Same Day Discharge After Mastectomy and Immediate Implant-Based Breast Reconstruction: A Retrospective Cohort Comparison Using the National Surgical Quality Improvement Program Database.

INTRODUCTION: Currently, overnight admission after immediate implant-based breast reconstruction (IBR) is the standard of care. Our study aims to analyze the safety, feasibility, and outcomes of immediate IBR with same-day discharge as compared with the standard overnight stay. METHODS: The 2015-2020 National Surgical Quality Improvement Program database was reviewed to identify all patients undergoing mastectomy with immediate IBR for malignant breast disease. Patients were stratified into study (patients discharged day of surgery) and control (patients admitted after surgery) groups. Patient demographics, comorbidities, surgical characteristics, implant type, wound complications, readmission, and reoperation rates were collected and analyzed. Univariate and multivariate logistic regression was used to determine independent predictors of same-day discharge versus admission. In addition, Pearson χ2 test was used for comparison of proportions and t test was used for continuous variables unless distributions required subsequent nonparametric analyses. Statistical significance was defined as a P value less than 0.05. RESULTS: A total of 21,923 cases were identified. The study group included 1361 patients discharged same day and the control group included 20,562 patient s admitted for average of 1.4 days (range, 1-86). Average age was 51 years for both groups. Average body mass index for the study group 27 and 28 kg/m2 for the control group, respectively. Total wound complication rates were similar (4.5% study, 4.3% control, P = 0.72). Reoperation rates were lower with same-day discharge (5.7% study, 6.8% control, P = 0.105), though not statistically significant. However, same-day discharge patients had a significantly lower readmission rate compared with the control (2.3% study, 4.2% control, P = 0.001). CONCLUSION: National Surgical Quality Improvement Program data analysis over a 6-year period reveals that immediate IBR with same-day discharge is associated with a significantly lower readmission rate when compared with the standard overnight stay. The comparable complication profiles show that immediate IBR with same-day discharge is safe, potentially benefiting both patients and hospitals.

The Utility of Smartphone-Based Thermal Imaging in the Management and Monitoring of Microvascular Flap Procedures: A Systematic Review and Meta-Analysis.

BACKGROUND: Smartphone-based thermal imaging (SBTI) has been reported in the literature to be an easy-to-use, contactless, cost-friendly alternative to standard imaging modalities in identifying flap perforators, monitoring flap perfusion, and detecting flap failure. Our systematic review and meta-analysis aimed to evaluate SBTI's accuracy in perforator identification and secondarily evaluate SBTI's utility in flap perfusion monitoring as well as ability to predict flap compromise, failure, and survival. METHODS: Following Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, a systematic review was performed using PubMed from inception to 2021. Articles were uploaded into Covidence and, following duplicate deletion, were initially screened for use of SBTI in flap procedures through title and abstract screening followed by full-text review. The following data points, if provided, were extracted from each included study: study design, number of patients, patient demographics, perforator number and location, flap number and location, room temperature, cooling method, imaging distance, time from cloth removal, primary (SBTI's accuracy in perforator identification), and secondary outcomes (prediction of flap compromise/failure/survival and cost analysis). Meta-analysis was performed using RevMan v.5. RESULTS: The initial search yielded 153 articles. Eleven applicable studies with a total of 430 flaps from 416 patients were ultimately included. The SBTI device assessed in all included studies was FLIR ONE. Four studies assessed the SBTI's perforated detection ability and were included in meta-analysis. Smartphone-based thermal imaging correctly identified 378 (93.3%; n = 405) perforators, and computed tomography angiography (CTA) correctly identified 402 (99.2%; n = 402), although in one study SBTI found additional perforators not detected on CTA. A random-effects model was used (I2 = 65%), and no significant difference in perforator detection ability was found between SBTI and CTA (P = 0.27). CONCLUSIONS: This systematic review and meta-analysis supports SBTI as user- and cost-friendly ($229.99), contactless imaging modality with perforator detection ability comparable to current criterion-standard CTA. Postoperatively, SBTI outperformed Doppler ultrasound in early detection of microvascular changes causing flap compromise, allowing for prompt tissue salvage. With a minimal learning curve, SBTI seems to be a promising method of postoperative flap perfusion monitoring able to be used by all hospital ranks. Smartphone-based thermal imaging could thus increase flap monitoring frequency and lower complication rates, although further study is warranted.

