Scar versus shape: patient-reported outcome after different surgical approaches to gynecomastia measured by modified BREAST Q®.

OBJECTIVES: The challenge in the operative therapy for enlargement of the male breast is to deal with the skin excess. Shape and scars are the major parameters after which patients assess their operative result. Therefore, we assessed the satisfaction rate among patients undergoing subcutaneous mastectomy at our institution with special regard to scar tissue formation and the postoperative appearance of the chest wall in dependence of the surgical approach (periarolar versus inframammary fold). METHODS: The study includes n = 36 male patients who underwent subcutaneous mastectomy at AGAPLESION Markus Hospital Frankfurt/Main. Patient's satisfaction dependent with the appearance of the chest wall and scar formation was evaluated by a modified BREAST Q® questionnaire plus two male-based additional questions. RESULTS: There is no statistically significant difference in satisfaction with the operative result depending on the pattern of incision (periareolar versus submammary periareolar; 81.9% versus 75.5%) with the operative result. Evaluation of additional questions of the modified BREAST Q® questionnaire showed that 86% of the patients (n = 31) would rather have more scars and a flatter chest wall. A BMI >25 kg/m2 is accompanied by a higher risk for complications (p = 0.04). CONCLUSIONS: Periareolar incision is still the method of choice, if promising an aesthetic appealing result. When reaching its limits though, we showed that a flat and male-shaped appearance of the chest wall is priority for the patients and should therefore be for the surgeon as well.

[Patient satisfaction following gender reassignment mastectomy in female-to-male transsexual patients: a questionnaire-based analysis using a modified version of the BREAST-Q]. / Patientenzufriedenheit nach geschlechtsangleichender Mastektomie in Frau-zu-Mann-transidenten Patienten ­ eine Analyse unter Verwendung eines modifizierten BREAST-Q-Fragebogens.

BACKGROUND: Mastectomy is an essential part of gender reassignment surgery for female-to-male transgender patients. Available studies indicate high patient satisfaction within this patient group; however, a standardised evaluation procedure is yet to be established. METHOD: Based on the BREAST-Q questionnaire, we developed a modified version targeting issues concerning FM patients; hence, all questions focussing on the physiology of biologically female patients were removed or tailored to address more specific transgender issues. Post-mastectomy transgender male patients from 1991 until 2017 were contacted and evaluated based on the questionnaire. This questionnaire comprises a total of 57 questions regarding general satisfaction with the ches area, as well as specific questions regarding satisfaction with the nipple-areola complex (NAC) and topics regarding expectations, regrets, self-confidence and sex life after mastectomy. RESULTS: Overall, we found a high level of patient satisfaction after mastectomy. The level of regret was low and all patients would repeat mastectomy if needed. CONCLUSION: For most transgender males, mastectomy plays an essential role in gender reassignment surgery, overall leading to an improved quality of life for this patient population.

Implant Replacement or Removal: What Happens after Capsular Contracture? A German Study Examining Breast Implant Revision Surgery and Patient Choices in 946 Cases.

INTRODUCTION: Capsular contracture most often leads to implant revision surgery for aesthetic or reconstructive purposes. However, little is known about which operation is chosen when revision surgery has to be performed. We performed analysis of revision indications and performed revision surgery considering implant removal or replacement and additional surgical procedures. To our knowledge, this study presents the largest German single-center analysis regarding implant revision surgery after the onset of complications. METHODS: Retrospective 10-year data analysis of a single-center population undergoing breast implant revision surgery. RESULTS: Capsular contracture was the most frequent finding before reoperation, both removal and replacement (p < 0.05). It was linked to longer duration of in situ implant placement (p < 0.05) and more frequently in reconstructive patients (p < 0.05). Implant replacement was performed more often before definite implant removal for reconstructive patients (p < 0.05). Mean duration of in situ implant placement before definite removal was lower for reconstructive patients (p = 0.005). Overall reconstructive patients were older than aesthetic patients (p < 0.05). After implant removal, 61.7% of aesthetic patients chose to undergo mastopexy, 54.7% of reconstructive patients opted for autologous breast reconstruction, and 25.4% did not choose an additional surgical procedure after implant removal. CONCLUSION: Significant differences are observed for reconstructive and aesthetic patients regarding indication leading to revision surgery, time of revision surgery, and the type of performed revision surgery itself. After implant removal, more than 60% of aesthetic patients undergo mastopexy, more than half of reconstructive patients choose autologous breast reconstruction, and over a quarter of patients choose no additional surgical procedures.

