Nipple Necrosis Research Articles

Mastectomy Surgical Recommendations for Female-to-Male Transgender Patients, and a Discussion of Gender-Affirming Care for Gender-Dysphoric Adolescents

Introduction: Subcutaneous mastectomy (top surgery) in female-to-male patients is one of the most common procedures gender-dysphoric patients will undergo in order to live as their desired gender. Procedure: By consistently using the technique described in this article, surgeons can achieve consistent and aesthetically pleasing results. Complications are rare, but it is important to inform the patient that there may be issues related to bleeding, infection, wound healing, nipple necrosis (if using a graft), or dog ears. Discussion: Multiple states in the United States are seeking to ban this type of care and are even attempting to restrict health care for adults. These bans are being enacted despite carefully researched and written guidelines from major international organizations. By following these guidelines, physicians can provide safe and evidence-based care to adolescents. Conclusion: The evidence conclusively demonstrates that providing gender-affirming care to patients of all ages improves their mental health, reduces rates of depression, and decreases the risk of suicide.

Reduction Mammaplasty

Background While there is mounting evidence that closed suction drains are not necessary, there is a paucity of literature to demonstrate that drains are harmful after breast reduction. The purpose of this study was to investigate the effect of drains on postoperative seroma, hematoma, and infection, as well as elucidate any risk factors that may be implicated in the development of these complications. Methods A retrospective cohort study was conducted of all reduction mammaplasty procedures at our university medical center between 2010–2020. Pedicle type, skin incision, drain utilization, breast excision mass, sternal notch to nipple distance, and inframammary fold to nipple distance were analyzed with postoperative outcomes including hematoma, seroma, infection, dehiscence, nipple necrosis, and fat necrosis. Results This study included 944 female patients undergoing reduction mammaplasty. Median age was 39.0 years, median body mass index was 31.9 kg/m2, and median breast mass resected was 742 grams per side. Drain utilization did not significantly reduce postoperative hematoma (P = 0.196), seroma (P = 0.185), nipple necrosis (P = 0.511), or fat necrosis (P = 0.113), but drain utilization significantly increased postoperative surgical site infection (P = 0.011). Patients with breast mass removed over 1500 g had significantly higher risk of hematoma (P = 0.002), fat necrosis (P < 0.001), and nipple necrosis (P < 0.001) compared to patients with less than 1500 g removed. In patients with greater than 1500 g resected, drain utilization did not significantly decrease risk of hematoma (P = 0.086) or seroma (P = 0.497). Conclusions Breast reduction greater than 1500 g per side significantly increased risk of hematoma, nipple necrosis, and fat necrosis. Drain utilization did not demonstrate any advantageous effects, rather it increased risk of infection. Future multicenter study will be needed to confirm these findings across different patient referral networks and practice patterns.

Advancing Reduction Mammaplasty Surgery: Advancements and Outcomes with Tumescent Local Anaesthesia.

Tumescent local anaesthesia (TLA) is a method of anaesthesia used for surgical procedures that involves the infusion of a saline solution containing lidocaine, sodium bicarbonate, and epinephrine. This anaesthetic technique is designed to achieve both vasoconstriction and anaesthesia. In this article, we present a modified TLA protocol specifically adapted for reduction mammaplasty, based on an analysis of clinical case histories collected over the past few years. During the period from 2012 to 2022, we performed a reduction mammaplasty procedure in 120 patients employing tumescent local anaesthesia (TLA). The composition of the tumescent solution included 25mL of 2% lidocaine, 8mEq of sodium bicarbonate, and 1mL of epinephrine (1mg/1mL) in 1000mL of 0.9% saline solution. The solution was injected diffusely throughout the mammary gland. The average volume of tumescent solution infiltrated during TLA was 350mL per breast. There were no cases of adrenaline or lidocaine toxicity, and no patients required conversion to general anaesthesia. No patient received sedation. Patients reported no pain or discomfort during pre-operative infiltration or during surgery. No reinterventions were necessary because of short-term complications. Among the complications, there were 4 cases of hematoma (3,3%), 3 cases of seroma (2,55%), 10 cases of wound dehiscence (8,3%), 5 cases of asymmetry (4,1%), 9 cases of T-junction breakdown (7,5%), 2 cases of (partial) nipple necrosis (1,6%), and 3 cases of liponecrosis (2,5%). No cases of infection or total nipple-areola loss were reported. The follow-up period was between 30 days and 1year. Reduction mammaplasty is a viable surgical option for women with macromastia seeking to enhance their physiognomy. It is imperative that patients fully understand the potential benefits and risks associated with the procedure and consult with healthcare professionals specialising in this field. The use of tumescent local anaesthesia (TLA) has been confirmed as a safe and effective methodology to perform reduction mammaplasty, ensuring adequate pain control with minimal post-operative complications and resulting in a high degree of patient satisfaction. 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 .

