"Inverted-Y": a modified vest-over-pants abdominoplasty pattern following bariatric surgery

Concordance between preoperative imaging methods in patients with limb lymphedema undergoing supermicrosurgical lymphaticovenular anastomosis

OBJECTIVE

Supermicrosurgical lymphaticovenular anastomosis (LVA) is increasingly being recognized as a first-line treatment of limb lymphedema because it is minimally invasive and highly effective. Lymphoscintigraphy and indocyanine green (ICG) lymphography are the two most commonly performed diagnostic imaging examinations to establish the indication and plan the procedure for patients affected by limb lymphedema. In a small group of patients, the information between these two imaging tools can be discordant, showing different anatomical drainage pathways or the absence of drainage and dermal backflow in one examination and valid drainage pathways in the other. The purpose of this study is to examine the types of possible discrepancies between lymphoscintigraphy of the superficial system and ICG lymphography and to describe the surgical outcomes after LVA for patients presenting with such discrepancies.

METHODS

We retrospectively reviewed the data of all patients who underwent LVA for upper or lower limb lymphedema between July 2015 and July 2023. From this series, we identified a group of patients with nonconcordant imaging results from lymphoscintigraphy and ICG lymphography before lymphatic surgery. Nonconcordant findings were described in terms of "pattern discordance" and "pathway discordance." The surgical outcome was measured by the change in the mean circumference of the limb after surgery. The changes between the preoperative and postoperative limb measures were analyzed using the Student t test. P values < .05 were considered significant.

RESULTS

A total of 28 patients with limb lymphedema exhibited inconsistencies between preoperative lymphoscintigraphy of the superficial system and ICG lymphography. Among these patients, 14 experienced pattern discordance, 13 had pathway discordance, and 1 patient had both. After LVA, we observed a significant reduction in the average circumference of the affected limb in the analyzed group.

CONCLUSIONS

The discrepancy in the information between lymphoscintigraphy and ICG lymphography in the preoperative study of patients affected by limb lymphedema is rare but possible. This phenomenon is still not fully explained; however, our results suggest that it does not correlate with the outcome of supermicrosurgical LVAs.

Tunnelised superiorly based preauricular flap and conchal cartilage graft for antihelix reconstruction

Reconstruction of a full-thickness defect of the auricle's anterior surface represents a challenge for plastic surgeons. This report describes the case of a man in his 70s, who underwent radical excision of a squamous cell carcinoma involving his right antihelix. We adopted an innovative approach for the reconstruction of the antihelix, using a tunnelled preauricular flap reinforced with an ipsilateral concha cartilage graft. The flap's base was de-epithelialised, allowing a single-stage procedure. Three months postoperation, no complications arose, and the scars at the donor site were effectively concealed. The aesthetic result was excellent, thanks to the perfect colour match, symmetry, shape of the auricle and the long-lasting integrity of the antihelical structure.This technique allows for accurate reconstruction of the convoluted surface of the auricle in cases of full-thickness defects of the antihelix, without the need to harvest cartilage from other donor sites and in a single surgical procedure.

Secondary post-oncologic vulvar reconstruction - a simplified algorithm

Introduction

Surgical treatment is the gold standard of care for vulvar cancer and is burdened by a high risk of wound complications due to the poor healing typical of the female genital area. Moreover, this malignancy has a high risk of local relapse even after wide excision. For these reasons, secondary reconstruction of the vulvoperineal area is a relevant and challenging scenario for gynecologists and plastic surgeons. The presence of tissue already operated on and undermined, scars, incisions, the possibility of previous radiation therapy, contamination of urinary and fecal pathogens in the dehiscent wound or ulcerated tumor, and the unavailability of some flaps employed during the primary procedure are typical complexities of this surgery. Due to the rarity of this tumor, a rational approach to secondary reconstruction has never been proposed in the literature.

Methods

In this observational retrospective study, we reviewed the clinical data of patients affected by vulvar cancer who underwent secondary reconstruction of the vulvoperineal area in our hospital between 2013 and 2023. Oncological, reconstructive, demographic, and complication data were recorded. The primary outcome measure was the incidence of wound complications. The secondary outcome measure was the indication of the different flaps, according to the defect, to establish an algorithm for decision-making.

