Update on Oblique Flankplasty: Easily Executed, Long-Lasting, Integral Component of Total Body Lift Surgery.

BACKGROUND: Twenty years ago, coordinated aesthetic surgery for laxity and lipodystrophy after massive weight loss (MWL), so-called total body lift surgery (TBL), encompassed circumferential hip hugging transverse lower body lift (LBL) with possible buttock auto-augmentation, and a transverse bra line upper body lift (UBL) with breast reshaping. Brachioplasty and vertical thighplasty were often included. Disappointing aesthetics of the posterior torso led to innovation with J-torsoplasty and oblique flankplasty. OBJECTIVES: The goal of this study was to demonstrate in a large clinical series and in a range of case presentations from 2 plastic surgeons that oblique flankplasty with lipoabdominoplasty (OFLA) optimally narrows the waist, suspends lateral buttocks and thighs, and integrates with J-torsoplasty and vertical thighplasty to tighten skin and aesthetically contour the torso and thighs with an acceptable rate of complications. METHODS: Retrospective chart review of 151 consecutive flankplasties between June 2010 and April 2023, including sex, age, BMI, associated operations, complications, and revisions was performed. Five case presentations were accompanied by limited photographs and a marking video. RESULTS: Across a broad clinical spectrum, malleable oblique flankplasty resected bulging flanks and, facilitated by neighboring liposuction and/or J-torsoplasty, consistently pulled in lax skin and anchored through cadaver-proven dense dermal adherences lax tissues to create a long-lasting skintight shapely torso and upper thighs, with only 3.3% problematic wounds. Five diverse cases showed broad applicability. CONCLUSIONS: OFLA, often with J-torsoplasty and neighboring liposuction, aesthetically recontours torso skin laxity in a variety of presentations with a low rate of complications in a high-risk population.

Non-surgical Management of Locally Advanced Basal Cell Carcinoma of the Upper Extremity With Vismodegib.

Basal cell carcinoma (BCC) is a common skin malignancy that can present reconstructive challenges in patients with locally advanced diseases of the extremities. This article highlights three cases of locally advanced BCC of the extremities managed with vismodegib (Erivedge, Genentech). Vismodegib is a sonic hedgehog pathway (Shh) inhibitor approved by the FDA for use in metastatic or recurrent BCC. All three patients in our case series demonstrated significant clinical responses with reductions in tumor size which obviated the need for complex reconstructive surgery or amputation.

Reducing Complications and Expanding Use of Robotic Rectus Abdominis Muscle Harvest for Pelvic Reconstruction.

SUMMARY: The rectus abdominis flap has long been a workhorse in perineal reconstruction. Although traditionally approached though an external incision, the morbid nature of the incision and subsequent violation of the anterior rectus sheath has encouraged innovation of minimally invasive approaches for harvest. In this study, we present our experience, evolution, and comparative outcomes of robotic rectus abdominis muscle harvest. A retrospective review of perineal reconstruction was performed for a 6-year period (2014 to 2019). Robotic rectus abdominis muscle flaps were compared to nonrobotic techniques performed during this time. Descriptive statistics and complication profiles were computed. The details of our surgical technique are also described. Thirty-six patients underwent perineal reconstruction. Sixteen were performed using the robotic rectus abdominis muscle and 20 with traditional repairs (12 vertical rectus abdominis myocutaneous flaps and eight gracilis flaps). Demographic profiles were similar between cohorts, including age, body mass index, smoking, diabetes, neoadjuvant radiation therapy, and need for vaginal wall repair. Six robotic patients underwent abdominal wall reinforcement with biological mesh. Length of stay, surgical times, and incidence of major complications were similar between cohorts with a trend toward increased minor complications in traditional reconstructions (55 percent versus 31 percent; p = 0.15). Robotic rectus abdominis muscle harvest is a powerful tool that continues to evolve the potential to mitigate common morbidities and complications of traditional repair and further enhance cosmetic outcomes. This study suggests that greater flexibility for reconstruction can be afforded with harvest of the posterior rectus sheath and complications avoided with prophylactic mesh reinforcement. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Contemporary Management of Gynecomastia.

