Prophylactic venous Supercharging in DIEP Flap Surgery: A Retrospective Dual-Center Study.

BACKGROUND: DIEP flap is nowadays considered the gold standard in breast reconstruction. However, venous congestion is still a leading cause of free flap failure. Despite the conspicuous articles regarding the use of a secondary venous anastomosis, there is a lack in the literature regarding the prophylactic use of a secondary venous route to reduce the incidence of complications during breast reconstruction. METHODS: A double-center retrospective study based on women undergoing DIEP breast reconstruction was conducted, dividing patients into case group(DIEP flaps with double venous anastomosis) and control group(DIEP flaps with single venous anastomosis). Demographic and surgical data and complications were compared and statistically analyzed and a reconstructive algorithm was proposed to improve the flap insetting. RESULTS: 154 patients were included in the study, divided into Case group(74 patients) and control group(80 patients). Median age at the time of surgery was 49,09 years (range 29 -68), slightly lower in Group 1 when compared to Group 2. Mean BMI was 25,52 kg/m2(range 21,09-29,37), in particular 25,47 kg/m2 (range 23,44 -28,63) in Group 1 and 25,58 kg/m2(range 21,09-29,37) in Group 2. No statistical differences were found between groups in terms of BMI and smoking and comorbidities history. Average operative times were 272,16 minutes in Group 1 (range 221 - 328) and 272,34 minutes in Group 2(range 221-327), with no significant difference between groups, as well as ischemia times(44,4 minutes in Group 1 (range 38 - 56) and 49,12 minutes in Group 2(range 41- 67). Statistical analysis showed a reduction in short term complications and a statistically significant reduction for take-backs in the comparison of two groups. CONCLUSIONS: Our study suggests that venous supercharging of DIEP flap by performing dual venous anastomosis can be routinely and safely done prophylactically, and thus not only after intraoperative assessment of venous congestion, in order to avoid flap venous congestion and rates of re-exploration.

Incidence of Complications for Different Approaches in Gynecomastia Correction: A Systematic Review of the Literature.

BACKGROUND: Gynecomastia is nowadays a very common disease, affecting a large cohort of patients with different ages. The aim of this literature review is to assess the incidence of complications with all proposed techniques and for combined procedures versus single approach procedures in gynecomastia correction. MATERIALS AND METHODS: A systematic review of the literature was performed to identify all reported techniques for gynecomastia correction covering a period from January 1, 1987 to November 1, 2020. For all selected papers, demographic data, proposed technique, and complications' incidence have been recorded. RESULTS: A total number of 3970 results was obtained from database analysis. A final total number of 94 articles was obtained for 7294 patients analyzed. Patients have been divided into three groups: aspiration techniques, consisting in 874 patients (11,98%), surgical excision techniques, consisting in 2764 patients (37,90%), and combined techniques, consisting in 3656 patients (50,12%). Complications have been recorded for all groups, for a total number of 1407, of which 130 among "Aspiration techniques" group (14,87%), 847 among "Surgical excision techniques" group (30,64%), and 430 in "Combined techniques" group (11,76%). CONCLUSIONS: Several techniques have been proposed in the literature to address gynecomastia, with the potential to greatly improve self-confidence and overall appearance of affected patients. The combined use of surgical excision and aspiration techniques seems to reduce the rate of complications compared to surgical excision alone, but the lack of unique classification and the presence of several surgical techniques still represents a bias in the literature review. 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 .

Gynecomastia and Chest Masculinization: An Updated Comprehensive Reconstructive Algorithm.

