Classification of Breast Implant Malposition.

BACKGROUND: Implant malposition is a well-recognized complication when using prosthetic implants in the breast for both reconstructive and aesthetic indications. However, to date, no objective classification system has been described. OBJECTIVES: This study presents a prospective trial of an objective and reproducible classification system for implant malposition formulated using retrospective data from a large cohort of patients with implant malposition. METHODS: The authors retrospectively analyzed the degree of medial/lateral and inferior/superior implant malposition relative to their optimal position within the breast footprint in a series of 189 breasts (n = 100 patients). An objective classification system for implant malposition was devised and then applied to a prospective cohort of 53 breasts in 28 patients with implant malposition. RESULTS: The degree of malposition in a single or combination of axes was categorised according to the distance from the ideal breast footprint and measured in centimeters (cms). The classification system incorporated the axis of malposition and distance to generate a treatment decision-making guide. Cases of Grade 1 malposition did not warrant surgical intervention, whilst surgical correction was warranted in all Grade 3 cases.In the combined patient cohort (n = 242 breasts, 128 patients), lateral, inferior, medial and superior displacement ranged between grades 1-3. There was no inter-observer variability in the grades assigned to nine out of ten patients in the prospective group. CONCLUSIONS: We have created a simple and reproducible classification system for implant malposition that allows surgeons to objectively record the extent of malposition, guides surgical decision-making and can be used to document the results of any intervention.

The British Association of Aesthetic Plastic Surgeons (BAAPS) Gluteal Fat Grafting Safety Review and Recommendations.

Superficial gluteal lipofilling is a fat grafting procedure performed to correct a trochanteric depression and buttock deflation. Brazilian butt lift (BBL) is a gluteal lipofilling procedure traditionally associated with exaggerated appearance and intramuscular fat transfer. The risk of mortality from fat embolism in BBL was previously reported as being 1:2500. The actual risk was later estimated to be nearer 1:15,000, which is similar to the mortality risk in abdominoplasty. There is increasing evidence regarding the safety of subcutaneous gluteal lipofilling. This has principally been related to new technologies, surgical techniques, and training being developed to avoid intramuscular injection of fat. The efficacy and benefits of intraoperative ultrasound for guiding the subcutaneous placement of fat and avoiding inadvertent deep lipofilling have been demonstrated. Other serious risks and complications must be considered in addition to mortality. These include hypothermia, sepsis, skin necrosis, and poor aesthetic results, as well as the much-publicized risk of fat embolism. Complications are better controlled and managed in strictly regulated healthcare settings. Patients seeking surgery at unregulated facilities or via medical tourism are deemed to be at higher risk of being exposed to these serious complications and/or inadequate subsequent management.

A Novel Application of the Hemostatic Net in Aesthetic Breast Surgery: A Preliminary Report.

BACKGROUND: Obtaining optimum breast aesthetics can be challenging in secondary aesthetic breast surgery, particularly with poor-quality skin, when downsizing implants, and in cases where patients will not accept additional mastopexy scars. Most techniques described in these cases rely on internal suturing and capsulorrhaphy, which can lack precision in tailoring the skin over the internal pocket. OBJECTIVES: The aim of this study was to present the authors' experience with utilizing the hemostatic net to help address a range of challenging breast cases in their practices. METHODS: A multicentre retrospective analysis of patients undergoing aesthetic and reconstructive breast surgery between 2019 and 2021 was conducted. A database was established to record patient demographics, indications for surgery, surgical technique, and complications. Following capsulorrhaphy, the hemostatic net was applied in as many rows as required with monofilament sutures and removed 3 to 7 days postoperatively. RESULTS: Twenty-four women (aged 23-67 years) underwent aesthetic or reconstructive breast surgery with the hemostatic net. This approach optimized stabilization of the inframammary fold and redraping of lax skin or irregularities in the skin envelope. At follow-up review, only 1 instance of the net failing to successfully redrape the skin was seen. CONCLUSIONS: The application of the hemostatic net is an option for patients who might otherwise require mastopexy but refuse to accept the scars. The technique has now been extended to primary cases where implant malposition or skin tailoring issues are anticipated, thus securing its place as a part of the surgical armamentarium.

Lower Pole Mastopexy-Augmentation: Indications and Applications.

