Local safety of immediate reconstruction during primary treatment of breast cancer. Direct-to-implant versus expander-based surgery.

INTRODUCTION: After mastectomy, immediate breast reconstruction is paramount. With the growing number of nipple-sparing mastectomies, the chances of successful one-stage reconstruction with implants are also increasing. Local safety is one of the main issues. This study investigated the factors that could lead to major or minor complications after expander-based versus direct-to-implant (DTI) reconstruction. METHODS: The studied factors were age, body mass index (BMI), hypertension, smoking, diabetes, type of mastectomy (nipple-sparing/total), implant size, neoadjuvant/adjuvant chemotherapy, and radiotherapy. The study sample included 294 immediate reconstructions over 3 years. The primary outcome was the incidence of complications, major or minor depending on the necessity of revision surgery. For the DTI pocket, we applied a variant of the conventional submuscular technique. RESULTS: In DTI reconstructions (median follow-up 26 months), the complication rate was 17.2% (4.3% major and 12.8% minor) with no significant association with clinical variables. In expander-based reconstructions (median follow-up 19 months), the complication rate was 18.3% (12.5% major and 5.8% minor). Univariate analysis showed a significant association between overall complications and radiotherapy (P = 0.01) as well as between major complications and expander size (P < 0.005), BMI (P < 0.005), and radiotherapy (P < 0.01); radiotherapy and BMI retained significance in multivariate analysis. Neoadjuvant/adjuvant chemotherapy did not affect the complication rate. CONCLUSIONS: There was evidence of an association between major complications and clinical variables in the expander-based cohort. Larger expander size was a predictor of failure, especially combined with radiation. Direct-to-implant reconstruction proved to be safe. We describe a reliable method of reconstruction and a safe range of implant sizes even beyond 500 g.

Associated use of silicone-vitamin E gauzes and α-tocopherol acetate oil in healing of skin graft donor sites.

Split-thickness skin graft is one of the most used procedures in plastic surgery. This procedure involves numerous painful dressings at the donor site. α-Tocopherol acetate has anti-oxidative and anti-inflammatory properties and it can reduce the local bacterial growth, thereby promoting wound healing. We designed a prospective study to evaluate the effects of two different kinds of dressings at skin graft donor sites. A total of 30 patients were subjected to daily dressings with α-tocopherol acetate oil and traditional moist gauzes (group 1). Another 30 patients were subjected to dressings every 4 days with α-tocopherol acetate oil and silicone-vitamin E gauzes (group 2). Healing time, infection rate, patient's pain perception and costs were evaluated in both the groups. No statistically significant difference was found in terms of healing time. The infection rate was slightly different in the two groups. Significant reduction of pain perception was detected in group 2. In the same group, significant reduction in the total cost of the treatment was also observed. α-Tocopherol acetate oil and silicone-vitamin E gauzes may represent a safe, simple, painless and inexpensive method for improving skin graft donor site healing.

Improving wound healing and preventing surgical site complications of closed surgical incisions: a possible role of Incisional Negative Pressure Wound Therapy. A systematic review of the literature.

Advances in preoperative care, surgical techniques and technologies have enabled surgeons to achieve primary closure in a high percentage of surgical procedures. However, often, underlying patient comorbidities in addition to surgical-related factors make the management of surgical wounds primary closure challenging because of the higher risk of developing complications. To date, extensive evidence exists, which demonstrate the benefits of negative pressure dressing in the treatment of open wounds; recently, Incisional Negative Pressure Wound Therapy (INPWT) technology as delivered by Prevena™ (KCI USA, Inc., San Antonio, TX) and Pico (Smith & Nephew Inc, Andover, MA) systems has been the focus of a new investigation on possible prophylactic measures to prevent complications via application immediately after surgery in high-risk, clean, closed surgical incisions. A systematic review was performed to evaluate INPWT's effect on surgical sites healing by primary intention. The primary outcomes of interest are an understanding of INPWT functioning and mechanisms of action, extrapolated from animal and biomedical engineering studies and incidence of complications (infection, dehiscence, seroma, hematoma, skin and fat necrosis, skin and fascial dehiscence or blistering) and other variables influenced by applying INPWT (re-operation and re-hospitalization rates, time to dry wound, cost saving) extrapolated from human studies. A search was conducted for published articles in various databases including PubMed, Google Scholar and Scopus Database from 2006 to March 2014. Supplemental searches were performed using reference lists and conference proceedings. Studies selection was based on predetermined inclusion and exclusion criteria and data extraction regarding study quality, model investigated, epidemiological and clinical characteristics and type of surgery, and the outcomes were applied to all the articles included. 1 biomedical engineering study, 2 animal studies, 15 human studies for a total of 6 randomized controlled trials, 5 prospective cohort studies, 7 retrospective analyses, were included. Human studies investigated the outcomes of 1042 incisions on 1003 patients. The literature shows a decrease in the incidence of infection, sero-haematoma formation and on the re-operation rates when using INPWT. Lower level of evidence was found on dehiscence, decreased in some studies, and was inconsistent to make a conclusion. Because of limited studies, it is difficult to make any assertions on the other variables, suggesting a requirement for further studies for proper recommendations on INPWT.

