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Bojanic C, Di Pace B, Ghorra DT, Fopp LJ, Rabey NG, Malata CM. A comparison of presentations and outcomes of salvage versus non-salvage abdominal free flap breast reconstructions-Results of a 15-year tertiary referral centre review. PLoS One 2023; 18:e0288364. [PMID: 37910518 PMCID: PMC10619878 DOI: 10.1371/journal.pone.0288364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Accepted: 06/24/2023] [Indexed: 11/03/2023] Open
Abstract
INTRODUCTION Salvage breast reconstruction with autologous tissue is becoming more prevalent due to a resurgence in implant-based procedures. The latter has caused a commensurate rise in failed or treatment-resistant prosthetic cases requiring conversion to free tissue transfers. Salvage reconstruction is often considered more challenging, owing to patient presentation, prior treatments and intraoperative difficulties. The aim of the study was to test this hypothesis by comparing outcomes of salvage versus non-salvage autologous microsurgical breast reconstructions in a retrospective matched cohort study. METHODS The demographics, risk factors, operative details and outcomes of patients who underwent free flap salvage of implant-based reconstructions by a single operator (2005-2019) were retrospectively evaluated. For each salvage reconstruction, the consecutive non-salvage abdominal free flap reconstruction was selected for comparison. The clinical outcomes including intraoperative blood loss, operative time, flap survival and complication rates were compared. RESULTS Of 442 microsurgical patients, 35 (8.0%) had salvage reconstruction comprising 41 flap transfers (29 unilateral, 6 bilateral) and 42 flaps (28 unilateral, 7 bilateral) in nonsalvage reconstruction. Deep inferior epigastric perforator (DIEP) flaps comprised the commonest autologous tissue used in both groups at 74% and 71% respectively. Most patients (83%) underwent salvage reconstruction for severe capsular contractures. There was a significant difference in radiation exposure between groups (salvage reconstruction 89%, non-salvage reconstruction 26%; p<0.00001). All 83 flaps were successful with similar reoperation rates and intraoperative blood losses. Unilateral salvage reconstruction took on average two hours longer than non-salvage reconstruction (p = 0.008). Overall complication rates were similar (p>0.05). CONCLUSION This 15-year study shows that despite salvage autologous free flap breast reconstruction requiring longer operation times, its intra and postoperative outcomes are generally comparable to non-salvage cases. Therefore, salvage breast reconstruction with free flaps provides a reliable option for failed or suboptimal implant-based reconstructions.
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Affiliation(s)
- Christine Bojanic
- Plastic & Reconstructive Surgery Department, Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Bruno Di Pace
- Scuola Superiore Meridionale, University of Naples “Federico II”, Naples, Italy
- School of Medicine, Anglia Ruskin University, Cambridge and Chelmsford, United Kingdom
| | - Dina T. Ghorra
- Plastic & Reconstructive Surgery Department, Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
- Department of Plastic Surgery, University of Alexandria, Alexandria, Egypt
| | - Laura J. Fopp
- Plastic & Reconstructive Surgery Department, Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Nicholas G. Rabey
- Plastic & Reconstructive Surgery Department, Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Charles M. Malata
- Plastic & Reconstructive Surgery Department, Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
- School of Medicine, Anglia Ruskin University, Cambridge and Chelmsford, United Kingdom
- Cambridge Breast Unit, Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
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Abstract
This article provides an overview of the principles and techniques of oncoplastic and reconstructive breast surgery for patients with early-stage breast cancer. Oncoplastic breast surgery (OPBS) with partial breast reconstruction is a natural evolution in the application of breast conserving surgery and permits wide surgical resection of tumours that might otherwise mandate mastectomy and whole breast reconstruction. These reconstructive techniques must be optimally selected and integrated with ablative breast surgery together with non-surgical treatments such as radiotherapy and chemotherapy that may be variably sequenced with each other. A multidisciplinary approach with shared decision-making is essential to ensure optimal clinical and patient-reported outcomes that address oncological, aesthetic, functional and psychosocial domains. Future practice of OPBS must incorporate routine audit and comprehensive evaluation of outcomes.
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Affiliation(s)
- Primeera Wignarajah
- Department of Breast Surgery, Royal Marsden Hospital NHS Trust, London, United Kingdom
- Department of Breast Surgery, Cambridge Breast Unit, Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Charles M Malata
- Department of Breast Surgery, Cambridge Breast Unit, Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
- Department of Plastic and Reconstructive Surgery, Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
- Anglia Ruskin University School of Medicine, Cambridge/Chelmsford, United Kingdom
| | - John R Benson
- Department of Breast Surgery, Cambridge Breast Unit, Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
- Anglia Ruskin University School of Medicine, Cambridge/Chelmsford, United Kingdom
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Carslaw CH, Samudrala H, Kerrison J, Brooker JE, Rabey NG, Malata CM. Increased Production of Abdominal Donor Site Fluid Following Microsurgical Breast Reconstruction With Superficial Inferior Epigastric Artery Versus Deep Inferior Epigastric Artery Perforator Flaps. Cureus 2023; 15:e38942. [PMID: 37313097 PMCID: PMC10259683 DOI: 10.7759/cureus.38942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/11/2023] [Indexed: 06/15/2023] Open
Abstract
Introduction and aims Donor site seroma following abdominal flap harvest for breast reconstruction is common in both deep inferior epigastric artery perforator (DIEP) and superficial inferior epigastric artery (SIEA) flaps. We tested the hypothesis that there is increased donor site fluid following SIEA dissection compared to DIEP. Materials and methods Of60 SIEA breast reconstructions performed by one surgeon in 50 patients (2004-2019), complete data were available for 31 patients. Eighteen unilateral SIEAs were matched with 18 unilateral DIEPs. Thirteen bilateral flap harvests involving an SIEA were matched with 13 bilateral DIEP controls. Their cumulative abdominal drain outputs, times to drain removal, hospital stay, and number and volume of seroma aspirations were compared. Results Patients who underwent an SIEA flap harvest had significantly increased drain output compared to only a DIEP flap harvest (SIEA=1,078 mL, DIEP=500 mL, p<0.001), which remained significant after controlling for confounding variables (p=0.002). There was increased time until drain removal (SIEA=11 days, DIEP=6 days, p=0.010), and patients who underwent an SIEA harvest were 14 times more likely to be discharged with a drain in situ (odds ratio (OR)=14.6, 95% confidence interval (CI)=2.8203-75.9565, p=0.0014). There was no significant difference in the number or volume of outpatient aspirations, length of hospital admission, or total seroma volume. Conclusion This study demonstrated that SIEA harvest is a significant predictor of increased abdominal drain output postoperatively. This accounted for longer periods before drain removal and more patients discharged with an abdominal drain in situ and should be an important consideration for reconstructive surgeons. There was no demonstrable difference in the number or volume of seroma aspirations after drain removal for either group.
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Affiliation(s)
- Calum H Carslaw
- School of Clinical Medicine, University of Cambridge, Cambridge, GBR
- Department of Intensive Care, Royal Papworth Hospital NHS Foundation Trust, Cambridge, GBR
| | - Havish Samudrala
- School of Clinical Medicine, University of Cambridge, Cambridge, GBR
| | - James Kerrison
- School of Clinical Medicine, University of Cambridge, Cambridge, GBR
| | - Jack E Brooker
- School of Clinical Medicine, University of Cambridge, Cambridge, GBR
| | - Nicholas G Rabey
- Department of Plastic and Reconstructive Surgery, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, GBR
| | - Charles M Malata
- School of Medicine, Anglia Ruskin University, Cambridge, GBR
- Department of Plastic and Reconstructive Surgery, and Cambridge Breast Unit, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, GBR
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Soh CL, Muktar S, Malata CM, Benson JR. Abstract P6-05-44: REASONS FOR CHOOSING DELAYED RATHER THAN IMMEDIATE CONTRALATERAL PROPHYLACTIC MASTECTOMY IN PATIENTS WITH UNILATERAL BREAST CANCER. Cancer Res 2023. [DOI: 10.1158/1538-7445.sabcs22-p6-05-44] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
Abstract
Abstract
Background: Rates of contralateral prophylactic mastectomy (CPM) have more than doubled in the past decade amongst breast cancer patients irrespective of inherited genetic predisposition related to high penetrance genes. Increasing numbers of women with unilateral breast cancer are opting for removal of both the affected ipsilateral and unaffected contralateral ‘normal’ breast even when suitable for breast conserving surgery. Reasons for requesting CPM include prevention of recurrence, peace of mind and moving on after breast cancer. Some women seek CPM as a delayed procedure but factors influencing this are poorly understood. Methods: A retrospective analysis examined patients undergoing CPM as either an immediate or delayed procedure with or without breast reconstruction (BR) at a single tertiary referral centre between January 2009 and December 2019. A cross-sectional survey was undertaken that was compiled and based on validated questionnaires and responses to defined statements generated using a 5-point Likert scale (1 = strongly disagree to 5 = strongly agree) with calculation of mean scores and standard deviation (SD). This questionnaire explored patient’s decision-making process in terms of timing of CPM and any BR and was supported by subjective free-text boxes to gauge qualitative and quantitative aspects of the patient-related decision-making process. Those patients who consented to participate were provided with access to an online questionnaire. Results: Amongst this cohort of 39 delayed CPM patients, there were 6 decliners and therefore questionnaires were issued to the remaining 33 patients. The response rate was 67% (22/33) and the most common reason for seeking delayed CPM was to allow completion of adjuvant treatment recommendations (including radiotherapy/chemotherapy) before surgery on the unaffected breast [mean score 2.91; SD 1.0]. This avoided risk of delay in commencement of adjuvant treatment consequent to potential complications of contralateral surgery (especially with BR). The second most important reason for choosing delayed CPM was unavailability of genetic test results at the time of therapeutic mastectomy [mean score 2.64; SD 1.4]. The third most common reason was a subsequent change in family history cancer history after their personal breast cancer diagnosis that often prompted genetic testing [mean score 2.55; SD 2.7]. Several patients cited a shorter recovery time as a strong reason for requesting delayed CPM. Conclusion: Factors determining delayed CPM are patient-driven and this accords with documented reasons for women seeking CPM in general. Patients tend to make decisions about CPM based on two main themes relating to either ‘fear’ of cancer or a desire to ‘take control’. Temporal factors are important in the context of a delayed procedure and relate to subsequent availability of genetic test results and changes in family history in relatives who were otherwise unaffected at the time of initial diagnosis. Completion of all cancer treatments prior to delayed CPM (with BR) can be advantageous when implant-based BR is planned at the time of an immediate CPM. Radiotherapy can increase capsular contracture rates and surgical complications can delay start of chemotherapy. CPM should be offered as a potentially delayed option with informed discussion of risks and benefits.
Citation Format: Chien Lin Soh, Samantha Muktar, Charles M Malata, John R Benson. REASONS FOR CHOOSING DELAYED RATHER THAN IMMEDIATE CONTRALATERAL PROPHYLACTIC MASTECTOMY IN PATIENTS WITH UNILATERAL BREAST CANCER. [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P6-05-44.
