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BACKGROUND:More than 70,000 reduction mammaplasties were performed in 2022. Previous studies have suggested equivalent overall complication rates with or without intraoperative drains but have been inadequately powered to assess individual outcomes. The authors assessed whether use of drains was associated with a lower risk of complications after breast reduction in a multi-institutional cohort study. METHODS:A retrospective multi-institutional cohort of 2488 patients undergoing breast reduction with and without drains was evaluated. Demographic and perioperative data were compared between groups and the impact of intraoperative drain placement on postoperative outcomes was evaluated. RESULTS:Drains were used in 1163 patients (46.7%) and 1325 cases (53.3%) were performed without drains. Patients with higher body mass index (BMI), greater preoperative breast anthropometrics, greater resection weight, multiple medical comorbidities, superior pedicle, or concomitant procedures ( P < 0.05) were more likely to have drains placed. Despite these preoperative differences, there was no significant difference in overall complication rate (30.7% versus 27.1%), wound dehiscence (12.3% versus 14.2%), seroma (1.8% versus 2.0%), hematoma (2.9 versus 3.7%), infection (9.7% versus 7.8%), or need for revision surgery (11% versus 10.2%). However, elevated BMI was significantly associated with overall complications, seroma, and wound dehiscence (all P < 0.01), and hematologic disease was associated with seroma ( P < 0.01). CONCLUSIONS:Drain placement was not associated with improved outcomes after breast reduction surgery in a large multicenter retrospective cohort. Surgeons were more likely to use drains in patients with a higher BMI, larger breasts, or greater medical complexity, with outcomes similar to those of the cohort without drains.

METHODS:A retrospective chart review of 2500 patients having undergone bilateral reduction mammoplasty at 5 institutions from 2010 to 2019 was performed to record pedicle selection, patient demographics, comorbidities, body mass index, patient measurements to determine patient selection for different pedicle techniques, and clinical outcomes associated with these techniques. RESULTS:A total of 1186 patients had inferior pedicle technique, 65 had superior pedicle technique, 807 had superomedial pedicle technique, 148 had free nipple graft, and the remainder were not specified. A total of 1899 reduction mammaplasties were closed with wise-pattern skin closure, and 189 were circumvertical. Demographics were similar across groups except for higher age ( P  < 0.001), BMI ( P  < 0.001), and ASA score ( P  < 0.001) in the free nipple graft cohort. Superomedial pedicle was used most frequently with lower sternal notch to nipple (SNN) distance, whereas inferior pedicle was performed most frequently with higher SNN distance. Inferior pedicle was most commonly employed for obesity class I-III patients, and free nipple graft was only used for obese patients. On linear regression, superior pedicle reduction (coefficient = -195.2, P  = 0.001) was significantly associated with lower resection weights, whereas free nipple grafting was associated with a higher resection weight (coefficient = 752.8, P  < 0.001). On univariate analysis, inferior pedicle technique was associated with higher dehiscence, delayed wound healing, and overall complication rates than other techniques ( P  < 0.001). Regression analysis demonstrated only age and BMI as independent risk factors for overall complications. CONCLUSIONS:Inferior pedicle reduction remains the most popular pedicle design followed by superomedial pedicle, with wise-pattern closure the most common skin closure type. SNN distance was the most impactful physical exam metric used to choose pedicles. Inferior pedicle and free nipple graft were used most commonly for obese patients, whereas superior reduction was associated with lower resection weights and BMI. Inferior pedicle technique was associated with increased wound healing complications, yet regression analysis implicated only BMI and smoking as statistically significant in this regard. Superomedial technique performed well across different BMI classifications.

