Inferolateral Pectoralis Sling Technique for Augmentation Mastopexy.

BACKGROUND: Augmentation mastopexy remains a challenging procedure. The goal is to achieve correction of breast ptosis whilst adding implant volume, and avoid complications of premature waterfall deformity, bottoming out and further revision surgery, particularly when using smooth implants. We aim to describe and evaluate a technique to reduce implant malposition in augmentation mastopexy. METHODS: This is a technical description and retrospective review of a single surgeons' cases from 2019 to 2022 of all patients who underwent 1 stage subpectoral breast augmentation mastopexy with the inferolateral pectoralis sling. RESULTS: Over the four year period, 284 patients (568 breasts) underwent augmentation mastopexy with the inferior pectoralis sling. Mean implant size was 360.7cc (range 180-625cc). There were no early complications and 6 (2.1%) patients had late minor complications, with five (1.8%) undergoing revision mastopexy with implant repositioning and 1 (0.4%) undergoing areola scar revision. 20 patients (7%) underwent an implant upsize procedure with the average volume increase being 218.5cc and the average time to upsize 13.6 months (range 6-36 months) CONCLUSIONS: Use of the inferolateral pectoralis muscle sling allows successful one stage augmentation mastopexy with low complication and revision rates. 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 .

FAM-Fat Augmentation Mastopexy: A Method to Avoid Implants.

BACKGROUND: Despite high complication rates, patients persistently present for single-stage augmentation mastopexy. In empty, deflated breasts, we perform one-stage augmentation mastopexy; however, in heavy ptotic breasts, our preference is to stage the procedure with mastopexy and fat graft first. With volume from fat grafting focussing on the upper pole and cleavage areas, many of our patients avoid implants altogether. This reduces subsequent risks of waterfall deformity, implant displacement, rupture and a lifetime of implant exchanges. OBJECTIVES: We aim to describe our findings and technique for reducing progression to the second stage of a two-stage augmentation mastopexy with the appropriate use of moderate to high volume of fat grafting at the primary operation. METHODS: This is a retrospective review of all patients who presented to the senior author (KT) requesting breast implants and requiring mastopexy, from January 2018 to December 2022. RESULTS: Over the five-year period, 137 patients were identified. Seventy-one (51.8%) underwent single-stage augmentation mastopexy, 55 (40.1%) underwent mastopexy with fat grafting and 11 (8.0%) underwent mastopexy with no fat grafting. Our key finding in this study is that 52 of 66 (78.8%) of planned staged patients, who underwent mastopexy with or without fat grafting, were happy with the volume attained and no longer wished to undergo further implant augmentation. CONCLUSION: In selected patients, appropriate volume and position of fat grafting at the time of primary mastopexy can significantly obviate the need for a second stage implant (alloplastic) augmentation. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

An Algorithm for Correction of Mild Tuberous Breast Deformity in Augmentation Mammaplasty: Camouflage or Correct?

BACKGROUND: Tuberous breast deformity (TBD) is a common abnormality, particularly in patients presenting for breast augmentation. Failure to correct each regional abnormality, including the inframammary fold, lower pole deficiency, nipple-areola complex widening or herniation, or any degree of ptosis, will result in exaggeration of the deformity and a poor aesthetic outcome. OBJECTIVES: To describe an algorithm, including novel techniques, to address each region of mild TBD in patients undergoing breast augmentation. METHODS: This is a retrospective review and description of the senior author's (K.T.) techniques for correction of early-stage TBD from 2016 to 2021. RESULTS: One hundred forty-two patients underwent a stepwise approach to correct milder TBD features when undergoing breast augmentation. CONCLUSIONS: The authors propose a regional algorithm for management of TBD, to allow mostly single-stage correction, except in cases with marked ptosis, severe asymmetry, or marked macroareola.

Topical Tranexamic Acid in Primary Breast Augmentation Surgery: Short- and Long-term Outcomes.

