Elaine M. Sassoon

Prospective trial of Adipose-Derived Regenerative Cell (ADRC)-enriched fat grafting for partial mastectomy defects: The RESTORE-2 trial

AIMS Women undergoing breast conservation therapy (BCT) for breast cancer are often left with contour defects and few acceptable reconstructive options. RESTORE-2 is the first prospective clinical trial using autologous adipose-derived regenerative cell (ADRC)-enriched fat grafting for reconstruction of such defects. This single-arm, prospective, multi-center clinical trial enrolled 71 patients post-BCT with defects ≤150 mL. METHODS Adipose tissue was collected via syringe lipoharvest and then processed during the same surgical procedure using a closed automated system that isolates ADRCs and prepares an ADRC-enriched fat graft for immediate re-implantation. ADRC-enriched fat graft injections were performed in a fan-shaped pattern to prevent pooling of the injected fat. Overall procedure times were less than 4 h. The RESTORE-2 protocol allowed for up to two treatment sessions and 24 patients elected to undergo a second procedure following the six month follow-up visit. RESULTS Of the 67 patients treated, 50 reported satisfaction with treatment results through 12 months. Using the same metric, investigators reported satisfaction with 57 out of 67 patients. Independent radiographic core laboratory assessment reported improvement in the breast contour of 54 out of 65 patients based on blinded assessment of MRI sequence. There were no serious adverse events associated with the ADRC-enriched fat graft injection procedure. There were no reported local cancer recurrences. Injection site cysts were reported as adverse events in ten patients. CONCLUSION This prospective trial demonstrates the safety and efficacy of the treatment of BCT defects utilizing ADRC-enriched fat grafts.

Effective treatment of chondrodermatitis nodularis chronica helicis using a conservative approach

Background  Chondrodermatitis nodularis chronica helicis (CNCH) is usually treated by surgical excision, but is prone to recurrence.

A novel imaging technique as an adjunct to the in vivo diagnosis of nonmelanoma skin cancer

Background  Spectrophotometric intracutaneous analysis (SIAscopy) is a light‐based imaging system capable of producing rapid images of melanin, blood and collagen of the skin. Although the SIAscope has been investigated for melanoma diagnosis, no formal study has been conducted to determine its use in the diagnosis of nonmelanoma skin cancer (NMSC).

A prospective comparison of spectrophotometric intracutaneous analysis to clinical judgment in the diagnosis of nonmelanoma skin cancer

Introduction:Research indicates that spectrophotometric intracutaneous analysis (SIAscopy) may be a useful adjunct in nonmelanoma skin cancer (NMSC) diagnosis. A study was performed to prospectively assess the accuracy of NMSC diagnosis by the SIAscope as compared with a clinician. Methods:Prior to excision, 323 consecutive lesions were examined and diagnosed by a clinician. SIAgraphs were then taken of the lesions and examined blindly at a later date. Diagnostic accuracy for the clinician and SIAscope was compared between the clinician and SIAscope and to histology. Results:Sensitivity, specificity, positive and negative predictive values for clinical diagnoses were 95.6%, 75.8%, 0.79, and 0.95, respectively. Results for SIA diagnoses were 97.5%, 86.7%, 0.88, and 0.97. Statistical comparison revealed comparable sensitivities for the 2 groups but significantly better specificity for the SIAscope at the 95% confidence level. Conclusion:This study indicates that the SIAscope may be useful in NMSC diagnosis, with accuracies comparable to a clinician.

Spectrophotometric intracutaneous analysis in the diagnosis of basal cell carcinoma: a pilot study

Background  The SIAscope is a portable imaging device that uses a hand‐held unit to emit light of varying wavelengths when placed on the skin. The components of skin absorb light to known extents and any reflected light is received by the hand‐held unit. This information is processed by the SIAscope software to produce images on a computer screen, displaying the melanin, blood, and collagen in the area of concern.

DIEP Flap Rescue by Venesection of the Superficial Epigastric Vein

Microsurgical breast reconstruction with the deep inferior epigastric perforator flap is a technically challenging procedure, where flap survival depends on sufficient arterial input and venous outflow. Rarely, these flaps can become congested because of insufficient venous pathways and dominance of the superficial venous system. We describe a simple technique to allow the rescue of congested flaps by intermittent venesection of the superficial inferior epigastric vein. This relieves the venous congestion in the immediate postoperative period, allowing the flap to develop venous drainage through alternate channels.

Arteriovenous fistula in a free pectoralis minor flap

The acquired arteriovenous fistula, a rare occurrence, usually results from an identifiable traumatic insult. The precipitating event is often a penetrating injury, although other factors such as blunt injury, infection and changes in local haemodynamics can also initiate changes leading to such vascular anomalies. The subject of this report, a 42-year-old female, previously had an acoustic neuroma excised in September 1991, which left her with a dense right facial palsy. In an attempt to reconstruct the nerve, a facial reanimation procedure was performed. This was a two-stage procedure that involved a cross facial nerve graft, followed a year later by a free pectoralis minor flap. The aim was to introduce innervated muscle into the cheek to restore function and symmetry. The surgery was successfully completed in June 1997. This case report describes the appearance of an arteriovenous fistula following the use of a pectoralis minor free flap in facial reanimation. There are no published accounts of arteriovenous fistulae arising in free flaps in head and neck surgery.

