BACKGROUND:Breast aesthetics impacts patients' quality of life after breast reconstruction, but patients and surgeons frequently disagree on the final aesthetic evaluation. The need for a comprehensive, validated tool to evaluate breast aesthetics independently from the patient motivated this study.METHODS:The 13-item Validated Breast Aesthetic Scale was developed after several internal meetings, and worded to be understood by a nonspecialist. Three items are common for both breasts, with the remaining being side-specific. To test the internal consistency of the scale subitems, postoperative photographs after different breast reconstruction techniques were graded by a six-member panel. To test interrater and intrarater correlation across time, four physicians evaluated the results of abdominally based breast reconstructions following nipple-sparing mastectomies.RESULTS:Graded aesthetic outcomes of 53 patients showed that the Cronbach alpha of the subitems of the scale was 0.926, with no single item that, if excluded, would increase it. Twenty-two patients underwent aesthetic outcomes grading at four different time points. The mean overall appearance was 3.71 ± 0.62. The mean grade for overall nipple appearance was 4.0 ± 0.57. The coefficient alpha of the panel overall aesthetic grade across different time points was 0.957; whereas intragrader reliability for graders 1 through 4 individually showed alpha coefficients of 0.894, 0.9, 0.898, and 0.688, respectively. Similar results were found for the other items of the scale.CONCLUSIONS:The proposed aesthetic scale evaluates different aspects of the breast reconstruction aesthetic result with excellent internal consistency among its subitems. Grading by a gender-balanced, diverse four-member panel using postoperative photographs showed higher reliability and reproducibility compared to single graders.

PURPOSE:The toxicity profile of breast reconstruction with postmastectomy radiation therapy (PMRT) varies by technique and timing, and long-term data are limited. We compared rates of complications requiring reoperation (CRR) and reconstruction failure (RF) between immediate autologous reconstruction (I-AR), immediate tissue expander/implant reconstruction (I-TE/I), delayed autologous reconstruction (D-AR), and delayed tissue expander/implant reconstruction (D-TE/I) in patients receiving PMRT. METHODS AND MATERIALS:Patients who received autologous reconstruction (AR) or tissue expander/implant reconstruction (TE/I) and PMRT between 2000 to 2008 were included. Reconstruction was immediate if performed on the same day as mastectomy followed by PMRT (I-AR or I-TE/I) or delayed if after PMRT (D-AR and D-TE/I). CRR was defined as an unplanned return to the operating room for infection, dehiscence, necrosis, hematoma, or hernia (with AR) and extrusion, leak, or contracture (with TE/I). RF was defined as unplanned conversion to another reconstruction technique or to flat chest wall. Cumulative incidence of CRR and RF was calculated using Kaplan-Meier and compared using the log-rank test. Logistic regression was used to identify variables associated with CRR and RF. RESULTS:Two hundred four patients were included. Median follow-up was 8 years. There were 127 AR cases (63%) and 77 TE/I cases (38%). At 5 years, CRR was 18%, 38%, 34%, and 70% (P = .010) and RF was 4%, 22%, 7%, and 56% (P < .0001) for I-AR, I-TE/I, D-AR, and D-TE/I, respectively. On multivariate analysis, TE/I (hazard ratio [HR] 2.0; P = .011), body mass index ≥30 (HR 3.9; P = .002), and smoking (HR 2.7; P = .001) were significant predictors for CRR, and TE/I (HR 6.6; P < .0001), diabetes (HR 4.1; P = .044), and hypertension (HR 3.5; P = .005) were significant for RF. When excluding RF because of infection, the rate of RF was not significantly different among the 4 groups (P = .23). CONCLUSIONS:With PMRT, TE/I reconstruction in the immediate and delayed setting is associated with higher CRR and RF compared with AR. Patient factors should guide selection of technique. Efforts to reduce rates of RF with TE/I should focus on minimizing risks for infection.

