Hinne A. Rakhorst

A Critical Review of Perioperative Complications in 175 Free Deep Inferior Epigastric Perforator Flap Breast Reconstructions

Background: The purpose of this study was to critically evaluate the perioperative complications for deep inferior epigastric perforator (DIEP) flap breast reconstruction. Methods: From February 2002 until February 2006, 175 consecutive abdominal free tissue breast reconstructions were performed in 131 patients. Perioperative risk factors and complications were evaluated for the entire group. Data analysis was performed to compare subsequent chronologic groups for a learning curve effect. Results: In 159 cases (90.9%) a DIEP flap could be raised. In 13 cases (7.4%), a mini-TRAM flap and in 3 cases (1.7%) a regular free TRAM flap was harvested. A learning curve was found showing a risk for flap complications in the first 30 DIEP flaps of 40% and in flaps 31 to 175 of 13.8% (P < 0.012). Microsurgical revision rate was 4% (n = 7), with a total flap failure rate of 0.6% (n = 1). Partial flap failure rate was 8.6% (n = 15), which was solved by debridement, medial advancement, and direct closure in 6.8% (n = 12) and latissimus dorsi flap transposition in 1.8% (n = 3). Multivariate analysis showed no significant influence of risk factors on development of postoperative flap complications. Conclusion: DIEP flap breast reconstruction is an excellent method, with limited donor-site morbidity. A definite learning curve was reflected in a larger number of flap complications in the beginning of our series.

International importance of robust breast device registries.

Background: Breast implants are high-risk devices that have been at the epicenter of much debate and controversy. In light of the Poly Implant Prothèse crisis, data registries among 11 national societies around the world are cooperatively calling for the urgent need to establish robust national clinical quality registries based on international best practice within a framework of international collaboration. Methods: A survey was conducted on the historic and current status of national breast device registries. Eleven countries participated in the study, illustrating different data collection systems and registries around the world. Data collection was designed to illustrate the capabilities of current national registries, with particular focus on capture rate and outcome reporting mechanisms. Results: A study of national breast implant registries revealed that less than half of the participating countries had operational registries and that none of these had adequately high data capture to enable reliable outcome analysis. The study revealed that the two most common problems that discouraged participation are the complexity of data sets and the opt-in consent model. Conclusions: Recent implant crises have highlighted the need for robust registries. This article argues the importance of securing at least 90 percent data capture, which is achievable through the opt-out consent model. Since adopting this model, the Australian Breast Device Registry has increased data capture from 4 percent to over 97 percent. Simultaneously, it is important to foster international collaboration from the outset to avoid duplication of efforts and enable the development of effective international early warning systems.

Breast Implants and the Risk of Anaplastic Large-Cell Lymphoma in the Breast

Importance Breast implants are among the most commonly used medical devices. Since 2008, the number of women with breast implants diagnosed with anaplastic large-cell lymphoma in the breast (breast-ALCL) has increased, and several reports have suggested an association between breast implants and risk of breast-ALCL. However, relative and absolute risks of breast-ALCL in women with implants are still unknown, precluding evidence-based counseling about implants. Objective To determine relative and absolute risks of breast-ALCL in women with breast implants. Design, Setting, and Participants Through the population-based nationwide Dutch pathology registry we identified all patients diagnosed with primary non-Hodgkin lymphoma in the breast between 1990 and 2016 and retrieved clinical data, including breast implant status, from the treating physicians. We estimated the odds ratio (OR) of ALCL associated with breast implants in a case-control design, comparing implant prevalence between women with breast-ALCL and women with other types of breast lymphoma. Cumulative risk of breast-ALCL was derived from the age-specific prevalence of breast implants in Dutch women, estimated from an examination of 3000 chest x-rays and time trends from implant sales. Main Outcomes and Measures Relative and absolute risks of breast-ALCL in women with breast implants. Results Among 43 patients with breast-ALCL (median age, 59 years), 32 had ipsilateral breast implants, compared with 1 among 146 women with other primary breast lymphomas (OR, 421.8; 95% CI, 52.6-3385.2). Implants among breast-ALCL cases were more often macrotextured (23 macrotextured of 28 total implants of known type, 82%) than expected (49 193 sold macrotextured implants of total sold 109 449 between 2010 and 2015, 45%) based on sales data (P < .001). The estimated prevalence of breast implants in women aged 20 to 70 years was 3.3%. Cumulative risks of breast-ALCL in women with implants were 29 per million at 50 years and 82 per million at 70 years. The number of women with implants needed to cause 1 breast-ALCL case before age 75 years was 6920. Conclusions and Relevance Breast implants are associated with increased risk of breast-ALCL, but the absolute risk remains small. Our results emphasize the need for increased awareness among the public, medical professionals, and regulatory bodies, promotion of alternative cosmetic procedures, and alertness to signs and symptoms of breast-ALCL in women with implants.

