Direct Excision Research Articles

Eyebrow reconstruction by simple elliptical excision with beveled incision – A case series of twelve patients

Patients seeking reconstructive facial surgery desire aesthetically pleasing outcomes with minimal visible scarring. For scalp incisions, bevelled angle of 45° is typicallypreferred to preserve hair follicles. However, no consensus exists regarding the ideal incision angle for the brow area. This observational study analyzed the surgical outcomes of 12 patients with eyebrow defects treated using a simple elliptical excision with a bevelled incision, addressing various indications such as posttraumatic scars, post-burn scars, and tumors. Outcomes were evaluated using the Physician Global Esthetic Improvement Scale at 7 days and 3 months post-surgery. At 7 days, 50% of patients showed very good improvement, and the other 50%showed moderate improvement. By 3 months, 33% of patients exhibited exceptional improvement, 50% showed very good improvement, and 17% demonstrated moderate improvement. This study concludes that direct excision and approximation with an angled incision along the hair follicle direction provide favorable aesthetic results for eyebrow reconstruction.

Resolving conjunctival prolapse following severe blepharoptosis correction: A simple sutureless direct excision technique and systematic review

BackgroundConjunctival prolapse (CP) is an uncommon but challenging condition following maximal levator resection (MLR) and other extensive periorbital procedures. MLR extending beyond the Whitnall’s ligament is frequently performed to address severe blepharoptosis with poor levator function (LF). Patients with CP may encounter symptoms such as ocular discomfort, tearing, vision impairment, persistent conjunctival chemosis, lagophthalmos, or exposure keratopathy. Typically, surgical intervention becomes necessary if conservative measures prove to be ineffective; nevertheless, there is no consensus regarding the optimal treatment approach. ObjectivesThis study aimed to propose a simple sutureless direct excision method and explore the surgical advancements in CP correction through a systematic review. MethodsPatients with recurrent CP after MLR who underwent sutureless direct excision of the conjunctiva using loupe magnifiers at a tertiary hospital were included in this study. The clinical evolution and surgical results were recorded. PubMed, MEDLINE, EMBASE, and Web of Science databases were queried following The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol. ResultsThe comprehensive analysis of 1858 articles identified 88 patients from 24 studies, highlighting that blepharoptosis surgery is predominantly associated with CP (36.6%). Surgically treated CP showed a higher resolution rate compared to those managed conservatively (54.8% vs. 45.2%; p = 0.034). No relapse was observed in patients treated with sutureless direct excision of CP in long-term follow-up. ConclusionWe proposed a simple sutureless direct excision technique that offers a straightforward and efficient approach in treating CP, which is particularly suitable for cases requiring excision lengths >16 mm during MLR. Furthermore, stitch removal can be obviated after surgery.

Direct Subscarpal Lipectomy Combined With Liposuction in Abdominoplasty: An Analysis of Safety and Efficacy in 200 Consecutive Patients.

Abdominoplasty procedures continue to evolve because combining techniques such as suction-assisted lipectomy or direct subscarpal lipectomy have proven to be powerful adjuncts to achieve optimal aesthetic results. However, concern has been expressed about combining techniques simultaneously given the potential to damage the vascularity of the abdominoplasty flap. The aim of this study was to assess the safety and efficacy of simultaneous direct subscarpal lipectomy combined with liposuction in abdominoplasty patients. A 4-year retrospective review of consecutive abdominoplasties (n = 200) performed by a single surgeon was conducted. Liposuction of the abdominal flap and flanks was performed in all patients. After raising the abdominoplasty flap, undermining was performed to just beyond the xyphoid, the lower rib margins superiorly, and the anterior axillary line laterally. Fat deep to Scarpa's fascia was then removed by direct tangential excision in all zones of the abdominal flap. The patients had a mean age of 42.19 years and BMI of 28.10 kg/m2; the mean follow-up time was 7 months. Seroma occurred in 13 patients (6.5%), superficial wound dehiscence treated with local wound care in 16 patients (8%), hypertrophic scarring in 16 patients (8%), partial umbilical necrosis in 1 patient (0.5%), and partial umbilical epidermolysis in 6 patients (3%). No patients experienced major or minor full-thickness tissue loss. No patients needed reoperation. Simultaneous direct excision of subscarpal fat with liposuction of the abdomen and flanks does not appear to subject any zone of the abdominoplasty flap to increased risks of vascular compromise. No flap necroses were observed. The technique described is safe and may provide superior abdominoplasty results.

