Chris Amro

Background: Direct-to-implant (DTI) reconstruction offers several advantages over the 2-stage implant-based breast reconstruction approach. However, the outcomes of prepectoral reconstruction are debated. Many previous studies contained confounders, making their conclusions less definitive. This study offers the first matched cohort analysis comparing DTI with 2-stage reconstruction in the prepectoral plane. Methods: Patients treated with postmastectomy implant-based breast reconstruction from 2018 through 2021 were retrospectively reviewed. Patients were propensity score matched by body mass index, smoking status, history of hypertension, mastectomy type, chemotherapy, radiotherapy, acellular dermal matrix use, and coverage type. Outcomes assessed included surgical site occurrences (SSOs), capsular contracture, and explantation of either expander or implant. Results: A total of 433 breasts were identified, and 154 breasts were matched (77 DTI; 77 2-stage). Two-stage prepectoral reconstruction was associated with greater rates of seromas (2-stage, 18.2%; DTI, 5.2% [ P < 0.05]) and overall SSOs (2-stage, 45.5%; DTI, 24.7% [ P < 0.05]). This approach was also an independent predictor on multivariate regression (adjusted odds ratio, 5.69, 4.86 [ P < 0.05]). There were no differences between the groups regarding final implant size, capsular contraction (grades 3 or 4), or implant or expander loss ( P > 0.05). There were also no significant differences in secondary reconstruction or failures of secondary reconstructions after explantation between the groups, with a mean follow-up of 22 months. Conclusions: Prepectoral 2-stage and DTI reconstruction have similar risk profiles; however, DTI may be more beneficial in the correctly identified patient. Prepectoral 2-stage reconstruction is associated with higher rates of seromas and SSOs compared with DTI reconstruction. Secondary reconstruction after explantation can readily achieve long-term success in both prepectoral 2-stage and DTI reconstruction.

Background: Nipple-sparing mastectomy (NSM), given demonstrated oncologic safety, is widely used for both therapeutic and prophylactic mastectomy. The popularity of NSM has spurred advancements by breast and plastic surgeons, liberalizing the indications for NSM and improving patient and aesthetic reconstructive outcomes. This review explores these developments and establishes up-to-date surgical tenets for successful NSM and reconstruction. Methods: A comprehensive literature review was conducted using the PubMed, Google Scholar, and Cochrane Library databases, focusing on peer-reviewed studies published up to 2024. Articles were selected based on relevance, quantity, and documentation of clinical outcomes and patient satisfaction. Results: NSM is utilized frequently for both invasive breast cancers and prophylactic mastectomy, with expanded criteria for candidacy by breast surgeons. Staged procedures such as adjunct reduction, mastopexy, or nipple delay allow patients with larger or ptotic breasts to undergo NSM with comparable outcomes. Long-term outcome studies have identified important risk factors for complications, including smoking history, higher mastectomy weight, certain medical comorbidities, and suboptimal mastectomy flaps. Evolutions in reconstructive decision making in direct-to-implant and staged tissue expander placement have improved aesthetic results while accounting for poor mastectomy flap quality or adjuvant therapy. Long-term outcomes show NSM remains safe and has comparable rates of local recurrence. Patient-reported outcomes demonstrate satisfaction with NSM, especially in sexual and psychological wellbeing metrics. Conclusions: NSM has been demonstrated to be safe in long-term oncologic outcomes. Its widespread popularity over the past ten years has helped identify methods to improve upon surgical and aesthetic outcomes, including decision-making in reconstruction; considerations for challenging patient-related characteristics such as macromastia, ptosis, and NAC asymmetry; and novel advances in areas such as neurotization.

Objective: The objective of this study was to determine the outcomes of robotic peritoneal flap vaginoplasty. Background: There is a lack of long-term outcomes data for gender-affirming vaginoplasty to inform patient decision-making. Methods: A retrospective cohort of 500 consecutive patients undergoing robotic peritoneal flap vaginoplasty from 2017-2023 were reviewed. Complications requiring procedural intervention, self-reported vaginal dimensions, and orgasm were recorded at each follow up visit and analyzed as outcomes. Results: 487 (97%) of patients were followed to 3 months, and 425 (85%) to 1 year or greater. Twenty patients (4%) had a complication requiring procedural intervention, and 61(12%) had elective revision surgery. Median self-reported vaginal depth and width at 1 year was 14.5 cm (14.5-14.5) and 3.8 cm (3.8-3.8 cm). There were 12 patients (4%) no longer dilating using standard dilators at this pre-scheduled 1-year appointment, and at last follow-up ≥1 year, 8% were no longer dilating. Thirty-six (8%) of patients were considered anorgasmic at last follow up. Difficulty with orgasm prior to surgery was associated with lower rates of achieving orgasm after surgery and less consistent vaginal depth at 1 year, however 80% of these patients were able to orgasm after surgery. Conclusions: Clinician-observed and patient-reported outcomes for robotic gender-affirming peritoneal flap vaginoplasty were superior to those reported in the literature for penile inversion vaginoplasty. Patients who do not achieve orgasm prior to surgery are less likely to achieve orgasm and maintain vaginal depth afterwards, however the majority of these patients have improved sexual health after surgery.

