Patient-reported outcomes of immediate implant-based breast reconstruction with and without biological or synthetic mesh.

BACKGROUND: Biological and synthetic meshes may improve the outcomes of immediate implant-based breast reconstruction (IBBR) by facilitating single-stage procedures and improving cosmesis. Supporting evidence is, however, limited. The aim of this study was to explore the impact of biological and synthetic mesh on patient-reported outcomes (PROs) of IBBR 18 months after surgery. METHODS: Consecutive women undergoing immediate IBBR between February 2014 and June 2016 were recruited to the study. Demographic, operative, oncological and 3-month complication data were collected, and patients received validated BREAST-Q questionnaires at 18 months. The impact of different IBBR techniques on PROs were explored using mixed-effects regression models adjusted for clinically relevant confounders, and including a random effect to account for clustering by centre. RESULTS: A total of 1470 participants consented to receive the questionnaire and 891 completed it. Of these, 67 women underwent two-stage submuscular reconstructions. Some 764 patients had a submuscular reconstruction with biological mesh (495 women), synthetic mesh (95) or dermal sling (174). Fourteen patients had a prepectoral reconstruction. Compared with two-stage submuscular reconstructions, no significant differences in PROs were seen in biological or synthetic mesh-assisted or dermal sling procedures. However, patients undergoing prepectoral IBBR reported better satisfaction with breasts (adjusted mean difference +6.63, 95 per cent c.i. 1.65 to11.61; P = 0.009). PROs were similar to those in the National Mastectomy and Breast Reconstruction Audit 2008-2009 cohort, which included two-stage submuscular procedures only. CONCLUSION: This study found no difference in PROs of subpectoral IBBR with or without biological or synthetic mesh, but provides early data to suggest improved satisfaction with breasts following prepectoral reconstruction. Robust evaluation is required before this approach can be adopted as standard practice.

Experiences of implant loss after immediate implant-based breast reconstruction: qualitative study.

BACKGROUND: Immediate implant-based breast reconstruction (IBBR) is the most commonly performed reconstructive procedure in the UK, but almost one in ten women experience implant loss and reconstructive failure after this technique. Little is known about how implant loss impacts on patients' quality of life. The first phase of the Loss of implant Breast Reconstruction (LiBRA) study aimed to use qualitative methods to explore women's experiences of implant loss and develop recommendations to improve care. METHODS: Semistructured interviews were conducted with a purposive sample of women who experienced implant loss after immediate IBBR, performed for malignancy or risk reduction across six centres. Interviews explored decision-making regarding IBBR, and experiences of implant loss and support received. Thematic analysis was used to explore the qualitative interview data. Sampling, data collection and analysis were undertaken concurrently and iteratively until data saturation was achieved. RESULTS: Twenty-four women were interviewed; 19 had surgery for malignancy and five for risk reduction. The median time between implant loss and interview was 42 (range 22-74) months. Ten women had undergone secondary reconstruction, two were awaiting surgery, and 12 had declined further reconstruction. Three key themes were identified: the need for accurate information about the risks and benefits of IBBR; the need for more information about 'early-warning' signs of postoperative problems, to empower women to seek help; and better support following implant loss. CONCLUSION: Implant loss is a devastating event for many women. Better preoperative information and support, along with holistic patient-centred care when complications occur, may significantly improve the experience and outcome of care.

