Patient-Reported Outcomes Following Breast Reconstruction With the Transverse Myocutaneous Gracilis Flap Using the BREAST-Q and Lower Extremity Function Scale.

BACKGROUND: The transverse myocutaneous gracilis (TMG) flap is a viable and safe option for breast reconstruction in patients with limited abdominal tissue or other contraindications for abdominal-based flaps. Although it is one of the most common flaps employed for breast reconstruction, data on patient-reported outcomes is limited. OBJECTIVES: The authors seek to evaluate patient satisfaction and aesthetic outcome after breast reconstruction with the TMG flap. METHODS: All patients who underwent breast reconstruction with a TMG flap between March 2010 and October 2020 were identified. Invitation to a digital version of the BREAST-Q reconstructive module and the Lower Extremity Function Scale (LEFS) was sent to 105 patients. Patient demographics, complications, and surgical details were collected and retrospectively analyzed. BREAST-Q and LEFS scores were calculated and compared to the literature. RESULTS: Eighty-two patients participated in the study. Median follow-up was 5.9 years, with a mean patient age of 45.7 years. Most patients (90.2%) received treatment due to previous cancer of the breast, and 17.1% underwent immediate reconstruction. The mean score for "Satisfaction with Breast" was 66/100. Postoperative lower extremity function was high, with a median LEFS score of 78/80. A LEFS score below the median value was found to be significantly associated with active smoking (P = .049). Patients also reported high satisfaction with donor sites (8/11). CONCLUSIONS: Patient satisfaction and aesthetic outcome after breast reconstruction with TMG flaps is high and comparable to other common techniques. Lower extremity function is not impaired after flap harvest.

Management of donor-site complications after breast reconstruction with the transverse musculocutaneous gracilis flap: Proposal of a treatment algorithm.

BACKGROUND: The transverse myocutaneous gracilis (TMG) flap is a popular choice for autologous breast reconstruction due to its consistent anatomy and reliability, especially for slim patients. While the incidence of donor-site morbidity is comparable with other free flaps, there is no literature about the management of donor-site complications available. Our study aims to provide an overview of encountered complications, associated risk factors and their management using a standardized algorithmic approach. METHODS: A retrospective review of all patients receiving breast reconstruction with a TMG flap at our institution between September 2010 and May 2021 was performed. Demographic data (age, BMI), comorbidities (diabetes, smoking), complication rates (major, minor) and treatment were evaluated. Medical records were screened for reasons and timing of performed reconstructions. Adapted from the Clavien-Dindo classification system, severity of complication was categorized as either class I-II minor or class IIIa-IIIb major. Data on follow-up procedures was collected. A treatment algorithm for the management of commonly occurring donor-site complications was created, based on our long-running institutional experience. RESULTS: Two-hundred and twenty-five patients (288 flaps) were included in our retrospective analysis. There were 43 (14.9%) minor and 4 (2.7%) major donor-site complications overall. Minor complications included superficial wound breakdown (26/9%), infection (10 cases, 3.5%) and hematoseroma (7 cases, 2.4%). Hematoseroma (2 cases, 0.7%) and severe wound breakdown (2 cases, 0.7%) needing revision surgery were the most common major complications. Patients with lower BMI (mean 22.9 kg/m2 vs. 24.0 kg/m2 ; p = .047) and active tobacco use (14.1% vs. 6.3%; p = .046; Relative risk = 1.71 95% CI 1.02-2.88) had a higher occurrence of donor-site complications. Age and operating time were not associated with higher complication rates. Four patients (1.4%) received donor-site refinement surgery. CONCLUSION: The TMG flap provides a reliable and safe alternative for breast reconstruction and most donor-site complications can be managed conservatively. Our proposed treatment algorithm aids with decision making in the management of donor-site complications.

Patient-Reported Outcome Analysis after Resident Performed Upper Blepharoplasty: A Suitable Procedure for Young Surgeons.