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Aslam A, Arshad Z, Ahmed A, Soh CL, Kazzazi F, Benson JR, Forouhi P, Agrawal A, Benyon SL, Irwin M, Malata CM. Bilateral risk-reducing mastectomy and reconstruction-A 12-year review of methodological trends and outcomes at a tertiary referral centre. PLoS One 2023; 18:e0281601. [PMID: 37043488 PMCID: PMC10096181 DOI: 10.1371/journal.pone.0281601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 01/27/2023] [Indexed: 04/13/2023] Open
Abstract
INTRODUCTION Bilateral risk-reducing mastectomy (BRRM) involves removal of healthy breast tissue to substantially decrease the risk of developing breast cancer in individuals with greater susceptibility due to a strong family history or genetic mutation. This retrospective study evaluates cases of BRRM and associated reconstruction performed at a tertiary centre, with emphasis on mastectomy and reconstructive trends. METHODS A retrospective review of all BRRM cases performed between January 2010 and May 2022 was conducted, with two separate cohorts corresponding to the earlier (group 1) and later (group 2) portion of the time-period. Data collected included demographics, genetic test results, family history of breast/ovarian cancer, co-morbidities, mastectomy type, reconstruction type, surgical histopathology findings and post-operative complications. RESULTS A total of 82 patients (group 1 = 41, group 2 = 41) underwent BRRM. The proportion of nipple-sparing mastectomy increased from 14.6% to 56.1% between the two time periods with a reduction in skin-sparing mastectomies from 75.6% to 20.3% (p<0.001). Of the 80 patients who opted to undergo reconstruction, there was a significant decrease in combined flap-implant reconstructions (19.51% to 0%, p<0.01). Importantly, for implant-only reconstruction, there were significant increases in prepectoral approaches (p = 0.0267) and use of acellular dermal matrix (ADM) (48.15% to 90.63%, p<0.001). CONCLUSION This study documents recent increases in nipple-sparing techniques for BRRM compared to more traditional skin-sparing methods. Concurrently, reconstruction following RRM has become predominantly implant-based without a flap, coinciding with more widespread usage of ADM. This is consistent with national trends towards fewer complex autologous procedures.
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Affiliation(s)
- Aiman Aslam
- School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Zaki Arshad
- School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Amir Ahmed
- School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Chien Lin Soh
- School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Fawz Kazzazi
- Imperial Healthcare NHS Trust, London, United Kingdom
- Mason Institute for Medicine, Life Sciences and Law, University of Edinburgh, Edinburgh, United Kingdom
| | - John R Benson
- Department of Surgery, Cambridge Breast Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
- School of Medicine, Anglia Ruskin University, Cambridge and Chelmsford, Cambridge, United Kingdom
| | - Parto Forouhi
- Department of Surgery, Cambridge Breast Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Amit Agrawal
- Department of Surgery, Cambridge Breast Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Sarah L Benyon
- Department of Plastic & Reconstructive Surgery, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Michael Irwin
- Department of Plastic & Reconstructive Surgery, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Charles M Malata
- Department of Surgery, Cambridge Breast Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
- School of Medicine, Anglia Ruskin University, Cambridge and Chelmsford, Cambridge, United Kingdom
- Department of Plastic & Reconstructive Surgery, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
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Soh CL, Asher CM, Forouhi P, Moyle P, Healy NA, Malata CM. Diagnosis and management of breast implant capsule recurrence following mastectomy and subpectoral implant - innovative use of ADM for reconstruction. J Surg Case Rep 2022; 2022:rjac432. [PMID: 36226136 PMCID: PMC9550353 DOI: 10.1093/jscr/rjac432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 08/29/2022] [Indexed: 11/14/2022] Open
Abstract
It is well reported that patients who have undergone breast augmentation and subsequently develop breast cancer can successfully undergo breast-conserving therapy with preservation of their implants. However, there is a paucity of literature on the radiological investigations and surgical techniques in postmastectomy implant-reconstructed patients who develop recurrences to enable preservation of their implant-based reconstruction whilst effectively treating the local recurrence. The wide adoption of acellular dermal matrix use in prosthetic breast reconstruction in recent years has made radiological evaluation of such patients challenging. Herein presented is a case of a 37-year-old woman where wide local excision of a local recurrence abutting a peri-implant capsule following previous mastectomy and implant-acellular dermal matrix (ADM) reconstruction was performed with successful preservation of reconstruction volume (and shape) using an ADM patch to repair the capsular defect whilst retaining the implant in situ. Radiological investigation facilitated and guided the surgical planning and oncological clearance.
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Affiliation(s)
- Chien Lin Soh
- University of Cambridge School of Clinical Medicine, Addenbrooke’s Hospital, Cambridge, UK
| | - Christian M Asher
- Department of Plastic and Reconstructive Surgery, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, UK
| | - Parto Forouhi
- Cambridge Breast Unit, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, UK
| | - Penelope Moyle
- Cambridge Breast Unit, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, UK
| | - Nuala Ann Healy
- Cambridge Breast Unit, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, UK
| | - Charles M Malata
- Correspondence address. Department of Plastic and Reconstructive Surgery, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, UK. E-mail:
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7
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Aslam A, Arshad Z, Ahmed A, Kazzazi F, Benson JR, Forouhi P, Agrawal A, Benyon SL, Irwin M, Malata CM. O050 A ten-year review of methodological trends and outcomes in riskreducing mastectomy and associated reconstruction at a tertiary referral centre. Br J Surg 2022. [DOI: 10.1093/bjs/znac242.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Abstract
Introduction
Risk-reducing mastectomy (RRM) is the removal of breast tissue to substantially decrease the risk of developing breast cancer in individuals with higher breast cancer susceptibility due to strong family history or genetic mutations. This retrospective study evaluates cases of RRM, and subsequent reconstruction performed at a tertiary referral centre over the last decade, with emphasis on mastectomy and reconstructive trends.
Methods
A retrospective review of all cases of RRM performed between January 2010 and January 2020, divided into two groups corresponding to the first half (group 1) and second half (group 2) of the decade was conducted. Data collected included demographics, genetic test results, family and personal history of breast cancer, co-morbidities, mastectomy type, reconstruction type, surgical histopathology findings and complications.
Results
A total of 167 patients (group 1=76, group 2=91) underwent RRM, with a significant increase in cases of RRM despite negative genetic test results (p=0.047). The proportion of nipple sparing techniques for RRM compared to more traditional skin-sparing techniques. Concomitantly, post-RRM reconstruction has progressively become solely implant-based, to coincide with a rise in ADM usage. This is consistent with national trends towards fewer complex autologous procedures.
Take-home message
Emergent trends in risk-reducing mastectomy and reconstructive techniques are occurring against a background of broadened indications for RRM and more frequent patient requests for RRM in the absence of any documented pathogenic gene mutation. As breast surgery continues to evolve, it is important to evaluate specific trends such as more conservative forms of mastectomy and novel techniques/devices for breast reconstruction to ensure optimal patient care and levels of satisfaction.
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Affiliation(s)
- A Aslam
- University of Cambridge School of Clinical Medicine , Cambridge
| | - Z Arshad
- University of Cambridge School of Clinical Medicine , Cambridge
| | - A Ahmed
- University of Cambridge School of Clinical Medicine , Cambridge
| | - F Kazzazi
- Imperial Healthcare NHS Trust , London
| | - JR Benson
- Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge Foundation Trust
| | - P Forouhi
- Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge Foundation Trust
| | - A Agrawal
- Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge Foundation Trust
| | - SL Benyon
- Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge Foundation Trust
| | - M Irwin
- Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge Foundation Trust
| | - CM Malata
- Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge Foundation Trust
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Banda CH, Wilson E, Malata CM, Narushima M, Ogawa T, Hassanein ZM, Shiraishi M, Okada Y, Ghorra DT, Ishiura R, Danno K, Mitsui K, Oni G. Clinical application and outcomes of reconstructive microsurgery in Africa: A systematic review and meta-analysis. J Plast Reconstr Aesthet Surg 2022; 75:2035-2048. [PMID: 35643598 DOI: 10.1016/j.bjps.2022.04.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Revised: 02/20/2022] [Accepted: 04/12/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Reconstructive microsurgical free flap techniques are often the treatment of choice for a variety of complex tissue defects across multiple surgical specialties. However, the practice is underdeveloped in low- and middle-income countries. The aim of this systematic review was to evaluate the clinical application and outcomes of reconstructive microsurgery performed in Africa. METHODS Seven databases (PubMed, Web of Science, MEDLINE, CINAHL, Academic Search Complete, Embase, and Google Scholar) were searched for studies reporting microsurgical procedures performed in Africa. The risk of bias was assessed using the Joanna Briggs Institute Critical Appraisal Tools and quality of evidence using the GRADE approach. Meta-analysis was performed using a random effects model to estimate the pooled proportion of events with 95% confidence intervals. The primary outcome was free flap success rate, and the secondary outcomes were the complication and flap salvage rates. RESULTS Ninety-two studies were included in the narrative synthesis and nine in the pooled meta-analysis. In total, 1376 free flaps in 1327 patients from 1976 to 2020 were analyzed. Head and neck oncologic reconstruction made up 30% of cases, while breast reconstruction comprised 2%. The pooled flap survival rate was 89% (95% CI: 0.84, 0.93), complication rate 51% (95% CI: 0.36, 0.65), and free flap salvage rate was 45% (95% CI: 0.08, 0.84). CONCLUSION This meta-analysis showed that the free flap success rates in Africa are high and comparable to those reported in high-income countries. However, the comparatively higher complication rate and lower salvage rate suggest a need for improved perioperative care. REVIEW REGISTRATION Registered with the International Prospective Register of Systematic Reviews (PROSPERO) on 25th September 2020, ID: CRD42020192344.
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Affiliation(s)
- Chihena H Banda
- Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, Mie University, 2-174 Edobashi, Tsu, 514-8507, Japan; Department of Surgery, Arthur Davison Children's Hospital, Ndola, Zambia.
| | - Emma Wilson
- Division of Epidemiology and Public Health, The University of Nottingham, Nottingham, United Kingdom
| | - Charles M Malata
- Department of Plastic and Reconstructive Surgery, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, United Kingdom; Anglia Ruskin University, School of Medicine, Chelmsford, Cambridge, United Kingdom
| | - Mitsunaga Narushima
- Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, Mie University, 2-174 Edobashi, Tsu, 514-8507, Japan
| | - Tomoko Ogawa
- Department of Breast Surgery, Mie University, Tsu, Japan
| | - Zeinab M Hassanein
- Division of Epidemiology and Public Health, The University of Nottingham, Nottingham, United Kingdom
| | - Makoto Shiraishi
- Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, Mie University, 2-174 Edobashi, Tsu, 514-8507, Japan
| | - Yoshimoto Okada
- Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, Mie University, 2-174 Edobashi, Tsu, 514-8507, Japan
| | - Dina T Ghorra
- Department of Plastic and Reconstructive Surgery, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, United Kingdom; Department of Plastic and Reconstructive Surgery, Alexandria University, Alexandria, Egypt
| | - Ryohei Ishiura
- Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, Mie University, 2-174 Edobashi, Tsu, 514-8507, Japan
| | - Kanako Danno
- Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, Mie University, 2-174 Edobashi, Tsu, 514-8507, Japan
| | - Kohei Mitsui
- Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, Mie University, 2-174 Edobashi, Tsu, 514-8507, Japan
| | - Georgette Oni
- Nottingham Breast Institute, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
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Hardwick S, Hariparsad S, Kain N, Malata CM. Importance of long-term monitoring of patients with breast reconstructions: a case of 10-year cancer recurrence. Case Reports Plast Surg Hand Surg 2021; 9:1-6. [PMID: 34926719 PMCID: PMC8676580 DOI: 10.1080/23320885.2021.2011288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
We report a case of breast cancer recurrence in a 41 -year old female ten years post mastectomy, and two years post tertiary DIEP flap reconstruction. Reconstructed patients, especially those with aggressive cancers, must be informed of long term risk of recurrence and monitored long term following mastectomy and reconstruction.
