Publications by authors named "René R W J van der Hulst"

117 Publications

Neuroimaging in Breast Implant Illness, an fMRI Pilot Study.

Aesthet Surg J 2022 Aug 4. Epub 2022 Aug 4.

Department of Plastic, Reconstructive and Hand Surgery, Maastricht University Medical Center, Maastricht, The Netherlands.

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.
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http://dx.doi.org/10.1093/asj/sjac216DOI Listing
August 2022

Innervation of the Female Breast and Nipple: A Systematic Review and Meta-Analysis of Anatomical Dissection Studies.

Plast Reconstr Surg 2022 08 3;150(2):243-255. Epub 2022 Jun 3.

From the Departments of Plastic, Reconstructive, and Hand Surgery and Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Center; and GROW-School for Oncology and Developmental Biology and Department of Anatomy and Embryology, Maastricht University.

Background: Primary cadaveric studies were reviewed to give a contemporary overview of what is known about innervation of the female breast and nipple/nipple-areola complex.

Methods: The authors performed a Preferred Reporting Items for Systematic Reviews and Meta-Analyses-compliant systematic review and meta-analysis. The authors searched four electronic databases for studies investigating which nerve branches supply the female breast and nipple/nipple-areola complex or describing the trajectory and other anatomical features of these nerves. Inclusion criteria for meta-analysis were at least five studies of known sample size and with numerical observed values. Pooled prevalence estimates of nerve branches supplying the nipple/nipple-areola complex were calculated using random-effects meta-analyses; the remaining results were structured using qualitative synthesis. Risk of bias within individual studies was assessed with the Anatomical Quality Assurance checklist.

Results: Of 3653 studies identified, 19 were eligible for qualitative synthesis and seven for meta-analysis. The breast skin is innervated by anterior cutaneous branches and lateral cutaneous branches of the second through sixth and the nipple/nipple-areola complex primarily by anterior cutaneous branches and lateral cutaneous branches of the third through fifth intercostal nerves. The anterior cutaneous branch and lateral cutaneous branch of the fourth intercostal nerve supply the largest surface area of the breast skin and nipple/nipple-areola complex. The lateral cutaneous branch of the fourth intercostal nerve is the most consistent contributory nerve to the nipple/nipple-areola complex (pooled prevalence, 89.0 percent; 95 percent CI, 0.80 to 0.94).

Conclusions: The anterior cutaneous branch and lateral cutaneous branch of the fourth intercostal nerve are the most important nerves to spare or repair during reconstructive and cosmetic breast surgery. Future studies are required to elicit the course of dominant nerves through the breast tissue.
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http://dx.doi.org/10.1097/PRS.0000000000009306DOI Listing
August 2022

Donor Site Satisfaction Following Autologous Fat Transfer for Total Breast Reconstruction.

Aesthet Surg J 2022 May 17. Epub 2022 May 17.

Department of Plastic, Reconstructive, and Hand Surgery, VieCuri Medical Center, Venlo, the Netherlands.

Background: With evolving breast cancer survival and patient preferences, it is essential that reconstructive surgeons worldwide keep searching for the best reconstruction technique for patients. Autologous fat transfer (AFT) is a relatively new technique for total breast reconstruction that has already proven to be effective and safe with all advantages of autologous tissue. However, little is known about aesthetic results and satisfaction concerning donor sites.

Objectives: The aim of this study was to measure donor site satisfaction following AFT for total breast reconstruction in breast cancer patients.

Methods: Between May and August of 2021, participants of the BREAST- trial who were at least 24 months after their final reconstruction surgery were invited to fill out an additional survey concerning donor sites. The BODY-Q was utilized for data collection. Results of AFT patients were compared to a control group: implant-based reconstruction patients who do not have a donor site.

Results: A total of 51 patients (20 control, 31 intervention) completed the questionnaire. No statistical differences in satisfaction with body were found between these groups. The most frequent complaint was contour irregularities (31 reports, 60.8%) with the least favorable donor site being thighs (23 reports, 53.5%) in the AFT group.

Conclusions: There is no difference in satisfaction with body between breast cancer patients receiving AFT or IBR, meaning that large volume liposuction does not aesthetically affect the utilized donor sites. Nevertheless, reconstructive surgeons should be aware of possible donor site complications, especially contour irregularities at the thighs, and discuss this with their patients.
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http://dx.doi.org/10.1093/asj/sjac125DOI Listing
May 2022

Long-term health status and systemic complaints following implant-based, autologous, or tertiary breast reconstruction.

J Plast Reconstr Aesthet Surg 2022 07 19;75(7):2387-2440. Epub 2022 Apr 19.

Department of Plastic, Reconstructive and Hand Surgery, Maastricht University Medical Center, P. Debyelaan 25, Maastricht 6229 HX, the Netherlands; NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Universiteitssingel 40, Maastricht 6229 ER, the Netherlands.

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http://dx.doi.org/10.1016/j.bjps.2022.04.003DOI Listing
July 2022

Donor site complications and satisfaction in autologous fat grafting for breast reconstruction: A systematic review.

J Plast Reconstr Aesthet Surg 2022 04 25;75(4):1316-1327. Epub 2022 Jan 25.

Department of Plastic-, Reconstructive-, and Hand Surgery, Maastricht University Medical Center+, Maastricht, the Netherlands; Department of Plastic-, Reconstructive-, and Hand Surgery, Viecuri Medical Center, Venlo, the Netherlands.

Background: Breast cancer is the most common cancer in females worldwide. One option for total breast reconstruction following total breast amputation is autologous fat transfer (AFT). However, this is still an upcoming reconstruction technique, and little is known about the donor site complications and their influence on the patient's overall satisfaction.

Objectives: This systematic review aims to review the current literature regarding donor site complications and donor site satisfaction following AFT for total breast reconstruction.

Search Methods: A literature search was performed in PubMed, Web of Science, Embase, Cochrane, TRIP pro, and Prospero. All published original literature reporting on complications or satisfaction at the donor site in patients who underwent liposuction, followed by high-volume lipofilling was considered.