Contemporary management of gynecomastia includes transareolar excision of gland, disruption of inframammary fold, ultrasonic-assisted lipoplasty with muscular definition, bipolar radiofrequency tightening, pedicled NAC mastopexy with boomerang pattern excision and J torsoplasty, NAC grafts with hockey stick excision pattern, and pectoralis muscle lipoaugmentation. Therapeutic options are arranged across a modified Simon classification. The aesthetic goal is near total glandular reduction, with proper position and shape of the nipple areolar complexes, and masculinity with skin adherence reflecting musculoskeleton. Clinical cases demonstrate these multiple approaches, successes, and pitfalls. Complications relate to delayed healing caused by excessive closure tension or inadequate or inappropriate treatment.

Anesthetic Exposure in Staged Versus Single-Stage Cleft Lip and Palate Repair: Can We Reduce Risk of Anesthesia-Induced Developmental Neurotoxicity?

ABSTRACT: Cleft lip and palate (CLP) repair is typically performed in a staged fashion, which requires multiple instances of anesthetic exposure during a critical period of infant neurodevelopment. One solution to this concern includes the implementation of a single-stage CLP repair performed between 6 and 12 months of age. This study aimed to compare total anesthetic exposure between single-stage and staged CLP repairs. A retrospective review of unilateral CLP repairs between 2013 and 2018 conducted at a single institution was performed. Patients underwent either traditional, staged lip and palate repair, or single-stage complete cleft repair, where palate, lip, alveolus, and nasal repair was performed simultaneously. Primary endpoints included: total surgical time and total anesthetic exposure. Secondary endpoints included: excess anesthesia time, recovery room time, length of stay, and type of anesthetic administered. Two hundred twenty-five (n = 225) unilateral CLP repairs were conducted at the Loma Linda University. Detailed anesthetic data for eighty-six (n = 86) single-stage and twenty-eight (n = 28) staged operations were available. There was a statistically significant decrease in anesthetic exposure in single-stage versus staged repairs (316 minutes versus 345 minutes, P = 0.017), despite similar procedure times (260 minutes versus 246 minutes, P = 0.224). This resulted in near double excess anesthetic exposure time in the staged group (98 minutes versus 56 minutes, P < 0.001), primarily occurring during induction. This analysis suggests that single-stage CLP repair can reduce wasted time under general anesthesia and potentially reduce harmful neuronal toxicity in the developmental period in this at-risk population.

Post-mastectomy reconstruction: a risk-stratified comparative analysis of outcomes.

INTRODUCTION: Although breast reconstruction following mastectomy plays a role in the psychological impact of breast cancer, only one in three women undergo reconstruction. Few multi-institutional studies have compared complication profiles of reconstructive patients to non-reconstructive. METHODS: Using the National Surgical Quality Improvement database, all patients undergoing mastectomy from 2006 to 2010, with or without reconstruction, were identified and risk-stratified using propensity scored quintiles. The incidence of complications and comorbidities were compared. RESULTS: Of 37,723 mastectomies identified, 30% received immediate breast reconstruction. After quintile matching for comorbidities, complications rates between reconstructive and non-reconstructives were similar. This trend was echoed across all quintiles, except in the sub-group with highest comorbidities. Here, the reconstructive patients had significantly more complications than the non-reconstructive (22.8% versus 7.0%, p < 0.001). CONCLUSION: Immediate breast reconstruction is a well-tolerated surgical procedure. However, in patients with high comorbidities, surgeons must carefully counterbalance surgical risks with psychosocial benefits to maximize patient outcomes. LEVEL OF EVIDENCE: Level 3.

The differential effect of BMI on prosthetic versus autogenous breast reconstruction: a multivariate analysis of 12,986 patients.

BACKGROUND: The comparative safety of breast reconstruction in obese patients remains to be clearly defined. This study utilized multi-institutional data to characterize the effect of body mass index (BMI) on breast reconstruction outcomes. METHODS: Utilizing Current Procedural Terminology (CPT) codes, patients undergoing tissue expander, pedicled transverse rectus abdominis myocutaneous (TRAM) flap, latissimus dorsi flap, and free flap breast reconstruction were identified in the National Surgical Quality Improvement Program (NSQIP) database. Patients were stratified as obese (BMI ≥ 30) and non-obese (BMI < 30). Overall postoperative morbidity, flap complications, non-flap complications, and reoperation rates were compared among the groups. RESULTS: Of 12,986 patients who underwent breast reconstruction, 3636 (28.0%) were obese. Overall morbidity was significantly elevated in obese patients across all forms of reconstruction (p < 0.05). BMI was correlated with increased surgical complications for tissue expander, pedicled TRAM, and free flap reconstructions (OR = 1.09, OR = 1.05, OR = 1.10, respectively; p < 0.05). Medical complications were higher in obese patients undergoing tissue expander and pedicled TRAM reconstructions (p = 0.001 and p < 0.001), but no significant difference was observed in latissimus and free flap reconstruction patients. Compared with obese tissue expander recipients, obese patients reconstructed using autologous tissue had higher rates of reoperations (12.8% versus 9.1%), overall morbidity (18.0% versus 9.5%), surgical (12.7% versus 8.3%), and medical complications (9.0% versus 2.2%). CONCLUSIONS: The NSQIP database allows for evaluation and comparison of reconstructive outcomes in the obese population. Increased BMI was associated with higher morbidity in autologous reconstruction than tissue expander reconstruction. Among autologous procedures, latissimus flaps experienced the lowest captured 30 day morbidity.

