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.

[Pyoderma gangrenosum following breast surgery]. / Pyoderma gangrenosum na mammachirurgie.

Pyoderma gangrenosum is a rare, destructive ulcerative condition of the skin. The painful ulcers may occur spontaneously, or result from a minor injury or surgery. The clinical presentation can mimic a necrotizing bacterial infection; however, no micro-organisms can be cultured from the skin lesions and the ulcers fail to respond to antibiotic therapy. Surgical interventions can aggravate the disease process. We describe 2 patients, a 22-year-old woman and a 45-year-old woman, with ulcerative wound abnormalities after breast surgery. After failure of antibiotic therapy and standard wound care, tissue biopsy of the wounds confirmed the clinical diagnosis 'pyoderma gangrenosum'. Wound healing began after systemic steroid treatment. Delays in diagnosis and treatment of pyoderma gangrenosum may result in extensive ulceration and scarring. It is, therefore, important to recognise the characteristic clinical features at an early stage and to start appropriate treatment immediately.

Functional and aesthetic outcome and survival after double free flap reconstruction in advanced head and neck cancer patients.

BACKGROUND: Extensive composite defects in the head and neck area may require the use of double free flap reconstructions. These reconstructions are not only surgically challenging but also challenging to patients. A realistic perspective on general outcome for the patient seems important. METHODS: From January of 2002 to August of 2003, double free flap reconstructions were used in 12 patients with extensive composite head and neck defects following malignant tumor (n = 7) and osteoradionecrosis (n = 5) resection. Six patients had a standardized interview, physical examination, and clinical photographs. RESULTS: All reconstructions were performed using an osteocutaneous fibula flap in combination with an anterolateral thigh flap (n = 8), a radial forearm flap (n = 1), or a lateral thigh flap (n = 1). The total flap survival rate was 96 percent. Mean mandibular bone defects were 10 cm. Mean skin island sizes of osteocutaneous fibula flaps were 67 cm. Mean external skin reconstruction flap sizes were 117 cm. Mean overall survival time was 20 months in patients with malignant tumors. Patients with osteoradionecrosis reconstruction survived free of disease for an average period of 38 months. Three patients (50 percent) were very satisfied, one was neutral, and two were very dissatisfied with their functional and aesthetic results. Objective evaluation of function showed mainly deteriorated speech (83 percent) and oral incontinence (67 percent). Objective evaluation of aesthetics showed mainly color mismatch (67 percent) and flap contracture of external flaps (50 percent). CONCLUSIONS: Reconstruction of these major composite through-and-through defects will often result in a modest functional and aesthetic outcome. Because selected patients require these procedures, the authors give information that matches with realistic expectations.

The facial artery perforator flap for reconstruction of perioral defects.

BACKGROUND: The concept of the facial artery perforator flap was developed to gain more freedom for reconstruction of perioral defects. Single perforators of the facial artery should supply a large area of facial skin for a pedicled perforator flap. METHODS: Five fresh cadavers yielding 10 facial arteries were dissected after Microfil vascular injection to study distribution, number, length, and diameter of facial artery perforators. Five clinical cases with cancer-related perioral defects were reconstructed with facial artery perforator flaps. In two cases, additional regional flaps were used. Surgical technique was governed by the aesthetic unit principle and Doppler identification of the facial artery, which was used as a guideline for identification of suitable facial artery perforators. RESULTS: Cadaver dissection showed a large number of evenly distributed facial artery perforators (average, 5.7; range, three to nine). The average perforator length was 25.2 mm (range, 13 to 51 mm). The average perforator diameter was 1.2 mm (range, 0.6 to 1.8 mm). In all clinical cases, a suitable facial artery perforator was identified to meet reconstructive demands. Flaps were rotated up to 180 degrees. Four flaps survived completely. One flap showed minor distal necrosis. CONCLUSIONS: The facial artery perforator flap offers a versatile tailor-made flap, because of the reliable presence of perforators, with a large arc of rotation and an aesthetically pleasing donor site. The thin pedicle makes it an ideal flap for one-stage reconstruction without secondary revisions.

Anterolateral thigh flap reconstruction of large external facial skin defects: a follow-up study on functional and aesthetic recipient- and donor-site outcome.

BACKGROUND: The purpose of this study was to investigate the subjective and the objective functional and aesthetic follow-up results of the recipient and donor sites after reconstruction of extensive facial defects with the anterolateral thigh flap. METHODS: Between December of 2001 and April of 2003, the anterolateral thigh flap was used to reconstruct large facial skin defects after malignant tumor resection in 23 white patients. All patients had a standardized interview, physical examination, and clinical photographs. RESULTS: The mean flap size was 108 cm2. Fasciocutaneous anterolateral thigh flaps were used in 15 patients and musculocutaneous flaps were used in eight patients with exposed dura, open sinuses, or orbital defects. An extra free osteocutaneous fibula flap was necessary to reconstruct the affected mandible in 10 patients. The donor site was skin grafted in 18 patients. The flap survival rate was 96 percent. At follow-up, color mismatch (71 percent) and flap bulkiness (50 percent) were encountered most often. Four of five patients with speech problems had received an additional free osteocutaneous fibula flap. Three flap contractures were seen in the neck region. A contour defect of the upper leg was encountered in five patients. Sensory disturbances of the upper leg were observed in 12 patients. Cold intolerance occurred three times after skin grafting. No significant impairment was found in range of motion and muscle strength of the donor leg. CONCLUSIONS: Careful patient selection may further improve aesthetic outcome of the anterolateral thigh flap. The versatility in design and composition of the anterolateral thigh flap and the low donor-site morbidity and satisfactory recipient-site outcome make it a valuable option in reconstruction of external skin defects in the head and neck region.