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Importance: Perineal wound complications are common following abdominoperineal resection for rectal cancer and might have substantial and long-lasting implications for patients' recovery., Objective: To evaluate the superiority of gluteal turnover flap closure compared to primary closure in patients with rectal cancer undergoing abdominoperineal resection., Design, Setting, and Participants: The BIOPEX-2 study was an investigator-initiated, parallel-group, multicenter randomized clinical trial conducted at 19 centers in the Netherlands and the UK between June 2019 and November 2023, including 12 months of follow-up. Data analysis was performed from October 2023 to December 2023. Independent perineal wound assessors were masked to the type of closure. Eligibility criteria were resection of rectal cancer by abdominoperineal resection, aged 18 years or older, and ability to complete follow-up. In modified intention-to-treat analyses, patients were assigned to either primary closure or gluteal turnover flap closure., Intervention: Gluteal turnover flap closure started with a half-moon-shaped perineal skin island that was incised and deepithelialized. Subsequently, the subcutaneous fat was dissected toward the gluteal fascia, after which the dermis was sutured to the contralateral levator remnant, followed by midline closure., Main Outcomes and Measures: The primary outcome was uncomplicated wound healing at 30 days postoperatively, defined as a Southampton wound score less than 2. Secondary outcomes included presacral abscess formation and wound-related readmissions., Results: A total of 175 patients were randomized, but 7 did not undergo abdominoperineal resection and 3 withdrew consent. In the modified intention-to-treat analyzes, 86 patients were assigned to primary closure and 79 patients to gluteal turnover flap closure. Of these 165 patients, mean (SD) patient age was 67 (10) years, and 57 patients (34.5%) were female. Uncomplicated perineal wound healing was present in 49 of 82 patients (60%) after primary closure, which did not significantly differ from flap closure (42 of 76 patients [55%]). Presacral abscess developed significantly more often after primary closure than flap closure (19 of 86 patients [22%] vs 7 of 78 patients [9%]; P = .02), and more percutaneous presacral abscess drainage was performed in the control group (primary closure) (7 patients [8%] vs 1 patient [1%]; P = .04). Perineal wound-related readmission occurred in 18 patients (21%) after primary closure and in 10 patients (13%) after gluteal flap closure (P = .17)., Conclusion and Relevance: In this parallel-group, multicenter randomized clinical trial, gluteal turnover flap closure did not show superiority over primary closure in 30-day perineal wound healing after abdominoperineal resection for rectal cancer. However, flap closure significantly reduced presacral abscess formation., Trial Registration: ClinicalTrials.gov Identifier: NCT04004650.

Background: Intralesional corticosteroid administration (ICA) is a first-line keloid treatment. However, it faces significant variability in current clinical and scientific practice, which hinders comparability of treatment results., Objectives: The aim of the study was to reach consensus on different aspects of ICA using hypodermic needles in keloids among an international group of dermatologists and plastic surgeons specialized in keloid treatment to provide consensus-based clinical treatment recommendations for all physicians treating keloids., Methods: The keloid expert panel of 12 dermatologists and 11 plastic surgeons rated 30 statements. Two online e-Delphi rounds were held, both with a response rate of 100%. Fifteen (65%) keloid experts participated in the final consensus meetings. Consensus was defined as ≥ 75% of the participants choosing agree or strongly agree on a 7-point Likert scale., Results: Consensus was reached on treatment goals, indication for ICA, triamcinolone acetonide (TAC) 40 mg/mL as the preferred corticosteroid administered at a maximum of 80 mg per month and at intervals of 4 weeks, minimizing pain during ICA, the use of 1 mL syringes and 25 or 27 Gauge needles, blanching as endpoint of successful infiltration, caution of not injecting subcutaneously, and the option of making multiple passes in very firm keloids prior to infiltration. Consensus could not be reached on TAC dosing, methods of prior local anesthesia, and location of injection., Conclusions: This e-Delphi study provides important clinical treatment recommendations on essential aspects of ICA in keloids. By implementing these recommendations, uniformity of ICA in keloid treatment will increase and better treatment results may be achieved., (© 2024. The Author(s).)

Background: The efficacy of keloid treatment in randomized studies is highly variable. However, no systematic review has been performed to evaluate the effect of different keloid properties on treatment efficacy., Objective: To identify clinically relevant keloid properties that may influence treatment efficacy., Materials and Methods: An electronic database search was conducted. Two reviewers independently selected randomized controlled trials (RCTs) and performed a methodologic quality assessment using the Cochrane risk-of-bias 2.0 tool., Results: One thousand five hundred twenty studies were screened, and 16 RCTs, involving 1,113 patients, were included. The authors found lower efficacy in older keloids ( n = 3), keloids located on the chest, extremities, pinna, and shoulder ( n = 3), larger keloids ( n = 2), lower baseline Vancouver Scar Scale score ( n = 1), and keloids with history of recurrence ( n = 1). Overall, most studies had a high risk of bias., Conclusion: Only a minority of studies specifically addressed keloid properties, which makes comparisons between studies challenging. The authors' results suggest that keloid location, duration prior to treatment, size, history of recurrence, and severity are clinically relevant keloid properties that affect treatment efficacy. Further studies are crucial to corroborate the authors' findings, establish a clinically relevant keloid classification, and ultimately develop an evidence-based treatment algorithm that takes these properties into account., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Society for Dermatologic Surgery, Inc.)

Intralesional corticosteroid injections are a first-line treatment for keloids; yet clinical treatment results are highly variable and often suboptimal. Variation in triamcinolone acetonide (TAC) biodistribution may be an important reason for the variable effects of TAC treatment in keloids. In this exploratory study we investigated the biodistribution of TAC in keloids and normal skin using different drug delivery techniques. Fluorescent-labeled TAC suspension was administered into keloids and normal skin with a hypodermic needle and an electronic pneumatic jet injector. TAC biodistribution was represented by the fluorescent TAC volume and 3D biodistribution shape of TAC, using a 3D-Fluorescence-Imaging Cryomicrotome System. Twenty-one keloid and nine normal skin samples were analyzed. With needle injections, the mean fluorescent TAC volumes were 990 µl ± 479 in keloids and 872 µl ± 227 in normal skin. With the jet injector, the mean fluorescent TAC volumes were 401 µl ± 252 in keloids and 249 µl ± 67 in normal skin. 3D biodistribution shapes of TAC were highly variable in keloids and normal skin. In conclusion, TAC biodistribution in keloids is highly variable for both needle and jet injection. This may partly explain the variable treatment effects of intralesional TAC in keloids. Future research is needed to confirm this preliminary finding and to optimize drug delivery in keloids., (© 2024. The Author(s).)

Introduction: Traditional on-site missions of plastic surgeons from "high-income countries" in "low- and middle-income countries" are often limited in time and lack proper follow-up. Regular digital collaboration could lead to a more impactful and durable exchange of knowledge for plastic surgeons and residents in both settings., Aims: The aim of this study was to evaluate the satisfaction of the first twelve months of weekly digital meetings, explore advantages/disadvantages, and to provide tools for similar initiatives., Methods: Weekly meetings started from August 2021. An encrypted digital connection allowed residents and plastic surgeons from Uganda and the Netherlands to discuss cases for educational purposes, where treatment options were considered. After twelve months, a survey was sent to participants from both countries to indicate the meetings' strengths, weaknesses, and possible improvements., Results: A total of 18 participants responded to the questionnaire (ten plastic surgeons, six residents, and two researchers). The strengths of the meetings were the accessibility of the meetings, knowledge exchange and practice for residents' final exams. Possible improvements included having a clear format for patient discussion, a session moderator and better internet connectivity. Moreover, a database to assess the impact of the given intervention on the patient cases by evaluating postoperatively (e.g. three months), could further improve clinical care., Conclusions: Virtual patient discussions subjectively contributed to medical education at both locations. Improved digital infrastructure and a collaborative database could further maximize learning capacity. Furthermore, digital proctoring is a promising way to establish sustainable collaborations between high- and low-resource countries., Competing Interests: Declaration of Competing Interest All authors declare that they have no conflicts of interest., (Copyright © 2023 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Background: Intralesional corticosteroid administration (ICA) is a first-line therapy in keloid treatment. However, its clinical results are still highly variable and often suboptimal. Treatment results may strongly be influenced by various ways of ICA., Objective: To explore the prevailing practice of ICA in keloid treatment among dermatologists and plastic surgeons in the Netherlands., Methods: The survey was constructed based on a scoping review on ICA in keloid treatment. Members of the Dutch Society for Plastic surgery and the Dutch Society for Dermatology and Venereology were asked to participate., Results: One hundred and thirty-six responses were obtained. One hundred and thirty (95.6%) participants used triamcinolone acetonide. The majority (54.7%) did not use local anesthesia for pain reduction. Reported corticosteroid dosing that one would inject in one specific keloid differed by a factor of 40. Treatment intervals varied from 1 week to more than 8 weeks. The keloid center was most often injected (46.9%), followed by subepidermal (18.0%)., Conclusions: A wide variety in ICA for keloids is noted among dermatologists and plastic surgeons, even in a limited geographic region and when evidence points toward an optimal way of treatment. Future studies and better implementation of existing evidence may reduce variation in ICA and optimize its treatment results.

