Does Staged Breast Reduction before Nipple-Sparing Mastectomy Decrease Complications? A Matched Cohort Study between Staged and Nonstaged Techniques Background: Nipple-sparing mastectomy in patients with large, ptotic breasts is a reconstructive challenge. Staged breast reduction before prophylactic nipple-sparing mastectomy has been shown to decrease complications; however, a direct comparison of outcomes between staged and nonstaged techniques is lacking. Methods: A retrospective review of all patients that underwent staged breast reduction before nipple-sparing mastectomy was conducted. Staged cases were matched to nonstaged nipple-sparing mastectomy cases according to known risk factors for complications. Individual staged cases with appropriate matches in all these categories were then each paired to two nonstaged cases according to the nearest higher and lower mastectomy weight. Staged and nonstaged cohorts were compared with regard to demographics, operative characteristics, and reconstructive outcomes. Results: Eighteen staged breast reductions were identified, performed at an average of 5.0 months before nipple-sparing mastectomy. Staged reductions were matched to 36 prophylactic nonstaged reductions. Average combined mastectomy weight (breast reduction and mastectomy weight) in the staged group was significantly higher than in the nonstaged group (992.6 g versus 640 g; p = 0.0004), although isolated mastectomy weights were comparable (607.1 g versus 640.0 g, respectively; p = 0.6311). Major mastectomy flap necrosis rates were significantly lower in the staged cohort than in the nonstaged cohort (0 percent versus 22.2 percent, respectively; p = 0.0415). Rates of minor mastectomy flap necrosis, partial nipple necrosis, and explantation trended lower in the staged cohort. Conclusion: In patients with large breast size, staged breast reduction before nipple-sparing mastectomy had significantly lower rates of major flap necrosis compared with nonstaged cases after controlling for other known risk factors for complications. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Outcomes in Patients Receiving Neoadjuvant Chemotherapy Undergoing Immediate Breast Reconstruction: Effect of Timing, Postoperative Complications, and Delay to Radiation Therapy Background: Neoadjuvant chemotherapy is offered to many patients with breast cancer. In patients undergoing mastectomy and immediate breast reconstruction, there is concern that this treatment could increase postoperative complications. The authors characterize which patients are at a higher risk of experiencing a postoperative complication, and assess the impact of postoperative complications on timing of radiation treatment. Methods: A retrospective review was performed on patients who underwent neoadjuvant chemotherapy with mastectomy and immediate breast reconstruction using tissue expanders. Multivariable binomial logistic regression analysis was used to identify risk factors for experiencing a postoperative complication. Independent samples t tests were used to compare means for neoadjuvant chemotherapy timing and time to commencement of radiation therapy between patients with and without complications. Results: A total of 128 patients were identified. Patients that experienced a complication had a statistically significant difference in time to commencement of radiation therapy (p = 0.021) and an elevated body mass index (p = 0.018) compared with patients who experienced no complication; there was no difference in timing interval of neoadjuvant chemotherapy (p = 0.692). Logistic regression showed an associate between body mass index and postoperative complication (OR, 1.09; 95 percent CI, 1.018 to 1.167; p = 0.013). Conclusions: Postoperative complications delay the commencement of radiation therapy in patients who received neoadjuvant chemotherapy and undergo mastectomy with immediate breast reconstruction. The period from the last dose of neoadjuvant chemotherapy was equivalent between those that experienced postoperative complications and those that did not. Patients with a higher body mass index are more likely to experience postoperative complications, and this should be considered when offering tissue expanders to obese patients who have received neoadjuvant chemotherapy and require adjuvant radiation treatment. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Outcomes of Breast Reduction Surgery Using the BREAST-Q: A Prospective Study and Comparison with Normative Data Background: This study aimed to assess breast-related satisfaction and well-being in women with breast hypertrophy before and after breast reduction surgery, and to compare these scores with Australian general population norms, using the BREAST-Q Reduction module. Methods: A prospective cohort study was conducted between March of 2010 and February of 2016. Participants self-completed the BREAST-Q preoperatively and 12 months postoperatively. Normative BREAST-Q data were generated from women aged 18 years and older for comparison. Statistical analysis was performed and values of p < 0.05 were considered significant. Results: The BREAST-Q was completed by 132 participants preoperatively and 12 months postoperatively. Statistically significant improvements were found following