Implant-Based Breast Reconstruction After Nipple-Sparing and Skin-Sparing Mastectomy in Breast-Augmented Patients: Prepectoral or Submuscular Direct-to-Implant Reconstruction?

BACKGROUND: Patients with breast augmentation facing a breast cancer diagnosis pose unique challenges for both breast and plastic surgeons in terms of treatment and reconstruction. Traditional submuscular direct-to-implant (DTI) breast reconstruction is often considered the standard approach, regardless of the previous implant pocket. However, recent trends in prepectoral reconstruction provide an innovative solution for patients with previous subglandular and submuscular implants. OBJECTIVES: In this study we aimed to share our experiences with DTI breast reconstruction in patients with a history of breast augmentation, with a specific focus on the viability of prepectoral reconstruction. METHODS: A retrospective review was conducted on 38 patients with previous breast augmentation who underwent either skin-sparing mastectomy or nipple-sparing mastectomy for breast cancer followed by DTI reconstruction between January 2015 and July 2023. Our analysis considered various factors, including previous implant positioning, capsular and implant status, and mastectomy flap thickness (MFT), offering insights into the rationale behind choosing the new implant positioning. RESULTS: Patients with a history of subglandular breast augmentation and an MFT greater than 1 cm were candidates for prepectoral reconstruction. When the MFT was less than 1 cm but flap vascularity was sufficient, a prepectoral reconstruction was performed; otherwise, retropectoral reconstruction was preferred. Patients with submuscular breast augmentation were evaluated similarly, with submuscular reconstruction chosen when the MFT was less than 1 cm and prepectoral reconstruction preferred when the MFT exceeded 1 cm. CONCLUSIONS: Immediate prepectoral DTI reconstruction represents a feasible option for specific patients with a history of breast augmentation. Decisions regarding the reconstructive approach are influenced by variables such as mastectomy flap thickness, implant status, and capsular conditions.

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.

The Effect of Adjuvant Radiotherapy on One- and Two-Stage Prosthetic Breast Reconstruction and on Autologous Reconstruction: A Multicenter Italian Study among 18 Senonetwork Breast Centres.

Purpose: In modern breast cancer treatment, a growing role has been observed for breast reconstruction together with an increase in clinical indications for postmastectomy radiotherapy (PMRT). Choosing the optimum type of reconstructive technique is a clinical challenge. We therefore conducted a national multicenter study to analyze the impact of PMRT on breast reconstruction. Methods: We conducted a retrospective case-control multicenter study on women undergoing breast reconstruction. Data were collected from 18 Italian Breast Centres and stored in a cumulative database which included the following: autologous reconstruction, direct-to-implant (DTI), and tissue expander/immediate (TE/I). For all patients, we described complications and surgical endpoints to complications such as reconstruction failure, explant, change in type of reconstruction, and reintervention. Results: From 2001 to April 2020, 3116 patients were evaluated. The risk for any complication was significantly increased in patients receiving PMRT (aOR, 1.73; 95% CI, 1.33-2.24; p < 0.001). PMRT was associated with a significant increase in the risk of capsular contracture in the DTI and TE/I groups (aOR, 2.24; 95% CI, 1.57-3.20; p < 0.001). Comparing type of procedures, the risk of failure (aOR, 1.82; 95% CI, 1.06-3.12, p=0.030), explant (aOR, 3.34; 95% CI, 3.85-7.83, p < 0.001), and severe complications (aOR, 2.54; 95% CI, 1.88-3.43, p < 0.001) were significantly higher in the group undergoing DTI reconstruction as compared to TE/I reconstruction. Conclusion: Our study confirms that autologous reconstruction is the procedure least impacted by PMRT, while DTI appears to be the most impacted by PMRT, when compared with TE/I which shows a lower rate of explant and reconstruction failure. The trial is registered with NCT04783818, and the date of registration is 1 March, 2021, retrospectively registered.

When to Consider Prepectoral Implant Conversion After Subpectoral Implant Breast Reconstruction and How to Plan It.

