Utilization of Intraparotid Segments of Superficial Temporal Vessels for Head and Scalp Free Flap Microanastomosis: A Clinical, Histological, and Cadaveric Study.

BACKGROUND: The superficial temporal vessels (STV) are an underutilized target for head and neck microvascular reconstruction. Most surgeons regard the dissection as difficult, unreliable, and the anastomosis prone to vasospasm. The intraparotid course of the STV may provide more reliable flow without accompanying morbidity. METHODS: A retrospective review of patients who underwent head and scalp free flap reconstruction utilizing STV intraparotid segment was performed. Demographic factors such as intraoperative and postoperative complications are reported. Five bilateral cadaver heads were dissected to describe the relationship to the facial nerve. STV histology was performed on four of the cadavers, noting intraluminal diameter and vessel wall thickness. RESULTS: Thirty-nine patients underwent free flap reconstruction with anastomosis to intraparotid STVs. Defect etiology included tumor resection (71.8%), traumatic brain injury (10.3%), intracranial bleed (12.8%), and acute trauma (5.1%). Flaps transferred included anterolateral thigh (51.3%), latissimus (33.3%), thoracodorsal artery perforator (7.7%), radial forearm (2.8%), and vastus lateralis (5.1%). Two flaps (5.1%) required takeback for arterial thrombosis, with one incidence of total flap loss (2.8%). There were no instances of transient or permanent facial nerve damage nor sialocele. On cadaver dissection, three distinct vessel segments were identified. Segments 1 and 2 represented the STVs superior to the upper tragal border. Segment 3 (intraparotid segment) began at the upper tragal border and STVs enlarged with a targeted anastomosis point at an average of 16.3 mm medial and 4.5 mm inferior to the upper border of the tragus. The frontal branch coursed 11.7 mm inferior and 11.5 mm anterior to this point. On histology, the intraluminal diameter of segment 3 was significantly larger than segment 2 (1.2 vs. 0.9 mm, p = 0.007). CONCLUSION: Head and neck free flap reconstruction with microanastomosis to the intraparotid segment of STVs can be safely and reliably performed.

Gluteal Vein Anatomy: Location, Caliber, Impact of Patient Positioning, and Implications for Fat Grafting.

BACKGROUND: Deaths in gluteal autografting occur due to gluteal vein injuries, but data are lacking on the precise location and caliber of these veins. OBJECTIVES: The authors sought to present the first in vivo study of gluteal vein anatomy utilizing magnetic resonance imaging. METHODS: Magnetic resonance imaging venography of 16 volunteer hemi-sections was conducted in the supine, prone, prone with a bump (jack-knife), and left and right decubitus positions in 1 session after a single contrast administration. Caliber and course of the superior and inferior gluteal veins (SGV/IGV) were analyzed vs bony landmarks and position changes. RESULTS: The SGV has a very short submuscular course before splitting into 2 smaller branches superolaterally. The IGV runs immediately deep to the gluteus maximus in the center of the buttock as a single large trunk, on average 56 mm deep (mean 27 mm of muscle belly and 30 mm subcutaneous fat). No intramuscular or subcutaneous branches greater than 2 mm were found. In the prone position, the IGV and SGV have an average caliber of 5.96 mm and 5.63 mm. Vessel caliber decreased by 21% and 27%, respectively, in the jack-knife position and by 14% and 15% in lateral decubitus. CONCLUSIONS: The SGV and IGV are immediately deep to gluteus maximus approximately 6 cm deep with a caliber on the order of 6 mm in the prone position. The distribution of these vessels suggests there is no "safe zone" in the intramuscular or submuscular planes. The jackknife or lateral decubitus positions can decrease vein caliber by up to 27%, possibly reducing the risk of injury due to either traction or direct cannula impact.

Loss of Anti-HER-3 CD4+ T-Helper Type 1 Immunity Occurs in Breast Tumorigenesis and is Negatively Associated with Outcomes.

