Optimizing Outcomes in Lymphedema Reconstruction.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Describe current surgical techniques for treating primary and secondary lymphedema. 2. Optimize the surgical care of patients with lymphedema. SUMMARY: Over the past decade, significant advances have been made in the surgical treatment of lymphedema. The most notable changes have been the reintroduction and evolution of physiologic techniques, including lymphovenous bypass-sometimes referred to as lymphovenous anastomosis in the literature-and vascularized lymph node transplant. These surgical modalities are now often used as first-line surgical options or may be combined with nonphysiologic approaches, including direct excision and suction-assisted lipectomy. Surgeons continue to debate the most appropriate sequence and combination of surgical treatment, particularly for patients at both extremes of the severity spectrum. Furthermore, debate remains around the need to apply different treatment approaches for patients with upper versus lower extremity involvement and primary versus secondary cause. In this article, we provide a summary of the surgical techniques currently used for both primary and secondary lymphedema and provide our recommendations for optimizing the surgical care of patients with lymphedema.

Prioritizing Native Breast Skin Preservation or Scar Symmetry in Autologous Breast Reconstruction? Using Crowdsourcing to Assess Preference.

Background: Recent literature on autologous breast reconstruction suggests that such factors as scar symmetry and skin paddle size impact patient preferences more than preservation of native breast skin. Since patient satisfaction with plastic surgery procedures can be largely influenced by beauty standards set by the general public, this study used a novel crowdsourcing method to evaluate laypeople's aesthetic preferences for different bilateral autologous breast reconstructions to determine the relative importance of scar and skin paddle symmetry and preservation of native skin. Methods: Using Amazon's Mechanical Turk crowdsourcing marketplace, participants ranked images of reconstructions based on overall aesthetic appearance. Images were digitally modified to reflect 4 types of reconstruction: immediate (IR), delayed symmetric (DS), delayed asymmetric (DA), or mixed (MR). Results: DS was ranked most favorably (1.74), followed by IR (1.95), DA (2.93), and MR (3.34). Friedman rank sum and pairwise tests showed statistical significance for comparisons of all 4 reconstruction types. Likert ratings were higher for IR than for DA reconstructions for skin quality (P = .002), scar visibility (P < .001), scar position (P < .001), and breast symmetry, shape, and position (P < .001). Ratings increased for all aesthetic factors following nipple-areolar-complex reconstruction (P < .001). Conclusions: More symmetric breast scars were rated aesthetically higher than nonsymmetric scarring, and our participants preferred maintenance of scar symmetry over preservation of native breast skin. These findings are consistent with previous studies that surveyed non-crowdsourced participants, which demonstrates the potential for crowdsourcing to be used to better understand the general public's preferences in plastic surgery.

"Immediate versus delayed autologous breast reconstruction in patients undergoing post-mastectomy radiation therapy: A paradigm shift".

BACKGROUND: While negative impacts of radiation on breast reconstruction have been well accepted, timing of autologous breast reconstruction in the setting of postmastectomy radiation therapy (PMRT) is still evolving. This study aims to address the dilemma of breast reconstruction timing in patients receiving PMRT. METHODS: A retrospective chart review was performed evaluating patients who underwent PMRT and autologous breast reconstruction. Postoperative complication and revision rates were compared. RESULTS: Thirty-six immediate (immediate breast reconstruction [IBR]) and 89 delayed reconstructions (delayed breast reconstruction [DBR]) were included with comparable patient characteristics between groups. Overall complication rates were not significantly different, or when separately assessing for surgical site infections, wound dehiscence, fat necrosis, or substantial volume loss. No free flaps were lost in either group. Revision rates were significantly lower in the IBR group (p = 0.02). DBR resulted in appreciably larger volumes of fat grafting to the therapeutically reconstructed breast (p = 0.01) and more contralateral mastopexies (p = 0.02). No significant difference was observed in fat necrosis excision, breast reduction, or need for secondary flap reconstruction or prosthetic use for volume loss. CONCLUSIONS: IBR in the setting of PMRT does not result in higher rates of complications and requires fewer overall revisions, making it a compelling option for patients undergoing PMRT.