A predictive model of risk and outcomes in tissue expander reconstruction: a multivariate analysis of 9786 patients.

Outcomes of tissue expander breast reconstruction show variability based on presurgical risk factors. Few comprehensive, multi-institutional risk analyses exist. Patients who underwent tissue expander reconstruction were identified in a multi-institutional registry that spans over 240 institutions with over 200 variables per patient. Bivariate analysis of preoperative variables was performed across outcomes. Multivariate logistic regression was used to adjust for confounders and identify risk factors for complications. In 9786 total tissue expander patients, 526 (5.38%) patients experienced one or more complications. Wound infection and reoperations occurred in 3.45% and 6.76% of patients, respectively. Body mass index (BMI) was found to be a significant independent risk factor for overall morbidity, reoperation, prosthesis failure, and wound infection. Overweight, obese, and morbidly obese patients were at 1.7-, 2.6-, and 5.1-times greater risk of morbidity, respectively (p < 0.001 for all). Reconstructive timing, combined surgical procedures, and neoadjuvant chemotherapy were not found to be significant predictors of morbidity. The odds of developing complications were 1.5- and 1.3-times greater in smokers and patients over the age of 50, respectively (p = 0.001 and p = 0.015). For each additional hour of surgery, the odds of morbidity increased 1.26-times (p < 0.001). Precise risk profiles garnered from multi-institutional studies can help improve patient selection and education. Overall, tissue expander reconstruction was found to be safe, with relatively few complications. Operative time, BMI, and smoking were consistently found to be independent risk factors for postoperative morbidity.

Immediate two-stage tissue expander breast reconstruction compared with one-stage permanent implant breast reconstruction: a multi-institutional comparison of short-term complications.

Prosthesis-based techniques are the predominant form of breast reconstruction worldwide, with two-stage tissue expander procedures being the most popular. In the past decade, there has been increasing interest in performing single-stage implant reconstruction immediately following mastectomy as an attempt to simplify the reconstructive course and improve psychosocial morbidity. However, there is a paucity of large-scale, multi-institutional data comparing the outcomes of these two reconstructive strategies. Patients who underwent immediate tissue expander or implant reconstruction following mastectomy from 2006-2010 were identified using standardised operation codes. Demographic information for patients, 30-day outcomes, and adverse events for each type of reconstruction were analysed and compared between groups. A total of 10,561 patients underwent immediate breast reconstruction. There were 9033 patients who underwent tissue expander placement (2752 bilateral), and 1528 patients who underwent immediate implant placement (485 bilateral). Patients who had implant placement demonstrated increased rates of overall complications (6.8% compared with 5.4%, p = 0.02) and prosthesis failure (1.4% compared with 0.8%, p = 0.04). There was no difference in the rate of any surgical site infections (3.9% compared with 3.4%, p = 0.39), reoperation (7.5% compared with 6.9%, p = 0.40), or major medical complications (1.8% compared with 1.6%, p = 0.57). Both immediate one-stage, direct-to-implant, and two-stage tissue expander reconstructions result in low rates of morbidity. One-stage reconstruction suggests a slightly higher complication rate related to prosthesis failure.

Human Acellular Dermis versus Submuscular Tissue Expander Breast Reconstruction: A Multivariate Analysis of Short-Term Complications.