BACKGROUND: We previously demonstrated a progressive loss of the anti-human epidermal growth factor receptor 2 (HER2) CD4+ T-helper type 1 (Th1) response during HER2pos breast tumorigenesis. This loss is associated with residual disease following neoadjuvant therapy and increased risk of recurrence. In this study, we assessed the fate of anti-HER3 Th1 immunity during breast tumorigenesis. METHODS: Peripheral blood from 131 subjects, including healthy donors (HDs), patients with benign breast disease (BD), ductal carcinoma in situ (DCIS) and invasive breast cancer (IBC), was collected. Interferon (IFN)-γpos immune responses to four HER3-derived major histocompatibility complex (MHC) class II promiscuous peptides were tested via enzyme-linked immunosorbent (ELISPOT) assays, and three immune response parameters were compared: anti-HER3 (i) responsivity, or proportion of subjects responding to at least one peptide; (ii) repertoire, or number of responding peptides; and (iii) cumulative response, or summed peptide response. RESULTS: A significant decline in anti-HER3 Th1 response was observed going from HDs to IBC patients; patients with triple-negative breast cancer (TNBC) demonstrated the lowest responses. HDs had significantly higher Th1 responses versus estrogen receptor (ER)pos IBC and TNBC patients across all three immune parameters; HER2pos IBC patients displayed responses similar to HDs and BDs. Patients with recurrent breast cancer and residual disease following neoadjuvant therapy demonstrated significantly lower anti-HER3 Th1 immunity compared with patients without recurrence or with a pathologic complete response to neoadjuvant therapy. CONCLUSIONS: Anti-HER3 CD4+ Th1 responses decline during breast tumorigenesis, particularly in TNBC. Attempts to immunologically restore depressed responses in vulnerable subgroups may help mitigate recurrence.

Managing Groin Wounds after Infrainguinal Vascular Procedures: Examining the Reoperative Events and Complication Profile of Muscle Flap Reconstruction.

BACKGROUND: The literature has been void of large outcome studies detailing the efficacy and complication profile of muscle flap reconstruction of complex groin wounds. Furthermore, a first-line choice for muscle flap selection remains unclear. The aim of this study is 2-fold: (1) to examine the complication profile and associated risk factors following muscle flap coverage and (2) to provide a compared efficacy analysis of the sartorius muscle flap (SMF) versus the rectus femoris flap (RFF) in the treatment of wounds following an infrainguinal vascular procedure. METHODS: A retrospective review of records was performed on all patients undergoing complex groin wound reconstruction from January 2005 to September 2014. RESULTS: A total of 201 flaps were performed on 184 patients. There were no sentinel bleeding events through the course of graft salvage or perioperative morbidity beyond local wound complications. Coronary artery disease (P = 0.049), dyslipidemia (P < 0.001), diabetes (P = 0.047), and history of multiple prior infrainguinal procedures (P = 0.029) were associated with increased complications following groin wound reconstruction. There was no statistically significant difference in complications in comparing the RFF versus the SMF (27.9% vs. 38.9% respectively; P = 0.109). There was no significant difference in the rates of graft salvage in comparing the RFF versus the SMF (21.6% vs. 16.1%, respectively; P = 0.459). CONCLUSIONS: Muscle flap coverage can be safely employed for vascular graft salvage. Medical comorbidities and multiple prior infrainguinal procedures are predictive of perioperative complications. The SMF and RFF demonstrated equivocal rates of complications and graft salvage. Given that the RFF risks increased functional morbidity and necessitates a second donor site, the SMF may be considered as an effective first-line approach for reconstruction of complex groin wounds.

Bilateral Free Flap Breast Reconstruction After Unilateral Radiation: Comparing Intraoperative Vascular Complications and Postoperative Outcomes in Radiated Versus Nonradiated Breasts.