Physical and Functional Outcomes of Simultaneous Vascularized Lymph Node Transplant and Lymphovenous Bypass in the Treatment of Lymphedema.

BACKGROUND: The authors analyze the outcomes of simultaneous vascularized lymph node transplant and lymphovenous bypass for treatment of primary and secondary lymphedema. To the best of their knowledge, this is the largest study to date with long-term outcome data of this novel approach. METHODS: Three hundred twenty-eight patients who underwent physiologic surgical treatment over a 5.5-year period were evaluated using a prospective database and chart review. Preoperative characteristics, operative details, and postoperative outcomes (volume difference change, Lymphedema Life Impact Scale score) were assessed. Statistical analysis including multivariate regression was performed. RESULTS: Two hundred twenty patients (67.1 percent) underwent simultaneous vascularized lymph node transplant and lymphovenous bypass. Mean body mass index was 26.9 ± 4.7 kg/m 2 . Ninety-two patients (41.8 percent) had lymphedema of the lower extremity, 121 (55.0 percent) had upper extremity involvement, and seven had lymphedema of upper and lower extremities (3.2 percent). Average duration of lymphedema was 95.4 ± 103.6 months. Thirty patients (13.6 percent) had primary lymphedema and 190 patients (86.4 percent) had secondary lymphedema. The majority improved and experienced volume reduction of an average 21.4 percent at 1 year ( p < 0.0001), 36.2 percent at 2 years ( p < 0.0001), 25.5 percent at 3 years ( p = 0.1), and 19.6 percent at 4 years. Median Lymphedema Life Impact Scale scores were 7.0 points lower ( p < 0.0001) at 3 months and improved progressively over time to 27.5 points lower at 3 years postoperatively ( p < 0.005). CONCLUSIONS: Simultaneous vascularized lymph node transplant and lymphovenous bypass is an appropriate and effective approach for both early and advanced stages of primary and secondary lymphedema, with significant objective and subjective improvements. Volume reduction in the affected limb was observed at all time points postoperatively, with significant improvement in Lymphedema Life Impact Scale scores. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Outcomes for Physiologic Microsurgical Treatment of Secondary Lymphedema Involving the Extremity.

OBJECTIVE: The aim of this study was to examine the long-term impact of physiologic surgical options, including VLNT and LVB, on patients with secondary lymphedema of the upper or lower extremity (UEL/LEL). SUMMARY BACKGROUND DATA: VLNT and LVB have become increasingly popular in the treatment of lymphedema. However, there is a paucity of long-term data on patient outcomes after use of these techniques to treat lymphedema. METHODS: An analysis of prospectively collected data on all patients who underwent physiologic surgical treatment of secondary lymphedema over a 5.5-year period was performed. Patient demographics, surgical details, subjective reported improvements, LLIS scores, and postoperative limb volume calculations were analyzed. RESULTS: Two hundred seventy-four patients with secondary lymphedema (197 upper, 77 lower) were included in the study. More than 87% of UEL patients and 60% of LEL patients had reduction in excess limb volume postoperatively. At 3 months postoperatively, patients with UEL had a 31.1% reduction in volume difference between limbs, 33.9% at 6 months, 25.7% at 12 months, 47.4% at 24 months and 47.7% at 4 years. The reduction in limb volume difference followed a similar pattern but was overall lower for LEL patients. Greater than 86% of UEL and 75% of LEL patients also had improvement in LLIS scores postoperatively. Fifty-nine complications occurred (12.9%); flap survival was >99%. CONCLUSIONS: Patients with secondary UEL/LEL who undergo VLNT/LVB demonstrate improved functional status and reduced affected limb volumes postoperatively. Patients with UEL seem to have a more substantial reduction in limb volume differential compared to LEL patients.

Review of Health Insurance Policy Inclusivity of Gender Nonconforming and Nonbinary Individuals Seeking Gender-Affirming Health Care.

