Robot-assisted lymphovenous anastomosis surgery for lymphocele in the groin.

We present the first-in-human robot-assisted microsurgery on a lymphocele in the groin involving a man in his late 60s who had been coping with the condition for 12 months. Despite numerous efforts at conservative treatment and surgical intervention, the lymphocele persisted, leading to a referral to our clinic.Diagnostic techniques, including indocyanine green lymphography and ultrasound, identified one lymphatic vessel draining into the lymphocele. The surgical intervention, conducted with the assistance of a robot and facilitated by the Symani Surgical System (Medical Microinstruments, Calci, Italy), involved a lymphovenous anastomosis and excision of the lymphocele. An end-to-end anastomosis was performed between the lymphatic and venous vessels measuring 1 mm in diameter, using an Ethilon 10-0 suture.The surgery was successful, with no postoperative complications and a prompt recovery. The patient was discharged 3 days postoperatively and exhibited complete recovery at the 14-day follow-up. This case marks the first use of robot-assisted microsurgical lymphovenous anastomosis to address a groin lymphocele, highlighting the benefit of advanced robotic technology in complex lymphatic surgeries.

Minimal important difference in weight loss following bariatric surgery: Enhancing BODY-Q interpretability.

BODY-Q is a patient-reported outcome measure for comprehensive assessment of outcomes specific to patients undergoing bariatric surgery. The clinical utility of BODY-Q is hampered by the lack of guidance on score interpretation. This study aimed to determine minimal important difference (MID) for assessment of BODY-Q. Prospective BODY-Q data from Denmark and the Netherlands pre- and post-bariatric surgery were collected. Two distribution-based methods were used to estimate MID by 0.2 standard deviations of baseline scores and the mean standardized response change of scores from baseline to 3-years postoperatively. In total, 5476 assessments from 2253 participants were included of which 1628 (72.3%) underwent Roux-en-Y gastric bypass, 586 (26.0%) sleeve gastrectomy, 33 (1.5%) gastric banding, and 6 (0.03%) other surgeries. The mean age was 45.1 ± 10.9 with a mean BMI of 46.6 ± 9.6. Baseline MID ranged from 1 to 4 in health-related quality of life (HRQL) and from 2 to 8 in appearance scales. The mean change of scores ranged from 4 to 5 in HRQL and from 4 to 7 in the appearance scales. The estimated MID for the change in BODY-Q HRQL and appearance scales ranged from 3 to 8 and is recommended for use to interpret BODY-Q scores and assess treatment effects in bariatric surgery.

Body Contouring Surgery After Bariatric Surgery Improves Long-Term Health-Related Quality of Life and Satisfaction With Appearance: An International Longitudinal Cohort Study Using the BODY-Q.

OBJECTIVE: To examine health-related quality of life (HRQL) and satisfaction with appearance in patients who have undergone bariatric surgery (BS) with or without subsequent body contouring surgery (BCS) in relation to the general population normative for the BODY-Q. BACKGROUND: The long-term impact of BS with or without BCS has not been established using rigorously developed and validated patient-reported outcome measures. The BODY-Q is a patient-reported outcome measure developed to measure changes in HRQL and satisfaction with appearance in patients with BS and BCS. METHODS: Prospective BODY-Q data were collected from 6 European countries (Denmark, the Netherlands, Finland, Germany, Italy, and Poland) from June 2015 to February 2022 in a cohort of patients who underwent BS. Mixed-effects regression models were used to analyze changes in HRQL and appearance over time between patients who did and did not receive BCS and to examine the impact of patient-level covariates on outcomes. RESULTS: This study included 24,604 assessments from 5620 patients. BS initially led to improved HRQL and appearance scores throughout the first postbariatric year, followed by a gradual decrease. Patients who underwent subsequent BCS after BS experienced a sustained improvement in HRQL and appearance or remained relatively stable for up to 10 years postoperatively. CONCLUSIONS: Patients who underwent BCS maintained an improvement in HRQL and satisfaction with appearance in contrast to patients who only underwent BS, who reported a decline in scores 1 to 2 years postoperatively. Our results emphasize the pivotal role that BCS plays in the completion of the weight loss trajectory.