Introduction Breast reduction surgery addresses both functional complaints and aesthetic concerns. Two commonly used incision patterns in the US are the Wise and vertical patterns, but there are limited data comparing their clinical and quality of life (QoL) outcomes. This study evaluates and compares these outcomes between the two techniques. Methods A retrospective review from 2016 to 2022 examined subjects who underwent breast reduction with either vertical or Wise incision patterns. A propensity-scored match was performed based on age, body mass index (BMI), ptosis grade, and breast tissue removal. Surgical and patient-reported outcomes (BREAST-Q) were analysed. Results Out of 379 patients, a total of 92 breasts (46 patients) were identified after propensity-score matching, with a mean age of 30.4 years and BMI of 26.5 kg/m². Vertical incisions were more likely to have the superomedial pedicle utilized and a larger nipple diameter. There was no significant difference in ptosis grade and tissue removal. There were no differences in clinical outcomes, aesthetic outcomes, reoperations, readmissions, or emergency room visits (p > 0.05). QoL analysis identified a significant improvement within both cohorts across domains: satisfaction with breast, psychosocial well-being, and physical well-being (p < 0.001). However, patients with the Wise pattern technique demonstrated a significant improvement in sexual well-being (p = 0.002). Conclusion Both the vertical and Wise incision patterns are safe and provide significant QoL improvements. While both techniques improve multiple QoL domains, the Wise pattern offers additional benefits in sexual well-being. These findings can guide surgeons in discussing outcomes with patients. 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

Background/Objectives: Implant-based breast reconstruction has been essential since the 1960s, offering a faster and less invasive alternative to autologous reconstruction. Recent innovations—including direct-to-implant (DTI) reconstruction, advancements in surgical planes, synthetic meshes, and nipple-areolar complex (NAC) neurotization—have improved patient outcomes. This review explores these developments, analyzing their impact on breast reconstruction over the past two decades. Methods: A comprehensive literature review was conducted using PubMed, Google Scholar, and Cochrane Library databases, focusing on peer-reviewed studies published up to 2024. Articles were selected based on relevance, quality, and documentation of clinical outcomes and patient satisfaction. Results: Findings indicate that DTI reconstruction reduces the need for multiple surgeries, especially in cases with sufficient mastectomy flap quality. Prepectoral placement showed benefits in postoperative comfort and recovery speed compared to subpectoral placement, but had specific risks, such as implant rippling. Synthetic meshes improved implant support and reduced complication rates, while neurotization has shown potential in restoring sensation to the nipple-areolar complex (NAC), addressing quality-of-life concerns. Conclusions: Innovations like DTI, prepectoral techniques, and adjunctive mesh and neurotization strategies are advancing patient outcomes. Future research should refine these methods, aiming to expand applicability and further improve aesthetic and sensory outcomes for breast cancer survivors.

Background Although intraperitoneal and retromuscular mesh placement in ventral hernia repair (VHR) are associated with lower recurrence rates, the onlay plane remains a well-established option for certain clinical scenarios. A knowledge gap remains regarding resorbable biosynthetic onlay mesh and mesh exposure. We aim to determine exposure rate, risk factors, and treatment options. Study design A single-center, two-surgeon retrospective review was performed examining patients who underwent VHR with onlay, Poly-4-hydroxybutyrate (P4HB) mesh from 2015 to 2021. Demographics, operative characteristics, outcomes, and mesh exposure management were analyzed. Results Of 346 patients, 15 (4.3%) experienced mesh exposure. The mean age was 53 years and BMI of 33.6 kg/m². Patients were majority ASA class 3 (65%), female (64.2%), and averaged a defect size of 307.9 ± 235.2 cm². Independent risk factors included diabetes (AOR = 4.3,CI 1.5–12.5;p < 0.005) and COPD (AOR = 5.2,CI 1.3–21.8;p = 0.02). Mesh exposures were identified as outpatient (20%) or intraoperative (80%). All underwent operative debridement, in which nine were managed with skin reclosure, two with partial closure, and four healed by secondary intention. Five patients required excision of unincorporated mesh. Four patients required further debridement from chronic surgical site occurrences; however, all mesh exposure patents healed after a mean of 260.8 ± 313.2 days and retained original mesh. The recurrence rate was 6.7% for mesh exposure patients. Conclusion When faced with mesh exposure, resorbable biosynthetic mesh placed in onlay fashion was retained in all patients. Patients with a history of diabetes or COPD have increased risk of mesh exposure and should be counseled.