Results

Sixty-six patients were included; mean age was 71.3 ± 9.4 years, and the mean BMI was 25.1 ± 4.9. The mean size of the defect repaired by secondary vulvar reconstruction was 178 cm² ± 163 cm². Vertical rectus abdominis myocutaneous (VRAM), anterolateral thigh (ALT), fasciocutaneous V-Y (VY), and deep inferior epigastric perforator (DIEP) were the flaps more frequently employed. We observed five cases of wound breakdown, one case of marginal necrosis of an ALT flap, and three cases of wound infection. The algorithm we developed considered the geometry and size of the defect and the flaps still available after previous surgery.

Discussion

A systematic approach to secondary vulvar reconstruction can provide good surgical results with a low rate of complications. The geometry of the defect and the use of both traditional and perforator flaps should guide the choice of the reconstructive technique.

Treatment of Early-Stage Gynecological Cancer-Related Lower Limb Lymphedema by Lymphaticovenular Anastomosis-The Triple Incision Approach

Background and Objectives: Lower extremity lymphedema (LEL) is one of the most relevant chronic and disabling sequelae after gynecological cancer therapy involving pelvic lymphadenectomy (PL). Supermicrosurgical lymphaticovenular anastomosis (LVA) is a safe and effective procedure to treat LEL, particularly indicated in early-stage cases when conservative therapies are insufficient to control the swelling. Usually, preoperative assessment of these patients shows patent and peristaltic lymphatic vessels that can be mapped throughout the limb to plan the sites of skin incision to perform LVA. The aim of this study is to report the efficacy of our approach based on planning LVA in three areas of the lower limb in improving early-stage gynecological cancer-related lymphedema (GCRL) secondary to PL. Materials and Methods: We retrospectively reviewed the data of patients who underwent LVA for the treatment of early-stage GCRL following PL. Patients who had undergone groin dissection were excluded. Our preoperative study based on indocyanine green lymphography (ICG-L) and color doppler ultrasound (CDU) planned three incision sites located in the groin, in the medial surface of the distal third of the thigh, and in the upper half of the leg, to perform LVA. The primary outcome measure was the variation of the mean circumference of the limb after surgery. The changes between preoperative and postoperative limbs’ measures were analyzed by Student’s t-test. p values < 0.05 were considered significant. Results: Thirty-three patients were included. In every patient, three incision sites were employed to perform LVA. A total of 119 LVA were established, with an average of 3.6 for each patient. The mean circumference of the operated limb showed a significant reduction after surgery, decreasing from 37 cm ± 4.1 cm to 36.1 cm ± 4.4 (p < 0.01). Conclusions: Our results suggest that in patients affected by early-stage GCRL secondary to PL, the placement of incision sites in all the anatomical subunits of the lower limb is one of the key factors in achieving good results after LVA.

Lymphatic Function of the Lower Limb after Groin Dissection for Vulvar Cancer and Reconstruction with Lymphatic SCIP Flap

Inguinofemoral lymphadenectomy, frequently performed for vulvar cancer, is burdened with substantial immediate and long-term morbidity. One of the most disabling treatment-related sequelae is lower limb lymphedema (LLL). The present study aims to describe the wound complications and the severity of LLL in patients who have undergone groin dissection for vulvar cancer and immediate inguinal reconstruction with the Lymphatic Superficial Circumflex Iliac Perforator flap (L-SCIP). We retrospectively reviewed the data of patients who underwent bilateral groin dissection and unilateral inguinal reconstruction with the L-SCIP. The presence and severity of postoperative LLL during the follow-up period were assessed by lymphoscintigraphy and limbs' volume measurement. In addition, immediate complications at the level of the inguinal area were registered. The changes between preoperative and postoperative limb volumes were analyzed by Student's t test. p values < 0.05 were considered significant. Thirty-one patients were included. The mean variation of volume was 479 ± 330 cc3 in the side where groin reconstruction had been performed, and 683 ± 425 cc3 in the contralateral side, showing smaller variation in the treated side (p = 0.022). Lymphoscintigraphy confirmed the clinical findings. Based on our results, inguinal reconstruction with L-SCIP performed at the same time of groin dissection in patients treated for vulvar cancer can provide a significant protective effect on LLL.

