Oncoplastic Surgery Outcomes in the Older Breast Cancer Population: A Matched-Cohort Comparison Study.

BACKGROUND: Oncoplastic breast surgery (OBS) is a form of breast conservation surgery (BCS) that involves a partial mastectomy followed by immediate volume displacement or volume replacement surgical techniques. To date, there are few studies evaluating OBS in older patients. Therefore, we sought to determine if outcomes differed between patients 65 years and older versus younger patients who underwent oncoplastic surgical procedures. METHODS: A retrospective chart review was performed for all oncoplastic breast operations within a single health system from 2015 to 2021. Patients were stratified by age, with patients 65 years and older (OBS65+) identified and then matched with younger patients (OBS <65) based on BMI. Primary outcomes were positive margin rates and overall complication rates; secondary outcomes were locoregional recurrence (LR), distant recurrence (DR), disease-free survival (DFS), overall survival (OS), and long-term breast asymmetry. RESULTS: A total of 217 patients underwent OBS over the 6-year period, with 22% being OBS65+. Preoperatively, older patients experienced higher American Anesthesia (ASA) scores, Charlson Co-morbidity index (CCI) scores, and higher rates of diabetes mellitus, hypertension, and grade 3 breast ptosis. Despite this, no significant differences were found between primary or secondary outcomes compared to younger patients undergoing the same procedures. CONCLUSIONS: Oncoplastic breast reconstruction is a safe option in patients 65 years and older, with overall similar recurrence rates, positive margin rates, and survival when compared to younger patients. Although the older cohort of patients had greater preoperative risk, there was no difference in overall surgical complication rates or outcomes. Supporting the argument that all oncoplastic breast reconstruction techniques should be offered to eligible patients, irrespective of age.

External Validation of the Breast Cancer Surgery Risk Calculator (BCSRc): A Predictive Model for Postoperative Complications.

BACKGROUND: The breast cancer surgical risk calculator (BCSRc) is a prognostic tool that determines a breast cancer patient's unique risk of acute complications following each possible surgical intervention. When used in the preoperative setting, it can help to stratify patients with an increased complication risk and enhance the patient-physician informed decision-making process. The objective of this study was to externally validate the four models used in the BCSRc on a large cohort of patients who underwent breast cancer surgery. METHODS: The BCSRc was developed by using a retrospective cohort from the National Surgical Quality Improvement Program database from 2005 to 2018. Four models were built by using logistic regression methods to predict the following composite outcomes: overall, infectious, hematologic, and internal organ complications. This study obtained a new cohort of patients from the National Surgical Quality Improvement Program by utilizing participant user files from 2019 to 2020. The area under the curve, brier score, and Hosmer-Lemeshow goodness of fit test measured model performance, accuracy, and calibration, respectively. RESULTS: A total of 192,095 patients met inclusion criteria in the development of the BCSRc, and the validation cohort included 60,144 women. The area under the curve during external validation for each model was approximately 0.70. Accuracy, or Brier scores, were all between 0.04 and 0.003. Model calibration using the Hosmer-Lemeshow statistic found all p-values > 0.05. All of these model coefficients will be updated on the web-based BCSRc platform: www.breastcalc.org . CONCLUSIONS: The BCSRc continues to show excellent external-validation measures. Collectively, this prognostic tool can enhance the decision-making process, help stratify patients with an increased complication risk, and improve expectant management.

Single Versus Dual Surgeon Approaches to Oncoplastic Surgery: A Comparison of Outcomes.

