Improving quality of life after breast cancer: a comparison of two microsurgical treatment options for breast cancer-related lymphedema (BCRL).

PURPOSE: Vascularized lymph node transfer (VLNT) entails the autologous relocation of lymph nodes to a lymphedematous region of the body, whereas lymphaticovenous anastomosis (LVA) creates a direct bypass between the lymphatic and venous system. Both techniques are meant to lastingly bolster the local lymphatic drainage capacity. This study compared safety and effectiveness of VLNT and LVA in patients with chronic breast cancer related lymphedema (BCRL). METHODS: A retrospective cohort study was conducted using data from our encrypted database composed of patients with chronic BCRL who were treated with either VLNT or LVA and had a minimum follow-up of two years. Patient-specific variables analyzed included pre- and postoperative arm circumferences, lymphedema stages and postoperative complications. RESULTS: A total of 105 patients met the inclusion criteria, of which 96 patients demonstrated a complete follow-up period of two years. The VLNT group displayed larger preoperative circumferential measurements, evident in both in the isolated examination of the affected arm, as well as when adjusted for the contralateral unaffected arm. Significant reduction in arm volume was achieved by both groups. However, VLNT demonstrated superior relative reduction rates than LVA, neutralizing any significant arm size disparities after 24 months. Surgery duration was slightly longer for VLNT than LVA. Postoperative complications, predominantly minor, were exclusively observed in the VLNT group. CONCLUSIONS: Both VLNT and LVA offer significant improvement for patients suffering from chronic BCRL. VLNT shows an even greater potential for improvement in more severe cases of BCRL, but involves a higher risk for (mostly minor) complications.

Radiofrequency and pulsed electromagnetic field application following liposuction-Clinical evaluation of performance and safety.

OBJECTIVE: With more than 1.5 million performed procedures, liposuction was the second most performed esthetic surgical procedure all over the world in males and in females in the year 2020. The objective of this open-label, evaluator-blinded study was to assess the efficacy and safety of an energy-based device that combines multipolar radiofrequency with pulsed electromagnetic field (PEMF) in patients that underwent liposuction. MATERIALS AND METHODS: A total of 30 subjects, of whom 24 were females (80%), with a mean age of 48.4 ± 11.0 years (range: 27-69 years) and a mean weight of 69.5 ± 11.7 kg underwent unilateral treatment with radiofrequency and application of PEMF after bilateral liposuction. One month after the last of a total of six weekly treatments, skin elasticity, visco-elasticity and net elasticity, as well as subject reported satisfaction on a 5-point scale ranging from -1 (worse) to 3 (very much improved) and esthetic improvement ranging from 0 (very unsatisfied) to 4 (very satisfied) rated by three independent reviewers were assessed. RESULTS: Three independent and blinded reviewers rated the improvement of the treated side on average as 1.17 + 0.07 compared with baseline. Subjects were very satisfied with their treatment, with a mean score of 3.24 (0.03) out of 4 at the 1-month follow-up visit. Cutometer measurements showed no significant changes. CONCLUSION: This study revealed that the subjective satisfaction with the results of the application of RF and PEMF after liposuction is high, while at the same time the esthetic appearance as rated by independent raters improved on the treated side.

[Breast Reconstruction Strategies in Case of Planned Radiotherapy]. / Rekonstruktives Vorgehen zum Brustwiederaufbau bei geplanter Bestrahlung.

INTRODUCTION: The ideal technical and chronological approach of breast reconstruction in case of planned radiotherapy after mastectomy (post-mastectomy radiotherapy, PMRT) continues to be controversially discussed. METHODS: The authors analysed the MEDLINE Database PubMed for relevant studies concerning PMRT and breast reconstruction. The main theses from these publications were extracted and summarised. RESULTS: An implant-based approach is the least invasive technique for immediate breast-mound formation in a PMRT setting. Reconstruction in a PMRT setting with a two-stage expander-implant technique or expander-implant-autologous procedure can provide good to excellent cosmetic outcomes. In contrast to the implant-based approach, autologous reconstruction methods provide an improved quality of life as well as haptic and sensory advantages and are usually associated with lower complication rates. PMRT after autologous reconstruction can have a negative impact on the autologous tissue. A delayed autologous approach can be advantageous and should be generally favoured in high-risk patients. CONCLUSION: Factors influencing a meticulous planning of breast reconstruction including PMRT are surgical, aesthetic and patient characteristics, quality of life, preference and expectation. Ideally, PMRT is completed before autologous reconstruction to avoid radiation-associated side-effects on the final reconstructive result. If PMRT is likely, but potentially not necessary, an immediate-delayed procedure may be of advantage.