Main Results: This systematic review resulted in the inclusion of 21 cohort studies, consisting of 2241 participants. None of the studies reported donor site satisfaction scores of any kind. The most frequently reported donor site complication was ecchymosis (268 cases), followed by pain (122 cases), haematoma (58 cases), irregularities (12 cases), burns (four cases), and infection (three cases). Reports on follow-up and management of donor site complications were generally lacking.

Author's Conclusions: Results regarding the donor site are inconclusive. Pre-specified complications, a standardized manner of reporting, long-term follow-up, and patient-reported outcome measures are lacking in most of the studies. The impact of the donor site on quality of life after autologous fat grafting in breast reconstruction remains a blind spot. PROSPERO registration number: CRD42020222870.
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http://dx.doi.org/10.1016/j.bjps.2022.01.029DOI Listing
April 2022

Near-Infrared Spectroscopy (NIRS) versus Hyperspectral Imaging (HSI) to Detect Flap Failure in Reconstructive Surgery: A Systematic Review.

Life (Basel) 2022 Jan 3;12(1). Epub 2022 Jan 3.

Department of Plastic, Reconstructive and Hand Surgery, Maastricht University Medical Center, 6229 HX Maastricht, The Netherlands.

Rapid identification of possible vascular compromise in free flap reconstruction to minimize time to reoperation improves achieving free flap salvage. Subjective clinical assessment, often complemented with handheld Doppler, is the golden standard for flap monitoring; but this lacks consistency and may be variable. Non-invasive optical methods such as near-infrared spectroscopy (NIRS) and hyperspectral imaging (HSI) could facilitate objective flap monitoring. A systematic review was conducted to compare NIRS with HSI in detecting vascular compromise in reconstructive flap surgery as compared to standard monitoring. A literature search was performed using PubMed and Embase scientific database in August 2021. Studies were selected by two independent reviewers. Sixteen NIRS and five HSI studies were included. In total, 3662 flap procedures were carried out in 1970 patients using NIRS. Simultaneously; 90 flaps were performed in 90 patients using HSI. HSI and NIRS flap survival were 92.5% (95% CI: 83.3-96.8) and 99.2% (95% CI: 97.8-99.7). Statistically significant differences were observed in flap survival ( = 0.02); flaps returned to OR ( = 0.04); salvage rate ( < 0.01) and partial flap loss rate ( < 0.01). However, no statistically significant difference was observed concerning flaps with vascular crisis ( = 0.39). NIRS and HSI have proven to be reliable; accurate and user-friendly monitoring methods. However, based on the currently available literature, no firm conclusions can be drawn concerning non-invasive monitoring technique superiority.
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http://dx.doi.org/10.3390/life12010065DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8778121PMC
January 2022

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

Diagnostics (Basel) 2022 Jan 13;12(1). Epub 2022 Jan 13.

Department of Plastic, Reconstructive and Hand Surgery, Maastricht University Medical Center, 6200 MD Maastricht, The Netherlands.

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 (StO%), 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 StO%, NIR%, and TWI% were observed when compared to the vital group. StO% was found to be the most sensitive parameter to detect MSFN with a statistically significant lower mean StO% (51% in the vital group versus 32% in the necrosis group, < 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.
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http://dx.doi.org/10.3390/diagnostics12010184DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8774932PMC
January 2022

Patient-Reported Outcome Measures Used for Assessing Breast Sensation after Mastectomy: Not Fit for Purpose.

Patient 2022 07 18;15(4):435-444. Epub 2022 Jan 18.

Department of Plastic, Reconstructive and Hand Surgery, GROW, School for Oncology and Developmental Biology, Maastricht University Medical Center, P.O. Box 5800, 6202 AZ, Maastricht, The Netherlands.

Aims: The aims of this review were (i) to evaluate whether patient-reported outcome measures used in clinical studies for assessing sensation after mastectomy and breast reconstruction are suitable for this purpose, and (ii) to explore whether any measures used for assessing sensation after non-oncologic breast surgery are worth modifying for use in post-mastectomy patients.

Methods: PRISMA guidelines were followed (PROSPERO number CRD42020178066). We searched six databases for studies of oncologic (i.e., therapeutic, prophylactic, and reconstructive) and non-oncologic breast surgery (e.g., breast reduction) in which sensation was assessed with a patient-reported outcome measure. From the selected studies, we extracted eligible measures, evaluated their fitness for purpose, and summarized the content of sensation-specific items.

Results: Of 6728 articles identified, we selected 135 studies that used 124 eligible patient-reported outcome measures. For 97% of these measures, details regarding development and measurement properties were unavailable. Four (3%) validated measures-the Sensory Disturbances subscale of the Breast Cancer Sequelae Cause Scales, the Discomfort subscale of the Breast Sensation Assessment Scale (BSAS), Didier et al.'s questionnaire for "Assessment of the patients' satisfaction with cosmetic results, physical and emotional impact of mastectomy", and the Breast Specific Pain subscale of the Breast Cancer Treatment Outcomes Scale (BCTOS)-each contain at least one item pertaining to breast sensation, but target different concepts of interest. In total, the measures feature 215 sensation-specific items, most of which concern symptom severity (97%) as opposed to impact on daily functioning (3%).

Conclusion: Patient-reported outcome measures used in clinical studies for assessing sensation after mastectomy and breast reconstruction are unsuitable for this purpose: they are either non-validated or non-specific. We failed to identify any measures for use in non-oncologic breast surgery populations worth modifying. To collect meaningful, patient-relevant data regarding sensation after mastectomy, it is pertinent that future clinical trials adopt psychometrically robust, specific patient-reported outcome measures.
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http://dx.doi.org/10.1007/s40271-021-00565-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9197899PMC
July 2022

One-Year Outcomes of the First Human Trial on Robot-Assisted Lymphaticovenous Anastomosis for Breast Cancer-Related Lymphedema.

Plast Reconstr Surg 2022 Jan;149(1):151-161

From the Departments of Plastic, Reconstructive, and Hand Surgery and Methodology and Statistics, Maastricht University Medical Center; and Department of Medical Robotic Technologies, Eindhoven University of Technology.

