Andri Thorarinsson

Risk factors for complications after breast reduction surgery.

Abstract Women who suffer from breast hypertrophy commonly have physical symptoms such as back pain and psychosocial problems. Breast reduction surgery is performed to relieve these problems. Side-effects must be kept to a minimum. Risk factors for developing postoperative complications have not clearly been identified so far. The aim of this study was to identify risk factors that lead to complications. The medical records of 512 consecutive women (mean age 40 years) who underwent bilateral breast reduction were retrospectively studied. All complications that occurred during the first 30 days after the operation were retrieved from medical records. Complications occurred in 32% of the patients within 30 days of surgery. The most common complication was infection at the surgical site (16%) followed by delayed wound healing (10%). Fat necrosis occurred in 2.5%, partial areola necrosis in 3.1%, and total areola necrosis in 0.6% of the patients. A longer suprasternal notch to nipple distance gave significantly higher risk of postoperative infection (p < 0.001) and necrosis in the mammilla (p < 0.001). The resected specimen weight during the operation was found to significantly influence the risk of delayed wound healing (p = 0.021) and fat necrosis (p < 0.001). Smokers had twice the risk of getting a postoperative infection, RR = 2.0 (95% CI = 1.3–3.1). Diabetics had a significantly higher risk of necrosis of the areola (p = 0.003). All the above predictors were identified as independent predictors. Complications after breast reduction are common. The study has identified several risk factors for complications, some of them independent, which might be avoidable by performing a careful preoperative evaluation of the patient.

A retrospective review of the incidence of various complications in different delayed breast reconstruction methods

Abstract Background: Breast reconstruction is a common standard procedure in many centres after breast cancer surgery. The aim of the present study was to investigate and compare the incidence of various complications in different reconstruction methods. Method: Six hundred and eighty-five patients were retrospectively classified into five groups: (1) Deep inferior epigastric perforator flap (DIEP), (2) latissimus dorsi flap (LD), (3) lateral thoracodorsal flap (LTDF), (4) expander with secondary implant (EXP), and (5) direct implant (DI). Demographic and perioperative data, the incidence of complications, and follow-up data were collected. Results: There was a significant difference between groups regarding overall early complications (p < 0.001). The DIEP group had the highest incidence of overall complications (50.0%) (p < 0.05). DIEP also had the highest incidence of fat necrosis (18.3%), skin necrosis (22.1%), and incidence of reoperation for complications (26.9%) compared to the other reconstruction methods. In the entire group of patients, the overall incidence of late complications (occurring >30 days after surgery) that needed surgical corrections was 54.7%. The incidence of late complications was 46.2% for DIEP, 66.4% for LD, 74.8% for LTDF, 44.9% for EXP, and 62.9% for DI. The DIEP group had higher incidences of late local complications (fat necrosis, skin necrosis, haematoma, seroma, and wound rupture combined), and scars requiring treatment than the other reconstruction methods. Conclusion: Meticulous registration of incidence of different complications in five different breast reconstruction methods revealed high complication rates with all methods. The differences in incidence of complications were related to the operation method used. Based on these results, careful individual planning of a breast reconstruction is mandatory.

A randomized prospective study of prophylactic cloxacillin in breast reduction surgery.

BackgroundPostoperative infection after breast reduction surgery is a common complication, with the most commonly involved pathogen being Staphylococcus aureus. Previous studies of antibiotic prophylaxis in breast reduction surgery have been inconclusive. The aim of the present study was to clarify the role of prophylactic antibiotics in breast reduction surgery. MethodsIn total, 325 women were randomized to antibiotic prophylaxis [with 2 g of cloxacillin intravenously (IV) or 600 mg of clindamycin IV] (intervention group) or no antibiotic prophylaxis (control group). Follow-up was conducted at 1 and 2 weeks postoperatively. Patients with signs of infections or other complications were followed up until resolution. Patients who received antibiotic treatment within 30 days from surgery (cloxacillin 750 mg or clindamycin 300 mg orally) were considered having an infection and this was the main outcome variable. All postoperative infections were also judged according to a graded scale. ResultsIn the intervention group, 26 (16.0%) patients were treated with antibiotic; and in the control group, 32 (19.6%) patients were treated with antibiotics. No difference was found between the groups (relative risk, 0.82; 95% confidence interval, 0.51–1.31; P = 0.49). Twenty-two (14%) patients in the intervention group were classified to have a possible infection according to the scale compared to 27 (17%) in the control group. No statistical difference was found (relative risk, 0.81; 95% confidence interval, 0.48–1.37; P = 0.54). ConclusionsProphylactic cloxacillin as a single-dose IV in breast reduction surgery does not reduce the incidence of postoperative infections.