Aesthetic, Quality-of-Life, and Clinical Outcomes after Inferior Pedicle Oncoplastic Reduction Mammoplasty.

BACKGROUND: Oncoplastic breast surgery is more likely to achieve superior aesthetic outcomes compared to lumpectomy alone. Oncoplastic reduction mammoplasty (ORM) is a volume displacement oncoplastic technique that combines lumpectomy and reduction mammoplasty. Data on aesthetic and quality-of-life (QoL) outcomes after ORM are scarce in the literature. Based on a literature review, this present study reports outcomes on the largest group of ORM patients to date. METHODS: A retrospective review was conducted of all patients who underwent ORM between 2011 and 2018 at a tertiary care centre. Patients were excluded if no pedicle information was available or did not undergo post-operative radiotherapy. All patients with available post-operative photographs were aesthetically evaluated by four blinded, independent investigators blinded based on breast symmetry, nipple symmetry, and overall appearance. The BREAST-Q (breast conserving module) was used to assess QoL outcomes. RESULTS: Two-hundred-and-sixteen consecutive patients (223 breasts) were included. Macromastia (cup size D or higher) was present in 173 patients (80.1%). Inferior pedicle ORM was utilized in 179 (80.3%) breasts. Eighty-eight patients (40.7%) were aesthetically evaluated, of whom 69 patients (78.4%) had "good", "very good", or "excellent" grades in all aesthetic categories. Seventy-five patients (85.2%) had "good" or better grades in overall appearance. Preoperative ptosis grade, cup size, presence of post-operative complications, and breast specimen weight had no significant correlations with aesthetic grades. Inferior pedicle ORM was associated with a higher "satisfaction with breast" Q-score (p=0.017) compared to other pedicle approaches. CONCLUSION: Inferior pedicle ORM achieves objectively excellent aesthetic outcomes and high patient satisfaction with the reconstruction. 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 .

Sensory Restoration in Abdominally Based Free Flaps for Breast Reconstruction Using Nerve Allograft.

BACKGROUND: Neurotization in breast reconstruction can be performed with the aid of nerve grafts and conduits to decrease the tedious dissection and overcome size mismatch. However, there has yet to be a formal analysis of this approach. The goal of this study was to evaluate sensory recovery after neurotized abdominally based free flaps for breast reconstruction using the authors' novel technique and analyze factors that could affect sensory recovery. METHODS: A novel technique using processed nerve allograft in combination with a nerve conduit was used. Dynamic and static sensation recovery tests were performed in patients who underwent neurotized or nonneurotized abdominally based free flap reconstructions. Demographics, surgical details, and complications were analyzed. Statistical analyses were performed using chi-square and Mann-Whitney tests. RESULTS: Fifty patients (78 breasts) were analyzed: 60 breasts with neurotized reconstruction and 18 breasts without. For patients with more than 12 months of follow-up, the neurotized cohort demonstrated improved dynamic tests compared to the nonneurotized cohort (38 ± 21.69 versus 56.17 ± 20.8, respectively; P = 0.014). Factors associated with decreased sensory return in patients who underwent neurotized reconstruction were diabetes, higher body mass index, skin-sparing mastectomy, higher American Society of Anesthesiologists class, history of radiation therapy, or history of hormonal therapy. CONCLUSIONS: This is the first study to report on outcomes of neurotized autologous breast reconstruction using a nerve graft and conduit technique. The authors' approach resulted in improved sensory outcomes compared to those in patients who did not undergo sensory reconstruction. Importantly, factors that can interfere with sensory recovery were identified. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

A retrospective review of submuscular implant-based breast reconstruction: The influence of dermal matrix (ADM) on complications and aesthetic outcomes.

