Prophylactic Venous Supercharging in Deep Inferior Epigastric Artery Perforator Flap Surgery: A Retrospective Dual-Center Study.

BACKGROUND: Deep inferior epigastric artery perforator (DIEP) flap is nowadays considered the gold standard in breast reconstruction. However, venous congestion is still a leading cause of free flap failure. Despite the conspicuous articles regarding the use of a secondary venous anastomosis, there is a lack in the literature regarding the prophylactic use of a secondary venous route to reduce the incidence of complications during breast reconstruction. METHODS: A double-center retrospective study based on women undergoing DIEP breast reconstruction was conducted, dividing patients into case group (DIEP flaps with double venous anastomosis) and control group (DIEP flaps with single venous anastomosis). Demographic and surgical data and complications were compared and statistically analyzed, and a reconstructive algorithm was proposed to improve the flap insetting. RESULTS: In total, 154 patients were included in the study, divided into case group (74 patients) and control group (80 patients). The median age at the time of surgery was 49.09 years (range: 29-68 years), slightly lower in group 1 when compared with group 2. The mean body mass index (BMI) was 25.52 kg/m2 (range: 21.09-29.37 kg/m2), in particular 25.47 kg/m2 (range: 23.44-28.63 kg/m2) in group 1 and 25.58 kg/m2 (range: 21.09-29.37 kg/m2) in group 2. No statistical differences were found between groups in terms of BMI and smoking and comorbidities history. The average operative times were 272.16 minutes (range: 221-328 minutes) in group 1 and 272.34 minutes (range: 221-327 minutes) in group 2, with no significant difference between groups, as well as ischemia time (44.4 minutes in group 1 [range: 38-56 minutes] and 49.12 minutes in group 2 [range: 41-67 minutes]). Statistical analysis showed a reduction in short-term complications and a statistically significant reduction for take-backs in the two groups. CONCLUSIONS: Our study suggests that venous supercharging of DIEP flap by performing dual venous anastomosis can be routinely and safely done prophylactically, and thus not only after intraoperative assessment of venous congestion, to avoid flap venous congestion and decrease the rates of re-exploration.

"TUBEROUS BREAST: A WIDE SPECTRUM OF FEATURES OF THE SAME DISORDER. 13-YEAR EXPERIENCE-BASED CLASSIFICATION AND RECONSTRUCTIVE ALGORITHM".

BACKGROUND: Due to the multitude of variants in which tuberous breast (TB) deformity could appear, a reconstructive algorithm could help to assess all features that affects the breast and, therefore, planning the most appropriate surgical strategy to correct the malformation. Although in the literature several efficient techniques have been successfully described, the authors propose their experience to standardize a diagnostic and therapeutic approach. The aim of this article is to assess the peculiar pathologic hallmarks of each type of deformity and to propose a one-step reconstructive algorithm tailored on the distinctive patients' characteristics, based on the use of three different adipo-glandular flaps. METHODS: From September 2006 to December 2019, 118 patients have been treated for TB deformity in one-step procedure using tailored local flaps according to the preoperatively assessed clinical variant. Minimum follow-up was 12 months. All the procedures were performed under local anesthesia. RESULTS: A total of 220 TBs (98 hypoplastic and 122 normoplastic) were treated. Patients' mean age was 20.2 years. Mean follow-up was 36.5 months. 6 minor complications (capsular contracture and nipple-areolar-complex hypoesthesia) and no major complications have been reported. In 9% of cases, minor secondary procedures, including lipofilling, scar revisions and breast implant substitution, have been performed. CONCLUSIONS: The proposed algorithm, including a comprehensive classification, preoperative planning and surgical approach derived from authors' experience, aims to propose a tailored surgical approach for each type of tuberous breast deformity.

Incidence of Complications for Different Approaches in Gynecomastia Correction: A Systematic Review of the Literature.

BACKGROUND: Gynecomastia is nowadays a very common disease, affecting a large cohort of patients with different ages. The aim of this literature review is to assess the incidence of complications with all proposed techniques and for combined procedures versus single approach procedures in gynecomastia correction. MATERIALS AND METHODS: A systematic review of the literature was performed to identify all reported techniques for gynecomastia correction covering a period from January 1, 1987 to November 1, 2020. For all selected papers, demographic data, proposed technique, and complications' incidence have been recorded. RESULTS: A total number of 3970 results was obtained from database analysis. A final total number of 94 articles was obtained for 7294 patients analyzed. Patients have been divided into three groups: aspiration techniques, consisting in 874 patients (11,98%), surgical excision techniques, consisting in 2764 patients (37,90%), and combined techniques, consisting in 3656 patients (50,12%). Complications have been recorded for all groups, for a total number of 1407, of which 130 among "Aspiration techniques" group (14,87%), 847 among "Surgical excision techniques" group (30,64%), and 430 in "Combined techniques" group (11,76%). CONCLUSIONS: Several techniques have been proposed in the literature to address gynecomastia, with the potential to greatly improve self-confidence and overall appearance of affected patients. The combined use of surgical excision and aspiration techniques seems to reduce the rate of complications compared to surgical excision alone, but the lack of unique classification and the presence of several surgical techniques still represents a bias in the literature review. 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 .

