Surgical options for lymphedema after gynecological cancer treatment: current trends and advances.

Lower leg lymphedema is an important complication after gynecological treatment that can severely affect the quality of life of long-term survivors of these malignancies. As a chronic and progressive disease, affected patients will require life-long therapy centered on compression. Although conventional compressive treatments can be effective, they are extremely burdensome and time-consuming for most patients and adherence is challenging. With advances in the field of reconstructive microsurgery, new procedures have been developed in the past decades to help these patients in their continuous care and have been offered at many oncological centers around the world as a first line of treatment. We performed a PubMed search using the Mesh terms 'Lymphedema/surgery' and 'Lower extremity' yielding a total of 508 articles. Of these, 35 articles were included for analysis. Articles that failed to provide a comprehensive analysis of outcomes following surgical treatment, studies examining treatment for upper limb lymphedema, primary lymphedema, or lower extremity lymphedema resulting from non-gynecologic etiologies, and studies that failed to have a minimum of 6 months follow-up were excluded. A comprehensive review of these 35 articles including over 1200 patients demonstrated large variability on the outcomes reported; however, an overall benefit from these procedures was found. Surgical options including lymphovenous anastomosis, vascularized lymph node transfers, and excisional procedures can be performed in patients with lower leg lymphedema, depending on staging and findings in indocyanine green lymphography. Surgical treatment of lymphedema is an effective option that can improve symptoms and quality of life of patients suffering from lymphedema following gynecologic cancers.

The Use of Machine Learning for Predicting Complications of Free-Flap Head and Neck Reconstruction.

BACKGROUND: Machine learning has been increasingly used for surgical outcome prediction, yet applications in head and neck reconstruction are not well-described. In this study, we developed and evaluated the performance of ML algorithms in predicting postoperative complications in head and neck free-flap reconstruction. METHODS: We conducted a comprehensive review of patients who underwent microvascular head and neck reconstruction between January 2005 and December 2018. Data were used to develop and evaluate nine supervised ML algorithms in predicting overall complications, major recipient-site complication, and total flap loss. RESULTS: We identified 4000 patients who met inclusion criteria. Overall, 33.7% of patients experienced a complication, 26.5% experienced a major recipient-site complication, and 1.7% suffered total flap loss. The k-nearest neighbors algorithm demonstrated the best overall performance for predicting any complication (AUROC = 0.61, sensitivity = 0.60). Regularized regression had the best performance for predicting major recipient-site complications (AUROC = 0.68, sensitivity = 0.66), and decision trees were the best predictors of total flap loss (AUROC = 0.66, sensitivity = 0.50). CONCLUSIONS: ML accurately identified patients at risk of experiencing postsurgical complications, including total flap loss. Predictions from ML models may provide insight in the perioperative setting and facilitate shared decision making.

Outcomes of Complex Abdominal Wall Reconstruction After Oncologic Resection: 14-Year Experience at an NCI-Designated Cancer Center.

BACKGROUND: Outcomes studies for abdominal wall reconstruction (AWR) in the setting of previous oncologic extirpation are lacking. We sought to evaluate long-term outcomes of AWR using acellular dermal matrix (ADM) after extirpative resection, compare them to primary herniorrhaphy, and report the rates and predictors of postoperative complications. METHODS: We conducted a retrospective cohort study of patients who underwent AWR after oncologic resection from March 2005 to June 2019 at a tertiary cancer center. The primary outcome was hernia recurrence (HR). Secondary outcomes included surgical site occurrences (SSOs), surgical site infection (SSIs), length of hospital stay (LOS), reoperation, and 30-day readmission. RESULTS: Of 720 consecutive patients who underwent AWR during the study period, 194 (26.9%) underwent AWR following resection of abdominal wall tumors. In adjusted analyses, patients who had AWR after extirpative resection were more likely to have longer LOS (ß, 2.57; 95%CI, 1.27 to 3.86, p < 0.001) than those with primary herniorrhaphy, but the risk of HR, SSO, SSI, 30-day readmission, and reoperation did not differ significantly. In the extirpative cohort, obesity (Hazard ratio, 6.48; p = 0.003), and bridged repair (Hazard ratio, 3.50; p = 0.004) were predictors of HR. Radiotherapy (OR, 2.23; p = 0.017) and diabetes mellites (OR, 3.70; p = 0.005) were predictors of SSOs. Defect width (OR, 2.30; p < 0.001) and mesh length (OR, 3.32; p = 0.046) were predictors of SSIs. Concomitant intra-abdominal surgery for active disease was not associated with worse outcomes. CONCLUSIONS: AWR with ADM following extirpative resection demonstrated outcomes comparable with primary herniorrhaphy. Preoperative risk assessment and optimization are imperative for improving outcomes.