LITAF protects against pore-forming protein-induced cell death by promoting membrane repair.

Pore-forming toxins (PFTs) are the largest class of bacterial toxins and contribute to virulence by triggering host cell death. Vertebrates also express endogenous pore-forming proteins that induce cell death as part of host defense. To mitigate damage and promote survival, cells mobilize membrane repair mechanisms to neutralize and counteract pores, but how these pathways are activated is poorly understood. Here, we use a transposon-based gene activation screen to discover pathways that counteract the cytotoxicity of the archetypal PFT Staphylococcus aureus α-toxin. We identify the endolysosomal protein LITAF as a mediator of cellular resistance to PFT-induced cell death that is active against both bacterial toxins and the endogenous pore, gasdermin D, a terminal effector of pyroptosis. Activation of the ubiquitin ligase NEDD4 by potassium efflux mobilizes LITAF to recruit the endosomal sorting complexes required for transport (ESCRT) machinery to repair damaged membrane. Cells lacking LITAF, or carrying naturally occurring disease-associated mutations of LITAF, are highly susceptible to pore-induced death. Notably, LITAF-mediated repair occurs at endosomal membranes, resulting in expulsion of damaged membranes as exosomes, rather than through direct excision of pores from the surface plasma membrane. These results identify LITAF as a key effector that links sensing of cellular damage to repair.

Surgical Treatment of Vascular Anomalies in the Extremities: A Single Surgeon Experience

Objective: The literature on surgical management of vascular anomalies has primarily focused on the head and neck area, while studies of anomalies on the extremities have typically included larger and more dramatic clinical presentations. In this article, we aim to present our experience with surgical management of smaller symptomatic anomalies of the extremities. Methods: We performed a retrospective review of a single surgeon’s experience at a large academic center on patients from January 2013 to March 2022. We collected data on patient demographics, past medical and surgical history, operative dictations, clinic notes, and postoperative follow-up. Included patients were required to have confirmed vascular anomalies based on final pathology reports. Results: A total of 47 patients underwent a total of 50 procedures, with 2 patients experiencing recurrence requiring repeat operative management. Our cohort had average age (standard deviation) of 27.16 (18.67). Sixteen patients had prior history of vascular anomalies upon presentation to our institution. The majority of lesions were located in a digit of the hand, the arm, or the foot. On surgical excision, the average size (range) of the excised lesions was 3.54 cm (0.5–15.0 cm) by 2.22 cm (0.3–8.0 cm). Four required coverage with local flaps, 3 with full-thickness skin graft (FTSG) and 2 with microvascular free flap. The 2 most common pathologic diagnoses were arteriovenous malformation and hemangioma, each with 14 patients. Overall complication rate was 2%, with 1 patient experiencing wound dehiscence requiring FTSG. Follow-up ranged from 0.1 months to 46.9 months with an average of 3.86 months. Conclusions: In the appropriately selected patient, surgical excision of symptomatic vascular anomalies of the extremities can be successfully performed with a low complication rate. Most lesions can be appropriately treated with direct excision and direct closure, although some may require FTSG, local flap, or microvascular free flap.

Optimizing Outcomes in Lymphedema Reconstruction.

After studying this article, the participant should be able to: 1. Describe current surgical techniques for treating primary and secondary lymphedema. 2. Optimize the surgical care of patients with lymphedema. Over the past decade, significant advances have been made in the surgical treatment of lymphedema. The most notable changes have been the reintroduction and evolution of physiologic techniques, including lymphovenous bypass-sometimes referred to as lymphovenous anastomosis in the literature-and vascularized lymph node transplant. These surgical modalities are now often used as first-line surgical options or may be combined with nonphysiologic approaches, including direct excision and suction-assisted lipectomy. Surgeons continue to debate the most appropriate sequence and combination of surgical treatment, particularly for patients at both extremes of the severity spectrum. Furthermore, debate remains around the need to apply different treatment approaches for patients with upper versus lower extremity involvement and primary versus secondary cause. In this article, we provide a summary of the surgical techniques currently used for both primary and secondary lymphedema and provide our recommendations for optimizing the surgical care of patients with lymphedema.

