Delayed Reconstruction of Nasal Tip Amputation After a Dog Bite Using a Cartilage Graft and Paramedian Forehead Flap.

The timing and method of reconstruction of an amputated nose due to a dog bite are still controversial. Here, we describe a delayed reconstruction using the paramedian forehead flap with a simultaneous cartilage graft to address a contracted nose from a dog bite. A healthy, 52-year-old patient was attacked by his acquaintance's dog, resulting nasal tip amputation that included cartilage. The composite graft was performed, and secondary healing resulted in a short nose deformity. Five months after the injury, a conchal cartilage graft and paramedian forehead flap were performed simultaneously to correct the shape of the deformity. At 1 year postoperatively, the flap survived without complications, and the short nose deformity was successfully corrected. In summary, immediate composite graft after a dog bite could result in a contracted nose, but the deformity can be corrected by a simultaneous paramedian forehead flap and cartilage graft.

Serial Comparison of Patient-Reported Outcomes of Immediate Breast Reconstruction: Direct-to-Implant Versus Deep Inferior Epigastric Perforator Flap.

BACKGROUND: Direct-to-implant (DTI) and deep inferior epigastric artery perforator (DIEP) flaps are the two most common methods of immediate breast reconstruction. This study aimed to compare patient-reported outcomes between the two methods and to evaluate whether outcomes change over time. METHODS: The data of patients who underwent immediate breast reconstruction using DTI or DIEP flaps between July 2017 and October 2021 were retrospectively reviewed. Patients who completed the BREAST-Q Reconstruction Module at 6 months and > 12 months after reconstruction were analyzed. Mann-Whitney and Wilcoxon signed-rank test were used to compare outcome between DTI and DIEP groups, and serial comparisons were performed. RESULTS: Of 375 patients included in the analysis, 146 patients completed questionnaires > 1 year of follow-up (20.79 ± 8.55 months). The DTI and DIEP groups had 102 (69.9%) and 44 (30.1%) patients, respectively. There were no intergroup differences in the mean scores representing any of the domains at 6 postoperative months. After > 1 year of follow-up, patients who underwent DIEP-flap reconstruction had greater satisfaction with their breast reconstructions (p < 0.001) and greater satisfaction with their overall outcomes (p < 0.001). In the DTI group, satisfaction scores did not change over time in any of the domains. In the DIEP group, however, the mean scores reflecting satisfaction with the breast (p = 0.001), overall outcome (p = 0.045), psychosocial well-being (p = 0.015), and sexual well-being (p = 0.042) significantly increased over long-term follow-up relative to the scores at 6 postoperative months. CONCLUSIONS: Patient-reported outcomes improved over time in association with DIEP reconstructions, reflecting higher satisfaction levels than those associated with DTI reconstruction. 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 .

Three-dimensional Volume Changes of the Reconstructed Breast Following DIEP Flap Breast Reconstruction.

BACKGROUND: This study aimed to assess whether the reconstructed breast volume changed postoperatively following a deep inferior epigastric artery perforator (DIEP) flap. METHODS: Patients were included if they had undergone unilateral breast reconstruction with a DIEP flap at the two selected centers between April 2017 and September 2019. Serial 3-D surface imaging of both breasts was taken at 1, 3, 6, and 12 months postoperatively. The primary outcome was a volume ratio of the reconstructed to the contralateral breast. A linear mixed-effect model was used to evaluate whether the DIEP flap volume changed according to the postoperative time. RESULTS: A total of 74 patients were included in the analysis. The mean volume ratio of the reconstructed side compared with the contralateral breast at 1, 3, 6, and 12 months postoperatively were 106.9%, 105.9%, 108.7%, and 107.6%, respectively. In the linear mixed effect model, the volume ratio of the reconstructed breast did not change over time for immediate reconstructions (p = 0.376). However, there was an increase over time in delayed reconstructions (p = 0.043). Adjuvant radiation, chemotherapy, and hormone therapy did not influence the volume ratio of the reconstruced breast. Correlation analysis using repeatedly measured values showed that both reconstruced and healthy breast volumes had positive correlation with the patient's body weight (p < 0.001). On the other hand, volume ratio of the breasts was not influenced by the patient's body weight (p = 0.493). The volume ratio of the reconstructed breast significantly decreased in the upper inner (p = 0.003) and the upper outer (p = 0.006) quadrants, while increasing in the lower outer (p = 0.002) quadrant throughout the first-year postoperative period. CONCLUSION: The volume ratio of the reconstructed to the contralateral breast does not decrease postoperatively following DIEP flap breast reconstruction.

