Trends in Post-Mastectomy Reconstruction in an Asian Population: A 12-Year Institutional Review.

Post-mastectomy breast reconstruction is an integral component of breast cancer treatment. It is often perceived that women in Asian countries have a lower rate of post-mastectomy reconstruction than Western populations. This study describes trends in timing and types of breast reconstruction performed in the largest healthcare provider in Singapore, over a period of 12 years. It also reports on the oncological outcomes and surgical safety. A retrospective review of all patients who underwent post-mastectomy reconstruction from January 2001 to December 2012 at the National Cancer Centre Singapore and Singapore General Hospital was performed. Six hundred and twenty post-mastectomy reconstructions were performed in 579 patients. The proportion of reconstructions increased from 4% in 2001 to 18% in 2012. Younger patients (<50 years old) and those with early stage cancer were more likely to undergo reconstruction. Immediate breast reconstruction was favored by more than 90% of patients. Postoperatively, 9% developed acute surgical complications that were treated surgically; 6% had additional surgery for late complications. Only 4% had delay of adjuvant chemotherapy. At median follow-up of 63 months (range 3-166), loco-regional recurrence was 4%, and distant metastases 8%. Post-mastectomy reconstruction for breast cancer is increasingly performed in our institution. Both younger age and lower stage disease were associated with choice for reconstruction in our study. Low rates of delay to adjuvant therapy were noted, and it may safely be offered to suitable women undergoing mastectomy.

Traumatic lower limb injury and microsurgical free flap reconstruction with the use of negative pressure wound therapy: is timing crucial?

BACKGROUND: The timing of microsurgical free flap reconstruction for traumatic lower limb injury has been described as being optimal if conducted within the early period following injury, as higher rates of infection and flap loss were reported in the subsequent time period. However, for various reasons, reconstruction of these defects may be delayed. The aim of this article is to show that adequate debridement, negative pressure wound dressing, and sound reconstructive principles has led to increased free flap success rates regardless of the period between injury and reconstruction. PATIENTS AND METHODS: A 10-year retrospective single-center analysis of 50 traumatic lower limb cases from 2002 to 2012 was conducted. All patients had microsurgical free flap reconstruction after a period of negative pressure wound therapy (NPWT). Patient factors and reconstructive methods were analyzed and outcomes were compared. RESULTS: Mean interval between admission and free flap coverage was 17.5 days, and patients underwent NPWT for an average of 12 days (range, 1-35). Approximately 8% of patients had postoperative infections. Overall free flap success rate was 96%. Approximately 90% of patients were able to return to their premorbid footwear, with 96% able to mobilize independently approaching the end of their follow-up period. CONCLUSION: Our study shows that traumatic lower limb reconstruction in the delayed period is no longer associated with high rates of flap failure. Improvements in microsurgery and the advent of NPWT have made timing no longer crucial in free flap coverage of traumatic lower limb injuries.

Decellularized porcine saphenous artery for small-diameter tissue-engineered conduit graft.

Decellularized xenografts have been identified as potential scaffolds for small-diameter vascular substitutes. This study aimed to develop and investigate a biomechanically functional and biocompatible acellular conduit using decellularized porcine saphenous arteries (DPSAs), through a modified decellularization process using Triton X-100/NH4 OH solution and serum-containing medium. Histological and biochemical analysis indicated a high degree of cellular removal and preservation of the extracellular matrix. Bursting pressure tests showed that the DPSAs could withstand a pressure of 1854 ± 164 mm Hg. Assessment of in vitro cell adhesion and biocompatibility showed that porcine pulmonary artery endothelial cells were able to adhere and proliferate on DPSAs in static and rotational culture. After interposition into rabbit carotid arteries in vivo, DPSAs showed patency rates of 60% at 1 month and 50% at 3 months. No aneurysm and intimal hyperplasia were observed in any DPSAs. All patent grafts showed regeneration of vascular elements, and thrombotic occlusion was found to be the main cause of graft failure, probably due to remaining xenoantigens. In conclusion, this study showed the development and evaluation of a decellularization process with the potential to be used as small-diameter grafts.