BACKGROUND: Gynecomastia is a common finding in males. Clinical aspect varies widely in world populations showing peculiar hallmarks according to different body shapes reflecting personal expectations; therefore, a surgical plan must be tailored on individual basis to all type of patients. MATERIALS AND METHOD: A total of 522 patients, treated for bilateral gynecomastia from January 2007 to January 2019, were included and reviewed in this retrospective study. Considering physical status BMI, muscular trophism, hypertrophy of the mammary region, nipple-areola disorder, gland and skin cover consistency, a four-tier classification system has been used to classify the deformity and to assess a surgical plan. In all cases, a subcutaneous mastectomy was performed under direct vision. RESULTS: No recurrence of the deformity was observed as well as major complications such as necrosis, and high level of satisfaction was observed in all groups. No breast cancer was found at the histological examinations Operative time ranged from 25 minutes up to 120 minutes and hospitalization time ranged from 1 to 3 days. CONCLUSION: Since the physical status is strictly related to the clinical features of the disorder, a comprehensive classification system and a reconstructive algorithm are proposed. 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.

Evaluation of Residual Neuro-Muscular Integrity in the Orbicularis Oculi Muscle After Lower Eyelid Transcutaneous Blepharoplasty According to Reidy Adamson-s Flap.

BACKGROUND: The aging process affects skin, muscle and fat of the eyes in a different manner. Their individual rejuvenation would require specific surgical treatment according to their particular demands during lower eyelid blepharoplasty. This would require the separate management of the skin and the muscle by separating them into two different flaps. Basing on the anatomy, during sub-ciliary myocutaneous incision in conventional lower eyelid transcutaneous blepharoplasty most of innervations of the lower orbicularis oculi muscle are transected and denervation sequelae at the pretarsal orbicularis oculi muscle would be expected. However, sub/ciliary approach is still popular. The absence of signs or symptom of denervation of in our large case series even though injury to the motor innervation of the orbicularis oculi muscle during the operation led the authors to investigate the discrepancy between the anatomical concept and clinical outcomes. The study aimed to investigate the residual functionality of the orbicularis oculi muscle after lower eyelid transcutaneous blepharoplasty according to Reidy Adamson-s flap. MATERIALS AND METHODS: Ten patients were enrolled in the study. Orbicularis oculi muscle functionality was investigated with electroneurography before and at least 6 months after the surgical procedure. Investigated parameters are: Compound Muscle Action Potential (CMAP) as expressions of quantity of activated muscular fibers by the electrical stimulation of the facial nerve. Pre- and post-op collected data were compared and statistically analyzed. RESULTS: The mean age was 52.9; minimum follow-up 6 months; twenty eyes were investigated; 1 patient was excluded. Postoperative data did not show any significant reduction in the CMAP at all. CONCLUSION: The study suggests that the buccal branch and medial branch of the zygomatic nerve of the facial nerve supplies efficiently to the orbicularis oculi innervation. 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 .

Surgical Calf Augmentation Techniques: Personal Experience, Literature Review and Analysis of Complications.

BACKGROUND: More attention is paid to calf appearance, both in males and females, and several surgical techniques are available. Different studies have been published over time for calf augmentation, but, to the best of our knowledge, no comprehensive literature review and complications analysis have been published. OBJECTIVES: The aim of the study is to analyse the overall complication rate of calf augmentation surgical procedures and complication rates associated with the investigated techniques, namely subfascial implant placement, submuscular implant placement and fat grafting or lipofilling. Demographic analysis, including age and gender, is also performed. MATERIALS AND METHODS: A literature review on the PubMed database was performed for clinical studies regarding calf augmentation surgical procedures. The authors selected and analysed 26 articles among the actual literature on this field and reported personal experience in calf augmentation surgery. RESULTS: Twenty-six studies, published from 1993 to 2018, were included in the study for a total amount of 1498 patients, with a total of 2629 calves treated. Three different surgical techniques have been reviewed, excluding medical procedures: subfascial implant augmentation (n = 1929), submuscular implant augmentation (n = 435) and fat grafting (n = 265). The overall complication rate was 4.4883%. Calf augmentation with subfascial implants presented a total complication rate of 5.702%. The submuscular implant placement complication rate was 0.92%. Fat grafting presented a global complication rate of 1.509%. CONCLUSIONS: Calf augmentation, with all reviewed surgical techniques, has a low rate of complications compared to other body contouring procedures, but a high rate of satisfaction among patients. Fat grafting has the lowest rate of complications, but multiple sessions are required. Specific complications of implants, such as capsular contracture, malposition or rupture, are less common compared to the use of implants for other cosmetic purposes. Procedures should always be performed by experienced plastic surgeons. 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 .

