deep inferior epigastric perforator flap harvest: A prospective clinical study.

BACKGROUND: Computed tomographic angiography (CTA) is the preferred diagnostic tool in preoperative deep inferior epigastric perforator (DIEP) flap assessment, though some surgeons prefer approaching perforator selection with intraoperative findings alone. METHODS: This prospective observational study conducted between 2015 and 2020 assessed our intraoperative decision-making "free-style" technique for DIEP flap harvest. Any patient with indication for immediate or delayed breast reconstruction using abdominally based flaps and who received preoperative CTA was enrolled. Only unilateral cases performed by the same surgeon were considered. Allergy to iodine-based contrast media, renal impairment and claustrophobia were other exclusion criteria. Primary endpoint consisted in comparing operative times and complication rates between free-style technique and CTA-guided approach. Secondary endpoints included evaluation of agreement rate between intraoperative findings and CTA, and identification of variables affecting operative time and complication rate. Demographics, surgical information, agreement versus non-agreement and complications were collected. RESULTS: Starting from 206 patients, 100 were enrolled. Fifty were assigned to Group A, receiving DIEP flap with free-style technique. The other 50 were assigned to Group B, receiving DIEP flap with CTA-guided perforators selection. Study groups' demographics were homogenous. Operative time was statistically lower (p = .036) in free-style group (252.4 ± 44.77 min vs. 265.6 ± 31.67 min). Complication rates were higher in CTA-guided group (10% vs. 2%) though this was not significant (p = .092). Overall agreement rate in dominant perforator selection between intraoperatively and CTA-based assessment was 81%. Multiple regression analysis showed no variable increased complication rate, though CTA-guided approach, BMI > 30 and harvesting more than one perforator were respectively associated with B-coefficient of 17.391 (2.430-32.351, 95% CI) [p = .023], 3.50 (0.640-6.379, 95% CI) [p = .017] and 18.887 (6.232-31.542, 95% CI) [p = .004], predicting increased operative time. CONCLUSIONS: The free-style technique proved to be a useful tool for guiding DIEP flap harvest with good sensibility in detecting the dominant perforator suggested by CTA without statistically increasing surgery duration and complications.

Determining Breast Implant Prevalence: A Population Study of Italian Chest Radiographs.

BACKGROUND: Current breast implant prevalence within the general population remains elusive. An accurate prevalence is critical to serve as the denominator for any assessment of breast implant-related complication. The purpose of this manuscript is to assess this prevalence in women aged 20-70 years in Italy. MATERIALS AND METHODS: Eight reviewers, demonstrating a mean sensitivity of 87.0% and specificity of 97.0%, were recruited for retrospective identification of implants on chest radiographs from a tertiary academic hospital in a major urban setting. Three final reviewers were selected, and they assessed all eligible chest radiographs collected between January and December 2019. The hospital-based population was compared to epidemiological data at a local, regional and national level to demonstrate homogeneity of age structures using the phi correlation coefficient. RESULTS: We identified 3,448 chest X-rays which yielded 140 implants, with an overall prevalence of 4.1% for women aged 20-70. Implants were bilateral in 76% of cases and unilateral in 24%. They were placed cosmetically in 47.1% cases and used for reconstruction in 52.9% cases. Phi correlation coefficient found no differences across hospital-based, local, regional and national populations. CONCLUSION: A validated method was performed to estimate implant prevalence from an academic hospital in a major urban setting at 4.1% and was used to estimate national prevalence in Italy. The implications of this epidemiologic study may reach across national borders for improved understanding of breast implant epidemiology and in predicting the total number of patients within a given population that may be affected by device complications. 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 .

Clinical recommendations for diagnosis and treatment according to current updated knowledge on BIA-ALCL.

