A Systematic Review of Breast Implant-Associated Squamous Cell Carcinoma

Breast augmentation is considered safe, but rare cases of breast implant-associated squamous cell carcinoma (BIA-SCC) have been reported. This study aimed to systematically review published cases of BIA-SCC, providing valuable clinical data. The review included 14 articles and 18 cases of BIA-SCC. An increasing trend in reported BIA-SCC cases was observed, with four cases in the 1990s and 14 cases since 2010. The mean age of affected patients was 56 years, and symptoms typically appeared around 21 years after breast augmentation. Silicone implants used in cosmetic procedures were most commonly associated with BIA-SCC. Implant removal was necessary in all cases, and some patients required a mastectomy. Treatment approaches varied, with the selective use of chemotherapy and/or radiotherapy. The estimated 6-month mortality rate was 11.1%, while the 12-month mortality rate was 23.8%. The estimated 6-month mortality rate should be cautiously interpreted due to the limited sample size. It appears lower than the rate reported by the American Society of Plastic Surgeons, without clear reasons for this discrepancy. This study highlights the importance of enhanced monitoring and information sharing to improve detection and management of BIA-SCC. Healthcare providers should maintain vigilance during the long-term follow-up of breast augmentation patients.

Lipoaspiration and Lymph Node Transfer for Treatment of Breast Cancer-related Lymphedema: A Systematic Review

Lipoaspiration and venous lymph node transfer have each been described as procedures that would improve symptoms of lymphedema. We aim to describe the efficacy of the combination of lipoaspiration and lymph node transfer and to report the outcomes in breast cancer-related lymphedema patients. The search was conducted by querying the PubMed, EMBASE, and Ovid Medline databases for studies that considered the use of lipoaspiration and venous lymph node transfer as surgical treatment for breast cancer-related lymphedema. Different combinations of the keywords “aspiration lipectomy” AND “lymphedema” AND “lymph node transfer” were used for the search. From a total of 20 articles, five met inclusion criteria. All patients included in these studies had stage II or III lymphedema. Two studies considered lipoaspiration as the first step followed by lymph node transfer, two considered lymph node transfer as the first step followed by lipoaspiration, and one applied both procedures simultaneously. A meaningful volume reduction was achieved in all cases. Patients who underwent lymph node transfer first followed by lipoaspiration appeared to have the best outcomes. This systematic review suggests that the combination of lymph node transfer and lipoaspiration is a potential surgical treatment that may improve outcomes achieved by one single procedure in patients with stage II to III breast cancer-related lymphedema.

MON-197 Peri-operative Outcomes of Vaginoplasty Using an Individualized Approach to Hormone Management in Transgender Women

For transgender and gender diverse individuals, gender identity is not congruent with the sex assigned at birth. Cross sex hormone therapy (HT) and gender affirming surgery can relieve significant dysphoria associated with gender incongruence and improve health outcomes. With changes in private insurance, state and federal regulations to cover gender-affirming treatments and procedures, there has been an increasing need and demand for trained providers and centers to provide gender-affirming health care. However, there is little data to guide management of peri-operative HT with regards to limiting risks. Most surgeons follow a protocol to stop feminizing HT 2 weeks before vaginoplasty with little data that this is effective and necessary or whether this might provoke significant dysphoria peri-operatively. We sought to determine if an age-specific and route-specific peri-operative protocol for feminizing HT was associated with increased risk for complications, changes in hormone concentrations or cardiometabolic profile. At our tertiary care academic center, transgender women over the age of 50 discontinued oral estradiol 6 weeks prior to surgery to allow enough time for clotting factors to normalize but could choose to switch to transdermal estradiol until 2 weeks prior to surgery. Younger women continued estradiol until surgery. All women restarted estradiol upon discharge from the hospital. We performed a retrospective review of pre and postoperative body mass index (BMI), blood pressure (BP), estradiol (E2) and total testosterone (TT) concentrations, fasting glucose and lipids 6 months before and after vaginoplasty. Results: A total of 59 transgender women underwent vaginoplasty over 20 months. Ten women age ≥ 50 (O) had a median age of 58 [Interquartile range (IQR) 56-62]. 49 women < age 50 (Y) had a median age of 31 [IQR 27-37]. O had significantly higher BMI than Y [29.7(IQR 28.3-34.2) vs 24.6 (21.6-28.4), p<0.01 and significantly higher BP, triglycerides, and LDL. More Y women were taking oral estradiol (53% vs 20%). There was no difference in baseline or post-surgical E2 or TT concentrations or fasting glucose. There were no complications of deep venous thrombosis, cardiovascular events or significant changes in BMI, BP, fasting glucose or lipids. In both age groups, only about half were able to decrease their estrogen dose post operatively (Y 57% vs O 44%, p=0.5). Conclusions: Continuing feminizing hormone therapy before vaginoplasty is not associated with an increased risk for complications in women under the age of 50. An individualized approach could be considered to limit the risk of worsening dysphoria post-operatively while avoiding increased risks in older women. Why estrogen doses could not be reduced more frequently after orchiectomy requires further investigation.

Lower Extremity Limb Salvage with Cross Leg Pedicle Flap, Cross Leg Free Flap, and Cross Leg Vascular Cable Bridge Flap

Background Lower extremity salvage following significant soft tissue loss can be complicated by lack of recipient vessel for free tissue transfer. We describe our experience in lower limb salvage for patients with no recipient vessels with the use of pedicle, free and cable bridge flaps.

Methods A retrospective review from 1985 to 2017 of patients undergoing lower limb salvage using a contralateral pedicle cross leg (PCL) flaps, free cross leg (FCL) flaps, or free cable bridge (FCB) flaps was conducted. Demographics, etiology of the reconstruction, type of flap used, donor-site vessels, defect size, operating time, time of pedicle division, length of hospital stay, time to ambulation, and complications were analyzed.

