Breast Reduction: 33 Years Using a Single Central Block

The Kempe incision for decompressive craniectomy, craniotomy, and cranioplasty in traumatic brain injury and stroke

OBJECTIVE

Decompressive craniectomy (DC) is an effective, lifesaving option for reducing intracranial pressure (ICP) in traumatic brain injury (TBI), stroke, and other pathologies with elevated ICP. Most DCs are performed via a standard trauma flap shaped like a reverse question mark (RQM), which requires sacrificing the occipital and posterior auricular arteries and can be complicated by wound dehiscence and infections. The Ludwig Kempe hemispherectomy incision (Kempe) entails a T-shaped incision, one limb from the midline behind the hairline to the inion and the other limb from the root of the zygoma to the coronal suture. The authors' objective in this study was to define their implementation of the Kempe incision for DC and craniotomy, report clinical outcomes, and quantify the volume of bone removed compared with the RQM incision.

METHODS

A retrospective review of a single-surgeon experience with DC in TBI and stroke was performed. Patient demographics, imaging, and outcomes were collected for all DCs from 2015 to 2020, and the incisions were categorized as either Kempe or RQM. Preoperative and postoperative CT scans were obtained and processed using a combination of automatic segmentation (in Python and SimpleITK) with manual cleanup and further subselection in ITK-SNAP. The volume of bone removed was quantified, and the primary outcome was percentage of hemicranium removed. Postoperative surgical wound infections, estimated blood loss (EBL), and length of surgery were compared between the two groups as secondary outcomes. Cranioplasty data were collected.

RESULTS

One hundred thirty-six patients were included in the analysis; there were 57 patients in the craniotomy group (44 patients with RQM incisions and 13 with Kempe incisions) and 79 in the craniectomy group (41 patients with RQM incisions and 38 Kempe incisions). The mean follow-up for the entire cohort was 251 ± 368 days. There was a difference in the amount of decompression between approaches in multivariate modeling (39% ± 11% of the hemicranium was removed via the Kempe incision vs 34% ± 10% via the RQM incision, p = 0.047), although this did not achieve significance in multivariate modeling. Wound infection rates, EBL, and length of surgery were comparable between the two incision types. No wound infections in either cohort were due to wound dehiscence. Cranioplasty outcomes were comparable between the two incision types.

CONCLUSIONS

The Kempe incision for craniectomy or craniotomy is a safe, feasible, and effective alternative to the RQM. The authors advocate the Kempe incision in cases in which contralateral operative pathology or subsequent craniofacial/skull base repair is anticipated.

Evaluation of the Sensitivity of the Nipple-Areola Complex in Patients Undergoing Breast Ptosis Correction with Periareolar Dermis Release: A Randomized Controlled Trial

BACKGROUND

In the surgical treatment of breast ptosis, the plastic surgeon's main challenge is to mobilize the nipple-areola complex (NAC) over long distances, preserving its sensitivity. Herein, we aimed to evaluate the NAC sensitivity following a periareolar dermis release in patients undergoing surgical correction of breast ptosis.

METHODS

This is a prospective, double-blinded, randomized study in which 39 patients (78 breasts) were operated on for the treatment of breast ptosis. Patients' breasts were divided into two groups, each breast in a group. In breasts of the experiment group, the periareolar dermis release was used after decortication. This maneuver was not used in the control group's breasts. To analyze the sensitivity in relation with the distance that the NAC should be mobilized to correct breast ptosis, the value of 6 cm was used as boundary. Sensitivity of the NAC was assessed with monofilaments preoperatively and postoperatively-at three and six weeks and one year.

RESULTS

Regarding the sensitivity of the areola, a significant difference was observed in the comparison between the control and experiment groups at the NAC mobility ≤ 6.0 cm in the preoperative. Regarding the nipple, a significant difference was observed in the comparison between the control and experiment groups at three weeks postoperatively for a NAC mobility ≤ 6.0 cm. After one year, there was no difference in the comparison between the groups in either areola or nipple.

CONCLUSION

The periareolar dermis release does not compromise NAC vascularization and pressure sensitivity in patients undergoing breast ptosis correction.

LEVEL OF EVIDENCE II

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 .