Revisiting vascular supply of the rectus femoris and its relevance in the harvest of the anterolateral thigh flap.

INTRODUCTION: The anterolateral thigh flap is one of the commonest soft tissue flap performed today. The rectus femoris is dominantly supplied by the vascular pedicle which takes off from the same source artery that is harvested with the anterolateral thigh flap. Therefore, the blood supply of the rectus femoris may potentially be compromised when harvesting the anterolateral thigh flap. This study revisits the blood supply of the rectus femoris in the light of recent advances in the understanding of the vascular anatomy of the anterolateral thigh. MATERIALS AND METHODS: From January 2010 to June 2011, a prospective intraoperative observational study was performed in 50 consecutive anterolateral thigh flaps, noting the dimensions and locations of (1) the descending branch, (2) the presence of the oblique branch of the lateral circumflex femoral artery, and (3) the number and size of the muscle branches supplying the rectus femoris. Temporary selective occlusion with microvascular clamps was performed to evaluate the dominance of the blood supply to the muscle. Flap harvest was then completed as planned. RESULTS: The oblique branch was noted to be present in 23 (46%) of 50 patients. Of these, 21 (91%) of 23 of oblique branches supplied a large muscle branch to the rectus femoris. When the descending branch alone was present, occluding the dominant pedicle will usually compromise the blood supply to the muscle. In situations where 2 large muscle branches arise from the descending and oblique branches, occlusion of either pedicle did not affect the circulation of the rectus femoris, demonstrating codominance in this situation. CONCLUSIONS: The vascularity of the rectus femoris can be classified as either a type A or B. Type A rectus femoris is the classic pattern with a single dominant pedicle from the descending branch. Type B rectus femoris is seen when an oblique branch supplies a codominant pedicle to the muscle. The implication of this anatomy is that in a type B rectus femoris, one of the 2 muscle branches can be safely ligated to increase the pedicle length when harvesting of the anterolateral thigh flap, without compromising the vascularity of the muscle.

The anterolateral thigh perforator flap for reconstruction of knee defects.

INTRODUCTION: Large defects around the knee remain challenging reconstructive problems. We report our experience with the use of the anterolateral thigh perforator flap for various defects in this area, based on the anatomy seen intraoperatively. METHODS AND MATERIALS: Eight knee defects were reconstructed with the anterolateral thigh flap in accordance with our algorithm. Of them, 6 were performed as pedicled flaps and 2 as free flaps. For the pedicled flaps, 1 patient was reconstructed with an anterolateral thigh rotation flap, 3 patients with a directly transposed distally based anterolateral thigh flap, 2 patients with a "propeller" distally based anterolateral thigh flap. In the 2 patients reconstructed with the free anterolateral thigh flaps, the intramuscular part of the descending branch of the lateral circumflex femoral artery was used as the recipient vessel. RESULTS: Reconstruction was successfully performed in all patients. Defects limited to the patella and above can be covered by antegrade anterolateral thigh rotation flaps. For larger defects, the distally based flap is needed. This can be used in cases where the perforators arise from the descending branch of the lateral circumflex femoral artery, either as a direct advancement or propeller flaps. In cases where the perforators are not usable or arises from the oblique branch of the lateral circumflex femoral artery, reconstruction was completed as a free flap. In such instances, the distal descending branch provides a reliable recipient vessel. CONCLUSION: The anterolateral thigh flap offers a versatile and reliable option for defects around the knee. Its use requires a certain degree of reconstructive flexibility as the anatomic variations of the flap may require the flap to be transferred as a free flap in some cases.

A rare case of extensive aplasia cutis congenita: Our surgical approach.

Aplasia cutis congenita (ACC) is a rare disorder resulting in the absence of skin or deeper layers, most often involving an isolated small area on the scalp. However, extensive cutis aplasia involving multiple large critical areas of the body is extremely uncommon and remains a challenging condition to manage. Initial concerns involve early mortality from excessive moisture loss, hypothermia, bleeding, sepsis, and brain herniation while subsequent sequelae from delayed wound healing resulting in scarring and loss of function also provide numerous management dilemmas. Conservative treatment with dressings, which typically allows epithelisation in small cases, is inadequate. Surgical approaches described such as skin grafts and rotational flaps are also insufficient in extensive ACC involving the chest and entire scalp. In this article, we present how our centre successfully treated a patient with a large total body surface area of ACC involving the entire scalp, neck, forehead, chest, trunk, lateral flanks, and patchy areas of all four limbs.

