A Decalogue on Enhanced Recovery After Breast Augmentation Surgery (ERABAS).

BACKGROUND: Medical and technical advances have changed the state of postoperative surgical patient care, allowing for better and faster recovery. Since its publication, predictable 24-hour recovery in breast augmentation surgery has been controversial and has generated discussion. In this study, we present a novel, easy, and reproducible protocol for Enhanced Recovery After Breast Augmentation Surgery (ERABAS), along with a summary of the ten points to follow. METHODS: We conducted a retrospective study of all primary breast augmentation surgeries performed between 2010 and 2020 by a private activity. All surgeries were performed by the same surgeon according to the same protocol, and all implants were obtained from the same company. Data were evaluated using two binary logistic regression models, taking as variables responses to recovery time and postoperative pain and as predictor or explanatory variables to the factors age, smoking, size, and location of the implant. RESULTS: In total, 2906 patients were included in this study. Of these, 2770 patients (95%) immediately returned to normal life within the first 24 h, 129 achieved normal life in four days, and only seven needed a week to recover. In these seven patients, the main acute complications were hemorrhage and acute hematoma. The implants were always round; textured implants were used in 88.8% of patients, while smooth implants were used in 11.2%. A subfascial pocket was used in 934 patients, and a dual-plane pocket was performed for 1972 patients. The only factor that showed a significant effect on recovery time was the location of the implant (p < 0.05), with the dual-plane pocket being the intervention associated with a later recovery, specifically a probability of recovery after 24 hour, 2.86 times greater than subfascial. CONCLUSIONS: The ERABAS protocol allowed rapid return to daily activities with low complication rates. Further prospective comparative multicenter studies are required to confirm these results. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Three-Dimensional Printing in Breast Reconstruction: Current and Promising Applications.

Three-dimensional (3D) printing is dramatically improving breast reconstruction by offering customized and precise interventions at various stages of the surgical process. In preoperative planning, 3D imaging techniques, such as computer-aided design, allow the creation of detailed breast models for surgical simulation, optimizing surgical outcomes and reducing complications. During surgery, 3D printing makes it possible to customize implants and precisely shape autologous tissue flaps with customized molds and scaffolds. This not only improves the aesthetic appearance, but also conforms to the patient's natural anatomy. In addition, 3D printed scaffolds facilitate tissue engineering, potentially favoring the development and integration of autologous adipose tissue, thus avoiding implant-related complications. Postoperatively, 3D imaging allows an accurate assessment of breast volume and symmetry, which is crucial in assessing the success of reconstruction. The technology is also a key educational tool, enhancing surgeon training through realistic anatomical models and surgical simulations. As the field evolves, the integration of 3D printing with emerging technologies such as biodegradable materials and advanced imaging promises to further refine breast reconstruction techniques and outcomes. This study aims to explore the various applications of 3D printing in breast reconstruction, addressing current challenges and future opportunities.

Synchronous pneumothorax and venous thromboembolism after body contouring surgery.

INTRODUCTION: Lipoabdominoplasty is one of the most common abdominal body contouring procedures performed today; however, it carries the risk of significant complications. Pneumothorax is a rare complication of liposuction, while, venous thromboembolism has a low short-term mortality and long-term morbidity. PRESENTATION OF CASE: A 57-year-old woman with a history of diabetes mellitus, hypertension, obesity, and severe COVID-19 three years earlier. The patient underwent 360-degree liposuction and abdominoplasty. In the immediate postoperative period, the patient developed a right pneumothorax and followed by deep vein thrombosis (DVT) and pulmonary embolism (PE), which were diagnosed and treated early. After six months of follow-up, the patient presented a complete recovery. DISCUSSION: Pneumothorax is recognized as a rare complication of liposuction and has been limited to case reports and small case series in the medical literature with an incidence of 0.04 %. In plastic and aesthetic surgery, body contouring procedures such as lipoabdominoplasty are associated with a risk of DVT and PE of 0.2-0.6 %, and 0.3 %, respectively. In addition, we believe that performing combined aesthetic procedures may increase the risk of complications. CONCLUSION: This is the first reported case of pneumothorax, DVT and PE after body contouring surgery. We highlight the importance of awareness of these complications and the need for a high index of suspicion for early diagnosis and treatment, which is critical for patient survival.

Reverse abdominoplasty as a salvage procedure for infected bilateral implant-based breast reconstruction.

