Complications in unilateral versus bilateral deep inferior epigastric artery perforator flap breast reconstructions: A multicentre study.

BACKGROUND: The deep inferior epigastric artery perforator (DIEP) flap is the first choice for autologous breast reconstruction. The aim of this retrospective cohort study was to analyse the recipient- and donor-site complications and compare them between unilateral and bilateral DIEP flap breast reconstructions. METHODS: Between January 2010 and December 2014, 530 DIEP flap reconstructions were performed in 426 consecutive patients in three Dutch hospitals. Major and minor complications were categorised into recipient- and donor-site complications. Post-operative flap re-explorations were recorded. RESULTS: Of the total 530 DIEP flap reconstructions performed (322 unilateral, 104 bilateral), recipient-site complications were major in 9.8% and minor in 20.2%. The patients developed fat necrosis (unilateral 14.0% vs. bilateral 7.7%; OR 1.950; 95% CI 1.071-3.550; p = 0.027) and infection (unilateral 5.6% vs. bilateral 1.9%; OR 3.020; 95% CI 1.007-9.052; p = 0.039) at the recipient site significantly more frequently in the unilateral DIEP flap reconstructions. The donor-site complications were major in 0.9% and minor in 19.5% of the cases. Body mass index (BMI) was significantly associated with complications (donor site: OR 1.137; 95% CI 1.075-1.201; p < 0.001, recipient site: OR 1.073; 95% CI 1.009-1.142; p = 0.026). Flap re-explorations were performed in 5.7% (n = 30) of the cases. Total flap loss occurred in 3.0% (n = 16) of the cases. CONCLUSIONS: Bilateral DIEP flap breast reconstructions can be performed with the same percentage of complications and re-explorations as unilateral reconstructions and even result in less fat necrosis and infection at the recipient site. Higher BMIs are significantly associated with recipient- and donor-site complications.

Improving the effect of shear on skin viability with wound dressings.

BACKGROUND: Pressure ulcers are a major healthcare problem and caused by pressure and shear-forces. Although shear-force is understood to be a major contributing factor, no preventive interventions are specifically aimed at relieving the effect of shear on skin to improve skin viability. METHODS: A physical model was used to apply a combined loading of 2.4kPa pressure and 14.5N shear-force on skin in humans. Loading was applied on the volar aspect of both forearms for 30min in ten healthy volunteers. One arm received loading on skin with a wound dressing, the other arm (control) received loading directly on skin. The following parameters were determined before and after loading: IL-1α/Total Protein-ratio (used as a measure of skin damage); Cutaneous blood cell flux ((CBF) measure of reactive hyperaemia); Lactate concentration (measure of tissue ischemia). Three different dressings were tested on three different days. The order of dressing application, dressing arm and start of the intervention were randomized. RESULTS: Participants mean age was 22.5±1.6 year with a BMI of 22.3±2.4kg/m(2). IL-1α/Total Protein-ratio of the skin was significantly lower after the application of pressure and shear when the Mepilex® (P<0.01), Allevyn (P<0.05) or Aquacel(TM) dressing (P<0.01) was used compared with the control measurement. The Mepilex® dressing was more effective in reducing post-load IL-1α/Total Protein-ratio compared to the Allevyn dressing (P<0.01). Post-load CBF was significantly lower when the Mepilex® or Aquacel dressing was used (P<0.001). Both dressings induced significantly less post-load CBF than the Allevyn dressing (P<0.01 and P<0.001, respectively). The concentration of lactate was not significantly increased after the application of pressure and shear and could not be used as a measure with this model. CONCLUSION: This is the first in vivo study to demonstrate that the effects of pressure in combination with shear on skin viability can be improved with foam dressings. In this study, the multi-layered dressings perform better than the single-layered dressing.

Biomechanical Properties of the Skin in Patients with Breast Cancer-Related Lymphedema Compared to Healthy Individuals.

BACKGROUND: Biomechanical skin changes in breast cancer-related lymphedema (BRCL) have barely been described and objectively tested. This study aims to compare the skin of upper limb lymphedema with skin of the healthy contralateral arm, in order to demonstrate changes of elasticity, viscoelasticity, and level of hydration of the skin in BCRL. The secondary aim is to investigate the correlation between biomechanical skin changes and measurements that are currently used in clinical practice, such as volume measurement and lymph-ICF score. METHODS AND RESULTS: Eighteen patients with BCRL and 18 healthy individuals were included in the study. A Cutometer® was used for measurements for skin elasticity and viscoelasticity on both arms of each subject. A Corneometer® was used for measurements of skin hydration. Measurements of both test groups were compared. In BCRL patients, there was a significant difference (p = < 0.028) between the elasticity of the skin of the lymphedema arm compared to the healthy contralateral arm. There were no significant differences for level of skin hydration or viscoelasticity in lymphedema patients between the measurements on the skin of the lymphedematous and healthy arm. In healthy individuals, there were no significant differences for all measurements between skin of both arms. Spearman's correlation was significant (p = < 0.01) for difference in volume and difference in elasticity in BCRL patients. CONCLUSION: This study shows an impaired elasticity for the skin of the lower arm in patients with lymphedema compared to the contralateral healthy arm. Promising evidence is suggested for the use of the Cutometer device in the diagnostic evaluation of BCRL.