Early Experiences With the Buttonhole Modification of the Double-Incision Technique for Gender-Affirming Mastectomies.

BACKGROUND: Little has been published about transmasculine and nonbinary gender-affirming mastectomies, particularly for patients with skin excess who desire reliable vascularity and sensation to the nipple-areolar complex. In this case series, we describe our experiences with the "buttonhole technique." METHODS: This was a retrospective case series of all consecutive patients who had a buttonhole mastectomy by a single surgeon. This technique maintains the nipple-areolar complex on a dermal pedicle rather than using a free nipple graft. RESULTS: Seventeen patients were included, with ages ranging from 21 to 49 years (median, 28 years). There were no major complications. Four patients had minor complications and/or required revision. CONCLUSIONS: The buttonhole technique should be considered for transmasculine and nonbinary patients with skin excess who are concerned about nipple vascularity and sensation.

Does Previous Breast Reduction Affect the Outcome of Gender-Affirming Subcutaneous Mastectomy?

INTRODUCTION: Despite the rising popularity of subcutaneous mastectomy (top surgery) in patients born female and identifying as male or nonbinary, there are limited studies on how prior breast surgeries affect subcutaneous mastectomy. This study evaluates if previous breast reduction affected subcutaneous mastectomy in this patient population. METHODS: The case series consists of 5 patients who, having had prior breast reductions, elected to have subcutaneous mastectomy. The data were collected retrospectively for mastectomy conducted from 2015 to 2016. Demographic data collected included age at surgery, body mass index, smoking status, medical comorbidity, and use of hormone medication. Outcome data included postoperative complications and need for operative revision. Postoperative follow-up was at 1 week and at 1, 3, 6, and 12 months. RESULTS: Patients' ages were between 29 and 46 years with body mass index from 24 to 33 kg/m. They underwent breast reduction approximately 9 to 26 months prior to subcutaneous mastectomy. All 5 patients successfully underwent subcutaneous mastectomy via double incision and free nipple grafts. Blood loss was estimated to be approximately 42 mL. All patients were discharged on the same day of surgery. The last follow-up averaged at 13 months after surgery and no major complication was reported. However, 1 patient required revision of the nipple graft and chest scars. CONCLUSIONS: This small case series suggests that subcutaneous mastectomy could be safely performed in transmasculine or nonbinary patients who had previous breast reduction.

Obese Women Experience Fewer Complications after Oncoplastic Breast Repair following Partial Mastectomy Than after Immediate Total Breast Reconstruction.

BACKGROUND: The authors hypothesized that obese patients would experience fewer complications after oncoplastic breast reconstruction following partial mastectomy than after immediate breast reconstruction following total mastectomy. METHODS: Complication rates were compared for oncoplastic breast reconstruction versus immediate breast reconstruction (with either implants or autologous tissue) in consecutive obese patients (body mass index ≥ 30 kg/m(2)) treated at a single center between January of 2005 and April of 2013. Logistic regression was used to analyze the associations between patient and surgical characteristics and postoperative outcomes. RESULTS: The study included 408 patients: 131 oncoplastic breast reconstruction and 277 immediate breast reconstruction patients. Presenting breast cancer stage was similar between the two groups. Oncoplastic breast reconstruction patients were older (55 years versus 53 years; p = 0.029), more obese (average body mass index, 37 kg/m(2) versus 35 kg/m(2); p < 0.001), and had more comorbidities. Nevertheless, the oncoplastic breast reconstruction group experienced fewer major complications requiring operative management (3.8 percent versus 28.5 percent; p < 0.001), fewer complications delaying adjuvant therapy (0.8 percent versus 14.4 percent; p < 0.001), and fewer incidences of hematoma/seroma formation (3.1 percent versus 11.6 percent; p < 0.004) than the immediate total breast reconstruction group. Univariate analysis found oncoplastic breast reconstruction to be an independent protector against major complications (OR, 0.1; p < 0.001) and complications that delayed adjuvant therapy (OR, 0.05; p = 0.002). CONCLUSION: Oncoplastic breast reconstruction likely represents a safer option than immediate total breast reconstruction following mastectomy for obese patients, particularly for patients who are superobese or present with preexisting medical comorbidities. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

The transition from pedicle transverse rectus abdominis myocutaneous to perforator flap: what is the cost of opportunity?