BACKGROUND: Breast augmentation in primary or secondary patients with long lower pole lengths but appropriately sited nipples is at high risk of "bottoming out" following surgery. The lower pole mastopexy-augmentation (LPMA) was developed to correct long lower pole lengths or preempt bottoming out in breasts deemed at risk, avoiding the requirement for periareolar and vertical breast scar as well as minimizing the requirement for the utilization of synthetic mesh. OBJECTIVES: The goal of this short report was to analyze outcomes in patients who underwent the LPMA to determine its application and limitations. METHODS: The author reviewed 12 consecutive cases of both primary and secondary situations over a 6-year period. Cases were objectively assessed according to the relationship of the nipple to the point of maximal breast projection on lateral view as well as the upper to lower pole breast proportions. RESULTS: All cases provided good outcomes, with improvements in both the position of the nipple in relation to the point of maximal breast projection and with respect to the upper to lower pole breast ratios. CONCLUSION: LPMA is a useful addition to the armamentarium in dealing with complex situations in breast augmentation.

Safety of Large-Volume Liposuction in Aesthetic Surgery: A Systematic Review and Meta-Analysis.

BACKGROUND: Current literature clearly outlines the complication rates of liposuction in general; however, data specific to large-volume liposuction (LVL) remain unclear. OBJECTIVES: The authors aimed to synthesize the current evidence on the safety of LVL with this systematic review. METHODS: A comprehensive search in the MEDLINE, EMBASE, and CENTRAL databases was conducted for primary clinical studies reporting on safety or complications related to aesthetic LVL from 1946 to March 2020. The primary outcome measure was the incidence of surgical complication, and the secondary outcome measure was changes in metabolic profile. Meta-analyses were conducted to pool the estimated surgical complication incidence and metabolic changes. RESULTS: Twenty-three articles involving 3583 patients were included. The average aspirate volume was 7734.90 mL (95% CI = 5727.34 to 9742.45 mL). The pooled overall incidence of major surgical complications was 3.35% (95% CI = 1.07% to 6.84%). The most common major complication was blood loss requiring transfusion (2.89% [95% CI = 0.84% to 6.12%]) followed by pulmonary embolism (0.18% [95% CI = 0.06% to 0.33%]), hematoma (0.16% [95% CI = 0.05% to 0.32%]), necrotizing fasciitis (0.13% [95% CI = 0.04% to 0.29%]), and deep vein thrombosis (0.12% [95% CI = 0.03% to 0.27%]). No fat embolism or death was reported in the included studies. The pooled overall incidence of minor surgical complication was 11.62% (95% CI = 6.36% to 18.21%), with seroma being the most common minor complication (5.51% [95% CI = 2.69% to 9.27%]). Reductions in lipid profile, glucose profile, body weight, and hematocrit level were observed after LVL. CONCLUSIONS: The authors meta-analyzed and highlighted the complication rates specifically related to LVL in this study; however, the current data are limited by the lack of level 1 evidence.

Summary document on safety and recommendations on liposuction for lipoedema: Joint British association of aesthetic plastic surgeons (BAAPS)/British association of plastic reconstructive and aesthetic surgeons (BAPRAS) expert liposuction group.

Liposuction plays an important role as a surgical treatment option for lipoedema. This article serves to critically review the evidence in the literature, as well as explain the differences between the lipoedema population compared with the aesthetic surgery population undergoing liposuction. It is not a comprehensive text on lipoedema management but serves to guide surgeons. This guidance was produced on behalf of the British Association of Aesthetic Plastic Surgeons (BAAPS) and the British Association of Plastic Reconstructive and Aesthetic Surgeons (BAPRAS) by the expert liposuction group. The guidance is based on the evidence available in the literature, along with a specialist expert opinion on liposuction for lipoedema, to provide plastic surgeons with a consensus recommendation for surgical treatment. The aim is to identify best practice to maximise the safety of patients. This article summarises current practices and safety considerations and outlines recommendations covering various aspects of patient care.

Should we be analysing breast reduction specimens? A systematic analysis of over 1,000 consecutive cases.

BACKGROUND: Reduction mammoplasty (RM) continues to be popular. The reported incidence of occult breast carcinoma in these specimens varies between 0.05 and 1.8 %. Literature review reveals a wide discrepancy in study methodology, outcome measures, and even what is constituted as a "significant" result. We set out to identify RM patients at increased risk of occult significant pathological findings to engender a systematic improvement in efficiency of those specimens sent for histopathological examination. METHODS: A single-centre retrospective study of the pathology results for 1,388 consecutive RM patients was undertaken. Patients were divided into three groups according to indication for surgery: group 1, macromastia; group 2, developmental asymmetry; and group 3, symmetrising surgery after breast cancer reconstructive surgery. RESULTS: Nine cases of occult carcinoma were found among the 1,388 women (0.65 %), all in patients over 35 years of age. Forty percent of all patients were under 35 years old. Histopathological analysis of 59 % of patients revealed nonsignificant findings. Patients with a breast cancer history were 4.3 times more likely to have occult breast cancer. Patients under 30 years of age had a significantly higher chance of nonsignificant findings than those over 30 (relative risk = 2.5). CONCLUSIONS: Although the overall incidence of occult breast cancer in reduction mammaplasty patients remains low, specific subgroups with a higher risk are identified. It is recommended that histological analysis of specimens should be restricted to high-risk patients and those over 30 years of age as significant pathology is uncommon in younger patients. These results will promote health-care-related economic benefits and a reduction of the burden placed on histopathology departments. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article.