Background: An increasing number of individuals who present to health care professionals identify as transgender, gender nonconforming (GNC), and gender nonbinary (NB). GNC/NB individuals experience higher rates of discrimination in health care settings compared with their binary (e.g., trans male and trans female) counterparts. Outdated language excludes the nuances of gender identity. The goal of this study was to evaluate whether current terminology found in health insurance policies may be a barrier to gender-affirming health care for GNC/NB individuals. Methods: Health insurance policies for a diverse subset of government (n=4) and private (n=6) payers were obtained in May 2020. Policies were reviewed independently by two members of the research team to determine whether each was supportive or unsupportive to GNC/NB individuals. An arbitrary scoring system was designed that allowed the reviewers to assign a specific number of points to each policy based on the aggregation of mention, coverage, and inclusivity. Results: Most policies performed poorly as indicated by a support score less than zero. It was also noted that most policies used binary, gendered language, and terminology that excludes the unique gender identities of many GNC/NB individuals. Conclusions: Most policies currently failed to provide clear, inclusive coverage to GNC/NB individuals for relevant and important aspects of their care. In their current state, these policies are a source of confusion, uncertainty, and discouragement for these individuals, which can present as a barrier to accessing quality, inclusive, gender-affirming health care.

Lymphatic Microsurgical Preventive Healing Approach (LYMPHA) for the prevention of secondary lymphedema.

Lymphedema is a chronic, morbid condition in which the upper or lower extremity experiences swelling and fibrosis due to impaired lymphatic clearance. Among breast cancer patients, this condition is primarily attributed to axillary lymph node dissection (ALND) performed for oncologic management. While nonoperative and operative approaches to lymphedema management may be implemented to "manage" this condition, they are typically not curative. Therefore, lymphedema prevention in patients who have undergone ALND is of critical importance. Here, we briefly describe lymphedema and available management strategies, and focus on prevention in patients undergoing ALND using the Lymphatic Microsurgical Preventive Healing Approach (LYMPHA). Currently available clinical and experimental evidence suggests that LYMPHA may provide protection against the development of lymphedema in carefully selected patients. This procedure can serve as an adjunct surgical option for patients at the time of ALND.

An Analysis of Differences in the Number of Children for Female and Male Plastic Surgeons.

BACKGROUND: Historically, the structure of surgical programs discourages women interested in both surgery and motherhood from pursuing a surgical career, and women plastic surgeons have been more likely than men to have no children or to have fewer, later in life. Female plastic surgery trainees now constitute over one-third of residents, and pregnancy rates can be expected to rise, but with women now a majority in medical schools, the specialty's maternity policies may be deterring interested women from entering the specialty. A survey study was conducted to measure reproductive outcomes and to identify current disparities between women and men plastic surgeons. METHODS: An anonymous electronic survey was distributed to American Society of Plastic Surgeons members and candidates, allowing comparisons of men's and women's responses. Differences were tested by the Fisher's exact and chi-square tests. RESULTS: Compared with male respondents, women were more likely than men to have no biological children (45.1 percent versus 23.1 percent). They were nearly twice as likely to delay having children because of the demands of training (72.6 percent versus 39.2 percent) and to experience infertility (26.3 percent versus 12.5 percent). Among the childless plastic surgeons, women were 11 times more likely to say they did not want children compared with men (20.1 percent versus 1.8 percent). CONCLUSIONS: Poor institutional maternity support results in a persistent, wide gap in reproductive outcomes between female and male plastic surgeons. Establishing a universal, comprehensive parental support policy is essential to closing that gap.

The Relationship Between Clinical and Indocyanine Green Staging in Lymphedema.

Background: Multiple staging systems for classifying the severity of lymphedema exist. The International Society of Lymphology (ISL) stage is considered standard for clinical reporting, but the relationship between clinical and functional/imaging stage remains poorly defined. Materials and Methods: We reviewed the prospectively collected data of all patients who underwent physiologic lymphedema surgery for a 3-year period by the senior author. Patients who underwent preoperative clinical staging with limb volume calculations and intraoperative indocyanine green (ICG) staging were included. Correlations were examined between ISL stage, ICG stage, and preoperative volume difference. Results: A total of 212 patients met inclusion criteria. ISL stage and preoperative volume difference had a Pearson correlation coefficient of 0.579 [p < 0.001, 95% confidence intervals, CIs (0.479-0.664)]; ICG stage and preoperative volume difference had a Pearson correlation coefficient of 0.338 [p < 0.001, 95% CIs (0.204-0.460)]; and ISL stage and ICG stage had a Pearson correlation coefficient of 0.254 [p < 0.001, 95% CIs (0.114-0.383)]. Conclusion: Clinical ISL stage does not correlate well with ICG stage in patients undergoing physiologic lymphedema surgery.