surgery in Satisfaction with Breasts, Psychosocial Well-being, Sexual Well-being, and Physical Well-being. In comparison with normative data, patients with breast hypertrophy had significantly lower scores preoperatively, with scores significantly increasing postoperatively to levels representative of the general population. Satisfaction with outcome was not significantly different between patients who were eligible by traditional insurance requirements (Schnur sliding scale/500-g minimum rule) and those who were not. The presence of surgical complications did not affect change in BREAST-Q scores or postoperative satisfaction with outcome. Differences were observed in mean BREAST-Q scores when comparing generated Australian norms to published U.S. norms. Conclusions: Breast reduction surgery significantly improves the satisfaction and quality of life in women with breast hypertrophy to a level that is at least equivalent to that of the normative population. Surgery is of benefit to all women, including those who do not meet traditional insurance requirements. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Comparative Study of Meshed and Nonmeshed Acellular Dermal Matrix in Immediate Breast Reconstruction Background: Acellular dermal matrices are commonly used to support implant-based breast reconstruction. Meshing may enhance integration, reduce drain time and seroma, and decrease surgical costs. Methods: This was a retrospective, single-center analysis of 83 adult women (115 breasts) undergoing one-stage (84.3 percent) or two-stage (15.7 percent) immediate breast reconstruction with bovine-derived acellular dermal matrix (SurgiMend) meshed at a 2:1 ratio. Outcomes were compared with previously published data from a control group of 111 patients (147 breasts) undergoing the same procedure with nonmeshed (fenestrated) acellular dermal matrix. Results: The mean age of patients receiving meshed acellular dermal matrix was 48.3 years and the mean body mass index was 23.6 kg/m2. There were no significant differences in baseline characteristics versus controls, other than chemotherapy history (received by fewer patients in the meshed acellular dermal matrix group). Mean follow-up was 23.6 months. Overall rates of minor and major complications in the meshed acellular dermal matrix group were 16.5 percent and 13.0 percent, respectively—similar to controls (25.2 percent and 12.9 percent). However, with meshed acellular dermal matrix, there were significantly fewer major seromas (0 percent versus 8.2 percent; OR, ∞; 95 percent CI, 1.927 to ∞), fewer total hematomas (0 percent versus 4.8 percent; OR, ∞; 95 percent CI, 1.022 to ∞), and fewer total infections (10.4 percent versus 23.8 percent; OR, 2.682; 95 percent CI, 1.259 to 5.802) compared with controls. Time to drain removal was reduced. Rates of capsular contracture (5.2 percent versus 2.7 percent) and explantation (5.2 percent versus 2.7 percent) were similar in the meshed acellular dermal matrix and control groups. Conclusion: Acellular dermal matrix meshing reduces rates of postoperative seroma, hematoma, and infection and decreases drain removal time compared with nonmeshed acellular dermal matrix. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Breast-Related Quality of Life in Young Reduction Mammaplasty Patients: A Long-Term Follow-Up Using the BREAST-Q Background: Reduction mammaplasty is the most effective means of improving symptoms of macromastia. Although studies have shown lasting benefits in adult patients, there is a paucity of data that explore this topic in young patients. In this study, the long-term satisfaction and well-being of young reduction mammaplasty patients was assessed. Methods: A retrospective review was performed for all female patients younger than 25 years who underwent reduction mammaplasty performed by a single surgeon from 1980 to 2003. Demographic characteristics, comorbidities, surgical details, and length of follow-up were recorded. Participants completed the postoperative version of the BREAST-Q Reduction module. Responses were scored on a scale of 0 to 100. Scores were summarized with descriptive statistics and compared to normative values. Results: Thirty-seven of 52 eligible participants completed the survey (response rate, 71.2 percent). Median age at surgery was 21 years (range, 12.4 to 24.6 years), and median follow-up was 21.4 years (range, 11.4 to 32.4 years). Overall, participants demonstrated high satisfaction and well-being. Mean Q-Scores for Satisfaction with Breasts and Sexual Well-being were significantly higher than normative values (p = 0.0012 and p < 0.0001, respectively), and were as follows: Satisfaction with Breasts, 66.6 ± 16.5 (normative, 57 ± 16); Psychosocial Well-being, 75.9 ± 21.3 (normative, 68 ± 1 9); Sexual Well-being, 72 ± 18.2 (normative, 55 ± 19); and Physical Well-being, 81.1 ± 13.6 (normative, 76 ± 11). Conclusions: Young reduction mammaplasty patients experience excellent breast-related quality of life decades after surgery. Compared with normative values, young reduction mammaplasty patients reported higher satisfaction with breasts and sexual well-being. Surgeons and third-party payers should be aware of these data and advocate for young patients to gain access to care.

