Combination of Superior and Superomedial Pedicle Techniques in Reduction Mammaplasty: A Modified Approach to Increase Upper Pole Fullness.

OBJECTIVE: Creation of the upper pole fullness is one of the basic goals in reduction mammaplasty. The superior pedicle (S-P) technique brings extra tissue to the upper pole, but folding of a long pedicle can compromise circulation of the nipple-areola complex (NAC). Although the pedicle is not folded in superomedial pedicle (SM-P) technique, it has disadvantage of not bringing extra tissue to the upper pole. We designed a new approach by combining the advantages of S-P and SM-P techniques. Thereby, we aimed to increase upper pole fullness in SM-P or superolateral pedicle (SL-P) mammaplasty. METHOD: We operated 20 female patients (study group) with the modified SM-P/SL-P technique for breast reduction between 2010 and 2022. Preoperatively, mean sternal notch-nipple distance was 32.6 ± 2.5 cm. The upper pole fullness was created by using a superiorly based glandular flap, while the SM-P (17 patients) or SL-P (three patients) was used to carry the NAC. We assessed the success rate of the upper pole fullness, compared with two control groups of 40 patients who underwent conventional SM-P mammaplasty (control group I: 20 patients) and who underwent conventional S-P mammaplasty (control group II: 20 patients). Two plastic surgeons, who do not know which technique was used, assessed before and after photographs of 60 patients regarding success rate of upper pole fullness. To evaluate the success rate, the degree of the difference in the upper pole fullness between before and after photographs has been scored 1-10 for each patient. Below 5 was considered as no difference (unsuccessful), 5-7 as moderate difference (average), 8-10 as significant difference (successful). Photographs of the patients had been taken from five different angles: frontal, right and left oblique views, and right and left sides. RESULTS: Out of 10, mean score was 8.2 ± 1.2 in study group, 7.1 ± 1.8 in control group I, 8.2 ± 1.5 in control group II. Postoperatively, no major complications were observed, such as glandular necrosis, total NAC necrosis, partial (> 50%) NAC necrosis, skin necrosis, or poor NAC sensitivity in none of 60 patients. CONCLUSION: By using this modification, it is possible to increase upper pole fullness in SM-P/SL-P mammaplasty. 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 https://www.springer.com/00266 .

Superomedial Pedicle Technique and Management of Circulation Problems in Gigantomastia : Treatment of Gigantomastia.

Breast reduction surgeries encompass a wide range of methods that are continuously evolving to discover more reliable and satisfactory techniques. This presentation aims to address the research gap by sharing outcomes and experiences using the superomedial pedicle in gigantomastia, as well as the implemented protocol for managing nipple-areola complex (NAC) ischemia. The Wise pattern and superomedial pedicle reduction mammaplasty method were utilized in treating 19 patients (38 breasts). The average age of the patients was 41.47 years, with a basal mass index (BMI) of 33.27 kg/m2. The mean sternal notch to nipple (SN-N) length for the entire population was found to be 40.97 cm. On both sides, this length was statistically similar at 41.11 cm on the right side and 40.84 cm on the left side. The average weight of resected tissue from all patients was calculated to be 1793.42 g, with slightly higher weight on the right side at 1800 g compared to the left side's weight of 1786.84 g. Postoperative NAC ischemia occurred in three patients, one bilateral case, and two unilateral cases. The study revealed that in both the groups with and without NAC ischemia, the average values were as follows: age, which ranged from 45.33 to 40.75 years; BMI, ranging from 35.01 kg/m2 to 32.95 kg/m2; SN-N distance, which varied from 40 cm to 41.09 cm; and excision material weights, ranging from 1650 g to 1810.29 g. The p-value in the comparisons was found to be greater than 0.05. These results indicate that age, BMI, SN-N distance, and excision material weight did not have an impact on NAC vascularity issues. All NACs were successfully saved through a protocol involving hyperbaric oxygen therapy (HOT) and vacuum-assisted therapy (VAT). The study suggests that utilizing a superomedial flap is a viable option for treating gigantomastia and highlights the effectiveness of their outlined protocol in managing postoperative complications. While acknowledging the need for comparative studies, the study proposes incorporating HOT and VAT into protocols aimed at saving NACs.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 .