Summary document on safety and recommendations for aesthetic liposuction: Joint British Association of Aesthetic Plastic Surgeons (BAAPS)/British Association of Plastic Reconstructive and Aesthetic Surgeons (BAPRAS) expert liposuction group.

Liposuction is one of the commonest surgical aesthetic procedures performed worldwide. Despite being perceived to be a technically simple procedure, poor patient selection, sub-optimal technical execution or sub-optimal peri­operative management could lead to significant harm. This guidance was produced on behalf of the British Association of Aesthetic Plastic Surgeons (BAAPS) and British Association of Plastic Reconstructive and Aesthetic Surgeons (BAPRAS) by the expert liposuction group. The guidance is based on the evidence available in the literature along with specialist expert opinion in aesthetic liposuction to provide plastic surgeons with consensus recommendation. The aim is to identify best practice to maximise the safety of patients. This article summarises current practices and safety considerations and outlines recommendations covering various aspects of patient care.

A solution to the high-riding nipple-areola complex.

There are limited techniques described in the literature on how to lower the nipple-areola complex following surgery to the breast. We present a case of successful correction of a high-riding nipple using a Z-plasty technique with an 8-year follow-up in a breast reconstruction patient. The technique described may also be applicable to cases of high-riding nipples following aesthetic breast surgery such as reduction mammaplasty.

Refining trunk contouring with reverse abdominoplasty.

BACKGROUND: The reverse abdominoplasty is an effective technique for selected patients seeking treatment for upper abdominal tissue excess and laxity. Specifically, the procedure is particularly effective in patients who have previously undergone conventional abdominoplasty or liposuction and have residual upper abdominal contour problems. It is a versatile technique that may be combined with a number of adjunctive procedures, notably autologous breast augmentation with the excess upper abdominal tissue. METHODS: The authors reviewed their experience with the reverse abdominoplasty in a series of 14 consecutive patients who underwent surgery over a five-year period. Patient case notes, as well as and pre- and postoperative clinical photographs, were analyzed. Furthermore, patients were directly questioned to assess their surgical result. RESULTS: The mean age of the cohort was 56.6 years and the majority of patients had undergone previous abdominal or breast aesthetic surgery. A mean of 6 cm of upper abdominal tissue was excised, weighing a mean of 326 g. There were no major complications and only three patients had to undergo minor revisional surgery postoperatively. CONCLUSIONS: The authors present their surgical outcomes and discuss the indications, benefits, and lessons they have learned from their experience with this useful technique in relation to the published literature. The ideal candidate for this procedure appears to be a patient who is older, presents with excess upper abdominal skin, has had a previous conventional abdominoplasty, and who has existing inframammary scars.

Fascial suspension mastopexy combined with augmentation mammaplasty.

BACKGROUND: We have modified our technique of fascial suspension mastopexy to be used in combination with augmentation mammaplasty. This study aimed to assess the results of the combined procedure in our first consecutive 10 patients. The surgery aims to maximize long-term upper-pole fullness as well as optimal projection and shape in volume-depleted ptotic breasts. METHODS: A retrospective case notes review was carried out, with details of patient demographics, indications, operative detail, and postoperative assessment recorded. In addition, patients were directly questioned to gain their opinion of the procedure. RESULTS: Nineteen breasts were operated on in ten patients. On preoperative assessment two women (20%) had grade 3 ptosis and the rest had grade 2 (83%). The majority of women had had children and had breast-fed (70%). The mean follow-up period was 33 months (range = 4-55) and overall patient satisfaction was high despite six of the 10 patients undergoing minor scar revisions for dog-ears under local anesthetic and two undergoing implant exchange to correct minor asymmetries. There were no major postoperative complications in this series. All patients demonstrated good projection and upper-pole fullness at postoperative review. CONCLUSION: The combined technique of fascial suspension mastopexy and breast augmentation with implants is a safe and reliable method to correct ptosis in volume-depleted breasts. Patients should be counseled on the possible need for minor revisional procedures. Importantly, the technique achieves excellent upper-pole fullness and the projected and rejuvenated breast has an overall pleasing result.

Columella erosion secondary to nasal prongs in the neonate.