PURPOSE: The use of acellular dermal matrix changed the breast reconstruction algorithm facilitating implant coverage and direct to implant technique. This study aims to evaluate the effect of the ADM surgical complications, breast aesthetics, and patient satisfaction. METHODS: In a tertiary hospital, patients that underwent implant-based breast reconstructions during a three-year period had their charts retrospectively reviewed, received post-operative BreastQ, and had their post-operative photos evaluated by a three-member panel using a multi-parameter breast specific scale (scored 1-5). The complication information was analysed per reconstructed breast while the analysis of aesthetic and patient-reported outcomes was done per patient. RESULTS: A total of 501 patients (990 breasts) were evaluated. In the complication analysis group, 20.3% of the breasts had ADM. Overall complications and major complications were more frequent in the ADM group. During the first 30 postoperative days the most frequent complications were: skin necrosis/delayed wound healing and haematoma, after 30 days was infection, and complications after 1 year being less than 1%. On the outcome analysis group, ADM was used in 21.5% patients, 44% had post-operative photos, and 29% answered the BreastQ. Factors associated with higher appearance score were bilateral reconstruction, prophylactic surgery, and nipple presence. ADM demonstrated no difference in satisfaction with breasts. CONCLUSION: In implant-based breast reconstructions ADM has been shown to increase rate of complications. The use of acellular dermal matrix did not influence the overall appearance or the patient-reported outcome. A good aesthetic outcome is positively influenced by bilateral reconstructions with preservation of the nipple.

Beauty Is in the Eye of the Beholder: Factors Influencing Disparity in Perceptions of Breast Reconstruction Aesthetic Outcomes.

BACKGROUND: Patient-reported outcomes are the primary measurement of breast reconstruction success, but results may be affected by nontechnical factors such as socioemotional determinants. Third-party observers provide an independent assessment of aesthetic outcomes. Factors associated with disparity between patient and observer perceptions of outcomes are not well understood. METHODS: One hundred forty-seven patients underwent breast reconstruction at the authors' institution between 2009 and 2011, completed the BREAST-Q, and had photographs graded by a diverse panel using the Validated Breast Aesthetic Scale. Patient satisfaction with breasts scores that aligned with observer scores were categorized as group 2; patient satisfaction that exceeded observer scores were group 1; and those lower than observer scores were group 3. Statistical analysis was performed using SPSS, with values of p < 0.05 considered statistically significant. RESULTS: Twenty-eight patients (19 percent) were categorized as group 1, 93 (63 percent) in group 2, and 26 (18 percent) in group 3. Median overall appearance was highest in group 3 (median, 4.0; interquartile range, 4 to 4) and lowest in group 1 (median, 3.0; interquartile range, 2 to 3) ( p < 0.001). Psychosocial, sexual, and physical well-being were significantly associated with disparity (group 1 or 3 status) ( p < 0.01). Satisfaction with outcomes, nipples, abdomen, and breasts were significantly associated with disparity. Factors not significantly associated with disparity include age, body mass index, autologous or implant-based, adjuvant therapies, and timing of reconstruction. CONCLUSIONS: Incongruously high patient satisfaction with breast reconstruction aesthetics relative to third-party perception of aesthetic outcomes is associated with high quality-of-life scores. Incongruously low patient satisfaction with breast cosmesis compared with higher third-party perceptions was associated with low quality-of-life scores. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Neurotization Does not Prolong Operative Time in Free Flap Breast Reconstruction.