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Affiliation(s)
- Sarah Hardwick
- Cambridge Breast Unit, Addenbrooke's University Hospital, Cambridge, UK
| | - Sanjeev Hariparsad
- Plastic & Reconstructive Surgery Department, Addenbrooke's University Hospital, Cambridge, UK
| | - Nakul Kain
- Plastic & Reconstructive Surgery Department, Addenbrooke's University Hospital, Cambridge, UK
| | - Charles M Malata
- Cambridge Breast Unit, Addenbrooke's University Hospital, Cambridge, UK.,Plastic & Reconstructive Surgery Department, Addenbrooke's University Hospital, Cambridge, UK.,Postgraduate Medical Institute at Anglia Ruskin University, Cambridge & Chelmsford, UK
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10
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Malata CM, See IJL, Kazzazi F, Forouhi P, Di Pace B. Combining the Grisotti Flap With a Secondary Dermoglandular Pedicle for Partial Breast Reconstruction Following Contiguous Central-Inferior Segment Breast Cancer Excision. Case Reports Plast Surg Hand Surg 2021; 8:203-207. [PMID: 34881350 PMCID: PMC8648006 DOI: 10.1080/23320885.2021.2008801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
A 61-year-old patient (38DD) with multifocal invasive ductal carcinomas requested breast-conserving surgery. An innovative two pedicle combination using a laterally-based Grisotti flap and an inferomedially-based secondary pedicle was designed to reconstruct a combined central breast (NAC included) and inferior segment resection defect. Satisfactory cosmesis with clear resection margins was achieved.
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Affiliation(s)
- Charles M Malata
- Department of Plastic and Reconstructive Surgery, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.,Anglia Ruskin School of Medicine, Anglia Ruskin University, Cambridge, UK.,Cambridge Breast Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Isabel Jia Le See
- Department of Plastic and Reconstructive Surgery, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.,Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Fawz Kazzazi
- Clinical School of Medicine, University of Cambridge, Cambridge, UK.,The Royal London Hospital, Barts NHS Health Trust, London, UK
| | - Parto Forouhi
- Cambridge Breast Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Bruno Di Pace
- Department of Plastic and Reconstructive Surgery, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.,Anglia Ruskin School of Medicine, Anglia Ruskin University, Cambridge, UK.,Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", PhD School of Translational Medicine of Development and Active Aging, University of Salerno, Salerno, Italy
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Bojanic C, Samaras S, Chishimba MM, Malata CM. First use of Braxon® acellular dermal matrix for complex revision aesthetic breast surgery-revision augmentation mastopexy. J Surg Case Rep 2021; 2021:rjab256. [PMID: 34211692 PMCID: PMC8241462 DOI: 10.1093/jscr/rjab256] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Accepted: 05/24/2021] [Indexed: 01/15/2023] Open
Abstract
Acellular dermal matrices (ADMs) have ushered in a paradigm shift in prosthetic breast reconstruction; however, there has hitherto been no reported use of Braxon® ADM in aesthetic breast surgery. Here, we describe the case of a 42-year-old woman who presented for revision of her bilateral aesthetic augmentation-mastopexy following multiple revision surgeries. The predominant concerns were persistent pain, implant malposition and a wide intermammary distance. Her predicament was worsened by inability to tolerate monopolar diathermy owing to a spinal stimulator-the least invasive operation was sought and Braxon® ADM met this criterion. The procedure was a success, and she remains symptom-free, with soft breasts and stable implant positions. Braxon® ADM, with its preformed shape, total implant-wrapping design and easy suture fixation, lends itself to easy use in cosmetic breast surgery. Its role in cosmetic breast surgery has yet to be established, but this case marks the beginning of this endeavor.
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Affiliation(s)
- Christine Bojanic
- Department of Plastic & Reconstructive Surgery, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Stavros Samaras
- Department of Plastic & Reconstructive Surgery, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | - Charles M Malata
- Department of Plastic & Reconstructive Surgery, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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12
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Di Pace B, Khan F, Patel M, Serlenga G, Sorotos M, Alfano C, Santanelli di Pompeo F, Rubino C, Malata CM. A multicentre study of the relationship between abdominal flap and mastectomy weights in immediate unilateral free flap breast reconstruction and the effect of adjuvant radiotherapy. J Plast Reconstr Aesthet Surg 2021; 75:61-68. [PMID: 34272176 DOI: 10.1016/j.bjps.2021.06.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 02/04/2021] [Accepted: 06/02/2021] [Indexed: 12/15/2022]
Abstract
Abdominal free flaps are considered the gold standard for post-mastectomy autologous breast reconstruction. A key element of outcome assessment is breast symmetry often achieved by approximating the reconstructed breast dimensions such as weight (wt) to those of the mastectomy. However, the ideal relationship between these two entities remains unclear. 525 immediate unilateral abdominal free flap breast reconstruction (FFBR) patients were enrolled in a multicentre study (UK 141; Italy 384) and subdivided into Group A (flap wt < mastectomy wt, n = 163), Group B (flap wt > mastectomy wt, n = 260) and Group C (flap wt = mastectomy wt, n = 102). Their rates of contralateral balancing and ipsilateral revision surgeries were compared using Chi-Square tests. Radiotherapy influence on these adjustment procedures was also assessed. More contralateral balancing procedures (17%) were performed than ipsilateral revisions (10%). Group A rates of contralateral balancing procedures were three times higher than Group B's with a ratio of 37 to 1 versus Group C (37% vs 11% vs 1% respectively, p < 0.001). Similarly, the ipsilateral breast revision surgery rate in Group A was double that of Group B and almost three times that of Group C (17% vs 8% vs 6% respectively, p = 0.01). Adjuvant radiotherapy disproportionately increased ipsilateral revisions versus contralateral balancing surgeries (p = 0.028). A flap-to-mastectomy weight ratio of less than 1 (Group A) significantly increases subsequent adjustments on both contralateral and reconstructed breasts whilst irradiation predisposes to ipsilateral revisions. This is important in patient counselling and intraoperative flap contouring. Flap weight should ideally approximate or exceed mastectomy weight in unilateral FFBR.
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Affiliation(s)
- Bruno Di Pace
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", PhD School of Translational Medicine of Development and Active Aging, University of Salerno, Salerno, Italy; Department of Plastic and Reconstructive Surgery, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK; School of Medicine, Anglia Ruskin University, Cambridge and Chelmsford, UK
| | - Farhaan Khan
- School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Manal Patel
- School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Gabriella Serlenga
- Plastic Surgery Unit, Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", San Giovanni di Dio e Ruggi D'Aragona University Hospital, University of Salerno, Salerno, Italy
| | - Michail Sorotos
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", PhD School of Translational Medicine of Development and Active Aging, University of Salerno, Salerno, Italy; Plastic Surgery Unit, Sant'Andrea Hospital, School of Medicine and Psychology, "Sapienza" University of Rome, Rome, Italy
| | - Carmine Alfano
- Plastic Surgery Unit, Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", San Giovanni di Dio e Ruggi D'Aragona University Hospital, University of Salerno, Salerno, Italy
| | - Fabio Santanelli di Pompeo
- Plastic Surgery Unit, Sant'Andrea Hospital, School of Medicine and Psychology, "Sapienza" University of Rome, Rome, Italy
| | - Corrado Rubino
- Department of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari, Italy; Plastic Surgery Unit, Department of Oncology and Haematology, University Hospital Trust of Sassari, Sassari, Italy
| | - Charles M Malata
- Department of Plastic and Reconstructive Surgery, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK; School of Medicine, Anglia Ruskin University, Cambridge and Chelmsford, UK; Cambridge Breast Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.
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13
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Bojanic C, Lawrence A, Mitrasinovic S, Samaras S, Fopp LJ, Forouhi P, Malata CM. Indications and Pitfalls of Prepectoral Breast Reconstruction with Braxon Ⓡ Acellular Dermal Matrix (ADM): A preliminary plastic surgical experience. J Plast Reconstr Aesthet Surg 2021; 74:1931-1971. [PMID: 33972202 DOI: 10.1016/j.bjps.2021.03.124] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 02/16/2021] [Accepted: 03/25/2021] [Indexed: 11/29/2022]
Affiliation(s)
- C Bojanic
- Department of Plastic & Reconstructive Surgery, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, England, United Kingdom
| | - A Lawrence
- Department of Plastic & Reconstructive Surgery, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, England, United Kingdom
| | - S Mitrasinovic
- Department of Plastic & Reconstructive Surgery, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, England, United Kingdom
| | - S Samaras
- Department of Plastic & Reconstructive Surgery, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, England, United Kingdom
| | - L J Fopp
- Department of Plastic & Reconstructive Surgery, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, England, United Kingdom
| | - P Forouhi
- Cambridge Breast Unit, Department of Surgery, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, England, United Kingdom
| | - C M Malata
- Department of Plastic & Reconstructive Surgery, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, England, United Kingdom; Cambridge Breast Unit, Department of Surgery, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, England, United Kingdom; School of Medicine, Anglia Ruskin University, Cambridge & Chelmsford, England, UK.
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14
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Malata CM, Madada-Nyakauru RN, Follows G, Wright P. Epstein-Barr Virus-associated Diffuse Large B-cell Lymphoma Identified in a Breast Implant Capsule: A New Breast Implant-Associated Lymphoma? Ann Plast Surg 2021; 86:383-386. [PMID: 33720919 DOI: 10.1097/sap.0000000000002537] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Breast implant-associated anaplastic large cell lymphoma is a relatively uncommon T-cell lymphoma with about 900 reported cases worldwide to April 2020 according to the American Society of Plastic Surgeons Breast Implant-Associated Anaplastic Large Cell Lymphoma Physician Resources information. CASE PRESENTATION A 51-year old woman was found to have an Epstein-Barr virus-related diffuse large B-cell lymphoma (EBV-DLCBCL) in her left breast periimplant capsule at the time of a second revision breast implant surgery for recurrent severe capsular contractures following cosmetic breast augmentation 21 years previously. The first revision operation, 15 years earlier, had comprised simple implant exchange from smooth-saline to textured-silicone gel prostheses. RESULTS Histopathological and immunohistochemical analyses of the periimplant capsulectomy specimen confirmed a B cell lymphoma which was, in addition, positive for EBV-encoded RNA on in-situ hybridization. Staging investigations including positron emission tomography-computed tomography did not reveal any metastatic disease. DISCUSSION AND CONCLUSION Despite recommendations to the contrary (by 2 independent hematological malignancy multidisciplinary teams), the patient has declined explantation of her new breast implants choosing instead to be observed under a watch-and-wait protocol. She remains disease-free 2 years postdiagnosis. To date, a diffuse B-cell lymphoma has never been documented as arising in a breast implant capsule or in association with breast augmentation whether associated with EBV or not. This is the first such report in the world.
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Bellizzi A, Vella Baldacchino R, Kazzazi F, Forouhi P, Malata CM. The successful use of disparate pedicle types for bilateral therapeutic mammaplasties during breast conservation surgery. J Surg Case Rep 2021; 2021:rjab064. [PMID: 33732428 PMCID: PMC7951460 DOI: 10.1093/jscr/rjab064] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 02/05/2021] [Indexed: 11/25/2022] Open
Abstract
This case illustrates the successful use of non-identical pedicles in bilateral therapeutic mammaplasty (TM). A 58-year-old patient presented with a left-sided upper inner quadrant multifocal invasive [no special type (NST)] tumour and a right-sided upper outer quadrant unifocal invasive tubular carcinoma with surrounding ductal carcinoma in situ (DCIS). Her tumour locations necessitated simultaneous bilateral TM using different pedicle types. A superomedial pedicle T-scar breast reduction was undertaken on the right to resect the upper outer quadrant tumour whilst a superolateral nipple transposition pedicle was used on the left breast to enable the wide resection of the two tumours located superomedial to the nipple. The location and size of the tumour also required the use of a secondary infero-medially based pedicle for volume displacement on the left breast. Patient received adjuvant chemotherapy and radiotherapy. A year after surgery the patient has acceptable cosmetic results in terms of symmetry, breast contour and increasingly inconspicuous scars.
