Breast reconstruction after mastectomy.

Patients requesting breast reconstruction after mastectomy is an increasing group at plastic- and breast surgery departments in Denmark. This review summarises the present surgical techniques for reconstruction with/without postoperative chemotherapy and/or radiation therapy. These surgical techniques are continuously updated. The most determining factor when selecting a reconstructive technique, is postoperative radiation therapy. Each patient is unique, and an individual assessment is made when planning surgery. The concept of a "babysitter implant" is currently being investigated in Denmark and might be an option for selected patients.

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.

Erratum to "surgical management of the Tessier 7 cleft: A review and presentation of 5 cases" [JPRAS open. Volume 22, December 2019, pages 9-18].

[This corrects the article DOI: 10.1016/j.jpra.2019.07.004.].

Surgical management of the Tessier 7 cleft: A review and presentation of 5 cases.

INTRODUCTION: Several variations on the surgical technique for macrostomia repair have been described in the literature. There has been controversy regarding the preferred method for commissuroplasty and skin closure for optimal functional and aesthetic results. The aim of this study is to present these techniques and the most described methods up to date.Further, five patients operated with a combination of techniques are presented. MATERIAL AND METHODS: PRISMA guidelines were followed for literature review.Five consecutive patients with unilateral macrostomia operated during a period of one and a half years at our craniofacial department were included in this study. RESULTS: 31 studies on macrostomia repair were obtained. The layered closure technique is widely described with several variations on closure of the inner mucosa, orbicularis muscle, commissure and skin. The inner mucosal layer is in most cases sutured with a straight line closure technique. The muscle is most often duplicated and sutured with upper branches overlapping lower branches. The skin is in most cases sutured with either a z- or a w-plasty with variations.The five presented patients all had satisfactory functional and aesthetic results at follow-up. CONCLUSION: Many variations of surgical techniques for macrostomia repair have been presented in the past. We believe that each case of macrostomia needs to be assessed with a tailored surgical plan in order to create the best results. A combination of different techniques with Bütow and Botha's and Kaplan's technique as a starting point, is believed to give satisfactory functional and aesthetic results.

[Treating scars with lipofilling].

Hypertrophic, keloidal and contracted scars can be cosmetically and functionally debilitating, and by patients this is often perceived as traumatising. Psychological and social impairments are common in these types of scars. Currently, autologous lipofilling, with or without enrichment with stem cells, is performed to improve scar quality. In this review, we evaluate the evidence on lipofilling as a treatment of scars. The literature mainly consists of studies of low-level evidence, i.e. they lack controls and randomisation. Nevertheless, all studies indicate, that lipofilling may improve the quality of scars.

[Amputation of the forefoot in a 14-year-old boy due to infiltrative glomus tumour].

Glomus tumours are rare dermal tumours, which very seldom can be seen viscerally. The majority is benign small tumours of the skin. Malignancy has been reported in very few cases worldwide. The diagnosis is made clinically supported by MRI-scans and biopsy of the lesion. We present a case story of a 14-year-old boy, who had an infiltrative glomus tumour of the foot. The tumour met the criteria for malignancy and was operated radically by amputation of the forefoot. The post-operative period was uncomplicated and no metastases were observed neither clinically nor by PET-CT scans.

Cyclooxygenase-2 inhibitors and free flap complications after autologous breast reconstruction: A retrospective cohort study.