Health Technology Readiness amongst Patients with Suspected Breast Cancer Using the READHY-tool - a Cross-sectional Study.

Information technologies are increasingly used when informing patients about their disease, treatment and prognosis. These digital platforms have many advantages compared to traditional education interventions. However, there are concerns that some patients may have difficulty with this mode of information delivery. Newly diagnosed breast cancer patients are dependent on understanding their treatment options to make informed treatment decisions. Yet, there is a lack of published material on breast cancer patients and their relationship with technology. We aimed to assess health technology readiness profiles amongst women with a suspected breast cancer diagnosis. Secondly, we wanted to investigate the potential differences between these profiles according to sociodemographic factors and the patients´ current use of technology. This cross-sectional study used the Readiness and Enablement Index for Health Technology (READHY) questionnaire. We included all patients (n = 92) referred to our department with suspected breast cancer. Cluster analysis revealed three distinct profiles: medium (n = 54), high (n = 18), and low (n = 20) health technology readiness. The third profile showed difficulties in health literacy, eHealth literacy, and health insights, along with higher emotional stress. Our study found that most patients had medium to high health technology readiness, but we also identified a group with lower health technology readiness. Based on our results, healthcare personnel dealing with women with suspected breast cancer should be aware of patients struggling with health technology. Age and technology familiarity may indicate vulnerable patients. Future studies should explore optimal methods for information delivery to these distinct profiles and evaluate the long-term impacts.

Can prophylactic incisional negative pressure wound therapy Reduce Wound Complications After Inguinal Lymph Node Dissection for Melanoma? Results from a Randomized Controlled Trial.

Background: Inguinal lymph node dissection (ILND) is associated with a high complication rate. Retrospective studies suggest that incisional negative pressure wound therapy (iNPWT) might reduce complications, especially seroma, following ILND. Methods: This was a prospective multicenter, randomized (1:1), open-labeled, parallel-group trial. Patients with macrometastic melanoma to the inguinal lymph nodes and eligible for ILND were randomized to receive either iNPWT for 14 postoperative days or conventional wound dressing. The primary outcome was seroma incidence. Secondary outcomes included surgical-site infection, wound rupture, wound necrosis, hematoma, rehospitalization and readmission rates between groups. All outcomes were registered 3 months after ILND and analyzed according to the intention-to-treat principle. Results: The trial was terminated early due to a low recruitment rate as a consequence of a change in the national treatment protocol, and the estimated sample size was not reached. Twenty patients were included and randomized in the study. The trial showed less seroma formation between the iNPWT 6/11 (55%) and control 7/9 (78%) groups; however, this was not statistically significant (p = 0.29). Similarly, there were no differences in the rates of surgical-site infection (p = 0.63), wound rupture (p = 0.19), wound necrosis (p = 0.82), hematoma (p = 0.19), reoperation (p = 0.82) or readmission (p = 0.34) between groups. Conclusion: There was a tendency toward fewer complications in the iNPWT group, however this trial was underpowered and could not confirm the hypothesis that iNPWT reduces complications after ILND. Future randomized controlled trials are required to fully evaluate the treatment potential of iNPWT. Trial registration: The trial was prospectively registered at https://clinicaltrials.gov/ct2/show/NCT03433937.

Reconstruction of a knee defect in a morbidly obese patient with a pedicled reverse anterolateral thigh flap.

The anterolateral thigh (ALT) flap is widely used in the reconstruction of a variety of soft tissue defects. Descriptions of patients with severe obesity in the literature are scarce. We report a case where a reverse pedicled fasciocutaneous ALT flap was successfully used for resurfacing of a knee defect measuring 12×6 cm in a patient with a body mass index (BMI) of 47.3. The flap was supercharged to the greater saphenous vein to optimise flap survival. Reconstruction of the soft tissue of the knee was achieved as planned. There were no flap or donor site complications.

