Direct-to-Implant Retropectoral Dual Plane Approach With Autologous Inferior-Based Dermal Flap: Does SPY-Elite Laser Angiographic System Reduce Complication Rates?

PURPOSE: The study aims to investigate the complications and long-term outcomes associated with retropectoral DTI breast reconstruction with IDF utilizing the SPY-Elite laser angiographic system. MATERIAL AND METHOD: This retrospective study was conducted from June 2017 to January 2023. We examined 52 patients (85 breasts) treated with a direct-to-implant retropectoral dual plane approach with IDF implant coverage. Informed consent was duly obtained from every participant. Inclusion criteria dictated that patients should have medium to large breasts and a second or third degree of ptosis, as per the Regnault ptosis scale. During the intraoperative evaluation, the mastectomy flaps and IDF were assessed with the SPY-Elite laser angiographic system using near-infrared imaging. We recorded patient demographics, characteristic data, and complications. RESULTS: A total of 52 patients, aged 27 to 63, underwent 85 mastectomies using a direct-to-implant retropectoral approach with inferior dermal flap. The average age of the patients was 48, and their average body mass index was 30.8, with a range of 28 to 43. The distance from the nipple to the inframammary fold varied between 14 and 24 cm. The implants used had an average size of 275 cc, ranging from 250 to 650 cc. Textured anatomic implants with either moderate plus or high profile were used in all cases. The sternal notch to nipple distance for these patients ranged from 24 to 38 cm. During the evaluation using the SPY-Elite laser angiographic system, insufficient distal marginal perfusion was detected in five out of 85 inferior dermal flaps, measuring between 2 and 5 cm2. These areas were subsequently debrided, and the reconstructions were successfully completed, representing 5.8% of cases. No instances of necrosis related to IDF have been observed. There have been no failed assessments conducted by SPY ICG. In total, the complication rate was 15.2%, with minor complications occurring in 8.2% of the breasts (7 out of 85) and major ones in 7% (6 out of 85). The subjects were monitored for an average of 14 months, the duration ranging from 12 to 24 months. CONCLUSION: Inferior dermal flaps have considerable advantages, such as a natural autologous blood supply, a more realistic tissue thickness and texture, lower costs, and better tolerance to post-reconstruction radiation. Moreover, using the IDF technique and assessing the perfusion of IDF and mastectomy flaps through the SPY-Elite laser angiographic system appears to be a dependable, efficient way to achieve good cosmetic results in one operation, eliminating the need for additional surgeries. 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 Table of Contents or online Instructions to Authors www.springer.com/00266.

Round Autoprosthesis: Use of Adipodermaglandular Flap in T Scar Mastopexy.

PURPOSE: This study focuses on the use of round or anatomically shaped breast autoprosthesis with different volumes prepared from the central and lower poles of the breast. The technical details and surgical outcomes for patients with varying degrees of breast ptosis are discussed. MATERIAL AND METHOD: This study involved 42 patients who underwent the Wise-pattern superior pedicle mastopexy procedure using the adipodermaglandular island flap technique. The research spanned from December 2017 to August 2022. The study participants had not previously undergone breast surgery, did not desire breast implants, and exhibited grade 2 and 3 breast ptosis according to the Regnault Classification. Age and preoperative breast measurements of the patients were recorded for subsequent analysis. Measurements, such as the distance from the nipple-areolar complex to the inframammary fold and the distance from the suprasternal notch to the nipple-areolar complex, were taken both before the surgery and one year after. A systematic process was followed to identify acute and subacute complications during the postoperative follow-up period. RESULTS: This study involved 42 patients with a mean age of 33.9 years (range: 23-49 years). These procedures were conducted between December 2017 and August 2022. The average SN-N distance before surgery measured 26.7 cm (range: 24-33 cm). One year after surgery, the average SN-N distance was 23.1 cm (range: 21.3-24.8 cm). The follow-up duration for the examined cases ranged from 12 to 18 months on average. Among the observed cases, delayed wound healing was noted in one instance, venous insufficiency of the nipple in another, and fat necrosis in a third case. The overall complication rate in the group was determined to be 7.1%. CONCLUSION: In our study, the detachment of dermal connections at the level of the inframammary fold (IMF) and the smooth advancement of the flap in the form of an "island flap" made a contribution to upper pole fullness. Furthermore, we hypothesize that the fusion of the medial and lateral ends of the flap will enhance tissue integration during the healing process, promoting compatibility between the autoprosthesis tissue and breast tissue. Regarding the rates of complications described, classic mastopexy techniques have exhibited similar rates in our findings. 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 Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Comparative Analysis of Lower Island Flap Transposition (LIFT) in Wise-Pattern Mastopexy: Does It Improve Upper Pole Fullness and Breast Harmony?

