A Novel Application of the Hemostatic Net in Aesthetic Breast Surgery: A Preliminary Report

Thoracoabdominal advancement flap for definition of inframammary fold in delayed breast reconstruction: A retrospective cohort study assessing safety and patient-reported satisfaction using the BREAST-Q

INTRODUCTION

Numerous inframammary fold reconstruction methods have been described. An update of the thoracoabdominal advancement flap technique has been proposed, enabling definition of the inframammary fold and significant skin recruitment. This study aimed to provide information on safety, patient management, and validated patient-reported outcomes, enabling a critical analysis of this technique.

METHOD

This single-centre retrospective cohort study included female patients, aged ≥18 years, with history of breast cancer treated by total mastectomy, and complete delayed breast reconstruction with thoracoabdominal advancement flap. The data collected included age, history of radiotherapy, surgical protocol, complications, reoperations of the inframammary fold, and BREAST-Q score at the end of reconstruction.

RESULTS

The 100 patients included underwent 102 delayed breast reconstructions. Reconstructive methods were deep inferior epigastric artery perforator flap (n=50), muscle sparring latissimus dorsi flap (n=29), transverse myocutaneous gracilis flap (n=7), prosthesis (n=4), and adipose tissue transfers (n=12). Thoracoabdominal advancement flap was associated with 4 Clavien-Dindo Grade I complication (delayed wound healing); 42 patients underwent surgical revision of inframammary fold (IMF) placement. BREAST-Q results at the end of reconstruction were available for 63 patients; the mean±standard deviation score for Satisfaction with breast was 61.9±12.3, and for Physical well-being: chest this was 71.9±20.2.

CONCLUSION

This IMF reconstructive technique is safe, with minimal complications, and compatible with all reconstructive methods. It ensures patient satisfaction, even in irradiated areas, and respects the aesthetic subunits of the breast, maintaining a single breast scar and providing skin similar to the thorax. The multistep reconstructive protocol allows for revision that further consolidates cosmetic results.

Percutaneous approach for inframammary fold creation combined with exclusive adipose tissue transfer in post-mastectomy breast reconstruction

INTRODUCTION

The inframammary fold has an important role in breast's aesthetic and maintain and should be restored during breast reconstruction after mastectomy. Several techniques have been described, mainly based on an open approach, not adapted in case of complete reconstruction by fat grafting. To address these concerns, the authors propose a percutaneous approach for inframammary fold reconstruction.

METHODS

This single-center, retrospective cohort study included female patients≥18 years old with a history of unilateral or bilateral mastectomy and deferred breast reconstruction using fat grafting with percutaneous inframammary fold creation. Patient data (age, BMI, prior radiotherapy, procedure details, complications) were collected. The percutaneous inframammary fold fixation combines a superficial liposuction of the lower thoracoabdominal area with a percutaneous overlock suture anchoring the dermis to the deep thoracic fascia, and a net suture in segment 4. This technique allows for moderate skin recruitment, simultaneous fat transfers in the same operation, and increase inframammary fold definition and breast ptosis.

RESULTS

A total of 26 patients (29 breast reconstructions) were included. The median age was 59 years, and patients underwent a median of 4 interventions with a total fat transfer volume of 1190mL. Six patients required IMF revisions, with no major complications observed. The technique showed favorable outcomes with stable IMF definition over time.

CONCLUSION

This percutaneous inframammary fold creation technique, combined with fat grafting, broadens reconstructive options for mastectomy patients. It is safe, reproducible, and enhances breast aesthetics with minimal morbidity.

Extended Superior Pedicle Autoaugmentation (ESPA) Mastopexy: A Review of 20 Consecutive Patients

BACKGROUND

Ptotic breast deformity arises from decreased breast tissue volume and skin laxity, causing descent of breast tissue due to gravity. Mastopexy lifts and reshapes the breast and can be potentially associated with breast implants in case of need of volume increase. However, this option is not accepted by all the patients. The extended autoaugmentation mastopexy (ESPA) incorporates an abdominal flap to increase breast volume without implants, reducing surgical time and offering stable long-term outcomes.

OBJECTIVES

The authors propose modifying the superior pedicle vertical mammaplasty to include glandular tissue transposition and an abdominal flap. This aims to restore central mound projection, narrow the lower breast base, and raise the inframammary fold.

METHOD

Twenty patients underwent superior pedicle extended autoaugmentation (ESPA) mammaplasty from 2020 to 2024. Patients, aged 25 to 45, with wide, low-lying breasts lacking central projection, were selected. Breast tissue was elevated on a superior dermal pedicle extended inferiorly to an abdominal flap and transposed into a prepectoral pocket. The inframammary fold was raised, and the dead space is closed using internal and external temporary sutures.