Long-term Surgical and Patient-Reported Outcomes Comparing Skin-Preserving, Staged Versus Delayed Microvascular Breast Reconstruction.

BACKGROUND: Skin-preserving, staged, microvascular, breast reconstruction often is preferred in patients requiring postmastectomy radiotherapy (PMRT) but may lead to complications. We compared the long-term surgical and patient-reported outcomes between skin-preserving and delayed microvascular breast reconstruction with and without PMRT. METHODS: We conducted a retrospective, cohort study of consecutive patients who underwent mastectomy and microvascular breast reconstruction between January 2016 and April 2022. The primary outcome was any flap-related complication. The secondary outcomes were patient-reported outcomes and tissue-expander complications. RESULTS: We identified 1002 reconstructions (672 delayed; 330 skin-preserving) in 812 patients. Mean follow-up was 24.2 ± 19.3 months. PMRT was required in 564 reconstructions (56.3%). In the non-PMRT group, skin-preserving reconstruction was independently associated with shorter hospital stay (ß - 0.32, p = 0.045) and lower odds of 30-days readmission (odds ratio [OR] 0.44, p = 0.042), seroma (OR 0.42, p = 0.036), and hematoma (OR 0.24, p = 0.011) compared with delayed reconstruction. In the PMRT group, skin-preserving reconstruction was independently associated with shorter hospital stay (ß - 1.15, p < 0.001) and operative time (ß - 97.0, p < 0.001) and lower odds of 30-days readmission (OR 0.29, p = 0.005) and infection (OR 0.33, p = 0.023) compared with delayed reconstruction. Skin-preserving reconstruction had a 10.6% tissue expander loss rate and did not differ from delayed reconstruction in terms of patient-reported satisfaction with breast, psychosocial well-being, or sexual well-being. CONCLUSIONS: Skin-preserving, staged, microvascular, breast reconstruction is safe regardless of the need for PMRT, with an acceptable tissue expander loss rate, and is associated with improved flap outcomes and similar patient-reported quality of life to that of delayed reconstruction.

Treatment of multiple limb lymphedema with combined supermicrosurgical techniques.

INTRODUCTION: Lymphedema surgery including lymphovenous anastomosis (LVA) and vascularized lymph node transfer (VLNT) are effective treatments for lymphedema; however, treating multiple limbs in a single operation using both approaches has not been described. We hypothesize multiple limb lymphedema can be treated effectively in one operation. PATIENT AND METHODS: Retrospective review of seven patients undergoing extreme lymphedema surgery (mean age: 53.2 years; range: 33-66 years) with an average BMI of 34.8 kg/m2 (range: 17.6-53.6 kg/m2 ). Two patients developed bilateral upper extremity (UE) lymphedema secondary to breast cancer treatment, three had bilateral lower extremity (LE) lymphedema, and two suffered from lymphedema of all four extremities due to breast cancer treatment. RESULTS: One patient with bilateral UE lymphedema was treated with bilateral inguinal node transfers with LVA and the other with combined bilateral DIEP flaps and inguinal node transfers with LVA. Three patients had bilateral LE lymphedema: two were treated with split omental/gastroepiploic nodes, and one underwent simultaneous supraclavicular and submental node transfers. LVAs were performed in one leg in each patient. Two patients with four-limb lymphedema underwent bilateral inguinal node transfers with DIEP flaps and bilateral LE LVA. In total, there were eight UE and 10 LE treated. Average follow-up was 15.8 months (range: 12.6-28.4 months), all patients reported subjective improvement in symptoms, were able to decrease use of compression garments and pumps, and no patients developed cellulitis. CONCLUSION: Patients suffering from lymphedema of multiple extremities can be treated safely and effectively combining both LVA and VLNT in a single operation.

