"Kris knife" brachioplasty after bariatric surgery and massive weight loss

Local Perineal Capillary Perforator Flaps: A Minimally Invasive Technique for the Correction of Vulvar Stenosis

BACKGROUND

Vulvar stenosis is a debilitating condition that compromises sexual function, urination, and the ability to undergo gynecological examinations. The purpose of this study is to describe the technique of capillary perforator perineal flaps (CPPF) for the correction of vulvar stenosis.

METHODS

We retrospectively examined patients with vulvar stenosis treated through surgical separation and reconstruction with CPPF. The procedure involved vulvar separation with the creation of a subsequent defect, repaired using a flap, harvested laterally to the labia majora including a capillary perforator and transferred through a subcutaneous tunnel to repair the vulvar defect. The functional outcome was evaluated with the Bradford scale, comparing the preoperative and postoperative scores using the Student's t-test.

RESULTS

thirteen patients were included, three with stenosis following treatment for vulvar cancer and ten due to lichen sclerosus. In total, we analyzed 29 flaps, with an average size of 15.6 cm2. We always included just one perforator in the flap and no postoperative complications. Stenosis was resolved in all patients, with no recurrences one year after the surgery. The preoperative average severity of the stenosis was 2.3 + 0.6, reducing to 0.3 + 0.4 post-intervention, indicating a significant improvement (p < 0.01).

CONCLUSIONS

CPPF has proven to be a quick and safe method for the reconstruction of vulvar stenosis.

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.

Brachioplasty with Extended Incision at the Elbow: A Comparison with the Traditional Short Technique

BACKGROUND

The elbow area is frequently affected by excessive sagging skin post-massive weight loss. The aim of this study is to present a brachioplasty with distal extension of incision to the anticubital surface, in order to make the transition from middle arm to distal arm/elbow more nuanced and aesthetically pleasing.

MATERIAL AND METHODS

An observational retrospective comparative study was performed confronting two groups of female patients. All patients treated with brachioplasty between January 2015 and December 2020 due to brachial laxity following massive weight loss were included in the study. Group A consisted of patients who underwent the novel procedure and Group B comprised subjects with the standard brachioplasty technique. Demographics, including age, BMI and comorbidities were taken into account. The mean outcome measure was the Body-QTM-satisfaction with upper arms score, which was administered preoperatively and one year postoperatively.

RESULTS

In the period considered, Group A consisted of 92 patients and Group B of 78. No difference was found between groups concerning BMI and age. The groups were comparable also based on the Body-Q pre-surgery levels. The Body-Q scores at one year postoperatively were 22.80 ± 2.28 in group A and 19.50 ± 2.42 in group B. The postoperative Body-Q scores across the two groups were a higher in group A, and the result is statistically significant (p < 0.05).

CONCLUSION

The utilization of the proposed elbow-extended technique allows an improvement of the upper limb profile, with far higher satisfaction of patients, at the price of minimal sequelae in terms of scar. The elbow area is a critical part in post-obese deformities of the brachium, and is frequently neglected. In case of skin laxity and redundancy an elbow extension of the brachioplasty incision is indicated. Results of elbow-extended brachioplasty are p valid and the additional scar well concealed and accepted by patients.

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 the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

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.

Complications in Brachioplasty: A Systematic Review and Meta-Analysis

BACKGROUND

Brachioplasty procedures have experienced a surge in popularity over the past decade, mirroring the rise in bariatric procedures and growing population of massive weight loss patients. The authors estimated the incidence of associated complications and identify possible patient- or procedure-related predictive factors.

METHODS

A systematic review was performed using the PubMed, Cochrane, and Embase databases; extracted data were synthesized through a random-effects meta-analysis of proportions and a multivariate meta-regression.

RESULTS

Twenty-nine studies were included in the meta-analysis, representing 1578 patients; all studies followed an observational design. The incidence of adverse outcomes assessed included aberrant scarring, 9.9 percent (95 percent CI, 6.1 to 15.6 percent); ptosis or recurrence, 7.79 percent (95 percent CI, 4.8 to 12.35 percent); wound dehiscence, 6.81 percent (95 percent CI, 4.63 to 9.90 percent); seroma, 5.91 percent (95 percent CI, 3.75 to 9.25 percent); infection, 3.64 percent (95 percent CI, 2.38 to 5.53 percent); nerve-related complications, 2.47 percent (95 percent CI, 1.45 to 4.18 percent); lymphedema or lymphocele formation, 2.46 percent (95 percent CI, 1.55 to 3.88 percent); skin necrosis or delayed healing, 2.27 percent (95 percent CI, 1.37 to 3.74 percent); and hematoma, 2.06 percent (95 percent CI, 1.38 to 3.06 percent). The operative reintervention rate for aesthetic purposes was 7.46 percent (95 percent CI, 5.05 to 10.88 percent), and the operative reintervention rate for nonaesthetic purposes was 1.62 percent (95 percent CI, 1.00 to 2.61 percent). Multivariate meta-regression demonstrated that medial incision placement was associated with a higher risk of complications, whereas the incidence of certain complications was lowered with adjunctive liposuction (p < 0.05).