Prediction of the Ideal Implant Size Using 3-Dimensional Healthy Breast Volume in Unilateral Direct-to-Implant Breast Reconstruction.

Background and objectives: There is no consensus regarding accurate methods for assessing the size of the implant required for achieving symmetry in direct-to-implant (DTI) breast reconstruction. The purpose of this study was to determine whether the ideal implant size could be estimated using 3D breast volume or mastectomy specimen weight, and to compare prediction performances between the two variables. Materials and Methods: Patients who underwent immediate DTI breast reconstruction from August 2017 to April 2020 were included in this study. Breast volumes were measured using 3D surface imaging preoperatively and at postoperative three months. Ideal implant size was calculated by correcting the used implant volume by the observed postoperative asymmetry in 3D surface imaging. Prediction models using mastectomy weight or 3D volume were made to predict the ideal implant volume. The prediction performance was compared between the models. Results: A total of 56 patients were included in the analysis. In correlation analysis, the volume of the implant used was significantly correlated with the mastectomy specimen weight (R2 = 0.810) and the healthy breast volume (R2 = 0.880). The mean ideal implant volume was 278 ± 123 cc. The prediction model was developed using the healthy breast volume: Implant volume (cc) = healthy breast volume × 0.78 + 26 cc (R2 = 0.900). The prediction model for the ideal implant size using the 3D volume showed better prediction performance than that of using the mastectomy specimen weight (R2 = 0.900 vs 0.759, p < 0.001). Conclusions: The 3D volume of the healthy breast is a more reliable predictor than mastectomy specimen weight to estimate the ideal implant size. The estimation formula obtained in this study may assist in the selection of the ideal implant size in unilateral DTI breast reconstruction.

Intraoperative Intercostal Nerve Block for Postoperative Pain Control in Pre-Pectoral versus Subpectoral Direct-to-Implant Breast Reconstruction: A Retrospective Study.

Background and Objectives: Patients undergoing mastectomy and implant-based breast reconstruction have significant acute postsurgical pain. The purpose of this study was to examine the efficacy of intercostal nerve blocks (ICNBs) for reducing pain after direct-to-implant (DTI) breast reconstruction. Materials and Methods: Between January 2019 and March 2020, patients who underwent immediate DTI breast reconstruction were included in this study. The patients were divided into the ICNB or control group. In the ICNB group, 4 cc of 0.2% ropivacaine was injected intraoperatively to the second, third, fourth, and fifth intercostal spaces just before implant insertion. The daily average and maximum visual analogue scale (VAS) scores were recorded by the patient from operative day to postoperative day (POD) seven. Pain scores were compared between the ICNB and control groups and analyzed according to the insertion plane of implants. Results: A total of 67 patients with a mean age of 47.9 years were included; 31 patients received ICNBs and 36 patients did not receive ICNBs. There were no complications related to ICNBs reported. The ICNB group showed a significantly lower median with an average VAS score on the operative day (4 versus 6, p = 0.047), lower maximum VAS scores on the operative day (5 versus 7.5, p = 0.030), and POD 1 (4 versus 6, p = 0.030) as compared with the control group. Among patients who underwent subpectoral reconstruction, the ICNB group showed a significantly lower median with an average VAS score on the operative day (4 versus 7, p = 0.005), lower maximum VAS scores on the operative day (4.5 versus 8, p = 0.004), and POD 1 (4 versus 6, p = 0.009), whereas no significant differences were observed among those who underwent pre-pectoral reconstruction. Conclusions: Intraoperative ICNBs can effectively reduce immediate postoperative pain in subpectoral DTI breast reconstruction; however, it may not be effective in pre-pectoral DTI reconstruction.

Comparative Study of Nipple-Areola Complex Position and Patient Satisfaction After Unilateral Mastectomy and Immediate Expander-Implant Reconstruction Nipple-Sparing Mastectomy Versus Skin-Sparing Mastectomy.