Split pedicle for bilateral free deep inferior epigastric perforator flap breast reconstruction: Use of contralateral recipient vessels with radiotherapy damage

Dear Sir, Radiotherapy damage to internal mammary (IM) vessels can increase complications in free flap breast reconstruction (Temple, Strom, Youssef, & Langstein, 2005). Contralateral IM vessels have been used as recipients in bilateral free flap breast reconstruction (Bains, Riaz, & Stanley, 2007; Zeltzer, Andrades, Hamdi, Blondeel, & Van Landuyt, 2011). We present the split pedicle for bilateral free deep inferior epigastric perforator (DIEP) flap breast reconstruction with simultaneous ipsilateral and contralateral microvascular anastomoses for artery and vein of a single flap, used in the case of an ipsilateral IM vein unsuitable for anastomosis due to radiotherapy damage. A 37-year-old lady underwent a left delayed and right immediate bilateral DIEP flap breast reconstruction. The patient had mastectomy, chemotherapy, and radiotherapy on the left side. Two hemi-DIEPs were raised uneventfully on a single perforator on each side. The left IM vessels were prepared and severe radiotherapy damage was noticed with very sluggish back-flow coming from retrograde and anterograde stumps of the single IM vein. The right IM vessels showed the presence of two patent IM veins. Microanastomoses of the right flap to right IM vessels were uneventful. On the left side, however, the flap quickly became congested despite patent anastomoses (Figure 1A). The decision was made to tunnel the left Deep Inferior Epigastric Vein (DIEV) across the midline (Figure 1B) and anastomose to the medial Internal Mammary Vein (IMV) with anterograde flow. Subsequently, venous congestion was resolved (Figure 1C). Both flaps showed good perfusion (Figure 1D) and the patient’s recovery was without complications. Different

The "periosteal anchor stitch": opening up the surgical field.

Recent trends in autologous breast reconstruction have moved away from use of the thoracodorsal vessels to use of the internal mammary vessels as the first-choice recipient site. The use of the internal mammary vessels may provide for a shorter operative time and a higher-quality aesthetic reconstruction as they allow medial placement of a flap. However their main disadvantage is the limited exposure of the vessels provided by removal of a segment of the rib cartilage. Clinical and anatomical studies of the internal mammary vessels suggest that the most appropriate sized portion of the recipient artery and vein for microanastomosis are located at the third intercostal space. Most surgeons therefore resect a segment of the third costal cartilage and rib. This is the basis of our practice. Where possible mastectomy scars are periareolar, or positioned as a transverse incision across the breast at the level of the nipple. In the male, the nipple is located over the 4th intercostal space, however this position is not reliable in women and may be considerably lower. As a result the edge of the upper, medial skin flap of a mastectomy overlaps the operative site, and thus requires retraction. This is especially so in immediate reconstructions. The fibers of the pectoralis major muscle are split to expose the third costal cartilage and also require retraction. One of the keys to maximize microsurgical efficiency is to create a wide, clear stable operative field. This means minimizing instrumentation including the number of retractors and pairs of hands. This can be achieved by the use of self-retaining retractors. The design of self-retainers such as the West’s and Travers’ is such that both limbs open outwards at equal distance from the central hinge-point. To provide adequate exposure of the third intercostal space a greater force for retraction is required on the upper, medial skin flap than on the lower skin flap. If both claws are positioned solely on the skin flaps or pectoralis major muscle, the self-retainer drifts caudally and laterally. The muscle is torn and the upper medial skin flap obscures the operative site. To overcome these problems, we use an anchoring suture for the lateral arm of our self-retaining retractor. Using a round bodied needle, a loose, double suture of 0 nylon is placed in the third costal cartilage 1 to 2 cm lateral to the planned cartilage excision. A double suture is used to spread the load and prevent tearing out. Silk was used initially, but this does not glide through the cartilage as easily as a monofilament suture. Once the first quarter of the needle is in the cartilage, the rest of the needle is ‘‘pushed’’ through, thus allowing the curve of the needle to come through the firm cartilage. The claw of the lateral arm of the self-retaining retractor is hooked into the loops of this suture, thereby providing an anchor point for retraction laterally (see Fig. 1). The retractor is opened with the medial claw retracting the upper medial portion of the mastectomy flap and split pectoralis major medially. This prevents stripping of the muscle laterally, allows for maximal medial retraction and exposure of the recipient vessels for further dissection and provides stability to the operative site for subsequent microsurgical anastomosis. We describe a surgical technique to improve the surgical exposure of the internal mammary recipient vessels. We *Correspondence to: Amit K. Shah, M.A.(Hons) M.B./B.Chir. M.R.C.S.(Eng), ST-4 Plastic and Reconstructive Surgery, Department of Plastic and Reconstructive Surgery, Norfolk and Norwich University Hospital, Colney Lane, Norwich NR4 7UY, UK. E-mail: as329@hotmail.com

Transplantation of a latissimus dorsi flap between identical twins

We present a case of composite tissue transplantation of a latissimus dorsi flap between monozygotic twins. The recipient twin, a 19 year old male, suffered from a complex spinal kyphoscoliosis for which he had undergone multiple previous operations over many years. Soft tissue breakdown on his back causing metalwork exposure had necessitated the removal of his most recent spinal rod. This in turn led to rapid severe deterioration of his spinal deformity and consequent critical impairment of lung function. Robust soft tissue cover was required urgently in order to allow the insertion of a new spinal rod. His previous surgeries and body habitus precluded an adequate autologous reconstruction. Instead, reconstruction using composite tissue transplantation from his identical twin brother was successfully undertaken. We discuss the ethical, psychological and surgical issues involved in this case.