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

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

Dehydrated Human Amniotic-Chorionic Membrane Reduces Incisional Hernia Formation in an Animal Model.

BACKGROUND: Currently there are no standard of care treatment strategies for IH prevention (IHP). Dehydrated human amnion-chorion (dHACM) is a healing adjunct that elutes growth factors including several that have reduced IH in animal models. We therefore performed a double-blinded, prospective randomized controlled trial (RCT) to test the hypothesis that dHACM significantly reduces IH formation in a well-studied animal model of acute IH. MATERIAL AND METHODS: Forty 16-week-old male Sprague-Dawley rats were randomized to one of four groups: No Treatment vs. dHACM Sheet (Group A), and Saline vs. dHACM Injection (Group B). Each animal underwent a 5-cm midline laparotomy which was incompletely closed with 5-0 plain gut sutures; this was performed by a surgeon blinded to treatment group (first blind). After 28 days, the primary endpoints of IH formation and hernia size were determined by study staff blinded to treatment (second blind). Secondary endpoints included healed fascia tensile strength as determined by tensiometry, systemic and local inflammatory markers as measured by ELISA, and fascial scar collagen I/III ratios per Western blotting. RESULTS: In Group A, No Treatment developed IH at 87.5% vs. 62.5% for Sheet (P = 0.28). Hernias that formed in the Sheet group were significantly smaller (P = 0.036). In Group B, Injection and Saline yielded identical IH rates of 77.8%. Molecular characterization of fascial scar demonstrated non-inferior tensile strength, collagen I/III ratios, and inflammatory markers in dHACM-treated animals. CONCLUSIONS: dHACM sheets significantly reduced the size of IH following laparotomy when compared to no treatment.

The Impact of Indocyanine Green Angiography on Fat Necrosis in Deep Inferior Epigastric Perforator Flap Breast Reconstruction.

BACKGROUND: The deep inferior epigastric perforator flap (DIEP) is a widely known reliable option for autologous breast reconstruction. One common complication of DIEP procedures is fat necrosis. Consequences of fat necrosis include wound healing complications, pain, infection, and the psychological distress of possible cancerous recurrence. Clinical judgment alone is an imperfect method to detect at-risk segments of adipose tissue. Objective methods to assess perfusion may improve fat necrosis complication rates, reducing additional surgeries to exclude cancer and improve cosmesis for patients. METHODS: The authors performed a retrospective review of patients who underwent analysis of DIEP flap vascularity with or without intraoperative indocyanine green angiography (ICGA). Flap perfusion was assessed using intravenous ICGA and was quantified with both relative and absolute value units of fluorescence. Tissue with observed values less than 25% to 30% relative value units was resected. Postoperative outcomes and fat necrosis incidence were collected. RESULTS: Three hundred fifty-five DIEP flaps were included in the study, 187 (52.7%) of which were assessed intraoperatively with ICGA. Thirty-nine patients (10.9%) experienced operable fat necrosis. No statistically significant difference in incidence of postoperative fat necrosis was found between the 2 groups (P = 0.732). However, a statistically significant relationship was found between fat necrosis incidence and body mass index as both a continuum (P = 0.001) and when categorized as greater than 35 (P = 0.038). CONCLUSIONS: Although ICGA is useful for a variety of plastic surgery procedures, our retrospective review did not show a reduction in operable fat necrosis when using this technology.

Treatment of Synchronous Traumatic Perforations of the Trachea and the Esophagus With Two Inferiorly Based Strap Muscle Interposition Flaps: An Innovative Approach.

: Traumatic perforations of the esophagus and trachea are devastating injuries that necessitate prompt treatment. Large defects benefit from coverage with well vascularized tissue. Injuries at the level of the thoracic inlet are more challenging, as the options for local tissue coverage are limited.This report describes the case of a 24-year-old male who suffered gunshot wounds to his neck resulting in right posterolateral tracheal perforation as well as esophageal perforation at the level of the thoracic inlet. Bronchoscopy and esophagogastroduodenoscopy showed injury of the trachea at 19 cm from the incisors and 2 large defects of the anterior and posterior esophagus at 26 cm. The esophageal defects were temporized with a stent at a first stage. Plastic surgery team was then consulted for flap coverage of the defects.The thoracic team exposed the tracheal and esophageal perforations with a j-type incision of the neck, extending to the sternal notch, and the esophageal stent was removed. The 2 muscles, sternohyoid (SH) and sternothyroid (ST), were dissected free and were inferiorly rotated after they were disinserted superiorly. The SH was placed between the trachea and the esophagus, and the ST between the esophagus and the spine.Postoperative, the patient was receiving nutrition via a gastrostomy tube. An esophagogram was performed on postoperative day (POD) # 7, which showed no esophageal leak. Postoperative diet was started and the patient was discharged on POD# 10 in a good condition. Twelve months postoperative, his wounds were found to be intact, and had no trouble either with breathing or swallowing. LEVEL OF EVIDENCE:: V.

