Common practices in patient care after mammaplasty and perioperative safety measures to prevent thromboembolic events - An observational study across all continents.

BACKGROUND: Most plastic surgeons have encountered complications related to venous thromboembolism in their profession. However, considerable deficits in risk assessment and prophylaxis have been described. As outpatient procedures are increasing, so are concerns with regard to patient safety. The presented study investigates the global distribution pattern of patient care for mammaplasties and compares international common practices of perioperative safety measures to prevent thromboembolic events. METHODS: A questionnaire was sent to over 5000 plastic surgeons in 77 countries. The survey inquired about surgeon demographics, standard perioperative safety measures, type of thrombosis prophylaxis, and international patterns of patient care. The results were evaluated and correlated with the evidence-based literature. RESULTS: A total of 1431 surveys were gathered (response rate: 29%). The gathered data show international disparity with regard to inpatient vs. outpatient care. Mammaplasties in the USA are being performed as same-day surgeries in > 80% of cases, while globally inpatient and outpatient procedures are distributed evenly. Also, we found no international consensus with regard to safety measures to prevent thromboembolic events. Geographical regions showed differences with regard to type, dosage, timing, and duration of thrombosis prophylaxis. CONCLUSIONS: International practice patterns remain incoherent. This highlights the need for coherent and detailed global guidelines for plastic surgical interventions. High-quality studies are needed in order to establish evidence-based, standardized, and universally applicable practice guidelines.

Uni-vs. bilateral DIEP flap reconstruction - A multicenter outcome analysis.

OBJECTIVE: Over the past decade numbers of bilateral mastectomy have increased steadily. As a result, bilateral breast reconstruction is gaining popularity. The presented study compares complications and outcomes of unilateral and bilateral DIEP free-flap breast reconstructions using the largest database available in Europe. METHODS: Female breast cancer patients (n = 3926) receiving DIEP flap breast reconstructions (n = 4577 free flaps) at 22 different centers were included in this study. Free flaps were stratified into two groups: a unilateral- (UL) and a bilateral- (BL) breast reconstruction group. Groups were compared with regard to surgical complications and free flap outcome. RESULTS: Mean operative time was significantly longer in the BL group (UL: 285.2 ± 107.7 vs. BL: 399.1 ± 136.8 min; p < 0.001). Mean ischemia time was comparable between groups (p = 0.741). There was no significant difference with regard to total (UL 1.8% vs. BL 2.6%, p = 0.081) or partial flap loss (UL 1.2% vs. BL 0.9%, p = 0.45) between both groups. Rates of venous or arterial thrombosis were comparable between both groups (venous: UL 2.9% vs. BL 2.2%, p = 0.189; arterial: UL 1.8% vs. BL 1.2%, p = 0.182). However, significantly higher rates of hematoma at the donor and recipient site were observed in the UL group (donor site: UL 1.1% vs. BL 0.1%, p = 0.001; recipient site UL 3.9% vs. BL 1.7%, p < 0.001). CONCLUSIONS: The data underline the feasibility of bilateral DIEP flap reconstruction, when performed in a setting of specialized centers.

Impact of body mass index on free DIEP flap breast reconstruction: A multicenter cohort study.

INTRODUCTION: Several patient-related factors have been identified with regard to the safety and efficacy of breast reconstructions. This study analyzed the largest series of microsurgical breast reconstructions in Germany using deep inferior epigastric perforator (DIEP) flaps, with a focus on the impact of patient body mass index (BMI). PATIENTS AND METHODS: A total of 3911 female patients underwent 4561 free DIEP flap breast reconstructions across 22 different centers. The cases were divided into five groups using World Health Organization BMI criteria: underweight group (BMI <18.5 kg/m2), normal weight/ control group (BMI: 18.5-24.9 kg/m2), overweight group (BMI: 25-29.9 kg/m2), moderately obese group (BMI: 30-34.9 kg/m2), and severely obese group (BMI ≥ 35 kg/m2). Surgical complications were accounted for and the five BMI groups were then compared. RESULTS: Overall, there was no significant difference regarding the rate of partial- and total flap loss between all BMI groups (p > 0.05). However, overweight and obese patients showed significantly higher rates of postoperative infections at the donor and recipient sites than the control group (donor site infections: overweight 0.6%; moderately obese 0.9%; severely obese 2.4% vs control 0.1%; all p<0.01; recipient site infections: overweight 0.5%; moderately obese 0.8%; severely obese 1.4% vs control 0.1%; all p < 0.05). The rate of medical complications also differed significantly between groups, with the highest rates in moderately and severely obese women (moderately obese: 8.4%; severely obese: 13.0% vs. control: 5.1%; p < 0.01). CONCLUSION: Our findings suggest that successful free tissue transfer can be achieved even in an underweight and severely obese population with acceptable risk for complications.

