Isabel Teo

Bilateral Breast Reconstruction with Abdominal Free Flaps: A Single Centre, Single Surgeon Retrospective Review of 55 Consecutive Patients

Breast reconstruction using free tissue transfer is an increasingly utilised oncoplastic procedure. The aim was to review all bilateral breast reconstructions using abdominal free flaps by a single surgeon over an 11-year period (2003–2014). A retrospective review was performed on all patients who underwent bilateral breast reconstruction using abdominal free flaps between 2003 and 2014 by the senior author (DAM). Data analysed included patient demographics, indication for reconstruction, surgical details, and complications. Fifty-five female patients (mean 48.6 years [24–71 years]) had bilateral breast reconstruction. The majority (41, 74.5%) underwent immediate reconstruction and DIEP flaps were utilised on 41 (74.5%) occasions. Major surgical complications occurred in 6 (10.9%) patients, all of which were postoperative vascular compromise of the flap. Failure to salvage the reconstruction occurred on 3 (5.5%) occasions resulting in a total flap failure rate of 2.7%. Obesity (>30 kg/m2) and age > 60 years were shown to have a statistically increased risk of developing postoperative complications (P < 0.05). Our experience demonstrates that abdominal free flaps for bilateral breast reconstruction fares well, with a flap failure rate of 2.7%. Increased body mass index and patient age (>60 years) were associated with higher complication rates.

Assessing the Risks Associated with Antidepressant Use in Plastic Surgery: A Systematic Review.

Background: Antidepressant use has increased dramatically over the past decade. Although there is no question about the benefits of these medications, uncertainty exists with regard to the implications of antidepressant treatment surrounding plastic surgery. This systematic review collates all of the available literature that evaluates the risks of patient antidepressant treatment, in relation to plastic surgery. Methods: A comprehensive literature review of the PubMed and Cochrane databases was conducted. Articles were assessed by two independent reviewers using predefined data fields and selected using specific inclusion criteria. The two authors independently reviewed the literature and extracted data from included reviews, and discrepancies were resolved by consensus. Results: Twenty-six articles were included in the analysis and were categorized into five groups for comparison: risk of bleeding, risk of breast cancer, risk of breast cancer recurrence, breast enlargement, and miscellaneous (unique complications). Extracted information included study type, statistical analyses, conclusion, and limitations. Conclusions: This review does not support the cessation of antidepressants in patients before plastic surgery, as the numbers needed to harm are low and the implications of withdrawal may prove to be detrimental to postoperative management. However, the use of antidepressants for mental disorders may also implicate key patient risk factors for surgical complications, and sufficient exploration into the patient’s indications for the prescription is crucial. Evidence so far does not suggest that antidepressants increase the risk of breast cancer or recurrence in general, but caution should be exercised for those specifically on concurrent tamoxifen and paroxetine treatment.

Seat belt injury causing bisection of the breast: A case report

Seat belt use has been mandatory in the United Kingdom since 1983 for front seat passengers, and since 1991 for rear seat users. This measure has hugely reduced the risk of serious injuries and death associated with road traffic accidents. However, this restraint system is associated with a particular pattern of injuries in the configuration of the seat belt, namely sternal fractures, bowel trauma or spinal injuries. There have been multiple publications on these injuries which have now been termed ‘seat belt syndrome’ or ‘seat belt injuries’. We report a case of breast bisection as a result of seat belt trauma with description of the reconstructive procedure. A 67 year old lady was involved in a road traffic accident resulting in severe bruising across her right breast from her seat belt. There were no open wounds and she did not require any medical treatment at this stage. Over the subsequent weeks, she noticed a worsening deformity of her right breast. Her past medical history included rheumatoid arthritis affecting her hips for which she took Naproxen 500 mg BD, and she was otherwise fit and well. She had attended regular mammograms that had been normal. She first attended the breast unit three months after her accident and was noted to have severe indentation of her right breast in line of her seat belt (Figure 1). A mammogram and ultra-sound scan was performed which revealed extensive fat necrosis. Core biopsies were performed despite a low index of suspicion by the radiologist. This showed fat necrosis with no suspicious features. Surgery was offered to correct the indentation of her breast. Ten months following the accident, she underwent a complex reconstructive procedure performed under general anesthetic. The edges of diagonal depression were incised and de-epithelised. The nipple areolar complex was

