Plastic and Reconstructive Surgery – Global Open

Quantitative 3-dimensional Geometry of the Aging Eyelids Background: Although facial aging is a well-known phenomenon, it has not been comprehensively characterized in 3 dimensions. This study introduces a novel technique for capturing periorbital structures across age groups using 3-dimensional (3D) imaging and point cloud data collection. Methods: Forty-six white women were divided into 3 age groups: 20–39 years, 40–59 years, and 60+ years. Patients were scanned with the Canfield 3D photogrammetry system, and data files were exported to the point cloud processing software CloudCompare. Manually selected points specifying eyelid margins, creases, and 5 key periorbital features provided the basis for a fitted model and principal component analysis (PCA). Potential statistical significance across age groups was assessed for PCA values corresponding to each subject's eyelid geometry. Results: Three tendencies emerged with respect to increasing age and eyelid anatomy: the width and height of the palpebral fissure decreases, with the width decreasing more rapidly; the depth of the lateral canthus relative to the medial canthus decreases; and the superior crease becomes more variable. Analyses of variance of PCA values across age groups show statistically significant differences between the youngest and oldest groups. Conclusions: Three-dimensional photogrammetry enables rigorous and reliable evaluation of the aging eyelid. Results suggest age-induced changes to eyelid margin, crease, and lateral canthus positions, which have been noted anecdotally but poorly quantified until now.

Lymphedema Liposuction with Immediate Limb Contouring Background: Liposuction is the treatment of choice for solid predominant extremity lymphedema. The classic lymphedema liposuction technique does not remove skin excess created following bulk removal. The skin excess is presumed to resolve with spontaneous skin contracture. We investigated the technique of simultaneously performing liposuction with immediate skin excision in patients with solid predominant lymphedema and compared the outcome with that from the classic technique. Methods: Modified liposuction with skin excision (mLIPO) and standard liposuction without skin excision (sLIPO) were offered to patients with solid predominant extremity lymphedema. Skin traction of 4 cm and undulating skin mobility constituted positive “flying squirrel” sign. Patients with negative “flying squirrel” sign were excluded. mLIPO patients underwent skin excision. Surgical outcomes and postoperative complications were compared. Results: The study enrolled 15 and 26 patients into the sLIPO and mLIPO groups, respectively. mLIPO patients demonstrated statistically significant decrease in seroma/hematoma, contour irregularity, and skin necrosis, while experiencing increased procedural satisfaction. Conclusions: Skin excision following liposuction for solid predominant lymphedema is safe. It decreases postoperative complication and improves surgical outcome.

A Comparison of Fat Graft Processing Techniques: Outcomes in 1,158 Procedures in Prosthetic Breast Reconstructions Background: As fat grafting in breast reconstruction evolves, questions of technique and outcomes persist. We compared 2 common fat processing techniques—decantation (DEC) versus closed wash and filtration (CWF)—with regard to outcomes and efficacy. Methods: Chart review of a single surgeon experience with breast fat grafting was performed. Data extracted included demographics, technique, complications, graft volume, and revision rates. Secondarily, the timeline of complication profiles was analyzed. Lastly, subgroup analysis of radiated versus nonradiated breast outcomes was performed. Results: One thousand one hundred fifty-eight fat grafting procedures were performed on 775 breasts (654 DEC, 504 CWF). Time-to-event analysis for all complications showed no difference between groups. Independent risk factors for fat necrosis included DEC technique, body mass index >30 kg/m2, and fat injection >75 mL. The majority of cases of fat necrosis, cyst/nodule formation, ultrasounds, and biopsies occurred more than 6 months after grafting. Average graft volume was lower in DEC compared with CWF breasts (50.6 versus 105.0 mL, P < 0.01), and more DEC breasts required repeat fat grafting procedures (39.9% versus 29.6%, P < 0.01). Radiated breasts received larger fat graft volume (89.9 versus 72.4 mL, P < 0.01) and required more fat graft procedures (average 1.62 versus 1.47, P < 0.01). Conclusions: This study represents the largest series of breast reconstruction fat grafting to date. DEC harvest technique may be a risk factor for fat necrosis, which results in less fat injection and greater need for repeat procedures. Similarly, radiated breasts require larger graft volume and more repeat procedures.

