Autologous Breast Reconstruction With a Delay Procedure of the Deep Inferior Epigastric Artery Perforator Flap Because of Venous Congestion of the Flap on Pedicle: A Case Series.

The deep inferior epigastric artery perforator (DIEP) flap is one of the most used free flaps for the reconstruction of the breast after a mastectomy. Despite careful selection of the patients and preoperative imaging, difficulties in vascularization of the flap can occur in some cases. Although multiple vascular connections (bipedicled, turbocharged, or stacked) can be made in selected cases, there can still be venous congestion before the flap is transferred.Between 2016 and 2018, 4 cases in our series of 281 patients experienced such problems. Three of 4 patients had undergone preoperative imaging of the perforators by a magnetic resonance angiography or computed tomography angiography, in which a good perforator was seen. All 4 patients had a venous problem of blood circulation in the flap intraoperatively. The flaps were left to rest to decide on its venous status. Without improvement after this period of 20 to 30 minutes, the surgeons decided to withhold the translocation of the flap to the chest wall and sutured the flap back into the donor side. The final anastomosis of the DIEP flap occurred on average 8 days after the prefabrication. The translocation of the DIEP flap to the chest in this second operation went uncomplicated in all cases. Postoperatively, all patients had adequate arterial inflow and venous outflow of the flap. There were no postoperative complications.In case a DIEP flap shows venous problems before translocation, a delay procedure can be applied. In this way, the vascularization of the flap can be improved, and the translocation of the DIEP flap in a second operation can be successfully performed.

Two-stage implant-based breast reconstruction compared with immediate one-stage implant-based breast reconstruction augmented with an acellular dermal matrix: an open-label, phase 4, multicentre, randomised, controlled trial.

BACKGROUND: The evidence justifying the use of acellular dermal matrices (ADMs) in implant-based breast reconstruction (IBBR) is limited. We did a prospective randomised trial to compare the safety of IBBR with an ADM immediately after mastectomy with that of two-stage IBBR. METHODS: We did an open-label, randomised, controlled trial in eight hospitals in the Netherlands. Eligible women were older than 18 years with breast carcinoma or a gene mutation linked with breast cancer who intended to undergo skin-sparing mastectomy and immediate IBBR. Randomisation was done electronically, stratified per centre and in blocks of ten to achieve roughly balanced groups. Women were assigned to undergo one-stage IBBR with ADM (Strattice, LifeCell, Branchburg, NJ, USA) or two-stage IBBR. The primary endpoint was quality of life and safety was assessed by the occurrence of adverse outcomes. Analyses were done per protocol with logistic regression and generalised estimating equations. This study is registered at Nederlands Trial Register, number NTR5446. FINDINGS: 142 women were enrolled between April 14, 2013, and May 29, 2015, of whom 59 (91 breasts) in the one-stage IBBR with ADM group and 62 (92 breasts) in the two-stage IBBR group were included in analyses. One-stage IBBR with ADM was associated with significantly higher risk per breast of surgical complications (crude odds ratio 3·81, 95% CI 2·67-5·43, p<0·001), reoperation (3·38, 2·10-5·45, p<0·001), and removal of implant, ADM, or both (8·80, 8·24-9·40, p<0·001) than two-stage IBBR. Severe (grade 3) adverse events occurred in 26 (29%) of 91 breasts in the one-stage IBBR with ADM group and in five (5%) of 92 in the two-stage IBBR group. The frequency of mild to moderate adverse events was similar in the two groups. INTERPRETATION: Immediate one-stage IBBR with ADM was associated with adverse events and should be considered very carefully. Understanding of selection of patients, risk factors, and surgical and postsurgical procedures needs to be improved. FUNDING: Pink Ribbon, Nuts-Ohra, and LifeCell.

Pregnancy after abdominoplasty with mesh placement: A case report.

A 32-year-old Caucasian female, who had an abdominoplasty with sublay mesh placement for rectus abdominis diastasis becamepregnant one year later. The gestation was uneventful and the baby was born healthy after 40 weeks of pregnancy. During and after the pregnancy the patient's abdomen had been evaluated intensively and there was no recurrence of rectus abdominis diastasis. In this particular case the tissues of the abdominal wall elongated as the foetus grew larger, except for the site where the rectus diastasis has been corrected. The experience with this particular case does not assure that all patients will have the same uneventful outcomes as described. Nonetheless, it shows that pregnancy after abdominoplasty with mesh placing for rectus abdominis diastasis can be safe for both mother and child. However, each patient must be informed about the risks of pregnancy in this particular situation and professional follow-up is mandatory when pregnancy does occur. This is, as far as we know, the first case report of an uneventful pregnancy after rectus abdominis diastasis repair with the placement of a sublay mesh and abdominoplasty.

Delay of adjuvant radiotherapy due to postoperative complications after oncoplastic breast conserving surgery.

BACKGROUND: In the past a mastectomy was the first approach of treating breast cancer. Oncoplastic techniques combined with breast conserving surgery (BCS) and radiotherapy has become an alternative to mastectomy in patients with non-metastasized breast cancer. The aim of this study was to analyse the amount and types of complications occurring after oncoplastic BCS before and after adjuvant radiotherapy and the delay of adjuvant therapy due to the complications. METHOD: A retrospective study based on all patients who received immediate oncoplastic BCS by a plastic surgeon at two medical hospitals in The Netherlands between 2013 and 2015. (n = 150). The performed oncoplastic BCS techniques were the primary outcome measures. In particular major complications with the need for antibiotics or surgical intervention. A one-year follow-up was achieved for all patients. RESULTS: 52% of the 150 included patients received an oncoplastic BCS through the reduction pattern, 35% with a LICAP and 10% with an AICAP. Complications occurred in 37.5% of the patients, 10% of the patients needed treatment with antibiotics and in 6.6% of the patients a revision operation was indicated. 79.6% of all postoperative complications occurred before the start of adjuvant radiotherapy. In 8.2% of the patients the adjuvant radiotherapy had to be delayed due to a complication. CONCLUSION: This study provides a detailed overview of the used techniques of oncoplastic BCS and their postoperative complications. Most complications occurred before the start of the adjuvant radiotherapy. Just a small amount caused a delay for the radiotherapy to start.

The effect of triclosan-coated sutures in wound healing. A double blind randomised prospective pilot study.

BACKGROUND: Wound infection and dehiscence are both major contributors to postoperative morbidity. One potential cause or co-factor is the use of suture material. A recently introduced subcutaneous suture is coated with triclosan (TC), an antiseptic drug. It is suggested to reduce wound complications. METHODS: To investigate the effect of TC on wound healing a double blind prospective pilot study in women undergoing a breast reduction was performed. Each patient was her own control. After randomisation the TC-coated sutures were used either on the left or right side. The contralateral side was used as the control. The incidence of dehiscence was studied. RESULTS: Twenty-six patients were included. In the TC breasts there was a wound dehiscence in 16 cases, whereas in the control breasts in seven cases a dehiscence was observed (P=0.023). CONCLUSION: These results suggest that TC-coated sutures should be used with caution. These sutures have already been introduced on to the market without good clinical studies and might have potential adverse effects as shown by these data.