Adipose tissue as a source of growth factors to promote wound healing: a human study of skin graft donor sites.

OBJECTIVE: In the microenvironment of wound sites, naturally occurring growth factors are crucial for cell migration, opsonisation, chemotaxis, differentiation and angiogenesis. Exogenous growth factors, such as platelet-rich plasma (PRP) and adipose tissue, also improve healing. METHOD: In the present within-subject study, we described the effects of PRP and adipose tissue extract (ATE) on skin graft donor site wound healing in patients requiring split-thickness skin grafts. Each patient, having at least two donor sites, received both control (no growth factor) and experimental (PRP or ATE) treatments. Wounds were evaluated on days 5, 7, 10, 15, 30 and 60. Digital photography and spectral images were used to analyse haemoglobin and melanin content, and re-epithelialisation area. Pain was assessed by visual analogue scale. Scar characteristics were scored on days 30 and 60. Biomaterial samples were analysed for growth factor and protein content. RESULTS: The study included 24 patients (18 male and six female; mean age: 59.1 years). PRP was topically applied to wounds in 11 patients (13 donor sites) and ATE in 13 patients (15 sites). ATE-treated donor sites exhibited significantly accelerated wound re-epithelialisation on days 5 and 7 compared with control sites (p=0.003 and 0.04, respectively). PRP accelerated healing on day 7 compared with control sites (p=0.001). Additionally, the application of ATE improved scar quality on days 30 and 60 (p=0.0005 and 0.02, respectively). Pain scores did not differ significantly between treatments. CONCLUSION: In this study, both growth factor sources stimulated wound healing. ATE is an alternative source of growth factors that promote early wound healing and improve scar quality.

Soft tissue reconstruction after pelvic amputation: The efficacy and reliability of free fillet flap reconstruction.

BACKGROUND: The majority of hindquarter amputation defects can be reconstructed with local anterior or posterior thigh flaps. Less than 5% of soft tissue defects require free flap reconstruction after tumour resection. Lower extremity fillet flap is described for reconstructing such defects, but the majority of publications are case reports or short single institutional series. There is a lack of data regarding the oncological outcomes of this highly selected patient group. METHODS: Three tertiary sarcoma units treated twelve patients with hindquarter amputation or hip disarticulation for oncological indications with a free flap reconstruction of the soft tissue defect. RESULTS: The median age of patients was 60 (range 12-76) years. Bone resection was carried out through the SI-joint in six patients and through the sacrum in five patients, with one patient undergoing hip disarticulation. Nine patients had R0 resection margin and three had R1 resection. The median surgical time and flap ischaemia time was 420 (249-650) and 89 (64-210) min, respectively. Median hospital and ICU stay was 18 (10-42) and 3 (1-8) days, respectively. Median blood loss was 2400 (950-10000) ml. There were three returns to theatre due to vascular compromise, with one total flap loss due to arterial thrombosis. Overall survival was 58% (95%CI 28-91%) both at 1-year and at 3-years. DISCUSSION: Carefully selected patients requiring hindquarter amputation with extensive soft tissue defect necessitating free flap reconstruction can be reconstructed with a lower extremity free fillet flap with low rate of local wound complications. Survival of these patients is similar to that in patients requiring less extensive resection.

Transverse myocutaneous gracilis flap reconstruction is feasible after pelvic exenteration: 12-year surgical and oncological results.

INTRODUCTION: Pelvic exenteration (PE) is the only curative treatment for certain locally advanced intrapelvic malignancies. PE has high morbidity, and optimal reconstruction of the pelvic floor remains undetermined. MATERIALS AND METHODS: A retrospective chart review was performed at a tertiary university center to assess the surgical and oncological outcomes of 39 PE procedures over a 12-year period. The majority of patients (n = 25) underwent transverse musculocutaneous gracilis (TMG) flap reconstruction for pelvic floor reconstruction. RESULTS: The 1- and 5-year overall survival (OS) was 72% (95%CI 58%-86%) and 48% (95%CI 31%-65%), respectively. In multivariate analysis, lymph node metastasis (HR 3.070, p = 0.024) and positive surgical margins (HR 3.928, p = 0.009) were risk factors for OS. In this population, 71.8% of the patients had at least one complication. The complication rate was 65.4% and 84.6% for patients with versus without flap reconstruction, respectively (p = 0.191). The length of stay was longer for patients with a major complication 16,0 ±â€¯5,9 days vs. 29,4 ±â€¯14,8 days, p = 0,001, but complications did not affect OS. CONCLUSION: For selected patients, PE is a curative option for locally advanced, residual, or recurrent intrapelvic tumors. Pelvic floor and vulvovaginal defects can reliably be reconstructed using TMG flaps. TMG flaps are favored in our institution over abdominal-based flaps because the donor site morbidity is reasonable and TMG does not interfere with enterostomy.

