Deep sternal wound infection after open heart surgery: current treatment insights. A retrospective study of 36 cases

The aim of this study was to retrospectively evaluate the results of reconstructing infected post-sternotomy wounds, with either sternal plating and/or pectoralis major flap transposition or pedicled omentoplasty after previous vacuum-assisted closure (VAC) therapy. Between January 2005 and December 2010, 36 patients, suffering from deep sternal wound infection (DSWI) after coronary artery bypass grafting procedure, received (plastic) reconstructive surgery. All patients, treated in the Maastricht University Medical Centre (Departments of Plastic Surgery and Cardiothoracic Surgery), were selected for this study. For 22 patients, sternal refixation and reconstruction were obtained by sternal internal plate fixation combined with bilateral pectoralis major advancement flap. In 11 patients, a pedicled omentoplasty was performed, with or without split-skin graft and additional VAC therapy. Three patients only received a pectoralis plasty. We evaluated preoperative characteristics and post-operative course. Twenty-four patients (66.7%) had an uneventful post-operative course. Complications in the other patients included wound dehiscence, herniation of the donor site and infection of sternal plating material. Average sternal wound healing after sternal plating plus pectoralis plasty, pectoralis plasty and omentoplasty respectively accounted 7.7, 8.0 and 11.6 weeks. From our experience, we recommend VAC therapy plus delayed sternal plating and additional bilateral pectoralis major flap advancement as first repair option in case of DSWI. However, individual clinical conditions need to be taken into account when making a decision between the different available reconstructive options. Omentoplasty should be reserved for cases in which the sternum has recurrently fallen open after previous sternal plate refixation, or for cases in which the sternum defect is too extended

Perioperative Hyperspectral Imaging to Assess Mastectomy Skin Flap and DIEP Flap Perfusion in Immediate Autologous Breast Reconstruction: A Pilot Study.

Mastectomy skin flap necrosis (MSFN) and partial DIEP (deep inferior epigastric artery perforator) flap loss represent two frequently reported complications in immediate autologous breast reconstruction. These complications could be prevented when areas of insufficient tissue perfusion are detected intraoperatively. Hyperspectral imaging (HSI) is a relatively novel, non-invasive imaging technique, which could be used to objectively assess tissue perfusion through analysis of tissue oxygenation patterns (StO2%), near-infrared (NIR%), tissue hemoglobin (THI%), and tissue water (TWI%) perfusion indices. This prospective clinical pilot study aimed to evaluate the efficacy of HSI for tissue perfusion assessment and to identify a cut-off value for flap necrosis. Ten patients with a mean age of 55.4 years underwent immediate unilateral autologous breast reconstruction. Prior, during and up to 72 h after surgery, a total of 19 hyperspectral images per patient were acquired. MSFN was observed in 3 out of 10 patients. No DIEP flap necrosis was observed. In all MSFN cases, an increased THI% and decreased StO2%, NIR%, and TWI% were observed when compared to the vital group. StO2% was found to be the most sensitive parameter to detect MSFN with a statistically significant lower mean StO2% (51% in the vital group versus 32% in the necrosis group, p < 0.0001) and a cut-off value of 36.29% for flap necrosis. HSI has the potential to accurately assess mastectomy skin flap perfusion and discriminate between vital and necrotic skin flap during the early postoperative period prior to clinical observation. Although the results should be confirmed in future studies, including DIEP flap necrosis specifically, these findings suggest that HSI can aid clinicians in postoperative mastectomy skin flap and DIEP flap monitoring

Substantial chest-wall deformity following tissue expansion after radiotherapy

We present the case of a 54-year-old woman who underwent a two-stage breast reconstruction with a tissue expander after sustaining a lumpectomy and local radiotherapy for breast cancer. During expansion, the woman developed an abnormal concave deformity of the chest wall. Although respiratory or aesthetic consequences were expected, our patient reported only pain and was satisfied with the end result. Osteoporosis or local recurrence was excluded as predisposing factors, and radiotherapy was considered to be the causal factor in our patient. On the basis of this finding, we advise surgeons to take the risk of chest-wall deformity into consideration when planning a reconstruction with tissue expanders, especially in patients with a history of radiotherapy, and we recommend an alternative reconstructive method in this group of patients

Fluid hydration to prevent post-ERCP pancreatitis in average- to high-risk patients receiving prophylactic rectal NSAIDs (FLUYT trial): Study protocol for a randomized controlled trial

Background: Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) is the most common complication of ERCP and may run a severe course. Evidence suggests that vigorous periprocedural hydration can prevent PEP, but studies to date have significant methodological drawbacks. Importantly, evidence for its added value in patients already receiving prophylactic rectal non-steroidal anti-inflammatory drugs (NSAIDs) is lacking and the cost-effectiveness of the approach has not been investigated. We hypothesize that combination therapy of rectal NSAIDs and periprocedural hydration would significantly lower the incidence of post-ERCP pancreatitis compared to rectal NSAIDs alone in moderate- to high-risk patients undergoing ERCP. Methods: The FLUYT trial is a multicenter, parallel group, open label, superiority randomized controlled trial. A total of 826 moderate- to high-risk patients undergoing ERCP that receive prophylactic rectal NSAIDs will be randomized to a control group (no fluids or normal saline with a maximum of 1.5 mL/kg/h and 3 L/24 h) or intervention group (lactated Ringer's solution with 20 mL/kg over 60 min at start of ERCP, followed by 3 mL/kg/h for 8 h thereafter). The primary endpoint is the incidence of post-ERCP pancreatitis. Secondary endpoints include PEP severity, hydration-related complications, and cost-effectiveness. Discussion: The FLUYT trial design, including hydration schedule, fluid type, and sample size, maximize its power of identifying a potential difference in post-ERCP pancreatitis incidence in patients receiving prophylactic rectal NSAIDs

