The Infero-Central Mound Reduction Mammoplasty: A Single Surgeon, 20-year Experience

BACKGROUND

Reduction mammoplasty (RM) remains one of the most common plastic surgeries worldwide. Many different techniques have been described in the literature, each with its advantages and limitations. Nipple-areolar complex necrosis remains a daunting complication, regardless of the chosen surgical approach.

OBJECTIVE

We describe the senior author's (HYK) unique reduction mammoplasty technique, employing the infero-central (IC) pedicle throughout the last two decades.

PATIENTS AND METHODS

A retrospective chart review of 520 patients undergoing breast reduction was performed. After exclusion criteria, 360 were included in the study. These patients underwent RM with the IC technique, with stabilization of the breast mound and plication of the inferior pole dermis to prevent bottoming out. Demographics, operative data, and complications were recorded. Pre- and postoperative photographs were evaluated by a specialists' panel. The BREAST-Q questionnaire was utilized to assess satisfaction rates.

RESULTS

BREAST-Q questionnaire-satisfaction with breast score was 84.19, and outcome score was 91.67. Aesthetic outcome evaluation, reviewed by four plastic surgeons, yielded a high score in all parameters (1.64-2; range 0-2). On a per-breast basis for all patients, the following complications were analyzed: dehiscence (3.61%), infection (2.22%), hematoma (1.66%), superficial wound healing problems (1.38%), seroma (0.83%), skin flap ischemia (1.52%), hypertrophic scar (1.38%), fat necrosis (0.97%), and partial nipple ischemia (0.27%).

CONCLUSION

Infero-central mound technique can be applied to breast reductions of nearly all sizes, allowing for consistently satisfactory aesthetic outcomes for most patients. Due to robust vascularity of the pedicle, complication rates are kept at a minimum. IC mound technique is an essential tool in the plastic surgeon's armamentarium.

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 .

Testing or Trusting? Urine Cotinine Levels in Plastic Surgery

BACKGROUND

Preoperative laboratory examinations are a common practice throughout all surgical disciplines. Smoking prior to and shortly after elective aesthetic surgery is generally discouraged, but abstinence is rarely examined. Nicotine's major metabolite is cotinine, which is distributed in various body fluids, including blood, saliva, and urine. Urine cotinine levels are a useful short-term marker of nicotine exposure, whether active or passive, and correlate with daily tobacco use. Urinary levels are precise, rapid, easy to examine, and accessible.

OBJECTIVES

The aim of this literature review was to describe the current body of knowledge relevant to cotinine levels in the fields of general and plastic surgery. It was hypothesized that the current available data are enough to support the judicial use of such tests in high-risk surgical candidates, especially in aesthetic surgeries.

METHODS

A literature review via PubMed was conducted to identify publications that used the terms "cotinine" and "surgery," according to the PRISMA standard flowchart.

RESULTS

After subtracting duplications, the search results yielded 312 papers. After a reduction process as per exclusion criteria, 61 articles were identified and fully reviewed by both authors. Fifteen full-text articles were eligible for qualitative synthesis.

CONCLUSIONS

Enough data have accumulated to strongly support the judicial use of cotinine tests prior to elective surgery and specifically in aesthetic surgery.

A Single Surgeon's experience with Motiva Ergonomix Round SilkSurface Silicone implants in breast reconstruction over a 5-year period

BACKGROUND

Numerous breast implants are used for breast reconstruction. Each has its advantages and disadvantages. Recent data regarding the link between BIA-ALCL and implant texture caused a significant paradigm shift toward the use of smooth round implants. Motiva Ergonomix, a silk-surface breast implant, is classified as a smooth implant. To date, there is little data regarding the use of this specific implant in breast reconstruction.

OBJECTIVE

Describe a single surgeon's experience with Motiva Ergonomix, silk-textured, round implant for breast reconstruction.

PATIENTS AND METHODS

A retrospective chart review of all patients undergoing primary or revisionary breast reconstruction procedures, using Motiva Ergonomix, from January 2017 to January 2022. Patient demographics and medical status were extracted. Surgical data, including reconstructive technique, implant size, plane, use of acellular dermal matrix, and complications, were recorded. BREAST-Q questionnaires were completed.

RESULTS

A total of 156 consecutive patients were retrieved (269 breasts). A total of 257 were direct-to-implant reconstructions and 12 expander-to-implant. Complications were described per breast. Capsular contraction, Baker grade 3-4, was seen in four breasts (1.49%) in the nonirradiated group and six (2.24%) in the irradiated group. Rippling was seen in 11 breast (4.08%), skin ischemia in 17 (6.31%), hematoma in 4 (1.49%), and seroma in 6 (2.23%). BREAST-Q: satisfaction with breast increased by a mean of 9.175 (60.7 points preoperatively to 69.875 postoperatively). Satisfaction with the implant was 6.52 out of 8.

