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Purpose Delayed breast reconstruction (DBR) is a valid option for postmastectomy breast cancer patients who have a desire for breast reconstruction but are not considered suitable for immediate breast reconstruction (IBR). The objective of this study was to investigate the clinical practice and predictors of the use of DBR in the Netherlands. Methods Stage I–III breast cancer patients diagnosed from January to March 2012 and treated with mastectomy were selected from the Netherlands Cancer Registry. Routinely collected patient, tumor, treatment and hospital characteristics were complemented with data about DBR up to 2018. Multivariable logistic regression analyses were performed to identify factors independently associated with postmastectomy DBR. Factors associated with time to DBR were identified through Cox regression analyses. Results Of all patients who underwent mastectomy (n = 1,415), 10.2% underwent DBR. DBR patients more often received autologous reconstruction compared to IBR patients (37.5% vs 6.2%, p Discussion The use of DBR after mastectomy could not be fully explained by age below 50 years, chemotherapy, and hospital volume. Treatment with radiotherapy and adjuvant chemotherapy increased time to DBR. More information about patient preferences is needed to understand the use and timing of reconstruction.

To provide patient-centered care, it is essential to explore what patients consider important and to adjust care accordingly. This may specifically be relevant for patients with complex skin cancer, for whom the care process is often more complicated and psychological and social problems may play a larger role. The objective was to explore the experiences and needs of patients who had undergone surgical treatment by a dermatologist for a complex skin cancer with a subsequent reconstruction by a plastic surgeon. An interview study was conducted among 16 patients who had undergone surgical treatment by a dermatologist and reconstruction by a plastic surgeon for basal cell carcinoma, cutaneous squamous cell carcinoma, or lentigo maligna. The interviews focused on patients’ experiences and needs regarding care using a predefined topic list. All interviews were audio-taped, transcribed verbatim and inductively analyzed using Atlas.ti. Patients reported a need for a skilled and friendly physician who tailors information and communication to their individual situation. A need for continuity of care and improved collaboration between healthcare providers was also emphasized. Furthermore, patients experienced complications and unmet expectations and expressed a need for shared decision-making at various steps throughout the treatment process (depending on age). Patients also considered completeness of tumor removal, follow-up visits with multiple specialists to be planned the same day and recognition of the psychological impact of the disease on the partner important. To improve patient-centered care for complex skin cancer patients, more efforts should be directed towards improving continuity of care and collaboration. Furthermore, it is advocated for physicians to be sensitive to the individual needs of patients and their partner and adjust information, communication and (supportive) care accordingly.

We present the case of a 74-year-old man with a history of a squamous cell carcinoma in the left axilla. The patient underwent a multidisciplinary surgical resection through an extended forequarter amputation with thoracic wall resection and reconstruction. With regard to the complexity of the case, three-dimensional virtual reality–based patient-specific reconstructions were used as a supplemental tool to conventional computed tomography imaging to plan the procedure. With this report, we aim to stimulate further research to improve and automate the workflow and to bring virtual and augmented reality reconstructions into the surgical theater of the future.

BACKGROUND: Nipple-sparing mastectomy (NSM) has emerged as an alternative procedure for skin sparing mastectomy (SSM), followed by immediate breast reconstruction. Because oncological safety appears similar, patient-reported outcomes (PROs) and complication risks may guide decision-making in individual patients. Therefore, the aim of this systematic review was to compare PROs and complication rates after NSM and SSM.METHODS: A systematic literature review evaluating NSM versus SSM was performed using Embase, Medline and Cochrane databases. Methodological quality of the included studies was assessed using the Newcastle-Ottawa Quality Assessment Form for Cohort Studies. Primary outcomes were PROs and complications. Studies that evaluated Breast-Q scores were used to perform meta-analyses on five Breast-Q domains.RESULTS: Thirteen comparative studies including 3895 patients were selected from 1202 articles found. Meta-analyses of the Breast-Q domains showed a significant mean difference of 7.64 in the Sexual Well-being domain (p = 0.01) and 4.71 in the Psychosocial Well-being domain (p = 0.03), both in favor of NSM. Using the specifically designed questionnaires, no differences in overall satisfaction scores were found. There were no differences in overall complication rates between the two groups.CONCLUSIONS: Patient satisfaction scores were high after both NSM and SSM, however, NSM led to a higher sexual and psychosocial well-being. No differences in complication rates were found. In combination with other factors, such as oncological treatments, complication risk profile, and fear of cancer recurrence, the decision for NSM or SSM has to be made on an individual basis and only if NSM is considered to be oncologically safe.

