Retrospective Study on Optimizing Breast Augmentation Outcomes in Transgender Patients: A Comprehensive Analysis of Tumescent Local Anesthesia Technique.

BACKGROUND: Tumescent local anesthesia (TLA) involves the infusion of a saline solution containing lidocaine and epinephrine into tissues to achieve localized anesthesia and vasoconstriction. While the use of TLA in sub-glandular augmentation mammoplasty has been documented, we present a modified TLA approach for primary sub-muscular breast augmentation in transgender patients based on our experience over the past years. METHODS: Between the years 2014 and 2021, we performed primary sub-muscular breast augmentation on 20 transgender patients under TLA and conscious sedation. The tumescent solution consisted of 25 mL of 2% lidocaine, 8 mEq of sodium bicarbonate, and 1 mL of epinephrine (1 mg/1 mL) in 1000 mL of 0.9% saline solution. Initially, the solution was infiltrated between the pectoral fascia and the mammary gland, and subsequently, during the surgery, under the pectoralis major muscle. RESULTS: The average volume of tumescent solution infiltrated during TLA was 740 mL per breast. There were no reports of adrenaline or lidocaine toxicity, and no cases required a conversion to general anesthesia. Patients experienced no pain or discomfort during the preoperative infiltration or surgical procedure. Reoperations due to short-term complications never occurred. We observed a major complication rate of 5%, represented by 1 hematoma. Long-term complications comprised one case of implant dislocation and one occurrence of dystrophic scar formation. No cases of capsular contracture needing reoperation, asymmetry, and implant rupture occurred. In total, one individual (5%) requested larger implants. Follow-up time ranged from 30 days to 1 years. CONCLUSIONS: Overall, augmentation mammaplasty is a valuable choice for transgender women aiming to enhance their feminine characteristics and alleviate gender dysphoria. It is imperative for patients to conduct thorough research, grasp the potential pros and cons, and consult experienced healthcare professionals in transgender care. Additionally, tumescent local anesthesia (TLA) has proven to be a safe and efficient method for sub-muscular breast augmentation, providing effective pain control with minimal postoperative complications, resulting in high patient satisfaction. 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 .

Multidisciplinary Management of Cutaneous Squamous Cell Carcinoma of the Scalp: An Algorithm for Reconstruction and Treatment.

Background: Scalp-associated cutaneous squamous cell carcinoma (cSCC) presents formidable treatment challenges, especially when it leads to full-thickness defects involving bone. Aggressive or recurring cases often demand a multidisciplinary approach. Leveraging our surgical experience and a literature review, we introduce a therapeutic algorithm to guide the selection of reconstruction methods, particularly for locally advanced lesions, furthermore showing the synergy between surgery and other therapies for comprehensive, multidisciplinary disease management. Methods: Our algorithm stems from a retrospective analysis of 202 patients undergoing scalp cSCC resection and reconstruction over a 7-year period, encompassing 243 malignancies. After rigorous risk assessment and documentation of surgical procedures, reconstruction methods were therefore related to malignancy extent, depth, and individual clinical status. Results: The documented reconstructions included 76 primary closures, 115 skin grafts, 7 dermal substitute reconstructions, 33 local flaps, 1 locoregional flap, and 1 microsurgical free flap. Patients unsuitable for surgery received radiotherapy or immunotherapy after histological confirmation. Precise analysis of tumor characteristics in terms of infiltration extent and depth guided the selection of appropriate reconstruction and treatment strategies Combining these insights with an extensive literature review enabled us to formulate our algorithm for managing scalp cSCCs. Conclusions: Effectively addressing scalp cSCC, especially in locally advanced or recurrent cases, demands a systematic approach integrating surgery, radiotherapy, and immunotherapy. Our multidisciplinary team's decision-making algorithm improved patient outcomes by offering a broader spectrum of therapeutic options that can synergistically achieve optimal results.

Technical Refinements and Outcomes Assessment in Prepectoral Pocket Conversion After Postmastectomy Radiotherapy.

