Rippling Following Breast Augmentation or Reconstruction: Aetiology, Emerging Treatment Options and a Novel Classification of Severity.

BACKGROUND: Implant rippling is a frequent complication following breast augmentation or implant-based reconstruction and results in significant patient dissatisfaction. Traditionally, the treatment has been to replace the implant, often placing it in a subpectoral pocket to reduce the risk of recurrence. Other techniques, such as increasing the implant size or tightening the capsule, can also be used. Recently, however, there has been much interest in alternative treatments, including fat grafting or insertion of an acellular dermal matrix. METHODS: We review the evidence base for emerging treatments and propose a classification to grade severity, based on the typical clinical presentation of rippling: Grade 1-MILD-rippling is palpable but not visible: (1a) palpable in the lower outer quadrant, (1b) palpable in the upper inner quadrant (cleavage area); Grade 2-MODERATE-rippling is visible only when the patient bends forward; Grade 3-SEVERE-rippling is visible with the patient upright. CONCLUSION: Our proposed classification aims to standardise the clinical description of rippling, which will be valuable in determining the efficacy of new treatments and better characterising long-term complications from breast augmentations or reconstructions. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Preadmission screening of adults highlights previously unrecognized carriage of Panton-Valentine leukocidin-positive methicillin-resistant Staphylococcus aureus in London: a cause for concern?

In the first study of its kind in the United Kingdom, we describe the colonization rate of ciprofloxacin-sensitive Panton-Valentine leukocidin-positive methicillin-resistant Staphylococcus aureus (PVL-MRSA) in adult patients who were screened systematically at the time of hospital admission. We also describe the molecular characteristics of PVL-MRSA and antibiotic resistance phenotypes. A total of 55,760 specimens were screened for MRSA between April 2008 and December 2010. MRSA was identified in 1,998 specimens, and ciprofloxacin-susceptible (CSMRSA) isolates (385/1,998, or 19.3%) were subjected to PVL testing. Of these, 70 (18.1%) were identified as PVL-CSMRSA. During the study period, the MRSA colonization rate decreased from 4.6% to 2.8%. In contrast, the colonization rate of PVL-CSMRSA increased over time, rising from 0.075% in 2008 and 0.07% in 2009 to 0.22% in 2010. The mean patient age was 52 years (range, 18 to 90 years); over two-thirds were male. Seven different lineages of PVL-CSMRSA were identified. Over the 3 years, the Southwest Pacific clone (CC30) was dominant in our population. The CC5 clone was detected once in 2008 and not at all in 2009 but accounted for a third of all PVL-CSMRSA strains in 2010. This lineage was commonly associated with clindamycin resistance and, less frequently, tetracycline resistance. We conclude that there is hitherto unrecognized low-level carriage of PVL-CSMRSA among patients being admitted to hospitals in northwest London. We observed the emergence of the CC5 clone in 2010 with associated clindamycin and tetracycline resistance.

Stacked TUG and DIEP flaps to reconstruct a single breast: Expanding the scope of autologous breast reconstruction.

When the entire abdominal tissue is inadequate to match the contralateral breast volume and shape or in bilateral cases, the deep inferior epigastric perforator (DIEP) flap alone might not be adequate, even if bipedicled. In such cases, using combinations of donor sites is useful and more effective. We present our series of breast reconstruction using stacked DIEP and transverse upper gracilis (TUG) flaps to achieve better breast volume and shape. Between 2015 and 2021, 7 patients underwent reconstruction with stacked flaps. Three surgical teams performed the surgery simultaneously. Flaps were stacked and shaped on a table; the DIEP was de-epithelised completely and placed upside down with the pedicle anteriorly. A cranial extension of the DIEP pedicle was anastomosed in series to the TUG vessels. The TUG was coned and placed above the DIEP, the skin paddle was used both to create a new nipple-areola complex and for monitoring. The stacked flaps were anastomosed to the recipient vessels and buried under the mastectomy flaps. No flap losses were encountered. The aesthetic outcome was good or excellent and patients considered the surgery as an improvement for their self-appearance. In patients with loose skin and minimal fat, or in bilateral reconstructions, the presented procedure can be considered as a reliable approach to obtain a better breast shape and simultaneously improve body contouring in the donor sites.

Unilateral breast reconstruction using double transverse upper gracilis (TUG) flaps.