Many deformities occur after subpectoral implant-based breast reconstruction. Today, immediate prepectoral reconstruction with implants shows a significant increase in popularity because it has many advantages over subpectoral positioning: absence of muscle deficit and breast animation deformity, reduced implant dislocation, and less postoperative pain and easy recovery. Implant pocket conversion from the submuscular to prepectoral plane has become our preferred strategy for solving most problems related to the submuscular implant position. The authors performed a retrospective review (from June 2018 to December 2022) of patients who underwent prepectoral implant conversion for correction of animation deformity, dysfunctional chronic pain, or to ameliorate poor cosmetic results. Acellular dermal matrix (ADM) was utilized in the first 7 cases; in the remaining 56 patients polyurethane-covered implants were placed. Resolution of animation deformity and chronic pain were evaluated, as were cosmetic results and any postoperative complications. Sixty-three patients (87 breasts) underwent prepectoral implant conversion with complete resolution of animation deformity and chronic pain as well as improved cosmetic results. Preventive lipofilling was done in 18 patients. Complication rate included 3 periprosthetic seromas in ADM group. All resolved after ultrasound-guided aspiration. Rippling was noted in 3 patients, and edge visibility was documented in 1 patient. There were no incidences of grade 3 or 4 capsular contracture. The prepectoral implant conversion improves functional and aesthetic results, reaching excellent outcomes. Preparation for this surgery with fat grafting is considered a complementary procedure that increases the indications for prepectoral implant conversion.

Preventing Soft Tissue Complications in Secondary Aesthetic Breast Surgery Using Indocyanin Green Angiography.

BACKGROUND: Secondary cosmetic breast surgery after primary augmentation with implant can be associated with an increased risk of adverse events. Partial/complete nipple-areola complex necrosis is particularly feared. In this preliminary study, the authors propose the utilization of indocyanine green (ICG) angiography to assess the blood supply of breast tissue after implant removal. OBJECTIVES: The main objective was to prevent skin and gland necrosis in revision breast surgery. METHODS: The authors performed a retrospective comparative analysis of 33 patients who underwent secondary breast surgery between 2018 and 2021 by a single surgeon (M.S.). Breast tissue perfusion was assessed in 16 patients by intraoperative ICG angiography at the end of implant removal and possible capsulectomy. Non-stained/non-fluorescent areas were judged to be low perfusion areas and were excised with short scar mastopexy. RESULTS: In the ICG angiography group, 7 patients (44%) showed an area of poor perfusion along the inferior pole; all of these patients underwent subglandular breast augmentation. Resection of the poor perfusion areas allowed an uneventful postoperative course. In the non--- ICG angiography group (17 patients), 5 patients experienced vertical-scar dehiscence/necrosis. We found a statistically significant association between the non-ICG angiography group and vertical scar dehiscence/necrosis, and also between vertical scar dehiscence/necrosis and subglandular implant placement (P = 0.04). CONCLUSIONS: Safer secondary surgery can be offered to patients undergoing secondary aesthetic breast procedures, especially when the first augmentation surgery is unknown-for example, implant plane, type of pedicle employed, if the implant is large and subglandular, and if capsulectomy is performed.

Lipobrachiopexy: Cosmetic Outcomes and Limb Lymphatic Function of a Novel Brachioplasty Technique in Massive Weight Loss Patients.