There is limited awareness of the risks of pressure necrosis to the columella when using nasal prongs in the neonate. Previous studies have found that signs of skin damage can occur rapidly-within days. This case report aims to illustrate a simple technique of prophylactically lowering the risk of septal injury (if prolonged use of nasal prongs is envisaged), as well as a way of conservatively treating already damaged skin areas. Routine daily skin inspections are also recommended.

nm23 as a prognostic marker in primary cutaneous melanoma: evaluation using tissue microarray in a patient group with long-term follow-up.

The accurate estimation of prognosis in patients with melanoma is of increasing importance with novel adjuvant therapies on the horizon. The current prediction of prognosis employs techniques involving sentinel lymph node biopsy, which carries an associated morbidity and is of little use in patients who develop direct distant metastases or direct in-transit metastases. New strategies or factors are therefore needed to improve the accuracy of determination of prognosis. nm23 is a putative metastasis suppressor; however, conflicting data exist as to its role in melanoma progression and its use as a potential prognostic marker. The purpose of this study was to use the technique of tissue microarray to study a cohort of melanoma patients with long-term follow-up data in order to ascertain its potential use as a prognostic marker. One hundred and twenty patients with primary cutaneous melanoma were included in the tissue microarray and a commercially available immunohistochemical marker for nm23 was used for protein detection. nm23 expression was strongly correlated with Clark's level (P<0.001), Breslow depth (P=0.002) and patient age (P=0.014). nm23 expression was significantly associated with a poor patient outcome (chi2=7.2219, P=0.0072). Further analysis revealed that the intensity of nm23 expression also correlated with patient outcome (chi2=11.3281, P=0.0035). However, on multivariate analysis, nm23 was shown not to be an independent marker of prognosis. The results of this study, when taken with the existing literature, suggest a role for nm23 in melanoma disease progression. However, its use as a prognostic marker in routine practice does not appear to be justified.

Validation of tissue microarray for the immunohistochemical profiling of melanoma.

Tissue microarray technology allows high throughput profiling of cancer specimens by immunohistochemical staining. Protein expression varies throughout tumour specimens resulting in heterogeneous staining patterns, which has led to doubts as to the accuracy of tissue microarray. In an effort to validate the use of tissue microarray for melanoma immunohistochemical investigation, a study was conducted comparing the concordance of MCAM staining between whole tumour specimens and tissue microarray core biopsies. Data on full tissue sections were compared with the results of one to four 0.6 mm core biopsies per tumour on a tissue array. It was revealed that concordance of tissue array core biopsies in quadruplicate compared with full-section analysis for the expression and intensity of expression of MCAM.

Lateralising paraumbilical medial row perforators: dangers and pitfalls in DIEP FLAP planning: a systematic review of 1116 DIEP flaps.

BACKGROUND: The DIEP flap remains the gold standard for autologous breast reconstruction. Recently, the 'perforasome concept' has advanced our understanding of DIEP flap physiology and planning. This study highlights a patient sub-population that produces anomalies to the perforasome hypothesis: those with paramedian, paraumbilical perforators. METHODS: Operation notes and pre-operative CT angiograms from 1116 consecutive DIEP flaps were reviewed retrospectively. Patients with paramedian, paraumbilical perforators (n = 153) were contrasted against a control group whose perforators were not paraumbilical (n = 963). Further sub-group analysis was performed within the study group, comparing paraumbilical perforators that held a lateral course within the flap (n = 25) versus those that held a medial course (n = 128). RESULTS: Rates of post-operative DIEP flap partial necrosis was greater in the study population compared with the control group (6.54% vs. 3% p = 0.032). When analysis was made contrasting paraumbilical perforators that held a lateral course in the flap versus perforators that held a median course, flap necrosis was significantly greater in those with a lateral course (24% vs. 3.13%). CONCLUSION: The perforasome concept has improved our understanding of perfusion from perforators in DIEP flaps. However when the umbilicus presents a physical barrier to blood vessel passage resulting in lateralizing paraumbilical medial row perforators it appears an exception to the "perforasome" rule. Our experience suggests that when a paraumbilical perforator is harvested, a hemi-flap is safe but caution should be exercised when further volume is needed from the contralateral side.

The safety of autologous fat transfer in breast cancer: lessons from stem cell biology.

Autologous fat grafting is versatile tool in plastic surgery and is increasing used for reconstruction following breast conserving surgery for breast cancer. Part of the reconstructive qualities of the transferred fat may be due to the presence of adipose derived mesenchymal stem cells (ADMSC) playing an angiogenic and an adipogenic role. In this context it must be considered if autologously engrafted fat tissue could contribute to carcinogenesis following breast conserving surgery. In this article we review the current stem cell biology evidence on engraftment, transdifferentiation and potential carcinogenic contribution in the breast and other solid organ stem cell niches in an attempt to highlight possible areas of concern.