Ciudad, Pedro

ABSTRACTBackgroundTactile sensory recovery in autologous breast reconstruction (ABR) has been shown to prevent injuries and improve quality of life. However, the studies comparing neurotized versus non‐neurotized outcomes are still controversial due to methodological heterogeneity. This review uses consistent and objective outcomes to evaluate the current evidence's qualitative characteristics and quantitative tactile sensory recovery.MethodsWe conducted a systematic electronic literature search from database inception through 10 February 2024, of the following databases: PubMed, Ovid MEDLINE, Embase, SCOPUS, and CINAHL to identify all studies reporting outcomes of tactile sensory recovery using the Semmes‐Weinstein Measuring scale in free‐flap ABR comparing neurotization versus non‐neurotization. The SWM scale score, demographic characteristics, and surgical features were extracted from each study. Due to the data heterogeneity within the studies, we transformed the data into means and pooled the qualitative information.ResultsWe identified 264 articles. After thorough screening, 12 fulfilled the inclusion criteria and were included in the qualitative synthesis. Finally, 7 were quantitatively analyzed with a total of 251 breasts that underwent ABR with free flap neurotization and 244 breasts without neurotization. This revealed a mean SWM score difference of −0.67 and a significant p‐value < 0.05. A subgroup DIEP flap analysis performed for 177 neurotized compared to 175 non‐eurotized flaps yielded a significant mean difference of −0.86 p < 0.05. There were no significant differences between groups in age (48.8 vs. 49.8, p = 0.5), history of chemotherapy (72 vs. 74, p = 0.91), radiotherapy (61 vs. 56, p = 0.84), or follow‐up time (21.85 vs. 25.09 months, p = < 0.05) that could have influenced tactile sensory recovery.ConclusionNeurotization in free‐flap ABR could allow better tactile sensory recovery than the spontaneous sensation gained without it. The additional surgical time required for coaptation is short, and no studies have reported associated complications, making it a safe procedure that can potentially improve patients´ quality of life. Nonetheless, higher‐quality studies, such as randomized control trials with standardized sensation testing and more rigorous methodologies, are needed before making final clinical recommendations.

Background: Primary lymphedema is a chronic condition caused by a developmental abnormality of the lymphatic system, leading to its malfunction. Various surgical options, including physiologic and excisional procedures, have been proposed. The aim of this study was to present a comprehensive algorithm for the treatment of primary lower extremity lymphedema: the Primary LYmphedema Multidisciplinary Approach (P-LYMA). Methods: Nineteen patients were treated following the P-LYMA protocol. Patients underwent pre- and postoperative complex decongestive therapy (CDT). A variety of physiologic and excisional procedures were performed, either independently or in combination. The primary outcome was to assess the circumferential reduction rate (CRR). The Lymphedema Quality of Life Score (LeQOLiS), reduction in the number of cellulitis episodes, and complications were recorded. Results: The mean CRR was 73 ± 20% at twelve months postoperatively. The frequency of cellulitis episodes per year decreased from a mean of 1.9 ± 0.8 preoperatively to 0.4 ± 0.6 during follow-up. Two patients experienced minor complications. The mean hospitalization time was 5 days. Patients’ quality of life, as measured by the LeQOLiS, significantly improved from 70.4 ± 12 preoperatively to 24 ± 14 at twelve months postoperatively. Conclusions: The P-LYMA algorithm maximizes surgical outcomes and improves the quality of life in patients with primary lymphedema. CDT is essential for optimizing results.

Abstract Background Posttraumatic lymphedema develops more frequently than expected and reports on its management are scarce in the literature. We aimed to report the clinical outcomes of a case series of posttraumatic lymphedema patients treated with different vascularized lymph node transfers (VLNTs). Patients and Methods Five patients with secondary posttraumatic lower limb lymphedema treated with VLNT were included in this report. The groin-VLNT (n = 1), supraclavicular-VLNT (n = 2), and gastroepiploic-VLNT (n = 2) were implemented. The average flap area was 69.8 cm2. Patients underwent postoperative complex decompressive therapy for an average of 10.0 months. Results The average mean circumference reduction rate was 24.4% (range, 10.2–37.6%). Postsurgical reduction in the number of infection episodes per year was observed in all patients. The mean follow-up was 34.2 months. Conclusions VLNT is a promising surgical treatment for posttraumatic lymphedema patients. In our report, VLNT has demonstrated to reduce the volume and number of infections per year in posttraumatic lymphedema.

AbstractBackground Abdominal wall vascularized composite allotransplantation (AW-VCA) is a novel reconstructive technique used for large abdominal wall defects in combination with intestinal transplantation (ITx) or multivisceral abdominal transplantation (MVTx). Since the introduction of this procedure, several studies have been published reporting their experience. This study aims to present a scoping review looking at all available evidence-based medicine information to understand the most current surgical techniques and clinical outcomes.Methods This scoping review followed the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) extension for scoping reviews checklist. A comprehensive research strategy of several databases was conducted.Results A total of 31 studies were included in this review, which comprised animal, cadaveric, and human studies. In human studies, four surgical techniques with high flap survival rates and low complication rates were found. In cadaveric studies, it was shown that the use of iliofemoral cuff-based flaps provided adequate tissue perfusion to the abdominal wall graft. Also, the use of thoracolumbar nerves have been described to provide functionality to the AW-VCA and prevent long-term muscle atrophy.Conclusion AW-VCA is a safe and efficient alternative for patients with large and complex abdominal wall defects. The future holds a promising evolution of a functional AW-VCA, though surgeons must face and overcome the challenge of distorted anatomy frequently present in this population. Forthcoming studies with a better level of evidence are required to evaluate functionality and differences between surgical techniques.