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Affiliation(s)
| | | | - Fawz Kazzazi
- School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Parto Forouhi
- Cambridge Breast Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Charles M Malata
- Cambridge Breast Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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16
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Bojanic C, To K, Hatoum A, Shea J, Seah KTM, Khan W, Malata CM. Mesenchymal stem cell therapy in hypertrophic and keloid scars. Cell Tissue Res 2021; 383:915-930. [PMID: 33386995 PMCID: PMC7960584 DOI: 10.1007/s00441-020-03361-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 11/19/2020] [Indexed: 12/20/2022]
Abstract
Scars are the normal outcome of wound repair and involve a co-ordinated inflammatory and fibrotic process. When a scar does not resolve, uncontrolled chronic inflammation can persist and elicits excessive scarring that leads to a range of abnormal phenotypes such as hypertrophic and keloid scars. These pathologies result in significant impairment of quality of life over a long period of time. Existing treatment options are generally unsatisfactory, and there is mounting interest in innovative cell-based therapies. Despite the interest in mesenchymal stem cells (MSCs), there is yet to be a human clinical trial that investigates the potential of MSCs in treating abnormal scarring. A synthesis of existing evidence of animal studies may therefore provide insight into the barriers to human application. The aim of this PRISMA systematic review was to evaluate the effectiveness of MSC transplantation in the treatment of hypertrophic and keloid scars in in vivo models. A total of 11 case-control studies were identified that treated a total of 156 subjects with MSCs or MSC-conditioned media. Ten studies assessed hypertrophic scars, and one looked at keloid scars. All studies evaluated scars in terms of macroscopic and histological appearances and most incorporated immunohistochemistry. The included studies all found improvements in the above outcomes with MSC or MSC-conditioned media without complications. The studies reviewed support a role for MSC therapy in treating scars that needs further exploration. The transferability of these findings to humans is limited by factors such as the reliability and validity of the disease model, the need to identify the optimal MSC cell source, and the outcome measures employed.
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Affiliation(s)
- Christine Bojanic
- Plastic & Reconstructive Surgery Department, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Kendrick To
- Division of Trauma and Orthopaedics, Department of Surgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Adam Hatoum
- School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Jessie Shea
- School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - K T Matthew Seah
- Division of Trauma and Orthopaedics, Department of Surgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Wasim Khan
- Division of Trauma and Orthopaedics, Department of Surgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK.
| | - Charles M Malata
- Plastic & Reconstructive Surgery Department, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- Cambridge Breast Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- School of Medicine, Anglia Ruskin University, Cambridge & Chelmsford, UK
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17
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Di Pace B, Benson JR, Malata CM. Breast reconstruction and the COVID-19 pandemic: Adapting practice. J Plast Reconstr Aesthet Surg 2020; 74:644-710. [PMID: 33060054 PMCID: PMC7521868 DOI: 10.1016/j.bjps.2020.08.117] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 08/24/2020] [Indexed: 11/18/2022]
Affiliation(s)
- Bruno Di Pace
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", PhD School of Translational Medicine of Development and Active Aging, University of Salerno, Salerno, Italy; Department of Plastic and Reconstructive Surgery, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK; Anglia Ruskin School of Medicine, Anglia Ruskin University, Cambridge & Chelmsford, UK
| | - John R Benson
- Anglia Ruskin School of Medicine, Anglia Ruskin University, Cambridge & Chelmsford, UK; Cambridge Breast Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Charles M Malata
- Department of Plastic and Reconstructive Surgery, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK; Anglia Ruskin School of Medicine, Anglia Ruskin University, Cambridge & Chelmsford, UK; Cambridge Breast Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.
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18
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Wignarajah P, Forouhi P, Malata CM. The past, the present and the future of UK breast reconstruction-are our practices outdated in 2020? Gland Surg 2020; 9:1076-1079. [PMID: 32953619 DOI: 10.21037/gs.2020.02.03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Primeera Wignarajah
- Cambridge Breast Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, England, UK
| | - Parto Forouhi
- Cambridge Breast Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, England, UK
| | - Charles M Malata
- Cambridge Breast Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, England, UK.,Department of Plastic & Reconstructive Surgery, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, England, UK.,Anglia Ruskin University School of Medicine, Cambridge & Chelmsford, England, UK
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19
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Samaras S, McKelvie MA, Oni G, Malata CM. An unusual "venous circle" of the internal mammary vein encountered during microvascular anastomosis and implications for practice. Case Reports Plast Surg Hand Surg 2020; 7:54-56. [PMID: 32373676 PMCID: PMC7191913 DOI: 10.1080/23320885.2020.1754129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Accepted: 03/29/2020] [Indexed: 10/24/2022]
Abstract
The internal mammary vessels are commonly used for anastomosis in breast reconstruction. The anatomy when using the 2nd ICS has been shown to be predictable and hence preferentially used by the senior author. We present an unusual case of internal mammary vein bifurcation and immediate confluence forming a 'venous circle'.
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Affiliation(s)
- S Samaras
- Department of Plastic & Reconstructive Surgery, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.,Department of Plastic & Reconstructive Surgery, 401 Military Hospital of Athens, Athens, Greece
| | - M A McKelvie
- Department of Plastic & Reconstructive Surgery, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - G Oni
- Department of Plastic & Reconstructive Surgery, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - C M Malata
- Department of Plastic & Reconstructive Surgery, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.,Anglia Ruskin School of Medicine, Anglia Ruskin University, Cambridge and Chelmsford, UK.,Cambridge Breast Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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20
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Kazzazi F, Malata CM. Application of the Lalonde (horizontal-only scar) breast reduction technique for correction of gynaecomastia in dark skinned patients. Gland Surg 2019; 8:287-293. [PMID: 31328108 DOI: 10.21037/gs.2018.10.03] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Surgical correction of gynaecomastia correction sometimes necessitates skin reduction in addition to resection of glandular tissue and liposuction of the fat deposits. Many skin reduction techniques have been described but all suffer from very noticeable and often poor scars that can manifest as hypertrophic or keloid scars in patients with dark skin. Three large gynaecomastia patients undergoing a modification of the Lalonde "no vertical scar" breast reduction technique designed to reduce the extent of scarring were reviewed. The Lalonde "no vertical scar" technique was successfully applied to three patients of African extraction with acceptable postoperative scarring. A description of the technique and the cosmetic results are presented. The Lalonde technique of female breast reduction can be applied to the treatment of male breast enlargement in patients at high risk of scar complications. It provides an alternative to the more widely used concentric skin reduction techniques. To our knowledge, this is the first report in literature of the application of the Lalonde "no vertical scar" surgical technique to the treatment of gynaecomastia in patients with darkly pigmented skin.
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Affiliation(s)
- Fawz Kazzazi
- School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Charles M Malata
- Department of Plastic & Reconstructive Surgery, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.,Cambridge Breast Unit, Cambridge, UK.,Anglia Ruskin University School of Medicine, Chelmsford & Cambridge, UK
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21
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Oni G, Malata CM. New surgical technique: Simultaneous use of contiguous intercostal spaces during total rib preservation exposure of the internal mammary vessels in microvascular breast reconstruction. J Plast Reconstr Aesthet Surg 2019; 72:1525-1529. [PMID: 31266736 DOI: 10.1016/j.bjps.2019.05.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 05/16/2019] [Indexed: 10/26/2022]
Abstract
INTRODUCTION Microvascular free tissue transfer is the gold standard for autologous breast reconstruction. For many surgeons, the internal mammary vessels (IMV) are the preferred recipient vessels. The merits of the rib preservation technique have been previously discussed. There are, however, instances in which greater access than afforded by one intercostal space (ICS) may be required, for example, multiple or redo anastomoses or inadvertent recipient vessel damage. We therefore have refined this technique further to allow exposure of two ICSs without sacrifice of the intervening rib cartilage. METHOD We identified all patients who had simultaneous contiguous ICSs dissected whilst preserving the intervening costal cartilage for microvascular anastomoses for breast free flaps. The indications, surgical technique, and its refinements are described. RESULTS Simultaneous exposure of the IMVs in both the second and third ICSs whilst preserving the intervening costal cartilage for microvascular anastomoses was successfully performed in 15 patients with no flap failures. Indications included bipedicled DIEP flaps (9), bipedicled DIEA/SIEA flap (1), stacked DIEP flaps (4), and salvage (1). One flap was successfully re-explored for venous congestion. There were no intraoperative complications. CONCLUSION We have demonstrated that simultaneous contiguous ICS exposure of the internal mammary recipient vessels with total rib preservation is technically feasible, has no adverse patient sequelae, and has the benefit of allowing multiple anterograde and retrograde microvascular anastomoses (even in patients with narrow ICSs). This technique preserves the intervening rib and is of particular utility in bipedicled flaps when multiple "extra-flap" anastomoses may be required.
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Affiliation(s)
- Georgette Oni
- Department of Plastic and Reconstructive Surgery, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, UK
| | - Charles M Malata
- Department of Plastic and Reconstructive Surgery, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, UK; Cambridge Breast Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, UK; Anglia Ruskin University School of Medicine, Cambridge and Chelmsford, UK.
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22
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Vella Baldacchino R, Bellizzi A, Madada-Nyakauru RN, Kazzazi F, Oni G, Forouhi P, Malata CM. Assessment of breast symmetry in breast cancer patients undergoing therapeutic mammaplasty using the Breast Cancer Conservation Therapy cosmetic results software (BCCT.core). Gland Surg 2019; 8:218-225. [PMID: 31328100 DOI: 10.21037/gs.2018.09.06] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Therapeutic mammaplasty (TM) is a standard oncoplastic technique utilising aesthetic breast reduction principles to facilitate tumour resection and breast reshaping. Simultaneous contralateral mammaplasties are often performed to maintain symmetry. BCCT.core software, which principally assesses breast symmetry, has been previously employed for evaluating cosmetic results after standard breast conservation therapy and latterly TMs for upper pole tumours. The purpose of this study was to validate this novel tool for TMs in all breast zones. Methods Standardised photographs of 20 consecutive patients who underwent TM were evaluated for symmetry using BCCT.core versus a plastic surgical panel completing a visual analogue scale. Results were rated as (excellent/good/fair/poor). Outcomes between the two methods were compared. Results Twenty patients aged 37 to 63 years with a median 36G bra size had 22 TMs (18 unilateral, 2 bilateral). Indications were invasive breast cancer (87%) and ductal carcinoma in situ (DCIS) (13%). The median (range) tumour size was 22.5 mm (6-90 mm) with a resection weight of 245.8 g (16-1,079 g). Primary nipple pedicles were superomedial (63%), inferior (21%) and superolateral (16%). Five patients required a secondary glandular pedicle for volume redistribution to maintain breast shape. The BCCT.core software vs. panel symmetry assessments were 37% vs. 39% (excellent), 63% vs. 50% (good) and 0% vs. 11% (fair). Wilcoxon matched-pairs sign rank tests and Spearman rank correlations found the pairings to be statistically significant (P<0.05). Conclusions Despite small patient numbers, BCCT.core gave comparable findings with the panel and is thus useful for objectively assessing cosmesis of TMs in all breast zones.