Introduction: We aimed to evaluate the incidence and risk factors for lymphedema secondary to pelvic lymph node dissection (PLND) in urologic surgery. Secondary lymphedema is the most common type of lymphedema in the U.S. and the role of PLND in lower extremity lymphedema etiology is less well-defined. Methods: We performed a retrospective review of all PLNDs performed for urologic malignancies at a single academic institution between April 2014 and April 2017. Patient demographics, comorbidities, cancer staging, and other treatment information were collected. Incidence of lower extremity lymphedema and associated risk factors were explored. Univariate analysis and multivariate logistic regression were performed. Results: A total of 235 patients were included in our study. Mean (standard deviation) age was 68.8 (8.9) years, and the mean followup duration was 2.4 (1.7) years. Lymphedema occurred in 22 (9.4%) patients, and the mean time to lymphedema diagnosis was 7.4 (8.0) months. Age, body mass index, smoking, diabetes, pre- or postoperative radiation, number of resected lymph nodes, and number of positive lymph nodes were not significantly associated with postoperative lower extremity lymphedema; however, metastatic recurrence was significantly associated with the development of postoperative lymphedema. (odds ratio 2.83, 95% confidence interval 1.1-7.32, p=0.03) Conclusions: While the incidence of lower extremity lymphedema after PLND is low in urologic cancer patients, this complication is associated with metastatic recurrence. These results may allow for improved preoperative counseling on the risk of lower extremity lymphedema and inform cancer surveillance in patients with this complication. More research is needed to elucidate this association.

Pedicle selection for reduction mammoplasty is dictated by surgeon experience and patient characteristics. We review clinical patient characteristics that dictate pedicle selection and review outcomes associated with the interplay between patient characteristics and technique. A retrospective chart review of 2500 patients having undergone bilateral reduction mammoplasty at 5 institutions from 2010 to 2019 was performed to record pedicle selection, patient demographics, comorbidities, body mass index, patient measurements to determine patient selection for different pedicle techniques, and clinical outcomes associated with these techniques. A total of 1186 patients had inferior pedicle technique, 65 had superior pedicle technique, 807 had superomedial pedicle technique, 148 had free nipple graft, and the remainder were not specified. A total of 1899 reduction mammaplasties were closed with wise-pattern skin closure, and 189 were circumvertical. Demographics were similar across groups except for higher age ( P < 0.001), BMI ( P < 0.001), and ASA score ( P < 0.001) in the free nipple graft cohort. Superomedial pedicle was used most frequently with lower sternal notch to nipple (SNN) distance, whereas inferior pedicle was performed most frequently with higher SNN distance. Inferior pedicle was most commonly employed for obesity class I–III patients, and free nipple graft was only used for obese patients. On linear regression, superior pedicle reduction (coefficient = −195.2, P = 0.001) was significantly associated with lower resection weights, whereas free nipple grafting was associated with a higher resection weight (coefficient = 752.8, P < 0.001). On univariate analysis, inferior pedicle technique was associated with higher dehiscence, delayed wound healing, and overall complication rates than other techniques ( P < 0.001). Regression analysis demonstrated only age and BMI as independent risk factors for overall complications. Inferior pedicle reduction remains the most popular pedicle design followed by superomedial pedicle, with wise-pattern closure the most common skin closure type. SNN distance was the most impactful physical exam metric used to choose pedicles. Inferior pedicle and free nipple graft were used most commonly for obese patients, whereas superior reduction was associated with lower resection weights and BMI. Inferior pedicle technique was associated with increased wound healing complications, yet regression analysis implicated only BMI and smoking as statistically significant in this regard. Superomedial technique performed well across different BMI classifications.

Background While the need for reconstructive microsurgical procedures has increased across the developing world, several constraints in low- and middle-income settings prevent its consistent performance. Our study aimed to understand the impact of microsurgery training on local capacity in a low-income setting, and to understand limitations that may affect long-term build-up of microsurgical capacity. Methods Cross-sectional study evaluating survey responses of trainees and surgeons who participated in a Flap Transfer and Microsurgery course held in Ibadan, Nigeria. The survey consisted of a pre- and postcourse questionnaire, and a 2-year posttraining survey. The questionnaire sought to assess training impact on microsurgical capacity and limitations at each participants institution. Fourteen surgeons completed all questionnaires and were included in the study. Results Thirteen (92.3%) participants had encountered at least one defect requiring microvascular surgery within 2 years of the training, and 9 (69.2%) reported having performed at least one surgery. Most surgeons indicated having performed less procedures than needed across all defect anatomical site/etiology. The most common limitation reported by participants consisted of man-power shortage (78.6%), followed by expense of each procedure, difficulty procuring materials, and trainers with limited experience. Conclusion There is a significant need for microsurgical reconstruction in sub-Saharan Africa, with varied local challenges preventing consistent delivery of microsurgical care. The analysis complements previous literature on microsurgical care in developing countries and highlights significant constraints preventing widespread adoption and the role of local training opportunities that help in building long-term local capacity.

