Breast Augmentation and Breast Reconstruction Demonstrate Equivalent Aesthetic Outcomes.
Plastic and reconstructive surgery. Global open
2016; 4 (7)
Use of Indocyanine Green-SPY Angiography for Tracking Lymphatic Recovery After Lymphaticovenous Anastomosis.
Annals of plastic surgery
2016; 76: S232-7
There is a perception that cosmetic breast surgery has more favorable aesthetic outcomes than reconstructive breast surgery. We tested this hypothesis by comparing aesthetic outcomes after breast augmentation and reconstruction.Postoperative images of 10 patients (cosmetic, n = 4; reconstructive, n = 6; mean follow-up, 27 months) were presented anonymously to participants who were blinded to clinical details. Participants were asked if they believed cosmetic or reconstructive surgery had been performed. Aesthetic outcome measures were quantified: (1) natural appearance, (2) size, (3) contour, (4) symmetry, (5) position of breasts, (6) position of nipples, (7) scars (1 = poor and 4 = excellent). Images were ranked from 1 (most aesthetic) to 10 (least aesthetic). Analyses included two-tailed t tests, Mann-Whitney U tests, and χ(2) tests.One thousand eighty-five images were quantified from 110 surveys (99% response rate). The accuracy of identifying cosmetic or reconstructive surgery was 55% and 59%, respectively (P = 0.18). Significantly more of the top 3 aesthetic cases were reconstructive (51% vs 49%; P = 0.03). Despite this, cases perceived to be reconstructive were ranked significantly lower (5.9 vs 5.0; P < 0.0001). Mean aesthetic outcomes were equivalent regardless of surgery for 5 categories (P > 0.05), with the exception of breast position that improved after reconstruction (2.9 vs 2.7; P = 0.009) and scars that were more favorable after augmentation (2.9 vs 3.1; P < 0.0001). Age and nipple position (R (2) = 0.04; P = 0.03) was the only association between a demographic factor and aesthetic outcome.Aesthetic outcomes after cosmetic and reconstructive breast surgery are broadly equivalent, though preconceptions influence aesthetic opinion. Plastic surgeons' mutually inclusive-reconstructive and aesthetic skill set maximizes aesthetic outcomes.
View details for DOI 10.1097/GOX.0000000000000824
View details for PubMedID 27536490
Using intraoperative laser angiography to safeguard nipple perfusion in nipple-sparing mastectomies.
2015; 4 (6): 497-505
Lymphaticovenous anastomosis (LVA) is a surgical treatment option for patients with early stage lymphedema. To date, no ideal imaging modality exists for tracking patency of the LVA postoperatively. We hypothesize that laser angiography utilizing indocyanine green (ICG) via the SPY system (Lifecell Corp.) would be a useful methodology for assessing the patency of the LVA and lymphatic recovery postoperatively.A prospective trial was performed on patients with stage II lymphedema who underwent LVA from 2013 to 2014 by a single surgeon. All candidates underwent preoperative and postoperative lymphatic mapping using ICG-SPY angiography. Postoperative analyses were performed at 1 month and at 9 months after surgery and assessed for patency at the site of the LVAs and for changes in lymphatic pattern.Five patients underwent LVA, 3 for upper extremity and 2 for lower extremity stage II lymphedema. The number of LVAs per extremity was 1 to 3 (total, 11). One month postoperative ICG-SPY angiography demonstrated flow through 9 of 11 anastomoses. Evaluation at 9 months postoperative showed improvement in lymphatic drainage.Indocyanine green-SPY angiography may be used to objectively evaluate the surgical outcome of LVA.
