The Vertical Profunda Artery Perforator Flap for Perineal Reconstruction.

BACKGROUND: Colorectal cancer is a significant cause of cancer-related death in the United States with abdominoperineal resection (APR) remaining a necessary procedure for many patients. The resultant defects of this radical operation are complex and characterized by significant tissue voids. Pedicled vertical profunda artery perforator flaps (vPAP) can be used to obliterate these defects in patients receiving minimally invasive APR or when the abdominal donor site is unavailable. METHODS: After receiving local institutional review board approval, a single center, retrospective cohort study from January 2020 to December 2021 was performed assessing pedicled vPAP flap reconstruction of APR defects. Age, sex, body mass index, primary diagnosis, comorbidities, concomitant oncologic procedures, radiation, timing, incorporation of gracilis flaps, follow-up, and complications were compared. RESULTS: Ten patients (70% male) with an average age of 56.2 years and BMI of 27.6 were included in the study. Rectal adenocarcinoma (50%) was the most common indication for APR, followed by rectal squamous cell carcinoma (30%), vulvar squamous cell carcinoma (10%), and Crohn disease (10%). Eighty percent of the patients received radiation, and 70% of reconstructions were delayed after the initial resection. The average length of clinical follow-up was 26.1 months. Concerning major complications, 2 patients were required to return to the operating room due to venous congestion (20%), and 2 patients suffered partial flap failure (20%). Minor complications were perineal dehiscence (50%), abscess requiring percutaneous drainage by interventional radiology (30%), and infection requiring antibiotics (20%). Twenty percent of patients developed fistulas requiring surgical excision. There were no instances of donor site dehiscence, and there was no complete flap loss, indicating successful reconstruction in all included cases. CONCLUSIONS: vPAP flaps are a reliable method to reconstruct perineal defects with less donor-site morbidity than previous reconstructive options. vPAP flaps should be considered in the setting of delayed reconstruction, minimally invasive APRs, and when the abdominal donor site is unavailable.

The Safety of Long Inframammary Fold to Nipple Lengths in Inferior Pedicle Breast Reductions: A Decade of Experience.

Background: Breast reduction is one of the most common procedures performed by plastic surgeons, and the inferior pedicle is a technique frequently used to maintain vascular supply to the nipple areolar complex (NAC). One of the relative contraindications for its use is the presence of a long nipple-to-inframammary fold (IMF) length; however, in the authors' practice, inferior pedicle mammoplasties have been successfully performed for over 10 years on almost all patients. Methods: The authors performed a retrospective study including patients who underwent bilateral breast reduction with inferior pedicle technique from October 2009 to April 2021 by 2 different surgeons in New Orleans, Louisiana. Patient baseline characteristics as well as surgical outcomes were recorded. Results: The study population consisted of 221 patients and 436 breasts. The average age of patients was 38 years, and average body mass index was 32.35 kg/m2. Average follow-up time was 135 days. The average nipple-to-IMF distance for the patient population was 16.03 cm, and the average pedicle width of the inferior pedicles used for breast reductions was 10 cm. There was no incidence of total nipple necrosis. The most common complication was a superficial wound at the T junction of the breast reduction incision (23%). Conclusions: Breast reductions with an inferior pedicle are safe to perform, without the risk of nipple necrosis, for all patients with inferior pedicle length up to 33 cm.

Autologous Heterogeneous Skin Construct Closes Traumatic Lower Extremity Wounds in Pediatric Patients: A Retrospective Case Series.

Lower extremity traumatic wounds pose unique challenges in pediatric patients, including vessel caliber, compliance with postoperative instructions, parental concerns about multiple operations, and long-term function. An autologous heterogeneous skin construct (AHSC) has demonstrated the ability to cover avascular structures and regenerate full-thickness functional skin. The objective of this study is to report our experience using AHSC in a cohort of pediatric trauma patients. This study is a noncontrolled, retrospective cohort analysis of all pediatric patients (<19 years of age) treated with AHSC for lower extremity traumatic wounds with at least one exposed deep structure (tendon, bone, and/or joint) at a single institution between May 1, 2018, and April 1, 2019. Seven patients with 10 traumatic wounds met inclusion criteria. The median follow-up time was 11.8 months. Five patients were male (71%); the median age was 7 years (range = 2-15 years). Average wound size was 105 cm2. All wounds achieved coverage of exposed structures and epithelial closure in a median of 13 and 69 days, respectively. There were no donor site complications and no reoperations required. All patients returned to normal activity, ambulate without limp, can wear shoes normally, and have normal tendon gliding. AHSC covered exposed structures and achieved closure within a single application in complex traumatic lower extremity wounds in a pediatric cohort.

The Impact of Exogenous Testosterone on Breast Cancer Risk in Transmasculine Individuals.

BACKGROUND: Exogenous testosterone is vital to gender-affirming therapy for transmasculine individuals. Testosterone may be implicated in breast cancer (BCa) because it can activate androgen and estrogen receptors. To further explore this risk, we performed a systematic review to investigate the impact of exogenous testosterone on BCa risk in transmasculine individuals. METHODS: We searched PubMed/MEDLINE and Ovid/Embase for clinical and preclinical studies assessing BCa and testosterone therapy and screened 6125 articles independently. We ascertained level of evidence using a modified tool from Cook et al (Chest. 1992;102:305S-311S) and risk of bias using a modified Joanna Briggs Institute's Critical Appraisal Tool. RESULTS: Seventy-six studies were included. Epidemiological data suggested that BCa incidence was higher in transmasculine individuals compared with cisgender men but lower compared with cisgender women. Histological studies of transmasculine breast tissue samples also demonstrated a low incidence of precancerous lesions. Interestingly, cases demonstrated that BCa occurred at a younger average age in transmasculine individuals and was predominantly hormone receptor positive. The mechanism for BCa in transmasculine individuals may be related to androgen receptor stimulation or conversion to estradiol. Serum studies reported varied estradiol levels associated with exogenous testosterone. Animal and in vitro studies demonstrated that testosterone was growth inhibitory but may induce proliferation at higher doses or with low estradiol levels. CONCLUSIONS: Plastic surgeons play a critical role in providing gender-affirming care for transmasculine patients. The limited studies available suggest that this patient population has decreased risk for BCa when compared with cisgender women; however, any BCa that does occur may have different clinical presentations and underlying mechanisms compared with cisgender women and men. Overall, the limitations for clinical studies and discrepancies among preclinical studies warrant further investigation.

