Autologous fat transplantation prior to permanent expander implant breast reconstruction enhances the outcome after two years: a randomized controlled trial.

Radiotherapy is important in breast cancer treatment. A side effect of the treatment is fibrosis that decreases the possibility for a successful breast reconstruction with expanders and with high patient satisfaction with the result. The most common option for mastectomized, irradiated women wishing for a breast reconstruction is autologous tissue transplantation. However, some patients are not suitable for flap surgery. Fifty mastectomized and irradiated women were included in a randomized controlled trial. They underwent breast reconstruction with expanders and were allocated 1:1 to either receive pre-treatment with autologous fat transplantation (AFT) or not. Primary outcomes were frequency of reoperations and complications. Secondary outcomes were number of days in hospital, number of outpatient visits to surgeon or nurse and patient reported outcome as reported with Breast Q. Follow-up time was 2 years. Fifty-two per cent of the intervention group and 68% of the controls underwent reoperations (p = 0.611). Thirty-two per cent of the intervention group and 52% of the controls had complications (p = 0.347). The median number of consultations with the nurse was four in the intervention group and six in the control group (p = 0.002). The AFT patients were significantly more satisfied with their breasts and psychosocial well-being after 2 years. They also had higher increase in satisfaction with breasts, psychosocial well-being, and sexual well-being when comparing baseline with 2 years postoperatively. This randomized controlled trial indicates benefits of AFT prior to breast reconstruction with expanders, especially on patient reported outcome even if the study sample is small.

Free Flap Surgery Outcome Related to Antithrombotic Treatment Regime: An Analysis of 1000 Cases.

Autologous free tissue transfer is today an integral part of reconstructive plastic surgery, but still lacks generally accepted guidelines regarding antithrombotic agents. We hypothesized that the overuse of antithrombotic agents could be a risk factor for free flap complications and therefore studied a treatment protocol adjustment. METHODS: Consecutive free flaps between 2005 and 2020 at a single center were analyzed for complications in relation to the use of pre- and intraoperative treatment with three different antithrombotic agents. The use of preoperative low molecular weight heparin (LMWH), intraoperative heparin, and dextran were analyzed in relation to outcome variables, thromboembolic events, or reexploration for hematoma. RESULTS: Nine hundred thirty-one patients underwent 1000 microvascular free flaps for breast (n = 487), head and neck (n = 365), and extremity (n = 148) reconstruction. Within the first postoperative week, 44 cases had a thromboembolic event and 58 cases underwent hematoma-related reexploration. In the multivariate analysis, thromboembolic events were associated with extremity reconstruction (P = 0.02) and smoking (P = 0.02). Hematoma-related reexploration was more common with triple antithrombotic therapy compared with all other treatment regimes (P < 0.05). The number of antithrombotic agents used perioperatively was linearly decreased, from three to none, over the elapsed time period (P < 0.001). CONCLUSIONS: Hematoma was the most common reason for reexploration and was further associated with the use of multiple antithrombotic agents. Cessation of triple treatment was associated with less hematomas and further reduction of antithrombotic agents did not result in any increase of thromboembolic events. Evidence-based guidelines are warranted for antithrombotic regimes in standard free flap surgery.

Beyond the 21-cm Notch-to-nipple Myth: Golden Proportions in Breast Aesthetics.

BACKGROUND: The 21-cm notch-to-nipple distance has been accepted without academic scrutiny as a key measure in breast aesthetics. The Fibonacci sequence and phi ratio occur frequently in nature. They have previously been used to assess aesthetics of the face, but not the breast. This study aims to assess if the static 21-cm measure or the proportional phi ratio is associated with ideal breast aesthetics. METHOD: Subclavicular-breast height and breast width were used to calculate the aesthetic ratio. Subjects were subsequently aesthetically rated. A one-sample t-test was used to determine if the ratio for each breast differed from phi. Breast scores with one, both, or no breasts were compared with an optimal phi ratio. Analysis of variance was performed. Tukey-Kramer adjustment for multiple comparisons was used when pairwise comparisons were conducted. RESULTS: Five subjects (14%) had bilateral optimal phi ratio breasts. Four subjects (11%) had one breast with an optimal phi ratio. Subjects with bilateral optimal phi ratios had significantly higher overall breast scores than those with only one optimal breast (Δ = 0.86, P = 0.025) or no optimal breast (Δ = 0.73, P = 0.008). Distance from optimal Fibonacci nipple position was moderately to strongly correlated with aesthetic score (-0.630, P = 0.016). No correlation was found between 21-cm notch-to-nipple distance and aesthetic score. CONCLUSION: The bilateral optimal phi ratio is correlated with high overall aesthetic scores, as is the optimal Fibonacci nipple position. No correlation was found between 21-cm notch-to-nipple distance and overall aesthetic score.