Surgical management of breast fat necrosis: Multi-institutional data analysis of early outcomes and risk factors for complications

BackgroundBreast fat necrosis (BFN) is a non-cancerous condition affecting the adipose tissue. Despite incidence rates of up to 25% after breast surgery, little is known about risk factors and postoperative outcomes following the surgical treatment of BFN. MethodsThe National Surgical Quality Improvement Program of the American College of Surgeons (2008–2021) was queried to identify female patients diagnosed with and surgically treated for BFN. Outcomes of interest included 30-day surgical and medical complications, reoperation, and readmission. We performed confounder-adjusted multivariable analyses to determine risk factors. ResultsThe study population included 1179 female patients (mean age: 55.8 ± 13.8 years), of whom 96% (n = 1130) underwent direct excision and 4.2% (n = 49) received debridement of necrotic tissue. The majority of cases were operated on by general surgeons (n = 867; 74%) in the outpatient setting (n = 1107; 94%). Overall, 74 patients (6.3%) experienced postoperative adverse events, most of which were surgical complications (n = 43; 3.7%). Twenty-one (1.8%) women had to return to operating room, while readmission was reported in 18 (1.5%) cases. Adverse events were significantly more likely to occur in patients with chronic heart failure (p = 0.002) and higher wound classes (p = 0.033). ConclusionComplication rates following the surgical management of BFN were found to be relatively high and seen to correlate with the setting. We identified chronic heart failure and wound contamination as risk factors for complication occurrence. These evidence-based insights may sensitize surgeons to critically balance patients’ eligibility for BFN surgery and refine perioperative algorithms.

HIV-1 Remission: Accelerating the Path to Permanent HIV-1 Silencing.

Despite remarkable progress, a cure for HIV-1 infection remains elusive. Rebound competent latent and transcriptionally active reservoir cells persevere despite antiretroviral therapy and rekindle infection due to inefficient proviral silencing. We propose a novel "block-lock-stop" approach, entailing long term durable silencing of viral expression towards an irreversible transcriptionally inactive latent provirus to achieve long term antiretroviral free control of the virus. A graded transformation of remnant HIV-1 in PLWH from persistent into silent to permanently defective proviruses is proposed, emulating and accelerating the natural path that human endogenous retroviruses (HERVs) take over millions of years. This hypothesis was based on research into delineating the mechanisms of HIV-1 latency, lessons from latency reversing agents and advances of Tat inhibitors, as well as expertise in the biology of HERVs. Insights from elite controllers and the availability of advanced genome engineering technologies for the direct excision of remnant virus set the stage for a rapid path to an HIV-1 cure.

The Lymphatic System—A Surgeon’s Point of View

Lymphedema is a chronic and debilitating disease that affects up to 250 million patients worldwide. Recent advances in understanding its pathophysiology, along with improved diagnosis and microsurgical techniques, have enhanced our ability to cope with the challenging task of treating this disease. This review provides an overview of the disease from a surgeon’s point of view, including existing imaging modalities used for preoperative assessment, as well as surgical procedures used in its treatment. The advantages and drawbacks of various existing modalities used for the pre- or intraoperative assessment of lymphatic vessels are discussed. Lymphedema treatment has shifted from palliative debulking procedures (liposuction and direct excision) to those aimed at restoring lymphatic flow and countering the pathophysiology of the disease (lymphaticovenous anastomosis and vascularized lymph node transfer). A combination of both approaches can result in a synergistic benefit for patients and is discussed in this review. Despite recent advances, some controversies persist, and further studies are needed to better define surgical treatment algorithms.

Outcomes of Surgical Treatment of Malar Mounds and Festoons.

