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Abstract Objectives To conduct a pilot population-based study within a general practice catchment area to determine whether the incidence of breast cancer was increased in the Ashkenazi population. Design Population-based cohort study. Setting A single general practice catchment area in North London. Participants 1947 women over the age of 16 who responded to a questionnaire about ethnicity and breast cancer. Main outcome measures Incidence of breast cancer, ethnicity. Results This study showed a 1.5-fold (95% CI 0.93–2.39) increase in breast cancer risk in the Ashkenazim compared with the non-Ashkenazi white population. The increased incidence was for both premenopausal and postmenopausal breast cancer (expected incidence pre:post is 1:4 whereas in the Ashkenazim it was 1:1; 51 and 52% of cases respectively). This increase was not shown in the Sephardim. Asians had a reduction in incidence (OR = 0.44; 95% CI 0.10–1.89). Results were adjusted for other risk factors for breast cancer. Conclusion This study showed a 1.5-fold increase in breast cancer rates in Ashkenazim compared with the non-Jewish white population when adjusted for age (i.e. corrections were made to allow comparison of age groups) and this is not observed in the Sephardic population. The proportion of premenopausal breast cancer was just over double that of the general population. This is the first general practice population-based study in the UK to address this issue and has implications for general practitioners who care for patients from the Ashkenazi community.

Introduction: With advances in AI and machine learning, platforms like OpenAI's ChatGPT are emerging as educational resources. While these platforms offer easy access and user-friendliness due to their personalized conversational responses, concerns about the accuracy and reliability of their information persist. As one of the most common surgical procedures performed by plastic surgeons worldwide, breast reduction surgery (BRS) offers relief for the physical and emotional burdens of large breasts. However, like any surgical procedure, it can raise a multitude of questions and anxiety., Methods: To evaluate the quality of medical information provided by ChatGPT in response to common patient inquiries about breast reduction surgery, we developed a 15-question questionnaire with typical patient questions about BRS. These questions were presented to ChatGPT, and the answers were compiled and presented to five board-certified plastic surgeons. Each specialist categorized the response as (1) Appropriate, the response accurately reflects current medical knowledge and best practices for BRS; (2) No, not thorough, the response lacks sufficient detail to be a helpful educational resource; (3) No, inaccurate, the response contains misleading or incorrect information., Results: A total of 75 survey responses were obtained, with five experts each analyzing 15 answers from ChatGPT. Of these, 69 (92%) responses were determined to be accurate. However, six (8%) responses were concerning to our experts: four (5.3%) lacked detail, and two (2.7%) were found to be inaccurate. Chi-square analysis revealed no statistical significance in the distribution of responses categorized as "accurate" versus "not thorough/inaccurate," and "not thorough" versus "inaccurate" (p=0.778 and p=0.306, respectively)., Conclusion: While ChatGPT can provide patients with basic background knowledge on BRS and empower patients to ask more informed questions during consultations, it should not replace the consultation and expert guidance of a board-certified plastic surgeon., Competing Interests: Human subjects: All authors have confirmed that this study did not involve human participants or tissue. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Brito et al.)

Pseudoangiomatous stromal hyperplasia (PASH) is a benign but rare mesenchymal proliferation of the mammary stroma, characterized by pseudovascular spaces within a hyperplastic matrix. PASH can be classified as either non-tumor-forming or tumor-forming. The non-tumor-forming type is an infiltrative and clinically undetectable mass, incidentally found in approximately a quarter of breast biopsies. Tumor-forming PASH, however, is a rare neoplasm of the breast parenchyma, with its occurrence in extra-mammary sites, such as the axilla, reported in less than a dozen cases. We report the case of a 38-year-old female who presented with bilateral, progressively enlarging axillary growths. Following mammography, which classified the masses as breast imaging-reporting and data system (BI-RADS) 2, the patient underwent bilateral subcutaneous mastectomy for the excision of the axillary ectopic breast tissue. Final pathology revealed PASH with complete excision. This report highlights the importance of including PASH as a differential diagnosis for any mass presenting along the mammary ridge. Diagnosing and properly managing this rare neoplasm require a nuanced examination integrating clinical, radiological, and histopathological perspectives., Competing Interests: Human subjects: Consent for treatment and open access publication was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Natoli et al.)