BACKGROUND: Major surgical concerns associated with nipple-sparing mastectomy (NSM) are partial or total nipple-areola complex (NAC) loss, decreased sensation, and nipple malposition. Patient satisfaction and NAC outcomes including malposition in patients who have undergone unilateral expander-implant reconstruction after NSM as compared with skin-sparing mastectomy (SSM) remain unclear. Therefore, the aim of this study was to assess patient satisfaction and NAC outcomes of breast cancer patients who underwent spared or reconstructed NAC after unilateral NSM as compared with unilateral SSM. METHODS: Patients who underwent immediate expander-implant breast reconstruction following unilateral NSM or SSM were included. Medical records of patients from April 2010 to February 2014 were retrospectively reviewed. Reconstruction-related complications such as infection, seroma, haematoma, delayed wound healing, and reconstruction failure were recorded. NAC outcome analysis was performed using preoperative and postoperative digital photographs for each patient. Patient satisfaction with the reconstructed breast and NAC was assessed using a study-specific questionnaire. RESULTS: Delayed wound healing occurred in 18 of 55 NSM patients and 15 of 85 SSM patients (p = 0.040). Final reconstruction failure occurred in 0 NSM patients and 6 SSM patients (p = 0.043). The mean photography analysis score of total aesthetic outcome was 13.12 ± 2.39 in the NSM group and 14.06 ± 2.75 in the SSM group (p = 0.052). The mean questionnaire score of NAC position was 2.88 ± 0.85 in the NSM group and 3.80 ± 0.84 in the SSM group (p = 0.001). The mean questionnaire score of NAC sensitivity was 2.12 ± 0.58 in the NSM group and 1.84 ± 0.46 in the SSM group (p = 0.003). Satisfaction with the reconstructed breast was similar (p = 0.913) after NSM and SSM. CONCLUSIONS: We observed no significant difference in breast reconstruction satisfaction between the NSM and SSM groups. Although overall satisfaction with breast reconstruction is high, patients in the NSM group often report dissatisfaction with nipple position. With a favourable score for NAC position, skin-sparing mastectomy followed by NAC reconstruction can be considered as a balanced alternative to NSM for properly selected patients with breast cancer. 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 .

Negative-Pressure Wound Therapy for Managing Complicated Wounds at Extracorporeal Membrane Oxygenation Sites.

OBJECTIVE: To evaluate the effectiveness of negative-pressure wound therapy (NPWT) for management of wound complications at extracorporeal membrane oxygenation (ECMO) removal sites. METHODS: The authors retrospectively reviewed patients who underwent NPWT at ECMO removal sites followed by the development of wound complications including skin necrosis, lymphorrhea, and femoral vessel exposure. A nonadhesive bacteria-binding mesh was used as a wound contact layer of NPWT application. Patient characteristics and clinical outcomes were evaluated. RESULTS: Nine patients underwent NPWT for complicated wounds at ECMO sites. The mean age of patients was 49.2 years (range, 14-64 years). All patients exhibited wound complications with lymphorrhea and skin necrosis. Seven of nine patients had wound cultures that were positive for microorganisms, but culture conversion to negative was achieved after NPWT application for a mean period of 21.2 days (range, 12-30 days). Lymphorrhea was successfully managed, and formation of fresh granulation tissue was observed in all patients. Wound healing either by primary closure, skin graft, or secondary healing was achieved without recurrence of wound complications. There were no cases of femoral vessel injury or aneurysm during NPWT application. CONCLUSIONS: Negative-pressure wound therapy appears to be a safe and effective treatment option in the management of complicated wounds at ECMO sites.

Silver-Impregnated Negative-Pressure Wound Therapy for the Treatment of Lower-Extremity Open Wounds: A Prospective Randomized Clinical Study.

