Jagdeep S. Chana

Stromal features are predictive of disease mortality in oral cancer patients

Worldwide, approximately 405 000 cases of oral cancer (OSCC) are diagnosed each year, with a rising incidence in many countries. Despite advances in surgery and radiotherapy, which remain the standard treatment options, the mortality rate has remained largely unchanged for decades, with a 5‐year survival rate of around 50%. OSCC is a heterogeneous disease, staged currently using the TNM classification, supplemented with pathological information from the primary tumour and loco‐regional lymph nodes. Although patients with advanced disease show reduced survival, there is no single pathological or molecular feature that identifies aggressive, early‐stage tumours. We retrospectively analysed 282 OSCC patients for disease mortality, related to clinical, pathological, and molecular features based on our previous functional studies [EGFR, αvβ6 integrin, smooth muscle actin (SMA), p53, p16, EP4]. We found that the strongest independent risk factor of early OSCC death was a feature of stroma rather than tumour cells. After adjusting for all factors, high stromal SMA expression, indicating myofibroblast transdifferentiation, produced the highest hazard ratio (3.06, 95% CI 1.65–5.66) and likelihood ratio (3.6; detection rate: false positive rate) of any feature examined, and was strongly associated with mortality, regardless of disease stage. Functional assays showed that OSCC cells can modulate myofibroblast transdifferentiation through αvβ6‐dependent TGF‐β1 activation and that myofibroblasts promote OSCC invasion. Finally, we developed a prognostic model using Cox regression with backward elimination; only SMA expression, metastasis, cohesion, and age were significant. This model was independently validated on a patient subset (detection rate 70%; false positive rate 20%; ROC analysis 77%, p < 0.001). Our study highlights the limited prognostic value of TNM staging and suggests that an SMA‐positive, myofibroblastic stroma is the strongest predictor of OSCC mortality. Whether used independently or as part of a prognostic model, SMA identifies a significant group of patients with aggressive tumours, regardless of disease stage. Copyright

Reconstruction of very large defects: a novel application of the double skin paddle anterolateral thigh flap design provides for primary donor-site closure

BACKGROUND The anterolateral thigh flap is becoming the flap of choice for reconstruction of soft tissue defects. By applying the chimaeric principle, we describe a technique to achieve primary donor-site closure in the use of the anterolateral thigh for the reconstruction of very large defects. METHODS A long anterolateral thigh flap is marked out using standard points of reference. At least two separate cutaneous perforator vessels are identified on hand-held Doppler and dissected in a retrograde fashion back to the descending branch of the lateral circumflex femoral artery. The skin paddle is then divided between the two cutaneous perforators to give two separate paddles with a common vascular supply. The skin paddles can now be stacked side by side on a flap inset, effectively doubling the width of the flap, whilst still allowing for primary donor-site closure. RESULTS We have used this flap to reconstruct chest-wall and extremity defects on six patients (mean age: 28.6 years; range: 24-35 years). The largest defect was 30x18cm and the smallest 11x12cm in diameter. In each case, the width of the defect was too great to allow for direct closure of the donor site had a conventional anterolateral flap design been used. There were no cases of flap failure or re-exploration, and in all cases the donor site was closed primarily. CONCLUSIONS The split-skin paddle anterolateral thigh flap provides bespoke cover for large soft tissue defects with improved morbidity and cosmesis of the donor site.

The drain game: Abdominal drains for deep inferior epigastric perforator breast reconstruction