BACKGROUND: Many types of brachioplasty techniques have been described in the literature, and the main focus has been scar aesthetics, reproducibility and safety. Little attention has been given to other two aspects of the procedure: overall aesthetic with a focus on the torso-brachial angle and on the lymphatic distress related to the procedure. In this paper, we described a novel technique of brachioplasty called lipobrachiopexy, a lymph-sparing procedure which includes tendon suspension suture to improve cosmetics . PATIENTS AND METHODS: Over 18 months, 22 consecutive patients underwent bilateral lipobrachioplasty with circumferential liposuction sparing brachial artery perforators, J-scar dermolipectomy and superficial fascia suspension to the pectoralis major tendon. Aesthetic outcomes, lymphatic function, sensory function and patient's satisfaction were evaluated at 1-year follow-up. The correction of the bat wing deformity and the shape of the transition of the upper arm to the chest was evaluated by quantifying the torso-brachial angle using Photoshop. Lymphatic function was analysed pre-operatively at 1, 6 and 12 months after surgery by indocyanine green lymphography (PDE, Hamamatsu Photonics, Japan). RESULTS: An average of 447.5 cc (range, 350-550 cc) of fat was aspirated for each side. No major complications were experienced. Patients' and surgeons' satisfaction was high to very high in all cases. The lymphatic function was found preserved, with the same physiological linear patterns and tracer progression pre-operatively and 1 year after surgery. The torso-brachial angles showed significant improvements (86.7 ± 14.7-100.7 ± 10.2 right side and 85.4 ± 16.3-101.5 ± 9.9 left side). CONCLUSION: Lipobrachiopexy is a safe and effective technique that adds to the recent trends in brachioplasty, a reestablishment of the brachial fascial systems and addressing the anatomical etiological factor of the bat wing deformity. 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 .

The Ultrasound Evolution of Lateral Thoracic Perforator Flaps Design and Harvest for Partial and Total Breast Reconstruction.

BACKGROUND: The lateral thoracic area is a known source for perforator flaps for partial breast reconstruction. In this paper, we report our experience in designing and harvesting lateral thoracic perforator flaps for partial and total breast reconstruction with the introduction of the "propuller" concept. PATIENTS AND METHODS: Between September 2013 and August 2021, 95 flaps were performed for immediate, partial and total breast reconstruction. On a total of 95 flaps, 30 (19 thoracodorsal artery perforator(TDAP) flaps, 10 lateral intercostal artery perforator(LICAP) flaps and 1 lateral thoracic artery perforator(LTAP) flap) were harvested in the traditional fashion (control group) and 65 (57 LICAP, 2 LTAP and 6 TDAP flaps) according to the propeller concept (study group). All cases were preoperatively planned with Color-Coded Duplex Ultrasound. RESULTS: No flap losses were experienced in both groups. The mean operative time was 156 minutes (range 118-234) for the control group and 75 minutes (range 53-125) for the study group (p < 0.0001). A significantly higher number of LICAP flaps were chosen in the study group compared to control group. None of the patients had donor site complications. Patients' and Surgeons' satisfaction was high to very high. CONCLUSION: The ultrasound preoperative planning led to the development of an easier and safer method of local perforator flap harvesting, that we named as propuller design. Its novelty lies in that perforator intraoperative selection and fully skeletonization are not needed and a more efficient flap movement (propeller plus advancement) which transfers more tissue into the new breast can be achieved safely, faster and easier.

Designing Lateral Thoracic Wall Perforator Flaps for Breast Reconstruction Using Ultrasound.

BACKGROUND: Lateral thoracic flaps represent a precious source for partial and total breast reconstruction, in some cases as first option and in other cases as alternative of free flaps. This article describes the ultrasound (US)-based planning of the lateral thoracic wall perforator adipocutaneous flaps and it reports our experience on 52 consecutive flaps. METHODS: From November 2018 to May 2021, 52 consecutive lateral thoracic wall perforator flaps were performed using the US-based method for reconstruction of partial breast defects and total breast reconstruction. High-frequency US was performed in all cases prior to surgery to select the best perforator and design the flap. RESULTS: Of the 52 cases, 41 were lateral intercostal artery perforator flaps (78.8%), and 11 were thoracodorsal artery perforator (TDAP) flaps. Of the 11 TDAP flaps, 2 cases were based on the direct cutaneous branch. Moreover, in two other cases clinically scheduled for lateral thoracic perforator flaps due to the presence of an appropriate axillary roll, no suitable local/regional perforators were detected with the preoperative US examination and the latissimus dorsi myocutaneous flap was performed. CONCLUSION: Preoperative planning of these flaps using US speeds the surgery and makes it easier and more efficient. Therefore, it is reasonable that the color duplex ultrasound is the operative surgeon's tool for mapping the lateral thoracic wall perforators and to appropriately plan each flap.