Introduction: Pectoral fascia (PF) removal during mastectomy still seems to be the standard procedure. However, preservation of the PF might improve postoperative and cosmetic outcomes, without compromising oncological safety. Here, we report on a national survey among Dutch plastic surgeons and oncological breast surgeons to evaluate their tech-niques and opinions regarding the PF. Materials and methods: A survey based study was performed in the Netherlands, in which both plastic surgeons and oncological breast surgeons were included, each receiving a different version of the survey. The surveys were distributed to 460 and 150 e-mail ad-dresses, respectively. Results: A total of 68 responses were included from more than half of all Dutch medical centers. The results of this study indicate that circa one in five plastic surgeons and breast surgeons routinely preserve the PF during mastectomies and even more surgeons preserve the PF in specific cases. The surgical techniques and opinions regarding PF preservation widely differ between surgeons. Conclusions: Preservation of the PF does occur in a substantial part of the Dutch medical centers and techniques and opinions are contradictory. Future studies on this topic should clarify the effect of PF preservation on oncological safety, complication rates, postoperative pain, cosmetic outcomes, and patient satisfaction. (c) 2022 The Author(s). Published by Elsevier Inc. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

Summary: The global burden of snakebites is growing, particularly its nonfatal sequelae. Therefore, the World Health Organization reinstated snakebites to its list of Neglected Tropical Diseases. We describe the case of a 4.5-year-old boy who was bitten by a spitting cobra, resulting in considerable local swelling accompanied by a right-sided facial paralysis due to neurotoxicity by cobra venom. Presently, surgical methods to recover facial paralysis include nerve repair, nerve grafting, nerve transfers, static slings, muscle transfers, and functional muscle transplantations. However, mime therapy consisting of neuromuscular retraining resulted in a good functional result with a moderate contour deficiency of the right cheek and a subtle paresis of the zygomatic muscles at 1 year and 9 months follow-up. The natural history of facial paralysis in our case shows that this condition can be transient and may resolve with mime therapy as a conservative measure.

Summary Background The goal of postmastectomy breast reconstruction (BR) is to improve the quality of life of patients. However, complications following autologous (A-BR) and implant-based breast reconstruction (I-BR) occur frequently and may even lead to BR-failure, which can be a distressing event for both patients and surgeons. The current study therefore looks at the experiences of both patients and surgeons after a BR-failure. Methods Patients with a failed BR from a large multicenter cohort study and participating plastic surgeons were invited to participate in semi-structured interviews focusing on their experiences. The interviews were analyzed according to the principles of grounded theory. Results Fourteen patients with a failed I-BR, four patients with a failed A-BR and four plastic surgeons participated. Three main categories emerged from the data: personal experiences with BR-failure, the motives for a redo of a failed BR, and patient-surgeon communication. Patients would like to be treated with more attention to their personal feelings and lives, instead of being approached from a purely medical-technical perspective. Surgeons may experience feelings of guilt leading to the strong urge to fix the failed BR, whereas patients may be less inclined to undergo additional operations. Patients want to know what the choice for a particular type of BR would mean to their personal lives. The impact of I-BR-failure may be underestimated and requires the same degree of intensive aftercare and attention. Conclusions Implementing the recommendations of this study in clinical practice may facilitate improvements in how both patients and surgeons cope with a BR-failure.

