Long-term sensory recovery of nipple-areola complex following superolateral pedicled reduction mammaplasty

Breast sensibility after reconstruction: Comparison of different methods

BACKGROUND AND OBJECTIVES

Sensibility of the breast area is a key factor in quality-of-life evaluation after breast reconstruction (BR). Breast sensation can be assessed using numerous tools that are already largely described in the literature, including the Semmes Weinstein filaments which remain the most frequently used. Although different reconstruction techniques are available, post-BR sensitivity is rarely described. The aim of this study was to evaluate post-BR sensibility of the breast according to each reconstruction technique.

MATERIAL AND METHODS

Fifteen patients were included in each group, i.e. 90 patients in total: before BR, Latissimus Dorsi (LD) flap with implant, LD flap with fat grafting, exclusive fat grafting, Deep Inferior Epigastric Perforator (DIEP) flap, implant. A single evaluator assessed the sensibility with Semmes Weinstein filaments testing 7 zones on both sides. The native breast was considered as control. Various potential confounding factors were collected.

RESULTS

Patients who benefited from BR with fat grafting alone had a significantly better sensation of the reconstructed breast compared to the other groups (DIEP flap (P<0.0001), LD flap+implant (P=0.0013), LD flap with fat grafting (P=0.0073), implant (P=0.00315)). Comparing those results to the ones obtained in the group before reconstruction, only the fat grafting and DIEP flap groups showed a difference, the fat grafting group (P=0.0061) had higher sensibility whereas DIEP flaps were less sensitive (P=0.00233).

CONCLUSION

We compared mammary sensibility depending on the BR technique used. Our study is the first comparing breast sensitivity among all major breast reconstruction methods. Fat grafting resulted in better breast sensitivity in delayed breast reconstruction than implant or flap-based BR.

Variability in Postoperative Nipple Sensation by Dermoglandular Pedicle in Bilateral Breast Reduction

BACKGROUND

Decreased nipple sensation following reduction mammoplasty can negatively affect a variety of patient-centered outcomes. This observational study examined the impact of dermoglandular pedicle type on subjective postoperative nipple sensation.

METHODS

A total of 178 women who underwent a bilateral reduction mammoplasty at a single institution from 2017 to 2023 and completed an 11-item survey assessing subjective postoperative nipple sensitivity across various tactile modalities were included. Patient-reported nipple sensations were compared across pedicle type and subgrouped by resection volume.

RESULTS

Of the included survey respondents, 72% (128) underwent reduction with an inferior pedicle and 28% (50) with a superior or superomedial pedicle. Over 92% of patients reported the preservation of postoperative nipple sensation. Compared to the inferior pedicle, the superior pedicle cohort reported decreased nipple sensitivity to light touch (56% vs 30%, respectively) and temperature (30% vs 15%). In resection weights greater than 500 grams, the superior pedicle cohort was less satisfied with postoperative nipple sensation (84% vs. 58%), reported decreased sensation in light touch (58% vs 24%), pressure (50% vs 21%), and experienced more numbness and tingling (17% vs 1.4%) (all p-values ≤0.05).

CONCLUSION

The majority of patients maintain some sensation after reduction mammoplasty; however, approximately 10% reported a relative decrease in subjective nipple sensation. Pedicle choice did not significantly affect sensory recovery in resection weights of less than 500 grams. When a greater resection weight is anticipated, the inferior pedicle may be associated with more favorable nipple sensation outcomes.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

"Toward Breast Reinnervation- What is our Endpoint" A systematic review of normal breast sensibility

BACKGROUND

To restore breast sensibility, some centers are offering nerve reconstruction as a component of implant and flap-based breast reconstruction. To interpret and contextualize the results of these procedures, it is necessary to understand the normal range of breast sensibility, the factors that affect it, and the best methods for its objective measurement.

METHODS

We conducted systematic and comprehensive searches across PubMed, Web of Science, and Cochrane Library databases using keywords and controlled vocabulary for the concepts of the breast, nipple, areola, and measurement. The search results were imported into Rayyan QCRI for a blinded screening of titles and abstracts. Studies were evaluated for bias using RevMan 5 software. The results of sensory measurements were pooled, and a quantitative summary of breast sensibility was generated.