Introduction: Chronic osteomyelitis is characterized by compromised blood supply and eventual osteonecrosis. Definitive treatment requires aggressive resection of affected bone. The resultant defect poses a unique challenge to reconstructive surgeons. Much of the literature on craniofacial osteomyelitis focuses on infection eradication, rather than subsequent reconstruction. This article reports representative cases from our experience with free flap reconstruction for defects secondary to chronic osteomyelitis of the craniofacial skeleton. Methods/Results: The authors selected 5 of the most difficult reconstructive cases of craniofacial osteomyelitis from our experience in a single tertiary referral institution with a follow-up of at least 6 months. Three of the 5 cases arose in the setting of previous head and neck cancer treated with resection and radiation therapy. One case had a previous surgical craniotomy complicated by osteomyelitis and multiple failed alloplastic reconstructions. The final case was due to multiple gunshots to the head, with subsequent cerebral and cranial abscess (>1000cc). In each case, the defect was successfully treated with free tissue transfer. Two cases required creation of recipient vessels with an arteriovenous loop. Conclusions: Free tissue transfer provides a versatile and effective tool in the reconstruction of extensive craniofacial osteomyelitis defects. Furthermore, the addition of vascularized tissue can protect against further episodes of osteomyelitis. Finally, arteriovenous loops can be employed successfully when prior radiation and infection of the wound bed precludes the use of local recipient target vessels.

Salvage mastectomy (SM) is the standard of care for patients with local recurrence (LR) after breast conservation therapy (BCT), often with immediate reconstruction. Complications of reconstruction are a concern for these patients, and long-term data are limited. We sought to compare rates of complications requiring re-operation (CRR) and reconstruction failure (RF) between autologous reconstruction (AR) and tissue expander/implant reconstruction (TE/I). Patients with locally recurrent breast cancer after BCT, treated with SM and immediate AR or TE/I between 2000 and 2008, were identified. CRR was defined as unplanned return to operating room for wound infection, dehiscence, necrosis (including flap, skin, or fat), hematoma, or hernia (for AR) and extrusion, leak, or capsular contracture (for TE/I). RF was defined as conversion to another reconstruction technique or to flat chest wall. This study included 103 patients with 107 reconstructions. Median follow-up was 6.6 years. CRR and RF were significantly higher with TE/I (n = 34) compared to AR (n = 73) at 5 years (50.9% vs 25.5%; P = 0.02) and (42.1% vs 5.8%; P < 0.001). On univariate analysis (UVA), TE/I (HR = 2.14; P = 0.02) and diabetes (HR = 5.10; P = 0.007) were significant predictors for CRR. On UVA, TE/I (HR = 7.30; P < 0.001) and older age at reconstruction (HR = 1.03; P = 0.003) were significant predictors for RF. In this population of previously irradiated patients, TE/I was associated with significantly higher CRR and RF. Complications continue to occur up to 10 years after TE/I. AR should be considered in appropriately selected patients, though TE/I may remain a reasonable option in patients without high-risk factors for surgical complications.