The combined profunda artery perforator-gracilis flap for immediate facial reanimation and resurfacing of the radical parotidectomy defect.

BACKGROUND: A radical parotidectomy with facial nerve sacrifice results in facial nerve paralysis as well as a volume and often cutaneous defect. Prior experience with nerve grafting and static suspension has yielded suboptimal results. The present report aims to examine the feasibility and outcomes of a combined free gracilis and profunda artery perforator (PAP) flap from a single donor site can reconstruct these extensive defects and potentially restore dynamic facial reanimation even in the setting of adjuvant radiation. PATIENTS AND METHODS: A retrospective review of 10 patients (6 males and 4 females) was performed from 2016 to 2020 that underwent a combined PAP-gracilis reconstruction of a radical parotidectomy defect. All patients (mean age: 71.3 years; range: 52-83 years) received adjuvant radiation. A chimeric PAP-gracilis flap requiring a single microvascular anastomosis was performed in three patients while the remaining patients underwent a double free flap reconstruction. RESULTS: The gracilis flap was innervated using the facial nerve stump, spinal accessory and massecteric nerve in three patients each. One patient's gracilis was innervated using the hypoglossal nerve. Three patients also underwent nerve grafting of the facial nerve. One patient was taken back to the operating room for a hematoma in the recipient site and there were not flap losses of either the PAP or gracilis flap. Two patients had delayed wound healing of the donor site that healed with conservative management. Average follow-up was 11.1 months (range: 8.1-19.5 months). Six patients were able to achieve dynamic animation while the others obtained a static reconstruction and did not have issues with drooling, eating, or speaking. CONCLUSIONS: Immediate functional muscle transfer can potentially restore dynamic facial reanimation even following radiation. Combining reconstruction using a PAP-gracilis flap addresses the soft tissue deficit and facial paralysis using a single donor site in a single operation.

The Cost Utility of Virtual Surgical Planning and Computer-Assisted Design/Computer-Assisted Manufacturing in Mandible Reconstruction Using the Free Fibula Osteocutaneous Flap.

BACKGROUND: The use of virtual surgical planning and computer-assisted design and computer-assisted manufacturing (CAD/CAM) has become widespread for mandible reconstruction with the free fibula flap. However, the cost utility of this technology remains unknown. METHODS: The authors used a decision tree model to evaluate the cost utility, from the perspective of a hospital or insurer, of mandible reconstruction using CAD/CAM relative to the conventional (non-CAD/CAM) technique for the free fibula flap. Health state probabilities were obtained from a published meta-analysis. Costs were estimated using 2018 Centers for Medicare and Medicaid Services data. Overall expected cost and quality-adjusted life-years (QALYs) were assessed using a Monte Carlo simulation and sensitivity analyses. Cost effectiveness was defined as an incremental cost utility ratio (ICUR) less than the empirically accepted willingness-to-pay value of $50,000 per QALY. RESULTS: Although CAD/CAM reconstruction had a higher expected cost compared with the conventional technique ($36,487 vs. $26,086), the expected QALYs were higher (17.25 vs. 16.93), resulting in an ICUR = $32,503/QALY; therefore, the use of CAD/CAM in free fibula flap mandible reconstruction was cost-effective relative to conventional technique. Monte Carlo sensitivity analysis confirmed CAD/CAM's superior cost utility, demonstrating that it was the preferred and more cost-effective option in the majority of simulations. Sensitivity analyses also illustrated that CAD/CAM remains cost effective at an amount less than $42,903 or flap loss rate less than 4.5%. CONCLUSION: This cost utility analysis suggests that mandible reconstruction with the free fibula osteocutaneous flap using CAD/CAM is more cost effective than the conventional technique.

Innovative Strategies in Microvascular Head and Neck Reconstruction.

The field of reconstructive microsurgery has witnessed considerable advancements over the years, driven by improvements in technology, imaging, surgical instruments, increased understanding of perforator anatomy, and experience with microsurgery. However, within the subset of microvascular head and neck reconstruction, novel strategies are needed to improve and optimize both patient aesthetics and post-operative function. Given the disfiguring defects that are encountered following trauma or oncologic resections, the reconstructive microsurgeon must always aim to innovate new approaches, reject historic premises, and challenge established paradigms to further achieve improvement in both aesthetic and functional outcomes. The authors aim to provide an up-to-date review of innovations in head and neck reconstruction for oncologic defects.