INTRODUCTION The deep inferior epigastric perforator (DIEP) flap is often preferred for breast reconstruction as it allows for autologous reconstruction with less donor site morbidity versus transverse rectus abdominis myocutaneous (TRAM) flap reconstruction. Our group has presented and published data for the duration of donor site back drain use in latissimus dorsi (LD) flap breast reconstruction due to insufficient evidence and a requirement for further investigation in the literature; this evidence is still lacking for DIEP reconstruction. AIM To compare inpatient hospital stay, drainage parameters and donor-site complications associated with closed suction abdominal drain removal by post-operative day (POD) 3 regardless of output (early group), with removal after POD 3 where instructions were by drainage volume/24 h±output consistency (late group), in post-mastectomy DIEP reconstruction donor sites. METHOD A retrospective review of DIEP breast reconstructions, between January 2011 and July 2012, was undertaken to facilitate 1 year minimum follow-up per patient. RESULTS Of 78 patients who underwent DIEP breast reconstructions, 74 hospital records contained complete documentation. There were 41 patients in the late, and 33 in the early removal group; both groups were matched for age and number of donor site drains (2 per patient). Mean drain removal day (4.32±0.10 days vs. 2.87±0.06 days, p<0.0001), total drainage (518.90±41.53 mls vs. 283.79±18.06 mls; p<0.0001) and hospital inpatient stay were greater for patients in the late versus early group. There were no differences in total complications (21.95% (9/41) vs. 12.12% (5/33); p=0.46), seroma (4.88% (2/41) vs. 0% (0/33); p=0.20), dehiscence (4.88% (2/41) vs. 9.09% (3/33); p=0.47) or haematoma (7.32% (3/41) vs. 3.0% (1/33); p=0.42) rates between the late and early groups. DISCUSSION These data suggest significant advantages for patients who have abdominal drains removed early by POD 3, without increased post-operative complications including seroma rates; these data are in keeping with our LD data. We recommend drain removal and patient discharge by POD 3.

Intercostal adipofascial perforator flap for reconstruction of overcorrected gynaecomastia deformity

The intercostal perforator fasciocutaneous flap has previously been described in addressing defects in the breast, trunk and arm 1,2,. We describe the first case of an inter-costal artery perforator adipofascial flap in the reconstruction of the male chest following overcorrection of gynaecomastia.

Muscle herniation: A complication at the anterolateral thigh perforator flap donor site

The anterolateral perforator flap is becoming the flap of choice for a wide variety of complex defects. It has been known to provide excellent donor site morbidity even in cases where vastus lateralis is included within the flap. We report a case of herniation of the vastus lateralis and rectus femoris muscles through the overlying fascia, following ALT perforator flap harvest. In this case muscle herniation at the donor site required surgical repair.

Deep inferior epigastric perforator (DIEP) flap: Impact of drain free donor abdominal site on long term patient outcomes and duration of inpatient stay

BACKGROUND The deep inferior epigastric perforator (DIEP) flap is widely regarded as the Gold Standard in autologous breast reconstruction. Although drain-free abdominoplasty is performed in many centres, there is a paucity of evidence comparing outcomes when applied to DIEP breast reconstruction. METHOD A retrospective review of patients who underwent DIEP breast reconstruction without abdominal drain insertion at Royal Free Hospital between Jan 2012-Nov 2016 was undertaken. Results were compared to previously published data from our centre on patients undergoing DIEP breast reconstruction with abdominal drains between Jan 2011-Jul 2012. RESULTS Thirty-five patients underwent abdominal drain-free reconstruction (GroupA). Of 74 patients who previously underwent reconstruction with abdominal drains, 33 patients underwent drain removal by postoperative day (POD)3 regardless of output (GroupB) and 41 underwent drain removal after POD3 following instructions on drainage volume/24 h (GroupC). There was no significant difference in the length of stay between patients in Group A and B (3.6 vs. 3.9 days; p = 0.204). Length of stay in Group C was significantly higher than Group A and B (p = 0.001, p = 0.001). There were no statistically significant differences in total (11.43% vs. 12.12% vs 17.07%, p = 0.780) or specific complications: Seroma: 2.86% vs. 0% vs. 4.88% (p = 0.774); Wound dehiscence: 8.57% vs. 9.09% vs. 4.88% (p = 0.728); Haematoma: 0% vs. 3.00% vs. 7.32% (p = 0.316) between Groups A, B and C, respectively. CONCLUSION Our data suggests that drain-free abdominal closure in DIEP reconstruction can be safely achieved without increased postoperative complications. These conclusions support existing evidence on the use of a drain-free approach in cosmetic abdominoplasty.