Background: The muscle-sparing descending branch latissimus dorsi muscle (MSLD) flap is a versatile flap with numerous benefits. It is an often overlooked but useful option when considering free flap donors. In this article, the authors present the largest experience with the MSLD flap, with focus on its use in lower extremity reconstruction. Methods: Patients undergoing lower extremity reconstruction with the MSLD flap at a single institution from 2012 to 2017 were identified. Patient and wound characteristics, surgical details, complications, and outcomes were examined. Outcomes were compared to a cohort who underwent lower extremity reconstruction with other free muscle flaps during the same period. Results: Thirty-six consecutive patients who underwent MSLD flap surgery were identified. Mean follow-up was 18.8 months. Mean body mass index was 29.2 kg/m2 and 56 percent were smokers. The most common wound causes were motor vehicle collision (46 percent) and fall (22 percent). The most common anatomical location was the distal third of the tibia (33 percent). Mean operative time was 380 minutes. Complications included three total losses (8 percent) and one partial loss (3 percent). No donor-site seromas were reported. Four patients required subsequent amputation for orthopedic issues (nonunion/pain). Patients receiving MSLD and other flaps had similar rates of amputation, donor- and recipient-site complications, and ambulation status (p > 0.05). Conclusions: The MSLD flap is a useful and reliable option for free flap reconstruction of the lower extremity. Advantages include an easily contourable flap, low revision rate, low complication rate, and the ability to harvest in supine position. In addition, the MSLD flap preserves donor function useful for rehabilitation and minimizes seroma risk. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Myopericytoma is a slow-growing, benign soft tissue neoplasm that arises from perivascular smooth muscle cells. This tumor is a rare entity itself, but it is only scarcely mentioned in the literature occurring secondary to trauma. The authors report a 21-year-old male patient who presented with a pulsatile mass in the medial canthal area where he had experienced previous trauma from a car accident 1-year prior. The mass was excised and histopathology revealed myopericytoma. This clinical report adds to the limited body of evidence supporting trauma as an etiology for this rare tumor.

Introduction: Despite the advances in cutaneous melanoma management, the false-negative rates (FNRs) of sentinel lymph node biopsy (SLNB) are still high. These rates are dependent not only on the technique but also on definitional terms and percentage of head/neck melanoma (highest false-negative SLNB). Fluorescence imaging technology is well acquainted in plastic surgery and other specialties. Having demonstrated that fluorescence-assisted SLNB is effective in melanoma, we are interested in determining its FNR. Methods: We obtained institutional review board approval to follow up prospectively all patients with cutaneous melanoma who underwent radioisotope/fluorescence-assisted SLNB with the intent to capture 100 negative SLNB patients. Inclusion criteria were as follows: (1) National Comprehensive Cancer Network criteria; (2) an SLNB report; (3) at least 24 months of follow-up in the negative SLNB group. The outcome variables were FNR and adjusted FNR of SLNB, considering the criterion standard of assessing the accuracy of SNLB. The FNR was defined as the proportion of patients with false-negative SLNB to patients with true-positive and false-negative SLNB [false negative/(false negative + true positive)]. Adjusted FNR refers to the previously described false-negative SLNB, but in the absence of local/in-transit recurrence or distant metastases. Furthermore, false-negative incidence (false-negative/negative SLNB patients) was also calculated. Length of follow-up was date of surgery to the date of last follow-up/death. Results: A total of 125 participants, with 52.0% being male and 48.0% being female, were included. One hundred patients had an SLNB negative for metastases, whereas the rest had positive SLNB results. Median follow-up time of the cohort and that of the negative SLNB group were 36.7 (2.6-58.5) and 37.9 (24.0-58.5) months, respectively. A relatively high number (24.8%) of head/neck melanoma were included. We identified 2 cases of false-negative SLNB, with one having intransit metastases. Thus, the FNR and adjusted FNR were 7.4% and 3.7%, respectively. The false-negative incidence and adjusted false-negative incidence were 2.0% and 1.0%, respectively. Conclusions: This is the first prospective study examining the FNR of fluorescence-assisted SLNB for patients with cutaneous melanoma. Our study reveals that this technique has one of the lowest FNRs published, especially considering the large percentage of participants with head/neck melanoma involved.