Background: Umbilical complications can be relatively common after breast reconstruction with deep inferior epigastric perforator (DIEP) flaps. The medial umbilical ligaments and the ligamentum teres hepatis can be the sole blood supply to the umbilicus after a DIEP flap harvest. Prior incisions along the epigastric midline may disrupt the ligamentum teres hepatis. In this retrospective study, we assess the influence of previous midline epigastric scars on umbilical complications after DIEP flap harvest. Methods: All patients who underwent breast reconstruction with DIEP flaps were identified at an academic institution over six years. Relevant sociodemographic and clinicopathologic factors were reviewed in the electronic medical records. Univariate and multivariate analyses were performed to determine the role of clinical variables to predict the chance of umbilical complications. Results: A total of 243 patients met inclusion criteria, with 39 patients (16%) having prior surgery utilizing midline epigastric incisions. Twenty-one patients had umbilical complications. No significant difference in patient characteristics was found between patients with and without prior midline epigastric scars. Patients with a history of previous midline epigastric scars had a higher rate of umbilical complications (20.5% vs. 6.4%, p < 0.01). Bilateral medial row perforator-based DIEP flap harvest was also related to a higher rate of umbilical complications (18.4% vs. 6.2% p < 0.01). Conclusion: Previous midline epigastric scars are associated with higher rates of umbilical complications after DIEP flap harvest. Bilateral medial row perforator-based DIEP flap harvest exacerbates the rate of umbilical complications and should be avoided in patients with prior midline epigastric incision whenever possible.

Background Free tissue transfer is a commonly used procedure to reconstruct defects of the lower extremity. However, measures of postoperative care to promote flap maturity vary greatly. Dangling protocols tend to be highly divergent regarding the start, duration, schedules and monitoring of dangling, as well as the additional use of compression stockings or bandaging. The aim of this systematic review to review and evaluate current literature and to provide recommendations. Methods A systematic literature review was performed in accordance with PRISMA guidelines. Literature databases were searched for relevant articles about early ambulation following lower leg reconstruction. Results A total of 10 articles met the inclusion criteria: 2 randomized controlled trials and 7 case-series and one cohort study. The optimal start, duration and frequency of the dangling and compression procedures remain unclear, and so does the necessity of dangling and compression in general. An early and aggressive dangling procedure can be safely introduced on postoperative day (POD) 3, taking possible comorbidities into consideration. Early initiation might help shorten hospital stay, thereby reducing associated medical costs. Furthermore, compressive wrapping applied to the dangled leg seems to have a positive effect on flap perfusion and patient comfort. Conclusion Based on the current literature, it is suggested that an early and aggressive dangling procedure can safely be started on POD 3. Compression therapy during dangling increases perfusion and venous return of the free flap and increases the comfort of the patient.