Effective minimally invasive strategy for mixed-type gynecomastia using vacuum-assisted mastectomy and power-assisted liposuction

IntroductionMixed-type gynecomastia is a benign male breast condition characterized by the proliferation of glandular and adipose tissues. Conventional open surgery has been the main approach for treating gynecomastia. However, this method has been associated with complications, including breast deformity, noticeable scar, nipple necrosis, and hypoesthesia. In contrast, Vacuum-assisted biopsy systems and liposuction have demonstrated significant advantages in minimal invasive breast surgery. AimsOur study aimed to investigate the effectiveness of combining vacuum-assisted mastectomy with power assistant liposuction (VAM+PAL) for patients with mixed-type gynecomastia compared to conventional open surgery. MethodsSixty patients with mixed-type gynecomastia, treated between January 2019 and June 2023, were included in this study. VAM+PAL was performed on 30 patients (59 breasts), while open excision with peri-areola approach was performed on another 30 patients (59 breasts). The efficacy, complications, outcomes, scar cosmesis, and patient satisfactions were assessed. ResultsCompared to open excision for gynecomastia, the VAM+PAL group demonstrated a substantial reduction in incision size (4.47±1.21cm vs. 0.97±0.74cm, p<0.001) and lower scores of Vancouver scar scale (3.23±2.27 vs. 1.10±1.47, p<0.001). No drainage tubes were required for postoperative hematoma/seroma prevention. The patients in the VAM+PAL group had a significantly lower complication rate (18.64% vs. 3.39%, p=0.008), particularly in bruise and hypoesthesia. All VAM+PAL patients reported superior satisfaction with the outcomes in breasts and nipples. ConclusionThe combination of vacuum-assisted mastectomy and power assistant liposuction can be used as an efficient minimally invasive method to treat mixed-type gynecomastia with acceptable complications, superior scar cosmesis, and satisfying outcomes.

Minimal Access vs Conventional Nipple-Sparing Mastectomy

While nipple-sparing mastectomy (NSM) for breast cancer was only performed using the open method in the past, its frequency using endoscopic and robotic surgical instruments has been increasing rapidly. However, there are limited studies regarding postoperative complications and the benefits and drawbacks of minimal access NSM (M-NSM) compared with conventional NSM (C-NSM). To examine the differences in postoperative complications between C-NSM and M-NSM. This was a retrospective multicenter cohort study enrolling 1583 female patients aged 19 years and older with breast cancer who underwent NSM at 21 university hospitals in Korea between January 2018 and December 2020. Those with mastectomy without preserving the nipple-areolar complex (NAC), clinical or pathological malignancy in the NAC, inflammatory breast cancer, breast cancer infiltrating the chest wall or skin, metastatic breast cancer, or insufficient medical records were excluded. Data were analyzed from November 2021 to March 2024. M-NSM or C-NSM. Clinicopathological factors and postoperative complications within 3 months of surgery were assessed. Statistical analyses, including logistic regression, were used to identify the factors associated with complications. There were 1356 individuals (mean [SD] age, 45.47 [8.56] years) undergoing C-NSM and 227 (mean [SD] age, 45.41 [7.99] years) undergoing M-NSM (35 endoscopy assisted and 192 robot assisted). There was no significant difference between the 2 groups regarding short- and long-term postoperative complications (<30 days: C-NSM, 465 of 1356 [34.29%] vs M-NSM, 73 of 227 [32.16%]; P = .53; <90 days: C-NSM, 525 of 1356 [38.72%] vs M-NSM, 73 of 227 [32.16%]; P = .06). Nipple-areolar complex necrosis was more common in the long term after C-NSM than M-NSM (C-NSM, 91 of 1356 [6.71%] vs M-NSM, 5 of 227 [2.20%]; P = .04). Wound infection occurred more frequently after M-NSM (C-NSM, 58 of 1356 [4.28%] vs M-NSM, 18 of 227 [7.93%]; P = .03). Postoperative seroma occurred more frequently after C-NSM (C-NSM, 193 of 1356 [14.23%] vs M-NSM, 21 of 227 [9.25%]; P = .04). Mild or severe breast ptosis was a significant risk factor for nipple or areolar necrosis (odds ratio [OR], 4.75; 95% CI, 1.66-13.60; P = .004 and OR, 8.78; 95% CI, 1.88-41.02; P = .006, respectively). Conversely, use of a midaxillary, anterior axillary, or axillary incision was associated with a lower risk of necrosis (OR for other incisions, 32.72; 95% CI, 2.11-508.36; P = .01). Necrosis occurred significantly less often in direct-to-implant breast reconstruction compared to other breast reconstructions (OR, 2.85; 95% CI, 1.11-7.34; P = .03). The similar complication rates between C-NSM and M-NSM demonstrates that both methods were equally safe, allowing the choice to be guided by patient preferences and specific needs.