BACKGROUND: Utilization of autologous parenchymal flaps aims to attain enduringly favourable outcomes and uphold volume in the upper breast pole after mastopexy procedures. The objective of this study was to juxtapose and scrutinize postoperative upper pole fullness, upper/lower pole ratios, occurrences of bottoming-out deformity, and complication rates between two patient cohorts: those who underwent the wise-pattern superior pedicle mastopexy with the LIFT technique and those who underwent the conventional wise-pattern superior pedicle mastopexy. MATERIALS AND METHODS: All the patients in this study were appropriately categorized as primary patients, signifying their lack of any prior breast surgery history. These individuals presented with grades II and III breast ptosis on both breasts, ranging from moderate to severe deformities per the Regnault classification. Importantly, all patients uniformly expressed their desire to achieve a firmer breast appearance without recourse to using breast implants. The patients' ages and preoperative breast measurements were recorded for analysis. Measurements, including the distance from the NAC to the inframammary fold and from the sternal notch to the NAC, were systematically measured both before the surgery and at the 1-year postoperative mark. RESULTS: The upper and lower pole ratios, defined by Mallucci and Branford, were found to be 45.22% ± 2.20% and 54.88% ± 2.20%, respectively, within the LIFT group. In 13 instances, a lower pole distance exceeding 55% indicated a potential bottoming-out deformity (value lower than 45%/55% ratio or 0.818). Conversely, within the control group, the upper and lower pole ratios were determined as 43.22% ± 2.80% and 56.88% ± 2.80%, respectively. These findings demonstrated statistical significance. Notably, in 39 cases within the superior pedicle wise-pattern mastopexy group, a lower pole distance surpassing 55% (value lower than 45%/55% ratio or 0.818) suggested a leaning towards a bottoming-out deformity (p: 0.003). A postoperative period of at least 12 months was essential to discern the emergence of upper pole fullness and the potential development of bottoming-out deformities. Among the cases within the LIFT group, 93% exhibited successful attainment of upper pole fullness, while in the control group, this outcome was achieved in 82% of cases (p>0.05). CONCLUSION: Implementing the LIFT technique alongside the wise-pattern superior pedicle mastopexy decreases the occurrence of bottoming-out deformity after 1 year. Although there is no statistically significant difference, the LIFT flap technique has contributed to some extent to upper pole fullness. 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 .

Lipoabdominoplasty: Comparing UAL Versus UAL/PAL Techniques on Complication Profile and Patient Safety.

PURPOSE: This study intends to assess the complications and outcomes related to the use of UAL (LIPO SAVER, LHbiomed Co, Gangnam-gu, Korea) versus a combination of UAL and PAL (Microaire, Charlottesville, VA, USA) within the abdominoplasty procedure. MATERIAL AND METHOD: A retrospective study used patient data and chart reviews in a single surgeon's private cosmetic practice. The study involved patients who underwent the lipoabdominoplasty technique with UAL and a combination of UAL and PAL (UAL/PAL) over 4 years from October 2017 through December 2022. A total of 280 patients (272 female, eight male) who underwent standard (n:258) or fleur-de-lis abdominoplasty (n:22) due to skin excess, musculofascial laxity, and lipodystrophy were included in the study. Patients with illnesses affecting microcirculation, such as diabetes mellitus type I and II, cardiopulmonary diseases, oral contraceptive usage, hereditary bleeding and thrombotic disorders, and those who had undergone revision abdominoplasties were excluded. RESULTS: BMI above 30 kg/m2 was associated with an increased risk of both minor and major complications in the UAL abdominoplasty group (P = 0.005 and 0.001, respectively). On the other hand, BMI over 30 kg/m2 was associated with an increased risk of major complications in the UAL/PAL abdominoplasty group (P = 0.011). BMI over 30 kg/m2 was associated with an overall increased rate of minor and major complications in both the UAL and UAL/PAL groups (P = 0.001 and 0.001, respectively). There was no statistical difference between the UAL and UAL/PAL groups regarding complications, but a slight increase in the overall complication rate was observed in the UAL group (P = 0.061). Additionally, the study unveiled that there was no correlation found between age, gender, duration of surgery, lipoaspirate volumes and combined surgeries with an increased risk of complications between groups. CONCLUSION: BMI over 30 kg/m2 has been shown to have an adverse effect on the profile of complications in both groups, resulting in an increased risk, especially for major and minor complications such as seroma in the UAL group. 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 .

Wise-Pattern Superomedial Dermoglandular Pedicle Technique: Improves Breast Upper Pole Fullness and Breast Proportions.