Clinical results and quality of life after reconstruction following sacrectomy for primary bone malignancy.

BACKGROUND: Sacrectomy is a rare and demanding surgical procedure that results in major soft tissue defects and spinopelvic discontinuity. No consensus is available on the optimal reconstruction algorithm. Therefore, the present study evaluated the results of sacrectomy reconstruction and its impact on patients' quality of life (QOL). METHODS: A retrospective chart review was conducted for 21 patients who underwent sacrectomy for a primary bone tumour. Patients were divided into groups based on the timing of reconstruction as follows: no reconstruction, immediate reconstruction or delayed reconstruction. QOL was measured using the EQ-5D instrument before and after surgery in patients treated in the intensive care unit. RESULTS: The mean patient age was 57 (range 22-81) years. The most common reconstruction was gluteal muscle flap (n = 9) and gluteal fasciocutaneous flap (n = 4). Four patients required free-tissue transfer, three latissimus dorsi flaps and one vascular fibula bone transfer. No free flap losses were noted. The need for unplanned re-operations did not differ between groups (p = 0.397), and no significant differences were found for pre- and post-operative QOL or any of its dimensions. DISCUSSION: Free flap surgery is reliable for reconstructing the largest sacrectomy defects. Even in the most complex cases, surgery can be safely staged, and final reconstruction can be carried out within 1 week of resection surgery without increasing peri­operative complications. Sacrectomy does not have an immoderate effect on the measured QOL.

Adipose tissue extract shows potential for wound healing: in vitro proliferation and migration of cell types contributing to wound healing in the presence of adipose tissue preparation and platelet rich plasma.

Growth factors are the key elements in wound healing signaling for cell migration, differentiation and proliferation. Platelet-rich plasma (PRP), one of the most studied sources of growth factors, has demonstrated to promote wound healing in vitro and in vivo. Adipose tissue is an alternative source of growth factors. Through a simple lipoaspirate method, adipose derived growth factor-rich preparation (adipose tissue extract; ATE) can be obtained. The authors set out to compare the effects of these two growth factor sources in cell proliferation and migration (scratch) assays of keratinocyte, fibroblast, endothelial and adipose derived stem cells. Growth factors involved in wound healing were measured: keratinocyte growth factor, epidermal growth factor, insulin-like growth factor, interleukin 6, platelet-derived growth factor beta, tumor necrosis factor alfa, transforming growth factor beta and vascular endothelial growth factor. PRP showed higher growth factor concentrations, except for keratinocyte growth factor, that was present in adipose tissue in greater quantities. This was reflected in vitro, where ATE significantly induced proliferation of keratinocytes at day 6 (p < 0.001), compared to plasma and control. Similarly, ATE-treated fibroblast and adipose stem cell cultures showed accelerated migration in scratch assays. Moreover, both sources showed accelerated keratinocyte migration. Adipose tissue preparation has an inductive effect in wound healing by proliferation and migration of cells involved in wound closure. Adipose tissue preparation appears to offer the distinct advantage of containing the adequate quantities of growth factors that induce cell activation, proliferation and migration, particularly in the early phase of wound healing.

Does Liposuction Improve Body Image and Symptoms of Eating Disorders?

BACKGROUND: Unpleasant attention to unfavorable fat may have harmful psychological effects in terms of body dissatisfaction. As a consequence, this may cause abnormal eating regulation. It has been noted that women interested in liposuction self-report more eating problems. As far as we know, there are no prospective studies with standardized instruments providing sufficient data regarding the effects of aesthetic liposuction on various aspects of quality of life. Nevertheless, publications on the effects of eating habits are lacking. METHODS: Sixty-one consecutive women underwent aesthetic liposuction. Three outcome measures were applied at baseline and at follow-up: the eating disorder inventory, Raitasalo's modification of the Beck depression inventory, and the 15-dimensional general quality of life questionnaire. RESULTS: The mean age at baseline was 44 years, and the mean body mass index was 26.0. Thirty-six (59%) women completed all outcome measures with a mean follow-up time of 7 months. A significant improvement from baseline to follow-up was noted in women's body satisfaction, and their overall risk for developing an eating disorder decreased significantly. CONCLUSION: Aesthetic liposuction results in a significantly reduced overall risk for an eating disorder in combination with improved body satisfaction.

