Lipedema Reduction Surgery Improves Pain, Mobility, Physical Function, and Quality of Life: Case Series Report.

Background: Lipedema is a chronic inflammatory subcutaneous adipose-rich connective tissue disease affecting millions of women worldwide. Disproportionate fat accumulation on the extremities characterized by heaviness, tenderness, and swelling can affect function, mobility, and quality of life. Treatments include conservative measures and lipedema reduction surgery (LRS). Here, we report lipedema comorbidities and surgical techniques, outcomes measures, and complications after LRS. Methods: This is a single outpatient clinic retrospective chart review case series of comorbidities and complications in 189 women with lipedema. Bioelectrical impedance analyses, knee kinematics, gait, physical examinations, Patient-Reported Outcomes Measurement Information System, and RAND Short Form-36 questionnaires collected before and after LRS were analyzed for 66 of the 189 women. Hemoglobin levels were measured by transdermal hemoglobin monitor (Masimo noninvasive hemoglobin monitoring; Irvine, Calif.). Results: Common comorbidities in 189 women were hypermobile joints (50.5%), spider/varicose veins (48.6/24.5%), arthritis (29.1%), and hypothyroidism (25.9%). The most common complication in 5.5% of these women after LRS was lightheadedness with a 2-g reduction or more in hemoglobin. After conservative measures and LRS in 66 women, significant improvements (P ≤ 0.0009) were found for: (1) knee flexion (10 degrees); (2) gait; (3) Patient-Reported Outcomes Measurement Information System T-score (16%); (4) mobility questions: gait velocity, rising from a chair, stair ascent; (5) RAND Short Form-36 scores: physical functioning, energy/fatigue, emotional well-being, social function, general health; (6) and Bioelectrical impedance analyses total and segmental body fat mass. Conclusion: LRS provided significant improvements to women with lipedema using direct physical measurements and validated outcome measures, comparable to those seen after total knee replacement.

Standard of care for lipedema in the United States.

BACKGROUND: Lipedema is a loose connective tissue disease predominantly in women identified by increased nodular and fibrotic adipose tissue on the buttocks, hips and limbs that develops at times of hormone, weight and shape change including puberty, pregnancy, and menopause. Lipedema tissue may be very painful and can severely impair mobility. Non-lipedema obesity, lymphedema, venous disease, and hypermobile joints are comorbidities. Lipedema tissue is difficult to reduce by diet, exercise, or bariatric surgery. METHODS: This paper is a consensus guideline on lipedema written by a US committee following the Delphi Method. Consensus statements are rated for strength using the GRADE system. RESULTS: Eighty-five consensus statements outline lipedema pathophysiology, and medical, surgical, vascular, and other therapeutic recommendations. Future research topics are suggested. CONCLUSION: These guidelines improve the understanding of the loose connective tissue disease, lipedema, to advance our understanding towards early diagnosis, treatments, and ultimately a cure for affected individuals.

Survey Outcomes of Lipedema Reduction Surgery in the United States.

BACKGROUND: Lipedema is a loose connective tissue disease affecting the limbs of women, that is difficult to lose by diet, exercise, or bariatric surgery. Publications from Europe demonstrate that lipedema reduction surgery improves quality of life for women with lipedema. There are no comparable studies in the United States (USA). The aim of this study was to collect data from women with lipedema in the USA who have undergone lipedema reduction surgery in the USA to determine if quality of life, pain, and other measures improved after lipedema reduction surgery. METHODS: Subjects were recruited and consented online for a 166-item questionnaire in REDCap. In total, 148 women answered the questionnaire after undergoing lipedema reduction surgery in the USA. Significance set at P < 0.05 was determined by ANOVA, Tukey's multiple comparison test, or paired t-test. RESULTS: Quality of life improved in 84% and pain improved in 86% of patients. Ambulation improved most in lipedema Stage 3 (96%). Weight loss occurred in all stages by 3 months after surgery. Complications included growth of loose connective tissue within and outside treated areas, tissue fibrosis, anemia, blood clots, and lymphedema. CONCLUSIONS: Women with lipedema noticed significant benefits after lipedema reduction surgery in the USA. Prospective studies are needed to assess benefits and complications after lipedema reduction surgery in the USA.