Shared strategies and correct information are essential to guide physicians in the management of such an uncommon disease as Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL). A systematic review of the literature was performed to collect the most relevant evidence on BIA-ALCL reported cases. A panel of multidisciplinary experts discussed the scientific evidence on BIA-ALCL, and updated consensus recommendations were developed through the Delphi process. The lastest reported Italian incidence of BIA-ALCL is 3.5 per 100.000 implanted patients (95% CI, 1.36 to 5.78), and the disease counts over 1216 cases worldwide as of June 2022. The most common presentation symptom is a late onset seroma followed by a palpable breast mass. In the event of a suspicious case, ultrasound-guided fine-needle aspiration should be the first step in evaluation, followed by cytologic and immunohistochemical examination. In patients with confirmed diagnosis of BIA-ALCL confined to the capsule, the en-bloc capsulectomy should be performed, followed by immediate autologous reconstruction, while delayed reconstruction applies for disseminate disease or radically unresectable tumor. Nevertheless, a multidisciplinary team approach is essential for the correct management of this pathology.

The use of Fat-Augmented Latissimus Dorsi (FALD) flap for male Poland Syndrome correction: a case report.

We present a 23-year-old male patient with severe PS, characterized by marked left thoracic wall deformity. Reconstruction was performed using the Fat-Augmented Latissimus Dorsi flap, which was fixed to the chest wall hollowing corresponding to where the pectoralis major muscle was missing. Patient was satisfied with final aesthetic and functional result.

Oncologic Outcome of 1000 Postmastectomy Breast Reconstructions with Fat Transfer: A Single-Center, Matched Case-Control Study.

BACKGROUND: Autologous fat transfer has an important role in breast reconstructive surgery. Nevertheless, some concerns remain with regard to its oncologic safety. The authors present a single-center, case-matching study analyzing the impact of autologous fat transfer in the cumulative incidence of local recurrences. METHODS: From a prospectively maintained database, the authors identified 902 patients who underwent 1025 breast reconstructions from 2005 to 2017. Data regarding demographics, tumor characteristics, surgery details, and follow-up were collected. Exclusion criteria were patients with distant metastases at diagnosis, recurrent tumor, or incomplete data regarding primary tumor; and patients who underwent prophylactic mastectomies and breast-conserving operations. Statistical analysis was conducted to evaluate the impact of the variables on the incidence of local recurrence. A value of p < 0.05 was considered statistically significant. RESULTS: After 1: n case-matching, we selected 919 breasts, of which 425 patients (46.2 percent) received at least one autologous fat transfer session versus 494 control cases (53.8 percent). Local recurrences had an overall rate of 6.8 percent, and we found local recurrences in 14 autologous fat transfer cases (3.0 percent) and 54 controls (9.6 percent). Statistical analysis showed that autologous fat transfer did not increase the risk of local recurrences (hazard ratio, 0.337; CI, 0.173 to 0.658; p = 0.00007). Multivariate analysis identified invasive ductal carcinoma subtype and lymph node metastases to have an increased risk of local recurrences (hazard ratio >1). Conversely, positive hormonal receptor status was associated with a reduced risk of events (hazard ratio <1). CONCLUSIONS: Autologous fat transfer was not associated with a higher probability of locoregional recurrence in patients undergoing breast reconstruction; therefore, it can be safely used for total breast reconstruction or aesthetic refinements. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Total breast reconstruction with the fat-augmented latissimus dorsi (FALD) flap: High safety in a single-center uncontrolled case series.

According to ASPS, 107,238 breast reconstructions (BR) have been performed in the United States this year. The latissimus dorsi (LD) flap is used for breast reconstruction (BR), either with an implant or an extended flap harvest. Implant-enhanced LD is associated with 50% reoperation rates. To avoid implant-related complications, we introduced the Fat-Augmented LD (FALD) flap. Several authors report 92% patient satisfaction and 36% complication rates (CR). The aim of our study is to present a single-center uncontrolled case series with long follow-up assessing CR and esthetic results. Women with small-to-moderate breasts requiring immediate or delayed BR were included, whereas athletic and paraplegic women or patients with contraindication for free flap BR were excluded. Clinical and surgical data were analyzed. Esthetic analysis was performed using a panel of independent observers. Between December 2010 and November 2019, 100 patients underwent 148 FALD-based BR. Average operative time was 193.5 min for unilateral procedure and 290.6 min for bilateral procedure. Mean immediate AFT volume was 105.3 cc (range 60-170) per breast. Major complication (total or partial flap necrosis > 30%) rate was 0%, and minor complication (partial flap necrosis < 30%, fat necrosis hematoma, seroma, donor site dehiscence, and chronic pain) rate was 6.76%. Esthetic analysis garnered satisfactory results for all types of mastectomies. For variables regarding skin texture (p = 0.001), scar location (p = 0.005), and total score (p = 0.001), patients undergoing Modified Radical Mastectomy scored lower than Skin-Sparing Mastectomy and Nipple-Sparing Mastectomy. We were able to confirm that the FALD flap is a safe with a low complication rate and high patient satisfaction. Level of Evidence IV.