To acellular dermal matrix or not to acellular dermal matrix?-outcomes of pre-pectoral prosthetic reconstruction after nipple-sparing mastectomy with and without acellular dermal matrix.

Acellular dermal matrix (ADM) has been the go-to biomaterial in post-mastectomy breast reconstruction, particularly in pre-pectoral reconstruction. ADM is thought to decrease capsular contracture, control the pocket, and increase soft tissue, but may yield more complications. This study evaluated whether ADM is even needed. All patients undergoing immediate breast reconstruction with pre-pectoral tissue expander (TE) or direct-to-implant (DTI) after nipple-sparing mastectomy (NSM) by the senior author between April 2013 and January 2021, were included in this study. Cohorts were stratified into breasts with ADM or no-ADM. Complications within 30 days post-operatively were analyzed. A total of 115 pre-pectoral reconstructions were performed in 66 patients. ADM was applied to 75 breasts. TEs were used in 80 breasts and DTI in 35 breasts. Controlling for implant type, breasts with ADM exhibited more nipple necrosis (28.0% vs. 10.0%, P=0.02). Controlling for ADM status, DTI compared to TE was associated with less necrosis of the nipple (11.4% vs. 26.3%, P=0.04), implant loss (5.7% vs. 38.8%, P=0.004), and surgery for any complication (14.3% vs. 27.5%, P=0.04). Outcomes of prosthetic reconstructions with ADM and no-ADM were similar. DTI reconstruction was associated with less complications, which was likely due to intraoperative bias and placement of TEs more often in breasts with perceived poorer vascularity.

Postoperative outcomes of minimally invasive versus conventional nipple-sparing mastectomy with prosthesis breast reconstruction in breast cancer: a meta-analysis.

Breast cancer is the most common malignant tumor worldwide, and mastectomy remains the primary strategy for treating early stage breast cancer. However, the complication rates, surgical variables, and oncologic safety of minimally invasive nipple-sparing mastectomy (MINSM) have not been fully addressed. We systematically searched PubMed, Web of Science, Embase, and the Cochrane Library for randomized-controlled trials (RCTs) and non-RCTs that compared MINSM with conventional nipple-sparing mastectomy (CNSM), both followed by Prosthesis Breast Reconstruction (PBR). The main outcomes observed included overall complications, (Grade III) complications, skin and nipple necrosis, wound dehiscence, infection, seroma, hematoma, implant loss, and oncologic safety (positive margins and recurrence). Secondary outcomes included operation time, blood loss, hospital stay, cost-effectiveness, and patient satisfaction. Binary and continuous variables were compared using odds ratios (OR) and mean differences (MD) with 95% confidence intervals (CI). A total of 10 studies involving 2,166 patients were included. There were no statistically significant differences between MINSM and CNSM in terms of skin necrosis, wound dehiscence, infection, seroma, hematoma, implant loss, or oncologic safety. However, MINSM significantly reduced overall complications (OR = 0. 74, 95% CI [0. 58, 0. 94], p = 0. 01) and (Grade III) complications (OR = 0. 47, 95% CI [0. 31, 0. 71], p = 0. 0003). Nipple necrosis events were also significantly reduced in the MINSM group (OR = 0. 49, 95% CI [0. 30, 0. 80], p = 0. 005). Patient satisfaction improved notably in the MINSM group. Additionally, compared with the CNSM group, the MINSM group had longer operating times (MD = 46. 88, 95% CI [19. 55, 74. 21], p = 0. 0008) and hospital stays (MD = 1. 39, 95% CI [0. 65, 2. 12], p < 0. 001), while intraoperative blood loss was significantly reduced (MD = -29. 05, 95% CI [-36. 20, -21. 90], p < 0. 001). Compared with CNSM, MINSM offers advantages in reducing complications and intraoperative blood loss, as well as improving aesthetic outcomes and patient satisfaction. Therefore, MINSM may become a viable option for breast surgery. Nevertheless, a long-term evaluation of the oncologic safety of this approach is necessary to ensure its efficacy and safety for patients.

Surgical Management of Postoperative Nipple Necrosis After Inverted Nipple Correction: Experiences From a Series of 25 Cases.