Reconstruction of the pelvic floor and the vagina after total pelvic exenteration using the transverse musculocutaneous gracilis flap.

BACKGROUND: Total pelvic exenteration (TPE) is a rare operation in which the pelvic contents are removed entirely. Several options for pelvic floor and vaginal reconstruction have been described including transverse rectus abdominis musculocutaneous (TRAM) or deep inferior epigastric perforator (DIEP) flaps. The transverse musculocutaneous gracilis (TMG) flap has been introduced for breast reconstruction as a free flap. We adopted the pedicled TMG flap for reconstructions after TPE. To the best of our knowledge, this is the first report of this method in the literature. METHODS: Between November 2011 and February 2014, 12 patients underwent TPE and reconstruction with unilateral (six patients) or bilateral (six patients) pedicled TMG flaps. Five patients underwent vaginal reconstruction with bilateral TMG flaps. We describe the operative procedure and the outcome of the operation in these patients. RESULTS: The total mean operative times for TPE with or without vaginal reconstruction were 467 ± 12 and 386 ± 59 min, respectively. The TMG flaps had enough vascular tissue and mobility for reconstructing the TPE defects. There was distal edge necrosis in one out of 18 flaps, while the rest survived completely. During the follow-up, complete wound healing with no signs of weakening of the pelvic floor was observed in all cases. CONCLUSIONS: Soft-tissue reconstructions are needed to reduce complications associated with TPE, to secure the pelvic floor and to reconstruct the vagina in select patients. The TMG flap is a logical flap choice that does not lead to functional deficits, complicate the abdominal ostomies or weaken the abdominal wall. It reduces the length of operation compared to that of abdominal flaps. LEVEL OF EVIDENCE: IV, therapeutic.

Abdominoplasty improves quality of life, psychological distress, and eating disorder symptoms: a prospective study.

Background. Only some studies provide sufficient data regarding the effects of nonpostbariatric (aesthetic) abdominoplasty on various aspects of quality of life. Nevertheless, when considering the effects on eating habits, publications are lacking. Therefore we decided to assess the effects of nonpostbariatric abdominoplasty on eating disorder symptoms, psychological distress, and quality of life. Materials and Methods. 64 consecutive women underwent nonpostbariatric abdominoplasty. Three outcome measures were completed: the Eating Disorder Inventory (EDI), Raitasalo's modification of the Beck Depression Inventory (RBDI), and the 15D general quality of life questionnaire. Results. The mean age at baseline was 42 years and the mean body mass index (BMI) 26.4. Fifty-three (83%) women completed all the outcome measures with a mean follow-up time of 5 months. A significant improvement from baseline to follow-up was noted in women's overall quality of life, body satisfaction, effectiveness, sexual functioning, and self-esteem. The women were significantly less depressive and had significantly less drive for thinness as well as bulimia, and their overall risk of developing an eating disorder also decreased significantly. Conclusions. Abdominoplasty results in significantly improved quality of life, body satisfaction, effectiveness, sexual functioning, self-esteem, and mental health. The risk of developing an eating disorder is decreased significantly. This trial is registered with Clinicaltrials.gov NCT02151799.

The effects of aesthetic breast augmentation on quality of life, psychological distress, and eating disorder symptoms: a prospective study.