Evolution of Medical Modeling and 3D Printing in Microvascular Midface Reconstruction: Literature Review and Experience at MD Anderson Cancer Center.

Reconstruction of the midface represents a challenge for reconstructive microsurgeons given the formidable task of restoring both aesthetics and functionality. In particular, preservation of proper globe positioning and maintaining normal vision are as important as restoring the proper projection of the midface and enabling a patient to speak and eat as normally as possible. The introduction of virtual surgical planning (VSP) and medical modeling has revolutionized bony reconstruction of the craniofacial skeleton; however, the overwhelming majority of studies have focused on mandibular reconstruction. Here, we introduce some novel advances in utilizing VSP for bony reconstruction of the midface. The present review aims (1) to provide a review of the literature on the use of VSP in midface reconstruction and (2) to provide some insights from the authors' early experience.

Impact of Body Mass Index on Surgical Outcomes in Oncologic Microvascular Head and Neck Reconstruction.

BACKGROUND: Despite increasing recognition, obesity continues to represent a major health issue for millions of people in the USA and worldwide. There is a paucity in the literature regarding the effect of body mass index (BMI) on microsurgical head and neck reconstruction. The present study hypothesized that high BMI is predictive of postoperative recipient- and donor-site complications with longer operative times. PATIENTS AND METHODS: Retrospective review of patients who underwent free flap surgery for head and neck reconstruction was performed between January 2005 and December 2018. Patients were categorized into four groups based on BMI: < 20 kg/m2, 20-30 kg/m2, 30-40 kg/m2, and ≥ 40 kg/m2. Patient characteristics and surgical outcomes were compared between the four groups. RESULTS: Overall, 4000 free flap surgeries were included in the present study, performed on 3753 patients, of whom 9.9% had a BMI < 20 kg/m2, 64.9% had a BMI between 20 and 30 kg/m2, 21.6% had a BMI between 30 and 40 kg/m2, and 3.6% had a BMI ≥ 40 kg/m2. After adjusting for potential confounders, multivariate analysis showed no association between BMI and any complication, major recipient complications, or total flap loss. However, multivariate linear regression model showed BMI 30-40 kg/m2 and BMI ≥ 40 kg/m2 to be independently associated with longer operative times compared with BMI < 20 kg/m2. CONCLUSION: Obesity and high BMI increase operative times; however, with meticulous surgical technique and diligent postoperative care, microvascular head and neck reconstructions can be performed safely and reliably in the majority of patients regardless of BMI with similar overall, recipient-site, and donor-site complications.

Lymphedema in Inflammatory Breast Cancer Patients Following Trimodal Treatment.

BACKGROUND: Breast cancer-related lymphedema (BCRL) is a debilitating sequela of breast cancer treatment and is becoming a greater concern in light of improved long-term survival. Inflammatory breast cancer (IBC) is a rare and aggressive malignancy for which systemic therapy, surgery, and radiotherapy remain the standard of care, thereby making IBC patients highly susceptible to developing BCRL. This study evaluated BCRL in IBC following trimodal therapy. METHODS: IBC patients treated from 2016 to 2019 were identified from an institutional database. Patients were excluded if they presented with recurrent disease, underwent bilateral axillary surgery, did not complete trimodal therapy, or were lost to follow-up. Demographic, clinicopathologic factors, oncologic outcomes, and perometer measurements were recorded. BCRL was defined by clinician diagnosis and/or objective perometer measurements when available. Time to development of BCRL and treatment received were captured. RESULTS: Eighty-three patients were included. Median follow-up was 33 months. The incidence of BCRL was 50.6% (n = 42). Mean time to BCRL from surgery was 13 (range 2-24) months. Demographic and clinicopathologic features were similar between patients with and without BCRL with exception of higher proportion receiving delayed reconstruction in the BCRL group (38.1% vs. 14.6%, p = 0.03). Forty patients (95.2%) underwent BCRL treatment, which included physical therapy (n = 39), compression (n = 38), therapeutic lymphovenous bypass (n = 13), and/or vascularized lymph node transfer (n = 12). CONCLUSIONS: IBC patients are at high-risk for BCRL after treatment, impacting 51% of patients in this cohort. Strategies to reduce or prevent BCRL and improve real-time diagnosis should be implemented to better direct early management in this patient population.