BACKGROUND: Breast augmentation mammaplasty (BAM) remains the most popular cosmetic procedure done worldwide. Bleeding in this procedure increases the chance of capsular contracture. Tranexamic acid (TXA), an antifibrinolytic, has been widely used by other surgical specialties to reduce bleeding. OBJECTIVES: We aimed to evaluate the use of TXA in BAM surgery. METHODS: This was a single-surgeon case series of all patients who underwent primary BAM from March 2017 to March 2018 and received topical TXA spray to the implant pocket before implant insertion. Early postoperative complications and long-term outcomes, such as capsular contracture and revisional surgery, were recorded and described. RESULTS: Two hundred and eighty-eight patients were included in the study with an overall complication rate of 2.8% over 5 years. No patients had postoperative bleeding or hematoma formation. One patient had a seroma, managed with ultrasound drainage. Complications requiring reoperation included rippling (3, 1.0%), pocket revision (2, 0.7%), capsule contracture (1, 0.3%) and rupture (1, 0.3%). CONCLUSIONS: This study highlights the safety and potential benefits of the use of topical TXA in breast augmentation, with low bleeding and capsular contracture rates.

Free Flap Monitoring, Salvage, and Failure Timing: A Systematic Review.

BACKGROUND: Microsurgical free tissue transfer has become a reliable technique with success rates around 99% and around 5% requiring exploration for vascular compromise. Protocols for flap monitoring between plastic surgery units vary. We aimed to elucidate the time period when monitoring is crucial for flap salvage. METHODS: A systematic search of literature was performed in PubMed, Cochrane Library, Medline, and Scopus databases from 1966 to July 2018 according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, identifying 3,844 studies with mention of free flap and monitoring or timing or salvage or compromise. Studies were screened for relevance according to predetermined inclusion criteria. Data was extracted from included studies relating to flap type, monitoring, timing and reason for failure, and success of salvage intervention. RESULTS: A total of 109 studies featuring 44,031 free flaps were included. A total of 2,549 (5.8%) flaps required return to theater for compromise; 926 (2.1%) were lost and 1,654 (3.7%) were salvaged. In the first 24 hours postoperatively 93.8% of explored flaps are successfully salvaged, by day 2: 83.33%, day 3: 12.1%, and beyond day 4: none were successful. Of the 355 flaps where the cause of failure was reported, 59.5% was venous, 27.9% was arterial, 2.3% was a combination of both, and 10.2% was hematoma or infection. The proportion of flap failures at various recipient sites was highest in the trunk/viscera (7%, 95% confidence interval [CI] 0.00, 0.36), followed by limbs (5%, 95% CI 0.02, 0.08), head and neck (3%, 95% CI 0.02, 0.04), and breast (<1%; 95% CI 0.00, 0.02). CONCLUSION: Close flap monitoring is of most value in the first 48 hours postoperatively, facilitating rapid detection of vascular compromise, early salvage, and better outcomes. The location of the flap has implications on its success and certain recipient sites may need particular attention to improve chances of success.

Technique for Management of Aplasia Cutis Congenita of the Scalp With a Skin Allograft.

Aplasia cutis congenital is a rare condition presenting with localized or widespread congenital absence of skin, most commonly affecting the scalp. Its management remains controversial due to risks associated with both conservative and surgical approaches. The authors report a new technique to manage a large area of aplasia cutis congenital on a newborn's scalp, initially 5.5 cm × 6 cm, with a single skin allograft application. This is a simple procedure, which can be performed on a ward without need for anaesthetic and led to complete epithelialization of the skin defect.

Pleomorphic dermal sarcoma of the scalp - A single-centre experience.

BACKGROUND: Pleomorphic dermal sarcoma (PDS) of the scalp is a rare tumour which is usually slow growing, but occasionally displays rapid growth and has a low rate of local recurrence. Surgical resection is the mainstay of treatment, with or without radiotherapy. The aim of this study is to describe the surgical approach and the additional benefit of radiotherapy to the treatment of these patients. METHODS: Retrospective, single-centre analysis of patients with PDS of the scalp that underwent surgical resection between 2007 and 2021 (n = 24). Treatment variables including depth of resection (superficial or deep to the galea aponeurotica) and adjuvant radiotherapy were investigated. RESULTS: Twenty-four patients were included in this study. Median age was 80 (range, 52-95), with a median ASA score of 3 (2-3). Sixteen (66.6 %) patients underwent surgical resection including the galea, while the rest (n = 8) did not or was not known. Radiotherapy was given in 7 (29 %) patients in which only 3 (12.5 %) were in the galeal resection group. Reasons for radiotherapy administration were concomitant SCC found at the same area of resection and close margins. In a median follow-up of was 26.2 months (range, 13.6-102.5) there was only one recurrence event. CONCLUSIONS: PDS of the scalp can be safely managed with a surgical resection if clear surgical margins are achieved without radiotherapy with good oncological outcomes.