Background: Lymphaticovenous anastomosis, a supermicrosurgical technique, creates bypasses between the lymphatic and venous systems. The quality of lymphaticovenous anastomosis depends on the surgeon's dexterity and precision, and is subject to imperfections caused by the physiologic tremor of the human hand. A dedicated robot for microsurgery has been created to overcome these limitations (MUSA, MicroSure, Eindhoven, The Netherlands). This study describes 1-year clinical outcomes of the first-in-human trial of robot-assisted and manual lymphaticovenous anastomosis in patients with breast cancer-related lymphedema.

Methods: In this prospective pilot study, women with breast cancer-related lymphedema were randomized into the robot-assisted or manual lymphaticovenous anastomosis group. Outcomes were quality of life, arm circumference, conservative treatment frequency, arm dermal backflow stage, and anastomosis patency.

Results: Twenty women were included, of whom eight underwent robot-assisted lymphaticovenous anastomosis surgery and 12 underwent manual surgery. In both groups, quality of life significantly improved at 12 months (robot-assisted surgery, p = 0.045; manual surgery, p = 0.001). Arm circumference did not decrease (robot-assisted surgery, p = 0.094; manual surgery, p = 0.240). Daily use of compression garments decreased by 61.9 percent (robot-assisted surgery) and 70.2 percent (manual surgery). The frequency of manual lymphatic drainage remained similar compared with baseline. Arm dermal backflow stage was reduced in one patient in the robot-assisted group and in five cases in the manual group. Overall, 76.5 percent of the anastomoses were patent (robot-assisted surgery, 66.6 percent; manual surgery, 81.8 percent).

Conclusions: After evaluating 1-year follow-up data, this study confirms the feasibility of robot-assisted lymphaticovenous anastomosis surgery. Clinical outcomes were comparable between robot-assisted and manual lymphaticovenous anastomosis. This encourages further research using the new microsurgical robot MUSA for lymphaticovenous anastomosis and other (super)microsurgical procedures.

Clinical Question/level Of Evidence: Therapeutic, II.
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http://dx.doi.org/10.1097/PRS.0000000000008670DOI Listing
January 2022

Nasal skin reconstruction: Time to rethink the reconstructive ladder?

J Plast Reconstr Aesthet Surg 2022 03 14;75(3):1239-1245. Epub 2021 Nov 14.

Dermatology Division, Memorial Sloan Kettering Cancer Center, New York, NY, USA. Electronic address:

Background: Nasal scarring can compromise aesthetics and function given its complex three-dimensional structure and central location. This study aimed to measure patients' satisfaction after reconstruction for nasal defects following Mohs micrographic surgery.

Methods: Patients presenting with nasal nonmelanoma skin cancer at Memorial Sloan Kettering Cancer Center New York, USA and Catharina Hospital Eindhoven, Netherlands from April 2017 to November 2019 were asked to participate. Reconstruction type, complications, and patients satisfaction were assessed. Patients completed the FACE-Q Skin Cancer - Satisfaction with Facial Appearance scale (preoperative and 1-year postoperative) and the Appraisal of Scars scale (1-year postoperative).

Results: A total of 128 patients completed the preand postoperative scales. There were 35 (27%) surgical defects repaired with primary closures, 71 (55.5%) with flaps, and 22 (17.2%) with full-thickness skin grafts (FTSG). Patients that underwent a flap or FTSG reconstruction had higher scar satisfaction scores than primary closures (p = 0.03). A trend was seen with patients following flap reconstructions scoring 7.8 points higher than primary closures and patients with upper nose defects scoring 6.4 points higher than lower nose defects. Males were significantly more satisfied than females. No significant difference was observed in the preoperative and postoperative facial appearance scores between the three groups (p = 0.39).

Conclusion: Patients are more satisfied in the long term with their scars after flap reconstructions compared to primary closures. Therefore, nasal skin reconstruction may not follow the traditional reconstructive ladder and more complex approaches may lead to higher long-term scar satisfaction.
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http://dx.doi.org/10.1016/j.bjps.2021.11.028DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8976754PMC
March 2022

BREAST trial study protocol: evaluation of a non-invasive technique for breast reconstruction in a multicentre, randomised controlled trial.

BMJ Open 2021 09 16;11(9):e051413. Epub 2021 Sep 16.

Plastic, Reconstructive, and Hand Surgery, Maastricht University Medical Centre+, Maastricht, The Netherlands.

Introduction: Pioneers have shown that it is possible to reconstruct a full breast using just autologous fat harvested by liposuction or autologous fat transfer (AFT). This study describes the first multicentre randomised study protocol to thoroughly investigate the effectiveness of AFT to reconstruct full breasts following mastectomy procedures (primarily and delayed).

Methods And Analysis: This study is designed as a multicentre, randomised controlled clinical superiority trial with a 1:1 allocation ratio. A total of 196 patients (98 patients per treatment arm) are aimed to be included. Patients who wish to undergo breast reconstruction with either one of the two techniques are randomly allocated into the AFT group (intervention) or the tissue-expander/prosthesis group (control). The primary outcome measure for the quality of life is measured by the validated BREAST-Q questionnaire.

Ethics And Dissemination: Approval for this study was obtained from the medical ethics committee of Maastricht University Medical Centre/Maastricht University; the trial has been registered at ClinicalTrials.gov. The results of this randomised controlled trial will be presented at scientific meetings as abstracts for poster or oral presentations and published in peer-reviewed journals.

Trial Status: Enrolment into the trial has started in October 2015. Data collection and data analysis are expected to be completed in December 2021.

Trial Registration Number: NCT02339779.
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http://dx.doi.org/10.1136/bmjopen-2021-051413DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8449986PMC
September 2021

Cancer worry after facial nonmelanoma skin cancer resection and reconstruction: A 1-year prospective study.

Psychooncology 2022 02 14;31(2):238-244. Epub 2021 Sep 14.

Department of Plastic and Reconstructive Surgery, Catharina Hospital, Eindhoven, The Netherlands.

Objective: Nonmelanoma skin cancer (NMSC) is one of the most diagnosed cancers in the world, with the number of new occurrences rising every year. Most patients with facial skin cancer experience cancer-related worry. Yet, little is known about their worry during the period after cancer treatment. This study aimed to assess the long-term change of cancer worry after surgical treatment in patients with NMSC.