Background: Chronic pelvic sepsis mostly originates from complicated pelvic surgery and failed interventions. This is a challenging condition that often requires extensive salvage surgery consisting of complete debridement with source control and filling of the dead space with well-vascularized tissue., Objective: This study aimed to describe the outcomes of gluteal fasciocutaneous flaps for the treatment of secondary pelvic sepsis., Design: Retrospective single-center cohort study., Settings: Tertiary referral center., Patients: Patients who underwent salvage surgery for secondary pelvic sepsis between 2012 and 2020 using a gluteal flap were included in this study., Main Outcome Measures: Percentage of complete wound healing., Results: In total, 27 patients were included, of whom 22 underwent index rectal resection for cancer and 21 had undergone (chemo)radiotherapy. A median of 3 (interquartile range, 1-5) surgical and 1 (interquartile range, 1-4) radiological interventions preceded salvage surgery during a median period of 62 (interquartile range, 20-124) months. Salvage surgery included partial sacrectomy in 20 patients. The gluteal flap consisted of a V-Y flap in 16 patients, superior gluteal artery perforator flap in 8 patients, and a gluteal turnover flap in 3 patients. Median hospital stay was 9 (interquartile range, 6-18) days. During a median follow-up of 18 (interquartile range, 6-34) months, wound complications occurred in 41%, with a reintervention rate of 30%. The median time to wound healing was 69 (interquartile range, 33-154) days, with a complete healing rate of 89% at the end of follow-up., Limitations: Retrospective design and heterogeneous patient population., Conclusions: In patients undergoing major salvage surgery for chronic pelvic sepsis, the use of gluteal fasciocutaneous flaps is a promising solution because of the high success rate, limited risks, and relatively simple technique. See Video Abstract at http://links.lww.com/DCR/C160 ., Reconstruccin Con Colgajo Fasciocutneo Glteo Despus De Una Ciruga De Rescate Por Sepsis Plvica: ANTECEDENTES:La sepsis pélvica crónica esta causada principalmente por cirugías pélvicas complicadas e intervenciones fallidas. Esta es una condición desafiante que a menudo requiere una cirugía de rescate extensa que consiste en un desbridamiento completo controlando el orígen infeccioso y rellenando el espacio muerto con tejido bien vascularizado, como por ejemplo un colgajo de tejido autólogo. La pared abdominal (colgajo de recto abdominal) o la pierna (colgajo de gracilis) se utilizan principalmente como sitios donantes para esta indicación, mientras que los colgajos glúteos pueden ser alternativas atractivas.OBJETIVO:Describir los resultados de los colgajos fasciocutáneos glúteos en el tratamiento de la sepsis pélvica secundaria.DISEÑO:Estudio de cohortes retrospectivo en un solo centro.AJUSTES:Centro de referencia terciario.PACIENTES:Todos aquellos que se sometieron a cirugía de rescate por sepsis pélvica secundaria entre 2012 y 2020 utilizando un colgajo fasciocutáneo glúteo.PRINCIPALES MEDIDAS DE RESULTADO:El porcentaje de cicatrización completa de la herida.RESULTADOS:En total, se incluyeron 27 pacientes, de los cuales 22 fueron sometidos a resección rectal por cáncer indicada y 21 pacientes que habían recibido (quimio)radioterapia. Una mediana de tres (RIC 1-5) intervenciones quirúrgicas y una (RIC 1-4) intervenciones radiológicas precedieron a la cirugía de rescate durante una mediana de 62 (RIC 20-124) meses.La cirugía de rescate incluyó una resección parcial del sacro en 20 pacientes. El colgajo fasciocutáneo glúteo consistió en la confección de un colgajo en V-Y en 16 pacientes, un colgajo incluyendo la perforante de la arteria glútea superior en 8 y un colgajo de rotación de músculo glúteo en 3 pacientes.La mediana de estancia hospitalaria fue de nueve (RIC 6-18) días. Durante una mediana de seguimiento de 18 (IQR 6-34) meses, se produjeron complicaciones de la herida en el 41%, con una tasa de reintervención del 30%.La mediana de tiempo hasta la cicatrización de la herida fue de 69 (IQR 33-154) días con una tasa de cicatrización completa del 89 % al final del seguimiento cicatricial.LIMITACIONES:Diseño retrospectivo y población heterogénea de pacientes.CONCLUSIONES:En pacientes sometidos a cirugía mayor de rescate por sepsis pélvica crónica, el uso de colgajos fasciocutáneos glúteos es una solución prometedora debido a la alta tasa de éxito, los riesgos limitados y la técnica relativamente simple. Video Resumen en http://links.lww.com/DCR/C160 . (Traducción-Dr. Xavier Delgadillo )., (Copyright © The ASCRS 2023.)

Background: Most breast reconstructions are implant-based and can be performed either in a one-stage, direct-to-implant or in a two-stage, expander-implant-based reconstruction. The objective of this systematic review is to compare the safety and patient satisfaction of the two reconstruction approaches., Methods: A literature search was conducted on 27 September 2022 using various databases. Studies comparing one-stage and two-stage implant reconstructions and reporting the following outcomes were included: patient satisfaction, aesthetics, complications, and/or costs. Reviews, case reports, or series with less than 20 patients and letters or comments were excluded. Comparisons were made between the one-stage reconstruction with and without acellular dermal matrix (ADM) and two-stage implant-based breast reconstruction groups. The data extracted from all articles were analysed using random-effects meta-analyses., Results: Of the 1381 records identified, a total of 33 articles were included, representing 21529 patients. There were no significant differences between the one-stage and two-stage groups, except for the costs. The one-stage operation without ADM had lower costs than the two-stage operation without ADM, although the use of an ADM substantially increased the price of the operation to more than a two-stage reconstruction., Discussion: Equal patient satisfaction, aesthetic outcomes, and complication rates with lower costs justify one-stage breast reconstruction in carefully selected patients. This review shows that there is no evidence-based superior surgical approach. Future research should focus on the costs of the ADM versus an additional stage and patient-reported outcomes., Competing Interests: Declaration of Competing Interest There is no conflict of interest declared., (Copyright © 2023 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Background: In shared decision-making (SDM), patients and healthcare professionals (HCPs) reach a joint clinical decision based on the best available evidence and the patient's preferences. SDM seems particularly valuable in plastic surgery, as often multiple treatment options are available. This cross-sectional online survey study aimed to assess HCPs' views and knowledge about SDM, identify facilitators and barriers of SDM, and determine specific requirements for SDM within plastic surgery., Methods: Participants were HCPs working in plastic surgery in the Netherlands. Participant characteristics, SDM knowledge, perceived facilitators and barriers, and requirements were assessed using a custom-made online survey. Two researchers thematically analyzed qualitative data., Results: We received 124 responses (with a response rate of 23%). Most respondents were attending plastic surgeons (79%), and 60% had more than 10 years of experience. Almost all respondents considered SDM important (91%), and most (78%) indicated that they applied SDM during consultations. However, only 15% of the HCPs showed a comprehensive understanding of the principle of SDM. Sufficient time, available sources of information (on treatment options and SDM), and decision support tools were identified as important requirements for SDM., Conclusions: Despite the positive attitudes toward SDM, there is a clear need for SDM training of HCPs, uniform sources of information and guidelines, and improved awareness and availability of decision support tools. National plastic surgery societies can play a crucial role in improving SDM-related knowledge, the availability of information and decision support tools, and the implementation of SDM in the field of plastic surgery., Competing Interests: Declaration of Competing Interest None declared., (Copyright © 2023 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Background: Several therapeutic options are available for the treatment of keloids, but it remains unclear which treatment options are most commonly used by practitioners., Objective: To explore the prevailing treatment for different keloid phenotypes among dermatologists and plastic surgeons in the Netherlands., Methods: Members of the Dutch society for Plastic surgery and the Dutch society for Dermatology and Venereology were asked to participate. Questions elaborated on the treatment for a small and a large keloid on the mandibula and multiple keloids on the chest., Results: One hundred forty-three responses were obtained. Heterogeneity in treatment was extremely high for the small, large, and multiple keloids with 27, 35, and 33 various first choices, respectively. Intralesional corticosteroids were most often chosen for all 3 different keloid phenotypes. These were mostly (61%) administered as monotherapy for the small keloid and mostly combined with other treatments for the large keloid (19%) and multiple keloids (43%). Surgery was chosen regularly (22%) for the large keloid, mostly combined with intralesional corticosteroids (10%) or brachytherapy (8.4%)., Conclusion: Keloid treatment is very heterogeneous among dermatologists and plastic surgeons, even in a relatively small country as the Netherlands. Moreover, the treatment choice depends on the keloid phenotype., (Copyright © 2023 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. All rights reserved.)

