Perforator Mapping Practice for Deep Inferior Epigastric Artery Perforator Flap Reconstructions: A Survey of the Benelux Region.

BACKGROUND: Numerous new and novel imaging techniques for preoperative perforator selection in deep inferior epigastric artery perforator (DIEP) flap planning have been introduced. To what extent, these have been adopted into or replaced routine practice has hitherto remained unknown. The purpose of this study was to identify the currently preferred technique by reconstructive surgeons, the criteria that they regard as most relevant and what impact these have on the preoperative decision-making. METHODS: An online survey consisting of 25 questions was sent to members of the Benelux Societies for Plastic Surgery. Information regarding experience and preferred imaging modality was requested. Specific questions addressed the utilization of computed tomography angiography (CTA) and factors that could inform preoperative perforator selection. Results were anonymously collected, managed using REDCap, and analyzed using Chi-square statistic. RESULTS: Seventy-nine principal surgeons could be included. A variation in surgeon experience was observed. On CTA, the preferred imaging modality, large-caliber vessels, the location of the perforator in the flap, and its intramuscular course were considered the most significant criteria. Surgeons doing more than 20 DIEP flaps per year are less concerned about the distance of the perforator from the umbilicus (p = 0.003) but more likely to choose a medial perforator (p = 0.011). No statistical difference was found in surgeons' experience between those who would choose and use one specific (medial or lateral) perforator when they are analogous on CTA, and those who would delay the decision until both perforators have been exposed. CONCLUSION: Advantages and disadvantages of the current practice of preoperative perforator selection by surgeons who are primarily responsible for harvesting a DIEP flap have been clearly identified. Indications are that these could be widely representative in which case, the quest for a protocol or modality that maximizes the benefit and minimizes harm in preoperative perforator mapping is urgently required.

Effectiveness of mini-open carpal tunnel release: An outcome study.

BACKGROUND: Carpal tunnel syndrome (CTS) is the most common peripheral entrapment neuropathy with a high morbidity and healthcare-related costs. Currently there is no consensus about the best treatment option. The purpose of this prospective cohort study conducted at a single institution was to evaluate the clinical outcomes and patient satisfaction following a mini-open carpal tunnel release for idiopathic CTS. METHODS: A total of 72 patients (53 female and 19 male patients; mean age, 57.8±15.3 years; range, 24-94 years) had a mini-open carpal tunnel release performed by a single senior surgeon between June 2015 and June 2016. The patients were evaluated preoperatively, and at 3 and 12 months post-intervention. At every follow-up, the Boston Carpal Tunnel Syndrome Questionnaire (BCTSQ) and visual analogue scale (VAS) scores for pain and satisfaction were completed. Digital sensibility (using Semmes- Weinstein monofilaments) was assessed and pinch and grip strengths were measured. RESULTS: Statistically significant and clinically relevant improvement was found in terms of digital sensibility, grip and pinch strength (except for 2-point pinch), BCTSQ scores and pain scores. The complication rate was minimal, and no major complications occurred. Two patients experienced recurrence. The availability of follow-up records (including patient-reported outcomes, BCTSQ and VAS scores, and the complication rate) at 1-year post-intervention varied between 69% and 74% (50-53 patients) depending on which parameter was assessed. Patient satisfaction was high (mean, 80.9±26.0; range, 0-100). CONCLUSIONS: This study demonstrates that mini-incision carpal tunnel release is clinically effective in the short and long term.

Concordance between preoperative computed tomography angiographic mapping and intraoperative perforator selection for deep inferior epigastric artery perforator flap breast reconstructions.

BACKGROUND: Preoperative imaging for perforator identification prior to a deep inferior epigastric artery perforator (DIEP) flap elevation for breast reconstruction has many advantages. Currently, computed tomography (CT) angiography provides good visualization of the perforators and their course, and is thus the imaging technique of choice. The primary aim of this study was to determine the concordance between the perforators identified preoperatively and the perforators ultimately selected intraoperatively, with a standardized protocol, in a single institution. Secondly, we wanted to compare our results with those of other, similar studies and, thirdly, to identify those factors that may lead to a higher concordance. METHODS: A retrospective review was undertaken of a case series of 49 consecutive patients undergoing unilateral autologous breast reconstruction with a DIEP flap at the Gelre Hospital, in the Netherlands, over a 4-year period from 2013 to 2017. The preoperative identification and selection of perforator number and location with the aid of CT angiography scanning were compared to the intraoperative findings and preference. RESULTS: Our study revealed a concordance of 67.3% between one or more perforators advised preoperatively by the radiologist and chosen intraoperatively by the surgeon. We identified significant differences in our protocol compared to others. CONCLUSIONS: The study confirmed the benefit to both the patient and the surgeon when preoperative CT angiography is used. Scanning protocols may vary considerably and should thus be carefully scrutinized before future comparisons are made. Based on this study, the scanning range, method of selecting perforators and timing of image acquisition may have to be optimized for future prospective clinical trials.

