Conventional surgical techniques and emerging transplantation in complex penile reconstruction

Complex penile reconstruction continues to pose a significant challenge to surgeons and patients alike. The ideal phalloplasty is one that can be reproducibly performed in a single stage, creates a neourethra that allows for voiding while standing, produces a phallus with tactile and erogenous sensation, allows for penetrative sexual intercourse, and offers satisfactory aesthetic results. With recent advances in microsurgery and perforator flap dissection, several techniques and modifications thereof have been described that aim to achieve these reconstructive goals. All of these now conventional techniques, however, fall short in one way or another - often with regards to urinary transport, the ability to achieve an erection, and the need for multiple surgical stages and revision operations. These limitations of conventional reconstruction have led some surgeons to explore new avenues for complex penis reconstruction, giving birth to the novel field of penile transplantation. In this article, we discuss the complexities of male genitourinary reconstruction in the context of conventional methods for reconstruction as well as the burgeoning field of penile transplantation

Functional reconstruction of lower extremity nerve injuries

Peripheral nerve injuries (PNI) in the lower extremity are an uncommon but highly morbid condition. Recent advances in our understanding of nerve physiology and microsurgical techniques have inspired renewed faith in nerve surgery and sparked a creative renaissance in the tools, approaches, and reconstructive schemas available to surgeons in the management of lower extremity PNIs. In this article, we review the literature and provide a principles-based approach for the surgical management of lower extremity PNIs with an emphasis on techniques for functional reconstruction after complete nerve injury. General principles in management include early diagnosis with electrodiagnostics and imaging, early surgical exploration, and opting for nerve and tendon transfers when primary reconstruction of the injured nerve is unfavorable (e.g., delayed reconstruction, unavailability of proximal or distal nerve stumps, or long regenerative distance). The goal of functional reconstruction should be to restore independent gait, so understanding the roles of major neuromuscular units during the gait cycle informs the selection of donor nerves and tendons for transfer. Based on these principles and literature to date, specific algorithms for surgical management are presented for femoral, sciatic, tibial, and common peroneal nerves. We recognize limitations of the current literature, namely the predominance of case series evidence, and call for the accrual of more patient data in surgical management of PNIs

Tabbed Tissue Expanders Improve Breast Symmetry Scores in Breast Reconstruction

Background Achieving symmetry is a key goal in breast reconstruction. Anatomically shaped tabbed expanders are a new tool in the armamentarium of the breast reconstruction surgeon. Suture tabs allow for full control over the expander position and thus inframammary fold position, and, in theory, tabbed expanders mitigate many factors responsible for poor symmetry. The impact of a tabbed expander on breast symmetry, however, has not been formally reported. This study aims to evaluate breast symmetry following expander-implant reconstruction using tabbed and non-tabbed tissue expanders. Methods A chart review was performed of 188 consecutive expander-implant reconstructions that met the inclusion criteria of adequate follow-up data and postoperative photographs. Demographic, oncologic, postoperative complication, and photographic data was obtained for each patient. The photographic data was scored using a 4-point scale assessing breast symmetry by three blinded, independent reviewers. Results Of the 188 patients, 74 underwent reconstruction with tabbed expanders and 114 with non-tabbed expanders. The tabbed cohort had significantly higher symmetry scores than the non-tabbed cohort (2.82/4±0.86 vs. 2.55/4±0.92, P=0.034). Conclusions The use of tabbed tissue expanders improves breast symmetry in tissue expander-implant-based breast reconstruction. Fixation of the expander to the chest wall allows for more precise control over its location and counteracts the day-to-day translational forces that may influence the shape and location of the expander pocket, mitigating many factors responsible for breast asymmetry

Individualized Risk of Surgical Complications: An Application of the Breast Reconstruction Risk Assessment Score.

BACKGROUND: Risk discussion is a central tenet of the dialogue between surgeon and patient. Risk calculators have recently offered a new way to integrate evidence-based practice into the discussion of individualized patient risk and expectation management. Focusing on the comprehensive Tracking Operations and Outcomes for Plastic Surgeons (TOPS) database, we endeavored to add plastic surgical outcomes to the previously developed Breast Reconstruction Risk Assessment (BRA) score. METHODS: The TOPS database from 2008 to 2011 was queried for patients undergoing breast reconstruction. Regression models were constructed for the following complications: seroma, dehiscence, surgical site infection (SSI), explantation, flap failure, reoperation, and overall complications. RESULTS: Of 11,992 cases, 4439 met inclusion criteria. Overall complication rate was 15.9%, with rates of 3.4% for seroma, 4.0% for SSI, 6.1% for dehiscence, 3.7% for explantation, 7.0% for flap loss, and 6.4% for reoperation. Individualized risk models were developed with acceptable goodness of fit, accuracy, and internal validity. Distribution of overall complication risk was broad and asymmetric, meaning that the average risk was often a poor estimate of the risk for any given patient. These models were added to the previously developed open-access version of the risk calculator, available at http://www.BRAscore.org. CONCLUSIONS: Population-based measures of risk may not accurately reflect risk for many individual patients. In this era of increasing emphasis on evidence-based medicine, we have developed a breast reconstruction risk assessment calculator from the robust TOPS database. The BRA Score tool can aid in individualizing-and quantifying-risk to better inform surgical decision making and better manage patient expectations

Is There a Safe Lipoaspirate Volume? A Risk Assessment Model of Liposuction Volume as a Function of Body Mass Index.

BACKGROUND: No concrete data exist to support a specific volume at which liposuction becomes unsafe; surgeons rely on their own estimates, professional organization advisories, or institutional or government-imposed restrictions. This study represents the first attempt to quantify the comprehensive risk associated with varying liposuction volumes and its interaction with body mass index. METHODS: Suction-assisted lipectomies were identified from the Tracking Operations and Outcomes for Plastic Surgeons database. Multivariate regression models incorporating the interaction between liposuction volume and body mass index were used to assess the influence of liposuction volume on complications and to develop a tool that returns a single adjusted odds ratio for any combination of body mass index and liposuction volume. Recursive partitioning was used to determine whether exceeding a threshold in liposuction volume per body mass index unit significantly increased complications. RESULTS: Sixty-nine of 4534 patients (1.5 percent) meeting inclusion criteria experienced a postoperative complication. Liposuction volume and body mass index were significant independent risk factors for complications. With progressively higher volumes, increasing body mass index reduced risk (OR, 0.99; 95 percent CI, 0.98 to 0.99; p = 0.007). Liposuction volumes in excess of 100 ml per unit of body mass index were an independent predictor of complications (OR, 4.58; 95 percent CI, 2.60 to 8.05; p \u3c 0.001). CONCLUSIONS: Liposuction by board-certified plastic surgeons is safe, with a low risk of life-threatening complications. Traditional liposuction volume thresholds do not accurately convey individualized risk. The authors\u27 risk assessment model demonstrates that volumes in excess of 100 ml per unit of body mass index confer an increased risk of complications. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III