Pathological internal mammary lymph nodes in secondary and tertiary deep inferior epigastric perforator flap breast reconstructions.

Use of internal mammary vessels during breast reconstruction provides information on part of the internal mammary chain lymph nodes (LNs). It was evaluated whether our current practice of screening should be changed to identify those delayed breast reconstruction patients with tumor-positive internal mammary nodes (IMNs) and whether breast reconstruction should be continued, in case suspicious IMNs were found intraoperatively. From February 2002 to December 2004, 81 patients had received 98 deep inferior epigastric perforator flaps for delayed breast reconstruction. Prospectively collected data for suspicious internal mammary LNs were evaluated. In 13 patients (16%) who had received a delayed breast reconstruction, macroscopically suspicious LNs were detected in the course of the internal mammary chain. Three patients (4%) had a pathologic diagnosis of malignancy, which was found to match their primary tumor. No relationship between positive internal mammary chain LNs and location of the primary tumor, TNM-stage, or previously administered adjuvant therapy was found. Suspicious internal mammary chain LNs found during recipient vessel dissection for breast reconstruction can have important consequences for treatment of malignant disease in individual patients. Presented data do not support changing the current perioperative approach of delayed breast reconstruction.

Differences in the Reporting of Racial and Socioeconomic Disparities among Three Large National Databases for Breast Reconstruction

Background: Research derived from large-volume databases plays an increasing role in the development of clinical guidelines and health policy. In breast cancer research, the Surveillance, Epidemiology and End Results, National Surgical Quality Improvement Program, and Nationwide Inpatient Sample databases are widely used. This study aims to compare the trends in immediate breast reconstruction and identify the drawbacks and benefits of each database. Methods: Patients with invasive breast cancer and ductal carcinoma in situ were identified from each database (2005–2012). Trends of immediate breast reconstruction over time were evaluated. Patient demographics and comorbidities were compared. Subgroup analysis of immediate breast reconstruction use per race was conducted. Results: Within the three databases, 1.2 million patients were studied. Immediate breast reconstruction in invasive breast cancer patients increased significantly over time in all databases. A similar significant upward trend was seen in ductal carcinoma in situ patients. Significant differences in immediate breast reconstruction rates were seen among races; and the disparity differed among the three databases. Rates of comorbidities were similar among the three databases. Conclusions: There has been a significant increase in immediate breast reconstruction; however, the extent of the reporting of overall immediate breast reconstruction rates and of racial disparities differs significantly among databases. The Nationwide Inpatient Sample and the National Surgical Quality Improvement Program report similar findings, with the Surveillance, Epidemiology and End Results database reporting results significantly lower in several categories. These findings suggest that use of the Surveillance, Epidemiology and End Results database may not be universally generalizable to the entire U.S. population.