[Surgical techniques for correction of the breast in women after massive weight loss].

Massive weight loss (MWL) results in significant changes of the female breast becoming deflated, ptotic and flat in the upper pole. It may cause physical discomfort such as infections, intertrigo and psychological discomfort including reduced health-related quality of life, where subsequent corrective surgery of the breast is indicated. In this review, we outline our experiences of the most commonly used surgical techniques for correction of the breast in women after MWL. We highlight the principles of the various surgical techniques.

Autologous Fat Grafting as Treatment of Postmastectomy Pain Syndrome: A Randomized Controlled Trial.

BACKGROUND: Postmastectomy pain syndrome is a common and disabling side effect of breast cancer treatment. Medical treatment seems to be insufficient for a considerable proportion of patients. Fat grafting has shown promise in relieving pain from postmastectomy pain syndrome, but no randomized clinical trial comparing fat grafting to a sham operation has been performed to date. The authors' objective was to compare the effect of fat grafting compared to a sham operation for treating postmastectomy pain syndrome. METHODS: The authors conducted a single-center, double-blind, randomized clinical trial with two arms between October of 2017 and September of 2020. The authors assessed four patients suffering from postmastectomy pain syndrome for inclusion. The intervention group received scar-releasing rigottomy and fat grafting to the area of pain. The control group received scar-releasing rigottomy and a placebo of saline solution. The primary outcome was the degree of pain measured using the Numerical Rating Scale. The secondary outcomes were the degree and quality of neuropathic pain (Neuropathic Pain Symptom Inventory) and quality of life (36-Item Short-Form Health Survey). Follow-up was 6 months. RESULTS: Thirty-five participants completed follow-up: 18 participants in the intervention group and 17 in the control group. The authors detected no statistically significant changes in average and maximum pain or neuropathic pain. Regarding quality of life, the control group reported a statistically significant improvement in emotional problem parameters, whereas the intervention group reported a deterioration. The authors observed no serious adverse effects. CONCLUSION: The authors did not find evidence to support that fat grafting is superior to a placebo when treating postmastectomy pain syndrome. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, I.

Abdominoplasty after massive weight loss.

Patients with excess skin after massive weight loss often experience skin maceration, infection, wounding and reduced quality of life. Abdominoplasty is a surgical procedure that removes excess skin aiming to relieve physical inconveniences and improve quality of life. The abdominoplasty can be performed with different techniques using a horizontal, vertical and/or a circumferential procedure. The purpose of this review is to describe the indications for the different surgical approaches, the surgical principles and the complications following abdominoplasty in patients after massive weight loss.

The vertical gracilis myocutaneous flap for breast reconstruction in a massive weight loss patient.

The number of patients undergoing bariatric surgery is increasing worldwide. Different types of free flaps are often used for breast reconstruction following mastectomy. We present a not previously described case using a vertical myocutaneous gracilis flap for breast reconstruction in a massive weight loss patient. The patient was a 61 year-old woman who previously had a lumpectomy for an in situ ductile carcinoma of her left breast. Subsequently the patient underwent a full mastectomy in 2020 due to a recurrence. The massive weight loss population poses a challenge in reconstructive surgery, due to their higher risk of complications. However, we still believe free flaps should be considered as a valid option for breast reconstruction in these patients. Due to the often increased size of perforator vessels in these patients, other flaps may prove more suitable than the usually preferred ones.

Cellulitis Is Associated with Severe Breast Cancer-Related Lymphedema: An Observational Study of Tissue Composition.