Effects of Cutaneous Negative Pressure Application on Perforator Artery Flow in Healthy Volunteers: A Preliminary Study.

BACKGROUND: The creation of skin flaps based on small perforator vessels is an increasingly popular procedure nowadays; the optimization of their blood supply enhances surgical success. This study evaluates the effects on the flowmetries of 7 days' negative pressure application on the skin surface overlying the muscle fascia emergence of periumbilical perforators of the deep inferior epigastric artery (DIEA). METHODS: Ten volunteer participants were enrolled. In each subject, one periumbilical perforator of the DIEA was identified on each side of the abdomen using an eco-color-Doppler. One of them was used as the control group, while the other (the study group) underwent 80 mm Hg negative pressure for 7 days. The flowmetries of both perforators were measured before and after the application of negative pressure wound therapy. RESULTS: After the application of negative pressure, randomly applied on the skin surface over one of the two selected periumbilical perforators, an increase in the flowmetries was observed in both groups of perforators (2.74 cm/s; p < 0.0001). The relative flowmetry increase in the control group was 9.55% (2.735 cm/s), while in the study group it was 44.03% (8.748 cm/s). CONCLUSION: The application of negative pressure system on the skin surface over the muscle fascia emergence of the selected periumbilical perforators showed an increase in flowmetry. Although this is a preliminary study, this simple and economical procedure before surgery could be usefully employed to increase the rate of success in microsurgical procedures.

Tuberous Breast: Past, Present, and Future: Personal Classification, Treatment, and Surgical Outcomes.

BACKGROUND: Tuberous breast (TB) is a rare congenital deformity, which may appear in different clinical forms representing various degrees of a single pathological entity. The worst cases are characterized by severe hypoplasia. Following a detailed analysis of the available relevant literature and a significant number of treated cases, in this article, the authors propose a new classification, with the aim of summarizing and simplifying a more intuitive categorization of the malformation, considering all the clinical aspects and including all types of TBs, even the minor ones, thus allowing a more immediate diagnosis and surgical planning. METHODS: Between September 2006 and December 2015, 78 patients with TBs underwent surgical procedures to correct the deformity. The patients' mean age was 18.6 years, ranging between 17 and 26 years. There being 11 monolateral deformities, the treated TBs amounted to 145. A periareolar approach, adipo-glandular flaps, and dual plane breast implant placements were performed. Postoperative follow-up include photos collected 12 months after operation. The authors present a personal classification including all the forms of the deformity, plus the minor forms based on the following 2 principal categories: hypoplastic and normoplastic TBs, taking into account all the clinical aspects of the malformation including the morphology and the consistency of the breast. CONCLUSIONS: Preoperative identification of the type of the deformity is essential to obtain satisfactory results and a complete and intuitive classification including all the possible variants of the deformity, even the minor forms, and fundamental in diagnosing and resolving the problem. In this article, the authors propose a personal classification and surgical procedure to resolve the malformation.

Refinements in Tear Trough Deformity Correction: Intraoral Release of Tear Trough Ligaments: Anatomical Consideration and Clinical Approach.

BACKGROUND: Correction of tear trough (TT) deformity is a crucial aspect of facial rejuvenation. Because the anatomical origins of TT deformity lie in the TT ligaments, which firmly attach the dermis to the periosteum, the release of TT ligaments should be considered when performing an etiological correction. The aim of this paper is to propose an alternative method for TT deformity correction, comprising use of filler together with the release of TT ligaments. This technique was compared to the procedure of only percutaneous filler. METHODS: From January 2014 to December 2015, 10 patients were enrolled in the study for recurrence of TT deformity. All the patients underwent TT ligament release and filler injections; all had been previously treated with percutaneous hyaluronic acid injection without ligament release. Under local anesthesia, the TT ligaments were detached using a blunt cannula introduced directly in the supra periosteal plane through an intraoral access. Once the ligament was released, the TT depression was evenly recontoured with a very small amount of filler. The clinical data, digital images, evaluations of outcomes, including patient satisfaction rates were collected and compared. RESULTS: Adding the procedure of TT ligament release to filler injections showed satisfactory results, avoiding an unnatural puffy appearance. The comparison between the two different methods showed improved outcomes and increased patient satisfaction with minor patient discomfort among those who underwent TT ligament release. CONCLUSION: Because TT ligaments are among the etiologic factors of TT deformity, they have a strong impact on procedures that are designed to improve TT deformity; therefore, TT ligament release should always be considered to obtain satisfactory, natural results. 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 .