Background: Recent studies reviewing large patient databases suggested that age may be an independent risk factor for abdominoplasty. However, these investigations by design considered only short-term major complications.Objectives: The purpose of this investigation was: (1) to compare the safety of abdominoplasty in an elderly and younger patient population; (2) to determine the complication rates across all spectrums: major, minor, local, and systemic; and (3) to evaluate complications occurring both short and long term.Methods: Abdominoplasty procedures performed from 2010 to 2015 were retrospectively reviewed. Subjects were divided into two groups: <= 59 years old and >= 60 years old. Major, minor, local, and systemic complications were analyzed. Patient demographics, comorbidities, perioperative details, adjunctive procedures were also assessed.Results: A total of 129 patients were included in the study: 43 in the older and 86 in the younger age group. The median age of the elderly and young groups was 65.0 and 41.5 years, respectively (P < 0.001). No statistically significant differences in major, minor, local, or systemic complications were found when both age groups were compared. Major local, major systemic, minor local, and minor systemic in the elderly were 6.9%, 2.3%, 18.6%, and 2.3%, while in the younger patients were 9.3%, 4.7%, 10.5%, and 0.0%, respectively (P > 0.05). Median follow-up time of the elderly (4.0 months) was no different than the younger (5.0 months) patients (P > 0.07). Median procedure time in the elderly (4.5 hours) was no different than the younger group (5.0 hours) (P = 0.4). The elderly exhibited a greater American Society of Anesthesiologist score, median body mass index (28.7 vs 25.1 kg/m(2)), and number of comorbidities (2.7 vs 0.9) (P < 0.001).Conclusions: There was no significant difference in either major or minor complications between the two groups. This suggests that with proper patient selection, abdominoplasty can be safely performed in the older age patient population.

Introduction: Large scalp soft tissue defects can present difficulties with reconstruction. The ideal flap for scalp reconstruction has yet to be described although the latissimus dorsi flap is frequently referred to as the first choice in this setting.Patients and Methods: Following institutional review board approval, the authors reviewed their experience in scalp reconstruction for the past 4 years. Patient demographics, reconstruction indication, flap choice, complications, and outcomes were recorded.Results: Thirteen patients underwent scalp reconstruction with an anterolateral thigh (ALT) free flap. In most patients, the indication was resection of a cutaneous malignancy. In all but 1 patient the facial or more proximal vessels were used for anastomosis. None of the patients required vein grafts to increase pedicle length. The median flap surface area was 156 cm(2). One flap had vascular compromise. All donor sites healed without complications.Discussion: The ALT flap can emerge as the flap of choice for scalp reconstruction, even when proximal neck vessels are used as the recipient targets. Using a suprafascial dissection and extending the vascular pedicle to the profunda femoris artery can optimize its role in this setting. The ALT flap provides excellent cosmesis and durable scalp coverage with minimal donor site morbidity.

Background The medial gastrocnemius muscle flap is commonly used for the reconstruction of defects around the knee and proximal leg. The flap can be raised using either a medial or a posterior midline incision, although no studies have been done comparing the 2 different surgical approaches. Methods We compared the reach of the medial gastrocnemius muscle flap using either of the 2 incisions in a series of 25 fresh cadavers. All muscle flaps were elevated without division of the muscle origin. Muscle reach was calculated using the distance from a fixed bony point with the leg fully extended and the muscle under no tension. Muscle width measurements were used to calculate surface area of coverage. Results Muscle flaps elevated through the posterior midline incision group reached 2.02 cm farther than flaps through the medial incision (P < 0.05). This resulted in 20.3 cm2 increase in surface area for the posterior midline incision group over the medial incision group (P < 0.05). The posterior midline incision allowed for better visualization of the vascular pedicle and dissection of fascial attachments around the pes anserinus. Conclusions The posterior midline incision for the elevation of the medial gastrocnemius pedicled muscle flap allows for a safe, thorough mobilization of the muscle resulting in increased muscle reach and increased surface area when compared with the medial incision. Furthermore, the posterior midline incision provides better access to the gastrocnemius muscle origin and the lateral muscle head.