Otoplasty through Ventral Skin Incision and Shaping of the Antihelix by Abrasion-A Retrospective Study.

(1) Background: Protruding ears are the most common auricular malformation affecting approximately 5% of the population. One common factor leading to auricular protrusion is a deficiency or total absence of the antihelix. A technique first described by Gottfried Lemperle in 2003 attempts cartilage thinning, folding, and fixation by non-absorbable mattress sutures after ventral skin incision along the ventral helical rim. (2) Methods: Retrospective analysis of patient records was performed for otoplasties according to this technique, performed between 1985 and 2014 at Agaplesion Markus Hospital in Frankfurt, Germany. All recorded complications were examined. (3) Results: A total of 912 single otoplasties were performed according to this technique from 1985 to 2014. Overall complications included 26% minor complications not requiring further surgery and 11% major complications leading to revision surgery. Within those requiring revision surgery, the most common reason was recurrence of auricular protrusion (5%), followed by suture granulomas (5%) and hematomas (2%). (4) Conclusions: Lemperle's otoplasty technique addresses the open thinning and shaping of the antihelix through a ventral incision along the helix to prevent irregularities and possible ridges. Results show a low complication rate comparable to data found in published studies. This technique is easy to perform, safe, and avoids often seen contour irregularities of the antihelix compared to techniques with a posterior approach.

A Training Model for Local Flaps Using Fresh Human Skin Excised During Body Contouring Procedures.

BACKGROUND: The safe execution of local flaps tends to be challenging for surgical residents. Thus, the purpose of the study was to evaluate a training model of local flaps based on fresh human skin excised from body contouring procedures. MATERIALS AND METHODS: A questionnaire and surgical skills evaluation-analyzing the theoretical and procedural knowledge about local flaps-were held both before and after the surgical skills training. All surgical procedures were executed on a simulation model based on fresh human skin. Skills evaluation was done according to a modified version of the Objective Structured Assessment of Technical Skills Score. Results before and after the training were compared using SPSS, version 21. RESULTS: In pretraining evaluation, residents showed great difficulty regarding the accuracy of flap design and sufficiency of wound coverage indicating the need for surgical training outside the operating theater. After training, the procedural skills significantly improved as depicted by the modified Objective Structured Assessment of Technical Skills score with a mean cumulative pretraining score of 26.81 ± 5.41 and posttraining score of 43.59 ± 5.72 (P = 0.008). Also, theoretical knowledge significantly improved in the posttraining evaluation with exception to the indication of a Z-plasty (P = 0.257). The training model itself was generally regarded as highly useful and thus recommendable to others. CONCLUSIONS: Surgical handling and the understanding of tissue rotation clearly improved by the presented model which mimics very realistic conditions. The simulation model based on fresh human skin shows cost-effectiveness and allows a broad range for flap procedures wherefore its use should be further promoted.

Perioperatives Management in der Mikrochirurgie ­ Konsensus-Statement der Deutschsprachigen Arbeitsgemeinschaft für Mikrochirurgie der peripheren Nerven und Gefäße.

Perioperative management in microsurgery is a key element of success in reconstructive surgery. There are no uniform concepts for this in the German-speaking countries and individual schemes differ significantly from each other, as ascertained in an expert survey. In the course of the 41st Annual Conference of the German-speaking Working Group for Microsurgery (DAM) held in Munich in November 2019, concepts were evaluated and a survey was carried out and summarised as a position paper in due consideration of the scientific literature.

[Successful free microvascular radial artery flap for phalloplasty in case of a persistent median artery - Retrospective analysis of 48 patients and review of the literature]. / Erfolgreiche freie mikrovaskuläre A. radialis-Lappenplastik zur Phalluskonstruktion bei persistierender A. mediana (PMA).