Management of Gynecomastia in Patients With Different Body Types: Considerations on 312 Consecutive Treated Cases.

BACKGROUND: Gynecomastia is a common finding in male subjects which incidence varies widely in the world population. In adolescents, it is frequently temporary but, if it becomes persistent, it generates considerable embarrassment, inducing the patients to seek surgical consultation. Even in patients with good body contour, gynecomastia creates even greater distress considering the special attention given by these subjects to their physical appearance. The authors present their experience in the treatment of gynecomastia comparing different body types of patients with the aim to investigate dissimilar expectations, needs and surgical outcomes thus optimizing the management of the pathological condition, achieving high levels of agreement and reducing unsatisfied patients arising from cosmetic surgery. MATERIALS AND METHODS: Between January 2007 and January 2015, 312 selected patients have been treated surgically for gynecomastia. Patients were grouped according to their physical aspect: 97 were classified as high muscle mass body type (group A), 106 as normal (group B) and 109 as overweight patients (group C). All of them were adults ranging in age between 18 and 52 years. Follow-up ranged from 12 to 60 months. In all cases, an excision of the gland in the form of a subcutaneous mastectomy was performed; the most common surgical access was in the inferior part of the areola. RESULTS: No breast cancers were found at the histological examinations. Also, no skin or areola necrosis have been referred, and no recurrence of gynecomastia disorder has been reported. Six cases of seroma (limited to the fatty gynecomastia) and 3 cases of hematomas (requiring immediate surgical revision) were found. Although the patients in group B resulted more distressed by the disorder, higher levels of postoperative satisfaction were recorded in this group. CONCLUSIONS: The study demonstrates the importance of the different management of the same disorder according to the different patients' expectations, related to the different body type. Our experience demonstrated that most of the cases did not require extensive skin incisions, reducing the risk of unpleasant scars and that direct excision of glandular tissue ensures stable and satisfactory results.

Periareolar Access for Pectus Excavatum Correction with Silicone Implants: A New Method to Minimize Postoperative Scars-Review of the Literature, Considerations and Statistical Analysis of Clinical Outcomes.

BACKGROUND: Pectus excavatum (PE) is one of the most frequent thoracic malformations. Generally, the malformation is not associated with functional disorders and often constitutes an aesthetic alteration with significant psychological distress. OBJECTIVES: To reduce the visibility of the residual scarring produced by corrective surgery and to improve the aesthetic outcome, the authors propose a new prosthetic implant technique through a periareolar access. METHODS: From January 2005 to January 2015, 11 patients affected with PE underwent the surgical procedure with a sternal prosthesis implanted through a periareolar access with the help of a fiberscope. The preoperative evaluation of the perception of the malformation and postoperation results were made using different questionnaires. The data collected in our series were compared with that reported in 4 different papers where other forms of access were used: sternal, inframammary and transumbilical. RESULTS: No major complications or dislocation of the implants were reported. Among the complications, 6 postoperative seromas were reported. The patients' perception of improvement through the use of 2 questionnaires and an evaluation scale showed substantial improvement in all the aesthetic outcomes. CONCLUSIONS: The periareolar technique provides excellent cosmetic results compared to the sternal one. This access causes fewer complications and necessitates a shorter average hospital stay than the sternum access. To conclude, according to what is shown in the literature, periareolar access seems to be a quicker procedure, requiring a shorter stay in hospital, and results in scars that can more easily be hidden and are more accepted by patients. 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 .