Designing An Anterolateral Thigh Flap Using Ultrasound.

BACKGROUND: Preoperative knowledge of themicrovascular anatomy of a patientmay improve safetyand efficacy and reduce morbidity. Today, with the advancement in technology, ultrasound can provide minute details of the structures within the body, which makes this technology very helpful in preoperative evaluation of the traditional perforator flaps as well as thin, superthin, and pure skin perforator flaps. METHODS: In this article, we will describe the design of one of the most popular perforator flaps, the anterolateral thigh (ALT) flap, using high-frequency and ultrahigh-frequency ultrasound technology. RESULTS: Ultrasound technology allows to study preoperatively the ALT donor-site and its microvascular anatomy by using different US modalities in order to provide a virtual surgical plan to the operating surgeon. CONCLUSION: Ultrasound technology allow to expand preoperative knowledge of flap microvascular anatomy and its course within the subcutaneous tissue up to and within the dermis, allowing to select the best perforator for the given reconstruction and the plane of elevation for thin, superthin and pure skin perforator flap.

Recipient Venule Selection and Anastomosis Configuration for Lymphaticovenular Anastomosis in Extremity Lymphedema: Algorithm Based on 1,000 Lymphaticovenular Anastomosis.

BACKGROUND: The lymphaticovenular anastomosis (LVA) has three components, lymphatics, venules, and anastomosis, and all of them influence the anastomotic pressure gradient. Although it has been demonstrated that venule flow dynamics has an independent impact on the outcomes regardless the degeneration status of lymphatic vessels, recipient venules (RV) have been mainly neglected in literature. METHODS: From January 2016 to February 2020, 232 nonconsecutive patients affected by extremity lymphedema underwent LVA, for a total of 1,000 LVAs. Only patients with normal-to-ectasic lymphatic collectors were included to focus the evaluation on the RV only. The preoperative collected data included the location, diameter, and continence of the selected venules, the expected number, the anastomoses configuration, and their flow dynamics according to BSO classification. RESULTS: The 232 patients included 117 upper limb lymphedema (ULL) and 115 lower limb lymphedema (LLL). The average size of RV was 0.81 ± 0.32 mm in end-to-end (E-E), 114 ± 0.17 mm in end-to-side (E-S), 0.39 ± 0.22 mm in side-to-end (S-E), and 0.76 ± 0.38 mm in side-to-side (S-S) anastomoses. According to the BSO classification, on a total of 732 RV, 105(14%) were backflow venules, 136 (19%) were slack, and 491 (67%) were outlet venules. Also, 824 (82%) were E-E, 107 (11%) were E-S, 51 (5%) were S-E, and 18 (2%) were S-S anastomoses. CONCLUSION: Based on 1,000 LVAs with similar lymphatic characteristics, we propose our algorithm that may aid the lymphatic microsurgeon in the selection of RV and the consequent anastomosis configuration, in order of obtain the best flow dynamic through the LVA. This therapeutic study reflects level of evidence IV.

The usefulness of the IMAP propeller flap for trachea and tracheostome reconstruction after resection of parastomal recurrence of squamous cell carcinoma following salvage total laryngectomy.

PURPOSE: Parastomal recurrence of squamous cell carcinoma (SCC) with tracheal involvement following salvage total laryngectomy after prior concurrent chemoradiotherapy is one of the most insidious challenges in head and neck surgery because a complex reconstruction is often required for covering a large area of skin loss, filling the dead space beneath, tracheal reconstruction and suspension, and tracheostome resurfacing. The aim is to describe our experience with the internal mammary artery perforator (IMAP) propeller flap for tracheal and tracheostome reconstruction and neck resurfacing after parastomal and cervical trachea resection, especially for suspension and anchoring the stump of the residual distal trachea to the island flap itself. METHODS: We describe IMAP flap reconstruction after resection of parastomal recurrence of SCC requiring cervical trachea resection in five patients between January 1, 2005 and August 30, 2019. RESULTS: IMAP propeller flap was successfully used for reconstruction after complex resection of parastomal recurrence of SCC with cervical trachea involvement in all cases. The mean length and width were, respectively, 16.8 cm (range 13-23) and 6.9 cm (range 5.5-8). We did not report complications of both the donor and the recipient site. Pharyngo-cutaneous or tracheoesophageal fistulas and wound dehiscence were not observed. CONCLUSIONS: to the best of our knowledge, this is the first report about the use of the IMAP propeller flap in this more complex clinical setting and we provide the message that this surgical procedure is worthy of consideration.