To (1) appraise current international classification and clinical management strategies for craniofacial microsomia (CFM) and microtia, and (2) to assess agreement with the European Reference Network "European Guideline Craniofacial Microsomia" recommendations on screening and monitoring., This was a cross-sectional online survey study. The survey consisted of 44 questions on demographics, diagnostics and classification, obstructive sleep apnea, feeding difficulties, speech and language development, hearing, ocular abnormalities, visual development, orthodontic screening, genetic counselling, psychological wellbeing, and extracraniofacial anomalies., Respondents were participants of 3 international cleft and craniofacial conferences, members of the American Cleft Palate and Craniofacial Association and members of the International Society for Auricular Reconstruction. Respondents were requested to complete 1 questionnaire per multidisciplinary team., Fifty-seven responses were received from 30 countries (response rate ∼3%).The International Consortium for Health Outcomes Measurement diagnostic criteria were used by 86% of respondents, though 65% considered isolated microtia a mild form of CFM. The Orbit, Mandible, Ear, Facial Nerve and Soft Tissue classification system was used by 74% of respondents. Agreement with standardized screening and monitoring recommendations was between 61% and 97%. A majority of respondents agreed with screening for extracraniofacial anomalies (63%-68%) and with genetic counselling (81%)., This survey did not reveal consistent agreement on the diagnostic criteria for CFM. Respondents mostly supported management recommendations, but frequently disagreed with the standardization of care. Future studies could focus on working towards international consensus on diagnostic criteria, and exploring internationally feasible management strategies.

Keloid tissues contain inflammatory cells and upregulated pro-inflammatory cytokines. The Janus kinase (JAK)-signal transducer and activator of transcription (STAT) pathway mediate cellular responses to these cytokines. We performed a systematic review on the role of the JAK-STAT pathway in keloid pathogenesis and the evidence for JAK-STAT inhibitors in keloid treatment. The search combined the terms (1) keloid and (2) JAK or TYK or STAT and included MeSH terms and synonyms. Two reviewers screened the articles and assessed the full texts on eligibility. Data were collected on the tested drugs and molecules, the type of cells and tissues used in the experiments, and study findings on the association between the JAK-STAT pathway and keloid cells and tissues. A total of twenty preclinical studies were included. Eleven preclinical studies proved that STAT3 expression and phosphorylation are enhanced in keloid tissue and keloid fibroblasts. Thirteen different JAK and/or STAT inhibitors were investigated. Tested drugs inhibited keloid progression as demonstrated by different processes, including reduced collagen production, cell proliferation and migration, increased cell cycle arrest and apoptosis, enhanced antioxidant responses, decreased (paracrine) signalling, and decreased profibrotic gene expression. No clinical studies have been published to date. Preclinical studies indicate a role for the JAK-STAT pathway in keloid pathogenesis and a potential role for JAK-STAT inhibitors in keloid treatment. The effect of these drugs should be further investigated on relevant biomarkers in a human keloid skin model, preferably including immune cells besides keloid fibroblasts and keratinocytes and in clinical studies., (© 2023 The Authors. Experimental Dermatology published by John Wiley & Sons Ltd.)

Background: Treatment indications of congenital melanocytic naevi (CMN) have shifted from the prevention of malignant transformation more towards the improvement of appearance and psychosocial health. Surgical excision is often preferred, but its safety and effectiveness remain unclear., Objective: To assess the outcomes of surgical excision of medium-to-giant CMN., Primary Outcome: safety (complications)., Secondary Outcome: effectiveness (satisfaction and CMN core outcomes)., Methods: PubMed, EMBASE, and CENTRAL were searched for studies on the excision of medium-to-giant CMN and/or CMN requiring reconstruction or serial excision. Meta-analyses of safety per patient were conducted, and pooled outcomes of safety and effectiveness were presented in summary-of-findings tables., Results: A total of 1444 studies were found, of which 22 were included, evaluating 643 eligible patients. Study quality varied, and reporting of baseline characteristics and outcomes was heterogeneous. Pooled proportions were overall 9.8% for major wound-related complications, 1.2% for minor wound-related complications, 1.2% for scar-related complications, and 4.3% for anatomical deformities. For large/giant CMN, complication rates were, respectively, 23.1%, 2.9%, 12.9%, and 2.4%; and for CMN with eyelid involvement, 0.5%, 3.3%, 0.4%, and 54.2%. Patients rated their satisfaction with the cosmetic outcome as 24.4% excellent, 71.0% good, and 4.6% poor/moderate. Physicians rated this as 18.3% excellent, 70.1% good, and 11.7% poor/moderate. Thirty-five other outcomes of effectiveness were summarized. However, many were rarely reported., Conclusions: Surgical excision of CMN appears to be safe and effective in many cases, depending on CMN size and location. Major wound-related complications and scar-related complications occurred more frequently with large/giant CMN, whereas anatomical deformities occurred with the majority of CMN with eyelid involvement., Competing Interests: Declaration of Competing Interest None., (Copyright © 2022 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Background: Intralesional corticosteroid administration (ICA) is a first-line treatment for keloids. However, its clinical results are still highly variable and often suboptimal. Treatment results may strongly be influenced by various operator-dependent factors. The aim of this study was to map the details of ICA in keloids described in randomized controlled trials (RCTs), hence presenting the scientific practice of a first-line treatment for keloids in the best available evidence., Summary: A systematic search was performed on PubMed, Ovid MEDLINE, Ovid EMBASE, and CENTRAL. Eligible studies were RCTs including patients with keloids treated with intralesional corticosteroids. Treatment and study design-related data were charted on a predefined form. Thirty-eight RCTs were included for data extraction. Triamcinolone acetonide was used in 37 (97.4%) studies. Dosing per cm2 could only be compared among ten (26%) studies and varied from 1 to 20 mg. The maximum dose per session varied from 20 to 80 mg. Local anesthetics were administered in seven (20%) RCTs. Treatment intervals varied from weekly to monthly, with 4 weeks most frequently (50%) used. Needle size was reported in eleven (29%) studies and varied from 26 to 30-gauge. Syringe size was specified in four (11%) studies, being 1 mL. The injection level was described in eleven (29%) studies. Blanching as endpoint was reported in ten (26%) studies. Outcome measures varied widely, from height, surface area, or volume, to Vancouver Scar Scale, Patient and Observer Scar Assessment Scale, pain and itch scores, patient satisfaction, and different efficacy rates. Only six studies had a follow-up of ≥6 months. Recurrence was identified in two studies with 18 weeks and 1 year of follow-up. Adverse events were reported in 23 (61%) studies., (© 2023 The Author(s). Published by S. Karger AG, Basel.)

