Indocyanine green angiography in oncoplastic breast surgery, a prospective study.

INTRODUCTION: The use of Indocyanine green angiography (ICG-A) in oncoplastic breast-conserving surgery (OBCS) has not yet been investigated. This prospective trial applied ICG-A in volume displacement and replacement OBCS to localize perforators and determine tissue supplied by the perforator. Furthermore, to investigate and correlate the intraoperative ICG-A to postoperative surgical site infection, skin necrosis, epidermolysis, and timely onset of adjuvant therapy. METHODS: ICG-A was performed at three pre-set timepoints during surgery; after lumpectomy, upon dissection of possible perforators, and after wound closure. All patients were followed with clinical evaluations before surgery, 4 weeks, 4-6 months, and 12 months postoperatively. RESULTS: Eleven patients were included: seven volume displacement and four volume replacement OBCS. ICG-A located the tissue supplied by the perforator and demonstrated sufficient perfusion in all cases. The ICG-A corresponded to the surgeons' clinical assessment. One patient developed a postoperative infection and seroma and was treated conservatively. No patients had postoperative necrosis, loss of reconstruction, or lymphedema of the arm. Edema of the breast occurred in four patients (36.4%). Scar assessments were significantly worse at 4-weeks and 4-6 months. The quality of life improved significantly during follow-up. Adjuvant treatment was administered timely in all cases. CONCLUSION: ICG-A was feasible for OBCS in assessing intraoperative perfusion. Perfusion was sufficient in all patients and corresponded to the surgeon's clinical evaluation. No patients developed postoperative necrosis. Though edema of the breast occurred in 36.4%, a larger sample size is needed to investigate a possible correlation with ICG-A. Further studies, which includes patients requiring extensive tissue replacement challenging the borders of perfusion, are needed.

[Corrosions and frostbites].

Thermal burns are by far the most frequent and account for approx. 90% of all burns, while frostbites, chemical and electrical burns (CB) cover the remaining approx. 10%. This review gives an overview of the treatment of corrosions and frostbites. CB and frostbites are relatively rare and prompt initiation of proper treatment is essential for both. CB should be diluted as soon as possible, preferably with a neutralizing solution. Treatment of systemic hypothermia comes before management of peripheral frostbite. Frostbites involve thawing in warm water, followed by vasodilation, thrombolysis and amputation if indicated.

Study protocol for a 10-year prospective observational study, examining lymphoedema and patient-reported outcome after breast reconstruction.

INTRODUCTION: Over the last decades, treatment of breast cancer has become increasingly more effective. Consequently, an increasing number of women are living with late effects of breast cancer treatment, including disfiguring scars, deformity or asymmetry of the breast, secondary lymphoedema and other physical and psychosocial late effects. Data from this study will provide knowledge on how to guide breast reconstruction in the future towards outcomes with fewer complications, higher long-term quality of life (QoL) and satisfaction with the aesthetic outcome. The development of secondary lymphoedema, for which the effect of breast reconstruction has yet to be established, will be thoroughly examined. METHODS AND ANALYSIS: Women receiving breast reconstruction (autologous and implant based) at the Department of Plastic Surgery and Burns Treatment, Rigshospitalet, will be invited to participate. The patients will be followed for 10 years postoperatively. Demographic, health-related, oncological characteristics and treatment data will be registered. Validated assessment tools, such as the BREAST-Q and Beck Depression Inventory, will be used to measure an extensive range of clinical outcomes, including QoL, life and aesthetic satisfaction and depression. Arm range of motion will be measured with a goniometer and lymphoedema by bioimpedance spectroscopy, compared with circular arm measurements. ETHICS AND DISSEMINATION: This study will be conducted according to the 5th version of the Helsinki Declaration. The regional ethical committee for Capital Region Denmark did not find the study notifiable, according to the law of the committee § 1, part 4. All data will be anonymised before its publication. This study will be conducted according to the Danish data protection regulation and is catalogued and approved by the Capital Region Head of Knowledge Centre. According to the Danish health law § 46, part 2, this study does not need the Danish Patient Safety Authority's approval. The findings of this study will be submitted to international peer-reviewed journals.

Use of Indocyanine Green Angiography decreases the risk of complications in autologous- and implant-based breast reconstruction: A systematic review and meta-analysis.