Lymphovenous bypass for the treatment of lymphedema.

Lymphovenous bypass (LVB) is a form of physiological lymphedema surgery, which was described decades ago, but recently it is gaining popularity with improved microsurgical technology available. Benefits of the procedure are its effectiveness in treating early stage lymphedema of either the upper or lower extremity and having low complication profile. In the following article, the history of the procedure, mechanism, and details of various LVB techniques, and outcomes will be discussed.

Gender Differences in the Professional and Personal Lives of Plastic Surgeons.

BACKGROUND: Although the number of women becoming plastic surgeons has increased during the past six decades, in comparison with the current gender parity in medical schools, plastic surgery still attracts disproportionately more men. Previous studies have shown disparities in the professional and personal lives of female and male plastic surgeons. A survey study was conducted to identify current challenges women and men encounter in the pursuit of a plastic surgical career to guide remedial strategies. METHODS: An anonymous electronic survey was distributed to American Society of Plastic Surgeons members and candidates for comparison between sexes. Differences were tested by the Fisher's exact and chi-square tests. RESULTS: Women were more likely than men to have experienced sexism or bias. Women were less likely to be married; be satisfied with work-life balance; or feel recognized for ideas, authorship, promotions, or raises. Women felt that their sex was a disadvantage in career advancement, with one exception: unlike men, women felt many patients chose them because of their sex. Despite these challenges, over 80 percent of all plastic surgeons were satisfied with their choice of career. CONCLUSIONS: Traditions and gender bias create disparities in the personal and professional lives of female and male plastic surgeons. Our specialty must make concrete changes to promote all plastic surgeons, both women and men, to thrive personally and professionally.

Superficial Inferior Epigastric Artery Flap Salvage Technique Using Deep Inferior Epigastric Artery Graft.

Superficial inferior epigastric artery (SIEA) flap salvage remains challenging, particularly in cases of arterial insufficiency due to vessel spasm, pedicle kinking, or thrombosis. The already small, short SIEA pedicle, in addition to its inherent tendency toward spasm, renders the SIEA flap more difficult to manage when anastomotic revision is required. Furthermore, arterial thrombosis will cause dilation of the internal mammary artery, exacerbating vessel mismatch. In our previously published experience with 145 SIEA flaps, no flap with postoperative arterial thrombosis was salvageable. Following this experience, a new salvage technique using deep inferior epigastric artery grafts has been utilized and is described here.

Mandibular Distraction in a Patient With Type II Collagenopathy.

Kniest dysplasia is an extremely rare form of type II collagenopathy associated with cleft palate, micrognathia, shortened trunk, arms and legs, and club foot. The authors present a case of an infant with this disorder who also had micrognathia and respiratory distress for which mandibular distraction was performed. Although abnormal collagen and impaired endochondral ossification is noted with Kniest dysplasia, adequate bone formation was observed across the distraction gap. Nonetheless, despite stable mandibular advancement, failure to consider concomitant restrictive lung disease resulted in tracheostomy dependence. The authors demonstrate that while successful bone regeneration can be achieved through distraction of intramembranous facial bones, discretion must still be employed in patients with collagenopathies.

Immunological Effect of Skin Allograft in Burn Treatment: Impact on Future Vascularized Composite Allotransplantation.

Skin allografts are the gold standard in temporary burn wound coverage, but allografts are hypothesized to place a high antigenic load on recipients. This project aims to determine the degree of human leukocyte antigen sensitization in burn patients treated with allografts. Serum was obtained from nine adult, nontransfused, and nontransplanted burn patients treated with allografts. Group 1 included patients tested in the acute burn period, while group 2 included different patients tested months to years after injury. A calculated panel reactive antibody (cPRA) percent was assessed for each patient, and data for a control group of 92 adult nontransplanted males were used for comparison. Each patient received allografts from an average 3.55 ± 1.24 different donors. cPRA in group 1 was lower than in group 2 (6 ± 12% vs 42 ± 33%, P = .08). cPRA in the study group was significantly higher than in the control group (26 ± 31% vs 8 ± 17%, P = .0075). Burn patients who receive skin allograft demonstrate increased immunological sensitization compared with unsensitized controls. Detection of human leukocyte antigen antibody is lower in the acute burn period than months to years after injury. Increased sensitization may ultimately limit burn patients' candidacy for vascularized composite allotransplantation or decrease success of these procedures.