RESULTS

A total of 36 articles were identified, including retrospective, cross-sectional, and prospective studies. Although there were some consistent findings across studies, such that breast sensibility is inversely related to breast volume, there was wide variability in the following parameters: population, breast condition, measurement modality, anatomic areas of measurement, and sensibility findings. This heterogeneity precluded the generation of normative breast sensibility measurements. Furthermore, we detected a high degree of bias in most studies, due to self-selection of participants and failure to record patient characteristics that may alter sensibility.

CONCLUSIONS

The literature lacks consistent data delineating normative values for breast sensibility. Standardized measurements of healthy volunteers with various breast characteristics are necessary to elucidate normative values and interpret efforts to restore sensibility in breast reconstruction.

The Impact of Reduction Mammaplasty on Breast Sensation: A Systematic Review

Loss of sensation is one of the most feared complications of breast reduction surgery. Although several techniques have been proposed to maximize sensitivity preservation, the scientific literature still reports contradictory findings. This systematic review aimed to assess whether breast reduction mammaplasty is associated with measurable changes in breast sensation. This review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed (National Institutes of Health, Bethesda, MD), Scopus (Elsevier, Amsterdam, the Netherlands), and Web of Science (Clarivate, Philadelphia, PA) databases were searched for clinical studies investigating breast sensation after breast reduction mammaplasty. The initial search identified 1523 studies of which 22 articles met our specific inclusion criteria. Most of the included studies are consistent in describing only transient sensation decrease or even sensation improvement after surgery compared to the presurgery condition with any approach, except those investigating outcomes after superior or superolateral pedicle reduction mammaplasty. Nevertheless, the overall quality of evidence is low or very low due to the limited availability of randomized controlled trials or controlled studies and the high risk of bias.

LEVEL OF EVIDENCE: 4

A New Method for Inverted Nipple Treatment with Diamond-Shaped Dermal Flaps and Acellular Dermal Matrix: A Preliminary Study

BACKGROUND

Patients with inverted nipples experience various uncomfortable complications including recurrent infections. Regarding the level of severity of inverted nipple, those that are higher than grade II (as classified by Han and Hong) requires surgical correction. Many methods have been proposed to treat the inverted nipple. However, even after treatment, recurrence has always posed a problem. Thus, we propose a new method using the diamond-shaped dermal flap with acellular dermal matrix to treat the inverted nipple.

METHOD

Between March 2019 and February 2022, a total of five patients with grade III were studied in this study. Two diamond-shaped flaps were designed at the 3 and 9 o'clock positions of the nipple. This dermal flap was elevated and wrapped around the nipple column at the nipple base. The lactiferous ducts in female were all divided. In addition, acellular dermal matrix was inserted to fill the dead space of the nipple base. The nipple height and scar evaluation were conducted on 6 month, 12 month postoperatively. Overall satisfaction and complications were also checked at the last visit.

RESULTS

The inverted nipple was resolved and no complications such as hematoma, infection, and necrosis were reported. The projection was maintained without any recurrence, with a slight decrease of 1.5 mm (reduction in 20%) in median value. There were no major or minor complications found except for a few small scars, and the patient was satisfied with the esthetic outcomes during the follow-up.

CONCLUSION

This is a fast and simple technique for the surgical correction of inverted nipples. Using the acellular dermal matrix, projection and suspension were safely maintained without complications. This technique could be an option for the surgical treatment of severe types of inverted nipples.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors   www.springer.com/00266 .

Sensibility Comparison in Reduction Mammoplasties: Is Superomedial or Inferior Pedicle Better?

Background Breast reduction (BR) techniques have evolved tremendously since their introduction. However, a comparison of these techniques has yet to clarify the best choice or whether there is only one choice. This study aims to contribute to this research by retrospectively comparing the missing points of superomedial (SM) and inferior (INF) pedicle techniques. Methodology A total of 93 patients underwent surgery for gigantomastia with SM or INF. Demographic data, surgery details, and postoperative course data were obtained using the sixth-month two-point static discrimination test (TPD) of breasts. Patients were divided into SM and INF groups and statistically analyzed for differences in TPD and breast attributes, including suprasternal notch-to-nipple distance, ptosis grade, age, smoking history, parity, and body mass index. Results Intergroup analysis revealed significant differences between the SM and INF groups in TPD, with mean values of 21.03 ± 4.28 and 33.39 ± 6.91, respectively. The correlations between TPD results were tested, and only ptosis grades 2-4 and right suprasternal notch-nipple-areolar complex (NAC) distance were related. Conclusions The SM technique has better sensibility because the distance for transposition of the NAC to the newly designated position is shorter.

