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Gynecomastia is a benign glandular proliferation that can affect adolescents causing significant psychological discomfort. Generally, it is idiopathic but underlying endocrinological conditions must be excluded. Different surgical techniques are available, the surgical correction with subareolar incision achieves the goal of satisfactory aesthetic result for patients. We studied all patients treated for gynecomastia in two centers of pediatric surgery. After collection of a detailed family history, we evaluated the presence of early onset of puberty, congenital abnormalities of the external genitalia, use of drugs, eating habits and the presence of genetic disorders. Laboratory tests and ultrasound were made to exclude endocrinological disorders. The surgical treatment was performed by a subareolar incision with gland and adipose tissue excision. A Body - Q chest module to evaluate patient satisfaction has been proposed to everyone before and after surgery. 47 adolescents with median age of 15 years were surgically treated. Three presented endocrinological disorders. Grade of gynecomastia for surgery was: III in 40 patients and IIb in 7 patients. Postoperative complications occurred in 5 patients. The Body - Q chest module was completed by 42 patients and showed good results for all points analyzed, except for social feelings. Gynecomastia in adolescents can be surgically treated with subareolar incision, reporting good aesthetic results and low incidence of complications. Specific tests are useful to assess patient satisfaction.

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BACKGROUND: The recipient vessel choice is very important when performing free-flap breast reconstructions. Usually, the concomitant vein of the recipient artery is anastomosed, and mismatches in the diameter are occasionally observed. We consider the thoracoepigastric vein (TEV) as a potential useful recipient vein. The use of the TEV is not a novel technique. It has been used by surgeons for free-flap anastomoses in the axillary region, but usually as an anastomotic site for the second vein. However, anatomical findings such as TEV diameter, its deficiency rate, and influence on mastectomy are not clear. In this study, computed tomography (CT) was performed to evaluate the use of the TEV as a recipient vein for breast reconstruction. METHODS: The medical records of patients who underwent breast reconstruction with free-flap transfer were retrospectively evaluated. In most cases, CT was performed using a tissue expander inserted after mastectomy. The TEV was considered suitable if its diameter on the mastectomy side was >1 mm and the vertical distance from the most distal slice level where the TEV could be seen at the third costal cartilage height of the parasternal region was <50 mm. RESULTS: Sixty-six sides of 33 patients were evaluated. The mean age of the patients was 49.3 ± 5.1 years. The TEV was used in five flaps. TEV diameters were not significantly different between the left and right sides (1.85 ± 0.53 vs. 1.82 ± 0.6, respectively, p = 0.836). On the mastectomy side, eight (25%) TEVs were injured, but only three (8.6%) were considered unavailable. On the healthy side, 96.4% TEVs were available. CONCLUSIONS: TEVs may be a good choice as vein anastomosis targets for breast reconstruction with a free flap because of their relatively large vessel diameter. TRIAL REGISTRATION: UMIN-CTR: R000061573.

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Polyacrylamide hydrogel mammoplasty is a simple and relatively affordable surgery. However, this procedure is associated with a significant frequency of late complications, prompting its suspension in 2006. Despite this, patients continue facing long-term consequences. These include hydrogel migration, changes in breast shape and volume, granulomas, fistulas, and abscess formation. The clinical case described here presents the surgical treatment after augmentation mammoplasty with polyacrylamide hydrogel performed 35 years ago.