Upper blepharoplasty is one of the most frequently performed aesthetic surgeries worldwide. While it is considered a low risk procedure, patients have high expectations regarding the outcome of elective surgery of the face and the majority of residents usually have little exposure to cosmetic surgeries in the early years of their training. All eligible patients who had undergone bilateral upper blepharoplasty at the senior author's institution between January 2016 and August 2019 were invited to participate in an online questionnaire. Our study used a 27-item questionnaire to evaluate postoperative patient satisfaction and compared the patient reported outcome between operations conducted by surgeons with more than 3 years of experience and less than 3 years. In total, 102 patients returned the completed questionnaire and were included in our study after further screening. There was no significant difference in patient reported satisfaction concerning the aesthetic outcome (8.75 vs. 8.29, p=0.49), and complications (6.2 vs. 18.6%, p=0.63), related to the experience of the surgeons. Overall patient satisfaction was very high, while the rate of complications was low. Patient reported aesthetic outcomes after blepharoplasty demonstrated no significant difference comparing the experience of the surgeons.

Donor Side Preference in Maxillary Reconstruction With the Free Fibula Flap.

BACKGROUND: The implications on the choice of donor side when using the free fibula flap for reconstruction of unilateral maxillectomy defects has not been discussed in the literature so far. METHODS: A unilateral maxillectomy reconstruction was replicated using a 3D-printed skull model and fresh cadaveric dissections of left and right osteomyocutaneous fibula flaps for comparison. Detailed photo documentation was conducted to analyze and illustrate the anatomical differences of performing a reconstruction using the ipsilateral or contralateral sides and their relative benefits and risks. RESULTS: A more favorable lie of the septum and skin paddle and flexor hallucis longus muscle is attainable depending on which donor side is used and the planned direction of the pedicle. CONCLUSION: This study demonstrates why it is preferable to use the ipsilateral fibula if anastomosis is to the ipsilateral facial or neck recipient vessels, or the contralateral fibula where the contralateral recipient vessels are preferred.

The Impact of Age on Perioperative Complications after Extremity Reconstruction with the Free Gracilis Flap: A Retrospective Cohort Study Involving 153 Patients.

BACKGROUND: The need for plastic and reconstructive surgery on elderly patients has been on the rise due to an increase in life expectancy in the past decades. Therefore, a study was conducted on young and elderly patients following microsurgical extremity reconstructions with free gracilis muscle flaps with the primary aim to investigate the influence of age and the American Society of Anesthesiologists (ASA) score on the general outcome, as well as surgical and medical complications. METHODS: A retrospective analysis of 153 patients receiving free gracilis muscle flaps for extremity reconstructions between November 2009 and January 2018 was performed at two partner institutions specialized in microsurgical reconstructions. A logistic regression analysis was performed to correlate age and the ASA score with postoperative complication probability. Patients younger than 70 years were directly compared with elderly patients with respect to age, gender, ASA score, preexisting comorbidities, localization, and postoperative medical and surgical complications. RESULTS: Age turned out to be not significantly associated with major flap complications (p = 0.925) but with higher ASA scores (p = 0.016). However, an age-related significant increase in minor flap complications could be observed in the elderly (p = 0.008). A significant correlation between minor medical complications and age could be observed (p = 0.001) in contrast to ASA score (p = 0.912). CONCLUSION: An increased minor flap, as well as minor and major medical complications, must be expected in extremity reconstructions with free gracilis flaps in elderly patients. Higher ASA scores correlate with a higher incidence of major flap complications. Septuagenarians are more prone to develop perioperative major medical complications than patients younger than 70 years. Age and general medical condition, coupled with the performance of each patient, should be thoroughly assessed individually to facilitate a tailored reconstructive approach using risk assessment tools and established scoring systems.

Redefining the vascular anatomy of the peroneus brevis muscle flap.

The peroneus brevis flap can be used as either proximally or distally based flap for coverage of small to medium-sized defects in the lower leg. The purpose of this study was to clarify the vascular anatomy of the peroneus brevis muscle. An anatomical dissection was performed on 17 fixed adult cadaver lower legs. Altogether, 87 segmental branches (mean 5.1 ± 1.6 per leg) either from the fibular or anterior tibial artery to the muscle were identified. Sixty-two were branches from the fibular artery (mean 3.4 ± 1.1 per fibular artery), whereas 25 (mean 1.4 ± 0.9 per anterior tibial artery) originated from the anterior tibial artery. The distance between the most distal vascular branch and the malleolar tip averaged 4.3 ± 0.6 cm. An axial vascular bundle to the muscle could be identified in all cadavers; in one leg two axial supplying vessels were found. Their average length was 5.5 ± 2.4 cm and the average arterial diameter was 1.1 ± 0.5 mm, the average venous diameter was 1.54 ± 0.7 mm. The constant blood supply to the peroneus brevis muscle by segmental branches from the fibular and tibial artery make this muscle a viable option for proximally or distally pedicled flap transfer. The location of the most proximal and distal branches to the muscle and conclusively the pivot points for flap transfer could be determined. Furthermore, a constant proximal axial vascular pedicle to the muscle may enlarge the clinical applications. Perfusion studies should be conducted to confirm these findings.