A breast cancer diagnosis imposes significant emotional and psychological duress. The purpose of this study is to assess the baseline quality of life (QOL) of immediate, delayed, and secondary breast reconstruction patients, comparing these results with QOL in women seeking plastic surgery for cosmetic breast, and non-breast procedures.From 2012 through 2013, immediate (group 1), delayed (group 2), and secondary (Group 3) reconstruction patients, aesthetic breast (group 4) and non-breast plastic surgery patients (group 5) answered Breast-Q questionnaires.Groups 1, 2, 3, 4, and 5 answered 141, 12, 23, 72 and 160 preoperative questionnaires respectively. There was no difference (p = NS) in breast satisfaction, psychosocial wellbeing, physical well-being-chest, and sexual well-being between groups 1 and 5. Group 1 had higher satisfaction with breast (p < 0.01), psychosocial (p < 0.01) and sexual well-being (p < 0.01) when compared to groups 2 and 4. Group 1 had higher satisfaction with breasts (p < 0.01) compared to group 3. Group 4 did not differ in satisfaction with breasts, psychosocial, and sexual well-being, compared to groups 2 and 3. Group 4 had lower scores in all domains, compared to groups 1 and 5 (p < 0.01). No significant difference in QOL was found between groups 2 and 3.Preoperatively, immediate reconstruction patients had similar satisfaction with breasts, psychosocial well-being, and chest physical well-being, compared to non-breast plastic surgery patients.Aesthetic breast surgery patients demonstrate similar low scores in satisfaction with breasts, psychosocial well-being, and sexual well-being to those of patients prior to delayed breast reconstruction, or secondary salvage procedures. (C) 2016 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

Purpose The purpose of this study was to analyze timing and frequency of complications following free tissue autologous reconstruction in a single tertiary care institution. Methods From August 2012 to December 2013, all patients operated on for abdominal-based free flap breast reconstruction at a single institution were included. Complications were identified and risk factors associated with them were analyzed using SPSS software. Results The total number of patients was 130 with a total of 191 flaps (69 for unilateral and 61 for bilateral reconstructions). Mean surgery time was 570.5 min (±151.24). Fifty-nine of the reconstructed breasts (30.8 %) had early complications. Reoperations due to complications were required in 16 (8.3 %) of the breasts during the first 30 days with seven patients requiring multiple reoperations. Twenty-eight patients required reoperations after 30 days, the most frequent reason being delayed wound healing and abdominal hernia. The most significant complication was a case of disseminated infection with loss of skin coverage of the breasts. Early complications and donor-site complications were higher in active smokers ( p = 0.005 and p < 0.001, respectively). Patients with a BMI < 25 had fewer total early complications ( p = 0.05), as well as fewer complications on the breast area ( p = 0.02). A longer time in the operating room was associated with an increase in late complications ( p = 0.018). Bilateral/unilateral operation, immediate/delayed surgery, radiotherapy, age, hypertension, diabetes, and surgery time were not associated with early complications, late complications, or reoperations ( p > 0.05). Conclusions Active smoking was found to be a significant risk factor for early complications, reoperations, and donor-site complications. Patients with a normal BMI had fewer early complications, reoperations at 30 days, and complications on the breast area. As a significant number of complications occurred beyond the standard 30-day reporting period, it is important to consider reoperations during an extended period. 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 .

Duraes, Eliana F.R. MD; Durand, Paul MD; Morisda, Megan; Baker, Todd A. MD; Rueda, Steven MD; Djohan, Risal MD; Moreira, Andrea MD; Bernard, Steven MD; de Sousa, Joao Batista MD, PhD; Schwarz, Graham S. MD, FACS Author Information