Bilateral Thoracic Outlet Syndrome from Anomalous 8th Cervical Vertebrae Ribs.

Thoracic outlet syndrome (TOS) is a group of diverse disorders resulting from compression of neurovascular structures as they pass from the lower neck to upper limb. Neurological symptoms, such as pain, weakness, or paraesthesia, are much more common than vascular symptoms such as pallor or venous congestion. Anatomical abnormalities can contribute to this condition. Thirty percent of patients with TOS can have a cervical rib, arising from the transverse process of the 7th cervical vertebra, compared with 1% of the general population. We report the first case in the literature of neurogenic TOS from a cervical rib arising from a supernumerary 8th cervical vertebra. This patient had immediate improvement in TOS symptoms following scalene muscle surgery and resection of cervical and first thoracic ribs.

Management of pleomorphic dermal sarcoma.

BACKGROUND: Pleomorphic dermal sarcoma (PDS) is a rare, poorly defined skin neoplasm with features similar to atypical fibroxanthoma, but with adverse histopathological characteristics indicating metastatic potential such as tumour necrosis, invasion beyond superficial subcutis or vascular and/or perineural infiltration. Optimal treatment for PDS is uncertain and reported outcomes vary due to the rarity of this diagnosis and uncertainty over histopathological categorization. The aim of this study was to review the clinical and histopathological features of PDS in a single Australian centre. METHODS: A retrospective review of all patients managed at the Peter MacCallum Cancer Centre with PDS between 2003 and 2017 was performed by a search of electronic records and histories reviewed. RESULTS: A total of 27 patients were identified, mostly elderly males (85.2%, mean age 79.8 years). Lesions were seen most commonly on the head and neck region (96.3%), predominantly on the scalp (63%). Mean tumour radial surgical excision margin was 12.8 mm. Eighteen patients (66.7%) underwent radiotherapy; 13 adjuvant, three neoadjuvant and two with palliative intent. After median follow-up of 46.4 months, two patients had recurrence (7.4%); both had inadequate deep margins at first excision. There were three all-cause deaths in the cohort. There was one disease-specific mortality with metastatic PDS disease at the time of initial presentation. CONCLUSION: PDS is a rare cutaneous malignancy most commonly found in the head and neck region in elderly men, which is best managed with adequate surgical excision. The role of radiotherapy is undefined and an area for future investigation.

Propeller flap reconstruction of irradiated sarcoma defects: A comparison✰.

INTRODUCTION: The treatment for soft tissue sarcomas has evolved to include radiotherapy, wide local excision and plastic surgical reconstruction. Goals for the reconstruction of these irradiated defects are the introduction of non-irradiated healthy tissue, tension-free closure and obliteration of potential dead space. Although many defects once required free tissue transfer for reconstruction, greater knowledge of anatomical vascular pattern has led to the increasing use of propeller perforator flaps, islanded and transposed into the defect. Propeller flap outcomes for the reconstruction of irradiated skin defects have only been reported in case reports. We evaluated the use of propeller perforator flaps at St Vincent's Hospital Melbourne in a series of patients for the reconstruction of irradiated sarcoma defects. METHODS: All patients who underwent sarcoma resection with plastic surgical reconstruction at St Vincent's Hospital from January 2009 to February 2017 were identified from unit audits and medical record data and compared depending on the type of reconstruction. Propeller perforator flaps were evaluated compared to other methods of reconstruction. RESULTS: Thirty-nine cases involved single perforator propeller flaps for reconstruction. The frequency of propeller flap reconstruction has greatly increased from 3 in their first year of use in 2013 to 12 in 2015. Most propeller flaps were used to reconstruct thigh defects (43.6%) followed by shoulder defects (17.9%). Generally the defects were smaller (138.7 cm2) than free flaps (214.2 cm2), and the usual composition of the defect was skin and subcutaneous tissue only. Patients who underwent propeller flap reconstruction had a significantly short length of inpatient stay (p < 0.01), and there were no total failures. CONCLUSION: Propeller perforator flaps are useful for the reconstruction of irradiated defects in sarcoma reconstruction surgery, particularly small- to moderate-sized fasciocutaneous defects. They offer less morbidity, faster recovery and better aesthetic results than free or standard pedicle flaps. The success of propeller flaps has changed the algorithm for how we approach towards the reconstruction of irradiated sarcoma defects to consider their use as the first reconstructive option for superficial sarcoma defects.