Randomized Single-Center Study of Effectiveness and Safety of a Resorbable Lysine-Based Urethane Adhesive for a Drain-Free Closure of the Abdominal Donor Site in a DIEP Flap Breast Reconstruction Procedure.

OBJECTIVE: The hypothesis of this parallel group randomized trial testifies if TissuGlu is a safe and an effective alternative to the conventional drainage placement in regard to post-operative fluid management in the abdominal donor site for autologous (DIEP flap) breast reconstruction with a higher postoperative patient quality of life. PATIENTS AND METHODS: Data was collected for 58 women who required to be at min.18 years old with a BMI < 30 and not taking any SSRIs (Selective Serotonin Reuptake Inhibitors).Exclusion criteria: Discharge with indwelling suction drains at the abdominal site or signs of wound infection during hospital stay.The patients were randomized into a study group (donor site closure with application of surgical adhesive without drains) and a control group (donor site closure with drains) using a randomly sorted sealed envelope system.Th e primary outcome was defined as the number of post-operative seroma formations.The secondary endpoint was the evaluation of patient satisfaction with both methods. RESULTS: 58 patients underwent a DIEP reconstruction (29 in the control- and 29 in the study group).Both groups were homogenous. Rate of seroma was 17%(5/29) in the study group and 10%(3/29) in the control group which showed no statistical significance (p-value = 0.71).Smoking and previous abdominal surgery turned out to be a risk factor for seroma formation in the study group.Overall satisfaction was evaluated with a questionnaire and was higher in the study group. CONCLUSION: The abdominal closure with the surgical adhesive seems to be a safe procedure that contributes to patient satisfaction and increases the independence upon discharge in patients with adequate inclusion criteria.

Risk Factor Analysis for Flap and Donor Site Related Complications in 1274 DIEP Flaps - Retrospective Single Center Study.

Background: Breast cancer is the most common cancer affecting women worldwide. In Germany, in almost 70% of cases, women require a complete mastectomy and wish for breast reconstruction which is especially difficult when the breast was previously irradiated. The DIEP flap is then the gold standard for autologous breast reconstruction and shows an overall low complication rate. This study aims to underline the safety of the procedure yet point out potential risk factors for flap edge and fat necrosis in a retrospective series of 1274 DIEP flaps in our center. Patients and Methods: 1274 autologous breast reconstructions with the DIEP flap were performed in 1124 patients between July 2004 and December 2014 in our department. Retrospective risk factor analysis included age, BMI, smoking, chemotherapy and/or radiotherapy and comorbidities. Mean follow-up constituted out of 24 months. Results: Out of 1274 free DIEP flap breast reconstructions, 150 were bilateral reconstructions. In 785 cases the primary indication was previous mastectomy, followed by prior implant-based reconstruction in 265 cases. The total flap loss rate was 0.6%. Patients with a higher BMI and smokers had significantly higher complication rates than the rest of the cohort. Elderly patients ( 65 years), patients with diabetes and ones who had undergone chemo-/ radiotherapy did not present with higher complication rates. Conclusions: The DIEP flap surgery is a well-established method for autologous breast reconstruction with a low complication rate. Yet patient characteristics in terms of risk factors need to be taken into account for result prognosis and satisfactory long-term reconstructive results.

Donor site aesthetics and morbidity after DIEP flap breast reconstruction-A retrospective multicenter study.