BACKGROUND: There are only a few studies that provide sufficient data regarding the effects of aesthetic breast augmentation on various aspects of quality of life. Significant improvement in body image, satisfaction with appearance, sexual attractiveness, and self-esteem has been observed in these studies. In contrast, however, a somewhat impaired general health-related quality of life has been reported at follow-up. Nevertheless, when considering the effects of aesthetic breast augmentation on eating habits, publications are lacking. We therefore decided to assess the effects of aesthetic breast augmentation on quality of life, psychological distress, and eating disorder symptoms. METHODS: This study included 79 consecutive women who underwent bilateral aesthetic augmentation mammaplasty. The women completed three outcome measures at baseline and at follow-up: the Eating Disorder Inventory, Raitasalo's modification of the Beck Depression Inventory, and the 15D general quality-of-life questionnaire. RESULTS: The mean age at baseline was 35 years (range = 18-52). The mean body mass index was 21.3 (range = 17.5-27.3). Sixty-five (82 %) women completed the outcome measures with a mean follow-up time of 7 months (range = 4-13). A significant improvement was observed in self-esteem and depression scores as well as body satisfaction from baseline to follow-up. Interpersonal trust also improved, and after the operation the women were more able to tolerate and understand their own feelings and sensations. A significant decrease in the overall risk for an eating disorder was also noted. CONCLUSIONS: Aesthetic breast augmentation results in significant improvement in women's body satisfaction and self-esteem. The level of risk for an eating disorder is also significantly reduced. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article.

Reconstruction of soft tissue defects in the extremities with a pedicled perforator flap: series of 25 patients.

Since the introduction of perforator-based flaps, new flaps have been described for reconstruction of soft tissue defects in the extremities. Pedicled perforator flaps, often called propeller flaps, are based on a single perforator and are local axial flaps that can be rotated up to 180(0) with the single perforator as the pivotal point. Pedicle perforator flaps have gained popularity because they have a shorter operating time than free flaps. However, some concern has been raised about their reliability. Here we report our results of 11 soft tissue reconstructions in the lower leg and 14 in the upper extremity. The defects were mostly traumatic or caused by release of burn scars. The mean size of the flaps in the lower leg was 52 cm(2) (range 126-15 cm(2)). In the upper extremity it was 24 cm(2) (range 12-35 cm(2)). All patients were followed until the wound had healed. In the upper extremity there was only one partial necrosis of the flap, and one patient had an infected wound. One haematoma was evacuated postoperatively, and all the rest healed uneventfully. In the lower leg we had one total necrosis and one partial necrosis of the flap and one infected wound. A free scapular flap was used for salvage in one case, and revision and skin grafting in two. The pedicled perforator flap is reliable, particularly in the upper extremity. The operation is quick and can be done under regional anaesthesia. The flap is thin and has a local texture that gives a good functional and aesthetic result. The pedicled perforator flap is a little unpredictable in the lower leg, probably because the directions of the vessels that arise from the perforator are not consistent.

The dermis graft: another autologous option for acute burn wound coverage.

BACKGROUND: Split-thickness skin autografts are the gold-standard in providing permanent acute wound closure in major burns. Split-thickness dermal grafts harvested from the same donor site may provide an additional autologous option for permanent acute coverage and increase the number of potential autologous donor sites. MATERIALS AND METHODS: We performed 16 dermis grafts (DG) harvested from the skin of the back in 9 consecutive burn patients. A control donor site consisted of an area of adjacent back skin from which a standard split-thickness skin graft was harvested. The mean age was 63 years (range 23-79 years). The mean initial burn size was 24% TBSA (range 2-40% TBSA). The size of the 16 DG recipient wound beds ranged from 20 to 180 cm2, with mean and median sizes of 62 and 45 cm2, respectively. RESULTS: Dermis graft take was complete in 15/16 cases. All grafts recorded >90% epithelialisation by 4 weeks. There was no significant difference in dermis graft and control donor site healing times (p value 0.05). CONCLUSION: Dermis grafts can provide an additional autologous option for permanent coverage in acute major burn wounds without increasing donor site size or morbidity.

The cost utility of reduction mammaplasty at medium-term follow-up: a prospective study.

PURPOSE: The effects of reduction mammaplasty (RM) have been proved in several randomised trials. However, publications regarding cost utility are infrequent and lacking with regard to medium-term follow-up. Therefore, we decided to assess the cost utility of RM at 2-5 years' follow-up, when later costs and possible re-operations have been incurred. METHODS: A total of 73 patients had bilateral RM between January 2005 and March 2007 in the Hospital District of Helsinki and Uusimaa, Finland. Health-related quality of life was measured with the 15D. Preoperative data were collected with an interview at an appointment and follow-up data by means of a postal survey. Direct hospital costs were obtained from the Ecomed(®) clinical patient administration database (Datawell Ltd., Espoo, Finland). RESULTS: A total of 62 (85%) patients agreed to participate in the study and returned the follow-up questionnaire. The mean follow-up time was 4.0 years (SD 0.53, range 2.3-4.6 years). The mean improvement in the 15D score change was 0.083 (SD 0.081). The mean number of quality-adjusted life years (QALYs) gained was 3.052 (SD 3.167, range 2.561-17.553). The mean hospital costs of the intervention were €3601 (SD 1321), and the mean cost per QALY gained was €1180. Roughly 76% of the costs were due to the hospital stay during the operation. Eight percent of the costs were incurred more than 6 months after the hospital stay. CONCLUSIONS: The cost per QALY gained by RM is low, even when considering later costs caused by possible re-operations, and compares favourably with a number of other surgical procedures.