BACKGROUND: Radiation induces vessel damage and impairs tissue healing. To date, only 1 study has examined radiation's impact in autologous breast reconstruction on intraoperative vascular complications and postoperative outcomes. In this follow-up paper, we examine a larger cohort with an improved study design to better control for patient characteristics. METHODS: A database of 1780 patients who underwent autologous breast free flap reconstruction at the University of Pennsylvania's Health System between 2003 and 2014 was searched for patients who underwent bilateral breast reconstruction after unilateral radiation, returning 199 patients for review. These were then analyzed for intraoperative vascular complications as well as postoperative complications. McNemar tests were performed on all variables, comparing between radiated and nonradiated fields. RESULTS: Fields with prior radiation were significantly more likely to have any type of intraoperative vascular complication and need for arterial anastomotic revision compared to fields without prior radiation (14% versus 7%, P = 0.03 and 8% versus 3%, P = 0.04, respectively). Although there was a trend for more frequent arterial thrombosis in radiated compared to nonradiated fields, this was nonsignificant (7% versus 3%, P = 0.08). There was no significant difference in venous thrombosis or need for venous anastomotic revision. Radiated fields were significantly more likely to have postoperative wound infections compared to nonradiated fields (4% versus 0.5%, P = 0.04). There was no difference in other postoperative complications, including postoperative thrombosis, flap loss, mastectomy flap necrosis, fat necrosis, hematoma, seroma, or delayed wound healing. CONCLUSIONS: Intraoperative vascular complications and postoperative wound infections are significantly more likely to occur in autologous breast free flap reconstruction with previous radiation therapy. It is important to plan for and counsel patients that fields with previous radiation are at higher risk for these complications.

Revision Breast Reconstruction With Biologic or Synthetic Mesh: An Analysis of Postoperative Capsular Contracture Rates.

Background: Both biologic and synthetic mesh have been found to reduce the risk of capsular contracture, yet there is limited data assessing the use of these scaffold materials in revision breast reconstruction. Objectives: This investigation sought to assess the ability of either biologic or synthetic mesh to prevent capsular contracture in the revision breast reconstruction population. Methods: A retrospective chart review was conducted of implant-based revision reconstructions performed by the senior author between 2008 and 2023. Patient demographics and outcomes were assessed, including the incidence of Baker Grade III or IV capsular contractures. Results were compared between biologic and synthetic mesh groups using univariate and multivariate analysis. Results: Ninety-five breasts underwent revision reconstruction with 90 (94.7%) for correction of malposition, 4 (4.2%) for size change, and 1 (1.1%) for revision after additional oncologic breast surgery. Of these breasts, 26 (27.4%) used biologic mesh and 69 (72.6%) used synthetic mesh. Capsular contracture occurred in 1 (3.8%) biologic mesh breast and 4 (5.8%) synthetic mesh breasts. There was no significant difference in the incidence of capsular contracture between the 2 groups (P = 1.000). None of the recorded demographics were risk factors for capsular contracture, including the use of biologic or synthetic mesh (P = .801). Conclusions: Both biologic and synthetic mesh are successful at preventing capsular contracture in patients undergoing implant-based revision reconstruction. This adds to the growing evidence that both scaffold materials can be used in complex revision breast reconstruction to aid in preventing capsular contracture.

A Comparison of Capsular Contracture Rates after Immediate Implant-based Breast Reconstruction Using Biologic versus Synthetic Mesh.

Background: Capsular contracture is one of the most common reasons for reoperation after implant-based breast reconstruction. Prior investigations have suggested that biologic mesh may mitigate capsular contracture development. This study sought to compare capsular contracture rates between patients undergoing immediate implant-based breast reconstruction with biologic versus synthetic mesh. Methods: A retrospective review was conducted of the senior author's primary implant-based breast reconstructions between 2008 and 2023. Demographics and the incidence of clinically significant Baker grade III or IV capsular contractures were compared between biologic and synthetic mesh cohorts. Univariate and multivariate logistic regressions were then performed to assess potential risk factors for the development of capsular contracture. Results: A total of 772 breasts underwent immediate reconstruction, of which 689 (89.2%) used biologic and 83 (10.8%) used synthetic mesh. Capsular contracture occurred in 15 (2.2%) biologic mesh breasts and three (3.6%) synthetic mesh breasts with no significant difference between the two groups (P = 0.430). Logistic regression showed that radiation was a borderline significant risk factor for developing capsular contracture, but the use of either biologic or synthetic mesh was not significant (P = 0.351). Conclusions: Biologic and synthetic meshes function as effective tools in prosthetic breast reconstruction. Our long-term data suggest that the risk of capsular contracture with these devices is low, and there does not seem to be a difference between the two materials. However, there does need to be a shift in how capsular contracture is assessed and discussed in the reconstruction population.

Early Experience with Mesh Suture for DIEP Flap Abdominal Site Closures.