BACKGROUND: A key component of modern analgesics is the use of multimodal opioid-sparing analgesia (MOSA). In the past, our analgesic regime after autologous breast reconstruction (ABR) included either NSAID or a selective cyclooxygenase-2 (COX-2) inhibitor. COX-2 inhibitors are superior to NSAIDs because of the well-known side effects of NSAID treatment (bleeding/gastrointestinal ulcers). However, COX-2 inhibitors have been suggested to increase flap failure rates. We report our experience in using COX-2 inhibitors as part of our post-operative MOSA after ABR using free flaps. MATERIALS AND METHODS: A total of 132 unilateral secondary ABR were performed (DIEP or MS-TRAM) in the NSAID period (2007-2011) and 128 in the COX-2 inhibitor period (2006, 2012-2014). The same surgical team operated all patients. Data were collected prospectively and reviewed to compare the two periods, with special focus on reoperations due to bleeding/haematomas and flap thrombosis/failure. Comparisons between the COX-2 inhibitor and NSAID were made. RESULTS: Median age, ischaemia time, blood loss and operating time were similar in the two periods. Significantly, more patients were re-operated because of post-operative haematoma in the NSAID group (n = 13/132, 9.8%) than in the COX-2 inhibitor group (n = 4/128, 3.1%) (p = 0.02). We found no difference in flap loss rates between the NSAID (n = 2/132, 1.5%) and the COX-2 inhibitor groups (n = 3/128, 2.3%) (p = 0.63). No patients suffered from thromboembolic complications or gastrointestinal bleeding. CONCLUSIONS: Multimodal analgesia using a COX-2 inhibitor is safe in ABR with free flaps and does not increase flap failure. COX-2 inhibitors seem superior to NSAID with reduced risk of post-operative haematomas.

Scientific impact of presentations from the EURAPS and the AAPS meetings: A 10-year review.

INTRODUCTION: Presentation at scientific meetings is the usual first step to communicate new research findings. However, without subsequent, peer-reviewed publication, the wider propagation and the permanent documentation of important scholarly work may be lost. Our aim was to analyze and compare the publication status of the work presented at the European Association of Plastic Surgeons' (EURAPS) and at the American Association of Plastic Surgeons' (AAPS) annual meetings. MATERIALS AND METHODS: By using the abstract booklets from the annual meetings, all presentations given over a 10-year period (2000-2009) were analyzed. A search using PubMed and Google Scholar was performed to obtain publication status of each presentation as of 2014 (observation period: 5 years). Data were analyzed according to subspecialty. Weighted chi-square was used to examine differences in publication rates for the two societies and for English speaking vs. non-English speaking countries. RESULTS: Seventy-two percent (n = 246) of the abstracts from the AAPS were published in peer-reviewed journals. The most published subspecialty was "Craniofacial surgery" followed by "Breast surgery." Mean time to publication was 22.1 months (range -72-111 months). The most common journal for publication was Plastic and Reconstructive Surgery (PRS). Sixty-seven percent (n = 449) of the EURAPS abstracts were published in peer-reviewed journals. The most published subspecialty was "Microsurgery" followed by "Clinical studies." The mean time to publication was 17.3 months (range -67-111 months). The most common journal for publication was PRS. Differences between the two societies' publication status were not observed (p = 0.157), but EURAPS abstracts had a significantly shorter time to publication (p = 0.007). Differences between English-speaking and non-English-speaking countries were not observed (p = 0.931). Mean level of evidence for published studies from the AAPS and the EURAPS meetings was 3.5 and 3.7, respectively. CONCLUSION: A majority of the presented abstracts from both societies have resulted in publication. After "The Society for Cardiothoracic Surgery," AAPS and EURAPS have the highest publication rates for surgical abstracts, indicating a high scientific value of these meetings.

Idiopathic pseudoaneurysm in a patient with breast implants.

Aneurysms and pseudoaneurysms of the internal mammary artery (IMA) are rare and the etiology uncertain although iatrogenic causes have been described. A 64-year-old woman suffered hematoma and bleeding from a pseudoaneurysm probably originating from a branch of the right IMA 16 years after breast implant surgery. After clinical assessment, the patient underwent surgery with resection of the aneurysm and ligation of the arterial branch. No early postoperative complications were reported. Pseudoaneurysms in small vessels such as the IMA or its branches are not well described in the literature. Proper diagnosis with imaging is of importance in order to determine treatment as each case is unique. Some cases can be managed conservatively.

Perioperative Optimization of Autologous Breast Reconstruction.