Economics of Lymphovenous Bypass Background: The objective of this study was to compare the economic impact of complete decongestive therapy and lymphovenous bypass in the management of upper extremity lymphedema. Methods: Economics were modeled for a patient with breast cancer–related lymphedema undergoing three different clinical pathways: (1) complete decongestive therapy alone; (2) lymphovenous bypass no longer requiring ongoing complete decongestive therapy; or (3) lymphovenous bypass requiring ongoing complete decongestive therapy. Activity-based cost analysis identified costs incurred with complete decongestive therapy and lymphovenous bypass. Costs were retrieved from supplier price lists, physician fee schedules, lymphedema therapists, and literature reviews. The net present value of all costs incurred for each clinical pathway were calculated. Results: The estimated net present value of all costs for a patient with breast cancer–related lymphedema undergoing treatment were as follows: (1) complete decongestive therapy alone ($30,400); (2) lymphovenous bypass no longer requiring ongoing complete decongestive therapy ($15,000); or (3) lymphovenous bypass requiring ongoing complete decongestive therapy ($42,100). The expected net present value of all costs for lymphovenous bypass was $26,800, which was comparable to that of complete decongestive therapy alone. Sensitivity analysis demonstrated that the expected net present value of lymphovenous bypass was dependent on the patient’s life expectancy, number of bypass anastomoses, and likelihood of discontinuing complete decongestive therapy. Conclusions: Lymphedema has substantial ongoing costs irrespective of the treatment modality. The cost of lymphovenous bypass appears comparable to that of complete decongestive therapy alone—the surgical costs of lymphovenous bypass are offset by the savings from discontinued ongoing therapy. Despite its limitations as a theoretical economic model, this study provides insight into the potential economic impact of lymphovenous bypass.