Defining post-sternotomy mediastinitis for clinical evidence-based studies.

BACKGROUND: Considerable advances have already been made in the treatment of deep thoracic wound infections following a median sternotomy for cardiac surgery. Further improvement in diagnosis, treatment, and outcome will require a targeted approach by multidisciplinary teams. Clear communication and synergy between the various clinical and supportive disciplines would assist in removing the last barriers to standardized evidence-based studies and the development of improved evidence-based guidelines. METHODS: An extensive literature search without language restrictions was carried out on PubMed (Medline), EMBASE, and Web of Science, covering the period 1988 to week 16, 2014, and a manual search of the reference lists was performed regarding all possible definitions and classifications of post-sternotomy mediastinitis. Two hundred and eighteen papers describing post-sternotomy infections in a multitude of terms were identified, and the strengths and weaknesses of the most popular definitions and terms relating specifically to post-sternotomy infections were examined. RESULTS: This study revealed that clinicians use a multitude of terms to describe post-sternotomy infections without defining the condition under treatment. Occasionally, older epidemiological (surveillance) definitions were used. It also shows that supportive disciplines have their own definitions, or interpretations of existing definitions, to describe these infections. CONCLUSION: The outcome of this study is that clinicians have adopted no single definition, which is essential for further improvement for evidence-based studies. We suggest that it is possible to adopt a single term for thoracic infection after a sternotomy (and only sternotomy), and propose a clinical definition for this purpose.

Diagnosing poststernotomy mediastinitis in the ED.

PURPOSE: Poststernotomy mediastinitis (PSM), the severe chest wall and mediastinal infection that may arise at any time after a sternotomy, causes significant morbidity and mortality globally. Late recognition and diagnosis are the major contributors to a poor outcome. This review focuses on recent advances in diagnosing PSM (particularly after cardiovascular surgery) at the earliest opportunity--in the emergency department. RECENT FINDINGS: Morbidity and mortality of PSM, especially when associated with numerous other complications, remain unaltered high. Careful history taking and clinical examination remain the mainstays of a preliminary diagnosis. No specific signs are indicative of PSM alone. Procalcitonin as a biomarker and neutrophil volume distribution width obtained during a complete blood count with differential, assessed in the clinical context, offer interesting prospects of obtaining a speedy and accurate diagnosis. Adjunctive diagnostic imaging modalities such as contrast-enhanced computed tomography can differentiate PSM from postcardiac injury syndrome and other causes of vague chest pain some time after sternotomy with increasing accuracy. CONCLUSION: The speed and accuracy of diagnosing PSM have improved with recent advances in imaging and laboratory methodologies. In the symptomatic patient with a closed sternotomy wound or scar, with either fever (>38°C) or sternal instability, together with well-described signs on contrast-enhanced computed tomography, in whom other life-threatening causes of chest pain have been excluded, the diagnosis of PSM can be made without awaiting the outcome of microbiological confirmation. Nevertheless, there still remain significant research opportunities for clinicians and scientists to improve the early diagnostic accuracy of PSM.

Sternotomy and intrathoracic omentum: two procedures, two innovators, and the river that runs through it - a brief history.

This is a small tribute to the monumental contributions of the early pioneers who introduced 2 invaluable thoracic procedures; an exposure through which the mediastinum and the heart could be safely approached, the median sternotomy, and an approach and method to revascularize an intrathoracic organ by transferring the omentum into the chest. The origin, rediscovery, and application of these procedures are strangely linked. With the renewed interest in variations of the median sternotomy and the effectiveness of using the intrathoracic omentum, the legacy of the original innovators lives on.

Poststernotomy mediastinitis: a classification to initiate and evaluate reconstructive management based on evidence from a structured review.