An Aesthetic Factor Priority List of the Female Breast in Scandinavian Subjects.

Background: There is little consensus about the relative determinative value of each individual factor in female breast aesthetics. When performing breast surgery with an aesthetic goal, certain factors will be more important than others. The purpose of this study was to make an aesthetic factor rank list to determine the relative contributions to overall breast aesthetics. Method: Volunteers were scanned using the 3-dimensional Vectra system. Ten Scandinavian plastic surgeons rated 37 subjects, using a validated scoring system with 49 scoring items. The correlation between specific aesthetic factors and overall breast aesthetic scores of the subjects were calculated using Pearson's r, Spearman's ρ, and Kendall's τ. Results: A very strong correlation was found between overall breast aesthetic score and lower pole shape (0.876, P < 0.0001). This was also true for upper pole shape (0.826, P < 0.0001) and breast height (0.821, P < 0.0001). A strong correlation was found between overall breast aesthetic score and nipple position (0.733, P < 0.0001), breast size (0.644, P < 0.0001), and breast width (0.632, P < 0.0001). Factors that were only moderately correlated with aesthetic score were intermammary distance (0.496, P = 0.002), nipple size and projection (0.588, P < 0.0001), areolar diameter (0.484, P < 0.0001), and areolar shape (0.403, P < 0.0001). Perceived symmetry was a weak factor (0.363, P = 0.027). Conclusions: Aesthetic factors of the female breast can be ranked in a priority list. Shape of the lower pole and upper pole and breast height are primary factors of female breast aesthetics. These should be prioritized in any aesthetic breast surgery. Vertical dimensional factors seem to be more determinative than horizontal factors.

KAMEDO Report No. 91: 2004 tsunami disaster in Asia--home transport and emergency care in Sweden.

This is a descriptive report of the Swedish authorities' responses to the tsunami that affected Southeast Asia in December 2004. The main focus is the care of survivors and the injured during their transportation from Thailand and their return to Sweden. The psychological and physical after-effects also are presented based on a poll conducted one year after the tsunami.

Breast free flap complications related to haematoma formation - do the risks of multiple antithrombotics outweigh the benefits today?

Background Free flap reconstruction is today a common operation for many breast cancer patients, but local protocols for microsurgery still predict the use of antithrombotic agents. Reduced operation times and complication rates together with faster mobilisation, after introduction of perforator flaps, call for less comprehensive antithrombotic regimens. It was hypothesised that multiple antithrombotics was a risk factor for bleeding-related flap complications. Methods A retrospective cohort study was conducted to study the association between reoperation for haematoma and flap-related complications after free flap breast reconstruction. A combination of heparin, low-molecular-weight heparin and dextran were used as antithrombotics. A sub-analysis was performed to compare non-dextran to dextran treated patients. Results One hundred and thirty-nine patients were identified, reconstructed with 150 consecutive perforator free flaps to the breast. Reoperation for breast haematoma (13%) was associated with concomitant re-operation for venous congestion (8.6%) (p < 0.001), but also for flap thrombosis (2.9%) (p = 0.007), highlighting haematoma as a risk factor for flap-related complications. An increased rate of haematoma re-operations of the breast was noted among the flap-related complications in the dextran (n = 79), compared to the non-dextran group (p = 0.011). Conclusion The current study highlights the use of multiple antithrombotics as a risk factor for haematoma reoperation. Liberal use of drains and evacuation of breast haematomas are, therefore, indicated together with limitation of antithrombotic agents. The highly variable use of antithrombotic agents worldwide call for evidence-based guidelines in standardised free flap breast reconstruction.