Reduction Mammaplasty: What Cup Size Will I Be?

BACKGROUND: Predicting cup size after reduction mammaplasty is a challenge well recognized by plastic surgeons. This study presents a method whereby the weight of tissue to be excised can be predicted on the basis of the initial and desired cup size. METHODS: Breast density was calculated from resection specimens. Cup volumes of a specific range of bra style were then measured by filling the bra cups with modeling clay on a mannequin and the volume measured via water displacement. These data were then correlated to breast tissue volume and weight. RESULTS: The average breast tissue density calculated was 0.98 g/ml (SD = 0.05). Bra cup volume measurements showed a steady progression according to both cup and band sizes. A table was constructed to predict the weight of tissue required for excision to achieve the desired change in cup size. CONCLUSION: These results can assist plastic surgeons in predicting the amount of breast tissue to excise to achieve a given cup size. A secondary use of these results is a breast volume guide for implant planning.

The innervated rectus abdominis flap for quadriceps reconstruction.

BACKGROUND: The vertical rectus abdominis myocutaneous (VRAM) and transverse rectus abdominis myocutaneous (TRAM) flaps have traditionally been excluded from consideration of reconstructions with functional potential, because of their segmental innervation. We present a case series that aimed to demonstrate that segmental innervation does not preclude successful neural anastomoses and can deliver a functional reconstruction of a total compartment in the anterior thigh. METHODS: This review included all patients who required total anterior thigh compartmentectomy and reconstruction between December 2009 and February 2016 were included from the first author's prospective database. RESULTS: Eleven cases were identified, with innervated rectus abdominis flaps used for anterior thigh reconstruction. During the median follow up period of 12 months, all patients had reinnervation of the rectus with six reaching M5, one M4+, one M4, two M3 and one M2, according to Medical Research Council power grades. CONCLUSION: All patients had successful functional reconstruction in the thigh using the rectus abdominis myocutaneous flap.

A systematic review of patient reported outcome measures for women with macromastia who have undergone breast reduction surgery.

Patient satisfaction and outcomes following reduction mammoplasty is important to measure, being a being a reconstructive procedure with physical and cosmetic benefits. This study aimed to evaluate patient satisfaction and the various questionnaires that have been devised for this measurement. A systematic search of literature was performed in PubMed, Cochrane Library, Medline and Scopus databases from 1966 to July 2018 according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. After application of pre-determined inclusion criteria by two authors, 95 articles were included. Data was extracted from included studies relating to demographics, surgical technique, questionnaires used and physical, psychological and aesthetic outcomes. Of the 95 studies included (9,716 patients), 58 studies (5,867 patients) reported on overall satisfaction with a mean rate of 90.26%. Researchers' own non-validated questionnaire was most commonly used in 52.6% of studies. Validated questionnaires used were most commonly the SF-36 (25.3%), Rosenberg self-esteem scale (RSES) (9.5%) and BREAST-Q (8.4%). All showed improvement in physical and mental health. Our findings suggest that women who have undergone reduction mammoplasty for breast hypertrophy report postoperative satisfaction and improvement in quality of life. Of the validated questionnaires used, a combination of those assessing both mental, physical and psychosocial health as well as breast-specific surveys were most commonly used and may provide an accurate assessment of patient outcomes.

Healing time and incidence of hypertrophic scarring in paediatric scalds.