Correlation Between General Satisfaction with the Breasts and Appearance of the Scars in Patients Undergoing Inverted T-Scar Reduction Mammaplasty: A Prospective PROMs-Based Study.

BACKGROUND: Inverted-T scar reduction mammaplasty is still the most chosen technique for breast reduction even if scars are relevant. Sometimes, surgical scars may be esthetically unpleasant and may cause severe pain, tenderness, sleep disturbances, anxiety, and depression in these patients. This study aimed to assess any possible correlation between general satisfaction with the breast and appearance of the scars in patients who underwent inverted T-scar reduction mammaplasty. Secondary aim was to evaluate average variations of BREAST-Q and SCAR-Q at different postoperative times. MATERIALS AND METHODS: 121 patients who underwent breast reduction using Pitanguy technique with inferiorly based dermo-adipose flap according to Ribeiro were enrolled in this prospective cross-sectional study. All patients filled the BREAST-Q REDUCTION and SCAR-Q questionnaires in paper form at 1, 6 and 12 months after surgery. BREAST-Q REDUCTION "Satisfaction with breast" scale was also administered preoperatively. Values were exported in Prism 9 for the statistical analysis. RESULTS: Correlation index of Pearson between "Satisfaction with breast" and "Appearance of scar" was 0.09 at 1 month post-operative and - 0.07 and 0.21 at 6 and 12 months PO respectively. "Satisfaction with breast" mean value tends to rise over time. "Appearance of scar" mean value tends to decrease over time. CONCLUSION: No correlation at different postoperative times between the general satisfaction with the breast and appearance of the scars was found. Data showed that satisfaction with the breast and appearance of the scars in patients who underwent inverted T-scar reduction mammaplasty tend to improve over time. 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 .

Breastfeeding Ability After Breast Reductions: What does the Literature Tell us in 2023?

INTRODUCTION: Reduction mammaplasties are routinely performed on women of child-bearing age, yet there still exists some uncertainty regarding a patient's ability to breastfeed following the procedure. This is due to inconsistent definitions of "successful" breastfeeding, a variety of pedicles implemented, and inadequate follow-up in the published literature. Our aim was to summarize the current data and provide clear recommendations for counseling patients on expected breastfeeding outcomes following reduction mammaplasty. METHODS: A systematic review and meta-analysis in accordance with the PRISMA guidelines was conducted. We included papers that reported proportion of breastfeeding ability following reduction mammaplasty. RESULTS: We identified 33 papers that met our inclusion criteria. We found that women who undergo reduction mammaplasty are at a 3.5 times increased odds of not being able to breastfeed compared to controls. Overall, reduction mammaplasty patients have a breastfeeding success rate of 62%. The breastfeeding success rate for patients with inferior pedicles was 64%, superior pedicles was 59%, and lateral pedicles was 55%. No conclusions could be drawn regarding medial, central, vertical, and horizontal pedicles on breastfeeding ability. CONCLUSION: Current data suggest that women undergoing reduction mammaplasty have an increased odds of unsuccessful breastfeeding when compared to similar women who have not undergone the procedure. Based on the current literature, pedicle type does play a role in rate of breastfeeding success, although there is a need for further research on the aforementioned pedicles. Physicians should be aware of the likelihood of successful breastfeeding following reduction mammaplasty so that patients can be more thoroughly counseled prior to a decision for surgery. LEVEL OF EVIDENCE I: 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 .

Complications of Superomedial Versus Inferior Pedicle Reduction Mammaplasty: A Systematic Review and Meta-Analysis.

