Delayed prosthetic seroma: a localized inflammatory response to COVID vaccination and infection?

We present a patient whom we believe developed a late abdominal mesh collection in response to COVID-19 mRNA vaccination booster and COVID-19 infection. A polypropylene mesh was placed during her right breast reconstruction operation 2 years ago where she underwent a right transverse abdominis rectus muscle (TRAM) free flap. She recovered uneventfully from this operation. This lady, though vaccinated, developed respiratory symptoms and tested positive for COVID-19 infection 3 days after her booster injection. She then noticed right-sided abdominal swelling 3 days after the onset of respiratory symptoms. She only presented 1 month later due to a 7-day history of pain at the site of abdominal swelling. A computed tomography scan confirmed the presence of a seroma, and she underwent ultrasound-guided percutaneous drainage. A COVID Antigen Rapid Test of the fluid returned positive, though the PCR swab returned negative. There have been no published reports of periprosthetic mesh seroma after COVID-19 vaccination or infection to date. We wanted to share our experience so that other surgeons may be aware of this potential presentation given the current ongoing pandemic. Level of evidence: Level V, risk/prognostic.

No-drain Technique in Abdominal Closure for Breast Reconstruction: Lower Complication Rate, Shorter Hospitalization Stay.

BACKGROUND: Progressive tension suture (PTS) technique in cosmetic abdominoplasty is safe in terms of seroma rates. This was extrapolated to deep inferior epigastric perforator (DIEP) flap donor site closure. No study to our knowledge has analyzed the PTS technique alone without drains in transverse rectus abdominis musculocutaneous (TRAM) flap donor sites. We aim to show that no-drain closure has similar complication rates and this may be applied to TRAM flaps safely even though they have higher drain output. METHODS: A single-center, single-surgeon retrospective study was performed over 4 years. Patients undergoing breast reconstruction with an abdominal flap were included. Data collected included patient's demographics, type of flap, usage of drains or PTS technique, drain output, date of fitness for discharge, date of discharge, and seroma rates. The outcomes studied were drain volumes, seroma rates, and duration of hospital stay. RESULTS: Fifty patients were recruited. The first 25 patients (13 DIEP and 12 TRAM) underwent conventional closure. The subsequent 25 patients (17 DIEP and 8 TRAM) underwent PTS technique. TRAM flaps had higher drain volume (785.6 mL) compared to DIEP flaps (366.2 mL) (P = 0.047). No patients developed a seroma. Patients who underwent the PTS technique had lower abdominal-specific complications (P = 0.021). Patients without drains were discharged faster at 5.4 versus 8.2 days (P ≤ 0.001). CONCLUSIONS: Patients who underwent the PTS technique had lower complication rates, faster time to fitness for discharge and shorter hospitalization stay. The PTS technique may be applied to TRAM flaps safely.

A Rare Case of Persistent Unilateral Gestational Gigantomastia.

A 34-year-old para 2 + 0 Indonesian woman presented with persistent right-sided gestational gigantomastia some 24 months following delivery. This was severely debilitating her activities of daily living, including caring for her children. On examination, she was found to have extreme hypertrophy of her right breast, which was nodular throughout on palpation. Biochemical investigations were unremarkable and revealed no obvious etiology. Magnetic resonance imaging identified grossly enlarged right breast tissue with prominent vessels. Given the minimal involution of her breast over the 24 months postpartum, she elected for a breast reduction with free nipple grafting following appropriate counseling. This was performed through excision of breast parenchyma preserving superior-medial tissue, followed by a free nipple graft.

Oncological screening for Bilateral Breast Reduction: a survey of practice variations in UK Breast and Plastics surgeons 2009.

INTRODUCTION: Bilateral Breast Reduction (BBR) is a common procedure performed by Breast and Plastic surgeons in the UK. No consensus exists regarding preoperative screening for malignancy or for selective criteria for such screening. Preoperative BBR screening practices among UK Breast and Plastic surgeons are unknown. AIMS: Ascertain the preoperative and postoperative BBR screening practices of UK Breast and Plastic surgeons. MATERIALS AND METHODS: A questionnaire was posted to all 434 Breast and 335 Plastic surgeons in the UK. All results were analysed with relevant statistical methods. KEY RESULTS: 64% of Breast surgeons and 72% of Plastic surgeons responded. 40% of Breast surgeons and 91% of Plastic surgeons perform BBR. Routine radiological screening: 92% Breast 41% Plastic (p < 0.05). Routine breast examination prior to BBR: 98% Breast 91% Plastic. Routine histology for BBR specimens: 96% Breast 90% Plastic. Selective screening of patients aged 30-40 years old: Breast 38% Plastic 10%. Selective screening of patients aged 40-50: Breast 78%, Plastic 53%. Selective screening of patients with strong family history of breast cancer: Breast 72%, Plastic 91%. Selective screening of patients with previous breast cancer: Breast 77%, Plastic 93%. CONCLUSIONS: There are significant differences in practice between UK Breast surgeons and Plastic surgeons in preoperative oncological screening for BBR. The large discrepancy in preoperative radiological screening, reflects a ubiquitous pro-screening ideology among Breast surgeons not prevalent among Plastic surgeons. These results will provoke debate towards the direction of consensus to ultimately reflect best practice.

Modelling of experimentally created partial-thickness human skin burns and subsequent therapeutic cooling: a new measure for cooling effectiveness.

Rapid post-injury cooling of a skin burn has been shown to have both symptomatic and therapeutic benefits. However, the latter cannot be explained by temperature reduction alone, and must thus be secondary to an altered biological response. In this study, we construct a computational model to calculate the heat transfer and damage accumulation in human skin during and after a burn. This enables us to assess the effectiveness of various cooling protocols (involving both free and forced convection to air and water respectively) in terms of their reduction in Arrhenius tissue damage. In this process, we propose an extension of the Arrhenius damage model in the form of a new measure xi, which estimates the relevance of post-burn accrued damage. It was found that the reduction in Arrhenius damage integrals near the skin surface was too small to be physiologically relevant. Hence our results confirm that while the reduction in tissue temperatures is indeed quicker, the therapeutic benefit of cooling cannot be explained by thermal arguments (i.e. based on Arrhenius damage models) alone. We plan to validate this hypothesis by conducting future microarray analyses of differential gene expression in cooled and non-cooled burn lesions. Our computational model will support such experiments by calculating the necessary conditions to produce a burn of specified severity for a given experimental setup.