Background: Surgery is considered to be the best treatment for recurrent hidradenitis suppurativa (HS). Although it is necessary to assess the effect on health-related quality of life (HR-QoL), patient-reported outcome measures (PROMs) are scarce and heterogeneously used in the literature about the surgical treatment of HS., Objective: The aim of this study was to provide a review of the complete literature for different PROMs used in the surgical treatment of HS and to assess their methodological qualities., Methods: A systematic literature search of PubMed, Medline, Cochrane, CINAHL, and Embase with an assessment following the COnsensus-based standards for the Selection of health status Measurement INstrument criteria., Results: The search identified 218 articles, with the inclusion of 6 studies for analysis. Identified PROMs were as follows: the Dermatology Life Quality Index (DLQI), the Derriford Appearance Scale-24 (DAS-24), and the Work Productivity and Activity Impairment (WPAI). These non-disease-specific PROMs seem to have poor results concerning development and content validation., Conclusion: The DLQI, WPAI, and DAS-24 are generic PROMs with poor methodological qualities for PROM development and content validation. Hidradenitis suppurativa-specific instruments are not used in available studies because they have been developed recently and, therefore, partially validated. More research is needed to further investigate methodological qualities of HS-specific instruments., (Copyright © 2022 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Background: A congenital melanocytic naevus (CMN) is a rare skin condition that can be associated with abnormalities of the central nervous system (CNS). These anomalies can sometimes cause severe complications, and rarely death. Adequate information about aetiology and management is therefore crucial. To identify how to monitor patients with CMN, we aimed to estimate the prevalence of neurological involvement in patients with CMN and to summarize what specific neurological signs and symptoms and MRI abnormalities are reported in the medical literature. In addition, we summarized and evaluated the recommendations regarding MRI-screening reported in the medical literature., Methods: This review was registered in PROSPERO and reported according to the MOOSE checklist. A search was conducted in EMBASE (Ovid), PubMed, and the Cochrane Library. We included studies with 10 or more patients with CMN, reporting on neurological signs and symptoms or CNS MRI. Study selection, data extraction and methodological quality assessment were performed by two independent reviewers. A meta-analysis was used to assess the prevalence of neurological signs and symptoms., Results: Out of 1287 studies, fourteen studies were eligible for inclusion of which eight were included in the meta-analysis. Neurological signs and symptoms prevalence was 7.04% (CI 95% 4.47-10.93%) in the meta-analysis group and 6.26% (95% CI 3.85-10%) in a subgroup of patients with a CMN > 6 cm, evaluated in seven studies. Neurodevelopmental delay and seizures were the most frequently reported signs and symptoms. CNS melanocytosis and hydrocephalus were the most frequently reported MRI abnormalities. It was not possible to estimate the increased risk of neurological involvement in patients with CMN due to low quality of evidence and clinical heterogeneity., Conclusion: Standardization in CMN studies and a multi-centre prospective study are needed to evaluate neurological involvement. Based on current literature, it is not possible to make strong recommendations on routine MRI-screening. For now, every clinical centre should decide on its own policy and weigh the advantages and disadvantages of routine MRI., (© 2022. The Author(s).)

Background: Transgender women and transfeminine spectrum nonbinary individuals may opt for breast augmentation. The aim of the study is to analyze the complications, surgical trends, and long-term follow-up of breast augmentations in this population over the past 30 years., Methods: All transgender women and nonbinary individuals who underwent breast augmentation at our center between 01-1990 and 01-2020 were retrospectively identified. A retrospective chart study was conducted, recording individual demographics, implant characteristics, surgical timing, postoperative complications or other reasons requiring reoperation, and implant survival. A literature search was performed in MEDLINE on clinical outcomes and revision surgery of this procedure., Results: A total of 527 individuals were identified. Median clinical follow-up time was 11.2 years (interquartile range 3.3-17.5). Median implant size increased significantly over the last years (1990-1990 median 275cc, 2000-2009 252cc, 2010-2019 375cc, p<0.01). Most individuals underwent breast augmentation and genital gender-affirming surgery in one-stage. Reoperations due to short-term complications were infrequent (hematoma (0.4%) or infection (0.4%)). Reoperations due to long-term complications comprised: implant rupture (5.7%), capsular contracture (4.9%), aesthetic problems (3.8%), low-grade infection (0.4%), or seroma (0.6%). In total, 2.5% of individuals requested larger implants. After performing the literature search and manuscript screening, 9 out of 115 identified studies were included for review. Follow-up time ranged from 30 days to 5.5 years. Reported complications requiring reoperation were capsular contraction (range 0.0-5.6%), asymmetry (3.6%), hematoma (range 0.0-2.9%), infection (range 0.0-0.9%) and implant rupture (0.7%), CONCLUSION: Implant-based breast augmentation is a safe procedure in transgender individuals., Competing Interests: Conflict of Interest None declared., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Background: The treatment of locally advanced or recurrent anorectal cancer requires radical surgery such as extralevator abdominoperineal resection and pelvic exenteration. Larger defects require flap reconstruction. The authors evaluated outcomes of different perineal reconstruction techniques., Methods: A systematic search was performed in the PubMed, Embase, and Cochrane databases. Studies reporting outcomes on perineal flap reconstruction in patients with anal or colorectal cancer were included. Data on patient characteristics, surgical details, perineal and donor-site complications, revision surgery, mortality, and quality of life were extracted. Articles were assessed using the Group Reading Assessment and Diagnostic Evaluation approach., Results: The authors included 58 mainly observational studies comprising 1988 patients. Seventy-three percent of patients had rectal cancer. The majority of 910 abdominoperineal resection patients underwent reconstruction with rectus abdominis flaps (91 percent). Dehiscence (15 to 32 percent) and wound infection (8 to 16 percent) were the most common complications. Partial flap necrosis occurred in 2 to 4 percent and flap loss occurred in 0 to 2 percent. Perineal herniation was seen in 6 percent after gluteal flap reconstruction and in 0 to 1 percent after other types of reconstruction. Donor-site complications were substantial but were reported inconsistently., Conclusions: Clinical outcome data on perineal reconstruction after exenterative surgery are mostly of very low quality. Perineal reconstruction after pelvic exenteration is complex and requires a patient-tailored approach. Primary defect size, reconstruction aims, donor-site availability, and long-term morbidity should be taken into account. This review describes the clinical outcomes of four flap reconstruction techniques. Shared clinical decision-making on perineal reconstruction should be based on these present comprehensive data., (Copyright © 2021 by the American Society of Plastic Surgeons.)

Study Design: Systematic review and meta-analysis., Objectives: To identify, critically appraise, and synthesize research findings on non-sensate versus sensate flaps among individuals with spinal cord disease and pelvic pressure ulcers, with pressure ulcer recurrence as primary outcome., Methods: PubMed, EMBASE, and Cochrane CENTRAL were screened for relevant studies. Data on surgical characteristics, ulcer recurrence, and sensory outcomes were retrieved and tabulated. Risk of bias was assessed with MINORS. The level of evidence was evaluated with GRADE. Meta-analysis was performed when possible., Results: Meta-analysis of 1794 non-sensate locoregional reconstructions indicated a recurrence rate of 34% within several years (95% CI, 27-42). Twenty-one articles provided data on 75 sensate reconstructions, performed in 74 individuals. Meta-analysis of the sensate reconstructions indicated a recurrence rate of 1% (95% CI, 0-8). Sensate reconstructions were not associated with an increase of wound complications (19%; 95% CI, 7-40) compared with non-sensate ones (34%; 95% CI, 27-42). A very low level of evidence was determined with use of GRADE., Conclusion: Although of a very low-level, the present evidence suggests that restoration of sensory innervation may be an effective intervention for the prevention of pressure ulcer recurrence among individuals with spinal cord disease. A prospective RCT is needed to confirm or refute the results of this systematic review.