PURPOSE: This study evaluates how the transition from pedicled transverse rectus abdominis myocutaneous (pTRAM) to perforator flaps at an academic center has affected outcome and reimbursement. METHODS: In 2006, our practice transitioned to almost exclusively perforator flaps for breast reconstruction. This study retrospectively compares pTRAM flaps performed from 2002 to 2006 (group 1) with perforator flaps from 2006 to 2010 (group 2). Operative time, complications, and reimbursement were compared between the 2 groups. RESULTS: We performed 93 pTRAM flaps in 69 patients in group 1 and 102 perforator flaps in 69 patients in group 2. Operative time was shorter in group 1 for unilateral breast reconstruction (399 vs. 543 minutes, P = 0.0001), but no significant difference was noted for bilateral cases (547 vs. 658 minutes, P = 0.1). Fat necrosis requiring reoperation (23.7% vs. 5.9%, P = 0.0004) and partial flap necrosis (20.6% vs. 7.2%, P = 0.045) were more frequent in group 1. There was a higher frequency of abdominal hernia (8.8% vs. 1.6%, P = 0.2) but fewer hematomas (1.5% vs. 10%, P = 0.06) in group 1, although statistical significance was not reached between the 2 groups. Mean adjusted payment per case was $3658.67 for group 1 versus $5256.48 for group 2 (P = 0.004), whereas payment per minute was $9.25 for group 1 versus $9.13 for group 2 (P = 0.9). Perforator flaps appear to be as profitable as pTRAM flaps with lower morbidity. CONCLUSIONS: The transition from pTRAM to perforator flap can be done successfully with appropriate resources and support. The development of a perforator flap practice represents an opportunity cost in optimizing patient care and should be an option to patients seeking breast reconstruction.

Management of recurrent hernia after components separation: 10-year experience with abdominal wall reconstruction at an academic medical center.

PURPOSE: Separation of the components has become the standard of care for abdominal wall reconstruction, especially in the setting of infected, previously infected, or contaminated wounds. Although the safety and efficacy of this technique have been established, less is known about long-term outcomes. This article focuses on the management of recurrent hernia after components separation for abdominal wall reconstruction. METHODS: We performed a retrospective, institutional review board-approved study of components separation for abdominal wall reconstruction at an academic medical center, over a 10-year period. RESULTS: Between 2000 and 2009, we performed components separation in 136 patients (mean follow-up, 4.4 years). Twenty-six patients (19.1%) developed recurrent hernia (mean age, 49.8 years; body mass index, 30.7; previous abdominal operations, 3.5; hernia size, 342 cm; length of stay, 9.1 days). Mean time to recurrence was 319 days. Of the 16/26 patients who underwent repair of recurrence, 15 had successful repair, leaving 11/136 patients (8.1%) with persistent hernia. Of the 26 recurrences, 22 (85%) occurred within the first half of the study. Repair of recurrent hernias was accomplished by placement of additional mesh in 14/15 patients. CONCLUSIONS: Recurrent hernia after components separation may be related to procedural learning curves and can be successfully treated through repeat repair, yielding high rates of successful abdominal wall reconstruction.

Comparison of outcome after mesh-only repair, laparoscopic component separation, and open component separation.

Component separation (CS) has been advocated as the technique of choice to reconstruct complex abdominal hernia defects, especially in the setting of gross contamination. However, open CS was reported to have relatively high incidences of wound complications. Minimally invasive approaches to CS were proposed by several surgeons to reduce wound morbidity. To date, there are limited comparative data between minimally invasive CS (MICS) versus open CS. In this article, we reviewed existing literature on open CS versus MICS with respect to their recurrence and complication rates. Our analysis appeared to show that MICS has comparable recurrence and complication rates relative to open CS although our analysis had several limitations. To demonstrate the management of complications after MICS, we reported our experience of using MICS to repair a recurrent incisional hernia in a 63-year-old man after a perforated ulcer.