Diagnosis and Management of a 4-Year-Old Male with Ulnar Artery Pseudoaneurysm.

Background: Pseudoaneurysms are a rare vascular phenomenon caused by an intimal tear leading to hemorrhaging into surrounding tissue. Upper extremity pseudoaneurysms are well documented in adult patients and are attributed to repetitive trauma. Pediatric pseudoaneurysms are rare and are frequently misdiagnosed, which could lead to serious complications. Methods: This report presents the case of a 4-year-old male patient with an ulnar pseudoaneurysm of the right upper extremity. The pseudoaneurysm was diagnosed by ultrasound and computed tomography angiography and subsequently resected. The ulnar artery was reconstructed with an arterial graft using the descending branch of the lateral circumflex femoral artery. Patency of the end-to-end anastomosis was confirmed by strip testing and Allen's test. Conclusions: The aim of this report is to provide a background of upper extremity pseudoaneurysms and describe their rare occurrence in pediatric patients and potential for complications upon misdiagnosis. Additionally, this report aims to highlight an alternative approach to management of pediatric pseudoaneurysms and advocate for reconstruction of the affected artery regardless of collateral flow being established.

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

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

A Second Drain Decreases Seroma Formation in Prepectoral Immediate Breast Reconstruction with an Acellular Dermal Matrix.

Seroma formation is the most common complication after mastectomy. While the exact pathophysiology behind seroma development has not been entirely elucidated, seromas are associated with negative outcomes in breast reconstruction. The utilization of drains is one method to combat seroma. However, the current state of plastic surgery is divided as to whether one drain or two drains is optimal in reducing seroma formation. We hypothesized that using two drains instead of one drain would reduce the risk of seroma more so than one drain. Methods: This was a retrospective cohort study of patients who underwent prepectoral direct to implant reconstruction at a single institution by a single surgeon. Each patient underwent reconstruction with either one or two drains. Patients were followed postoperatively for rates of seroma formation. Seroma were classified as either minor or major. Secondary variables including drain duration, infection, and necrosis were also analyzed. Results: A total of 99 breasts and 71 patients experienced breast reconstruction with two drains, and 163 breasts corresponding to 135 patients received reconstruction with one drain. In the two drain cohort, 14 (14.1%) developed a seroma, with 11 (11.1%) being minor seromas and three (3.03%) being major seromas. In comparison, out of the one drain cohort, 41 (25.2%) developed a seroma, with 35 (21.5%) being a minor seroma and six (3.68%) being classified as major. Conclusion: This study suggests that two drains decreases the rate and risk of seroma formation compared to one drain in prepectoral breast reconstruction with an acellular dermal matrix.

Autologous Breast Reconstruction with Bilateral Stacked Free Flaps in Massive Weight Loss Patients.

Patients with a history of massive weight loss who are undergoing autologous breast reconstruction after mastectomy represent a unique surgical challenge. Although these patients often have an abundance of excess skin, it may be difficult to acquire sufficient tissue volume for adequate reconstruction of bilateral breasts using single flap techniques due to the paucity of subcutaneous fat. Stacked flap techniques have emerged as an effective method in thinner patients with suboptimal fat distribution who desire autologous breast reconstruction. This can serve as an ideal strategy, specifically in this patient population, when it serves the dual function of providing adequate volume for bilateral breast reconstruction and the secondary benefit of removing the excess skin present after massive weight loss. In this article, we discuss surgical techniques used during two cases of bilateral stacked flap breast reconstruction in cancer patients subsequent to massive weight loss.

Simplifying Bony Midface Reconstruction with Patient-specific Titanium Plates.

