The Impact of Reduction Mammaplasty on Breast Sensation: A Systematic Review.

Loss of sensation is one of the most feared complications of breast reduction surgery. Although several techniques have been proposed to maximize sensitivity preservation, the scientific literature still reports contradictory findings. This systematic review aimed to assess whether breast reduction mammaplasty is associated with measurable changes in breast sensation. This review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed (National Institutes of Health, Bethesda, MD), Scopus (Elsevier, Amsterdam, the Netherlands), and Web of Science (Clarivate, Philadelphia, PA) databases were searched for clinical studies investigating breast sensation after breast reduction mammaplasty. The initial search identified 1523 studies of which 22 articles met our specific inclusion criteria. Most of the included studies are consistent in describing only transient sensation decrease or even sensation improvement after surgery compared to the presurgery condition with any approach, except those investigating outcomes after superior or superolateral pedicle reduction mammaplasty. Nevertheless, the overall quality of evidence is low or very low due to the limited availability of randomized controlled trials or controlled studies and the high risk of bias.

A Shakespearean Dilemma in Breast Augmentation: to Use Drains or not? a Systematic Review : Drains in Breast Augmentation.

BACKGROUND: Breast augmentation is one of the most commonly requested and performed plastic surgery procedures. In order to prevent early postoperative complications such as seroma or hematoma, surgical drains could be useful. The aim is to perform a systematic review of the literature on the use of surgical drains in primary breast augmentation. METHODS: This review was performed following the PRISMA guidelines. PubMed, SCOPUS, Web of Science and Cochrane Library databases were queried in search of clinical studies describing the use of surgical drains in women undergoing primary breast augmentation with implants and documenting seroma and/or hematoma formation rate and/or infection rate. RESULTS: Initial search identified 2596 studies, and 162 were found relevant. Full-text review and application of our inclusion criteria to all retrieved papers produced 38 articles that met inclusion criteria. Among the included studies, 16 papers reported the use of surgical drains in breast augmentation, while in the remaining 22 articles drains were not used. Only 5 studies specifically investigated the role and effectiveness of surgical drains in augmentation mammaplasty and its possible relationship with complication rate such as seroma, hematoma or infection. CONCLUSIONS: Despite similar complication rates emerged from the analyzed articles, because of the heterogeneity of the studies, we were not able to demonstrate specifically whether drain use affects the rate of early postoperative complications such as seroma, hematoma and infection. Additional randomized controlled trials are strongly advocated in order to provide the necessary scientific evidence. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The "Arrow Flap" Technique in Reduction Mammaplasty: Combining Short Scars, Narrow Base, and High and Persistent Breast Projection.

INTRODUCTION: Breast reduction is one of the most common procedures performed by plastic surgeons worldwide. Despite that several techniques have been proposed for management of ptotic or hypertrophic breasts, most of them often deal with too large breast bases, poor breast projection, persistent "dog ears," and a certain percentage of bottoming out. Lower-pole shaping of the breast remains one of the challenge of vertical mammoplasty. MATERIALS AND METHODS: The authors report their 5-year-long experience with a modification of the vertical scar technique, the "arrow flap," in which they harvest a double lateral glandular and cutaneous flap, to tighten and better shape the base of the breast and to improve the breast projection with a "double-bra" effect. From April 2015 to February 2019, 75 patients with moderate to severe macromastia/breast ptosis underwent bilateral reduction mammoplasty. RESULTS: Postoperative outcomes showed an overall satisfactory results and low incidence of complications. Two patients presented with an asymmetry between the 2 breasts, and no nipple-areola complex necrosis occurred. One patient reported a wider vertical scar, whereas no bottoming out was observed. CONCLUSIONS: All patients reported a stable and durable projection of the breast, with pleasant cosmetic results. By combining short scars and narrow base, we can obtain a pleasant lower pole reshaping of the breast, even in that challenging cases of large and squared breast. The authors believe that this technique provides a useful surgical option, increasing the versatility of the superior pedicle vertical mammaplasty both for mastopexy and breast reduction, even in cases of severe macromastia.