OBJECTIVE: To investigate the antibacterial efficacy of silver-impregnated negative-pressure wound therapy (NPWT) in lower-extremity acute traumatic wounds. METHODS: Open contaminated wounds caused by high-velocity trauma in the lower extremities were randomly allocated into two groups. The wounds in the control and experimental groups were treated with conventional NPWT (n = 31) and silver-impregnated NPWT (n = 35), respectively. MAIN OUTCOME MEASURES: Serial bacterial cultures were obtained from the participants' wounds, polyurethane foam, and suction tubes weekly during the 4-week follow-up to identify bacteria and follow their conversions. MAIN RESULTS: Bacterial colonization rates in the silver NPWT group were generally lower than those in the conventional NPWT group, and the difference increased with time. For methicillin-resistant Staphylococcus aureus colonization, wounds treated with silver-impregnated NPWT showed a significant reduction in bacterial load compared with those treated with conventional NPWT. CONCLUSIONS: Silver-impregnated NPWT effectively decreases bacterial load in open contaminated wounds of the lower extremities. It can be used as a temporizing measure to manage bacterial colonization while patients and wounds are being prepared for final wound reconstruction.

The lateral calcaneal artery as an alternative recipient vessel option for heel and lateral foot reconstruction.

BACKGROUND: Clinical outcomes of consecutive use of the lateral calcaneal artery (LCA) as a recipient vessel for microsurgical reconstruction have not been reported. This study aimed to evaluate the feasibility and safety of the LCA as a recipient vessel for microsurgical foot reconstruction based on anatomical study of CT angiography and clinical results of using this vessel as the recipient. METHODS: Anatomic study was performed using CT angiography of 61 lower extremities (31 patients). The emerging point, course, and diameter of the LCA were evaluated using 3-D reconstructed images. The LCA was used as the recipient artery in 17 consecutive patients with a mean age of 59 years (range: 23-77 years). Thoracodorsal artery perforator flap was used in most cases (16 of 17), and clinical outcomes were evaluated. RESULTS: The LCA emerged 31.1 ± 9.8 mm proximal and 14.7 ± 5.0 mm posterior to the tip of the fibula and traversed 13.9 ± 2.7 mm posterior to the posterior margin of the lateral malleolus. The accompanying vein was used for venous outflow in five patients and the small saphenous vein was used in the remaining cases. Emergent re-operation was performed in one case due to venous thrombosis, and salvage was successful. All flaps except for one with partial flap necrosis completely survived. During a mean follow-up of 13 months, all but one of the patients were able to wear shoes and walk. CONCLUSIONS: The LCA may be safely used as a recipient vessel for microsurgical heel and lateral foot reconstruction. LEVEL OF EVIDENCE: IV.

Effects of Transfusion on Free Flap Survival: Searching for an Optimal Hemoglobin Threshold for Transfusion.

BACKGROUND: Microsurgical free tissue transfer is a popular technique nowadays. Because of its considerably exquisite procedure, various risk factors can affect surgical outcome. However, current key practices, especially those in blood transfusion, are in contention due to the lack of enough evidence. Therefore, the objective of this study was to investigate the impact of perioperative blood transfusion on microsurgical complication. METHODS: Data of a total of 168 patients who underwent microvascular free tissue transfer from 2013 through 2016 were retrospectively reviewed. Age, comorbidity, anatomical surgical site, preoperative and postoperative lowest hemoglobin (Hb) level, estimated blood volume loss, and final clinical flap outcome were compared between patients with and without transfusion treatment. Factors with a significance of p < 0.05 in univariate analysis were included in the multivariate logistic regression model to identify independent risk factors. RESULTS: Of 168 patients, 72 (43%) were in the transfusion group. Cross analysis statistics showed that flap failure in the transfusion group was 3.6 times higher (p = 0.018) than that in the control group. Multivariable analysis revealed that age (p = 0.083) and perioperative lowest Hb level (p = 0.021) remained as significant predictors of flap failure. Receiver-operating characteristic curve analysis showed that the appropriate lower limit of transfusion commencement of Hb was 8.75 g/dL (area under the curve: 0.721). CONCLUSION: A transfusion during perioperative period of free flap did not increase its failure rate. Rather than appropriate transfusion strategy, perioperative lowest Hb level, and age were significant predictors of flap failure. Therefore, transfusion can be confidently used in patients who undergo free flap without any hesitation. Results of this study provide practical evidence of performing perioperative transfusion for free tissue transfer patients.

Does the Use of Acellular Dermal Matrix Increase Postoperative Complications of the First-Stage Reconstruction of Immediate Expander-Implant Breast Reconstruction: A Matched Cohort Study.

