Bioimpedance spectroscopy for breast cancer-related lymphedema assessment: clinical practice guidelines.

PURPOSE: Breast cancer-related lymphedema (BCRL) represents a significant concern for patients following breast cancer treatment, and assessment for BCRL represents a key component of survivorship efforts. Growing data has demonstrated the benefits of early detection and treatment of BCRL. Traditional diagnostic modalities are less able to detect reversible subclinical BCRL while newer techniques such as bioimpedance spectroscopy (BIS) have shown the ability to detect subclinical BCRL, allowing for early intervention and low rates of chronic BCRL with level I evidence. We present updated clinical practice guidelines for BIS utilization to assess for BCRL. METHODS AND RESULTS: Review of the literature identified a randomized controlled trial and other published data which form the basis for the recommendations made. The final results of the PREVENT trial, with 3-year follow-up, demonstrated an absolute reduction of 11.3% and relative reduction of 59% in chronic BCRL (through utilization of compression garment therapy) with BIS as compared to tape measurement. This is in keeping with real-world data demonstrating the effectiveness of BIS in a prospective surveillance model. For optimal outcomes patients should receive an initial pre-treatment measurement and subsequently be followed at a minimum quarterly for first 3 years then biannually for years 4-5, then annually as appropriate, consistent with previous guidelines; the target for intervention has been changed from a change in L-Dex of 10 to 6.5. The lack of pre-operative measure does not preclude inclusion in the prospective surveillance model of care. CONCLUSION: The updated clinical practice guidelines present a standardized approach for a prospective model of care using BIS for BCRL assessment and supported by evidence from a randomized controlled trial as well as real-world data.

Distinguishing Authentic Voices in the Age of ChatGPT: Comparing AI-Generated and Applicant-Written Personal Statements for Plastic Surgery Residency Application.

BACKGROUND: ChatGPT, a generative artificial intelligence model, may be used by future applicants in the plastic surgery residency match. METHODS: Ten personal statements (5 generated by ChatGPT, 5 written by applicants) were rated by 10 reviewers, blinded to the source of the essay. RESULTS: A total of a 100 evaluations were collected. There was no significant difference in ratings for readability, originality, authenticity, and overall quality (all P > 0.05) when comparing computer-generated and applicant essays. CONCLUSION: Personal statements prepared by ChatGPT are indistinguishable from essays written by actual applicants. This finding suggests that the current plastic surgery application format be reevaluated to better aid in holistic evaluation of students.

Long-term efficacy of lymphovenous anastomosis for the treatment of retroperitoneal lymphangiectasia: A case report and a review of literature.

Lymphovenous anastomosis (LVA) represents an alternative treatment for retroperitoneal lymphangiectasia. In contrast to sclerotherapy or excision, which may risk lymphatic obstruction and subsequent lymphedema, LVA preserves existing lymphatic architecture and transit. This report shows long-term efficacy of LVA for functional decompression of a symptomatic pathologically dilatated retroperitoneal lymphatics. A 47-year-old female with retroperitoneal lymphangiectasia refractory to multiple percutaneous drainages and treatments with sclerosing agents underwent LVA with anastomosis of a dominant segment of retroperitoneal lymphangiectasia to the deep inferior epigastric vein. Postoperative serial magnetic resonance imaging with 3-dimensional volume calculation over the 27 months follow-up showed evidence of decompression of the lesion with patent bypass. There were no known immediate complications nor requirement of further interventions. The patient's subjective pain also decreased substantially. This report confirms long-term efficacy of LVA for retroperitoneal lymphangiectasia as an alternative to sclerotherapy and surgical excision in the setting of previously failed treatments.

Risk of Complications in Combined Plastic Surgery Procedures Using the Tracking Operations and Outcomes for Plastic Surgeons Database.