In Defense of the International Collaboration of Breast Registry Activities (ICOBRA)

The International Collaboration of Breast Registry Activities (ICOBRA) involves the national plastic surgery societies of several countries, including Australia, Austria, Canada, France, Germany, Ireland, Italy, the Netherlands, New Zealand, South Africa, the United Kingdom, and the United States.1 Its inception was triggered by the Poly Implant Prostheses (PIP) crisis in France in 2010. It was clear at this time that no existing or past breast implant registry was in a position to alert government and regulatory authorities. In Australia, an inclusive approach backed by surgical societies, government and regulatory bodies has now resulted in the design and implementation of what we now believe is an optimal model for a breast device registry. In 2010, the Australian Society of Plastic Surgeons and the Australasian Foundation for Plastic Surgery, with support from reputable registry scientists, sought to design a “best-practice” Breast Device Registry. Australias new national opt-out Breast Device Registry was designed along similar lines to the Australian Orthopedic Associations National Joint Replacement Registry. The orthopedic experience, with successful detection of clinical failure of metal-on-metal hip joint prostheses provided a valuable and parallel experience of how a device registry could function as an important tool to ensure patient safety.2 The Australian Government tendered for the design and implementation of the registry and the Monash Universitys Department of Epidemiology and Preventive …

The Prevalence of Triangular Fibrocartilage Complex Signal Abnormalities on Magnetic Resonance Imaging Relative to Clinical Suspicion of Pathology

PURPOSE To determine the prevalence of triangular fibrocartilage complex (TFCC) signal changes in patients undergoing magnetic resonance imaging (MRI) of the wrist and its relationship to a clinical suspicion of TFCC pathology. The secondary purpose was to study factors that are associated with TFCC signal changes. METHODS In this retrospective study, we looked for any TFCC signal changes in the reports of MRI findings performed during a 3-year period in 1,134 patients. Demographic characteristics, the categorized indications for MRI, and symptoms at the time of the MRI were also retrieved from the medical records. Patients were divided into 6 groups, based on age, to calculate the proportions of TFCC signal changes in the entire cohort and as an incidental finding among patients without a clinical suspicion of TFCC pathology within each age group. RESULTS A total of 321 patients (28%) had incidental TFCC signal changes. The prevalence among 18- to 30 year-olds was 19%, and increased to 64% in patients older than 70 years. Multivariable logistic regression analysis demonstrated that an increase in age is significantly associated with having TFCC signal changes on MRI in patients who have a low clinical suspicion of TFCC pathology. The rate of incidental TFCC signal changes steadily increases with age. CONCLUSIONS The TFCC signal abnormalities on MRI are more common with increasing age in patients with low clinical suspicion of TFCC pathology. At age 70, more than half of all patients will have TFCC signal changes, and more than 90% are present in patients with a low clinical suspicion of TFCC pathology. TYPE OF STUDY/LEVEL OF EVIDENCE Diagnostic IV.

Breast Implant Registries: A Call to Action

Silicone breast implants have evolved through five generations and over 240 styles of breast implants have been delivered to the marketplace.1 However, there are little high quality data with which to make reliable, evidence-based evaluations of the risks of breast implants, and to date, the advantage of one type over the other is uncertain. Clinical quality registries (CQRs) enable evaluation of device performance, safety, and quality of care for patients. Just as breast implants have evolved and improved over the last decades, so too has clinical registry expertise and technology.2 Registries now support improved data capture, data linkage, analysis and reporting, and are a recognized contributor to health systems that provide high-quality patient care.3 The current generation breast implant registries promises to improve long-term breast implant safety, but key stakeholder support and participation is critical.

Abstract: Sexual Inequality for Women in Plastic Surgery

INTRODUCTION: In response to a growing opioid crisis, there is an increased focus on reducing opioid consumption perioperatively. Pectoral nerve blocks (Pecs blocks) have previously been shown to successfully manage postoperative pain in mastectomy patients, decreasing perioperative opioid consumption and postoperative nausea. Over the past several years, we have begun incorporating Pecs blocks into our routine breast surgeries including reduction mammoplasty. The purpose of this study is to examine the impact of Pecs blocks on opioid consumption and antiemetic requirement in reduction mammoplasty patients.

Prevalence of psychiatric comorbidities among women undergoing free tissue autologous breast reconstruction

Autologous breast reconstruction (BR) can be a stressful life event. Therefore, women undergoing mastectomy and autologous BR are required to have sufficient coping mechanisms. Although mental health problems are widespread, information regarding the prevalence of psychiatric diagnosis among these patients is scarce.