Improving quality of life after breast cancer: a comparison of two microsurgical treatment options for breast cancer-related lymphedema (BCRL).

PURPOSE: Vascularized lymph node transfer (VLNT) entails the autologous relocation of lymph nodes to a lymphedematous region of the body, whereas lymphaticovenous anastomosis (LVA) creates a direct bypass between the lymphatic and venous system. Both techniques are meant to lastingly bolster the local lymphatic drainage capacity. This study compared safety and effectiveness of VLNT and LVA in patients with chronic breast cancer related lymphedema (BCRL). METHODS: A retrospective cohort study was conducted using data from our encrypted database composed of patients with chronic BCRL who were treated with either VLNT or LVA and had a minimum follow-up of two years. Patient-specific variables analyzed included pre- and postoperative arm circumferences, lymphedema stages and postoperative complications. RESULTS: A total of 105 patients met the inclusion criteria, of which 96 patients demonstrated a complete follow-up period of two years. The VLNT group displayed larger preoperative circumferential measurements, evident in both in the isolated examination of the affected arm, as well as when adjusted for the contralateral unaffected arm. Significant reduction in arm volume was achieved by both groups. However, VLNT demonstrated superior relative reduction rates than LVA, neutralizing any significant arm size disparities after 24 months. Surgery duration was slightly longer for VLNT than LVA. Postoperative complications, predominantly minor, were exclusively observed in the VLNT group. CONCLUSIONS: Both VLNT and LVA offer significant improvement for patients suffering from chronic BCRL. VLNT shows an even greater potential for improvement in more severe cases of BCRL, but involves a higher risk for (mostly minor) complications.

[Breast Reconstruction Strategies in Case of Planned Radiotherapy]. / Rekonstruktives Vorgehen zum Brustwiederaufbau bei geplanter Bestrahlung.

INTRODUCTION: The ideal technical and chronological approach of breast reconstruction in case of planned radiotherapy after mastectomy (post-mastectomy radiotherapy, PMRT) continues to be controversially discussed. METHODS: The authors analysed the MEDLINE Database PubMed for relevant studies concerning PMRT and breast reconstruction. The main theses from these publications were extracted and summarised. RESULTS: An implant-based approach is the least invasive technique for immediate breast-mound formation in a PMRT setting. Reconstruction in a PMRT setting with a two-stage expander-implant technique or expander-implant-autologous procedure can provide good to excellent cosmetic outcomes. In contrast to the implant-based approach, autologous reconstruction methods provide an improved quality of life as well as haptic and sensory advantages and are usually associated with lower complication rates. PMRT after autologous reconstruction can have a negative impact on the autologous tissue. A delayed autologous approach can be advantageous and should be generally favoured in high-risk patients. CONCLUSION: Factors influencing a meticulous planning of breast reconstruction including PMRT are surgical, aesthetic and patient characteristics, quality of life, preference and expectation. Ideally, PMRT is completed before autologous reconstruction to avoid radiation-associated side-effects on the final reconstructive result. If PMRT is likely, but potentially not necessary, an immediate-delayed procedure may be of advantage.

Randomized Single-Center Study of Effectiveness and Safety of a Resorbable Lysine-Based Urethane Adhesive for a Drain-Free Closure of the Abdominal Donor Site in a DIEP Flap Breast Reconstruction Procedure.

OBJECTIVE: The hypothesis of this parallel group randomized trial testifies if TissuGlu is a safe and an effective alternative to the conventional drainage placement in regard to post-operative fluid management in the abdominal donor site for autologous (DIEP flap) breast reconstruction with a higher postoperative patient quality of life. PATIENTS AND METHODS: Data was collected for 58 women who required to be at min.18 years old with a BMI < 30 and not taking any SSRIs (Selective Serotonin Reuptake Inhibitors).Exclusion criteria: Discharge with indwelling suction drains at the abdominal site or signs of wound infection during hospital stay.The patients were randomized into a study group (donor site closure with application of surgical adhesive without drains) and a control group (donor site closure with drains) using a randomly sorted sealed envelope system.Th e primary outcome was defined as the number of post-operative seroma formations.The secondary endpoint was the evaluation of patient satisfaction with both methods. RESULTS: 58 patients underwent a DIEP reconstruction (29 in the control- and 29 in the study group).Both groups were homogenous. Rate of seroma was 17%(5/29) in the study group and 10%(3/29) in the control group which showed no statistical significance (p-value = 0.71).Smoking and previous abdominal surgery turned out to be a risk factor for seroma formation in the study group.Overall satisfaction was evaluated with a questionnaire and was higher in the study group. CONCLUSION: The abdominal closure with the surgical adhesive seems to be a safe procedure that contributes to patient satisfaction and increases the independence upon discharge in patients with adequate inclusion criteria.