Methods: Patients undergoing surgery for facial NMSC between December 2017 and March 2020 were asked to complete the FACE-Q Skin Cancer-Cancer Worry scale before (baseline), 3-month, and 1-year post-surgery.

Results: A total of 151 patients completed the baseline and 3-month, and 99 (65.6%) the 1-year post-operative survey. A significant decrease in cancer worry score was seen between baseline and 3-month post-surgery (p < 0.001). No difference was found between the 3-month and 1-year post-surgery scores (p = 0.78). Less improvement in cancer worry was seen for patients who had one facial skin cancer in their medical history (p = 0.001) and patients who had a history of facial surgery (p < 0.001).

Conclusion: Post-surgery patients still experience cancer worry. Therefore, targeted counseling might be of value when coping with cancer-related concerns. Patients with a history of facial NMSC and patients with a history of facial surgery might benefit from additional counseling.
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http://dx.doi.org/10.1002/pon.5810DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9255639PMC
February 2022

Visualization of Both the Superficial and Deep Lymphatic System of the Upper Extremity Using Magnetic Resonance Lymphography.

Lymphat Res Biol 2022 06 2;20(3):275-281. Epub 2021 Sep 2.

Department of Plastic, Reconstructive and Hand Surgery, Maastricht University Medical Center, Maastricht, The Netherlands.

The lymphatic system consists of the superficial and deep lymphatic system. Several diagnostic methods are used to assess the lymphatic system. Lymphoscintigraphy and indocyanine green lymphography are widely applied, both showing disadvantages, such as a poor resolution and lack of field of view. Magnetic resonance lymphography (MRL) shows satisfactory temporal and spatial resolution. The aim of this study was to assess both the superficial and deep lymphatic system in the upper extremity of healthy subjects, using an MRL protocol. Ten healthy volunteers underwent an MRL examination, using a three Tesla MRI unit. Water-soluble gadolinium was used as a contrast agent. MRL images were evaluated by an experienced radiologist on image quality, enhancement of veins and lymphatic vessels, and characteristics of the latter. Overall image quality was good to excellent. In all subjects, veins and lymphatic vessels could be distinguished. Superficial and deep lymphatic vessels were seen in 9 out of 10 subjects. Lymphatic vessels with a diameter between 0.9 and 4.3 mm were measured. Both veins and lymphatic vessels showed their characteristic appearance. Enhancement of veins was seen directly after contrast agent injection, which decreased over time. Lymphatic vessel enhancement slowly increased over time. Mean total MRL examination (room) time was 110 minutes (81 minutes scan time). The MRL protocol accurately visualizes both deep and superficial lymphatic vessels showing their characteristic appearances with high spatial resolution, indicating the MRL can be of value in diagnosing and staging peripheral lymphedema.
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http://dx.doi.org/10.1089/lrb.2021.0012DOI Listing
June 2022

Applying Computerized Adaptive Testing to the FACE-Q Skin Cancer Module: Individualizing Patient-Reported Outcome Measures in Facial Surgery.

Plast Reconstr Surg 2021 Oct;148(4):863-869

From the Patient-Reported Outcomes, Value & Experience Center, Department of Surgery, Brigham and Women's Hospital; Department of Surgery, Harvard Medical School; Department of Pediatrics, McMaster University; Department of Plastic and Reconstructive Surgery, Catharina Ziekenhuis; John Radcliffe Hospital, University of Oxford Medical Sciences Office; Dermatology Division, Memorial Sloan Kettering Cancer Center; and Department of Plastic and Reconstructive Surgery, Maastricht University Medical Center.

Background: Skin cancer is among the most frequently occurring malignancies worldwide, which creates a great need for an effective patient-reported outcome measure. Providing shorter questionnaires reduces patient burden and increases patients' willingness to complete forms. The authors set out to use computerized adaptive testing to reduce the number of items needed to predict results for scales of the FACE-Q Skin Cancer Module, a validated patient-reported outcome measure that measures health-related quality of life and patient satisfaction in facial surgery.

Methods: Computerized adaptive testing generates tailored questionnaires for patients in real time based on their responses to previous questions. The authors used an open-source computerized adaptive testing simulation software to run item responses for the five scales from the FACE-Q Skin Cancer Module (i.e., scar appraisal, satisfaction with facial appearance, appearance-related psychosocial distress, cancer worry, and satisfaction with information about appearance). Each simulation continued to administer items until prespecified levels of precision were met, estimated by standard error. Mean and maximum item reductions between the original fixed-length short forms and the simulated versions were evaluated.

Results: The number of questions that patients needed to answer to complete the FACE-Q Skin Oncology Module was reduced from 41 items in the original form to a mean of 23 ± 0.55 items (range, 15 to 29) using the computerized adaptive testing version. Simulated computerized adaptive testing scores maintained a high correlation (0.98 to 0.99) with the score from the fixed-length short forms.

Conclusions: Applying computerized adaptive testing to the FACE-Q Skin Cancer Module can reduce the length of assessment by more than 50 percent, with virtually no loss in precision. It is likely to play a critical role in the implementation in clinical practice.
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http://dx.doi.org/10.1097/PRS.0000000000008326DOI Listing
October 2021

Nerve Coaptation Improves the Sensory Recovery of the Breast in DIEP Flap Breast Reconstruction.

Plast Reconstr Surg 2021 Aug;148(2):273-284

From the Department of Plastic, Reconstructive, and Hand Surgery, GROW-School for Oncology and Developmental Biology, and the Department of Surgery, Maastricht University Medical Center; and the Department of Anatomy and Embryology, Maastricht University.

Background: Restoring the sensation of the reconstructed breast has increasingly become a goal of autologous breast reconstruction. The aim of this study was to analyze the sensory recovery of the breast and donor site of innervated compared to noninnervated deep inferior epigastric perforator (DIEP) flap breast reconstructions, to assess associated factors, and to compare the differences between preoperative and postoperative sensation.

