Short-term versus extended chemoprophylaxis against venous thromboembolism in DIEP flap breast reconstruction: A retrospective study of 424 patients.

BACKGROUND: Autologous breast reconstruction is considered high-risk for deep vein thrombosis (DVT) and thromboembolism (PE). It is therefore recommended to treat patients undergoing these complex and lengthy procedures with DVT chemoprophylaxis. The optimal anticoagulation protocol is still not established. The objective of our study was to evaluate the need of a prolonged anticoagulation in patients undergoing microsurgical breast reconstruction. METHODS: This retrospective cohort study compares our former anticoagulation protocol, which was given during the in-hospital stay, with our new protocol consisting of extended anticoagulation until postoperative day 25, in terms of DVT/PE risk reduction. A logistic regression was used to evaluate the risk of DVT/PE between the two groups, while adjusting for several covariates. RESULTS: Our cohort consisted of 205 patients in the short-term anticoagulation group and 219 in the extended protocol group. Five patients (2.4%) in the short-term anticoagulation group had a DVT/PE event versus 4 patients (1.8%) in the extended protocol group. Logistic regression revealed no difference in the incidence of DVT/PE between the two groups. Similarly, there was no differences in terms of hematoma and infection rate between the two groups. Finally, we found an increased risk of DVT/PE in patients with a Caprini score equal or greater than 8. CONCLUSION: In our experience, short-term anticoagulation during the hospital stay is equivalent to extended thromboprophylaxis in terms of DVT/PE prevention.

Immediate fine-tuning of DIEP flaps using the Wise pattern mastectomy: Description of the technique and a retrospective analysis of complication rates.

INTRODUCTION: Elliptical skin-sparing mastectomy in patients with large or ptotic breasts usually leaves loose mastectomy skin flaps, which need to be either resected or gathered over the DIEP flap. This results in poor control of the breast footprint and under-projected DIEP flaps in a loose mastectomy skin pocket, that tend to slip laterally towards the axilla. We believe that the use of a Wise pattern mastectomy will allow for immediate treatment of these concerns. MATERIALS AND METHODS: A retrospective, uncontrolled analysis of a prospectively-maintained database of patients operated by the five surgeons performing breast reconstructions at the University of Montreal Hospital Centre. Study population was patients with a BMI of over 25 and grade II/III breast ptosis who underwent a Wise pattern mastectomy with immediate DIEP flap reconstruction. Analysis was performed of the complication rates of the technique in the first six months after the surgery. RESULTS: Out of a total of 53 breasts in 44 patients reconstructed with a DIEP flap immediately post Wise pattern mastectomy, we report nine cases of partial mastectomy-flap necrosis not needing revision, five cases of significant mastectomy flap necrosis needing debridement and skin grafting, and two cases of inability to adequately close the Wise pattern intraoperatively after DIEP placement, necessitating retention of DIEP skin in the inferior pole. None of the mastectomy flap complications occurred in irradiated breasts. CONCLUSION: In patients with large or ptotic breasts, the Wise pattern mastectomy before an immediate DIEP reconstruction allows for immediate shaping of the breast by controlling the breast pocket, footprint, and excess skin.

[Impact of Facebook patient groups in the surgical decision making process: The example of Biocell® macro-textured implants recall]. / Impact des groupes de patientes Facebook dans le processus décisionnel chirurgical : l'exemple du rappel des implants macro-texturés Biocell®.

BACKGROUND: The use of social media, has been a major upheaval in our lifestyles in the last decade. At the forefront in the crisis of BIA-ALCL, as soon as February 2019, our university centre took steps to identify and contact all patients with macro-textured implants. The purpose of this recall was to educate patients and establish a monitoring system. The purpose of this work is to analyse the patients' decision-making process. METHODS: A retrospective study of patients, who requested and attended appointments with a surgeon, was made. The number of patients with clinical symptoms of BIA-ALCL, the number of patients who requested implant removal surgery, the histological diagnoses found after surgery were collected. We then calculated the proportion of Facebook group members among patients who required implant removal in the absence of a diagnosis or even warning signs. RESULTS: Seven hundred and seventy women requested an appointment with one of the surgeons in our department. Of all the women who requested consultation, 497 (64.55%) had symptoms. 199 patients were members or had attended one of the Facebook groups of patients. At the end of the consultation with their surgeon, almost 25% of patients made a decision to have the implant removed against medical advice. Among these patients, 67% were part of a group of patients on the Facebook network. To date, no patient has been diagnosed with BIA-ALCL. CONCLUSIONS: These results support the hypothesis that belonging to Facebook groups of patients becomes, for some, a key element in the decision-making process beyond expert opinion. In the future, preliminary work with patient groups on social networks should be done in order to obtain additional health efficiency.