Alteration of Skin Mechanical Properties in Patients Undergoing Botulinum Toxin Type A Injections of Forehead Rhytides.

BACKGROUND: Although application of botulinum toxin type A (BTX-A) for the treatment of forehead rhytides has become very popular, the effects of its intramuscular injections on the skin mechanical properties remain unclear. OBJECTIVES: We prospectively investigated the alterations in the mechanical properties of the skin of patients who received intramuscular injections of botulinum toxin A (BTX-A) for forehead rhytides and compared two injection doses. METHODS: Of the 42 enrolled patients, one randomly assigned half received intramuscular injections of two units (group I), and the other half received four units (group II) of BTX-A in each injection point. The baseline and post-treatment skin mechanical parameters, including gross elasticity (R2), net elasticity (R5), viscoelastic ratio (R6) and biological elasticity (R7), were measured using the Cutometer(®) and compared. RESULTS: Treatment with BTX-A resulted in significant overall alterations in the mechanical properties of skin at the injection sites of both treatment groups during the 16-week period, and no significant differences were observed between groups. Significant decreases in biological elasticity, net elasticity and viscoelasticity properties were observed at 2 weeks follow-up and began to recover at that time. All of the skin mechanical properties recovered to baseline levels by 16 weeks of follow-up in both dosage groups, which indicates that the higher dosage (4 units) did not delay relapse compared to the two-unit dosage. CONCLUSIONS: We concluded that intramuscular injections of BTX-A significantly regulated the gross elasticity, net elasticity, functional elasticity and viscoelastic elasticity at the injection point over a radius of 1.5 cm at 2, 4 and 8 weeks follow-up. The alteration in the skin measurements had completely diminished by the 16-week follow-up. 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 .

Bipaddle radial forearm flap for head and neck reconstruction.

BACKGROUND: Although the radial forearm free flap has become a workhorse flap in head and neck reconstruction, the skin grafting of the donor is the main drawback resulting in an unacceptable contour deformity and an unsightly appearance. Several technical modifications have been therefore applied to the radial forearm (RF) flap marking, elevation, and inset to overcome this major shortcoming. In this article, we report our clinical series with the bipaddle RF flap. METHODS: The authors described their 11 cases of head and neck oncologic reconstruction with the bipaddle RF flap. The skin island is designed longer and narrower and split into 2 separate skin paddles each nourished by a proximal and a distal independent perforators raising from the radial artery so that the donor site could be closed directly. The narrow design of the skin paddle and the subsequent splitting in its 2 components applying the "perforator-pedicle propeller flap method" allow for the changing of the flap shape according to the shape of the recipient site defect. RESULTS: From 2007 to 2013, the bipaddle RF flap method was used in 11 patients to restore head and neck defects following cancer ablation. The mean age of the patients was 43 years, ranging from 31 to 50 years. The location of the defects was the tongue (n = 7) and the intraoral region (n = 4). The defect sizes varied from 4 × 5 cm to 5 × 6 cm, and the flap maximum width was 3 cm with mean area of 26.4 cm. The healing was uneventful in all patients with excellent cosmetic and functional results of both donor site and recipient site after 20 months of mean follow-up. CONCLUSIONS: The bipaddle RF free flap is a reliable and versatile option for the reconstruction of a wide range of soft tissue defects of head and neck region. This method allows for a customized resurfacing of the defect because of its large variability in shape and size. The harvesting site is closed primarily, and a second donor site for skin graft is avoided.Clinical Question, Level of Evidence: Therapeutic, IV.

Preliminary Outcomes of Distal IMAP and SEAP Flaps for the Treatment of Unstable Keloids Subject to Recurrent Inflammation and Infections in the Lower Sternal and Upper Abdominal Areas.