Impact of Patient and Operative Factors on Nipple-Areola Complex Sensation after Bilateral Reduction Mammaplasty

Background

Alteration of nipple-areola complex (NAC) sensation following reduction mammoplasty is commonly reported and may impact patient satisfaction. The goal of this study was to evaluate the patient and procedural factors that influence the rates of subjective NAC sensation change.

Methods

A retrospective review of all patients who underwent primary bilateral reduction mammoplasty between January 2014 and August 2018 at the senior author's institution was performed. The primary outcome measured was subjective NAC sensation via digital stimulation of the NAC with the patient reporting sensation as decreased, unchanged, or increased.

Results

In total, 274 patients met inclusion criteria. NAC sensation was decreased in 19% of breasts, unchanged in 74%, and increased in 7.3%. Patients who underwent vertical pattern, superomedial pedicle reductions were more likely to report a decrease in sensation than those who underwent Wise pattern, inferior pedicle reductions (26% versus 13%; P = 0.0025). Patients with minor complications were more likely to report decreased NAC sensation than those who did not (23% versus 15%; P = 0.0264). The only factor found to be associated with increased sensation was operative time.

Conclusions

Patients were more likely to report decreased sensation if a vertical skin resection, superomedial pedicle was chosen, or if patients experienced a minor complication. The only factor found to correlate with increased NAC sensation was longer operative times.

Interindividual and Intraindividual Variations of Breast Sensitivity Before and After Breast Reduction: A Prospective Study

BACKGROUND

More than 300,0000 breast plastic surgery procedures are performed annually worldwide, of which more than 100,000 are reduction mammoplasties carried out in the United States. Although most patients tend to be satisfied with the immediate outcomes of this procedure, there is increasing concern among surgeons as well as patients with regard to breast sensibility and the postoperative recovery.The objectives of this study were to assess the variation in the sensibility in patients undergoing hypertrophic breast surgery by quantification of the impact of various variables and to evaluate its progression from before the surgery to between 3 and 6 months and 1 year postoperatively.

METHODS

We carried out a nonrandomized, monocentric, prospective study. All of the patients were examined by the same evaluator using a set of 20 von Frey monofilaments on the day before the surgery and at 3 to 6 months and 1 year postoperatively. The breast skin, areola, and nipple sensibilities were tested. Age, body mass index, tobacco use, and the breast volume were recorded.

RESULTS

We did not find any significant effect of the body mass index, tobacco use, or age on breast sensibility. The nipple and areola complex (NAC) sensibility was inversely correlated with the degree of hypertrophy before the surgery, but this difference disappeared in the postoperative evaluations. After the surgery, the NAC sensibility decreased at the first follow-up at 4.5 months and returned to normal after 1 year.

CONCLUSIONS

The inverse relationship between breast volume and sensibility in the preoperative evaluation disappeared after mammaplasty reduction. In the early postoperative period, the sensibility decreased on the NAC but returned to normal after 1 year.

Evaluation of the Sensitivity of the Nipple-Areola Complex in Patients Undergoing Breast Ptosis Correction with Periareolar Dermis Release: A Randomized Controlled Trial

BACKGROUND

In the surgical treatment of breast ptosis, the plastic surgeon's main challenge is to mobilize the nipple-areola complex (NAC) over long distances, preserving its sensitivity. Herein, we aimed to evaluate the NAC sensitivity following a periareolar dermis release in patients undergoing surgical correction of breast ptosis.

METHODS

This is a prospective, double-blinded, randomized study in which 39 patients (78 breasts) were operated on for the treatment of breast ptosis. Patients' breasts were divided into two groups, each breast in a group. In breasts of the experiment group, the periareolar dermis release was used after decortication. This maneuver was not used in the control group's breasts. To analyze the sensitivity in relation with the distance that the NAC should be mobilized to correct breast ptosis, the value of 6 cm was used as boundary. Sensitivity of the NAC was assessed with monofilaments preoperatively and postoperatively-at three and six weeks and one year.