CONCLUSION

In the absence of large clinical trials, the present meta-analysis can serve to provide plastic surgeons with an evidence-based reference to improve informed consent and guide procedure selection with respect to the complication profile of brachioplasty.

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

Risk factors for late-onset lower limb lymphedema after gynecological cancer treatment: A multi-institutional retrospective study

INTRODUCTION

Late-onset lower limb lymphedema (LLL) is a significant clinical challenge for physicians dealing with patients that undergo treatment involving the pelvic cavity. We aimed to clarify the prevalence of and risk factors for late-onset LLL after treatment for gynecological cancer.

METHODS

We conducted a multicenter retrospective study using records of cases in which LLL diagnosed by physical findings and measurement of limbs girths. Patients with LLL after treatment for uterine cervical, endometrial, and ovarian cancer were sequentially enrolled. We examined the timing of LLL onset and the associations between the time to onset and clinical characteristics, including age, type of cancer, lymphadenectomy sites, and performance of radiotherapy. We also investigated the risk factors for late-onset LLL and their effects on the cumulative incidence of late-onset LLL.

RESULTS

In total, 711 patients fulfilled the required criteria. Mean age of was 50.2 years old and median follow-up period was 5.05 years. More than half of them (50.5%) presented with LLL ≥5 years after undergoing treatment for gynecological cancer. A substantial number of patients (29.4%) developed LLL ≥10 years after undergoing treatment for gynecological cancer. Being aged <50 years [(odds ratio (OR): 1.919, P = 0.001), cervical cancer (OR: 1.912, P = 0.001), and radiotherapy (OR: 1.664, P = 0.017) were identified as significant risk factors for late-onset LLL in multivariate logistic regression analysis.

CONCLUSIONS

A substantial number of patients present with LLL ≥5 years after receiving treatment for gynecological malignancies. Clinicians are required to identify high-risk patients and inform them of the risk of late-onset LLL.

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.

Postbariatric Brachioplasty with Posteromedial Scar: Physical Model, Technical Refinements, and Clinical Outcomes

BACKGROUND

Brachioplasty is an increasingly performed procedure following massive weight loss. A visible scar is the main hindrance to this surgery. The aims of the study were to develop a physical model to investigate the ideal location of the surgical incision and to present the authors' technical refinements with the posteromedial scar approach.

METHODS

Twenty-four postbariatric patients underwent brachioplasty with posteromedial scar placement, concomitant liposuction, fascial plication, and axillary Z-plasty. Skin specimens were tested and a physical model of the arm was set up to investigate the difference in mechanical stress on the posteromedial and medial scars. The validated Patient and Observer Scar Assessment Scale, the Vancouver Scar Scale, and a questionnaire assessing subjective improvements were administered to patients. Preoperative and postoperative photographs were assessed by three independent plastic surgeons.

RESULTS

The physical model showed that stress intensity and distribution along the scar were reduced in the posteromedial location, with smaller scar displacement in the loading simulations. Twenty-three patients healed uneventfully. One (4.1 percent) had a 2-cm dehiscence. Mean Patient and Observer Scar Assessment Scale scores were, respectively, 2 ± 0.76 and 2.13 ± 0.64 in the patients' and observers' questionnaires. The mean Vancouver Scar Scale value was 3.5 ± 1.7. Questionnaires assessing the subjective outcomes showed a mean value of 3.45 ± 0.63 of 4. The surgeons' assessment resulted in a score of 4.5 ± 0.4 of 5.

CONCLUSIONS

The physical model demonstrated that the posteromedial scar was subjected to lower mechanical stress and displacement. The reported technical refinements allowed pleasant arm recontouring to be achieved with acceptable scarring and a low incidence of complications.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

'J' brachioplasty technique in massive weight loss patients

Upper extremity body reshaping is a very frequent surgical procedure in massive weight loss patients. Many surgeons have presented different patterns of brachioplasty skin excision and a variety of adjunctive techniques, each of them claiming improvements in scar aesthetic, arm shape or overall safety of the procedure. In this pape,r we want to illustrate our personal brachioplasty technique for massive weight loss patients. Our incision design named 'J' Brachioplasty is described. Between March 2013 and March 2016, a retrospective study of patients with massive weight loss and clinical diagnosis of brachial ptosis undergoing surgical reconstruction with 'J' brachioplasty was performed. All patients were treated according to a standard surgical procedure described in detail in the paper. The presence of axillary and thoracic skin excess was also recorded for every subject, as well as clinical and surgical postoperative complications. A total number of 73 Caucasian underwent J-shaped brachioplasty. Our technique allowed us to treat both arm and thoracic skin excess with a single skin incision. Among our casuistic we had only two cases of postoperative bleeding and four cases of partial wound dehiscence due to tension. Seroma was reported only in one (female) patient. Despite the recent introduction our technique has proven to reach good results in massive weight loss patients.