Improving Outcomes in Anterolateral Thigh Flap Donor-Site Reconstruction Using Propeller Flaps: A Retrospective Comparative Study with Skin Grafting.

BACKGROUND: After anterolateral thigh (ALT) flap harvesting, skin graft of the donor site is commonly performed. When the defect width exceeds 8 cm or 16% of thigh circumference, it can determine lower limb function impairment and poor aesthetic outcomes. In our comparative study, we assessed the functional and aesthetic outcomes related to ALT donor-site closure with split-thickness skin graft compared with thigh propeller flap. METHODS: We enrolled 60 patients with ALT flap donor sites. We considered two groups of ALT donor-site reconstructions: graft group (30 patients) with split-thickness skin graft and flap group (30 patients) with local perforator-based propeller flap. We assessed for each patient the range of motion (ROM) at the hip and knee, tension, numbness, paresthesia, tactile sensitivity, and gait. Regarding the impact on daily life activities, patients completed the lower extremity functional scale (LEFS) questionnaire. Patient satisfaction for aesthetic outcome was obtained with a 5-point Likert scale (from very poor to excellent). RESULTS: In the propeller flap group, the ROMs of hip and knee and the LEFS score were significantly higher. At 12-month follow-up, in the graft group, 23 patients reported tension, 19 numbness, 16 paresthesia, 22 reduction of tactile sensitivity, and 5 alteration of gait versus only 5 patients experienced paresthesia and 7 reduction of tactile sensitivity in the propeller flap group. The satisfaction for aesthetic outcome was significantly higher in the propeller flap group. CONCLUSION: In high-tension ALT donor-site closure, the propeller perforator flap should always be considered to avoid split-thickness skin graft with related functional and aesthetic poor results.

Nipple-sparing mastectomy combined with endoscopic immediate reconstruction via axillary incision for breast cancer: A preliminary experience of an innovative technique.

INTRODUCTION: Nipple-sparing mastectomy (NSM) has known an exponential diffusion worldwide for prophilaxis and therapeutic mastectomies in selected candidates, being oncologically safe and improving reconstructive outcomes and patients' satisfaction. The two most common used skin incisions are the radial and inframammary fold ones, which represent an imperfect aesthetic solution. The aim of this work was to give insights on our surgical technique, which allows to perform the NSM, node surgery, and endoscopic direct-to-implant reconstruction using a cosmetic axillary incision. MATERIALS AND METHODS: Between June 2016 and January 2019, 7 consecutive patients underwent NSM, lymph node surgery and endoscopic direct-to-implant reconstruction using a small cosmetic axillary incision for breast cancer treatment in a single Institution. An operative rigid endoscope with working channel (Richard Wolf) was used to dissect the entire submuscular-subfascial pocket. The mean age of the patients was 42.8 years old (range: 36-49 years). The evaluation methods were clinical and photography-based assessments, as well as the BREAST-Q which was used to quantify patient satisfaction. RESULTS: The average follow-up time was 9 months (range 3-22 months). Tumor-free margins were obtained in all cases. No tumor recurrence or metastasis occurred during follow-up. No major complications were experienced. There were no cases of malposition, wrinkling, or rippling. All patients were satisfied with their esthetic results, especially the absence of visible scars. CONCLUSIONS: From our preliminary experience, NSM combined with endoscopic immediate reconstruction via axillary incision for breast cancer treatment seems to be a promising new procedure in cup A and B breasts alternative to the conventional techniques, as it allowed to have safe and pleasant aesthetic and oncologic outcomes.