BACKGROUND: Neurotization during the breast reconstruction process can improve patient quality-of-life and satisfaction with reconstructive outcomes. One concern with neurotization is increased total operative time due to the need for additional dissection and nerve coaptation. The purpose of this study was to compare total operative time between neurotized and non-neurotized abdominal-based, free flap breast reconstruction. METHODS: A retrospective review was conducted of consecutive patients who underwent unilateral, abdominal-based, free flap breast reconstruction between 2016 and 2018 at a single tertiary care center. Data were collected on patient demographics, surgical techniques, and length of surgery. Data analysis was performed using chi-square test, independent t-test, and multivariate linear regression analysis. A p-value ≤0.05 was considered statistically significant. RESULTS: Seventy-three patients were included in this study. Twenty-three patients (31.50%) underwent flap neurotization (N group) and 50 (68.49%) underwent standard breast reconstruction without neurotization (NO group). The groups were similar in age, BMI, smoking status, and ASA class. No difference was found between the two groups in timing of reconstruction (p = 0.388). Average operative times were 467.73 ± 145.52 minutes and 455.28 ± 111.19 minutes for the N and NO groups, respectively, with no significant difference between the two groups (two-tailed p-value = 0.72). CONCLUSION: Seamless integration of neurotization in abdominal-based, free flap breast reconstruction is possible without significant prolongation of total operative time. 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 .

A Novel Validated Breast Aesthetic Scale.

BACKGROUND: Breast aesthetics impacts patients' quality of life after breast reconstruction, but patients and surgeons frequently disagree on the final aesthetic evaluation. The need for a comprehensive, validated tool to evaluate breast aesthetics independently from the patient motivated this study. METHODS: The 13-item Validated Breast Aesthetic Scale was developed after several internal meetings, and worded to be understood by a nonspecialist. Three items are common for both breasts, with the remaining being side-specific. To test the internal consistency of the scale subitems, postoperative photographs after different breast reconstruction techniques were graded by a six-member panel. To test interrater and intrarater correlation across time, four physicians evaluated the results of abdominally based breast reconstructions following nipple-sparing mastectomies. RESULTS: Graded aesthetic outcomes of 53 patients showed that the Cronbach alpha of the subitems of the scale was 0.926, with no single item that, if excluded, would increase it. Twenty-two patients underwent aesthetic outcomes grading at four different time points. The mean overall appearance was 3.71 ± 0.62. The mean grade for overall nipple appearance was 4.0 ± 0.57. The coefficient alpha of the panel overall aesthetic grade across different time points was 0.957; whereas intragrader reliability for graders 1 through 4 individually showed alpha coefficients of 0.894, 0.9, 0.898, and 0.688, respectively. Similar results were found for the other items of the scale. CONCLUSIONS: The proposed aesthetic scale evaluates different aspects of the breast reconstruction aesthetic result with excellent internal consistency among its subitems. Grading by a gender-balanced, diverse four-member panel using postoperative photographs showed higher reliability and reproducibility compared to single graders.

Color Doppler Ultrasound versus Computed Tomography Angiography for Preoperative Anterolateral Thigh Flap Perforator Imaging: A Systematic Review and Meta-Analysis.

BACKGROUND: The anterolateral thigh (ALT) perforator flap is a commonly used flap with a predictable, though often variable, perforator anatomy. Preoperative imaging with color Doppler ultrasound (CDU) and computed tomography angiography (CTA) of ALT flap perforators can be a useful tool for flap planning. This study provides a complete review and analysis of the relevant preoperative ALT imaging literature. METHODS: Studies related to preoperative CDU and CTA imaging were reviewed, and information related to imaging method, sensitivity, false-positive rates, and perforator course identification (musculocutaneous vs. septocutaneous) were analyzed. RESULTS: A total of 23 studies related to preoperative ALT flap CDU and CTA imaging were included for review and analysis. Intraoperative perforator identification was compared with those found preoperatively using CDU (n = 672) and CTA (n = 531). Perforator identification sensitivity for CDU was 95.3% (95% CI: 90.9-97.6%) compared with the CTA sensitivity of 90.4% (95% confidence interval [CI]: 74.4-96.9%). The false-positive rate for CDU was 2.8% (95% CI: 1.1-4.5%) compared with 2.4% (95% CI: 0.7-4.1%) for CTA. Accuracy of perforator course identification was 95.5% (95% CI: 93.6-99.2%) for CDU and 96.9% (95% CI: 92.7-100.1%) for CTA. CONCLUSION: CDU provides the reconstructive surgeon with greater preoperative perforator imaging sensitivity compared with CTA; however, false-positive rates are marginally higher with preoperative CDU. Preoperative imaging for ALT flap design is an effective tool, and the reconstructive surgeon should consider the data presented here when selecting a flap imaging modality.