Metabolism in pedicled and free TRAM flaps: a comparison using the microdialysis technique.

The most common complication in flap surgery is of a circulatory nature. Impeded blood flow leads to altered metabolism in the tissue. Possible metabolic differences between different zones of the transverse rectus abdominis muscle (TRAM) flap were studied and the metabolism of pedicled and free TRAM flaps was compared intraoperatively and postoperatively. The method used was microdialysis, which is a useful technique for following local metabolic changes continuously in various tissues.Twenty-two patients with a pedicled or free TRAM flap were monitored using the microdialysis technique. Two microdialysis catheters were placed subcutaneously in the flap (zone I and zone II), and a third one was placed subcutaneously in the flank to serve as a control. The flaps were monitored intraoperatively and postoperatively for 3 days with repeated analyses of extracellular glucose, lactate, and glycerol concentrations. An additional analysis of pyruvate was performed in some patients to calculate the lactate-to-pyruvate ratio. This study showed that glucose, lactate, and glycerol change in a characteristic way when complete ischemia (i.e., complete inhibition of the blood circulation) is present. A slower stabilization with prolonged metabolic signs of ischemia, such as lower glucose and higher lactate and glycerol concentrations, was seen in zone II compared with zone I, and more pronounced metabolic signs of ischemia, but with a faster recovery, were detected in the free TRAM flap group than in the pedicled TRAM flap group. The fact that the metabolites returned to normal earlier in free flaps than in pedicled flaps may indicate that free TRAM flaps sustain less ischemic damage because of better and more vigorous perfusion.

Threshold of tactile perception after nipple-sharing: a prospective study.

Reconstruction of the nipple-areola complex is the final procedure of a breast reconstruction. The method of choice in our department for nipple reconstruction is nipple-sharing and tattooing of the areola. Some patients are reluctant to use a part of the healthy nipple, as it is not fully known how the sensibility in the remaining donor nipple is affected by surgery. Twenty patients admitted to the hospital for nipple-sharing were invited to participate in the study. The tactile perception threshold of the donor nipple was assessed using von Frey monofilaments preoperatively, and 1, 6, and 12 months postoperatively. The patients' subjective impressions one year postoperatively were also evaluated. The donor nipple had regained sensibility to touch six months after nipple-sharing. All patients reported that the nipple felt the same as before surgery and could become erect. We therefore recommend the nipple-sharing technique for completion of a breast reconstruction.

Objective evaluation of two differently-shaped permanent expander prostheses used for breast reconstruction.

When a breast is being reconstructed with an implant, a capsule of connective tissue always forms around the implant and a capsular contracture can develop. Radiotherapy increases the incidence of capsular contracture. To evaluate the results after breast reconstruction with differently-shaped textured implants, and the effect of radiotherapy on the softness of the reconstruction, 140 patients given permanent breast expander prostheses between 1994 and 2000 were studied. In 99 patients a round implant and in 41 an anatomically-shaped implant was used. Radiotherapy was given to 24 patients. For objective assessment, applanation tonometry was recorded when the desired breast volume was achieved, and 6 and 12 months later. This study showed that, regardless of the shape of the implant, the softness of the breast reconstruction was similar, as shown by the contact area of the applanation tonometry disc. Radiotherapy transiently reduced the softness of the breast.

Postmastectomy breast reconstruction in the irradiated breast: a comparative study of DIEP and latissimus dorsi flap outcome.

BACKGROUND: Autologous tissue transfer is often indicated to achieve improved tissue quality during breast reconstruction after radiotherapy. The authors evaluated satisfaction with postmastectomy breast reconstruction among irradiated patients. The aim was to compare deep inferior epigastric perforator (DIEP) and latissimus dorsi flaps regarding satisfaction with aesthetic outcome between patients and plastic surgeons. METHODS: Patients who underwent reconstruction with 24 consecutive DIEP flaps and 21 consecutive latissimus dorsi flaps in combination with prostheses were reviewed retrospectively. They received the Michigan Outcomes Study 36-Item Short Form Health Survey and a complementary form regarding patient satisfaction. They were photographed, and aesthetic results were evaluated by an independent board of plastic surgeons. RESULTS: There was no significant difference between the groups regarding demographic data or 36-Item Short Form Health Survey results. Plastic surgeons found the DIEP flap superior regarding size (p = 0.024) and shape (p = 0.039), whereas patients were more satisfied with the size (p = 0.046) and shape (p = 0.017) of the latissimus dorsi flap when patients' and surgeons' opinions were compared. Discrepancy between patients' and surgeons' opinions was verified with weighted kappa analysis. Regarding the donor scar, the latissimus dorsi flap was favored compared with DIEP flap reconstruction by both patients (p = 0.036) and surgeons (p = 0.001). CONCLUSIONS: There is a difference between patients' and plastic surgeons' opinions regarding breast reconstruction outcomes in the irradiated breast. The patients were more satisfied with latissimus dorsi flap reconstruction, which may relate to the donor-site scar. Surgeons favored DIEP flap reconstruction with regard to the size and shape of the breast. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