Short-Scar Augmentation Mastopexy in Massive-Weight Loss Patients: Four-Step Surgical Principles for Reliable and Reproducible Results.

BACKGROUND: Single-stage augmentation mastopexy is considered a challenging procedure, and its safety and efficacy remain controversial for breasts with grade-2 and grade-3 ptosis. In this paper, we report our experience in single-stage augmentation mastopexy with implants, using a short-scar technique, outlining the four-step principles of our technique which maximizes the cosmetic outcomes though being safe, reliable and reproducible. PATIENTS AND METHODS: Forty consecutive massive-weight loss (MWL) patients undergoing short-scar augmentation mastopexy with implants between September 2010 and August 2018 were retrospectively analysed. The preoperative evaluation and our four-step surgical principles are presented in detail. Breast shape analysis was performed separately by a blinded group of plastic surgeons and by the attending surgeon using a standardized evaluation method. Breast-Q was used to evaluate patients' satisfaction. RESULTS: Patients' average age was 43 (range from 29 to 54). Among the 40 patients, 2 patients were rated as grade 1 (5%), 21 cases (52.5%) grade 2 and 17 (42.5%) grade 3 according to Pittsburgh Rating Scale. The average follow-up time was 40 months (ranging from 3 to 96 months). No major postoperative complications were experienced. Patients' satisfaction was high to very high. CONCLUSIONS: Augmentation mastopexy with implant in the MWL population remains a challenging procedure, especially in Pittsburgh grade-3 breasts. A bilamellar approach using proper footprint reconstruction allows for very satisfying cosmetic results using the short-scar mastopexy pattern with a very low complication rate. Our four-step surgical principles are provided, which may aid in the surgical planning and execution of such demanding cases. 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.

Transaxillary Nipple-Sparing Mastectomy and Direct-to-Implant Breast Reconstruction Using a Simplified Endoscopic Approach: Indications, Cosmetic Outcomes and Technical Refinements.

BACKGROUND: The increasing demand for further aesthetic outcome improvement in implant-based breast reconstruction after nipple-sparing mastectomy (NSM) leads to major novelties, including endoscopic and robotic NSM with the aim to limit scar visibility. In this paper, we report our experience with a novel and simplified surgical approach-single-axillary-incision non-endoscopic NSM and node surgery followed by an endoscopic DTI breast reconstruction-by focusing on reconstructive indications, technical refinements and aesthetic outcomes. METHODS: Between June 2016 and October 2019, 14 women underwent this novel technique using definitive anatomical silicone gel filled, totaling 20 breasts. Reconstructive evaluation methods were clinically and photography-based assessment. Breast-Q has been used to quantify patient satisfaction. Feasibility and safety data are also provided. RESULTS: The average follow-up time was 11 months (range 3-42 months). No local-regional recurrence occurred during follow-up. Median operation time was 340 min; mean hospital stay was 4.1 days. The average mastectomy specimen weight was on average 139 g (ranging from 98 to 182 g). The average implant volume for the reconstructed side was 306 cc (ranging from 165 to 550 cc). Patients' satisfaction was high to very high. CONCLUSION: Authors' experience suggests that non-endoscopic transaxillary NSM, node surgery and endoscopic direct-to-implant breast reconstruction is a valid, oncological safe, aesthetically sound scarless option in breast cancer patients with small to moderate breast size. It should represent the incision of choice in patient with previous breast surgery with scars that may compromise flap/NAC vascularity using traditional NSM incisions. 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 .

Indocyanine Green Lymphography, Lymphoscintigraphy, and Genetic Analysis in Nonsyndromic Primary Lymphedema: The Distal Dermal Backflow Grading System and the Print Sign.