A Comparison of Applicant and Resident Physician Demographics Among Surgical Subspecialties From 2009 to 2019: Trends in Gender and Underrepresented Minorities in Medicine.

BACKGROUND: The purposes of this study were to compare applicant statistics to resident physician demographics among several surgical subspecialties (SSSs), to identify trends of gender and underrepresented minorities in medicine (UIM), and to evaluate current diversity among these specialties. METHODS: Graduate medical education reports from 2009 to 2019 were queried to determine trends among programs. Further identification of gender and UIM statistics was obtained in 4 several SSSs: integrated plastic surgery, orthopedic surgery (OS), otolaryngology surgery (ENT), and neurosurgery (NS). These were compared with Association of American Medical Colleges data of residency applicants for the respective years. RESULTS: Significant differences were seen among gender and UIM(s) of the applicant pool when compared with resident data. All specialties had significantly fewer American Indian and African American residents compared with applicants. Significant differences between applicants and residents were also found among Hispanic, Native Hawaiian, and female demographics. All SSSs had a significant positive trend for the percentage of female residents. Significant differences between specialties were identified among African American, Hispanic, and female residents. Orthopedic surgery and NS had significantly higher percentage of African American residents compared with ENT and integrated plastic surgery. Neurosurgery had significantly higher percentage of Hispanic residents compared with OS and ENT. Integrated plastic surgery and ENT had significantly higher percentage of female residents compared with OS and NS. CONCLUSIONS: There has been significant increase in number of residency programs and resident positions since 2009. However, increase in female residents and UIM(s) among SSSs has not matched the pace of growth.

The Anatomic Feasibility of a Functional Chimeric Flap in Complex Abdominal Wall Reconstruction.

BACKGROUND: Dynamic and functional abdominal wall reconstruction (FAWR) remains a complex challenge. The ideal flap should have a minimal donor-site morbidity and cover a large surface area with motor and sensory capabilities. The goal was to investigate the feasibility of using a free chimeric flap with anterolateral thigh (ALT) and rectus femoris (RF) components pedicled only on the motor nerve branch. METHODS: Ten fresh cadavers were dissected with a designed chimeric thigh flap including ALT and RF flaps. Anterolateral thigh was designed and raised with the lateral femoral cutaneous nerve integrated, and the descending branch of the lateral circumflex femoral artery was preserved. Rectus femoris was elevated and the common pedicle was dissected up to the femoral origin. Accompanying motor nerve branches were carefully dissected to their femoral origin. RESULTS: Twenty RF flaps were dissected and 9 were harvested as a true chimeric flap with ALT. The mean number of neurovascular bundles associated with RF flap was 2.11 ± 0.47, and the mean primary motor nerve average length was 9.40 ± 2.42 cm. The common vascular bundle in all 9 chimeric flaps was ligated, and the flap was rotated toward the abdomen pedicled only by primary motor nerve of the RF muscle. Nerve length was adequate for reach up to xiphoid area in all 20 flaps. CONCLUSIONS: This study demonstrates the feasibility of the chimeric ALT/RF muscle free flap pedicled only by the motor nerve branch, with adequate flap rotation. Even with the limitations in a live patient, this flap would be an excellent option for FAWR in the right patient.

A controlled cost and outcomes analysis of acellular dermal matrix and implant-based reconstruction.