BACKGROUND:Improved breast cancer treatment has lengthened survival but also has long-term impacts. Lymphedema and peripheral neuropathy are treatment-related sequelae that extend into survivorship. Co-occurrence of these conditions may further impair functional well-being. Few studies have estimated the burden of these conditions among diverse survivors. METHODS:Carolina Breast Cancer Study Phase 3 enrolled survivors diagnosed between 2008 and 2013 in North Carolina. Black and younger women (aged <50 years at diagnosis) were oversampled. With the use of ≥10 years of follow-up data, the prevalence of persistent lymphedema, peripheral neuropathy, and their co-occurrence was assessed. Prevalence differences (PDs) and 95% confidence intervals (CIs) were assessed according to patient and disease characteristics. RESULTS:A total of 1688 survivors were included, with an average of 11.1 years (SD, 0.6) postdiagnosis. The prevalence of persistent lymphedema, peripheral neuropathy, and their co-occurrence was 18.7%, 27.7%, and 8.8%, respectively. Lymphedema was higher among those receiving a mastectomy and with >5 lymph nodes removed, and peripheral neuropathy was higher among women treated with taxane-based chemotherapy. Co-occurrence was higher among women with >5 lymph nodes removed (vs. <5; PD, 5.4; 95% CI, 2.1 to 8.8) and those treated with taxane-based chemotherapy (vs. no chemotherapy; PD, 6.8; 95% CI, 3.9 to 9.7). The burden of lymphedema (PD, 2.7; 95% CI, 0.9 to 6.3) and peripheral neuropathy (PD, 5.8; 95% CI, 1.7 to 9.9) was higher among Black than White women. The prevalence of lymphedema (PD, 1.8; 95% CI, -1.5 to 5.1) and peripheral neuropathy (PD, 4.6; 95% CI, 0.8 to 8.4) was elevated among younger compared to older women. CONCLUSIONS:Lymphedema and peripheral neuropathy affect a substantial proportion of survivors. Interventions are needed to reduce this burden.

Lower extremity lymphedema (LEL), which causes ankle, leg, and feet swelling, poses a significant challenge for endometrial cancer survivors, impacting physical functioning and psychological well-being. Inconsistent LEL diagnostic methods result in wide-ranging LEL incidence estimates. We calculated the cumulative incidence of LEL based on survivor-reported Gynecologic Cancer Lymphedema Questionnaire (GCLQ) responses in addition to survivor- and nurse-reported leg circumference measurements among a pilot sample of 50 endometrial cancer survivors (27 White, 23 Black) enrolled in the ongoing population-based Carolina Endometrial Cancer Study. Self-leg circumference measurements were perceived to be difficult and were completed by only 17 survivors. Diagnostic accuracy testing measures (sensitivity, specificity, positive and negative predictive value) compared the standard nurse-measured ≥ 10 ≥ 4 GCLQ cutpoint while 24 ≥ 5 GCLQ symptoms. However, Cohen’s kappa, a measure of reliability that corrects for agreement by chance, was highest at ≥ 4 GCLQ symptoms (κ = 0.27). Our findings emphasize the need for high quality measurements of LEL that are feasible for epidemiologic study designs among endometrial cancer survivors. Future studies should use patient-reported survey measures to assess lymphedema burden and quality of life outcomes among endometrial cancer survivors.