Malar mounds (congenital) and festoons (acquired) are persistent puffiness in the prezygomatic space between the orbicularis retaining ligament (ORL) and zygomatico-cutaneous ligament (ZCL). Non-surgical treatments often yield unsatisfactory results. This paper aims to demonstrate a surgical approach for the treatment of malar bags by outlining the author's surgical technique of treating malar mounds and festoons and reviewing outcomes in 89 cases. Correction of malar mounds and festoons was achieved with subciliary skin-muscle flap, release of the ORL and ZCL, midface lift, canthopexy, and muscle suspension. We performed a retrospective study of 89 patients, all of whom had surgical correction of malar mounds or festoons in the past 10 years and a follow-up period of at least 6 months. This study was conducted over the course of the past year and involved reviewing patient charts in the office. Specifically, patient data spanning 2012 to 2022 were analyzed. The predictor variable in this study is the specific class of malar bags the patient has, as determined by the underlying pathophysiology. Outcome variables include the presence or absence of prolonged lid or malar edema, necessary re-excision of excess orbicularis oculi of the subciliary area, lid malposition, permanent visual changes, the need for additional non-operative treatment, and recurrence requiring reoperation. The majority of patients presented with acquired festoons (81/89) with prior attempts of correction (49/89). The mean follow-up is 11.2 months. Persistent malar edema (> 6 weeks) was documented in 14 patients and mainly resolved with Medrol Dosepak (methylprednisolone) and hydrochlorothiazide. A two-proportion Z-test was conducted, comparing the proportion of patients with poor protoplasm who experienced postoperative malar edema to the proportion of those with excellent protoplasm who experienced postoperative malar edema. A p-value of 3.414e-7 was obtained, indicating a statistically significant difference of proportions between the two groups. Five patients received additional injections of deoxycholic acid and two needed fillers for smoother contour of the lower eyelids. Two patients with severe malar mounds required multiple reoperations including direct excision in one patient. One incidence of transient lid retraction was reported in a patient with previous facelift and facial nerve injury. Malar mounds and festoons present a unique challenge to plastic surgeons. They are persistent in nature and require close-interval, long-term follow-up as additional injections and reoperations are warranted. Our approach to malar mound and festoon correction is safe and effective and provides long-lasting results. 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 .

D37. Commercial Insurance Rates and Coding for Lymphedema Procedures: The Current State of Confusion and Need for Consensus

PURPOSE: Surgical treatment of lymphedema has outpaced coding paradigms. In the setting of ambiguity regarding coding for physiologic procedures [(lymphovenous bypass (LVB) and vascularized lymph node transplant (VLNT)], we hypothesized that there would be variation in commercial reimbursement based on coding pattern. METHODS: We performed a cross-sectional analysis of 2021 nationwide hospital pricing data for 21 Current Procedural Terminology (CPT) codes encompassing debulking (direct excision, liposuction), physiologic (LVB, VLNT), and ancillary (lymphangiography) procedures. Within-hospital ratios (WHRs) and across-hospital ratios (AHRs) for adjusted commercial rates per CPT code quantified price variation. Mixed effects linear regression modeled associations of commercial rate with public payer (Medicare and Medicaid), self-pay, and chargemaster rates. RESULTS: 270,254 commercial rates, including 95,774 rates for physiologic procedures, were extracted from 2,863 hospitals. Lymphangiography codes varied most in commercial price (WHR 1.76 - 3.89, AHR 8.12 - 44.38). For physiologic codes, WHRs ranged from 1.01 (VLNT; free omental flap) to 3.03 (LVB; unlisted lymphatic procedure), and AHRs ranged from 5.23 (LVB; lymphatic channel incision) to 10.36 (LVB; unlisted lymphatic procedure). Median adjusted commercial rates for debulking procedures ($3,635.84) were higher than for physiologic procedures ($2,560,40; p<0.001). Commercial rate positively correlated with Medicare rate for all physiologic codes combined, though regression coefficients varied by code. CONCLUSION: Commercial payer-negotiated rates for physiologic procedures were highly variable both within and across hospitals, reflective of variation in CPT codes. Physiologic procedures may be undervalued relative to debulking procedures. Consistent coding nomenclature should be developed for physiologic and ancillary procedures.

