The 5 D's to Dunk the Dog: A Retrospective Clinical Review to Prevent Dog-Ear Contour Abnormalities in Vertical Breast Reductions and Breast Lifts.

Background: In 2020, reduction mammoplasties and mastopexies comprised 34.2% of all breast surgeries performed by plastic surgeons. Various approaches for the skin incision of these procedures have been described. The vertical pattern has become an increasingly popular option due to its lower scar burden. However, it is prone to dog-ear formation along the caudal aspect of the incision. Herein, we describe 5 technical steps to eliminate the dog-ear in patients undergoing vertical mammoplasties. Methods: A retrospective chart review was performed on all patients who underwent vertical breast reduction and mastopexy between the years 2008 and 2020 performed by the senior author. The 5 steps employed in eliminating the dog-ear are delineated and depicted pictorially. Results: A total of 58 patients and 89 breasts were operated upon. A majority of 66.6% were Caucasian, 33.3% were African American, and 1 patient was of Hispanic descent. The mean age was 53.2 years (19-73 years), and average BMI was 31.5 kg/m2 (21.3-42.7 kg/m2). The average resection weights for reduction and mastopexy patients were 479 grams (100-1500 grams) and 58.1 grams (18-100 grams), respectively. Mean follow-up was 10.5 months (1-35 months). Only one patient developed a dog-ear (1.7%) in bilateral breasts (2.2%); however, the patient did not request a revision. Our revision rate over 13 years remained at 0%. Conclusions: Utilizing these 5 technical steps reduces the risk of dog-ear deformity and thereby diminishes the overall need for revisional surgery in patients undergoing short scar vertical mammoplasties.

Anatomic surface landmarks to guide injection for posterior interosseous nerve block.

Proper injection of the posterior interosseous nerve (PIN) is important for both the therapeutic and diagnostic management of wrist pain. However, no anatomical study exists describing the site of injection based on individual wrist width. We sought to develop a reproducible anthropometric ratio utilizing external wrist surface anatomy to predict a safe and accurate injection site for the PIN. Fresh frozen cadaver forearms were dissected at the University of Louisville tissue lab. Several anthropometric measurements were obtained in order to develop a reproducible ratio to calculate location of injection. A total of 16 cadaver forearms of equal male to female ratio were obtained. On average, the male forearm had a greater mean wrist circumference obtained at the level of Lister's tubercle compared to female forearms, 17.1 cm vs. 13.5 cm. An injection given ulnar to proximal edge of Lister's tubercle at a length of one-fourth the distance between Lister's tubercle and radial aspect of ulnar styloid resulted in 100% accurate perineural injection without intraneural injection. An anthropometric ratio of one-fourth the distance from Lister's tubercle to the ulnar styloid was able to predict accurate injection sites for the distal PIN in cadaveric specimens of varying anatomical proportions.

Breast Reconstruction With Local Flaps: Don't Forget Grandma.

Objective: Lateral breast defects of various causes can be reconstructed with random patterned local flaps utilizing oncoplastic techniques. These local flaps are used frequently in other areas but are infrequent in breast reconstruction despite affording excellent utility in small lateral defects. We sought to demonstrate this with a case series involving 5 patients who underwent oncoplastic breast surgery with random patterned flap reconstruction. Methods: From 2016 to 2017, 3 different varieties of random flaps were used in 5 women requiring lateral breast defect reconstruction secondary to resection of localized cancer or cutaneous lesion. The local flaps included a rhomboid flap, the bilobed flap, and a rotational flap. Patients were then evaluated in the clinic 10 to 12 months postoperatively for complications, symmetry, and satisfaction of reconstruction. Results: In 4 of 5 patients, the local flap remained fully viable and there was no incidence of seroma, infection, or further complications. One patient developed a post-operative hematoma requiring evacuation and a second patient experienced distal flap necrosis and delayed wound healing. Patients reported satisfaction with the reconstruction. Conclusions: Several random patterned local flaps exist for a variety of breast defects. They can yield excellent cosmetic results, high patient satisfaction, and bolster a low rate of complications. Our case series emphasizes the utility of random patterned flaps for lateral breast oncoplastic reconstruction.

Bilateral Sciatic Neuropathy after an Autologous Breast Reconstruction in a Massive Weight Loss Patient.

Perioperative compression neuropathy is a known potential complication of prolonged surgical procedures. Sciatic postoperative neuropathy has rarely been reported. We present a 34-year-old woman who underwent right breast reconstruction with supercharged (venous anastomosis) transverse rectus abdominis flap and developed bilateral sciatic compression neuropathy. Her history was remarkable for sleeve gastrectomy 2 years earlier resulting in 105 pound weight loss 1 year before breast reconstruction. During the procedure, the patient was in the supine position for 8 hours and in the semirecumbent position for an additional 2 hours with the torso flexed at 30 degrees and knees flexed at approximately 45 degrees in addition to standard padding. Postoperatively, the patient was found to have loss of sensation and motor paralysis distal to her knees bilaterally. Pain sensation was preserved distally and no other neurological abnormalities were noted. Laboratory tests, magnetic resonance imaging, electromyography, and nerve conduction studies all revealed no evidence of neurological lesions and peroneal or lumbosacral radiculopathy. Motor strength gradually returned to her lower extremities over 4-5 weeks, whereas sensory function continued to improve over 7 weeks. The patient had complete neurological recovery 2 months postoperatively.

FIGO staging for carcinosarcoma: can the revised staging system predict overall survival?

OBJECTIVES: The purpose of this study is to detect differences in overall survival between the 1988 FIGO staging and current staging of uterine carcinosarcomas to determine if revised 2009 staging accurately predicts actual patient survival. METHODS: From 1988 until 2010, patients with uterine carcinosarcoma were retrospectively identified from tumor registry records. Patients were grouped in both broad stages (1-4) and all FIGO substages in order to detect differences. Time-dependent receiver operating characteristic curves (ROC) were generated to predict death before the end of the second year post-diagnosis for both the new and revised system. Kaplan Meier estimated median survival time was utilized to compare actual patient survival. RESULTS: Of 112 patients with carcinosarcoma, 37 patients (33%) had FIGO Stage I disease, 15 patients (13.4%) had Stage II disease, 36 patients (32%) were diagnosed as Stage III, and 24 patients (21.4%) had Stage IV disease. 106 of 112 (94.6%) patients underwent lymphadenectomy (pelvic +/- para-aortic). Four patients (3.6%) were downstaged when utilizing broad staging criteria: 2 patients were downstaged from Stage II to I, and 2 patients were downstaged from Stage III to Stage I and II respectively. When looking at substage, the area under the ROC was 0.67 for the former staging system, and 0.65 for the revised staging. Kaplan-Meier estimated median survival time post-diagnosis was 610 days (95% CI [478,930]). CONCLUSION: Based upon our reclassification of 112 patients with uterine carcinosarcoma, the revised FIGO staging system does not predict survival more accurately than former staging. Carcinosarcoma has an overall poor prognosis and better indicators of survival are needed.