Immediate versus secondary DIEP flap breast reconstruction: a multicenter outcome study.

PURPOSE: Immediate breast reconstruction (IBR) at the time of mastectomy is gaining popularity, as studies show no negative impact on recurrence or patient survival, but better aesthetic outcome, less psychological distress and lower treatment costs. Using the largest database available in Europe, the presented study compared outcomes and complications of IBR vs. delayed breast reconstruction (DBR). METHODS: 3926 female patients underwent 4577 free DIEP-flap breast reconstructions after malignancies in 22 different German breast cancer centers. The cases were divided into two groups according to the time of reconstruction: an IBR and a DBR group. Surgical complications were accounted for and the groups were then compared. RESULTS: Overall, the rate of partial-(1.0 versus 1.2 percent of cases; p = 0.706) and total flap loss (2.3 versus 1.9 percent of cases; p = 0.516) showed no significant difference between the groups. The rate of revision surgery was slightly, but significantly lower in the IBR group (7.7 versus 9.8 percent; p = 0.039). Postoperative mobilization was commenced significantly earlier in the IBR group (mobilization on postoperative day 1: 82.1 versus 68.7 percent; p < 0.001), and concordantly the mean length of hospital stay was significantly shorter (7.3 (SD3.7) versus 8.9 (SD13.0) days; p < 0.001). CONCLUSION: IBR is feasible and cannot be considered a risk factor for complications or flap outcome. Our results support the current trend towards an increasing number of IBR. Especially in times of economic pressure in health care, the importance of a decrease of hospitalization cannot be overemphasized.

Augmented reality of indocyanine green fluorescence in simplified lymphovenous anastomosis in lymphatic surgery.

BACKGROUND: A physiological and minimal invasive form of surgery with minimal risk to treat lymphedemas is the so-called supermicrosurgical lymphovenous anastomosis (LVA) where a lymph vessel is connected with a venule. METHODS: 30 patients (between 2018 and 2019) with secondary upper extremity lymphedema refractory to conservative therapy (manual lymph drainage and compression therapy were operated using the "simplified lymphovenous anastomosis" method). For the assessment of lymphatic supermicrosurgery, an operating microscope in which a near-infrared illumination system is integrated (Leica M530 OHX with glow technology ULT530, Leica Microsystems) and the IC-FlowTM Imaging System(Diagnostic Green)/Visionsense System (Medtronic) together with a ZEISS S8 microscope was used. Augmented reality intraoperative indocyanin green (ICG) lymphography-navigated modified "simplified lymphovenous anastomosis" were performed on the Leica microscope. All patients were informed about Off-label-use of ICG lymphography. RESULTS: 57 LVAs were performed with modified "simplified lymphovenous anastomosis" lymphography-guidance on 30 upper extremities. All patients showed good patency after lymphovenous anastomosis. CONCLUSIONS: Supermicrosurgery in the case of LVA is minimally invasive, highly effective, and shows a very low complication rate. The surgeon/equipment-related factors restrict the pratice of LVA, and its effectiveness limited by technical constraints.

Impact of intraoperative use of vasopressors in lower extremity reconstruction: Single centre analysis of 437 free gracilis muscle and fasciocutaneous anterolateral thigh flaps.

BACKGROUND: While complication rates in free tissue transfers have continuously decreased over time due to improved techniques, the intraoperative use of vasopressors and their negative effects on flap microcirculation and patency of the anastomoses remains controversial. To further elucidate this matter, this retrospective study examines the effect of intraoperative vasopressors on free gracilis muscle and free fasciocutaneous anterolateral thigh (ALT) flaps for lower extremity reconstruction. METHODS: A total of 425 patients underwent 437 free flaps for lower limb reconstruction. The series was divided into two groups: use of intraoperative vasopressors (V, n = 318) or no use (NV, n = 119). The data were retrospectively screened for patients' demographics, perioperative details, and surgical complications. RESULTS: The two groups were comparable regarding patient comorbidities. Independently of flap type, there were no significant difference between the groups regarding major complications, i.e. total flap loss (V: 5.35% versus NV: 5.04%, p = 0.899) or revision rate (V: 18.87% versus NV: 12.61%; p = 0.122), or minor complications, i.e. partial flap loss (V: 6.29% versus NV: 5.88%, p = 0.875). CONCLUSION: This study confirms that the usage of intraoperative vasopressors has no influence on free flap survival rate in lower extremity reconstruction. It seems to be no difference between free muscle or fasciocutaneous flaps.