Purpose/Objective(s)To evaluate long term rates of reoperation and toxicity following mastectomy and tissue expander (M/TE) based reconstruction, and to explore the effect of radiotherapy (RT) on toxicity with breast reconstruction.Materials/MethodsAll patients undergoing M/TE between January 2000 and October 2007 at a single tertiary care institution were retrospectively reviewed. Major toxicity was defined as any blood transfusion, hematoma or seroma requiring reoperation, capsular contracture (Baker grade III-IV or requiring reoperation), wound infection requiring home IV antibiotics or implant removal, wound dehiscence, implant leak, or extrusion. Risk factors for reoperation or major toxicity were evaluated using Cox proportional hazards regression analysis. Rates of reoperation and toxicity were determined by Kaplan-Meier method. Likelihood ratios were used for association between individual toxicities and RT parameters.ResultsFive hundred ninety-three patients with 785 M/TE were identified, with a median follow-up of 6.5 years. Overall, 53% of M/TE were conducted for invasive cancer, 19% for DCIS, and 22% were prophylactic. The median age was 45 years (range, 32-84), and BMI was 28.4 (range, 16.4-47.3); 17.5% had hypertension and 3.2% had diabetes. One hundred thirty-two patients (16.8%) received RT to a median dose of 50 Gy (range, 40-50.4). In 67% bolus was applied to the skin, and 39% received a chest wall boost to a median dose of 10 Gy (range, 10-16.2). On univariate analysis, hypertension, diabetes and RT were significantly associated with major toxicity (p = 0.0045, 0.046, and < 0.0001, respectively). On multivariable analysis, hypertension and RT remained significant predictors of major toxicity (HR = 2.64, p = 0.0094, and HR = 1.62, p < 0.0001, respectively). Major toxicity was significantly increased with RT vs. no RT at 5 (51.6% vs 25%) and 10 years (62.2% vs 29.7%), p < 0.0001. Rates of reoperation similarly increased with RT vs. no RT at 5 (52.8% vs 29.8%) and 10 years (59.5% vs 37.3%), p < 0.0001. RT was associated with higher odds of wound infection (OR = 2.51, p = 0.0002), wound dehiscence (OR = 3.92, p = 0.0001), capsular contracture (OR = 3.48, p = 0.0001), and implant extrusion (OR = 8.00, p = 0.0001). While RT timing, use of skin bolus or chest wall boost were not significantly associated with major toxicity, chest wall boost was significantly associated with implant extrusion (OR = 3.65, p = 0.04).ConclusionsThis represents one of the largest reported series examining toxicity following M/TE reconstruction, with a median follow-up of 6.5 years. Rates of long-term major toxicity and reoperation following M/TE are significant, and RT is the strongest predictor of toxicity. RT is particularly associated with increased rates of wound infection, wound dehiscence, capsular contracture, and implant extrusion. Purpose/Objective(s)To evaluate long term rates of reoperation and toxicity following mastectomy and tissue expander (M/TE) based reconstruction, and to explore the effect of radiotherapy (RT) on toxicity with breast reconstruction. To evaluate long term rates of reoperation and toxicity following mastectomy and tissue expander (M/TE) based reconstruction, and to explore the effect of radiotherapy (RT) on toxicity with breast reconstruction. Materials/MethodsAll patients undergoing M/TE between January 2000 and October 2007 at a single tertiary care institution were retrospectively reviewed. Major toxicity was defined as any blood transfusion, hematoma or seroma requiring reoperation, capsular contracture (Baker grade III-IV or requiring reoperation), wound infection requiring home IV antibiotics or implant removal, wound dehiscence, implant leak, or extrusion. Risk factors for reoperation or major toxicity were evaluated using Cox proportional hazards regression analysis. Rates of reoperation and toxicity were determined by Kaplan-Meier method. Likelihood ratios were used for association between individual toxicities and RT parameters. All patients undergoing M/TE between January 2000 and October 2007 at a single tertiary care institution were retrospectively reviewed. Major toxicity was defined as any blood transfusion, hematoma or seroma requiring reoperation, capsular contracture (Baker grade III-IV or requiring reoperation), wound infection requiring home IV antibiotics or implant removal, wound dehiscence, implant leak, or extrusion. Risk factors for reoperation