BACKGROUND: Combining multiple surgical procedures into a single operative session is widespread in the field of plastic surgery; however, the implications of this practice are not fully understood. OBJECTIVES: This study compared 30-day complication rates associated with combined plastic surgery procedures with the rates for index procedures. METHODS: This retrospective cohort analysis utilized the Tracking Operations and Outcomes for Plastic Surgeons database from 2016 to 2020 to identify the 3 most frequent combinations of augmentation mammaplasty, reduction mammaplasty, trunk liposuction, mastopexy, and abdominoplasty. RESULTS: The 30-day overall complication rate was 5.0% (1400 of 26,771 patients), with a higher complication rate for combined procedures compared with index (7.6% vs 4.2%, adjusted odd ratio [aOR], 1.91 [95% CI, 1.61-2.27], P < .001). There were no significant differences in complication rates for abdominoplasty or mastopexy combinations compared with index. Complication rates for reduction mammaplasty combinations compared with index were not statistically different after controlling for demographics (aOR, 1.02 [95% CI, 0.61-1.64], P = .93). Higher rates of minor and major complications were observed for combinations of trunk liposuction (aOR, 4.84 [95% CI, 3.31-7.21), P < .001) and augmentation mammaplasty (aOR, 1.60 [95% CI 1.13-2.22], P = .007) compared with index. CONCLUSIONS: Combinations with trunk liposuction or augmentation mammaplasty present with increased risk of complications compared with index, controlling for demographics. Abdominoplasty and mastopexy may be combined with other plastic surgery procedures without increased risk to patients. The complication risk of reduction mammaplasty combinations is mediated by other variables, suggesting the need for shared surgical decision-making when recommending these combinations to patients.

Oncologic safety of axillary lymph node dissection with immediate lymphatic reconstruction.

PURPOSE: Immediate lymphatic reconstruction (ILR) at the time of axillary lymph node dissection (ALND) can reduce the incidence of lymphedema in patients with breast cancer. The oncologic safety of ILR is unknown and has not been reported. The purpose of this study was to evaluate if ILR is associated with increased breast cancer recurrence rates. METHODS: Patients with breast cancer who underwent ALND with ILR from September 2016 to December 2020 were identified from a prospective institutional database. Patient demographics, tumor characteristics, and operative details were recorded. Follow-up included the development of local recurrence as well as distant metastasis. Oncologic outcomes were analyzed. RESULTS: A total of 137 patients underwent ALND with ILR. At cancer presentation, 122 patients (89%) had clinically node positive primary breast cancer, 10 patients (7.3%) had recurrent breast cancer involving the axillary lymph nodes, 3 patients (2.2%) had recurrent breast cancer involving both the breast and axillary nodes, and 2 patients (1.5%) presented with axillary disease/occult breast cancer. For surgical management, 103 patients (75.2%) underwent a mastectomy, 22 patients (16%) underwent lumpectomy and 12 patients (8.8%) had axillary surgery only. The ALND procedure, yielded a median of 15 lymph nodes pathologically identified (range 3-41). At a median follow-up of 32.9 months (range 6-63 months), 17 patients (12.4%) developed a local (n = 1) or distant recurrence (n = 16), however, no axillary recurrences were identified. CONCLUSION: Immediate lymphatic reconstruction in patients with breast cancer undergoing ALND is not associated with short term axillary recurrence and appears oncologically safe.

Neurotization Does not Prolong Operative Time in Free Flap Breast Reconstruction.

BACKGROUND: Neurotization during the breast reconstruction process can improve patient quality-of-life and satisfaction with reconstructive outcomes. One concern with neurotization is increased total operative time due to the need for additional dissection and nerve coaptation. The purpose of this study was to compare total operative time between neurotized and non-neurotized abdominal-based, free flap breast reconstruction. METHODS: A retrospective review was conducted of consecutive patients who underwent unilateral, abdominal-based, free flap breast reconstruction between 2016 and 2018 at a single tertiary care center. Data were collected on patient demographics, surgical techniques, and length of surgery. Data analysis was performed using chi-square test, independent t-test, and multivariate linear regression analysis. A p-value ≤0.05 was considered statistically significant. RESULTS: Seventy-three patients were included in this study. Twenty-three patients (31.50%) underwent flap neurotization (N group) and 50 (68.49%) underwent standard breast reconstruction without neurotization (NO group). The groups were similar in age, BMI, smoking status, and ASA class. No difference was found between the two groups in timing of reconstruction (p = 0.388). Average operative times were 467.73 ± 145.52 minutes and 455.28 ± 111.19 minutes for the N and NO groups, respectively, with no significant difference between the two groups (two-tailed p-value = 0.72). CONCLUSION: Seamless integration of neurotization in abdominal-based, free flap breast reconstruction is possible without significant prolongation of total operative 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 .

Mixed Reality and 3D Printed Models for Planning and Execution of Face Transplantation.

