The difference in local, regional and distant breast cancer recurrence between the immediate and delayed DIEP flap procedure; a retrospective cohort study.

PURPOSE: It has been hypothesized that autologous breast reconstruction can cause reactivation of dormant micro metastases by its extensive tissue trauma, influencing the risk of breast cancer recurrence. However, about the specific effect of timing on breast cancer recurrence in the deep inferior epigastric perforator (DIEP) flap reconstruction is not much known. In this study the rate of local, regional and distant recurrence between patients undergoing an immediate and delayed autologous DIEP flap breast reconstruction were evaluated. METHODS: In this retrospective cohort study, breast cancer patients undergoing a DIEP flap breast reconstruction between 2010 and 2018 in three hospitals in the Netherlands were evaluated. Cox proportional hazards regression analyses were performed to assess the impact of different factors on breast cancer recurrence. The primary endpoint was local breast cancer recurrence. Secondary endpoints were regional and distant recurrence. RESULTS: A total of 919 DIEP-flap reconstructions were done in 862 women of which 347 were immediate- and 572 were delayed DIEP flap reconstructions. After a median follow-up of 46 months and 86 months respectively (p < 0.001), local breast cancer recurrence occurred in 1.5% and in 1.7% of the patients resulting in an adjusted hazard ratio of 2.890 (p = 0.001, 95% CI 1.536, 5437). CONCLUSION: This study suggests an increased risk for breast cancer recurrence in women receiving a delayed DIEP flap reconstruction as compared to women receiving an immediate DIEP flap reconstruction. However, these data should be interpreted carefully as a result of selection bias.

Standardized human bone marrow-derived stem cells infusion improves survival and recovery in a rat model of spinal cord injury.

Spinal cord injury (SCI) is an incurable disorder with an unmet need of an effective treatment. Recently, autologous human bone marrow-derived stem cells have shown to promote functional improvement, due to their anti-inflammatory and regenerative/apocrine properties. In this study, the primary objective was to test whether a single intrathecal injection with a 100 µL suspension of 400,000 fresh human bone marrow-derived CD34+ and an equal number of CD105+ stem cells (Neuro-Cells (NC)), one day after balloon-compression of the spinal cord, improves motor function and reduces secondary damage in immunodeficient rats. During the first 5 weeks after this intervention, NC significantly improved locomotor recovery and induced less injury-associated adverse events compared to vehicle-treated rats. Histological analysis showed that NC reduced astrogliosis, and apoptosis early after administration (day 4), but not at a later stage (day 56) after SCI. Proteomic studies (at day 56) pointed to the release of paracrine factors and identified proteins involved in regenerative processes. As stem cells seem to reach their effects in acute lesions by mainly suppressing (secondary) inflammation, it is thus realistic to expect a lower magnitude of their eventual beneficial effect in T-cell deficient rats, a fact reinforcing the robustness of Neuro-Cells efficacy. Taken together, this study indicates that an intrathecal instillation of Neuro-Cells holds great promise as a neuro-regenerative intervention in a clinical setting with acute SCI patients.

The influence of neoadjuvant chemotherapy on complications of immediate DIEP flap breast reconstructions.

PURPOSE: The impact of neoadjuvant chemotherapy on the surgical outcomes of immediate breast reconstruction remains controversial. The aim of this study was to analyze the incidence of complications of immediate deep inferior epigastric artery perforator (DIEP) flap breast reconstructions in patients who received neoadjuvant chemotherapy compared to patients without neoadjuvant chemotherapy prior to surgery. METHODS: A multicenter, retrospective cohort study was conducted of all patients who underwent immediate DIEP flap breast reconstruction between January 2010 and June 2017. Patients were divided in two groups as breast reconstructions with or without neoadjuvant chemotherapy, respectively. The primary outcome was the incidence of postoperative flap re-explorations, recipient-site complications and donor-site complications. RESULTS: In total 432 immediate DIEP flap breast reconstructions in 326 patients were included. Forty-eight patients (n = 67 flaps) received neoadjuvant chemotherapy prior to immediate breast reconstruction and 278 patients (n = 365 flaps) did not. No statistically significant differences for any major (4.5% vs. 10.4%; p = 0.175) or minor (16.4% vs. 24.7%; p = 0.191) recipient-site complication were observed. Donor-site complications were recorded in 9 (18.8%) and 62 (22.2%) patients, respectively (p = 0.587). There was no difference in need for flap re-exploration between groups (3.0% vs. 8.5%; p = 0.139). Correction for potential confounding variables did not result in significant differences. CONCLUSIONS: This study demonstrated similar complication rates for patients with and without neoadjuvant chemotherapy prior to immediate breast reconstruction, indicating that it is safe to perform an immediate DIEP flap breast reconstruction after neoadjuvant chemotherapy.