Background: The gold standard of microsurgical breast reconstruction is the deep inferior epigastric perforator (DIEP) free flap. As techniques have evolved, DIEP flaps have significantly reduced the morbidity previously caused by transverse rectus abdominis muscle (TRAM) and muscle-sparing TRAM flaps. However, abdominal wall complications continue to persist after DIEP flap surgery, with bulge rates reported as high as 33%. Methods: The first 25 patients undergoing DIEP flap surgery with the use of Duramesh (MSI, Chicago, Ill.) by the senior author were identified. A retrospective chart review of patient and surgical details was performed. Charts were reviewed for outcomes, including surgical site infections, surgical site events, incisional hernia formation, and/or bulge. Standard descriptive summary statistics were used for patient characteristics, surgical details, and primary and secondary outcomes. Results: Twenty-five patients were reviewed. Average follow-up duration was 216 ±â€…39 days. One patient (4%) developed a surgical site infection, and four patients (16%) developed a surgical site event. One patient developed a bulge, but no patients developed an incisional hernia. Conclusions: Duramesh mesh suture provides a promising opportunity for DIEP surgeons to minimize both abdominal wall morbidity and mesh-related complications. Mesh suture can be used in a similar fashion as other sutures to perform primary closure of the anterior rectus sheath while also providing force-distribution benefits typically unique to planar mesh. This pilot study suggests that Duramesh is a safe, simple alternative to existing techniques in DIEP flap surgery and can be considered by microsurgeons to reduce fascial dehiscence, bulge, and/or hernia formation.

Breast Implant Silicones and B Cell-Mediated Immune Responses: A Systematic Review of Literature.

Introduction: Breast implants are under recent scrutiny owing to concerns about their potential for inducing immunological diseases, namely breast implant-associated anaplastic large cell lymphoma and breast implant illness. However, the impact of silicone on biologic systems remains unclear. Therefore, we performed a systematic literature review to evaluate the information available on silicone breast implants and their effect on one arm of the adaptive immune response-B lymphocytes and antibody formation. Methods: We conducted a systematic review in EMBASE/PUBMED in accordance with the PRISMA guidelines, with search entry terms requiring discussion of silicone and immunity. The initial review returned 1079 citations. Manual screening was performed to include studies that were specific to the humoral response after exposure to silicone. Secondary full text review was performed. The extracted data included animal models and findings pertinent to B cells/antibodies in response to breast implant silicones. Results: In total, 39 studies on B cells/antibodies and breast-implant-associated silicones were identified. Among them, 23 studies were in humans, 14 in animal models, and 2 were in vitro. Common themes included identification of antisilicone antibodies in women with breast implants, anticollagen antibodies, presence of activated B cells or immunoglobulin G in implant capsules, and sensitization of lymphocytes to silicone in vitro. Conclusion: Despite controversial findings in the literature, there is evidence that silicone breast implants activate B cells in the breast implant capsule and may have systemic effects on the production of autoantibodies and/or sensitization of B lymphocytes to silicone. Further research is needed on how breast implants impact other arms of the immune system to understand their long-term biological impact.

Cosmetic implant placement in the female breast yields an altered local and systemic immune response: evidence for breast cancer immunosurveillance.

BACKGROUND: Women with cosmetic implants have lower rates of future breast cancer than the general population. We hypothesized the implant foreign body response could induce a local protective anti-cancer immunosurveillance. We expanded on our previous finding which showed women with breast implants have elevated antibody responses to certain breast cancer proteins. METHODS: Blood samples and breast tissue were collected from women undergoing first time breast augmentation (implant-naive, IN) and revision breast augmentation (implant-exposed, IE). Sera were collected and antibody levels to common breast cancer proteins were quantified by enzyme-linked immunosorbent assay (ELISA). RT-PCR was performed on breast tissue samples to quantify immune-related gene expression levels between IN and IE. Bulk RNA sequencing was performed to identify differentially expressed genes and altered signaling pathways in the breasts of IN versus IE. RESULTS: In total, 188 patients were recruited (117 IN, 71 IE). Data demonstrated that IE patients had higher levels of antibodies to MUC-1, ER, and mammaglobin A compared to IN patients. MUC-1 expression was found to be higher in IE compared to IN breast tissue. RNA-seq analysis demonstrated upregulated pathways in IE breast tissue for B cell activation and development, Th2 related genes, T cell activation, chemotactic factors, and responses to estrogen. CONCLUSION: This is the first study to demonstrate that peri-implant inflammation extends beyond the implant capsule to breast parenchyma. Women with breast implants have more activated B cells in the breast parenchyma and elevated antibody responses to breast cancer antigen.