Risk Factor Analysis for Flap and Donor Site Related Complications in 1274 DIEP Flaps - Retrospective Single Center Study.

Background: Breast cancer is the most common cancer affecting women worldwide. In Germany, in almost 70% of cases, women require a complete mastectomy and wish for breast reconstruction which is especially difficult when the breast was previously irradiated. The DIEP flap is then the gold standard for autologous breast reconstruction and shows an overall low complication rate. This study aims to underline the safety of the procedure yet point out potential risk factors for flap edge and fat necrosis in a retrospective series of 1274 DIEP flaps in our center. Patients and Methods: 1274 autologous breast reconstructions with the DIEP flap were performed in 1124 patients between July 2004 and December 2014 in our department. Retrospective risk factor analysis included age, BMI, smoking, chemotherapy and/or radiotherapy and comorbidities. Mean follow-up constituted out of 24 months. Results: Out of 1274 free DIEP flap breast reconstructions, 150 were bilateral reconstructions. In 785 cases the primary indication was previous mastectomy, followed by prior implant-based reconstruction in 265 cases. The total flap loss rate was 0.6%. Patients with a higher BMI and smokers had significantly higher complication rates than the rest of the cohort. Elderly patients ( 65 years), patients with diabetes and ones who had undergone chemo-/ radiotherapy did not present with higher complication rates. Conclusions: The DIEP flap surgery is a well-established method for autologous breast reconstruction with a low complication rate. Yet patient characteristics in terms of risk factors need to be taken into account for result prognosis and satisfactory long-term reconstructive results.

The DIEP Flap as Well-established Method of Choice for Autologous Breast Reconstruction with a Low Complication Rate - Retrospective Single-centre 10-Year Experience.

Background Breast cancer is the most common cancer affecting women in Germany. Despite breast-conserving therapy (BCT) being carried out in almost 70% of cases, a high number of women still require complete mastectomy. Prophylactic mastectomy is also indicated for women with a BRCA 1/2 gene mutation. In addition to implant-based heterologous breast reconstruction, autologous breast reconstruction using a DIEP flap has been found to be beneficial, particularly for patients who had prior radiotherapy. This study aims to show that DIEP flap reconstruction surgery is the method of choice for autologous breast reconstruction with a low rate of complications. Patients and Methods Autologous breast reconstruction using a DIEP flap was performed in 1124 patients between July 2004 and December 2014. Retrospective study criteria included potential risk factors such as age, BMI, smoking, chemotherapy and/or radiotherapy, and comorbidities as well as outcome parameters such as postoperative complications. Outcomes were evaluated with a mean follow-up of 24 months. Results A total of 1124 patients underwent 1274 free DIEP flap breast reconstructions, of which 150 were bilateral reconstructions. The primary indication was previous mastectomy in 785 cases, followed by prior implant-based reconstruction in 265 cases. The total flap loss rate was 0.6%. Postoperative surgical revision for abdominal wall hernia was required in 0.2% of cases. The group with a higher BMI and the group of smokers had significantly higher complication rates. Elderly patients (> 65 years), patients who had undergone chemo-/radiotherapy and patients with diabetes did not have higher complication rates. Conclusion DIEP flap surgery is an excellent option for autologous breast reconstruction, with a low rate of donor site morbidity and low complication rates. DIEP flap surgery carried out in a specialised interdisciplinary breast centre in a standardised clinical setting after prior careful patient selection to take account of risk factors such as high BMI and smoking is a reliable method with a low complication rate and satisfactory long-term reconstruction results.