Cellulitis is a common complication in Breast Cancer-Related Lymphedema (BCRL). The excess amount of fat and lean mass in BCRL is a vital factor in patient stratification, prognosis, and treatments. However, it is not known whether cellulitis is associated with the excess fat and lean mass in BCRL. Therefore, this prospective observational study was designed to fundamentally understand the heterogonous biocomposition of BCRL. For this study, we consecutively enrolled 206 patients with unilateral BCRL between January 2019 and February 2020. All patients underwent Dual-Energy X-Ray Absorptiometry scans, bioimpedance spectroscopy, indocyanine green lymphangiography comprehensive history of potential risk factors, and a clinical exam. Multivariate linear and beta regression models were used to determine the strength of association and margins effect. Sixty-nine patients (33%) had at least one previous episode of cellulitis. Notably, a previous episode of cellulitis was associated with 20 percentage points more excess fat and 10 percentage points more excess lean mass compared to patients without cellulitis (p < 0.05). Moreover, each 1 increase in the patients BMI was associated with a 0.03 unit increase in the fat mass proportion of the lymphedema arm. Cellulitis was associated with more excess fat and lean arm mass in BCRL. In addition, patients BMI affect the proportion of fat mass in the arm.

Prospective Validation of Indocyanine Green Lymphangiography Staging of Breast Cancer-Related Lymphedema.

Indocyanine green lymphangiography (ICG-L) allows real-time investigation of lymphatics. Plastic surgeons performing lymphatic reconstruction use the ICG-L for patient selection and stratification using the MD Anderson (MDA) and the Arm Dermal Backflow (ADB) grading systems. However, the applicability of ICG-L in evaluating breast cancer-related lymphedema (BCRL) is sparse and not well established. This study comprehensively examines the usability of ICG-L in the assessment of BCRL. We prospectively performed ICG-L in 237 BCRL patients between January 2019 and February 2020. The aim of this study was to assess the interrater and intrarater agreement and interscale consensus of ratings made using the MDA and ADB scales. Three independent raters performed a total of 2607 ICG-L assessments. The ICG-L stage for each grading system was correlated to the lymphedema volume to assess the agreement between the ICG-L stage and clinical severity. The interrater agreement was near perfect for the MDA scale (kappa 0.82-0.90) and the ADB scale (kappa 0.80-0.91). Similarly, we found a near-perfect intrarater agreement for the MDA scale (kappa 0.84-0.94) and the ADB scale (kappa 0.88-0.89). The agreement between the MDA and the ADB scales was substantial (kappa 0.65-0.68); however, the ADB scale systematically overestimated lower ICG-L stages compared to the MDA scale. The volume of lymphedema correlated slightly with MDA stage (Spearmans rho = 0.44, p < 0.001) and ADB stage (rs = 0.35, p < 0.001). No serious adverse events occurred. The staging of BCRL with ICG-L is reliable, safe, and provides unique disease information unobtainable with clinical measurements alone. The MDA scale seems to provide better disease stratification compared to the ADB scale.

Thoracodorsal artery flaps for breast reconstruction-the variants and its approach.

Thoracodorsal artery (TDA) flaps, ranging from the vascular-pedicled thoracodorsal artery perforator (TDAP) flap, the propeller TDAP flap, and the muscle-sparing latissimus dorsi (MSLD) flap to the conventional latissimus dorsi (LD) flap and the extended LD flap, can all be used for breast reconstruction. The aim of this paper and review is to share our experiences and recommendations for procedure selection when applying TDA-based flaps for breast reconstruction. We describe the different surgical techniques and our thoughts and experience regarding indications and selection between these procedures for individual patients who opt for breast reconstruction. We have performed 574 TDA flaps in 491 patients: 60 extended LD flaps, 122 conventional LD flaps, two MSLD flaps, 233 propeller TDAP flaps, 122 TDAP flaps, and 35 free contralateral TDAP flaps for stacked TDAP breast reconstruction. All the TDA flaps are important flaps for reconstruction of the breast. The LD flap is still an option, although we prefer flaps without muscle when possible. The vascular-pedicled TDAP flap is an option for experienced surgeons, and the propeller TDAP flap can be used in most reconstructive cases of the breast, although a secondary procedure is often necessary for correction of the pedicle bulk. The extended LD flap is an option for women with a substantial body mass index, although it is associated with the highest morbidity of all the TDA flaps. The MSLD flap can be used if the perforators are small or if dissection of the perforators is assessed to be hazardous.