OBJECTIVE: The aim of this study was to evaluate a novel holographic craniofacial surgical planning application and its implementation throughout the planning and operative stages of facial transplantation by performing a critical analysis of comparative utility, cost, and limitations of MR and 3D printing. SUMMARY OF BACKGROUND DATA: Face transplantation is a highly complex form of craniofacial reconstruction requiring significant planning, knowledge of patient-specific spatial relationships, and time-sensitive decision making. Computer-aided 3D modeling has improved efficiency and outcomes of complex craniofacial reconstruction by enabling virtual surgical planning and 3D printed model generation. MR technology can enhance surgical planning, improve visualization, and allow manipulation of virtual craniofacial biomodels within the operative field. METHODS: Accounting for the time-sensitive nature of face transplantation, a unique, highly coordinated workflow for image acquisition and processing was designed to facilitate rapid holographic rendering and 3D printing. During recent face transplantation, both holographic and 3D printed models were utilized, and the time and cost of fabrication were compared. RESULTS: Holographic models required less time and cost for fabrication. They provided both comprehensive visualization of 3D spatial relationships and novel means to perform VSP and virtual face transplantation by interacting with and manipulating patient-specific, anatomic holograms. CONCLUSION: Time efficiency, low-cost biomodel production, provision of unlimited preoperative surgical rehearsal, and potential for intraoperative surgical guidance makes holographic VSP and MR highly promising technology for use in complex craniofacial surgery.

Lymphedema Prevention Surgery: Improved Operating Efficiency Over Time.

BACKGROUND: Lymphedema prevention surgery (LPS), which identifies, preserves, and restores lymphatic flow via lymphaticovenous bypasses (LVB), has demonstrated potential to decrease lymphedema in breast cancer patients requiring axillary lymph node dissection. Implementing this new operating technique requires additional operating room (OR) time and coordination. This study sought to evaluate the improvement of LPS technique and OR duration over time. METHODS: A prospective database of patients who underwent LPS at our institution from 2016 to 2019 was queried. Type of breast and reconstruction surgery, number of LVB performed, and OR times were collected. LPS details were compared by surgical group and year performed. RESULTS: Ninety-four patients underwent LPS, and 88 had complete OR time data available for analysis. Average age was 51 years, body mass index of 28, with an average of 15 lymph nodes removed. Reconstructive treatment groups included prosthetic reconstruction 56% (49), oncoplastic reduction 10% (9), and no reconstruction 34% (30). The number of patients undergoing LPS increased significantly from 2016 to 2019, and average number of LVB per patient doubled. In patients without reconstruction, the average time for LPS improved significantly from 212 to 87 min from 2016 to 2019 (p = 0.015) and similarly in patients undergoing LPS with prosthetic reconstruction from 238 to 160 min (p = 0.022). CONCLUSIONS: LVB is an emerging surgical lymphedema prevention technique. While requiring additional surgical time, our results show that with refinement of technique, over 4 years, we were able to perform double the number of LVB per patient in half the OR time.

Factors Influencing the Aesthetic Outcome and Quality of Life After Breast Reconstruction: A Cross-sectional Study.

BACKGROUND: The most important purpose of reconstruction is to increase or restore the patient's quality of life (QOL). The purpose of our study was to evaluate the QOL and aesthetic outcomes of patients after autologous versus implant-based breast reconstruction. METHODS: Patients who underwent breast reconstruction between 2009 and 2011 were included. The Breast-Q, a validated breast reconstruction QOL questionnaire, was used along with postoperative photographs panel analyses using a multiparameter breast-specific aesthetic outcome scale and retrospective evaluation of demographic and treatment data. RESULTS: Of 820 patients, 261 complete questionnaires were evaluated. On the multivariable linear regression, the "satisfaction with breasts" was positively influenced by autologous and bilateral reconstructions, whereas radiation therapy (RTx), the time between the reconstruction and the questionnaire, and the number of surgeries due to complications were negative factors (adjusted R = 0.183; P < 0.001). The same factors influenced the "satisfaction with the outcomes." The mean "overall breast appearance" was also positively influenced by autologous and bilateral reconstructions, and RTx and the total number of surgeries were negative predictive factors (adjusted R = 0.311, P < 0.001). CONCLUSIONS: The aesthetic result and QOL after breast reconstruction for breast cancer treatment are positively influenced by the use of autologous tissue and bilaterality. Factors that negatively influenced the aesthetic result and the QOL include use of RTx, a higher number of surgeries needed for the reconstruction, reoperations due to complications, higher body mass index, and a longer time elapsed between reconstruction and the questionnaire.