Long-Term Clinical and Aesthetic Results of a Systematic Fat Transfer Protocol for Total Breast Reconstruction after Nipple-Sparing Mastectomy.

BACKGROUND: Autologous fat transfer can be safely offered for total breast reconstruction after nipple-sparing mastectomy. The aim of this study was to extend a fat transfer protocol to smokers and compare the long-term results among them and irradiated and nonirradiated patients. METHODS: One hundred seventeen breasts after nipple-sparing mastectomy were prospectively enrolled and stratified in group A (25 irradiated), group B (21 smokers), or group C (71 controls). A standardized fat transfer protocol was used. Data collected were patient demographics, surgery information, and aesthetic analysis. Continuous and categorical variables were analyzed with the Kruskal-Wallis test, and the Cohen Kappa test was used to test interrater variability for the aesthetic analysis. RESULTS: Groups were homogeneous for demographics ( p > 0.05) but significantly different in number of fat transfer sessions ( p < 0.001), mean volume of the first two treatments ( p = 0.003), and mean total volume of injected fat ( p = 0.002). Volume, shape, position of the breast mound, inframammary fold, and scar location subscales obtained high score evaluations without a significant difference among groups ( p > 0.05), whereas skin texture subscale showed a lower score evaluation in group A ( p = 0.003). Although a significant difference for total subscales was worse in group A ( p = 0.004), the global score had a high rate evaluation in all groups ( p = 0.145). Interrater reliability showed substantial agreement among all categories. CONCLUSION: Although further investigation is required, the authors confirm the efficacy of their fat transfer protocol for both irradiated and nonirradiated nipple-sparing mastectomy patients and propose its indication to smokers with comparable clinical and aesthetic results. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Septum-Based Mammaplasties: Surgical Techniques and Evaluation of Nipple-Areola Sensibility.

BACKGROUND: The aim of the study was to describe details of surgical techniques and objectively evaluate nipple-areola (NAC) sensibility and viability of septum-based mammaplasties compared to not septum-based reduction techniques. METHODS: Data regarding NAC sensibility for static and moving one- and two-point discrimination were prospectively collected from 63 active group hypertrophic-breasted patients undergoing septum-based reduction mammaplasty preoperatively, at 6 and 12 months postoperatively, and from a control group of 60 patients who underwent not septum-based techniques. Fixed and mixed effect models were used for statistical analysis. RESULTS: Comparison of complications showed no significant differences between groups (p = 0.07). After adjusting the results of the active group according to type of sensory testing, it emerged that the threshold decreases by 10% (p = 0.0003) at 6 months and even reaches 43% (p < 0.0001) at 12 months. The results have been modulated according to age, since the variation is less marked when age increased, by 0.6% at 6 months and 0.8% at 12 months (p = 0.019). The effects of the BMI can only be seen at 12 months, with an increase by 1.3% per year (p = 0.033). Among septum-based techniques, the inferior-central pedicle showed better sensibility outcomes even if not significantly (p = 0.06). Comparison of NAC sensibility outcomes showed that active group had thresholds that were 48% lower when compared to those of the control group at 12 months postoperatively (p < 0.001). CONCLUSION: Septum-based mammaplasty gives optimal results in terms of NAC viability with a significant improvement of sensibility postoperatively. Comparative outcomes on sensibility were also significantly better than not septum-based techniques. LEVEL OF EVIDENCE II: 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.