Background: Oncological safety of different types and timings of PMBR after breast cancer remains controversial. Lack of stratified risk assessment in literature makes current clinical and shared decision-making complex. This is the first systematic review and meta-analysis to evaluate differences in oncological outcomes after immediate versus delayed postmastectomy breast reconstruction (PMBR) for autologous and implant-based PMBR separately. Methods: A systematic literature search was performed in MEDLINE, Cochrane Library, and Embase. The Cochrane Collaboration Handbook and Meta-analysis Of Observational Studies in Epidemiology checklist were followed for data abstraction. Variability in point estimates attributable to heterogeneity was assessed using I 2-statistic. (Loco)regional breast cancer recurrence rates, distant metastasis rates, and overall breast cancer recurrence rates were pooled in generalized linear mixed models using random effects. Results: Fifty-five studies, evaluating 14,217 patients, were included. When comparing immediate versus delayed autologous PMBR, weighted average proportions were: 0.03 (95% confidence interval [CI], 0.02–0.03) versus 0.02 (95% CI, 0.01–0.04), respectively, for local recurrences, 0.02 (95% CI, 0.01–0.03) versus 0.02 (95% CI, 0.01–0.03) for regional recurrences, and 0.04 (95% CI, 0.03–0.06) versus 0.01 (95% CI, 0.00–0.03) for locoregional recurrences. No statistically significant differences in weighted average proportions for local, regional and locoregional recurrence rates were observed between immediate and delayed autologous PMBR. Data did not allow comparing weighted average proportions of distant metastases and total breast cancer recurrences after autologous PMBR, and of all outcome measures after implant-based PMBR. Conclusions: Delayed autologous PMBR leads to similar (loco)regional breast cancer recurrence rates compared to immediate autologous PMBR. This study highlights the paucity of strong evidence on breast cancer recurrence after specific types and timings of PMBR. Lay summery: Oncologic safety of different types and timings of postmastectomy breast reconstruction (PMBR) remains controversial. Lack of stratified risk assessment in literature makes clinical and shared decision-making complex. This meta-analysis showed that delayed autologous PMBR leads to similar (loco)regional recurrence rates as immediate autologous PMBR. Data did not allow comparing weighted average proportions of distant metastases and total breast cancer recurrence after autologous PMBR, and of all outcome measures after implant-based PMBR. Based on current evidence, oncological concerns do not seem a valid reason to withhold patients from certain reconstructive timings or techniques, and patients should equally be offered all reconstructive options they technically qualify for.

Background Correct registration of implant characteristics is essential to monitor implant safety within implant registries. Currently, in the nationwide Dutch Breast Implant Registry (DBIR), these characteristics are being registered manually by plastic surgeons, resulting in administrative burden and potentially incorrect data entry. Objectives This study evaluated the accuracy of manually registered implant data, possible consequences of incorrect data, and the potential of a Digital Implant Catalog (DIC) on increasing data quality and reducing the administrative burden. Methods Manually entered implant characteristics (fill, shape, coating, texture) of newly inserted breast implants in the DBIR, from 2015 to 2019, were compared with the corresponding implant characteristics in the DIC. Reference numbers were employed to match characteristics between the 2 databases. The DIC was based on manufacturers’ product catalogs and set as the gold standard. Results A total of 57,361 DBIR records could be matched with the DIC. Accuracy of implant characteristics varied from 70.6% to 98.0%, depending on the implant characteristic. The largest discrepancy was observed for “texture” and the smallest for “coating.” All manually registered implant characteristics resulted in different conclusions about implant performance compared with the DIC (P Conclusions Implementation of a DIC increases data quality in the DBIR and reduces the administrative burden. However, correct registration of reference numbers in the registry by plastic surgeons remains key for adequate matching. Furthermore, all implant manufacturers should be involved, and regular updates of the DIC are required.

Background: Postmastectomy immediate breast reconstruction (IBR) may improve the quality of life (QoL) of breast cancer patients. Guidelines recommend to discuss the option IBR with all patients undergoing mastectomy. However, substantial hospital variation in IBR-rates was previously observed in the Netherlands, influenced by patient, tumour and hospital factors and clinicians’ believes. Information provision about IBR may have a positive effect on receiving IBR and therefore QoL. This study investigated patient-reported QoL of patients treated with mastectomy with and without IBR. Methods: An online survey, encompassing the validated BREAST-Q questionnaire, was distributed to a representative sample of 1218 breast cancer patients treated with mastectomy. BREAST-Q scores were compared between patients who had undergone mastectomy either with or without IBR. Results: A total of 445 patients were included for analyses: 281 patients with and 164 without IBR. Patients who had received IBR showed significantly higher BREAST-Q scores on “psychosocial well-being” (75 versus 67, p < 0.001), “sexual well-being” (62 versus 52, p < 0.001) and “physical well-being” (77 versus 74, p = 0.021) compared to patients without IBR. No statistically significant difference was found for “satisfaction with breasts” (64 versus 62, p = 0.21). Similar results were found after multivariate regression analyses, revealing IBR to be an independent factor for a better patient-reported QoL. Conclusions: Patients diagnosed with breast cancer with IBR following mastectomy report a better QoL on important psychosocial, sexual and physical well-being domains. This further supports the recommendation to discuss the option of IBR with all patients with an indication for mastectomy and to enable shared decision-making.