Surgical and Ophthalmologic Outcomes of Reconstruction in Patients Treated With Eye-Sparing Surgery and Radiation Therapy for Tumors of the Lacrimal Drainage Apparatus.

INTRODUCTION: Tumors involving the lacrimal drainage apparatus can be effectively treated with oncologic eye-sparing resection, immediate reconstruction, and adjuvant radiation. The extirpative technique is well described, whereas the reconstructive approach and outcomes are limited and largely anecdotal. The present study describes the largest series in the literature evaluating outcomes after reconstruction after globe-preserving oncologic resection. METHODS: A retrospective review was performed for all patients undergoing reconstruction after resection of lacrimal gland tumors from 2008 to 2019. Reconstruction and ophthalmologic outcomes were assessed. RESULTS: Of the 17 patients included, 2 underwent complex repair, 6 were reconstructed with a locoregional flap, and 9 underwent free flap reconstruction. All patients were treated with adjuvant radiation therapy. The median follow-up was 19 months (range, 5-126 months). Defects reconstructed with free flaps had lower rates of wound dehiscence and fistula formation compared with those reconstructed with other techniques (11% vs 25%, P = 0.45). Patients undergoing reconstruction with free tissue transfer also tended to have lower rates of ectropion, keratopathy and decreased visual acuity compared with those undergoing nonmicrosurgical reconstruction (33% vs 50%, P = 0.48; 11% vs 38%, P = 0.20; 56% vs 75%, P = 0.40, respectively). These differences were not statistically significant. CONCLUSIONS: This is the first study to compare reconstructive and functional outcomes of nonmicrosurgical reconstruction and microsurgical free tissue transfer in the setting of eye-sparing surgery for tumors of the lacrimal drainage apparatus. Although various reconstructive options are feasible, microsurgical free tissue transfer is often used at our center and is associated with reliable outcomes.

The Effect of Lipoaspirate Processing Technique on Complications in Autologous Fat Grafting for Breast Reconstruction: A Propensity Score Analysis Study.

BACKGROUND: The use of autologous fat grafting (AFG) is becoming increasingly common as an adjunct to breast reconstruction. However, there is a paucity of data comparing the varying processing devices. OBJECTIVES: The goal of this study was to compare the outcomes of 2 commercially available AFG processing devices. METHODS: A retrospective review was conducted of patients who underwent AFG with dual-filter (Puregraft) or single-filter (Revolve) processing systems between 2016 and 2019. Propensity score matching was utilized to adjust for confounding. A total of 38 breasts from the Puregraft group were matched with 38 breasts from the Revolve group. RESULTS: Matching was successful in achieving a similar distribution of baseline characteristics between the 2 groups. The mean number of AFG sessions was comparable between the 2 groups (P = 0.37) with a similar median total volume (Puregraft, 159 mL vs Revolve, 130 mL; P = 0.23). Complication rates were similar between the 2 devices (Puregraft, 26%; Revolve, 18%; P = 0.47). Patients with at least 1 complication had higher overall AFG volume (median, 200 mL vs 130 mL; P = 0.03) and number of sessions (mean, 2.4 vs 1.8, P = 0.009) compared with those without any postoperative complication. CONCLUSIONS: Overall complication rates were comparable between 2 commonly used, commercially available AFG processing systems, and therefore the choice of which to use should be based on surgeon preference. Future studies are underway to decipher whether either system offers superior graft retention, cosmetic, or patient-reported outcomes.

Association between postoperative complications and long-term oncologic outcomes following total laryngectomy: 10-year experience at MD Anderson Cancer Center.