Response to HER-2 pulsed DC1 vaccines is predicted by both HER-2 and estrogen receptor expression in DCIS.

BACKGROUND: Patients with estrogen-independent (ER(neg)) human epidermal growth factor receptor-2 (HER-2)-positive ductal carcinoma in situ (DCIS) treated with lumpectomy alone or lumpectomy and radiation are at increased risk of developing subsequent breast cancer events. METHODS: Thirty-eight patients with HER-2 expressing DCIS received a HER-2 pulsed autologous dendritic cell (DC1) vaccine administered over 4-6 weeks before surgical resection. HER-2 and estrogen receptor (ER) expression were determined by immunohistochemistry. In 35 patients, CD4(pos) T-cell sensitization to HER-2 peptides was identified by ELISPOT. In 19 patients, CD8(pos) T-cell responses were identified by ELISA. Clinical and immune responses postvaccination were compared between intermediate-expressing HER-2 (2+) and high-expressing HER-2 (3+) patients, as well as ER(neg) and estrogen-dependent (ER(pos)) patients. RESULTS: There was no significant difference in immune response after HER-2 vaccination in patients with HER-2 (2+) and (3+) tumors or ER(neg) and ER(pos) tumors. Complete tumor regression rates were similar in patients with HER-2 (2+) and (3+) DCIS. Overall, clinical response rates were similar in patients with ER(neg) and ER(pos) DCIS, but complete tumor regression was significantly more common in patients with ER(neg) DCIS. CONCLUSIONS: Despite equivalent immune responses after vaccination in patients with HER-2 (2+), HER-2 (3+), ER(neg) and ER(pos) DCIS, HER-2 pulsed DC1 induces more complete responses in patients with ER(neg) DCIS. These data provide a rationale for developing vaccinations to reduce recurrence in patients with ER(neg) DCIS for whom there are currently limited adjuvant options.

Targeted Muscle Reinnervation and Regenerative Peripheral Nerve Interfaces for Prophylactic Pain Control in Neurofibromatosis Type 1 Amputees.

Neurofibromatosis type 1 (NF1) is an inherited multisystem disorder that affects one in 2500 to one in 5000 people. Neurofibromas are the second-most common benign peripheral nerve sheath tumors arising from Schwann cells and are associated with neurofibromatosis. Chronic pain and opioid use is elevated in patients with NF1 when neurofibromas are associated with sensory nerves. Surgical excision is the primary treatment of neurofibromas when they become large, malignant, or painful, but they are associated with high rates of recurrence. Targeted muscle reinnervation and regenerative peripheral nerve interfaces are two prophylactic surgical techniques that are used to prevent neuroma-associated residual limb and phantom pain in amputees. Both techniques stimulate physiologic regeneration of the nerve via trophic stimulus from denervated muscle. This case report describes two patients with NF1 who underwent targeted muscle reinnervation and/or regenerative peripheral nerve interfaces at the time of amputation. Despite the abnormality of the peripheral nerves involved, both patients had excellent postoperative outcomes with minimal pain. This experience advocates for the use of prophylactic nerve management techniques in neurofibromatosis patients despite baseline nerve pathology.

A Spectrum of Disease: Breast Implant-Associated Anaplastic Large Cell Lymphoma, Atypicals, and Other Implant Associations.

Breast implant associated anaplastic large cell lymphoma (BIA-ALCL) is an uncommon and emerging malignancy caused by textured breast implants. The most common patient presentation is delayed seromas, other presentations include breast asymmetry, overlying skin rashes, palpable masses, lymphadenopathy, and capsular contracture. Confirmed diagnoses should receive lymphoma oncology consultation, multidisciplinary evaluation, and PET-CT or CT scan evaluation prior to surgical treatment. Disease confined to the capsule is curable in the majority of patients with complete surgical resection. BIA-ALCL is now recognized as one disease among a spectrum of inflammatory mediated malignancies which include implant-associated squamous cell carcinoma and B cell lymphoma.

Pushing the DIEP Envelope with ERAS: 24 Hour Discharge is Safe in Appropriately Selected Patients.