No differences in aesthetic outcome or patient satisfaction between anatomically shaped and round expandable implants in bilateral breast reconstructions: a randomized study.

BACKGROUND: The demand for bilateral mastectomy and immediate breast reconstruction has increased in recent years, primarily due to the development of genetic testing. The aim of this study was to evaluate if there was a difference between anatomically shaped and round permanent expandable implants in one-stage bilateral breast reconstruction after bilateral prophylactic mastectomy. METHODS: The anatomically shaped permanent expander implant McGhan Style 150 (Inamed, Santa Barbara, Calif.) was compared with the round permanent expander implant Siltex Becker 25 (Mentor, Santa Barbara, Calif.). Thirty-six women who opted for bilateral prophylactic mastectomy and immediate reconstruction with implants from 2004 to 2006 were included and randomly assigned to each group [18 women (36 breasts) per group]. Time to follow-up was a minimum of 2 years after the bilateral prophylactic mastectomy. Implant-related complications, breast symmetry, aesthetic outcome, and patient satisfaction were evaluated. Aesthetic outcome was evaluated by an expert panel that also tried to recognize if the breasts were reconstructed with anatomically shaped or round implants. Patient satisfaction was evaluated by a questionnaire. RESULTS: Average time to follow-up was 30 months (range, 24 to 49 months). There was no statistical difference between the two implant groups in terms of complications, breast symmetry, or outcome scores from the expert panel and patient assessment. The expert panel guessed the right implant shape in 42 percent of the anatomically shaped implants and 66 percent of the round implants. CONCLUSION: In immediate one-stage breast reconstruction after bilateral prophylactic skin-sparing mastectomy, anatomically shaped and round permanent expander implants had comparable complication rates, aesthetic outcomes, and patient satisfaction after 2 years of follow-up.

Patient satisfaction with aesthetic outcome after bilateral prophylactic mastectomy and immediate reconstruction with implants.

UNLABELLED: Previous studies regarding body image after bilateral prophylactic mastectomy with breast reconstruction have reported a risk of reduced satisfaction with body image and adverse effects on sexual life. The aim of this retrospective study was to find areas for future surgical improvements to optimize patient satisfaction with the aesthetic result after bilateral prophylactic mastectomy and immediate breast reconstruction with implants. Nipple-areola complexes were reconstructed. Twenty-four consecutive and standardized operated women were included. The follow-up time was an average of 5.4 (range: 2.4-10.2) years. The outcome in terms of breast symmetry, size, and firmness were measured with objective and subjective methods, and results were compared to those from a control group of 24 women. Patient satisfaction was evaluated with a questionnaire. Main findings were that the overall aesthetic result was regarded as good in both objective and subjective evaluations and that breast symmetry in patients was as common as in the control group, but reconstructed breasts were firmer. Twenty of 24 patients thought that the aesthetic result exceeded their expectations, and 22/24 would recommend this kind of breast reconstruction to another woman. In contrast with the predictions of plastic surgeons, patients were most dissatisfied with the nipple-areola reconstruction. CONCLUSIONS: The overall aesthetic result after bilateral prophylactic mastectomy and immediate breast reconstruction with implants was good and symmetrical. Patient satisfaction with nipple-areola reconstruction was only moderate. The results emphasize the importance of a preoperative discussion with the patient regarding whether to keep or reconstruct the nipple-areola complex while planning a prophylactic mastectomy.