BACKGROUND: The superomedial pedicle reduction mammoplasty has gained popularity and is an important alternative approach for reduction mammoplasty, while the inferior pedicle reduction mammaplasty remains by far the most performed as it is considered to provide the best vascularization to the nipple-areola complex, allowing safe removal of large amount of redundant tissue. The authors conducted the first systematic review and meta-analysis in an attempt to declare the differences of the superomedial pedicle versus the inferior pedicle reduction technique by comparing the postoperative complications. METHODS: PubMed, MEDLINE, and Cochrane Library for clinical studies were queried from inception to January 1, 2024. Review Manager Version 5.4 was used for this meta-analysis. A random effects model was applied to OR, and 95%CI were determined using the Mantel-Haenszel method. The I2 test was used to assess heterogeneity, and the Newcastle-Ottawa scale was used to assess the risk of bias in the nonrandomized studies. RESULTS: Twelve observational comparative studies were included. The superomedial pedicle technique had a statistically lower rate of overall complications (OR 0.59, 95% CI 0.47-0.75; p < 0.0001) and delayed wound healing (OR 0.46, 95% CI 0.33-0.64; p < 0.00001) than the inferior pedicle technique. No significant differences in wound dehiscence, infection, seroma, hematoma, skin necrosis, fat necrosis, NAC necrosis, nipple sensation decrease or loss, asymmetry, hypertrophic scarring, and reoperation were noted. CONCLUSIONS: Both two techniques are equally safe and reliable, while the superomedial pedicle technique resulted in a statistically lower rate of overall complications and delayed wound healing. LEVEL OF EVIDENCE III: 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 .

Defect-Oriented Versus Back Scar-Oriented Flap Design in Breast Reconstruction with Latissimus Dorsi Musculocutaneous Flap: A Patient-Reported Satisfaction Outcome Comparison Using BREAST-Q.

BACKGROUND: The design of the latissimus dorsi musculocutaneous flap in breast reconstruction has several options. To date, there have been no reports on the surgical outcomes with flap designed based on the defect shape of the mastectomy site and flap shape of the donor site. To compare patient satisfaction according to the flap design, we designed and conducted independent three sub-studies targeting fifty-three breast reconstruction patients using BREAST-Q© scale. METHODS: In study 1, there was no difference in patient satisfaction between the group with the flap designed according to the shape of mastectomy defect (defect-oriented group) that with the flap designed according to patient's wish regardless of defect shape (back scar-oriented group). In study 2, comparing the results based on the shape of the flap, vertically designed flap showed a statistically significant difference in the psychosocial well-being. In study 3, comparing the results based on the shape of the defect, no significant difference was noted. RESULTS: Even though designing a donor flap based on the shape and orientation of the mastectomy defect has no statistical significance in patient satisfaction or quality of life compared with that based on the patient preference in placement of the donor site scar, the group with the vertical donor design showed better psychosocial well-being than the group with other shapes of the donor flap. By considering the advantages and disadvantages of each flap design, enhanced patient satisfaction and durability and natural aesthetic goal can be achieved. This is the first study to compare the differences in results according to the flap design method during breast reconstruction. Patient satisfaction according to the design of the flap was investigated in the form of a questionnaire survey, and the results were displayed. In addition to breast shape, donor scars and complications were also investigated. 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 .

Application of Liposuction and Superior Pedicle Vertical Mammoplasty for Severe Breast Hypertrophy.

BACKGROUND: Vertical mammoplasty techniques have been widely used for breast reduction. The authors present the combination of superior pedicle vertical mammoplasty with liposuction in different regions in the treatment of severe breast hypertrophy in obese patients. We also propose some innovative methods in terms of surgical approach, breast parenchymal anatomy pattern and liposuction. METHODS: A retrospective study of 50 female patients with severe hypertrophic breasts and obesity who underwent breast reduction in our department from February 2019 to February 2022 was performed. Pre- and postoperative photographs, breast parenchyma distribution and postoperative patient satisfaction were recorded. RESULTS: Fifty patients underwent breast reduction. Through clinical examination, patient photo evaluation and satisfaction survey results. Good breast shape and projection, full upper pole of the breast, and high satisfaction results were obtained. There were no serious complications. CONCLUSION: This technique is acceptable and reproducible. It is suitable for patients with varying degrees of breast hypertrophy, especially those with severe hypertrophic breasts and obesity. There are fewer associated complications and a lower rate of re-repair. LEVEL OF EVIDENCE V: 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 .

The Modified Superomedial Pedicle Breast Reduction Technique for Cases with SN-N Distance Exceeding 33 cm.

