Complications in DIEP Flap Breast Reconstruction After Mastectomy for Breast Cancer: A Prospective Cohort Study Comparing Unilateral Versus Bilateral Reconstructions.

BACKGROUND: The demand for bilateral breast reconstructions is rising worldwide. In the UK, approximately 30% of breast cancer patients undergoing mastectomy choose autologous tissue breast reconstruction. Although the deep inferior epigastric perforator (DIEP) flap is gaining popularity, bilateral DIEP flap breast reconstruction remains a complex procedure and reliable outcome data are lacking. In the absence of clinical trials, evidence from cohort studies is needed to better inform clinicians and patients. METHODS: Over a 6-year period, all consecutive patients undergoing DIEP flap breast reconstruction were prospectively included and categorized as unilateral or bilateral reconstruction for comparative analyses of outcomes and complications, with the patient as the unit of analysis. RESULTS: Overall, 565 DIEP flaps were performed on 468 women (371 unilateral and 97 bilateral reconstructions [194 flaps]). Postoperative complications requiring reoperation were twice as likely for bilateral reconstructions (risk ratio [RR] 2.1, 95% CI 1.4-3.4, p = 0.002) and were mainly due to venous congestion (RR 3.1, 95% CI 1.2-7.5, p = 0.011). The risk of total flap loss was six times greater in bilateral reconstruction (RR 6.4, 95% CI 1.6-26, p = 0.011). The rates of revision breast and abdominal surgery were similar between groups. CONCLUSIONS: Both unilateral and bilateral DIEP flap breast reconstructions are safe, with a low risk of complications; however, bilateral reconstruction was associated with a higher risk of complications and total flap loss. This information should be highlighted to patients requesting bilateral breast reconstruction, particularly those requesting risk-reducing mastectomy and reconstruction.

Correction to: Reply to ''Complications in DIEP Flap Breast Reconstruction After Mastectomy for Breast Cancer: A Prospective Cohort Study Comparing Unilateral Versus Bilateral Reconstructions".

In the original article Justin C. R. Wormald's middle initials were incorrect. They are correct as reflected in this erratum. The original article has also been corrected.

DIEP flap rescue by venesection of the superficial epigastric vein.

Microsurgical breast reconstruction with the deep inferior epigastric perforator flap is a technically challenging procedure, where flap survival depends on sufficient arterial input and venous outflow. Rarely, these flaps can become congested because of insufficient venous pathways and dominance of the superficial venous system. We describe a simple technique to allow the rescue of congested flaps by intermittent venesection of the superficial inferior epigastric vein. This relieves the venous congestion in the immediate postoperative period, allowing the flap to develop venous drainage through alternate channels.

Contralateral breast symmetrisation in unilateral DIEP flap breast reconstruction.

INTRODUCTION: Women undergoing unilateral deep inferior epigastric artery perforator (DIEP) flap breast reconstruction may be offered a contralateral symmetrisation either at the time of reconstruction (simultaneous/immediate) or at a later stage (delayed). Simultaneous contralateral breast symmetrisation may be more beneficial to patients and healthcare institutions by avoiding staged surgery, although there is limited evidence on which to base practice. This deficit formed the rationale for our study. The primary outcome was the overall rate of revision surgery. METHODS: Over a 6-year period, this prospective cohort study recorded the demographics, cancer treatments and operative outcomes of all consecutive unilateral DIEP flap breast reconstructions with or without contralateral symmetrising surgery. Patients were categorised into three groups: (1) simultaneous symmetrisation, 2) delayed symmetrisation and (3) no symmetrisation for comparative analysis. RESULTS: During the study period, 371 women underwent unilateral DIEP flap breast reconstruction 194 (52.3%) were not symmetrised, 155 (41.8%) were simultaneously symmetrised and 22 (5.9%) underwent delayed symmetrisation. Simultaneous symmetrisation of the contralateral breast and unilateral DIEP flap breast reconstruction increased the mean total operative time by 28 min. There were no differences in the rates of peri-operative complications. There were significantly higher rates of all-cause revision surgery (OR 3.97 [1.58, 9.94], p = 0.003) in women undergoing delayed symmetrisation, because of higher rates of revision lipomodelling, scar revision and revision contralateral symmetrisation. CONCLUSION: Simultaneous contralateral breast symmetrisation was associated with a lower risk of all-cause revision surgery. It is safe, beneficial and likely to be more cost-effective for women undergoing unilateral free DIEP flap breast reconstruction.