INTRODUCTION: The use of acellular dermal matrix (ADM) for breast reconstruction continues to change in both single- and two-stage reconstruction. Determining optimal outcomes clinically, aesthetically, financially as well as for the patient's quality of life has become a priority. METHODS: A retrospective review of implant-based reconstructions was performed at a single center from 2010 to 2016, with patients blindly matched 1:1:1 into three cohorts based on reconstruction type: 1) single stage direct to implant with ADM, 2) two-stage tissue expander to implant (TE/I) without ADM, and 3) two-stage TE/I with ADM. Relative cost between groups, esthetic outcomes, and quality of life within each group was analyzed. RESULTS: Group 1 was more likely to be older and use intraoperative angiography, but with fewer overall surgeries and postoperative visits (p<0.001). There was no statistically significant difference in reconstructive success among all three groups (p = 0.85). Cost was significantly higher for group 3 relative to groups 1 and 2. Overall appearance was higher in groups 1 and 3 relative to group 2, with radiation therapy the only independent factor. Group 1 had higher scores using Breast-Q for the physical well-being domain (p = 0.01). CONCLUSION: This is the first study to incorporate clinical outcomes, esthetic visual grading, and patient-reported quality within the same cohort of individuals, considering both use of ADM and staging. Despite the added ADM cost, it is proven safe, eliminates time and cost associated with tissue expanders, decreases post-operative visits and can lead to equally as functional and aesthetically pleasing outcomes in single- and two-stage breast reconstructions.

Pushing the Envelope: Skin-Only Mastopexy in Single-Stage Nipple-Sparing Mastectomy with Direct-to-Implant Breast Reconstruction.

BACKGROUND: Despite advances in skin envelope reduction techniques and experienced nipple-sparing mastectomy flap procedures, the rate of nipple malposition and secondary revision in these patients remains high and eligible candidates are limited. In this article, the authors present a novel technique combining skin reduction nipple-sparing mastectomy surgery with single-stage skin-only mastopexy and direct-to-implant reconstruction. METHODS: A retrospective review was performed at a single institution from 2015 to 2018. All patients were operated on using this technique consecutively, by a breast and plastic surgeon team (A.F. and A.M.). Surgical technique and outcomes were compared with the currently accepted literature. RESULTS: Twenty-six patients (40 breasts) underwent this technique; all were single-stage direct-to-implant reconstructions. The average body mass index was 31 kg/m2. A Wise pattern was used in 35 breasts (87.5 percent) and prepectoral placement was used in 25 breasts (62.5 percent). Overall complications included seroma [n = 6 (15 percent)], vertical/T-junction dehiscence [n = 4 (10 percent)], skin necrosis [n = 4 (10 percent)], superficial or partial nipple necrosis [n = 4 (10 percent)], with no total nipple-areola complex lost and no reconstructive failures at 18.7 months' average follow-up. CONCLUSIONS: In this article, the authors share a novel reconstructive technique in which the skin envelope is reduced, the nipple-areola complex is repositioned, and a direct-to-implant reconstruction is performed in a single stage at the time of mastectomy. Consideration of pearls and pitfalls accompanies a review of the authors' experienced complication profile, and is discussed in the context of current literature. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Anterior Approach to the Neck: Long-Term Follow-Up.

BACKGROUND: The anterior or submental necklift has been well described. Long-term results have been demonstrated in patients with minimal, mild, and moderate skin excess. It relies on the skin's unique ability to contract once separated from its attachments and further enhances the surgical result with treatment of the intermediate layer- subplatysmal fat, anterior digastric, submandibular gland, and platysma. Treatment of this layer differentiates this operation from liposuction and offers benefits beyond liposuction alone. OBJECTIVES: The authors sought to assess the long-term success of the anterior necklift for neck rejuvenation and determine its utility in patients with severe cervicomental angles. METHODS: This was a single-surgeon, retrospective review of patients who underwent an isolated anterior necklift with no additional procedures between 1998 and 2017. Pre- and postprocedure photographs were scrambled and examined by independent evaluators grading the change in cervicomental angle based on the Knize scale. The reduction in apparent age was calculated utilizing the validated apparent age assessment scale. RESULTS: Twenty-seven patients were evaluated (42% mild and 58% moderate to severe necks preoperatively). The average follow-up was 24.7 months. There was an average 3.6-year age reduction and 1.0-grade improvement in all patients. In moderate to severe necks, there was a 3.9-year age reduction and 1.4-grade improvement in the cervicomental angle following surgery. CONCLUSIONS: This study demonstrates the effectiveness of the operation in improving the cervicomental angle and reducing the overall apparent age of patients, even more so in severe cases. The operation is an option for patients who desire neck improvement but are unwilling to undergo a facelift.