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BACKGROUND: Developmental breast asymmetry (DBA) is a largely underreported condition where the natural growth of one breast is smaller than the other. While some degree of asymmetry or difference in size and shape is present in most women, DBA can result in more profound differences that can impact a woman's psychosocial well-being. OBJECTIVES: This study aims to better understand the experiences of women living with DBA, their experiences seeking treatment, and their reconstructive surgical journey and outcomes. DESIGN: This was a qualitative study involving in-depth, one-on-one semi-structured interviews with women diagnosed with DBA. METHODS: Participants were women seeking treatment for DBA through the Plastic and Reconstructive Surgery Unit at Flinders Medical Centre, a tertiary healthcare centre in Adelaide, South Australia. Interviews were recorded digitally, transcribed verbatim and analysed thematically. RESULTS: Fourteen interviews were conducted with 14 women; 13 women had completed their reconstruction and 1 was undergoing reconstruction at the time of their interview. Interviews highlighted the significant psychosocial impact of DBA, the different experiences in seeking help for DBA, the information received or lack thereof, the need for medical and social support throughout the surgical process, and the varied satisfaction with surgical outcomes. CONCLUSION: This study highlighted the subjective experiences of women who have grown up with DBA, improving our understanding of the significant psychosocial impact of DBA. Not all participants experienced post-operative improvements in psychosocial well-being due to surgical complications or unmet expectations. This study also demonstrated the need to raise awareness about DBA and the importance of additional medical and social support for women throughout their surgical journey.

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BACKGROUND: The incidence of breast cancer in Pakistan has been rising with approximately one third of these patients requiring mastectomy. Among breast reconstruction treatment options, the use of Acellular Dermal Matrix (ADM) for pre-pectoral breast implant surgery has proven effective with improved cosmetic outcome. However, due to high cost it cannot be regularly implemented in a developing country like Pakistan. An alternative to ADM, Polyglactin 910 (Vicryl™, Ethicon) mesh has been introduced in pre-pectoral breast reconstructive surgery which has shown to be almost 10 times lower in cost. We set out to determine the frequency of early postoperative complications when using Polyglactin 910 mesh for pre-pectoral implant-based breast reconstruction surgery. METHODS: A single centre, retrospective, chart review was conducted, and a total 28 women were included in the study. Thirty-two pre-pectoral implant-based mastectomies with Polyglactin 910 mesh were performed. Early post-operative outcomes (within 12 months of procedure) including duration of antibiotic use, post-operative infection, implant displacement, flap necrosis, seroma formation, wound dehiscence, hematoma formation, capsular contracture and reconstruction failure, were recorded. RESULTS: Only 4 (12.5%) women experienced early post-operative morbidity. One patient developed a wound dehiscence, which eventually led to reconstruction failure and removal of the implant. Another patient had seroma formation and flap necrosis. None of the patients developed postoperative implant displacement, hematoma formation or capsular contracture in the early post-operative period. CONCLUSION: This study reveals that early post-operative outcomes with Polyglactin 910 mesh in breast reconstructive surgery are few, thus making it a cost effective, reliable, and safe treatment option, especially in developing countries like Pakistan.

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BACKGROUND: Breast cancer is a common malignancy, and early detection coupled with standardized treatment is crucial for patient survival and recovery. This study aims to scrutinize the current state of breast cancer diagnosis and treatment in Shaanxi province, providing valuable insights into the local practices and outcomes. METHODS: We selected 25 hospitals that typically represent the current diagnosis and treatment strategy of breast cancer in Shaanxi (a province in northwest China). The questionnaire comprised sections on fundamental information, outpatient consultations, breast-conserving surgery, neoadjuvant and adjuvant therapy, sentinel lymph node biopsy, breast reconstruction surgery. RESULTS: A total of 6665 breast cancer operations were performed in these 25 hospitals in 2021. The overall proportion of breast-conserving surgery (BCS) is 23.6%. There was a statistically significant positive correlation between the annual volume of breast cancer surgery and the implementation rate of BCS (P = 0.004). A total of 2882 cases of neoadjuvant treatment accounted for 43.24% of breast cancer patients treated with surgery in 2017. Hospitals in Xi'an performed more neoadjuvant therapy for patients with breast cancer compared to other districts (P = 0.008). There was a significantly positive correlation between outpatient visits and the implementation rate of sentinel lymph node biopsy (SLNB) (P = 0.005). 14 hospitals in Shaanxi performed reconstructive surgery. CONCLUSIONS: Breast conserving surgery, adjuvant and neoadjuvant therapy and sentinel lymph node biopsy in Shaanxi province have reached the China's average level. Moreover, hospitals in Xi 'an have surpassed this average. However, a disparity is observed in the development of breast reconstruction surgery when compared to top-tier hospitals.