The Use of Hydrodissection in Nipple- and Skin-sparing Mastectomy: A Retrospective Cohort Study Background: Hydrodissection (HD) is a method to create a subcutaneous and prepectoral plane during mastectomy using a mixture of crystalloid solution with local anesthetic and epinephrine. The aim of this study was to evaluate postoperative complications and surgical outcomes of this technique compared with standard mastectomy. Methods: This is a retrospective cohort study of patients who underwent bilateral risk-reducing, nipple-sparing mastectomy and immediate implant-based reconstruction through an inframammary crease incision either with standard electrocautery (control group) or HD (HD group) between January 2013 and January 2017. Patient demographics, procedural details, surgical outcomes, and complications were compared using nonparametric statistical tests and logistic regression analysis. Results: Forty-one patients (82 nipple-sparing mastectomies) were analyzed (23 patients in the HD group and 18 in the control group). Patients' demographics were similar for both groups. Surgical time was shorter with HD compared with standard mastectomy (median 168 versus 207.5 minutes, P = 0.016) with shorter median hospital stay (2 versus 2.5 days, P = 0.033). Complication rates were similar in both groups, and fewer patients in the HD group required Coleman fat transfer to improve cosmesis (12 versus 3, P = 0.003). Conclusions: HD mastectomy is a safe alternative to standard technique in selected patients. Further surgical research to explore the role of HD in a wider clinical setting is warranted.

Considering Breast Reconstruction after Mastectomy: A Patient Decision Aid Video and Workbook Background: Women report difficulty understanding and personalizing breast reconstruction information during the complex and time-limited period of cancer treatment planning. Patient decision aids can help patients become well informed, form realistic expectations, prepare to communicate with the surgical team, and be more satisfied with their decision-making process. Methods: We engaged patients, providers, and stakeholders in a user-centered design process to develop an online patient decision aid video and interactive workbook for breast reconstruction after mastectomy. The video and workbook introduce breast reconstruction and compare the risks and benefits of 3 key decisions: reconstruction versus no reconstruction, immediate versus delayed, and tissue- versus implant based. Pilot testing using cognitive interviews and pre-/postdecision aid questionnaires assessed acceptability, knowledge, and decision-making values. Results: After viewing the decision aid, patients (n = 20) scored 97.5% correct on a knowledge test; however, the factors driving their decisions were varied. All (n = 40) patients and providers/stakeholders provided over 80% positive acceptability ratings. 97.5% said they would recommend the video and workbook to other women with breast cancer. Conclusions: The Considering Breast Reconstruction after Mastectomy patient decision aid video and workbook show potential for improving informed decision-making. Delivery before the initial plastic surgery consultation was well supported as a way to give women time to process the information and prepare to talk with the surgical team about their options. The Personal Decision Worksheet shows potential for assessing patients’ knowledge and the factors driving their personal decision-making process.