Background Traditional methods for assessing facial beauty rely on subjective measures like averages or "golden ratios." However, artificial intelligence (AI) offers a data-driven approach to analyzing attractiveness. This study explores how AI-generated beauty criteria compare to established ideals, considering cultural influences and the evolving concept of beauty. Methods To explore how AI-generated beauty ideals compare to traditional standards, we used three AI text-to-image generation tools (Dezgo (Dezgo SAS LLC, France), Freepik (FreePik Company, Malaga, Spain), and ImagineArt (Vyro, Islamabad, Pakistan)) to create images from a specific prompt. The first four generated images for each gender that met our criteria were included in this study. A single researcher used MediaPipe Studio software to identify ten key facial landmarks on each image. Landmark distances were measured twice in Adobe Photoshop 2023 (Adobe, San Jose, California, United States) and averaged for each measurement. The average values were then used to calculate 23 facial proportion ratios based on established neoclassical canons and golden facial ratios. We then compared these AI-generated ratios to the ideal values using one-sample t-tests in IBM SPSS Statistics for Windows, Version 29 (Released 2023; IBM Corp., Armonk, New York, United States), p < 0.05 significance, to assess alignment with traditional beauty standards. Results AI-generated faces displayed statistically significant differences, p < 0.05, from established beauty standards in both neoclassical canons and golden ratios for both males and females. Differences were seen in facial width, upper and lower face proportions, and eye symmetry. Conclusion AI-generated faces deviated from traditional beauty standards of neoclassical canons and golden ratios for both genders. This suggests AI incorporates factors beyond established ideals, potentially reflecting contemporary preferences, cultural biases, or emerging trends., Competing Interests: Human subjects: All authors have confirmed that this study did not involve human participants or tissue. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Bernal et al.)

As more female surgical residents choose to start families during training, concerns regarding program support and peer perceptions emerge. Delayed parenthood, stress, and even attrition can result from inadequate support systems. Database search (MEDLINE, PubMed, EMBASE) in June 2022 identified 17 relevant studies published between 2012-2022, including systematic reviews and qualitative surveys, focused on surgical residents/fellows and program directors. The thematic analysis explored themes related to supporting residents navigating parenthood. Thematic analysis of 17 studies (systematic reviews and qualitative surveys with residents/fellows and program directors) identified key recurring themes related to challenges experienced by surgical residents navigating parenthood. The themes included modified work schedules, mentorship programs, cross-coverage plans, lactation support, childcare options, and clear leave policies. By understanding these challenges and implementing tailored support strategies, surgical residency programs can foster a more inclusive and supportive environment for residents starting families. This can improve resident well-being, reduce attrition, and create a significantly more enjoyable training experience for all involved. This review aims to provide insight into residents' difficulties while pregnant or considering pregnancy and identify changes programs could implement to promote a more supportive culture for pregnant residents., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2024, Bernal et al.)

Background: In recent years, indocyanine green angiography (ICG-A) has been used increasingly to assist tissue perfusion assessments during plastic and reconstructive surgery procedures, but no guidelines exist regarding its use. We sought to identify areas of consensus and non-consensus among international experts on the use of ICG-A for tissue-perfusion assessments during plastic and reconstructive surgery., Methods: A two-round, online Delphi survey was conducted of 22 international experts from four continents asking them to vote on 79 statements divided into five modules: module 1 = patient preparation and contraindications (n = 11 statements); module 2 = ICG administration and camera settings (n = 17); module 3 = other factors impacting perfusion assessments (n = 10); module 4 = specific indications, including trauma debridement (n = 9), mastectomy skin flaps (n = 6), and free flap reconstruction (n = 8); and module 5 = general advantages and disadvantages, training, insurance coverage issues, and future directions (n = 18). Consensus was defined as ≥70% inter-voter agreement., Results: Consensus was reached on 73/79 statements, including the overall value, advantages, and limitations of ICG-A in numerous surgical settings; also, on the dose (0.05 mg/kg) and timing of ICG administration (∼20-60 seconds preassessment) and best camera angle (61-90 o ) and target-to-tissue distance (20-30 cm). However, consensus also was reached that camera angle and distance can vary, depending on the make of camera, and that further research is necessary to technically optimize this imaging tool. The experts also agreed that ambient light, patient body temperature, and vasopressor use impact perfusion assessments., Conclusion: ICG-A aids perfusion assessments during plastic and reconstructive surgery and should no longer be considered experimental. It has become an important surgical tool., (Copyright © 2022 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Perineal wound complications after extralevator abdominoperineal resection for cancer are common with no consensus on optimal reconstructive technique. We compared short- and long-term results of laparoscopic abdominoperineal resection with open surgery ± vertical rectus abdominis myocutaneous flap., Methods: This is a single-institution retrospective observational study of 204 consecutive patients with advanced low rectal cancer who underwent extralevator abdominoperineal resection from January 2010 to August 2020. Main outcome measures were short-term results, wound complications, and incisional, parastomal, and perineal hernia rates., Results: Fifty-five (27%) patients had a laparoscopic approach, 80 (39%) open, and 69 (33%) open + vertical rectus abdominis myocutaneous flap. The groups had similar median length of follow up (P = .75). Patients' age and radiation, intraoperative and postoperative complications, mortality, and readmission rates were similar among the 3 groups. Perineal wound infection and dehiscence rates were not influenced by surgical approach. Laparoscopy resulted in higher perineal (7.3 vs 2.5 vs 0%; P = .047) and parastomal (23.6 vs 13.8 vs 5.8%; P = .016) hernia rates than did open or open + vertical rectus abdominis myocutaneous flap. Patients who underwent an open approach had a higher body mass index and rate of prior surgeries and preoperative ostomies. Laparoscopic and open approaches had significantly shorter operative times (300 vs 303 vs 404 minutes, respectively; P < .001) and shorter length of stay (7.6 vs 10.8 vs 11.12, respectively; P = .006) compared to open with a flap approach., Conclusion: Open and open + vertical rectus abdominis myocutaneous flap approaches for reconstruction after abdominoperineal resection had lower parastomal and perineal hernias rates but similar postoperative morbidity as did the laparoscopic approach., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Although less common than other types of skin cancers, melanoma is accountable for the majority of skin cancer-related deaths. The standard management for patients with clinically negative nodes includes a sentinel lymph node (SLN) biopsy, which is commonly performed using a combination of radioactive tracer (Tc-99) and a blue dye (isosulfan or patent blue). There are numerous drawbacks associated with Tc-99 and blue dyes such as elevated costs, logistical challenges, and anaphylactic reactions among others. In recent years, near-infrared (NIR) fluorescence imaging using indocyanine green (ICG) has emerged as a safe, effective, less costly, and more convenient alternative for the identification of SLNs in melanoma. We discuss the case of a 51-year-old man with melanoma in his left upper back. Two SLNs in the left axilla were successfully identified using NIR fluorescence. NIR fluorescence with ICG for SLN identification has proven to increase the sensitivity and accuracy when used in combination with lymphoscintigraphy., Competing Interests: The senior author (Dr Martin I Newman) is a consultant and speaker for Stryker Corporation., (Copyright © 2021, Ferri et al.)