Immediate Versus Staged Soft Tissue Reconstruction After Soft Tissue Sarcoma Resection Has Similar Wound and Oncologic Outcomes.

BACKGROUND: The aim of this study was to compare the wound complication rate and oncologic outcome in patients undergoing immediate versus staged soft tissue reconstruction after soft tissue sarcoma (STS) resection. METHODS: This is a retrospective analysis of a single sarcoma referral center between 2006 and 2016 which identified a cohort that underwent resection of an extremity or trunk STS with reconstruction surgery (split thickness skin graft or flap coverage). Patients were divided into 2 groups based on the reconstruction timing: immediate (same day) versus staged (later date). Demographic characteristics, wound complications, and oncologic outcomes were compared. RESULTS: Of the 491 patients who underwent resection of an extremity or trunk STS, 81 (16%) received reconstructive surgery, with 26 patients undergoing immediate reconstruction and 55 patients undergoing staged reconstruction. Overall wound complication (58% vs 45%, P = 0.347) and infection rates (35% vs 25%, P = 0.602) were similar between immediate and staged groups, respectively. Likewise, local recurrence (8% vs 7%, P = 1.000), metastasis (19% vs 20%, P = 0.755), and all-cause mortality (27% vs 27%, P = 1.000) rates after reconstruction was similar. Patients in the staged group with positive margins after resection were re-excised before definitive reconstruction, whereas those in the immediate group were not. The staged group required fewer surgical intensive care unit stays after resection surgery (22% vs 58%, P = 0.006). The mean ± SD final follow-up was 38 ± 33 months. CONCLUSIONS: Wound complication rates and oncologic outcomes remain similar, regardless of timing for reconstruction. Staged reconstructions were associated with fewer surgical intensive care unit stays, while also affording opportunity for reintervention after positive margins with little additional morbidity.

Lymphaticovenous Bypass for Immediate Lymphatic Reconstruction in Locoregional Advanced Melanoma Patients.

BACKGROUND: Extremity lymphedema is a dreaded complication of ilioinguinal or axillary lymphadenectomy. In conventional lymph node dissection, no effort is performed to maintain or reestablish extremity lymphatic circulation. We hypothesized that immediate lymphatic reconstruction (ILR) could be a reproducible procedure to maintain functional lymphatic flow after ilioinguinal and axillary lymphadenectomy in patients with malignant melanoma. This is the first report describing prophylactic ILR in patients with melanoma who underwent complete lymph node dissection for gross nodal disease. PATIENTS AND METHODS: We report a case series of 22 malignant melanoma patients who had axillary or ilioinguinal lymph node dissection for bulky locoregional invasion with immediate lymphatic reconstruction. A novel method to identify and select lymphatics with high flow using fluorescent lymphangiogram with indocyanine green dye gradient software is described. Surgical details, common difficulties, as well as indications are discussed. Instructional videos are also provided. RESULTS: Our technique is reproducible, since we have successfully completed immediate lymphatic reconstruction in 22 cases consecutively. Intradermal indocyanine green injections allowed for visualization of 1 to 3 transected lymphatics after lymphadenectomy. An average of 1.8 lymphaticovenous bypass (range 1-3) was performed per patient. CONCLUSION: Reestablishment of lymphatic circulation after ilioinguinal or axillary lymphadenectomy in patients with melanoma characterizes a novel method that may reduce the problem of upper and lower extremity iatrogenic lymphedema. This is particularly important given the emergence of new adjuvant treatment modalities that considerably improve patients' survival after lymphadenectomy.

Axillary reverse mapping and lymphaticovenous bypass: Lymphedema prevention through enhanced lymphatic visualization and restoration of flow.