BACKGROUND: Symptomatic breast hypertrophy affects the quality of life of a large number of women globally. Many reduction mammoplasty techniques have been described for patients with breast hypertrophy. The aim of this study was to provide our clinic's experience in utilizing the modified superomedial pedicle breast reduction technique in specific patients suffering from breast hypertrophy, with sternal notch-to-nipple distance of more than 33 cm. METHOD: Our study included twenty patients who underwent, from January 2022 to December 2023, the modified superomedial pedicle breast reduction technique due to symptomatic breast hypertrophy with sternal notch-to-nipple distance of more than 33 cm in the Plastic and Reconstructive Surgery Department at Nicosia General Hospital in Cyprus. Patient demographics, comorbidities, pre- and postoperative breast anthropometric measurements and surgical complications were recorded and analyzed. RESULTS: The average age at the time of the reduction was 48 years. The mean preoperative body mass index was 28.52 kg/m2. Patients' comorbidities included one (5%) patient with diabetes, seven (35%) with obesity and three (15%) with hypertension. The mean preoperative sternal notch-to-nipple distance was 35.25 cm for the right breast and 34.90 cm for the left breast, while the mean postoperative was 20.65 cm for both breasts. The total mean resection weight of both breasts was 1643.45 g. Surgical complications were minor including two (10%) cases of local hematoma and one (5%) case of T-Junction wound breakdown. All patients were relieved from their preoperative symptoms and were satisfied with the final result. CONCLUSION: Our modified superomedial pedicle technique is a safe, effective and versatile pedicle to be used with many advantages, in specific patients suffering from breast hypertrophy with sternal notch-to-nipple distance of more than 33 cm, including its shape and rotational abilities, viability of the nipple and excellent outcome of glandular plication and breast reshaping. 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 .

Robotic-assisted free flap harvesting for diverse soft tissue reconstruction: a PRISMA scoping review of clinical outcomes over the last decade.

Introduction: The aim of our study was to assess the advantages and limitations of robotic technology in diverse reconstructive procedures. METHODS: A scoping review was conducted in Oct'23, on published studies from 2013 to 2023, focussing on robotic-assisted free flap harvesting. Three databases Ovid-MEDLINE, Scopus, and PubMed were searched. Original research studies reporting robotic-assisted free flap harvest were included. Studies on lesion excision, microvascular anastomosis, local flap harvest, roboticassisted flap inset, review articles, abstract-only studies, non-English documents, and animal studies were excluded from this review. RESULTS: Sixteen studies met the inclusion criteria out of a total of 318, searched initially. These studies included a total of 128 patients, who underwent robotic-assisted free flap harvest for the reconstruction of various defects, with 140 free flaps harvested. The most common flaps harvested by robotic technique were deep inferior epigastric artery perforator (DIEP) flap 120 (85.7%), radial forearm free (RFF) flap 11 (7.9%), latissimus dorsii flap 4 (2.9%), rectus abdominus flap 4 (2.9%), and omental flap 1 (0.7%). Breast reconstruction was the major procedure done i.e. 120 (85.7%) followed by head and neck 11 (7.9%) and limb defects 9 (6.4%) reconstruction procedures. The reported clinical outcomes were acceptable in all the studies with a 99% flap success rate and minimal complications. Variability in operating time was observed depending upon surgical steps undertaken with robotic systems. CONCLUSIONS: This scoping review highlights the role of robotic-assisted free flap harvesting in plastic surgery and its potential benefits on clinical outcomes, due to its high precision and minimal invasiveness. However, challenges like cost effectiveness, resource distribution and learning curve are there.

No drains in reduction mammaplasty - a systematic review.

Breast reduction mammaplasty is the only effective therapeutic intervention for patients with symptomatic breast hypertrophy. In this procedure, closed suction drains have become a standard of care, while the literature supporting use of drains is lacking. In fact, with emerging data we found out that drains might not be so necessary. This review aimed to systematically compare the number of complications in drained and undrained breasts and to evaluate the safety of omitting drains in reduction mammaplasty in clinical practice. A systematic review of literature was conducted identifying all studies on drainage in reduction mammaplasty. The analysed databases revealed 13 eligible studies to be included in this review. There were 308 drained breasts and 859 undrained breasts in total in patients from 16 to 73 years of age. The resected tissue weight per side fluctuated from 108 to 1,296 grams. In total, there was only 2.4% incidence of haematoma complications in undrained breasts and 3.9% in drained breasts. Closed suction drains are still being routinely used in reduction mammaplasty, although aborting drain use is proven to be not only safe, but advantageous. The clear benefit is increased patient comfort, shortened hospital stay, decreased cost of the procedure and nurse care, and decreased rate of complications.