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BACKGROUND: Pre-operative radiotherapy (PRT) and pre-operative chemoradiotherapy (PCRT) prior to mastectomy and immediate breast reconstruction for locally advanced breast cancer have the potential to reduce radiation late-effects and expedite oncologic treatment. Recent feasibility work indicates that PCRT is safe and technically possible. Here, we present a systematic review of currently available data on clinical, oncological, reconstructive and aesthetic outcomes. METHODS: A prospectively registered search of Medline (Ovid), EMBASE (Ovid), EMCARE (Ovid) and CINAHL (EBSCO) databases was performed in August 2023. Clinical, oncological, reconstructive and aesthetic outcomes were appraised with risk of bias (ROBINS-I) and methodological quality determined (STROBE checklist) for each study. RESULTS: Twenty-two published articles (19 journal articles and 3 abstracts) were identified reporting the outcomes of 1258 patients with median follow-up between 19.0-212.4 months. Patients received neoadjuvant chemotherapy in 20 studies. Rates of locoregional recurrence and overall survival ranged between 0-21.7% and 82.0%-98.3% respectively. Rates of flap loss or necrosis ranged from 0-7.6%. Rates of revisional procedures ranged between 1.9-35.3%. Patient-reported outcomes were reported in 7 studies and were mostly 'good' or 'excellent'. CONCLUSION: PRT and PCRT preceding mastectomy and breast reconstruction produce acceptable oncological outcomes with rates of surgical complication and reconstructive outcomes within normal limits, however, the majority of available studies are of low methodological quality and at high risk of bias. A pragmatic randomised trial comparing PRT versus PMRT in the setting of breast reconstruction is now urgently required to guide surgical practice.

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The outbreak of the coronavirus disease 2019 (COVID-19) pandemic caused global challenges, including the restriction of surgical options for women with breast cancer. Autologous reconstruction availability has still not returned to pre-COVID-19 levels. This study aimed to collect data about waiting lists for autologous breast reconstruction and is the first of its kind. A total of 31 units were approached and asked to complete a study specific questionnaire. In total, there are at least 2255 patients on a waiting list, which equates to a 2-year and 5-month backlog at the current level of provision, without the inclusion of new referrals. Alarmingly, 40 women reportedly developed breast cancer whilst on the waiting list. The impact of COVID-19 has been significant, revealing national inequity in reconstruction provision and long waiting lists. Recommendations include increasing theatre capacity, optimising plastic surgeons' job plans to prevent waiting lists from growing as well as training more surgeons in autologous reconstruction.

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BACKGROUND: When performing breast reconstruction using a deep inferior epigastric artery (DIEA) perforator (DIEP) flap, including Hartrampf zone IV, the bipedicled DIEP flap has been argued to be necessary to ensure stable perfusion. However, a proximal medial branch (PMB), which is the most proximal perforator of DIEA, may make it possible to obtain adequate perfusion in a unilateral DIEP flap. This study aimed to clarify the detailed anatomical characteristics of PMB and its potential clinical applications in breast reconstruction. METHODS: This retrospective study was conducted on breast reconstruction using the DIEP flap between May 2020 and July 2023. Data on PMB anatomy were collected from preoperative contrast-enhanced computed tomography angiography, and contralateral perfusion of the flap was estimated using intraoperative indocyanine green angiography. RESULTS: PMB was present in approximately 85% of the cases, arising near the lateral border of the rectus abdominis, branching caudomedially in more than half of the cases, and perforating 2.3 cm laterally and 8.8 cm caudally, on average, from the umbilicus. The average perfusion area of zones II and IV significantly expanded to 96.5% and 74.2%, respectively, when PMB was included in the DIEP flap, and 9 of 22 cases showed contrast extending to the entire zone IV. CONCLUSIONS: The use of the DIEP flap with PMB is a good option for substantial-volume breast reconstruction. When utilizing PMB, it is important to consider its specific anatomy, location of the main perforator, and pedicle length.