Volpara™ as a measurement tool for breast volume☆

Mammography has been a standard form of imaging the breast in the United Kingdom since 1988. With the advent of full-field digital mammography, software tools designed to provide automated breast density assessment are now available. These tools have emerged because mammographic breast density is an important risk factor for breast cancer. The two commercially available systems are Quantra (Hologic Inc., Bedford, MA, USA) and Volpara (Matakina, Wellington, New Zealand). They calculate breast volume and density based on area and thickness measurements derived from the raw versions of the two-view digital mammograms. The overall breast volume is then used as the denominator for the volumetric percentage of fibroglandular tissue. We aim to assess the validity of Volpara as a breast volume measurement tool by comparing Volpara volume measurements to actual skin sparing mastectomy (SSM) specimen volumes obtained intra-operatively. A prospective database of 43 SSM specimens in 39 women were analysed. Immediately following SSM, direct volume measurements were performed intra-operatively using a water displacement technique. The excised breast tissue was placed in a cylinder of water and the volume of displaced water measured. Intraoperative volumes were compared to the Volpara volumes using the Pearson’s coefficient test and intraclass correlation coefficient (ICC). Analysis was performed using SPSS v21 by the authors following advice from a trust statistician. The mean Volpara volume measurement was 660 cc (range 285e1270 cc) and the mean mastectomy volume measured intra-operatively 393 cc (range 50e900 cc). Pearson’s correlation test showed a statistically significant correlation of 0.81, p < 0.01 (R Z 0.657). ICC established moderate agreement with n Z 0.67 for mean values and n Z 0.51 for single measures, 95% CI. Breast density measurements in radiological investigations have been widely researched, with papers substantiating the correlation of density with the risk of malignancy. It is only in the last decade that interest in volume has grown. In breast conservation surgery, the ratio of parenchyma removed has been shown to greatly affect cosmetic outcome and patient satisfaction. In mastectomies, pre-operative knowledge of breast volume can guide the surgeon in estimating what is required to be replaced, either in the form of flaps, implants or a combination of both. There are many merits to using mammography to calculate breast volumes. It is almost invariable that any patient who undergoes a mastectomy for oncological

Outcome of single-stage breast reconstruction using the Natrelle 150 expander implant.

AbstractThe Natrelle 150 offers the advantage of single-stage reconstruction. However, there is lack of published data on its long term outcomes, which does not allow for definitive conclusions as to whether it truly meets its design objective of a lasting single stage breast reconstruction. This is a retrospective review of all Natrelle 150 reconstructions by a single surgeon over 5 years. A total of 143 procedures were performed in 125 patients with a mean follow-up of 33 months (range, 3–65 months). Most (120, 84%) received the implant after oncological mastectomies, 22 (15%) after risk-reducing mastectomies, and 1 (0.8%) for hypoplasia. Fifty-one (35.7%) implants were explanted an average of 12.9 months after implantation. A Kaplan-Meier survival analysis demonstrates an explantation rate of 25% by 11 months. Explantation was more likely after subpectoral placement compared to reconstructions in combination with latissimus dorsi flaps (P < 0.05). Risk-reducing reconstructions were also more likely to undergo explantation (P < 0.05) compared to reconstructions for oncological reasons. Our data suggest that this prosthesis is only successful as a 1-stage procedure in certain patients, and has led to more careful patient selection and counseling.

Multiple enlarging nodules on the lower limb

A 99 year old white woman presented with a 12 month history of nodules and plaques on her left shin. They had been slowly increasing in size and bled intermittently. She denied any history of trauma to her leg and had been systemically well. She reported having high blood pressure and that she had previously had “skin problems” affecting her lower left leg that required surgery. Her only regular drug was bendroflumethiazide, and she had no known drug allergies. She was a non-smoker and drank minimal alcohol. She lived in a ground floor flat and used a walking stick. On review of her medical notes, it was discovered that two areas of squamous cell carcinoma were excised from her left shin 10 years earlier. On examination, she was fair skinned (Fitzpatrick skin type II). There were several distinct, shiny, well circumscribed nodules on her left shin with surrounding hyperkeratotic plaques. These lesions were tender on palpation. ### 1 What is the most likely diagnosis? #### Short answer Squamous cell carcinoma (SCC). Given her history of SCC, these lesions are highly suspicious of a recurrence. #### Long answer In a patient with a history of slow growing nodules (figure⇓) at a site where SCC had previously been excised, SCC is the most likely diagnosis. SCC is a malignant tumour that arises from the keratinising cells of the epidermis. It is locally invasive and has metastatic potential. The density of these lesions is highest on the face and neck, although lesions are more common on the extremities (arms, backs of hands, and lower limbs).1 SCC is more common in people over the …