Background: Recent work suggests that bacterial biofilms play a role in capsular contracture (CC). However, traditional culture techniques provide only a limited understanding of the bacterial communities present within the contracted breast. Next generation sequencing (NGS) represents an evolution of polymerase chain reaction technology that can sequence all DNA present in a given sample., Objectives: The aim of this study was to utilize NGS to characterize the bacterial microbiome of the capsule in patients with CC following cosmetic breast augmentation., Methods: We evaluated 32 consecutive patients with Baker grade III or IV CC following augmentation mammoplasty. Specimens were obtained from all contracted breasts (n = 53) during capsulectomy. Tissue specimens from contracted capsules as well as intraoperative swabs of the breast capsule and implant surfaces were obtained. Samples were sent to MicroGenDX Laboratories (Lubbock, TX) for NGS., Results: Specimens collected from 18 of 32 patients (56%) revealed the presence of microbial DNA. The total number of positive samples was 22 of 53 (42%). Sequencing identified a total of 120 unique bacterial species and 6 unique fungal species. Specimens with microbial DNA yielded a mean [standard deviation] of 8.27 [4.8] microbial species per patient. The most frequently isolated species were Escherichia coli (25% of all isolates), Diaphorobacter nitroreducens (12%), Cutibacterium acnes (12%), Staphylococcus epidermidis (11%), fungal species (7%), and Staphylococcus aureus (6%)., Conclusions: NGS enables characterization of the bacterial ecosystem surrounding breast implants in unprecedented detail. This is a critical step towards understanding the role this microbiome plays in the development of CC., (© 2020 The Aesthetic Society. Reprints and permission: journals.permissions@oup.com.)

Background: Mastectomy flap necrosis remains a major cause of failed breast reconstruction with an associated significant financial/psychological burden. Language describing ischemic mastectomy flaps is imprecise as ischemia can result from many causes and can manifest in different ways. Similarly, management of mastectomy flap ischemia varies depending on its etiology. Intraoperative near-infrared imaging (NIR) with indocyanine green (ICG) is an established modality for evaluation of mastectomy flap perfusion. Herein, we define the types of flap ischemia demonstrated via NIR imaging and propose an algorithm for its management., Method: A retrospective review was performed of patients who underwent mastectomy and NIR imaging of mastectomy flaps from 2014 to 2017. Patient characteristics, operative details, and outcomes were recorded. Following retrospective review, distinct patterns of ischemia were identified, and a classification system and treatment algorithm were developed., Result: Type A; diffuse hypoperfusion can be caused by a number of factors (hypotension, vasoconstrictive agents, etc.). It is best treated with delayed reconstruction. Type B; geographic hypoperfusion may be caused by electro-cautery burn, inaccurate dissection, or retractor injury. It can be treated by resection/primary closure or delayed reconstruction. Type C; marginal/incisional hypoperfusion is best treated with debridement. Type D; diffuse marginal perfusion is seen with overfilled tissue-expanders or an oversized implant within a smaller skin envelope. Management includes deflation/downsizing. An algorithm was developed for treatment of the four ischemia types., Conclusion: NIR imaging aides in delineating the type of ischemic injury. Classification of mastectomy flap ischemia allows precise communication between providers and provides a framework for decision-making., Competing Interests: Declaration of Competing Interest None declared., (Copyright © 2020 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Background: The authors report their experience using extended transversely oriented skin paddles in muscle-sparing latissimus dorsi pedicled flaps for breast reconstruction as an alternative to thoracodorsal artery perforator flaps., Methods: A retrospective review was conducted of patients who underwent muscle-sparing latissimus dorsi flap pedicled breast reconstruction from January of 2009 to July of 2014 with at least 3-month follow-up. Surgical outcomes and complications were analyzed., Results: Fifty-three patients underwent a total of 81 muscle-sparing latissimus dorsi pedicled flaps for breast reconstruction. Extended transversely oriented skin paddles ranged from 7 to 9 cm vertically by 25 to 35 cm horizontally and were perfused by a strip of latissimus dorsi muscle that was approximately 25 percent of the total muscular volume. Twenty patients had indocyanine green angiography revealing three distinct zones of perfusion in the extended transversely oriented skin paddles. The area of earliest perfusion (designated zone 1) was directly over the muscle containing the perforators. The second best area of perfusion (zone 2) was lateral to the muscle (toward the axilla). The last and relatively least well-perfused area (zone 3) was medial to the muscle (toward the spine). Zone 3 still had adequate viability. There were no flap losses. Minor complications included wound infection [six of 81 (7.4 percent)], fat necrosis [three of 81 (3.7 percent)], and seroma [four of 81 (4.9 percent)]., Conclusions: Muscle-sparing latissimus dorsi pedicled flaps with extended transversely oriented skin paddles are reliable alternatives to thoracodorsal artery perforator flaps for breast reconstruction. Three zones of perfusion were delineated in the extended transversely oriented skin paddles on indocyanine green imaging, and all three zones were viable., Clinical Question/level of Evidence: Therapeutic, IV.