INTRODUCTION: Oncoplastic surgery (OPS) is traditionally performed using a dual surgeon (DS) approach that involves both a breast surgeon and a plastic surgeon. It is also performed using a single surgeon (SS) approach with a surgeon trained in both breast surgical oncology and plastic surgery. We sought to determine if outcomes differed between SS versus DS OPS approaches. METHODS: A retrospective chart review was conducted of all OPS performed in a single health system over a 6-y period by either an SS or a DS approach. Primary outcomes were rates of positive margins and the overall complication rate; secondary outcomes were loco-regional recurrence, disease-free survival, and overall survival. RESULTS: A total of 217 patients were identified; 117 were SS cases and 100 were DS cases. Baseline preoperative patient characteristics were similar between the two groups as there was no difference in mean Charlson Comorbidity Index scores (P = 0.07). There was no difference in tumor stage (P = 0.09) or nodal status (P = 0.31). Rates of positive margins were not significantly different (10.9% (SS) versus 9% (DS); P = 0.81), nor were rates of complications (11.1% (SS) versus 15% (DS); P = 0.42). Rates of locoregional recurrence were also not significantly different (1.7% (SS) versus 0% (DS); P = 0.5). Disease-free survival and overall survival were not significantly different at 1-y, 3-y, and 5-y time points (P = 0.20 and P = 0.23, respectively) although follow-up time was not sufficient for definitive analysis regarding survival. CONCLUSIONS: Both SS and DS approaches to OPS have similar outcomes with regards to positive margin rates and surgical complication rates and are comparably safe.

Examining a decade of racial disparity in partial mastectomy and oncoplastic surgery.

BACKGROUND AND OBJECTIVES: Understanding racial disparity is crucial to addressing health equity and access to care. Our study aims to examine racial differences in breast conserving surgery (BCS) utilization rates and determine how these rates have changed over time. METHODS: This retrospective cohort analysis utilized the NSQIP database to identify women diagnosed with breast cancer who underwent BCS procedures between 2008 and 2019. Racial utilization trends were analyzed using a Cochran-Armitage test and Index of Disparity analysis. RESULTS: In the 12-year period, 202 492 women underwent a breast cancer surgery, of which 47% underwent BCS. Within the BCS subgroup, oncoplastic surgery utilization increased from 3% to 10%, leading to a declining proportion of partial mastectomies: 97% to 90.0% (both p < 0.01). The racial index of disparity for overall BCS patients decreased from 7% to 6%, remained unchanged (1%) for partial mastectomies, and significantly decreased in oncoplastics (23%-7.6%). CONCLUSION: BCS represents a mainstay option for early-staged breast cancer interventions, this study demonstrate promising progress in decreasing the index of disparity among races and persistent racial inequalities.

The adoption of oncoplastic surgery: Is there a learning curve?

INTRODUCTION: Oncoplastic surgery (OPS) is a form of breast conservation surgery involving partial mastectomy followed by volume displacement or replacement surgery. As the field of OPS is growing, we sought to determine if there was a learning curve to this surgery. METHODS: A retrospective chart review was conducted of all patients who underwent OPS over a 6-year period with a single surgeon formally trained in both Plastic Surgery and Breast Oncology. Cumulative summation analysis (CUSUM) was performed on mean operative time to generate the learning curve and learning curve phases. Outcomes were compared between phases to determine significance. RESULTS: Mean operative time decreased significantly across the 6-year period, generating three distinct learning curve phases: Learner phase (cases 1-23), Competence phase (24-73), and Mastery phase (74 and greater). The overall positive margin rate was 10.9% and there was no significant difference in rates between phases (p = 0.49). Overall complication rates, reoperation rates, and locoregional recurrence remained the same across all phases (p = 0.16; p = 0.65; p = 0.41). The rate of partial nipple loss decreased between phases (p = 0.02). CONCLUSION: As with many complex operations, there does appear to be a learning curve with OPS, as the operative time and the rates of partial nipple loss decreased over time.

Comparing oncoplastic breast reduction with immediate symmetry surgery to standard breast reduction surgery: Are postoperative complications worse?

