Minimizing Nipple-Areolar Complex Complications in Prepectoral Breast Reconstruction After Nipple-Sparing Mastectomy.

PURPOSE: Nipple-areolar complex (NAC) viability remains a significant concern following prepectoral tissue expander (TE) reconstruction after nipple-sparing mastectomy (NSM). This study assesses the impact of intraoperative TE fill on NAC necrosis and identifies strategies for mitigating this risk. METHODS: A chart review of all consecutive, prepectoral TEs placed immediately after NSM was performed between March 2017 and December 2022 at a single center. Demographics, mastectomy weight, intraoperative TE fill, and complications were extracted for all patients. Partial NAC necrosis was defined as any thickness of skin loss including part of the NAC, whereas total NAC necrosis was defined as full-thickness skin loss involving the entirety of the NAC. P < 0.05 was considered statistically significant. RESULTS: Forty-six patients (83 breasts) with an average follow-up of 22 months were included. Women were on average 46 years old, nonsmoker (98%), and nondiabetic (100%) and had a body mass index of 23 kg/m2. All reconstructions were performed immediately following prophylactic mastectomies in 49% and therapeutic mastectomies in 51% of cases. Three breasts (4%) were radiated, and 15 patients (33%) received chemotherapy. Mean mastectomy weight was 346 ± 274 g, median intraoperative TE fill was 150 ± 225 mL, and median final TE fill was 350 ± 170 mL. Partial NAC necrosis occurred in 7 breasts (8%), and there were zero instances of complete NAC necrosis. On univariate analysis, partial NAC necrosis was not associated with any patient demographic or operative characteristics, including intraoperative TE fill. In multivariable models controlling for age, body mass index, mastectomy weight, prior breast surgery, and intraoperative TE fill, partial NAC necrosis was associated with lower body mass index (odds ratio, 0.53; confidence interval [CI], 0.29-0.98; P < 0.05) and higher mastectomy weight (odds ratio, 1.1; CI, 1.01-1.20; P < 0.05). Prior breast surgery approached significance, as those breasts had a 19.4 times higher odds of partial NAC necrosis (95% CI, 0.88-427.6; P = 0.06). CONCLUSIONS: Nipple-areolar complex necrosis following prepectoral TE reconstruction is a rare but serious complication. In this study of 83 breasts, 7 (8%) developed partial NAC necrosis, and all but one were able to be salvaged.

The Evolving Plastic Surgery Applicant: How Far Have We Come in 30 Years?

BACKGROUND: Plastic surgery training has undergone tremendous change and transitioned through many models over the years, including independent, combined, and integrated. This study evaluates how these changes and others have affected plastic surgery applicants' demographics and academic qualifications over the last 30 years. METHODS: Data on applicant demographics and academic qualifications were extracted from multiple sources including the National Resident Matching Program, the American Association of Medical Colleges, and cross-sectional surveys of plastic surgery applicants for the years 1992, 2005, 2011, and 2022. Data were compared using pairwise χ2 goodness of fit tests. RESULTS: The sex distribution of plastic surgery applicants changed significantly over the last 30 years: whereas men predominated in 1992 (86% male vs 14% female), by 2011, the distribution was nearly equal (54% male vs 46% female in both 2011 and 2022, P < 0.001).The racial makeup of applicants also changed over time (P < 0.05). White applicants decreased from 73% in 1992 to 55% in 2011, and 53% in 2022. While there was an increase in Asian (7% to > 17% to > 20%) and other (13% to > 14% to > 21%) applicants over time, whereas the proportion of Black applicants remained stagnant (5% to > 6% to > 8%).Applicants with prior general surgery experience declined precipitously over the years: 96% in 1992, 64% in 2005, 37% in 2011, and 26% in 2022 (P < 0.001). When compared with 1992, Alpha Omega Alpha status increased significantly in 2011 (36% vs 12%, P < 0.05) but did not change considerably in 2005 (22%) and 2022 (23%). Research experience increased dramatically over the years, with the proportion of applicants with at least one publication going from 43% in 1992, to 75% in 2005, to 89% in 2011, and to 99% in 2022 (P < 0.001). Applicant interest in academic plastic surgery did not change considerably over the years at roughly ranging from 30% to 50% of applicants (P = ns). CONCLUSIONS: There has been a shift in the demographics and academic qualifications of plastic surgery applicants over the last 3 decades. Understanding this evolution is critical for reviewing and evaluating the makeup of our specialty, and enacting changes to increase representation where necessary.

The First Successful Combined Full Face and Bilateral Hand Transplant.

BACKGROUND: Vascularized composite allotransplantation has redefined the frontiers of plastic and reconstructive surgery. At the cutting edge of this evolving paradigm, the authors present the first successful combined full face and bilateral hand transplant. METHODS: A 21-year-old man presented for evaluation with sequelae of an 80 percent total body surface area burn injury sustained after a motor vehicle accident. The injury included full face and bilateral upper extremity composite tissue defects, resulting in reduced quality of life and loss of independence. Multidisciplinary evaluation confirmed eligibility for combined face and bilateral hand transplantation. The operative approach was validated through 11 cadaveric rehearsals utilizing computerized surgical planning. Institutional review board and organ procurement organization approvals were obtained. The recipient, his caregiver, and the donor family consented to the procedure. RESULTS: Combined full face (i.e., eyelids, ears, nose, lips, and skeletal subunits) and bilateral hand transplantation (i.e., forearm level) was performed over 23 hours on August 12 to 13, 2020. Triple induction and maintenance immunosuppressive therapy and infection prophylaxis were administered. Plasmapheresis was necessary postoperatively. Minor revisions were performed over seven subsequent operations, including five left upper extremity, seven right upper extremity, and seven facial secondary procedures. At 8 months, the patient was approaching functional independence and remained free of acute rejection. He had significantly improved range of motion, motor power, and sensation of the face and hand allografts. CONCLUSIONS: Combined face and bilateral hand transplantation is feasible. This was the most comprehensive vascularized composite allotransplantation procedure successfully performed to date, marking a new milestone in plastic and reconstructive surgery for patients with otherwise irremediable injuries.

