R.R.W.J. van der Hulst

Microsurgical techniques for the treatment of breast cancer-related lymphedema: a systematic review.

BACKGROUNDnUpper limb lymphedema is one of the most underestimated and debilitating complications of breast cancer treatment. The aim of this review is to summarize the recent literature for evidence of the effectiveness of lymphatic microsurgery for the treatment of breast cancer-related lymphedema (BCRL).nnnMETHODSnA search was conducted for articles published from January 2000 until January 2012. Only studies on secondary lymphedema after breast cancer treatment and those examining the effectiveness of microsurgery were included.nnnRESULTSnNo randomized clinical trials or comparative studies were available. Ten case-series met inclusion criteria: (composite) tissue transfer (n = 4), lymphatic vessel transfer (n = 2), and derivative microlymphatic surgery (n = 4). Limb volume/circumference reduction varied from 2 to 50% over a follow-up time ranging from 1 to 132 months. Postoperative discontinuation rates of conservative therapy were only reported after composite tissue transfer, ranging from 33 to 100% after 3 to 24 months. Clear selection criteria for lymphatic surgery and lymphatic flow assessment were absent in most studies.nnnCONCLUSIONnWe identified important methodological shortcomings of the available literature. Evidence acquired through comparative studies with uniform patient selection is lacking. Consistent positive findings with regards to limb volume reduction and limited complications are reasons to further explore these techniques in methodologically superior studies.

Septocutaneous tensor fasciae latae perforator flap for breast reconstruction: radiological considerations and clinical cases.

INTRODUCTIONnThe deep inferior epigastric artery perforator (DIEP) flap is the first choice in autologous breast reconstruction; in cases when it cannot be used, alternative flaps are available. A radiological study and clinical cases using septocutaneous tensor fasciae latae (sc-TFL) flap for breast reconstruction are presented.nnnMATERIALSnMagnetic resonance angiographies (MRAs) of 55 patients were evaluated. The pedicle and the perforators of the TFL were studied. Five consecutive sc-TFL flaps for breast reconstruction were performed.nnnRESULTSnThirty-seven MRA scans were included. There was a mean of 1.5 septocutaneous perforators per thigh. The mean pedicle length was 8.3xa0cm. Every perforator originated from a branch of the lateral circumflex femoral artery (LCFA). The LCFA originated from the arteria femoralis profunda in 89.2% of cases. In the vertical plane, the mean distance of the perforator from the antero-superior iliac spine was 8.7xa0cm. There were no major complications in the five sc-TFL performed.nnnCONCLUSIONnOn MRA, the septocutaneous pedicle of the TFL perforator flap was consistently present. MR angiographic assessment of the septocutaneous branches was very helpful in the preoperative evaluation of our patients. Dissection of the sc-TFL can be performed in a supine position simultaneously with mastectomy and/or dissection of the mammary vessels. Finally, the donor-site scar can be hidden by underwear, giving minimal deformity. We recommend the sc-TFL flap as a good alternative to the DIEP flap for autologous breast reconstruction. Preoperative imaging is mandatory for correct planning of the flap.

Complications in unilateral versus bilateral deep inferior epigastric artery perforator flap breast reconstructions: A multicentre study

BACKGROUNDnThe deep inferior epigastric artery perforator (DIEP) flap is the first choice for autologous breast reconstruction. The aim of this retrospective cohort study was to analyse the recipient- and donor-site complications and compare them between unilateral and bilateral DIEP flap breast reconstructions.nnnMETHODSnBetween January 2010 and December 2014, 530 DIEP flap reconstructions were performed in 426 consecutive patients in three Dutch hospitals. Major and minor complications were categorised into recipient- and donor-site complications. Post-operative flap re-explorations were recorded.nnnRESULTSnOf the total 530 DIEP flap reconstructions performed (322 unilateral, 104 bilateral), recipient-site complications were major in 9.8% and minor in 20.2%. The patients developed fat necrosis (unilateral 14.0% vs. bilateral 7.7%; OR 1.950; 95% CI 1.071-3.550; pxa0=xa00.027) and infection (unilateral 5.6% vs. bilateral 1.9%; OR 3.020; 95% CI 1.007-9.052; pxa0=xa00.039) at the recipient site significantly more frequently in the unilateral DIEP flap reconstructions. The donor-site complications were major in 0.9% and minor in 19.5% of the cases. Body mass index (BMI) was significantly associated with complications (donor site: OR 1.137; 95% CI 1.075-1.201; pxa0<xa00.001, recipient site: OR 1.073; 95% CI 1.009-1.142; pxa0=xa00.026). Flap re-explorations were performed in 5.7% (nxa0=xa030) of the cases. Total flap loss occurred in 3.0% (nxa0=xa016) of the cases.nnnCONCLUSIONSnBilateral DIEP flap breast reconstructions can be performed with the same percentage of complications and re-explorations as unilateral reconstructions and even result in less fat necrosis and infection at the recipient site. Higher BMIs are significantly associated with recipient- and donor-site complications.

