Indocyanine green angiography in oncoplastic breast surgery, a prospective study

INTRODUCTION

The use of Indocyanine green angiography (ICG-A) in oncoplastic breast-conserving surgery (OBCS) has not yet been investigated. This prospective trial applied ICG-A in volume displacement and replacement OBCS to localize perforators and determine tissue supplied by the perforator. Furthermore, to investigate and correlate the intraoperative ICG-A to postoperative surgical site infection, skin necrosis, epidermolysis, and timely onset of adjuvant therapy.

METHODS

ICG-A was performed at three pre-set timepoints during surgery; after lumpectomy, upon dissection of possible perforators, and after wound closure. All patients were followed with clinical evaluations before surgery, 4 weeks, 4-6 months, and 12 months postoperatively.

RESULTS

Eleven patients were included: seven volume displacement and four volume replacement OBCS. ICG-A located the tissue supplied by the perforator and demonstrated sufficient perfusion in all cases. The ICG-A corresponded to the surgeons' clinical assessment. One patient developed a postoperative infection and seroma and was treated conservatively. No patients had postoperative necrosis, loss of reconstruction, or lymphedema of the arm. Edema of the breast occurred in four patients (36.4%). Scar assessments were significantly worse at 4-weeks and 4-6 months. The quality of life improved significantly during follow-up. Adjuvant treatment was administered timely in all cases.

CONCLUSION

ICG-A was feasible for OBCS in assessing intraoperative perfusion. Perfusion was sufficient in all patients and corresponded to the surgeon's clinical evaluation. No patients developed postoperative necrosis. Though edema of the breast occurred in 36.4%, a larger sample size is needed to investigate a possible correlation with ICG-A. Further studies, which includes patients requiring extensive tissue replacement challenging the borders of perfusion, are needed.

Antibiotic implant irrigation and deep infection: A retrospective study of 1508 patients undergoing breast reconstruction with implants

BACKGROUND

Antibiotic implant irrigation is increasingly used to prevent deep infection after implant-based breast reconstruction. However, there is limited evidence of the clinical effect. In this study, we compare the risk of a deep infection in a Danish population of women who either received antibiotic implant irrigation with gentamycin or vancomycin, or no irrigation.

METHODS

We retrospectively reviewed consecutive patients undergoing all types of breast reconstruction with implants at Rigshospitalet and Herlev Hospital, Denmark, in 2010-2019. Logistic regression was used to compare the risk of deep infection between no irrigation and irrigation with gentamicin or vancomycin, and to account for the difference in risk between patient subgroups and risk factors.

RESULTS

We included 1508 patients who received antibiotic irrigation with gentamicin (500 patients), vancomycin (304 patients) or no irrigation (704 patients). The univariable risk analysis showed a significant decreased risk of deep infection using gentamicin irrigation compared with no irrigation (OR 0.58, p<0.05). However, when adjusting for risk factors for infection, there was no significant decrease in the risk of infection when using gentamicin (OR 0.90, p=0.71) or vancomycin (OR 1.0, p=0.99) compared with the control group.

CONCLUSIONS

We found no significant effect of using antibiotic implant irrigation after isolating it from risk factors for deep infection. However, due to the limitations of the study, we cannot conclude that there is no effect of antibiotic implant irrigation. There is a need for a randomized, placebo-controlled trial to investigate the effect, and potential side-effects, of antibiotic implant irrigation.

Prophylactic treatment of breast implants with a solution of gentamicin, vancomycin and cefazolin antibiotics for women undergoing breast reconstructive surgery: protocol for a randomised, double-blind, placebo-controlled trial (The BREAST-AB trial)

INTRODUCTION

Periprosthetic infection is one of the most severe complications following implant-based breast reconstruction affecting 5%-10% of the women. Currently, many surgeons apply antibiotics locally on the breast implant to reduce the risk of postoperative infection, but no randomised, placebo-controlled trials have tested the treatment's efficacy.

METHODS AND ANALYSIS

The BREAST-AB trial (BREAST-AntiBiotics) is an investigator-initiated, multicentre, randomised, placebo-controlled, double-blind trial of local treatment with gentamicin, vancomycin and cefazolin on breast implants in women undergoing implant-based breast reconstruction. The trial drug consists of 80 mg gentamicin, 1 g vancomycin and 1 g cefazolin dissolved in 500 mL of isotonic saline. The placebo solution consists of 500 mL isotonic saline. The trial drug is used to wash the dissected tissue pocket and the breast implant prior to insertion. The primary outcome is all-cause explantation of the breast implant within 180 days after the breast reconstruction surgery. This excludes cases where the implant is replaced with a new permanent implant, for example, for cosmetic reasons. Key long-term outcomes include capsular contracture and quality of life. The trial started on 26 January 2021 and is currently recruiting.

ETHICS AND DISSEMINATION

The trial was approved by the Regional Ethics Committee of the Capital Region (H-20056592) on 1 January 2021 and the Danish Medicines Agency (2020070016) on 2 August 2020. The main paper will include the primary and secondary outcomes and will be submitted to an international peer-reviewed journal.

TRIAL REGISTRATION NUMBER

NCT04731025.

[Advanced locoregional chest wall recurrence of breast cancer]

Locoregional recurrence of breast cancer continues to be a significant clinical issue involving extensive examination programmes, modified oncologic therapy and advanced surgery. The latter includes tumour resection followed by reconstruction of the thoracic wall. The type of reconstruction depends on tumour location, depth, aetiology and whether the resection involves the stabilising osseous structures as summarised in this review. The treatment strategy is planned at multidisciplinary team conferences with the presence of relevant specialists to ensure evidence-based treatment of consistent quality.