ANTECEDENTES: La reconstrucción mamaria inmediata con prótesis (implant-based breast reconstruction, IBBR) es el procedimiento reconstructivo más utilizado en el Reino Unido, pero casi una de cada diez mujeres presentará pérdida de la prótesis y fallo del procedimiento reconstructivo tras esta técnica. Se sabe poco de cómo la pérdida de la prótesis afecta la calidad de vida de las pacientes. La primera fase del estudio LiBRA tuvo como objetivo explorar la percepción de las mujeres ante la pérdida de la prótesis, utilizando métodos cualitativos, y proponer una serie de medidas para mejorar la atención sanitaria de estas pacientes. MÉTODOS: Se realizaron entrevistas semiestructuradas en una muestra de mujeres que padecieron la pérdida de la prótesis tras una IBBR inmediata, realizada por neoplasia o como procedimiento de reducción de riesgo, en seis centros. Las entrevistas analizaron la toma de decisiones con respecto a la IBBR inmediata, así como la percepción ante la pérdida del implante y el soporte recibido. Se utilizó un análisis por temas para examinar los datos de la entrevista cualitativa. El muestreo, la recopilación de datos y el análisis se realizaron de forma simultánea e iterativa hasta que se logró la saturación de datos. RESULTADOS: Se entrevistaron 24 pacientes; 19 en las que la indicación quirúrgica fue por cáncer y 5 por reducción de riesgo. La mediana del tiempo entre la pérdida del implante y la entrevista fue de 42 (rango 22-52) meses. Diez mujeres se habían sometido a una reconstrucción secundaria; dos estaban a la espera de la cirugía y 12 habían rechazado la reconstrucción posterior. Se identificaron tres temas clave, siendo las necesidades de: i) información precisa sobre los riesgos y beneficios de la IBBR, ii) más información sobre los signos de "alarma precoz" de las complicaciones postoperatorias que permitiesen a las mujeres buscar ayuda, y iii) mejor soporte tras la pérdida de la prótesis. CONCLUSIÓN: La pérdida de una prótesis es una complicación catastrófica para muchas mujeres. Una mejor información y apoyo preoperatorios, junto con una atención holística centrada en la paciente cuando se presentan las complicaciones, podrían mejorar significativamente la experiencia y el resultado de la atención.

Therapeutic mammaplasty is a safe and effective alternative to mastectomy with or without immediate breast reconstruction.

BACKGROUND: Therapeutic mammaplasty (TM) may be an alternative to mastectomy, but few well designed studies have evaluated the success of this approach or compared the short-term outcomes of TM with mastectomy with or without immediate breast reconstruction (IBR). Data from the national iBRA-2 and TeaM studies were combined to compare the safety and short-term outcomes of TM and mastectomy with or without IBR. METHODS: The subgroup of patients in the TeaM study who underwent TM to avoid mastectomy were identified, and data on demographics, complications, oncology and adjuvant treatment were compared with those of patients undergoing mastectomy with or without IBR in the iBRA-2 study. The primary outcome was the percentage of successful breast-conserving procedures in the TM group. Secondary outcomes included postoperative complications and time to adjuvant therapy. RESULTS: A total of 2916 patients (TM 376; mastectomy 1532; mastectomy and IBR 1008) were included in the analysis. Patients undergoing TM were more likely to be obese and to have undergone bilateral surgery than those having IBR. However, patients undergoing mastectomy with or without IBR were more likely to experience complications than the TM group (TM: 79, 21·0 per cent; mastectomy: 570, 37·2 per cent; mastectomy and IBR: 359, 35·6 per cent; P < 0·001). Breast conservation was possible in 87·0 per cent of patients who had TM, and TM did not delay adjuvant treatment. CONCLUSION: TM may allow high-risk patients who would not be candidates for IBR to avoid mastectomy safely. Further work is needed to explore the comparative patient-reported and cosmetic outcomes of the different approaches, and to establish long-term oncological safety.

ANTECEDENTES: La mamoplastia terapéutica (therapeutic mammaplasty, TM) puede ser una alternativa a la mastectomía, pero hay pocos estudios bien diseñados que hayan evaluado el éxito de esta estrategia o hayan comparado los resultados a corto plazo de la TM con la mastectomía con o sin (+/-) reconstrucción mamaria inmediata (immediate breast reconstruction, IBR). Para comparar la seguridad y los resultados a corto plazo de la TM y la mastectomía +/- IBR se combinaron los datos de los estudios nacionales iBRA-2 y TeaM. MÉTODOS: En el estudio TeaM se identificó el subgrupo de pacientes al que se realizó una TM para evitar la mastectomía y se compararon los datos demográficos, las complicaciones, los resultados oncológicos y el tratamiento adyuvante con las pacientes sometidas a mastectomía +/- IBR del estudio iBRA-2. La variable principal fue el porcentaje de éxito de la cirugía conservadora de mama en el grupo TM. Las variables secundarias fueron las complicaciones postoperatorias y el intervalo de tiempo hasta el inicio del tratamiento adyuvante. RESULTADOS: Se incluyeron en el análisis 2.916 pacientes (TM n = 376; mastectomía n = 1.532; IBR n = 1.008). La TM era más frecuente en pacientes obesas o en las sometidas a cirugía bilateral en comparación con las pacientes con IBR. Sin embargo, las pacientes sometidas a una mastectomía +/- IBR tenían más probabilidades de desarrollar complicaciones que las del grupo TM (TM n = 79, 21,0%; mastectomía n = 570, 37,2%; mastectomía y IBR n = 359, 35,6%; P < 0,001). La conservación de la mama fue posible en el 87% de las pacientes con TM y el procedimiento no retrasó el inicio del tratamiento adyuvante. CONCLUSIÓN: La TM puede permitir que pacientes de alto riesgo que no serían candidatas a IBR eviten la mastectomía de una forma segura. Se necesitan más trabajos para comparar los resultados percibidos por las pacientes y los estéticos de las diferentes estrategias terapéuticas y establecer la seguridad oncológica a largo plazo.