PURPOSE: Controversy exists regarding complications associated with the use of acellular dermal matrix (ADM). This likely stems from the heterogeneous and unmatched patient characteristics in study groups. The purpose of this study was to analyze complications in a matched cohort to identify whether ADM use increased postoperative complications of the first-stage immediate expander-implant breast reconstructions. METHODS: A retrospective matched-cohort study was performed. We retrospectively reviewed prospectively collected data from patients who underwent immediate expander-implant breast reconstruction after mastectomy between February 2010 and January 2016. Independent variables included clinical characteristics, mastectomy weight, mastectomy type, expander size, initial inflation volume, number of days to drain removal, and adjuvant or neoadjuvant therapies. Different independent variables between the ADM and non-ADM groups were used for propensity score matching. After matching, a pairwise comparison of the 2 cohorts' independent variables was carried out using the Wilcoxon signed rank test and McNemar test. Incidence of complications was evaluated for the 2 matched cohorts. To adjust for ablative and reconstructive surgeons, a multivariable generalized estimating equation analysis was performed. RESULTS: A total of 574 immediate expander-implant breast reconstructions in 533 patients were included in this study. We identified 398 reconstructions (199 for each group; ADM and non-ADM group) of matched cohorts using propensity score matching. Characteristics were similar between the 2 matched cohorts. In the matched analysis, there were no significant differences in the rate of skin flap complications (16.1% vs 16.1%, P > 0.999), seroma (4.0% vs 8.5%, P = 0.065), infection (3.0% vs 3.5%, P = 0.781), and overall complications (21.1% vs 26.1%, P = 0.251). Acellular dermal matrix was not associated with increased risk of complication when ablative and reconstructive surgeon factors were considered in a multivariable analysis (P = 0.511). CONCLUSIONS: A matched cohort analysis demonstrated that ADM usage is not associated with an increased risk of complications, including skin flap complications, seroma, and infection. Our result suggests that ADM can be safely used in immediate expander-implant breast reconstruction when necessary.

Estimation of DIEP flap weight for breast reconstruction by the pinch test.

BACKGROUND: Various methods have been introduced for estimating deep inferior epigastric artery perforator (DIEP) flap volume based on computed tomography or magnetic resonance angiographic images. However, when radiologic images cannot be obtained, estimations are subjective. The purpose of this study was to develop a prediction model for estimating DIEP flap weight using the pinch test. METHODS: The pinch test was performed at three paraumbilical sites using a skin-fold caliper in 107 consecutive patients who underwent DIEP flap breast reconstruction. Multiple linear regression analysis was used to develop a formula to estimate flap weight. Predictor variables included body mass index (BMI, kg/m2 ), flap height (H, cm), flap width (W, cm), and flap thickness (mm) measured by the pinch test at the following three paraumbilical sites: 5 cm right (R), left (L), and inferior (I) of the umbilicus. The model accuracy was tested using leave-one-out cross-validation. RESULTS: A prediction model was developed from the multiple regression analysis (R2 = 89.03%, P < .001); flap weight, g = -1308 + 24.57 × BMI + 6.80 × (R + L)/2 + 7.89 × I + 20.51 × H + 32.55 × W. The formula was implemented in a smartphone application, DIEP-W version 2.0, for real-time use. The mean absolute percentage error in the cross-validation was 12.15%. CONCLUSIONS: DIEP flap weight can be estimated by the pinch test with the developed prediction model in an easy, cost-effective, and relatively accurate manner. This method will improve surgical planning and allow surgeons to provide better counselling for patients when radiologic images are not available.

The Impact of Expander Inflation/Deflation Status During Adjuvant Radiotherapy on the Complications of Immediate Two-Stage Breast Reconstruction.