Partial DIEP flap loss in a patient with history of abdominal liposuction.

Classically, history of prior abdominal liposuction has been considered a relative contraindication for breast reconstruction using deep inferior epigastric perforator (DIEP) flap. The rationale for this is based on the fact that liposuction can possibly damage perforating vessels, which could compromise flap survival. However, multiple recently published reports have shown that imaging using CT angiography or colour Duplex ultrasonography could be used to accurately assess the adequacy of the perforating vessels before DIEP flap harvest. This contraindication is currently being reconsidered in the scientific literature. We present a case of partial DIEP flap loss in a patient with history of abdominal liposuction that happened despite preoperative identification of adequate perforators using CT angiography and intraoperative clear evidence of patent anastomoses. This occurrence reopens in our view the question of whether DIEP flaps can be safely performed on patients with a history of abdominal liposuction, even in the presence of adequate perforators on regular CT angiography or Doppler ultrasonography. While abdominal liposuction may not injure perforating vessels, its detrimental effect on linking micro-vessels within the flap cannot be fully evaluated using CT Angiography. Therefore, the use of another imaging modality, such as the indocyanine green laser angiography, to assess perfusion before DIEP flap harvesting is performed and could be considered in patients with history of abdominal liposuction.

Immediate breast reconstruction surgery with expander/direct implant and use of acellular dermal matrix: Does hormone therapy increases the risk of infection?

BACKGROUND: The use of hormone therapy (tamoxifen and aromatase inhibitors) has been shown to increase venous thromboembolism. However, while estrogens play a crucial role in wound healing, no study has assessed the impact of tamoxifen or aromatase inhibitors on other postoperative breast reconstruction complications, including infections, necrosis, capsular contracture and seroma. As breast cancer patients undergoing Implants-ADMs breast reconstruction are often receiving hormone therapy, it is unclear whether this increased infection risk is associated with increased infections cases. METHODS: A prospective study was performed on patients undergoing breast reconstruction at an academic institution from 2013 to 2016. Patients were divided by use of hormone therapy at the time of surgery. Complication rates, including infections, necrosis, seroma and hematomas, were compared and analyzed using univariate and logistic regression models. RESULTS: Among a total of 112 patients (183breasts), 58 patients (91 breasts) were receiving hormone therapy and 54 patients (92 breasts) were not. The hormone therapy group had a higher incidence of postoperative mastectomy skin infection (20.7% versus 7.4%; P=0.0447), we didn't find any significant differences in necrosis. CONCLUSIONS: Hormone therapy was associated with a higher incidence of Infections after breast reconstruction with ADMs and implants. The authors propose an individualized approach to the preoperative cessation of tamoxifen or aromatase inhibitors. Immediate breast reconstruction surgery with expander/direct implant and use of acellular dermal matrix: does hormone therapy increases the risk of infection?

Comparison of venous couplers versus hand-sewn technique in free flap breast reconstruction.