Methods: A prospective cohort study was conducted, including patients who underwent innervated or noninnervated DIEP flap breast reconstruction between August of 2016 and August of 2018. Nerve coaptation was performed to the anterior cutaneous branch of the third intercostal nerve. Preoperative and postoperative sensory testing of the breast and donor site was performed with Semmes-Weinstein monofilaments.

Results: A total of 67 patients with 94 innervated DIEP flaps and 58 patients with 80 noninnervated DIEP flaps were included. Nerve coaptation was significantly associated with lower mean monofilament values for the breast (-0.48; p < 0.001), whereas no significant differences were found for the donor site (-0.16; p = 0.161) of innervated compared to noninnervated DIEP flaps. Factors positively or negatively associated with sensory recovery of the breast and donor site were identified. Preoperative versus postoperative comparison demonstrated significantly superior sensory recovery of the breast in innervated flaps (adjusted difference, -0.48; p = 0.017).

Conclusions: This study demonstrated that nerve coaptation in DIEP flap breast reconstruction significantly improved the sensory recovery of the breast compared to noninnervated flaps. The sensory recovery of the donor site was not compromised in innervated reconstructions. The results support the role of nerve coaptation in autologous breast reconstruction.

Clinical Question/level Of Evidence: Therapeutic, II.
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http://dx.doi.org/10.1097/PRS.0000000000008160DOI Listing
August 2021

Reply: "Nonsurgical Correction of Congenital Ear Anomalies: A Review of the Literature".

Plast Reconstr Surg Glob Open 2021 Jun 15;9(6):e3562. Epub 2021 Jun 15.

Department of Plastic Surgery, Maastricht University Medical Center, Maastricht, the Netherlands.

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http://dx.doi.org/10.1097/GOX.0000000000003562DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8205219PMC
June 2021

Facial Scars Due to Prone Position Pressure Ulcers: Underestimated Sequelae in COVID-19 Survivors?

Aesthet Surg J 2021 Oct;41(11):NP1812-NP1813

Department of Plastic, Reconstructive and Hand Surgery, Maastricht University Medical Center, Maastricht, the Netherlands.

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http://dx.doi.org/10.1093/asj/sjab251DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8344651PMC
October 2021

Influence of intraoperative vasopressor use on indocyanine green fluorescence angiography: first evaluation in an experimental model.

Sci Rep 2021 05 6;11(1):9650. Epub 2021 May 6.

IRCAD, Research Institute Against Digestive Cancer, 1, Place de l'Hôpital, 67000, Strasbourg, France.

Intraoperative indocyanine green (ICG) fluorescence angiography has gained popularity and acceptance in many surgical fields for the real-time assessment of tissue perfusion. Although vasopressors have the potential to preclude an accurate assessment of tissue perfusion, there is a lack of literature with regards to its effect on ICG fluorescence angiography. An experimental porcine model was used to expose the small bowel for quantitative tissue perfusion assessment. Three increasing doses of norepinephrine infusion (0.1, 0.5, and 1.0 µg/kg/min) were administered intravenously over a 25-min interval. Time-to-peak fluorescence intensity (TTP) was the primary outcome. Secondary outcomes included absolute fluorescence intensity and local capillary lactate (LCL) levels. Five large pigs (mean weight: 40.3 ± 4.24 kg) were included. There was no significant difference in mean TTP (in seconds) at baseline (4.23) as compared to the second (3.90), third (4.41), fourth (4.60), and fifth ICG assessment (5.99). As a result of ICG accumulation, the mean and the maximum absolute fluorescence intensity were significantly different as compared to the baseline assessment. There was no significant difference in LCL levels (in mmol/L) at baseline (0.74) as compared to the second (0.82), third (0.64), fourth (0.60), and fifth assessment (0.62). Increasing doses of norepinephrine infusion have no significant influence on bowel perfusion using ICG fluorescence angiography.
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http://dx.doi.org/10.1038/s41598-021-89223-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8102475PMC
May 2021

Correction to: Deriving an overall appearance domain score by applying bifactor IRT analysis to the BODY‑Q appearance scales.

Qual Life Res 2021 May;30(5):1523-1524

Patient‑Reported Outcomes, Value & Experience (PROVE) Center, Department of Surgery, Brigham and Women's Hospital, 75 Francis St, Boston, MA, 02115, USA.

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http://dx.doi.org/10.1007/s11136-020-02735-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8068694PMC
May 2021

Subjective Cognitive Functioning in Silicone Breast Implant Patients: A Cohort Study.

Plast Reconstr Surg Glob Open 2021 Feb 17;9(2):e3394. Epub 2021 Feb 17.

Department of Plastic, Reconstructive and Hand Surgery, Maastricht University Medical Center, Maastricht, The Netherlands.

Cognitive impairment is frequently reported by silicone breast implant (SBI) patients. The aim of our study is to investigate whether subjective cognitive failure indeed is more frequent in a cohort of SBI patients compared with healthy controls (HCs). Furthermore, the severity of this cognitive failure and a possible relation to other symptoms as well as the duration of SBI exposure was examined. In addition, we assessed the effect of ruptures and reinterventions on cognitive failure severity.

Methods: A cohort study was performed, including 376 women and consisting of 3 different groups of patients; 143 SBI patients (group 1), 94 age- and sex-matched HC patients (group 2), and 139 women with SBI and health issues who registered themselves at a Dutch foundation for women with illness due to SBI (group 3). All patients filled in the Cognitive Failure Questionnaire (CFQ). The American College of Rheumatology Fibromyalgia Diagnostic Criteria (2010) were used to score other symptoms.

Results: Completed CFQ data from 222 patients were available for analysis: n = 79 for group 1, n = 62 for group 2, and n = 81 for group 3. SBI patients from group 3 had a significantly higher prevalence of subjective cognitive dysfunction (CFQ score ≥ 43) compared with SBI patients from group 1 and HC (60.5% versus 13.9% and 12.9%; = 0.000). Linear regression showed a statistically significant relation between subjective cognitive functioning scores and other symptoms ( = 0.000). Implant duration as well as rupture rate and reinterventions were not found to significantly influence CFQ scores.