Arm Contouring After Massive Weight Loss: Liposuction-Assisted Brachioplasty Versus Standard Technique

Massive weight loss (MWL) brachioplasty is frequently requested for the improvement of the appearance and function of arms. Despite its diffusion, this procedure can be associated with significant complications. Liposuction-assisted brachioplasty (LAB) preserves the vascular, nervous, and lymphatic network and reduces the incidence of postoperative complications. This retrospective cohort study is aimed at analyzing two different modalities of arm contouring after MWL by evaluating the outcomes and complications. Of 31 patients (all females, average age 43.5 years), 20 were managed with standard brachioplasty represented by a swallowtail scar and monobloc resection and 11 with brachioplasty combined with aggressive liposuction. Evaluated parameters included age, body mass index, method of weight loss, and complications rate. No statistical analysis was used. Major postoperative complications (reoperation, bleeding, or thromboembolism) were not reported in both groups. The incidence of minor complications (wound separation, wound infection, and seroma) was globally 42%; the incidence of complications was significantly lower in the LAB group (9% vs. 60%). The incidence of hypertrophic scarring or keloid was higher in the control group (55% vs. 18%). Most patients were satisfied after surgery: in the LAB group, 81.8% of the patients expressed a high degree of satisfaction and 18.2% a good degree of satisfaction after 4 months of follow-up. In our experience, the LAB should be preferred in MWL patients because it has a lower rate of complications and a faster recovery than the standard technique. Proper execution requires considerable technical skill and experience.

Complications associated with brachioplasty: a literature review

Background:

Paralleling the growth of bariatric surgery, the demand for post-bariatric body-contouring surgery is increasing. Weight loss is the main cause, although not the only one, that drives patients to arm lift surgery. Several surgical techniques have been proposed over the years. Our aim was to consider the complications and outcomes according to the performed technique, through a wide review of the literature.

Methods:

A search on PubMed/Medline was performed using “brachioplasty”, “upper arm lifting”, and “techniques” as key words. Embase, Medline (OvidSP), Web of Science, Scopus, PubMed publisher, Cochrane, and Google Scholar were searched as well. As inclusion criteria, we selected the clinical studies describing techniques of brachioplasty. We excluded the papers in which complications related to brachioplasty were not specified. We also excluded literature-review articles.

Results:

We found 27 studies from 1995 to 2015. Overall, 1065 patients were treated. Different techniques were applied. Complications were observed in 308/1065 patients (28.9%). The most frequent complications were hypertrophic scarring, seroma and hematoma. Surgical revision rate ranged from 0 to 21 percent. Nerve damage occurred in a modest percentage of patients (16/1065, 1.5%). No major complications, such as thromboembolism and sepsis, were observed.

Conclusions:

Brachioplasty is a safe surgical procedure. All the brachioplasty techniques showed positive outcomes, in term of patients’ satisfaction and clinical results. Nevertheless, minor complications occurred in a high percentage of patients, regardless the performed surgical procedure. Patients should be informed about the possible formation of hypertrophic scars and nerve injuries. (www.actabiomedica.it)

Lymphatic and Sensory Function of the Upper Limb After Brachioplasty in Post-Bariatric Massive Weight Loss Patients

BACKGROUND

Varied deformities of the upper arm are common after massive weight loss. Brachioplasty techniques have been successively modified to improve aesthetic outcomes and avoid complications, especially lymphedema and sensory damage.

OBJECTIVES

The authors evaluated lymphatic drainage and sensory function of the upper limbs after brachioplasty performed with a double-ellipse marking technique, a medial incision, superficial undermining, and posterior arm liposuction.

METHODS

This prospective study included 12 women who underwent brachioplasty after bariatric surgery and massive weight loss. Lymphatic drainage was evaluated by forearm volumetry and indocyanine green lymphography of the entire limb. Cutaneous sensitivity thresholds were determined with Semmes-Weinstein monofilaments.

RESULTS

Patients received postoperative follow up for 12 months. Complications included a small dehiscence for 1 patient and hypertrophic scarring for 2 patients. Cutaneous sensitivity and forearm volumetry were unchanged after brachioplasty for all patients. Results of indocyanine green lymphography indicated that all patients had normal linear lymphatic patterns pre- and postoperatively.