RESULTS

Regarding the sensitivity of the areola, a significant difference was observed in the comparison between the control and experiment groups at the NAC mobility ≤ 6.0 cm in the preoperative. Regarding the nipple, a significant difference was observed in the comparison between the control and experiment groups at three weeks postoperatively for a NAC mobility ≤ 6.0 cm. After one year, there was no difference in the comparison between the groups in either areola or nipple.

CONCLUSION

The periareolar dermis release does not compromise NAC vascularization and pressure sensitivity in patients undergoing breast ptosis correction.

LEVEL OF EVIDENCE II

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Septum-Based Mammaplasties: Surgical Techniques and Evaluation of Nipple-Areola Sensibility

BACKGROUND

The aim of the study was to describe details of surgical techniques and objectively evaluate nipple-areola (NAC) sensibility and viability of septum-based mammaplasties compared to not septum-based reduction techniques.

METHODS

Data regarding NAC sensibility for static and moving one- and two-point discrimination were prospectively collected from 63 active group hypertrophic-breasted patients undergoing septum-based reduction mammaplasty preoperatively, at 6 and 12 months postoperatively, and from a control group of 60 patients who underwent not septum-based techniques. Fixed and mixed effect models were used for statistical analysis.

RESULTS

Comparison of complications showed no significant differences between groups (p = 0.07). After adjusting the results of the active group according to type of sensory testing, it emerged that the threshold decreases by 10% (p = 0.0003) at 6 months and even reaches 43% (p < 0.0001) at 12 months. The results have been modulated according to age, since the variation is less marked when age increased, by 0.6% at 6 months and 0.8% at 12 months (p = 0.019). The effects of the BMI can only be seen at 12 months, with an increase by 1.3% per year (p = 0.033). Among septum-based techniques, the inferior-central pedicle showed better sensibility outcomes even if not significantly (p = 0.06). Comparison of NAC sensibility outcomes showed that active group had thresholds that were 48% lower when compared to those of the control group at 12 months postoperatively (p < 0.001).

CONCLUSION

Septum-based mammaplasty gives optimal results in terms of NAC viability with a significant improvement of sensibility postoperatively. Comparative outcomes on sensibility were also significantly better than not septum-based techniques.

LEVEL OF EVIDENCE II

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Comparison of Sensory Changes Following Superomedial and Inferior Pedicle Breast Reduction

BACKGROUND

More attention is focused on sensory outcomes following breast reduction operations. We conducted this prospective, non-randomized study to compare two commonly used breast reduction techniques, superomedial pedicle and inferior pedicle, regarding sensation of the nipple-areolar complex.

METHODS

We prospectively assigned 60 patients with macromastia into the superomedial pedicle group (SMP group, n = 30) or the inferior pedicle (IP group, n = 30) group. Six patients who withdrew from the study and another six patients who did not attend return visits were excluded. Algometry was used to measure the sensation of breast skin, cardinal points of the areola and the nipple. Two-point discrimination was also measured on the areola. Measurements were performed before surgery, at 3 weeks, and 6 months postoperatively.

RESULTS

There were 20 patients in the SMP group and 28 patients in the IP group. The mean ages of the patients were 43.2 ± 12.7 and 45.9 ± 10.8 years, respectively (p = 0.438). The mean BMI of the patients were 32.4 ± 6.7 and 30.4 ± 5.3 kg/m², respectively (p = 0.257). The mean weights of resected tissues were 802.5 (280-2180) versus 773.7 (349.5-1425.0) g, respectively (p = 0.900). Although breast sensation did not change in the SMP group, sensation in the upper medial and lower lateral portions of breast skin was reduced in the IP group. Two-point discrimination test results did not change in either group. The amount of changes in algometry and two-point discrimination tests were similar in both groups.

CONCLUSION

Both superomedial and inferior pedicle breast reduction techniques are safe and reliable in terms of sensory changes.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Management of the Nipple-Areola Complex in Selected Patients Undergoing Primary Breast Reconstruction: A Comparison of Immediate Replantation and Delayed Reconstruction

BACKGROUND

Management of the nipple-areola complex is an important issue in primary breast reconstruction. When nipple-sparing mastectomy is not suitable, alternatives are immediate nipple-areola complex replantation and delayed reconstruction. The aim of this study was to examine whether patients benefit more from nipple-areola complex preservation by immediate replantation or delayed nipple-areola complex reconstruction.