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BACKGROUND: Reduction mammaplasty improves the quality of life by providing functional and aesthetic benefits to women with macromastia. This study contributes to the existing literature on socioeconomic and clinical barriers to referral for plastic surgery procedures by focusing specifically on reduction mammaplasty. METHODS: Patients with macromastia were identified via a chart review in a single institution from 2021-2022. The treatment pathway for each patient was characterized by reception of referral, completion of plastic surgery consultation, and eventual reception of surgery. After controlling for clinical covariates, multivariate logistic regression was applied to quantify the independent impact of race, insurance, and language status on the completion of surgery (p < 0.05). RESULTS: The final patient cohort included 425 women with macromastia. Among the 151 patients who were first seen by a primary care physician, 64 (42%) completed an initial plastic surgery consultation. Among all patients, 160 (38%) eventually underwent reduction mammaplasty. Multivariate regression predictions indicated a lower likelihood of completing breast reduction surgery in patients with current smoking history (OR: 0.08, 95% CI: 0.01-0.59) and higher body mass index (BMI) (OR: 0.94, 95% CI: 0.90-0.97) (p < 0.05). Minority race and ethnicity, private insurance status, and primary language status were not significant predictors of this outcome (p > 0.05). CONCLUSIONS: In this study, the socioeconomic variables were not independent predictors of breast reduction surgery completion. However, the association of minority race and ethnicity and nonprivate insurance status with the most common reasons for breast reduction deferral suggest an indirect influence of socioeconomic status on the treatment pathway.

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BACKGROUND: The extent of perfusion of a deep inferior epigastric artery perforator (DIEP) flap is a primary concern for surgeons. This study aimed to determine whether the flap area or volume can be estimated using perforator and flap characteristics. METHODS: Intraoperative flap perfusion was assessed using indocyanine green angiography in patients who underwent DIEP flap breast reconstruction between November 2018 and February 2023. The area perfused by a single dominant perforator was delineated on the surface of the flap and measured using the ImageJ software. Multiple linear regression analysis was conducted to estimate the 'perfusion ratio,' defined as the perfused area divided by the total flap area. Potential predictor variables included flap size (cm2), flap thickness (mm), perforator diameter (mm), perforator rows (medial/lateral), vertical location of perforator (at or above/below the umbilicus), and perforator eccentricity (vertical distance from upper flap margin to perforator, cm). RESULTS: In total, 101 patients were included in this analysis. The mean 'perfusion ratio' was 67.8% ± 11.5%, predicted by perforator diameter (p = 0.022) and vertical location below umbilicus (p < 0.001) with positive correlations and negatively correlated with flap thickness (p = 0.003) in the multivariable analysis. Both perfusion area and weight were predicted by perforator diameter, vertical location of perforator, flap size, and flap thickness (p < 0.001). The coefficient of determination (adjusted R2) for prediction of perfusion weight was higher than that for the perfusion area (75.5% vs. 69.4%). CONCLUSIONS: Flap volume, rather than area, is determined by a perforator of a given diameter and location.

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Autologous breast reconstruction using abdominally based perforator flaps has become increasingly popular following mastectomy for breast cancer. Of these, the deep inferior epigastric artery perforator (DIEP) flap represents one of the most popular techniques. However, surgeons must remain cognizant of anatomic variations in the abdominal wall vasculature that could complicate or preclude planned DIEP flaps. In this case, a 64-year-old female with a history of prior tubal ligations and caesarean sections underwent preoperative computed tomographic angiography (CTA) for planned autologous breast reconstruction with a DIEP flap. CTA revealed complete absence of the left deep inferior epigastric artery, with a sizeable left abdominal wall perforator visualized receiving retrograde flow from a crossing midline branch originating from the contralateral right deep inferior epigastric system. This vessel traversed the midline in a superficial plane in the subcutaneous tissue. Despite this aberrant anatomy, the surgical team successfully raised a unilateral DIEP flap based on the right pedicle. This case represents a unique anatomical variation of the abdominal wall and emphasises the importance of preoperative imaging when planning abdominally based free flaps.