Virtual surgical planning and patient-specific osteosynthesis plates provide reconstructive surgeons with the ability to proceed with facial reconstruction of expanding complexity. Moreover, these advances have been shown to reduce the energy, effort, and operating time while helping guide the surgeon toward anatomically correct results. The currently available literature regarding custom-milled plates pertains mostly to reconstructive surgery of the mandible. This small 3-patient series illustrates the use of patient-specific titanium plating to simplify complex reconstruction of the midface. Composite defects requiring multiple bony and soft tissue segments are difficult to reconstruct intraoperatively without prior planning. Custom plates and associated cutting guides based on patient-specific anatomy allow for a more streamlined, stepwise protocol for assembly of intricate constructs. Custom-manufactured hardware will precisely fit bony contours and minimize additional manipulation of both the bone and plate, maximally preserving internal strength and allowing for improved stability, dental occlusion, and spatial positioning. In addition to these mechanical benefits, the ease of mind and overall cost reduction through a reduction in procedural time are significant advantages offered by pre-designed plates. We hope that this series illustrates the value of custom-printed plates for midface reconstruction.

Snapshot Multispectral Imaging Is Not Inferior to SPY Laser Fluorescence Imaging When Predicting Murine Flap Necrosis.

BACKGROUND: Objective assessment of tissue viability is critical to improve outcomes of cosmetic and reconstructive procedures. A widely used method to predict tissue viability is indocyanine green angiography. The authors present an alternative method that determines the relative proportions of oxyhemoglobin to deoxyhemoglobin through multispectral reflectance imaging. This affordable, hand-held device is noninvasive and may be used in clinic settings. The authors hypothesize that multispectral reflectance imaging is not inferior to indocyanine green angiography in predicting flap necrosis in the murine model. METHODS: Reverse McFarlane skin flaps measuring 10 × 3 cm were raised on 300- to 400-g male Sprague-Dawley rats. Indocyanine green angiography and multispectral reflectance imaging was performed before surgery, immediately after surgery, and 30 minutes after surgery. Clinical outcome images acquired 72 hours after surgery were evaluated by three independent plastic surgeons. Objective data obtained immediately after surgery were compared to postsurgical clinical outcomes to determine which method more accurately predicted flap necrosis. RESULTS: Nine reverse McFarlane skin flaps were evaluated 72 hours after flap elevation. Data analysis demonstrated that the 95 percent confidence intervals for the sensitivity of postoperative multispectral reflectance imaging and indocyanine green angiography imaging to predict 72-hour tissue viability at a fixed specificity of 90 percent for predicting tissue necrosis were 86.3 to 91.0 and 79.1 to 86.9, respectively. CONCLUSIONS: In this experimental animal model, multispectral reflectance imaging does not appear to be inferior to indocyanine green angiography in detecting compromised tissue viability. With the advantages of noninvasiveness, portability, affordability, and lack of disposables, multispectral reflectance imaging has an exciting potential for widespread use in cosmetic and reconstructive procedures.

Prepectoral Site Conversion for Animation Deformity.

A signifcant disadvantage of subpectoral breast reconstruction procedures is animation deformity during pectoralis major contraction. In this study, we discuss one surgeon's experience with elective subpectoral to prepectoral implant site conversion as a definitive solution to animation deformity.. METHODS: Authors performed a retrospective review of pre-pectoral and sub-pectoral breast reconstructions performed by a single surgeon. Implants placed in the prepectoral plane were supported with total anterior AlloDerm coverage. RESULTS: One hundred forty-two breasts in 90 patients who had underwent elective subpectoral to prepectoral implant site conversion. Postoperative resolution of animation deformity was 100%. Overall, complications are minimal with rates at 4.2% for infection, 2.1% for seroma, and 0.7% for hematoma, dehiscence, partial thickness necrosis, and explantation. One patient requested reoperation for reduction in implant volume. Baker grades II-IV capsular contractures are 0% at 43 months. CONCLUSION: Breast implant site conversion from the subpectoral to the prepectoral plane is a safe and definitive solution for animation deformity.

Use of New Technologies in Implant-Based Breast Reconstruction.

Outcomes after mastectomy and prosthetic-based breast reconstruction have improved immensely since the development of the first tissue expander and breast implant in the 1960s. One major factor contributing to our improved outcomes over the past two decades is the increasing availability and improvement of perfusion assessment technology. Instrumental methods now exist which allow surgeons to assess tissue viability intraoperatively, and provide actionable, objective data that augments clinical assessment. In this article, the authors detail two commercially available, state-of-the-art technologies that surgeons may use to assist in mastectomy flap assessment and facilitate the reconstructive process.

Focused Neuro-Otological Review of Superficial Siderosis of the Central Nervous System.