CONCLUSIONS

Results of the study support the belief that this type of brachioplasty does not disrupt sensory or lymphatic function of the limb.

LEVEL OF EVIDENCE

4.

Incidence and Risk Factors of Major Complications in Brachioplasty: Analysis of 2,294 Patients

BACKGROUND

Brachioplasty is a popular procedure to correct upper arm ptosis. However, current literature on complications and risk factors is scant and inconclusive.

OBJECTIVES

Using a large, prospective, multicenter database, we report the incidence of major complications and risk factors in patients undergoing brachioplasty.

METHODS

Patients who underwent brachioplasty between 2008 and 2013 were identified from the CosmetAssure (Birmingham, AL) database. The primary outcome was the occurrence of major complication(s), defined as complications requiring emergency room visit, hospital admission, or reoperation within 30 days of the procedure. Risk factors including age, gender, body mass index (BMI), smoking, diabetes, combined procedures, and type of surgical facility were evaluated using univariate and multivariate analysis.

RESULTS

Within the 129,007 patients enrolled in CosmetAssure, 2294 (1.8%) underwent brachioplasty. Brachioplasty patients were more likely to be older than 50 years (50.1%), obese (36.3%), diabetic (5.5%), but less likely smokers (5.5%). Major complications occurred in 3.4% brachioplasties with infection (1.7%) and hematoma (1.1%) being most common. Combined procedures, performed in 66.8% cases, had a complication rate of 4.4%, in comparison to 1.3% for brachioplasties performed alone. Combined procedures (RR = 3.58), males (RR = 3.44), and BMI ≥ 30 kg/m(2) (RR = 1.92) were identified as independent risk factors for the occurrence of any complication. Combined procedures (RR = 12.42), and the male gender (RR = 8.89) increased the risk of hematoma formation.

CONCLUSIONS

Complication rates from brachioplasty are much lower than previously reported. Hematoma and infection are the most common major complications. Combined procedures, male gender, and BMI ≥ 30 kg/m(2) are independent risk factors for complications. LEVEL OF EVIDENCE 2: Risk.

Modified fish-incision technique in brachioplasty: a surgical approach to correct excess skin and fat of the upper arm (restoring the armpit contour)

Brachial ptosis is one of the consequences of massive weight loss. At an early stage, brachial ptosis can be corrected by liposuction, dermolipectomy and liposuction, or minibrachioplasty while the most advanced stage requires extended brachioplasty. Since brachioplasty was first described, various techniques have been proposed in the management of upper extremity contour deformities. Modifications to the original technique were mainly made to shape arm contour, to obtain good morphological reconstruction with attention directed toward improving and refining the resulting scar. We describe a modified approach to the "fish incision" technique defining a preoperative marking procedure that permits the reduction of overcorrection problems to reshape and improve the contour of the armpit with camouflage of scar sequelae. Our modifications to the original technique focus on incision placement along the medial bicipital groove and armpit, based on the the drawings of the tails following dynamic lines of the armpit contour established by the underlying muscles. We drew the tails slightly with a 60° angle between the tails and the width depending on patient's arm contour and on the excess of the skin in the armpit to be removed. The modified technique has obtained satisfactory results for patients and may be considered as a new surgical approach in the management of brachial ptosis.

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.

Posterior Scar Brachioplasty with Fascial Suspension: A Long-term Follow-up of a Modified Technique

Background:

The traditional long medial arm incision with its resultant scar is not acceptable. The author presents his long-term experience in performing the posterior scar brachioplasty with fascial suspension. The technique is a modification described by other authors. The aim of the author is to demonstrate the reasons for the choice of the posterior scar technique with fascial suspension.

Methods:

Between 1999 and 2012, the posterior scar technique with fascial suspension was used to treat 205 patients with brachial deformities. Age at operation ranged between 21 and 66 years. All patients were examined, and the author reviewed their medical charts during the follow-up period (29–98 mo). A Likert scale and an evaluation questionnaire were used to assess the aesthetic outcome of the posterior scar brachioplasty technique.

Results:

All patients who underwent the posterior scar technique were free of postoperative contour deformities. Postoperatively, the scar was completely invisible when viewed from patient’s front and patient’s lateral but was partially visible when viewed from patient’s back. And 88.8% of patients tolerated the scar with high satisfaction.

Conclusions:

The current posterior scar maneuver with fascial suspension prevented the tension on the suture line and consequently prevented the widening of the scar and facilitated the modeling procedure by removing the appropriate amount of skin and subcutaneous tissues. It creates a low-lying, posterior, well-hidden scar when viewed from the patient’s front or patient’s lateral. The scar is partially (upper third) visible when viewed from patient’s back. The technique is avoiding injury to the sensory and motor nerves of the arm and decreases the insult to the lymphatic.