Commercial Insurance Rates and Coding for Lymphedema Procedures: The Current State of Confusion and Need for Consensus.

Surgical treatment of lymphedema has outpaced coding paradigms. In the setting of ambiguity regarding coding for physiologic procedures [lymphovenous bypass (LVB) and vascularized lymph node transplant (VLNT)], we hypothesized that there would be variation in commercial reimbursement based on coding pattern. The authors performed a cross-sectional analysis of 2021 nationwide hospital pricing data for 21 CPT codes encompassing excisional (direct excision, liposuction), physiologic (LVB, VLNT), and ancillary (lymphangiography) procedures. Within-hospital ratios (WHRs) and across-hospital ratios (AHRs) for adjusted commercial rates per CPT code quantified price variation. Mixed effects linear regression modeled associations of commercial rate with public payer (Medicare and Medicaid), self-pay, and chargemaster rates. A total of 270,254 commercial rates, including 95,774 rates for physiologic procedures, were extracted from 2863 hospitals. Lymphangiography codes varied most in commercial price (WHR, 1.76 to 3.89; AHR, 8.12 to 44.38). For physiologic codes, WHRs ranged from 1.01 (VLNT; free omental flap) to 3.03 (LVB; unlisted lymphatic procedure), and AHRs ranged from 5.23 (LVB; lymphatic channel incision) to 10.36 (LVB; unlisted lymphatic procedure). Median adjusted commercial rates for excisional procedures ($3635.84) were higher than for physiologic procedures ($2560.40; P < 0.001). Commercial rate positively correlated with Medicare rate for all physiologic codes combined, although regression coefficients varied by code. Commercial payer-negotiated rates for physiologic procedures were highly variable both within and across hospitals, reflective of variation in CPT codes. Physiologic procedures may be undervalued relative to excisional procedures. Consistent coding nomenclature should be developed for physiologic and ancillary procedures.

Aesthetic Surgical Pathway in Permanent Facial Filler Removal.

Although permanent fillers have been introduced in order to get long-lasting results, many studies have shown numerous severe and disfiguring complications. Nonsurgical procedures may mitigate those adverse events but the only way to remove the filler previously injected is represented by surgical excision. We present a pathway of facial surgical accesses to be performed achieving two goals: permanent filler removal and restore facial aesthetic balance. The proposed surgical accesses are already standardized in aesthetic surgical practice in order to avoid direct excision and unpleasant facial scar. A total of 231 patients underwent surgery for permanent filler removal and aesthetic restoration of the involved facial area, represented by forehead, glabella, nose, cheeks, eyelids, chin, jawline, and lips. Magnetic resonance evaluation was performed with the exception of lip patients who were evaluated with ultrasound. Postoperative follow-up was 12 months to 6 years. Subjective and objective methods were used for outcome evaluation according to the FACE-Q questionnaire. Functional and aesthetic correction was scored using the patient-graded Global Aesthetic Improvement Scale (GAIS), overall patient satisfaction was assessed by a five-point scale questionnaire. Functional and aesthetic restoration was globally recognized as improved according to the GAIS. Patients reported high levels of satisfaction assessed by a five-point scale questionnaire. A very good satisfaction level was registered in both subjective and objective judgment scores. To the best of our knowledge, we present the largest case series regarding surgical removal of permanent facial fillers. A proper preoperative evaluation, filler removal followed by restorative facial aesthetic surgery technique is paramount to approach challenging cases.

Flap Debulking and Secondary Revisions in Head and Neck Reconstruction: A Systematic Review with Clinical Applications.

Flap debulking and secondary revisions are an integral factor in providing optimum outcomes to reconstructive patients. This review article summarizes systematically the available literature on flap debulking in head and neck reconstruction. The clinical applications of debulking techniques are discussed, including fractional direct excision, liposuction, and single-stage excision or planning with skin grafting. New technologies are also discussed.

Aesthetic Refinements in Male Chest Lifting.