or major toxicity were evaluated using Cox proportional hazards regression analysis. Rates of reoperation and toxicity were determined by Kaplan-Meier method. Likelihood ratios were used for association between individual toxicities and RT parameters. ResultsFive hundred ninety-three patients with 785 M/TE were identified, with a median follow-up of 6.5 years. Overall, 53% of M/TE were conducted for invasive cancer, 19% for DCIS, and 22% were prophylactic. The median age was 45 years (range, 32-84), and BMI was 28.4 (range, 16.4-47.3); 17.5% had hypertension and 3.2% had diabetes. One hundred thirty-two patients (16.8%) received RT to a median dose of 50 Gy (range, 40-50.4). In 67% bolus was applied to the skin, and 39% received a chest wall boost to a median dose of 10 Gy (range, 10-16.2). On univariate analysis, hypertension, diabetes and RT were significantly associated with major toxicity (p = 0.0045, 0.046, and < 0.0001, respectively). On multivariable analysis, hypertension and RT remained significant predictors of major toxicity (HR = 2.64, p = 0.0094, and HR = 1.62, p < 0.0001, respectively). Major toxicity was significantly increased with RT vs. no RT at 5 (51.6% vs 25%) and 10 years (62.2% vs 29.7%), p < 0.0001. Rates of reoperation similarly increased with RT vs. no RT at 5 (52.8% vs 29.8%) and 10 years (59.5% vs 37.3%), p < 0.0001. RT was associated with higher odds of wound infection (OR = 2.51, p = 0.0002), wound dehiscence (OR = 3.92, p = 0.0001), capsular contracture (OR = 3.48, p = 0.0001), and implant extrusion (OR = 8.00, p = 0.0001). While RT timing, use of skin bolus or chest wall boost were not significantly associated with major toxicity, chest wall boost was significantly associated with implant extrusion (OR = 3.65, p = 0.04). Five hundred ninety-three patients with 785 M/TE were identified, with a median follow-up of 6.5 years. Overall, 53% of M/TE were conducted for invasive cancer, 19% for DCIS, and 22% were prophylactic. The median age was 45 years (range, 32-84), and BMI was 28.4 (range, 16.4-47.3); 17.5% had hypertension and 3.2% had diabetes. One hundred thirty-two patients (16.8%) received RT to a median dose of 50 Gy (range, 40-50.4). In 67% bolus was applied to the skin, and 39% received a chest wall boost to a median dose of 10 Gy (range, 10-16.2). On univariate analysis, hypertension, diabetes and RT were significantly associated with major toxicity (p = 0.0045, 0.046, and < 0.0001, respectively). On multivariable analysis, hypertension and RT remained significant predictors of major toxicity (HR = 2.64, p = 0.0094, and HR = 1.62, p < 0.0001, respectively). Major toxicity was significantly increased with RT vs. no RT at 5 (51.6% vs 25%) and 10 years (62.2% vs 29.7%), p < 0.0001. Rates of reoperation similarly increased with RT vs. no RT at 5 (52.8% vs 29.8%) and 10 years (59.5% vs 37.3%), p < 0.0001. RT was associated with higher odds of wound infection (OR = 2.51, p = 0.0002), wound dehiscence (OR = 3.92, p = 0.0001), capsular contracture (OR = 3.48, p = 0.0001), and implant extrusion (OR = 8.00, p = 0.0001). While RT timing, use of skin bolus or chest wall boost were not significantly associated with major toxicity, chest wall boost was significantly associated with implant extrusion (OR = 3.65, p = 0.04). ConclusionsThis represents one of the largest reported series examining toxicity following M/TE reconstruction, with a median follow-up of 6.5 years. Rates of long-term major toxicity and reoperation following M/TE are significant, and RT is the strongest predictor of toxicity. RT is particularly associated with increased rates of wound infection, wound dehiscence, capsular contracture, and implant extrusion. This represents one of the largest reported series examining toxicity following M/TE reconstruction, with a median follow-up of 6.5 years. Rates of long-term major toxicity and reoperation following M/TE are significant, and RT is the strongest predictor of toxicity. RT is particularly associated with increased rates of wound infection, wound dehiscence, capsular contracture, and implant extrusion.

Fat embolism syndrome (FES) is a rare but potentially fatal postoperative complication from liposuction. We present the case of a 24-year-old woman with Klippel-Trenaunay syndrome who developed FES as a complication of lower extremity liposuction. There may be an increased risk of FES in patients with vascular malformations undergoing liposuction.