INTRODUCTION: Oncoplastic breast reduction mammoplasty (ORM) is an excellent treatment option for women with breast cancer and macromastia undergoing breast conservation therapy. Here, we aim to better understand the risks associated with ORM compared to standard reduction mammoplasty (SRM). METHODS: A retrospective chart review was performed of patients undergoing ORM or SRM from 2015 to 2021. Primary outcomes included the occurrence of major or minor postoperative complications in the two groups and delays to adjuvant therapy (>90 days) among the women undergoing ORM. RESULTS: Women in the ORM group (n = 198) were significantly older (p < 0.001) with a higher prevalence of smoking (p < 0.001), diabetes mellitus (p < 0.01), and a Charlson comorbidity index ≥ 3 (p < 0.001) compared to women undergoing SRM (n = 177). After controlling for potential confounders, there were no significant between-group differences in the odds of developing postoperative complications (odds ratio = 0.80, 95% confidence interval: 0.36-1.69). Only 3% (n = 4) of the 150 women undergoing adjuvant radiation or chemotherapy experienced delays related to postoperative complications. CONCLUSION: ORM has a similar safety profile as SRM, despite the older age and higher number of comorbidities often seen in patients undergoing ORM, and is a safe option for achieving contralateral symmetry at the time of partial mastectomy without delays to adjuvant therapy.

Portable Color-Flow Ultrasound Facilitates Precision Flap Planning and Perforator Selection in Reconstructive Plastic Surgery.

BACKGROUND: Precise flap planning and perforator selection are paramount for successful perforator flap surgery. Portable color-flow ultrasound (PCFU) is a convenient, low-cost, easily accessible imaging modality that is pivotal in the planning of perforator flaps where anatomic variability is the rule. METHODS: Perforator mapping was performed using an L12-4 linear-array ultrasound probe connected to an Android tablet. Images were obtained with the Lumify app (Philips Lumify, usa.philips.com). Perforator characteristics were recorded (arterial diameter, emergence points from fascia, subcutaneous course, and projection onto the skin surface) using still images and real-time videos. RESULTS: Thirty consecutive patients had 40 perforator or musculocutaneous flap reconstructions over a 2-year period. For the 15 flaps that had preoperative computed tomographic angiography (CTA) imaging, the preoperative sonographic measurements correlated with CTA and intraoperative findings. Portable color-flow ultrasound allowed perforator flap design and selection based on the largest available perforator, the most appropriate flap thickness, and comparison of multiple donor sites including left versus right. Two deep inferior epigastric perforator patients required take-back to the operating room for debridement of devitalized nonflap tissue. The superior gluteal artery perforator flap was abandoned intraoperatively due to proximal vascular anomalies. Overall flap success rate was 98% (39/40 flaps). CONCLUSIONS: Our experience with PCFU has rapidly improved, allowing individualized perforator flap selection and design based on each patient's unique perforator anatomy, reconstructive requirements, and donor site characteristics. In our practice, PCFU has supplemented CTA and in many cases has supplanted CTA as the primary imaging modality of choice in the planning of perforator flap reconstruction.

Regional Anesthetic Blocks in Plastic Surgery Using Portable Ultrasound: A Simplified Approach.

BACKGROUND: With the introduction of latest generation ultrasound technology and its easy availability and portability, regional anesthetic blocks, which were formally in the domain of anesthesiologists, have now become available to practicing plastic surgeons. Enhanced Recovery After Surgery protocols for other specialties such as orthopedics and colorectal surgery have incorporated regional anesthetic blocks. These regional blocks have been shown to be effective in improving the patient comfort and experience and decreasing reliance on opioid medications. METHODS: Patients scheduled for elective plastic surgery received PEC-1, serratus anterior plane, or transversus abdominis plane blocks as indicated for the proposed procedure. All blocks were performed under ultrasound guidance using the Philips Lumify system with the linear array 12-4 probe by the operating surgeon. RESULTS: A total of 83 patients received regional anesthetic blocks by the senior author. Thirty-three patients undergoing cosmetic breast augmentation or implant-based breast reconstruction received the PEC-1 and the serratus anterior plane blocks after the induction of anesthesia but before the prep and drape. Fifty patients undergoing either abdominoplasty or deep inferior epigastric perforator flap reconstruction received intraoperative transversus abdominis plane blocks. Anatomic planes were clearly visualized with this new ultrasound technology. Patients experienced good to excellent analgesia with less reliance on opioid medications and decreased need for refills. For hospitalized patients, length of stay in some cases was decreased up to 1 day, and PCA pumps were eliminated. There were no complications or adverse sequelae observed in any of these patients related to the regional blocks. CONCLUSIONS: Incorporation of these known regional anesthetic techniques in this single-surgeon experience seems to confirm reports of effectiveness in the anesthesia literature and may be of benefit to a wide range of plastic surgery patients.