Abstract The authors describe aesthetic refinements to the approach for male chest lifting in male patients with grade 3 gynecomastia and/or significant chest skin excess. An inferior pedicle is used to transpose the nipple–areolar complex allowing preservation of pigment and sensation, liposuction and direct excision are used to reduce volume and excess skin, and the resulting curvilinear scar along the inferior and lateral border of the chest provide a more masculine appearance. Early experience with this technique has shown it to be safe and effective. Perioperative management and the detailed steps of the procedure are outlined. Level of Evidence: 5

Labiaplasty for Symptomatic Grade III-BCD1 Labia Minora

A 16-year-old girl presented with symptomatic symmetrically enlarged butterfly-shaped Grade III (4.1–6 cm, measured from the hymen to the distal edge (cranial/caudal)-BCD [1] (‘B’ – Cosmetic bother, ‘C’ –Clitoral hood involvement, ‘D’ –Dyspareunia due to labia minora or Discomfort with physical activity) labia minora of 4 years duration. She was a virgointacta, hence ‘D’ was Discomfort from physical activity. She had an uncomplicated surgical reduction direct excision labiaplasty1 10 years ago. At her six week review, her labiaminora had completely healed with very satisfactory results.

Extending the Indications for Direct Transcutaneous Lower Blepharoplasty With an Infraorbital Incision to Tear Trough Deformities, Suborbicularis Oculi Fat, Festoons, and Revision Blepharoplasty.

Introduction: Treatment of high-grade lower eyelid deformities with massive skin laxity and retroseptal fat pads can be challenging. Common techniques such as the transconjunctival approach and transcutaneous technique performed through a subciliary incision are associated with increased complication rates. Direct excision of the lower eyelid through an infraorbital incision is an alternative technique that allows safe treatment of dermatochalasis and pigmentation and correction of tear trough deformities, suborbicularis oculi fat, and festoons. This study aimed to determine whether direct transcutaneous blepharoplasty with an infraorbital incision could be indicated for these conditions instead of the established operative methods. Methods: A retrospective study of 21 patients with Fratila grades 9 or 10, Hirmand grade 3, and Barton grade 3 who underwent direct transcutaneous lower eyelid blepharoplasty via an infraorbital incision under local anesthesia was performed. All patients underwent surgery during a 9-year period from January 2010 to December 2018. The follow-up period was 12 months. Results were rated postoperatively using Barton grading. Results: Of 21 consecutive patients (13 women and 8 men), 18 required retroseptal fat pad removal, 3 had laxity of the skin and orbicularis muscle, and 5 had triangular cheek festoons. Combined lower and upper blepharoplasty was performed for 12 patients. All patients were satisfied with their surgical results and major improvements were observed. Scar quality was considered good by all patients. Conclusion: Direct transcutaneous lower blepharoplasty of the orbital rim can be indicated for different tear trough deformities, suborbicularis oculi fat laxity, and festoons.

Pediatric temporal intracerebral Langerhans cell histiocytosis: A case report

Langerhans cell histiocytosis (LCH) is a rare condition of unknown etiology characterized by infiltration of one or more organs by Langerhans-type dendritic cells, most often organized into granulomas. This entity was initially described in young adult children. We report an infant case of 4 years old boy with clinical particularities such as tinnitus, imbalance of movement coordination, and itching. The MRI revealed a temporal mass lesion. Surgical management was performed by direct excision. The tumor excision was subtotal with simple postoperative outcomes, and good clinical improvement at discharge. Then we address him to the pediatric oncology hospital center. We will present also the state of current knowledge concerning infant LCH and recent data to guide therapeutic management. LCH has an extremely polymorphic clinical presentation. Its management in children must be multidisciplinary between neurooncologists and pediatric neurosurgeons.