Autologous fat grafting seems to alleviate postherpetic neuralgia - a feasibility study investigating patient-reported levels of pain.

BACKGROUND: Postherpetic neuralgia (PHN) is a relatively common side effect after an outbreak of herpes zoster (HZ), characterized by chronic neuropathic dermal pain. No effective treatment exists today. Fat grafting has shown promise in alleviating neuropathic pain, yet the exact mechanism of action, at a biological level, is not yet known. We report on the first human study using autologous fat grafting for treating PHN. Our hypothesis was that fat grafting can alleviate pain and improve the quality of life (QoL) in patients suffering from PHN. If successful, this could be a safe, cost-effective alternative to analgesics. This safety and feasibility study aimed to investigate the possible pain-relieving effect of autologous fat grafting on PHN. METHODS: Ten adult patients suffering from PHN underwent autologous fat grafting to a dermal area of neuralgia, with a 12-week follow up. The primary endpoint was patient-reported pain. Secondary endpoints were patient-reported changes in QoL, and the degree and quality of the neuropathic pain. RESULTS: The pain was measured by using a visual analog scale (range: 0-10). We observed improvements in both the average and maximum level of pain with a reduction of (-4.0 ± 3.1) and (-5.1 ± 3.9), respectively, (Δ mean ± SD), P<0.05. All parameters investigating neuropathic pain were significantly reduced. No improvement was seen in the QoL. The average amount of fat grafted was 208 ml. We observed no serious adverse effects. CONCLUSION: This study suggests that autologous fat grafting can relieve chronic pain resulting from HZ. The next step toward routine clinical translation is to perform a randomized, blinded, placebo-controlled trial with a more extended follow-up period.

Research trends and performances of breast reconstruction: a bibliometric analysis.

BACKGROUND: The need for postmastectomy breast reconstruction surgery has increased dramatically, and significant progress has been made both in implant and autologous based breast reconstruction in recent decades. In this paper, we performed a bibliometric analysis with the aim of providing an overview of the developments in breast reconstruction research and insight into the research trends. METHODS: We searched the Science Citation Index Expanded database and the Web of Science Core Collection for articles published between 1991 to 2018 in the topic domain, using title, abstract, author keywords, and KeyWords Plus. Four citation indicators TCyear, Cyear, C0 and CPPyear were employed to help analyse the identified articles. RESULTS: The number of scientific articles in breast reconstruction in this period steadily increased. It took most articles nearly a decade to hit a plateau in terms of citation counts. Plastic and Reconstructive Surgery, Annals of Plastic Surgery, and Journal of Plastic Reconstructive and Aesthetic Surgery published the largest number of articles on breast reconstruction. Nine of the top ten most prolific publications were based in the USA. The research highlights related to breast reconstruction were implant-based breast reconstruction, deep inferior epigastric perforator (DIEP) flap breast reconstruction, and superficial inferior epigastric artery (SIEA) flap breast reconstruction. CONCLUSIONS: This bibliometric analysis yielded data on citation number, publication outputs, categories, journals, institutions, countries, research highlights and tendencies. It helps to picture the panorama of breast reconstruction research, and guide the future research work.

Tumescent technique versus electrocautery mastectomy: A randomized controlled trial.