INTRODUCTION: When the deep inferior epigastric perforator (DIEP) flap is unavailable, autologous reconstruction of a moderate-to-large breast presents a surgical challenge. We retrospectively review our experience of unilateral breast reconstruction using double transverse upper gracilis (TUG) flaps and highlight specific technical considerations. METHODS: Thirty-four patients underwent double TUG flaps for unilateral breast reconstruction between 2012 and 2020. The average patient age was 50 years and the average body mass index (BMI) was 23.1 kg/m2. In all cases, the indication for surgery was breast cancer: 31 patients had immediate reconstruction, 11 had simultaneous axillary surgery and eight had primary contralateral symmetrising surgery. RESULTS: Of the 68 TUG flaps, 67 (98.5%) were successful. The mean operative time was 5 h 50 min (195-460 min) and the mean combined flap weight was 551 g (279-916 g). Eight patients returned to the operating theatre in the early post-operative period and five patients underwent secondary lipofilling to address contour deformities. Most commonly (n = 22), the flaps were oriented horizontally/obliquely, with one flap anastomosed medially to the internal mammary axis and the other anastomosed lateral to the subscapular system. The internal mammary artery perforators and serratus anterior artery provided the best vessel calibre match with the TUG vessels. CONCLUSIONS: Double TUG reconstruction is a safe and reliable option for unilateral breast reconstruction and is an important option when the DIEP flap is unavailable.

Indications and outcomes of the components separation technique in the repair of complex abdominal wall hernias: experience from the cambridge plastic surgery department.

OBJECTIVES: The components separation technique (CST) is a widely described abdominal wall reconstructive technique. There have, however, been no UK reports of its use, prompting the present review. METHODS: Between 2008 and 2012, 13 patients who underwent this procedure by a single plastic surgeon (C.M.M.) were retrospectively evaluated. The indications, operative details, and clinical outcomes were recorded. RESULTS: There were 7 women and 6 men in the series with a mean age of 53 years (range: 30-80). Patients were referred from a variety of specialties, often as a last resort. The commonest indication for CST was herniation following abdominal surgery. All operations except 1 were jointly performed with general surgeons (for bowel resection, stoma reversal, and hernia dissection). The operations lasted a mean of 5 hours (range: 3-8 hours). There were no major intra- and postoperative problems, except in 1 patient who developed intra-abdominal compartment syndrome, secondary to massive hemorrhage. All patients were satisfied with the cosmetic improvement in their abdominal contours. None of the patients have developed a clinical recurrence after a mean follow-up of 16 months (range: 3-38 months). CONCLUSIONS: The components separation technique is an effective method of treating large recalcitrant hernias but appears to be underutilized in the United Kingdom. The management of large abdominal wall defects requires a multidisciplinary approach, with input across a variety of specialities. Liaison with plastic surgery teams should be encouraged at an early stage and the CST should be more widely considered when presented with seemingly intractable abdominal wall defects.

Reverse abdominoplasty: a practical option for oncological trunk reconstruction.

OBJECTIVES: Following radical oncological resection, full-thickness upper central trunk defects present a significant challenge. Common reconstructive options include pedicled flaps, such as pectoralis major, rectus abdominis, and latissimus dorsi. In complex cases, free tissue transfer may be required. Reverse abdominoplasty, although initially described for cosmetic body contouring, can be used to reconstruct upper central trunk defects following radical tumour ablation. We present 4 such applications in the management of advanced or recurrent malignancies and review the relative indications for this approach. METHODS: Four consecutive cases (2004-2010) were reviewed with respect to indication, operative procedure, and complications. RESULTS: There were no cases of complete flap loss. One patient underwent revision for marginal flap necrosis while another developed local recurrence, requiring re-excision and reconstruction with flap advancement. CONCLUSIONS: Where pedicled flaps are unavailable or insufficient, adjacent abdominal tissue can be recruited into chest wall defects, avoiding microsurgical free tissue transfer. The authors feel that the reverse abdominoplasty is currently underused in this context and offers an excellent alternative in complex cases where other reconstructive options are unavailable, or where comorbidities preclude free-tissue transfer. The technique is versatile, simple to perform and affords an acceptable cosmetic outcome, yet is not widely reported in the literature. It has particular merit in cases with a high chance of disease recurrence, in the management of recurrent breast cancer, and in patients with multiple comorbidities. The reverse abdominoplasty should therefore be considered when evaluating patients for oncological trunk reconstruction.

Lymphoepithelioma-like carcinoma of the urinary bladder: A case report and review of systemic treatment options.

Lymphoepithelioma-like carcinoma (LELC) of the urinary bladder is a rare variant, which can occur in a pure form or in conjunction with transitional cell carcinoma. Owing to the scarcity of reported cases, the optimum treatment is yet to be defined, although the benefits of chemotherapy are increasingly recognised. We present a case of a 64-year-old man with pure LELC, treated with trans-urethral resection of the bladder tumor (TURBT) and primary gemcitabine and platinum-based chemotherapy. He remained free of disease at six-month follow-up cystoscopy. The case adds to the growing evidence for the efficacy of chemotherapy, coupled with TUR, as part of a bladder-preserving treatment option for LELC.