Optimizing Aesthetics in Reconstructive Breast Surgery Using Muscle-Sparing Latissimus Dorsi Flap in Radiated and Nonradiated Patients.

BACKGROUND: The latissimus dorsi musculocutaneous flap (LDMF) has been a workhorse for breast reconstruction. Its high rate of donor-site morbidity has led to the advent of the muscle-sparing latissimus dorsi flap (MSLDF). However, there are very limited reports using the MSLDF in irradiated patients. Prior studies of MSLDF have either precluded previously radiated patients from receiving MSLDF or have included them as part of their larger MSLSDF cohort without specifically analyzing their outcome as a separate group or comparing them to the traditional LDMF group. OBJECTIVE: We describe the technique and outcome of MSLDF in both radiated and nonradiated patients and compare the outcome to our LDMF patients. METHODS: A retrospective chart review of patients undergoing breast reconstruction between 2003 and 2020 using either a pedicled MSLDF or LDMF with a transverse skin paddle was conducted. All patients underwent a 2-stage reconstruction with the flap and tissue expander placement done during the first stage, and replacement with implant and, if needed, fat grafting to enhance soft tissue during the second stage. Complications, subjective functional morbidity, and aesthetic outcomes were reviewed. RESULTS: A total of 35 MSLDFs and 40 LDMFs were performed: 24 MSLDFs (69%) and 25 LDMFs (63%) were inset into a previously irradiated field. There were 2 cases of infection requiring explantation in both MSLDF (8.3%) and LDMF (8.0%) radiated cohorts. There were no cases of donor-site seroma in the MSLDF cohorts versus 12 (30%) in the LDMF cohorts. Minor distal tip superficial epidermolysis was seen in 5 MSLDFs (14.3%), 3 of which were in the radiated cohort, and in 1 LDMF (2.5%) radiated cohort with no cases of flap loss. Functional and aesthetic outcomes were satisfactory. Four patients who had a unilateral MSLDF had a completion upper back lift. CONCLUSIONS: This is the largest series to date demonstrating the use of the MSLDF in both nonradiated and radiated patients and comparing it to a standard LDMF for breast reconstruction by the same surgeon. The pedicled MSLDF is a versatile option for breast reconstruction in radiated patients, and radiation should not be considered a contraindication for its use.

An Update on Cryopreservation of Adipose Tissue.

Currently, fat transplantation occurs immediately after harvesting procedures. Because low rates of fat graft take are well reported in the literature, many patients require multiple surgical procedures for fat graft harvest. These subsequent procedures lead to increased cost, donor-site morbidity, and patient discomfort in the long term. The ability to preserve our patients' own adipose aspirate would allow us to counteract these shortcomings and ultimately improve the clinical outcome after fat grafting. Unfortunately, there is no optimal and practical adipose tissue cryopreservation protocol for use by the plastic surgeon at the present time. Because of this dilemma, the senior author (L.L.Q.P.) has investigated this concept in an effort to create a protocol that is both technically sound and clinically achievable to allow for the long-term preservation of adipose tissue. In this article, the authors aim to outline this effort, review current clinical applications that have been reported in the literature, and detail exciting future perspectives in the use of preserved lipoaspirates for repeated fat grafting procedures or in the form of cell-based therapy engineered for reconstructive endeavors for their patients.

A Case Report of Nicolau Syndrome After Aesthetic Breast Surgery: A Review of the Literature and Introduction to a New Treatment Modality.

Nicolau syndrome (NS) is a rare iatrogenic syndrome usually following intramuscular (IM) injection of various described medications. The typical presentation involves immediate injection site pain and development of a livedoid reticular patch, which can progress to muscle necrosis requiring surgical debridement. The pathophysiology is unclear, although vasoconstrictive etiologies have been implicated. Treatment ranges from supportive care to surgical debridement. The authors present a case report of this syndrome as well as a review of the literature and introduction to a new treatment modality. NS in a 52-year-old woman following IM injection of Demerol and Phenergan to address pain and nausea before discharge is reported. This occurred in the post-anesthesia care unit after aesthetic breast surgery in an ambulatory surgery center. Our patient had immediate injection site pain and a hemorrhagic patch was evident on her physical examination the following day. With local care and hyperbaric oxygen therapy, her lesion improved in appearance. However, she continued to have debilitating pain and was referred to a specialist for osteopathic manipulative therapy (OMT), which had the greatest impact on her pain level. After multi-modal therapy was initiated, the syndrome ultimately resolved without the need for surgical debridement. However, she continues to experience pain and ambulates with a limp due to muscle atrophy. NS is a rare diagnosis that can have devastating complications that can be averted by early recognition and initiation of treatment modalities. In this case, the authors introduced OMT as a new treatment modality, with the potential to improve the progression of this syndrome.