BACKGROUND: Breast cancer is the most common cancer in Danish women. In 2016 about 1450 (31%) Danish breast cancer patients had a mastectomy. The aim was to compare the frequency of postoperative complications in two methods of surgery, electrocautery dissection and tumescent technique, when performing a mastectomy. METHODS: Open randomized controlled trial of all consecutive primary breast cancer or DCIS female patients who underwent either a simple mastectomy or a modified radical mastectomy in Vejle Hospital, from January 2012 to October 2017. Primary outcomes were seroma production, bleeding, infection and necrosis. Secondary outcomes were duration of surgery and delay of adjuvant treatment caused by complications. Categorical outcome variables were compared between randomization groups using chi-square of Fisher exact test and continuous outcome variables by using Wilcoxon rank test. All analyses were performed at a 5% two-sided significance level. RESULTS: 357 patients met the inclusion criteria. 14 had bilateral mastectomy, i.e. 371 breasts. The two randomization groups consisted of 105 patients/107 breasts operated by tumescent technique and 98 patients/102 breasts operated by electrocautery technique. Tumescent technique produced more seroma though not significant (p = 0.631) (mean 605 vs. 630 ml). Bleeding in the tumescent group was 10.3% vs. 5.9% in the electrocautery group (p = 0.245). Infection (5.9% vs. 7.5% p = 0.645) and necrosis (4.9% vs. 4.7% p = 0.938) was uncommon with no difference between the intervention groups. Infection was most common cause of delay of adjuvant treatment; 3.9% in the electrocautery technique group. No significant difference in duration of surgery (p = 0.392). CONCLUSION: Both techniques are equally safe for simple and modified radical mastectomy.

A simple clinical assessment of breast animation deformity following direct-to-implant breast reconstruction.

BACKGROUND: A high incidence of breast animation deformity (BAD) has been reported following immediate breast reconstruction with subpectorally placed implants. The aim of this study was to assess and compare the incidence of BAD in women who underwent either subpectoral or prepectoral immediate breast reconstruction. Therefore, we developed a grading tool and tested its reproducibility in a clinical setting. METHODS: Video recordings of 37 women who had undergone unilateral or bilateral immediate breast reconstruction were evaluated by two consultant plastic surgeons. The degree of BAD was assessed by our grading tool, named the Nipple, Surrounding Skin, Entire Breast (NSE) grading scale, which evaluates the degree of tissue distortion in three areas of the breast. Blinded assessments were performed twice by each observer. RESULTS: Eighteen patients were reconstructed with subpectoral implant placement and 19 with prepectoral implant placement. Using the NSE grading scale, we found a significant difference in the degree of BAD between the groups, in favor of patients who underwent prepectoral immediate breast reconstruction (0.2 vs. 4, P=0.000). Inter- and intraobserver agreement was moderate (74%) to strong (88%). CONCLUSIONS: The incidence and severity of BAD was significantly lower in women reconstructed with a prepectorally placed implant than in those who underwent subpectoral immediate breast reconstruction. All patients reconstructed using the subpectoral technique had some degree of BAD. The inter- and intraobserver agreements were high when using the NSE grading scale, suggesting it is an easy-to-use, reproducible scale for assessing BAD in women who undergo immediate breast reconstruction.

Visualized bilateral breast reconstruction by propeller thoracodorsal artery perforator flaps.

Thoracodorsal artery perforator (TAP) flaps are versatile flaps that provide a consistent and aesthetically pleasing breast reconstruction. We prefer the TAP flap to the latissimus dorsi (LD) flap due to the morbidity associated with the LD flap. In this paper we aim to show how we perform bilateral TAP flap breast reconstruction and present our preliminary results from 32 bilateral reconstructions in 16 patients. The TAP flap breast reconstruction can be performed as a direct-to-implant or a delayed procedure depending on patient factors. Color Doppler ultrasonography (CDU) is used in the preoperative planning which promotes the safety and reliability of the flap by mapping perforators thus enabling faster dissection. The bilateral TAP flap breast reconstruction is usually performed in three steps: (I) raising the flaps at the recipient site; (II) rotating the TAP flaps and (III) completion of the breast reconstruction.