Background: Pelvic sepsis after surgery for rectal cancer is a severe complication, mostly originating from anastomotic leakage. Complex salvage surgery, during which an omentoplasty is often used for filling of the pelvic cavity, is seldomly required. If this fails, a symptomatic recurrent presacral abscess with a risk of progressive inflammation can develop. Such patients have often undergone multiple surgeries and have disturbed abdominal wall integrity, adhesion formation, and presence of one or two stoma(s). Subsequent salvage surgery via the conventional anterior abdominal approach is therefore less suitable. We describe three cases with a chronic presacral sinus and failure of first salvage surgery. All three patients underwent a prone only approach with tailored sacrectomy. This novel approach provided direct access to the pelvic abscess with optimal exposure for complete and safe debridement. A unilateral or bilateral gluteal V-Y fasciocutaneous advancement flap was created to completely fill the cavity with well vascularized tissue., Case Presentations: Three male patients of 80, 66 and 51 years of age initially underwent low anterior resection with neo-adjuvant radiotherapy for rectal cancer. The first patients underwent intersphincteric resection of the anastomosis with omentoplasty 128 months after index surgery, and second salvage surgery 2 months later. The second patient underwent abdominoperineal resection with omentoplasty for locally recurrent rectal cancer, cystoprostatectomy with revision of the omentoplasty for pelvic sepsis 100 months after index surgery, and second salvage surgery 16 months later. In the third patient, the anastomosis was dismantled with subsequent intersphincteric proctectomy and omentoplasty 20 months after index surgery, and second salvage surgery was performed 93 months later. Second salvage surgery in all three patients was indicated because of symptomatic recurrent pelvic sepsis. Second salvage surgery consisted of sacrectomy, complete debridement of the presacral area, and filling with a gluteal advancement flap. This resulted in favorable postoperative recovery with ultimate healing of the pelvic cavity., Conclusion: The dorsal approach with tailored sacrectomy and gluteal V-Y advancement flap is a valuable option in highly selected patients to treat recurrent pelvic sepsis after multiple prior transabdominal interventions for chronic presacral sinus.

Background: Wide excision (WE) is generally considered to be the most common treatment for recurrent hidradenitis suppurativa. When performed, excision is followed by decisions regarding best options for management of the surgical defect. Different reconstructive strategies (RSs) have been used, with varying rates of recurrence., Objective: To provide an up-to-date systematic review of the complete literature for different RS after WE and their recurrence rates., Methods: A systematic literature search of the complete available literature and a meta-analysis of proportions were performed on the included studies., Results: Of a total of 1,813 retrieved articles, 79 were included in the analysis. Most were retrospective analyses, with only one randomized controlled trial (RCT) and 7 prospective analyses. The RS described were divided into primary closure (PC), secondary intention healing (SIH), skin graft (SG), and fasciocutaneous flaps (FCF). The average estimated recurrence for PC was 22.0% (95% confidence interval [CI], 8.0%-40.0%), for SIH 11.0% (95% CI, 5.0%-20.0%), for SG 2.0% (95% CI, 0.0%-5.0%), and for FCF 2.0% (95% CI, 1.0%-5.0%) (p < .001). Hidradenitis suppurativa below the umbilicus was significantly associated with overall recurrence (p = .006). Quality of evidence was poor, and the reporting of results was mostly heterogeneous., Conclusion: After WE, PC has the highest recurrence rates, whereas SG and FCF have the lowest rates. There is a need for more RCTs and guidelines, to be able to report uniformly on treatment outcomes., (Copyright © 2020 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Background: An appropriate reconstruction strategy after wide excision for severe cases of anogenital hidradenitis suppurativa (aHS) is important to optimize outcomes, but there is no consensus on which reconstruction strategy should be preferred., Objective: Evaluate which reconstruction strategy after wide excision in patients with severe aHS is associated with the best outcomes in terms of recurrence rate, complications and patient-reported outcomes on range of motion, pain, appearance, sexual health and satisfaction., Methods: Multicenter retrospective analysis between 2009 and 2019 of wide excision and reconstruction by primary closure, secondary intention healing, split-thickness skin grafts or fasciocutaneous flaps (FCF). The recurrence rate was the primary endpoint of multivariable logistic regressions to determine variables with an independent effect on recurrence., Results: A total of 93 patients were included. The overall recurrence rate was 62% after a median follow-up of 43 months, without statistical significance between reconstruction strategies (P = 0.737). The number of interventions during follow-up was an independent risk factor for recurrence (odds ratio, 2.55; confidence interval, 1.24-5.25; P = 0.011). Complications (37%) were more severe after FCF (P = 0.007). The mean score regarding patient-reported outcomes was 14.9 ± 2.8, of 24, with best appearance after FCF (P = 0.042)., Conclusions: These long-term follow-up data on severe aHS demonstrate a high recurrence rate after wide excision and reconstruction. Patients should be informed that treatment consists of long-term medicinal and surgical interventions with high recurrence rates, and surgeons may choose their own preferred reconstruction methods. Furthermore, more attention should be paid to the sexual health of patients with aHS., Competing Interests: Conflict of interest and sources of funding: none declared., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Pathological scars can result in functional impairment, disfigurement, a psychological burden, itch, and even chronic pain. We conducted a systematic review to investigate the influence of incisional Negative Pressure Wound Therapy (iNPWT) on scarring. PubMed, EMBASE and CINAHL were searched for preclinical and clinical comparative studies that investigated the influence of iNPWT on scarring-related outcomes. Individual studies were assessed using the OHAT Risk of Bias Rating Tool for Human and Animal studies. The body of evidence was rated using OHAT methodology. Six preclinical studies and nine clinical studies (377 patients) were identified. Preclinical studies suggested that iNPWT reduced lateral tension on incisions, increased wound strength, and reduced scar width upon histological assessment. Two clinical studies reported improved patient-reported scar satisfaction as measured with the PSAS (1 year after surgery), POSAS, and a VAS (both 42, 90, and 180 days after surgery). Five clinical studies reported improved observer-reported scar satisfaction as measured with the VSS, SBSES, OSAS, MSS, VAS, and POSAS (7, 15, 30, 42, 90, 180, and 365 days after surgery). Three clinical studies did not detect significant differences at any point in time (POSAS, VAS, and NRS). Because of imprecision concerns, a moderate level of evidence was identified using OHAT methodology. Preclinical as well as clinical evidence indicates a beneficial influence of iNPWT on scarring. Moderate level evidence indicates that iNPWT decreases scar width and improves patient and observer-reported scar satisfaction., (© 2020 The Authors. Wound Repair and Regeneration published by Wiley Periodicals LLC on behalf of The Wound Healing Society.)

The triquetrum is rarely affected by avascular necrosis compared with other carpal bones. We report a case of avascular necrosis of the triquetrum in a 50-year-old patient, with a history of wrist trauma, local corticosteroid injections, and heavy smoking. She presented with severe wrist pain and signs of cystic changes and avascular necrosis determined by magnetic resonance imaging. She was effectively treated with a proximal row carpectomy. We suspect that the combination of the injury in combination with local corticosteroids and smoking may have led to the necrosis., Competing Interests: Conflict of Interest None declared.

Background: Surgery is considered to be the best treatment for recurrent hidradenitis suppurativa (HS). Varying recurrence rates have been reported in the literature., Objective: To provide an up-to-date systematic review of the complete literature for different excision strategies and their recurrence rates in HS., Methods: A systematic literature search of the complete available literature and a meta-analysis of proportions were performed on the included studies., Results: Of a total of 1,593 retrieved articles, 125 were included in the analysis. Most of these studies were retrospective with 8 prospective analyses and one randomized controlled trial (RCT). The techniques described were divided into partial excision (PE) and wide excision (WE), described in 33 and 97 included studies, respectively. The average estimated recurrences were 26.0% (95% confidence interval [CI], 16.0%-37.0%) for PE and 5.0% (95% CI, 3.0%-9.0%) for WE (p < .01). Female sex (p = .016) and HS caudal of the umbilicus (p = .001) were significantly associated with the overall recurrence rate. Quality of evidence was poor, and the reporting of results was mostly heterogeneous., Conclusion: This systematic review showed higher recurrence rates when it was not intended to resect affected HS tissue with a radical margin. There is a need for more RCT's and uniformly reported treatment outcomes.

Background: Abdominoperineal resection (APR) for rectal cancer is associated with high morbidity of the perineal wound, and controversy exists about the optimal closure technique. Primary perineal wound closure is still the standard of care in the Netherlands. Biological mesh closure did not improve wound healing in our previous randomised controlled trial (BIOPEX-study). It is suggested, based on meta-analysis of cohort studies, that filling of the perineal defect with well-vascularised tissue improves perineal wound healing. A gluteal turnover flap seems to be a promising method for this purpose, and with the advantage of not having a donor site scar. The aim of this study is to investigate whether a gluteal turnover flap improves the uncomplicated perineal wound healing after APR for rectal cancer., Methods: Patients with primary or recurrent rectal cancer who are planned for APR will be considered eligible in this multicentre randomised controlled trial. Exclusion criteria are total exenteration, sacral resection above S4/S5, intersphincteric APR, biological mesh closure of the pelvic floor, collagen disorders, and severe systemic diseases. A total of 160 patients will be randomised between gluteal turnover flap (experimental arm) and primary closure (control arm). The total follow-up duration is 12 months, and outcome assessors and patients will be blinded for type of perineal wound closure. The primary outcome is the percentage of uncomplicated perineal wound healing on day 30, defined as a Southampton wound score of less than two. Secondary outcomes include time to perineal wound closure, incidence of perineal hernia, the number, duration and nature of the complications, re-interventions, quality of life and urogenital function., Discussion: The uncomplicated perineal wound healing rate is expected to increase from 65 to 85% by using the gluteal turnover flap. With proven effectiveness, a quick implementation of this relatively simple surgical technique is expected to take place., Trial Registration: The trial was retrospectively registered at Clinicaltrials.gov NCT04004650 on July 2, 2019.