BACKGROUND: Postoperative complications are an independent predictor of poor survival across several tumors. However, there is limited literature on the association between postoperative morbidity and long-term survival following total laryngectomy (TL) for cancer. METHODS: We conducted a retrospective review of all TL patients at a single institution from 2008 to 2013. Demographic and clinical data were collected and analyzed, including postsurgical outcomes, which were classified using the Clavien-Dindo system. Multivariable Cox regression analyses were performed to identify factors associated with overall survival (OS) and disease-free survival (DFS). RESULTS: A total of 362 patients were identified. The mean age was 64 years, and the majority of patients were male (81%). The median follow-up interval was 21 months. Fifty-seven percent of patients had received preoperative radiation, and 40% had received preoperative chemotherapy. Fifty-seven percent of patients underwent salvage TL, and 60% underwent advanced reconstruction (45% free flap and 15% pedicled flap). A total of 136 patients (37.6%) developed postoperative complications, 92 (25.4%) of which were major. Multivariable modeling demonstrated that postoperative complications independently predicted shorter OS (hazard ratio [HR], 1.50; 95% CI, 1.16-1.96; P = .002) and DFS (HR, 1.36; 95% CI, 1.05-1.76; P = .021). Other independent negative predictors of OS and DFS included positive lymph node status, preoperative chemotherapy, comorbidity grade, and delayed adjuvant therapy. Severity of complication and reason for TL (salvage vs primary) were not shown to be predictive of OS or DFS. CONCLUSION: Postoperative complications are associated with worse long-term OS and DFS relative to uncomplicated cases. Patient optimization and timely management of postoperative complications may play a critical role in long-term survival.

Flattening the curve in oncologic surgery: Impact of Covid-19 on surgery at tertiary care cancer center.

INTRODUCTION: Covid-19 has ushered in drastic changes to the healthcare system in order to "flatten the curve"; in particular, surgical operations that can consume vital, limited resources, not to mention the risk to staff, anesthesiologists, and surgeons. However, under unique circumstances with diligent preparation, vital oncologic operations can be performed safely. METHODS: Prospective comparison of surgical cases during the pandemic from December 2019 to May 2020 to the correlating time frame from December 2018 to May 2019. RESULTS: A significant decline in case volume was not appreciated until the United States declared a national state of emergency, allowing patients with cancer to continue to undergo curative tumor resection until then (428.3 ± 51.5 vs 166.6 ± 59.8 cases/week; P < .001). The decrease was consistent with the mean case volume during the holidays (213.8 ± 76.8 vs 166.6 ± 59.8 case/week; P = .648). Evaluation of surgical subspecialties demonstrated a significant decrease for all subspecialties with the greatest decline in sarcoma (P = .002) and endocrine (P = .001) surgeries, while vascular (P = .004) and thoracic (P = .011) surgeries had the least. CONCLUSIONS: The novel coronavirus has drastically reduced oncologic operations, but with proper evaluation of patients and allocation of resources, surgery can be performed safely without compromising the aim to flatten the curve and control the coronavirus pandemic.

Application of the ORBEYE three-dimensional exoscope for microsurgical procedures.

BACKGROUND: Advances in digital imaging, screen technology, and optics have led to the development of extracorporeal telescopes, also known as exoscopes, as alternatives to surgical loupes (SLs) and traditional operating microscopes (OMs) for surgical magnification. Theoretical advantages of the exoscope over conventional devices include improved surgeon ergonomics; superior three-dimensional, high-definition optics; and greater ease-of-use. The ORBEYE exoscope, in particular, has demonstrated early efficacy in the surgical arena. The purpose of this study was to compare the ORBEYE with conventional microscopy. METHODS: In this case-control pilot study, we compared the ORBEYE (n = 22) with conventional microscopy (n = 27) across 49 consecutive microsurgical cases during a 6-week period. Both visualization methods consisted of breast, and head and neck cases, while the ORBEYE was also used for extremity and lymphedema microsurgical cases. The ORBEYE was utilized during flap dissection and microvascular anastomosis. Baseline demographics, operative time, ischemia time, and intra- and postoperative microvascular complications were examined and compared. Attending surgeons completed an ergonomics and performance survey postoperatively comparing the ORBEYE with their previous use of SL/OM using a 5-point Likert scale. RESULTS: There was no difference in operative time (507 ± 132 min vs. 522 ± 139, p = .714), ischemia time (77.9 ± 31.4 min vs. 77.5 ± 36.0, p = .972), or microsurgical complications (0% vs. 4%, p = 1) between the ORBEYE and conventional microscopy groups. In a survey administered immediately postoperatively, surgeons reported favorable ergonomics, excellent image quality, and ease of equipment manipulation using the exoscope. CONCLUSIONS: The ORBEYE is an effective microsurgical tool and may be considered as an alternative to conventional optical magnification technology.