Enhanced recovery after surgery protocols have become increasingly adopted for autologous breast reconstruction, demonstrating improved quality of care and reduced hospital stays. Despite this, average length of stay remains over 3 days. We have found, in appropriately selected patients, hospital length of stay can be safely reduced to less than 48 hours. Methods: Retrospective review was performed of patients who underwent microsurgical breast reconstruction by the senior author (M.H.) from April 2019 to December 2021. Demographics, operative details, length of stay, and postoperative complications are reported to assess for safety of discharge within 48 hours, with the primary outcome measure being flap loss. Results: In total, 188 flaps were performed on 107 patients. Average age was 51.4 years (SD 10.1 years) with average BMI 26.6 kg/m2 (SD 4.8 kg/m2). Average length of stay was 1.97 days (SD 0.61 days), and 96 patients (89.7%) were discharged within 48 hours. Six flaps (3.2%) required operative takebacks. Five of the six (83.3%) takebacks occurred on postoperative days zero or one, and all five of these flaps were salvaged. There were four breast hematomas (2.1%), four breast seromas (2.1%), eight breast infections (4.3%), 13 breasts (6.9%) with wound dehiscence, four flaps (2.1%) with partial flap loss, and 24 breasts (12.8%) with mastectomy flap necrosis. One hundred fifty flaps (79.8%) had no complications. Overall success rate of flap reconstruction was 99.5%. Conclusion: Hospital discharge in 24-48 hours is safe in appropriately selected patients undergoing autologous tissue breast reconstruction.

An In Vivo Comparison: Novel Mesh Suture Versus Traditional Suture-Based Repair in a Rabbit Tendon Model.

Purpose: Despite advancements in surgical techniques, suture pull-though and rupture continue to limit the early range of motion and functional rehabilitation after flexor tendon repairs. The aim of this study was to evaluate a suturable mesh compared with a commonly used braided suture in an in vivo rabbit intrasynovial tendon model. Methods: Twenty-four New Zealand female rabbits (3-4 kg) were injected with 2 units/kg botulinum toxin evenly distributed into 4 sites in the left calf. After 1 week, the animals underwent surgical tenotomy of the flexor digitorum tendon and were randomized to repair with either 2-0 Duramesh suturable mesh or to 2-0 Fiberwire using a 2-strand modified Kessler and 6-0 polypropylene running epitendinous suture. Rabbits were killed at 2, 4, and 9 weeks after surgery. Results: Grouping across time points, 58.3% (7 of 12) of Duramesh repairs were found to be intact for the explant compared with 16.7% (2 of 12) of Fiberwire repairs (P = .09). At 2 weeks, the mean Duramesh repairs were significantly stronger than the Fiberwire repairs with a mean failure load of 50.7 ± 12.7 N compared to 14.8 ± 18.3 N (P = .02). The load supported by the Duramesh repairs at 2 weeks (mean 50.7 ± 12.7 N) was similar to the load supported by both Fiberwire (52.2 ± 13.6 N) and Duramesh (57.6 ± 22.3 N) at 4 weeks. The strength of repair between Fiberwire and Duramesh at 4 weeks and 9 weeks was not significantly different. Conclusions: The 2-strand tendon repair with suturable mesh achieved significantly greater strength at 2 weeks than the conventional suture material. Future studies should evaluate the strength of repair prior to 2 weeks to determine the strength curve for this novel suture material. Clinical Relevance: This study evaluates the utility of a novel suturable mesh for flexor tendon repair in an in vivo rabbit model compared with conventional suture material.

The Palpable Nodule after Autologous Fat Grafting: Distinguishing Benign versus Malignant Lesions in Breast Reconstruction.

