Good health-related quality-of-life and high patient-reported satisfaction after delayed breast reconstruction with pedicled flaps from the back.

BACKGROUND: This paper presents the results of a randomized controlled trial (RCT) that focus on health-related quality-of-life (QoL) and patient-reported satisfaction following breast reconstruction with pedicled flaps from the back. MATERIALS & METHODS: We included women for unilateral delayed breast reconstruction. Patients were randomized to reconstruction by either a latissimus dorsi (LD) flap or a thoracodorsal artery perforator (TAP) flap. Assessment of QoL and patient satisfaction was made using two different patient-reported outcome measures (PROMs): The EORTC QLQ-30 and the Breast-Q questionnaire for post-mastectomy breast reconstruction. RESULTS: A total of 50 women were enrolled over a two-year period and allocated to reconstruction. Forty patients completed both surgery and follow-up and were included in the analysis - 18 in the LD group and 22 in the TAP group. The EORTC QLQ-30 was administered at the baseline and at one-year follow-up. There was no significant effect of introducing the TAP flap on either the summary score, the global QoL-score or the financial impact-score when compared to the LD flap. The Breast-Q questionnaire was administered only at one-year follow-up. There was no significant difference between the two groups for the scores for satisfaction with the reconstructed breast, the overall outcome and QoL related to psycho-social, sexual and physical well-being. CONCLUSION: Women from both groups report high satisfaction and QoL following the reconstruction. The quality of the dataset and the study design are, however, insufficient to rule out any existing difference. A larger cohort, longer follow-up and different design are warranted to assess the true clinical significance these reconstructions might have on satisfaction and QoL.

[Chainsaw lacerations of the face].

This is a case report of two patients, who had accidental self-inflicted chainsaw lacerations of the face. The injuries were remarkably similar with jagged soft tissue lacerations and soft tissue parts of questionable vitality. These cases and their treatment are presented to show examples of the handling of soft tissue injuries of the face in an emergency department setting and to show, that very conservative debridement of these injuries is the recommended approach.

Visualized bilateral breast reconstruction by propeller thoracodorsal artery perforator flaps.

Thoracodorsal artery perforator (TAP) flaps are versatile flaps that provide a consistent and aesthetically pleasing breast reconstruction. We prefer the TAP flap to the latissimus dorsi (LD) flap due to the morbidity associated with the LD flap. In this paper we aim to show how we perform bilateral TAP flap breast reconstruction and present our preliminary results from 32 bilateral reconstructions in 16 patients. The TAP flap breast reconstruction can be performed as a direct-to-implant or a delayed procedure depending on patient factors. Color Doppler ultrasonography (CDU) is used in the preoperative planning which promotes the safety and reliability of the flap by mapping perforators thus enabling faster dissection. The bilateral TAP flap breast reconstruction is usually performed in three steps: (I) raising the flaps at the recipient site; (II) rotating the TAP flaps and (III) completion of the breast reconstruction.

Shoulder-related donor site morbidity after delayed breast reconstruction with pedicled flaps from the back: An open label randomized controlled clinical trial.

BACKGROUND: This randomized controlled trial (RCT) investigates differences in shoulder-related morbidity after delayed breast reconstruction by either a latissimus dorsi (LD) flap or a thoracodorsal artery perforater (TAP) flap. MATERIAL AND METHODS: In accordance with the CONSORT guidelines, we included women for unilateral delayed breast reconstruction. Patients were randomized to reconstruction by either of the two flaps. Shoulder-function was assessed at baseline and at 3, 6 and 12 months after surgery. The primary endpoint was patient-reported shoulder-related pain. A further objective assessment by the Constant Shoulder Score (CSS) was included as secondary endpoints. RESULTS: A total of 50 women were enrolled over a two-year period and allocated to reconstruction, with 25 patients in each group. Patient-reported shoulder-related pain was significantly lower in the TAP group at 12 months after surgery when adjusting for pain at baseline: OR = 0.05 95%CI(0.005-0.51), p-value = 0.011. The estimated effect on the total CSS at 12 months, when applying the TAP flap instead of the LD flap and adjusting for the baseline score, was 6.2 points with 95%CI(0.5-12.0), p-value 0.033. The TAP flap seems to have a statistically significant positive effect on pain and activity in daily life (ADL), while there were no significant effect on range of motion and strength after one year. CONCLUSION: Patient reconstructed by the TAP flap are less likely to experience shoulder-related pain and have a better shoulder-function one year after the reconstruction. Harvest of the LD flap carries a higher risk of shoulder-function impairment, chronic pain and reduced ADL.

[Microsurgery in plastic surgery].