Suprathel(®) causes less bleeding and scarring than Mepilex(®) Transfer in the treatment of donor sites of split-thickness skin grafts.

Split-thickness skin grafts are routine in the treatment of deep dermal burns and various other wounds. Healing of the donor site of the graft has an impact on the total recovery of the patient. We conducted a prospective clinical study at Tampere University Hospital to compare the effect of two adhesive wound dressings, Suprathel(®) and Mepilex(®) Transfer. The donor sites of 22 split-thickness skin grafts were studied, each of which was covered with Suprathel(®) and Mepilex(®) Transfer dressings side by side. Significantly less pain and bleeding was associated with Suprathel(®) treatment compared with Mepilex(®) Transfer (p < 0.05). Suprathel(®) produced a better scar at the three months' follow-up as measured using the Vancouver Scar Scale (VSS). The results show that Suprathel(®) is a better dressing for the donor sites than Mepilex(®) Transfer.

How to assess scar hypertrophy--a comparison of subjective scales and Spectrocutometry: a new objective method.

Scar hypertrophy is a significant clinical problem involving both linear scars from elective surgery and scars caused by trauma or burns. The treatment of hypertrophic scars is often time consuming, and patients may need to be followed up for months or even years. The methods for reliable quantification of scar hypertrophy are at present unsatisfying. We have developed a new, objective method, Spectrocutometry, for documentation and quantification of scar hypertrophy. The instrument is based on standardized digital imaging and spectral modeling and calculates the estimated concentration change of hemoglobin and melanin from the entire scar and also provides standardized images for documentation. Three plastic surgeons have assessed 37 scars from melanoma surgery using Spectrocutometry, the Vancouver scar scale, and the patient and observer scar assessment scale. The intraclass correlation coefficient for the Vancouver scar scale and the patient and observer scar assessment scale was lower than required for reliable assessment (r=0.66 and 0.60, respectively). The intraclass correlation coefficient for Spectrocutometry was high (r=0.89 and 0.88). A Bayesian network analysis revealed a strong dependency between the estimated concentration change of hemoglobin and scar pain. Spectrocutometry is a feasible method for measuring scar hypertrophy. It is shown to be more reliable than subjective rating in assessing linear surgical scars.

The outcome of reduction mammaplasty remains stable at 2-5 years' follow-up: a prospective study.

PURPOSE: Several randomised studies have proved the effectiveness of reduction mammaplasty in short-term follow-up. However, medium-term prospective follow-up studies are rare. Therefore, a prospective study was conducted to assess the medium-term results and to see whether there are any changes in the intervention effect during the first years. METHODS: A total of 73 patients were operated on between January 2005 and March 2007. Patients completed the 15D health-related quality-of-life questionnaire, The Finnish Breast-Associated Symptoms (FBAS) questionnaire and Raitasalo's modification of the short form of the Beck Depression Inventory (RBDI). In July 2009, follow-up data was collected by postal mail. RESULTS: As many as 62 patients (85%) agreed to participate in the study and returned the follow-up data. Non-responders did not differ from responders in baseline characteristics. Mean follow-up time was 4.0 years (range, 2.3-4.6). Preoperatively, patients had significantly inferior quality of life when compared with the age-standardised population (p < 0.001). This health burden was removed after reduction mammaplasty. At follow-up, patients had significantly better quality of life, less breast-associated symptoms, less depression and anxiety and better self-esteem when compared with the preoperative situation (p < 0.001). CONCLUSIONS: Reduction mammaplasty results in remarkable alleviation in breast-associated and psychological symptoms, and improvement in quality of life. This remains clearly significant and stable at 2-5 years follow-up.

Objective scar assessment--a new method using standardized digital imaging and spectral modelling.