Objective: Although breast reconstruction has become an important treatment modality following mastectomy, few studies assessed predictors of postoperative sexual outcomes after breast reconstruction. Therefore, we aimed to study three sexual outcomes following implant-based breast reconstruction (IBBR), and associate multiple biopsychosocial factors with these outcomes. Methods: Data collection was part of a multicenter prospective study on IBBR. A predictive model was tested including medical, background and psychological predictors, partner relationship factors and physical sexual function. Data collection included clinical and questionnaire data (preoperatively and 1 year following reconstruction) using the BREAST-Q Sexual well-being scale (BQ5), and questions regarding sexual dysfunction and sexual satisfaction questions (Female Sexual Function Index). Results: The study sample consisted of 88 women who underwent mastectomy and IBBR. Mean postoperative BQ5 scores were lower than before surgery (M = 58 [SD = 18] vs 65 [SD = 20]; P =.01, Wilks' Lamdba =.88). Sexual dysfunctions were related strongest to orgasm inability and vaginal lubrication issues. The tested models predicted 37%-46% of the sexual outcomes: sexual outcomes were mostly predicted by psychosocial well-being, physical sexual function and partner support. Preoperative sexual and psychosocial well-being were positively associated with postoperative sexual well-being (r = 0.45 and r = 0.47). Conclusions: Although moderately positive sexual outcomes were reported after IBBR, some women reported issues with vaginal lubrication, breast sensation and orgasm. Sexual dysfunctions were predicted by vaginal lubrication and medical treatments, while sexual well-being and satisfaction were more predicted by psychosocial well-being and partner support. We advocate supportive care that includes partners and psychosocial functioning to optimize sexual outcomes after IBBR.

Background: The Poly Implant Prothese incident and breast implant-associated anaplastic large cell lymphoma have pointed to the need for uniform registries for breast implants as key features to monitoring the outcomes of breast implant surgeries internationally. The purpose of this study was to identify and harmonize common data elements collected by breast implant registries across the International Collaboration of Breast Registry Activities (ICOBRA) global consortium. Methods: The authors convened an international group of surgeons, consumers, nurses, registry experts, and regulators to review the data points. A modified Delphi approach was applied, to rate the importance of each point on a six-point Likert scale. Results: Data points from six national breast implant registries were divided into categories: clinical, implant-related, patient-reported findings; operation details and implanting technique details; patient characteristics; unique device identifiers; unique patient identifiers; and clinical demographics. A total of 52 data points collected by over 33 percent of national registries were identified. After five rounds, 34 data points formed the final set with agreed definitions. The group recognized the critical importance of additional elements that are currently not uniformly collected (e.g., patient-reported outcomes and longterm data) and set out the process for the dynamic global set updates driven by evidence gaps. Conclusions: The authors defined internationally agreed on common data elements and definitions used in breast implant registries. This collaboration will allow data sets to be combined, enabling an effective global early warning system of implant-related problems and further work on data sets.

