One-stop autologous breast reconstruction: A safe and effective cost-saving pathway.

INTRODUCTION: Patients undergoing autologous breast reconstruction usually require further operations as part of their reconstructive journey. This involves contralateral breast symmetrization and nipple-areola complex (NAC) reconstruction. Restrained access to elective operating space led us to implement a one-stop breast reconstruction pathway. METHODS: Patients undergoing contemporaneous contralateral breast symmetrization and immediate NAC reconstruction with free nipple grafts between July 2020 and June 2021 were identified. A retrospective review of our prospectively maintained database was conducted, to retrieve surgical notes, postoperative complications, and length of inpatient stay. A cost analysis was performed considering savings from contralateral symmetrization. RESULTS: A total of 50 eligible cases were identified, which had unilateral one-stop breast reconstructions. Complication rates and length of stay were not affected by this approach, with only one free flap being lost for this cohort. This approach resulted in £181,000 being saved for our service over a calendar year. DISCUSSION: A one-stop breast reconstruction pathway has proven to be safe and effective in our unit. During these uncertain times, it has streamlined the management of eligible patients, while releasing capacity for other elective operations. Patients avoid having to wait for secondary procedures, finishing their reconstructive pathway earlier. We plan to continue providing this service which has shown to be beneficial clinically and financially.

A novel algorithm to reduce VTE in peri-operative patients on tamoxifen.

INTRODUCTION: Venous thromboembolism (VTE) is a serious adverse event associated with tamoxifen use, with a 2 to 3-fold increase incidence in users. We aimed to reduce the incidence of venous thromboembolism in patients undergoing breast related surgery by implementing a risk stratifying algorithm for the perioperative management of tamoxifen. METHODS: A retrospective control cohort was compared to a prospective interventional cohort to validate the algorithm which was created by a multidisciplinary team. The algorithm classed patients as low, moderate, high, or very high risk, based on patient factors, and then managed their tamoxifen accordingly during the perioperative period. Each case was then analysed for the presence of a symptomatic, diagnosed venous thromboembolic event up to 60 days post operatively. RESULTS: A total of 446 (n = 446) consecutive patients were analysed between May 2015 and July 2018 with a 3.36% (15/446) incidence of venous thromboembolism. The retrospective arm consisting of 306 cases, not subjected to the algorithm, showed a 4.58% (14/306) event rate while the prospective arm of 140 cases, managed with the algorithm, showed an event rate of 0.71% (1/140). Analysis with Fisher's exact test showed a significant reduction in VTE using the algorithm (p = 0.0447, CI = 0.95). The cessation of tamoxifen was more rationalised (no algorithm-18.1 days, low risk-0.125 days, moderate risk-14.988 days, high risk-29.6 days, very high risk-32.5 days) and stopped for 11.6% fewer days when using the algorithm. CONCLUSION: The use of this algorithm significantly reduces the risk of venous thromboembolism in this population while reducing the number of omitted tamoxifen doses.

The Ideal Nipple Reconstruction Shield.

Reconstruction of the nipple-areola complex is the culmination of a long road for patients who have suffered breast cancer. The postoperative dressing of the reconstructive nipple must protect it from mechanical forces, trauma, and infection. A broad array of dressings has been used for the reconstructed nipple. The authors propose the use of a readily available adhesive eye protector as a simple and cost-effective dressing for the reconstructed nipple-areola complex.

Radiation Therapy and Immediate Breast Reconstruction: Novel Approaches and Evidence Base for Radiation Effects on the Reconstructed Breast.

Patients who undergo breast reconstruction experience higher complication rates if they have had a history of radiotherapy. However, implant-based reconstruction confers significantly higher complication and reconstruction failure rates compared with autologous reconstruction. This article analyses the factors that contribute to the complications of the different breast reconstruction modalities and the strategies described to mitigate these problems.

Incidence of 'Incidentalomas' in over 100 consecutive CT angiograms for preoperative DIEP flap planning.

The gold standard in breast reconstruction is the deep inferior epigastric perforator (DIEP) flaps, although muscle-sparing tranverse rectus abdominis myocutaneous (TRAM) flaps are still being performed due to variations in the abdominal vasculature and to reduce flap complications. Recently, there has been a rise in interest in preoperative imaging, in particular, by means of computer tomography angiogram (CTA). CTA has been shown to delineate the vascular anatomy, improve preoperative decision making and possibly reduce operating time and constitutes a routine preoperative investigation in our unit. Of the 104 consecutive patients who had undergone CTA prior to breast reconstruction, we have found a 13% incidence of unexpected findings or 'incidentalomas' in otherwise asymptomatic women. None were malignant, but changes to the initial operative plan included deferring immediate breast reconstruction, further surgery and further investigations for these incidentalomas. We recommend that all women are counselled of the possibilities of incidentalomas prior to CTA. Furthermore, clinicians need to be receptive to the possibility of a delayed or alternative reconstruction, and closely liaise with other specialties to avoid damage to the deep inferior epigastric vasculature.