Outcomes of infrainguinal bypass determined by age in the Vascular Study Group of New England.

BACKGROUND: Many believe extremes of age correlate with poorer outcomes in treatment for lower extremity peripheral arterial disease (PAD). We hypothesized that the youngest patients would have significantly poorer outcomes compared with older cohorts due to the precocious nature of their PAD. METHODS: We studied all patients in the Vascular Study Group of New England database undergoing infrainguinal bypass for PAD between 2003 and 2013. Age was grouped by <50 years, 50 to 79 years, and ≥80 years. Our primary outcomes were 1-year freedom from a major adverse limb event (MALE), defined as ipsilateral amputation or need for secondary intervention, and amputation-free survival. A second analysis was performed to analyze the subgroup of patients aged <50 years with critical limb ischemia (CLI), which included a Cox regression model to determine risk factors for MALE or death at 1 year. RESULTS: Of 5265 patients who were treated with infrainguinal bypass for PAD, 324 (6.2%) were aged <50 years. The mean age was 44.6 years, and 66.4% were male. The proportion of African Americans was significantly higher in the youngest age group (<50 years: 6.8% vs 50-79 years: 3.5%, P = .002; vs ≥80 years: 3.5%, P = .013). More bypasses were done for claudication than acute limb ischemia in patients aged <50 years (33.3% vs 11.4%). More vein grafts were used vs prosthetic (<50 years: 72.1% vs 50-79 years: 65.9%, P = .024; vs ≥80 years: 62.6%, P = .002). Fewer concomitant proximal procedures were performed compared with the older groups (<50 years: 37.7% vs 50-79 years: 51.1%, P < .001; vs ≥80 years: 39.5%, P = .045). More young patients returned to the operating room within their initial hospitalization for early graft thrombosis (<50 years: 5.6% vs 50-79 years: 2.9%, P = .001; vs ≥80 years: 2.4%, P = .009) and revision (<50 years: 4.7% vs 50-79 years: 2.2%, P = .012; vs ≥80 years: 1.4%, P = .002) compared with the older patients. Overall, MALE-free survival was similar across age groups (P = .323), as were patency and amputation rates. When considering only patients with CLI, MALE-free survival in the youngest patients was again similar (P = .171) but with significantly more major amputations at 1 year (P = .022). CONCLUSIONS: For patients aged <50 undergoing infrainguinal bypass surgery, this large series demonstrates similar overall medium-term graft-related outcomes compared with older cohorts. Further, although the youngest patients with CLI have similar MALEs, their amputation rates are higher than in older cohorts.

The Keystone Perforator Island Flap: Review of Utility and Versatile Clinical Applications.

Background: The keystone perforator island flap (KPIF) was described almost a decade ago. However, this flap has only recently been recognized for its advantages in various clinical applications in plastic surgery. A better understanding of the versatility of KPIFs can help promote the widespread adoption of this technique for complex wounds in various anatomical regions. Methods: A retrospective chart review was conducted of patients undergoing KPIFs from December 2018 to March 2022 at the authors' home institution. The indications, surgical approaches, patient characteristics, and outcomes were extracted for review and analysis. Results: A total of 12 patients (ages 13-86 years) underwent reconstruction with KPIFs for oncologic and nononcologic defects. By anatomic region, three cases involved the upper back, six involved the lumbosacral region, one involved the perineum, and two involved the midfoot. Half of the patients (n = 6) had failed previous attempts at wound closure. The mean defect size was 13.8 × 10.0 cm for the upper back lesions, 13.7 × 4.8 for the lumbosacral defects, and 3.5 × 2.0 for the metatarsal wounds. Median follow-up time for all patients was 7.5 months (IQR: 4-10.5). On follow-up, there was 100% flap survival. Conclusion: KPIFs are a simple, safe, and suitable option for reconstructive closure of defects in many anatomical areas, including wounds complicated by previous failed closure attempts, with low complication risk profile.