The use of resected SMAS as autologous graft for the correction of nasolabial folds during rejuvenating procedures.

BACKGROUND AND AIM: Despite several techniques are proposed, treatment of nasolabial folds is often challenging. During rejuvenation procedures, the SMAS could be redraped or partially resected during the procedure. The aim of this study is to investigate the use of obtained SMAS strip as autologous graft, because of its solid but pliable consistence and fatty composition, to correct nasolabial folds during procedures with SMAS resection.Methods Between 2015 and 2018, 23 patients underwent SMAS graft for nasolabial fold correction. All procedures were performed under local anesthesia and no other cosmetic treatments, including HA fillers, have been done in the past 12 months. RESULTS: 22 patients were declared eligible for the study. 20 patients were female, accounting for 90,91%. Mean age was 53 years old. Ancillary procedures were performed in 17 patients, including upper blepharoplasty (3, 13,63%), upper and lower blepharoplasty (5, 22,73%) and submental neck lift with platysma plication (15, 68,18%). Mean follow-up was 9 months. No major complications have been recorded: only 1 case of minimal hematoma in the retroauricular region have been recorded and 1 patient required laser treatment for pathological scars. At follow-up, graft is completely integrated into the mid-fat compartment. As evinced from the FACE-Q analysis, the overall satisfaction rate is extremely high. These are very convincing data regarding the effectiveness of the technique and, despite a little bit longer downtime, is not invasive and led to natural long-lasting results event during motion. CONCLUSIONS: The use of SMAS graft during face-lift as nasolabial fold filler results in a satisfactory but natural filling of the folds, reducing the need for lateral tension and therefore assuring more natural results. Since its nature, SMAS, reduced in width to properly fit into the nasolabial fold, can be considered as an optimal autologous graft for replenish loss volumes of the face with aging.

Immediate-implant-based-breast-reconstruction with two-stage expander-implant reconstruction versus one-stage-reconstruction with acellular dermal matrix: analysis of patients' satisfaction.

Background The aim of this retrospective study is to evaluate the patient-reported outcome after immediate ADM-assisted implant- based breast reconstruction. Material and Methods Patients underwent breast reconstruction from 2015 to 2019 have been retrospectively divided into group A (partial subpectoral implant and ADM and group B (expander/implant). For each patient we evaluated retrospectively postoperative complications and patients' satisfaction. Results 26 patients from the case group and 40 from the control group completed the BREAST-Q. The incidence of complications in the cases was 18.4%, while in the control group was 20.4%.  We found no statistical difference in most of the domains and in the mean score of the questionnaire (mean score cases=69.0±14.4 vs controls=68.4±15.7; p=0.888). A significant difference results only in the domains Q2a and Q2b, sensation of rippling. Conclusions. The use of ADM in one-stage reconstruction allows to perform breast reconstruction in only one surgery, with similar complication rates and patient satisfaction.

Gynecomastia and Chest Masculinization: An Updated Comprehensive Reconstructive Algorithm.

BACKGROUND: Gynecomastia is a common finding in males. Clinical aspect varies widely in world populations showing peculiar hallmarks according to different body shapes reflecting personal expectations; therefore, a surgical plan must be tailored on individual basis to all type of patients. MATERIALS AND METHOD: A total of 522 patients, treated for bilateral gynecomastia from January 2007 to January 2019, were included and reviewed in this retrospective study. Considering physical status BMI, muscular trophism, hypertrophy of the mammary region, nipple-areola disorder, gland and skin cover consistency, a four-tier classification system has been used to classify the deformity and to assess a surgical plan. In all cases, a subcutaneous mastectomy was performed under direct vision. RESULTS: No recurrence of the deformity was observed as well as major complications such as necrosis, and high level of satisfaction was observed in all groups. No breast cancer was found at the histological examinations Operative time ranged from 25 minutes up to 120 minutes and hospitalization time ranged from 1 to 3 days. CONCLUSION: Since the physical status is strictly related to the clinical features of the disorder, a comprehensive classification system and a reconstructive algorithm are proposed. LEVEL OF EVIDENCE IV: 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.