Evidence-Based Performance Measures: Quality Metrics for the Care of Patients Undergoing Breast Reconstruction.

The American Society of Plastic Surgeons commissioned the Breast Reconstruction Performance Measure Development Work Group to identify and draft quality measures for the care of patients undergoing breast reconstruction surgery. Two outcome measures were identified. The first desired outcome was to reduce the number of returns to the operating room following reconstruction within 60 days of the initial reconstructive procedure. The second desired outcome was to reduce flap loss within 30 days of the initial reconstructive procedure. All measures in this report were approved by the American Society of Plastic Surgeons Breast Reconstruction Performance Measures Work Group and the American Society of Plastic Surgeons Executive Committee. The Work Group recommends the use of these measures for quality initiatives, Continuing Medical Education, Maintenance of Certification, American Society of Plastic Surgeons' Qualified Clinical Data Registry reporting, and national quality reporting programs.

Evidence-Based Clinical Practice Guideline: Autologous Breast Reconstruction with DIEP or Pedicled TRAM Abdominal Flaps.

The American Society of Plastic Surgeons commissioned a multistakeholder Work Group to develop recommendations for autologous breast reconstruction with abdominal flaps. A systematic literature review was performed and a stringent appraisal process was used to rate the quality of relevant scientific research. The Work Group assigned to draft this guideline was unable to find evidence of superiority of one technique over the other (deep inferior epigastric perforator versus pedicled transverse rectus abdominis musculocutaneous flap) in autologous tissue reconstruction of the breast after mastectomy. Presently, based on the evidence reported here, the Work Group recommends that surgeons contemplating breast reconstruction on their next patient consider the following: the patient's preferences and risk factors, the setting in which the surgeon works (academic versus community practice), resources available, the evidence shown in this guideline, and, equally important, the surgeon's technical expertise. Although theoretical superiority of one technique may exist, this remains to be reported in the literature, and future methodologically robust studies are needed.

Outcome assessment of breast distortion following submuscular breast augmentation.

BACKGROUND: Animation deformity or breast distortion during pectoralis muscle contraction following subpectoral breast augmentation is a known entity, but its prevalence and significance remain unclear. The purpose of this study was to identify the incidence and severity of animation deformity as well as its effect on patient satisfaction and interference with certain activities. METHODS: All procedures were performed by the senior author using a variation of a previously described dual-plane technique. The first part of this study was an evaluation of breast distortion by a group of independent observers in a series of 40 consecutive patients who underwent primary subpectoral breast augmentation. The second part of the study was a questionnaire sent to 195 consecutive patients asking about overall satisfaction, degree of animation deformity, and whether there was interference with any activities. RESULTS: Of the 40 patients' photographs that were evaluated, 9 (22.5%) had no distortion, 25 (62.5%) had minimal distortion, 4 (10%) had moderate distortion, and 2 (5%) had severe distortion. Of the 195 questionnaires, there were 69 responses, a 35% response rate. Fifty-six (82%) described mild to no distortion, 7 (10%) were moderate, and 5 (7%) were severe. According to the survey, the most common activities that were problematic were lifting weights and exercising (24 and 19%, respectively). Only one (1%) patient stated that she would not recommend subpectoral positioning. CONCLUSION: Although animation deformities do exist, nearly all patients in this study would still choose subpectoral positioning. Patients who may be better candidates for subglandular placement are those for whom exercise is central to their daily living. As a result of this study, surgeons and patients should have more accurate and reliable information regarding the significance of animation deformity after subpectoral breast augmentation.

A retrospective analysis of outcomes using three common methods for immediate breast reconstruction.