Background: The superomedial pedicle reduction mammaplasty has been noted in the literature to provide superior aesthetic results and longevity as well as shorter operative times. However, the inferior pedicle continues to be the most commonly utilized technique in the United States. There is a lack of large-volume outcome studies examining how the superomedial pedicle technique compares against more established reduction methods., Methods: A retrospective review of 938 reduction mammaplasties was performed at a single institution over a 10-year period. A literature review of superomedial and inferior pedicle complication rates were performed. Study variables were compared against overall mean complication rates for the two techniques. Logistic regression, paired student T-Tests, and Chi-square analyses were used to calculate adjusted odds ratios and to compare continuous and categorical variables., Results: Mean reduction weight was 730 g per breast, ranging from 100 to 4700 g. Overall complication rate was 16%, of which 10% were minor complications related to delayed wound healing. No cases of skin flap necrosis occurred. Increased complications were highly correlated with a BMI > 30, breast reduction weights > 831 g, and sternal notch to nipple distances > 35.5 cm., Conclusions: The superomedial pedicle reduction mammaplasty technique is safe and reliable with a complication rate lower than the inferior pedicle technique. Based on our findings we propose that residents should be exposed to this method of reduction mammaplasty as part of a compilation of techniques learned in residency and that practicing surgeons would benefit from becoming familiar with its applications., (Copyright © 2018. Published by Elsevier Ltd.)

Enhanced recovery after surgery is a multidisciplinary perioperative clinical pathway that uses evidence-based interventions to improve the patient experience as well as increase satisfaction, reduce costs, mitigate the surgical stress response, accelerate functional recovery, and decrease perioperative complications. One of the most important elements of enhanced recovery pathways is multimodal pain management. Herein, aspects relating to multimodal analgesia following breast surgical procedures are discussed with the understanding that treatment decisions should be individualized and guided by sound clinical judgment. A review of liposomal bupivacaine, a prolonged-release formulation of bupivacaine, in the management of postoperative pain following breast surgical procedures is presented, and technical guidance regarding optimal administration of liposomal bupivacaine is provided.

Anastomotic leaks represent one of the most alarming complications following any gastrointestinal anastomosis due to the substantial effects on post-operative morbidity and mortality of the patient with long-lasting effects on the functional and oncologic outcomes. There is a lack of consensus related to the definition of an anastomotic leak, with a variety of options for prevention and management. A number of patient-related and technical risk factors have been found to be associated with the development of an anastomotic leak and have inspired the development of various preventative measures and technologies. The International Multispecialty Anastomotic Leak Global Improvement Exchange group was convened to establish a consensus on the definition of an anastomotic leak as well as to discuss the various diagnostic, preventative, and management measures currently available.