The Role of Oncoplastic Surgery for Breast Cancer.

OPINION STATEMENT: Oncoplastic surgery (OPS) expands the indications and possibilities of breast-conserving surgery (BCS) by allowing for a wider cancer resection than lumpectomy. Ongoing investigation and reporting of OPS outcomes along with improvements in comprehensive training in breast surgical oncology will impact on awareness and lead to increased adoption of these techniques. Indications for OPS include concern about clear margins, poor tumor location (upper inner pole and lower quadrant), multifocality, need for skin excision, and poor candidacy for mastectomy and reconstruction. OPS has been proven to be oncological safe with comparable rates of complications, positive margins, and re-excisions with BCS. Additionally, OPS has a positive impact on the quality of life and self-esteem when compared with those patients that underwent BCT.

Neurotization of the Nipple-Areola Complex during Implant-Based Reconstruction: Evaluation of Early Sensation Recovery.

The concept of sensate autologous breast reconstruction is not novel, and prior literature has focused mainly on sensate abdominally based breast reconstruction. The goal of this article is to present the authors' results with a novel technique performing sensate implant-based reconstruction. A database was prospectively maintained for patients who underwent implant-based sensate breast reconstruction. The anterior branch of the lateral fourth intercostal is identified and preserved during the mastectomy by the breast surgeon. A processed nerve allograft is used as an interpositional graft connecting the donor nerve to the targeted nipple-areola complex. The sensory recovery process was objectively monitored using a pressure-specified sensory device. Thirteen patients underwent the proposed technique. Eight patients with 15 breasts were monitored for sensory recovery. For sensory measurement, the nipple had a mean threshold of 67.33 ± 34.48 g/nm. The upper inner (29 ± 26.75 g/nm) and upper outer (46.82 ± 32.72 g/nm) nipple-areola complex quadrants demonstrated better scores during the moving test compared with the static test. Mean time between the test and surgery was 4.18 ± 2.3 months, and mean time between the second test and surgery was 10.59 ± 3.57 months. Threshold improvements were documented after the second test for all nipple-areola complex areas evaluated. This is the first study to report on early results obtained after performing sensate implant-based breast reconstruction. More studies are required to determine the long-term outcomes and impact on quality of life and to assess whether patient or breast characteristics impact the success of this procedure.

Facelift Surgery Following Superficial Parotidectomy: Is it Safe?

INTRODUCTION: Patients who have previously undergone superficial parotidectomy may also seek facelift surgery for facial aging and rejuvenation. These patients present unique challenges compared to a standard facelift patient. Most concerning is the location of facial nerve branches, which may be superficial and displaced. In addition, significant contour deformities and abnormal scar patterns may be present. The purpose of the study is to review our series of patients and assess potential morbidity and safety of facelift surgery in superficial parotidectomy patients. METHODS: A retrospective case series was performed reviewing all patients who underwent facelift surgery following superficial parotidectomy from 2000 to 2017. Data were collected for: postoperative facial nerve deficit, soft tissue contour and scar deformities, facelift technique, ancillary soft tissue augmentation procedures and pre- and postoperative photographs. An evidence-based treatment algorithm to address specific problems in this patient population was developed. RESULTS: A total of seven patients were identified who underwent facelift surgery following parotidectomy. Patients underwent one of the standard SMAS procedure on the non-parotidectomy side, and surgical modifications were made to address the parotidectomy side; soft tissue augmentation was performed in two patients. Precautions to identify the facial nerve and prevent injury, including nerve monitoring and stimulation, were utilized in all seven patients. No permanent postoperative facial nerve injury was noted. CONCLUSION: Facelift following superficial parotidectomy was safely performed in all cases. Special consideration should be given to contour deformities, facial nerve location and scar placement. However, if approached properly, these patients can still be considered as suitable candidates for facelift surgery. 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.