METHODS

Postoperative results and patient satisfaction after 54 primary breast reconstructions with immediate nipple-areola complex replantation or delayed nipple-areola complex reconstruction were retrospectively evaluated.

RESULTS

The nipple-areola complex was replanted immediately in 37 cases and reconstructed later with nipple sharing and full-thickness skin grafting in 17 cases. Compared with immediate replantation, delayed reconstruction resulted in significantly better postoperative nipple projection (P = 0.01*, Mann-Whitney U test), greater similarity of color and projection with the contralateral side and greater patient satisfaction (Breast-Q). Complete loss of projection occurred in 4 of the 37 replanted nipple-areola complexes. No complete nipple-areola complex necrosis or tumor recurrence was observed in any patient.

CONCLUSIONS

Immediate nipple-areola complex replantation is a safe and reliable procedure for selected patients with contraindications for nipple-sparing mastectomy who have a strong desire to maintain their own nipple-areola complexes, or in bilateral cases. However, drawbacks of this procedure include loss of projection and depigmentation. Delayed reconstruction with nipple sharing and full-thickness skin grafting is a good alternative, especially in unilateral cases; it leads to better postoperative results and greater patient satisfaction, but it involves a nipple-areola complex-free period.

Septum-Inferior-Medial (SIM)-Based Pedicle: A Safe Pedicle with Well-Preserved Nipple Sensation for Reduction in Gigantomastia

BACKGROUND

Reduction in breasts with well-preserved nipple sensation and a viable nipple-areola complex (NAC) is one of the basic core concepts of reduction mammoplasty. Many techniques have been described with enthusiasm advocating full achievement of the aforementioned goals. The goal of this study is to introduce a novel technique that provides an intact neurovascular source to the nipple-areola complex for reduction in gigantic breasts.

PATIENTS AND METHODS

Twenty-six patients operated on from December 2010 through April 2015 were included in the study. The reduction was performed by isolating Wuringer's septum and the inferior pedicle in continuity with the medial pedicle to save the neurovascular supply to the NAC and its accompanying breast parenchyma. This pedicle is called as septum-inferior-medial-based pedicle. Inclusion criteria, marking and planning with detailed description of the surgical procedure are presented.

RESULTS

The overall satisfaction rate was high. Eighty percent of the patients rated their results. The results were as follows: 81% rated as 'very satisfied'; 19% rated as 'somewhat satisfied.' NAC sensation was intact in all cases at all time intervals even immediately after surgery.

CONCLUSION

The united pedicle technique provides an intact neurovascular source to the nipple-areola complex. Reduction with this pedicle is a safe procedure. Remodeling the gigantic breast can be accomplished without any restriction because of the flexibility of this pedicle. The very early results are promising, but long-term results needed to be evaluated.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Lumbar artery perforator (LAP) flap: a salvage tool for extended lumbo-sacral necrosis after bilateral internal iliac arteries embolization

We report the case of a 52-year-old man presenting an extensive lumbosacral necrosis after bilateral internal iliac arteries embolization following unstable pelvic fracture. Coverage of the defect was performed using two extended lumbar artery perforator flaps in a propeller fashion. Good functional and esthetic result was achieved at one-year follow-up.

Anatomy of the nipple and breast ducts

Over time, variations of mastectomy came up and started allowing the oncological safety and the possibility of an immediate breast reconstruction. Nipple sparing mastectomy (NSM) procedures have strongly increased in frequency and have become one of the best alternatives to treat breast cancer, also improving overall aesthetic outcomes and the achievement of contralateral breast symmetry. The nipple areola-complex (NAC) must be considered the identity of the breast concerning self-esteem of patients. This paper will remind the main anatomical topics around the nipple and breast ducts.

Correction of Inverted Nipple Using Subcutaneous Turn-Over Flaps to Create a Tent Suspension-Like Effect

Background

Many techniques have been reported for the correction of inverted nipples. However, the conventional methods may be insufficient, especially for moderate to severe inversions. We propose a modification of Elsahy’s method and report satisfactory results.