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Affiliation(s)
| | - Annalise Bellizzi
- Mater Dei Hospital, Malta Medical School, University of Malta, Msida, Malta
| | - Rudo N Madada-Nyakauru
- Department of Plastic and Reconstructive Surgery, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Fawz Kazzazi
- School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Georgette Oni
- Department of Plastic and Reconstructive Surgery, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Parto Forouhi
- Cambridge Breast Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Charles M Malata
- Department of Plastic and Reconstructive Surgery, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.,Cambridge Breast Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.,Anglia Ruskin School of Medicine, Anglia Ruskin University, Chelmsford and Cambridge, UK
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23
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Sasaki Y, Madada-Nyakauru RN, Samaras S, Oni G, Di Candia M, Malata CM. The ideal intercostal space for internal mammary vessel exposure during total rib-sparing microvascular breast reconstruction: A critical evaluation. J Plast Reconstr Aesthet Surg 2019; 72:1000-1006. [PMID: 30824382 DOI: 10.1016/j.bjps.2019.01.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Revised: 12/27/2018] [Accepted: 01/06/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND Total rib-preserving free flap breast reconstruction (RP-FFBR) using internal mammary vessel (IMV) recipients usually involves vessel exposure in the second or third intercostal spaces (ICS). Although the third one is more commonly used, no direct comparisons between the two have hitherto been performed. OBJECTIVES To compare the in-vivo topography and vascular anatomy of second and third ICSs in patients undergoing FFBR using the rib-preservation technique of IMV exposure. METHODS An analysis of prospectively collected data on intercostal space distance (ISD), number and arrangement of IMVs, location of venous confluence, and vessel exposure time was conducted on a single surgeon's consecutive RP-FFBRs. RESULTS A total of 296 RP-FFBRs were performed in 246 consecutive patients. The second, third, or both second and third spaces were utilized in 282, 28, and 22 cases, respectively. The ISDs were 20.6 mm ± 3.52 for the second ICS and 14.0 mm ± 4.35 for the third ICS (p<0.0001, CI = 5.17-7.97, t-test). The second versus third ICS vein content was as follows: single 81.4% vs. 74%, dual 18.6% vs. 26%, and confluence 3.7% vs. 13%. The second ICS single vein was medial to the artery in 92.6%. The third ICS single vein was medial to the artery in 88.2% Vessel exposure times for second (47.2 mins ± 26.7) and third (46.5 mins ± 31.4) spaces were similar (p = 0.93). The overall intraoperative anastomotic revision rate was 9.1%, and the postoperative flap re-exploration rate was 4.0%, with 99.7% overall flap success. DISCUSSION AND CONCLUSION Preferential use of the second ICS is supported by its more predictable vascular anatomy, a broader space for performing the microanastomoses and a higher frequency of a single postconfluence (and thus larger) vein facilitating the microsurgery.
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Affiliation(s)
- Y Sasaki
- Department of Plastic Surgery, Showa University, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, Japan
| | - R N Madada-Nyakauru
- Department of Plastic and Reconstructive Surgery, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge, UK
| | - S Samaras
- Department of Plastic and Reconstructive Surgery, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge, UK
| | - G Oni
- Department of Plastic and Reconstructive Surgery, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge, UK
| | - M Di Candia
- Department of Plastic and Reconstructive Surgery, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge, UK; University Department of Plastic Surgery, University di Bari, Piazza Giulio Cesare, 11, 70124 Bari, Italy
| | - C M Malata
- Department of Plastic and Reconstructive Surgery, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge, UK; Cambridge Breast Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge, UK; Anglia Ruskin University School of Medicine, Cambridge and Chelmsford, East Road, Cambridge, UK.
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Leach L, Shamil E, Malata CM. Indications and Long-term Outcomes of Open Augmentation Rhinoplasty with Autogenous L-shaped Costal Cartilage Strut Grafts - A Single Plastic Surgeon's Experience. Otolaryngol Pol 2018; 72:26-32. [PMID: 29989560 DOI: 10.5604/01.3001.0011.7258] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Introduction We present a single surgeon's experience of open augmentation rhinoplasty with autogenous L-shaped costal cartilage grafts, with long-term patient-reported outcome data. We highlight the salient operative steps and outline the peri-operative care required to optimise outcomes. Materials and Methods A retrospective review of eleven such augmentation rhinoplasties performed between 2008 and 2016 was undertaken. Indications included saddle nose deformity [granulomatosis with polyangiitis (n=7) and relapsing polychondritis (n=1)], post-traumatic nasal collapse (n=1) and advanced cosmetic westernisation of the nose (n=2). Long-term patient-reported outcome was assessed with a patient questionnaire. Results All patients achieved marked improvement in nasal position, shape and function. There was no cartilage exposure, warping or resorption and no recurrent deformities. One patient's dorsal graft was fractured two years later during an ophthalmological procedure and the deformity was re-corrected successfully, again with the above technique. Average follow up was 5.2 years. Of the nine patients who responded to the follow-up questionnaire, 100% were satisfied with their nasal appearance. 100% of responders at follow-up reported that they have had no problems relating to their nose (n=9). Discussion L-shaped costal cartilage grafts provided a reliable, reproducible approach in augmentation rhinoplasty for disparate indications (inflammatory, traumatic and cosmetic) in the hands of a low-volume operator. With careful patient selection and planning, this technique can provide pleasing aesthetic outcomes and high patient satisfaction, with good long-term outcomes.
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Affiliation(s)
- Laura Leach
- Department of Plastic and Reconstructive Surgery, Addenbrooke's University Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK Department of Otorhinolaryngology, Peterborough City Hospital, North West Anglia NHS Foundation Trust, UK
| | - Eamon Shamil
- Department of Plastic and Reconstructive Surgery, Addenbrooke's University Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK Department of Otorhinolaryngology, Guy's & St Thomas' NHS Foundation Trust London, UK
| | - Charles M Malata
- Department of Plastic and Reconstructive Surgery, Addenbrooke's University Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK Postgraduate Medical Institute, Faculty of Medical Sciences, Anglia Ruskin University, Cambridge & Chelmsford, UK
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Kankam HKN, Hourston GJM, Forouhi P, Di Candia M, Wishart GC, Malata CM. Combination of acellular dermal matrix with a de-epithelialised dermal flap during skin-reducing mastectomy and immediate breast reconstruction. Ann R Coll Surg Engl 2018; 100:e1-e6. [PMID: 30112950 PMCID: PMC6204518 DOI: 10.1308/rcsann.2018.0127] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/02/2018] [Indexed: 11/22/2022] Open
Abstract
Introduction Patients with large ptotic breasts undergoing immediate implant-based reconstruction often require skin-reducing mastectomy to optimise the aesthetic outcome. However, healing complications, especially at the resulting inverted T-junction, leading to wound dehiscence, infection, skin necrosis, implant exposure and failed reconstruction have been widely reported. We present an innovative approach for immediate implant-based reconstruction combining porcine- or bovine-derived acellular dermal matrices with a de-epithelialised dermal sling to protect and support the implant, while improving clinical outcomes in this challenging group of patients. Materials and methods Demographic, tumour and surgical data were reviewed for patients undergoing Wise pattern (T-scar) skin-reducing mastectomies with immediate implant-based reconstruction combining porcine- or bovine-derived acellular dermal matrices with a de-epithelialised dermal sling. Results This technique was successfully employed to reconstruct five large pendulous breasts in four breast cancer patients with a median age of 50.5 years (range 34-61 years) who were not suitable for, or had declined, flap-based reconstruction. The acellular dermal matrices used were SurgiMend®, StratticeTM and Braxon® and the expandable implants were placed in the sub-pectoral (n = 3) and pre-pectoral (n = 1) planes. The technical steps and clinical outcomes are presented. One patient experienced T-junction breakdown overlying the de-epithelialised dermis without implant loss. Conclusion The combination of an acellular dermal matrix and a dermal sling provides a double-layer 'water-proofing' and support for the implants inferiorly, avoiding T-junction breakdown complications, since any dehiscence is on to well-vascularised dermis. Furthermore, the acellular dermal matrix stabilises the implant in the large mastectomy cavity (pocket control). This approach provides a viable option which facilitates mastectomy and immediate implant reconstruction in large-breasted patients.
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Affiliation(s)
- HKN Kankam
- University of Cambridge School of Clinical Medicine, Cambridge, UK
| | - GJM Hourston
- University of Cambridge School of Clinical Medicine, Cambridge, UK
| | - P Forouhi
- Cambridge Breast Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - M Di Candia
- University Department of Plastic Surgery, University di Bari, Bari, Italy
| | - GC Wishart
- Anglia Ruskin University School of Medicine, Chelmsford and Cambridge, UK
- Cambridge Breast Clinic, Cambridge, UK
| | - CM Malata
- Cambridge Breast Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- Anglia Ruskin University School of Medicine, Chelmsford and Cambridge, UK
- Department of Plastic and Reconstructive Surgery, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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Kazzazi F, Haggie R, Forouhi P, Kazzazi N, Malata CM. Utilizing the Total Design Method in medicine: maximizing response rates in long, non-incentivized, personal questionnaire postal surveys. Patient Relat Outcome Meas 2018; 9:169-172. [PMID: 29922103 PMCID: PMC5995290 DOI: 10.2147/prom.s156109] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Maximizing response rates in questionnaires can improve their validity and quality by reducing non-response bias. A comprehensive analysis is essential for producing reasonable conclusions in patient-reported outcome research particularly for topics of a sensitive nature. This often makes long (≥7 pages) questionnaires necessary but these have been shown to reduce response rates in mail surveys. Our work adapted the "Total Design Method," initially produced for commercial markets, to raise response rates in a long (total: 11 pages, 116 questions), non-incentivized, very personal postal survey sent to almost 350 women. PATIENTS AND METHODS A total of 346 women who had undergone mastectomy and immediate breast reconstruction from 2008-2014 (inclusive) at Addenbrooke's University Hospital were sent our study pack (Breast-Q satisfaction questionnaire and support documents) using our modified "Total Design Method." Participants were sent packs and reminders according to our designed schedule. RESULTS Of the 346 participants, we received 258 responses, an overall response rate of 74.5% with a useable response rate of 72.3%. One hundred and six responses were received before the week 1 reminder (30.6%), 120 before week 3 (34.6%), 225 before the week 7 reminder (64.6%) and the remainder within 3 weeks of the final pack being sent. The median age of patients that the survey was sent to, and the median age of the respondents, was 54 years. CONCLUSION In this study, we have demonstrated the successful implementation of a novel approach to postal surveys. Despite the length of the questionnaire (nine pages, 116 questions) and limitations of expenses to mail a survey to ~350 women, we were able to attain a response rate of 74.6%.
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Affiliation(s)
- Fawz Kazzazi
- Clinical School, University of Cambridge, Cambridge, UK
| | | | - Parto Forouhi
- Cambridge Breast Unit, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke’s University Hospital, Cambridge, UK
| | - Nazar Kazzazi
- Jasmine Breast Centre, Doncaster Royal Infirmary, Doncaster, UK
| | - Charles M Malata
- Cambridge Breast Unit, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke’s University Hospital, Cambridge, UK
- Department of Plastic and Reconstructive Surgery, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke’s University Hospital, Cambridge, UK
- Postgraduate Medical Institute, Faculty of Medical Sciences, Anglia Ruskin University School of Medicine, Cambridge, UK
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See JL, Przybylska J, MacLennan L, Malata CM. Letter to the Editor regarding "Use of both anterograde and retrograde internal mammary vessels in the bipedicled deep inferior epigastric perforator flap for unilateral breast reconstruction". J Plast Reconstr Aesthet Surg 2018; 71:431-433. [PMID: 29329744 DOI: 10.1016/j.bjps.2017.12.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Accepted: 12/05/2017] [Indexed: 10/18/2022]
Affiliation(s)
- Jia Le See
- University of Auckland, Faculty of Medical and Health Sciences, Auckland, New Zealand
| | - Julia Przybylska
- Poznań University of Medical Sciences, Faculty of Medicine, Poznań, Poland
| | - Louise MacLennan
- Cambridge Breast Unit, Addenbrooke's University Hospital, Cambridge, UK; Department of Plastic and Reconstructive Surgery, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, UK
| | - Charles M Malata
- Cambridge Breast Unit, Addenbrooke's University Hospital, Cambridge, UK; Department of Plastic and Reconstructive Surgery, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, UK; Anglia Ruskin University School of Medicine, Chelmsford & Cambridge, UK.