BACKGROUND: A lymphedema (LE) prevention surgery (LPS) paradigm for patients undergoing axillary lymphadenectomy (ALND) was developed to protect against LE through enhanced lymphatic visualization during axillary reverse mapping (ARM) and refinement in decision making during lymphaticovenous bypass (LVB). METHODS: A retrospective analysis of a prospective database was performed evaluating patients with breast cancer who underwent ALND, ARM, and LVB from September 2016 to December 2018. Patient and tumor characteristics, oncologic and reconstructive operative details, complications and LE development were analyzed. RESULTS: LPS was completed in 58 patients with a mean age of 51.7 years. An average of 14 lymph nodes (LN) were removed during ALND. An average of 2.1 blue lymphatic channels were visualized with an average of 1.4 LVBs performed per patient. End to end anastomosis was performed in 37 patients and a multiple lymphatic intussusception technique in 21. Patency was confirmed 96.5% of patients. Adjuvant radiation was administered to 89% of patients. Two patients developed LE with a median follow-up of 11.8 months. CONCLUSION: We report on our experience using a unique LPS technique. Refinements in ARM and a systematic approach to LVB allows for maximal preservation of lymphatic continuity, identification of transected lymphatics, and reestablishment of upper extremity lymphatic drainage pathways.

Vascularized Fibula Epiphysis Transfer for Pediatric Extremity Reconstruction: A Systematic Review and Meta-analysis.

BACKGROUND: Vascularized fibula epiphysis transfer for pediatric extremity reconstruction intends to preserve growth potential. However, few cases are reported, and outcomes are poorly characterized. METHODS: Systematic review was performed through a MEDLINE search using keywords "pediatric" or "epiphyseal" and "vascularized fibula." Patients were divided into upper extremity or lower extremity groups. Functional and growth outcomes were assessed, and indications, pedicle, complications, and need for secondary surgery were recorded. RESULTS: Twenty publications with 62 patients were included. Mean age was 5.9 years, and mean follow-up was 5.8 years. Indications included sarcoma (60%), congenital deformity (21%), trauma (13%), and infection (6%). Anterior tibial pedicle was most common (63%) and was associated with significantly improved growth outcomes compared with the peroneal pedicle (23%; P < 0.001). Fifty-three patients underwent upper extremity reconstruction, with the most common complication being fracture (35%) and most common secondary surgery flap salvage (7%). Among upper extremity patients, full function was achieved in 25% and impaired function in 75%. Full growth was observed in 63% of patients, partial growth in 31%, and no growth in 4%. Nine patients underwent lower extremity reconstruction, with the most common complication being fracture (22%) and most common secondary surgery derotational osteotomy (22%). Among lower extremity patients, full function was achieved in 44% and impaired function in 56%. Full growth was observed in 56% of patients, partial growth in 22%, and no growth in 22%. CONCLUSIONS: Vascularized fibula epiphysis transfer can accomplish full long-term growth and function. However, complications, revision surgery, and chronic impairment are common.

Long-term Outcomes of Cranioplasty: Titanium Mesh Is Not a Long-term Solution in High-risk Patients.

BACKGROUND: Titanium mesh is a popular material for cranioplasty. However, long-term outcomes of these reconstructions remain unknown. We aimed to compare long-term outcomes between patients undergoing both (1) skull reconstruction with titanium mesh and other commonly used cranioplasty materials and (2) scalp reconstructions with locoregional flaps and free tissue transfers. METHODS: A retrospective review of patients treated with 466 cranioplasties (401 patients) between 2002 and 2014 was performed. RESULTS: Materials used for reconstructions included nontitanium alloplast (52.0%), titanium mesh (38%), and autologous bone (10%). Median cranial defect size was 58.4 cm. Eighty-three reconstructions (18%) included full-thickness scalp defect with a median area of 155.4 cm. Median follow-up was 3.9 years. Retention rate for isolated cranioplasty was 90%, 89.9%, and 77.1% for titanium mesh, nontitanium alloplast, and autologous bone, respectively (P > 0.05). In composite defect cases, retention rate for autologous bone was comparable, 81.8% (P > 0.05), whereas for titanium mesh and nontitanium alloplast it was significantly lower, 46.8% and 72.0%, respectively (P < 0.05). The retention rate of titanium mesh cranioplasty with free fascio- and myocutaneous flaps was higher when compared with locoregional and free muscle flaps (P < 0.05). CONCLUSIONS: Titanium mesh offers a durable repair of isolated bone defects. However, in high-risk patients with soft-tissue defect, the outcomes are significantly worse. In these cases, free tissue transfer for soft-tissue coverage tends to be more successful, especially when using a myocutaneous or fasciocutaneous free flap. This is the first study to identify a high complication rate of this popular material, especially when it is combined with a locoregional scalp flap or free muscle flap. Therefore, in these cases, titanium mesh should be used with caution.