The inverted nipple is a condition that affects approximately 10% of women and can have negative cosmetic and psychological implications. Surgical correction is a common approach to address this concern; however, this method can lead to complications, such as nipple necrosis. As comprehensive guidelines are currently lacking for postoperative nipple necrosis management, this study reports our experience in the management of postoperative nipple necrosis following initial attempt at surgical management. A retrospective chart review was conducted and included female patients who experienced postoperative nipple necrosis after inverted nipple correction between 2018 and 2021. Cases of recurrent nipple retraction following partial necrosis and cases of complete nipple necrosis were evaluated. Recurrent nipple retraction was managed using various inverted nipple correction techniques, while complete necrosis required a modified C-V flap for nipple reconstruction. A total of 25 patients with a total of 42 affected nipples were included. Thirteen cases (26 nipples) experienced recurrent nipple retraction following partial necrosis, while 12 cases (16 nipples) exhibited complete necrosis. No significant predictive variables for these complications were found. Notably, all patients achieved successful healing following single-stage surgical repair. At 6 months postoperation, the treated nipples exhibited satisfactory healing and appearance and an absence of infection or papillary necrosis. Seven reconstructed nipples showed a mean loss of projection (2.7 ± 0.98) compared with only 2 nipples in the inverted nipple correction group. Distinguishing between recurrent nipple retraction after partial necrosis and complete nipple necrosis is crucial and should be taken into consideration when managing patients following inverted nipple correction.

Tailor-Made Mastopexy Plus Implant, A Safe Journey Toward Breast Reshaping and Augmentation.

Augmentation/mastopexy represents one of the most complex procedures in the setting of cosmetic surgery, and there is still an ongoing debate about the most suitable approach to undertake to avoid major complications and deliver the desired result. The present study aims to offer a further contribute to the topic by presenting our personal experience with an implant-guided tailor-made mastopexy technique to manage moderate breast ptosis and hypotrophy. A retrospective analysis of our database was carried out, and a total of 194 women who underwent a tailor-made resection pattern mastopexy plus implant from November 2016 to December 2021 were enrolled. All patients included in the study presented breast hypoplasia and ptosis classified as Regnault grade II. At the first-year follow-up visit, patients received an anonymous written questionnaire that addressed their self-perception of cosmetic results and overall satisfaction. The technique presented in the study showed a favorable safety profile with a total complication rate accounting for an 8.2% and an overall reoperation rate as low as 4.6%. Major concerns including wound dehiscence, implant exposure, and nipple necrosis are not reported. Patients' self-reported outcomes revealed high satisfaction rates and stable results in the long-term follow-up. The described approach ensures proper reshaping together with the desired increased breast volume minimizing the chance of implant exposure due to wound dehiscence or any sort of tissue necrosis from devascularized skin edges. The surgical procedure described herein is safe and reliable. 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 .

Abstract PO5-22-11: Radiotherapy-associated Complications in Breast Cancer patients treated with Nipple-Sparing Mastectomy: Results of the Reconstruction-after-Mastectomy AGO R02 Registry

Abstract Nipple-Sparing mastectomy (NSM) followed by implant-based breast reconstruction is an oncologically safe procedure increasingly used in patients with breast cancer. A proportion of patients treated with NSM will be receiving adjuvant radiotherapy according to contributing factors indicating radiotherapy use. Methods Data from six breast centers in Austria were entered in the AGO R02 Registry from women who underwent breast reconstruction after mastectomy between 2012 and 2022 to evaluate complications associated with surgical techniques and selection of patients. Univariate analysis was used to identify factors that may impact surgical outcome. Results The registry included a total of 744 female patients. Of 913 NSMs, 730 NSMs were followed by implant-based reconstruction. Adjuvant radiotherapy was administered in 132/730 patients (18%). In this group minor complications (infection, hematoma) were observed in 6 patients (4.5%) and major complications requiring additional surgery (wound breakdown, skin and/or nipple necrosis) were observed in 16 patients (12.1%) in a short term follow up of 4 months (mean). In the group of patients without adjuvant radiotherapy minor complications (infection, hematoma) were observed in 33 patients (4.5%) and major complications (wound breakdown, skin and/or nipple necrosis) were observed in 75 patients (10.3%). In both groups no statistically significant association was observed between complications and age, body mass index, diabetes, preoperative chemotherapy, implant position (pre/subpectoral), use of mesh. Smoking and chemotherapy were the only factors associated with higher proportion of minor complications in patients not receiving radiotherapy. Conclusions Women treated with adjuvant radiotherapy after NSM followed by implant-based reconstruction have a higher incidence of major complications requiring additional surgery in comparison with women treated without radiotherapy in a short term follow up. Considering new radiotherapy techniques/volumes and early multidisciplinary planning may optimize multimodal treatment in these patients. Supported by AGO Österreich Citation Format: Florentia Peintinger, Elisa Sieghartsleitner, Bernhard Pfeifer, Gunda Pristauz-Telsnigg, Georg Tsangarakis, Rüdiger Hochstätter, Rupert Koller, Ursula Denison, Christopher Hager, Roland Reitsamer. Radiotherapy-associated Complications in Breast Cancer patients treated with Nipple-Sparing Mastectomy: Results of the Reconstruction-after-Mastectomy AGO R02 Registry [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO5-22-11.