BACKGROUND: Several studies show how submuscular breast reconstruction is linked to animation deformity, shoulder dysfunction, and increased postoperative chest pain, when compared to prepectoral breast reconstruction. In solving all these life-impairing side effects, prepectoral implant pocket conversion has shown encouraging results. OBJECTIVES: The aim of this study was to propose a refinement of the prepectoral implant pocket conversion applied to previously irradiated patients. METHODS: We conducted a retrospective study on 42 patients who underwent previous nipple- or skin-sparing mastectomy and immediate submuscular reconstruction, followed by radiotherapy. We performed fat grafting sessions as regenerative pretreatment. Six months after the last fat graft, we performed the conversion, with prepectoral placement of micropolyurethane foam-coated implants. We investigated the preconversion and postconversion differences in upper limb range of motion, Upper Extremity Functional Index, and patient satisfaction with the breast and physical well-being of the chest. RESULTS: We reported a resolution of animation deformity in 100% of cases. The range of motion and the Upper Extremity Functional Index scores were statistically improved after prepectoral implant pocket conversion. BREAST-Q scores for satisfaction with the breast and physical well-being of the chest were also improved. CONCLUSIONS: The refined prepectoral implant pocket conversion is a reliable technique for solving animation deformity and improving quality of life in patients previously treated with submuscular reconstruction and radiotherapy.

A rare case of radiation-induced breast angiosarcoma: a case report.

We describe a rare case of a 77-year-old woman with radiation-induced breast angiosarcoma (RIAS) in whom radical surgery with negative margins determined that at 14-month of follow-up there is no evidence of either local or systemic recurrence without having to resort to adjuvant chemotherapy.

Objective Non-Invasive Bio-Parametric Evaluation of Regenerated Skin: A Comparison of Two Acellular Dermal Substitutes.

Several dermal substitutes are available on the market, but there is no precise indication that helps surgeons choose the proper one. Few studies have tried to compare different xenogeneic bioengineered products, but no objective bio-parametric comparison has been made yet. Fifteen patients who underwent skin reconstruction with Integra® or Pelnac® were retrospectively evaluated. After at least 12 months of follow-up, an objective and quantitative assessment of several skin biophysical properties, such as color, texture, elasticity, hydration, glossiness and trans-epidermal water loss, were measured with non-invasive skin measurement devices. The grafted skin showed a reduction of the superficial hydration level and a tendency to lower values of trans-epidermal water loss with both dermal substitutes. Melanic and hemoglobin pigmentation were higher in comparison to the donor site in both groups, while a melanic pigmentation increase versus the surrounding skin was seen just with Integra®. Finally, the skin was found to be more elastic when reconstructed with Integra®. The skin barrier appeared to be intact in both groups. Hence, these substitutes are valuable means of skin regeneration. Integra® seems to be more advantageous for reconstructing areas that need more skin flexibility.

Salvage Strategies for Local Recurrences of Squamous Cell Carcinoma of the Nasal Vestibule: A Single-Center Experience of 22 Years.

Squamous cell carcinomas of the nasal vestibule are an extremely rare neoplastic disease. Although brachytherapy is gaining popularity for primary treatment, surgery remains the best option in case of recurrences. The aim of this paper is to outline our treatment experience of local recurrence of SCCNVs over the past 22 years. We retrospectively reviewed the clinical data of the patients who underwent surgical treatment for local recurrence of SCCNV: data regarding age, sex, primary tumor treatment, recurrence location and time of appearance, surgical resection, type of reconstruction, postoperative complication, surgical revision, and re-recurrence rate were analyzed. Twenty patients were included in the study. The median period for recurrence appearance was 17 months, and the prevalent location of recurrence was the nasal alae. Prevalent reconstructive procedures were the nasolabial flap and paramedian forehead flap. No postoperative complications were observed, and one case of re-recurrence was detected at 12-months of follow-up. Based on our experience, salvage surgical procedures for SCCNV recurrences must be individualized and carefully planned, taking into account the peculiar pattern of tumor spread and the presence of scar and heavily radiotherapy damaged tissue from previous treatment; delayed reconstruction should be considered for all the cases with skeletal involvement.