Clinical outcome, quality of life, patients' satisfaction, and aesthetic results, after reduction mammaplasty.

Macromastia is a common indication for breast reduction within the public health care system in Sweden. To reduce the waiting time, a project was launched to operate on patients during a three-month period at a local hospital in Stockholm (Nacka Hospital). The operations were done by specialists and residents from the Karolinska University Hospital, using a medial flap technique. The aim of this prospective study was to evaluate the results of this project, focusing on clinical outcome, quality of life, patients' satisfaction, and aesthetic results. Personal and preoperative clinical data and information about risk factors were extracted from the patients' records. At the 6 month follow-up the patients were asked to fill in two questionnaires: "Short Form-36" and another form about patients' satisfaction and sensitivity. Four digital photos taken during the follow-up were graded by three plastic surgeons. Diabetes and oral contraceptives, respectively, were risk factors for infection and delayed wound healing. Patients reported a significantly increased quality of life after six months, regardless of body mass index. Patients were generally more satisfied with the aesthetic outcome than were the surgeons, had satisfactory aesthetic results (89%), acceptable levels of complications (31%), and increased quality of life. The medial flap technique should be evaluated further for its loss of sensitivity.

Wound Complications from the Tsunami Disaster: A Reminder of Indications for Delayed Closure.

OBJECTIVES: To illustrate the character, clinical course and late complications of wounds caused by high energy with severe contamination during a natural disaster, as a basis for designing principles for primary treatment under these conditions. PATIENTS AND METHODS: This paper presents case reports from complicated wounds treated at a specialized unit for wound management in a hospital receiving patients after transfer from primary to definitive treatment. RESULTS: Of the Swedish citizens evacuated from the disaster zone in Thailand after the tsunami disaster in 2004, 174 of those arriving at Stockholm Airport were referred to the Karolinska Hospital for treatment, of whom 75 were admitted. Forty of the patients admitted were seen by the surgeons at the Department of Plastic and Reconstructive Surgery because of complicated wounds requiring special treatment. Fifteen of these could be treated as ambulatory patients and 25 required hospitalization for a mean time of 10.5 days (range 1-48). The majority had multiple injuries, 93% on the lower limbs and 47% on the upper limbs. The majority had been primarily closed at primary treatment. Treatment strategies included removal of all sutures, wound excision, secondary healing (38/40, 95%), delayed primary closure (40/40, 100%), vacuum-assisted closure (VAC) (3/40, 8%), splitthickness skin grafts (23/40, 58%), pedicled perforator flap (1/40, 2%) and free flap (1/40, 2%). Amputation was requested in two cases. Aside from long-lasting psychological sequelae and varying degrees of physical disability, unusual late infections occurred with progressing and migrating abscesses. Cultures and skin biopsies from these revealed both mycobacteria and pigmented fungal hyphae. CONCLUSIONS: The patterns of injury and clinical courses in these patients illustrate the risk of complications in wounds caused by high energy, with severe contamination and which arrive late for primary treatment by staff who are not fully aware of the risk of secondary complications under these conditions. Recommendations for primary treatment should include extensive cleaning, excision of dead tissue and delayed primary closure, according to the well-established principles of management of war wounds, where the conditions are similar.

Long-term sensibility following nonautologous, immediate breast reconstruction.

Immediate breast reconstruction after mastectomy, using submuscular expander prostheses, is well established in the treatment of breast cancer. The aim of this study was to survey the postoperative cutaneous somatosensory status and to analyze the patients' subjective opinion about the sensibility in the reconstructed breast. Fourteen patients were included and examined 3-6 years after reconstruction. The untreated contralateral breast served as control. None of the patients had received any locoregional radiotherapy. The perception thresholds to touch, cold, warmth, and heat pain were assessed and a questionnaire about the patients' subjective experience of sensibility was completed. In the quantitative somatosensory testing, statistically significant impairment concerning all the examined modalities was demonstrated. The least affected was the heat pain modality. In the questionnaire, the patients reported weaker nonmodality specific sensibility from the reconstructed breast compared with the control breast. More than half of the patients reported that the reconstructed breast felt like a real breast. In conclusion, the study revealed long-term, overall sensibility impairment following nonautologous, immediate breast reconstruction.