Excoriation or skin picking disorder is described as compulsive picking of the skin that cannot be explained by an underlying dermatological condition. There are unfortunately no clear guidelines in the literature for reconstruction of wounds in this patient population. The authors describe the cases of 2 patients with the skin picking disorder who underwent free flap reconstruction for scalp wounds, which were complicated by wound recurrence due to manipulation of the surgical site. The literature is reviewed in detail, and steps to potentially prevent recurrence in this patient population are discussed.

Genital gender affirming surgery is an effective treatment for gender dysphoria in transgender individuals. Optimization of medical and mental health conditions, including coordination with a patient's entire care team, is essential. Feminizing procedures include vaginoplasty (creation of female genitalia with a vaginal canal) and vulvoplasty (creation of female genitalia with a short or absent vaginal canal). Masculinizing procedures include metoidioplasty (construction of male genitals via local tissue rearrangement) and phalloplasty (creation of a phallus from extra-genital tissue). We aim to provide an overview of genital gender affirming surgery for providers who are interested in learning more about genital gender affirming surgery.

The replication of human epidermoid carcinoma A431 cells is inhibited by epidermal growth factor (EGF), with 5 ng/ml of EGF causing 50% inhibition of cellular proliferation. EGF resistant clones isolated from A431 cells were able to replicate in the presence of 100 ng/ml of EGF. That this insensitivity to EGF was probably due to a decrease in the expression of EGF receptors (EGFR) on the cell surface was shown using an EGFR cDNA probe to detect a 68% to 85% decrease relative to parental cells in the amount of EGFR mRNA in the EGF resistant clones. A corresponding decrease in surface EGFR levels was also detected in EGF resistant clones as measured by 125I-EGF binding. Eighteen percent of A431 cells cultured in serum-free medium for 6 days entered a pathway of terminal differentiation, as expressed by the formation of envelope-competent cells, whereas EGF resistant clones exhibited a considerably greater capacity to mature, even when cultured in serum-containing medium. The findings suggest that the concentration of EGFRs is important for the capacity of epidermal cells to undergo terminal differentiation in vitro.

INTRODUCTION: Gender dysphoria is estimated to affect 0.6% of the population in the US, and top surgery is the most common procedure in the transgender male population, but few studies exist examining postoperative patient satisfaction. We examined clinical and patient satisfaction outcomes after transmale top surgery with a view on improving presurgical patient optimization and patient education. METHODS: Thirty transgender male and nonbinary patients undergoing gender-affirming top surgery completed a satisfaction survey regarding outcomes such as overall satisfaction and nipple sensation after their surgery. Retrospective chart review was performed to obtain patient demographics, comorbidities, surgical technique, and other perioperative information. Univariate and multivariate logistic regression was performed. RESULTS: Eighteen (60%) patients underwent double incision mastectomy with free-nipple graft (DIM+FNG), whereas 8 (26.67%) patients had DIM+FNG and neurotization, 3 (10%) underwent periareolar incision mastectomy, and 1 (3.33%) patient had breast reduction. Mean BMI was 30.8 ± 7.4. The average overall satisfaction score was 2.76 out of 3. Higher BMI was significantly associated with lower postoperative body image scores (p = 0.029). Postoperative nipple sensation was significantly associated with higher average satisfaction scores with chest appearance (p = 0.02), the medical team (p = 0.02), nipple (p = 0.002), and overall satisfaction (p = 0.02; Table). In multivariate analysis controlling for other factors, higher BMI remained significantly associated with lower average body image scores (p = 0.023) and with lower average sexual satisfaction score (p = 0.016). Table. - Surgical Characteristics and Satisfaction Scores Variable Data Surgery technique (%) Double incision mastectomy with FNG 18 (60) Double incision mastectomy with FNG, neurotization 8 (26.67) Periareolar incision mastectomy 3 (10) Breast reduction 1 (3.33) Complications, n (%) Hematoma 3 (10) Average satisfaction scores, score (maximum) Body image 4.15 (5) Chest appearance 3.32 (5) Sexual intimacy 3.63 (5) Nipple 3.10 (4) Overall 2.76 (3) CONCLUSION: Higher BMI was associated with lower postoperative patient satisfaction scores, and therefore these patients should be counseled appropriately on postoperative expectations. Techniques to improve postoperative nipple sensation may improve patient satisfaction.