The Global Prevalence of Seroma After Abdominoplasty: A Systematic Review and Meta-Analysis

BACKGROUND

Abdominoplasty is one of the most common cosmetic surgeries performed worldwide. Seroma is also the most common local complication associated with abdominoplasty, which increases care costs, reduces patient satisfaction, and has serious complications for patients. Results of previous studies report different levels of seroma prevalence after abdominoplasty. The aim of this study is to standardize the statistics of the prevalence of seroma after abdominoplasty using meta-analysis.

METHODS

In this systematic review and meta-analysis study, data from studies conducted on the global prevalence of seroma after abdominoplasty was extracted using the keywords "Prevalence, Epidemiology, Complications, Abdominoplasty, Seroma, and Lipo abdominoplasty" in the databases of Science, Scientific Information Database, MagIran, Embase, Scopus, PubMed, Web of Science, and Google Scholar search engine without time limit until October 2020. The random-effects model was used to analyze the eligible studies, and the heterogeneity of the studies was investigated with the I² index. Data analysis was performed using Comprehensive Meta-Analysis software (Version 2).

RESULTS

In reviewing 143 studies (five studies related to Asia, 55 studies related to Europe, three studies related to Africa, and 80 studies related to the Americas) with a total sample size of 27834 individuals, the global prevalence of seroma after abdominoplasty was obtained as 10.9% (95% CI: 9.3-3.6.6%) and the highest prevalence of seroma was related to the Europe continent with 12.8% (95% CI: 10.15-3.9%). The results from meta-regression showed a declining trend in the global prevalence of seroma after abdominoplasty with an increase in the sample size, age of study participants, and the year of study (p < 0.05).

CONCLUSIONS

This study shows that the prevalence of seroma after abdominoplasty is high globally. Therefore, physicians and specialists must consider its importance and take the controlling and treatment measures seriously.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine Ratings, please refer to Table of Contents or online Instructions to Authors www.springer.com/00266 .

Feasibility, indications and complications of SCIP flap for reconstruction after extirpative surgery for vulvar cancer

INTRODUCTION

Surgical therapy for vulvar cancer involves wide defects that often require flap-based reconstruction. The goal of the reconstruction is fast wound healing with low donor site morbidity.

MATERIALS AND METHODS

This is a retrospective observational cohort study in which we reviewed all patients who underwent surgery for vulvar cancer followed by reconstruction using the Superficial Circumflex Iliac Artery Perforator (SCIP) flap between 2015 and 2020. The primary outcome measure of this investigation was the incidence of wound complications. The secondary outcomes were the surgical indications in terms of establishing the anatomical subunits involved in the resection that made us choose this flap for reconstruction. This study adheres to the STROBE guidelines.

RESULTS

Thirty-two patients were included; in two cases, the flap was performed bilaterally for a total of 34 SCIP flaps. The mean age of patients was 70.6 ± 8.6 years, and the mean BMI was 26.8 ± 4.7. The SCIP flap was always feasible. The mean flap size was 128.8 ± 74.3cm². Three patients showed wound complications. In every patient, the defect involved the vulva, perineum and inguinal area; in 18 patients, the mons pubis was also involved. The mean follow-up was 30 months. During the follow-up, six patients died, and four showed local or nodal cancer relapse.

CONCLUSION

Our results suggest that the advantages of SCIP flap for the reconstruction of vulvoperineal defects secondary to vulvar cancer surgery include low complication rate, minimal donor site morbidity, quick dissection, proximity of donor and recipient sites, possibility to harvest large skin islands of variable thickness and chimeric flaps.