BACKGROUND: The question of whether expander inflation/deflation status has any bearing on surgical complications in the setting of adjuvant radiation (XRT) has not been addressed. The objective of this study is to investigate whether the inflation/deflation status of the expander at the time of XRT is associated with complications in immediate two-stage expander-implant breast reconstruction. METHODS: A retrospective review of 49 consecutive patients who underwent immediate two-stage expander-implant breast reconstruction and received post-mastectomy XRT was conducted. Full deflation of the expanders was performed in the deflation group (20 patients), while the expanders remained inflated in the inflation group at the time of XRT (29 patients). XRT-related complications of each stage of reconstructions were compared between the two groups, and multivariable regression analysis was performed to identify risk factors for XRT-related complications. RESULTS: Overall XRT-related complications (65.0 vs. 6.9%, p < 0.001) and reconstruction failures (35.0 vs. 6.9%, p = 0.022) of the first-stage reconstructions were significantly higher in the deflation group. The most common cause of reconstruction failure in the deflation group was failure to re-expand due to skin fibrosis and contracture. In multivariable analysis, deflation of expanders was a significant risk factor for overall complications (odds = 94.4, p = 0.001) and reconstruction failures (odds = 9.09, p = 0.022) of the first-stage reconstructions. CONCLUSIONS: Maximal inflation without deflation before XRT can be an option to minimize XRT-related complications and reconstruction failure of the first-stage reconstructions. 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 Complications in Immediate Expander-Implant Breast Reconstruction for Non-obese Patients: Impact of Breast Size on Complications.

BACKGROUND: Although obesity is a well-known risk factor for complications in immediate expander-implant breast reconstruction, no studies have identified risk factors for non-obese patients. The purpose of this study was to identify risk factors for complications in non-obese patients. METHODS: A retrospective analysis of prospectively collected data from 397 consecutive immediate expander-implant breast reconstructions in 367 non-obese patients at a single institution over a 5-year period was conducted. Univariable and multivariable analysis were performed to determine the influence of six patient-related and eight procedure-related characteristics on complications. RESULTS: Mean BMI was 21.7 ± 2 kg/m(2) and median mastectomy weight was 298.0 g (range: 40-1164 g). Multivariable analysis showed that neither BMI nor the use of acellular dermal matrix was a predictor for complications. Adjuvant radiation (odds = 3.12, p < 0.001) and mastectomy weight (p < 0.001) were independent risk factors for complications. A 100 g increase in the mastectomy weight was significantly associated with a 23 % increase in the odds of overall complications (p = 0.003), major complications (p = 0.004), and skin flap complications (p = 0.007), as well as a 28 % increase in the odds of seroma (p = 0.044), but was not associated with reconstruction failure. Adjuvant radiation (p < 0.001) and hypertension (p < 0.001) were risk factors for reconstruction failure. CONCLUSIONS: Breast size was an independent risk factor for complications in non-obese patients while BMI was not. In the reconstruction of large breasts, greater attention and additional adjunctive procedures would be needed to prevent complications. 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.

A Novel Method to Estimate the Weight of the DIEP Flap in Breast Reconstruction: DIEP-W, a Simple Calculation Formula Using Paraumbilical Flap Thickness.

Background Preoperative estimation of abdominal flap volume is valuable for breast reconstruction, especially in lean patients. The purpose of this study was to develop a formula to estimate the weight of the deep inferior epigastric artery perforator (DIEP) flap using unidimensional parameters. Methods We retrospectively collected data on 100 consecutive patients who underwent breast reconstruction using the DIEP flap. Multiple linear regression analysis was used to develop a formula to estimate the weight of the flap. Predictor variables included body mass index, height of the flap, width of the flap, and flap thickness on computed tomography angiographic images at three paraumbilical sites: 5 cm right, left, and inferior from the umbilicus. Then we prospectively tested the accuracy of the developed formula in 38 consecutive patients who underwent breast reconstruction with free DIEP flaps. Results A calculation formula and a smartphone application, DIEP-W was developed from retrospective analysis (R (2) = 92.7%, p < 0.001). In the prospective study, the average estimated weight was 96.3% of the actual weight, giving the formula a mean absolute percentage error of 7.7% (average differences of 45 g). The flap size in the prospective group was significantly smaller (p < 0.001) and donor-site complications were less (p = 0.002) than those of retrospective group. Conclusion Surgeons can easily calculate the DIEP weight with varying flap dimensions in a real-time fashion using this formula during preoperative planning and intraoperative design. Estimating the flap weight facilitates economical use of the flap, which can lead to reduced donor-site complications.

Comparison of the Rate of Concomitant Proximal Venous Stenosis between the Upper and Lower Extremities in Patients with Secondary Lymphedema Undergoing Lymphatico-venous Anastomosis.