Pregnancy and the Plastic Surgery Resident.

BACKGROUND: Combining pregnancy with plastic surgery residency has historically been difficult. Two decades ago, 36 percent of plastic surgery program directors surveyed actively discouraged pregnancy among residents, and 33 percent of women plastic surgeons suffered from infertility. Most alarmingly, 26 percent of plastic surgery trainees had had an elective abortion during residency. With increasing numbers of women training in plastic surgery, this historical lack of support for pregnancy deserves further attention. METHODS: To explore the current accommodations made for the pregnant plastic surgery resident, an electronic survey was sent to 88 plastic surgery program directors in the United States. RESULTS: Fifty-four responded, for a response rate of 61.36 percent. On average, a director trained a total of 7.91 women among 17.28 residents trained over 8.19 years. Of the women residents, 1.43 were pregnant during a director's tenure, with 1.35 of those residents taking maternity leave. An average 1.75 male residents took paternity leave. Approximately one-third of programs had a formal maternity/paternity leave policy (36.54 percent) which, in most cases, was limited to defining allowed weeks of leave, time required to fulfill program requirements, and remuneration during leave. CONCLUSIONS: This survey of plastic surgery directors is a first step in defining the challenges training programs face in supporting the pregnant resident. Directors provided comments describing their challenges accommodating an absent resident in a small program and complying with the American Board of Plastic Surgery's required weeks of training per year. A discussion of these challenges is followed by suggested solutions.

Should We Excise Native Breast Skin Envelope to Achieve Symmetric Scars in Bilateral Autologous Breast Reconstruction?--A Survey of Surgeon and Patient Preference.

BACKGROUND: Given the multiple possible scar patterns in autologous breast reconstruction and combinations of such patterns in bilateral reconstruction, the present study aimed to determine the importance of scar symmetry in achieving aesthetically pleasing results. METHODS: A survey was administered to 128 participants including plastic surgeons and female breast reconstruction patients. In part A of the survey, participants were provided with photos of bilateral autologous breast reconstructions, and scar placement was varied to represent bilateral (1) immediate, (2) delayed symmetric, (3) delayed asymmetric, and (4) a mixture of immediate and delayed free flap reconstructions. Participants were asked to rank the photos in order of best to worst aesthetic outcome. In part B, pairs of the same reconstruction before and after nipple-areolar complex (NAC) reconstruction were presented, and participants were asked to assign a score to each photo according to aesthetic outcome. RESULTS: In part A, immediate reconstructions that included the smallest flap skin paddles ranked best among 52.5% ± 30% of participants, followed by delayed symmetric reconstructions that ranked best in 46.7% ± 29.6%. Mixed reconstructions ranked worst among 53.6% ± 37.6% of participants, followed by delayed asymmetric reconstructions (42.5% ± 37.9%). When NAC reconstruction was added to 1 set of the photos in part A, the same immediate reconstruction was ranked best, a significantly higher proportion of the time (36.3% increase, P < 0.001). This was accompanied by a significant decrease in top ranking for the delayed symmetric reconstruction (37.9% decrease, P < 0.001). In part B, addition of NAC increased each reconstruction's score by an average of 1.36 points on a 5-point scale with patients citing less improvement between the conditions (0.93 ± 0.03) than plastic surgeons (1.13 ± 0.49) (P = 0.03). CONCLUSIONS: More symmetric breast scars led to higher aesthetic ranking of bilateral autologous breast reconstructions. Participants in our survey preferred symmetric scars, even if achieving such a scar pattern would require excision of native breast skin and inclusion of more flap skin. Furthermore, NAC reconstruction alone improves aesthetic outcome, and improvement was most notable among immediate reconstructions.