Anisometric Cell and Dysplastic Lipomas in a Retinoblastoma Patient.

Anisometric cell lipoma (ACL) and dysplastic lipoma (DL) are underrecognized subtypes of benign lipomatous tumors, with wide variation in cell size, microscopic fat necrosis, and no or mild nuclear changes (DL). ACL/DL appear more commonly in retinoblastoma patients, in whom an increased incidence of lipomas has been established. The occurrence of ACL/DL in retinoblastoma patients suggests that RB1 aberrations play a role in its pathogenesis, similar to spindle cell/pleomorphic lipoma. In this article, we present a patient with a history of retinoblastoma with multiple lipomas histologically consistent with ACL/DL. Analysis of the lipomas supports involvement of RB1 in the development of ACL/DL. Dysplastic changes were only seen in a single lipoma, which harbored an additional TP53 mutation. While providing further support for the occurrence of ACL/DL in retinoblastoma patients, we also suggest that DL is an ACL with TP53 mutation.

Improving outcomes in microsurgical breast reconstruction: lessons learnt from 406 consecutive DIEP/TRAM flaps performed by a single surgeon.

BACKGROUND: Multiple preoperative, intraoperative and postoperative decisions can influence the outcome of microsurgical breast reconstruction. We have simplified the decision-making process by incorporating a number of algorithms into our microsurgical breast reconstruction practice and critically review our results in this study. METHODS: Prospectively maintained databases for all microsurgical breast reconstructions performed by a single surgeon over a nine-year period were examined to determine: patient demographics; operative details including flap choice, donor and recipient vessel selection; and, details of intraoperative and early postoperative (

Pulmonary embolism after abdominal flap breast reconstruction: prediction and prevention.

BACKGROUND: Symptomatic pulmonary embolism constitutes a significant risk following abdominal flap breast reconstruction. Reported rates vary from 0 to 6 percent. The authors assessed risk factors associated with symptomatic pulmonary embolism and constructed a prediction model to identify high-risk patients. METHODS: Patients undergoing deep inferior epigastric perforator or transverse rectus abdominis musculocutaneous flap breast reconstructions at two academic centers from January of 2005 through January of 2011 were included. Thromboprophylaxis measures included early ambulation, low-molecular-weight heparin, elastic stockings, A-V Impulse System foot pumps, and pneumatic stockings. Risk factors for symptomatic pulmonary embolism were analyzed and weights were assigned to these risk factors. Sensitivity and specificity were maximized using receiver operating characteristic curves. RESULTS: Of 430 consecutive patients, symptomatic pulmonary embolism occurred in 17 cases (4.0 percent). Two independent predictors for symptomatic pulmonary embolism were found, body mass index higher than 25, additionally higher than 28, and the BRCA gene mutation. Operation duration and bilaterality of reconstructions were dependent on the BRCA mutation and both indirect predictors for symptomatic pulmonary embolism. Optimization of sensitivity and specificity resulted in a prediction model. No significant differences in efficacy were found between the different thromboprophylaxis measures. CONCLUSIONS: The rate of symptomatic pulmonary embolism was 4.0 percent, despite standard thromboprophylaxis. Body mass index and BRCA were significant predictors for symptomatic pulmonary embolism. The authors integrated these factors into a prediction model, which provides a useful tool for identification of high-risk patients. This latter category may benefit from a more aggressive thromboprophylaxis approach. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Patients' preferences for breast reconstruction: a discrete choice experiment.

BACKGROUND: Patients' preferences are important determinants in the decision for a specific type of breast reconstruction (BR). Understanding their considerations in the decision for a specific type of BR can contribute to further improvement in patient counselling. We explored patients' preferences for three BR modalities in a discrete choice experiment (DCE). METHODS: We approached 386 patients who had previously undergone a therapeutic (n=309) or prophylactic (n=79) mastectomy, of whom 247 had also undergone a BR. These women were asked to choose between hypothetical BR profiles that were characterised by six treatment attributes: (1) material used for reconstruction, (2) number and duration of operations, (3) short-term complication rate, (4) long-term complication rate, (5) aesthetic result and (6) waiting time. The relative importance of attributes and trade-offs that the patients were willing to make among them were analysed using a multinomial logit regression model. RESULTS: The overall response rate was 71%. All treatment characteristics proved important for patients to make their choices. Respondents generally expressed a preference for autologous material and an excellent aesthetic result, which had the biggest positive effect on preferences. Complication rates of 20-30% had a similar negative effect. In this DCE, autologous free flap BR fitted in best with patients' preferences. CONCLUSIONS: Our study provides insight into the relative weight patients place on various aspects of BR and trade-offs they make among BR characteristics. In addition to understanding patients' considerations, professional assessment of the technical feasibility, acceptable risks and obtainable aesthetic result of different techniques will always remain crucial in deciding which technique is best suited for an individual patient.