Early recognition and, where possible, avoidance of risk factors that contribute to the development of poststernotomy mediastinitis (PSM) form the basis for successful prevention. Once the presence of PSM is diagnosed, the known risk factors have been shown to have limited influence on management decisions. Evidence-based knowledge on treatment decisions, which include the extent and type of surgical intervention (other than debridement), timing and others is available but has not yet been incorporated into a classification on management decisions regarding PSM. Ours is a first attempt at developing a classification system for management of PSM, taking the various evidence-based reconstructive options into consideration. The classification is simple to introduce (there are four Types) and relies on the careful establishment of two variables (sternal stability and sternal bone viability and stock) prior to deciding on the best available reconstructive option. It should allow better insight into why treatment decisions fail or have to be altered and will allow better comparison of treatment outcomes between various institutions.

Gynaecomastia surgery in the Netherlands: what, why, who, where .

Gynaecomastia, breast enlargement in men, is common in all age groups. It is operated on by plastic surgeons, general surgeons and paediatric surgeons. It is therefore possible that there is a difference in the populations treated, the indications for surgery and the management used by the different practitioners. We performed a survey in order to assess the approach to treatment of gynaecomastia by the different disciplines. An electronic survey questionnaire was sent to members of the Dutch societies of surgery, paediatric surgery and plastic surgery. We received 105 responses from plastic surgeons, 95 from general surgeons and 15 from paediatric surgeons, representing respective response rates of 38.7%, 23.8% and 42.8%. Plastic surgeons operated on gynaecomastia most frequently. The diagnostic criteria and workup were similar for all disciplines, although general surgeons used more imaging. There was a difference in the side operated on. General surgeons and paediatric surgeons operated mainly on unilateral cases (74% and 52%), while plastic surgeons operated mainly on bilateral cases (85%). Pharmaceutical treatment with Tamoxifen was reported only by general surgeons (13%). All disciplines used mainly the periareolar incision. Plastic surgeons reported more often the use of other surgical approaches as well as adjunctive liposuction and they did not always submit tissue for pathological examination. Perioperative antibiotics, drains and pressure garments were not always used. All disciplines agreed that the most common complication was bleeding, followed by seroma, infection, insufficient results, inverted nipple and nipple necrosis. This survey highlights some differences in the practice of gynaecomastia surgery. The findings appear to point to the fact that the indications are different, being more aesthetic in the case of plastic surgeons. The results of this survey are important in establishing the standard of care and may be helpful for setting guidelines.

Bridging phenomenon - Simplifying complex ear reconstructions.

BACKGROUND: Extirpation of noninvasive skin tumors of the anterior ear may create large defects. Various flaps, described to cover these defects, demand special knowledge without which a loss of the fine detail of the ear may result. METHODS: Healthy, exposed cartilage is deliberately excised leaving a basic framework for support, thus preserving contours and a well-vascularized recipient bed for full-thickness skin grafting. The grafts heal by revascularization and "bridging," a phenomenon whereby grafts on avascular beds (such as denuded cartilage) are revascularized. RESULTS: By marrying clinical experience gained during microtia reconstruction with insights regarding the bridging phenomenon derived from the laboratory, our 17 reconstructed ears healed without serious complications and kept their normal contours and shape, and there was no recurrence of the carcinoma. CONCLUSION: Satisfactory patient-centered outcome can be obtained in reconstructing defects of one-third to two-thirds of the total anterior surface of the ear relying on the bridging phenomenon.

Tamoxifen therapy for the management of pubertal gynecomastia: a systematic review.

OBJECTIVE: A systematic review to assess the efficacy of tamoxifen in the management of idiopathic pubertal gynecomastia. DATA SOURCES: Searches were conducted using the databases of Medline (search engine PubMed) and Web of Science®. STUDY SELECTION: Studies reporting the use of Tamoxifen for the treatment of gynecomastia in adolescents. OUTCOME MEASURE: Resolution of gynecomastia. RESULTS: A total of 164 publications were found; 59 were selected for retrieval and six were included in the review. There were no randomized controlled studies; the studies found have methodological flaws but show promising results. No clinical side-effects were reported or observed. CONCLUSION: Tamoxifen may be effective for the treatment of pubertal gynecomastia, and it seems safe to use. Randomized controlled studies are necessary to confirm this indication.