The deep inferior epigastric artery perforator flap (DIEP) has gained widespread popularity in autologous breast reconstruction due to its natural aesthetic results and muscle-sparing design. However, donor site results regarding aesthetic outcome are often less favorable. We therefore aimed to identify crucial factors that might increase the risk for abdominal bulging and an impaired aesthetic appearance. We conducted a multicenter study evaluating all patients receiving autologous breast reconstruction using a DIEP flap between 2013 and 2017. Medical records were analyzed with special attention to flap technique, number of perforators, localization of perforator, and donor site complications. In addition, the aesthetic appearance of the abdominal donor site was evaluated by blinded clinicians at one-year follow-up. A total of 242 patients underwent DIEP flap breast reconstruction. Abdominal bulging occurred in 7%. Further subgroup analysis revealed a significant correlation between abdominal bulging and two or more perforators (P = .003), the use of lateral row perforators (P = .009), and a higher BMI (P = .002). Obesity (P = .003) and higher patient's age (P = .003) could be identified as risk factors for an undesirable appearance of the donor site. We recommend the use of a medial-row single perforator whenever possible in order to optimize donor site morbidity and decrease the risk of abdominal bulging. Proper patient selection and careful donor site closure following a standardized approach should be performed to limit the risk of aesthetically undesirable results.

The DIEP Flap as Well-established Method of Choice for Autologous Breast Reconstruction with a Low Complication Rate - Retrospective Single-centre 10-Year Experience.

Background Breast cancer is the most common cancer affecting women in Germany. Despite breast-conserving therapy (BCT) being carried out in almost 70% of cases, a high number of women still require complete mastectomy. Prophylactic mastectomy is also indicated for women with a BRCA 1/2 gene mutation. In addition to implant-based heterologous breast reconstruction, autologous breast reconstruction using a DIEP flap has been found to be beneficial, particularly for patients who had prior radiotherapy. This study aims to show that DIEP flap reconstruction surgery is the method of choice for autologous breast reconstruction with a low rate of complications. Patients and Methods Autologous breast reconstruction using a DIEP flap was performed in 1124 patients between July 2004 and December 2014. Retrospective study criteria included potential risk factors such as age, BMI, smoking, chemotherapy and/or radiotherapy, and comorbidities as well as outcome parameters such as postoperative complications. Outcomes were evaluated with a mean follow-up of 24 months. Results A total of 1124 patients underwent 1274 free DIEP flap breast reconstructions, of which 150 were bilateral reconstructions. The primary indication was previous mastectomy in 785 cases, followed by prior implant-based reconstruction in 265 cases. The total flap loss rate was 0.6%. Postoperative surgical revision for abdominal wall hernia was required in 0.2% of cases. The group with a higher BMI and the group of smokers had significantly higher complication rates. Elderly patients (> 65 years), patients who had undergone chemo-/radiotherapy and patients with diabetes did not have higher complication rates. Conclusion DIEP flap surgery is an excellent option for autologous breast reconstruction, with a low rate of donor site morbidity and low complication rates. DIEP flap surgery carried out in a specialised interdisciplinary breast centre in a standardised clinical setting after prior careful patient selection to take account of risk factors such as high BMI and smoking is a reliable method with a low complication rate and satisfactory long-term reconstruction results.

D-SUN Method to Prevent Double-Bubble Deformity in Broad Base Breasts with High-Rising Inframammary Fold.

Breast augmentation is the most commonly performed plastic surgery among women worldwide. With time, implant selection shifted from arbitrary implantation to precise planning. Different methods address the dimensional planning process. Many of them are complex to put into practice, focusing mainly on the breast base. Constricted, short lower pole breasts are morphologically predisposed to complication such as double-bubble deformity. Yet, by focusing on the distance between the nipple on stretch and the inframammary fold, the D-SUN method guides the surgeon to find the most appropriate implant volume for anatomical form-stable silicon implants and IMF incision to avoid complications.Level of evidence IV 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.

Autologous Breast Reconstruction with SIEA Flaps: An Alternative in Selected Cases.