Study of lymph node vascular relationships of the inferior epigastric veins: The solve anatomical study.

INTRODUCTION: Tissue surrounding the superficial inferior epigastric vein (SIEV) can be harvested for vascularised lymph node transfer (vLNT) for the treatment of lymphoedema. The aim of this study is to define the anatomical relationship of lymph nodes surrounding the SIEV. METHODS: Twenty-five fresh-frozen cadaveric groin specimens were harvested en bloc to the level of the deep fascia along the following anatomical boundaries, yielding quadrilateral tissue blocks: pubic tubercle (medial), anterior superior iliac spine (lateral), 5 cm superior and inferior to the inguinal ligament. The SIEV was marked at its entry point with the femoral vein. Specimens were oriented, secured and fixed in formaldehyde and analysed using longitudinal slices at 3 mm intervals. RESULTS: A total of 86 lymph nodes were identified. The average position of lymph nodes examined was 0.4 cm medial and 3.2 cm inferior to the mid-inguinal point. CLINICAL RELEVANCE: An improved understanding of the anatomical locations of lymph nodes surrounding the SIEV will allow a more purposeful harvest during vLNT, allowing a greater number of lymph nodes to be captured whilst limiting donor site morbidity.

Oncoplastic techniques: Attitudes and changing practice amongst breast and plastic surgeons in Great Britain.

PURPOSE: The availability, acceptability and practice of oncoplastic surgery has increased over the last 5 years. This study aims to describe how the breast and plastic surgical workforce has adapted to provide oncoplastic breast surgery. METHODS: A questionnaire was distributed to members of the Association of Breast Surgery and BAPRAS, and results compared to a survey completed in 2010. RESULTS: In 2010, 228 respondents completed the survey compared to 237 in 2015, of whom 204 were consultants (105 General or Breast Surgeons and 99 Plastic Surgeons). The range of procedures performed by Plastic Surgeons has remained static, the General and Breast Surgeons are performing proportionally more therapeutic mammaplasty (p < 0.001), breast reduction/mastopexy, and latissimus dorsi reconstructions. In 2015, surgeons are less concerned about the risks of lipomodelling than in 2010, with an increase the proportion of breast (55% vs. 26%) and plastic (91% vs. 58%) surgeons performing the technique. DISCUSSION: Specific concerns about oncoplastic surgery have decreased over the last five years, with a greater proportion of surgeons performing oncoplastic surgery including lipomodelling. The majority of breast surgeons in 2015 remain interested in further training in oncoplastic techniques (75%) but over the last 5 years, plastic surgeons interest in further training in oncoplastic surgery has dropped from 62% to 27%. About half of all breast and plastic surgeons felt that oncoplastic surgery should be available for all women and oncological and wound healing concerns had significantly reduced between 2010 and 2015 (p < 0.05).

The impact of a dedicated orthoplastic operating list on time to soft tissue coverage of open lower limb fractures.