Skin-sharing Augmentation Mastopexy for Reconstruction of an Adult Female Breast After Severe Childhood Scalds: A Case Report.

This case report describes our treatment of a 37-year-old female, Caucasian patient with a severe unilateral breast deformity after childhood scald trauma. Thermal injuries of the breast in female children pose a challenge for breast reconstruction after puberty since they impede normal development and can lead to psychological trauma. To achieve satisfactory results, a combination of different reconstructive techniques and a multistage approach is required. The patient was initially treated with an augmentation mastopexy of the left breast and a reverse abdominoplasty to correct the asymmetry and replace resected scar tissue. Following the surgery, skin necrosis of the lower breast pole due to insufficient perfusion of the skin occurred. A full-thickness skin graft, using the resected tissue from the healthy right breast after mastopexy, was used for reconstruction. This resulted in a successful outcome and proved to be a possible primary choice as well as a helpful option for salvage procedures. To our knowledge, this is the first case report describing the use of a contralateral mastopexy using the full-thickness skin graft for reconstruction of a burned breast.

Anaphylactic Reaction to Patent Blue Dye After Supermicrosurgical Lymphaticovenular Anastomosis for the Treatment of Secondary Lymphedema.

For decades, patent blue dye (PBV) has been utilized for sentinel lymph node biopsy and lymphatic mapping in breast cancer and melanoma staging and treatment. Fistulography and intraoperative display of lymphatic vessels for lymphaticovenular anastomosis (LVA) are frequent applications. Although its anaphylactic potential is well described, PBV is used routinely. We present the case of a 71-year-old female patient, who underwent LVA for the treatment of chronic secondary lymphedema and experienced a postoperative anaphylactic reaction including a blue-colored drug-induced maculopapular exanthema after PBV administration. This article aims to raise awareness of potential life-threatening allergic reactions and propose an alternative to PBV.

Seasonal Impact on Wound Healing and Surgical Site Infections after Reduction Mammoplasty.

Background: The incidence of reduction mammoplasty has been steadily increasing over recent decades. Surgical site infections (SSIs) represent a common yet preventable complication across surgical disciplines. Studies across various surgical specialties have indicated a seasonal influence on SSIs, primarily correlated with higher temperatures and humidity. However, there remains a scarcity of clear data regarding the seasonal effects on complications specifically in breast surgery. Methods: We conducted a retrospective review encompassing all patients who underwent primary bilateral reduction mammoplasties at our institution between 1 June 2016, and 1 September 2019. The data collected included patient demographics, surgical details, and postoperative complications. The rates of SSIs and wound healing disturbances (WHDs) were correlated with local meteorological data at the time of surgery. Results: A total of 808 patients (1616 breasts) met the inclusion criteria. The mean age was 41 ± 14.8 years, with a mean BMI of 28.9 ± 5.2 kg/m2 and a mean follow-up duration of 8.9 ± 9.8 months. Nineteen cases (2.35%) of surgical site infections and 77 cases (9.52%) of wound healing disturbances were reported. No statistically significant increase in the risk of SSIs (p = 0.928) or WHDs (p = 0.078) was observed during the warmer months of the year. Although no specific risk factors were identified for surgical site infections, both resection weight (p < 0.001) and diabetes mellitus (p = 0.001) demonstrated increased risks for wound healing disturbances. Conclusions: While seasonal temperature variations have been shown to impact SSIs and WHDs in body contouring procedures, our findings suggest that breast reduction surgery may not be similarly affected.

"Identifying complication risk factors in reduction mammaplasty: a single-center analysis of 1021 patients applying machine learning methods".