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Kankam HK, Hourston GJ, Fopp LJ, Benson JR, Benyon SL, Irwin MS, Agrawal A, Forouhi P, Malata CM. Trends in post-mastectomy breast reconstruction types at a breast cancer tertiary referral centre before and after introduction of acellular dermal matrices. J Plast Reconstr Aesthet Surg 2018; 71:21-27. [DOI: 10.1016/j.bjps.2017.08.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Revised: 07/20/2017] [Accepted: 08/14/2017] [Indexed: 10/19/2022]
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Tomouk T, Mohan AT, Azizi A, Conci E, Brickley EB, Malata CM. Donor site morbidity in DIEP free flap breast reconstructions: A comparison of unilateral, bilateral, and bipedicled surgical procedure types. J Plast Reconstr Aesthet Surg 2017; 70:1505-1513. [DOI: 10.1016/j.bjps.2017.05.044] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2016] [Revised: 04/10/2017] [Accepted: 05/26/2017] [Indexed: 11/24/2022]
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Elfaki A, Gkorila A, Khatib M, Malata CM. Infection of PTFE mesh 15 years following pedicled TRAM flap breast reconstruction: mechanism and aetiology. Ann R Coll Surg Engl 2017; 100:e18-e21. [PMID: 29046098 DOI: 10.1308/rcsann.2017.0181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The pedicled transverse rectus abdominis myocutaneous (TRAM) flap procedure is still widely used for breast reconstruction. The repair of the flap harvest site in the transverse rectus abdominis muscle and sheath is often assisted by the use of prosthetic meshes. This decreases the risk of abdominal wall weakness and herniation but, being a foreign body, it also carries the risk of infection. In this report, we describe the case of a 63-year-old patient who, whilst receiving chemotherapy for metastatic breast cancer, presented with an infected polytetrafluoroethylene mesh 15 years after pedicled TRAM flap immediate breast reconstruction. This necessitated mesh removal to treat the infection. Following a thorough review of the English literature, this is the longest recorded presentation of an abdominal prosthetic mesh infection. The mechanism and aetiology of such a late complication are discussed.
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Affiliation(s)
- A Elfaki
- Department of Plastic and Reconstructive Surgery, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust , Cambridge , UK
| | - A Gkorila
- Clinical School of Medicine, University of Cambridge , Cambridge , UK
| | - M Khatib
- Department of Plastic and Reconstructive Surgery, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust , Cambridge , UK
| | - C M Malata
- Department of Plastic and Reconstructive Surgery, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust , Cambridge , UK.,Cambridge Breast Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust , Cambridge , UK.,Postgraduate Medical Institute, Faculty of Health Sciences, Anglia Ruskin University , Cambridge and Chelmsford , UK
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Choo AMH, Forouhi P, Malata CM. Innovative combination of therapeutic mammoplasty and expandable-implant breast augmentation for immediate partial breast reconstruction. Int J Surg Case Rep 2016; 23:146-50. [PMID: 27132043 PMCID: PMC4855789 DOI: 10.1016/j.ijscr.2016.04.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Accepted: 04/16/2016] [Indexed: 10/29/2022] Open
Abstract
INTRODUCTION Therapeutic mammoplasty is used in the treatment of suitably-sized and appropriately-located breast cancers to achieve adequate cancer excision, resulting in well-shaped but smaller breasts. In patients wishing to maintain or increase their breast size, simultaneous augmentation will be required. PRESENTATION OF CASE A 48-year-old female underwent an "augmentation-therapeutic mastopexy". She required mastectomy for a multifocal cancer of the right breast and breast conservation for a unifocal localised cancer in the upper part of the left breast. She requested right immediate breast reconstruction and hoped for larger breasts than she had. Due to complications during neoadjuvant chemotherapy, the right reconstruction plan was changed from a deep inferior epigastric perforator (DIEP) flap to an implant-based technique. On the left, an extended superomedial pedicle therapeutic mammoplasty was combined with a subpectoral augmentation using an expandable-implant. DISCUSSION The use of expandable-implants for reconstruction of partial mastectomy defects in combination with therapeutic mammoplasty has not been reported. This case report shows that such "augmentation-therapeutic mastopexy" is feasible. CONCLUSION A "novel" oncoplastic technique herein termed "augmentation-therapeutic mastopexy" is described for partial breast reconstruction during the treatment of a patient with bilateral breast cancer. It enabled adequate treatment of her cancer while reshaping the breast and achieving the desired larger breast size. It should be considered in selected breast-conservation patients who wish to maintain or increase their breast size.
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Affiliation(s)
- A M H Choo
- University of Cambridge, Cambridge, United Kingdom
| | - P Forouhi
- Cambridge Breast Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - C M Malata
- Cambridge Breast Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom; Department of Plastic and Reconstructive Surgery, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom; Postgraduate Medical Institute, Faculty of Health Sciences at Anglia Ruskin University, Cambridge, Chelmsford, United Kingdom.
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Abstract
Conservative mastectomy is a form of nipple-sparing mastectomy which is emerging as a surgical option for selected breast cancer patients. This technique differs from subcutaneous mastectomy which is well established as a technique for risk reduction but leaves behind a finite remnant of retro-areolar breast tissue. Clinical trials have confirmed the efficacy and safety of breast conservation therapy for smaller localised breast tumors whereby a variable amount of surrounding normal tissue is excised with administration of breast radiotherapy post-operatively. Conservative mastectomy aims to remove all breast tissue with dissection continued into the core of the nipple. However, the indication for conservative mastectomy remains to be defined but generally includes tumors of modest size located at least 2 cm away from the nipple. Patients undergoing conservative mastectomy do not necessarily receive adjuvant radiotherapy and this may only be intra-operative irradiation of the nipple-areola complex (NAC). Preservation of the NAC as part of a skin-sparing mastectomy in patients who might otherwise require standard mastectomy is of unproven safety from an oncologic perspective but is associated with enhanced cosmetic outcomes and quality-of-life. The advent of conservative mastectomy has coincided with a trend for "maximal surgery" with bilateral extirpation of all breast tissue in conjunction with immediate breast reconstruction. It is essential there is no compromise of local recurrence and survival in terms of ipsilateral breast cancer treatment. Further studies are required to clarify the indications for conservative mastectomy and confirm oncologic equivalence to either wide local excision and breast irradiation or conventional/skin-sparing mastectomy with sacrifice of the nipple areola complex.
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Affiliation(s)
- John R Benson
- 1 Cambridge Breast Unit, Addenbrooke's Hospital, Cambridge CB2 0QQ, UK ; 2 Faculty of Medical Science, Anglia Ruskin University, Cambridge and Chelmsford, CM1 1SQ, UK
| | - Dorin Dumitru
- 1 Cambridge Breast Unit, Addenbrooke's Hospital, Cambridge CB2 0QQ, UK ; 2 Faculty of Medical Science, Anglia Ruskin University, Cambridge and Chelmsford, CM1 1SQ, UK
| | - Charles M Malata
- 1 Cambridge Breast Unit, Addenbrooke's Hospital, Cambridge CB2 0QQ, UK ; 2 Faculty of Medical Science, Anglia Ruskin University, Cambridge and Chelmsford, CM1 1SQ, UK
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Tan HB, Mohan AT, Coonar AS, Malata CM. Creative Use of Contralateral Combined Myocutaneous Free Flap for Empyema Cavity. Ann Thorac Surg 2015; 101:e1-3. [PMID: 26694302 DOI: 10.1016/j.athoracsur.2015.06.106] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2015] [Revised: 05/16/2015] [Accepted: 06/25/2015] [Indexed: 11/25/2022]
Abstract
Treatment of chronic postpneumonectomy empyema is a reconstructive problem that is always complicated by previous thoracic surgical procedures. Free flaps may be used because they effectively obliterate remaining pleural cavity dead space. Combined muscle free flaps with common vascular pedicles are viable alternatives when single muscle flaps do not possess adequate bulk. This case describes a contralateral combined latissimus dorsi-serratus anterior myocutaneous free flap with anastomoses to thoracodorsal vessels used for correction of chronic empyema. We also describe successful correction of a posterolateral chest wall defect using the adjacent axillary system as a recipient vessel. An accompanying skin paddle also enabled reliable cutaneous coverage of the external defect.
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Affiliation(s)
- Hannah B Tan
- Alfred Health, Victoria, Melbourne, Australia; University of Cambridge, School of Clinical Medicine, Cambridge, United Kingdom.
| | - Anita T Mohan
- Department of Plastic and Reconstructive Surgery, Addenbrooke's University Hospital, Cambridge, United Kingdom; Mayo Clinic, Rochester, Minnesota; Research Fellow at Restoration of Appearance and Function Charitable Trust (RAFT), London, United Kingdom
| | - Aman S Coonar
- Department of Thoracic Surgery, Papworth Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Charles M Malata
- University of Cambridge, School of Clinical Medicine, Cambridge, United Kingdom; Department of Plastic and Reconstructive Surgery, Addenbrooke's University Hospital, Cambridge, United Kingdom; Postgraduate Medical Institute at Anglia Ruskin University, Cambridge and Chelmsford, United Kingdom
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Malata CM, Rabey NG. Decision Making in Double-Pedicled DIEP and SIEA Abdominal Free Flap Breast Reconstructions: An Algorithmic Approach and Comprehensive Classification. Front Surg 2015; 2:49. [PMID: 26579526 PMCID: PMC4620682 DOI: 10.3389/fsurg.2015.00049] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Accepted: 09/10/2015] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION The deep inferior epigastric artery perforator free flap is the gold standard for autologous breast reconstruction. However, using a single vascular pedicle may not yield sufficient tissue in patients with midline scars or insufficient lower abdominal pannus. Double-pedicled free flaps overcome this problem using different vascular arrangements to harvest the entire lower abdominal flap. The literature is, however, sparse regarding technique selection. We therefore reviewed our experience in order to formulate an algorithm and comprehensive classification for this purpose. METHODS All patients undergoing unilateral double-pedicled abdominal perforator free flap breast reconstruction (AFFBR) by a single surgeon (CMM) over 40 months were reviewed from a prospectively collected database. RESULTS Of the 112 consecutive breast free flaps performed, 25 (22%) utilised two vascular pedicles. The mean patient age was 45 years (range = 27-54). All flaps, but one (which used the thoracodorsal system), were anastomosed to the internal mammary vessels using the rib-preservation technique. The surgical duration was 656 min (range = 468-690 min). The median flap weight was 618 g (range = 432-1275 g) and the mastectomy weight was 445 g (range = 220-896 g). All flaps were successful and only three patients requested minor liposuction to reduce and reshape their reconstructed breasts. CONCLUSION Bipedicled free abdominal perforator flaps, employed in a fifth of all our AFFBRs, are a reliable and safe option for unilateral breast reconstruction. They, however, necessitate clear indications to justify the additional technical complexity and surgical duration. Our algorithm and comprehensive classification facilitate technique selection for the anastomotic permutations and successful execution of these operations. LEVELS OF EVIDENCE Therapeutic level IV.