An observational study was conducted of 105 patients presenting with an open fracture of the tibia or ankle to determine the impact of a dedicated orthoplastic operating list on our management of these injuries over the time period January 2012 to July 2014. There were 51 patients before and 54 after the introduction of the orthoplastic list. Significant improvements were noted in our ability to deliver a service in line with national guidelines across all Gustilo-Anderson grades of injury. Among patients with the most severe grades of injury (Gustilo types IIIB and IIIC), there was a trend towards an improved time to first skeletal stabilisation (29.5 vs 14.2 hours, p=0.068), an improvement in time to soft tissue coverage (173.6 vs 88.1 hours, p=0.009) and a trend towards a reduced length of inpatient stay (32.6 vs 23.2 days, p=0.138). Where the 72-hour target had been breached, there was a significant improvement in the proportion of patients covered within 7 days of injury (48.2% vs 83.3%, p=0.017). Our compliance with national management standards increased significantly to reflect these improvements in care. These results support the implementation of dedicated orthoplastic operating sessions to meet the growing burden of patients presenting with open fractures at specialist centres.

Skin reducing mastectomy and immediate reconstruction: the effect of radiotherapy on complications and patient reported outcomes.

AIM: Skin reducing mastectomy, dermal sling and immediate implant reconstruction (SRMIR) is an emerging technique where, de-epithelialised inferior skin flap sutured to pectoralis major provides vascularised, dermal sling for the implant. We aimed to assess patient satisfaction following SRMIR and determine if radiotherapy affected patient reported outcomes. METHOD: A prospective database of women undergoing SRMIR was analysed. SRMIR was performed in 92 women (116 breasts). Radiotherapy was received by 45 women and it was not required in 47 women. Forty eight women had contralateral surgery: 21 breast reduction/mastopexy, 1 augmentation, 26 mastectomy/reconstruction. A validated breast evaluation questionnaire provided patient reported outcomes. RESULTS: Median follow up was 20 months. Early complications were similar in both groups, but those in the radiotherapy group had a higher incidence of implant loss (6/45 = 13% vs 1/47 = 2%; p = 0.06) and grade III/IV capsular contracture (11/45 = 24% vs 6/47 = 13%; p = 0.20). The outcome questionnaire was sent to 83 women who were disease free and had retained their implants. Sixty three women responded (76%). Patient reported satisfaction was high, with or without radiotherapy. Women receiving radiotherapy gave lower scores, but it was statistically significant only for general appearance and symmetry. CONCLUSIONS: Although complications after radiotherapy are higher in patients who had SRMIR, the majority of women who retained their implant are highly satisfied with their reconstruction. Majority of these patients were happy to recommend SRMIR procedure to their friend.

Ligating perforators in abdominoplasty reduces the risk of seroma.

BACKGROUND: Seroma formation, a common complication of abdominoplasty, can cause patient discomfort and inconvenience. This study aimed to compare seroma rates after ligation and diathermy of large abdominal perforating vessels during abdominoplasty. METHODS: Consecutive patients undergoing abdominoplasty with epigastric undermining between 2004 and 2011 were studied. Body mass index (BMI), age at operation, smoking history, preoperative weight loss, operative details, perioperative fluid infiltration, concomitant abdominal liposuction, ligation of perforators by clips, suture or diathermy, use of quilting sutures, weight of tissue removed, postoperative drainage, inpatient stay, and seroma rates were recorded. Statistical analysis was undertaken using the unpaired t test, Fisher's exact test, the Mann-Whitney U test, and Kendall's tau-b test. RESULTS: The study included 90 patients. The incidence of seroma was significantly lower among the patients who had perforators ligated (4/60, 6.7%) than among those who had diathermy (10/30, 33%) (p=0.002, Fisher's exact test). Seroma formation was significantly associated with a higher BMI, (27.45 vs. 25.16 kg/m2; p=0.025, t test) but not with preoperative weight loss. Postoperative fluid drainage did not differ significantly between ligated and diathermied perforators (p=0.716 Mann-Whitney U test). CONCLUSIONS: Use of ligation by clip or suture rather than by diathermy to ablate large abdominal perforators significantly reduced the incidence of seroma among abdominoplasty patients. LEVEL OF EVIDENCE IV: 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 .

Sodium supplementation in neonates with pierre robin sequence significantly improves weight gain if urinary sodium is low.