Background Fleur-de-lis panniculectomy (FDL), a contouring technique involving vertical and horizontal tissue resections, often involves longer operative times and potential complications. This study assessed operative time, postoperative outcomes, and patient-reported quality of life (PRO) with Insorb^® Absorbable Subcuticular Skin Stapler versus traditional sutures during FDL. Methods A retrospective review from 2015 to 2022 of FDL patients excluded those with complex concomitant procedures. Demographics, operative details, and surgical outcomes were compared between patients using the dermal stapler and those with suture-only closures. Results Forty subjects were identified, with 25 (62.5%) in the dermal stapler cohort. The dermal stapler significantly reduced total procedure time (66.76 vs. 125.33 min, p < 0.05). There were no significant differences in surgical site occurrences, aesthetic outcomes, readmissions, or reoperations. Multivariate regression analysis further highlighted the choice of closure technique as an independent predictor of operative time, with traditional sutures indicating a significantly increased operative time compared to using the dermal stapler (AOR 76.53, CI 38.11-114.95, p < 0.001). Regarding PROs, both groups saw improvements across multiple BODY-Q domains, but the dermal stapler group reported greater enhancements (six out of nine domains vs. three for sutures). Conclusion The absorbable dermal stapler significantly reduces FDL operative time without increasing wound healing or aesthetic dissatisfaction incidents and maintains comparable quality-of-life improvements to standard suture closure. 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 https://link.springer.com/journal/00266.

Introduction: The ideal mesh type for hernia repair in a contaminated field remains controversial. Data regarding outcomes beyond 1 year and the impact on quality of life (QoL) are unknown. This study aims to evaluate the long-term surgical outcomes and patient-reported outcomes (PROs) after contaminated repair with poly-4-hydroxybutyrate (P4HB) mesh. Materials & Methods: Patients undergoing a contaminated hernia repair with P4HB between 2015 and 2020 were identified. Surgical site occurrences and hernia recurrences were recorded. Long-term PROs as defined by the Abdominal Hernia-Q and Hernia-Related Quality-of-Life Survey were assessed. Results: Fifty-five patients were included with a mean age of 54.5 years, a body mass index of 34 kg/m², and a defect size of 356.9 ± 227.7 cm². Median follow-up time was 49 months with a reoperation rate of 14.5% and a hernia recurrence rate of 7.3%. Of the 55 patients, 37 completed preoperative and postoperative PRO questionnaires. When comparing preoperative with postoperative Abdominal Hernia-Q, there was significant improvement in overall PROs (2.1 vs 3.5, P < 0.001). This improvement was maintained with no significant changes between postoperative scores over the course of 5 years. Patients with complications saw the same improvement in postoperative PRO scores as those without complications. Conclusions: Our study found a low hernia recurrence and acceptable long-term reoperation rates in patients undergoing hernia repair with P4HB mesh in a contaminated setting. We demonstrate a sustained significant improvement in QoL scores after hernia repair. These data yield insight into the long-term outcomes and QoL improvement, providing physicians further knowledge to better counsel their patients.

Introduction: Amid rising obesity, concurrent ventral hernia repair and panniculectomy procedures are increasing. Long-term outcomes of transverse abdominis release (TAR) combined with panniculectomy remain understudied. This study compares clinical outcomes and quality of life (QoL) after TAR, with or without panniculectomy. Methods: A single-center retrospective review from 2016 to 2022 evaluated patients undergoing TAR with and without panniculectomy. Propensity-scored matching was based on age, body mass index, ASA, and ventral hernia working group. Patients with parastomal hernias were excluded. Patient/operative characteristics, postoperative outcomes, and QoL were analyzed. Results: Fifty subjects were identified (25 per group) with a median follow-up of 48.8 months (interquartile range, 43–69.7 months). The median age and body mass index were 57 years (47–64 years) and 31.8 kg/m² (28–36 kg/m²), respectively. The average hernia defect size was 354.5 cm² ± 188.5 cm². There were no significant differences in hernia recurrence, emergency visits, readmissions, or reoperations between groups. However, ventral hernia repair with TAR and panniculectomy demonstrated a significant increase in delayed healing (44% vs 4%, P < 0.05) and seromas (24% vs 4%, P < 0.05). Postoperative QoL improved significantly in both groups (P < 0.005) across multiple domains, which continued throughout the 4-year follow-up period. There were no significant differences in QoL among ventral hernia working group, wound class, surgical site occurrences, or surgical site occurrences requiring intervention (P > 0.05). Patients with concurrent panniculectomy demonstrated a significantly greater percentage change in overall scores and appearance scores. Conclusions: Ventral hernia repair with TAR and panniculectomy can be performed safely with low recurrence and complication rates at long-term follow-up. Despite increased short-term postoperative complications, patients have a significantly greater improvement in disease specific QoL.