[A critical analysis of perception of plastic surgery in Germany]. / Kritische Perzeptionsanalyse der plastischen Chirurgie in Deutschland.

BACKGROUND AND OBJECTIVES: Plastic surgery includes a broad range of activities; however, there are no studies available in Germany which evaluated the specific role plastic surgeons play in providing patient care. The aim of the project was thus to analyze the public and professional perception of plastic surgery in Germany and to what degree the range of activities is appropriately represented. MATERIAL AND METHODS: An anonymous survey inquiring about demographic data and specific knowledge regarding plastic surgery procedures was conducted in various regions in German. Furthermore, factors that potentially influence the state of knowledge and personal perception were collated. The questionnaire was distributed among healthcare professionals and patients in plastic surgery. The statistical evaluation was performed using SPSS software. RESULTS: A total of 2100 people participated in the nationwide survey. While classical aesthetic operations were mostly assigned to plastic surgery, there was no uniformity as to whether other indications, such as reconstructive interventions and hand surgery were assigned to this specialty or not. In this context various factors could be elucidated, such as the place of residence, education and age of the survey participants and the respective knowledge, which influence the perception. CONCLUSION: Plastic surgery in Germany classically consists of the four pillars of general reconstruction, hand surgery, burn management and aesthetic procedures; however, the results of this survey revealed that plastic surgery in Germany is predominantly understood as burn management and aesthetic surgery. As a multidisciplinary specialty, plastic surgery could apparently benefit from a more positive lobby and from a better portrayal of its scope in the media and general public.

Presentation of a variation of the chorioallantoic membrane set up as a potential model for individual therapy for squamous cell carcinoma of the oropharynx.

The chorioallantoic membrane of fertilized chicken eggs in an early phase of breeding presents an approved test situation for the growth and treatment of human cancer cells.These models work due to the inoculation of cells into the membrane that stays within the egg shell during the time of investigation. In this study a modification of this model is presented. Samples of native tumors, rather than cell lines, are transplanted into the membrane and the body of the egg is taken out of the shell and placed in a plastic bowl. These modifications lead to an enhanced accessibility to the chorioallantoic membrane and the surrounding vessels thus facilitating intra venous access and application of pharmaceuticals and a focused radiotherapy. With the current modifications the embryo was kept alive and additionally, the vascularized tumor environment was preserved.

Beard reconstruction: A surgical algorithm.

BACKGROUND AND AIM: Facial defects with loss of hair-bearing regions can be caused by trauma, infection, tumor excision, or burn injury. The presented analysis evaluates a series of different surgical approaches with a focus on male beard reconstruction, emphasizing the role of tissue expansion of regional and free flaps. METHODS: Locoregional and free flap reconstructions were performed in 11 male patients with 14 facial defects affecting the hair-bearing bucco-mandibular or perioral region. In order to minimize donor-site morbidity and obtain large amounts of thin, pliable, hair-bearing tissue, pre-expansion was performed in five of 14 patients. Eight of 14 patients were treated with locoregional flap reconstructions and six with free flap reconstructions. Algorithms regarding pre- and intraoperative decision making are discussed and long-term (mean follow-up 1.5 years) results analyzed. RESULTS: Major complications, including tissue expander infection with the need for removal or exchange, partial or full flap loss, occurred in 0% (0/8) of patients with locoregional flaps and in 17% (1/6) of patients undergoing free flap reconstructions. Secondary refinement surgery was performed in 25% (2/8) of locoregional flaps and in 67% (4/6) of free flaps. CONCLUSION: Both locoregional and distant tissue transfers play a role in beard reconstruction, while pre-expansion remains an invaluable tool. Paying attention to the presented principles and considering the significance of aesthetic facial subunits, range of motion, aesthetics, and patient satisfaction were improved long term in all our patients while minimizing donor-site morbidity.