Methods

A single-institutional retrospective review was performed for all patients who received the modified operation. Patient charts were reviewed for demographic data, pertinent preoperative factors such as Han and Hong classification, and clinical outcomes including postoperative nipple height and sensation. Surgical details are described within the main text.

Results

The review identified 26 female patients amongst whom 47 inverted nipples were corrected using the modified method. The mean nipple height was 9 mm with an average follow-up period of 14 months. Brush stimulation elicited nipple contraction in all patients. There was no recurrence of nipple inversion, nor were there any surgical complications to report.

Conclusion

The suspension technique is a simple, reliable method for correcting grade II and III nipple inversions.

Objective and subjective evaluation of donor-site morbidity after nipple sharing for nipple areola reconstruction

Nipple reconstruction is of importance in achieving the best possible aesthetic outcome after breast reconstruction. Nipple sharing is a common technique; this study focused on the potential morbidity at the donor nipple. Between 2008 and 2012, 26 patients underwent nipple sharing at our institution. The donor nipple was examined before and after the procedure (mean follow-up of 21 months). Sensitivity, projection, diameter, and patient satisfaction were evaluated. The sensitivity in the donor nipple decreased, albeit insignificantly, from 1.2 g/mm2 (0.8-1.6) to 1.8 g/mm2 (0.8-4.8) (p=0.054, n=26). The projection due to graft removal decreased from 8.0 mm (6.8-10.0) to 4.5 mm (4.0-5.0) (p=0.001). Of the patients, 88% were "very satisfied" or "somewhat satisfied" with the sensitivity and 89% with the symmetry between the donor and reconstructed nipple. At least 60% of the patients were "very satisfied" with all aesthetic outcome parameters (projection, appearance, naturalness, color, and shape). All patients would agree to undergo this procedure again, if necessary. Nipple sharing was associated with minimal morbidity at the donor nipple. The postoperative projection was adequate. Regardless of whether simultaneous mastopexy was performed, the loss of sensitivity was minimal and presumably imperceptible to the patient. By using no sutures after graft removal and letting the donor nipple heal spontaneously, scarring was minimized and the natural appearance and good sensitivity of the donor nipple were preserved.

Plantar pressure in diabetic peripheral neuropathy patients with active foot ulceration, previous ulceration and no history of ulceration: a meta-analysis of observational studies

Aims

Elevated dynamic plantar pressures are a consistent finding in diabetes patients with peripheral neuropathy with implications for plantar foot ulceration. This meta-analysis aimed to compare the plantar pressures of diabetes patients that had peripheral neuropathy and those with neuropathy with active or previous foot ulcers.

Methods

Published articles were identified from Medline via OVID, CINAHL, SCOPUS, INFORMIT, Cochrane Central EMBASE via OVID and Web of Science via ISI Web of Knowledge bibliographic databases. Observational studies reporting barefoot dynamic plantar pressure in adults with diabetic peripheral neuropathy, where at least one group had a history of plantar foot ulcers were included. Interventional studies, shod plantar pressure studies and studies not published in English were excluded. Overall mean peak plantar pressure (MPP) and pressure time integral (PTI) were primary outcomes. The six secondary outcomes were MPP and PTI at the rear foot, mid foot and fore foot. The protocol of the meta-analysis was published with PROPSERO, (registration number CRD42013004310).

Results

Eight observational studies were included. Overall MPP and PTI were greater in diabetic peripheral neuropathy patients with foot ulceration compared to those without ulceration (standardised mean difference 0.551, 95% CI 0.290–0.811, p<0.001; and 0.762, 95% CI 0.303–1.221, p = 0.001, respectively). Sub-group analyses demonstrated no significant difference in MPP for those with neuropathy with active ulceration compared to those without ulcers. A significant difference in MPP was found for those with neuropathy with a past history of ulceration compared to those without ulcers; (0.467, 95% CI 0.181– 0.753, p = 0.001). Statistical heterogeneity between studies was moderate.

Conclusions

Plantar pressures appear to be significantly higher in patients with diabetic peripheral neuropathy with a history of foot ulceration compared to those with diabetic neuropathy without a history of ulceration. More homogenous data is needed to confirm these findings.