SUMMARYA multidisciplinary work group involving stakeholders from various backgrounds and societies convened to revise the guideline for reduction mammaplasty. The goal was to develop evidence-based patient care recommendations using the new American Society of Plastic Surgeons guideline methodology. The work group prioritized reviewing the evidence around the need for surgery as first-line treatment, regardless of resection weight or volume. Other factors evaluated included the need for drains, the need for postoperative oral antibiotics, risk factors that increase complications, a comparison in outcomes between the two most popular techniques (inferior and superomedial), the impact of local anesthetic on narcotic use and other nonnarcotic pain management strategies, the use of epinephrine, and the need for specimen pathology. A systematic literature review was performed, and an established appraisal process was used to rate the quality of relevant scientific research (Grading of Recommendations Assessment, Development and Evaluation methodology). Evidence-based recommendations were made and strength was determined based on the level of evidence and the assessment of benefits and harms.

Background Gender-affirmation surgery is a rapidly growing field in plastic surgery, urologic surgery, and gynecologic surgery. These procedures offer significant benefit to patients in reducing gender dysphoria and improving well-being. However, the details of gender-affirmation surgery are less well-known to other surgical subspecialties and other medical subspecialties. The data behind gender-affirmation surgery are comparatively sparse, and due to the recency of the field, large gaps exist in the literature. Methods PubMed searches were carried out specific to gender-affirming mastectomies, vaginoplasty, vulvaplasty, mastectomy, metoidioplasty, and phalloplasty. Combinations and variants of "gender affirming," "gender confirming," "transgender," and other variants were used to ensure broad capture. Historical articles were also reviewed. The data gathered were collated and summarized. Results Gender-affirmation surgery is generally safe. Complication rates for gender-affirming mastectomy and breast augmentation are very low, and complication rates for genital surgeries are also reasonably low. Gender-affirmation surgery decreases rates of gender dysphoria, depression, and suicidality, and significantly improves quality-of-life measures. Data regarding facial gender-affirming surgery are limited. There are very few patient-reported outcome measures specific to gender-affirmation surgery. Conclusion Although the data behind male-to-female gender-affirming surgery are more robust, there are significant gaps in the literature with respect to female-to-male surgery, surgical complication rates for genital surgery, facial masculinization and feminization, and patient-reported outcomes. We therefore present recommendations for further study.

Importance Vulvar reconstruction may be required after vulvectomy or any vulvar surgery. Providers should be familiar with techniques for reconstruction to improve clinical outcomes. Objective This article reviews the different techniques for reconstruction after vulvectomy and describes the decision-making process for selection of appropriate techniques, postoperative care, and expected outcomes. Evidence Acquisition A literature search was conducted, focusing on the plastic surgery and gynecologic oncology literature, using the following search terms: "vulvar reconstruction," "perineal reconstruction," "vulvectomy," and "vulvar cancer." The search was limited to English publications. Results Reconstruction after vulvectomy can be performed using a variety of techniques ranging from simple or complex closure to adjacent tissue rearrangement to skin grafting, locoregional, and free flaps. The appropriate technique is best chosen based on the characteristics of the patient and postablative defect, as well as the reconstructive goals. Postoperative complications are usually minor. Conclusions Vulvar reconstruction techniques vary widely and offer patients improved outcomes. Relevance Knowledge of vulvar reconstruction techniques is necessary for gynecologists performing vulvar surgery to ensure optimal patient outcomes. Target Audience Obstetricians and gynecologists, Family Physicians Learning Objectives After completing this activity, the learner should be better able to describe 3 different techniques of vulvar reconstruction; explain the factors involved in choosing a technique; and identify possible complications of vulvar reconstruction.