Pedicled descending branch latissimus dorsi mini-flap in repairing partial mastectomy defect: Shoulder functional and esthetic outcomes.

BACKGROUND: The axillary-approach pedicled descending branch latissimus dorsi (LD) mini-flap presents clear benefits in repairing partial mastectomy defects. This study assessed the functional and esthetic outcomes of this flap compared with conventional breast-conserving surgery (BCS). METHODS: From October of 2015 to March of 2017, patients with early breast cancer were enrolled and assigned to the LD group or conventional BCS (CCS) group according to the need of using the pedicled descending branch LD mini-flap for volume replacement. Muscle strength and range of motion (ROMs) of bilateral shoulders, a disabilities of the arm, shoulder and hand (DASH) questionnaire, and an esthetic evaluation were conducted in all patients at 1 year after surgery. RESULTS: Thirty-two patients were assigned in the LD group, and 28 in the CCS group. There was no significant difference in muscle strength, ROMs of the shoulder or DASH scores between LD and CCS groups. The results of esthetic survey also revealed a similarly high level of esthetics in both groups. Donor-site seroma occurred in three patients in the LD group, and no other complication was observed. CONCLUSIONS: The pedicled descending branch LD mini-flap enabled larger excision with favorable esthetics, minimal functional impairment, low rate of complications, and high level of satisfaction.

Contemporary Approach to Locally Advanced Oral Cavity Squamous Cell Carcinoma.

PURPOSE OF REVIEW: Surgical management of locally advanced oral cavity squamous cell carcinomas (OCSCC) has long been recognized as a primary treatment modality. Technological advances have led to significant improvements in our surgical approach, from improvement in the visualization of tumors to more efficient and precise reconstruction. Here, we review the latest technological advances in surgical extirpation and reconstruction of locally advanced OCSCCs. RECENT FINDINGS: The focus of technological innovation in surgical extirpation has been on improving visualization, with the use of intraoperative ultrasound for margin delineation, intraoperative navigation, narrow-band imaging, and the use of fluorescence. Though early, these are promising steps to ensuring complete resection of the cancer. Advances in reconstruction have been centered on the incorporation of computer assisted design, manufacturing, and virtual surgical planning, allowing for more complex three-dimensional defects to be expeditiously reconstructed. As these technologies are still under development, their impact on oncologic outcomes are not yet robustly defined; however, as technology continues to advance and become more widely available, new technologies will undoubtedly become integrated into enhancing surgical precision and planning.

A Prospective Pilot Study Comparing Rate of Processing Techniques in Autologous Fat Grafting.

BACKGROUND: Autologous fat grafting (AFG) is increasing in popularity to address a variety of defects. There is interest in developing techniques to harvest, process, and inject fat to improve clinical outcomes as well as operative efficiency. OBJECTIVES: The purpose of this pilot study is to compare the rate of graft processing of two commercially available systems for graft preparation. METHODS: Twenty consecutive cases using an active filtration system (system-AF) were observed followed by 20 consecutive cases using a passive filtration system (system-PF) to compare efficiency rate. Fat processing rate was quantified in milliliters/minute. RESULTS: Forty patients underwent AFG with no differences in patient characteristics between the groups. There was 1 incidence of palpable fat necrosis per group (5%). For all patients, this was the first fat grafting procedure; 20% of patients (n = 4 per group) had additional fat grafting. Overall, the rate of adipose tissue preparation was significantly higher with system-AF compared to system-PF (19.8 mL/min vs 5.3 mL/min, P ≤ 0.001). The resulting percent of graftable fat was comparable (AF: 41% vs PF: 42%; P = 0.83). CONCLUSIONS: Time and motion studies such as this provide a means to systematically document each of the steps involved in fat grafting in a reliable fashion. The authors demonstrate a significantly higher rate of lipoaspirate processing using an active filtration system compared to a passive system. Further large-scale studies of the efficacy and cost analysis of AFG are a necessary component of determining best practices in the field.