UNLABELLED: The authors recently showed that fast-track surgery could reduce the length of stay after a deep inferior epigastric perforator flap procedure from 7.4 days to 6.2 days without increasing complication rates or flap loss. This study improves the protocol and identifies specific factors that kept patients in the hospital. The authors present their results from the first 16 consecutive cases. Multimodal opioid-sparing analgesia was used. Nurses removed suction drains, without consulting the doctors. Fulfillment of functional discharge criteria (e.g., flap monitoring, ambulation) was assessed twice daily, and specified reasons for not allowing discharge were registered. All patients were discharged to home after approximately 72 hours, on the third postoperative day, except one patient who was discharged on day 4. Drains were removed on postoperative day 2 (n = 3) or 3 (n = 13). All patients had normal gastrointestinal tract function and minimal pain, and were eating and managing personal hygiene on the morning of postoperative day 2. All were mobilized by the afternoon of postoperative day 2. Median visual analogue scale score at discharge was 1 (range, 0 to 4). There were no reoperations and no major complications. Length of stay after autologous breast reconstruction using deep inferior epigastric perforator flaps can be reduced to approximately 3 days using the fast-track methodology. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Introducing the fast track surgery principles can reduce length of stay after autologous breast reconstruction using free flaps: A case control study.

INTRODUCTION: The concept of fast-track surgery (FTS) is a peri- and postoperative care concept developed to reduce length of hospital stay (LOS) and morbidity after surgery. FTS programmes have been reported from other surgical specialities, but there are few reports of FTS in plastic surgery. MATERIALS AND METHODS: Autologous breast reconstructions have been performed with abdominal free flaps since 1994. In 2006, an FTS program was introduced. Important changes in procedure were: early mobilisation, fewer/faster removal of drains and urinary catheter, discontinuation of epidural analgesia, planned early discharge, and multimodal opioid-sparing analgesia. The results from all unilateral, breast reconstructions in the first 5 years after the implementation of the FTS (n = 177) were compared to results prior to the FTS (n = 292). Flap type, operating time, blood loss and ischaemic time, LOS, early flap related and systemic complications (< 30 days) were analysed. RESULTS: FTS significantly reduced mean LOS from 7.4 days to 6.2 days (p = 0.0002). When compared to pre-FTS results, similar flap types, operating time, blood loss and ischaemic time were found. LOS > 7 days were due to complications, the most common being haematoma. Prevalence of complications (6.5 vs 7.9%) and flap loss (2 vs 2%) did not increase. Haematomas seemed more frequent with the use of NSAID than with COX-2 inhibitors (9 vs 4%); however, the difference was not statistically significant. CONCLUSION: By introducing a simple, peri- and postoperative care concept it is possible to reduce LOS after microsurgery by at least 1 day without an increase in complications or flap loss.

Role of endocrine disrupting chemicals in the occurrence of benign uterine leiomyomata: special emphasis on AhR tissue levels.

Although benign uterine leiomyomata (LMA) is the most common reproductive tumor in premenopausal women, its etiology is largely unknown. We aimed in the present study to demonstrate the potential role of environmental factors with estrogenic activity in tumor etiology by focusing on the role of aryl hydrocarbon receptor (AhR) which mediates the effects of many environmental endocrine disruptors and contributes to the loss of normal ovarian function in polluted environments. This case-control study aimed to compare the interactions between AhR and lifestyle factors in a clinical setting for the first time among 138 newly diagnosed LMA patients and 138 normal controls who lived in Tehran and Mashhad, respectively, during the last 10 years. To conduct immunohistochemical studies using appropriate monoclonal antibodies, 30 cases were selected retrospectively from 2009-2011 from the pathology departments of two university hospitals in Tehran. Although the levels of sex steroid receptors were similar in adjacent myometrium and uterine leiomyomas of all cases, AhR was significantly overexpressed (p=0.034, OR=1.667) in uterine LMA and this overexpression was correlated with living in Tehran [(p=0.04, OR=16 (1.216-210.58)], smoking[P=0.04, OR=2.085 (1.29-3.371)], living near polycyclic aromative hydrocarbon producing companies [p=0.007, OR=2.22 (1.256-3.926)] and eating grilled meat [p=0.042, OR=1.28 (1.92-3.842)]. Our study contributes to the understanding of the effects of EDCs on AhR levels as well as women's health and points out possible risk factors for the development and growth of uterine LMA. It seems that the development of LMA could be the result of interactions between hormonal and environmental factors.