RESULTS

Patients tolerated well the procedure, with one developing a seroma, successfully managed. All 20 patients expressed high satisfaction with postoperative breast shape and size, with no desire for subsequent augmentation.

CONCLUSIONS

The technique extends the superior pedicle to include abdominal tissue, restoring central mound projection and modifying the inframammary fold. It reliably recreates a more youthful breast shape in suitable patients without the need for implants.

LEVEL OF EVIDENCE V

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Evolution of the Surgical Net

The surgical net technique, originally conceptualized to mitigate postoperative hematomas, has evolved into a versatile tool, transcending its initial purpose, and signaling a new era of surgical innovation. This article provides a comprehensive overview of the surgical net's journey from a targeted solution to a multifaceted surgical asset and explores its burgeoning applications, challenges, and future trajectories. Despite early reluctance due to anatomical concerns and unfamiliarity with the novel technique, the surgical net's consistent success in various surgical contexts from facial surgeries to gynecological applications has catalyzed its widespread global adoption. The technique's integration of the progressive tension method and enhanced skin redraping capabilities underscores its contribution to optimal aesthetic outcomes and improved surgical control. Noteworthy is its role in the innovative concept of gliding surgery, marked by procedures like the gliding brow lift and Glidelift, demonstrating the surgical net's adaptability and effectiveness in diverse surgical environments.Contributions from international surgeons have expanded its applications to areas like axillary space obliteration after breast implant, postmastectomy closure, and the management of postpartum hemorrhage, showcasing the surgical net's global impact and universal commitment to optimizing surgical outcomes. The article delves into the anatomical considerations essential for adapting the surgical net technique to various surgical contexts, emphasizing the need for continuous research, clinical trials, and multidisciplinary collaboration to navigate emerging challenges and ensure its sustained efficacy and safety.In conclusion, the article highlights the surgical net technique's unwavering potential for further advancements, greater procedural efficiency, and the continued elevation of patient care standards. The consistent evolution of its applications, paired with a dedicated approach to addressing emergent challenges, reinforces the surgical net's enduring contribution to surgical innovation and global patient welfare.

Available techniques to minimize scars in surgical management of gynecomastia - a comprehensive review

Objective

Gynecomastia and lipomastia are benign proliferations of the male breast affecting 32-65% of men. Numerous surgical procedures often result in stigmatizing scars when it comes to skin resection. The purpose of this study was to review skin-sparing techniques and to describe our skin-sparing approach to treat skin excess using transcutaneous netting.

Materials and Methods

A comprehensive review of the literature was conducted aiming at identifying available techniques to avoid skin resection in gynecomastia or lipomastia patients (Simon's grade IIb and III). Surgical techniques, patient satisfaction, time of follow-up, and complications were assessed.

Results

Seven studies detailed skin retraction techniques, including laser-, ultrasound-, and radiofrequency-assisted liposuction (LAL, UAL, and RAL), microneedling, and nipple-areolar complex (NAC) plaster lifting. All articles provided Simon's grade classification, with most studies including patients with and without skin laxity. Complication rates were low (1.5-10%), and patient satisfaction ranged from 87.5% to 100%.While transcutaneous netting has been reported to reduce hematoma in gynecomastia surgery, no studies specifically examined its role in managing skin redundancy.

Conclusions

Limited data exist on scarless skin retraction techniques for gynecomastia. While LAL, UAL, and RAL show some potential, controlled studies are lacking, and skin resection is often performed for high skin redundancy. We recommend a skin-sparing approach using liposuction and transcutaneous netting for gynecomastia up to Simon's grade III, which allows for skin retraction and NAC fixation. No literature was found assessing the efficacy of transcutaneous netting in promoting skin retraction in gynecomastia.

Classification of Breast Implant Malposition

BACKGROUND

Implant malposition is a well-recognized complication of prosthetic breast implants. However, to date, no objective classification system has been described.

OBJECTIVES

The aim of this study was to perform a prospective trial of an objective and reproducible classification system for implant malposition formulated by analyzing retrospective data from a large cohort of patients with implant malposition.

METHODS

The authors retrospectively analyzed the degree of medial/lateral and inferior/superior implant malposition relative to their optimal position within the breast footprint in a series of 189 breasts (n = 100 patients). An objective classification system for implant malposition was devised and then applied to a prospective cohort of 53 breasts in 28 patients with implant malposition.