A case of disintegrated Strattice™ 4 years after immediate breast reconstruction

Acellular dermal matrices (ADMs) are used frequently in immediate breast reconstruction (IBR). In general, the porcine-derived ADM Strattice™ has been reported with good outcomes and low complication rates. Nonetheless, we report here a case of a 42-year-old, otherwise healthy woman with a history of uncomplicated bilateral prophylactic nipple-sparing mastectomies and subpectoral IBRs performed using Strattice™ and Mentor^® CPG™, who was referred to the Department of Plastic Surgery 4 years after this surgery due to changed appearance of her breast implants. Both CPG implants were found intact and there were no signs of infection but, surprisingly, the Strattice™ had completely disintegrated on both sides. Examinations did not show any malignancies, and at 1-year clinical follow-up, the patient had no signs of relapse. Thus, we suggest that the Strattice™ had disintegrated as a late aseptic foreign body reaction and emphasise the importance of surgeons being aware of this late and rare complication.

[Fat embolism syndrome after liposuction and lipoinjection]

Fat embolism syndrome (FES) after liposuction and lipoinjection especially gluteal augmentation is a rare, but potentially life-threatening complication. Plastic surgeons should only inject fat into the superficial planes and stay away from the gluteal veins. The three main symptoms include respiratory distress, neurological symptoms and petechial rash, but many patients fail to develop the classic triad, and there are no specific laboratory findings. As argued in this review, there is currently no specific therapy, so prevention, early detection and supportive care are the main strategies to prevent and treat FES.

[Melanonychia]

Melanonychia is seen, when melanin is incorporated in the nail, which gives a band of dark discolouration of the nail. Nail discolouration is a common cause for patients to seek medical attention, and it is often benign. Melanonychia can be seen due to melanocytic proliferation (ungual naevi), benign hyperplasia (lentigo) and hypermelanosis (infections, traumas). However, subungual melanoma also commonly presents with melanonychia and is often overseen, leading to a worse prognosis. It is therefore important systematically to examine all nail discolourations to find the cause and rule out malignancy.

Iatrogenic Pneumothorax as a Complication to Delayed Breast Reconstruction With Tissue Expander—A Case Report

Breast reconstruction with expander implant is the most common breast reconstructive procedure. Irradiated patients are seldom reconstructed this way because the tissue expansion is difficult and the complication rates are higher. Pneumothorax is a serious condition and can be seen as a complication to the operation. Literature is sparse; hence, the only study is by Schneider et al who found an incidence of 0.55%. The study focused on immediate reconstruction only and did not report the percentage of irradiated patients. We present a unique case of iatrogenic pneumothorax in a previously irradiated patient undergoing delayed reconstruction with expander insertion. This provides a new perspective to the complication, raising the question whether irradiated patients are at higher risk. As a plastic surgeon, it is important to be aware of this complication and to take account of radiation when selecting reconstruction method.

[Hemifacial atrophy treated with lipofilling]

Autologous lipofilling is a relatively new method of reconstructing congenital and acquired soft tissue defects. However, long-term results are unpredictable due to varying survival rate of the fat graft, and additional treatments are often required. We present a case of a 53-year-old woman who had a right hemifacial soft tissue deficit and received lipofilling twice with no complications and satisfactory cosmetic results. We consider conventional lipofilling to be safe and viable for facial soft tissue augmentation.

[Severe corneal scald after steam explosion]

Facial burns and scalds are common but the eyes are rarely affected. We present a case of a 40-year-old female patient with severe eye injury due to facial scald. Although initial examination in the emergency department did not reveal signs of serious injury, the patient was referred to the burns unit two days later due to suspicion of infection of the facial burns. She was found to have seriously impaired vision and was transferred to a department of ophthalmology. Examination revealed bilateral severe corneal injuries and bilateral limbal ischaemia, presumably leading to permanently impaired vision.

[Pyogenic granuloma]

Pyogenic granuloma is a common benign, rapidly growing vascular papule or polyp. The tumour is very vulnerable and bleeds easily after minor trauma. It can occur in the skin or mucosa and is typically localized within the gingiva, the lips, the mucosa of the nose and the face. It can occur at any age but is often seen on children and young adults. The diagnosis pyogenic granuloma is often straightforward, but several differential diagnoses should be considered, including malignant tumour.

Recurrence of cutaneous malignant melanoma after more than 20 years

Late recurrence 10 years or more after treatment for localised cutaneous malignant melanoma is unusual. We present three cases with recurrences of cutaneous melanoma after 20 years or more. Two patients presented with a nodal recurrence and one patient with systemic disease. According to published reports, risk factors for late recurrence cannot be defined. Prognosis depends on the site of recurrence with short survival after distant metastases and longer survival after local and regional recurrence. Long-term follow up is advocated.

Information processing and attentional dysfunctions as vulnerability indicators in schizophrenia spectrum disorders

The schizotypal personality disorder is believed to be part of the schizophrenic spectrum of disorders including schizophrenic patients as well as some of their seemingly unaffected relatives with discreet symptoms. Spectrum-individuals are characterised by a genetic vulnerability for schizophrenia. The vulnerability is connected with neurocognitive deficits independent of clinical state. Some cognitive dysfunctions are unspecific and probably related to non-genetic brain damage. A consistent finding has, however, been poor performance in tasks involving information processing and attention. The findings point to the existence of specific sensory-perceptual deficits or a general attentional dysfunction. Identification of cognitive disturbances characteristic not only of schizophrenics, but also of schizotypal disordered and their relatives in the boundaries of schizophrenia, is relevant in order better to understand the pathogenetic mechanisms and treatment of schizophrenia. In the present review clinical data are analysed based on models of vulnerability and information processing with reference to a characterisation of the neuro-integrative deficits that form the core abnormalities of the spectrum.