BACKGROUND: We present the clinical application of the sixth internal mammary artery perforator (IMAP) and superior epigastric artery perforator (SEAP) flaps for the treatment of defects resulting from the excision of large lower sternal and upper abdominal keloids. Perforator selection and flap design were based solely on preoperative multidetector-row computed tomographic angiography (MDCTA) of the areas adjacent to the soft tissue defects. METHODS: Between January 2009 and June 2014, 15 patients with large, unstable keloids subject to recurrent inflammation and infections and with a history of multiple failed treatments underwent surgical excision and early postoperative radiation therapy. The defects were located in the upper abdomen (n = 6) or lower sternum (n = 9). All patients underwent preoperative MDCTA for perforator localization. RESULTS: A total of 15 patients underwent keloid removal followed by IMAP (n = 10) and SEAP (n = 6) flap coverage combined with early postoperative low-dose radiation therapy (350 cGy/5 fractions/5 days or 400 cGy/4 fractions/4 days). Flap sizes ranged from 9 × 5 to 17 × 6 cm. Only one IMAP flap developed a 2 × 2 cm tip necrosis, which was managed with dressing changes. The remaining flaps healed uneventfully with no keloid recurrence at 23.4 months. In all cases, the perforator location determined by preoperative MDCTA was precisely consistent with the intraoperative findings. CONCLUSION: The sixth IMAP and SEAP flaps combined with early postoperative radiation therapy provided a valid and feasible approach for the surgical treatment of large keloids in the lower sternal and upper abdominal. MDCTA enabled detailed preoperative assessment of the perforators, facilitating both flap design and dissection, and saving operating time. Although longer follow-up is required, these preliminary results are encouraging.

Sebum Production Alteration after Botulinum Toxin Type A Injections for the Treatment of Forehead Rhytides: A Prospective Randomized Double-Blind Dose-Comparative Clinical Investigation.

BACKGROUND: Research has investigated the decrease in human skin sebum after the application of botulinum toxin. Few studies of the mechanism and objective assessments of this phenomenon have been conducted and the correlation between the sebum production and injection dosages or techniques remains unclear. OBJECTIVES: We prospectively investigated the sebum regulation and its gradient around the injection site in patients who received intramuscular injections of botulinum toxin A (BTX-A) for forehead rhytides, comparing two injection doses. METHODS: Forty-two female volunteers with rhytides on the forehead region were randomly assigned to receive 10 or 20 units of BTX-A, which was administered in five standard injection sites. The baseline and post-treatment sebum production was measured using a Sebumeter. RESULTS: Treatment with BTX-A exhibited significant sebum alteration at the injection site of both groups, with a sebum gradient surrounding the injection point. The efficacy did not improve at higher injection doses, with the four-unit regimen generally not being more potent than the two-unit regimen. The sebum production recovered to normal levels at the 16 week follow-up for both treatment groups, indicating that a higher dosage (four units) did not result in a longer duration until relapse compared with the two-unit dose. CONCLUSIONS: We determined that the sebum production has a positive correlation with the distance away from the injection point. Intramuscular injection of BTX-A significantly reduces sebum production at the injection site but increases the sebum production of the surrounding skin at a radius of 2.5 cm at the 2, 4, and 8 week follow-ups. LEVEL OF EVIDENCE: 2 Therapeutic.

Microsurgical reconstruction after bisphosphonate-related osteonecrosis of the jaw: our experience with fibula free flap.

BACKGROUND: Bisphosphonate-related osteonecrosis of the jaws (BRONJ) is the most serious complication of bisphosphonates therapy. Despite that several treatment modalities have been described, aggressive surgical treatment approach with wide bone resection and vascularized microsurgical reconstruction are controversial. The aim of this study was to evaluate the clinical outcome of 8 new cases of BRONJ treated with radical resection and mandibular reconstruction with fibula free flap, to enforce the evidence about the reliability of this treatment option. METHODS: Retrospective data of 8 patients with BRONJ who underwent segmental mandibulectomy and reconstruction with osteocutaneous fibula free flap from January 2004 to January 2008 were collected, including 6 patients with stage 3 BRONJ and 2 patients with recalcitrant stage 2 BRONJ. RESULTS: All patients were white, with a mean age of 64.7 years (range, 53-77 y), and 62.5% were women. All bisphosphonates were administered intravenously, and all patients had mandibular localization. The mean period of follow-up was 28.9 months. No flap loss or minor complications and no BRONJ recurrence were observed. All patients were able to ambulate pain-free. CONCLUSIONS: Despite initial concerns regarding reliability of the mandibular free-flap reconstruction after BRONJ, this method seems to be a safe and feasible option in cancer patients with reasonable life expectancy, with complete BRONJ resolution and life quality improvement. Our findings confirm data previously published by other authors, without complication and with a much longer median follow-up time.