BACKGROUND: Anomalies of the radial arterial system can be of importance during harvesting of a radial forearm flap. In particular when using the forearm flap for phalloplasty due to the required dimensions of the flap, sufficient arterial supply is of fundamental importance. In case of a persistent median artery perfusion conditions in the supply area of ​​the A. radialis and the A. ulnaris may have been altered or even completely regressed. METHODS: A retrospective evaluation of all phalloplasties performed in our institution was carried out from January 2016 to December 2018. In all patients technique according to Gottlieb and Levine or Chang was applied. RESULTS: In the retrospectively evaluated population of 48 patients, a persistent arteria mediana was found intraoperatively in two patients, corresponding to an incidence of 4.2 %. In both patients, the phalloplasty was accomplished without restriction of flap perfusion or hand perfusion. A review of the literature provides an overview of the incidence of aberrant vascularization of the forearm and the consequences that can be derived for the planning of a radial artery flap. CONCLUSION: Variations in the arterial anatomy of the forearm, as the presence of a persistent median artery, are sufficiently common to warrant careful preoperative evaluation when planning a free vascularized forearm flap for reconstructive surgery. The preoperative performed Allen-test provides no clear inference possibility and therefore often requires intraoperative random findings. The reconstructive surgeon should be aware of these possible variations because it can affect the harvest and the survival of the forearm flap as well as causing ischaemia of the hand.

Mastectomy in female-to-male transgender patients: A single-center 24-year retrospective analysis.

BACKGROUND: Mastectomy in male transgender patients is an important (and often the first) step toward physical manhood. At our department, mastectomies in transgender patients have been performed for several decades. METHODS: Recorded data were collected and analyzed for all male transgender patients undergoing mastectomy over a period of 24 years at our department. RESULTS: In total, 268 gender-reassigning mastectomies were performed. Several different mastectomy techniques (areolar incision, n=172; sub-mammary incision, n=96) were used according to patients' habitus and breast features. Corresponding to algorithms presented in the current literature, certain breast qualities were matched with a particular mastectomy technique. Overall, small breasts with marginal ptosis and good skin elasticity allowed small areolar incisions as a method of access for glandular removal. In contrast, large breasts and those with heavy ptosis or poor skin elasticity often required larger incisions for breast amputation. The secondary correction rate (38%) was high for gender reassignment mastectomy, as is also reflected by data in the current literature. Secondary correction frequently involved revision of chest wall recontouring, suggesting inadequate removal of the mammary tissue, as well as scar revision, which may reflect intense traction during wound healing (36%). Secondary corrections were performed more often after using small areolar incision techniques (48%) than after using large sub-mammary incisions (21%). CONCLUSIONS: Choosing the suitable mastectomy technique for each patient requires careful individual evaluation of breast features such as size, degree of ptosis, and skin elasticity in order to maximize patient satisfaction and minimize secondary revisions.

[Osseous Tuberculosis - interdisciplinary treatment from diagnostics to microsurgical defect reconstruction - Case report and review of the literature and proposal of a therapeutic algorithm]. / Knochentuberkulose ­ interdisziplinäre Therapie von der Diagnosestellung bis zur plastisch- chirurgischen Deckung.

Tuberculosis is a central global health problem with an incidence of 10 million new cases per year and more than one million deaths per year. Contrary to this, osseous tuberculosis represents an extremely rare entity of tuberculosis. Osseous tuberculosis is challenging beginning with the correct diagnosis, adequate surgical as well infectiological treatment as well as extremity reconstruction. Facing increased migration and therefore increasing numbers of cases of tuberculosis in western countries, the question of a reliable diagnosis, therapy and protective measures in dealing with those patients is becoming increasingly important for Central Europe.In the present case, a 49-year-old female patient from Pakistan, the first presented to our institution with a clinical picture of an exanthema at the level of the upper ankle joint with radiological signs of osteolysis. Pathological and molecular pathological diagnostics revealed the presence of an infection caused by Mycobacteria tuberculosis complex. In the initial phase over 6 weeks, a 4-fold therapy with isoniazid (INH), rifampicin (RMP), pyrazinamide (PZA) and ethambutol (EMB) was administered in accordance with the WHO guidelines, followed by 2-fold therapy with INH and RMP for 12 months in the subsequent continuity phase.14 months later, the patient was re-admitted to hospital because of a recurrent abscess. Therefore tuberculostatic therapy as a quadruple combination of INH, RMP, PZA and EMB was initiated for 6 weeks and as a double combination of INH and RMP for a total of one year.After the abscess had been eradicated, the joint was immobilized by ankle arthrodesis and the deep necrosis of the right ankle was finally reconstructed with allergenic bone grafts and a free microvascular M. gracilis flap.In the case presented here, successful treatment was possible via an interdisciplinary treatment consisiting of infectiology, orthopaedic surgery as well as plastic surgery specialists. Osseous tuberculosis could be eradicated and the bony defect could be reconstructed together with resulting soft tissue defect ultimately preserving of the extremity. In the context of this case study, a comprehensive overview of the current literature is described and a therapy algorithm is proposed due to the increasing relevance of this entity.