Results A total of 53 patients (48 males and 5 females) with an average age of 35 years (range, 29–38 years) were identified. The etiology for the reconstruction was trauma in 52 patients and oncological resection in 1 patient. There were 18 PCL, 25 FCL, and 10 FCB completed. The recipient vessels for all flaps were the posterior tibial artery and vein. The average operating room times for PCL, FCL, and FCB flaps were 4, 9, and 10 hours, respectively. The average length of hospital stay was 5 weeks and average time to ambulation was 4 weeks. The average follow-up time was 7.5 years (range, 3–12 years). Complications encountered were hematoma (six), prolonged pain (six), total flap loss (two), reoperation (five), and infection (four). Limb salvage rates were 96.2%.

Conclusion When ipsilateral limb vessels are not available, and other reconstructive options have been exhausted, cross leg flaps can be a viable option for limb salvage in the setting of extensive defects.

Anterograde injection of low-dose urokinase salvages free anterolateral thigh flap: A case report of safe and effective treatment

RATIONALE

A 54-year-old Taiwanese male came to our hospital presented with right retromolar mucoepidermoid carcinoma. Composite resection and right modified radical neck dissection were performed. We then use free anteral lateral thigh flap to reconstruct the defect. However, venous congestion was found 32 h after the surgery.

PATIENT CONCERNS

The main concerns of the patient is complete salvage of the free flap, and avoiding the secondary free flap harvesting and reconstruction surgeries.

DIAGNOSES

Right retromolar mucoepidermoid carcinoma.

INTERVENTIONS

We report the case of a patient with an anterolateral thigh flap with venous perianastomosis thrombosis and intraflap microvascular thrombosis successfully salvaged using anterograde intra-arterial injection of low-dose urokinase (60,000 U), without administering intravenous anticoagulation heparin during the postoperative period.

OUTCOMES

The flap was completely salvaged 3 days after treatment. No other flap-associated or bleeding complications were noted. The intra-oral wounds around the flap completely healed without any post-ischemic complications.

LESSONS SUBSECTIONS

Although the ideal urokinase doses and delivery procedures for free flap salvage have not been developed thus far, our method maximizes the urokinase gradient in the flap, minimizes the total dose required for flap salvage, and ensures no systemic spread. Thus, compared with other thrombolytic agents, urokinase may be more effective and safe for free flap salvage. With more experience, a standardized dosage and procedure can be developed.

Early Markers of Angiogenesis and Ischemia during Bowel Conduit Neovascularization

Background Bowel flaps are a good and reliable method to restore the continuity of the aerodigestive tract. Radiated fields, contaminated recipient sites, or depleted recipient vessels may increase the risk for ischemic injury after transfer. During ischemic events, we believe that bowel conduits with serosa have a delayed neovascularization process at its new recipient site.

We conducted an ischemia/reperfusion murine model to understand the difference among bowel conduits with and without serosa.

Materials and Methods Two groups of rats were compared: control group (jejunal conduit with serosa) and a target group (jejunal conduit without serosa). These conduits were harvested from the peritoneal cavity and transferred into a subcutaneous pocket. After 72 hours of transfer and pedicle ligation, histological changes related to ischemia/reperfusion were assessed. In addition, tissue markers of angiogenesis (CD34), ischemia (lactate dehydrogenase [LDH]), and inflammation (interleukin [IL]-1β and IL-6) were analyzed.

Results Two groups (n = 20) of male rats were analyzed. Histology showed intact jejunal mucosa in the target group. The control group showed decreased number of mucin, globet cells, decreased height, and fragmentation of villi with the absence of intestinal glands. Markers of angiogenesis (CD34) were higher in the target group. In addition, markers of ischemia (LDH) (p = 0.0045) and inflammation (IL-1b, p = 0.0008, and IL-6, p = 0.0008) were significantly lower in the target group as compared with the control group.

Conclusions In circumstances in which the recipient site does not offer an adequate and healthy bed or a vascular insult occurs, bowel flaps with less amount of serosa may be able to neovascularize faster thereby increasing its chances of survival.

Lymphatic mapping and lymphedema surgery in the breast cancer patient

Upper limb lymphedema can be an unfortunate sequela following the oncologic treatment of breast cancer. The surgical treatment of lymphedema has had a recent renewed clinical interest paralleling innovative descriptions of surgical techniques and imaging modalities. In addition, an improved understanding of the physiology and pathophysiology of lymphedema has allowed improved translation to the clinical condition. Various surgical options exist to decrease the symptom-burden of upper limb lymphedema, including vascularized lymph node (VLN) transfer, lymphovenous bypass (LVB), liposuction, lymphatic grafting, and excisional procedures. Modern imaging techniques help to improve the consistency and accuracy of these surgical treatment options. A multi-modal treatment plan utilizing non-operative and surgical therapies has the potential to improve various factors related to overall patient quality of life. This review details all of the current operative treatment strategies and modern imaging modalities used in the treatment of lymphedema.

[Congenital hydronephrosis. An evolutionary study of renal function]

Between 1986 and 1995, 24 newborn and young infants underwent to surgical repair of 32 renal units affected by congenital hydronephrosis in spite of their levels of renal function and dilation. 22 renal units were pelviureteral junction obstruction and 10 were vesico-ureteral obstruction. Isotopic studies were made pre- and post-operatively, resulting in a high percentage of kidneys with the highest values of relative renal function showing a downward after surgery, and a general improvement among the renal units with previously moderate function. Drainage slope curves showed an improvement of its partial obstruction, and no change when dilation without obstruction. The clearance half-time showed a reduction in the slower renal units. We conclude that the natural evolution of these age-group kidneys is a counterbalance with the healthy contralateral renal unit.