DISCUSSION

This cohort describes the current most extensive experience with Motiva Ergonomix implant used for reconstructive surgeries. Motiva Ergonomix breast implant endows a unique set of technologies to provide good results with a low complication rate.

Safety of body contouring surgery in an aging patient population

The fastest-growing age group undergoing cosmetic procedures are those over age 60, i.e. the aging patient group. While advanced age is a known predictor for increased surgical complications, the effects of age on complications in specific plastic procedures have yet to be thoroughly investigated. To determine the relationship between increased age and risk of surgical complications following body contouring procedures, specifically: abdominoplasty, brachioplasty, mastopexy, bilateral reduction, and thigh lift. A retrospective analysis of all patients undergoing body contouring procedures of the categories mentioned above between 2000-2018 at a tertiary university medical center. Patients were divided into two age groups: those below and those above, age 60. Data analysis included: demographics, underlying medical conditions, procedure type, and occurrence of postoperative complications (according to the Clavien-Dindo classification system). 803 body contouring procedures were identified, with 12% performed on the aging population. Aging patients had more underlying medical conditions than the younger ones. While the distribution of procedure type was similar in both groups, mastopexy was more common in aging patients. Of the 107 procedures identified as having complications, 37 were classified as grade I, 38 as grade II, and 32 as grade III. As a categorical variable, no relationship was found between the age of the patients and an increased risk of postoperative complications (age cut-off as 60). However, as a continuous variable, increased age did increase the overall risk of postoperative complications, although no optimal age as a cut-off point was identified. In multivariant analysis, diabetes mellitus with abdominoplasty was identified as a risk factor for postoperative complications. Conclusions: When undergoing body contouring procedures, we found that patients over the age of 60 are not at increased risk for postoperative complications than those under that age. Although age as a continuous variable was found to increase the overall postoperative complications, no optimal age could be defined as a cut-off point.

Pre-infection 25-hydroxyvitamin D3 levels and association with severity of COVID-19 illness

Objective

Studies have demonstrated a potential correlation between low vitamin D status and both an increased risk of infection with SARS-CoV-2 and poorer clinical outcomes. This retrospective study examines if, and to what degree, a relationship exists between pre-infection serum 25-hydroxyvitamin D (25(OH)D) level and disease severity and mortality due to SARS-CoV-2.

Participants

The records of individuals admitted between April 7^th, 2020 and February 4^th, 2021 to the Galilee Medical Center (GMC) in Nahariya, Israel, with positive polymerase chain reaction (PCR) tests for SARS-CoV-2 (COVID-19) were searched for historical 25(OH)D levels measured 14 to 730 days prior to the positive PCR test.

Design

Patients admitted to GMC with COVID-19 were categorized according to disease severity and level of 25(OH)D. An association between pre-infection 25(OH)D levels, divided between four categories (deficient, insufficient, adequate, and high-normal), and COVID-19 severity was ascertained utilizing a multivariable regression analysis. To isolate the possible influence of the sinusoidal pattern of seasonal 25(OH)D changes throughout the year, a cosinor model was used.

Results

Of 1176 patients admitted, 253 had records of a 25(OH)D level prior to COVID-19 infection. A lower vitamin D status was more common in patients with the severe or critical disease (<20 ng/mL [87.4%]) than in individuals with mild or moderate disease (<20 ng/mL [34.3%] p < 0.001). Patients with vitamin D deficiency (<20 ng/mL) were 14 times more likely to have severe or critical disease than patients with 25(OH)D ≥40 ng/mL (odds ratio [OR], 14; 95% confidence interval [CI], 4 to 51; p < 0.001).

Conclusions

Among hospitalized COVID-19 patients, pre-infection deficiency of vitamin D was associated with increased disease severity and mortality.

COVID-19 classification of X-ray images using deep neural networks

Objectives

In the midst of the coronavirus disease 2019 (COVID-19) outbreak, chest X-ray (CXR) imaging is playing an important role in diagnosis and monitoring of patients with COVID-19. We propose a deep learning model for detection of COVID-19 from CXRs, as well as a tool for retrieving similar patients according to the model’s results on their CXRs. For training and evaluating our model, we collected CXRs from inpatients hospitalized in four different hospitals.