BACKGROUND: Concomitant iatrogenic proximal venous stenosis increases venous pressure and can be a risk factor for unfavorable outcomes of lymphaticovenular anastomosis (LVA) in extremities with secondary lymphedema. This study investigated the frequency and relevant factors of venous stenosis in patients diagnosed with secondary lymphedema who underwent LVA. METHODS: Patients who underwent preoperative computed tomographic venography (CTV) and LVA for secondary lymphedema of the extremities from October 2018 to March 2022 were included. The incidence of proximal venous stenosis in the affected limb on preoperative CTV and the rate of endovascular intervention were compared between upper and lower extremities. Factors affecting proximal venous stenosis were identified through multivariable analysis using independent variables, including patient age, body mass index, comorbidities, smoking history, radiation therapy, duration of lymphedema, and location of lymphedema. RESULTS: A total of 211 patients were analyzed, including 83 patients with upper extremity and 128 patients with lower extremity lymphedema. The incidence of proximal venous stenosis in the preoperative CTV was 32.5% and 7.8% in upper extremity, and lower extremity lymphedema, respectively (p < 0.001). The incidence of venous stenosis requiring endovascular intervention was significantly higher in the upper extremity compared to the lower extremity (16.9 % vs. 6.3 %, p = 0.014). In multivariable analysis, risk factors affecting incidence of venous stenosis requiring endovascular intervention was the patient age (p = 0.007) and upper extremity (p = 0.009). CONCLUSIONS: Preoperative evaluation and treatment of venous stenosis in extremities with secondary lymphedema are necessary before LVA surgery, particularly in upper extremity lymphedema.

Separate axillary incision for surgery of axillary lymph node can decrease drain amount and days to drain removal of the breast in direct-to-implant breast reconstruction.

PURPOSE: Sentinel lymph node biopsy (SLNB) or axillary lymph node dissection (ALND) can be performed either with a separate axillary incision or through the mastectomy incision. The authors hypothesized that after SLNB or ALND through a single incision, connection of the axilla with mastectomy pocket could increase drainage. This study investigated whether a separate incision decreases drainage amount and duration in implant-based breast reconstruction. METHODS: Medical records of breast cancer patients who underwent nipple-sparing or skin-sparing mastectomy with immediate breast reconstruction with prosthesis from March 2018 to February 2021 in a single tertiary center were reviewed. Demographic data, intraoperative details, and postoperative complications were reviewed. Breast drains were removed if the drain amount was less than 30cc for two consecutive days. Total breast drain amount, duration until removal, and prolonged drainage were compared with multivariate analysis. RESULTS: A total of 206 patients were included in the study, with separate incisions placed in 145 breasts and a single breast incision placed in 70 breasts. Mean duration and amount until drain removal were 12.8 ± 4.9 days and 817 ± 520 cc in the single incision group, respectively, and 9.9 ± 3.1 days and 434 ± 228 cc in the separate incision group, respectively Separate incision placement (p < 0.001), lower mastectomy weight (p < 0.001), and prepectoral plane of insertion (p < 0.001) were significantly associated with less drain amount and duration. None-separate incision placement (p = 0.01) and preoperative radiation therapy (p = 0.023) were significant factors for prolonged drainage. CONCLUSION: Placing a separate incision for axillary surgery during mastectomy and immediate implant-based reconstruction can decrease both drain amount and duration and reduce the risk of prolonged drainage.

Efficacy of preoperative lymphoscintigraphy in predicting surgical outcomes of lymphaticovenous anastomosis in lower extremity lymphedema: Clinical correlations in gynecological cancer-related lymphedema.