The Triple Plane, the Bra-Flap, and the Inverted Bra-Flap Modified Dual Plane Techniques for Breast Augmentation

BACKGROUND

Breast augmentation (BA) is a very common procedure performed for a wide range of indications. The short-term and long-term outcomes are strongly correlated with the choice of the correct implant pocket, which should be tailored to the anatomic features of the breast.

OBJECTIVES

The aim of this study was to report the safety and efficacy of the triple-plane technique and Bra-flap modified dual-plane techniques for BA.

METHODS

From January 1995 to January 2016, 605 patients underwent BA procedures that utilized the triple-plane technique or Bra-flap modified dual-plane techniques. Patient evaluation was performed preoperatively and postoperatively at 6 and 12 months and every 5 years thereafter. The occurrence of ptosis and implant malposition, as well as breast animation deformity, were assessed. Patient satisfaction was evaluated with the BREAST-Q Augmentation Module.

RESULTS

The average patient age was 39.3 years. The follow-up period ranged from 24 months to 20 years. The triple-plane technique was performed in 450 patients, the Bra-flap modified dual-plane technique in 97, and the inverted Bra-flap modified dual-plane technique in 58. No cases of double-bubble deformity or implant bottoming-out were observed. Regarding animation deformity, 209 patients presented with mild to moderate distortion, whereas no patients presented with severe distortion. The BREAST-Q questionnaire reported significant postoperative improvements in all scales.

CONCLUSIONS

In over 20 years of experience, the triple-plane technique has proven to be a reliable procedure that offers natural and long-lasting results. The Bra-flap and inverted Bra-flap modified dual-plane techniques are efficient options to expand the range of breast conditions treated.

LEVEL OF EVIDENCE: 4

New Approach for Post-bariatric Abdominoplasty with Extended Vertical Resection: A Prospective Cohort Study

INTRODUCTION

As the number of bariatric surgeries has increased, so has the demand for post-bariatric abdominoplasty. The aim of this study was to describe a new approach to anchor-line abdominoplasty for the treatment of post-bariatric surgery patients.

METHODS

This prospective, longitudinal, single-center study was conducted with 20 women, 23-47 years of age, with a body mass index < 30 kg/m², who had undergone gastroplasty. The vertical amount of tissue to be excised was estimated preoperatively by the pinch test. The amount of tissue to be removed by transverse resection was determined intraoperatively. Patient satisfaction with the body contour result was assessed.

RESULTS

Patient self-assessment showed that 85% of patients were very satisfied, 10% were satisfied, and 5% were not very satisfied with the surgical results. There were no cases of flap necrosis or surgical wound dehiscence.

CONCLUSION

The described technique resulted in improved body contour, good scar quality, and a high level of patient satisfaction.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Evidence-Based Abdominoplasty Review With Body Contouring Algorithm

Abdominal contour deformities are an aesthetic challenge to the plastic surgeon. Patients present with diverse clinical histories, multiple comorbidities, and unique aesthetic demands. Weight loss, previous pregnancy, and aging are 3 principal indications for abdominoplasty. Bariatric surgery has increased demand for body contouring procedures. This heterogeneous patient cohort means a "one-size-fits-all" abdominoplasty is not appropriate. Precise evaluation, evidence-based decision-making, and artistic acumen are required while balancing patient goals with safe, realistic, and long-lasting aesthetic outcomes. This article reviews surgical options for abdominal body contouring, providing an evidence-based treatment algorithm for selecting the appropriate procedure for each patient to maximize clinical and patient reported outcomes.