Background: Increasingly affordable three-dimensional (3D) printing technologies now make it possible for surgeons to create highly customizable patient-tailored products. This process provides the potential to produce individualized artificial and biologic implants, regenerative scaffolds, and cell-specific replacement tissue and organs. The combination of accurate volumetric analysis and production of 3D printed biologic materials are evolving techniques that demonstrate great promise in achieving an accurate and naturally appearing anthropomorphic reconstruction. This systematic review summarizes the current published literature and known ongoing research on 3D printing in the field of plastic and reconstructive surgery (PRS)., Methods: Three medical databases (PubMed, Ovid MEDLINE, and Google Scholar) as well as recent news articles and university websites were searched using PRS and industry-related search terms. Inclusion criteria consisted of any publication or reputable news or academic article in electronic or printed media directly studying or commenting on the use of 3D printing technology in relation to PRS. The current literature was critically appraised, and quality of selected articles was assessed and manually filtered for relevance by 2 reviewers., Results: A total of 1092 articles were identified from the aforementioned sources discussing 3D printing in medicine. The 3D printing in relation to biologic and surgical applications was discussed in 226 articles. Within this subset, 103 articles were included in the review. Of those selected, 5 were pertinent to surgical planning, training, and patient education; 4 to upper extremity and hand prosthetics; 24 to bone and craniomaxillofacial (CMF) reconstruction; 10 to breast reconstruction; 20 to nose, ear, and cartilage reconstruction; 20 to skin; and finally 20 involving overlapping general topics in 3D printing and PRS., Conclusions: The 3D printing provides the ability to construct complex individualized implants that not only improve patient outcomes but also increase economic feasibility. The technology offers a potential level of accessibility that is paramount for remote and resource-limited locations where health care is most often limited. The 3D printing-based technologies will have an immense impact on the reconstruction of traumatic injuries, facial and limb prosthetic development, as well as advancements in biologic and synthetic implants.

Background: Small promoters that recapitulate endogenous gene expression patterns are important for basic, preclinical, and now clinical research. Recently, there has been a promising revival of gene therapy for diseases with unmet therapeutic needs. To date, most gene therapies have used viral-based ubiquitous promoters-however, promoters that restrict expression to target cells will minimize off-target side effects, broaden the palette of deliverable therapeutics, and thereby improve safety and efficacy. Here, we take steps towards filling the need for such promoters by developing a high-throughput pipeline that goes from genome-based bioinformatic design to rapid testing in vivo., Methods: For much of this work, therapeutically interesting Pleiades MiniPromoters (MiniPs; ~4 kb human DNA regulatory elements), previously tested in knock-in mice, were "cut down" to ~2.5 kb and tested in recombinant adeno-associated virus (rAAV), the virus of choice for gene therapy of the central nervous system. To evaluate our methods, we generated 29 experimental rAAV2/9 viruses carrying 19 different MiniPs, which were injected intravenously into neonatal mice to allow broad unbiased distribution, and characterized in neural tissues by X-gal immunohistochemistry for icre, or immunofluorescent detection of GFP., Results: The data showed that 16 of the 19 (84 %) MiniPs recapitulated the expression pattern of their design source. This included expression of: Ple67 in brain raphe nuclei; Ple155 in Purkinje cells of the cerebellum, and retinal bipolar ON cells; Ple261 in endothelial cells of brain blood vessels; and Ple264 in retinal Müller glia., Conclusions: Overall, the methodology and MiniPs presented here represent important advances for basic and preclinical research, and may enable a paradigm shift in gene therapy.

Background: Aesthetic breast augmentation can be fraught with postoperative complications, particularly capsular contracture (CC), skin surface irregularities, and implant or inframammary fold malposition. Similar complications have been addressed successfully in reconstructive breast surgery with acellular dermal matrix (ADM) products., Objective: The authors present their initial experience with porcine ADM (PADM) in aesthetic breast augmentation., Methods: Retrospective chart review was performed for 93 consecutive patients (179 breasts) who underwent revisionary cosmetic breast augmentation with or without mastopexy between May 2009 and September 2012. Porcine ADM (Strattice; Lifecell Corp, Branchburg, New Jersey) was placed bilaterally in 74 patients and unilaterally in 19 patients. All patients were operated upon by 1 surgeon (J.N.P.). Product use description and complications were recorded, including infection, extrusion, CC, and implant malposition., Results: Average follow-up was 12 months (range, 1-39 months). There were 2 major complications (1.6% of breasts): an infection in 1 breast that required implant explantation approximately 2 weeks postoperatively and an extrusion that required PADM removal. Two additional patients had high-riding implants resulting from folded PADM that required revision; both cases were corrected by excising the folded PADM segment. Seven other patients required office procedures to correct minor imperfections. Two CC recurrences were suspected (1 patient) in the 76 breasts that underwent capsulectomy and PADM placement., Conclusions: Porcine ADM demonstrated great utility as an adjunct in revisionary cosmetic breast surgery. The product helped to provide good aesthetic outcomes with low complication rates. Prospective, randomized trials may prove helpful in defining the role of PADM further in these challenging cases.

Background: Previously, we and other investigators have reported the benefits of using SPY Intraoperative Perfusion Assessment System to assist in the prediction of mastectomy flap necrosis. To date, analysis of the SPY images has been subjective. However, the new SPY-Q postprocessing software allows for objective quantification of SPY images through the application of absolute and relative values of fluorescence intensity. This study seeks to determine the use of these objective, numerical data and their role in potentially predicting mastectomy flap necrosis., Methods: In a retrospective fashion, 20 SPY images from immediate breast reconstructions were randomly selected from a database of more than 100 images: 10 from breasts that developed flap necrosis and 10 from breasts that demonstrated adequate healing. Groups were matched for age, body mass index, and comorbidities. The points of necrosis and points of adequate healing were evaluated using the postprocessing software, and the groups were compared., Results: The mean "relative" fluorescence of the necrosis and the adequate healing groups was 25.2% and 43.3%, respectively (P < 0.001). The mean absolute fluorescence of the 2 groups was 18.5 and 25.0, respectively (P = 0.07)., Conclusions: These findings suggest that quantitative "relative" perfusion values as generated by the postprocessing software may augment clinical judgment of flap viability in an objective and reproducible fashion.