BACKGROUND: The deep inferior epigastric perforator flap has been shown to be a reliable option for autologous breast reconstruction. A further refinement in the transfer of lower abdominal tissue is the superficial inferior epigastric artery (SIEA) flap that does not require any incision of the rectus abdominis fascia or muscle and is superior regarding donor-site morbidity. OBJECTIVES: We conducted a retrospective study to assess reliability and outcomes of autologous breast reconstruction using SIEA flaps. METHODS: We performed autologous breast reconstruction in 1708 patients at our department between 2009 and 2018. Of those, 28 patients that underwent breast reconstruction using a SIEA flap were included for a retrospective chart review. RESULTS: Given an overall flap loss rate of 1.8%, we observed total flap necrosis following a SIEA flap in four patients (13%). All cases were secondary to arterial thrombosis. We further recognized a significant correlation between flap failure and a history of spontaneous deep vein thrombosis (p < 0.0001). There was no statistically significant relationship between flap failure and obesity (BMI > 30 kg/m2;p = 0.9) or flap failure and a history of abdominal operations (p = 0.6). CONCLUSIONS: The SIEA flap provides a reasonable option for autologous breast reconstruction with the great advantage of minimal donor-site morbidity. Nevertheless, its use should be preserved to selected cases with favorable anatomy. We therefore recommend proper patient selection based on preoperative computed tomography angiography, intraoperative clinical evaluation and history of hypercoagulable state. LEVEL OF EVIDENCE IV: 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.

Increased risk of recurrence associated with certain risk factors in breast cancer patients after DIEP-flap reconstruction and lipofilling-a matched cohort study with 200 patients.

BACKGROUND: Lipofilling is performed in breast cancer patients to optimize the aesthetic outcome following breast reconstruction after mastectomy. Despite its common usage worldwide, little is known about the interaction of the lipoaspirate and dormant cancer cells. Up to date, no risk factors that increase the risk for cancer recurrence have been established. This study aims to identify risk factors for lipofilling candidates after breast cancer and questions the oncological safety of lipofilling in lymph node positive disease. METHODS: Matched retrospective cohort study: the disease-free survival (DFS) between 100 breast cancer patients undergoing a lipofilling after their DIEP-flap reconstruction and 100 matched control patients with no subsequent lipofilling was analyzed. Further, patients were subdivided according to risk factors, which were categorized as patient-dependent factors (PDFs) and tumor-dependent factors (TDFs). DFS and hazard ratios (HR) were compared to identify potential risk factors that may increase cancer recurrence. RESULTS: Median follow-up was 76.5 months from the mastectomy, and 31 months from the startpoint to the end of follow-up. Seven and eleven patients had recurrence in the lipofilling and control group, respectively, presenting with comparable DFS rates and an insignificant HR =0.57, 95% confidence interval (CI): 0.22-1.47, P=0.24. According to subgroup survival analysis, lipofilling increased the risk of recurrence in women with a positive nodal status (P=0.035) and a high-grade neoplasia (P=0.049). CONCLUSIONS: No general increased recurrence risk was observed between the lipofilling and control group. The subgroup analysis identified high-grade neoplasia and positive nodal status to be a risk factor for cancer recurrence. Patients with a known node positive disease have an increased risk of occult micrometastases in their lymph nodes. Further studies are necessary to clarify whether dormant breast cancer cells in form of micrometastases in the lymph nodes can be reactivated by the factors secreted by adipose derived stem cells.

Immediate-DElayed AutoLogous (IDEAL) Breast Reconstruction with the DIEP Flap.

Background: The most common cancer worldwide in women is breast cancer. The increasing number of cases each year, requires a novel curative approach that can combine oncological treatments and breast reconstruction yielding a pleasing and aesthetic breast that is a definitive and long lasting solution. Thus, the Immediate-DElayed AutoLogous (IDEAL) breast reconstruction principle was created to hold up to the standards of the needs of contemporary women. METHOD: The IDEAL protocol for breast reconstruction was developed in our department in cooperation with our breast surgery unit and describes a two-stage approach that implicates neoadjuvant radio-/ chemotherapy treatment regimes and tumor staging before the mastectomy in order to avoid post-mastectomy radiation. In a second step the breast is then reconstructed with autologous tissue for optimal and natural results. CONCLUSION: More and more patients decide to undergo breast reconstruction after breast cancer. The IDEAL concept offers a life-long and safe solution with a low rate of late complications.

Dupuytren Disease: Is There Enough Comprehensive Patient Information on the Internet?