Surgical results, aesthetic outcome, and patient satisfaction after microsurgical autologous breast reconstruction following failed implant reconstruction.

BACKGROUND: The majority of breast reconstructions are performed using implant material. Implants have some major long-term disadvantages. Long-term implant-related complications and improved microsurgical techniques have led to an increased number of women requesting conversion of their implant breast reconstruction to autologous breast reconstruction. The aim of this study was to evaluate surgical and aesthetic outcome and patient satisfaction after tertiary autologous breast reconstruction. METHODS: Between 2001 and 2007, 42 women underwent 61 tertiary autologous breast reconstructions. Surgical outcome and complications were evaluated. Patient satisfaction was assessed using a study-specific questionnaire. Aesthetic result was rated by an expert panel using standardized photographs. RESULTS: Forty-seven deep inferior epigastric artery perforator, 10 mini-transverse rectus abdominis musculocutaneous, and four transverse musculocutaneous gracilis flaps were performed. Eight patients required reoperation because of complications (19 percent). Total flap loss did not occur. Nineteen patients underwent one or more additional operations to improve aesthetic outcome. Physical discomfort caused by implants and dissatisfaction with the aesthetic result were the main patient motivations to opt for autologous breast reconstruction. Reduction or disappearance of physical discomfort was noted in the vast majority of patients. Most patients were very satisfied with the aesthetic result (mean, 8 of 10), but the mean panel satisfaction score was lower (7 of 10). However, the panel noted a significant improvement of the aesthetic result after conversion to autologous breast reconstruction (from 5 of 10 to 7 of 10). CONCLUSION: Autologous breast reconstruction after failed implant reconstruction is a technically feasible and reliable procedure that leads to improved physical condition and aesthetic results and a high degree of patient satisfaction.

High satisfaction rates in women after DIEP flap breast reconstruction.

BACKGROUND: Breast reconstruction (BR) is aimed at improving quality of life (QoL) after mastectomy. Patient satisfaction is an important indicator to evaluate the success of BR. This study explored patient satisfaction and its determinants in women undergoing deep inferior epigastric artery perforator (DIEP) flap BR as well as the impact of the procedure on body image, sexuality and QoL. METHODS: Patient satisfaction and QoL were studied in 72 women who underwent DIEP flap BR using a study-specific questionnaire as well as the Short Form-36 (SF-36). RESULTS: Patient satisfaction was very high. Approximately 90% of the patients reported that they had been sufficiently informed about the procedure and its consequences, that their preoperative expectations had been met, that the reconstructed breast felt like their own and that they would choose the same procedure again and would recommend this procedure to a friend. Patient satisfaction was positively and significantly related to the reconstructed breast(s) feeling like their own. Women with secondary reconstructions were more positive about changes in sexuality and femininity than women with primary BRs. There were no clinically relevant differences in QoL between our study population and a random sample of Dutch females. CONCLUSIONS: Women with DIEP flap BRs reported high satisfaction rates. However, to compare these satisfaction rates with other forms of BR, prospective studies in comparable groups are necessary.

A critical review of perioperative complications in 175 free deep inferior epigastric perforator flap breast reconstructions.

BACKGROUND: The purpose of this study was to critically evaluate the perioperative complications for deep inferior epigastric perforator (DIEP) flap breast reconstruction. METHODS: From February 2002 until February 2006, 175 consecutive abdominal free tissue breast reconstructions were performed in 131 patients. Perioperative risk factors and complications were evaluated for the entire group. Data analysis was performed to compare subsequent chronologic groups for a learning curve effect. RESULTS: In 159 cases (90.9%) a DIEP flap could be raised. In 13 cases (7.4%), a mini-TRAM flap and in 3 cases (1.7%) a regular free TRAM flap was harvested. A learning curve was found showing a risk for flap complications in the first 30 DIEP flaps of 40% and in flaps 31 to 175 of 13.8% (P < 0.012). Microsurgical revision rate was 4% (n = 7), with a total flap failure rate of 0.6% (n = 1). Partial flap failure rate was 8.6% (n = 15), which was solved by debridement, medial advancement, and direct closure in 6.8% (n = 12) and latissimus dorsi flap transposition in 1.8% (n = 3). Multivariate analysis showed no significant influence of risk factors on development of postoperative flap complications. CONCLUSION: DIEP flap breast reconstruction is an excellent method, with limited donor-site morbidity. A definite learning curve was reflected in a larger number of flap complications in the beginning of our series.