Summary Background Today, the deep inferior epigastric perforator (DIEP) flap is considered to be the gold standard in microvascular breast reconstruction. Although this procedure is known as technically demanding, novice plastic surgeons must be able to perform these procedures to meet the rising demand. The purpose of this study was to evaluate if the young junior professional is trained adequate enough to set up and safely perform microsurgical breast reconstructions. Methods We compared outcomes of three identically trained novice plastic surgeons who all introduced the DIEP flap in their working environment. Their hospitals differed in size and experience with microsurgery. Outcomes were compared between all start-ups and to a center of excellence (EMC). Results A total of 152 DIEP flaps were performed in 123 patients among all start-ups together. Baseline characteristics and major complications were comparable between all groups. The total flap loss rate was 2% in the start-ups versus 3.9% in the control group (p=0.5). Although there seems to be a trend in a longer operating time in both training and non-training academic centers, no statistical significance was found between the start-ups (p=0.13) and compared to the control group (p=0.17). However, a learningcurve seems to be present when it comes to duration of surgery and is greatest in the community centers with zero experience in microsurgery (ZGT p=0.002, Amphia p=0.065). The same accounts for hospital stay. Conclusion Although there seems to be a learningcurve in terms of duration of surgery in hospitals with no experience in microsurgery, it is safe to perform microvascular breast reconstructions as a novice plastic surgeon.

Purpose The aim of this study was to compare patient-reported outcomes (PROs) of BRCA1/2 mutation carriers, either after bilateral prophylactic mastectomy (BPM) or during breast surveillance, to improve shared decision-making in their cancer risk management. Methods Unaffected BRCA1/2 mutation carriers at least one year after BPM followed by immediate breast reconstruction (BPM-IBR) or one year under surveillance were eligible. After informed consent, the Hospital Anxiety and Depression Scale (HADS) and BREAST-Q were administered and compared between the different strategies. PROs were also compared to available normative data. Results Ninety-six participants were analyzed in this study and showed significant differences between strategies in age, age at genetic testing, and time since BPM or starting breast surveillance. All HADS scores were below 8 suggesting no signs of anxiety or depression in both groups. Higher mean ‘Q-physical well-being’ scores were reported by the surveillance group (81.78 [CI 76.99–86.57]) than the BPM group (76.96 [CI 73.16 – 80.75]; p = 0.011). Overall, for both questionnaires better scores were seen when compared to age-matched normative data. Conclusions No signs of anxiety or depression were seen in the surveillance or BPM-IBR group. Slightly better mean BREAST-Q scores were seen for the surveillance group in comparison to BPM-IBR, except for ‘Q-psychological well-being’. The difference in ‘Q-physical well-being’ was significantly worse for BPM-IBR. Approaches to obtain longitudinal PROs and reference values should be explored in the future, which could add value to shared decision-making in regards to breast cancer risk management in this specific patient population.

Strategies to avoid and manage complications following autologous breast reconstruction using free abdominal flaps are comprehensively presented and discussed. Advances in microsurgical materials and techniques as well as improved knowledge of the vascular anatomy of flaps have made microsurgical abdominal flap breast reconstruction a safe and reliable method. Despite these improvements, major complications such as flap failure, donor site morbidity, or thromboembolic events still occur with potentially serious consequences. Complications following autologous breast reconstructions have been shown to negatively affect early physical health, mental health, abdominal strength, and patient satisfaction. In addition, major surgical and medical complications following autologous breast reconstruction are associated with increased hospital length of stay and greater costs. Therefore, every effort should be made to minimize the chance of complications and if a complication should occur, adequate management is imperative to minimize its consequences.

Background The aim was to evaluate the cost-utility of four common surgical treatment pathways for breast cancer: mastectomy, breast-conserving therapy (BCT), implant breast reconstruction (BR) and autologous-BR. Methods Patient-level healthcare consumption data and results of a large quality of life (QoL) study from five Dutch hospitals were combined. The cost-effectiveness was assessed in terms of incremental costs and quality adjusted life years (QALYs) over a 10-year follow-up period. Costs were assessed from a healthcare provider perspective. Results BCT resulted in comparable QoL with lower costs compared to implant-BR and autologous-BR and showed better QoL with higher costs than mastectomy (€17,246/QALY). QoL outcomes and costs of especially autologous-BR were affected by the relatively high occurrence of complications. If reconstruction following mastectomy was performed, implant-BR was more cost-effective than autologous-BR. Conclusion The occurrence of complications had a substantial effect on costs and QoL outcomes of different surgical pathways for breast cancer. When this was taken into account, BCT was most the cost-effective treatment. Even with higher costs and a higher risk of complications, implant-BR and autologous-BR remained cost-effective over mastectomy. This pleas for adapting surgical pathways to individual patient preferences in the trade-off between the risks of complications and expected outcomes.