Inadequate tissue perfusion is a key contributor to early complications following reconstructive procedures. Accurate and reliable intraoperative evaluation of tissue perfusion is critical to reduce complications and improve clinical outcomes. Clinical judgment is the most commonly used method for evaluating blood supply, but when used alone, is not always completely reliable. A variety of other methodologies have been evaluated, including Doppler devices, tissue oximetry, and fluorescein, among others. However, none have achieved widespread acceptance. Recently, intraoperative laser angiography using indocyanine green was introduced to reconstructive surgery. This vascular imaging technology provides real-time assessment of tissue perfusion that correlates with clinical outcomes and can be used to guide surgical decision making. Although this technology has been used for decades in other areas, surgeons may not be aware of its utility for perfusion assessment in reconstructive surgery. A group of experts with extensive experience with intraoperative laser angiography convened to identify key issues in perfusion assessment, review available methodologies, and produce initial recommendations for the use of this technology in reconstructive procedures.

Background: Pedicle transverse rectus abdominus myocutaneous (pTRAM) flaps remain the most common method of autologous tissue breast reconstruction. Using pTRAM flaps, complications often arise postoperatively, secondary to inadequate circulation. Tissues from distant angiosomes are associated with poorer perfusion, but this differs among patients. Many modalities have been used to reduce the risk of complications, but none have achieved widespread application. The authors believe that laser-assisted indocyanine green fluorescent dye angiography (LA-ICGA) can potentially reduce the risk of complications., Methods: In two routine, single-pedicle, ipsilateral pTRAM flaps, LA-ICGA imaging was performed following the division of the distal rectus muscle and deep inferior epigastric pedicle. The resulting images were used to guide design of the flap and debridement., Results: In case 1, good perfusion was observed in zone 1 and part of zone 2. In case 2, good perfusion was observed in zone 1 and 50% of zone 3, with little perfusion in zone 2. In both cases, tissues with poor perfusion were debrided before transfer and inset. In both patients, there were no issues with wound healing, tissue necrosis or fat necrosis., Conclusions: The variability of perfusion of the pTRAM flap among individuals is well appreciated. LA-ICGA helped to determine the limits of good perfusion and, therefore, the limits of tissue to be preserved for transfer and inset. This helped to avoid harvesting poorly perfused tissue that would have almost certainly experienced necrosis and, ultimately, would have reduced the risk of postoperative complications.

Background: The use of human acellular dermal matrix (HADM) materials in prosthetic-based breast reconstruction has gained popularity in recent years. Questions remain, however, regarding the nature and incidence of postoperative complications associated with this technique. The results reported in the available literature vary widely. This meta-analysis examines this question further with a broad review of the available literature in an effort to better define the true nature and incidence of near-term complications associated with the use of HADM in prosthetic-based breast reconstruction. It does not aim to compare this method of reconstruction to others., Methods: A review of the available literature was performed in July 2009. The goal was to identify all previous works describing the placement of HADM at prosthetic-based breast reconstruction. Included were studies that documented the use of HADM for coverage of tissue expanders or permanent implants following therapeutic or prophylactic mastectomy. Excluded were studies that reported on the use of HADM in cosmetic breast surgery or studies that included the use of xenografts. Data collected included demographics as well as the nature and incidence of complications, with separate categories assigned for seroma, infection, flap necrosis, and "other." Data were analyzed using Comprehensive Meta-Analysis(®) software (Biostat, Englewood, NJ). Raw proportions, fixed-effect models, and random-effect models were used to assess the complication rates across studies., Results: Eleven published articles and one abstract that was later published as an article were identified. Within these 12 studies, a total of 789 breasts were identified that had undergone reconstruction with HADM. The mean follow-up was 13.7 months. Under the random-effects model, the total complication rate was 12.0%. The most common complications were flap necrosis (3.3%), seroma (3.3%), and infection (5.6%). All complications not included in these categories were set apart in a separate category, "Other," and totaled 3.0%, Conclusion: The true incidence of postoperative complications in the near term utilizing HADM in prosthetic-based breast reconstruction appears to be approximately 12%. The incidence of long-term complications such as capsular contracture remains unknown. However, as surgical experience with HADM grows, operative techniques designed at reducing risks will mature, strategies for managing complications will advance, and more advanced products designed to reduce the incidence of complications are likely to become available.