Preferred use of the ipsilateral pedicled TRAM flap for immediate breast reconstruction: an illustrated approach.

BACKGROUND: Recent experience with the ipsilateral TRAM flap has shown that it has the advantage of a longer functional pedicle length, which allows tension-free inset of well-vascularized tissue into the breast pocket. This leads to better positioning and shaping of the reconstructed breast with minimal disruption of the inframammary fold. The purpose of this article was to provide an illustrated approach to the ipsilateral TRAM flap and to clarify the technique when applied in the context of immediate breast reconstruction following cancer extirpation. METHODS: A prospective evaluation of 89 patients who underwent immediate breast reconstruction following skin-sparing mastectomy for breast cancer was performed. All patients underwent ipsilateral TRAM reconstruction. The innate insetting advantage of the ipsilateral TRAM flap is illustrated in the article. The key steps of the technique were as follows: (1) The ipsilateral corner of the flap was used as the axillary tail, leaving the more bulky part to form the main body of the breast; (2) To avoid undesirable twists, a right TRAM was rotated clockwise so that its apex points superiorly; (3) This flap was subsequently tunneled into the breast pocket while preserving the inframammary fold. The opposite maneuvers were done for the left side; (4) If the flap was congested, venous augmentation was performed where the tributary of the axillary vein or the thoracodorsal vein was anastomosed with the inferior epigastric vein from the flap with an interposed vein graft (17% of cases). RESULTS: All flaps survived and flap-related complications included partial necrosis of tissue across the midline (2.2%), palpable fat necrosis (22%), and hematoma requiring drainage (2.2%). All flaps were raised concurrent with the resection, and the combined operative time ranged from 3.5 to 6 h, with a mean hospital stay of 7 days. CONCLUSION: The ipsilateral TRAM flap was a reliable flap with low complication rates and short surgery time. It was our preferred choice for pedicled breast reconstruction in all cases, except for the ptotic breast or if abdominal scarring excludes its use.

Challenges in the management of extensive aplasia cutis congenita.

Aplasia cutis congenita (ACC) is a rare group of congenital disorders characterised by focal or widespread absence of skin, predominantly affecting the scalp. A Malay female infant was born at 37 weeks with extensive ACC, affecting 37% of total body surface area, including her scalp and trunk. There is no consensus on the management of ACC given the rarity and variable presentation. A multi-disciplinary team comprising neonatologists, paediatric dermatologists, plastic surgeons and medical laboratory scientists at the skin bank, employed a more aggressive surgical approach with the aim of avoiding potentially catastrophic morbidity, including sagittal sinus haemorrhage and brain herniation. Out of several surgical options, the team used a staged artificial dermal matrix (Integra) and cultured epithelial autograft application, followed by regular wound dressing, and eventually allowed the child to achieve complete epithelialisation of her trunk, and most of scalp before she was discharged from hospital.

Large unilateral breast autoinflation after breastfeeding linked to polyacrylamide hydrogel injection augmentation mammaplasty.

Augmentation mammaplasty using polyacrylamide hydrogel (PAAG) injection is associated with myriad complications. A patient treated by the authors had bilateral breast augmentation with PAAG injection and experienced large unilateral right breast autoinflation after breastfeeding, which required surgical clearance of a likely galactocele or sterile pus collection that resulted in deformity. Patients with PAAG filler injection-augmented breasts should avoid breastfeeding. The authors recommend against using PAAG injection for augmentation mammaplasty, especially in women intending to breastfeed. Physicians and patients must be aware of the complications associated with PAAG before gel administration.

Serratus anterior venous tributary as a second outflow vein in latissimus dorsi free flaps.

