Higher reconstruction failure and less patient-reported satisfaction after post mastectomy radiotherapy with immediate implant-based breast reconstruction compared to immediate autologous breast reconstruction.

PURPOSE: To improve shared decision making, clinical- and patient-reported outcomes between immediate implant-based and autologous breast reconstruction followed by postmastectomy radiotherapy (PMRT) were compared. METHODS: All women with in situ and/or invasive breast cancer who underwent skin sparing mastectomy with immediate breast reconstruction (IBR) (autologous- or implant based, one- or two staged) followed by PMRT in the Utrecht region between 2012 and 2016 were selected from the Netherlands Cancer Registry, of which 112 (59%) agreed to participate. The primary outcome was reconstruction failure after the start of radiotherapy, and secondary outcomes were patient-reported outcomes measured with BREAST-Q. RESULTS: 109 patients underwent skin-sparing mastectomy, of which 29 (27%) underwent immediate autologous reconstruction and 80 (73%) received immediate implant-based reconstruction. After PMRT, reconstruction failure occurred in 17 patients (21%) with implant-based reconstruction, while no failure was seen in the autologous group (p = 0.04). Mean patient-reported 'Satisfaction with Breasts' (50.9 vs. 63.7, p = 0.001) and 'Sexual Well-being' (46.0 vs. 55.5, p = 0.037) were lower after implant-based reconstruction compared to autologous reconstruction. Thirteen patients with autologous flaps underwent surgical cosmetic corrections compared to ten patients in the implant group (45 vs. 13%, p = 0.001). IBR and PMRT in this study resulted in a high rate of severe capsular contraction in implant-based reconstruction (16.9%) and fibrosis in autologous reconstruction (13.8%). CONCLUSIONS: Patients treated with PMRT and one or two stage immediate implant-based reconstruction were at greater risk of developing reconstruction failure and were less satisfied when compared to one or two stage immediate autologous reconstruction. Since fairly high complication rates in both reconstruction methods after PMRT are observed, it raises the question whether immediate breast reconstruction should be considered at all when PMRT is indicated. Patients considering or potential candidates for IBR should be informed about the consequences of PMRT and especially when opting for autologous reconstruction one should possibly perform reconstruction in a secondary setting.

[A giant pseudocyst following repair of an incisional hernia by a propylene mesh]. / Een reuzenpseudocyste na correctie van een hernia cicatricalis met een propyleenmat.

A 79-year-old woman presented with a huge, asymptomatic, balloon-like abdomen, which gradually developed after polypropylene mesh repair of an incisional hernia following a median laparotomy. Additional CT showed a huge cyst measuring 20 x 24 cm which seemed to originate from the anterior abdominal wall and lacked communication with the inner abdominal space. Subsequently an explorative laparotomy was performed. The content of the cyst consisted of dark brown serosanguineous material. The inferior portion was firmly affixed to the mesh. The entire cyst, except for the part fixed to the mesh, was excised followed by an abdominoplasty. Histological examination showed aspecific signs of inflammation due to a foreign body, and haemorrhagic material without epithelial lining. The diagnosis 'giant pseudocyst' was established. Etiologically, this condition is probably related to postoperative formation of a seroma, which is a well-known complication after mesh repair, especially when a polypropylene mesh is used. Postoperative formation of a haematoma might be a causative factor as well. Former literature reports 11 cases of such giant cyst formation after mesh repair ofhernias. In one study a prevalence of 0.45% is mentioned. This complication may be an underreported phenomenon.

Hemispheric specialization in children as reflected in the longitudinal development of ear asymmetry.

The longitudinal development of ear asymmetry has been investigated in two samples of kindergarten and primary school children over an age range of six years. Ear preference in a dichotic digit test, administered four times, did not appear to be affected by age and sex: right ear advantage was predominant at all times. Individual comparison showed the development of ear advantage to depend on initial preference. Initially left eared subjects when changing ear advantage do so from left to right at early and from right to left at later school ages. The left-right shift may be due to the school teaching of linguistic skills which could selectively activate the left cerebral hemisphere. This explanation is supported by the finding that initially right eared subjects tended to conserve that preference at early school ages. Acknowledgements. We would like to thank Mr. P. Borgman and his staff of the Johannesschool in Amsterdam as well as their pupils who did not protest despite being examined year after year. The cooperation of the Free University Audio-Visual Center (Mr. Fred Van Hilst) is kindly acknowledged. Finally we would like to thank Dr. Paul Harris who was willing to read the English text critically and all others who assisted in the completion of this research.