BACKGROUND: Dupuytren disease is a chronic nonmalign fibroproliferative disorder that causes finger contractures via proliferation of new tissue under the glabrous skin of the hand, resulting in multiple functional limitations for the patient. As many surgical therapy options exist, patients suffering from this condition actively search for information in their environment before consulting a health professional. OBJECTIVE: As little is known about the quality of Web-based patient information, the aim of this study was to conduct its systematic evaluation using a validated tool. METHODS: A total of 118 websites were included, and qualitative and quantitative assessment was performed using the modified Ensuring Quality Information for Patients (EQIP) tool. This standardized and reproducible tool consists of 36 items to assess available information in three categories: contents, identification, and structure data. Scientific data with restricted access, duplicates, and irrelevant websites were not included. RESULTS: Only 32 websites addressed more than 19 items, and the scores did not significantly differ among the website developers. The median number of items from the EQIP tool was 16, with the top websites addressing 28 out of 36 items. The quality of the newly developed websites did not increase with passing time. CONCLUSIONS: This study revealed several shortcomings in the quality of Web-based information available for patients suffering from Dupuytren disease. In the world of continuously growing and instantly available Web-based information, it is the health providers' negligence of the last two decades that there are very few good quality, informative, and educative websites that could be recommended to patients.

Conservative mastectomies and Immediate-DElayed AutoLogous (IDEAL) breast reconstruction: the DIEP flap.

BACKGROUND: With the development of conservative mastectomies, there are an increasing number of women seeking immediate implant based and autologous breast reconstruction. Despite the oncologic safety of the procedures, the focus will be on the timing of reconstruction. METHODS: Our plastic surgery unit is focused primarily on autologous breast reconstruction and is part of an interdisciplinary breast center. We offer immediate breast reconstruction (IBR) with autologous tissue for patients with positive BRCA 1 and 2, ductal carcinoma in situ (DCIS), invasive cancer without margin problems to the skin, as well as to correct poor oncologic and aesthetic breast conserving therapy (BCT) outcomes. In the majority of cases we prefer an Immediate-DElayed AutoLogous (IDEAL) breast reconstruction concept with a two-stage procedure. RESULTS: Over the last 10 years we performed more than 1,600 breast reconstructions with free flaps, performing the deep inferior epigastric perforator (DIEP) flap as our first choice for autologous tissue. We recommend IDEAL breast reconstruction, however approximately 15% of our cases are immediate one stage conservative mastectomies and breast reconstruction with the DIEP flap. CONCLUSIONS: For immediate reconstruction, the aesthetic outcome should not take precedence over oncologic considerations. Immediate one-stage, breast reconstruction with autologous tissue can be offered to the suitable patients which is most likely a healthy women with a small-to-medium sized non ptotic breast receiving a conservative mastectomy. In all other cases, we recommend an IDEAL breast reconstruction approach in order to achieve a final result that is both satisfyingly pleasing and oncologically safe.

Vacuum-assisted core-needle biopsy as a diagnostic and therapeutic method in lesions radiologically suspicious of breast fibroadenoma.

BACKGROUND: Treatment of breast fibroadenoma remains a subject of clinical discussion. Recommended methods include clinical observation or surgical excision of the lesion. The procedure involves hospitalisation and anaesthesia, leaving a scar on the breast. AIM: The aim of this study was to present the Centre's experience in removing lesions radiologically suspicious of fibroadenoma by means of an ultrasound-guided vacuum-assisted core-needle biopsy as an alternative to a classical surgery. MATERIALS AND METHODS: Between March 2007 and April 2010, 196 ultrasound-guided vacuum-assisted biopsies were performed in the Mammotome Biopsy Laboratory of the 1st Surgical Oncology and General Surgery Department at the Greater Poland Cancer Centre in Poznan. The procedure was delivered to female patients aged 17-91 years (mean 40.8, median 39). Qualified for removal were ultrasound identified lesions described as fibroadenomas. RESULTS: The average size of excised lesions according to pre-biopsy ultrasound image was 13.53 ± 8.92 mm (median 11 mm, range 4-60 mm). In 184 cases (93.9%), benign lesions were found in the final histopathologic examination. Pre-cancer lesions were found in 10 cases, and invasive lesions in two cases. Overall, after follow-up ultrasound examination, four patients were qualified for subsequent surgical resection of lesions that had been left behind. CONCLUSION: Vacuum core-needle biopsy is an effective tool enabling removal of breast fibroadenomas. It combines features of a lesion resection and histopathologic material collection providing an access with minimum invasiveness.