Successful breastfeeding after breast reduction surgery or mastopexy: A retrospective comparative study.

Breastfeeding has been widely encouraged by health care systems for many years. Breast reduction or mastopexy, are very frequent procedures often performed on young women. The main objective of this study is to evaluate the impact of breast surgery on breastfeeding by comparing the success rate of breastfeeding in operated women versus unoperated women. Secondary objectives are to evaluate the breastfeeding success rate according to the surgical technique or the weight resected. A retrospective comparative study was conducted. Women of childbearing age who underwent breast reduction surgery or mastopexy at Henri-Mondor Hospital were contacted to answer a questionnaire about their pregnancies. Two hundred nine patients answered and two groups of patients were constituted, a preoperative group of 104 women who had a pregnancy before surgery and a postoperative group formed by 61 women who had a pregnancy after surgery. Breastfeeding success rate was 82% in the preoperative group versus 41% in the postoperative group. A statistically significant difference was found on the success rate of breastfeeding, as well as the rate of exclusive breastfeeding, with significantly lower rates in the postoperative group. In contrast, there was no significant difference between the different pedicles used, neither according to the weight of the resected gland. The cause of failure in the postoperative group was in most cases insufficient milk. Breast reduction surgery or mastopexy seems to have negative impact on the ability of operated women to breastfeed. This impact is multifactorial so these results should be interpreted with caution and further studies are needed to improve the management of these patients.

[Comparison of breastfeeding duration in women before and after breast reduction surgery]. / Comparaison de la durée d'allaitement maternel chez les femmes avant et après mammoplastie de réduction.

BACKGROUND: Breast reduction surgery often concern women of childbearing age. However, it can interfere with the ability to breastfeed, whereas the benefits of breastfeeding are well known. Current data in the literature do not provide precise information on the possibilities of breastfeeding after breast reduction surgery. OBJECTIVES: The aim of this study was to assess long-term breastfeeding ability of women after breast reduction performed in our centre. METHODS: This is a retrospective comparative study including patients treated with breast reduction at Saint-Louis Hospital between 2010 and 2017 and who have had children before or after surgery. Operative details were retrieved from medical records and ability to breastfeed was assessed during a phone interview. Breastfeeding before surgery was compared to breastfeeding after surgery. RESULTS: We analysed 21 births before and 35 births after breast reduction. Breastfeeding initiation was similar in the two groups (90% vs. 83%, P=0.7), but the median duration was significantly shorter after breast reduction compared with before (3 weeks vs. 10 weeks; P<0.01), the rate of breastfed child at 3 months was lower after surgery (11% vs. 43%; P<0.01), the use of infant formula was higher after surgery (100% vs. 74%, P<0.01), and we found a higher rate of discontinuation caused by hypogalactia (69% vs. 11%; P<0.001). CONCLUSION: Breastfeeding is possible but more difficult to sustain over time after breast reduction. Patients need to be made aware of that before surgery, and patients who still want to breastfeed should be encouraged at the maternity.

Current practice and provision of oncoplastic breast-conserving surgery in the UK: results of the ANTHEM national practice questionnaire.

PURPOSE: Oncoplastic breast-conserving surgery (OPBCS) may be a better option than mastectomy ± immediate breast reconstruction (IBR) for women with breast cancer but studies directly comparing the techniques are lacking. We surveyed UK breast units to determine the current practice of OPBCS to inform the design of a future comparative study. METHODS: An electronic survey was developed to explore the current practice of OPBCS. This included the local availability of volume displacement and/or replacement techniques; number of cases performed; contraindications and approach to contralateral symmetrisation. Summary data for each survey item were calculated and overall provision of care examined. RESULTS: 58 UK centres completed the survey, including 43 (74%) stand-alone breast and 15 (26%) combined breast/plastics units. Over 40% of units (n = 24) treated more than 500 cancers/year. Most units offered volume displacement techniques (TMs) (97%). Over two-thirds (n = 39. 67%) of units offered local perforator flaps (LPF). Approximately a half of units (10/19) not performing LPF were planning to introduce them in the next 12-24 months. A third (n = 19, 33%) of units routinely performed simultaneous contralateral symmetrisation mostly with two-surgeon operating. There were limited oncological restrictions to OPBCS with no contraindications for multifocal cancers in most centres; 65% of units (36/55) offered OPBCS for multicentric disease. Extensive DCIS was a contraindication in a minority of units. CONCLUSIONS: OPBCS is widely available in the UK but contraindications and approaches to contralateral symmetrisation were variable. Work is now needed to prospectively evaluate the outcomes of OPBCS vs mastectomy ± IBR to support informed decision-making.