The most common indication for free flap surgery is breast reconstruction. Deep inferior epigastric perforator flaps are safe, quick and provide excellent cosmetic results. The reconstruction in head and neck cancer patients is more complex. The aims are preservation of function and appearance. Free flaps are important in traumatology and the timing of intervention can make the difference between amputation and extremity conserving treatment. Due to the improvement in surgical technique failure rates as low as 2% can be seen. Post-operative monitoring is well-established in all microsurgical centres.

[Microsurgery in reanimation, lymphoedema and hand surgery].

Microsurgery is defined as surgery performed with the aid of ocular magnification. In Denmark, this is undertaken by four units. This review describes the history of microsurgery which evolved during the 1960s. Microsurgery in hand surgery is primarily replantation and revascularisation but also peripheral nerve surgery as well as brachial plexus surgery. Lymphoedema is being treated with super microsurgery on an experimental basis. Dynamic reconstruction of facial palsy is performed in a two-stage operation with cross-over nerve graft and a free microvascular muscle flap, typically gracilis.

Transgender Surgery in Denmark From 1994 to 2015: 20-Year Follow-Up Study.

INTRODUCTION: Gender dysphoria is a mismatch between a person's biological sex and gender identity. The best treatment is believed to be hormonal therapy and gender-confirming surgery that will transition the individual toward the desired gender. Treatment in Denmark is covered by public health care, and gender-confirming surgery in Denmark is centralized at a single-center with few specialized plastic surgeons conducting top surgery (mastectomy or breast augmentation) and bottom surgery (vaginoplasty or phalloplasty and metoidioplasty). AIMS: To report the first nationwide single-center review on transsexual patients in Denmark undergoing gender-confirming surgery performed by a single surgical team and to assess whether age at time of gender-confirming surgery decreased during a 20-year period. METHODS: Electronic patient databases were used to identify patients diagnosed with gender identity disorders from January 1994 through March 2015. Patients were excluded from the study if they were pseudohermaphrodites or if their gender was not reported. MAIN OUTCOME MEASURES: Gender distribution, age trends, and surgeries performed for Danish patients who underwent gender-confirming surgery. RESULTS: One hundred fifty-eight patients referred for gender-confirming surgery were included. Fifty-five cases (35%) were male-to-female (MtF) and 103 (65%) were female-to-male (FtM). In total, 126 gender-confirming surgeries were performed. For FtM cases, top surgery (mastectomy) was conducted in 62 patients and bottom surgery (phalloplasty and metoidioplasty) was conducted in 17 patients. For MtF cases, 45 underwent bottom surgery (vaginoplasty), 2 of whom received breast augmentation. The FtM:MtF ratio of the referred patients was 1.9:1. The median age at the time of surgery decreased from 40 to 27 years during the 20-year period. CONCLUSION: Gender-confirming surgery was performed on 65 FtM and 40 MtF cases at our hospital, and 21 transsexuals underwent surgery abroad. Mastectomy was performed in 62 FtM and bottom surgery in 17 FtM cases. Vaginoplasty was performed in 45 MtF and breast augmentation in 2 MtF cases. There was a significant decrease in age at the time of gender-confirming surgery during the course of the study period.

The Versatile Extended Thoracodorsal Artery Perforator Flap for Breast Reconstruction.

BACKGROUND: The thoracodorsal artery perforator (TAP) flap is a versatile tool that can be used to reconstruct the breast. The authors use preoperative perforator mapping using color Doppler ultrasonography and present a safe, efficient harvesting technique to demonstrate reliable use of the TAP flap in reconstructive surgery. METHODS: A multicenter, retrospective review was performed on all patients undergoing TAP flap reconstruction from August 2011 to November 2014. Data were collected from patient records as well as outpatient interviews. RESULTS: A total of 106 TAP flaps were performed in 97 patients. The flaps were raised with either 1 perforator (42/106), 2 perforators (55/106), or three perforators (9/106), and turned as a propeller in 99 of 106 (93%) flaps or buried as a turnover in 7 of 106 (7%) of flaps. The mean operative time was 200 minutes (range, 60-485). Major complications occurred in 10 of 106 (10%) cases and included hematoma (1/108), venous congestion (2/108), and partial flap necrosis (7/108). The reconstructive goal was achieved in 103 of 106 (97%) flaps. CONCLUSIONS: The TAP flap is a pedicled, fasciocutaneous flap that can be used for total breast reconstruction as well as breast conserving surgery. This large, multicenter series describes our techniques of preoperative perforator mapping and a fast, reliable harvest. Reconstructive goals are accomplished in the great majority of patients.