Efficacy of custom-made pressure clips for ear keloid treatment after surgical excision

BACKGROUNDnMechanical pressure is increasingly applied as a means to prevent or treat keloid scars.nnnAIMnThe aim of this study is to analyze the long-term efficacy of our custom-molded pressure-adjustable earclips to prevent keloid recurrence after surgical excision.nnnMETHODSnUsing our custom-molded earclip, 88 patients who had undergone ear surgery for keloid scars were treated for 12 h a day for 6-18 months. The mean follow-up was 6.5 years. The primary outcome was the recurrence of keloids with patient satisfaction being the secondary outcome as assessed by Patient and Observer Scale (POSAS).nnnRESULTSnKeloid scars did not recur in 70.5% of treated patients. The Fitzpatrick scale, which classifies human skin by type, was significantly different between the recurrence and nonrecurrence group. Differences in other patient characteristics were not found between both groups. All parameters mentioned in the POSAS patient scale drastically improved after therapy. There were no severe side effects observed after the therapy.nnnCONCLUSIONnOur pressure-adjustable earclip model is an effective tool in the prevention of ear keloid recurrence and is associated with high patient satisfaction. Its benefits should prompt further studies on its value as an adjuvant therapy to surgery in keloid treatment.nnnLEVEL OF EVIDENCEnLevel III on the Evidence Rating Scale for Therapeutic Studies.

Perfusion of the deep inferior epigastric perforator flap measured by laser Doppler imager

Background:During surgery, circulation changes in the deep inferior epigastric perforator free flap (DIEP). Although blood flow is an important parameter for surgical outcome, little research has been performed on this topic, especially during the process of transplantation. This study examined the pattern of perfusion of DIEP flaps over time. Methods:In all, 16 flaps were studied in 14 DIEP patients. Flap perfusion was measured with the laser Doppler imager at 4 different time points—before, during, and after surgery. Results:Both central and peripheral perfusion did not alter after dissection, when blood supply became restricted to the abdominal vascular pedicle. After transplantation, blood flow was higher in the central part of the flap compared with the peripheral border. Central flow increased after transplantation, compared with measurements before and during surgery. Peripheral flow, however, decreased after transplantation. Conclusions:Surprisingly, flap perfusion did not alter after dissection. It only changed after flap transplantation, when central blood flow increased and peripheral flow decreased.

The role of antioxidants in ischaemia-reperfusion in a human DIEP flap model☆

BACKGROUNDnA better understanding of the pathophysiology of ischaemia-reperfusion injury and a possible treatment for it, is of great importance. The deep inferior epigastric perforator (DIEP) flap is an innovative, clinical model of ischaemia-reperfusion. There has been an ongoing interest in the health benefits and medical applications of antioxidants. We hypothesised that during ischaemia-reperfusion, specific antioxidants are depleted.nnnMETHODSnSeventeen DIEP flaps were performed in 15 patients undergoing breast reconstruction. In each free flap, 3-mm skin biopsies were taken from the DIEP flap at four different time points during and after surgery. In those tissue biopsies, concentrations of the antioxidants vitamin E, glutathione (GSH) and uric acid and total antioxidant capacity (TEAC) were measured.nnnRESULTSnUnexpectedly, no immediate change was observed in GSH concentrations during ischaemia-reperfusion. Uric acid concentrations were significantly increased at all time points following reperfusion. Vitamin E concentrations also showed a significant incline 30min and 1h after reperfusion. However, 1h after reperfusion, a significant decrease in total hydrophilic antioxidant capacity (TEAC) was seen. In the next hour, this capacity recovered.nnnCONCLUSIONSnDuring ischaemia-reperfusion, a deficiency in hydrophilic antioxidant capacity develops. This is a potential cause for the development of ischaemia-reperfusion injury by reactive oxygen species. This clinical trial is registered on Clinical Trials: http://www.clinicaltrials.gov/. Trial registry name: The DIEP-flap as a model of ischaemia-reperfusion. Registration identification number (NCT): 00482469.

Smoking and its effect on scar healing

Scar formation is influenced by several factors such as wound infection, tension, wound depth and anatomical localization. Hypertrophic scarring is often the result of an imbalance in the wound and scar healing process. The exact underlying pathophysiological mechanism remains unclear. Smoking has a higher risk of postoperative complications probably due to a diminished macrophage induction. Following our clinical impression that smokers without postoperative wound infections show esthetically better scars, we evaluated the scars after a reduction mammaplasty in smoking and nonsmoking patients in a prospective clinical trial. Between July 2006 and September 2007, 13 smokers and 30 non smokers with a reduction mammaplasty were included. They were recruited from Viecuri Medical Centre and Atrium Medical Centre in the Netherlands after written consent. Surgical data and data of the patients condition were collected. Follow-up for erythema values of the scars was done with a colorimeter (The Minolta CR-300, Minolta Camera Co., Ltd., Osaka Japan) at 1, 3, 6 and 9xa0months postoperatively on four standardized postsurgical sites. ANOVA and Chi-square test were used for statistical analysis. In the smoking group, the scars were significantly less red compared to the nonsmoking group. No significant differences were found in BMI, resection weight and drain production between both groups. Although smoking is certainly not recommended as a preventive therapy to influence scar healing, this study confirms our assumption that smokers tend to have faster and less erythemateous scar healing to nonsmokers. Further research is needed to understand the mechanism of the effect of smoking on scars.