The latissimus dorsi (LD) flap is a large and reliable myocutaneous flap with a consistently long vascular pedicle. However, the limitation of the thoracodorsal pedicle is that it has only one draining vein for anastomosis. We describe a simple technique of recruiting the tributary vein to the serratus anterior and using it as a second draining vein to alleviate congestion in lower limb reconstruction. The serratus anterior venous tributary segment is cut back to an avalvular segment which averages 5 mm in length. Provision of an additional venous outflow to the flap enabled a second venous anastomosis to the short saphenous vein (N = 1), the long saphenous vein (N = 2), a deep vein (N= 1), and to a deep vein via a vein graft (N = 1), respectively. Five patients with degloving injury of the lower extremity of sizes 150 cm(2) (10 × 15 cm) to 260 cm(2) (10 × 26 cm) underwent successful reconstruction using the LD muscle flap with the serratus anterior tributary vein as a second outflow vein. This serratus anterior venous tributary serves as a useful second outflow channel for alleviating venous congestion during lower limb reconstructive surgery and should be routinely preserved as a lifeboat.

Modifications of the radial forearm flap phalloplasty for female-to-male gender reassignment.

The radial forearm flap remains the preferred technique for phalloplasty. From 1999 to 2009, 19 patients with primary female transsexualism underwent gender reassignment surgery at our center. The radial forearm flap phalloplasty is modified as a two-stage procedure, with prelamination of the neourethra on the donor forearm before microsurgical transfer 3 months later. At 5-year follow-up, patients were asked to complete a survey on the functional, aesthetic, and psychological results postsurgery. The radial forearm flap reliably provided sufficient bulk with stiffness for the neophallus with acceptable aesthetic appearance. We further describe technical modifications to reduce the rate of urethral strictures and fistulas. None of the patients regretted undergoing gender transformation. Patients are satisfied with the surgical result and generally prepared to accept its potential costs, in view of the significant psychological and legal benefits.

An algorithm for recipient vessel selection in microsurgical head and neck reconstruction.

This article details an algorithm we used for selection of recipient vessels in free tissue transfer to the head and neck. Eighty-eight consecutive free flaps to the head and neck were performed in 85 patients. The superior thyroid was the commonest recipient artery used (61%). The facial artery, used in 14% of our cases, is the choice vessel in instances where neck dissection is not performed. In these cases, we have to access the neck separately for recipient vessels and it can be exposed easily via a short (3-cm) incision. The superficial temporal artery (11%) is our choice vessel for patients with previous neck dissection or radiotherapy as it is well outside the previous operative or irradiated field. Other vessels such as the transverse cervical and end-to-side anastomosis to the carotid artery were also used when appropriate. Recipient vein selection depends primarily on the selected artery. Corresponding veins and large branches of the internal jugular vein (IJV) in the vicinity of the selected artery are preferred. When these are exhausted, the external jugular vein and end-to-side anastomosis to the IJV are considered. We found this algorithm to be reliable in identifying the appropriate vessels in all cases.

Scar Assessment Tools: How Do They Compare?

Healing after dermal injury is a complex but imperfect process that results in a wide range of visible scars. The degree of disfigurement is not the sole determinant of a scar's effect on patient well-being, with a number of other factors being critical to outcome. These include cosmetic appearance, symptoms such as itch and pain, functional loss, psychological or social problems, and quality of life. An accurate assessment of these domains can help clinicians measure outcomes, develop, and evaluate treatment strategies. A PubMed literature search was performed up to 31st March 2020. Ten objective scar measurements, four Clinician-Reported Outcome Measures (CROMs), six Patient-Reported Outcome Measures (PROMs), and one combined measure were evaluated for their reliability, clinical relevance, responsiveness to clinical change, and feasibility. Many quantitative tools were limited in their clinical relevance and feasibility, whereas few qualitative CROMs and PROMs have undergone rigorous assessment. This review examines currently available assessment tools, focusing primarily on subjective scar measurements (CROMs, PROMs), and offers a perspective on future directions in the field.

A treatment strategy for postburn neck reconstruction: emphasizing the functional and aesthetic importance of the cervicomental angle.