Abstract PO4-22-11: Study to Compare the Safety of Immediate One-stage IBBR With Expander-Implant Two-stage IBBR Augmented With TiLoop® Bra(COSTA)

Abstract Background: The use of TiLOOP@ Bra in implant-based breast reconstruction (IBBR) becomes standard of care in mainland China. But evidence is limited about complication of one-stage and two-stage IBBR using TiLOOP@ Bra. A prospective randomized trial was conducted to compare the safety of immediate IBBR with that of immediate-delayed IBBR, both with TiLOOP@ Bra. Methods: We did an open label, randomized, controlled trial in eleven hospitals in the mainland China. Inclusion criteria: Women aged above 18 with cT0-T2N0M0 breast carcinoma which requires to undergo nipple or skin-sparing mastectomy (NSM or SSM) and immediate IBBR. Randomization was done electronically, stratified per center and in blocks of four of six to achieve approximately balanced groups of patients assigned to undergo one-stage or two-stage IBBR. Both procedures were undergone pectoralis major and TiLOOP@ Bra to build pockets. The primary endpoint of the present study was the incidence of postoperative complications (within 90 days after surgery), while the secondary endpoints were the quality of life at 18 months after surgery, satisfaction with breast appearance, aesthetic scores of reconstructed breasts, type of reoperation and TiLOOP@ Bra angiopathological assessment. This study is registered at clinicaltrials.gov, number NCT03589924. Findings: Between June 2018 and May 2022, a total of 418 eligible patients were randomly assigned to either two-stage implant reconstruction (n=194) group or immediate one-stage implant reconstruction (n=224) group. In terms of surgical procedures, NSM was more commonly (72.7%) chosen, with the two-stage implant reconstruction group having a lower proportion compared to the immediate one-stage implant reconstruction (66.3% vs. 78.3%; p=0.010). At 3 months after breast reconstruction surgery, the incidence of complications was lower in the two-stage implant reconstruction group than that in the immediate one-stage implant reconstruction group, with significant difference of 14.5% vs 23%; p=0.038. The incidence of nipple or areola necrosis was lower in the two-stage implant reconstruction group compared to the immediate one-stage implant reconstruction group, with statistically significant difference of 9.8% vs 17.1%; p=0.048. The implant loss rate was only 0.7%. It was discovered that the incidence of severe complications was lower in the two-stage implant reconstruction group than in the immediate one-stage implant reconstruction group (2.6% vs. 3.7%), and the difference was not statistically significant. Patients who experienced complications had a higher proportion of chemotherapy (69.2% vs. 38.9%; p&amp;lt; 0.001), endocrine therapy (74.4% vs. 53.9%; p=0.002), and targeted therapy (24.4% vs. 9.6%; p=0.001), and the differences were statistically significant. In terms of surgical procedures, 67 (85.9%) patients who experienced complications underwent NSM, while the proportion of NSM in patients who did not experience complications was lower at 69.6%, which were 231 patients, and the difference was statistically significant (p=0.011). In addition, the complication incidence of patients who received implants sizes of 300-400ml was higher than that of the group that did not (32.1% vs. 17.8%; p=0.012). Conclusion: Both one-stage and two-stage TiLOOP@-assisted IBBR demonstrated perioperative safety. The complication rate within three month of two-stage is lower than one-stage. The implant loss rate was only 0.7% perioperatively. Our results suggest that use of TiLOOP@ Bra be considered carefully for one-stage NSM with IBBR but can be considered for SSM patients. Citation Format: Benlong Yang, Jian Liu, Haibo Wang, Yiding Chen, Cuizhi Geng, Nanyan Rao, Siyuan Han, Antai Zhang, Jinping Shi, Qiang Zhang, Wenhe Zhao, Jiong Wu. Study to Compare the Safety of Immediate One-stage IBBR With Expander-Implant Two-stage IBBR Augmented With TiLoop® Bra(COSTA) [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO4-22-11.