Self-Trephination in Cranial Excoriation Disorder.

BACKGROUND AND IMPORTANCE: Trephination is a procedure in which a small hole is made in the skull. Rare cases of self-trephination by individuals seeking medical benefit have been reported. Excoriation disorder is a compulsive skin-picking condition in which an individual self-inflicts cutaneous lesions. Left untreated, severe excoriation disorder can pose significant health risks. CLINICAL PRESENTATION: Here, we describe 5 patients who presented with self-trephination due to a severe form of compulsive cranial excoriation at 2 neighboring academic medical centers over a 4-year period. We review the clinical presentation of self-trephination in cranial excoriation disorder and associated risk factors, surgical and nonsurgical interventions, complications of the disease, treatments, and mortality. Defining clinical characteristics include repetitive self-induced destruction of the scalp and skull with entry into the intracranial compartment, frequent psychiatric comorbidities, infection or injury of the brain with consequent neurological morbidity or mortality, and frequent treatment failures because of poor adherence. CONCLUSION: Self-trephination in cranial excoriation disorder is a severe neuropsychological disorder and neurosurgical emergency that exposes the brain and is often life-threatening. Appropriate therapy requires antibiotics, surgical debridement and repair of the wound, and concomitant effective psychiatric management of the underlying compulsion, including the use of antidepressants and behavioral therapy.

A Cost-Utility Analysis of the Use of Closed-Incision Negative Pressure System in Vascular Surgery Groin Incisions.

OBJECTIVE: Closed-incision negative pressure therapy (CINPT) with the Prevena system has been used and clinically evaluated in high-risk groin incisions to reduce the risk of postoperative complications. We performed a cost-effectiveness analysis evaluating CINPT in femoral-popliteal bypass with prosthetic graft. METHODS: A literature review looking at prospective randomized trials determined the probabilities and outcomes for femoral-popliteal bypass with and without CINPT. Reported utility scores were used to estimate the quality adjusted life years (QALYs) associated with a successful procedure and postoperative complications. Medicare current procedure terminology and diagnosis-related group codes were used to assess the costs for a successful surgery and associated complications. A decision analysis tree was constructed with rollback analysis to highlight the more cost-effective strategy. An incremental cost-effectiveness ratio (ICER) analysis was performed with a willingness to pay at $50,000. Deterministic and probabilistic sensitivity analyses were performed to validate the robustness of the results, and to accommodate for the uncertainty in the literature. RESULTS: Femoral-popliteal bypass with CINPT is less costly ($40,138 vs $41,774) and more effective (6.14 vs 6.13) compared to without CINPT. This resulted in a negative ICER of -234,764.03, which favored CINPT, indicating a dominant strategy. In one-way sensitivity analysis, surgery without CINPT was more cost-effective if the probability of successful surgery falls below 84.9% or if the cost of CINPT exceeds $3139. Monte Carlo analysis showed a confidence of 99.07% that CINPT is more cost-effective. CONCLUSIONS: Despite the added device cost of CINPT, it is cost-effective in vascular surgical operations using groin incisions.

Closed Incision Negative Pressure Therapy in Oncoplastic Breast Surgery: A Comparison of Outcomes.