Various surgical approaches and pedicles have been described to ensure safe and satisfactory results in reduction mammaplasty. Although different breasts require different techniques, complications are common. This study aims to assess the incidence of complications following primary bilateral reduction mammaplasties across a diverse range of pedicle methods within one of the largest single-center cohorts to date, utilizing machine learning methodologies. A retrospective review of primary bilateral reduction mammaplasties at a single surgical center between January 2016 and March 2020 was performed. Patient medical records and surgical details were reviewed. Complications were compared among three different pedicles. Binary recursive partitioning (CART) machine learning was employed to identify risk factors. In total, 1021 patients (2142 breasts) met the inclusion criteria. The superomedial pedicle was the most frequently utilized (48.0%), with an overall complication rate of 21%. While pedicle-based subgroups demonstrated significant demographic variance, overall complication rates differed most between the inferior (24.9%) and the superomedial pedicle (17.7%). Statistical analysis identified resection weight as the sole significant independent risk factor (OR 1.001, p = 0.007). The machine learning model revealed that total resection weights exceeding 1700 g significantly increased the risk of overall complications, while a sternal notch to nipple (SNN)-distance > 36.5 cm correlated with complications involving the nipple-areola complex (NAC). Higher resection weights are associated with elevated complication rates. Preoperative assessment utilizing SNN-distance can aid in predicting NAC complications.

Photometric Comparison of Skin Color Match between Abdominal- and Thigh-Based Free Flaps for Breast Reconstruction in Caucasian Patients".

BACKGROUND: With the increasing demand for autologous breast reconstruction, different surgical techniques have emerged to provide patients with the best possible result tailored to their individual needs. The upper thigh provides an alternative tissue resource in patients where abdominal based flaps are not feasible. While surgical outcomes and donor-site morbidity demonstrate favorable results using abdominal as well as thigh based free flaps for autologous breast reconstruction, the differences in skin constitution and color between the two flap donor-sites have not been investigated. METHODS: From our flap data base, 60 patients who underwent unilateral secondary breast reconstruction with free DIEP or TMG flaps where randomly selected from our database. In both cohorts, postoperative pictures were used for photometric color evaluation of the reconstructed breast using the Delta E 2000 score at Time A (1.5 - 3 months), Time B (6 - 8 months) and Time C (12 - 20 months). Standard univariate descriptive statistics and group comparisons were performed. RESULTS: The DIEP flap demonstrated a better skin color match at Time A (p < 0.001), Time B (p = 0.003) and Time C (p = 0.009). Over time, both flaps showed improved Delta E 2000 values, and patient age was only associated with higher Delta E 2000 values in TMG flaps after 1.5 - 3 months (p = 0.021). CONCLUSION: The study provides the first objective analysis of skin color match in secondary autologous breast reconstruction. The DIEP flap reconstruction shows a preferable color match compared to the TMG flap. Both free flaps demonstrate an improved skin color match 12 - 20 months after secondary breast reconstruction.

Corset trunkoplasty is able to preserve postoperative abdominal skin sensation in massive weight loss patients.

Conventional abdominoplasty techniques commonly cause postoperative peri- and infraumbilical skin hypesthesia due to abdominal skin flap undermining. The aim of this study was to evaluate abdominal skin sensation after corset trunkoplasty in massive weight loss patients. Forty-nine massive weight loss patients suffering from excess skin underwent corset trunkoplasty between April 2017 and July 2021. Patient demographics and perioperative complications were recorded. Sensibility of the abdominal skin was measured in three qualities postoperatively using a Semmes-Weinstein monofilament, Tip-Therm® device for thermal sensation and a cotton wooden stick for sharp/blunt discrimination. Results were compared with a control group of healthy individuals to create a baseline. Revision surgery for major complications was necessary in five cases (10%) including hematoma and major wound healing disturbances. Minor complications that did not require surgical intervention were observed in eight cases (16%). Postoperative abdominal sensibility did not show any significant difference between the patient and the control group in all 16 measured areas. Sharp/blunt and thermal discrimination was positive in all patients for the whole abdominal surface area. The corset trunkoplasty technique is able to address both horizontal and vertical soft tissue excess in massive weight loss patients and at the same time limits loss of sensibility of the abdominal skin. Compared to conventional abdominoplasty techniques the abdominal sensation can mainly be preserved due to absence of undermining abdominal skin flaps.