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BACKGROUND: The free deep inferior epigastric artery perforator (DIEP) flap is the gold standard in autologous breast reconstruction. Asian patients often present with a smaller body mass index with relatively insufficient tissue. To restore appropriate symmetry, a larger flap inset ratio must be transferred. Supercharging of the second vein or inclusion of bilateral pedicle is commonly required. Current paradigm shifts in mastectomy has also resulted in more minimally invasive surgeries (MIS) espousing smaller lateral incisions, leading to a significant change in available recipient vessels. This study aimed to demonstrate our experience in changing strategies of DIEP flaps following the evolution of mastectomy techniques. METHODS: Between October 2008 and March 2022, retrospective data was gathered for 278 patients who underwent breast reconstruction surgery utilizing DIEP flaps by a single plastic surgeon. These patients were divided into two distinct groups based on their operation dates, with November 2018 marking a pivotal moment when the first MIS, including endoscopic-assisted and robot-assisted mastectomy, was introduced. RESULTS: A total of 278 patients were included. Bipedicle vessel utilization for flap supercharge saw a significant increase (15.9% vs. 7%, p < 0.001), while the use of the superior inferior epigastric vein (SIEV) decreased (5.1% vs. 17.1%, p = 0.01). Preceding MIS, SIEV was the primary choice for flap supercharge (96.0%, p < 0.001), whereas post-introduction, the contralateral DIEP pedicle gained prominence (75.9%, p < 0.001). There was also an increased utilization of thoracodorsal artery and lateral thoracic artery following MIS. CONCLUSION: These findings underscore the profound impact of MIS on the strategic choices made in DIEP flap-based breast reconstruction. TRIAL REGISTRATION: This study is retrospectively registered on ClinicalTrials.gov (NCT06321549).

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INTRODUCTION: Indocyanine green (ICG) angiography for the intraoperative evaluation of tissue perfusion is commonly used in implant-based breast reconstruction (IBR). The assessment of ICG images depends on the surgeon's interpretation and is qualitative or semiqualitative in nature. To quantify ICG metrics, this study aimed to apply a novel assessment of fill-rate dynamics to predict wound-healing complications and provide pragmatic assessment tools in IBR. METHODS: This was a retrospective cohort study of patients who underwent IBR with ICG using the photodynamic eye (PDE-Neo II) qualitative imaging system between April 2021 and September 2023. ICG recordings were reviewed to quantify the relative surface area and fluorescence intensity of visual perfusion deficits using ImageJ. The primary outcome was the incidence of wound-healing complications. t-tests and logistic regression were performed for statistical testing. RESULTS: A total of 112 patients (201 breasts) were included. The incidence of wound-healing complications was 12.9%. A higher relative surface area of ischemic regions was significantly associated with wound-healing complications (3.3% vs. 0.90%; p = 0.001). The rate of change in the surface area of ischemic regions was significantly associated with wound-healing complications (0.35% per second vs. 1.29% per second; p = 0.003%). On average, the duration of transient ischemic areas was significantly longer in breasts with wound-healing complications (46.0 s vs. 36.0 s, p = 0.01). CONCLUSION: A transient ischemic area of > 5% of the breast and/or failure to resolve transient ischemic areas after 60 s may predict wound-healing complications and inform surgical reconstructive decision-making in IBR.