INTRODUCTION: Infection is one of the most feared complications of implant-based breast reconstruction and is difficult to manage in irradiated patients. We present the first case of bilateral breast reconstruction with infected expanders salvaged by performing a reverse abdominoplasty. PRESENTATION OF CASE: A 64-year-old woman with a history of locally advanced bilateral breast cancer underwent modified bilateral radical mastectomy and postmastectomy radiotherapy. We performed two-stage breast reconstruction with implants. However, the patient developed a mild infection of the expanders, which was treated with targeted oral antibiotic therapy. The response to treatment was favorable, allowing us to salvage the reconstruction with a reverse abdominoplasty. DISCUSSION: Traditionally, the management of infected breast prostheses has consisted of removal of the infected implant, a complication that forces a delay in the reconstructive process. Successful reports of salvage of infected prostheses have been described in the literature. On the other hand, we were able to salvage the reconstruction by performing a reverse abdominoplasty, which allowed us to resect the irradiated tissue and provide adequate non-irradiated soft tissue coverage for the replaced implants. CONCLUSION: Reverse abdominoplasty offers an acceptable aesthetic result with much less donor site morbidity and represents a valid alternative to other complex reconstruction techniques.

Breast Reconstruction after Blunt Breast Trauma: Systematic Review and Case Report Using the Ribeiro Technique.

Blunt breast trauma occurs in 2% of blunt chest injuries. This study aimed to evaluate the evidence on breast reconstruction after blunt trauma associated with the use of a seat belt. Also, we describe the first case of breast reconstruction using the Ribeiro technique. In November 2022, a systematic search of MEDLINE, EMBASE, and Google Scholar databases was conducted. The literature was screened independently by two reviewers, and the data was extracted. Our search terms included breast, mammoplasty, blunt injury, and seat belts. In addition, we present the case of a woman with a left breast deformity and her reconstruction using the inferior Ribeiro flap technique. Six articles were included. All included studies were published between 2010 and 2021. The studies recruited seven patients. According to the Teo and Song classification, seven class 2b cases were reported. In five cases a breast reduction was performed in the deformed breast with different types of pedicles (three superomedial flaps, one lower flap, one superior flap). Only one case presented complications. The case here presented was a type 2b breast deformity in which the lower Ribeiro pedicle was used successfully without complications during follow-up. Until now there has been no consensus on reconstructive treatment due to the rarity of this entity. However, we must consider surgical treatment individually for each patient. We believe that the Ribeiro technique is a feasible and safe alternative in the treatment of posttraumatic breast deformities, offering very good long-term results.

Silicone Pectoral Implant to Solve Aesthetic Chest Deformity After Pectoralis Flap Harvesting for Laryngotracheal Reconstruction.

BACKGROUND:  The pectoralis major musculocutaneous flap has been considered for decades the workhorse in head and neck reconstruction. However, the disadvantages of the pectoralis flap include the morbidity of the donor site in terms of cosmetic and functional results. A silicone pectoral implant  can be used to solve such aesthetic chest deformity in male patients. METHODS: A 33-years-old man with a history of cervical tracheoesophageal fistula after a blunt trauma due to a motorcycle accident, previously reconstructed with a pectoralis major flap, consulted our Plastic Surgery Department for an aesthetic defect of the donor site . The use of an anatomical pectoral implant was planned with the aim of aesthetic reshaping of the male chest. A pocket was created following the preoperative design to position a 190 cc pectoral implant. Dissection was performed in a subcutaneous plane that included the underneath adipose tissue layer and then over the pectoralis minor and the serratus muscle. Three months later, in a second stage, lipofilling of the depressed areas was performed with 100 ml of adipose tissue obtained from the abdomen. RESULTS: After two years of follow-up, the patient obtained a satisfactory aesthetic result, with an improvement in the projection of the thorax and the symmetry of the body contour. As the implant was placed into the subcutaneous pocket, no functional compromise in shoulder flexion or adduction was detected during follow-up. CONCLUSIONS:  The pectoral implant technique seems safe and provides reshaping of the male chest wall, significantly improving the cosmetic appearance of the patient. In addition, its use with associated procedures such as lipofilling allows optimal results to be obtained. To the best of our knowledge, this is the first case to describe the use of a pectoral implant to solve donor site morbidity after pectoralis flap harvesting for any reconstructive purpose. Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Cross-leg free flaps and cross-leg vascular cable bridge flaps for lower limb salvage: experience before and after COVID-19.