Corporal Excavation and Grafting for Inflatable Penile Prosthesis Implantation in Severe Corporal Fibrosis

ABSTRACT Introduction Inflatable Penile Prosthesis (IPP) insertion becomes substantially more difficult in men with severe corporal fibrosis due to the need for dilation through scar tissue and decreased diameter of the corporal bodies. In this setting, traditional strategies of dilation have increased risk of urethral and glanular perforation given obliteration of normal dilation planes. This is a rare, but significant surgical challenge whose body of evidence contains few studies with small cohorts. Objective To describe and analyze our institution's experience with complex IPP placement in patients with severe corporal fibrosis using corporal excavation and/or grafting. Methods We performed a retrospective review of all patients with severe corporal fibrosis who underwent IPP placement using a technique of corporal excavation and/or grafting between 01/2006—05/2021. Corporal excavation involved a penoscrotal incision extending the full length of penile shaft for complete exposure of the corpus spongiosum and direct excision of the entire central fibrotic core. Corporal grafting involved sewing grafts in areas of the corporal implant bed that remained severely narrowed after excavation to accommodate the IPP cylinder(s). Our two primary outcomes were (1) post-operative complications and (2) surgical success, which was defined as erections sufficient for intercourse in the absence of post-operative complication requiring re-operation. Results Ten cases meeting inclusion criteria were identified with 1 involving corporal excavation only, 4 involving grafting only, and 5 involving corporal excavation and grafting. In all cases, severe fibrosis was due to trauma (n=3), priapism requiring corporal shunting (n=3) or prior IPP infection and explant (n=4). All were implanted with an AMS-700 three-piece IPP and five patients required insertion of a reduced diameter IPP. Five out of 9 (55.6%) cases involving grafting used a Tutoplast pericardium allograft and 4/9 (44.4%) cases used a Gore-Tex synthetic graft. When graft was used, the median area used was 10.0 centimeters (IQR 4.5-11.8). Median operative duration was 315 minutes (IQR 243.75-370.5). Median post-operative hospital stay was 1 day. Post-operative complications included 2 (20%) cases of infection requiring antibiotics and 1 (10%) case of post-operative neuropathic pain/distal glans numbness. Median follow-up duration was 3.8 months (IQR 1.5-65.7) across all groups, with surgical success seen in 3/4 (75%) grafting cases, 1/1 (100%) excavation cases, and 5/5 (100%) simultaneous excavation and grafting cases. Failure was seen in one case due to penile shortening that required a penile lengthening procedure and IPP upsizing 10 months post-operatively. Conclusions IPP insertion in the setting of corporal fibrosis is complex. Downsized cylinders may be required due to contracture of the tunica albuginea. However, patients with corporal fibrosis may safely undergo IPP placement with good intermediate term outcomes using corporal excavation and/or grafting. Disclosure No

Breast Cancer-Related Lymphedema: A Review of Management and Innovative Surgical Techniques

Lymphedema is one of the most feared complications of breast cancer treatment. The objective of this article is to review the basic workup, staging, and diagnostic criteria for lymphedema and to discuss non-surgical and surgical treatments, with a focus on breast-cancer related lymphedema. Non-surgical treatment consists of intensive physical therapy including manual lymphatic drainage via massage, daily compression wraps, and exercises to prevent scarring and increase mobility. Surgical intervention is considered when non-surgical treatment is ineffective or more recently as a preventive measure. Surgical interventions, used once lymphedema has developed, include 1) lympho-venous bypass, which is the anastomosis of lymphatic vessels distal to the site of dermal backflow to neighboring venules to shunt lymphatic drainage away from the area of lymphatic injury; 2) vascularized lymph node transplant, in which lymph nodes are harvested from a donor site with their supporting artery and vein and transferred to the affected recipient site; and 3) debulking procedures including liposuction and direct excision. Preventive surgical interventions include 1) lymphatic microsurgical preventive healing approach, known as LYMPHA, which also utilizes lympho-venous anastomoses but at the time of lymph node dissection to anastomose lymphatic channels transected during lymph node dissection with adjacent veins to preserve lymphatic drainage of the arm; and 2) axillary reverse mapping, which involves tracer or dye injection within the ipsilateral arm before axillary surgery so that the breast surgeons are able to delineate nodal drainage and therefore attempt to spare nodes specific to arm tissue provided they are not the sentinel lymph node. Patient selection is critical for these procedures, and requires a multi-disciplinary approach.