Perforator Variability of the Anterolateral Thigh Flap Identified on Computed Tomographic Angiography: Anatomic and Clinical Implications.

BACKGROUND: The anterolateral thigh (ALT) flap is a useful flap with minimal donor site morbidity. Preoperative computed tomographic angiography (CTA) for lower extremity reconstruction can determine vessel integrity and plan for recipient vascular targets. This study reviews lower extremity CTAs to further characterize ALT vascular anatomy and associated clinical implications thereof. PATIENTS AND METHODS: Lower extremity CTA studies were retrospectively reviewed, and information on ALT cutaneous perforator location, origin, and course was collected. RESULTS: A total of 58 lateral circumflex femoral artery (LCFA) systems in 31 patients were included. Average age was 38.8 ± 15.9 years with mean body mass index of 27.2 ± 5.7 kg/m2. The majority of patients were females (23, 74.2%). The LCFA most commonly originated from the profunda femoris artery (87.3%), followed by the distal common femoral artery (9.1%). On average, there were 1.66 ± 0.69 cm perforators per extremity, with an average of 5.38 cm between adjacent perforators. Perforators originated from the descending branch of the LCFA in 89.6% of studies. Perforator caliber was <1 mm (29, 30.2%), 1 to 2 mm (55, 57.3%), or >2 mm (12, 12.5%). Mean distance from the most proximal perforator to the anterior superior iliac spine was 20.4 ± 4.82 cm. Perforators were musculocutaneous (46.9%), septocutaneous (34.4%), or septomyocutaneous (18.8%). In 58.1% of patients, only one thigh had easily dissectable septocutaneous and/or septomyocutaneous perforators, in which case preoperative CTA aided in donor thigh selection. CONCLUSION: ALT flap cutaneous perforator anatomy varies considerably. Using CTA, we report on rates of septocutaneous, myocutaneous, and septomyocutaneous perforators and underscore its utility in perforator selection.

Robotic Excision of Vaginal Remnant/Urethral Diverticulum for Relief of Urinary Symptoms Following Phalloplasty in Transgender Men.

OBJECTIVE: To describe the technique of robotic remnant vaginectomy/excision of urethral diverticulum in transmen and report postoperative outcomes. MATERIALS AND METHODS: Between 2015 and 2018, 4 patients underwent robotic remnant vaginectomy/excision of urethral diverticulum for relief of urinary symptoms. Patients were of mean age 36 ± 10.1 years (range 26-50) at time of vaginal remnant excision, and were 26 ± 9.1 months (range 20-39) post-op following their primary vaginectomy and radial forearm free flap (n = 3) or anterolateral thigh (n = 1) phalloplasty. All had multiple urologic complications after primary phalloplasty, most commonly urinary retention (n = 4), urethral stricture (n = 3), fistula (n = 3), dribbling (n = 2), and obstruction (n = 2). Indication for revision was obstruction and retention (n =3 ) and/or dribbling (n = 2). In each case, the robotic transabdominal dissection freed remnant vaginal tissue from the adjacent bladder and rectum without injury to these structures. Concurrent first- or second-stage urethroplasty was performed in all cases at a more distal portion of the urethra using buccal mucosa, vaginal, or skin grafts. Intraoperative cystoscopy was used in each case to confirm complete resection and closure of the diverticulum. RESULTS: At mean follow-up of 294 ± 125.6 days (range 106-412), no patients had persistence or recurrence of vaginal cavity/urethral diverticulum on cystoscopic follow-up. Of 3 patients who wished to ultimately stand to void, 2 were able to do so at follow-up. CONCLUSION: Robotic transabdominal approach to remnant vaginectomy/excision of urethral diverticulum allows for excision without opening the perineal closure for management of symptomatic remnant/diverticulum in transgender men after vaginectomy.

Restoration of Nrf2 Signaling Normalizes the Regenerative Niche.

Chronic hyperglycemia impairs intracellular redox homeostasis and contributes to impaired diabetic tissue regeneration. The Keap1/Nrf2 pathway is a critical regulator of the endogenous antioxidant response system, and its dysfunction has been implicated in numerous pathologies. Here we characterize the effect of chronic hyperglycemia on Nrf2 signaling within a diabetic cutaneous regeneration model. We characterized the effects of chronic hyperglycemia on the Keap1/Nrf2 pathway within models of diabetic cutaneous wound regeneration. We assessed reactive oxygen species (ROS) production and antioxidant gene expression following alterations in the Nrf2 suppressor Keap1 and the subsequent changes in Nrf2 signaling. We also developed a topical small interfering RNA (siRNA)-based therapy to restore redox homeostasis within diabetic wounds. Western blotting demonstrated that chronic hyperglycemia-associated oxidative stress inhibits nuclear translocation of Nrf2 and impairs activation of antioxidant genes, thus contributing to ROS accumulation. Keap1 inhibition increased Nrf2 nuclear translocation, increased antioxidant gene expression, and reduced ROS production to normoglycemic levels, both in vitro and in vivo. Topical siKeap1 therapy resulted in improved regenerative capacity of diabetic wounds and accelerated closure. We report that chronic hyperglycemia weakens the endogenous antioxidant response, and the consequences of this defect are manifested by intracellular redox dysregulation, which can be restored by Keap1 inhibition. Targeted siRNA-based therapy represents a novel, efficacious strategy to reestablish redox homeostasis and accelerate diabetic cutaneous tissue regeneration.