Pedicled neurocutaneous anterolateral thigh flap for groin reconstruction - A case report

Several different flaps based on the feeding vessels of sensitive nerves have been described in the limbs. This article reports the case of a neurocutaneous flap based on the lateral femoral cutaneous nerve (LFCN), employed for reconstruction of an inguinal defect. A 61-years-old female patient had undergone vulvectomy and bilateral inguinal lymphadenectomy for vulvar cancer with postoperative left groin wound breakdown. After a 3 weeks negative pressure therapy course, she presented a 10 × 4 cm skin and subcutaneous defect with undermined edges in the left inguinal area. Reconstruction with 14 × 6 cm pedicled left anterolateral thigh flap was planned. After the dissection of the vascular pedicle and of the sensitive nerve, complete thrombosis of both the veins and arterial spasm of perforating pedicle was detected. As the flap color was good, and slow marginal bleeding was present, we inspected the small vessels surrounding the nerve that were pulsating. To confirm the vascularization coming from the neural pedicle, we clamped the perforator and performed intraoperative indocyanine green (ICG) fluorescence angiography that showed a good fluorescence of the flap with a proximal to distal pattern of progression. The flap was transferred on the neural pedicle, survived completely, and wounds healed normally. Three months after surgery, the patient underwent radiotherapy, with uneventful course. In her last follow-up, 2 years after surgery, patient was free of disease and the flap showed normal scarring. This is the first case reported of a pedicled neurocutaneous flap based on the LFCN, indicating that in case of unsuitable perforators it could be an alternative pedicle.

Simultaneous correction of breast hypertrophy and vaginal agenesis: Aesthetic surgery to the aid of reconstructive surgery

Mayer-Rokitansky-Küster-Hauser syndrome is characterized by aplasia of the uterus and the upper ⅔ of the vagina, with normal female genotype (46,XX) and the development of secondary sexual characters. One of the most popular surgical treatment is the McIndoe procedure, which major drawbacks are the scar of split thickness skin graft (STSG)harvesting, and risk of vaginal stenosis for graft retraction. We report the case of a patient, operated modifying the McIndoe technique, by harvesting a full thickness skin grafts (FTSG) from patient's breasts, undergone simultaneous reduction mammoplasty. The FTSG provided a complete lining of the reconstructed neovagina. At 6 months, we observed complete mucinous metaplasia of the vaginal walls and 1 year after surgery no sign of stenosis, without the use of the mold. The advantages of this technique are reduced donor site morbidity, when compared with traditional McIndoe technique, and reduced risk of neovagina retraction ensured by FTSG, compared with STSG. If future patients' series confirm the good results achieved, we could consider it as a first-line option in patients undergoing neovagina reconstruction, seeking breasts or body contouring surgery.

Quality of life and predictive factors for complications in patients undergoing abdominoplasty after gastric bypass: A retrospective cohort

BACKGROUND

Obesity is a major health risk factor associated with medical complications, such as cardiovascular disease, that may compromise outcomes. Furthermore, obesity may lead to difficulties in daily life, altering the quality of life and generating psychological disorders such as devalued self-image and depression.

OBJECTIVES

This study evaluated the quality of life and predictive factors of postoperative complications in patients who underwent abdominoplasty after Roux-en-Y gastric bypass.

SETTING

Bariatric and postbariatric center, North Wing Regional Hospital, Brasília, Brazil.

METHODS

Data were analyzed from a prospective registry of postbariatric patients who underwent abdominoplasty from January 2011 to December 2016. Variables examined included age, sex, body mass index (BMI), complications, and comorbidities. Multivariate analyses were performed to assess outcome measures. The quality-of-life assessment was measured with the Moorehead-Ardelt quality-of-life questionnaire.

RESULTS

One hundred and seven postbariatric patients were included. The mean age of the patients was 41 years. BMI at the time of abdominoplasty (current BMI) was 27.6 ± 3.7 kg/m², and the average weight loss before abdominoplasty was 47.7 ± 17.3 kg. Pre-weight loss BMI (max BMI) was 45.5 ± 7.6 kg/m², and ∆BMI was 18.6 ± 9.3 kg/m². The overall rate of complications was 23.4%. Among the studied factors in the multivariate analysis, amount of removed tissue in the abdomen >2000 g, ∆BMI >20 kg/m², and age >40 years significantly increased the rates of postoperative complications. In our study, abdominoplasty improved the quality of life of patients (mean quality-of-life scores, 2.1 ± 0.9).

CONCLUSION

The amount of removed tissue in the abdomen, ∆BMI >20 kg/m², and age >40 years led to significantly more complications in patients undergoing abdominoplasty after gastroplasty. In addition, this study demonstrated that abdominoplasty should be proposed to patients with massive weight loss to improve quality of life.