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INTRODUCTION: Post-mastectomy radiation therapy is an important component of adjuvant therapy for high-risk patients. However, radiation to reconstructed breasts can cause various complications. Recently, hypofractionated (HF) protocols have been adopted in several countries. Here, we aimed to assess the impact of HF protocols on implant-reconstructed breasts through a meta-analysis and systematic review of the currently available literature. METHODS: Records published until August 2023 were systematically searched in PubMed, Cochrane Library, and EMBASE databases. Keywords included hypofractionation radiotherapy, mastectomy, and breast reconstruction. Studies that utilized HF and conventional fractionation (CF) after prosthetic reconstruction were selected. Due to the rarity of events in outcomes, Mantel-Haenszel's odds ratios were calculated using a fixed-effect model to compare the complication rates between HF and CF groups. For analysis with high heterogeneity, a random effect model was used. RESULTS: Seven articles with 924 implant reconstructions, in which 506 (54.8 %) underwent HF were included. HF patients received 43.8 Gy on average, while CF patients received 51.2 Gy. Mean follow-up ranged from 10.6 to 35 months. Seven studies were included in the meta-analysis. HF groups had a significantly lower risk of capsular contracture (OR 0.25, 95 % CI 0.11-0.55), major revision surgery (OR 0.19, 95 % CI 0.05-0.80), and wound dehiscence (OR 0.24, 95 % CI 0.07-0.78) compared to CF groups. The risks of other complications were not statistically significant. CONCLUSION: This study indicates that HF protocols are associated with fewer complications than CF protocols in implant-reconstructed patients. These findings suggest that the application of HF PMRT in implant-reconstructed patients with breast cancer is plausible.

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INTRODUCTION: Although higher preoperative physical activity levels have been shown to be beneficial to postoperative recovery at large, their effect on patient-reported outcomes after deep inferior epigastric perforator (DIEP) flap breast reconstruction has yet to be investigated. This study aimed to correlate patient physical activity levels with patient-reported outcome measures. METHODS: A prospectively maintained database of patients who underwent DIEP flap breast reconstruction between July 2021 and June 2022 was analysed. Physical activity levels were assessed using the Global Physical Activity Questionnaire (GPAQ) and patient-reported outcomes were measured using the BREAST-Q questionnaire, both preoperatively and 1 year postoperatively. Patients were stratified into low (<1000 METs) and high (>1000 METs) physical activity groups. RESULTS: Of the 136 patients who underwent surgery, 51 completed both questionnaires, with 34 responses meeting completeness criteria for statistical analysis. The low-MET group (n = 19) and high-MET group (n = 15) were comparable in age and comorbidities. Postoperatively, the low-MET group exhibited a 54% increase in physical activity levels, whereas the high-MET group showed a 17% decrease (p < 0.01). The low-MET group experienced significant declines in psychosocial well-being (9.3%, p = 0.04) and sexual well-being (14%, p = 0.02), whereas the high-MET group did not show significant changes in these domains. Satisfaction with the unclothed abdomen increased significantly in the low-MET group (2.9 from 2, p = 0.001), while the high-MET group showed a nonsignificant decrease (3.2 from 2.9, p = 0.43). However, abdominal well-being significantly decreased in both groups, with a 56% decline in the high-MET group (p = 0.006) and a 51% decline in the low-MET group (p = 0.0002). The latter reflects the perceived difference between aesthetic appearance and well-being. CONCLUSIONS: Patients with lower preoperative physical activity levels showed improved activity postsurgery, potentially due to motivational factors from the reconstructive process. Conversely, those with higher preoperative activity levels faced greater challenges in maintaining their activity levels postsurgery, potentially arising from disruptions in daily routines and donor site symptoms, indicating a need for targeted interventions to support this group. Concurrently, patients with higher baseline exercise levels did not show a decrease in psychosocial and sexual well-being, possibly reflecting a higher resilience to the operative process. These findings underscore the importance of integrating physical activity assessments into preoperative evaluations to inform patient-centred care and optimise recovery outcomes.

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3D-printed vascular models can enhance flap harvesting efficiency in abdominal free flap breast reconstruction, reducing the use of operating room time. However, no economic analyses with respect to model use in this context have been conducted to date. As such, this study examines model cost-benefit tradeoffs for use in abdominal free flap breast reconstruction.

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