BACKGROUND: Nodule formation after autologous fat grafting to the breast is the most common complication. In the reconstructive population, this generates significant patient anxiety and presents a diagnostic challenge. The authors characterized palpable nodule occurrence after autologous fat grafting in breast reconstruction and compared benign versus malignant nodule characteristics. METHODS: Chart review of the senior author's experience with breast fat grafting was performed. Data extracted included demographics, intraoperative details, nodule data, radiographic characteristics, and biopsy results. Logistic regression identified risk factors for nodule formation. Unpaired t tests and Fisher exact tests compared characteristics of benign versus malignant nodules. RESULTS: In total, 775 breasts were identified that underwent 1158 fat grafting procedures, of which 67 (8.6 percent) developed palpable nodules. Sonographic characterization of nodules included presumed fat necrosis (38.2 percent), benign lesions (27.6 percent), presumed oil cysts (17.1 percent), indeterminate (8.9 percent), and concerning for malignancy (8.1 percent). Lesions concerning for malignancy were more often irregular (10.0 percent versus 0 to 2.9 percent of benign nodules) and more often larger than 0.8 cm in greatest dimension (80 percent versus 42.9 to 61.8 percent of benign nodules). Six patients developed a palpable local recurrence. Malignant nodules tended to be larger (1.45 cm versus 0.70 cm; p = 0.03), were more often vascular (50 percent versus 3.8 percent; p = 0.03), and tended to occur later (17.5 months versus 10.0 months; p = 0.60). Benign nodules occurred in the setting of larger fat graft volumes (64.2 cc versus 40.0 cc; p = 0.008). CONCLUSION: This study provides the first comparison of radiographic and clinical characteristics between benign and malignant palpable nodules after autologous fat grafting in breast reconstruction. CLINICAL QUESTION/LEVEL OE EVIDENCE: Risk, III.

Free Vascularized Fibular Flap with Bilateral Bipolar Latissimus Transfer for Upper Extremity Reconstruction: A Case Report.

CASE: A 19-year-old woman presented with bilateral mangled upper extremities after jumping in front of a moving train. After revascularization, osteocutaneous free vascularized fibula flap was performed to reconstruct the right humerus. The left forearm required transradial amputation with acute targeted muscle reinnervation. Finally, staged bilateral bipolar latissimus dorsi functional muscle flaps were performed to restore elbow flexion. CONCLUSION: Staged orthoplastic reconstruction of the upper extremities is an effective treatment approach for traumatic bone and soft-tissue defects. This patient's recovery demonstrates improved quality of life after severe upper extremity trauma.

Targeted Muscle Reinnervation for the Treatment of Neuroma.

Targeted muscle reinnervation (TMR) is the surgical rerouting of severed nerve endings to nearby expendable motor nerve branches. These nerve transfers provide a pathway for axonal growth, limiting the amputated nerve ends' disorganized attempt at regeneration that leads to neuroma formation. In the amputee population, TMR is successful in the treatment and prevention of chronic phantom limb pain and residual limb pain. In the nonamputee population, applications of TMR are ever expanding in the treatment of chronic neuroma pain owing to trauma, compression, or surgery. This article reviews the indications for TMR, preoperative evaluation, and various surgical techniques.

Judging an Expander by Its Cover: A Propensity-Matched Analysis of the Impact of Tissue Expander Surface Texture on First-Stage Breast Reconstruction Outcomes.

BACKGROUND: There is increased scrutiny of texturing on implants and a paucity of data looking at texturing on expanders. Because of the difficulty in controlling potential confounders with these comparative studies, the authors performed propensity matching between smooth and textured tissue expander cohorts to provide definitive insight into the impact of expander texture on breast reconstruction outcomes. METHODS: A single-surgeon experience with immediate two-stage breast reconstruction was reviewed for 90-day postoperative complications after mastectomy and expander placement. Variables extracted included demographics, comorbidities, tissue expander texturing, mastectomy type, infection, seroma, skin flap necrosis, dehiscence, explantation, and overall complication rates. Subjects were 1:1 propensity matched using the nearest neighbor matching algorithm with caliper (maximum propensity score difference) of 0.2, and chi-square test was performed for statistical analysis. RESULTS: After 1:1 propensity matching, 282 reconstructed breasts were analyzed (141 textured versus 141 smooth expanders). Textured expanders had higher minor infection rates than smooth expanders (5.0 percent versus 0 percent; p = 0.024). Smooth expanders had higher seroma rates than textured expanders (5.0 percent versus 0.7 percent; p = 0.031). Smooth expanders also had longer drain retention (20.4 days versus 16.8 days; p = 0.001). There was no difference in other complications, including major infection, explantation, or any complication, between textured and smooth expanders. CONCLUSIONS: Textured expanders are associated with increased minor infection risk, whereas smooth expanders are associated with increased seroma formation. However, these differing complication profiles coalesce to equal explantation rates. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.