BACKGROUND: Acellular dermal matrix (ADM) allografts and their putative benefits have been increasingly described in prosthesis based breast reconstruction. There have been a myriad of analyses outlining ADM complication profiles, but few large-scale, multi-institutional studies exploring these outcomes. In this study, complication rates of acellular dermis-assisted tissue expander breast reconstruction were compared with traditional submuscular methods by evaluation of the American College of Surgeon's National Surgical Quality Improvement Program (NSQIP) registry. METHODS: Patients who underwent immediate tissue expander breast reconstruction from 2006-2010 were identified using surgical procedure codes. Two hundred forty tracked variables from over 250 participating sites were extracted for patients undergoing acellular dermis-assisted versus submuscular tissue expander reconstruction. Thirty-day postoperative outcomes and captured risk factors for complications were compared between the two groups. RESULTS: A total of 9,159 patients underwent tissue expander breast reconstruction; 1,717 using acellular dermis and 7,442 with submuscular expander placement. Total complications and reconstruction related complications were similar in both cohorts (5.5% vs. 5.3%, P=0.68 and 4.7% vs. 4.3%, P=0.39, respectively). Multivariate logistic regression revealed body mass index and smoking as independent risk factors for reconstructive complications in both cohorts (P<0.01). CONCLUSIONS: The NSQIP database provides large-scale, multi-institutional, independent outcomes for acellular dermis and submuscular breast reconstruction. Both thirty-day complication profiles and risk factors for post operative morbidity are similar between these two reconstructive approaches.

A novel prospective three-dimensional analysis of nasolabial fold augmentation.

BACKGROUND: There are many products approved for aesthetic soft tissue augmentation. Despite this abundance, there is limited objective data regarding safety, longevity, and complication rates. Instead, most reports rely on subjective measures to report volume changes and outcomes, making product comparison difficult. OBJECTIVES: The authors developed and validated a mathematical model to prospectively calculate and analyze three-dimensional (3D) volumetric changes associated with nasolabial fold augmentation based on human acellular dermis. METHODS: Seven consecutive patients were included in this prospective review. The patients underwent nasolabial fold treatment with BellaDerm (Musculoskeletal Transplant Foundation, Edison, NJ), administered by a single surgeon. 3D photographs were obtained and analyzed with a novel mathematical model to determine absolute volumetric changes and objective longevity. RESULTS: Mean preoperative nasolabial fold volume was 0.17 mL. The mean one-, three-, and six-month postoperative fill volumes were 0.35, 0.19, and 0.07 mL, respectively. Fill volumes and contour changes returned to baseline by 24 weeks postoperatively in the majority of patients. CONCLUSIONS: The mathematical model utilized in this study provided prospective and objective data regarding longevity and volumetric changes associated with nasolabial fold augmentation. The analysis demonstrated minimal objective filler permanence beyond six months, with peak volume enhancement between one and three months. Adoption of objective 3D mathematical metrics into the assessment of soft tissue filler outcomes is critical to obtaining more accurate product-to-product comparisons.

A meta-analysis of human acellular dermis and submuscular tissue expander breast reconstruction.

BACKGROUND: Human acellular dermal matrix has become an increasingly used adjunct to traditional submuscular tissue expander/implant breast reconstruction, but there is no strong consensus regarding complication outcomes. This study stratified outcomes based on a meta-analysis of complications. METHODS: A query of the MEDLINE database for articles on human acellular dermal matrix and submuscular tissue expander breast reconstruction yielded 901 citations. Two levels of screening identified 48 relevant studies. The DerSimonian and Laird random-effects model was used to perform the meta-analysis. Risk ratios and pooled complication rates were calculated for each outcome of interest. RESULTS: Nineteen studies reporting human acellular dermal matrix (n = 2037) and 35 reporting submuscular outcomes (n = 12,847) were used to estimate complication rates. Rates were generally higher in acellular dermis patients: total complications, 15.4 versus 14.0 percent; seroma, 4.8 versus 3.5 percent; infection, 5.3 versus 4.7 percent; and flap necrosis, 6.9 versus 4.9 percent. Six studies reporting both acellular dermis and submuscular outcomes were used to estimate relative risks. There was an increased risk of total complications (relative risk, 2.05; 95 percent CI, 1.55 to 2.70), seroma (relative risk, 2.73; 95 percent CI, 1.67 to 4.46), infection (relative risk, 2.47; 95 percent CI, 1.71 to 3.57), and reconstructive failure (relative risk, 2.80; 95 percent CI, 1.76 to 4.45) in acellular dermis patients. CONCLUSIONS: The meta-analysis suggests that the use of human acellular dermal matrix increases complication rates vis-à-vis submuscular expander/implant reconstruction. This must be weighed against its reported advantages in enhancing cosmesis and ameliorating contracture. CLINICAL QUESTION/LEVEL OF EVIDENCE: : Therapeutic, III.