When Is the Deep Inferior Epigastric Artery Flap Indicated for Breast Reconstruction in Patients not Treated With Radiotherapy

BackgroundIt is controversial whether breast reconstruction with a microvascular free flap should be done without restrictions in patients who have not had radiotherapy. Many regard it as too expensive, but some consider it better and more economically advantageous than an implant reconstruction. MethodsDatabases of publications were searched to find out under what conditions is it suitable to offer a deep inferior epigastric perforator (DIEP) or a transverse rectus abdominis myocutaneous flap to normalize the body’s appearance in a woman whose breast(s) had been removed for cancer or to prevent the development of breast cancer. The effect of breast reconstruction with DIEP flaps was analyzed, taking account of the following factors: general satisfaction (quality of life), aesthetic satisfaction (cosmesis), and morbidity. To find out which factors were of potential importance, we recorded age, hypertension, whether scars from previous abdominal surgery were present, microcirculation, whether the patient was overweight or obese, and costs of the procedure. ResultsPatients planning to have DIEP flaps should be willing to stop smoking at least 4 weeks before and after the procedure and have a body mass index of less than 30 kg/m2 to avoid a higher risk of complications. Because of the paucity of papers, it is difficult to recommend one approach over the other when considering general satisfaction, aesthetic satisfaction, and health economics. However, economical long-term outcome is highly dependent on the initial costs of each procedure and the cumulative costs of complications for each reconstruction method. ConclusionsThe scientific foundation of assessment of methods of techniques of breast reconstruction is weak. Therefore, it is important that future studies should present more comparable series, highlight the long-term effects in high-quality studies, to provide the patients with optimal results without undue risks and to avoid financial burdens on society.

fmri after Phalloplasty with Nerve Anastomosis in a Trans-man Patient

Summary: We report on a case of a trans-man patient, who underwent penile reconstruction with the use of a radial forearm flap, urethroplasty, vaginectomy and scrotoplasty, insertion of testicle implants, and penile erection implants, similar to previously described methods. One of the requirements for an ideal phalloplasty is the preservation of erogenous sensitivity, which is often demanded by the patients for fulfilling their sexual well-being. For the first time known to us, we use a functional magnetic resonance imaging following radial forearm flap phalloplasty with nerve anastomosis to assess the cortical activation after clitoral stimulation. The patient was poked with a plastic pen on the neophallus and the groin. Regular block design with T1 and BOLD-T2* images were used. The results contradict the classic Penfield and Rasmussen homunculus, that is, the activations in the primary somatosensory cortex (S1) were bilateral with a left-sided dominance in the lateral parts of the medial postcentral gyrus (same region as the groin), and no activations were observed in the mesial parts of the postcentral gyrus. We also reported bilateral activations with a left-sided dominance in the secondary somatosensory cortex (S2) and near Broca’s area at the sylvian fissure just posterior to ramus ascendens. Our findings are similar to previous studies reporting on imaging related to genital sensitivity.

Blood loss and duration of surgery are independent risk factors for complications after breast reconstruction

Abstract Background: Complications after breast reconstructive surgery are common, and they can be caused by a wide range of factors. The aim of the present study was to identify independent perioperative risk factors for postoperative complications after breast reconstruction. Methods: A retrospective study was performed of 623 consecutive breast cancer patients who had undergone deep inferior epigastric perforator (DIEP) flap, latissimus dorsi (LD) flap, lateral thoracodorsal flap (LTDF), or tissue expander with secondary implant (EXP). Data on demography, perioperative parameters, and complications were collected. Logistic regression models adjusted to the reconstruction method and to confounding demographic factors were used for statistical analysis. Results: Increased blood loss for each 10-ml step increased the risk for overall early complications (p = 0.017), early seroma (p = 0.037), early resurgery (p = 0.010), late local overall complications (p = 0.024), and late fat necrosis (p = 0.031). Longer duration of surgery for each 10-minute step increased the risk of overall early complications (p = 0.019), but, in the univariate model, there was an increased risk for nine different types of complications (p = 0.004–0.029). There was no association between the experience of the surgeon performing the procedure and the frequency of complications. Conclusions: Duration of surgery and blood loss during surgery are independent risk factors for postoperative complications, and should be minimised. Further research is needed to establish the association between the experience of the surgeon and the occurrence of complications.

Patient determinants as independent risk factors for postoperative complications of breast reconstruction

BACKGROUND Breast reconstruction is an essential component in the treatment of breast cancer. Postoperative complications after breast reconstruction are common and affect patient satisfaction. Determining independent risk factors using patient characteristics could be advantageous for patient assessment and counseling. METHODS We retrospectively enrolled 623 consecutive patients who underwent reconstruction with a deep inferior epigastric perforator flap (DIEP), latissimus dorsi flap (LD), lateral thoracodorsal flap (LTDF), or tissue expander with a secondary implant (EXP) in this study. Information on demographic and perioperative factors was collected, as well as information on all postoperative complications. Logistic regression was used to analyze associations between possible patient-related risk factors and postoperative complications. RESULTS Smoking was associated with the highest number of early overall complications [odds ratio (OR) 2.05, 95% confidence interval (CI) 1.25-3.37, P=0.0005], followed by body mass index (BMI) (OR 1.07, 95% CI 1.01-1.13, P=0.017). High BMI was associated with the highest number of late overall postoperative complications (OR 1.06, 95% CI 1.00-1.11, P=0.042), followed by history of radiotherapy (OR 1.66, 95% CI 1.01-2.74, P=0.046). When the risk factors were combined, the risk for postoperative complications rose exponentially. CONCLUSIONS Our results provide evidence that patients should cease smoking and overweight patients should lose weight before undergoing breast reconstruction. Additionally, if the patient has received radiotherapy, the reconstruction method should be carefully chosen. High BMI, history of radiotherapy, and smoking are independent risk factors for many types of both early and late postoperative complications in breast reconstructive surgery. Combining these risk factors multiplies the risk of postoperative complications.

Microsurgically aided upper lip replantation – case report and literature review

Abstract A case with a patient who suffered an upper lip amputation and a lower lip laceration due to dog bite is presented. The amputated segment was replanted using microsurgical technique. The operative technique and postoperative care is presented, as well as a review of the current literature on the subject.