Safety of long-term subcutaneous free flap skin banking after skin-sparing mastectomy.

BACKGROUND: A persistent problem in autologous breast reconstruction in skin-sparing mastectomies is skin restoration after skin necrosis or secondary oncological resection. As a solution to facilitate reconstruction, skin banking of free-flap skin has been proposed in cases where the overlying skin envelope must be resected, as this technique spares the patient an additional donor site. Herein, we present the largest series to date in which this method was used. We investigated its safety and the possibility of skin banking for prolonged periods of time. METHODS: All skin-sparing mastectomies and immediate autologous breast reconstructions from December 2009 until June 2013 at our institution were analysed. RESULTS: We identified 31 patients who underwent 33 free flap reconstructions in which skin banking was performed. Our median skin banking period was 7 days, with a maximum duration of 171 days. In 22.5% of cases, the banked skin was used to reconstruct overlying skin defects, and in 9.6% of cases to reconstruct the nipple-areolar complex. Microbiological and histological investigations of the banked skin revealed neither clinical infections nor malignancies. CONCLUSIONS: In situ skin banking, even for prolonged periods of time, is a safe and cost-effective method to ensure that skin defects due to necrosis or secondary oncological resection can be easily reconstructed.

Role of bacterial biofilms in patients after reconstructive and aesthetic breast implant surgery.

INTRODUCTION: Capsular contracture is a feared complication following both reconstructive and aesthetic breast surgery. The etiology is uncertain, but bacterial biofilms have been suggested as trigger for chronic peri-implant inflammation, eventually leading to capsular contracture. METHODS: Data were extracted from patient records included in a prospective cohort between 2008 and 2010. We compared patients who underwent submuscular breast reconstruction using expander implants and those needing implant removal for capsular contracture after aesthetic submuscular breast augmentation. RESULTS: Of 36 included breast implants from 27 patients, 18 implants were inserted for reconstructive reasons and 18 for aesthetic reasons. The median indwelling time was 3 years for aesthetic implants and 3 months for reconstructive expanders. Overall, sonication cultures were positive in 13 implants (36%). In aesthetic implants, sonication cultures were positive in 28% and sonication cultures were positive in expander implants in 44%. Propionibacterium acnes and coagulasenegative staphylococci were predominant. CONCLUSION: Sonication cultures were positive in approximately 33% of removed breast implants and were comparable for reconstructive expander and aesthetic implants. These findings support the hypothesis that bacterial biofilms play a role in the pathogenesis of capsular contracture, especially after expander reconstruction, as these implants are at the highest risk of contamination during repeated implant-filling procedures.

Body taping for contour surgery.

BACKGROUND: Preoperative marking is of primary importance in body contouring and when precise simulation of skin excisions is difficult. Because the "cut as you go" principle can be delicate, especially in patients after massive weight loss, a simple and quick method is needed for preoperative planning. We suggest an approach that helps visualize the optimal skin incision lines and simulates the postoperative result by body taping. METHODS: Twelve patients who underwent abdominal contouring, including classic and vertical abdominoplasties as well as dog ear and scar revision, were prospectively analyzed. The skin to be excised was preoperatively folded, taped, and then marked. The area marked was measured and compared with the actual intraoperatively resected area and the postoperative result was evaluated after 1 year by the patients and three surgeons. RESULTS: With body taping, an 83% congruence between the preoperative planning and the surgery was obtained and only two patients had additional skin resected. No wound dehiscence and flap necrosis occurred and patients as well as surgeons scored the final body contour positively. CONCLUSION: Body taping is a simple, quick, and economic method for planning contour surgery with high accuracy as demonstrated by the low rate of intraoperative changes of the planned resection and low complication rate.