OBJECTIVE: To investigate whether sodium supplementation increases weight gain in babies with grade 3 Pierre Robin sequence if their urinary sodium is low. DESIGN: Retrospective review of all medical, dietitian, and nursing notes of babies admitted from 2000 to 2007, inclusive. SETTING: Tertiary center for cleft care. PATIENTS: A total of 33 babies requiring nasogastric and nasopharangeal intubation for Pierre Robin sequence were identified. Those for whom weights could not be measured accurately (n  =  4) were excluded from further study. INTERVENTIONS: Urinary sodium was low and weight gain poor in 21 of the remaining 29 babies (72%), and oral sodium supplementation was given to establish and maintain a normal urinary sodium (10 to 20 mmol/L). MAIN OUTCOME MEASURE: Mean daily weight gain. RESULTS: The mean daily weight gain of the 18 babies with low urinary sodium admitted in the first few days of life improved from 20 to 34 g (p < .001) following oral sodium supplementation. This gave a mean difference of 14 g (lower quartile  =  6 g, upper quartile  =  25 g, 95% confidence interval  =  20, 90% confidence interval  =  10). The mean daily weight gain of the eight patients who did not require sodium supplementation was 33.6 g. CONCLUSIONS: Urinary sodium tests are simple and noninvasive and allow monitoring of urinary sodium. If low, adequate supplementation improved weight gain (p < .001), reversing failure to thrive in babies with severe Pierre Robin sequence. These findings have been unreported previously.

Use of the orbicularis retaining ligament in lower eyelid reconstruction.

INTRODUCTION: The orbicularis retaining ligament (ORL) is a distinct anatomical structure that has only been recently characterised. A variety of techniques, based on Hamra's concepts, now divide this ligament during lower lid blepharoplasty. This often produces a substantial skin excess which is discarded. We set out to investigate the validity of this surgical manoeuvre as a means of recruiting anterior lamella for the purposes of lower lid reconstruction. MATERIALS AND METHODS: Between September 2002 and August 2004, 23 patients underwent reconstruction of the anterior lamella of their lower eyelid using this technique. The mean age of the patients was 56 years (range 26-86 years). The mean follow-up time was 20 months (range 12-36 months). Clinical evaluation was carried out preoperatively and postoperatively to assess the presence of palpebral non occlusion, epiphora, the sensation of a dry eye, ectropion, conjunctivitis and keratitis. Assessment of the tissue deficit was made clinically and with standardised digital photographs. RESULTS: Satisfactory reconstruction of the anterior lamella of the lower eyelid was achieved in 19/23 patients. Preoperative symptoms of epiphora and lower lid position were improved. The visual analogue scale of appearance was improved postoperatively. In some cases, particularly in the atrophic lower lid, the results were short lived and further surgery was required to achieve optimal results. CONCLUSION: In cases of isolated cutaneous deficit where the lid support mechanisms are intact, the procedure is both successful and aesthetically favourable for resurfacing this challenging area.

A method for optimising excision of the nail bed matrix.

This paper describes a useful way of ensuring complete surgical ablation of the germinal matrix of the nail bed by staining the proximal envelope with Bonney's Blue dye.

The Marshall technique: an economic one-stage technique for nipple-areola reconstruction.

The goals of nipple-areola reconstruction are symmetry in position, shape, size, colour, tone, texture, sensation and responsiveness. These goals are best attempted when the breast-mound reconstruction has been completed. We describe a technique in which the skin of the neo-areola is raised as a split-thickness skin graft, and then re-grafted to the same site with a free nipple graft. This technique is always available, requires no special equipment, causes no donor-site morbidity and produces excellent results. The disadvantage is that it may be more difficult following radiotherapy or if the mastectomy scar traverses the desired site of nipple-areola reconstruction. As with any skin graft, the neo-areola may lose pigmentation, imperfectly 'take' or contract with time. This technique has not been previously described in the literature.

Halo naevus or malignant melanoma? A case report.

It is generally felt that a halo naevus is benign, and patients can be reassured. The lesion is frequently left alone. We present a case where the clinician felt reassured, but at the patient's insistence the lesion was excised. The histology result was not anticipated.

Piercing the upper ear: a simple infection, a difficult reconstruction.

Piercing the upper ear to retain jewellery is now commonplace. When infection ensues, devastating chondritis leads to collapse of the ear. To our knowledge, the surgical reconstruction of post-piercing deformities has not been documented in the literature. We present five such cases referred for autogenous-tissue ear reconstruction. In four of these, the destroyed segments of ear cartilage were replaced with a carved costal-cartilage framework. One patient declined surgery. The importance of preventing infection is stressed.