We aim to discern the impact of closed incision negative pressure therapy (ciNPT) on wound healing in the oncoplastic breast surgery population. Methods: A retrospective analysis was conducted on patients who underwent oncoplastic breast surgery with and without ciNPT in a single health system over 6 years. Oncoplastic breast surgery was defined as breast conservation surgery involving partial mastectomy with immediate volume displacement or replacement techniques. Primary outcomes were rates of clinically significant complications requiring either medical or operative intervention, including seroma, hematoma, fat necrosis, wound dehiscence, and infection. Secondary outcomes were rates of minor complications. Results: ciNPT was used in 75 patients; standard postsurgical dressing was used in 142 patients. Mean age (P = 0.73) and Charlson Comorbidity Index (P = 0.11) were similar between the groups. The ciNPT cohort had higher baseline BMIs (28.23 ± 4.94 versus 30.55 ± 6.53; P = 0.004), ASA levels (2.35 ± 0.59 versus 2.62 ± 0.52; P = 0.002), and preoperative macromastia symptoms (18.3% versus 45.9%; P ≤ 0.001). The ciNPT cohort had statistically significant lower rates of clinically relevant complications (16.9% versus 5.3%; P = 0.016), the number of complications (14.1% versus 5.3% with one complication, 2.8% versus 0% with >2; P = 0.044), and wound dehiscence (5.6% versus 0%; P = 0.036). Conclusions: The use of ciNPT reduces the overall rate of clinically relevant postoperative complications, including wound dehiscence. The ciNPT cohort had higher rates of macromastia symptoms, BMI, and ASA, all of which put them at increased risk for complications. Therefore, ciNPT should be considered in the oncoplastic population, especially in those patients with increased risk for postoperative complications.

Poor accessibility to consumer pricing exists for elective hernia repair surgery.

BACKGROUND: Hospital price transparency is federally mandated to improve consumer accessibility. We aimed to evaluate how hospitals were complying with these regulations for elective hernia repairs. METHODS: Searches were performed for different hospital systems in attempt to find a price for the procedure using author's own health insurance. Data collected included time to reach the cost estimate tool, time to obtain price estimates, and price ranges. With prices for inguinal and ventral hernia repairs varying across the state's medical centers. RESULTS: Fourteen medical centers across the country were included, all had a cost estimate calculator. The average success rate of obtaining a cost for inguinal hernia was 48%. Comparatively, the average success rate of obtaining a cost for ventral hernia was 12%. Of the successful searches for price, significant variation exists amongst the accessed hernia procedure cost. CONCLUSION: Despite federal mandates for hospital price transparency, online cost-estimate calculators are underperforming, thus exposing a need for more accessible cost-estimates for patients undergoing elective hernia repair.

Rare Presentation of Breast Implant Infection and Breast Implant Illness Caused by Penicillium Species.

What is breast implant illness? What is the proposed pathophysiology behind breast implant illness? What are the most common etiologies of fungal breast implant infections? What risks should patients undergoing breast augmentation be informed of?

The Thoracodorsal Artery Perforator Flap: A Powerful Tool in Breast Reconstruction.

BACKGROUND: Perforator flap use in breast cancer reconstruction has evolved significantly in the last decade. The authors reviewed their experience and evaluated thoracodorsal artery perforator (TDAP) flap outcomes in breast reconstruction. METHODS: A retrospective chart review was conducted of all women undergoing breast reconstruction between 2012 and 2018. Included were patients who underwent a mastectomy (unilateral or bilateral) with immediate reconstruction or requiring a revision reconstruction with a TDAP flap. Reconstruction for nonmalignant causes were excluded. Patient demographics, risk factors, indications, operative details, and complications were reviewed. Major (partial or total flap necrosis, hematoma, and wound breakdown requiring operative management) and minor (cellulitis, seroma, and minor wound breakdown managed with local wound care) complications were recorded. RESULTS: A total of 138 charts were reviewed for the years 2012 and 2018, and 126 patients met inclusion criteria. Mean patient age was 52.1 years. Mean patient body mass index was 29.1 kg/m 2 . A total of 174 TDAP flaps were performed. The success rate was 98.3 percent. There were three flap losses (all partial). Operable fat necrosis rate was 3 percent. Donor-site morbidity was low at a rate of 1.2 percent. There was no difference in complications between patients who had a history of radiation therapy and those who did not (16.7 and 18.6 percent, respectively; p = 0.829). CONCLUSIONS: This study is the largest series in the literature that highlights the utility of the TDAP flap in breast reconstruction. This flap is a powerful tool that should be considered in patients for whom other reconstructive options have been exhausted or unavailable. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Breast Implant Illness: Treatment Using Total Capsulectomy and Implant Removal.