BACKGROUND: Lymphaticovenous anastomosis (LVA) is a promising microsurgical treatment for lower extremity lymphedema (LEL). Lymphoscintigraphy effectively assesses lower limb lymphatic systems before LVA, but its role in predicting the therapeutic outcomes of LVA is indeterminate. In this study we investigate the efficacy of preoperative lymphoscintigraphy using clinical findings to predict outcomes in gynecological cancer-related LEL patients who underwent LVA. METHODS: A retrospective review was conducted on consecutive gynecological cancer patients with LEL who had undergone LVA between June 2018 and June 2021. The therapeutic efficacy was assessed by measuring the change rate of the lower extremity lymphedema index (LELi) six months after surgery. Clinical data and lymphoscintigraphic findings were analyzed to assess therapeutic efficacy of LVA. RESULTS: Out of the 60 evaluated legs, 83.3% of the legs showed improved results after LVA. Univariable linear regression analysis revealed that higher preoperative LELi, and ovarian cancer were associated with superior LELi change rate (LC rate). Absence of dermal backflow (DBF) on lymphoscintigraphy was associated with inferior LC rate. Multivariable linear regression analysis identified ovarian cancer and higher preoperative LELi were independently correlated with favorable outcomes, while the absence of DBF was independently correlated with inferior outcomes. CONCLUSION: The results of this study emphasizes the effectiveness of preoperative lymphoscintigraphy, preoperative LELi, and primary malignancy as predictors of LVA outcomes in gynecological cancer-related LEL patients.

Lymphatic flow velocity is a predictor of functional lymphatic vessels for lymphaticovenous anastomosis.

BACKGROUND: Indocyanine green (ICG) lymphography is widely used to localize functional lymphatic vessels for lymphaticovenous anastomosis (LVA); however, flow velocity is rarely assessed. We aimed to evaluate the correlation between lymphatic flow velocity and the presence of functional lymphatic vessels. METHODS: Data of a total of 924 lymphatic vessels from 273 lymphedema patients who underwent LVA between July 2018 and December 2020 were retrospectively reviewed. Lymph flow velocity was defined by considering the most proximal anatomic location enhanced by ICG at 30 min after injection and categorized into four groups; grade 1 (foot or hand), grade 2 (below knee or elbow), grade 3 (at/above knee or eblow), or grade 4 (axilla or groin). The presence of functional lymphatic vessels, which showed lymphatic fluid flow when the vessels were cut for anastomosis, was compared between the four groups. RESULTS: A higher rate of functional lymphatic vessels was observed among lymphatic vessels with grade 3 or 4 flow velocity compared with those with grade 1 or 2 flow velocity (67.5% vs. 44.5%; p < 0.001). These findings were consistent with the observations for lymphatic vessels with a non-linear pattern in ICG lymphography (59.4% vs. 26.5%; p < 0.001). The rate of completion of LVA at surgical sites in extremities with grade 3 or 4 flow velocity was 88.1% compared with 65.8% in extremities with grade 1 or 2 velocity (p < 0.001). CONCLUSIONS: Lymph flow velocity grading can be a simple and easy adjunctive method to determine indication for LVA in extremities with lymphedema.

Effects of Prostaglandin E1 on Mastectomy Flap Necrosis in Immediate Implant-based Breast Reconstruction.

PURPOSE: Necrosis of a cutaneous flap including the nipple-areolar complex is a common complication in immediate implant-based breast reconstruction following nipple/skin-sparing mastectomy (NSM/SSM). This study aimed to evaluate the efficacy of prostaglandin E1 (PGE1) in reducing such complications. METHODS: A retrospective analysis of prospectively collected data was conducted at two centers, and the cohort consisted of patients undergoing NSM/SSM followed by immediate reconstruction with a prosthesis. Patients who were randomly allocated to the treatment group were administered daily intravenous PGE1 (10 mcg/2 mL) beginning intraoperatively through postoperative day 6. Skin flap complications including nipple/skin necrosis, delayed wound healing, and postoperative wound revision were recorded. Complication rates were compared between the PGE1 and control groups. RESULTS: A total of 276 breasts in 259 patients were included for analysis (139 breasts to the treatment group and 137 breasts to the control group). There was no difference in patient demographics between the control and treatment group. Reconstructed breasts receiving PGE1 had significantly lower rates for overall skin complications (21.6% vs. 34.3%, p=0.022) and wound revision (2.9% vs. 9.5%, p=0.025). Among NSM cases, the PGE1 group showed a significantly lower rate of nipple necrosis (15.5% vs. 29.4%, p=0.027). In the multivariate analysis, the use of PGE1 significantly reduced the risk of overall skin flap complications (odds=0.491, p=0.018), wound revision (odds=0.213, p=0.018) in NSM/SSM cases, and nipple necrosis (odds=0.357 p=0.008) in NSM cases. CONCLUSION: PGE1 can be effective in reducing risk of mastectomy flap complications in immediate implant-based breast reconstructions.