Background: This study aimed to analyze postoperative upper pole fullness, upper/lower pole ratios, bottoming-out deformity, and complication rates for patients who underwent planned bilateral reduction mammoplasty for gigantomastia using the superomedial dermoglandular pedicle technique and Wise-pattern skin excision. Methods: A total of 105 consecutive patients were evaluated postoperatively within a year in full lateral position, and the upper pole was between the lines drawn horizontally from the nipple meridian, where the breast became evident on the chest wall. Flat and slightly convex upper pole slopes were considered well-rounded; the concave ones were evaluated as exhibiting decreased fullness. The lower pole was the height between the horizontal line passing through the level of the inframammary fold and nipple meridian. Bottoming-out deformity was evaluated according to the 45/55% ratio developed by Mallucci and Branford, where the bottom pole was above 55%, at which it was held to be leaning toward bottoming-out deformity. Results: The upper and lower pole ratios were 44.79% ± 2.80% and 55.21% ± 2.80%, respectively. In 4 cases, a lower pole distance of >55% was leaning toward bottoming-out deformity. A minimum of 12 months was required after surgery to detect upper pole fullness and any possible bottoming-out deformity. The upper pole fullness was achieved in 94% of cases that underwent superomedial dermoglandular pedicle Wise-pattern breast reduction. Conclusion: The use of the superomedial dermoglandular pedicle technique with the Wise-pattern in breast reduction operations helps in ensuring upper pole fullness, resulting in less bottoming-out deformity and requiring less revision.

Historique: La présente étude vise à analyser le volume du pôle supérieur, le ratio entre les pôles supérieur et inférieur, les malformations en creux et le taux de complications chez les patientes qui ont subi la mammoplastie de réduction bilatérale planifiée d'une gigantomastie au moyen de la technique à pédicule dermoglandulaire supéro-interne et de l'excision cutanée selon le modèle de Wise. Méthodologie: Au total, 105 patientes consécutives ont été soumises à une évaluation postopératoire en position latérale complète dans l'année suivant l'intervention, et le pôle supérieur se situait entre les lignes dessinées dans un plan horizontal à partir du méridien des mamelons, où la poitrine devenait évidente sur la paroi thoracique. Une inclinaison plate et légèrement convexe du pôle supérieur était considérée comme bien ronde. Une inclinaison concave était plutôt perçue comme présentant un volume réduit. Le pôle inférieur correspondait à la hauteur entre la ligne horizontale passant au niveau du pli inframammaire jusqu'au méridien des mamelons. Une anomalie en creux était évaluée en fonction du ratio 45 %-55 % établi par Mallucci et Branford, où un pôle inférieur supérieur à 55 % était considéré comme une tendance vers une malformation en creux. Résultats: Le ratio entre le pôle supérieur et inférieur s'élevait à 44,79 % ± 2,80 et 55,21 ± 2,80 %, respectivement. Dans les quatre cas, une distance du pôle inférieur supérieure à 55 % démontrait une tendance vers une malformation en creux. Il fallait au moins 12 mois après l'opération pour établir le volume du pôle supérieur et toute anomalie en creux. Le volume du pôle supérieur était satisfaisant dans 94 % des cas soumis à une réduction mammaire au moyen de la technique à pédicule dermoglandulaire supéro-interne et de l'excision cutanée selon le modèle de Wise. Conclusion: L'utilisation de la technique à pédicule dermoglandulaire supéro-interne selon le modèle de Wise lors des opérations de réduction mammaire contribue à assurer le volume satisfaisant du pôle supérieur, lié à moins de malformations en creux et moins de révisions chirurgicales.

A Case of Nonsyndromic Unilateral Cleft Hand with Central Polydactyly, Syndactyly, and Thumb Hypoplasia: Support for a Common Etiology.

Experimental studies showed that central polydactyly, syndactyly, and cleft hand might appear when the same teratogenic factor acts on embryos at the same developmental stage. These observations and some clinical cases support the concept that a common etiologic mechanism is involved in the development of these malformations. We report a clinical case that demonstrates the association previously observed in experimental studies. Here, a patient with unilateral nonsyndromic cleft hand, central polydactyly, first web syndactyly, osseous syndactyly between the ring and long fingers, and minor thumb hypoplasia was presented.

Chronic Boutonniere Deformity: Cross-Lateral Band Technique Using Palmaris Longus Autograft.