INTRODUCTION: Despite positive outcomes reported in the literature, some surgeons remain reluctant to the systematic use of venous couplers in free flap tissue transfer. In our institution, the use of the coupler devices for venous anastomosis in free flap breast reconstruction has yet to be adopted by all surgeons. The purpose of the study was to compare postoperative outcomes of coupler-assisted venous anastomoses with hand-sewn techniques in free flap breast reconstruction. METHODS: An analysis of collected data was performed on cases of breast reconstruction with free tissue transfer after mastectomy in breast cancer or BRCA-positive patients from 2010 to 2016. Patients were divided into two groups: coupler device and hand-sewn. The primary outcome was survival rate of free flaps. Secondary outcomes included potential complications, as well as surgical characteristics (recipient artery/vein, coupler size, type of hand-sewn anastomosis, size of sutures, number of venous anastomoses, ischemia time, operative time) RESULTS: We included 289 cases in our study. There were no significant differences between groups in terms of post-operative complications or survival rate of the free flaps. Ischemia time was significantly lower in both immediate and delayed reconstruction cases. Operative and anesthesia times were significantly lower only in immediate unilateral cases. CONCLUSION: Although ischemia time was reduced in the coupler group, we didn't find any significant difference in the operative and anesthesia time in the subgroup analysis, except for the group of immediate unilateral breast reconstruction. Couplers are safe and efficient; nevertheless, our study shows that their qualities cannot yet justify the disappearance of the manual sutures.

The impact of autologous breast reconstruction using DIEP flap on the oncologic efficacy of radiation therapy.

INTRODUCTION: In the management of breast cancer radiation therapy plays a substantive role in decreasing local recurrence and increasing overall survival. Still, there exists controversy concerning compromised radiation delivery plans and suboptimal delivery after immediate autologous breast reconstruction. Our study aims to assess the oncologic safety of immediate breast reconstruction (IBR) with a Deep inferior epigastric perforator flap (DIEP), in the setting of adjuvant radiation therapy. METHODS: We conducted a retrospective analysis using a prospectively maintained database of all consecutive women undergoing breast reconstruction with a DIEP flap in the setting of radiation therapy. Independent variables included patient age, cancer stage, tumor grade type and subtype, adjuvant and neoadjuvant chemotherapy, hormonal therapy, diabetes mellitus, and tobacco use. Main outcome variables were: local recurrence, distant metastasis, patient demise and total flap failure. RESULTS: From July 2008 to January 2014, and out of 450 patients who underwent reconstruction with a DIEP flap, 62 were considered eligible. Thirty patients (48%) had IBR followed by radiation therapy and 32 (52%) had delayed reconstruction preceded by radiation therapy. The two groups were comparable with respect to the independent variables. Local recurrence occurred in 3.2% of patients; 3.3% in the immediate group and 3.1% in the delayed (P=0.963). Distant metastasis occurred in 6.4% of patients: 10% in the immediate group and 3.1% in the delayed (P=0.27). Breast cancer related mortality occurred in 4.8%: 6.7% in the immediate group and 3.1% in the delayed (P=0.52). CONCLUSION: Immediate reconstruction with a DIEP flap in the setting of adjuvant radiation therapy is an acceptable approach and appears not to influence the oncologic efficacy of radiation treatment. Further prospective studies are advocated.

Impact of the number of veins repaired in short-term digital replantation survival rate.

BACKGROUND: Venous congestion/insufficiency plays a major role in failure of finger replantation. Despite acceptable salvage rates with postoperative anticoagulation or leeching, operative technique remains the most important predictor of success. However, there are no indications in the literature on the benefit of anastomosing single versus multiple veins. METHODS: A retrospective review of finger amputations from 2011 to 2013 was conducted. The analyzed endpoint was the finger survival rate at discharge depending on the number of veins repaired: multiple veins (group 1), only one vein (group 2), or no veins (group 3). Proportions were compared using v2 tests/Fisher's exact tests; p-value <0.05 was considered significant. RESULTS: Seventy-two patients with complete digital amputation were operated including 101 fingers. Twenty-seven fingers (26.7%) failed before hospital discharge, with 78% of failures due to venous complications versus 22% with an arterial etiology. Group 2 had 15 replantation failures due to venous causes as opposed to only one from group 1, representing a 1.27-fold (95% confidence interval (CI): 0.99, 1.34) increased relative risk of failure (p = 0.032). Similarly, five fingers from group 3 suffered venous complications, resulting in a 1.49-fold (95% CI: 1.02, 1.73) increased likelihood of failure in comparison to group 1 (p = 0.008). No significant difference was observed between having only one vein repaired versus none (RR: 1.1792, 95% CI: 0.83, 2.10, p = 0.502). CONCLUSION: Efforts toward favoring two-vein repair lead to better survival of the replanted fingers. More cases need to be analyzed before formulating conclusions on specific levels of amputation with regard to venous anastomoses.