Conclusion: An increased risk of cognitive failure in consecutive SBI patients when compared with HCs could not be found.
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http://dx.doi.org/10.1097/GOX.0000000000003394DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7929599PMC
February 2021

A Systematic Review and Overview of Flap Reconstructive Techniques for Nasal Skin Defects.

Facial Plast Surg Aesthet Med 2021 12 1;23(6):476-481. Epub 2021 Mar 1.

Dermatology Division, Memorial Sloan Kettering Cancer Center, New York, New York, USA.

Reconstruction of nasal skin defects can be challenging due to limited skin laxity and underlying cartilage and, therefore, often require a complex repair. The aim of this review is to systematically analyze the literature on nasal skin reconstructions with specific detail to flap reconstructions. A systematic literature review of nasal skin reconstruction was performed and focused on flap reconstructions. Flap reconstructions were stratified based on defect size, nasal subunit, and reconstruction type. Complication rates (CRs) and patient outcomes were also assessed. A total of 176 articles (11,370 patients) met the inclusion criteria. Of these, 59 articles showed various flap techniques. For defects ≤1.5 cm, every subunit had four to six options except the alar rim, which showed one option. Rotation-advancement flaps were mostly used for the nasal tip and sidewall, whereas bilobed flaps were used more for the ala and dorsum. Defects >1.5 cm were most commonly reconstructed with the forehead flap. The mean CR of flap reconstructions was 13.8%. Only 8 of the 176 articles (4.5%) reported patient satisfaction using a standardized questionnaire. This review shows various flap reconstruction options with their corresponding CR that will help guide the surgeon in choosing reconstructive options for different nasal skin defects.
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http://dx.doi.org/10.1089/fpsam.2020.0533DOI Listing
December 2021

Lymph Flow Before and After Lymphaticovenous Anastomosis Measured Using Transonic Transit-Time Ultrasound Microvascular Flowprobe.

Lymphat Res Biol 2021 12 9;19(6):539-544. Epub 2021 Feb 9.

Department of Plastic, Reconstructive and Hand Surgery, Maastricht University Medical Center, Maastricht, The Netherlands.

Assessment of lymph flow has proven challenging. Transit-time ultrasound technique (TTUT) is the first technique that provides real-time quantitative lymphatic flow values. In cardiothoracic surgery and neurosurgery, this technique has tremendous clinical value in assessing surgery quality and predicting outcomes. The objective of this study was to measure lymph flow before and after lymphaticovenous anastomosis (LVA), using TTUT. Consecutive patients with peripheral lymphedema undergoing LVA were included. Preoperative workup was performed using indocyanine green (ICG) lymphangiography. Perioperatively, the Transonic Microvascular Flowprobe was used to measure lymph flow before and after anastomosis. Twenty-five patients with International Society of Lymphology stage IIA (68%) and stage IIB (32%) peripheral lymphedema were included. Lymph flow velocities ranged from 0.02 to 0.80 mL/min (mean 0.25 ± 0.19) before anastomosis and from 0.02 to 0.86 mL/min (mean 0.27 ± 0.22) after anastomosis ( = 0.340). Mean flow values were significantly higher in the upper extremities compared with the lower extremities. Furthermore, there was a decrease in flow in patients with ICG stage IV in comparison with ICG stage III. Clinical outcomes could not be directly correlated with flow values in these individual cases. TTUT micro-flowprobe is a suitable instrument to measure real-time quantitative lymphatic flow in both lymphatics and LVA. It can confirm patency of lymphatic collectors and LVA peroperatively. Significantly higher lymph flow velocities were found in upper extremities in comparison with lower extremities, both before and after LVA. Further studies should be performed to evaluate lymph flow values and clinical correlation.
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http://dx.doi.org/10.1089/lrb.2019.0088DOI Listing
December 2021

To see or not to see: Impact of viewing facial skin cancer defects prior to reconstruction.

Arch Dermatol Res 2021 Dec 30;313(10):847-853. Epub 2021 Jan 30.

Department of Plastic and Reconstructive Surgery, Catharina Hospital, Michelangelolaan 2, 5623EJ, Eindhoven, The Netherlands.

Patient expectations of the scar after Mohs micrographic surgery (MMS) are often not realistic, leading to subsequent psychosocial sequelae such as anxiety, depression, and avoidance of social situations. When patient expectations are not met, this may also contribute to a decrease in patient satisfaction after surgery. Therefore, altering expectation levels may change patient satisfaction and psychosocial distress levels after surgery. To assess whether patient satisfaction improves in patients after MMS when patients view the surgical defect prior to reconstruction. Patients undergoing facial MMS between December 2017 and September 2019 were included. Patients received or did not receive a mirror after MMS to view the surgical defect before closing the defect. Patients were asked to complete the Dutch FACE-Q Skin Cancer before, one-week, three-months, and one-year after MMS. A total of 113 patients where included. One-hundred-eight (95.6%), 113 (100%), and 93 (82.3%) questionnaires were completed, one-week, three-months, and one-year follow-up, respectively. Satisfaction with facial appearance and appraisal of scars significantly improved over time for all patients, no such improvement was seen for appearance-related distress. Female patients who looked in the mirror had higher satisfaction with facial appearance than female patients who did not look in the mirror. Also, lower appearance-related distress scores were seen in patients who looked in the mirror prior to a flap reconstruction. Showing the defect in the mirror prior to the reconstruction may result in higher patient satisfaction in female patients and patients before undergoing a flap reconstruction.
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http://dx.doi.org/10.1007/s00403-021-02187-1DOI Listing
December 2021

Chromosome 20 loss is characteristic of breast implant-associated anaplastic large cell lymphoma.