Background: Previous reports have evidenced the disruptive effect of the COVID-19 in microsurgical and reconstructive departments. We report our experience with cross-leg free flaps and (CLFF) and cross-leg vascular cable bridge flaps (CLVCBF) for lower limb salvage, technical consideration to decrease morbidity, and some structural modifications to our protocols for standard of care adapted to the COVID-19. Methods: We retrospectively included consecutive patients undergoing reconstruction with CLFFs and CLVCBFs for lower limb salvage from January 2003 to May 2022. We extracted data on baseline demographic characteristics, mechanism of trauma, and surgical outcomes. Results: Twenty-four patients were included, 11 (45.8%) underwent reconstruction with CLFF while 13 had CLVCBFs (54.2%). Fifteen patients (62.5%) underwent lower limb reconstruction under general anesthesia while 9 (37.5%) had combined spinal-epidural anesthesia. During COVID-19 pandemic, six CLFF cases were performed under S-E (25%). The average time for pedicle transection of muscle CLFFs and muscle CLVCBFs was comparable between groups (60 days versus 62 days, p = 0.864). A significantly shorter average time was evidenced for pedicle division of fasciocutaneous flaps in the CLFF group when compared to CLVCBFs (45 days versus 59 days, p = 0.002). Conclusions: In selected patients, CLFFs and CLVCBFs offer an optimal alternative for lower limb salvage using recipient vessels out of the zone of injury from the contralateral limb. Modification in the surgical protocols can decrease improve resource allocation in the setting of severely ill patients during COVID-19.Level of evidence: Level III, Therapeutic.

Mini-invasive technique of sclerotherapy with talc in chronic seroma after abdominoplasty - a case report and literature review.

The formation of a seroma after abdominoplasty is one of the most common complications faced by plastic surgeons. A 59-year-old man underwent lipoabdominoplasty and developed a large subcutaneous seroma that persisted for 7 months. Percutaneous sclerosis with talc was performed. We present the first report of chronic seroma after lipoabdominoplasty successfully treated with talc sclerosis.

Metastasis of invasive ductal breast cancer in the subcutaneous tissue of the back: Report of a relapse at 15 years.

INTRODUCTION AND IMPORTANCE: Soft tissue metastases from any primary malignant tumor are considered very rare and can be found in subcutaneous or muscle tissue. We present the fifth case of breast cancer (BC) metastasis in subcutaneous tissue of the back and with an interval of 15 years between its detection and the diagnosis of BC. CASE PRESENTATION: A 57-year-old woman with a history of left mastectomy with axillary lymphadenectomy and immediate breast reconstruction due to invasive ductal BC with positive hormone receptors and HER2 negative 15 years ago. She consulted for a mass on her back and elevated levels of CA15-3. Nuclear magnetic resonance showed a tumor in the subcutaneous tissue in contact with the muscular aponeurosis. Radical metastasectomy was performed with curative intent and intraoperative control of the margins by freezing. Histopathology and immunohistochemistry reported a lesion consistent with breast adenocarcinoma metastasis, with positive estrogen and progesterone receptors, positive GATA-3, negative HER2, and free margins. The patient is free of disease 4 years after surgery. CLINICAL DISCUSSION: The incidence of soft tissue metastasis of breast cancer is 0.2-0.8 %. To date, only four cases of BC metastasis in the subcutaneous tissue of the back have been reported. This is the case with the longest relapse time reported in the literature. CONCLUSION: Soft tissue metastases should be suspected in all patients with a history of breast cancer, even 15 years after diagnosis.

Experimental Models and Practical Simulators for Supermicrosurgery: An Updated Systematic Review and Meta-Analysis.

BACKGROUND: Supermicrosurgical simulators and experimental models promote test viability, a faster learning curve, technical innovations, and improvements of the surgical dexterities. The authors aimed to present a systematic review and meta-analysis of preclinical experimental models and simulation platforms used for supermicrosurgery. METHODS: An electronic search was conducted across the PubMed MEDLINE, Embase, Web of Science, and Scopus databases in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Data collection included the types of experimental models and outcomes. Pooled estimates were calculated with a random-effect meta-analysis using the DerSimonian-Laird model. RESULTS: Thirty-eight articles were incorporated in the qualitative synthesis. Twenty-three articles reported the use of in vivo models (60.5%), 12 used ex vivo models (31.5%), and three used synthetic models (7.9%). The superficial inferior epigastric system of rats was the most common in vivo model, whereas chicken wings and hindlimbs were the most common methods used in ex vivo models. The most common methods to evaluate patency of anastomoses were gross inspection, passage of nylon thread into the lumen, and intravascular flow of an injected dye. Nineteen studies were incorporated in the meta-analysis. The overall rate of a successful anastomosis was 94.9% (95% CI, 92.3 to 97.5%). The success rate of in vivo models using rats was 92.5% (95% CI, 88.8 to 96.3%). The success rate of ex vivo models was 97.7% (95% CI, 94.6 to >99%). CONCLUSION: Simulators that have high fidelity concerning the dissection of the vascular pedicle, flap elevation, supermicrovascular anastomosis, and adequate assessment of a successful anastomosis possess adequate predictive validation to evaluate and simulate the supermicrosurgical technique. CLINICAL RELEVANCE STATEMENT: Supermicrosurgical simulators are designed to reproduce specific clinical scenarios; therefore, these should be implemented sequentially to develop specific competencies. Supermicrosurgical models must be regarded as mutually inclusive learning platforms to optimize the learning curve.