Marijuana Use in Aesthetic Surgery Patients: A Retrospective Review of 441 Cases

Abstract Goals/Purpose Marijuana use is increasing in Canada following its legalization in 2018. 27% of Canadians were reported to have consumed marijuana in 2022. Marijuana use in surgical patients is a topic that has had exponential growth in the literature recently. The drug has many therapeutic effects such as analgesia, muscle relaxation, sedation and mood improvement. However, it is also associated with deleterious cardiovascular, respiratory and coagulopathic effects that can significantly impact the care of surgical patients in the peri-operative period. Literature from other surgical specialities has shown similar recovery and ultimate surgical outcome between marijuana users and non-marijuana users despite increased pain and poorer quality of life associated with marijuana use. There is a paucity of information about the effects of marijuana on aesthetic plastic surgery outcomes. The prevalence of marijuana use in aesthetic plastic surgery patients is currently unknown and there is a need for more evidence to develop clinical practice guidelines regarding the use of marijuana in the perioperative period. The purpose of this study is to describe the effects of marijuana consumption on aesthetic plastic surgery outcomes. Methods/Technique A single-center retrospective review was completed including all patients who underwent abdominoplasty, mastopexy and/or other body contouring surgery (such as brachioplasty, thigh lift or lower body lift) between January 2021 and August 2023. Other procedures such as liposuction, fat grafting, implant insertion or removal were also reviewed if they took place during the same general anesthetic. Marijuana use was defined as use within 4 weeks pre- and/or post-operatively. Data collection included patient demographics, body mass index (BMI), marijuana use, smoking status, comorbidities, surgical procedure(s) performed, operative time, resection weight and/or liposuction volume (if applicable), complications and follow up. Results/Complications A total of 1000 procedures in 441 patients were reviewed during the 32-month study period. Average patient age was 43 years old and average patient BMI was 27.3 kg/m2. 20.4% of patients were marijuana users. The average number of procedures completed per patient was 2.3 and average operative time was 167 minutes (2 hours and 47 minutes). 79% of cases involved more than one surgical procedure. 63% of the 441 cases involved an abdominoplasty, 49% involved a mastopexy, 5% involved a brachioplasty and 4% involved a thigh lift procedure. 33% of cases included breast implants and 47% liposuction. Average follow up time was 5.2 months. Overall surgical complications consisted of a 5% superficial infection rate, 1% deep infection rate, 9% seroma rate, 1% hematoma and lymphocele rates, 3% rate of wound dehiscence requiring surgical intervention and 11% rate of superficial delayed wound healing. There were no cases of nipple necrosis or full thickness skin necrosis. A comparison of patient demographics between marijuana and non-marijuana user groups revealed that marijuana users were significantly younger than non-marijuana users (average age 39 and 44 years old respectively). Surgical data, outcomes and complications were not found to be significantly different between the 2 groups for all variables. Conclusion Marijuana consumption in the perioperative period does not appear to affect aesthetic surgery outcomes such as post-operative infections, seroma, lymphocele, wound dehiscence, or fat necrosis based on the results of this study. There is a need for prospective work on this topic to produce better quality evidence and ultimately to create evidence-based guidelines on the perioperative use of marijuana for aesthetic surgery patients.

Predicting Nipple Necrosis with a "Lights-on" Indocyanine Green Imaging System: A Report of Two Patients.

Nipple-areolar complex (NAC) necrosis is a devastating complication in nipple-sparing mastectomies (NSMs) that significantly impacts patient's quality of life. The use of fluorescence angiography for intraoperative assessment of mastectomy skin flap perfusion in NSM has been successfully described and can be utilized to help guide surgical decision-making. Recently, a novel fluorescence-guided surgical imager was developed, OnLume Avata System (OnLume Surgical, Madison, WI), which provides intraoperative evaluation of vascular perfusion in ambient light. In this case report, we describe the use of OnLume fluorescence-guided surgery technology to help aid in clinical decision-making for two breast reconstruction cases with concern for intraoperative nipple hypoperfusion.

Techniques in Nipple Areolar Reconstruction: A Retrospective Analysis of Surgical Interventions and Patient-reported Satisfaction Scores.

Nipple areolar complex (NAC) reconstruction often signifies completion of the breast reconstruction process for some patients and has been shown to improve both psychosocial and sexual well-being. Several techniques have been described; however, there currently exists little evidence in the literature describing outcomes or patient satisfaction. A retrospective analysis of NAC reconstructions over the last decade was queried for patient demographics, operative technique, and postoperative outcomes. A standardized, validated survey was also utilized to evaluate overall satisfaction, with a focus on aesthetic outcome, shape, color, and projection. Eighty-three patients were identified, with 49 (59.0%) completing the survey. The modalities used for reconstruction include the C-V flap (45.7%), the modified skate flap technique (42.2%), and free nipple grafting (FNG, 12.0%). No significant differences in age, BMI, or comorbidities were found among the three types. The most utilized donor site for skate flap reconstruction was the suprapubic area (37.1%). There were also no significant differences in complication rate (C-V 10.5%, FNG 10%, skate 5.7%, P = 0.630) or revision surgery (C-V 2.6%, FNG 0%, skate 5.7%, P = 0.732). The most common complication was nipple necrosis. Adjusting for time to follow-up using multivariate analysis, there was a significant difference in overall patient satisfaction when compared across all three techniques, with the modified skate flap having the highest mean overall satisfaction scores. NAC reconstruction can be completed safely and effectively with a variety of techniques. The modified skate flap technique was associated with high levels of patient satisfaction and a low complication rate.