BACKGROUND: Investigating correlations between clinical, instrumental, and genetic features of primary lymphedema (PL) with the aim to facilitate the diagnosis, the staging, and the management of this subgroup of patients. METHODS: A prospective observational study was conducted from September 2016 to May 2018, including patients with diagnosis of nonsyndromic PL. All patients underwent a lymphoscintigraphic rest-stress test, an indocyanine green (ICG) lymphographic test, and a genetic test from sputum sample. RESULTS: A total of 20 patients were enrolled in the study and 44 limbs were examined. The totality of clinically affected limbs (32/44) showed lymphographic and lymphoscintigraphic abnormalities. Concerning clinically healthy limbs (12/44), an abnormal pattern was demonstrated in 33.3% of ICG lymphographic test and 75% of lymphoscintigraphy. Regarding lymphography findings, the most frequent pattern was the distal dermal backflow (DDB). We distinguished four grades of DDB, which correlates with clinical and lymphoscintigraphic features. Furthermore, we found a new lymphographic alteration consisting of fluorescence appearing distally to the injection site of ICG, including fingers/toes and palmar/plantar surface of the hand and of the foot. This alteration, called "print sign," seems to be typical of DDB pattern PL. Genetic test did not help us make any etiological diagnosis. CONCLUSION: To our knowledge, this is the first study about PL comparing clinical, ICG lymphographic, lymphoscintigraphic, and genetic findings. As expected, all clinically affected limbs showed abnormalities in ICG lymphographic and lymphoscintigraphic tests. In opposition to what has previously been reported, also clinically healthy limbs showed lymphographic and lymphoscintigraphic alterations and this could suggest the existence of a subclinical form of PL. We proposed a grading of the DDB pattern, which correlates with clinical and lymphoscintigraphic features. Furthermore, we have described a new lymphographic alteration that seems to be typical of DDB pattern PL, the "print sign."

Simultaneous correction of breast hypertrophy and vaginal agenesis: Aesthetic surgery to the aid of reconstructive surgery.

Mayer-Rokitansky-Küster-Hauser syndrome is characterized by aplasia of the uterus and the upper ⅔ of the vagina, with normal female genotype (46,XX) and the development of secondary sexual characters. One of the most popular surgical treatment is the McIndoe procedure, which major drawbacks are the scar of split thickness skin graft (STSG)harvesting, and risk of vaginal stenosis for graft retraction. We report the case of a patient, operated modifying the McIndoe technique, by harvesting a full thickness skin grafts (FTSG) from patient's breasts, undergone simultaneous reduction mammoplasty. The FTSG provided a complete lining of the reconstructed neovagina. At 6 months, we observed complete mucinous metaplasia of the vaginal walls and 1 year after surgery no sign of stenosis, without the use of the mold. The advantages of this technique are reduced donor site morbidity, when compared with traditional McIndoe technique, and reduced risk of neovagina retraction ensured by FTSG, compared with STSG. If future patients' series confirm the good results achieved, we could consider it as a first-line option in patients undergoing neovagina reconstruction, seeking breasts or body contouring surgery.

Pedicled neurocutaneous anterolateral thigh flap for groin reconstruction - A case report.

Several different flaps based on the feeding vessels of sensitive nerves have been described in the limbs. This article reports the case of a neurocutaneous flap based on the lateral femoral cutaneous nerve (LFCN), employed for reconstruction of an inguinal defect. A 61-years-old female patient had undergone vulvectomy and bilateral inguinal lymphadenectomy for vulvar cancer with postoperative left groin wound breakdown. After a 3 weeks negative pressure therapy course, she presented a 10 × 4 cm skin and subcutaneous defect with undermined edges in the left inguinal area. Reconstruction with 14 × 6 cm pedicled left anterolateral thigh flap was planned. After the dissection of the vascular pedicle and of the sensitive nerve, complete thrombosis of both the veins and arterial spasm of perforating pedicle was detected. As the flap color was good, and slow marginal bleeding was present, we inspected the small vessels surrounding the nerve that were pulsating. To confirm the vascularization coming from the neural pedicle, we clamped the perforator and performed intraoperative indocyanine green (ICG) fluorescence angiography that showed a good fluorescence of the flap with a proximal to distal pattern of progression. The flap was transferred on the neural pedicle, survived completely, and wounds healed normally. Three months after surgery, the patient underwent radiotherapy, with uneventful course. In her last follow-up, 2 years after surgery, patient was free of disease and the flap showed normal scarring. This is the first case reported of a pedicled neurocutaneous flap based on the LFCN, indicating that in case of unsuitable perforators it could be an alternative pedicle.