Preoperative Computed Tomography Angiography for ALT Flaps Optimizes Design and Reduces Operative Time.

BACKGROUND: Computed tomography angiography (CTA) has been widely used for perforator mapping in abdominal-based reconstruction, but it is less widespread in the anterolateral thigh (ALT) flap. However, CTA may be quite useful for ALT planning, as this flap has demonstrated substantial variability in intrapatient bilateral vascular anatomy. This study investigated whether standard use of preoperative CTA resulted in selection of the donor extremity with preferential perforator anatomy, and whether this affected operative time and postoperative outcomes. METHODS: A retrospective review of 105 patients who underwent proposed ALT flap reconstruction was performed. Seventy-nine patients received bilateral lower extremity CTAs, which were evaluated for dominant perforator anatomy (septocutaneous, musculoseptocutaneous, or musculocutaneous). Donor extremity selection was noted, and predicted perforator anatomy was compared with that encountered intraoperatively. RESULTS: Among the 73 patients who received bilateral imaging and ultimately received an ALT, congruent findings between imaging and surgical exploration were observed in 51 (69.8%) patients. Thirty (37.9%) patients had asymmetric perforator anatomy between their bilateral extremities on imaging. Among these, the leg with optimal perforator anatomy was selected in 70% of cases. There were no significant reductions among postoperative complication rates, but selection of the donor site with preferential anatomy was associated with a decrease in operative time (p = 0.049) among patients undergoing extremity reconstruction. CONCLUSION: CTA is a useful tool for optimizing donor site selection for ALT flaps and reducing operative time. We believe that standard use of preoperative CTA in ALTs warrants further consideration.

Stratification of Surgical Risk in DIEP Breast Reconstruction Based on Classification of Obesity.

BACKGROUND: From both a medical and surgical perspective, obese breast cancer patients are considered to possess higher risk when undergoing autologous breast reconstruction relative to nonobese patients. However, few studies have evaluated the continuum of risk across the full range of obesity. This study sought to compare surgical risk between the three World Health Organization (WHO) classes of obesity in patients undergoing deep inferior epigastric perforator (DIEP) flap breast reconstruction. METHODS: A retrospective review of 219 obese patients receiving 306 individual DIEP flaps was performed. Subjects were stratified into WHO obesity classes I (body mass index [BMI]: 30-34), II (BMI: 35-39), and III (BMI: ≥ 40) and assessed for risk factors and postoperative donor and recipient site complications. RESULTS: When examined together, the rate of any complication between the three groups only trended toward significance (p = 0.07), and there were no significant differences among rates of specific individual complications. However, logistic regression analysis showed that class III obesity was an independent risk factor for both flap (odds ratio [OR]: 1.71, 95% confidence interval [CI]: 0.91-3.20, p = 0.03) and donor site (OR: 2.34, 95% CI: 1.09-5.05, p = 0.03) complications. CONCLUSION: DIEP breast reconstruction in the obese patient is more complex for both the patient and the surgeon. Although not a contraindication to undergoing surgery, obese patients should be diligently counseled regarding potential complications and undergo preoperative optimization of health parameters. Morbidly obese (class III) patients should be approached with additional caution, and perhaps even delay major reconstruction until specific BMI goals are met.

A Novel Technique for Radiographic Diagnosis of Sarcopenia that Accurately Predicts Postoperative Complications in Lower Extremity Free Flap Patients.

BACKGROUND: Sarcopenia is linked to poor outcomes throughout the surgical literature and can be assessed on preoperative imaging to potentially aid in risk stratification. This study examined the effects of sarcopenia on surgical morbidity following lower extremity (LE) reconstruction, and also compared two methods of assessment, one of which is novel ("ellipse method"). METHODS: A retrospective cohort study of 50 patients receiving free flap-based reconstruction of the LE was performed. Bilateral psoas density and area were quantified at L4 through tracing ("traditional method") and encircling ("ellipse method") to calculate Hounsfield unit average calculation (HUAC). Logistic regression and receiving operator curve analysis for the primary outcome of any postoperative complication was used to determine HUAC cutoffs (≤ 20.7 vs. ≤ 20.6) for sarcopenia. Risk of complications associated with sarcopenia was evaluated using Fisher's exact tests. RESULTS: Twelve patients (24%) met criteria for sarcopenia via the traditional method and 16 (32%) via the ellipse method. By both methods, sarcopenic patients were older and more often female and diabetic. These patients also had higher American Society of Anesthesiologists scores and lower serum prealbumin levels. The ellipse method was found to be more accurate, sensitive, and specific than the traditional method in predicting postoperative morbidity (p = 0.009). Via the ellipse method, sarcopenic patients were at higher risk for any complication (p = 0.002) and were at a higher risk for a deep vein thrombus or pulmonary embolism via the traditional method (p = 0.047). CONCLUSION: Sarcopenia is associated with greater pre- and postoperative morbidity in LE reconstruction. The novel ellipse method is a simplified and accurate method of assessing sarcopenia that can be easily performed in the clinical setting.