Immediate fine-tuning of DIEP flaps using the Wise pattern mastectomy: Description of the technique and a retrospective analysis of complication rates.

INTRODUCTION: Elliptical skin-sparing mastectomy in patients with large or ptotic breasts usually leaves loose mastectomy skin flaps, which need to be either resected or gathered over the DIEP flap. This results in poor control of the breast footprint and under-projected DIEP flaps in a loose mastectomy skin pocket, that tend to slip laterally towards the axilla. We believe that the use of a Wise pattern mastectomy will allow for immediate treatment of these concerns. MATERIALS AND METHODS: A retrospective, uncontrolled analysis of a prospectively-maintained database of patients operated by the five surgeons performing breast reconstructions at the University of Montreal Hospital Centre. Study population was patients with a BMI of over 25 and grade II/III breast ptosis who underwent a Wise pattern mastectomy with immediate DIEP flap reconstruction. Analysis was performed of the complication rates of the technique in the first six months after the surgery. RESULTS: Out of a total of 53 breasts in 44 patients reconstructed with a DIEP flap immediately post Wise pattern mastectomy, we report nine cases of partial mastectomy-flap necrosis not needing revision, five cases of significant mastectomy flap necrosis needing debridement and skin grafting, and two cases of inability to adequately close the Wise pattern intraoperatively after DIEP placement, necessitating retention of DIEP skin in the inferior pole. None of the mastectomy flap complications occurred in irradiated breasts. CONCLUSION: In patients with large or ptotic breasts, the Wise pattern mastectomy before an immediate DIEP reconstruction allows for immediate shaping of the breast by controlling the breast pocket, footprint, and excess skin.

Biocell-Initial patents versus user instructions guide: A discrepancy at the core of a crisis.

PURPOSE: Our aim is to do a comparative qualitative analysis of patents and "User Manuals" of the Biocell textured implants in order to determine if red flags were omitted when marketing and using Biocell textured implants. MATERIALS AND METHODS: We performed a systematic qualitative analysis using the NVivo software version 11 of the patents describing the Biocell textured implants prior to their approval by the FDA and of user guides published by the 3 companies owning the patents (McGhan, Inamed, Allergan). To guide our thematic analysis, we used a form of systems theory known as the complexity theory. RESULTS: Four patents related to Biocell and 2 user manuals (McGhan- Inamed and Allergan) were analyzed. Four themes emerged from the patents: invention description, mechanism of action (Tissue ingrowth), the timing of the mechanism of action and hypothetical actions on capsular contractures prevention. Of all patent's content, 34% described the invention, 29% the mechanism of action (tissue ingrowth), 1% the timing of this mechanism of action and 34% a hypothetical action against capsular contracture. Solid evidence was found on the concept of anchoring and very little on capsular contracture. On the user guide side, the main themes were indications and contraindications, surgical techniques and long-term effects. The "directed" content analysis approach of the user guides regarding the patent's themes reflected that 94% of the user guides content related to the patent thematics was about the hypothetical role on capsular contracture while only 4% was about invention description and 1.5% about tissue ingrowth. CONCLUSIONS: This analysis highlights the discrepancies between patents of Biocell textured implants and user guides for these implants. The indications of use of a treatment or device can evolve quicker than the study of its potential complications and side effects. The BIA-ALCL crisis should serve as a cautionary tale to the plastic surgery community which embraces new technologies eagerly, and sometimes precariously, in a mission to advance patient care.

[Impact of Facebook patient groups in the surgical decision making process: The example of Biocell® macro-textured implants recall]. / Impact des groupes de patientes Facebook dans le processus décisionnel chirurgical : l'exemple du rappel des implants macro-texturés Biocell®.

BACKGROUND: The use of social media, has been a major upheaval in our lifestyles in the last decade. At the forefront in the crisis of BIA-ALCL, as soon as February 2019, our university centre took steps to identify and contact all patients with macro-textured implants. The purpose of this recall was to educate patients and establish a monitoring system. The purpose of this work is to analyse the patients' decision-making process. METHODS: A retrospective study of patients, who requested and attended appointments with a surgeon, was made. The number of patients with clinical symptoms of BIA-ALCL, the number of patients who requested implant removal surgery, the histological diagnoses found after surgery were collected. We then calculated the proportion of Facebook group members among patients who required implant removal in the absence of a diagnosis or even warning signs. RESULTS: Seven hundred and seventy women requested an appointment with one of the surgeons in our department. Of all the women who requested consultation, 497 (64.55%) had symptoms. 199 patients were members or had attended one of the Facebook groups of patients. At the end of the consultation with their surgeon, almost 25% of patients made a decision to have the implant removed against medical advice. Among these patients, 67% were part of a group of patients on the Facebook network. To date, no patient has been diagnosed with BIA-ALCL. CONCLUSIONS: These results support the hypothesis that belonging to Facebook groups of patients becomes, for some, a key element in the decision-making process beyond expert opinion. In the future, preliminary work with patient groups on social networks should be done in order to obtain additional health efficiency.