BACKGROUND: Breast reconstruction outcome studies typically evaluate satisfaction, complications, or aesthetic results. Some studies report better outcomes with autologous reconstruction, whereas other studies report no difference in outcomes across multiple reconstructive methods. METHODS: The authors retrospectively studied all patients undergoing immediate breast reconstruction over a 5-year period. Questionnaires were sent to all patients to assess satisfaction; preoperative bra size, height, and weight; smoking history; radiation history; length of stay; narcotic use; and recovery time. All charts were reviewed for complications. Four blinded reviewers performed aesthetic evaluations of patient results. RESULTS: One hundred eighty-six consecutive immediate breast reconstruction patients were surveyed. Charts and photographs were reviewed for complication data and aesthetic results. The survey response rate was 42 percent, including 48 of 106 expander/implant patients, 13 of 28 latissimus patients, and 18 of 52 transverse rectus abdominis musculocutaneus (TRAM) flap patients. Patient satisfaction was rated as moderate or better for 93.8 percent of the expander/implant patients, 76.9 percent of the latissimus flap patients, and 83.3 percent of the TRAM flap patients. Expander/implant patients were significantly more satisfied than latissimus flap patients. Complication rates were 21.7 percent for expander/implant patients, 67.9 percent for latissimus flap patients, and 26.9 percent for TRAM flap patients. Reoperation rates were 11.3 percent for expander/implant patients, 10.7 percent for latissimus flap patients, and 5.8 percent for TRAM flap patients. Aesthetic scores were significantly higher for TRAM flap patients compared with expander/implant and latissimus flap patients. CONCLUSION: High satisfaction rates were seen across all three reconstructive groups, with the highest satisfaction levels seen in the expander/implant group, despite higher reoperation rates and lower aesthetic scores for this group.

Portion distortion: typical portion sizes selected by young adults.

OBJECTIVE: The incidence of obesity has increased in parallel with increasing portion sizes of individually packaged and ready-to-eat prepared foods as well as foods served at restaurants. Portion distortion (perceiving large portion sizes as appropriate amounts to eat at a single eating occasion) may contribute to increasing energy intakes and expanding waistlines. The purpose of this study was to determine typical portion sizes that young adults select, how typical portion sizes compare with reference portion sizes (based in this study on the Nutrition Labeling and Education Act's quantities of food customarily eaten per eating occasion), and whether the size of typical portions has changed over time. SUBJECTS: Young adults (n=177, 75% female, age range 16 to 26 years) at a major northeastern university. METHODS: Participants served themselves typical portion sizes of eight foods at breakfast (n=63) or six foods at lunch or dinner (n=62, n=52, respectively). Typical portion-size selections were unobtrusively weighed. A unit score was calculated by awarding 1 point for each food with a typical portion size that was within 25% larger or smaller than the reference portion; larger or smaller portions were given 0 points. Thus, each participant's unit score could range from 0 to 8 at breakfast or 0 to 6 at lunch and dinner. Analysis of variance or t tests were used to determine whether typical and reference portion sizes differed, and whether typical portion sizes changed over time. RESULTS: Mean unit scores (+/-standard deviation) were 3.63+/-1.27 and 1.89+/-1.14, for breakfast and lunch/dinner, respectively, indicating little agreement between typical and reference portion sizes. Typical portions sizes in this study tended to be significantly different from those selected by young adults in a similar study conducted 2 decades ago. CONCLUSIONS: Portion distortion seems to affect the portion sizes selected by young adults for some foods. This phenomenon has the potential to hinder weight loss, weight maintenance, and/or health improvement efforts. Thus, to ensure more effective nutrition counseling, food and nutrition professionals must develop ways to "undistort" what clients perceive to be typical portion sizes and help them recognize what is an appropriate amount to eat at a single eating occasion.

Clinical approach to wounds: débridement and wound bed preparation including the use of dressings and wound-healing adjuvants.

This is a clinical review of current techniques in wound bed preparation found to be effective in assisting the wound-healing process. The process begins with the identification of a correct diagnosis of the wound's etiology and continues with optimizing the patient's medical condition, including blood flow to the wound site. Débridement as the basis of most wound-healing strategies is then emphasized. Various débridement techniques, including surgery, topical agents, and biosurgery, are thoroughly discussed and illustrated. Wound dressings, including the use of negative pressure wound therapy, are then reviewed. To properly determine the timing of advance therapeutic intervention, the wound-healing progress needs to be monitored carefully with weekly measurements. A reduction in wound area of 10 to 15 percent per week represents normal healing and does not mandate a change in the current wound-healing strategy. However, if this level of wound area reduction is not met consistently on a weekly basis, then alternative healing interventions should be considered. There is a growing body of evidence that can provide guidance on the appropriate use of such adjuvants in the problem wound. Several adjuvants are discussed, including growth factor, bioengineered tissues, and hyperbaric medicine.