Skin-sparing mastectomy has been associated with flap ischemia and necrosis. Current clinical methods for assessment of flap viability following mastectomy are largely subjective and lack objective data to guide intraoperative decisions. Intraoperative laser-assisted indocyanine green angiography (LA-ICGA) was performed on 20 skin sparing mastectomy flaps. LA-ICGA data were retrospectively compared with clinical outcome. Preoperative, intraoperative, and postoperative digital photographs along with clinical course were evaluated in an effort to identify potential complications. LA-ICGA was performed on 20 breasts in 12 patients. Eleven breasts (55%) demonstrated no wound-healing issues. Nine breasts (45%) experienced wound-healing issues, which were stratified as follows: 1 (5%) mild, 1 (5%) moderate, and 7 (35%) severe. Of these seven severe wound-healing issues, 5 (25%) required debridement and 2 (10%) required complete removal of the prosthetic device. Retrospective analysis demonstrated a 95% correlation between intraoperative imaging and clinical course with 100% sensitivity and 91% specificity. There was a false-positive rate of 9%. This series suggests LA-ICGA is a useful adjunct to determine mastectomy flap viability. Further quantitative advances in this technology may provide objective numerical thresholds to guide intraoperative mastectomy flap debridement when indicated., ((c) Thieme Medical Publishers.)

The benefits of laser-assisted indocyanine green fluorescence angiography have previously been demonstrated in cardiac surgery. The purpose of this study was to determine the value of this technology in microsurgical breast reconstruction. Intraoperative laser-assisted indocyanine green fluorescence angiography was performed on all microsurgical breast reconstruction cases (deep inferior epigastric perforator flap or free transverse rectus abdominus muscle flap) during the study period. Ten consecutive free tissue transfer autologous breast reconstructions were performed on 8 women. In four cases, imaging demonstrated flow or perfusion deemed "marginal" or "poor" by the operating surgeons. In three of these cases, one involving poor arterial inflow, one of poor venous outflow, and one of poor perfusion of a mastectomy flap, the intraoperative plan was adjusted accordingly and follow-up imaging demonstrated improvement. In the fourth case, no adjustment was made at operation. However this patient required a return to the operating room for venous congestion of the flap, which was corrected without sequela. Overall flap survival was 100%. We concluded that laser-assisted indocyanine green fluorescence angiography appears to provide important information that has helped guide intraoperative decision making in our series.

Objective: To review the authors' experience with activated type I collagen in the treatment of recalcitrant wounds in the diabetic population resulting from minor trauma and/or venous stasis disease. With regard to activated collagen, CellerateRx's patented activated collagen fragments are a fraction of the size of the native collagen molecules and particles found in other products, delivering the benefits of collagen to the body immediately., Design: A 2-case presentation wherein patients were treated with CellerateRx (activated, fragmented, and nonintact type I collagen) in a gel and powder form., Subjects: Two middle-aged diabetic male patients with lower extremity wounds refractory to conservative wound care., Results: Complete resolution of recalcitrant wounds in 6 to 7 weeks., Conclusions: Wound resolution was evident when using the authors' practice protocol, which includes the application of activated collagen. The inherent properties of type I collagen may contribute to a more rapid healing process.

Background: Implant reconstruction in breast cancer patients treated with radiation therapy is controversial. Prior studies are limited by older prosthetic devices, reconstructive techniques, and radiation therapy protocols., Methods: A retrospective review was performed of patients who underwent tissue expansion and implant breast reconstruction performed by a single surgeon after mastectomy for breast cancer from 1996 to 2003. Complications and aesthetic results were compared between patients who received radiation therapy and those who did not., Results: A total of 104 patients (123 breasts) who underwent mastectomy and implant breast reconstruction were included in the study. Twenty-seven patients (27 breasts) received either premastectomy or postmastectomy radiation therapy for breast cancer. All patients who received radiation therapy did so before completion of their implant reconstruction. Complications ultimately requiring prosthetic device removal or replacement, as well as total complications (those requiring prosthetic removal or replacement and those not requiring prosthetic removal or replacement), were more frequent in breasts that received radiation than breasts that did not (18.5 percent versus 4.2 percent for complications requiring prosthetic removal or replacement, p < or = 0.025, and 40.7 percent versus 16.7 percent for total complications, p < or = 0.01). Breast symmetry was significantly better in patients who did not receive radiation compared with those who did (p < 0.01)., Conclusions: Implant breast reconstruction in patients who receive radiation therapy is possible but associated with more frequent complications and decreased aesthetic results. However, the present results compare favorably to those reported in prior studies. Improved results in the present study may be attributable to the use of newer prostheses, staged breast reconstruction with initial tissue expansion, total muscular coverage of the implant, and modern radiation therapy protocols.