Immediate prepectoral breast reconstruction in nipple-sparing mastectomy with Wise-pattern incision in large and ptotic breasts: Our experience and short-term results

IntroductionCurrent trends in treatment of breast cancer advocate nipple-sparing mastectomy (NSM) as the technique of choice in selected patients. A large and ptotic breast is often considered a relative contraindication for NSM, due to the increased risk of skin and nipple necrosis. MethodsA retrospective review was performed for patients who underwent immediate prepectoral breast reconstruction (PPBR) after NSM with Wise-pattern incision between February 2020 and February 2023 at our institution. This procedure was offered to patients with grade II or III ptosis or large breasts who were candidates to NSM for therapeutic or prophylactic purpose. Exclusion criteria were: a preoperative nipple-sternal notch distance greater than 30cm, previous radiotherapy, pinch test < 1cm, BMI greater than 34 and active smoke. We present our short-term results with this technique. ResultsDuring the considered period, 62 patients (76 breasts) had NSM with Wise-pattern incision. Patients had immediate PPBR with implant or tissue expander, both entirely wrapped with ADM. The median age of the patients was 57.0 years (IQR 50.0-68.6) with a median BMI of 25.5 (IQR 23.3-28.4). The median mastectomy specimen weight was 472g (341-578). Median implant volume was 465g (IQR 370-515). Major complications occurred in 8 patients (10.5%). Three patients had total NAC necrosis (3.9%), partial NAC necrosis occurred in 2 patients (2.6%). Two patients developed implant infection (2.6%). Univariate analysis showed a statistically significant correlation between major complications and the mastectomy specimen weight (p 0.003). ConclusionsIf oncologically indicated, NSM with Wise-pattern incision and immediate PPBR can safely be performed in selected patients with large and ptotic breasts.

Temporary external skin plication: a helpful new technique in gynecomastia surgery.

The aim of this study was to elucidate the external temporary skin plication (ETSP) technique in gynecomastia surgery and evaluate its role in mitigating complications and enhancing cosmetic outcomes. This study was conducted on patients diagnosed with gynecomastia, explicitly falling under Rohrich Grades IIB and III, with dermal quality being a crucial determinant. Between September 2018 and November 2021, surgical interventions were performed on 96 qualifying patients by the senior author. The operative protocol consisted of ultrasonic and suction-assisted liposuction, supplemented by lateral periareolar piecemeal gland excision. Within the cohort, 42 patients were subjected to the novel ETSP technique. In contrast, the remaining 54 patients underwent standard treatment, serving as the control group for subsequent comparative assessment. One patient required revisions for contour irregularities, while partial nipple necrosis was observed in two patients but healed without surgical intervention. However, saucer-like deformity and total nipple necrosis were not observed in our series. The overall complication rate in our series was 19%, with 9.5% of cases requiring revision. In our control group, the overall complication rate in our series was found to be 22%, with 13% of cases requiring revision. ETSP provides a homogeneous spread of the excess skin and greatly reduces or eliminates the amount of skin fold formation. ETSP reduces the need for possible skin excision and reduces visible scars and incisions, and it helps improve the results of skin-protective surgeries that are widespread today.

Usefulness of cordless ultrasonic cutting energy devices in endoscopic nipple-sparing mastectomy: a retrospective study.

Endoscopic nipple-sparing mastectomy (E-NSM) is a minimally invasive surgical technique that shows good results in patients with breast cancer. The authors compared 3 different types of commercial energy devices to examine their efficacy and safety in E-NSM performed with breast reconstruction. A total of 36 cases of E-NSM were conducted with either Sonicision (S group, n = 11), Harmonic (H group, n = 6), or Thunderbeat (T group, n = 19). The clinicopathologic factors and postoperative complications, including nipple or skin necrosis and surgical site seroma volume, were evaluated for 3 months after surgery. The surgical duration of E-NSM was significantly shorter in the S group than in the H group (P = 0.043) and T group (P = 0.037). However, the total surgical duration including E-NSM and breast reconstruction, and the total and daily drainage volume of postoperative seroma did not differ significantly among the 3 groups. Even when the energy devices were compared according to their working principle, i.e., ultrasonic (S and H) vs. hybrid (T), the total breast surgery duration and total and daily drainage volume of seroma showed no difference between the 2 groups. Although surgeon satisfaction did not significantly differ when using 3 devices for E-NSM (P = 0.428), surgeon's fatigue was found to be lowest in the S group, though it was not significant (P = 0.064). Any energy device can be safely used for E-NSM with breast reconstruction without causing any major complications. However, cordless ultrasonic energy devices allow greater mobility for the surgeon and, therefore, may shorten surgical time in breast surgery.