INTRODUCTION: Indocyanine Green Angiography (ICG-A) is an imaging technique used to visualize tissue perfusion in real time. The aim of this systematic review and meta-analysis is to evaluate all published papers on breast reconstruction using ICG-A, which provides information on complication rates and to investigate whether the use of this peroperative method decreases the risk of complications. MATERIALS AND METHODS: MEDLINE/PubMed, EMBASE, Cochrane, and UpToDate were searched using relevant terms. The literature was assessed using the PRISMA guidelines. Inclusion criteria were: original articles written in English assessing ICG-angiography in breast reconstruction. The individual studies were evaluated according to Cochrane guidelines. RESULTS: The search yielded 243 papers on ICG-A and breast reconstruction. Twenty-six of these were included for analysis. The risk of overall major complications ([OR] = 0.53, 95% confidence interval (CI) = 0.43-0.66, p = 0.00001) and overall loss of reconstruction ([OR] = 0.58, 95% CI = 0.37-0.92, and p = 0.020) was significantly lower when peroperative ICG-A was used. When using ICG-A to evaluate mastectomy flaps, a statistically lower risk of major complications ([OR] = 0.56 and p = 0.0001) and the loss of reconstruction was found ([OR] = 0.46, p = 0.006). ICG-A used in autologous breast reconstruction significantly reduced the risk of minor ([OR] = 0.62 and p = 0.001) and major complications ([OR] = 0.53 and p = 0.0028). CONCLUSIONS: This is the first systematic review to analyze the use of ICG-A on both mastectomy flaps and autologous reconstruction. The results obtained in the current study indicate that the use of ICG-A in breast reconstructive procedures reduces the complications as well as the loss of reconstruction.

[Reconstruction by means of fillet flaps].

The purpose of this review is to summarise the literature and provide an overview of the topic and use of fillet flaps. Large and complex defects remain a reconstructive challenge balancing the benefits of reconstruction against donor-site morbidity. The spare-part concept involves using parts of amputated, non-salvageable or intact tissue for reconstruction. Fillet flaps are axial pattern flaps and can be harvested as pedicled-, island- or free flaps. Using fillet flaps for reconstruction is a valuable tool to obtain reconstruction in a one-stage procedure while minimising donor-site morbidity.

[Dercum's disease].

Dercum's disease is a rare disease, which mainly affects women and has an unknown prevalence and aetiology. The disease is characterised by generalised obesity and more than three-month painful subcutaneous adipose tissue not responding to usual pain treatment. A suggested classi-fication of the disease includes four types: generalised diffuse, generalised nodular, localised nodular and juxta-articular. Diagnosis is one of exclusion, and treatment includes medical and surgical options with the aim of pain palliation and increased mobility and function.

[Fillet flap used for reconstruction after hemipelvectomy and amputation of a lower extremity].

In this case report, a 67-year-old woman presented with increasing pain in the left side of the thigh and pelvis. A PET scan revealed a large malignant tumour in the left side of the pelvis and proximal left femur, and an ultrasound-guided biopsy diagnosed an undifferentiated pleomorphic sarcoma. Combined orthopaedic and plastic surgery resulted in a left-sided hemipelvectomy and amputation of the left leg. The amputated left leg was used as a free fillet flap for reconstruction of the pelvis. The patient healed without complications, and seven months post-operatively she was able to use a prosthesis.

The Danish translation and validation of the Berlin Questionnaire for sleep apnoea.

INTRODUCTION: Obstructive sleep apnoea (OSA) is an increasing health problem related to cardiovascular disease, poor quality of life, daytime sleepiness and un-restorative sleep with an estimated prevalence up to 20% in the adult population. Approximately 82% of men and 93% of women with moderate to severe OSA remain undiagnosed. Relevant, fast, accurate and cost-effective screening methods are essential. The aim of this study was to translate and validate the Danish version of the Berlin Questionnaire (BQ), and to investigate if the questionnaire can be used for screening of OSA in a Danish population. METHODS: The BQ was translated into Danish according to guidelines producing the Danish Berlin Questionnaire (DBQ). The study population included 206 adult patients referred to the Sleep Clinic of Zealand University Hospital, Denmark, on suspicion of OSA. RESULTS: 69.4% were males, 53.3% were obese (BMI > 30), the mean BMI was 32.01. A total of 135 patients had hypertension (65.5%). Apnoea/hypopnoea Index (AHI) ≥ 15 was present in 141 of 206 patients (68.4%). We observed a sensitivity of the DBQ of 84% and a positive predictive value of 69%. CONCLUSIONS: We have successfully translated and partially validated the DBQ for OSA. Our study showed that the DBQ is useful for screening of Danish patients suspected of OSA. Further studies with improved screening methods and further development of questionnaires are recommended. FUNDING: none. TRIAL REGISTRATION: The study was approved by the Danish Data Protection Agency.

Breastfeeding difficulty after polyacrylamide hydrogel (PAAG) mediated breast augmentation.