Risk Factors and Complications in Reduction Mammaplasty: A Systematic Review and Meta-analysis.

BACKGROUND: Reduction mammaplasty (RM) has become established as the standard effective method for treating macromastia, but reports on the risk factors that predispose to postoperative complications have been conflicting. This meta-analysis aimed to pool the available data to identify predictors of complications following RM. METHODS: The PubMed, Web of Science, Embase, and Cochrane databases were screened from inception to 1 Jan 2022, and studies were included based on predefined criteria. The perioperative risk factors BMI, smoking, age, diabetes, radiation therapy, and tissue resection weight were extracted and their correlation with complications assessed. RESULTS: A total of 40 studies comprising of 5908 patients were included. BMI ≥ 30kg/m2 (OR = 1.65, 95% CI 1.35-2.02; p < 0.01) and ≥ 40 kg/m2 (OR = 1.97, 95% CI 1.26-3.08; p < 0.01), smoking (OR = 2.57, 95% CI 2.01-3.28; p < 0.01), diabetes (OR = 2.21, 95% CI 1.19-4.07; p < 0.05), a unilateral resection weight ≥ 1000 g (OR = 1.76, 95% CI 1.02-3.05; p < 0.05), and radiation therapy (OR = 11.11, 95% CI 2.01-3.28; p < 0.01) were associated with higher rates of postoperative complications. Obese patients (BMI ≥ 30 kg/m2) were more likely to experience fat necrosis (OR = 3.00, 95% CI 1.37-6.57; p < 0.01) and infection (OR = 1.66, 95% CI 1.15-2.40; p < 0.05). Smokers had a 2.03 times higher risk of infection (95% CI 1.24-3.31; p < 0.01) and 2.34 times higher risk of dehiscence (95% CI 1.38-3.98; p < 0.01). No association between complication occurrence and age 40 or 50 years or total tissue resection weight ≥ 1000 g was identified. CONCLUSIONS: This meta-analysis provides evidence that obesity, smoking, diabetes, unilateral resection weight ≥ 1000 g, and preoperative radiation therapy predispose to complication occurrence in RM. This information can optimize the ability of surgeons to provide preoperative patient education, perioperative assessment, and postoperative care planning. LEVEL OF EVIDENCE III: 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 .

Risk Factors for Capsular Contracture in Alloplastic Reconstructive and Augmentation Mammaplasty: Analysis of the National Surgical Quality Improvement Program (NSQIP) Database.

BACKGROUND: Capsular contracture is the most common complication of breast augmentation and reconstruction. It occurs in up to 45% of patients and is theorized to occur secondary to an immune reaction. It can lead to pain, dissatisfaction with aesthetic outcomes, and reoperation. The gold standard for management is capsulectomy. Prior similar studies are limited by narrow inclusion criteria, single-surgeon analysis, small sample size, or univariate analysis. The goal of the following study is to prospectively identify possible risk factors for capsular contracture using a national database. METHODS: A retrospective review was conducted utilizing the National Surgical Quality Improvement Program (NSQIP) Database of prospectively collected data of patients undergoing periprosthetic and/or total capsulectomy for capsular contracture from 2013 to 2016. Odds ratios (OR) with 95% confidence intervals (CI) were calculated for variables using a multivariable binary logistic regression model. RESULTS: A total of 6547 patients underwent reconstructive or augmentation mammaplasty with a prosthetic implant, out of which 2543 (39%) underwent capsulectomy. Capsular contracture was more likely in older (OR: 1.10, 95% CI: 1.09-1.10, p<.001), overweight (OR: 1.12, 95% CI: 1.10-1.13, p<.001), and cancer patients (OR: 7.71, 95% CI: 2.22-28.8, p=0.001). Wound infection was associated with capsulectomy (OR: 6.69, 95% CI: 1.74-25.8, p<.001). CONCLUSION: These identified risk factors should be comprehensively addressed with patients during the informed consent process before breast augmentation or reconstruction with implants. LEVEL OF EVIDENCE III: 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 .