Blood 2020 12;136(25):2927-2932

Department of Pathology, Cancer Center Amsterdam, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is a very rare type of T-cell lymphoma that is uniquely caused by a single environmental stimulus. Here, we present a comprehensive genetic analysis of a relatively large series of BIA-ALCL (n = 29), for which genome-wide chromosomal copy number aberrations (CNAs) and mutational profiles for a subset (n = 7) were determined. For comparison, CNAs for anaplastic lymphoma kinase (ALK)- nodal anaplastic large cell lymphomas (ALCLs; n = 24) were obtained. CNAs were detected in 94% of BIA-ALCLs, with losses at chromosome 20q13.13 in 66% of the samples. Loss of 20q13.13 is characteristic of BIA-ALCL compared with other classes of ALCL, such as primary cutaneous ALCL and systemic type ALK+ and ALK- ALCL. Mutational patterns confirm that the interleukin-6-JAK1-STAT3 pathway is deregulated. Although this is commonly observed across various types of T-cell lymphomas, the extent of deregulation is significantly higher in BIA-ALCL, as indicated by phosphorylated STAT3 immunohistochemistry. The characteristic loss of chromosome 20 in BIA-ALCL provides further justification to recognize BIA-ALCL as a separate disease entity. Moreover, CNA analysis may serve as a parameter for future diagnostic assays for women with breast implants to distinguish seroma caused by BIA-ALCL from other causes of seroma accumulation, such as infection or trauma.
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http://dx.doi.org/10.1182/blood.2020005372DOI Listing
December 2020

Non-surgical Correction of Congenital Ear Anomalies: A Review of the Literature.

Plast Reconstr Surg Glob Open 2020 Nov 24;8(11):e3250. Epub 2020 Nov 24.

Department of Plastic Surgery, Maastricht University Medical Center, Maastricht, the Netherlands.

Congenital ear anomalies have been known to cause lasting psychosocial consequences for children. Congenital ear anomalies can generally be divided into malformations (chondro-cutaneous defect) and deformations (misshaped pinna). Operative techniques are the standard for correction at a minimal age of 5-7, exposing the children to teasing and heavy complications. Ear molding is a non-operative technique to treat ear anomalies at a younger age. Having been popularized since the 1980s, its use has increased over the past decades. However, uncertainties about its properties remain. Therefore, this review was conducted to look at what is known and what has been newly discovered in the last decade, comparing different treatment methods and materials. A literature search was performed on PubMed, and 16 articles, published in the last decade, were included. It was found that treatment initiated at an early age showed higher satisfactory outcome rates and a shorter duration of treatment. A shorter duration of treatment also led to higher satisfactory rates, which might be attributable to age at initiation, individual moldability, and treatment compliance. Complications were minor in all articles. Recurrence rate was low and mostly concerned prominent ears, which proved to be the most difficult to correct deformity as well. Malformations, however, were even more difficult to treat than deformations. Our analysis shows ear molding to be a successful treatment method for ear anomalies with a preference for early diagnosis and treatment.
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http://dx.doi.org/10.1097/GOX.0000000000003250DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7722567PMC
November 2020

Clinical Assessment of Breast Volume: Can 3D Imaging Be the Gold Standard?

Plast Reconstr Surg Glob Open 2020 Nov 25;8(11):e3236. Epub 2020 Nov 25.

Department of Plastic and Reconstructive Surgery, Maastricht University Medical Centre+, Maastricht, the Netherlands.

Three-dimensional (3D) camera systems are increasingly used for computerized volume calculations. In this study we investigate whether the Vectra XT 3D imaging system is a reliable tool for determination of breast volume in clinical practice. It is compared with the current gold standard in literature, magnetic resonance imaging (MRI), and current clinical practice (plastic surgeon's clinical estimation).

Methods: Breast volumes of 29 patients (53 breasts) were evaluated. 3D images were acquired by Vectra XT 3D imaging system. Pre-existing breast MRI images were collected. Both imaging techniques were used for volume analyses, calculated by two independent investigators. Breast volume estimations were done by plastic surgeons during outpatient consultations. All volume measurements were compared using paired samples -test, intra-class correlation coefficient, Pearson's correlation, and Bland-Altman analysis.

Results: Two 3D breast volume measurements showed an excellent reliability (intra-class correlation coefficient: 0.991), which was comparable to the reliability of MRI measurements (intra-class correlation coefficient: 0.990). Mean (SD) breast volume measured with 3D breast volume was 454 cm (157) and with MRI was 687 cm (312). These volumes were significantly different, but a linear association could be found: y(MRI) = 1.58 × (3D) - 40. Three-dimensional breast volume was not significantly different from volume estimation made by plastic surgeons (472 cm (69), = 0.323).

Conclusions: The 3D imaging system measures lower volumes for breasts than MRI. However, 3D measurements show a linear association with MRI and have excellent reliability, making them an objective and reproducible measuring method suitable for clinical practice.
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http://dx.doi.org/10.1097/GOX.0000000000003236DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7722547PMC
November 2020

Treatment Outcome Measurement Instruments for Port Wine Stains: A Systematic Review of Their Measurement Properties.

Dermatology 2021 3;237(3):416-432. Epub 2020 Dec 3.

Department of Pharmaceutics, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands, E.

Background: A plethora of outcome measurement instruments (OMIs) are being used in port wine stain (PWS) studies. It is currently unclear how valid, responsive, and reliable these are.

Objectives: The aim of this systematic review was to appraise the content validity and other measurement properties of OMIs for PWS treatment to identify the most appropriate instruments and future research priorities.

Methods: This study was performed using the updated Consensus-Based Standards for the Selection of Health Measurement Instruments (COSMIN) methodology and adhered to PRISMA guidelines. Comprehensive searches in Medline and Embase were performed. Studies in which an OMI for PWS patients was developed or its measurement properties were evaluated were included. Two investigators independently extracted data and assessed the quality of included studies and instruments to perform qualitative synthesis of the evidence.

Results: In total, 1,034 articles were screened, and 77 full-text articles were reviewed. A total of 8 studies were included that reported on 6 physician-reported OMIs of clinical improvement and 6 parent- or patient-reported OMIs of life impact, of which 3 for health-related quality of life and 1 for perceived stigmatization. Overall, the quality of OMI development was inadequate (63%) or doubtful (37%). Each instrument has undergone a very limited evaluation in PWS patients. No content validity studies were performed. The quality of evidence for content validity was very low (78%), low (15%), or moderate (7%), with sufficient comprehensibility, mostly sufficient comprehensiveness, and mixed relevance. No studies on responsiveness, minimal important change, and cross-cultural validity were retrieved. There was moderate- to very low-quality evidence for sufficient inter-rater reliability for some clinical PWS OMIs. Internal consistency and measurement error were indeterminate in all studies.