Background: Although the use of breast implants is generally considered to be safe, breast implants are associated with short- and long-term complications. To evaluate and improve the quality of breast implant surgery, and increase our knowledge of implant performance, the national Dutch Breast Implant Registry (DBIR) was established in 2015. DBIR is one of the first up-and-running breast implant registries worldwide and follows an opt-out structure.Objective: This article provides an overview of the first outcomes and experiences of the DBIR.Methods: The national coverage of DBIR was studied using data from the Dutch Health and Youth Care Inspectorate. The incidence rate of breast implants was calculated for 2016 and 2017, and patient, device, and surgery characteristics were compared between cosmetic breast augmentations or reconstructive indications. Four infection control, measures were selected to demonstrate the variation in the Dutch clinical practice.Results: In 2016, 95% of the hospitals and 78% of the private clinics participated in DBIR. Between 2015 and 2017, a total of 15,049 patients and 30,541 breast implants were included. A minimum breast implant incidence rate of 1 per 1,691 women could be determined for 2017. The majority of devices were inserted for a cosmetic indication (85.2%). In general, patient, device, and surgery characteristics differed per indication group. Substantial variation was seen in the use of infection control measures (range 0-100%).Conclusion: Preliminary results obtained from DBIR show high national participation rates and support further developments toward the improvement of breast implant surgery and patient safety. (C) 2019 Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons.

textabstractDermatofibrosarcoma protuberans is a rare soft tissue tumour with a very low (< 0.5%) rate of metastasis. Rates of re-excision and recurrence were determined using data from the Netherlands Cancer Registry between 1989 and 2016. Of the 1,890 instances of dermatofibrosarcoma protuberans included, 87% were treated with excision, 4% with Mohs micrographic surgery, and 9% otherwise or unknown. Linked pathology data were retrieved for 1,677 patients. Half of all excisions (847/1,644) were incomplete and 29% (192/622) of all re-excisions were incomplete. The cumulative incidence of a recurrence was 7% (95% confidence interval (CI) 6–8) during a median followup of 11 years (interquartile range (IQR) 6–17). After Mohs micrographic surgery (n = 34), there were no recurrences during a median follow-up of 4 years (IQR 3–6). Due to the high rate of incomplete excisions and recurrences after excision, this study supports the European guideline, which recommends treating dermatofibrosarcoma protuberans with Mohs micrographic surgery in order to decrease the rate of recurrence.

In 2012 vismodegib (Erivedge), an oral hedgehog pathway inhibitor, was approved by the US Food and Drug Administration for the treatment of locally advanced or metastatic basal cell carcinoma (BCC).1 Marketing authorization, however, does not account for long-term obstacles as seen in daily clinical practice. For example, one dilemma is the positioning of vismodegib in the treatment of giant, locally advanced BCC, especially regarding its position as part of a palliative and curative treatment. Another issue is how to deal with tumor resistance to vismodegib in giant, locally advanced BCC in a specific group of patients who avoid health care, often because of fear of surgery or radiotherapy. Gaining insight in the treatment process of these patients is therefore urgently needed to improve decision making in these complex cases. We report on 3 patients treated with vismodegib for giant, locally advanced BCC and 1 patient treated for a metastasized BCC to illustrate and discuss the possibilities and limitations of vismodegib treatment in clinical practice.