Replantation vs revision amputation in single digit zone II amputations.

The objective of this study was to compare the functional outcomes of zone II amputations treated with either replantation or revision amputation at our institution to better aid patients in their decision making process regarding these treatment options. We conducted a comparative retrospective study. All cases of single digit amputations received at our replantation center between 2007 and 2011 were screened for single digit zone II injuries. These patients were stratified based on the treatment received: replantation vs revision amputation. Patients were called and invited to participate in the research project. Those who accepted to enter the study were asked to complete the Quick-DASH, the Beck Depression Inventory-short form, and a custom made questionnaire. There were seventeen patients with single digit zone II replantation and fourteen patients with similar injuries who underwent revision amputation and agreed to take part in the study. Our data revealed that the duration of sick leave, occupation after injury, professional and social reintegration, discontinued activities, and self-confidence were not statistically different between the two groups. The average hospital stay and the follow-up period of replanted individuals were longer. The replantation group did not have higher levels of pain or cold intolerance, and the global functional and esthetic satisfaction levels were similar between the two groups. Also, Beck Depression Inventory and Quick-DASH scores were not statistically different. Yet, significantly more patients in the replantation group would opt to repeat the replantation than revised patients would opt for revision amputation. From a functional viewpoint, our study suggests that revision amputation is not superior to replantation in zone II single digit amputations. This is valuable information that should be given to patients when deciding on the treatment process and to insure a proper informed consent.

[A surgical follow-up platform to reduce complications in free flap surgery]. / Une plateforme de suivi chirurgical pour réduire les complications en reconstruction par lambeau libre.

STUDY OBJECTIVE: In 2007, the WHO adopted surgical safety as the theme for the 2nd global patient safety challenge. Measurement of surgical services was identified as a surgical care area in need of major improvements. Aware of this recommendation, a preliminary study was conducted in our hospital and showed that the incidence of complete necrosis in free flap surgery was 10.0 %, a rate among the highest found in medical literature. In that context, an interactive surgical follow-up platform (PICS) was implemented to monitor outcomes in free flap surgery. The hypothesis was to reduce the short-term failure of microsurgical reconstructions. PATIENTS AND METHODS: In Summer 2010, the tool for capturing and analyzing data (PICS) was implemented. All patients who underwent free flap reconstruction were prospectively registered in the platform. The primary endpoints to evaluate the effectiveness of the tool are the rates of surgical re-exploration and complete necrosis of the flap. RESULTS: From May 2010 to December 2011, 129 cases of free flap reconstruction were recorded. The rate of total flap necrosis was 10.0 % before database introduction and declined to 3.1 % afterwards (P<0.05). Take-backs occurred in 27.0 % of free flap reconstructions at baseline and in 10.1 % after implementation (P<0.01). CONCLUSION: The implementation of PICS is associated with a significant improvement of postoperative short-term outcomes in free flap surgery. This tool is effective to evaluate care services and provides an increased surgical safety for patients. Surgical teams are encouraged to implement a data collection tool in order evaluate operative care on a routine basis.

"Trigger finger at the wrist" due to anomalous flexor digitorum superficialis muscle belly within the carpal tunnel.

"Triggering of the fingers at the wrist" is a relatively unusual condition. It consists in a triggering at the wrist produced by finger motion. Its etiology and presentation may vary. This condition should be clearly differentiated from the other clinical entity called "trigger wrist", occurring on wrist movement. In the present article, we report the case of an anomalous flexor digitorum superficialis muscle belly, arising from the right ring finger at the carpal tunnel, in a 47-year old female patient, causing triggering of the right ring finger at the wrist and a carpal tunnel syndrome. Surgical excision of the muscle mass and carpal tunnel release relieved patient's symptoms and has led to the disappearance of the triggering phenomenon. To date, few cases of trigger finger at the wrist have been reported in the literature. These reported cases were reviewed. The clinical entity of "true trigger wrist" and its etiology are also discussed.