Background: Breast implant illness (BII) is extramammary systemic symptoms that are caused by breast implants. The emergence of this controversial topic has spurred patients with breast implants who are experiencing these symptoms to seek implant removal, hoping to feel better. This article presents novel outcomes and suggestions for plastic surgeons in managing BII using total capsulectomy and breast implant removal. Methods: In this retrospective cohort study conducted between 2016 and 2020, medical records of all patients undergoing breast implant removal were reviewed. Inclusion criteria consisted of all patients with history of breast implant placement presenting with mastodynia and capsular contracture on physical examination. Patients with history of implant-based reconstruction following mastectomy and patients who underwent implant exchange were excluded. All patients underwent bilateral implant removal and total capsulectomies. Results: A total of 200 patients who fulfilled the inclusion criteria were identified. Average age was 45.5 (range: 29-73) years and average body mass index was 26.28 (range: 19-36.8), with an average follow-up time of 5 months postoperatively. Of patients with a presentation of BII, 96% reported improved or complete resolution of their systemic symptoms after implant removal and total capsulectomy. A positive microbial culture was found in 68.5% of patients, and all culture-positive patients reported improvement post-treatment. The most common organisms found were Propionibacterium acnes (49.6%). There were no associations between implant characteristics and rate of positive microbiology findings. Conclusions: Our study shows that implant removal with capsulectomy drastically improves BII symptoms. Further large prospective cohort studies are needed to better understand this entity.

Surgical Lymphedema Treatment: A Meta-Analysis and Recommendations.

Background: Lymphedema is a common complication of lymph node surgery; however, evidence on diagnosing, monitoring, and treating the condition is sparse. This meta-analysis evaluates the outcomes of common surgical treatments of lymphedema and provides suggestions for future research directions. Methods: A review of PubMed and Embase was performed according to Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines. All English-language studies published through June 1, 2020, were included. We excluded nonsurgical interventions, literature reviews, letters, commentaries, nonhuman or cadaver studies, and studies with inadequate sample size (N < 20). Results: A total of 583 cases from 15 studies in patients with lymphedema met our inclusion criteria for our 1-arm meta-analysis: 387 upper extremity treatments and 196 lower extremity treatments. The volume reduction rates of lymphedema for upper extremity and lower extremity treatments were 38.0% [95% confidence interval (CI), 25.9%-50.2%] and 49.5% (95% CI, 32.6%-66.3%), respectively. The most common postoperative complications were cellulitis, reported in 4.5% of patients (95% CI, 0.9%-10.6%), and seromas, reported in 4.6% (95% CI, 0%-17.8%) of patients. Average quality of life measures across all studies improved by 52.2% (95% CI, 25.1%-79.2%) for patients who underwent upper extremity treatment. Conclusions: Surgical management of lymphedema shows great promise. Our data suggest that adopting a standardized system of limb measurement and disease staging can increase effectiveness of treatment outcomes.

Management of Gynecomastia and Male Benign Diseases.

Gynecomastia is a common benign breast disease involving abnormally increased mammary gland tissue that can affect men of all ages. It is usually due to a hormonal imbalance without a definitive underlying cause (idiopathic), or secondary to medications/drugs, systemic disorders, or malignancy. Gynecomastia is often self-limiting, and its management is watchful waiting. Other male benign breast diseases, such as cysts, lipomas, seromas, infections, and pseudoangiomatous stromal hyperplasia, should be worked up in a similar manner and often require surgical drainage or excision.