D-SUN Method to Prevent Double-Bubble Deformity in Broad Base Breasts with High-Rising Inframammary Fold.

Breast augmentation is the most commonly performed plastic surgery among women worldwide. With time, implant selection shifted from arbitrary implantation to precise planning. Different methods address the dimensional planning process. Many of them are complex to put into practice, focusing mainly on the breast base. Constricted, short lower pole breasts are morphologically predisposed to complication such as double-bubble deformity. Yet, by focusing on the distance between the nipple on stretch and the inframammary fold, the D-SUN method guides the surgeon to find the most appropriate implant volume for anatomical form-stable silicon implants and IMF incision to avoid complications.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.

Autologous Breast Reconstruction with SIEA Flaps: An Alternative in Selected Cases.

BACKGROUND: The deep inferior epigastric perforator flap has been shown to be a reliable option for autologous breast reconstruction. A further refinement in the transfer of lower abdominal tissue is the superficial inferior epigastric artery (SIEA) flap that does not require any incision of the rectus abdominis fascia or muscle and is superior regarding donor-site morbidity. OBJECTIVES: We conducted a retrospective study to assess reliability and outcomes of autologous breast reconstruction using SIEA flaps. METHODS: We performed autologous breast reconstruction in 1708 patients at our department between 2009 and 2018. Of those, 28 patients that underwent breast reconstruction using a SIEA flap were included for a retrospective chart review. RESULTS: Given an overall flap loss rate of 1.8%, we observed total flap necrosis following a SIEA flap in four patients (13%). All cases were secondary to arterial thrombosis. We further recognized a significant correlation between flap failure and a history of spontaneous deep vein thrombosis (p < 0.0001). There was no statistically significant relationship between flap failure and obesity (BMI > 30 kg/m2;p = 0.9) or flap failure and a history of abdominal operations (p = 0.6). CONCLUSIONS: The SIEA flap provides a reasonable option for autologous breast reconstruction with the great advantage of minimal donor-site morbidity. Nevertheless, its use should be preserved to selected cases with favorable anatomy. We therefore recommend proper patient selection based on preoperative computed tomography angiography, intraoperative clinical evaluation and history of hypercoagulable state. 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.

Subcutaneous mastectomy in female-to-male transsexuals: Optimizing perioperative and operative management in 8 years clinical experience.

INTRODUCTION: The incidence of complications, especially acute hematoma requiring surgical revision in female-to-male transsexuals (FTMTS), is consistently highly documented in literature with up to 33%. Since 2008 we perform subcutaneous mastectomies in FTMTS with an annually increasing number of cases. Due to an initially high hematoma revision rate in the previously published cohort (2008-2013), we implemented peri- and postoperative preventive measures and compared the results with the recent patient cohort (2014-2016). PATIENTS AND METHODS: The records of 356 patients (712 mastectomies) were retrospectively reviewed. We compared the first cohort (C1, 01/2008 - 12/2013, 346 mastectomies; peri- and postoperative standard procedure and implementation of an algorithmic care path in our institution) with the recent cohort (C2, 01/2014 - 01/2016, 366 mastectomies) and introduced in C2 the following preventive measures: perioperative administration of tranexamic acid, intraoperative elevation of blood pressure to at least 120 mmHg before wound closure, bedrest and consequent wearing of compression bandage without removal 12 hours postoperatively. Comparison of complication rate, patient satisfaction and secondary revision rate was obtained in both cohorts. RESULTS: The mean operation time could be reduced from 103.6 minutes to 72.5 minutes (p < 0.05). The overall complication rate could be diminished from 11.8% to 5.5% (p < 0.05), the acute hematoma revision rate from 9.2% to 4.1% (p < 0.05). Secondary revisions were similar in both patient cohorts. Patient satisfaction rate was ameliorated from 88% to 93.5% "very satisfied" to "satisfied" patients. CONCLUSION: Hematoma is the most common reason for reoperation in FTMTS patients. By implementation of peri- and postoperative preventive measures and additional application of an algorithmic care path we could achieve a significant reduction of complications, particularly of the hematoma evacuation rate. During 8 years clinical and operative treatment in FTMTS we could furthermore achieve a decrease in operative time and an ameliorated patient satisfaction with the aesthetic results.