RESULTS

The degree of malposition in a single or combination of axes was categorized according to the distance (measured in centimeters) from the ideal breast footprint. The classification system incorporated the axis of malposition and distance to generate a treatment decision-making guide. Cases of Grade 1 malposition did not warrant surgical intervention, whereas surgical correction was warranted in all Grade 3 cases. In the combined patient cohort (n = 242 breasts, 128 patients), lateral, inferior, medial, and superior displacement ranged between Grades 1 and 3. There was no interobserver variability in the grades assigned to 9 out of 10 patients in the prospective group.

CONCLUSIONS

A simple and reproducible classification system for implant malposition has been created that allows surgeons to objectively record the extent of malposition, guides surgical decision-making, and can be used to document the results of any intervention.

LEVEL OF EVIDENCE: 3

Skin Perfusion After Hemostatic Net: An Anatomic and Radiologic Study in a Cadaver Model

BACKGROUND

The hemostatic net is a recent technique initially developed to reduce the occurrence of postoperative hematomas following facelift procedures. Its applications have expanded to include skin redraping, deep plane fixation, and other areas beyond the face. However, no experimental study has investigated its effect on skin blood supply.

OBJECTIVES

The aim of this study was to analyze facial skin vascularization after applying a hemostatic net to fresh cadavers.

METHODS

Fourteen hemifaces from fresh adult cadavers were examined. The study model involved a deep plane facelift procedure with the use of a hemostatic net. The first step, involving 4 hemifaces, included dissections and two-/three-dimensional angiographies by digital microangiography and computed tomography scan, respectively. The purpose was to evaluate the influence of the hemostatic net on vascular perfusion. The second step involved a sequential dye perfusion study performed on 10 other hemifaces that underwent facelift procedures with the hemostatic net to determine its impact on skin perfusion.

RESULTS

The anatomic and radiologic techniques enabled visualization of skin, and showed the arterial system reaching the subdermal vascular plexus and branching between the vascular territories, without interference from the net. The sequential dye perfusion study showed staining after injection in each facelift flap, with comparable coloration distributions before and after the application of the net.

CONCLUSIONS

The hemostatic net did not affect the skin blood supply, correlating with no clinical increases in ischemia and necrosis rates in the facelift flap. This study provides additional evidence supporting the safety of the hemostatic net in clinical practice.

LEVEL OF EVIDENCE: 5

Nerve Injury and Peripheral Nerve Functional Loss From Injection and Suture Needles: An Experimental Study on Rats

BACKGROUND

During invasive procedures involving needles, there is a chance of damage to peripheral nerves. Therefore, a method for experimentally simulating these situations is needed.

OBJECTIVES

In this study we aimed to evaluate peripheral nerve lesions caused by the entry and exit of an injection needle, nerve transfixion through a suture stitch, and the injection of saline solution and lidocaine into the nerve.

METHODS

After obtaining approval from the Animal Ethics Committee, we randomly divided 36 Wistar rats, weighing approximately 250 g each, into 6 groups (control, sham, suture, needle, saline, and lidocaine groups), with 6 animals in each group. All procedures were performed on the left paws of the rats. After the procedure, walking track analysis was performed to assess the walking function of rats for 8 weeks. Four months after the procedures, we performed bilateral electrophysiological studies (measuring the latency and amplitude of the electrical impulse in the peroneal nerve). Subsequently, the rats were euthanized, and bilateral tissue samples were collected from the peroneal nerve and tibialis cranialis muscle for morphometric histological analysis.

RESULTS

In the walking track analysis, all groups showed normalization of walking functionality after 13 days. There was little histological change between the groups, and no functional loss related to the procedures was observed.

CONCLUSIONS

Procedures involving the infusion of local anesthetic or saline solution, or suture needles, are safe with regard to peripheral nerve function loss. Accidents tend not to cause nerve impairment.

Hemostatic Net in Facelift Surgery: A 5-Year Single-Surgeon Experience

BACKGROUND

The hemostatic net has been promoted as a safe and effective method to prevent hematoma formation following facelift procedures. To date there is little published evidence to validate the replicability and effectiveness of the technique.

OBJECTIVES

This study presents 2 cohorts of facelift patients from a single surgeon's practice to assess the impact of the hemostatic net on hematoma formation.

METHODS

The records of 304 patients were reviewed on whom the hemostatic net was placed following a facelift between July 2017 and October 2022. Data were collected and assessed for complications and compared with a control group of 359 patients who underwent a facelift procedure without placement of a hemostatic net by the same surgeon between 1999 and 2004.

RESULTS

A total of 663 patients were included. In this retrospective cohort study, analysis of available data showed a significantly reduced hematoma rate of 0.6% in the intervention group compared with 3.9% in the control group (P = .006722).

CONCLUSIONS

The use of the hemostatic net is a safe, reproducible, and effective technique in reducing the risk of hematoma in facelift surgery.

LEVEL OF EVIDENCE: 4