A comparison of presentations and outcomes of salvage versus non-salvage abdominal free flap breast reconstructions-Results of a 15-year tertiary referral centre review.

INTRODUCTION: Salvage breast reconstruction with autologous tissue is becoming more prevalent due to a resurgence in implant-based procedures. The latter has caused a commensurate rise in failed or treatment-resistant prosthetic cases requiring conversion to free tissue transfers. Salvage reconstruction is often considered more challenging, owing to patient presentation, prior treatments and intraoperative difficulties. The aim of the study was to test this hypothesis by comparing outcomes of salvage versus non-salvage autologous microsurgical breast reconstructions in a retrospective matched cohort study. METHODS: The demographics, risk factors, operative details and outcomes of patients who underwent free flap salvage of implant-based reconstructions by a single operator (2005-2019) were retrospectively evaluated. For each salvage reconstruction, the consecutive non-salvage abdominal free flap reconstruction was selected for comparison. The clinical outcomes including intraoperative blood loss, operative time, flap survival and complication rates were compared. RESULTS: Of 442 microsurgical patients, 35 (8.0%) had salvage reconstruction comprising 41 flap transfers (29 unilateral, 6 bilateral) and 42 flaps (28 unilateral, 7 bilateral) in nonsalvage reconstruction. Deep inferior epigastric perforator (DIEP) flaps comprised the commonest autologous tissue used in both groups at 74% and 71% respectively. Most patients (83%) underwent salvage reconstruction for severe capsular contractures. There was a significant difference in radiation exposure between groups (salvage reconstruction 89%, non-salvage reconstruction 26%; p<0.00001). All 83 flaps were successful with similar reoperation rates and intraoperative blood losses. Unilateral salvage reconstruction took on average two hours longer than non-salvage reconstruction (p = 0.008). Overall complication rates were similar (p>0.05). CONCLUSION: This 15-year study shows that despite salvage autologous free flap breast reconstruction requiring longer operation times, its intra and postoperative outcomes are generally comparable to non-salvage cases. Therefore, salvage breast reconstruction with free flaps provides a reliable option for failed or suboptimal implant-based reconstructions.

Core training and surgical opportunities: A UK-based analysis.

Background and Aim: The COVID-19 pandemic, the new Intercollegiate Surgical Curriculum Programme curriculum and the European Work Time Directive significantly reduced surgical exposure for trainees. This study analyzed the operative experience of Phase 1 trainees (CT1/ST1 vs. CT2/ST2) against the Annual Review of Competence Progression (ARCP) criterion of 120 procedures yearly. Methods: National survey research in October 2021. Study end-point was the completion of >4 weekly procedures, equivalent to 120 cases per year. Chi-square test and multivariate regression analysis were performed. Results: 205 participants from 5 Deaneries were included, 48.3% were CT1/ST1 and 51.7% were CT2/ST2. About 54.5% of year-1 and 50% of year-2 trainees were 28 30 years old, 55.6% and 50.9% were male, and 39.4% and 38.7% were White British. About 39.4% of CT1/ST1 and 22.6% of CT2/ST2 performed <4 weekly procedures (P = 0.01), with no difference in the "Observed" (P = 0.6) or "Assisted" (P = 0.3) number of cases. CT2/ST2 recorded more "ST-S" (p 0.04), "S-TU" (P = 0.03), and "Performed" (P = 0.02) operations. For CT1/ST1, older age (HR 2.4, 95% CI [1.1; 5.3], P = 0.02) and southern deaneries (HR 1.7, 95% CI [1.2; 2.4], P = 0.004) were independent factor for <4 weekly procedures. For CT2/ST2, northern regions were associated with more favorable training (HR 1.4, 95% CI [1.1; 1.7], P = 0.01). Conclusion: Over one third of Phase 1 trainees do not meet the ARCP requirement of >120 procedures annually. Age and region of training are independent factors in the number of logbook cases. Relevance for Patients: This research focuses on training opportunities for junior surgical residents across the United Kingdom. The degree and type of exposure to the operating theatre have a significant impact on the development of surgical competencies. These are undoubtedly related to patient outcomes, as the quality of care delivered to patients and relatives greatly relies on the training background of future consultant surgeons.