Objective: The aim of this study was to evaluate the efficacy of iNPWT for the prevention of postoperative wound complications such as SSI., Summary of Background Data: The 2016 WHO recommendation on the use of iNPWT for the prevention of SSI is based on low-level evidence, and many trials have been published since. Preclinical evidence suggests that iNPWT may also prevent wound dehiscence, skin necrosis, seroma, and hematoma., Methods: PubMed, EMBASE, CINAHL, and CENTRAL were searched for randomized and nonrandomized studies that compared iNPWT with control dressings. The evidence was assessed using the Cochrane Risk of Bias Tool, the Newcastle-Ottawa scale, and GRADE. Meta-analyses were performed using random-effects models., Results: High level evidence indicated that iNPWT reduced SSI [28 RCTs, n = 4398, relative risk (RR) 0.61, 95% confidence interval [CI]: 0.49-0.76, P < 0.0001, I = 27%] with a number needed to treat of 19. Low level evidence indicated that iNPWT reduced wound dehiscence (16 RCTs, n = 3058, RR 0.78, 95% CI: 0.64-0.94). Very low-level evidence indicated that iNPWT also reduced skin necrosis (RR 0.49, 95% CI: 0.33-0.74), seroma (RR 0.43, 95% CI: 0.32-0.59), and length of stay (pooled mean difference -2.01, 95% CI: -2.99 to 1.14)., Conclusions: High-level evidence indicates that incisional iNPWT reduces the risk of SSI with limited heterogeneity. Low to very low-level evidence indicates that iNPWT also reduces the risk of wound dehiscence, skin necrosis, and seroma.

Background: Physiologic studies show that tissue perfusion increases during moderate amounts of tissue compression. This is attributed to sensory nerves initiating a vasodilatory cascade referred to as pressure-induced vasodilation., Methods: PubMed, Embase, and the Cochrane Central Register of Controlled Trials were searched for studies investigating perfusion during pressure exposure longer than 10 minutes. Retrieved studies were assessed using the Office of Health Assessment and Translation Risk of Bias Rating Tool for Human and Animal Studies. Results were pooled with random effects models. The body of evidence was rated using the Office of Health Assessment and Translation approach., Results: Twenty-nine articles were included, of which 19 articles were included in meta-analyses. The evidence indicates that moderate amounts of tissue compression have the capacity to increase perfusion in healthy humans by 46 percent (95 percent CI, 30 to 62 percent). Using the Office of Health Assessment and Translation approach, the authors found a high level of confidence in the body of evidence. Pressure-induced vasodilation blockade was associated with increased pressure ulcer formation. Pressure-induced vasodilation was impaired by neuropathy and by the drugs diclofenac and amiloride., Conclusions: This systematic review and meta-analysis indicates that healthy humans have the capacity to increase local perfusion in response to mechanical stress resulting from tissue compression. Because pressure-induced vasodilation is mediated by sensory nerves, pressure-induced vasodilation emphasizes the importance of sensory innervation for durable tissue integrity. Pressure-induced vasodilation impairment seems to provide a complementary explanation for the susceptibility of neuropathic tissues to pressure-induced lesions.

An appropriate reconstruction strategy after wide excision for severe cases of axillary hidradenitis suppurativa (HS) is important to optimize outcomes, but no consensus exists on which reconstruction strategy should be preferred., Objective: Evaluate which reconstruction strategy after wide excision in patients with severe axillary HS is associated with improved outcomes in terms of recurrence rate, complications, post-reconstruction limb function, aesthetics, and patient satisfaction., Methods: Retrospective analysis between 2008 and 2018 of wide excision and reconstruction by primary closure (PC), secondary intention healing (SIH), split thickness skin grafts (STSG), or fasciocutaneous flaps (FCF). The primary endpoint was the rate of recurrence during follow-up., Results: A total of 107 surgical interventions were performed on 54 patients. The overall recurrence rate was 31.8% after a median follow-up of 30 months, with a significant difference between PC (48%), SIH (16%), STSG (29%), and FCF (10%) ( P = 0.03). Surgical complications requiring reoperation occurred in 2% after PC, 0% after SIH, 13% after STSG, and 15% after FCF ( P = 0.11). The median score regarding function, aesthetics, and satisfaction after all interventions was 17 out of 20 points, but the score was lower after FCF than PC, SIH, and STSG ( P = 0.03)., Conclusions: Reconstruction by PC should be reserved for patients with limited HS lesions, whereas FCF was most effective in avoiding recurrence, but was associated with unfavorable short-term results and patient-reported outcomes regarding function and aesthetics. FCF should generally be reserved for patients with recurrent, severe HS comprising an extensive surface of the axillary skin., (Copyright © 2019 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Background: There is increasing interest in the use of acellular dermal matrices (ADMs) in implant-based breast reconstruction (IBBR). Suggested advantages are that ADMs facilitate one-stage IBBR and improve aesthetic outcomes. We compared immediate one-stage ADM-assisted IBBR with two-stage IBBR (current standard of care). Our previously reported secondary endpoint showed that one-stage ADM-assisted IBBR was associated with significantly more adverse outcomes. Here, we present the primary endpoint results aiming to assess whether one-stage IBBR with ADM provides higher patient-reported quality of life (QOL) compared with two-stage IBBR., Methods: This multicentre, open-label, randomised controlled trial (BRIOS study) was done in eight hospitals in the Netherlands. We recruited women aged older than 18 years with breast carcinoma or a genetic predisposition who intended to undergo skin-sparing mastectomy and immediate IBBR. Participants were randomly assigned to undergo one-stage IBBR with ADM (Strattice, LifeCell, Branchburg, NJ, USA) or two-stage IBBR. Randomisation was stratified by centre and indication for surgery (oncological or prophylactic) in blocks of ten participants. The primary endpoint was patient-reported QOL, as measured with the BREAST-Q (ie, health-related QOL scales and satisfaction scales), in the modified intention-to-treat population. The study follow-up is complete. This study is registered with the Netherlands Trial Register, number NTR5446., Findings: Between April 14, 2013, and May 29, 2015, we enrolled 142 women, of whom 69 were randomly assigned to receive one-stage ADM-assisted IBBR and 73 to receive two-stage IBBR. After exclusions, the modified intention-to-treat population comprised 60 patients in the one-stage group and 61 patients in the two-stage group. Of these, 48 women (mean follow-up 17·0 months [SD 7·8]) in the one-stage group and 44 women (17·2 months [SD 6·7]) in the two-stage group completed the BREAST-Q at least 1 year after implant placement. We found no significant differences in postoperative patient-reported QOL domains, including physical wellbeing (one-stage mean 78·0 [SD 14·1] vs two-stage 79·3 [12·2], p=0·60), psychosocial wellbeing (72·6 [17·3] vs 72·8 [19·6], p=0·95), and sexual wellbeing (58·0 [17·0] vs 57·1 [19·5], p=0·82), or in the patient-reported satisfaction domains: satisfaction with breasts (63·4 [15·8] vs 60·3 [15·4], p=0·35) and satisfaction with outcome (72·8 [19·1] vs 67·8 [16·3], p=0·19)., Interpretation: Taken together with our previously published findings, one-stage IBBR with ADM does not yield superior results in terms of patient-reported QOL compared with two-stage IBBR. Risks for adverse outcomes were significantly higher in the one-stage ADM group. Use of ADM for one-stage IBBM should be considered on a case-by-case basis., Funding: Pink Ribbon, Nuts-Ohra, and LifeCell., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Background: Basal cell carcinomas (BCCs) excised leaving positive tumour margins, are at a higher risk of recurrence. Accordingly, complete tumour removal with preservation of healthy tissue, aiming for low recurrence rates, is the main goal in treating BCCs., Objective: The present study aimed to identify the reliability of the Whole Specimen Intraoperative Frozen Section Analysis (WIFSA) technique by comparing intraoperative WIFSA and postoperative Formalin-Fixed Paraffin-Embedded section analysis (FFPE) results in 1082 basal cell carcinomas and by assessing the recurrence rates during a follow-up period up to 10 years., Methods: A single-centre retrospective cohort of all patients with BCC of the face receiving surgical excision with the WIFSA method between January 2007 and December 2013 was evaluated. We compared the intraoperative frozen section results with postoperative FFPE in order to assess accuracy of the WIFSA. Recurrence rates were assessed among all BCCs with a tumour-free margin at final excision that had a minimum follow-up of 6 months., Results: A total of 996 patients with 1082 BCCs were treated with the WIFSA. Overall agreement of WIFSA with conventional postoperative FFPE was 98·8%, sensitivity and specificity being 99·0% and 98·7% respectively. We excluded 23 BCCs that still had positive tumour margins at the end of the procedure and another 67 for the analysis of recurrence rate because follow-up was shorter than 6 months. A total of 992 BCCs with a tumour-free margin at final excision had a mean follow-up of 5·6 years (mean 67 ± 27·7 months (range 6-117 months)). The total recurrence rate was 2·1% (21 out of 992 BCCs). The recurrence rate among the primary tumours was 1·6% (13 out of 828 cases) and 4·9% among the recurring tumours (8 out of 164 cases)., Conclusion: This study indicates that, in patients with primary or recurring BCCs, WIFSA provides a high accuracy for intraoperative specimen analysis and has a low recurrence rate after a mean follow-up of 5·6 years., Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors., (Copyright © 2017 Elsevier Ltd, BASO ~ The Association for Cancer Surgery, and the European Society of Surgical Oncology. All rights reserved.)