[Ribeiro-Technique in Gigantomastia - Review of 294 Reduction Mammaplasties in 8 Years]. / Die Ribeiro-Technik bei Gigantomastie ­ Review von 294 Reduktionsplastiken in 8 Jahren.

INTRODUCTION: Reduction mammaplasty in patients with gigantomastia is challenging even to very experienced plastic surgeons. Extremely elongated pedicles impair the vascular supply of the nipple-areola complex. Breast shaping and effective reduction are difficult due to the severely stretched skin envelope. The Ribeiro technique is the standard technique for reduction mammaplasty in our clinic. The aim of this study is to review our approach in patients with gigantomastia in comparison to the current literature. PATIENTS UND METHODS: From 01/2009 to 12/2016, we performed 1247 reduction mammaplasties in 760 patients. In 294 reduction mammoplasties (23.6 %), resection weight was more than 1000 g per breast corresponding to the definition of gigantomastia. The Ribeiro technique with a superomedial pedicle and inferior dermoglandular flap for autologous augmentation of the upper pole was implemented as standard procedure. In cases with a sternal notch-nipple distance > 40 cm, free nipple grafting was performed. The outcome parameters complication rate, patient satisfaction with the aesthetic result, nipple sensitivity and surgical revision rate were obtained and retrospectively analysed. RESULTS: In 174 patients, 294 reduction mammaplasties were performed with a resection weight of more than 1000 g per breast. Average resection weight was 1389.6 g (range, 1000-4580 g). Average age was 43.5 years (range, 18-76 years), average body mass index (BMI) was 29.2 kg/m2 (range, 19-40 kg/m2), average sternal notch-nipple distance was 34.8 cm (range, 27-52 cm), average operation time was 117 minutes (range, 72-213 minutes). A free nipple graft was necessary in 30 breasts. Overall complication rate was 7.8 %; secondary surgical revision rate was 16 %. 93 % of the patients were "very satisfied" and "satisfied" with the aesthetic result. Nipple sensitivity was rated "very good" and "good" in 88 %. CONCLUSION: The Ribeiro technique is a well established, versatile standard technique for reduction mammaplasty, which helps to create high-quality reproducible results with longterm formstable shape. In gigantomastia, this procedure is also very effective to achieve volume reduction and aesthetically pleasing results with a low complication rate.

[Mastopexy in Massive Weight Loss Patients - Extended Ribeiro Technique and Usage of the Lateral Intercostal Artery Perforator Flap (LICAP Flap) for Autoaugmentation]. / Mastopexie nach massivem Gewichtsverlust ­ Erweiterte Ribeiro-Technik und Einsatz der lateralen Interkostalarterien-Perforatorlappenplastik (LICAP-Flap) zur Autoaugmentation.

INTRODUCTION: Mastopexy in massive weight loss patients is challenging. The breast mound is often unstable and deflated, with a loose inelastic skin envelope. It has become apparent that mammaplasty techniques in these cases should rely more on glandular recontouring rather than on the skin envelope for shaping. Published methods include plication, suspension and autoaugmentation. The residual local tissue (glandular breast tissue, fat tissue, dermoglandular fat flap) is utilised to its full extent in order to reshape a form-stable breast with full upper pole projection. The evolution of a technique is presented. PATIENTS AND METHODS: In this study we retrospectively analysed 68 massive weight loss patients who underwent an extended Ribeiro technique with a superomedial pedicle mastopexy and suspension by an inferior dermoglandular flap. The current procedure involves incorporating the lateral intercostal artery perforator flap (LICAP flap) and medial breast pillar additionally to the inferior dermoglandular Ribeiro flap. This essentially autoaugments the upper pole by creating an "autoprosthesis", narrows the widened breast, and redefines the inframammary fold. The outcome parameters complication rate, patient satisfaction with the aesthetic result, nipple sensibility and surgical revision rate were obtained. RESULTS: From 01/2011 to 12/2016, we performed 136 autoaugmentation mastopexies. The average age was 41.2 years, average body mass index (BMI) was 27,1 kg/m2, average weight loss was 54.3 kg, average sternal notch-NAC distance was 32.3 cm, average operation time was 109 minutes. In 12 breasts, a free-nipple graft was necessary. The complication rate was 5.1 %, surgical revision rate was 17.6 %. 95 % of the patients were "very satisfied" or "satisfied" with the aesthetic result. Nipple sensibility was rated as "very good" or "good" by 85 % of patients. CONCLUSION: Modification of the Ribeiro technique by using the medial and lateral breast pillar (LICAP flap) allows autoaugmentation of the upper pole. Parenchymal shaping through plication and suspension of the breast mound should improve breast shape over time, with the aim of reducing the incidence of recurrent ptosis. The presented technique is a reproducible and reliable method with a low complication rate.