Risk of perioperative hormonal breast cancer therapy for microvascular flap complications in breast reconstruction.

BACKGROUND: Hormone therapy with selective estrogen modulators (tamoxifen) and aromatase inhibitors is commonly used in the treatment of breast cancer. While the increased risk for thromboembolic events has been known since their early application, the potential risk in microsurgical breast reconstruction is still debated. This study aimed to evaluate the risk for microvascular flap complications in patients with perioperative hormone therapy. METHODS: All patients who underwent microsurgical breast reconstruction with a deep inferior epigastric perforator (DIEP) or transverse myocutaneous gracilis flap at our institution between March 2010 and November 2020 were retrospectively identified in our records. Patients were grouped according to the type and use of perioperative hormone therapy. Flap-related thromboembolic events, flap loss, and revision procedures were compared and analyzed between groups. Risk factors associated with postoperative microsurgical complications were determined. RESULTS: A total of 560 patients (656 flaps) were included in our analysis. One hundred ninety-eight patients (224 flaps) received perioperative hormone therapy (35.4%) and 50 (8.9%) postoperative microsurgical events occurred. Tamoxifen and aromatase inhibitors were not associated with postoperative microsurgical events (p = 0.254), full flap loss (p = 0.702), or partial flap loss (p = 0.916). Patients receiving DIEP flaps had a higher risk for postoperative microsurgical complications (OR 2.36, p = 0.004) and partial flap loss (OR 14.66, p < 0.001). A BMI > 30 was associated with an increased risk for partial flap loss (OR 4.2; p < 0.001) CONCLUSION: This article presents one of the largest single-center datasets for the risks of hormone therapy in microsurgical breast reconstruction. Our results show that perioperative hormone therapy does not increase the risk for microsurgical complications. The findings of our study do challenge the common practice of discontinued hormone therapy before microsurgical breast reconstruction.

Potential immune response to breast implants after immunization with COVID-19 vaccines.

Besides reports of alarming potential side effects after COVID-19 vaccinations there have been rare observations of rather benign reactions to foreign materials such as cosmetic hyaluronic acid filler injections after a COVID-19 immunization. Likewise to dermal fillers any foreign material may cause a reaction when the immune system is triggered. In the recent weeks we observed four noteworthy potential reactions in association with breast implants between one and three days after COVID-19 vaccinations. We release these information at the earliest to educate colleagues and draw attention to possible reactions between the COVID-19 vaccines and foreign bodies such as breast implants.

Development of A Surgical Treatment Algorithm for Breast Reconstruction in Poland Syndrome Patients Considering Severity, Sex, and BMI.

INTRODUCTION: Poland syndrome is a rare, challenging combination of chest wall and breast deformities for reconstructive surgeons and selecting the treatment can prove difficult. This study aims to help surgeons in choosing the best viable option for treatment by sharing our institutional experience and proposing a guiding algorithm. METHODS: A retrospective analysis of all patients with Poland syndrome undergoing treatment for breast and chest wall deformities at a single institution between December 2011 and May 2020 was performed. Medical charts were reviewed to allow for a description of patient demographics, treatment modalities and complications. A treatment algorithm to aid in selecting the adequate reconstructive option based on our institutional experience was formulated. RESULTS: A total of 22 patients (six male, 16 female) were identified who received treatment for Poland Syndrome related deformities. Nine received microsurgical free flap reconstruction (three Deep Inferior Epigastric Perforator flaps, six Transverse Myocutaneous Gracilis flaps), two received reconstruction with a local flap (two Latissimus dorsi flaps), nine received implant based reconstruction, and two were treated with autologous free fat transfer only (17 in combination with other surgical methods). CONCLUSION: Free flap reconstruction with the TMG flap is a valid option for patients with low Body Mass Index (BMI), while Deep Inferior Epigastric Perforator flaps should be considered for patients with a higher BMI. Autologous free fat transfer proves to be a safe and efficient treatment option in mild cases of Poland syndrome for male and female patients, in combination with or without implant based reconstructive surgery. Multicentre studies should be conducted to achieve higher case numbers of this rare disease and support clinical decisions with more data.