Breast sensibility after mastectomy and implant-based breast reconstruction.

PURPOSE: The aim of the study is to evaluate the level of sensible impairment after mastectomy or implant-based breast reconstruction (IBBR). In addition, factors influencing breast sensibility were evaluated. METHODS: A cross-sectional study was performed in Maastricht University Medical Center between July 2016 and August 2018. Women with unilateral mastectomy with or without IBBR were included. Objective sensory measurements were performed using Semmes-Weinstein monofilaments. Their healthy breast served as control, using a paired t test. Differences between mastectomy with and without IBBR were evaluated using the independent t test. Linear regression was performed to evaluate the association between patient characteristics on breast sensibility. The paired t test was used to evaluate in which part of the breast the sensibility is best preserved. RESULTS: Fifty-one patients were eligible for inclusion. Sixteen patients underwent IBBR after mastectomy. Twenty-three patients received radiotherapy and 35 patients received chemotherapy. Monofilament values were significantly higher in the operated group compared to the reference group (p < 0.001). Linear regression showed a statistically significant association between IBBR and objectively measured impaired sensation (p = 0.008). After mastectomy, the cutaneous protective sensation is only diminished. After IBBR, it is lost in the majority of the breast. The medial part of the breast was significantly more sensitive than the lateral part in all operated breasts (p < 0.001). CONCLUSION: IBBR has a significantly negative impact on the breast sensibility compared to mastectomy alone. This study shows that the protective sensation of the skin in the breast is lost after IBBR. To our knowledge, this is the first study to evaluate the level of sensible impairment after mastectomy or IBBR. More research is necessary to confirm these results.

Correction to: Randomized Controlled Study Comparing Disposable Negative-Pressure Wound Therapy with Standard Care in Bilateral Breast Reduction Mammoplasty Evaluating Surgical Site Complications and Scar Quality.

The second to last sentence in the Results section of the Abstract should be corrected to, "At 180-days follow-up, there was a significant improvement in total VAS scores."

Randomized Controlled Study Comparing Disposable Negative-Pressure Wound Therapy with Standard Care in Bilateral Breast Reduction Mammoplasty Evaluating Surgical Site Complications and Scar Quality.

BACKGROUND: Negative pressure wound therapy (NPWT) for postsurgical incision treatment has demonstrated benefits. A prospective randomized study was developed including 32 patients who underwent bilateral breast reduction mammoplasty. Patients served as their own control and received NPWT to one breast and fixation strips to the other breast. METHODS: The primary outcome was the number of wound healing complications within 21 days when comparing NPWT treatment with fixation strips. The secondary outcome was aesthetic appearance and quality of scarring using questionnaires [visual analogue scale (VAS) and Patient and Observer Scar Assessment Scale (POSAS)] scored at day 42-, 90-, 180- and 365-day follow-up using additional scar measurement modalities, such as viscoelasticity. RESULTS: For the 32 included patients, the number of wound complications was significantly lower (p < 0.004) for the NPWT treated sites compared to fixation strips. POSAS and VAS scores at 42 and 90 days revealed a significantly better quality of scarring in the NPWT treatment breasts than in fixation strips. At 180-day follow-up, there was a significant improvement in total VAS scores, as well as a comparable improvement in POSAS scores. No consistent significant improvement in scar quality was demonstrated with the assays that were used. CONCLUSIONS: Our study showed less complications and a significant improvement in quality of scarring in favor of the NPWT-treated sites. The results indicate NPWT to be an attractive option for these patients. LEVEL OF EVIDENCE II: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Complications following immediate compared to delayed deep inferior epigastric artery perforator flap breast reconstructions.