Conclusions: There was insufficient evidence to properly guide outcome selection. Additional assessment of the measurement properties of OMIs is needed, preferentially guided by a core domain set tailored to PWS.
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http://dx.doi.org/10.1159/000511438DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8117375PMC
November 2021

Self-Reported Health Complaints in Women Undergoing Explantation of Breast Implants.

Aesthet Surg J 2022 01;42(2):171-180

From the Department of Plastic, Reconstructive and Hand Surgery, Maastricht University Medical Center, Maastricht, The Netherlands.

Background: Concerns about the safety of silicone breast implants (SBIs) have existed for years, but a causal relation between systemic complaints and SBIs has not been proven. Nevertheless, some women are worried and even request explantation.

Objectives: This study aimed to review the explantation procedures performed, focusing on patient-reported symptoms preoperatively, the effect of explantation, and the effect of breast reconstruction on these symptoms.

Methods: A retrospective chart review was performed for patients who had undergone explantation between 2010 and 2020 at Maastricht University Medical Center. Patients who had undergone tissue expander removal, tissue expander-implant exchange, or direct implant exchange were excluded.

Results: More than half of the patients undergoing explantation reported complaints, mostly pain. Some 15% reported systemic complaints they believed were implant related. Breast implant illness (BII) was found to be the fifth most common indication for explantation (11.2%). A history of either allergies or implant rupture resulted in higher odds ratios of having BII (odd ratios, 2.1 and 2.1, respectively). Subjective improvement of BII after explantation was reported by about 60% of patients.

Conclusions: A relatively low prevalence of suggested BII exists among women undergoing explantation; 1 in 9 procedures were performed for this reason. Allergy and implant rupture may increase the likelihood of having BII. About 60% of BII patients experienced an improvement in their complaints after implant removal. Autologous breast reconstruction appears a good alternative. Prospective studies into health complaints and quality of life should be performed to confirm the effectiveness of explantation as a therapy for BII.

Level Of Evidence: 4:
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http://dx.doi.org/10.1093/asj/sjaa337DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8756082PMC
January 2022

Sensory Recovery of the Breast following Innervated and Noninnervated Lateral Thigh Perforator Flap Breast Reconstruction.

Plast Reconstr Surg 2021 02;147(2):281-292

From the Department of Plastic, Reconstructive, and Hand Surgery, GROW-the School for Oncology and Developmental Biology, and the Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Center; and the Department of Anatomy and Embryology, Maastricht University.

Background: The lateral thigh perforator flap, based on the tissue of the upper lateral thigh, is an excellent option for autologous breast reconstruction. The aim of this study was to introduce the technique to perform a nerve coaptation in lateral thigh perforator flap breast reconstruction and to analyze the results by comparing the sensory recovery of the reconstructed breast and donor site between innervated and noninnervated lateral thigh perforator flaps.

Methods: A prospective cohort study was conducted of patients who underwent an innervated or noninnervated lateral thigh perforator flap breast reconstruction between December of 2014 and August of 2018. Direct nerve coaptation was performed between a branch of the lateral femoral cutaneous nerve and the anterior cutaneous branch of the intercostal nerve. Sensory testing was performed with Semmes-Weinstein monofilaments to assess the sensation of the native skin, flap skin, and donor site during follow-up.

Results: In total, 24 patients with 37 innervated lateral thigh perforator flaps and 18 patients with 26 noninnervated lateral thigh perforator flaps were analyzed (median follow-up, 17 and 15 months, respectively). Significantly lower mean monofilament values were found for the native skin (adjusted difference, -0.83; p = 0.011) and flap skin (adjusted difference, -1.11; p < 0.001) of the reconstructed breast in innervated compared to noninnervated flaps. For the donor site, no statistically significant differences were found between both groups.

Conclusions: Nerve coaptation in lateral thigh perforator flap breast reconstruction resulted in a significantly better sensory recovery of the reconstructed breast compared to noninnervated flaps. The data also suggest that harvesting a sensory nerve branch does not compromise the sensory recovery of the upper lateral thigh.
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http://dx.doi.org/10.1097/PRS.0000000000007547DOI Listing
February 2021

Rerouting of the pectoralis major muscle for breast animation deformity in sub-pectoral autologous breast reconstruction: A case report and review of the literature.

Int J Surg Case Rep 2020 22;77:28-31. Epub 2020 Oct 22.

Department of Plastic and Reconstructive Surgery, Maastricht University Medical Center, Maastricht, the Netherlands; GROW - School for Oncology and Developmental Biology, Maastricht University, Maastricht, the Netherlands. Electronic address:

Introduction: Breast animation deformity (BAD) is a known complication of sub-pectoral implant placement that is usually corrected by simply repositioning the implant to a pre-pectoral position. However, when this complication occurs in the case of a sub-pectorally placed free-flap, the solution becomes a lot less straightforward: repositioning of the flap carries the risk of possible damage to the pedicle. In order to avoid having to re-do the anastomoses we opted for a rerouting of the pectoralis major muscle around the vascular anastomoses.

Presentation Of Case: We present a 26-year old patient with unsatisfactory aesthetic outcomes of her bilateral deep inferior epigastric perforator (DIEP) flap breast reconstruction. The flaps were placed sub-pectorally, in the already existing pocket that was created during her first breast reconstruction with silicone implants, resulting in severe BAD. Repositioning the free flap from the sub-pectoral to the pre-pectoral plane allowed for reinsertion of the pectoralis major muscle to its anatomical position without jeopardizing the vascular anastomoses. The patient was satisfied with the increased projection of the breasts.

Discussion: Changing the plane from sub-pectoral to pre-pectoral remains the best treatment option for patients experiencing BAD. In combination with an acellular dermal matrix, this would have been a good option for our patient. However, when choosing to perform autologous breast reconstruction instead, our recommendation would be to always place the flap in the pre-pectoral plane to avoid BAD.

Conclusion: The report shows that the plane of a flap can be successfully changed without jeopardizing the pedicle of the flap.
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http://dx.doi.org/10.1016/j.ijscr.2020.10.044DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7610019PMC
October 2020
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