Methods

In this retrospective study, 1384 frontal CXRs, of COVID-19 confirmed patients imaged between March and August 2020, and 1024 matching CXRs of non-COVID patients imaged before the pandemic, were collected and used to build a deep learning classifier for detecting patients positive for COVID-19. The classifier consists of an ensemble of pre-trained deep neural networks (DNNS), specifically, ReNet34, ReNet50¸ ReNet152, and vgg16, and is enhanced by data augmentation and lung segmentation. We further implemented a nearest-neighbors algorithm that uses DNN-based image embeddings to retrieve the images most similar to a given image.

Results

Our model achieved accuracy of 90.3%, (95% CI: 86.3–93.7%) specificity of 90% (95% CI: 84.3–94%), and sensitivity of 90.5% (95% CI: 85–94%) on a test dataset comprising 15% (350/2326) of the original images. The AUC of the ROC curve is 0.96 (95% CI: 0.93–0.97).

Conclusion

We provide deep learning models, trained and evaluated on CXRs that can assist medical efforts and reduce medical staff workload in handling COVID-19.

Key Points

• A machine learning model was able to detect chest X-ray (CXR) images of patients tested positive for COVID-19 with accuracy and detection rate above 90%.

• A tool was created for finding existing CXR images with imaging characteristics most similar to a given CXR, according to the model’s image embeddings.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00330-021-08050-1.

Complications of Post-Burn Tissue Expansion Reconstruction: 9 Years Experience with 42 Pediatric and 26 Adult Patients

BACKGROUND

Burn scar reconstruction is extremely challenging, even for the most proficient reconstructive surgeon. Within the arsenal of tools at the plastic surgeon's disposal, tissue expansion provides an efficient modality for reconstruction despite the reported complication rates.

OBJECTIVES

To critically review our experience with tissue expansion for burn scar reconstruction, comparing particularly the adult and pediatric populations.

METHODS

We conducted a retrospective study of the outcomes of patients who underwent burn scar reconstruction with tissue expansion at Hadassah Medical Center between January 2003 and July 2012. The data included patient age, anatomical site of expansion, number of procedures, and associated complications. The outcomes of the above-mentioned populations were also compared with those in a control group of patients undergoing reconstruction with tissue expansion for indications other than burn scars.

RESULTS

Sixty-seven tissue expansion procedures were carried out in 50 patients, 42 in the pediatric population (< 16 years of age) and 25 in the adult population. Complications were observed in 10 of the 42 pediatric procedures (23.8%) and in 3 of the 25 adult procedures (12%). This difference was found to be statistically significant. When the complication rate for each population was compared to its control group (tissue expansion for indications other than burn scar reconstruction, such as reconstruction for motor vehicle accident scarring, congenital nevi, or vascular malformations), no statistically significant difference was found between them (complication rates 19.8% and 12.5%, respectively). Furthermore, there was no statistically significant difference in complication rates between the different anatomical areas of expansion within both populations undergoing burn scar reconstruction. Most of the complicated cases completed successful reconstruction.

CONCLUSIONS

Tissue expansion is a useful surgical tool in post-burn scar reconstruction, both in the adult and pediatric populations and in all anatomic sites, despite consistently high complication rates, especially in the pediatric population. This complication rate is not higher than in patients undergoing tissue expansion for indications other than burn scar reconstruction.

Management of Inguinal Involvement of Peritoneal Surface Malignancies by Cytoreduction and HIPEC with Inguinal Perfusion

Background: Achieving complete cytoreduction of peritoneal surface malignancies (PSM) can be challenging. In most cases, delivery of heated intra-peritoneal chemotherapy (HIPEC) is straightforward. However, using the closed technique in some cases may be technically challenging; for example, in patients requiring abdominal closure using a large synthetic mesh. In cases where groin hernias are present, it is imperative to resect the hernia sac, since it may contain tumor deposits. In cases with major inguinal involvement where disease may spread out of the hernia sac or in cases where a hernia repair was performed while disease is present, inguinal perfusion should be considered.

Aim: To describe our experience with combined intra-peritoneal and inguinal perfusion of HIPEC following cytoreductive surgery.

Patients and Methods: This is a retrospective review of all patients who underwent cytoreductive surgery (CRS) and HIPEC at our institution. A prospectively maintained database containing data of patients treated by CRS and HIPEC (n=122) was reviewed. All patients with macroscopic inguinal involvement by PSM with complete cytoreduction perfused by HIPEC were included.

Results: We identified five cases who underwent CRS and combined intraperitoneal and inguinal perfusion after resection of large inguinal tumor deposits (n=4) or after a recent hernia repair with hernial sac involvement by mucinous adenocarcinoma (n=1). All five patients were successfully perfused using an additional outflow catheter placed in the groin.

Discussion: In cases of inguinal involvement by PSM, complete cytoreduction should be achieved and perfusion of the involved groin considered as it is feasible and safe.