SPECT/CT and fusion ultrasound to target the efferent groin lymph node for lymphatic surgery.

INTRODUCTION: Pelvic lymphadenectomy (PL) causes changes to the inguinal lymph nodes with progressive loss of immune and lymphatic pump function. Efferent lymphatic vessel-to-venous anastomosis (ELVA) has been reported to address this problem. The aim of this report was to describe the feasibility of the SPECT/CT combined with ultrasound fusion imaging (UFI) to target the groin efferent lymph node (GELN) for ELVA. PATIENTS AND METHODS: Twelve patients with lower limb lymphedema after PL were scheduled for peripheric lymphaticovenular anastomosis (LVA) combined with ELVA. All-patients were clinically ISL-stage1, with good visualization of the inguinal lymph nodes at preoperative lymphoscintigraphy. The mean patient age was 55.4 years and the mean BMI was 25.5.The mean limb circumference (MLC) was calculated before surgery and 1 year after surgery. The LymQoL-Leg questionnaire was administered before surgery and 6 months after surgery. Before surgery, the GELN was identified by SPECT/CT and its location was marked on the skin by UFI virtual navigation. Peripheric LVA sites were planned by ultrasound and indocyanine green (ICG) lymphography. Pre and postoperative MLC and LymQoL-Leg scores were compared. RESULTS: In all-patients, the SPECT/CT succeeded at detecting and targeting the GELN. In all-patients, real-time anatomical coregistration with US was feasible, and it was possible to mark on the groin skin the depth and position of the GELN on the skin at the groin. During surgery, in every patient, we found the GELN marked before surgery and performed ELVA. We also performed two or three peripheric LVAs in every patient. The mean value of MLC decreased (38.2 ± 2.13 cm vs. 36.33 ± 2.14 cm; p = .04) and the mean score of the LymQoL-Leg questionnaire improved (9.3 ± 1.7 vs. 7.7 ± 1.1; p = .02). CONCLUSION: SPECT/CT combined with UFI is feasible for the preoperative identification of GELN for ELVA.

Radioanatomical Study of the Pedicle of the Superficial Circumflex Iliac Perforator Flap.

BACKGROUND: The superficial circumflex iliac perforator (SCIP) flap has many ideal features, such as fast dissection, possibility to harvest thin, pliable, wide skin island, and concealed donor site scar. In spite of these features, its use was limited because of the wide anatomical variation of the pedicle, which is relatively shorter and has a smaller caliber than other more popular perforator flaps. Several names were given to the branches and perforators in the literature, thus adding confusion to the understanding of its anatomy. METHODS: We performed a surgical and a radioanatomical study of the SCIP pedicles analyzing high-resolution contrast-enhanced computed tomography (CT) scan of 95 groins, with particular attention to the deep branch (DB) of the superficial circumflex iliac artery (SCIA). Twenty-three of these patients were also studied by detecting the surgical anatomy during SCIP flap harvest. We employed a system of coordinates based on the line between pubic tubercle (PT) and anterior superior iliac spine (ASIS) to describe the position of the perforator of the DB. RESULTS: We found a 100% correlation between surgical and radiological findings. The length of the DB from the origin to the point in which its perforator pierced the sartorius fascia ranged from 1.6 to 6.5 cm, mean = 3.62 ± 0.92 cm. The distance between the origin of the DB and the inguinal ligament ranged from 1.1 to 7.5 cm, mean = 2.8 ± 1 cm. The perforator of the DB could be found in 91% of the cases within a box of 4 cm × 3 cm drawn caudally to the line joining the PT with the ASIS. This vessel can show a vertical or horizontal course in the subcutaneous layer. CONCLUSION: Our findings confirm other previous studies and add new information about the position and the course of the perforator of the DB of the SCIA. Important features of the SCIP pedicles can be investigated by the color Doppler ultrasound and CT scan.