Dysregulated expression of adamalysin-thrombospondin genes in human breast carcinoma.

The adamalysin-thrombospondin (ADAMTS) proteinases are a relatively newly described branch of the metzincin family that contain metalloproteinase, disintegrin, and thrombospondin motifs. They have been implicated in various cellular events, including cleavage of proteoglycans, extracellular matrix degradation, inhibition of angiogenesis, gonadal development, and organogenesis. However, in many cases, their normal physiological roles and their potential for dysregulation in malignancy remain to be established. The expression profile of ADAMTS1-20 in human breast carcinoma was undertaken by real-time PCR using RNA isolated from malignant tumors, nonneoplastic mammary tissue, and breast cancer cell lines to identify altered regulation that may have potential pathogenetic and prognostic significance. Our studies show that seven of the ADAMTS genes (ADAMTS1, 3, 5, 8, 9, 10, and 18) are consistently down-regulated in breast carcinomas with respect to nonneoplastic mammary tissue, irrespective of the heterogeneity of the samples and the tumor type or grade (Mann-Whitney U test, P < 0.0001 for each gene). Conversely, ADAMTS4, 6, 14, and 20 are consistently up-regulated in breast carcinomas (P = 0.005, P < 0.0001, P = 0.003, and P = 0.001, respectively). ADAMTS2, 7, 12, 13, 15, 16, 17, and 19 show no significant difference between the sample types. ADAMTS1, 2, 7, 8, 10, and 12 are expressed predominantly in stromal fibroblasts. ADAMTS3, 4, 5, 6, 9, and 13-20 inclusive are expressed predominantly in myoepithelial cells; all appear to be relatively poorly expressed in luminal epithelial cells. ADAMTS15 has emerged as being an independent predictor of survival, with RNA expression levels significantly lower (P = 0.007) in grade 3 breast carcinoma compared with grade 1 and 2 breast carcinoma.

Acute radial artery ischemia following therapeutic steroid injection.

Intra-arterial corticosteroid injection at the wrist can have devastating consequences. Anatomic arterial variation of the hand can lead to atypical presentation. A careful history and examination, with appropriate investigations, can lead to an accurate diagnosis in such difficult cases.

A prospective comparison of spectrophotometric intracutaneous analysis to clinical judgment in the diagnosis of nonmelanoma skin cancer.

INTRODUCTION: Research indicates that spectrophotometric intracutaneous analysis (SIAscopy) may be a useful adjunct in nonmelanoma skin cancer (NMSC) diagnosis. A study was performed to prospectively assess the accuracy of NMSC diagnosis by the SIAscope as compared with a clinician. METHODS: Prior to excision, 323 consecutive lesions were examined and diagnosed by a clinician. SIAgraphs were then taken of the lesions and examined blindly at a later date. Diagnostic accuracy for the clinician and SIAscope was compared between the clinician and SIAscope and to histology. RESULTS: Sensitivity, specificity, positive and negative predictive values for clinical diagnoses were 95.6%, 75.8%, 0.79, and 0.95, respectively. Results for SIA diagnoses were 97.5%, 86.7%, 0.88, and 0.97. Statistical comparison revealed comparable sensitivities for the 2 groups but significantly better specificity for the SIAscope at the 95% confidence level. CONCLUSION: This study indicates that the SIAscope may be useful in NMSC diagnosis, with accuracies comparable to a clinician.