A simple method to inset and position polyurethane-covered breast implants.

BACKGROUND: Polyurethane-covered breast implants have been used increasingly for cosmetic and revision breast surgery. The incision for insertion should be of minimal length and the placement of these implants in the pocket can be more difficult than that of conventional implants because of the highly adherent textured surface of the polyurethane external layer that grasps the surrounding tissues. The use of a sterile plastic insertion sleeve that is open on both sides is suggested by the manufacturer to overcome the friction between the polyurethane implant and the skin and surrounding tissues. METHODS: A new method to facilitate polyurethane implant insertion and adjustment in all cases of primary breast augmentation and revision surgery is presented. After the implant, which is in the sleeve, is located in the pocket, the plastic sleeve is filled with saline and antibiotics so the solution lubricates the surface around the implant. The sleeve is then twisted so that the solution is squeezed inside the pocket while the sleeve itself is pulled back and removed. RESULTS: Between 2010 and 2013, this method was used in 73 cases of primary augmentation and revision breast surgery without any complications. CONCLUSION: The method described here allows for easier removal of the plastic sleeve during polyurethane implant insertion without any complications or evidence of implant migration or rotation at follow-up. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors http://www.springer.com/00266 .

Augmentation mammoplasty/mastopexy: lessons learned from 107 aesthetic cases.

BACKGROUND: One-stage augmentation/mastopexy entails the challenge of augmenting breast volume with an implant while resecting excess skin. Although both augmenting and lifting the breast in a one-stage operation is gaining in popularity, its safety and its efficacy are still under debate and merit deeper evaluation. METHODS: We retrospectively reviewed our experience over a 5-years period with patients who underwent augmentation mammoplasty/mastopexy with the specific objectives of documenting their outcomes and formulating algorithms for safe, simple, and effective operative strategies to manage such patients. Our surgical approach to augmentation/mastopexy breast ptosis was described step by step. Patient satisfaction with the results was also evaluated. RESULTS: One hundred seven patients underwent successful simultaneous augmentation/mastopexy surgery. Sixty-nine underwent primary breast surgery and 38 underwent secondary breast surgery. In 12 cases a periareolar mastopexy scar was used, while in 51 patients a vertical approach was preferred; in 11 and 33 patients a short "T" and an inverted "T" scar mastopexy was necessary, respectively. Few complications were observed, with a very low overall complication rate (14 %) and a reoperation rate of 12.1 % at 14.7 months. Patient satisfaction with the results of this procedure was extremely high. CONCLUSIONS: Simultaneous augmentation/mastopexy is an effective and versatile way to lift the NAC, tighten the breast skin, increase breast projection, and fill in the upper pole. Our technique of simultaneous breast mastopexy after augmentation through a lower periareolar approach showed excellent correction of pre-existing ptosis, making this method highly reliable because the intraoperative tailor-tacking was customized to the patient, implant size, and projection.

The Oxygen Therapy Tube as a Tool for Breast Squeezing during Pedicle De-epithelialization in Reduction Mammaplasty.

During breast reduction, pedicle de-epithelialization, as meticulous as possible, is necessary to ensure satisfying breast sculpting and to avoid any epidermoid cyst. To perform an effective and rapid de-epithelialization, a good tension of the skin is mandatory. Several techniques to improve skin tension of the breast are described in the literature. We report a cheap, effective, and easily reproducible method, based on the use of an oxygen tube with nasal cannula.