Importance: Hidradenitis suppurativa (HS) is a chronic, inflammatory disorder affecting skin of intertriginous areas that is often encountered and treated by nondermatologic specialists. Objective; The purpose of this literature review is to provide a comprehensive, clinical source of information on HS as it relates to incidence of disease, pathophysiology, diagnosis, and overall management of this condition. Evidence Acquisition: Sources were obtained through a comprehensive literature search using PubMed and PMC. Various terms were used to query the database, including "hidradenitis suppurativa," "pathogenesis," "prevalence," "management," "surgery," "perineal," and "vulva." Results: Underreported prevalence and unknown pathogenesis have subsequently led to variable approaches in clinical management, often employing a combination of medical and surgical management. Conclusion: Early diagnosis and treatment of HS may lead to better disease control and minimize patients' associated morbidity related to disease. Relevance: Knowledge of vulvoperineal hidradenitis is necessary for gynecologists and primary care physicians to ensure early diagnosis, management, and referral for optimal patient outcomes. Target Audience: Obstetricians and gynecologists, family physicians. Learning Objectives: After completing this activity, the learner should be better able to describe the presentation and staging of hidradenitis suppurativa; explain possible medical and surgical treatments; and identify options for correction of vulvar deformities.

Background Three-dimensional (3D) model printing improves visualization of anatomical structures in space compared to two-dimensional (2D) data and creates an exact model of the surgical site that can be used for reference during surgery. There is limited evidence on the effects of using 3D models in microsurgical reconstruction on improving clinical outcomes.Methods A retrospective review of patients undergoing reconstructive breast microsurgery procedures from 2017 to 2019 who received computed tomography angiography (CTA) scans only or with 3D models for preoperative surgical planning were performed. Preoperative decision-making to undergo a deep inferior epigastric perforator (DIEP) versus muscle-sparing transverse rectus abdominis myocutaneous (MS-TRAM) flap, as well as whether the decision changed during flap harvest and postoperative complications were tracked based on the preoperative imaging used. In addition, we describe three example cases showing direct application of 3D mold as an accurate model to guide intraoperative dissection in complex microsurgical reconstruction.Results Fifty-eight abdominal-based breast free-flaps performed using conventional CTA were compared with a matched cohort of 58 breast free-flaps performed with 3D model print. There was no flap loss in either group. There was a significant reduction in flap harvest time with use of 3D model (CTA vs. 3D, 117.7±14.2 minutes vs. 109.8±11.6 minutes; P=0.001). In addition, there was no change in preoperative decision on type of flap harvested in all cases in 3D print group (0%), compared with 24.1% change in conventional CTA group.Conclusions Use of 3D print model improves accuracy of preoperative planning and reduces flap harvest time with similar postoperative complications in complex microsurgical reconstruction.

Roberson, Mya L. MSPH; Strassle, Paula D. PhD, MSPH; Ogunleye, Adeyemi A. MD, SM Author Information

Background: Access to breast reconstruction is limited in low-income countries. Identifying current barriers that plague both providers and patients can inform future interventions focused on improving access to care. The goal of this study was to delineate perceptions of breast reconstruction among providers in West Africa and define current barriers to care. Methods: Surveys were administered to surgeons attending the annual meeting of the West African College of Surgeons in 2018. Surgeons were surveyed regarding their practices and perceptions of breast reconstruction. Information on barriers to breast reconstruction focused on patient- and surgeon-related factors was also obtained. A univariate analysis was performed to assess association of demographic and practice information with perceptions of reconstruction barriers. Results: Thirty-eight surgeons completed the questionnaires; 10 of the respondents were plastic surgeons (27%). The survey response rate was 40%. Factors that a majority of surgeons believed to limit access to reconstruction included limited experience (72.9%), resources (76.3%), and a lack of referrals for reconstruction (75%). In total, 76.5% of surgeons had performed <10 breast reconstruction cases in the past year. Two patient factors highlighted by most surgeons (>80%) were a lack of knowledge and concerns about cost. Conclusions: Perspectives from surgeons in the West African College of Surgeons suggest that barriers in access, patient awareness, surgeon technical expertise, and cost limit the delivery of breast reconstructive services to women in the region. Implementation of interventions focused on these specific metrics may serve as valuable first steps in the movement to increase access to breast reconstruction.