Extensive screening for primary tumor is redundant in melanoma of unknown primary.

For decades, patients in our institution with metastastic melanoma of unknown primary have been subjected to extensive examinations in search of the primary tumor. This retrospective study questions the results, and thus the feasibility of these examinations. Of 103 patients diagnosed with unknown primary tumor during the period 1986-2006, 39 (38%) presented primarily with a cutaneous or a subcutaneous metastasis, and 63 (61%) with a lymph node metastasis. One patient presented with a bone metastasis (1%). Eighty-seven patients (84%) were examined by an ophthalmologist. A choroidal melanoma was suspected as the primary tumor in one patient. Eighty-four patients (82%) were examined by an oto-rhino-laryngologist, whereby no primary tumor was found. Ninety-five patients (92%) were examined by sigmoideoscopy/rectoscopy. No primary tumor was found. Of the 36 women, 32 had a gynecological examination (89%), revealing no primary tumor. We conclude, that only one possible (but not verified) primary tumor was disclosed by various specialists examinations of 103 patients referred with the diagnosis metastatic melanoma with no primary tumor. Special screenings can thus be considered as redundant. Thus, for patients referred with metastastic melanoma of unknown primary, we recommend that a detailed history is obtained, and a standard physical examination performed, in addition to a histopathological review and CT/PET for staging.

Increasing annual incidence of vestibular schwannoma and age at diagnosis.

During the last 26 years the annual number of diagnosed vestibular schwannomas (VS) has been increasing. The aim of this study is to describe and analyse this increase. Since 1976, 1446 new cases of VS have been diagnosed at the authors' centre. Special focus was on the age at diagnosis, the localization and the size of the tumour. The size of the tumour was registered as either intrameatal or with the largest extrameatal diameter. The annual number of diagnosed VS has increased from 26 in 1976 to 101 in 2001. The size of the diagnosed tumours has decreased from a median of 35 mm in 1979 to 10 mm in 2001. In the first years large and giant tumours dominated, in contrast to recent years in which intrameatal and small tumours dominated. The median age at the time of diagnosis has been almost unchanged through the period (median 55 years). If the decreasing size of the tumour and the increasing incidence of VS can be explained only by earlier diagnosis and easier access to magnetic resonance (MR) scanning it should be expected that the median age at the time of diagnosis would decrease simultaneously. In this study, the median age at the time of diagnosis has been almost unchanged throughout the 26-year period. This paradox can be explained by the fact that, with easier access to MR scanning, the examination has been offered also to elderly patients, in whom the small and intrameatal tumours dominate.

What is the real incidence of vestibular schwannoma?

OBJECTIVES: To present the incidence of vestibular schwannoma (VS) in Denmark, compare the incidence with that of previous periods, and discuss the real incidence of VS. DESIGN, SETTING, AND PATIENTS: Prospective registration of all diagnosed VS in Denmark, with a population of 5.1 to 5.2 million, during the 6 years from January 1996 through December 2001. Incidence in this period was compared with that of 3 previous periods (July 1976 through June 1983 [first period], July 1983 through June 1990 [second period], and July 1990 through December 1995 [third period]). RESULTS: In the 1996-2001 period, 542 cases of VS were diagnosed, representing a mean incidence of 17.4 VS/1 million inhabitants per year. Of these, 227 tumors underwent operation, 14 underwent irradiation, and 301 were allocated to observation (wait-and-scan policy). One hundred sixty-six tumors were intrameatal. Size of extrameatal tumors was small in 104; medium in 194; large in 68; and giant (>40 mm) in 10. Compared with incidences of 7.8 VS/1 million inhabitants per year in the first, 9.4 VS/1 million inhabitants in the second, and 12.4 VS/1 million inhabitants in the third periods, the incidence for the 1996-2001 period represents an increase to 17.4 VS/1 million inhabitants per year. The mean incidence for the entire 25.5-year period was 11.5 VS/1 million inhabitants per year. CONCLUSIONS: An estimate of a realistic mean incidence of VS depends on the observation period. Our 25.5-year registration of an entire population showed a mean incidence of 11.5 VS/1 million inhabitants per year. However, the latest period registered represents an incidence of 17.4 VS/1 million inhabitants per year, which, combined with a probable further increase of diagnosed tumors in forthcoming years, suggests a realistic incidence of approximately 13 VS/1 million inhabitants per year.

Patients' fears, expectations and satisfaction in relation to management of vestibular schwannoma: a comparison of surgery and observation.