An unusual case of dermatofibrosarcoma protuberans misdiagnosed as vascular malformation for over 30 years: A case report.

INTRODUCTION: Dermatofibrosarcoma protuberans (DFSP) is a rare and slowly growing soft tissue tumor and it is frequently misdiagnosed and mismanaged like more common masses. Therefore diagnostic delays are common and may result in challenging reconstructions. CASE PRESENTATION: We report the peculiar case of a 36-year-old patient with dermatofibrosarcoma protuberans of the right iliac fossa misdiagnosed as vascular malformation for over 30 years. Due to the delayed diagnosis resulting in a large tumor to be resected, surgical reconstruction was performed with a miniabdominoplasty approach with an excellent cosmetic and functional result. DISCUSSION: The review of the literature showed that mismanagements and delayed diagnosis of this sarcoma are frequent. Large skin and soft-tissue defects are frequently encountered in the surgical treatment of this tumor, and adequate knowledge of the reconstructive options is mandatory to provide the best possible outcome. CONCLUSIONS: Superficial skin masses could be easily misdiagnosed. These diagnostic delays may lead to increased patient morbidity and more challenging reconstructive procedures. In this scenario, preoperative biopsies of suspicious lesions may be useful to avoid mismanagement of rare malignant neoplasms such as DFSP. In some challenging cases, the use of a surgical approach typical of cosmetic procedures may be useful to obtain satisfactory aesthetic and functional results.

Aeromonas hydrophila Infection following Leech Therapy for the Treatment of Nipple-Areola Complex Congestion after Breast Reduction: A Case Report.

Several strategies for the management of venous congestion of the nipple-areola complex (NAC) after reduction mammaplasty have been proposed. Among these, hirudotherapy represents an ancient but still effective method, even though the risk of infections related to leeches should be considered. We report a peculiar case of breast infection and sepsis after leech therapy in a patient who underwent a reduction mammaplasty. A prompt surgical debridement of the wounds and necrotic tissues associated with targeted antibiotic therapy led to a fast improvement of clinical conditions, and partial preservation of the NAC was obtained. Accurate knowledge of the clinical presentation of soft tissue infections related to leeching allows for an early diagnosis and would serve as a warning for surgeons who approach such breast cosmetic procedures.

Nasal Retainer 2.0: A New, Cheap, and Reliable Method to Prepare Custom-made Nostril Retainer for Nasal Reconstruction.

Total nasal reconstruction always represents a challenge for the plastic surgeon, who must deal both with the reconstructive procedure and compliance of the patient. This kind of reconstruction often requires more than one step. Therefore, more prolonged and emphasized scarring than normal can occur, thus resulting in a higher risk of nostril stenosis. Although several nasal retainers have been described, traditional premade retainers could be poorly tolerated by patients and need to be adequately customized to improve patient compliance. Herein, the authors propose a new, cheap, and reliable method to prepare customized nasal retainers which can be used after every step of nasal reconstruction.

The effects of breast reduction on pulmonary functions: A systematic review.

Breast reduction is one of the most commonly requested and performed plastic surgery procedures, and its psychological, esthetic, and analgesic benefits are well known. Several studies dealing with the effects of reduction mammoplasty on the physiology of respiration have been published in the past decades. This systematic review aims to assess whether bilateral breast reduction is associated with measurable improvement in lung function in women with macromastia. This review was performed in accordance with the PRISMA guidelines. PubMed, SCOPUS, and Web of Science databases were queried in search of clinical studies that investigated lung function in women undergoing breast reduction for macromastia and reported any type of parameter or outcome measure relevant to pulmonary function. The search yielded 394 articles of which 15 articles met our specific inclusion criteria. The primary outcome measures of the studies and their respective results were tabulated, contrasted, and compared. The 15 studies included in this review cover the period from 1974 to 2018. According to most included studies, reduction mammaplasty produces a change of objective respiratory parameters, such as spirometric tests or arterial blood gas (ABG) measurements; nevertheless, the clinical and functional relevance of the observed changes is debatable.