AbstractBackground Studies reporting on the deep circumflex iliac artery (DCIA) free flap are restricted to a limited number of patients and areas of application. The aim of this review was to assess the reliability and versatility of the DCIA free flap during reconstruction.Methods A comprehensive review was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) guidelines using PubMed, Web of Science, Cochrane CENTRAL, and SCOPUS. A critical analysis of pooled data was performed to assess outcomes employing the DCIA free flap.Results A total of 445 DCIA free flaps were included. The main recipient sites were head and neck (72.35%), lower extremity (20.67%), and upper extremity (6.74%). The main indications for reconstruction were tumor resection (73.8%) and trauma (17.43%). Fifty non-DCIA flaps were required to finalize the reconstruction of several defects. The pooled flap failure rate using the DCIA free flap was 4% (95% confidence interval: 1–8%). No significant heterogeneity was present across studies (Q statistic 22.12, p = 0.14; I 2 = 27.68%, p = 0.139). Complication rates for head and neck and limb reconstruction were 57.37 and 40.16%, respectively. The average length and surface area of bone flaps were 7.79 cm and 22.8 cm2, respectively. The area of the skin paddles was 117 cm2.Conclusion The DCIA free flap has shown to be a versatile reconstructive alternative for head and neck and short-medium size limb defects. However, the complexity of functions, the recipient site location, and a potential large defect can detract from the use of the DCIA free flap as an initial reconstructive option for head and neck and extensive limb defects.

AbstractChylous ascites is the leakage of lipid‐rich lymph into the peritoneal cavity usually due to disruption of lymphatics or increased peritoneal lymphatic pressure. Various surgical options have been proposed to treat chylous ascites but most have shown suboptimal outcomes. The gastroepiploic vascularized lymph node (GE‐VLN) flap has been described previously for the treatment of lymphedema. In chylous ascites, this flap could provide an alternate drainage pathway for the intraperitoneal chylous fluid. The purpose of this report is to present another option for the microsurgical treatment of refractory chylous ascites. Herein, we report two patients with refractory chylous ascites secondary to cancer who have undergone deep inferior epigastric‐based lymphatic “cable” flap (DIE‐LCF) connected to a pedicle GE‐VLN flap. Patients were followed‐up for a minimum of 2 years. Within the first 3 months following surgery, the patient's nutritional parameters improved along with drastic reduction of ascites. At 2 years follow‐up postoperative abdominal circumference decreased significantly. None required further peritoneal paracentesis and all patients were free of chylous ascites symptoms. In conclusion, the DIE‐LCF connected to a pedicle GE‐VLN flap could be a feasible option for the microsurgical treatment of refractory chylous ascites.

Background: Every day, we see more patients present to hospitals and clinics seeking gender-affirmation care to ameliorate the symptoms of gender dysphoria. However, to provide a multidisciplinary approach, it is important to offer an integrated clinical program that provides mental health assessment, endocrine therapy, physical therapy, research, and the full spectrum of surgical services devoted to transgender patients. This article describes our experience on building a specialized, multidisciplinary, academic state-of-the-art gender-affirmation program. Methods: Herein, we describe the main and critical components on how to build a multidisciplinary academic gender-affirmation program. We share our lessons learned from this experience and describe how to overcome some of the obstacles during the process. Results: Building a multidisciplinary academic gender-affirmation program requires an invested team, as each and every member is essential for feedback, referrals, and to improve patient’s experience. Institutional support is essential and by far the most important component to overcome some of the obstacles during the process. Having all team members working under the same institution provides all the critical components needed to improve outcomes and patient satisfaction. In addition, the collection of prospective data with a well-structured research team will provide information needed to improve clinical services and standardize clinical protocols, while leaving space for innovation. Conclusions: This article describes the steps and experience needed to build a multidisciplinary holistic academic gender-affirmation program. We provide our lessons learned during the process that will help guide those who intend to start an academic gender-affirmation program.

Background: There is an unknown percentage of transgender and gender non-confirming individuals who undergo gender-affirmation surgeries (GAS) that experiences regret. Regret could lead to physical and mental morbidity and questions the appropriateness of these procedures in selected patients. The aim of this study was to evaluate the prevalence of regret in transgender individuals who underwent GAS and evaluate associated factors. Methods: A systematic review of several databases was conducted. Random-effects meta-analysis, meta-regression, and subgroup and sensitivity analyses were performed. Results: A total of 27 studies, pooling 7928 transgender patients who underwent any type of GAS, were included. The pooled prevalence of regret after GAS was 1% (95% CI <1%–2%). Overall, 33% underwent transmasculine procedures and 67% transfemenine procedures. The prevalence of regret among patients undergoing transmasculine and transfemenine surgeries was <1% (IC <1%–<1%) and 1% (CI <1%–2%), respectively. A total of 77 patients regretted having had GAS. Twenty-eight had minor and 34 had major regret based on Pfäfflin’s regret classification. The majority had clear regret based on Kuiper and Cohen-Kettenis classification. Conclusions: Based on this review, there is an extremely low prevalence of regret in transgender patients after GAS. We believe this study corroborates the improvements made in regard to selection criteria for GAS. However, there is high subjectivity in the assessment of regret and lack of standardized questionnaires, which highlight the importance of developing validated questionnaires in this population.