Prevention of Breast Cancer-Related Lymphedema: An Up-to-Date Systematic Review of Different Surgical Approaches.

Breast cancer-related lymphedema (BCRL) affects approximately 20% of women after breast cancer therapy. Advances in treatment have increased the life expectancy; thus, the prevalence of BCRL will continue to rise with the number of cancer survivors, hence the need to develop strategies to prevent this condition. We provide a systematic review of the literature on the primary prevention of BCRL by prophylactic lymphatic surgery (PLS). Between June and August 2022, we conducted a search of PubMed, Google Scholar and Cochrane. In the end, a total of eighteen papers were selected. The eleven studies without a control group reported only 15 of 342 patients who developed lymphedema at least six months after PLS (4.59%). The seven studies with a control group included 569 patients, 328 cases and 241 controls. Among the cases, 36 (10%) developed lymphedema. In contrast, the incidence of lymphedema in the controls was 40% (98 of 241 patients). The formulation of definite recommendations in favor of PLS is hindered by low-quality studies. There is no consensus on which technique should be preferred, nor on whether adjuvant radiotherapy might affect the efficacy of PLS. Randomized controlled trials are mandatory to conceive evidence-based recommendations.

Outcomes of Abdominoplasty in Tumescent Local Anesthesia Combined with Subdural Anesthesia.

BACKGROUND: Abdominoplasty is a common surgical procedure performed under general anesthesia, and although the use of TLA combined with subdural anesthesia has never been reported in abdominoplasty, it offers several benefits such as safe and effective local anesthesia and vasoconstriction. We outline our experience with the TLA technique for primary abdominoplasty over the last 7 years. METHODS: From 2014 to 2021, TLA and subdural anesthesia have been used in primary abdominoplasty surgeries for 106 patients. The TLA solution consisted of 25 mL of 2% lidocaine, 8 mEq of sodium bicarbonate, and 1 mL of epinephrine (1 mg/1 mL) diluted in 1000 mL of 0.9% saline solution. The solution was then injected with a 2-mm cannula into the subcutaneous adipose tissue in the suprafascial plane. The subdural anesthesia was performed at intervertebral level L1-L2 using Ropivacaine 15/18 mg in 4 ml. RESULTS: Patients aged from 32 to 75 years. The amount of tumescent solution infiltrated ranged between 500 and 1000 mL. Mean surgery time was 70 minutes, and recovery room time averaged at 240 minutes. Major complications related to the surgery were observed in 12.26% of patients, including eight hematomas and five seromas. Two patients experienced wound dehiscence, and no dystrophic scar formation was observed. Eventually, there was no need for a conversion to general anesthesia. CONCLUSIONS: Tumescent local anesthesia combined with subdural anesthesia is a highly effective and safe method for performing abdominoplasty. This technique has proven to be an excellent choice for primary abdominoplasty, providing significant benefits to patients and surgeons alike due to its safe administration, precise pain management during and after surgery, and minimal postoperative side effects. 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 .

Rising age-specific rates of immediate breast reconstruction after mastectomy: Report from an Italian Breast Unit.

BACKGROUND AND OBJECTIVES: Immediate breast reconstruction (IBR) represents a fundamental part in the management of patients receiving mastectomy. In recent years, there has been an increasing trend in the use of IBR in all age groups. The study aims were to evaluate the age-specific trend of IBR, and to discuss its effects in work organization at an Italian Breast Unit. METHODS: We searched for women diagnosed with breast cancer between 2010 and 2019, focusing on IBR rates in patients who received mastectomy. Age-specific trends were assessed using the Cochrane-Armitage test. Differences in operative times and hospital stay between women undergoing mastectomy + IBR (Ma + IBR) or mastectomy alone (Ma) were evaluated by Student's t test or χ2 test. RESULTS: Among 1915 patients, 62.4% underwent breast conserving surgery (BCS), and 37.6% mastectomy. Overall, rates of Ma + IBR increased from 32% in 2010 to 58% in 2019 (p < 0.001). Although rates of IBR rose in all age groups, the trend was significantly increased among patients aged 50-59 (p < 0.001), 60-69 (p < 0.0001), and 70-79 (p < 0.05). CONCLUSIONS: Rates of Ma + IBR have increased over years, especially among older women. Ma + IBR resulted in longer operative times and hospital stay than Ma alone. These findings imply that, in the near future, resources should be implemented to improve and strengthen the surgical activity of Breast Units, to support the increasing use of IBR in women of all age groups.