Free flap transfer with supermicrosurgical technique for soft tissue reconstruction: A systematic review and meta-analysis.

BACKGROUND: Supermicrosurgery is a technique that allows microsurgeons to accomplish dissections and anastomoses of vessels and nerve fascicles with diameters of ≤0.8 mm. Considering the potential benefits of this technique and limited literature synthesizing the outcomes of supermicrosurgery, the aim of this study was to summarize the available evidence of reconstructive supermicrosurgery and to estimate the success rate. METHODS: We conducted a comprehensive search across PubMed, Scopus, Embase, and Web of Science. We included patient-based studies reporting on procedures for soft-tissue reconstruction with free flaps specifying the use of supermicrosurgery. We excluded studies reporting on lymphatic surgery, solely peripheral nerve surgery, and tissue replantation. Our primary endpoint was to calculate the flap success rate. Pooled estimates were calculated using a random-effects meta-analytic model. RESULTS: Forty-seven studies reporting outcomes of 698 flaps were included for qualitative synthesis. Overall, 15.75% of flaps were used for head and neck, 4.4% for breast and trunk, 9.3% for upper limb, and 69.2% for lower limb reconstruction. The most used flap was the superficial circumflex iliac artery perforator flap (41.5%). The overall flap success rate was 96.6% (95%CI 95.2%-98.1%). The cumulative rate of partial flap loss was 3.84% (95%CI 1.8%-5.9%). The overall vascular complication rate resulting in complete or partial flap loss was 5.93% (95%CI 3.5%-8.3%). CONCLUSIONS: Supermicrosurgery displays a high success rate. Further studies are necessary to explore the true potential of supermicrosurgery. This technique reformulates the boundaries of reconstructive surgery due to its extensive application.

Modified facelift in severe plexiform neurofibromatosis associated with venous vascular malformation: Case report.

Neurofibromatosis is an autosomal dominant disorder characterized by tumors of the nervous system and skin. Plexiform neurofibromas are common complications of neurofibromatosis type 1 and can cause large facial deformities. Vascular anomalies are in turn a rare manifestation of neurofibromatosis. We present the case of a 48-year-old female patient with right hemifacial neurofibromatosis associated with venous vascular malformation, previously treated surgically and then with sclerosing agents, determining severe residual facial deformity. Her surgical approach using a modified facelift technique associated with partial tumor debulking and lipofilling seems to be a valid technical alternative for these highly complex cases that require a customized approach after exhaustive preoperative evaluation.

The breast cancer-related lymphedema multidisciplinary approach: Algorithm for conservative and multimodal surgical treatment.

BACKGROUND: Multiple surgical alternatives are available to treat breast cancer-related lymphedema (BCRL) providing a variable spectrum of outcomes. This study aimed to present the breast cancer-related lymphedema multidisciplinary approach (B-LYMA) to systematically treat BCRL. METHODS: Seventy-eight patients presenting with BCRL between 2017 and 2021 were included. The average age and BMI were 49.4 ± 7.8 years and 28.1 ± 3.5 kg/m2 , respectively. Forty patients had lymphedema ISL stage II (51.3%) and 38 had stage III (48.7%). The mean follow-up was 26.4 months. Treatment was selected according to the B-LYMA algorithm, which aims to combine physiologic and excisional procedures according to the preoperative evaluation of patients. All patients had pre- and postoperative complex decongestive therapy (CDT). RESULTS: Stage II patients were treated with lymphaticovenous anastomosis (LVA) (n = 18), vascularized lymph node transfer (VLNT) (n = 12), and combined DIEP flap and VLNT (n = 10). Stage III patients underwent combined suction-assisted lipectomy (SAL) and LVA (n = 36) or combined SAL and VLNT (n = 2). Circumferential reduction rates (CRR) were comparable between patients treated with LVA (56.5 ± 8.4%), VLNT (54.4 ± 10.2%), and combined VLNT-DIEP flap (56.5 ± 3.9%) (p > .05). In comparison to LVA, VLNT, and combined VLNT-DIEP flap, combined SAL-LVA exhibited higher CRRs (85 ± 10.5%, p < .001). The CRR for combined SAL-VLNT was 75 ± 8.5%. One VLNT failed and minor complications occurred in the combined DIEP-VLNT group. CONCLUSION: The B-LYMA protocol directs the treatment of BCRL according to the lymphatic system's condition. In advanced stages where a single physiologic procedure is not sufficient, additional excisional surgery is implemented. Preoperative and postoperative CDT is mandatory to improve the outcomes.

