Prospective Sensory Outcomes for Targeted Nipple Areola Complex Reinnervation (TNR) in Gender-Affirming Double Incision Mastectomy with Free Nipple Grafting.

OBJECTIVE: This study analyses the anatomy and sensory outcomes of targeted nipple areola complex reinnervation (TNR) in gender-affirming double incision mastectomy with free nipple grafting (FNG). BACKGROUND: TNR is a novel technique to preserve and reconstruct intercostal nerves (ICN) to improve postoperative sensation. There is little evidence on relevant anatomy and outcomes. METHODS: 25 patients were prospectively enrolled. Data included demographics, surgical technique, and axon/fascicle counts. Quantitative sensory evaluation using monofilaments and qualitative patient reported questionnaires were completed preoperatively, and at one, three, six, nine and twelve months postoperatively. RESULTS: 50 mastectomies were performed. Per mastectomy, the median number of ICN found and used was 2 (1-5). Axon and fascicle counts were not significantly different between ICN branches ( P >0.05). BMI ≥30 kg/m 2 and mastectomy weight ≥800 g were associated with significantly worse preoperative sensation ( P <0.05). Compared to preoperative values, NAC sensation was worse at 1 month ( P <0.01), comparable at 3 months ( P >0.05), and significantly better at 12 months ( P <0.05) postoperatively. Chest sensation was comparable to the preoperative measurements at 1 and 3 months ( P >0.05), and significantly better at 12 months ( P <0.05) postoperatively. NAC sensation was significantly better when direct coaptation was performed compared to use of allograft only ( P <0.05), and with direct coaptation of ≥2 branches compared to direct coaptation of a single branch ( P <0.05). All patients reported return of nipple and chest sensation at one year postoperatively and 88% reported return of some degree of erogenous sensation. CONCLUSION: TNR allows for restoration of NAC and chest sensation within 3 months postoperatively. Use of multiple ICN branches and direct coaptation led to the best sensory outcomes.

Refractory occipital neuralgia treatment with nerve decompression surgery: a case series.

Background: The management of refractory occipital neuralgia (ON) can be challenging. Selection criteria for occipital nerve decompression surgery are not well defined in terms of clinical features and best preoperative medical management. Methods: In total, 15 patients diagnosed with ON by a board-certified, fellowship-trained headache specialist and referred to a plastic surgeon for nerve decompression surgery were prospectively enrolled. All subjects received trials of occipital nerve blocks (NB), at least three preventive medications, and onabotulinum toxin (BTX) prior to surgery before referral to a plastic surgeon. Treatment outcomes included headache frequency (headache days/month), intensity (0-10), duration (h), and response to medication/injectable therapies at 12 months postoperatively. Results: Preoperatively, median headache days/month was 30 (20-30), intensity 8 (8-10), and duration 24 h (12-24). Patients trialed 10 (±5.8) NB and 11.7 (±9) BTX cycles. Postoperatively, headache frequency was 5 (0-16) days/month (p < 0.01), intensity was 4 (0-6) (p < 0.01), and duration was 10 (0-24) h (p < 0.01). Median patient-reported percent resolution of ON headaches was 80% (70-85%). All patients reported improvement of comorbid headache disorders, most commonly migraine, and a reduction, discontinuation, or increased effectiveness of medications, NB and BTX. Conclusion: All patients who underwent treatment for refractory ON by a headache specialist and plastic surgeon benefited from nerve decompression surgery in various degrees. The collaborative selection criteria employed in this study may be replicable in clinical practice.

The Timing of Acute and Late Complications Following Mastectomy and Implant-based Reconstruction.

BACKGROUND/OBJECTIVE: Implant-based breast reconstruction is a common plastic surgery procedure with well-documented clinical outcomes. Despite this, the natural history and timing of key complication endpoints are not well described. The goal of this study is to determine when patients are most likely to experience specific adverse events after implant-based reconstruction. METHODS: Retrospective consecutive series of patients who received mastectomy and implant-based reconstruction over a 6-year period were included. Complications and unfavorable outcomes including hematoma, seroma, wound infection, skin flap necrosis, capsular contracture, implant rippling, and implant loss were identified. A time-to-event analysis was performed and Cox regression models identified patient and treatment characteristics associated with each outcome. RESULTS: Of 1473 patients and 2434 total reconstructed breasts, 785 complications/unfavorable outcomes were identified. The 12-month cumulative incidence of hematoma was 1.4%, seroma: 4.3%, infection: 3.2%, skin flap necrosis: 3.9%, capsular contracture: 5.7%, implant rippling: 7.1%, and implant loss: 3.9%. In the analysis, 332/785 (42.3%) complications occurred within 60 days of surgery; 94% of hematomas, 85% of skin necrosis events, and 75% of seromas occurred during this period. Half of all infections and implant losses also occurred within 60 days. Of the remaining complications, 94% of capsular contractures and 93% of implant rippling occurred >60 days from surgery. CONCLUSIONS: Complications following mastectomy and implant-based reconstruction exhibit a discrete temporal distribution. These data represent the first comprehensive study of the timing of adverse events following implant-based reconstruction. These findings are immediately useful to guide postoperative care, follow-up, and clinical trial design.