Forehead Fat Grafting: Asian Facial Contouring and Augmentation Background: Aesthetic facial contouring procedures, particularly forehead augmentation, continue to increase in popularity in the Asian population. However, there are very few reports in the literature specifically examining the long-term outcomes of forehead fat grafting. In the present study, the authors aimed to objectively evaluate the efficacy of autologous forehead fat grafting through evaluation of facial proportions and patient-reported outcomes. Methods: Patients who underwent autologous fat grafting for forehead contouring procedures between July of 2011 and June of 2017 were recruited for participation in the study. Patient demographic and clinical variables were collected preoperatively and postoperatively. Facial proportion analysis was collected and compared from preoperative and postoperative photographs. Satisfaction with outcome was assessed by the patient, the surgeon, and a layperson postoperatively. A related-samples Wilcoxon signed rank test was used for statistical analysis. Results: Postoperative outcomes were evaluated in a total of 24 patients who underwent forehead autologous fat-grafting procedures. The average postoperative follow-up was 8.1 months. There were no intraoperative or postoperative complications. More than 50 percent of the postoperative results were evaluated as “satisfactory” by all three groups (i.e., patient, surgeon, and layperson) in terms of aesthetic contouring. Average forehead projection increased 0.24 U (ratio of horizontal distance from midforehead plane to cornea plane/cornea diameter) after one round of fat grafting (p = 0.01). Seven patients (29.2 percent) required more than a single round of fat grafting to achieve optimal results. Conclusions: Autologous fat grafting remains a viable option for forehead contouring and augmentation. The findings of this study demonstrate that the operation is effective and offers stable satisfactory results after long-term follow-up. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Subbrow Blepharoplasty Combined with Periorbital Muscle Manipulation for Periorbital Rejuvenation in Asian Women Background: With advancing age, Asian women are often plagued by lateral hooding of the upper eyelid skin, eyebrow ptosis, and obvious periorbital wrinkles. The authors propose a novel technique to revive the natural eyelid shape with a stable eyebrow position and alleviate periorbital wrinkles in Asian women. Methods: Sixty-six patients underwent subbrow blepharoplasty combined with periorbital muscle manipulation. An ellipse shape of the skin and subcutaneous tissue below the eyebrow was measured, demarcated, and removed. Then, the orbicularis oculi muscle beneath the subcutaneous tissue was exposed and dissected at the upper third. The lower muscle flap was fixed to the supraorbital rim periosteum and the upper musculocutaneous flaps, forming a cross flap for interlocking fixation. The lateral border of the orbicularis oculi muscle was detached from the subcutaneous tissue, splayed out, and sutured upward and inward to the periosteum. The corrugator supercilii muscle temporal to the origin of the supraorbital nerve notch was separated by 1 to 2 mm. The operation results were evaluated by patient satisfaction and comparisons between preoperative and postoperative photographs. Results: Subbrow blepharoplasty combined with periorbital muscle manipulation significantly corrected lateral hooding with a stable eyebrow position and reduced the crow’s feet and glabellar frown lines in all patients. The persistence of the improved outcome was stable during the follow-up period. Postoperative scarring was inconspicuous; however, eight cases had transient postoperative forehead numbness. Conclusions: This novel procedure provides a simple, effective, and comprehensive technique for improving periorbital aging in Asian women. The surgical outcomes are predictable, and the postoperative scarring is inconspicuous. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Discussion: Subbrow Blepharoplasty Combined with Periorbital Muscle Manipulation for Periorbital Rejuvenation in Asian Women No abstract available

Control of Nasal Tip Position: Quantitative Assessment of Columellar Strut versus Caudal Septal Extension Graft Background: Control and maintenance of nasal tip position are critical in rhinoplasty. Two frequent methods of exerting tip control are columellar strut and caudal septal extension graft. However, no quantitative data exist comparing the two methods over time. The purpose of this study was to analyze maintenance of tip projection and rotation following either columellar strut or septal extension graft. Methods: A retrospective cohort study of patients undergoing rhinoplasty was reviewed. Three-dimensional photogrammetric evaluation of patients with either columellar strut or septal extension graft to increase tip projection was performed. Anthropometric points were analyzed in a blinded fashion. Outcome variables were tip projection, nasal length, the Goode ratio, and tip rotation. Results were stratified based on technique and compared statistically. Results: One hundred six patients were included. Overall, 66 percent were female, with an average age of 34.5 years. A columellar strut was used in 42 percent of cases (n = 45), and a septal extension graft was used in 57 percent (n = 61). Analysis showed greater maintenance of tip rotation over time with the septal extension graft compared with the columellar strut [−1.01 percent change (p = not significant versus −5.08 percent change (p = 0.009)]. Tip projection, nasal length, and the Goode ratio decreased over time for both groups, but the differences were not statistically different. Conclusions: Nasal tip projection and rotation appear to decrease from the immediate postoperative position. In this study, both septal extension graft and columellar strut exhibit similar changes in tip projection with time; however, septal extension graft is better able to preserve tip rotation compared with the columellar strut. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.