Quantity of Lymph Nodes in the Vascularized Lymph Node Transfer Influences Its Lymphaticovenous Drainage.

BACKGROUND: The purpose of this study was to: (1) evaluate the mechanism of lymph drainage through a vascularized lymph node (VLN) flap, and (2) investigate if the number of VLNs impacts lymph transit time through the flap. METHODS: Twenty-seven axillary VLN flaps were elevated in 14 Sprague-Dawley rats and divided into three groups (n = 9 each) based on the number of lymph nodes present: group 1 (0-VLNs), group 2 (2-VLNs), and group 3 (4-VLNs). Indocyanine green (n = 8/group) and Alexa680-albumin (n = 1/group) were injected into the edge of flaps and the latency period between injection and fluorescence in the axillary vein was recorded. Stereomicroscopic fluorescent lymphography was performed to directly visualize lymphatic transit through VLNs. RESULTS: Fluorescence was detected in the axillary vein after 229s [47-476], 79s [15-289], and 56s [16-110] in group 1, 2, and 3, respectively (p < 0.01). There was a negative correlation between the number of VLNs in the flap and the latency period (r = -0.59; p < 0.05). Median flap weights were comparable in group 1, 2, and 3 (258 mg [196-349], 294 mg [212-407], 315 mg [204-386], respectively; p = 0.54). Stereoscopic lymphography allowed direct visualization of lymphatic fluid transit through VLNs. CONCLUSION: Lymphatic fluid in VLN flaps drains into the venous system mainly by passing through the afferent lymphatics and lymph nodes. A secondary mechanism appears to be the diffusion of fluid into the venous system via intratissue lymphaticovenous connections created during flap elevation. Increasing the number of lymph nodes in the flap is associated with a more rapid transit of fluid.

Vascularized axillary lymph node transfer: A novel model in the rat.

Vascularized lymph node transfer (VLNT) is a promising microvascular free flap technique for the surgical treatment of lymphedema. To date, few experimental animal models for VLNT have been described and the viability of lymph nodes after the transfer tested. We aimed to evaluate the feasibility of axillary VLNT in the rat. Lymph node containing flaps were harvested from the axillary region in 10 Lewis rats based on the axillary vessels. Flaps were transferred to the ipsilateral groin and end-to-side microanastomosis was performed to the femoral vessels using 10-0 sutures. Indocyanine green (ICG) angiography was used to confirm flap perfusion. On postoperative day 7, flaps were elevated to assess their structure and vessel patency. Hematoxylin and eosin staining was used to confirm the presence and survival of lymph nodes. All animals tolerated the procedure well. Immediate post-procedure ICG angiography confirmed flap perfusion. No signs of ischemia or necrosis were observed in donor extremities. At postoperative day 7, all flaps remained viable with patent vascular pedicles. Gross examination and histology confirmed the presence of 3.6 ± 0.5 lymph nodes in each flap without any signs of necrosis. This study showed that the transfer of axillary lymph nodes based on the axillary vessels is feasible. The flap can be used without the need for donor animals and it contains a consistent number of lymph nodes. This reliable VLNT can be further utilized in studies involving lymphedema, transplantation, and induction of immunologic tolerance.

Dual Fluorescent Tracers for Surgical Guidance: Preventing Donor-site Lymphedema in Vascularized Lymph Node Transfer.

Introduction: Vascularized lymph node transfer (VLNT) restores physiological lymphatic function. Although effective, postoperative impairment of donor-site lymphatic function and iatrogenic lymphedema following lymph node transfer remains a pressing concern. Methods: Prospective analysis of VLNT patients undergoing dual fluorescent tracers-assisted harvest was performed at our institution from September 2013 to April 2022. Reverse lymphatic mapping of the lower extremity was performed with indocyanine green (ICG). Blue dye was utilized in both white light and near-infrared spectra for visualization of donor-site lymphatic structures. Demographics, intraoperative details, and surgical outcomes were recorded. Results: Twenty-five patients were included. Median age was 52.9 years with a body mass index of 29.1 kg/m2 and mean follow-up of 44 months (range 24 to 90 months). Lymphedema stage ranged from Campisi 2 to 4. Inguinal VLNT was performed in 13 patients, and 12 patients received combined VLNT and free flap breast reconstruction. No patients required change in lymph node donor site intraoperatively. All ICG stained nodes were preserved in situ. No cases of iatrogenic lower extremity lymphedema were observed. Postoperative bioimpedance spectroscopy, circumferential, and volumetric measurements of the donor-site limb did not show evidence of subclinical or clinical lymphedema. The donor site healed appropriately in 92% of patients; one patient developed methylene blue-induced skin necrosis. Conclusion: Reverse lymphatic mapping and surgical guidance with dual ICG and blue dye fluorescent tracers provides surgeons with real-time surgical guidance without radioisotope, improves surgical visualization in both white light and near-infrared spectra, and avoids iatrogenic lymphatic dysfunction in the donor limb.