Background: Elimination of glabellar frown lines by direct denervation of the corrugator and procerus muscles has proven elusive. Furrows often persist after the frontal branch of the facial nerve has been divided. In order to find an explanation for these observations and to provide an anatomic basis for future surgical strategies, the pattern of innervation of these muscles was studied., Methods: Two separate investigations were performed: (1) cadaveric anatomical dissection in 18 fresh cadaver hemi-faces utilizing loupe magnification, operating microscope, and template tracings; and (2) electrophysiologic testing performed in 12 healthy volunteers utilizing a Viking Ile nerve stimulator (Nicolet, Madison, WI)., Results: The corrugator was found to have a dual nerve supply with contributions from branches of the frontal, zygomatic and buccal branches of the facial nerve. The frontal branch passes deep to the orbicularis at the level of the eyebrow; and the buccal branch, after receiving a contribution from the zygomatic, forms the angular nerve, which then passes superiorly in front of the medial canthus to supply both corrugator and procerus. The procerus muscle was found to receive contributions from the angular nerve exclusively., Conclusions: Procedures designed to denervate the corrugator should be directed at both components of its redundant nerve supply, the frontal branch as well as the angular nerve. Division of the angular nerve will also denervate the procerus muscle. Both frontal nerve branches and angular nerve components are accessible through an upper blepharoplasty incision.

We recently encountered 5 patients with Mycobacterium abscessus infection following cosmetic procedures performed at a surgicenter located off the United States coastline which, by report, actively recruits domestic patients. Additional patients with similar clinical histories and presentation have been identified at other practices along the Eastern seaboard as well. A recent Centers for Disease Control and Prevention investigation has confirmed a common link. All procedures were performed in Santo Domingo, Dominican Republic, between 2003 and 2004. More than half were performed at the same facility. We report herein a series of patients presenting with M. abscessus infections who underwent cosmetic surgery offshore. The goal of this manuscript is to heighten awareness among physicians who may encounter such patients in their practices. The indolent clinical presentation, laboratory studies utilizing acid-fast stains and cultures, and treatment including surgical debridement and pharmacologic regimens in the ultimate diagnosis and therapy for M. abscessus infections are discussed.

Although debridement and pectoralis major musculocutaneous advancement flap closure has proved to be an effective treatment of sternal wounds in the general population, the purpose of this study was to examine the use of these flaps in patients with previously irradiated chest walls. The authors examined 5 patients with a history of breast cancer and chest wall radiation therapy who developed poststernotomy wound complications that were treated with debridement and pectoralis major musculocutaneous advancement flaps. The average patient age was 76 years. Three patients had previously undergone a radical mastectomy and had only 1 pectoralis major muscle remaining. There were no intraoperative deaths. One patient died during the 30-day postoperative period. There were no hematomas, seromas, or dehiscences. One woman developed a postoperative wound infection. Functional and aesthetic results were excellent. This study demonstrates that early, aggressive sternal debridement and closure with pectoralis major musculocutaneous advancement flaps is effective in patients with a history of chest wall irradiation, including those who have had 1 pectoralis major muscle previously resected.

Scalp reconstruction after ablative surgery can be challenging. A useful reconstructive algorithm is lacking. The purpose of this study was to evaluate the authors' experience and to identify an appropriate reconstructive strategy. This was a retrospective review of all patients treated by the authors' service for scalp defects during a 15-year period. Reconstructive methods, independent factors, and outcomes were analyzed. A total of 73 procedures were performed in 64 patients. Techniques for reconstruction included primary closure, grafts, and local and distal flaps. A correlation between reconstructive technique and complications could not be demonstrated. However, an increased incidence of complications was correlated with a history of radiation, chemotherapy, cerebrospinal fluid leaks, and an anterior location of the ablative defect (P < 0.05). Important tenets for successful management of scalp defects are durable coverage, adequate debridement, preservation of blood supply, and proper wound drainage. Local scalp flaps with skin grafts, and free tissue transfer remain the mainstay of reconstruction in most instances.

Large, complex lower-extremity defects in the region of the Achilles tendon occur when tendon loss or disruption is complicated by damage to surrounding structures, including soft tissue, vessels, or bone. The surgical approach to these complex defects has evolved from simple amputation to the recognition that satisfactory reconstruction has three components: functional reconstruction of the tendon, importation of vascularized soft tissue, and skin coverage. Many techniques have been developed to address these difficult reconstructive goals, which often require multiple procedures or complicated single-stage operations. Microsurgical advances have begun to reduce the complexity of Achilles tendon region reconstruction, and excellent results can be obtained which restore function, form, and cosmesis with minimal morbidity., (Copyright 2003 Wiley-Liss, Inc.)

Compartment syndrome is a documented and potentially lethal complication of thrombolytic therapy. With the increasing use of catheter-directed thrombolytic therapy, a high index of suspicion for the potential occurrence of this surgical emergency must be maintained. Errors of omission in the diagnosis of compartment syndrome, even for a few hours, may lead rapidly to limb loss, renal failure, and possibly death. The authors present a case of compartment syndrome arising in the forearm of a patient being treated with continuous catheter-directed thrombolytic therapy for an occluded arterial bypass graft associated with an ischemic lower extremity. Specific to this presentation is their management of compartment syndrome during thrombolytic therapy as well as previously unreported use of a homograft (cadaveric skin) to control ongoing blood loss from a fasciotomy site in this fully anticoagulated patient. The authors think their management in this case may help to provide direction to others faced with a similar, increasingly common, surgical dilemma.