INTRODUCTION: Scald burns, which heal in less than 14 days, are seen to be at low risk of hypertrophic scar (HTS) formation. Consequently surgery is usually reserved for scalds likely to take more than 14 days to heal. With the use of silver based dressings over the past few years, anecdotally, we have observed a tendency to improved healing of scalds with conservative management and reduced need for surgical intervention. We aimed to investigate the effect of overall healing time of paediatric scalds on HTS formation over a five-year period (2011-15). METHODS: We retrospectively identified all new patients attending the Royal Children's Hospital (RCH) burns clinic from 31st January 2011-31st July 2015. Medical histories were reviewed for burns caused by scalds. Scar quality was determined from written records or clinical photographs. Patients were compared in groups based on healing time of <10 days, 10-14 days, 15-21 days, 22-30 days or >30 days. RESULTS: We studied 322 children, of which 52 (16.1%) developed HTS. There was a significantly higher incidence of HTS with increased time to healing (mean 34.5 days compared to 12.1 days, p<0.01). There were 25 patients that underwent surgical treatment with excision or debridement and split thickness skin graft of which 21 (84%) developed HTS. Grafting offered no benefit in HTS rate in the 22-30 days to heal group. CONCLUSIONS: Our study confirms that there is a link between prolonged healing time of scald wounds and HTS. The danger of slow healing for scarring despite grafting, suggests this operation should be performed earlier than current practice to allow complete healing in less than 3 weeks.

Steam vaporizers: A danger for paediatric burns.

BACKGROUND: Steam vaporizers are used to humidify air in dry environments. They are marketed to moisten children's airway secretions and thus to help relieve symptoms associated with upper respiratory tract infections. Unfortunately the steam emitted from the unit can also pose a significant risk of burns to children. Our study aimed to ascertain patterns of injury and treatment outcomes from steam burns resulting from these devices. Potential preventative measures are discussed. METHODS: Children who had sustained vaporizer scald burns were identified at the outpatient burns clinic over a 10-month period (November 2014-August 2015). Medical records were reviewed retrospectively and data collected on pattern of injury, management and outcomes. RESULTS: Ten children were treated for vaporizer steam burns over the study period. The mean age was 1.6 years and 8 (80%) patients were male. Operative intervention was undergone in 5 (50%) cases; four acutely and one as a secondary reconstructive procedure. Hand burns accounted for 8 (80%) of cases. CONCLUSIONS: Steam vaporizers can cause significant burns in the paediatric population. Toddlers were most at risk, frequently sustaining hand burns that underwent skin grafting. Greater public awareness of the danger is indicated and measures to prevent such injuries should be addressed by appropriate authorities.

A Prognostic Dilemma of Basal Cell Carcinoma with Intravascular Invasion.

Basal cell carcinoma is the most common malignancy; however, it very rarely metastasizes. Despite the low mortality caused by this cancer, once it spreads, it has dim prognosis. We report a case of basal cell carcinoma with rare intravascular invasion and review the literature for risk factors and management of metastasis.

Median Nerve Trifurcation.

Median nerve trifurcation in the carpal tunnel has only rarely been described and never reported to be found at surgery. We present the first such case, highlighting a median nerve trifurcation found at carpal tunnel release. Consideration of amendment of the Lanz classification should be made to account for such cases, and surgeons should be aware of possible anatomical variations to avoid iatrogenic injury.

Mandibular reconstruction: meta-analysis of iliac- versus fibula-free flaps.

BACKGROUND: Free vascularized bone flaps are widely recognized as the optimal reconstruction for patients who undergo mandibular resection. The fibula-free flap is currently considered the gold standard, workhorse flap for mandibular reconstruction. Although previous studies have analysed individual success of each flap type, few have compared iliac- and fibula-free flaps. METHODS: A systematic review of the literature was conducted in line with the PRISMA protocol searching the PubMed and EBSCO databases. Twenty-four studies were included as per predetermined inclusion criteria. Double-arm random effect meta-analysis was conducted with STATA 12, and single-arm meta-analysis was conducted utilizing Meta-XL. RESULTS: The results of this meta-analysis confirm that there is no significant difference in total flap loss between fibula- and iliac-free flap reconstruction of mandibular defects. In terms of recipient site complication, there was a significantly higher risk of delayed healing and suture line breakdown in the iliac flap group (P = 0.05). Donor site complications showed a trend towards being higher in the fibula flap group. Osseointegrated dental implant loss in fibula flaps was higher than in iliac flaps (5.3% compared with 1.7%). CONCLUSION: Both iliac- and fibula-free flaps should be considered for use in mandibular reconstruction. We suggest the iliac crest as the first choice for mandibular angle or body defects (better contour match) or also defects requiring greater soft-tissue bulk for intra-oral lining. The fibula flap is best when bony length is required such as in subtotal or total mandibulectomy.