PURPOSE: The purpose of this study was to evaluate the outcomes of treatment of chronic boutonniere deformity with a reconstruction technique using palmaris longus autograft. MATERIALS AND METHODS: Seven patients with chronic, posttraumatic, flexible boutonniere deformities referred to our clinic between January 2010 and September 2014 were included in the study. In all 7 patients, the lateral bands were deficient or damaged beyond repair. A novel reconstruction technique for chronic boutonniere deformity utilizing palmaris longus autograft was used. The 2 lateral bands were reconstructed by attaching the palmaris longus tendon grafts from the lateral part of the central slip proximally to the volar aspect of the distal phalanx distally using pull-out sutures. The grafts were positioned so that they crossed over one another at the level of the middle phalanx. The patients were followed for a mean of 14 months (range, 12-16 months). The principal outcome measure was the range of motion of the proximal (PIP) and distal (DIP) interphalangeal joints. RESULTS: Before surgery, the average PIP joint active flexion was 69° (range, 60°-85°). After surgery, the average PIP joint active flexion increased to 92° (range, 90°-100°). Before surgery, the average PIP joint extension deficit was 54° (range, 40°-60°); after surgery, the average deficit was reduced to 7° (range, 5°-15°). Before surgery, the average DIP posture was 9° of hyperextension (range, 5°-12°); after surgery, DIP hyperextension was reduced to 2° (range, 0°-5°). Before surgery, the average DIP active flexion was 40° (range, 35°-55°); after surgery, this increased to 55° (range, 43°-72°). No patients developed a DIP flexion contracture. CONCLUSIONS: In the chronic boutonniere deformity, when the lateral bands are deficient or damaged, our cross-lateral band reconstruction technique using palmaris longus autograft is a treatment option with satisfactory results. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic V.

Leg ulcer in a patient with Rothmund-Thomson syndrome.

BACKGROUND: Rothmund-Thomson syndrome is a rare genetic condition exhibiting some dermatological, craniofacial, ophthalmological, and central nervous system abnormalities. CASE DESCRIPTION: A 51-year-old male patient, diagnosed with Rothmund-Thomson syndrome, attended to our outpatient clinic with complaint of unhealing wound in lower part of his left leg. Over this period, he had received various local therapies such as creams, wound dressings and hyperbaric oxygen therapy but no progress could be achieved. The wound gradually enlarged. Negative pressure wound therapy was applied at -125 mmHg for 20 days. Wound was finally covered with split-thickness skin graft. DISCUSSION AND EVALUATION: There is only one case of Rothmund-Thomson syndrome with leg ulcer reported in the literature. However, complete closure has not been achieved with non-surgical therapies in this case. Therefore we performed negative pressure wound therapy followed by skin grafting. CONCLUSIONS: It is useful to treat therapy resistant wounds in Rothmund-Thomson syndrome by negative pressure, which can preserve residual vital tissue, and help clear away necrotizing tissue effectively and close the wound promptly.

A classification system for ulnar polydactyly and clinical series.

PURPOSE: To describe a modified classification that includes both complicated ulnar polydactyly and ulnar polydactyly with bifid or duplicated proximal phalanx and to apply it to a clinical series. METHODS: A total of 42 patients with ulnar polydactyly were admitted to our outpatient clinic between January 2004 and January 2014 and were included in the study. Patients' clinical and radiological data were evaluated retrospectively and organized into 5 different subgroups. RESULTS: There were 20 bilateral and 22 unilateral patients with polydactyly. These were composed of 32 supernumerary digits represented as type I, 7 as type II, 9 as type III, 12 as type IV, and 2 as type V. Nine patients had bifid or duplicated proximal phalanges (types IIIA and IIIB) and 2 were of the complicated type (type V). We identified 5 types based on morphology, level of duplication, and other complicating features. CONCLUSIONS: Complicated ulnar polydactyly and ulnar polydactyly with bifid proximal phalanx are 2 important types of ulnar polydactyly with surgical implications, both separately included in the Pritsch classification system and Rayan and Al-Qattan classification systems. None of the current classification systems include both types. We believe our modified classification system will help to better define diagnosis and treatment plans for bifid proximal phalanx and complicated type ulnar polydactyly. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic III.

A rare phenomenon: oculonasal synkinesis.

Oculonasal synkinesis is the simultaneous contraction of the orbicularis oculi and the compressor narium minor muscles. The etiology of this phenomenon is still unclear; congenital and traumatic reasons are considered to be responsible. Here we report a case of oculonasal synkinesis.

Supernumerary nostril: Congenital adrenal hyperplasia with a rare congenital anomaly.

Multiple or supernumerary nostril is a rare congenital anomaly with unknown etiology. The first case was reported by Lindsay as bilateral supernumerary nostrils. Supernumerary nostril cases are mostly unilateral and isolated. They are also reported with other congenital malformations like facial clefts and congenital anomalies like congenital auricular hypoplasia, congenital cataracts, eusophageal atresia and patent ductus arteriosus. Here, we report a case of supernumerary nostril with congenital adrenal hyperplasia.