OBJECTIVE: To investigate patients' expectations, fears and satisfaction in relation to management of vestibular schwannoma in a comparison of observed and operated patients. MATERIAL AND METHODS: A total of 768 patients operated on for vestibular schwannoma and 247 patients diagnosed with and observed for the same condition answered a mailed questionnaire. Among several questions, the patients were asked to indicate the worst aspect of the management (surgery or observation) of their condition. Furthermore, the patients were asked if they regretted the choice of management and if the information provided by the medical staff was satisfactory. RESULTS: Of the operated patients, 37% reported loss of hearing (anacusis) on the operated side to be the worst aspect of the operation and 38% of the observed patients found decreased hearing on the affected side to be the worst aspect. Of the operated patients, 653 (85%) did not regret having the operation, whereas 62 (8%) did. In the observed series, 206 patients (83%) did not regret the choice of observation, 12 (5%) did regret it and 29 (12%) did not answer the question. Of the operated patients, 448 (58%) were satisfied with the information given, whereas 289 (38%) were not satisfied. Of the observed patients, 175 (71%) were satisfied with the information given and 59 (24%) were not. The ratio of satisfied to dissatisfied patients did not change during the period 1976-2000. CONCLUSION: Overall, the worst aspect of vestibular schwannoma is the associated hearing loss, regardless of the treatment modality. A majority of both the operated and observed patients did not regret their choice of treatment modality and were satisfied with the information given by the medical staff, although there may be scope for further improvement in terms of the latter aspect.

Need for facial reanimation after operations for vestibular schwannoma: patients perspective.

A total of 779 patients operated on for vestibular schwannoma mostly by the translabyrinthine approach in Denmark during the period 1976-2000 answered a questionnaire about various postoperative consequences. In this paper we describe the patients' facial function evaluated by professionals one year postoperatively and self-evaluated by each patient according to the House-Brackmann scale at the time of the questionnaire. The patients' self-evaluation was more pessimistic than that of the professionals with 26% reporting House-Brackmann grade IV-VI, compared with 20%. One hundred and seventeen (15%) of 779 patients considered their facial palsy to be a big problem and 125 patients (16%) were interested in surgical treatment for the sequelae of facial palsy. Seventy-eight (10%) had already had some kind of operation, usually the VII-XII coaptation. Thirty-three of 61 patients who had already been operated on for facial palsy were interested in further surgical treatment. One hundred and ninety-five patients (25%) had some kind of operation on the eye, mostly (88%) a tarsorrhaphy. Reanimation procedures such as a palpebral gold weight or a spring, apparently still have a small place in Denmark. In conclusion, there seem to be a considerable and unmet need for surgical reanimation of facial function in patients with facial palsy after operations for vestibular schwannoma in Denmark.

Long-term socio-economic impact of vestibular schwannoma for patients under observation and after surgery.

This study describes and compares the long-term socio-economic impact for patients diagnosed with a vestibular schwannoma and either operated on or observed. A consecutive sample of patients diagnosed with vestibular schwannoma in Denmark and either operated on (748 patients) or observed by the wait-and-re-scan policy (272 patients) during the period 1976-2000 were studied retrospectively. The consequences of operation/diagnosis (and observation) on vocational status, ability to handle daily chores and some psycho-social aspects were studied by means of a prospective postal questionnaire. Ninety-six per cent of the operated and 83 per cent of the observed patients answered the questionnaire. Overall, 34 per cent of operated patients resumed their daily activities within one to two months, and 76 per cent within four to six months. Patients operated on for a large tumour resumed their daily activities later than patients with a small tumour. Regardless of tumour size, employment was unchanged for the majority of observed and operated patients. The vocational consequences were significantly worse for operated patients with a large tumour, than for observed patients. However, no difference existed between the observed group and operated patients with a tumour below 20 mm in size. A change in vocational status was most frequent for assisting spouses, unskilled manual workers and the self-employed. The majority of both observed and operated patients experienced no change in their ability to handle daily chores. The changed ability of operated patients was worse than that of observed patients. Among various changes in their psycho-social well-being, decrease in social ability was the most frequent complaint in both groups, followed by increased fatigue, decreased concentration, increased irritability, depression and headache, decreased intellect and libido. Regardless of tumour size, the change in social ability, concentration and fatigue was worse for operated patients. Concerning headache, patients operated on for a large tumour were better off than observed patients and patients operated on for a small tumour. There was no difference between the operated and observed groups concerning irritability, intellect and libido. Deterioration of vocational status, ability to handle daily chores and several aspects of psycho-social well-being are reported both by patients operated on and observed for vestibular schwannoma. However, the negative changes were more frequent among the operated patients, although the differences were surprisingly modest, especially when comparing observed patients with patients operated on for a small tumour.