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Affiliation(s)
- Charles M Malata
- Postgraduate Medical Institute, Faculty of Health Sciences, Anglia Ruskin University , Cambridge and Chelmsford , UK ; Cambridge Breast Unit, Plastic and Reconstructive Surgery Department, Cambridge University Hospitals NHS Foundation Trust , Cambridge , UK
| | - Nicholas G Rabey
- Cambridge Breast Unit, Plastic and Reconstructive Surgery Department, Cambridge University Hospitals NHS Foundation Trust , Cambridge , UK ; Cambridge Breast Unit, Plastic and Reconstructive Surgery Department, Cambridge University Hospitals NHS Foundation Trust , Cambridge , UK
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Allan J, Dusseldorp J, Rabey NG, Malata CM, Goltsman D, Phoon AF. Infrared evaluation of the heat-sink bipolar diathermy dissection technique. J Plast Reconstr Aesthet Surg 2015. [PMID: 26195271 DOI: 10.1016/j.bjps.2015.04.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND The use of the bipolar diathermy dissection technique is widespread amongst surgeons performing flap perforator dissection and microvascular surgery. The 'heat-sink' modification uses a DeBakey forcep as a heat sinking interposition between the bipolar tip and the main (vascular or flap) pedicle aiming to protect it from the thermal effects of the bipolar diathermy. This study examines the thermal effects of bipolar cautery upon the microvasculature and investigates the efficacy of heat sinking as a thermally protective technique in microsurgical dissection. METHODS A chicken thigh microsurgical training model was used to examine the effects of bipolar cautery. The effects of bipolar were examined using high definition, real-time infrared thermographic imaging (FLIR Systems) and temperature quantitatively assessed at various distances away from the point of bipolar cautery. Comparison was made using the heat sink technique to determine if it conferred a thermoprotective effect compared to the standard technique without heat sink. RESULTS Using paired t-test analysis (SPSS) the heat sink modification of the bipolar dissection technique was found to have a highly statistically significant effect (P < 0.000000001) in reducing the conductive temperature along the vascular pedicle. This protective effect kept temperatures comparable to controls. CONCLUSION Bipolar cautery is an extremely safe method of electrosurgery, however when its use is required within 3 mm of important vascular architecture, the heat-sink method is a viable and easy technique to prevent thermal spread and limit potential coagulopathic changes.
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Affiliation(s)
- J Allan
- Plastic Surgery Department, Royal Prince Alfred Hospital, Sydney, Australia.
| | - J Dusseldorp
- Plastic Surgery Department, Royal Prince Alfred Hospital, Sydney, Australia
| | - N G Rabey
- Department of Plastic Surgery and Cambridge Breast Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - C M Malata
- Department of Plastic Surgery and Cambridge Breast Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK; Postgraduate Medical Institute at Anglia Ruskin University, Cambridge & Chelmsford, UK
| | - D Goltsman
- Plastic Surgery Department, Royal Prince Alfred Hospital, Sydney, Australia
| | - A F Phoon
- Plastic Surgery Department, Royal Prince Alfred Hospital, Sydney, Australia; Department of Plastic Surgery and Cambridge Breast Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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Richards K, Forouhi P, Johnston A, Malata CM. Pre-operative thrombotic complications of neoadjuvant chemotherapy for breast cancer: Implications for immediate breast reconstruction. Ann Med Surg (Lond) 2015; 4:80-4. [PMID: 25834732 PMCID: PMC4372642 DOI: 10.1016/j.amsu.2014.11.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Revised: 11/01/2014] [Accepted: 11/04/2014] [Indexed: 01/05/2023] Open
Abstract
UNLABELLED Thrombotic complications arising during the treatment of breast cancer can impact the breast reconstruction pathway. We set out to review the details of cases of thromboembolism occurring during neoadjuvant chemotherapy and peri-operatively to study the impact of the event and its management on subsequent breast reconstruction. METHODS We retrospectively reviewed the medical records of seven patients who had experienced a thrombotic event during their treatment of breast cancer between 2008 and 2012, who then proceeded to breast reconstruction. We recorded size and grade of tumour, neoadjuvant chemotherapeutic regimen, details of port insertion, planned reconstruction, thrombotic event and its management and the surgery performed and outcome. RESULTS All patients received chemotherapy via central venous access and went on to present with local symptomatic thrombosis. They were managed with anticoagulant regimens at the time of mastectomy and reconstruction, which were unique for each patient. The results revealed delays to surgery and modifications to planned reconstruction. DISCUSSION The majority of patients developing thrombotic complications go on to achieve successful reconstruction. There is significant variation in the anticoagulation management in this patient group. Identification of optimal anticoagulant regimes and the possibilities for prophylaxis may prove key in informing surgeons when planning the reconstructive process. CONCLUSION An awareness of the effects of thrombotic events in this patient group is important in terms of developing an understanding of its impact on the performance of reconstruction, on the management of anticoagulation peri-operatively and on monitoring for post-operative complications.
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Affiliation(s)
- K Richards
- Clinical School of Medicine, Cambridge University, UK
| | - P Forouhi
- Cambridge Breast Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - A Johnston
- Department of Anaesthesia and ICU, Cambridge University Hospitals NHS Foundation Trust, UK
| | - C M Malata
- Cambridge Breast Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK ; Plastic & Reconstructive Surgery Depatment, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK ; Postgraduate Medical Institute at Anglia Ruskin University, Cambridge, Chelmsford, UK
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Xie H, Malata CM. Cryptogenic stroke following abdominal free flap breast reconstruction surgery. Int J Surg Case Rep 2014; 5:1247-50. [PMID: 25437687 PMCID: PMC4275804 DOI: 10.1016/j.ijscr.2014.10.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2013] [Revised: 09/05/2014] [Accepted: 10/12/2014] [Indexed: 11/24/2022] Open
Abstract
Air embolism can have catastrophic effects in PFO patients due to right-left shunting. Major operations carry higher risks of vascular air entrapment from operative field. Physicians should be aware of a probable cerebrovascular accident secondary to PFO. Routine use of CVP lines in free flap breast reconstructions should be reconsidered.
INTRODUCTION Abdominal free flap breast reconstruction is regarded as the gold standard method of post-mastectomy breast reconstruction by many. It is a major surgery which can be associated with varied systemic complications. To date, there have been no reports of cerebrovascular complications in the literature which examine the possible relation between thromboembolism and patent foramen ovale (PFO) in patients undergoing microvascular breast reconstruction. PRESENTATION OF CASE A 54-year old female with a pre-existing PFO developed a stroke following bilateral mastectomies and immediate free flap breast reconstruction on postoperative day 5. This was attributed to an air embolus caused by central venous pressure line removal. After uneventful intra and early postoperative periods, the patient had collapsed suddenly on day 5 and become unresponsive immediately following the removal of a central venous line. Brain magnetic resonance imaging confirmed a cerebrovascular accident. This resolved within 48 h following therapeutic heparinisation. A clinical diagnosis of paradoxical embolism was made and she was subsequently referred to the cardiologists for angiographic closure of the PFO. DISCUSSION The case study herein reported gives an account that PFO can have considerable health implications in the early postoperative period and conceivably intraoperatively in patients undergoing major reconstructive surgeries. CONCLUSION Surgeons and cardiologists should be aware of this cerebrovascular complication secondary to PFO following major reconstructive surgery such as microvascular breast reconstruction. It also serves to challenge microvascular surgeons to reconsider routine use of central venous pressure lines in free flap patients who might otherwise have good peripheral vessels for postoperative fluid and antibiotic administration.
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Affiliation(s)
- Huizhuang Xie
- School of Clinical Medicine, University College Cork, Ireland
| | - Charles M Malata
- Plastic & Reconstructive Surgery Department, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK; Cambridge Breast Unit, Cambridge University Hospitals NHS Foundation Trust, UK; Postgraduate Medical Institute at Anglia Ruskin University, Cambridge & Chelmsford, UK.
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Nabulyato WM, Alsahiem H, Szepelak K, Boyle JR, Malata CM. Successful use of a gastrocnemius flap for an exposed PTFE femorodistal graft: a case report. J Wound Care 2014; 23:S9-11. [PMID: 25289653 DOI: 10.12968/jowc.2014.23.sup10.s9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Peripheral vascular disease (PVD) is a condition requiring aggressive management to minimise the associated increased morbidity and mortality. Femoro-distal bypass grafting is used in patients with extensive occlusion affecting the crural arteries and poor limb function, but is associated with infection, wound dehiscence and graft exposure. We report a case of a 73-year-old male with history of PVD and occluded ipsilateral femoro-distal bypass graft who underwent limb salvage surgery with a left 6 mm heparin-bonded polytetrafluoroethylene femoro-distal bypass graft in September 2011. He later presented with exposure of the graft over the lateral aspect of the knee following wound dehiscence. During surgery, the exposed portion of the graft was covered by a lateral gastrocnemius muscle flap with an overlying split thickness skin graft. Minor donor site healing problems were noted, but he otherwise made an excellent recovery. While gastrocnemius muscle flaps have been used to cover soft tissue tibial defects secondary to sarcoma and exposed knee joint prostheses, our case adds to the limited literature demonstrating successful salvage of an exposed synthetic graft as a viable alternative to amputation. We therefore recommend prompt referral to plastic services for the management of these complex wounds.
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Affiliation(s)
- W M Nabulyato
- Department of Plastic and Reconstructive Surgery, Addenbrooke's Hospital
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Mohan AT, Patel NG, Malata CM. Combination of the superior and inferior pedicle “continuities” for anastomosis of an SIEA flap to a contralateral DIEP flap in double-pedicled abdominal free flaps: A further modification of the Hamdi classification. J Plast Reconstr Aesthet Surg 2014; 67:e237-9. [DOI: 10.1016/j.bjps.2014.06.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2014] [Revised: 06/01/2014] [Accepted: 06/10/2014] [Indexed: 11/28/2022]
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Brooker JE, Malata CM. Innovative surgical treatment of persistent unilesional breast mycosis fungoides by mastopexy. J Plast Reconstr Aesthet Surg 2014; 68:132-4. [PMID: 25150931 DOI: 10.1016/j.bjps.2014.08.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2014] [Revised: 07/04/2014] [Accepted: 08/05/2014] [Indexed: 10/24/2022]
Affiliation(s)
- J E Brooker
- School of Clinical Medicine, University of Cambridge, United Kingdom
| | - C M Malata
- Department of Plastic & Reconstructive Surgery, Cambridge University Hospitals NHS Foundation Trust, United Kingdom; Cambridge Breast Unit, United Kingdom; Postgraduate Medical Institute, Anglia Ruskin University (Chelmsford & Cambridge), United Kingdom.
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Qian SY, Malata CM. Avoiding pitfalls in open augmentation rhinoplasty with autologous L-shaped costal cartilage strut grafts for saddle nose collapse due to autoimmune disease: the Cambridge experience. J Plast Reconstr Aesthet Surg 2014; 67:e195-203. [PMID: 24742691 DOI: 10.1016/j.bjps.2014.03.029] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2014] [Accepted: 03/24/2014] [Indexed: 10/25/2022]
Abstract
INTRODUCTION Saddle nose deformity due to autoimmune diseases such as Wegener's Granulomatosis and Relapsing Polychondritis is aesthetically, functionally and psychologically distressing for patients. However, "reliable" options for surgical correction remain limited in the literature. We present our experience of augmentation rhinoplasty in this patient population focussing on the techniques and pitfalls of L-shaped costal cartilage grafting. METHODS Five patients undergoing rhinoplasty for saddle nose deformity due to an autoimmune condition were identified over an 11-year period at a major tertiary centre. All patients were in remission from their condition at surgery and underwent L-shaped costal cartilage grafting at augmentation rhinoplasty. Case notes were reviewed retrospectively. RESULTS All patients achieved a marked improvement in nasal position, shape and contour and were very pleased with their overall appearance. The average length of follow up was 2.8 years. There were no infections, graft exposure or warping. No resorption of cartilage was observed and there have been no recurrent deformities. CONCLUSION This case series describes a possible approach to corrective rhinoplasty in patients with saddle nose deformity caused by autoimmune disease, highlighting the key technical steps and potential pitfalls of intraoperative and perioperative care in this population. The approach is straightforward, reproducible, and achieved pleasing aesthetic outcomes and high patient satisfaction. Given careful planning and meticulous execution, L-strut cartilage grafts for augmentation rhinoplasty to correct saddle nose deformity in these patients is of great benefit. LEVEL OF EVIDENCE Therapeutic Study Level IV, case series with pre/post test.