Intranipple injection with methylene blue for tracing axillary sentinel lymph nodes in rats: A preliminary feasibility study

Background and purpose: Investigate the feasibility of intranipple injection (INN) of methylene blue dye (MB) for tracing the axillary sentinel lymph node (SLN) in rats, to provide different injection methods for finding SLN injection tracers and offer an experimental basis for specific localization of SLN. Methods: Eleven Sprague-Dawley female rats with body masses of 150-400g. Ten rats were randomly selected to use the third pair of mammary glands as the tracer injection site, and the left side was injected with MB (0.05 mL, 1% concentration) by intracutaneous injection of areola (IAA), while the right side was injected with MB(0.05 mL, 1% concentration) by INN. After 5 minutes, the rats were dislocated and dissected, and the blue-stained SLNs were found and recorded, The effectiveness evaluation was based on the number and rate of detection of SLNs as indicators, and the differences between the indicators of the two injection methods of IAA and INN were compared and analyzed. The safety evaluation was based on whether the nipple showed blood flow disorders and necrosis after MB injection by INN in the remaining 1 rat as the criteria. The data were stored and analyzed using Microsoft Excel and SPSS 25.0 statistical software. Νon-normally distributed measurement data were expressed as M (Q1, Q3) and compared by rank sum test, and count data were expressed as cases or percentages and compared by 2 test. p &lt; 0.05 was considered a statistically significant difference. Results: (i)100% (10/10) detection rate of SLNs by applying MB to both INN and IAA modalities;(ii) median number of SLNs detection was 2.0 (1.0,2.0) vs. 1.5 (1.0,2.0) for INN and IAA, respectively (P=0.66), and the difference was not statistically significant;(iii) No nipple necrosis was observed for 4 consecutive days after INN with MB. Conclusion: Tracer detection of SLNs by INN injection in rats is feasible, and the detection rate of SLNs by INN is the same as that of IAA; there is no significant difference in the median number of detected SLNs between the two injection methods. No nipple necrosis was observed after INN with MB.

Sun-Cross Running Suture Combined with Transverse to Longitudinal Skin Closure to Correct Severe Inverted Nipple.

Inverted nipple deformity presents an unsatisfactory appearance that may induce an unpleasant sex life, but can also be associated with psychological discomfort and increased the functional problems, such as local irritation and inflammation. Multiple techniques have been used to correct inverted nipples, but they mostly lead to different problems such as deficiency of the nerve or duct, recurrence of the inverted nipple, and hypopigmented scars in the areola. To minimize complications and maintain the stability of the reconstructed nipple, we presented a minimal incision technique that designed four 3-mm-sized horizontal microincisions, which ran a sun-cross through the periphery and the core of the nipple to push the nipple together, then a vertical suture ran longitudinal to close the transverse incision to stabilize the projection. This technique was performed in 71 patients classified as grade II or III of the inverted nipples, comprising 53 congenital cases and 18 patients with acquired deformity. Thirty-four patients had bilateral inverted nipples, and 37 patients had unilateral inverted nipple. During a mean follow-up period of 15months, 70 corrected nipples remained raised without recurrence, and one nipple was found retracted at the outpatient clinic after 3months. There were no serious complications associated with surgery regarding nipple necrosis, seven patients got temporary swelling, two patients got infected after touching water, three patients got extravasated blood, eight patients indicated that they touched scar under the nipple, and two patients reflected nipple dysesthesia. In the 15months follow-up, the patients with Grade II nipple inversion maintained a nipple average height of 9.54 ± 0.95, and the patients with Grade III nipple inversion maintained a nipple average height of 9.19 ± 1.09, and 86.63% of patients were satisfied with their results. This is a simple, safe, effective and reliable technique that should be considered, providing sustained results over the long-term follow-up period with a high rate of stable eversion and low incidence of ischemia, necrosis, scarring and dysesthesia. The vertical scar of the transverse incision closure leads to an esthetic appearance without apparent scarring and minimizes the risk of an altered nipple sensation. 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 .

Nipple necrosis rate with submuscular versus prepectoral implant-based reconstruction in nipple sparing mastectomy: Does it differ?

BackgroundThis study aims to compare the rate of nipple necrosis between the submuscular (SM) versus the prepectoral (PP) implant placement after immediate breast reconstruction (IBR). MethodsAn institutional review board-approved database was reviewed of patients who underwent nipple sparing mastectomy (NSM) with IBR at our institution between 2016 and 2019. Patients who had SM versus PP IBR were compared. Incidence of nipple necrosis was evaluated between the two groups. ResultsA total of 525 NSM with IBR were performed in 320 patients with SM reconstruction in 61% (n ​= ​322) and PP in 39% (n ​= ​203) of the mastectomies. Overall, 43 nipples experienced some form of necrosis with 1% of mastectomies experiencing nipple loss. There was no difference between SM group and PP group at the rate of nipple necrosis (9 ​% vs 7 %, P ​= ​0.71). ConclusionIn patients undergoing NSM with IBR, the rate of nipple necrosis, nipple loss or complications did not differ between groups whether the implant was placed SM or PP, supporting the safety of this newer procedure.