Update on hyperbaric oxygen therapy in burn treatment.

Hyperbaric oxygen therapy (HBOT) has been shown to improve tissue hypoxia, neovascularization and ischemia reperfusion injury and reduce pathologic inflammation in various clinical settings and was proposed to be a game changer in treatment of burns. Improved and faster wound healing as well as a reduction of morbidity and mortality after thermal and concomitant carbon monoxide poisoning are expected. In defiance of the observed benefits for burn wounds and carbon monoxide poisoning in animal models and few randomized controlled trials there is an ongoing controversy regarding its use, indications and cost effectiveness. Furthermore, the use of HBOT, its indications and the evidence behind its efficiency are still widely unknown to most physicians involved in the treatment of burn patients. Therefore, a review of the up to date evidence-based literature was performed with a focus on available data of HBOT in burn care, to elaborate its use in acute thermal injury and carbon monoxide intoxication. Although beneficial effects of HBOT seem very likely insufficient evidence to support or disprove the routine use of HBOT in the treatment of burn care was found. Although difficult to carry out because of the high interindividual variability of burns and chronic wounds, the need for larger high-quality prospective randomized double-blinded controlled multicenter trials are necessary to be able to evaluate useful applications, expense and cost-efficiency of HBOT for burn care.

Lessons Learned from 30 Years of Transverse Myocutaneous Gracilis Flap Breast Reconstruction: Historical Appraisal and Review of the Present Literature and 300 Cases.

BACKGROUND: Happy 30th birthday to the transverse myocutaneous gracilis (TMG) flap. Since 1991 the TMG flap has been used to reconstruct a wide variety of defects and became a workhorse flap and reliable alternative to the deep inferior epigastric perforator (DIEP) flap in many breast reconstruction services worldwide. This manuscript sheds light on the history and success of the TMG flap by critically reviewing the present literature and a series of 300 patients receiving a breast reconstruction. PATIENTS AND METHODS: The present literature and history of the TMG flap was reviewed and a retrospective double center cohort study of 300 free TMG free flaps for autologous breast reconstruction was conducted. Patient demographics, perioperative data, and post-operative complications were recorded and compared with literature findings. RESULTS: Mean flap weight was 320 g. Mean pedicle length was 70 mm. Complications included 19 (6.3%) flap loss. 10 patients (3.3%) had postoperative cellulitis and 28 (9.3%) wound healing disturbance of the donor site. CONCLUSION: Recipient and donor site complications were comparable to other free flaps used for breast reconstruction. A low BMI or the lack of an abdominal based donor site do not represent a limitation for breast reconstruction and can be overcome using the TMG flap.

Age and Overweight Are Not Contraindications for a Breast Reconstruction with a TMG-Flap-A Risk and Complication Analysis of a Retrospective Double Center Study Including 300 Patients.

INTRODUCTION: The transverse myocutaneous gracilis (TMG) flap has become a popular and reliable alternative for autologous breast reconstruction. Initially described as a valuable tissue source for women with low body-mass index, indications nowadays have widely expanded. The Western civilization demographic development with its aging population and the steady growing average BMI has led to increasing breast reconstructions with TMG flaps in overweight and aged individuals. PATIENTS AND METHODS: A total of 300 TMG free flaps for unilateral autologous breast reconstruction were evaluated in the form of a retrospective double center cohort study. Data extraction, study group formation and statistical analysis (One-way analysis of variance (ANOVA), Pearson's chi-squared statistical analysis and relative risk calculation) were done specifically to evaluate age and BMI as risk factors for postoperative complications and outcome. RESULTS: No significant differences in patients' age and BMI in the complication groups compared to the no-complication group could be found. No significant difference regarding the occurrence of complications could be found in any of the formed risk-groups. No significant increase of minor-, major- or overall complications, flap loss or revision surgeries were found in the elderly patient groups or for patients with overweight. CONCLUSION: Age and overweight do not significantly increase the risk for postoperative complications after breast reconstructions with free TMG flaps. The findings of this study support the fact that microsurgical breast reconstruction with a free TMG flap should not solely be reserved for younger patients and females with a lower BMI.