Make Your Own Deep Inferior Epigastric Artery Perforator Flap: Perforator Delay Improves Deep Inferior Epigastric Artery Perforator Flap Reliability Background: Abdominal-based autologous breast reconstruction remains a conflict between blood supply and donor site complication. Optimizing esthetics and minimizing recovery and postoperative pain add further complexity. We present a 2-stage technique of deep inferior epigastric artery perforator flap reconstruction to (1) reliably harvest single-vessel flaps while minimizing fat necrosis, (2) decrease abdominal wall morbidity, and (3) improve breast and donor site esthetics. Methods: Female subjects presenting between August 2017 and January 2019 to the senior surgeon for abdominal-based breast reconstruction were included. After mastectomy, the subjects underwent subcutaneous placement of tissue expanders and in situ selection of a low, centrally located perforator based on preoperative computed tomographic angiography imaging through an infraumbilical “T” incision with ligation of all other perforators and superficial system. Subjects underwent tissue expander explant and flap transfer at a second stage. Results: One hundred thirty-five subjects undergoing 215 free flaps met criteria. Mean age and body mass index were 52.1 years and 29.3 kg/m2, respectively. Seven perforator complications (3.3%) occurred with 2 (0.9%) total and 5 (2.3%) partial flap losses. There were 20 (14.8%) readmissions and 26 (19.3%) reoperations. Breast complications included arterial thrombosis (0.5%), venous congestion (1.9%), and fat necrosis (5.1%). The mastectomy skin flap necrosis rate decreased from 14.9% to 2.3% following staged reconstruction. Abdominal donor site complications included delayed healing (11.1%), seroma (5.9%), and hematoma (2.2%). Conclusions: The 2-stage delayed deep inferior epigastric artery perforator flap technique represents a safe, efficacious modality to allow for reliable harvest of single-vessel flaps with low rates of fat necrosis while improving donor site esthetics and morbidity.

Four-step Augmentation Mastopexy: Lift and Augmentation at Single Time (LAST) Background: Augmentation mastopexy is one of the most difficult challenges plastic surgeons face, especially concerning sustainability of upper pole fullness and lower pole ptosis correction. We describe our technique for augmentation mastopexy that provides inferolateral muscular support for the implant and standardizes a sequence of surgical stages to resolve multiple situations and present the outcomes of patients who underwent such an approach. Methods: Our technique proposes the following: (a) modified subpectoral pocket, with muscular inferolateral support for the implant; (b) independent approaches to the submuscular (implant) pocket and parenchymal resection/reshaping; and (c) pre-established 4-step surgical sequence. Data from office files of our private practice were collected for 266 patients who underwent the technique from October 2015 to January 2019. Patient perception about esthetic outcomes, photographs from multiple postoperative follow-ups, and surgical complications/reoperation rates were analyzed. Results: Overall mid-term and long-term results (39 months) were positive for lift and augmentation at single time mastopexy; >90% of patients reported satisfaction with their esthetic outcomes, including absence of ptosis. No major complications occurred. The total revision rate was 16%, but it became <5% in 2018 as the learning curve progressed. Conclusions: Augmentation mastopexy is complex, and the myriad of approaches and possibilities may cause confusion when selecting the most suitable one. The 4-step sequence provides a reliable option, offering a predefined execution plan, whereas inferolateral muscular support prevents recurrence of lower pole ptosis. Other surgeons’ experience with lift and augmentation at single time mastopexy and further studies are necessary to validate these findings.

Erector Spinae Plane Block Decreases Pain and Opioid Consumption in Breast Surgery: Systematic Review Background: Adequate control of acute postoperative pain is crucial in breast surgeries, as it is a significant factor in the development of persistent chronic pain. Inadequate postoperative pain control increases length of hospital stays and risk of severe complications. Erector spinae plane block (ESPB) is a novel regional block that has the ability to sufficiently block unilateral multidermatomal sensation from T1 to L3. By reviewing the literature on ESPB, this paper aimed to elucidate its efficacy in breast surgery analgesia and its role in addressing the opioid crisis in North America. Methods: PUBMED, EMBASE, and Cochrane databases were systematically searched for relevant articles according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Inclusion criteria included any articles that described ESPB in breast surgery. Exclusion criteria composed of articles that exclusively discussed other kinds of regional blocks. Results: Thirty-two articles including 6 randomized controlled trials were included in this review. ESPB demonstrated superior pain control and less opioid consumption compared with tumescent anesthesia or using no block. However, ESPB showed lower efficacy in pain control compared with pectoral nerve block. Patients experienced less nausea and vomiting and were overall more satisfied with ESPB compared with other pain control modalities. The vast majority of the studies reported the ease of ESPB administration, and only 1 case presented with a complication. Conclusions: ESPB is a promising form of regional anesthesia that can decrease postoperative pain and opioid consumption when used as part of multimodal pain analgesia for patients undergoing breast surgery.