Easy and cheap way to prepare skin extenders.

Skin extender is a very useful method to repair wounds when oedema and skin retraction make a direct suture impossible. We have developed a new, simple and cheap way to prepare skin extenders based only on elastic vessel loops and metal clips stapler commonly used for skin suture and available in any operating room. This simple method can be performed both in the operating room and at the patient bedside, even under local anaesthesia, causes no bleeding and appears to be inexpensive and rapidly usable and should be made readily available in any hospital.

Profunda Femoris Artery Perforator Propeller Flap: A Valid Method to Cover Complicated Ischiatic Pressure Sores.

We report the case of a 50-year-old paraplegic man with a complicated grade III/IV ischiatic pressure sore treated with a propeller flap based on the first perforator of the profunda femoris artery. Our aim was to surgically reconstruct an ischiatic pressure sore in a patient with ankylosis using a fasciocutaneous perforator propeller flap obtained from the posterior region of the thigh. Our decision to perform a profunda femoris artery perforator propeller flap reconstruction was mainly due to the anatomical contiguity of the flap with the site of the lesion and the good quality of the skin harvested from the posterior region of the thigh. The use of the perforator fasciocutaneous flap represents a muscle-sparing technique, providing a better long-term result in surgical reconstruction. The choice of the 180-degree propeller flap was due to its ability to provide a good repair of the pressure ulcer and to pass over the ischiatic prominence in the patient in the forced decubitus position. The operatory course did not present any kind of complication. Using this reconstructive treatment, we have obtained complete coverage of the ischiatic pressure sore.

[An example of a hub and spoke network system in Plastic Surgery: the Regional reference center for non-healing wounds in Ancona (Italy)]. / Esempio di sistema in rete Hub & Spoke in Chirurgia Plastica: il Centro di Riferimento Regionale "Ferite Difficili" di Ancona.

Chronic wounds cause morbidity due to local infections, sepsis, osteomyelitis, but also increase mortality in the most severe cases and in patients with multiple comorbidities. Their increasing prevalence, associated disabilities and relevant health costs make chronic wounds a real social disease. At a time in which we hear more and more about spending reviews and reduction of health care costs, the natural evolution of Medicine and Health Care is increasingly directed towards the achievement of high quality standards while at the same time, reducing costs. It is in this framework that a hub and spoke model was used for organizing Plastic Surgery services in Ancona (Italy). In order to ensure appropriate clinical and organizational management of services, the activities of reference centres need to be widely integrated, by functional interconnections with activities of peripheral hospitals and local centres. Through a careful analysis of the Regional Reference Center for non - healing wounds in Ancona, the authors make some considerations regarding appropriate diagnostic-therapeutic-healthcare pathways and the correct use of human, material and technological resources in the area of wound healing.

The enhanced healing of a high-risk, clean, sutured surgical incision by prophylactic negative pressure wound therapy as delivered by Prevena™ Customizable™: cosmetic and therapeutic results.

According to the literature, incisional closure complications may range from postoperative surgical site infections, representing 17-22% of health care-associated infections, surgical wound dehiscence and formation of haematomas or seromas, and can lead to delayed or impaired incision healing. These kinds of situations are more common when wounds are closed under tension or in specific patient morbidities. Obesity, in particular, is associated with an impaired blood flow to tissues, predisposing the patient to increased risk of wound complications by various mechanisms. Incisional complications can become relevant economic burdens for health care systems because of an increase in the average length of hospital stay and readmissions, and additional medical and surgical procedures. Thus, a preventive therapy may have a critical role in the management of healing. Negative pressure wound therapy (NPWT) technology as delivered by Prevena™ Customizable™ (Kinetic Concepts Inc., San Antonio, TX) has recently been the focus of a new investigation, as a prophylactic measure to prevent complications via immediate postoperative application in high-risk, clean, closed surgical incisions. The authors present a 62-year-old class II obese female, who underwent bilateral inguinal dermolipectomy. Prophylactic NPWT as delivered by Prevena™ was performed successfully over surgical incisions. Cosmetic and therapeutic results are shown.