The authors describe an algorithm for reconstruction of both the soft tissue and skeletal components of severe postburn neck deformities. The critical functional and aesthetic importance of the cervicomental angle is emphasized. The neck is subdivided into 3 anatomic subunits: (1) lower lip/chin subunit, (2) submental subunit, and (3) anterior neck subunit. After release of contractures, platysmaplasty is performed to prevent recurrence and to deepen the cervicomental angle. In cases where chin retrusion is present, sliding genioplasty is performed. The 3 subunits are resurfaced individually by skin grafts and free flaps. The combined scapular and parascapular bilobed free flap is an ideal flap for cases involving 2 subunits. Fifty patients with severe postburns neck contractures were treated. After excision and release of scar, 47 (94%) patients underwent platysmaplasty, and 12 (24%) patients underwent sliding genioplasty. Defects were covered with skin grafts alone in 20 (40%) patients, with free flaps only in 22 (44%) patients, and with a combination of skin grafts and free flaps in 8 (16%) patients.

Connexin 43 upregulation in burns promotes burn conversion through spread of apoptotic death signals.

BACKGROUND: Burn wounds continue to worsen after initial injury in a process known as burn conversion, which lasts about 3-5 days. It causes burn wounds to enlarge and deepen, leading to greater morbidity. Apoptosis is one of the factors contributing to the conversion of the zone of stasis into the zone of coagulation. Suppression of apoptosis has been associated with reducing burn conversion. Connexin 43 (Cx43) gap junctions facilitate the spread of apoptotic signals from dying cells to healthy neighbouring cells in injured tissues through the bystander effect. OBJECTIVES: The study is to understand the role of Cx43 in burn conversion. METHODS: In our study, 15 burn tissue samples were arranged into three groups as early (beginning of burn conversion), intermediate (extensive burn conversion) and late (established burn conversion) burns. RESULTS: We found a striking increase in the amount of Cx43 protein expressed in the dermal fibroblasts (identified with heat shock protein 47 (HSP47) staining) in the zone of stasis in early and intermediate burns. These dermal fibroblasts also express high levels of cleaved-Caspase 3 indicating on-going apoptosis. CONCLUSIONS: Our findings suggest that elevation of Cx43 may play an active role in burn conversion spreading apoptosis in the early and intermediate burn wound.

Surgical and oncological safety of nipple-sparing mastectomy in an Asian population.

BACKGROUND: Nipple-sparing mastectomy (NSM) allows for excellent postmastectomy reconstruction aesthetics and is used for both therapeutic and risk-reducing purposes. Reservations regarding the potential for locoregional recurrence and concerns about nipple-areolar complex (NAC) necrosis remain amongst many surgeons. We review the surgical and oncological outcomes after NSM in our institution. METHODS: All NSM cases at the National Cancer Centre Singapore and Singapore General Hospital between 2005 and 2015 were reviewed. Tumour characteristics, reconstruction methods, surgical and oncological outcomes are described. RESULTS: A total of 139 NSMs were performed for 130 patients. The median age was 46 years (range 21-66). The use of NSM increased from 2% of all breast reconstructions in 2005 to 37% in 2015. The majority (n = 119; 86%) were for cancer treatment and 20 (14%) for risk-reducing purposes. Among those performed for cancer, patients mainly had early stage breast cancer (n = 106, 89%). Autologous reconstruction (n = 111, 80%) was most common. Early complications requiring surgical intervention occurred in 24 (17%) NSMs, including 9 partial/complete flap loss and 2 complete NAC loss. Smoking, previous breast radiation and periareolar incision were all not associated with a higher re-intervention rate (p = 0.93, 0.41 and 0.91, respectively). Median follow-up was 43 months (range 5-145). Five patients (4%) developed local recurrence, including 2 NAC recurrences. The 2- and 5-year overall survival rate is 97 and 90%, respectively. CONCLUSION: NSM is an oncologically safe procedure in selected patients with acceptable low complication rates.

Immediate breast reconstruction following nipple-sparing mastectomy in an Asian population: Aesthetic outcomes and mitigating nipple-areolar complex necrosis.