Beauty Is in the Eye of the Beholder: Factors Influencing Disparity in Perceptions of Breast Reconstruction Aesthetic Outcomes.

BACKGROUND: Patient-reported outcomes are the primary measurement of breast reconstruction success, but results may be affected by nontechnical factors such as socioemotional determinants. Third-party observers provide an independent assessment of aesthetic outcomes. Factors associated with disparity between patient and observer perceptions of outcomes are not well understood. METHODS: One hundred forty-seven patients underwent breast reconstruction at the authors' institution between 2009 and 2011, completed the BREAST-Q, and had photographs graded by a diverse panel using the Validated Breast Aesthetic Scale. Patient satisfaction with breasts scores that aligned with observer scores were categorized as group 2; patient satisfaction that exceeded observer scores were group 1; and those lower than observer scores were group 3. Statistical analysis was performed using SPSS, with values of p < 0.05 considered statistically significant. RESULTS: Twenty-eight patients (19 percent) were categorized as group 1, 93 (63 percent) in group 2, and 26 (18 percent) in group 3. Median overall appearance was highest in group 3 (median, 4.0; interquartile range, 4 to 4) and lowest in group 1 (median, 3.0; interquartile range, 2 to 3) ( p < 0.001). Psychosocial, sexual, and physical well-being were significantly associated with disparity (group 1 or 3 status) ( p < 0.01). Satisfaction with outcomes, nipples, abdomen, and breasts were significantly associated with disparity. Factors not significantly associated with disparity include age, body mass index, autologous or implant-based, adjuvant therapies, and timing of reconstruction. CONCLUSIONS: Incongruously high patient satisfaction with breast reconstruction aesthetics relative to third-party perception of aesthetic outcomes is associated with high quality-of-life scores. Incongruously low patient satisfaction with breast cosmesis compared with higher third-party perceptions was associated with low quality-of-life scores. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Skeletal and Dental Outcomes after Facial Allotransplantation: The Cleveland Clinic Experience and Systematic Review of the Literature.

BACKGROUND: Most of the literature surrounding face transplantation focuses on technique, immunology, and psychology. Dental and skeletal outcomes remain persistently underreported. This study critically examined the worldwide face transplant experience to evaluate such outcomes. METHODS: A systematic review of all composite allografts containing midface and/or mandible was performed. Dental and skeletal complications were recorded. Formal imaging and photographs available in the literature were analyzed using skeletal measurements, soft-tissue cephalometrics, and the Angle classification. Outcomes of our face transplant patients, including condylar assessment and airway volume measurements, is also presented. RESULTS: Twenty-five patients received allografts containing midface (n = 7) or mandible (n = 2), whereas 16 contained a double-jaw. All midface-only transplants developed skeletal deformity; 57 percent developed a palatal fistula. Both partial and full arch transplantation patients developed skeletal deformity. Among double-jaw transplants, 69 percent developed palatal fistula or floor-of-mouth dehiscence, 66 percent developed malocclusion, 50 percent developed trismus, and 31 percent required corrective orthognathic surgery. In 40 percent of patients, malocclusion recurred after corrective orthognathic surgery. Forty percent of all patients developed dental cavities or periodontal disease. All of our patients received midface and/or mandible. One patient required corrective orthognathic surgery. Midfacial segments showed clockwise rotation. Airway volumes decreased over time. CONCLUSIONS: Skeletal and dental complications remain extremely common after facial allotransplantation involving either single- or double-jaw composites. Corrective orthognathic surgery and dental extraction is often necessitated. These data will aid face transplant teams during surgical planning and preoperative counseling. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.