Antibiotic Prophylaxis in Reduction Mammaplasty: A Network Meta-Analysis.

BACKGROUND: Mounting evidence suggests that breast reduction surgery displays higher rates of surgical site infections (SSI) than initially presumed. Objective of this network meta-analysis is to evaluate the effectiveness of different antibiotic regimens in the prophylaxis from surgical site infections and delayed wound healing (DWH) following breast reduction. METHODS: A network meta-analysis was conducted using a predetermined protocol after searching the electronic databases MEDLINE, Scopus, the Cochrane Library and US National Institutes of Health Ongoing Trials Register from inception to July 2022. The included studies had to examine breast reduction in females with at least 1-month follow-up, receiving antibiotics in an intervention arm compared to a control arm. The quality of studies was assessed using the Cochrane risk of bias tool. A frequentist Mantel-Haenszel approach was adopted for the reported SSI rates while an inverse variance random effects model was used for the DWH rates. RESULTS: A total of 10 studies was included in the analysis involving 1331 patients. All but one study controlled for major risk factors, and no differences were observed in patients' baseline characteristics. Antibiotic administration significantly reduced the SSI rate after breast reduction, with the prolonged antibiotic regimen being the most efficacious (odds ratio [OR]: 0.36 [95%CI: 0.15-0.85]). No statistically significant reduction in delayed wound healing rate was revealed among the regimens. CONCLUSIONS: Antibiotics mitigate the SSI rate after breast reduction. This meta-analysis provides an evidence-based strategy to optimize antibiotic administration. Further research is needed though to examine antibiotic prophylaxis on delayed wound healing. LEVEL OF EVIDENCE III: 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 .

Comparison of Performance Characteristics and Efficacy of Bilateral Thoracic Paravertebral Blocks in Obese and Non-Obese Patients Undergoing Reduction Mammaplasty Surgery: A Historical Cohort Study.

BACKGROUND: Although ultrasound (US)-guided regional anesthesia techniques are advantageous in the management of obese patients; the procedures can still be associated with technical difficulties and greater failure rates. The aim of this study is to compare the performance properties and analgesic efficacy of US-guided bilateral thoracic paravertebral blocks (TPVBs) in obese and non-obese patients. METHODS: Data of 82 patients, who underwent bilateral reduction mammaplasty under general anesthesia with adjunctive TPVB analgesia between December 2016 and February 2020, were reviewed. Patients were allocated into two groups with respect to their BMI scores (Group NO: BMI < 30 and Group O: BMI ≥ 30). Demographics, ideal US visualization time, total bilateral TPVB procedure time, needle tip visualization and performance difficulties, number of needle maneuvers, surgical, anesthetic and analgesic follow-up parameters, incidence of postoperative nausea and vomiting (PONV), sleep duration, length of postanesthesia care unit (PACU) and hospital stay, and patient/surgeon satisfaction scores were investigated. RESULTS: Seventy-nine patients' data were complete. Ideal US visualization and total TPVB performance times were shorter, number of needle maneuvers were fewer and length of PACU stay was shorter in Group NO (p < 0.05). Postoperative pain scores were generally similar within first 24 h (p > 0.05). Time to postoperative pain, total analgesic requirements, incidence of PONV, sleep duration, length of hospital stay were comparable (p > 0.05). Satisfaction was slightly higher in Group NO (p < 0.05). CONCLUSIONS: US-guided TPVB performances in obese patients might be more challenging and take longer time. However, it is still successful providing good acute pain control in patients undergoing reduction mammaplasty surgeries. LEVEL OF EVIDENCE III: 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 . TRIAL REGISTRATION: NCT04596787.

Association Between Body Weight and Removed Weight in Women Undergoing Reduction Mammaplasty-A 17-year Retrospective Study of 1777 Breasts.