Giant Rhinophyma: A Rare Case of Total Nasal Obstruction and Restitutio Ad Integrum.

Rhinophyma is considered the end stage in the development of rosacea, accompanied by hypertrophy of the sebaceous glands, which causes an enlargement of the nose. It is an uncommon condition that often results in both functional and cosmetic impairment. A large variety of surgical and nonsurgical treatments have been published to treat it. Closure is usually obtained by wound granulating in by secondary intention, skin grafting or local flaps. Rarely these lesions can attain a giant size and pose a challenge in surgical treatment. We present a 63-year-old male with the necessity for tracheostomy at the ICU due to total nasal obstruction and recurrent episodes of pneumonia caused by a huge giant rhinophyma, which had undergone extreme growth in the last five years. The tumor was removed under general anesthesia by decortication with an electrosurgical wire loop to recreate the aesthetic units of the nose preserving the alar cartilage as well as the pilosebaceous appendages. The wounds healed in by secondary intention with a very pleasant cosmetic and improved functional result. The relevant literature is discussed. Level of Evidence V 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 .

A novel amino-on CPG-support for the synthesis of 3'-aminoalkylated oligonucleotides.

The synthesis of a novel amino-ON CPG support and its application in the synthesis of 3'-aminoalkylated oligonucleotides is reported. The release of oligonucleotides with free 3'-amino groups is accomplished by treatment with concentrated ammonia for 2 h at 55 degrees C.

Novel method for the covalent immobilization of oligonucleotides via Diels-Alder bioconjugation.

The synthesis of cyclohexadiene and maleimide derivatives and their use for the functionalization of oligonucleotides and the coating of glass surfaces is reported. A method for the covalent attachment of diene or maleimide modified oligonucleotides to the coated glass surfaces via aqueous Diels-Alder reactions is presented.

Enhanced allele-specific PCR discrimination in SNP genotyping using 3' locked nucleic acid (LNA) primers.

The specificity and reliability of locked nucleic acid (LNA) substitution at the 3' position of allele-specific PCR (AS-PCR) primers for SNP detection was investigated in direct comparison to DNA primers. Both plasmid and human genomic DNA templates were examined in this study. All possible DNA and 3' LNA mismatch combinations were tested in triplicate with the plasmid target. LNA primers yield consistently low amounts of mismatch products with all base combinations, whereas certain mismatches with DNA primers generate strong false positive amplicons. Amplified human SNP alleles within the cystic fibrosis (CFTR) gene were analyzed in AS-PCR by gel analysis and real-time fluorescence generation. A 3' LNA residue in the primer at the SNP site improves allelic discrimination and functions under a wide window of PCR conditions. We demonstrate increased AS-PCR specificity with comparable sensitivity using 3' LNA primers in gel electrophoresis and real-time detection experiments. This increase in AS-PCR discrimination with 3' LNA primers should facilitate the use of this simple, rapid, and inexpensive technique for SNP genotyping applications.

Synthesis of oligonucleotide conjugates via aqueous Diels-Alder cycloaddition.

The conjugation of maleimide reporter groups to 5'-diene-modified oligonucleotides via aqueous Diels-Alder cycloaddition is described. Detailed basic protocols are provided for the preparation of a diene-amidite (5'-diene modifier), for the attachment of a diene group to the 5'-terminus of oligonucleotides, and for the conjugation of maleimide reporter groups to diene-modified oligonucleotides.