BACKGROUND: Infratentorial siderosis (iSS) is a progressive degenerative disorder targeting primarily the cerebellum and cranial nerve eighth; therefore, progressive ataxia and its neuro-otological findings are common. Toxicity from hemosiderin involves selectively vulnerable neurons and glia in these posterior fossa structures. Other neurologic findings may be present, though our focus relates to the cochlea-vestibular cerebellar involvement. Radiographic evidence of siderosis may be the result of recurrent, albeit covert bleeding in the subarachnoid space, or the consequence of an overt post-traumatic or aneurysmal subarachnoid hemorrhage (SAH). The radiographic iSS appearance is identical regardless of the SAH cause. A recent study provides compelling evidence to search and correct possible hemorrhage sources in the spinal canal. The removal of residual existing hemosiderin deposits that may potentially cause clinical symptoms remains as a major therapeutic challenge. METHODS: We reviewed large data sources and identified salient papers that describe the pathogenesis, clinical and neurotologic manifestations, and the radiographic features of iSS. RESULTS: The epidemiology of iSS is unknown. In a recent series, clinically evident iSS was associated with recurrent SAH; by contrast, in a follow-up period ranging from weeks up to 11 years after a monophasic episode of SAH, radiographic siderosis was clinically silent. However, the post-aneurysmal or post-trauma SAH sample size in this single study was small and their observation period relatively short; moreover, the burden of intraneuronal hemosiderin is likely greater with recurrent SAH. There are a few reports of late iSS, several decades after traumatic SAH. A recent report found subjective hearing loss in aneurysmal SAH individuals with radiographic siderosis. Only in recent years, it is safe to perform magnetic resonance imaging (MRI) in post-aneurysmal SAH, because of the introduction of titanium, MRI-compatible aneurysm clips. CONCLUSION: iSS can be associated with significant neurotologic and cerebellar morbidity; the recurrent SAH variant is frequently clinically symptomatic, has a shorter latency and greater neurotologic disability. In these cases, a thorough search and management of a covert source of bleeding may stop clinical progression. The frequency and clinical course of radiographic iSS after traumatic and post-aneurysmal SAH is largely unknown. Detection of radiographic iSS after trauma or aneurysm bleeding suggests that the slower clinical course could benefit from an effective intervention if it became available. The use of cochlear implants is a valid alternative with advanced hearing impairment.

Two-stage Reconstruction of the Large and Ptotic Breasts: Skin Reduction Mastectomy with Prepectoral Device Placement.

Wise pattern skin reduction mastectomy with prepectoral placement of the device is a recent technique for reconstruction in patients with large and ptotic breasts. Expanders in the first stage, followed by implant exchange in the second stage are placed above the pectoralis major muscle, totally covered by acellular dermal matrix and an inferior dermal flap. This technique was performed on 6 breasts in 4 obese patients with macromastia and grade 2 and 3 ptosis. Two patients experienced complications at the T-junction. One patient experienced superficial skin sloughing managed conservatively. The second patient developed full-thickness necrosis treated with excision and primary closure. No implant loss occurred. All patients were exchanged in a second stage to an implant, and 2 of them had symmetry procedures, with good cosmetic results. Larger, long-term studies are required to further characterize results and define the limitations of this newer surgical technique.

Prepectoral Immediate Direct-to-Implant Breast Reconstruction with Anterior AlloDerm Coverage.

BACKGROUND: Staged subpectoral expander-implant breast reconstruction is widely performed. Disruption of the pectoralis major origin and the frequent occurrence of animation deformity and functional discomfort associated with subpectoral reconstruction remain ongoing concerns. Prepectoral single-stage direct-to-implant reconstruction resolves many of these issues. In this study, the authors explored the rationale for prepectoral single-stage implant-based breast reconstruction with anterior AlloDerm coverage as an alternative to the staged approach. METHODS: Seventy-three breasts in 50 patients were reconstructed using a single-stage direct-to-implant prepectoral approach with total anterior AlloDerm coverage during a 24-month period. The decision to proceed with single-stage reconstruction was predicated upon the adequacy of mastectomy skin flap blood flow based on indocyanine green fluorescence perfusion assessment. The patients were followed up for a maximum of 32 months. RESULTS: Ninety-seven percent of patients achieved complete healing within 8 weeks. There were 2 implant losses (2.7%) due to infection. Major seroma rate requiring repeated aspiration and drain insertion was 1.2%. There were no full-thickness skin losses. Capsular contracture was 0% in nonradiated patients. There were no cases of animation deformity. The authors were unable to establish significant correlation between complications and any of the usually stated risk factors, such as smoking, obesity, and large mastectomy weights, presumably due to the rigorous application of intraoperative skin perfusion assessment. CONCLUSION: Single-stage direct-to-implant reconstruction using a prepectoral approach appears to be a safe and effective means of breast reconstruction in many patients, assuming adequate skin perfusion is present.