L-Shaped Lipothighplasty

BACKGROUND

In addition to the already-known postoperative complications in patients formerly obese, for medial thigh lift, there are many more problematic issues. The main ones are represented as follows: by the frequent downward displacement of the scars that become, in this way, extremely visible; by the distortion of the vulva or scrotal region; by serious and disabling disorders of the lymphatic system; and by the early recurrence of ptosis in this anatomical site.

MATERIALS AND METHODS

From 2004 to 2010, 16 patients with moderate to severe laxity of the medial area of the thighs were treated by an L-shaped medial thigh lift after selective liposuction. Ten have been previously treated with biliopancreatic diversion and 6 have been previously treated with gastric bypass. Mean (standard deviation [SD]) height before bariatric surgery was 1.62 (0.08) m, mean (SD) weight was 141.53 (23.12) kg, and mean (SD) body mass index was 57.13 (8.21) kg/m. After the intervention, mean (SD) weight decreased to 81.12 (16.43) kg, whereas mean (SD) body mass index decreased to 31.83 (8.51) kg/m.

RESULTS

After L-shaped lipothighplasty, 13 patients (81%) had no complications in the postoperative period. No skin necrosis, hematoma, seroma, or thromboembolic events were reported. Two patients experienced hypertophic scarring and 1 patient had a wound infection because of poor hygienic care.

CONCLUSIONS

The medial lifting technique defined as L-shaped lipothighplasty is a valid, fast, and safe technique and can reduce early and late postoperative complications in a critical and troublesome area for the surgeon who is going to correct the deformity.

Postabdominoplasty Wound Dehiscence in Bariatric Patients: Biliopancreatic Diversion Versus Gastric Bypass: A Preliminary Study

BACKGROUND

Surgical procedures with an extended follow-up and therefore recognized as safe in literature are classified into 2 categories: procedures limiting the introduction of food mechanically (restrictive interventions such as adjustable gastric banding, vertical banded gastroplasty, and sleeve gastrectomy) or functionally (mini gastric bypass or gastric bypass) and procedures limiting absorption (mainly biliopancreatic diversion [BPD]).

MATERIALS AND METHODS

Seventy-nine patients who underwent postbariatric abdominoplasty to correct serious flaws resulting from weight loss surgery were included in this retrospective study. Dehiscence of the surgical wound was carefully investigated between the population previously submitted to BPD and gastric bypass. The data were analyzed by correlating the incidence of postoperative dehiscence by Fisher exact test, with a statistical significance level of P<0.05.

RESULTS

Among the 42 abdominoplasties after BPD, dehiscence rate was 33% (14 patients), whereas in the group of 37 patients who underwent gastric bypass, the occurrence of dehiscence was 8% (3 patients).The Fisher exact test highlighted previously performed BPD as statistically significant for the onset of postoperative dehiscence (P=0.012).

CONCLUSIONS

There is a great need to validate these data on large or multicentric studies. The previous bariatric surgery procedure may play a role similar to so many other widely investigated risk factors such as smoking and body mass index, and some categories of patients should require even more attention in the preoperative, intraoperative, and postoperative management.

Minimising complications in abdominoplasty: An approach based on the root cause analysis and focused preventive steps

Significant complications still occur after abdominoplasty, the rate varies widely in different series. This variation suggests that there is a lot of scope for improvement. This paper reviews the various complications and also the technical improvements reported in the last 20 years. The root cause of each complication is analysed and preventive steps are suggested based on the literature and the author's own personal series with very low complication rates. Proper case selection, risk stratified prophylaxis of thromboembolism, initial synchronous liposuction, flap elevation at the Scarpa fascia level, discontinuous incremental flap dissection, vascular preservation and obliteration of the sub-flap space by multiple sutures emerge as the strongest preventive factors. It is proposed that most of the complications of abdominoplasty are preventable and that it is possible to greatly enhance the aesthetic and safety profile of this surgery.