What Do We Know Now About Autologous Fat Grafting?

Autologous fat grafting has remained part of the plastic surgeon's armamentarium. Although there have been numerous articles written on this topic, its scientific basis has recently come under some scrutiny with authors questioning what we really know about fat grafting. This article reviews the various fat grafting techniques used today based on the volume and specific need of the patient. Moreover, this review acts as a guideline to the plastic and reconstructive surgeon to choose the fat grafting technique tailored to the specific goal of the procedure. Once volume of fat and the final goal of the procedure is determined, fat grafting becomes a more individualized approach for our patients. While fat grafting is not a cookie-cutter procedure, it can be defined by the volume needed and divided into 3 categories of small, mega or large, and nanofat grafting techniques. A discussion of these 3 main categories of fat grafting techniques will be presented, along with a discussion of the mechanisms of adipocyte survival after transplant based on the graft survival and graft replacement theories. Finally, the role of adipose-derived stem cells in fat grafting based on clinical studies will be delineated. It is our hope to provide the most updated information on what do we know now about autologous fat grafting.

Autologous fat grafting does not improve burn scar appearance: A prospective, randomized, double-blinded, placebo-controlled, pilot study.

OBJECTIVE: It has been proposed that fat grafts can improve the appearance of mature burn scars. The pluripotent progenitor cells contained within autologous adipose tissue grafts are believed to induce skin repair and improve scar appearance. We conducted a prospective, randomized, double-blinded, placebo-controlled study to evaluate the effects of fat grafts on the appearance of mature burn scars. METHODS: Pediatric burn survivors with mature scars were recruited for this study. A homogeneous scar measuring 10×5cm was randomized into two halves: one was injected with autologous fat graft and the other with normal saline. Scar injection was performed using standard Coleman technique. Appearance of the two scar halves was assessed, six to twelve months later by the operating surgeon, by blinded observers and by the blinded patients. RESULTS: Eight patients completed the study pilot with 6-12 month follow-up. Assessment by the patients did not clearly favor fat grafts or saline injections; the operating surgeon did not identify any differences on any of the patients; the blinded observers measured all scars using Vancouver Scar Scale and noticed no differences in pigmentation, vascularity and height; differences in pliability showed similar changes in both the fat grafted and control arms. After the pilot was completed, decision was made to stop enrolling patients for this study since no benefit to fat grafting was observed. CONCLUSIONS: Single treatment with autologous fat grafts did not improve mature pediatric burn scars when compared to normal saline injections.

Late results after laparoscopic fundoplication denote durable symptomatic relief of gastroesophageal reflux disease.

BACKGROUND: Late outcomes after laparoscopic Nissen fundoplication are only now becoming available. This study was undertaken to document late outcomes after laparoscopic Nissen fundoplication. METHODS: Five hundred ten patients underwent laparoscopic Nissen fundoplication >10 years ago and were prospectively followed. Preoperatively and postoperatively, patients scored the frequency and severity of symptoms (from 0 = never/not bothersome to 10 = always/very bothersome). Symptom scores before and after fundoplication were compared. Median symptom scores are presented. RESULTS: Early after fundoplication, significant improvements were noted in the frequency and severity of symptoms (e.g., for heartburn, from 8 to 0 and from 8 to 0, respectively, P < .001 for each). Late after fundoplication, significant improvements were maintained in the palliation of symptoms (e.g., frequency and severity for heartburn, 2, 1; respectively). At latest follow-up, 89% of patients were pleased with their symptom resolution. CONCLUSIONS: With long-term follow-up, laparoscopic Nissen fundoplication durably and significantly palliates symptoms of gastroesophageal reflux disease. This trial promotes the application of laparoscopic Nissen fundoplication.