Sensory recovery of the breast after innervated and non-innervated autologous breast reconstructions: A systematic review

BACKGROUNDnThe sensory recovery of the reconstructed breast is an undervalued topic in the field of autologous breast reconstruction. This systematic review aimed to evaluate the available literature on the sensory recovery of the breast after innervated and non-innervated autologous breast reconstructions and to assess the possible benefits of sensory nerve coaptation compared to spontaneous reinnervation of the flap.nnnMETHODSnA comprehensive literature search was conducted in PubMed, Embase and the Cochrane Library to identify all eligible studies regarding the sensory recovery of all types of innervated and non-innervated autologous breast reconstructions.nnnRESULTSnThe search yielded 334 hits, of which 32 studies concerning 1177 breast reconstructions were included. The amount of heterogeneity between the studies was high, which made the pooling of data difficult. The studies indicated that spontaneous reinnervation of autologous breast reconstructions occurred to a variable extent, depending on how and when it was measured. Despite these variable results, the sensory recovery of innervated flaps, however, was superior, started earlier and gradually improved over time with a higher chance of approaching normal values than non-innervated flaps. There is a lack of studies that assess the return of erogenous sensation and quality of life.nnnCONCLUSIONnThe current evidence shows that nerve coaptation results in superior sensory recovery of the reconstructed breast compared to spontaneous reinnervation of the flap. This review illustrates that more standardised, high-quality studies with adequate sample sizes are needed to objectively evaluate the sensory recovery of the breast after autologous breast reconstructions.

A simplified three-dimensional volume measurement technique in keloid scars: Validity and reliability

INTRODUCTIONnEffective treatment of keloid scars is important because patients are often confronted with major cosmetic, psychological, and social consequences. Three-dimensional (3D) imaging has been reported for the evaluation of keloid treatment. These techniques were complex to use in clinical practice. In this study, the validity and reliability of a simplified 3D volume measurement technique are defined.nnnMETHODSnThirty-three scars were simulated using deformable modeling compound. The volume of the compound is calculated using the weight and density of the modeling compound, and it is compared with the 3D volume measurement.nnnRESULTSnThe mean simulated keloid volume was 2.884 cc. The correlation was very high (r = 0.999), but there was a significant mean difference of 0.252 cc (p < 0.001). This was corrected using a formula, actual volume = 1.072 × measured volume. This formula was validated using a new data set of 33 simulated scars. There was a nonsignificant mean difference of 0.010 cc (p = 0.731).nnnCONCLUSIONnThis 3D measurement technique combined with the correcting formula is valid and reliable to be used in practice for the evaluation of keloid scar treatment.

Improving the effect of shear on skin viability with wound dressings

BACKGROUNDnPressure ulcers are a major healthcare problem and caused by pressure and shear-forces. Although shear-force is understood to be a major contributing factor, no preventive interventions are specifically aimed at relieving the effect of shear on skin to improve skin viability.nnnMETHODSnA physical model was used to apply a combined loading of 2.4kPa pressure and 14.5N shear-force on skin in humans. Loading was applied on the volar aspect of both forearms for 30min in ten healthy volunteers. One arm received loading on skin with a wound dressing, the other arm (control) received loading directly on skin. The following parameters were determined before and after loading: IL-1α/Total Protein-ratio (used as a measure of skin damage); Cutaneous blood cell flux ((CBF) measure of reactive hyperaemia); Lactate concentration (measure of tissue ischemia). Three different dressings were tested on three different days. The order of dressing application, dressing arm and start of the intervention were randomized.nnnRESULTSnParticipants mean age was 22.5±1.6 year with a BMI of 22.3±2.4kg/m(2). IL-1α/Total Protein-ratio of the skin was significantly lower after the application of pressure and shear when the Mepilex® (P<0.01), Allevyn (P<0.05) or Aquacel(TM) dressing (P<0.01) was used compared with the control measurement. The Mepilex® dressing was more effective in reducing post-load IL-1α/Total Protein-ratio compared to the Allevyn dressing (P<0.01). Post-load CBF was significantly lower when the Mepilex® or Aquacel dressing was used (P<0.001). Both dressings induced significantly less post-load CBF than the Allevyn dressing (P<0.01 and P<0.001, respectively). The concentration of lactate was not significantly increased after the application of pressure and shear and could not be used as a measure with this model.nnnCONCLUSIONnThis is the first in vivo study to demonstrate that the effects of pressure in combination with shear on skin viability can be improved with foam dressings. In this study, the multi-layered dressings perform better than the single-layered dressing.