PURPOSE: As more breast cancer patients opt for immediate breast reconstruction, the incidence of complications should be evaluated. The aim of this study was to analyze the recipient-site complications and flap re-explorations of immediate compared to delayed deep inferior epigastric artery perforator (DIEP) flap breast reconstructions. METHODS: For this multicenter retrospective cohort study, the medical records of all patients who underwent DIEP flap breast reconstruction in three hospitals in the Netherlands between January 2010 and June 2017 were reviewed. Patient demographics, risk factors, timing of reconstruction, recipient-site complications, and flap re-explorations were recorded. RESULTS: A total of 910 DIEP flap breast reconstructions (n = 397 immediate and n = 513 delayed reconstructions) in 737 patients were included. There were no significant differences in major complications or flap re-explorations between immediate and delayed reconstructions. The total flap failure rate was 1.5 and 2.5% in the immediate and delayed group, respectively. Significantly more hematomas (OR 2.91; 95% CI 1.59-5.30; p = 0.001) and seromas (OR 3.60; 95% CI 1.14-11.4; p = 0.029) occurred in immediate reconstructions, whereas wound problems were more frequently observed in delayed reconstructions (OR 1.99; 95% CI 1.27-3.11; p = 0.003). Correction for potential confounders still showed significant differences for hematoma and seroma, but no longer for wound problems (p = 0.052). CONCLUSIONS: This study demonstrated similar incidences of major recipient-site complications and flap re-explorations between immediate and delayed DIEP flap breast reconstructions. However, hematoma and seroma occurred significantly more often in immediate reconstructions, while wound problems were more frequently observed in delayed reconstructions.

Sensory recovery of the breast after innervated and non-innervated autologous breast reconstructions: A systematic review.

BACKGROUND: The sensory recovery of the reconstructed breast is an undervalued topic in the field of autologous breast reconstruction. This systematic review aimed to evaluate the available literature on the sensory recovery of the breast after innervated and non-innervated autologous breast reconstructions and to assess the possible benefits of sensory nerve coaptation compared to spontaneous reinnervation of the flap. METHODS: A comprehensive literature search was conducted in PubMed, Embase and the Cochrane Library to identify all eligible studies regarding the sensory recovery of all types of innervated and non-innervated autologous breast reconstructions. RESULTS: The search yielded 334 hits, of which 32 studies concerning 1177 breast reconstructions were included. The amount of heterogeneity between the studies was high, which made the pooling of data difficult. The studies indicated that spontaneous reinnervation of autologous breast reconstructions occurred to a variable extent, depending on how and when it was measured. Despite these variable results, the sensory recovery of innervated flaps, however, was superior, started earlier and gradually improved over time with a higher chance of approaching normal values than non-innervated flaps. There is a lack of studies that assess the return of erogenous sensation and quality of life. CONCLUSION: The current evidence shows that nerve coaptation results in superior sensory recovery of the reconstructed breast compared to spontaneous reinnervation of the flap. This review illustrates that more standardised, high-quality studies with adequate sample sizes are needed to objectively evaluate the sensory recovery of the breast after autologous breast reconstructions.

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.

Efficacy of custom-made pressure clips for ear keloid treatment after surgical excision.

BACKGROUND: Mechanical pressure is increasingly applied as a means to prevent or treat keloid scars. AIM: The aim of this study is to analyze the long-term efficacy of our custom-molded pressure-adjustable earclips to prevent keloid recurrence after surgical excision. METHODS: Using our custom-molded earclip, 88 patients who had undergone ear surgery for keloid scars were treated for 12 h a day for 6-18 months. The mean follow-up was 6.5 years. The primary outcome was the recurrence of keloids with patient satisfaction being the secondary outcome as assessed by Patient and Observer Scale (POSAS). RESULTS: Keloid scars did not recur in 70.5% of treated patients. The Fitzpatrick scale, which classifies human skin by type, was significantly different between the recurrence and nonrecurrence group. Differences in other patient characteristics were not found between both groups. All parameters mentioned in the POSAS patient scale drastically improved after therapy. There were no severe side effects observed after the therapy. CONCLUSION: Our pressure-adjustable earclip model is an effective tool in the prevention of ear keloid recurrence and is associated with high patient satisfaction. Its benefits should prompt further studies on its value as an adjuvant therapy to surgery in keloid treatment. LEVEL OF EVIDENCE: Level III on the Evidence Rating Scale for Therapeutic Studies.