INTRODUCTION: Breast augmentation using polyacrylamide hydrogel (PAAG) has been routinely used in the past as a minimal invasive procedure. However, several patients undergoing this procedure have started to report complications. We report a case of breast augmentation using PAAG leading to a delayed infection and breastfeeding complication. CLINICAL CASE: A 36-year-old Danish female who was treated with PAAG fifteen years earlier, presented with difficulty in breastfeeding and fistulation. Clinical evaluation revealed structural deformity of the right breast and a 5×5mm skin defect. Mammography showed diffuse microcalcification density grade 4. Ultrasound and MRI displayed inhomogeneous gelatinous material in both breasts diffused into the pectoralis major muscle. Initial management involved aspiration of the material. The patient developed infection and was subjected to modified radical debridement removing the PAAG. The patient healed without any further complications. DISCUSSION: The prevalence of PAAG mediated breast augmentation related complications are increasing. The most prominent complication being late infections, breast hardening and subsequent breastfeeding difficulties. In this case, the difficulty in breastfeeding was induced by the PAAG within the breast tissue. The inhomogeneous gelatinous material was surgically removed leading to complete remission. CONCLUSION: Long-term complications, among others breast feeding difficulty, in women treated with PAAG are increasing and need appropriate management strategy. PAAG mediated breast augmentation may cause irreversible damage to the breast in healthy women necessitating complex debridement.

[Turban tumour with intracranial invasion].

This is a case report of a 76-year-old woman, who had Brooke-Spiegler syndrome (BSS) and presented with multiple confluent tumours of the scalp. An MRI showed an intracranial invasion. Multiple excisions were made due to recurrence of the intracranial tumour, and reconstruction was achieved with free flaps and skin grafts. BSS is caused by a mutation in CYLD, a tumour suppressor gene located on chromosome 16q12-q13. Surgical excision is often not a curative treatment, and the recurrence rate is 35%. Quality of life is significantly affected with regards to cosmetic appearance, painful tumours and multiple surgical treatments.

Validation of the Danish STOP-Bang obstructive sleep apnoea questionnaire in a public sleep clinic.

INTRODUCTION: Obstructive sleep apnoea is common; a prevalence of 1-5% was previously reported. However, only few cases are diagnosed and receive treatment. The aim of this study was to validate the Danish translated version of the STOP-Bang screening tool for obstructive sleep apnoea (OSA) in a public sleep clinic. 
 METHODS: A study population of 208 patients who were referred to a public sleep clinic on suspicion of OSA were assessed with the STOP-Bang questionnaire and at-home cardiorespiratory monitoring in order to assess the quality of the questionnaire as an OSA screening tool. 
RESULTS: In the study population, 73% were males, and 51% of the population had an Apnoea-Hypopnoea Index (AHI) ≥ 15. The STOP-Bang screening tool had a sensitivity of 0.98 for detection of OSA with AHI ≥ 15 and a corresponding specificity of 0.09. Hence, the questionnaire is able to detect almost all patients suffering from OSA. However, using the tool will cause many healthy subjects to be falsely classified as having OSA. 
 CONCLUSIONS: The Danish version of the STOP-Bang screening tool does not seem useful for OSA screening of patients in a sleep clinic setup, but it may be useful in primary care. 
 FUNDING: The Zealand Research Foundation. 
 TRIAL REGISTRATION: not relevant.

[Metformin and surgery before general anaesthesia].

Danish national guidelines recommend discontinuation of metformin 48 h prior to general anaesthesia due to the presumed increased risk of lactic acidosis. By reviewing recent studies concerning the risk of metformin-associated lactic acidosis it is found, that studies indicate, that metformin does not increase the risk of lactic acidosis. However, comorbidities such as cardiovascular insufficiency, sepsis, dehydration and impaired kidney function are risk factors. New guidelines propose discontinuation of metformin on the day of surgery. Patients with Type 2 diabetes and comorbidities should have the levels of arterial pH and lactate monitored.

[Melkersson-Rosenthal syndrome in a young man].

A 24-year-old man presented with orofacial swelling, peripheral facial palsy and fissured tongue. Apart from a previous episode of peripheral palsy, he had no history of illness. Biopsy of the lip, blood tests, magnetic resonance imaging of the head and lumbar puncture showed no pathology. He received systemic prednisone for ten days, and follow-up showed sparse improvement in facial movements. The patient could have been misdiagnosed with Bell's palsy, but the symptoms rather indicated a case of Melkersson-Rosenthal syndrome. This rare syndrome is presenting in oligo- or monosymptomatic forms and is often mistaken for Bell's palsy. There is no existing gold standard of treatment, and different modalities have been considered with no consistent response.