Comparative evaluation using PRO of an algorithm of one-stage immediate alloplastic breast reconstruction versus two-stage reconstruction.

BACKGROUND: One-stage direct-to-implant (DTI) immediate breast reconstruction has proven to be an oncologically safe technique, but there are some conditions that do not allow its performance. The introduction of new surgical techniques and the recent COVID-19 pandemic have pushed us to introduce a breast reconstruction algorithm in our clinical practice. This allows a one-stage immediate reconstruction for all patients, regardless of their anatomical characteristics, the type of implants used, and the need for postoperative radiotherapy. METHODS: A total of 40 patients were recruited and divided into two cohorts, 20 patients underwent immediate one-stage breast reconstruction in the period between October 2019 and January 2021, and 20 patients completed the two-stage reconstructive process in the period prior to October 2019. During the follow-up at 6 months, all patients who had completed the reconstructive process filled out the Breast-Q Reconstruction Module Pre and Postoperative scales questionnaire. The outcomes of the questionnaires were compared between the two cohorts, and statistical analysis was carried out using SPSS Statistics 20 (IBM Corporation, Armonk, NY, USA). RESULTS: The analysis of patient-reported outcomes showed that patients from the one-stage group reported better outcomes in all items evaluated. We did not find statistically significant differences concerning the rate of complications and length of hospital stay between the two groups. CONCLUSIONS: The analysis of the results shows that the outcomes reported by patients who completed breast reconstruction according to our algorithm are statistically better than those with the two-stage technique.

Use of Radiofrequency-Assisted Liposuction (BodyTite) for Upper Arms Lifting.

BACKGROUND: Body contouring surgery is increasingly requested by patients, both for aesthetic and post-bariatric purposes. There has also been a rapid increase in demand for noninvasive aesthetic treatments. While brachioplasty is burdened by numerous complications and unsatisfactory scars, and conventional liposuction is unsuitable for all patients, nonsurgical arm remodeling performed with radiofrequency-assisted liposuction (RFAL) allows to effectively treat most of patients, regardless of the amount of fat and ptosis of the skin and avoiding surgical excision. METHODS: A prospective study was conducted on 120 consecutive patients who presented to the author's private clinic and required upper arm remodeling surgery for aesthetic purposes or after weight loss. Patients were classified according to the modified classification of El Khatib and Teimourian. Pre- and posttreatment upper arm circumferences were taken after 6 months of follow-up to assess the degree of skin retraction obtained by treating the arm with RFAL. A satisfaction questionnaire regarding the appearance of the arms (Body-Q upper arm satisfaction) was administered to all patients before surgery and after 6 months of follow-up. RESULTS: All patients were effectively treated with RFAL, and no cases required conversion to brachioplasty. The average reduction in arm circumference was 3.75 cm at 6 months follow-up, and patients' satisfaction increased from 35 to 87% posttreatment. CONCLUSIONS: Radio frequency is a valid tool to treat most patients with upper limbs skin laxity, with significant aesthetic results and a high degree of patient satisfaction, regardless of the degree of skin ptosis and lipodystrophy of the arm. 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 .

Squamous cell carcinoma of the scalp: a combination of different therapeutic strategies.

A case study of a 71-year-old man with a giant cutaneous squamous cell carcinoma of the scalp and calvaria is presented, where a combination of surgical excision, reconstruction with a latissimus dorsi muscular free flap, immunotherapy, and radiotherapy were used to control the disease for two years without recurrence.

Outcomes of Intramuscular Gluteal Augmentation With Implants Using Tumescent Local Anesthesia.