Assessment of the reproducibility of facial expressions with 3-D stereophotogrammetry.

OBJECTIVE: There is little research into analyzing whether facial expression changes are secondary to actual treatment or normal day-to-day variation. This study aims to ascertain whether nine-facial expressions were reproducible. SUBJECTS AND METHODS: Thirty-nine white subjects performed nine-facial expressions, captured by three-dimensional stereophotogrammetry in three sessions. After initial capture (session 1), each expression was repeated after 15 minutes (session 2) and then 4 weeks (session 3) after the initial session. Statistical analysis was performed on the mean variability of facial landmarks between session 1 and 2 and session 1 and 3. RESULTS: Repose was the most reproducible expression. The least reproducible was "blow-out-the-cheeks." Analysis between session 1 and 2 showed no significant differences in expression reproducibility. Analysis between session 1 and 3 showed significant differences for the "smile-with-lips-open" and "blow-out-the-cheeks" expressions. CONCLUSION: Facial expressions are reproducible in a 15-minute period. There are significant differences in the ability to reproduce facial expressions 4 weeks apart for "smile-with-lips-open" and "blow-out-the-cheeks."

3D stereophotogrammetry quantitative lip analysis.

BACKGROUND: Reduction in lip volume is a stigmata of the aging face. There are many lip augmentation techniques but very few studies analyzing how these techniques change the three-dimensional structure of the lips. Furthermore, there is no consensus about whether the lip position should be standardized to either the lips closed or parted. The aim of this study was first to obtain a three-dimensional quantitative analysis of the lips in adults and to look for sexual dimorphism and, second, to compare whether more consistent measurements of the oral region can be obtained with the mouth open compared with it closed. METHODS: Seventy young Caucasian volunteers underwent lip dimension analysis using 3D stereophotogrammetry with lips parted and closed. Parameters measured for consistency of results were linear distances (e.g., mouth width, total lip height, upper lip height), surface distances (e.g., upper vermilion), areas (e.g., vermilion upper and lower lip, total vermilion), and volumes (upper and lower lip volume, total lip volume). Analysis also compared lip dimensions between male and female subjects. RESULTS: Consistent and reproducible results were seen with the lips closed compared with lips apart. All lip parameters (distances, areas, and volumes) were larger in men than in women. The following measurements had significant differences between males and females: mouth width, upper lip height median, upper white lip height median, upper white lip height lateral, lower vermilion surface distance, and area of vermilion (p < 0.05). CONCLUSION: We present a novel technique for aesthetic assessment of the lips that is objective and achieves consistency with the lips in the closed position. Males have greater lip dimensions compared with females.

Age- and gravity-related changes in facial morphology: 3-dimensional analysis of facial morphology in mother-daughter pairs.

PURPOSE: There is increasing focus on the effects of gravity and age on facial appearance. Understanding these effects on facial morphology requires an accurate means of measuring surface topography. We present a preliminary study on the changes in facial topographic landmarks in a cohort of mothers and their daughters. MATERIALS AND METHODS: The faces of mother-daughter pairs (N = 15, aged 13 to 61 years) were imaged by stereophotogrammetry in the upright and supine positions. Twenty anthropometric surface landmarks were placed, and the corresponding x, y, and z coordinates were generated with custom software. The relative excursion of each landmark from the upright to the supine position was calculated. RESULTS: Movement of up to 7.3 mm occurred in the horizontal (x) plane, 5.7 mm in the vertical (y) plane, and 7.6 mm in the dorsoventral (z) plane. Significant movement (P < .05) in the vertical plane occurred in the upper lip, lateral canthi, labial commissures, and gonia. There was no significant movement in the dorsoventral plane. Maximal movement occurred in the lower third of the face in both groups but was more marked in the mothers. CONCLUSIONS: Age- and gravity-related effects on the face can be accurately measured and documented with 3-dimensional imaging. This technique will allow comparison of rejuvenation techniques and a better understanding of the mechanisms of facial aging.