Summary: Lymphedema affects up to 250 million people worldwide. The understanding of the pathophysiology of the condition, however, is incomplete and a cure remains elusive. A growing body of evidence supports the effectiveness of modern surgical techniques in ameliorating the long-term disability and functional impairment inflicted by lymphedema on the lives of those affected. These procedures can be broadly categorized as physiologic, including lymphovenous bypass and using a vascularized lymph node transplant; or de bulking, by suction-assisted lipectomy or direct excisional procedures. The lymphovenous bypass procedure involves identification of obstructed lymphatic vessels and targeted bypass of these into neighboring venules. The vascularized lymph node transplant procedure involves microvascular anastomosis of functional lymph nodes into an extremity, either to an anatomical (orthotopic) or nonanatomical (heterotopic) location, to restore physiologic lymphatic function. In patients undergoing postmastectomy breast reconstruction, this may be performed by transferring a deep inferior epigastric artery perforator flap with a chimeric groin lymph node flap. For patients that have undergone breast-conserving surgery, in those for whom a free abdominal flap is contraindicated, or for those with lymphedema affecting the lower extremity, many other vascularized lymph node transplant options are available; these include flaps harvested from within the axillary, inguinal, or cervical lymph node basins, or from within the abdominal cavity. Chronic lymphedema is characterized by fibroadipose soft-tissue deposition that can only be removed by lipectomy, either minimally invasively using liposuction, or by direct excision. This article reviews the techniques and outcomes of surgical procedures used to treat lymphedema.

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Objective: To analyze the long-term safety and efficacy outcomes of patients with breast implants. Summary Background Data: Research is ongoing regarding the safety of silicone breast implants. Despite the number of patients with breast implants followed by United States Food and Drug Administration large postapproval studies (LPAS), this database has not been thoroughly analyzed or reported. Methods: This is a multicentered, cohort study. LPAS prospectively monitor long-term implant-related outcomes and systemic harms for silicone/saline implants from 2 manufacturers (Allergan and Mentor) placed for primary/revision augmentation/reconstruction. Systemic harms, self-harm, and reproductive outcomes are compared with normative data. Implant-related complications are analyzed by implant composition and operative indication in the short and long terms. Results: LPAS data includes 99,993 patients, 56% of implants were silicone for primary augmentation. Long-term magnetic resonance imaging surveillance is under 5%. Compared with normative data, silicone implants are associated with higher rates of Sjogren syndrome (Standardized incidence ratio [SIR]8.14), scleroderma (SIR 7.00), rheumatoid arthritis (SIR5.96), stillbirth (SIR4.50), and melanoma (SIR3.71). One case of BI-ALCL is reported. There is no association with suicide. In the short term, rupture is higher for saline (2.5% vs. 0.5%, P < 0.001), and capsular contracture higher for silicone (5.0% vs. 2.8%, P < 0.001). At 7 years, reoperation rate is 11.7% for primary augmentation, and 25% for primary/revision reconstruction. Capsular contracture (III/IV) occurs in 7.2% of primary augmentations, 12.7% primary reconstructions, and is the most common reason for reoperation among augmentations. Conclusions: This is the largest study of breast implant outcomes. Silicone implants are associated with an increased risk of certain rare harms; associations need to be further analyzed with patient-level data to provide conclusive evidence. Long-term safety and implant-related outcomes should inform patient and surgeon decision-making when selecting implants.

ObjectiveThe objective of this study was to establish an evidence-based clinical practice guideline for the primary management of obstetrical brachial plexus injury (OBPI). This clinical practice guideline addresses 4 existing gaps: (1) historic poor use of evidence, (2) timing of referral to multidisciplinary care, (3) Indications and timing of operative nerve repair and (4) distribution of expertise.SettingThe guideline is intended for all healthcare providers treating infants and children, and all specialists treating upper extremity injuries.ParticipantsThe evidence interpretation and recommendation consensus team (Canadian OBPI Working Group) was composed of clinicians representing each of Canada's 10 multidisciplinary centres.Outcome measuresAn electronic modified Delphi approach was used for consensus, with agreement criteria defined a priori. Quality indicators for referral to a multidisciplinary centre were established by consensus. An original meta-analysis of primary nerve repair and review of Canadian epidemiology and burden were previously completed.Results7 recommendations address clinical gaps and guide identification, referral, treatment and outcome assessment: (1) physically examine for OBPI in newborns with arm asymmetry or risk factors; (2) refer newborns with OBPI to a multidisciplinary centre by 1 month; (3) provide pregnancy/birth history and physical examination findings at birth; (4) multidisciplinary centres should include a therapist and peripheral nerve surgeon experienced with OBPI; (5) physical therapy should be advised by a multidisciplinary team; (6) microsurgical nerve repair is indicated in root avulsion and other OBPI meeting centre operative criteria; (7) the common data set includes the Narakas classification, limb length, Active Movement Scale (AMS) and Brachial Plexus Outcome Measure (BPOM) 2 years after birth/surgery.ConclusionsThe process established a new network of opinion leaders and researchers for further guideline development and multicentre research. A structured referral form is available for primary care, including referral recommendations.

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