Surgical management of breast cancer-related lymphedema: a narrative review of contemporary practices.

Background and Objective: Breast cancer-related lymphedema (BCRL) represents a colossal burden in terms of health and patient-reported outcomes. Surgical management plays a prominent role in the psychological and physical well-being of women suffering from BCRL. Therefore, we performed a narrative review of the current surgical management of BCRL and analyzed the postoperative results. Methods: A literature search was conducted across PubMed MEDLINE, Scopus, and Web of Science from database inception through January 2, 2023. We included English-written studies evaluating postoperative outcomes of lymphatic surgery for the management of BCRL. Key Content and Findings: The surgical management of lymphedema can be classified into two approaches: (I) physiologic procedures and (II) debulking or ablative procedures. While ablative procedures are intended to lessen the symptomatic burden of lymphedema via the removal of pathological tissues, physiologic procedures are performed to restore the abnormal lymphatic flow by creating bypasses into the venous or lymphatic circulation, or by creating new lymphatic connections by means of lymphangiogenesis. Physiologic procedures generate better outcomes in the early stages of lymphedema as there is some residual physiologic flow and vessels are less fibrotic, while ablative procedures are regarded to be the best alternative in very advanced lymphedema stages. A combination of physiologic and ablative procedures provides more comprehensive surgical management to BCRL. Conclusions: Lymphedema is a common complication of breast cancer treatment with an extensive incidence range. Postoperative outcomes of the surgical management of BCRL are heterogeneous despite most studies indicating favorable results after lymphatic surgery.

Usefulness of Glucose Measurement To Assess Tissue Perfusion of the Nipple-Areola Complex in Conservative Mastectomy: A Prospective Cohort Study Protocol.

In recent decades, the mastectomy technique has undergone progressive adaptations in order to preserve the integrity of the breast structure and the nipple-areola complex (NAC), allowing reconstruction to be performed immediately after ablation. However, mastectomy flap necrosis or NAC has become a common complication, with an incidence between 2% and 22.3%. Blood glucose measurement to monitor microsurgical flaps has been reported as a simple method for the early detection of venous compromise. In this scenario, we propose the need to use an alternative, cost-effective method to assess the vitality of NAC in conservative oncological mastectomies. This protocol describes a prospective cohort study and was approved by the Research Protocols Ethics Committee of our institution. Patients will be included after signing informed consent. The anonymity and confidentiality of the information collected will be respected according to the Declaration of Helsinki and according to local and national guidelines. Highlights: The rate of flap necrosis or nipple-areola complex (NAC) after mastectomy with reconstruction ranges from 2% to 22.3%.Glucose measurement has been reported in microsurgical flaps.This protocol seeks to determine the use of glucose as an early predictor of NAC necrosis.Participants will be recruited from a high-volume breast pathology hospital.

Lymphedema prevention and immediate breast reconstruction with simultaneous gastroepiploic vascularized lymph node transfer and deep inferior epigastric perforator flap: A case report.

Breast cancer-related lymphedema following axillary lymph node dissection (ALND) has been documented in 6%-55% of patients, mostly occurring within the next 3 years after radiation or surgery. We present a case of a 53-year-old patient with hormone positive, stage IB, left breast invasive ductal carcinoma treated with immediate lymphatic and microvascular breast reconstruction (MBR) using vascularized lymph node transfer (VLNT) for lymphedema prevention. A deep inferior epigastric perforator (DIEP) flap (18.3 × 11.2-cm) and simultaneous prophylactic gastroepiploic-VLNT (7 × 3-cm), orthotopically inset in the axilla, were used for reconstruction following mastectomy and radical ALND. The procedure was uneventful. The patient did not display increased postoperative arm circumferences. ICG lymphography did not show any changes at 2- and 3-years after surgery. Preventive lymphatic reconstruction with GE-VLNT and immediate MBR using the DIEP flap offers a new possibility for the primary prevention of lymphedema and simultaneous immediate autologous breast reconstruction without the risk of iatrogenic lymphedema. Further studies will be directed to unveil the external validity of these findings and the risk reduction rate of this approach.