The aim of this study is to determine whether the use of a mobile ultra-clean laminar airflow screen reduces the air-borne particle counts in the setting of a simulated procedure of an intra-vitreal injection. A mobile ultra-clean unidirectional airflow (UDF) screen was tested in a simulated procedure for intra-vitreal injections in a treatment room without mechanical ventilation. One UDF was passed over the instrument tray and the surgical area. The concentration of particles was measured in the background, over the instrument table, and next to the ocular area. The degree of protection was calculated at the instrument table and at the surgical site. Use of the UDF mobile screen reduced the mean particle concentration (particles > 0.3 microns) on the instrument table by a factor of at least 100.000 (p < 0.05), and over the patient's eye by at least a factor of 436 (p < 0.05), which in clinical practice translates into significantly reduced air contamination. Mobile UDF screen reduces the mean particle concentration substantially. The mobile UDF screen may therefore allow for a safer procedural environment for ambulatory care procedures such as intra-vitreal injections in treatment rooms.

Objectives/hypothesis: Head and neck cancer (HNC) patients may develop oropharyngeal dysfunction as result of volume loss or muscle atrophy of the tongue or pharyngeal musculature following treatment with surgery and/or chemoradiotherapy. If intensive swallowing therapy offers no further improvement, and the functional problems persist, transplantation of autologous adipose tissue (lipofilling) might restore functional outcomes by compensating the existing tissue defects or tissue loss., Study Design: Case series., Methods: In this prospective pilot feasibility study, the application of lipofilling was studied in seven HNC patients with chronic dysphagia. The procedure was carried out under general anesthesia in several sessions using the Coleman technique. Swallowing outcomes were evaluated with standard videofluoroscopy (VFS) for obtaining objective Penetration Aspiration Scale (PAS) and residue scores. Subjective Functional Oral Intake Scale scores and Swallowing Quality of Life Questionnaire were also completed. Magnetic resonance imaging was used to evaluate the post-treatment injected fat., Results: Five patients completed the intended three lipofilling sessions, whereas two completed two injections. One patient dropped out of the study after two injections because of progressive dysphagia requiring total laryngectomy. Four of the six remaining patients showed improved PAS scores on post-treatment VFS assessments, with two patients no longer showing aspiration for a specific consistency. Two patients were no longer feeding tube dependent. Patient-reported swallowing and oral intake improved in four out of six patients., Conclusions: Based on the results, the lipofilling technique seems safe and, in selected cases, of potential value for improving swallowing function in this small therapy-refractory HNC patient cohort., Level of Evidence: 4 Laryngoscope, 126:2672-2678, 2016., (© 2016 The American Laryngological, Rhinological and Otological Society, Inc.)

Shared decision-making (SDM) invokes the bidirectional communication between physicians and patients required to involve the patient's preference in the eventual treatment choice. This paper will explain what SDM is, why it is important, and how it is performed in clinical practice. It is an essential part of evidence-based medicine, as it helps determine whether the available evidence on the possible benefits and harms of treatment options match the patient's characteristics and preferences. Cosmetic medicine and aesthetic surgery seem to be obvious fields of medicine in which SDM should be applied to achieve high-quality care., (© 2015 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com.)

Objective: The aim of this study was to assess the opinion of obstetric care providers who perform prenatal ultrasounds to screen for anomalies and who advise women about their options, including termination of pregnancy, when an oral cleft is detected. We compared providers' opinions about pregnancy termination for isolated oral cleft in The Netherlands, where the number of terminations is low, and in Israel, where the number is high., Methods: Online questionnaires were used. The questions assessed the providers' views regarding the estimated burden of treatment, the functioning ability, and the level of happiness of children with an oral cleft and their parents. Additionally, we assessed providers' opinions on pregnancy termination for isolated oral cleft., Results: In The Netherlands, more professionals considered oral cleft a disability (rate differences 17.8%, 95% confidence interval: 0.5-33.1%) than in Israel. In the Netherlands, 10.6% of respondents (compared with 11.1% in Israel) thought that an isolated cleft was a reason for terminations of pregnancy (TOP) (rate differences 0.6%, 95% confidence interval: -12% to 10.9%)., Conclusions: Prenatal care providers in The Netherlands and Israel do not differ in their opinions about the severity of oral cleft and the acceptability of TOP for an isolated oral cleft. This study shows that prenatal care providers' attitudes do therefore not explain the dramatic difference between these countries in the number of TOP for isolated oral cleft., (© 2015 John Wiley & Sons, Ltd.)

Gynecomastia is the most common abnormality of the male breast. However, breast cancer may occur, albeit with a significantly lower incidence than in females. Imaging is often used as part of the diagnosis. The aim of this study was to assess the utilization and outcome of imaging with mammography or ultrasound of the male breast in a university hospital's department of radiology. A retrospective study assessing the imaging of the male breast in 557 patients over a 10-year period. Referral was done mainly by general surgeons and general practitioners. The most common indication was enlargement of the breast, described as gynecomastia or swelling in 74% of patients, followed by pain in 24% and "lumps" in 10%. The modalities used were mammography in 65%, ultrasound in 51% and both in 26%. Most examinations, 519, were BI-RADS 1 or 2, and 38 were BI-RADS 3 or higher. Altogether 160 patients had additional fine-needle aspiration or biopsy. Malignancies were diagnosed in five patients (0.89%). Imaging had a sensitivity of 80% and a specificity of 99%. The positive predictive value was 44% and the negative predictive value 99.8%. Malignancies are rare in the male breast. The probability of finding cancer when performing imaging of clinically benign findings in the male breast is negligible. Imaging is not warranted unless there are suspicious abnormalities. Routine imaging of gynecomastia should be discouraged., (© 2015 Wiley Periodicals, Inc.)

Objective: This study aimed to analyze the histopathology results of surgically excised breast specimens with the diagnosis of gynecomastia (GM)., Summary Background Data: Gynecomastia is a term used to describe benign hypertrophy of the breast in men; it is a common, mostly transient, phenomenon in adolescents, but may also be seen in older men. Breast enlargement can lead to psychological problems; if it persists it can be surgically corrected. The obtained breast tissue specimens are routinely submitted for pathological examination. We performed this study to assess the prevalence of pathological findings after surgical management of GM., Methods: Pathology reports were obtained from the nationwide network and registry of histopathology and cytopathology in the Netherlands (PALGA). The reports of 5113 breasts were analyzed for the prevalence of pathologies in different age groups., Results: The average age of the patients was 35.3 ± 18.3 years (range, 1-88 years). The most common finding was GM followed by pseudo-GM. The overall prevalence of invasive carcinomas was 0.11% and of in situ carcinomas was 0.18%. The youngest patient with invasive cancer was 65 years old and the youngest patient with carcinoma in situ was 24 years old. The overall prevalence of atypical ductal hyperplasia was 0.4%; in patients younger than 20 years, it was 0.23%. The youngest patient with atypical ductal hyperplasia was 16 years old. Pathological findings were found more often in unilateral procedures., Conclusions: The prevalence of malignancies in GM resection specimens is low; however, it increases with patient age. Unilateral cases have a statistically nonsignificant higher prevalence of pathologies., Level of Evidence: Prognostic/risk II.