BACKGROUND: Tumescent local anesthesia (TLA) describes the practice of injecting a very dilute solution of local anesthetic combined with epinephrine and sodium bicarbonate into the tissue until it becomes firm and tense to obtain local anesthesia and vasoconstriction. The use of TLA in augmentation intramuscular gluteoplasty has never been described for implants positioning. Advantages of the TLA technique include a reduction in blood loss through epinephrine-induced vasoconstriction and hydrostatic compression from the tumescent effect. We describe TLA technique for primary intramuscular gluteal augmentation, reporting our experience during the last 5 years. METHODS: From 2017 to 2021, 20 patients underwent bilateral primary gluteal augmentation under TLA and conscious sedation. The tumescent solution was prepared with 25 mL of 2% lidocaine, 8 mEq of sodium bicarbonate, and 1 mL of epinephrine (1 mg/1 mL) in 1000 mL of 0.9% saline solution. The solution was infiltrated with a cannula inside the gluteus maximus muscle intra-operatively. RESULTS: The mean age of the patients was 39, 15 years. The average amount of tumescent solution infiltrated was 240 mL per gluteus. Operating time was 1 h and 40 min, and recovery room time averaged 240 min. Major surgery-related complications were found in 15% of patients (2 hematomas and 1 seroma) and minor complications were described in a total of 8 patients (4 wound dehiscence and 1 dystrophic scar formation). No signs of adrenaline nor lidocaine toxicity were reported and conversion to general anesthesia was never required. CONCLUSIONS: The tumescent local anesthesia technique represents a safe and efficacious technique for performing gluteal augmentation surgery with an intramuscular implant positioning. The advantages of this technique are safety, reasonable pain control during and after surgery and a low incidence of postoperative side effects due to general anesthesia avoidance. 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 .

One-Stage Immediate Alloplastic Breast Reconstruction in Large and Ptotic Breasts: An Institutional Algorithm.

Immediate implant-based breast reconstruction in patients with large and ptotic breasts may be challenging due to skin redundancy. The use of a reduction mammoplasty pattern for the mastectomy skin excision has proven to be a reliable option for these patients as it allows for a better shape, projection, and symmetrization. This approach has been described in the literature for both one- and two-stage reconstruction with either sub- or pre-pectoral reconstruction with an acellular dermal matrix (ADM) or non-biological mesh. One-stage immediate breast reconstructions have a positive significant impact on patients' psychosocial well-being and quality of life. The purpose of this paper is to describe an institutional algorithm that allows one to perform one-stage implant-based breast reconstructions in patients with large and ptotic breasts.

Predicting Mastectomy Skin Flap Necrosis: A Systematic Review of Preoperative and Intraoperative Assessment Techniques.

Mastectomy skin-flap necrosis (MSFN) is one of the most feared complications of immediate implant-based breast reconstruction (IIBR). Traditionally, mastectomy skin-flap viability was based only on surgeons' clinical experience. Even though numerous studies have already addressed the patients' risk factors for MSFN, few works have focused on assessing quality of breast envelope. This review investigates mastectomy's flap viability-assessment methods, both preoperative (PMFA) and intraoperative (IMFA), to predict MSFN and its sequalae. Between June and November 2022, we conducted a systematic review of Pubmed/MEDLINE and Cochrane electronic databases. Only English studies regarding PMFA and IMFA applied to IIBR were selected. The use of digital mammography, ultrasound, magnetic resonance imaging, and a combination of several methods before surgery was shown to be advantageous by several authors. Indocyanine performed better than other IMFA, however both thermal imaging and spectroscopy demonstrated novel and promising results. Anyway, the best prediction comes when preoperative and intraoperative values are combined. Particularly in prepectoral reconstruction, when mastectomy flaps are essential to determine a successful breast reconstruction, surgeons' clinical judgment is insufficient in assessing the risk of MSFN. Preoperative and intraoperative assessment techniques play an emerging key role in MSFN prediction. However, although there are several approaches to back up the surgeon's processing choice, there is still a dearth of pertinent literature on the subject, and more research is required.

Heel reconstruction with ALT free flap in a 4-year-old patient after a severe lawnmower injury. A case report.

