Delayed-immediate breast reconstruction: An assessment of complications and outcomes in the context of anticipated post-mastectomy radiotherapy.

INTRODUCTION: The detrimental effects of post-mastectomy radiotherapy on breast reconstruction are well known. We report our experience with a delayed-immediate approach involving an initial subcutaneous implant with definitive reconstruction after adjuvant radiotherapy. METHODS: Patients were identified retrospectively from hospital, theatre and implant registry records. Details regarding demographics, cancer pathology, surgical data and oncological therapies were collected. Primary outcomes included complication rates of first-stage surgery and time to definitive reconstruction. RESULTS: A total of 115 patients underwent mastectomy and temporary subcutaneous implant (36 nipple sparing) between 2008 and 2019. Five were smokers with eleven having a body mass index > 30. The median age was 46 years (27-76 years) and tumour size 50 mm. Almost 95% underwent radiotherapy, 82% chemotherapy and 70% had axillary node clearance. Median mastectomy weight was 464 g (123-1300 g) with median temporary implant volume 375 cc (180-655 cc). Complications of first-stage surgery at three months included 5.2% implant loss (n = 6), 14.8% infection rate, 17.4% readmission rate and 10.4% returned to theatre. Reconstructive failure occurred in four cases (3.5%). A total of 76 patients completed definitive reconstruction, including 26 autologous, 21 latissimus dorsi with implant, and 28 implant-only reconstructions. The median time to reconstruction following the completion of radiotherapy was 12 months. This increased in those who had implant complications (28 vs. 15 months) or radiotherapy (16 vs. 10 months) versus those without. CONCLUSIONS: Delayed-immediate breast reconstruction using a temporary subcutaneous implant has been shown to be a safe, feasible and potentially beneficial method than simple mastectomy and delayed reconstruction with a complication rate comparable to that of immediate implant reconstruction.

Sentinel lymph node biopsy in melanoma: The Oxford ten year clinical experience.

Sentinel lymph node biopsy (SLNB) has become an established investigation for assessing microscopic nodal metastasis in melanoma. The American Joint Committee on Cancer (AJCC) incorporates the sentinel node status in its staging criteria for melanoma. We present our clinical evaluation of performing SLNB in a single UK centre between 1998 and 2008. There were 697 patients with a mean age 53 years (range 13-92). We were able to surgically harvest at least one sentinel node in 694 patients of which 532 (76%) were negative. Of the 162 positive patients, 129 underwent further completion lymphadenectomy with 29 showing further pathologically positive nodes. At median follow up of 46 months, mortality from melanoma for SLN positive and negative patients was 32% and 4%, respectively. Disease recurrence was noted in 10% of the SLN negative group. Survival curves showed significant difference (p<0.001) in outcomes for patients grouped by Breslow thickness. Postoperative complications were noted in 6% of patients. No life-threatening complications were noted. Our results are comparable to other national and international studies. We await the outcomes of ongoing trials to assess the therapeutic value of SLNB for melanoma.

Shotgun "12/20 burst" injuries to the upper limb.

Barrel explosions (or "bursts") can occur when different gauge cartridges are inadvertently placed into the breech of a shotgun. This article describes two cases in which injuries were sustained to the left hand and forearm as a result of the placement of 12- and 20-gauge cartridges into 12-bore shotguns. Although the incidence of catastrophic barrel failure and the injuries they cause are not known, there is concern that such cases may be increasing as the use of 20-gauge shotguns is becoming more popular. The unusual nature of this type of injury has not been described in the medical literature.

Evaluation of hand circulation before radial forearm free flap surgery.

The radial forearm free flap (RFFF) is a versatile flap offering many reconstructive options for head and neck defects. Its low bulk, ease of dissection, and excellent vascularity are among its advantages. Its low flap loss and complication rates offer the best choice for the reconstruction of oral, oropharyngeal, and hypopharyngeal lining. Evaluation of collateral circulation to the hand is important to avoid distal ischemia and donor site morbidity. Pulse oximetry can be used to augment Allen's test to assess collateral supply to the hand. This cost-neutral technique can be used in routine preoperative screening prior to RFFF surgery.

Herb of grace: an unusual cause of phytophotodermatitis mimicking burn injury.

We report the case of a 2-year-old child who suffered an acute phytophotodermatitis with systemic upset after contact with the herb Ruta Graveolens (common rue, Herb of Grace). We review the literature detailing the mechanism of the phytophotodermatitis and the mainstream and alternative medicinal uses of the herb. Clinicians treating burns should consider phytophotodermatitis in their differential diagnosis of any partial-thickness burn injury. Furthermore, the hazards of growing this widespread herb in gardens where children play should be well publicized.

A late complication following the insertion of hydrogel breast implants.

This case report draws attention to an unusual presentation and subsequent complication following the insertion of a PIP Hydrogel implant for breast augmentation. A cutaneous and capsular foreign body giant cell reaction was identified, and was preceded by the development of a notable increase in breast volume prior to spontaneous discharge. We believe that this was caused by subclinical leakage of the implant contents through a degrading shell. The biodegradability of hydrogel makes it impossible to ascertain the precise nature of the material that leaked out. Given this demonstrable leakage, the adverse clinical effects and the potential for toxicity that is currently unknown, we question whether this product (and other hydrogel breast implants like it) should be formally recalled for the benefit of patient safety.