The Role of Surgical Drainage on Complications after Sentinel Lymph Node Biopsy for Melanoma.

The real benefit of using drains for reducing the risk of complications in sentinel lymph node biopsy (SLNB) has not been investigated yet. We aimed to evaluate the role of drain after SLNB and to determine if a correlation exists between drains and early complications. Methods: This is a retrospective study of patients who underwent SLNB for melanoma from 2016 to 2021. Patients were dichotomized into two groups according to the use of drain. The between-group comparison (drainage group versus no drainage group) was performed by using Mann-Whitney U test and chi-square test. A regression analysis was conducted to identify predictors of complications. Results: Of 218 individuals analyzed, 18 (8.4%) had postoperative complications. The most common complications were seroma (5.1%) and wound dehiscence (1.4%). The between-group analysis showed no significant differences in complication rate, whereas the operative time was significantly higher in the drainage group (P = 0.007), as well as the hospital stay (P ≤ 0.0001) and the duration of postoperative antibiotic therapy (P = 0.02). The regression analysis found body mass index and multiple basins of SLNB (axilla with groin) to be significant predictors of having a complication (P = 0.03 and P = 0.05, respectively). The operative time was found to be a predictor of seroma (P = 0.04). Conclusions: Drainage use in SLNB prolonged hospital stays and duration of postoperative antibiotic therapy, thus resulting in higher costs. The preemptive use of drainage is suggested in selected settings of patients.

Heel reconstruction for a Marjolin's ulcer in a patient with multiple limb amputations: a case report.

Coverage of the heel defects usually represents a challenge for the proper reconstructive requirements of the weight-bearing area of the foot. The presence of multiple limb amputation may represent a further concern for conventional free flap donor sites and the patient's functional limitation, thus making reconstruction even more challenging. Amputee patients may be subjected to a higher risk of foot ulcerations and choosing the more appropriate reconstructive option in such patients is crucial. Here we describe the application of the medial plantar flap as a first-line option in a 66-year-old amputee patient with a squamous cell carcinoma arising from chronic ulceration on the left heel, that was successfully treated with limited functional limitations and excellent anatomical contour of the foot. Despite its use has been widely described for heel reconstruction, we believe that medial plantar flap would deserve greater relevance in the reconstructive scenario in such challenging cases.

Use of porcine acellular dermal matrix to repair lung Hernia after minithoracotomy: A case report with 6-Year follow-up.

Lung hernia following minimally invasive cardiac surgery is rare with few reported cases in the literature. Surgical repair is debated, and several methods have been described including a variety of synthetic and biological materials. We report a case of a 36-year-old woman who developed lung hernia and a strong retraction of the pectoralis major muscle after minithoracotomy that was performed for mitral valve surgery. The herniated lung was reduced and the chest wall defect was repaired with a non-cross linked acellular dermal matrix (ADM) anchored to the thoracic wall. At a 6-year follow-up, she was asymptomatic and without recurrence of the hernia. Our experience suggests that ADMs are a safe and reliable surgical technique for lung hernia repair due to their biological and mechanical properties, even in those secondary hernias to minithoracotomy where a complete muscle coverage of the matrix could not be provided.

A Peculiar Case of Large and "Unresectable" Primary Localized Cutaneous Nodular Amyloidosis of the Ankle.

Nodular cutaneous amyloidosis represents the rarest variant of primary localized cutaneous amyloidosis. The proposed management ranges from topical or systemic agents to surgical treatment. Complete surgical excision is advisable due to its potential progression to systemic amyloidosis due to dermis and subcutaneous tissue infiltration. However, in particular locations, the risk of functional complications is high, so an alternative treatment option should be considered. We report a case of a large primary nodular cutaneous amyloidosis of the leg involving the joint capsule which was successfully treated by incomplete surgical removal, without recurrences at 7-year follow-up.