Lawnmowers represent a danger in pediatric population. Frequently, traumas involve limbs. Among the different reconstructive techniques, a free flap is often needed. We discuss the first case of heel reconstruction with an anterolateral thigh flap in a 4-years-old patient after a lawnmower's trauma.

Improving Decision-making in Prepectoral Direct-to-implant Reconstruction After Nipple Sparing Mastectomy: The Key Role of Flap Thickness Ratio.

We report our experience in direct-to-implant breast reconstruction with prepectoral polyurethane implants, with a focus on intraoperative mastectomy flap thickness compared to preoperative data (flap thickness ratio) as a reliable predictive variable of ischemic complications and reconstructive outcomes (satisfaction with breast). BACKGROUND: The optimization of nipple sparing mastectomy and implant-based reconstruction techniques led to an increase in the popularity of prepectoral reconstruction. The aim of this study is to explore the ratio between the intraoperative and preoperative breast tissue coverage assessment as reliable tool in order to predict the risk of ischemic complications in prepectoral reconstruction. METHODS: We analyzed 124 preoperative digital mammograms of 100 patients who underwent prepectoral implant-based reconstruction. We applied a Rancati modified score for breast tissue coverage classification, adding 4 measurements on the craniocaudal view. The intraoperative mastectomy flap thickness was measured using an intraoperative ultrasound assessment. We investigated the differences between the groups with and without ischemic complications related to the preoperative, intraoperative, and flap thickness ratio data. RESULTS: The flap thickness ratio was lower in ischemic complication group compared to no ischemic complication group (0.4 vs. 0.8) with statistically significant differences for all ischemic complication subgroups: major mastectomy flap necrosis (P = .000), minor mastectomy flap necrosis (P = .005), partial nipple areola complex necrosis (P = .007), and implant exposure (P = .001).

Hybrid breast augmentation: our surgical approach and formula for preoperative assessment of fat graft volume.

Background: Autogenous fat grafting (AFG) is a well-known procedure utilized in addition to breast augmentation (BA) to improve breast appearance. Plastic surgeons usually estimate the ideal AFG volume relying on their personal experience based on similar previous cases: inaccurate predictions could result in incorrect evaluation of donor sites and even needless fat transfer. The purpose of this paper is to describe and prove the validity of our surgical technique and provide a simple and easy-to-use mathematical formula to assess the adequate proportion, between the volume of the implants and of the AFG, in order to obtain a natural shape and a proper volume in BA. Methods: One hundred and twenty-two patients (244 breasts) were subjected to primary/secondary hybrid BA (HBA). A formula was utilized to assess the volume of fat graft. Data about their age, body mass index (BMI), incision and implants were collected. Follow-up for analysis was fixed at less than 15 days, 1, 3, 6 and 12 months for analysis. Preoperative photographs were compared with postoperative at 12 months. Pre and postoperative Breast-Q© were administered to every patient. A statistical analysis was performed comparing Breast-Q© preoperative means with postoperative ones through t-student test. We globally defined the patients as follows: "very dissatisfied" if total score 0-25; "somewhat dissatisfied", score 26-50; "somewhat satisfied", score 51-75; "very satisfied", score 76-100. Results: All patients received Ergonomix-style Motiva Smooth/SilkSurface with low/high projection (range, 120-225 mL, mean 170 mL) and an average AFG volume of 600 mL (range, 480-720 mL). Breast-Q© analysis showed a statistically significant difference between preoperative and postoperative modules; 122 (100%) patients were "very satisfied". Thirteen cases of complications presented in 12 patients (10.65%): 5 hypertrophic scarring (4.09%), 3 wound dehiscence (2.46%), 3 hematomas (2.46%), 1 seroma (0.82%), 1 fat necrosis (0.82%). Conclusions: Our surgical technique proves low complication rate and short recovery times. Our mathematical formula to calculate the AFG seems to be both predictive and a precise guide for surgical decision-making in planning the treatment of patients candidated for HBA. In fact, the analysis of Breast-Q© questionnaires shows a high grade of satisfaction among patients. Further investigations should be performed in order to study a wider population and different type of implants.