BACKGROUND: Nipple-sparing mastectomies (NSMs) are increasingly performed to obtain the best aesthetic and psychological outcomes in breast cancer treatment. However, merely preserving the nipple-areolar complex (NAC) does not guarantee a good outcome. Darkly pigmented NACs and a tendency for poor scarring outcomes are particular challenges when treating Asian patients. Herein, we review the reconstructive outcomes following NSM at Singapore General Hospital. METHODS: All breasts reconstructed following NSM over an 11-year period from 2005 to 2015 were reviewed. Information was collected from the patients' records on mastectomy indications, operative details, and complications. Patient satisfaction, breast sensation, and aesthetic outcomes were evaluated in 15 patients. Sensation was quantified using the Semmes-Weinstein monofilament test. RESULTS: A total of 142 NSMs were performed in 133 patients for breast cancer (n=122, 85.9%) or risk reduction (n=20, 14.1%). Of the procedures, 114 (80.2%) were autologous reconstructions, while 27 (19.0%) were reconstructions with implants. Complications occurred in 28 breasts (19.7%), with the most common complication being NAC necrosis, which occurred in 17 breasts (12.0%). Four breasts (2.8%) had total NAC necrosis. The overall mean patient satisfaction score was 3.0 (good). The sensation scores were significantly diminished in the skin envelope, areola, and nipple of breasts that had undergone NSM compared to non-operated breasts (P<0.05). Half of the subset of 15 patients in whom aesthetic outcomes were evaluated had reduced nipple projection. CONCLUSIONS: Immediate reconstruction after NSM was performed with a low complication rate in this series, predominantly through autologous reconstruction. Patients should be informed of potential drawbacks, including NAC necrosis, reduced nipple projection, and diminished sensation.

Meta-analysis of early excision of burns.

AIMS: This meta-analysis sought to establish if early excision and grafting is better or equivalent to the conservative treatment of burns in both children and adults with minor or major burns. The outcomes of interest are mortality, wound healing time, duration of sepsis, operating hours, complications of surgery, length of hospital stay, blood transfusion requirements and long term morbidity like joint contractures and hypertrophic scarring. METHODS: We searched MEDLINE (1966-July 2004), EMBASE (1980-August 2004) and the Cochrane Central Register of Controlled Trials (CENTRAL) with the keywords 'early excision' and 'burns'. This yielded 441 articles of which 15 were randomized controlled trials. Only six trials met the inclusion criteria. RESULTS: There was a significant reduction in mortality with early excision of burns when compared with traditional treatment only in patients without inhalational injury (RR 0.36, 95% CI 0.20 to 0.65). The blood transfusion requirement is significantly higher in the early excision group but the length of hospital stay was significantly shorter (WMD -8.89, 95% CI -14.28 to -3.50). There was no conclusive evidence on the difference between the two groups in terms of duration of sepsis, wound healing time and skin graft take. CONCLUSION: Early excision of burns is beneficial in reducing mortality (in patients without inhalational injury), length of hospital stay. The only drawback is the greater volume of blood loss.

Optimising Aesthetic Reconstruction of Scalp Soft Tissue by an Algorithm Based on Defect Size and Location.

INTRODUCTION: Scalp soft tissue defects are common and result from a variety of causes. Reconstructive methods should maximise cosmetic outcomes by maintaining hair-bearing tissue and aesthetic hairlines. This article outlines an algorithm based on a diverse clinical case series to optimise scalp soft tissue coverage. MATERIALS AND METHODS: A retrospective analysis of scalp soft tissue reconstruction cases performed at the Singapore General Hospital between January 2004 and December 2013 was conducted. RESULTS: Forty-one patients were included in this study. The majority of defects <100 cm² were reconstructed with local flaps and were subdivided by location. Methods included rotation, transposition and free flaps. The most common type of reconstruction performed for defects ≥100 cm² was free flap reconstruction. Multistage reconstruction using tissue expanders aided in optimising cosmetic outcomes. There were no major complications or flap failures. CONCLUSION: By analysing our experience with scalp soft tissue reconstruction, we have developed an algorithm based on defect size and location, achieving excellent closure and aesthetic outcome while minimising complications and repeat procedures.