INTRODUCTION: Quantitative assessment of scars is needed in clinical practice and in scientific studies. To date, there have been no entirely objective methods available for these purposes. We introduce a new method developed for scar assessment combining standardized digital imaging (SDI) and spectral modelling (SpM). With this method, the estimated concentration changes (ECCs) of haemoglobin and melanin in the scar can be determined quantitatively. PATIENT AND METHODS: In the current study, 22 skin graft donor site (SGDS) wounds were treated with two alternative dressing materials, Suprathel® and Mepilex Transfer®, side by side on the same wound. The SGSD scars were assessed using SDI and SpM. The scars were given subjective ratings by three surgeons using the POSAS and the Vancouver Scar Scale (VSS). The correlations between the ECCs of melanin and haemoglobin and the corresponding subjective ratings were calculated as well as the Intraclass Correlation Coefficient (ICC) of the subjective ratings. RESULTS: There was a statistically significant correlation between the ECCs of melanin and haemoglobin and the subjective ratings. A single observer could reliably assess pigmentation with the POSAS scale (ICC = 0.75) but not vascularity (ICC = 0.51). The reliability ratings of the VSS were unacceptably low. CONCLUSIONS: The ECC values of haemoglobin and melanin give accurate documentation of the scar status. The results also show that the subjective ratings in this study were unreliable especially when interfering pigmentation and increased vascularity were both present at the same time.

Breast reduction alleviates depression and anxiety and restores self-esteem: a prospective randomised clinical trial.

Of women who seek reduction mammaplasty, up to a third have pathological degrees of anxiety or depression, or both. The psychological aspect of reduction mammaplasty is therefore an important consideration. We did a prospective randomised clinical trial to see how reduction mammaplasty affected macromastia patients' depression, anxiety, and self-esteem. Eighty-two patients were randomised, 40 to have the operation, and 42 patients to conservative treatment. Both groups were followed for six months. The patients completed the RBDI questionnaire (Raitasalo's modification of the short form of the Beck Depression Inventory). Twenty-nine patients in the operated group and 35 patients in the conservative group completed the study. At the second examination, the patients who had been operated on, had significantly less depression (p<0.01) and better self-esteem (p=0.03) than the conservative group. The proportions of depressed (p<0.01) and anxious (p=0.04) patients were also smaller in the group who were operated on. There is significantly less depression and anxiety after reduction mammaplasty, and patients' self-esteem is restored.

The improvement in quality of life after breast reduction is comparable to that after major joint replacement.

The loss of health-related quality of life (QoL) associated with symptomatic breast hypertrophy has been well documented. Measuring QoL with a generic, single index, instrument enables comparisons between different diseases, conditions, and specialities. The aim of this study was to measure the health-related QoL of patients before and after reduction mammaplasty, and to compare it to that of the age-standardised female population, and patients treated by total joint replacement. Health-related QoL was measured using the 15D score from 82 patients at baseline, and at six months after breast reduction surgery from 29 patients who had been randomised to the procedure. At baseline those who had had reduction mammaplasty had significantly lower health-related QoL than the age-standardised female population, but by six months it had improved to the same level with population. The preoperative health deficit of symptomatic breast hypertrophy was equal to that of symptomatic major joint arthrosis. The effect of intervention of reduction mammaplasty was comparable to that of hip and more than knee total joint replacement.

Complications of skin-sparing mastectomy followed by immediate breast reconstruction: a prospective randomized study comparing high-frequency radiosurgery with conventional diathermy.

Skin-sparing mastectomy (SSM) followed by immediate breast reconstruction delivers superior cosmetic and functional outcome. However, SSM is vulnerable to complications of the native skin envelope. This study aims to compare the effects of radiofrequency coagulation and conventional diathermy on complications of SSM. Sixty consecutive patients suitable for SSM were randomized into conventional diathermy and radiosurgery groups. These groups were compared and the risk factors for SSM flap complications were evaluated. The SSM flap complication rate was 23.4%. There was no difference between the study groups regarding the SSM flap complications. Increased SSM flap complication rate was associated with smoking and the type of skin incision used. This study shows that high-frequency radiosurgery is comparable to conventional diathermy in terms of complication rates of SSM. Furthermore, this study reports an association between the tennis-racquet-type incision and an increased SSM flap complication rate compared with the round periareolar type incision.