Thiel-embalmed porcine placenta: A valid and reusable microsurgical practice model.

BACKGROUND: Simulation models are increasingly important for skill acquisition during microsurgery training. Prosthetics, living and non-living biological models have been proposed in the literature in the optics of recreating real-life scenarios in a controlled environment. This study aims to validate and prove the reusability of a novel non-living biological model: the porcine placenta. METHODS: A prospective comparative study was carried out to assess face and content validities of the proposed model, as well as the reusability and quality of the Thiel-embalming method. Participants were asked answer a questionnaire for each anastomosis they performed on porcine placental vessels of ≤2mm (small) and 2-4mm (large). Scores were classified according to different subgroups, either small or large vessels and first or second sessions. Reliability analysis of the questionnaire was carried out using Cronbach's α, to ensure an α>0.7. Median scores for each question were analyzed using boxplots and compared amongst each subgroup using a non-parametric independent Mann-Whitney U test. RESULTS: With nine participants, the Cronbach's α for each category of question was 0.867, 0.778, 0.720 and 0.593. Statistical differences were found between responses of small and large vessels on 5/10 questions, where large vessels reported higher validity. No statistical differences were found between scores of the first and second sessions. CONCLUSION: By evaluating face and content validity, the Thiel-embalmed porcine placenta has proven its suitability as a microsurgery model, especially for vessels of larger caliber. Qualities that distinguish this model is its reliable reusability, its low cost-effectiveness, and its ethical acceptability.

Partial DIEP flap loss in a patient with history of abdominal liposuction.

Classically, history of prior abdominal liposuction has been considered a relative contraindication for breast reconstruction using deep inferior epigastric perforator (DIEP) flap. The rationale for this is based on the fact that liposuction can possibly damage perforating vessels, which could compromise flap survival. However, multiple recently published reports have shown that imaging using CT angiography or colour Duplex ultrasonography could be used to accurately assess the adequacy of the perforating vessels before DIEP flap harvest. This contraindication is currently being reconsidered in the scientific literature. We present a case of partial DIEP flap loss in a patient with history of abdominal liposuction that happened despite preoperative identification of adequate perforators using CT angiography and intraoperative clear evidence of patent anastomoses. This occurrence reopens in our view the question of whether DIEP flaps can be safely performed on patients with a history of abdominal liposuction, even in the presence of adequate perforators on regular CT angiography or Doppler ultrasonography. While abdominal liposuction may not injure perforating vessels, its detrimental effect on linking micro-vessels within the flap cannot be fully evaluated using CT Angiography. Therefore, the use of another imaging modality, such as the indocyanine green laser angiography, to assess perfusion before DIEP flap harvesting is performed and could be considered in patients with history of abdominal liposuction.

Immediate breast reconstruction surgery with expander/direct implant and use of acellular dermal matrix: Does hormone therapy increases the risk of infection?

BACKGROUND: The use of hormone therapy (tamoxifen and aromatase inhibitors) has been shown to increase venous thromboembolism. However, while estrogens play a crucial role in wound healing, no study has assessed the impact of tamoxifen or aromatase inhibitors on other postoperative breast reconstruction complications, including infections, necrosis, capsular contracture and seroma. As breast cancer patients undergoing Implants-ADMs breast reconstruction are often receiving hormone therapy, it is unclear whether this increased infection risk is associated with increased infections cases. METHODS: A prospective study was performed on patients undergoing breast reconstruction at an academic institution from 2013 to 2016. Patients were divided by use of hormone therapy at the time of surgery. Complication rates, including infections, necrosis, seroma and hematomas, were compared and analyzed using univariate and logistic regression models. RESULTS: Among a total of 112 patients (183breasts), 58 patients (91 breasts) were receiving hormone therapy and 54 patients (92 breasts) were not. The hormone therapy group had a higher incidence of postoperative mastectomy skin infection (20.7% versus 7.4%; P=0.0447), we didn't find any significant differences in necrosis. CONCLUSIONS: Hormone therapy was associated with a higher incidence of Infections after breast reconstruction with ADMs and implants. The authors propose an individualized approach to the preoperative cessation of tamoxifen or aromatase inhibitors. Immediate breast reconstruction surgery with expander/direct implant and use of acellular dermal matrix: does hormone therapy increases the risk of infection?