Keystone Perforator Island Flap for Postmastectomy Defect Resurfacing in Late-stage Breast Cancer Patients Background: Late-stage breast cancer usually presents with locally advanced disease, with or without metastasis. The primary tumor is typically large with skin infiltration which affects quality of life. Surgical resection will result in an extensive defect which potentially deteriorates patients’ quality of life if not properly managed. Keystone perforator island flap (KPIF) is a local advancement flap based on multiple perforators which can be a reliable reconstructive method to close an extensive defect. Methods: This is a case series of 11 patients with symptomatic late-stage breast cancers indicated for neoadjuvant chemotherapy and subsequent mastectomy at Dharmais Cancer Hospital. The postmastectomy defect was closed with KPIF and clinical evaluation included flap success rate, percentage of flap necrotic area, and quality of life. There are modifications of the KPIF consisting of the more rounded shape and additional flap movement of the flap’s distal lateral ends to the center resembling an “omega” conformation. Results: Mean percentage of flap necrosis area was 9.7% and none of the patients needed additional surgery. The patients’ quality of life evaluated using Patient-reported Aesthetic European Organization for Research and Treatment of Cancer (EORTC) Quality of Life, Questionnaire-Core 30-questions (QLQ-C30) and Quality of Life, Questionnaire-Breast Cancer-23-questions (QLQ-BR23) was fair, with sufficiently good scores for global health status and functional scale, and minimal symptomatology burden. The lowest score was for fatigue and financial difficulties parameters from QLQ-C30 and sexual functioning and future perspective from QLQ-BR23. Conclusion: This is a preliminary study to show that a KPIF could be considered as a method for defect-resurfacing reconstruction after mastectomy.

Dermal Triangular Flaps to Prevent Pseudoptosis in Mastopexy Surgery: The Hammock Technique Background: Mastopexy is one of the most performed cosmetic surgery procedures in the United States. Despite the numerous mastopexy techniques that were published in the past decades, preventing pseudoptosis to ensure longer lasting results remains the principal challenge. Objectives: This paper describes a new mastopexy technique developed for moderate to severe ptosis/pseudoptosis associated with upper pole deflation. Considering some of the commonest risk factors generally considered predictive of worse outcomes (massive weight loss, multiple pregnancies, skin quality, smoking, age), we aimed to assess whether this technique could be beneficial in the support of the desired breast shape over time. Methods: Twelve patients, all featuring 1 or more of the abovementioned preoperative risk factors, were operated on by the same senior surgeon with the hammock mastopexy technique using dermal flaps as a support for the glandular reshaping (6 bilateral mastopexies and 6 unilateral mastopexies for contralateral symmetrization after breast reconstruction). Patients’ characteristics, such as smoking, weight loss, or multiparity with consequent inelastic skin, age, and lengthy nipple–areola complex lift, were considered as independent risk factors for ptosis recurrence and bottoming out. Patients were divided into 3 subgroups according to the number of their risk factors. Aesthetic results were assessed at 12 months postoperatively. Changes in postoperative were assessed for each patient by breast measurements and a superposition of the standardized breast photographs. Long-term outcomes were compared with a control group of 6 patients who benefited from mastopexy without “hammock technique.” Results: Satisfactory maintenance of shape and stable nipple–areola complex position was seen at 12 months regardless of the number of risk factors. However, a statistically significant difference was found in lower pole lengthening between patients with more than 3 risk factors compared to other groups. Aesthetic measurement results were consistent between the patient and surgeon reporting a satisfying cosmetic result, regardless of the number of risk factors. In the control group, we found a significant increase in breast lower pole measurements at 12 months when compared with the hammock group. Conclusions: This mastopexy technique improves projection and reinforces the lower pole support with lateral and medial dermal flaps. The technique is safe and reliable and provides easily reproducible results for patients with risk factors for postoperative pseudoptosis.