View details for DOI 10.1097/SAP.0000000000000766
View details for PubMedID 27070461
Motion Analysis for Microsurgical Training: Objective Measures of Dexterity, Economy of Movement, and Ability
PLASTIC AND RECONSTRUCTIVE SURGERY
2015; 136 (2): 231E-240E
The superior aesthetic outcomes of nipple-sparing mastectomies (NSM) explain their increased use and rising popularity. Fortunately, cancer recurrences involving the nipple-areolar complex (NAC) have been reassuringly low in the range of 1%. Technical considerations and challenges of this procedure are centered on nipple ischemia and necrosis. Patient selection, reconstructive strategies and incision placement have lowered ischemic complications. In this context, rates of full NAC necrosis are 3% or less. The emergence of noninvasive tissue angiography provides surgeons with a practical tool to assess real-time breast skin and NAC perfusion. Herein, we review our classification system of NAC perfusion patterns defined as V1 (from subjacent breast), V2 (surrounding skin), and V3 (combination of V1 + V2). Additionally, we describe the benefits of a first stage operation to devascularize the NAC as a means of improving blood flow to the NAC in preparation for NSM, helping extend the use of NSM to more women. Intraoperative evaluation of skin perfusion allows surgeons to detect ischemia and modify the operative approach to optimize outcomes.
View details for DOI 10.3978/j.issn.2227-684X.2015.04.15
View details for PubMedID 26645004
Quantity of lymph nodes correlates with improvement in lymphatic drainage in treatment of hind limb lymphedema with lymph node flap transfer in rats
Developing a Lower Limb Lymphedema Animal Model with Combined Lymphadenectomy and Low-dose Radiation.
Plastic and reconstructive surgery. Global open
2014; 2 (3)
Evaluation of skill acquisition in microsurgery has traditionally relied on subjective opinions of senior faculty, but is shifting toward early competency-based training using validated models. No objective measures of dexterity, economy of movement, and ability exist. The authors propose a novel video instrument motion analysis scoring system to objectively measure motion.Video of expert microsurgeons was analyzed and used to develop a resident motion analysis scoring system based on a mathematical model. Motion analysis scores were compared to blinded, global rating scores of the same videos using the Stanford Microsurgery and Resident Training scale.Eighty-five microsurgical anastomoses from 16 residents ranging from postgraduate years 1 through 6 were analyzed. Composite motion analysis scores for each segmented video correlated positively to arterial anastomotic experience (rho, +0.77; p < 0.001). Stanford Microsurgery and Resident Training scale interrater reliability was consistent between expert assessors, and mean composite motion analysis overall performance and Stanford scores were well matched for each level of experience. Composite motion analysis scores correlated significantly with combined Stanford Microsurgery and Resident Training [instrument handling (rho, +0.66; p < 0.01), efficiency (rho, +0.59; p < 0.01), suture handling (rho, +0.83; p < 0.001), operative flow (rho, +0.67; p < 0.001), and overall performance (rho, +89; p < 0.001)] motion components of the scale.Instrument motion analysis provides a novel, reliable, and consistent objective assessment for microsurgical trainees. It has an associated cost, but is timely, repeatable, and senior physician independent, and exposes patients to zero risk.
View details for DOI 10.1097/PRS.0000000000001469
View details for Web of Science ID 000359715200001
This study was aimed to establish a consistent lower limb lymphedema animal model for further investigation of the mechanism and treatment of lymphedema.Lymphedema in the lower extremity was created by removing unilateral inguinal lymph nodes followed by 20, 30, and 40 Gy (groups IA, IB, and IC, respectively) radiation or by removing both inguinal lymph nodes and popliteal lymph nodes followed by 20 Gy (group II) radiation in Sprague-Dawley rats (350-400 g). Tc(99) lymphoscintigraphy was used to monitor lymphatic flow patterns. Volume differentiation was assessed by microcomputed tomography and defined as the percentage change of the lesioned limb compared to the healthy limb.At 4 weeks postoperatively, 0% in group IA (n = 3), 37.5% in group IB (n = 16), and 50% in group IC (n = 26) developed lymphedema in the lower limb with total mortality and morbidity rate of 0%, 56.3%, and 50%, respectively. As a result of the high morbidity and mortality rates, 20 Gy was selected, and the success rate for development of lymphedema in the lower limb in group II was 81.5% (n = 27). The mean volume differentiation of the lymphedematous limb compared to the health limb was 7.76% ± 1.94% in group II, which was statistically significant compared to group I (P < 0.01).Removal of both inguinal and popliteal lymph nodes followed by radiation of 20 Gy can successfully develop lymphedema in the lower limb with minimal morbidity in 4 months.
View details for DOI 10.1097/GOX.0000000000000064
View details for PubMedID 25289315