The Influence of Personality on Health Complaints and Quality of Life in Women With Breast Implants

BACKGROUND: A causal relation between systemic symptoms and breast implants is not established. Psychological factors, such as personality and psychological distress, are strongly associated with the development of medically unexplained symptoms. It could be hypothesized that psychological factors may be related to the development of breast implant illness (BII). OBJECTIVES: This study was conducted to evaluate the correlation between self-reported health complaints, health- and breast-related Quality of Life (QoL), and personality, in women with cosmetic breast implants. METHODS: Women who attended the plastic surgery outpatient clinic of Maastricht University Medical Center between October 2020 and October 2021 for reasons related to their implants and women recruited for one of our BII-studies during this period were invited to this study. Only women who underwent cosmetic breast augmentation were eligible. Participants completed a physical complaints score form and BREAST-Q, SF-36, EPQ-RSS questionnaires via an online survey. RESULTS: In total, 201 women completed the questionnaires. Extroversion and social desirability were predominant personality traits in women with breast implants, followed by neuroticism. Relatively high levels of neuroticism were found compared to normative data. Neuroticism correlated significantly with health status and breast-related QoL. Health related QoL had the strongest correlation with neuroticism (β= -3.94, β= -4.86 p <.001). CONCLUSIONS: Personality can play a role in the development of complaints. High levels of neuroticism are seen in cosmetic surgery patients and are negatively correlated with subjective health and patient-reported outcomes in women with breast implants. Therefore, neuroticism may be a factor in the development of BII

'Treating the Saddlebag Deformity in Massive Weight Loss Patients:The Vertical Lower Body Lift versus the Lower Body Lift''

The saddlebag deformity remains a persistent and difficult-to-treat problem following body contouring surgery (BCS). A new way to handle the saddlebag deformity is with the vertical lower body lift (VLBL) as described by Pascal [1]. This retrospective cohort study evaluated the overall reconstruction outcome of the VLBL in 16 patients, respectively 32 saddlebags, and compared it to standard LBL. The BODY-Q as well as the Pittsburgh Rating Scale (PRS)-saddlebag scale were used in the evaluation process.The authors showed that surgical outcomes regarding the saddlebag deformity are in favor of the VLBL technique in patients with marked saddlebag deformity. A decrease of 1.16 in mean PRS-saddlebag score and relative change of 61.67% is observed for the VLBL group, while the LBL group shows only a mean decrease of 0.29 and relative change of 21.6%. BODY-Q endpoint and change in scores did not differ between the VLBL and LBL group at 3 months follow-up and were at one year follow-up in favor of the VLBL group in the body appraisal domain. Patients are greatly satisfied with the contour and appearance of their lateral thigh despite the extra scarring that had to be made by using this novel technique. Therefore, the authors advise clinicians to consider performing a VLBL instead of the standard LBL in massive weight loss patients with a notable saddlebag

Neuroimaging in Breast Implant Illness, an fMRI Pilot Study

BACKGROUND: Some women with breast implants report systemic and cognitive symptoms known as breast implant illness (BII), which are very similar to those of fibromyalgia. Functional MRI has shown altered brain activity in fibromyalgia patients. OBJECTIVES: In this pilot study, we investigated whether brain alterations could be observed in BII patients using fMRI. METHODS: Women aged 18 to 76 with silicone breast implants for cosmetic reasons were recruited through a Dutch online BII support organization (MKS) and through Maastricht University Medical Center. Twelve women with BII and twelve women without symptoms were included. Participants completed questionnaires regarding demographic characteristics, medical history, psychosocial complaints (4DSQ), cognitive failure (MSSE), pain intensity and pain-related disability (CPGS). Subsequently, brain images of all participants were obtained using resting-state fMRI (rs-fMRI) and Diffusion Tensor Imaging (DTI) at a 3 Tesla MRI scanner (Siemens Medical System, Erlangen, Germany). RESULTS: Eleven BII patients and 12 healthy controls were included for analysis. Baseline characteristics were similar in the two groups and the mean silicone exposure was 15 years. Patients scored significantly higher on both pain intensity and disability than controls. Patients scored worse on depression, somatization, distress, and anxiety compared to asymptomatic women. MMSE scores were normal. However, the analyses of both functional connectivity and structural integrity showed no significant differences between the two groups. CONCLUSIONS: This pilot study showed no evidence of brain alterations in BII patients. However, patients scored significantly worse on psychosocial symptoms than controls. Psychological factors appear to play an important role in BII and should be further investigated