Cost analysis of pre-pectoral implant-based breast reconstruction.

With improvement in mastectomy skin flap viability and increasing recognition of animation deformity following sub-pectoral implant placement, there has been a transition toward pre-pectoral breast reconstruction. While studies have explored the cost effectiveness of implant-based breast reconstruction, few investigations have evaluated cost with respect to pre-pectoral versus sub-pectoral breast reconstruction. A retrospective review of 548 patients who underwent mastectomy and implant-based breast reconstruction was performed from 2017 to 2020. The demographic and surgical characteristics of the pre-pectoral and sub-pectoral cohorts were well matched, except for reconstructive staging, as patients who underwent pre-pectoral reconstruction were more likely to undergo single-stage instead of two-stage reconstruction. Comparison of institutional cost ratios by reconstructive technique revealed that the sub-pectoral approach was more costly (1.70 ± 0.44 vs 1.58 ± 0.31, p < 0.01). However, further stratification by laterality and reconstructive staging failed to demonstrate difference in cost by reconstructive technique. These results were confirmed by multivariable linear regression, which did not reveal reconstructive technique to be an independent variable for cost. This study suggests that pre-pectoral breast reconstruction is a cost-effective alternative to sub-pectoral breast reconstruction and may confer cost benefit, as it is more strongly associated with direct-to-implant breast reconstruction.

Revisiting the Role of Occipital Artery Resection in Greater Occipital Nerve Decompression.

BACKGROUND: Greater occipital nerve surgery has been shown to improve headaches caused by nerve compression. There is a paucity of data, however, specifically regarding the efficacy of concomitant occipital artery resection. To that end, the goal of this study was to compare the efficacy of greater occipital nerve decompression with and without occipital artery resection. METHODS: This multicenter retrospective cohort study consisted of two groups: an occipital artery resection group (artery identified and resected) and a control group (no occipital artery resection). Preoperative, 3-month, and 12-month migraine frequency, duration, intensity, Migraine Headache Index score, and complications were extracted and analyzed. RESULTS: A total of 94 patients underwent greater occipital nerve decompression and met all inclusion criteria, with 78 in the occipital artery resection group and 16 in the control group. The groups did not differ in any of the demographic factors or preoperative migraine frequency, duration, intensity, or Migraine Headache Index score. Postoperatively, both groups demonstrated a significant decrease in migraine frequency, duration, intensity, and Migraine Headache Index score. The decrease in Migraine Headache Index score was significantly greater among the occipital artery resection group than the control group ( p = 0.019). Patients in both groups had no major complications and a very low rate of minor complications. CONCLUSION: Occipital artery resection during greater occipital nerve decompression is safe and improves outcomes; therefore, it should be performed routinely. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Estrogen-Associated Headaches Can Be Treated by Surgery: A Multicenter Retrospective Cohort Study.

BACKGROUND: Nerve decompression surgery has been successful in treating headaches refractory to traditional medical therapies. Nevertheless, a subset of patients remains unresponsive to surgical treatment. METHODS: The authors conducted a retrospective chart review of the two senior authors' (J.E.J. and W.G.A.) patient data from 2007 to 2020 to investigate differences in surgical outcomes in women reporting estrogen-associated headaches (headaches associated with menstrual period, oral contraceptives, pregnancy, or other hormonal drugs) compared with those who did not. For these two groups, the authors used the migraine headache index as the metric for headache severity and compared the mean percent change in migraine headache index score at 3 months and 1 year. RESULTS: Of the 99 female patients who underwent nerve decompression surgery and met inclusion criteria, 50 reported estrogen-associated headaches and were found to have significantly earlier age of onset ( p = 0.017) and initial presentation to clinic ( p = 0.046). At 1 year postoperatively, migraine headache index score had improved more than 80 percent in the majority of patients (67 percent), but there was a subset of patients whose score improved less than 5 percent (12.5 percent). The authors did not find a significant difference in percent change in postoperative migraine headache index score between women with estrogen-associated headaches and those without such headaches. CONCLUSIONS: Women with estrogen-associated headaches have surgical outcomes comparable to those of women without this association. Nerve decompression surgery should be offered to women experiencing estrogen-associated headaches as an option for treatment. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.