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Affiliation(s)
- S Y Qian
- Clinical School of Medicine Elective Student, Cambridge University Medical School, Cambridge, England, UK; Clinical School of Medicine, Monash University, Clayton, Victoria, Australia
| | - C M Malata
- Department of Plastic and Reconstructive Surgery, Addenbrooke's University Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, England, UK; Anglia Ruskin University Postgraduate Medical Institute, Chelmsford & Cambridge, England, UK.
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Khoo A, Rosich-Medina A, Woodham A, Jessop ZM, Di Candia M, Malata CM. The relationship between the intercostal distance, patient height and outcome in microsurgical breast reconstruction using the second interspace rib-sparing internal mammary vessel exposure. Microsurgery 2014; 34:448-53. [DOI: 10.1002/micr.22238] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2013] [Revised: 02/11/2014] [Accepted: 02/14/2014] [Indexed: 11/11/2022]
Affiliation(s)
- Anna Khoo
- Department of Plastic and Reconstructive Surgery; Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust; Cambridge UK
| | - Anais Rosich-Medina
- Department of Plastic and Reconstructive Surgery; Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust; Cambridge UK
| | - Amandine Woodham
- Department of Plastic and Reconstructive Surgery; Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust; Cambridge UK
| | - Zita M. Jessop
- Department of Plastic and Reconstructive Surgery; Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust; Cambridge UK
| | - Michele Di Candia
- Department of Plastic and Reconstructive Surgery; Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust; Cambridge UK
| | - Charles M. Malata
- Department of Plastic and Reconstructive Surgery; Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust; Cambridge UK
- Cambridge Breast Unit; Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust; Cambridge UK
- Professor of Academic Plastic Surgery; Postgraduate Medical Institute at Anglia Ruskin University, Cambridge and Chelmsford; UK
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Tomouk T, Mahler-Araujo B, Gaskarth MTG, Malata CM, Forouhi P. Mastopexy sutures masquerading as an organic breast lesion on MRI scan. J Plast Reconstr Aesthet Surg 2014; 67:e182-3. [PMID: 24559730 DOI: 10.1016/j.bjps.2014.01.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2013] [Revised: 01/21/2014] [Accepted: 01/23/2014] [Indexed: 10/25/2022]
Affiliation(s)
- T Tomouk
- University of Cambridge, School of Clinical Medicine, Cambridge, United Kingdom
| | - B Mahler-Araujo
- Histopathology Department, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - M T G Gaskarth
- Cambridge Breast Unit, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - C M Malata
- Cambridge Breast Unit, Addenbrooke's Hospital, Cambridge, United Kingdom; Department of Plastic and Reconstructive Surgery, Addenbrooke's Hospital, Cambridge, United Kingdom; Postgraduate Medical Institute, Anglia Ruskin University, Cambridge, United Kingdom
| | - P Forouhi
- Cambridge Breast Unit, Addenbrooke's Hospital, Cambridge, United Kingdom.
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Wong KY, Yu JT, Mahler-Araujo B, Forouhi P, Malata CM. Opportunistic internal mammary lymph node biopsy during microvascular free flap breast reconstruction: A useful technique? Int J Surg 2013; 11:1027-8. [DOI: 10.1016/j.ijsu.2013.07.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2013] [Revised: 05/05/2013] [Accepted: 07/25/2013] [Indexed: 11/28/2022]
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Adekunle S, Pantelides NM, Hall NR, Praseedom R, Malata CM. Indications and outcomes of the components separation technique in the repair of complex abdominal wall hernias: experience from the cambridge plastic surgery department. Eplasty 2013; 13:e47. [PMID: 24058718 PMCID: PMC3776569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVES The components separation technique (CST) is a widely described abdominal wall reconstructive technique. There have, however, been no UK reports of its use, prompting the present review. METHODS Between 2008 and 2012, 13 patients who underwent this procedure by a single plastic surgeon (C.M.M.) were retrospectively evaluated. The indications, operative details, and clinical outcomes were recorded. RESULTS There were 7 women and 6 men in the series with a mean age of 53 years (range: 30-80). Patients were referred from a variety of specialties, often as a last resort. The commonest indication for CST was herniation following abdominal surgery. All operations except 1 were jointly performed with general surgeons (for bowel resection, stoma reversal, and hernia dissection). The operations lasted a mean of 5 hours (range: 3-8 hours). There were no major intra- and postoperative problems, except in 1 patient who developed intra-abdominal compartment syndrome, secondary to massive hemorrhage. All patients were satisfied with the cosmetic improvement in their abdominal contours. None of the patients have developed a clinical recurrence after a mean follow-up of 16 months (range: 3-38 months). CONCLUSIONS The components separation technique is an effective method of treating large recalcitrant hernias but appears to be underutilized in the United Kingdom. The management of large abdominal wall defects requires a multidisciplinary approach, with input across a variety of specialities. Liaison with plastic surgery teams should be encouraged at an early stage and the CST should be more widely considered when presented with seemingly intractable abdominal wall defects.
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Affiliation(s)
- Shola Adekunle
- aDepartments of Plastic and Reconstructive surgery, Addenbrooke's University Hospital, Cambridge, UK
| | - Nicholas M. Pantelides
- aDepartments of Plastic and Reconstructive surgery, Addenbrooke's University Hospital, Cambridge, UK
| | - Nigel R. Hall
- bDepartments of General Surgery, Addenbrooke's University Hospital, Cambridge, UK
| | - Raaj Praseedom
- bDepartments of General Surgery, Addenbrooke's University Hospital, Cambridge, UK
| | - Charles M. Malata
- aDepartments of Plastic and Reconstructive surgery, Addenbrooke's University Hospital, Cambridge, UK,Correspondence:
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Rizki H, Nkonde C, Ching RC, Kumiponjera D, Malata CM. Plastic surgical management of the contralateral breast in post-mastectomy breast reconstruction. Int J Surg 2013; 11:767-72. [PMID: 23845265 DOI: 10.1016/j.ijsu.2013.06.844] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2013] [Revised: 04/27/2013] [Accepted: 06/28/2013] [Indexed: 01/08/2023]
Abstract
Breast reconstruction following mastectomy can be reliably undertaken using many different techniques. Although excellent cosmetic results can be achieved without contralateral balancing surgery, many unilateral breast reconstructions require a balancing procedure on the contralateral breast in order to achieve symmetry; the ultimate goal in breast reconstruction. This article attempts to summarise the existing literature on the plastic surgical management of the contralateral breast. It also outlines the multifactorial and complex issues involved in the planning and undertaking of such surgery with illustrative examples. The implications for future oncological management and radiological surveillance following the procedure are also discussed in brief.
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Affiliation(s)
- H Rizki
- Department of Plastic and Reconstructive Surgery, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
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Segaran A, Mohammad M, Sterling JC, Malata CM. Pyoderma gangrenosum arising in a breast reduction scar: seven years post-procedure. J Plast Reconstr Aesthet Surg 2013; 66:e370-2. [PMID: 23759719 DOI: 10.1016/j.bjps.2013.05.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2012] [Revised: 02/26/2013] [Accepted: 05/05/2013] [Indexed: 10/26/2022]
Abstract
Pyoderma gangrenosum (PG) is an unusual skin condition causing inflammation and sterile ulceration. It may occur in the context of a systemic disease or in otherwise healthy patients following trauma. Treatment is immunosuppression. Surgical debridement may worsen the disease. Post-surgical PG of the breast is rare and in previous reports has occurred within days or weeks of surgery. We report a highly unusual case of PG occurring at an incision site seven years after reduction mammoplasty.
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Affiliation(s)
- A Segaran
- Department of Plastic and Reconstructive Surgery, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, UK
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Segaran A, Reid AWN, Malata CM. Post-operative rhabdomyolysis in a bilateral immediate DIEP flap breast reconstruction. J Plast Reconstr Aesthet Surg 2013; 66:1297-9. [PMID: 23602268 DOI: 10.1016/j.bjps.2013.03.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2013] [Revised: 03/14/2013] [Accepted: 03/16/2013] [Indexed: 10/26/2022]
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Manley K, Gelvez S, Meldon CJ, Levai I, Malata CM, Coonar AS. Free deep inferior epigastric perforator flap used for management of post-pneumonectomy space empyema. Ann Thorac Surg 2013; 95:e83-5. [PMID: 23522238 DOI: 10.1016/j.athoracsur.2012.09.091] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2012] [Revised: 07/18/2012] [Accepted: 09/28/2012] [Indexed: 11/18/2022]
Abstract
Various solutions exist for management of post-pneumonectomy space empyema. We describe the use of a free deep inferior epigastric perforator (DIEP) flap to fill the space and close a pleural window. Previously, flaps involving abdominal muscle or omentum have been used for this purpose. Abdominal surgery to harvest such flaps can impair ventilatory mechanics. The DIEP flap--harvested from the abdomen, and composed primarily of skin and muscle avoids this problem, thus is a desirable technique in patients with impaired lung function. We believe this is the first report of the DIEP flap to close a postpneumonectomy empyema space.
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Affiliation(s)
- Kate Manley
- Department of Thoracic Surgery, Papworth Hospital, and University of Cambridge, School of Clinical Medicine, Cambridge, United Kingdom.
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Hughes T, Yu JTS, Wong KY, Malata CM. "Emergency" definitive reconstruction of a necrotising fasciitis thigh debridement defect with a pedicled TRAM flap. Int J Surg Case Rep 2013; 4:453-5. [PMID: 23548707 DOI: 10.1016/j.ijscr.2013.02.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2013] [Accepted: 02/12/2013] [Indexed: 10/27/2022] Open
Abstract
INTRODUCTION Necrotising fasciitis (NF) is a rare, severe, rapidly progressing and life-threatening synergistic infection primarily affecting the superficial fascia. A novel method of definitive and aesthetic reconstruction of NF thigh defects by using a pedicled transverse rectus abdominis myocutaneous (TRAM) flap without recourse to temporising skin grafts is presented. PRESENTATION OF CASE A 30-year-old parous woman presented in extremis with fulminant NF of her left anteromedial thigh. Following emergency radical debridement and intensive care stabilisation she was reconstructed 48h later in a single stage with a pedicled TRAM flap islanded on the ipsilateral deep inferior epigastric vessels. There was excellent contour restoration of her thigh and coverage of the exposed femoral vessels. DISCUSSION Pedicled flaps based on the rectus abdominis muscle provide a large, readily available reconstructive option for correction of substantial regional defects as herein illustrated. They are robust when based on dominant inferior vascular pedicle with a long reach and wide arc of rotation when designed transversely (as a TRAM flap). CONCLUSION This case also illustrates that definitive flap reconstruction of NF can be successfully undertaken in the emergent setting, thereby negating the need for large areas of skin grafting which can lead to contractures with consequent functional impairment and suboptimal aesthetic results.
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Affiliation(s)
- Tom Hughes
- Clinical School of Medicine, University of Cambridge, UK.
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