Background: The popularity of cosmetic breast augmentation and the incidence of breast cancer have been increasing worldwide. It has been hypothesized that the risk of breast cancer may be greater among patients who have undergone cosmetic breast implantation., Objectives: The authors performed a meta-analysis of the available literature on the risk of breast cancer among women with cosmetic breast implants., Methods: The study was designed as a meta-analysis of observational studies. A systematic search of the English literature (published by August 28, 2013) was conducted in PubMed and EMBASE. Eligible reports were those that included relative risk (RR; the increased or decreased risk of breast cancer associated with breast implants) or the standardized incidence ratio (SIR) of the observed number of cases of breast cancer to the expected number of cases among patients that previously underwent cosmetic breast augmentation., Results: Seventeen studies representing 7 cohorts were selected. Some of these were follow-up reports of previously published studies; in such cases, only the most recent reports were included in the meta-analysis. Summary SIR and RR rates and the corresponding 95% confidence intervals (CIs) were calculated with a random-effects (SIR) or fixed-effects (RR) model. The overall SIR estimate was 0.69 (95% CI, 0.56-0.85), and the overall RR, based on 4 studies, was 0.63 (95% CI, 0.56-0.71)., Conclusions: Finding of this meta-analysis suggest that women who have undergone cosmetic breast implantation do not have an increased risk of breast cancer., (© 2015 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com.)

Background: Patients who desire reduction mammaplasty (RM) also may seek relief from social and emotional challenges that accompany their physical condition, including low self-confidence and impaired body image. Reduction mammaplasty is known to improve patients' physical and psychological well-being. It may be speculated that patients who undergo RM are motivated by psychological problems and have psychopathologies. Health care insurers reluctant to cover the expense of this surgery may cite mental health as a reason to deny coverage., Objectives: The authors assessed the psychopathological profile of patients who presented for RM, utilizing a validated instrument, and compared scores with standard norm values., Methods: Preoperatively, 67 women were assessed with the Symptom Checklist-90-Revised (SCL-90-R), a validated instrument for evaluating a broad range of psychopathological problems and symptoms. The SCL-90-R provides a general psychoneurosis score, as well as scores for 8 symptom subscales., Results: The mean patient age was 36 ± 11.2 years. The mean (SD) total score on the SCL-90-R was 130 (38.7), which was not significantly higher than the norm score of 123. Only the subscores for somatization and sleep disturbance were significantly higher than the norm scores for these subscales. Compared with the norm score for women who presented with chronic pain, the total score for our study population was significantly lower., Conclusions: Patients who undergo RM have normal scores for psychoneurosis according to the SCL-90-R. Health care insurance coverage for RM should not be denied on the basis that the motivation for surgery relates to psychopathology. Additionally, psychological testing is not recommended for most patients who desire breast reduction surgery; rather, clinical judgment based on common sense should be applied., Level of Evidence: 3., (© 2014 The American Society for Aesthetic Plastic Surgery, Inc.)

Background: After breast augmentation, additional operations are often needed for revision or explantation. Although the surgeon may elect to leave the capsule in situ during these procedures, excised capsule tissue may be examined histopathologically for cancer cells., Objectives: The authors assessed pathologic findings from breast implant capsules submitted for histopathologic examination and evaluated whether it is oncologically safe to leave capsule tissue in situ., Methods: The authors searched PALGA, the nationwide histopathology and cytopathology data network and registry in the Netherlands, for primary capsulectomy specimens excised between 2003 and 2012. The authors applied a sensitive search strategy with low specificity that included female and breast as the sex and anatomic location keywords, and wildcards were used to detect different spellings. Cases were excluded if previous examinations showed compatibility with a history of breast cancer, prophylactic mastectomy, or prophylactic oophorectomy. The pathologic reports were manually reviewed for relevance, and each case's diagnosis was registered. A total of 6803 reports were available, representing 4948 patients; 2574 reports from 2531 patients were included in this study. The median age of patients was 51.2 ± 12.0 years (range, 15-88 years)., Results: Invasive carcinoma was detected in 4 patients (0.16%). Four patients (0.16%) had ductal carcinoma in situ, and 1 patient (0.04%) had lobular carcinoma in situ. Metaplasia was noted in 51 patients (2.0%), calcifications in 375 (14.6%), and silicone in 701 (27.2%)., Conclusions: The incidence of occult invasive or in situ carcinoma in capsulectomy specimens of patients with no previous breast pathology is low. Therefore, it appears oncologically safe to leave capsule tissue in situ., Level of Evidence: 3., (© 2014 The American Society for Aesthetic Plastic Surgery, Inc.)

Background: Extirpation of noninvasive skin tumors of the anterior ear may create large defects. Various flaps, described to cover these defects, demand special knowledge without which a loss of the fine detail of the ear may result., Methods: Healthy, exposed cartilage is deliberately excised leaving a basic framework for support, thus preserving contours and a well-vascularized recipient bed for full-thickness skin grafting. The grafts heal by revascularization and "bridging," a phenomenon whereby grafts on avascular beds (such as denuded cartilage) are revascularized., Results: By marrying clinical experience gained during microtia reconstruction with insights regarding the bridging phenomenon derived from the laboratory, our 17 reconstructed ears healed without serious complications and kept their normal contours and shape, and there was no recurrence of the carcinoma., Conclusion: Satisfactory patient-centered outcome can be obtained in reconstructing defects of one-third to two-thirds of the total anterior surface of the ear relying on the bridging phenomenon., (Copyright © 2013 Wiley Periodicals, Inc.)

Gynaecomastia, breast enlargement in men, is common in all age groups. It is operated on by plastic surgeons, general surgeons and paediatric surgeons. It is therefore possible that there is a difference in the populations treated, the indications for surgery and the management used by the different practitioners. We performed a survey in order to assess the approach to treatment of gynaecomastia by the different disciplines. An electronic survey questionnaire was sent to members of the Dutch societies of surgery, paediatric surgery and plastic surgery. We received 105 responses from plastic surgeons, 95 from general surgeons and 15 from paediatric surgeons, representing respective response rates of 38.7%, 23.8% and 42.8%. Plastic surgeons operated on gynaecomastia most frequently. The diagnostic criteria and workup were similar for all disciplines, although general surgeons used more imaging. There was a difference in the side operated on. General surgeons and paediatric surgeons operated mainly on unilateral cases (74% and 52%), while plastic surgeons operated mainly on bilateral cases (85%). Pharmaceutical treatment with Tamoxifen was reported only by general surgeons (13%). All disciplines used mainly the periareolar incision. Plastic surgeons reported more often the use of other surgical approaches as well as adjunctive liposuction and they did not always submit tissue for pathological examination. Perioperative antibiotics, drains and pressure garments were not always used. All disciplines agreed that the most common complication was bleeding, followed by seroma, infection, insufficient results, inverted nipple and nipple necrosis. This survey highlights some differences in the practice of gynaecomastia surgery. The findings appear to point to the fact that the indications are different, being more aesthetic in the case of plastic surgeons. The results of this survey are important in establishing the standard of care and may be helpful for setting guidelines., (Copyright © 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Hypertrophy in capillary malformation (CM) may be present at birth or manifest itself later in life. To gain insight into the pathology of hypertrophic CM, we investigated a series of 11 excisional biopsies of hypertrophic lips.All biopsies showed dilated thin-walled microvessels in the superficial dermis without a neural component. However, large multinodular conglomerates of thick-walled vessels with a substantial increase in nerve fibers were found in the deeper parts of the lesions. These veins extended deep into the facial musculature. Hypertrophy in CM is caused by venous malformation underlying the CM. So CM associated with hypertrophy should be considered as Capillary Venous malformations.