BACKGROUND: Breast hypertrophy causes physical and psychological symptoms. Reduction mammaplasty is a surgical procedure to lessen discomfort. However, there is a dispute about whether the weight of breast resection is related to body weight. This study aims to provide Chinese data and assess the association between body weight and removed weight in women undergoing reduction mammaplasty. METHODS: Retrospective data were collected from 1777 breasts in a single center in 17 years. Simple linear regression analysis was performed to establish whether removed weight and removed weight ratio (removed weight/body weight) correlated with the body weight. The correlations were then analyzed again after grouping according to the removed weight. RESULTS: For all breasts included, removed weight or ratio positively correlates with body weight. When the removed weight is more than 1000g, there is no statistically significant correlation between body weight and removed breast weight. When removed per breast weight is more than 600g, there is no correlation between body weight and removed breast weight ratio. CONCLUSIONS: The correlation between body weight and removed weight or ratio decreased with increasing removed weight. When removed weight >600g, the degree of breast hypertrophy is not related to body shape. 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 . Therapeutic study.

Superomedial-Posterior Pedicle-Based Reduction Mammaplasty: Evaluation of Effectiveness and BREAST-Q Outcomes of a Rapid and Safer Technique.

INTRODUCTION: Breast hypertrophy, a common pathological condition, often requires surgical intervention to alleviate musculoskeletal pain and improve patients' quality of life. Various techniques have been developed for breast reduction, each with its own advantages and complications. The primary aim of this study is to evaluate the efficacy, safety, and patient-reported outcomes of the authors technique: the Superomedial-Posterior Pedicle-Based Reduction Mammaplasty. MATERIAL AND METHODS: A prospective study was conducted on 912 patients who underwent breast reduction surgery between November 2012 and July 2020. The surgical technique involved preserving all glandular tissue from the areola to the pectoralis major muscle using the superomedial-posterior pedicle. The patients' demographic data, operative details, complications, breast-related quality of life (measured using the Breast-Q questionnaire), and nipple-areola complex sensitivity were analyzed. RESULTS: The average operative time was 62.12 ± 10.3 minutes. Complications included minor wound dehiscence (4.05%) and hematoma (1.2%), with no cases of nipple-areola complex necrosis. Nipple-areola sensitivity was fully restored in all patients at the 2-year follow-up. Patient satisfaction with the procedure was high with a statistically significant difference observed between pre- and postoperative scores (p < 0.001) of the Breast-Q questionnaire. CONCLUSION: Authors technique offers reliable vascularization and innervation of the nipple-areola complex and achieves satisfactory aesthetic outcomes. It is associated with shorter operative times compared to other techniques reported in the literature. The Superomedial-Posterior Pedicle-Based Reduction Mammaplasty represents a safe and effective method for breast reduction surgery, providing significant benefits to patients with breast hypertrophy. LEVEL OF EVIDENCE I: 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 .

A Clinical Score For Predicting Complications Following Breast Reduction.

Objectives: To establish a clinical score for morbidity prediction based on patient-related risk factors after breast reduction surgery. Method: The retrospective study was conducted at the Department of Plastic and Reconstructive Surgery, Kafrelsheikh University Hospital, Egypt, and comprised data of female patients with bilateral macromastia who underwent breast reduction, using the inferior pedicle invertedT technique between February 2019 and June 2020. After data retrieval, risk factors and complications were documented and related to the patients'risk factors Data was analysed using SPSS 20. RESULTS: Of the 30 cases, 20(66.7%) were aged ≥35 years, 16(53.3%) had body massindex ≥37kg/m2 and 27(90%) were non-smokers. The mean preoperative haemoglobin level was 12.15±1.115g/dL and the mean weight of tissue resected on both sides was 2074.17±696.12gm. Factors significantly associated with complications included smoking, suprasternal notch to nipple distance ≥38cm, haemoglobin <12.5g/dL, the weight of excised tissue ≥2000gm and a positive family history of macromastia. The total score of the morbidity prediction scale ranged 2-190, with the best cut-off value being ≥93. The scale had 100% sensitivity,specificity, positive predictive value, negative predictive value and 100 percent accuracy. CONCLUSIONS: Ability to predict postoperative surgical-site morbidity may optimise safety as well as outcome after reduction mammaplasty.