First use of Braxon® acellular dermal matrix for complex revision aesthetic breast surgery-revision augmentation mastopexy.

Acellular dermal matrices (ADMs) have ushered in a paradigm shift in prosthetic breast reconstruction; however, there has hitherto been no reported use of Braxon® ADM in aesthetic breast surgery. Here, we describe the case of a 42-year-old woman who presented for revision of her bilateral aesthetic augmentation-mastopexy following multiple revision surgeries. The predominant concerns were persistent pain, implant malposition and a wide intermammary distance. Her predicament was worsened by inability to tolerate monopolar diathermy owing to a spinal stimulator-the least invasive operation was sought and Braxon® ADM met this criterion. The procedure was a success, and she remains symptom-free, with soft breasts and stable implant positions. Braxon® ADM, with its preformed shape, total implant-wrapping design and easy suture fixation, lends itself to easy use in cosmetic breast surgery. Its role in cosmetic breast surgery has yet to be established, but this case marks the beginning of this endeavor.

Meta-Analysis of Adipose Tissue Derived Cell-Based Therapy for the Treatment of Knee Osteoarthritis.

Osteoarthritis (OA) is a degenerative disorder associated with cartilage loss and is a leading cause of disability around the world. In old age, the capacity of cartilage to regenerate is diminished. With an aging population, the burden of OA is set to rise. Currently, there is no definitive treatment for OA. However, cell-based therapies derived from adipose tissue are promising. A PRISMA systematic review was conducted employing four databases (MEDLINE, EMBASE, Cochrane, Web of Science) to identify all clinical studies that utilized adipose tissue derived mesenchymal stem cells (AMSCs) or stromal vascular fraction (SVF) for the treatment of knee OA. Eighteen studies were included, which met the inclusion criteria. Meta-analyses were conducted on fourteen of these studies, which all documented WOMAC scores after the administration of AMSCs. Pooled analysis revealed that cell-based treatments definitively improve WOMAC scores, post treatment. These improvements increased with time. The studies in this meta-analysis have established the safety and efficacy of both AMSC therapy and SVF therapy for knee OA in old adults and show that they reduce pain and improve knee function in symptomatic knee OA suggesting that they may be effective therapies to improve mobility in an aging population.

Mesenchymal stem cell therapy in hypertrophic and keloid scars.

Scars are the normal outcome of wound repair and involve a co-ordinated inflammatory and fibrotic process. When a scar does not resolve, uncontrolled chronic inflammation can persist and elicits excessive scarring that leads to a range of abnormal phenotypes such as hypertrophic and keloid scars. These pathologies result in significant impairment of quality of life over a long period of time. Existing treatment options are generally unsatisfactory, and there is mounting interest in innovative cell-based therapies. Despite the interest in mesenchymal stem cells (MSCs), there is yet to be a human clinical trial that investigates the potential of MSCs in treating abnormal scarring. A synthesis of existing evidence of animal studies may therefore provide insight into the barriers to human application. The aim of this PRISMA systematic review was to evaluate the effectiveness of MSC transplantation in the treatment of hypertrophic and keloid scars in in vivo models. A total of 11 case-control studies were identified that treated a total of 156 subjects with MSCs or MSC-conditioned media. Ten studies assessed hypertrophic scars, and one looked at keloid scars. All studies evaluated scars in terms of macroscopic and histological appearances and most incorporated immunohistochemistry. The included studies all found improvements in the above outcomes with MSC or MSC-conditioned media without complications. The studies reviewed support a role for MSC therapy in treating scars that needs further exploration. The transferability of these findings to humans is limited by factors such as the reliability and validity of the disease model, the need to identify the optimal MSC cell source, and the outcome measures employed.

A meta-analysis of clinical and radiological outcomes in simultaneous bilateral unicompartmental knee arthroplasty.

BACKGROUND: The most common pattern seen in bilateral knee osteoarthritis involves only the medial compartment in both knees. In such cases, bilateral Unicompartmental Knee Arthroplasty (UKA) would be a suitable surgery, this can be done simultaneously in one surgery or in stages with a period of time between each UKA. Simultaneous bilateral UKA in appropriately selected patients have the potential advantages of a lower cost, a shorter hospital stay, and a shorter overall recovery process. Despite this, there are concerns that operating on both knees in one surgery may increase the risk of complications, revisions and mortality. METHODS: A PRISMA systematic review and meta-analysis was conducted using three databases (MEDLINE, EMBASE, and Scopus) to identify all studies which investigated either clinical or radiological outcomes in simultaneous bilateral UKA. RESULTS: All sixteen studies included found that simultaneous bilateral UKA improved clinical and radiological outcomes. Eight studies compared clinical or radiological outcomes between simultaneous and staged bilateral UKA. Simultaneous bilateral UKA was found to have a significantly shorter length of operation, length of hospital stay, and a lower treatment cost (P < 0.001). Our meta-analysis found no statistically significant difference in the all-cause complication rate between simultaneous and staged bilateral UKA (P = 0.36). Only one study compared radiological outcomes between simultaneous and staged bilateral UKA which found no significant difference. CONCLUSION: Our review suggests that simultaneous bilateral UKA is comparable to staged bilateral UKA in terms of clinical and radiological outcomes and has the potential to be increasingly adopted in clinical practice due to its superior cost-effectiveness.

Orienting the superficial inferior epigastric artery (SIEA) pedicle in a stacked SIEA-deep inferior epigastric perforator free flap configuration for unilateral tertiary breast reconstruction.

Superficial inferior epigastric artery (SIEA) flaps represent a useful option in autologous breast reconstruction. However, the short-fixed pedicle can limit flap inset options. We present a challenging flap inset successfully addressed by de-epithelialization, turnover, and counterintuitive rotation. A 47-year-old woman underwent left tertiary breast reconstruction with stacked free flaps using right deep inferior epigastric perforator and left SIEA vessels. Antegrade and retrograde anastomoses to the internal mammary (IM) vessels were preferred; additionally, the thoracodorsal vessels were unavailable due to previous latissimus dorsi breast reconstruction. Optimal shaping required repositioning of the lateral ends of the flaps superiorly, which would position the ipsilateral SIEA hemi-flap pedicle lateral to and out of reach of the IM vessels. This problem was overcome by turning the SIEA flap on its long axis, allowing the pedicle to sit medially with the lateral end of the flap positioned superiorly. The de-epithelialized SIEA flap dermis was in direct contact with the chest wall, enabling its fixation. This method of flap inset provides a valuable solution for medializing the SIEA pedicle while maintaining an aesthetically satisfactory orientation. This technique could be used in ipsilateral SIEA flap breast reconstructions that do not require a skin paddle, as with stacked flaps or following nipple-sparing mastectomy.

Human umbilical cord derived mesenchymal stem cells in peripheral nerve regeneration.

BACKGROUND: Peripheral nerve injury can occur as a result of trauma or disease and carries significant morbidity including sensory and motor loss. The body has limited ability for nerve regeneration and functional recovery. Left untreated, nerve lesions can cause lifelong disability. Traditional treatment options such as neurorrhaphy and neurolysis have high failure rates. Surgical reconstruction with autograft carries donor site morbidity and often provide suboptimal results. Mesenchymal stem cells (MSCs) are known to have promising regenerative potential and have gained attention as a treatment option for nerve lesions. It is however, unclear whether it can be effectively used for nerve regeneration. AIM: To evaluate the evidence for the use of human umbilical cord derived MSCs (UCMSCs) in peripheral nerve regeneration. METHODS: We carried out a systematic literature review in accordance with the PRISMA protocol. A literature search was performed from conception to September 2019 using PubMed, EMBASE and Web of Science. The results of eligible studies were appraised. A risk of bias analysis was carried out using Cochrane's RoB 2.0 tool. RESULTS: Fourteen studies were included in this review. A total of 279 subjects, including both human and animal were treated with UCMSCs. Four studies obtained UCMSCs from a third-party source and the remainder were harvested by the investigators. Out of the 14 studies, thirteen conducted xenogenic transplantation into nerve injury models. All studies reported significant improvement in nerve regeneration in the UCMSC treated groups compared with the various different controls and untreated groups. CONCLUSION: The evidence summarised in this PRISMA systematic review of in vivo studies supports the notion that human UCMSC transplantation is an effective treatment option for peripheral nerve injury.