Background: Breast cancer reconstructive surgery is supposed to contribute to patients' body image and quality of life. However, complications after autologous breast reconstruction (A-BR) and implant-based breast reconstruction (I-BR) do occur in approximately 40% of the women, and may even lead to complete failure in rare cases. This study explores both patients' and surgeons' experiences after failed breast reconstruction. Increased knowledge in this field could help to improve not only the care for women with failed breast cancer reconstructive surgery but may also help to guide professionals in dealing with such failures. Methods: Patients with reconstructive failure form a large multicenter cohort study and participating plastic surgeons were invited to participate in this study. A topic list consisting of ten topics served as a general outline of a semi-structured interview on their experiences with the reconstructive failure, lasting about one hour. The interview data were transcribed and after that analyzed according to the principles of grounded theory by two researchers independently of each other. Data were coded in NVivo software. Next, data were discussed in a larger team, thereby moving back and forth between data and emerging theory. Results: Fourteen patients with a failed I-BR, four patients with failed A-BR and four plastic surgeons participated in this study. Three main categories emerged from the data: personal experiences, the motivation for a redo of the failed reconstructive surgery and patient-doctor communication. With regard to personal experiences, a main patient category was the importance of being (appreciated as) a person as a whole, in his/her specific context (versus focusing on reconstructive technique). This in contrast to the surgeons, for whom it did matter whether the failure concerned an I-BR or A-BR. The latter was perceived as more intense. Some took it as a personal failure, leading to insecurity and feelings of regret towards the patient. This was especially true if they felt a strong bond with that particular patient. With regard to motivation for a redo of the failed reconstructive surgery, both patients and surgeons emphasized the importance of shared decision making. Nevertheless, patients seemed to remain more ambivalent than surgeons about pursuing additional reconstruction after failure. Finally, regarding patient-doctor communication, we found that surgeons were more distant or reflective on these matters, whereas patients expressed their experiences in a more emotional way. Patients expressed a desire to be seen and treated as an unique individual. Experiencing trustfulness, sincerity and empathy from the surgeon in discussing the failure were highly valued. Discussion: Implementing the results of this study in clinical practice may facilitate coping with the distressing or even traumatic event of failed breast reconstruction, in both patients and surgeons. Citation Format: Kouwenberg CA, Hoogdalem LE, Gopie JP, Tibben A, Mureau MA, Ismail SY, Kranenburg LW. Patients' and surgeons' experiences after failed breast reconstruction: A qualitative study [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P4-12-08.

Background: Comparing the quality of life (QoL) for all common breast cancer surgery options could support decision-making. However, current evidence generally consists of non-preference-based outcomes for sub-comparisons of options which are unsuitable for the calculation of Quality Adjusted Life Years (QALYs), the preferred outcome in health economics. The preference-based EQ-5D-5L is specifically designed to provide the Q in QALY and could facilitate a (health-care) wide comparison of breast cancer surgery options. This study gives an overview of both non-preference and preference-based QoL after four common surgical breast cancer treatment pathways. Method: Breast cancer patients from a large multicenter observational cohort in the Netherlands were invited for participation in an online survey. QoL was obtained by the EQ-5D-5L, EORTC-QLQ-C30/-BR23 and Breast-Q questionnaires. Patient cohorts based on surgical procedure (breast-conserving surgery (BCS), mastectomy (MAS), autologous breast reconstruction (A-BR) and implant-based breast reconstruction (I-BR) were compared after propensity-weighted adjustment of pretreatment differences. Results: Of all invited patients, 1871 responded, respectively patients treated with BCS (n=615), MAS (n=507), A-BR (n=330), and I-BR (n=419). Table 1 shows QoL outcomes without overlapping 95% CI. Patients reported complications in 47% of the A-BR, 32% of the I-BR, 18% BCS and 22% of the MAS groups. QoL outcomes differed statistically significantly between patients with and without complications for all groups, except the I-BR group. Table 1:patient-reported quality of life per surgical treatment for propensity-weighted cohorts BCSMASA-BRI-BR Estimated sample sizen=434.0n=386.3n=178.6n=295.5EQ-5D-5L Utility Overall0.844a0.805b0.849a0.850a No complication0.859a0.878b0.847a0.818a,b Complication0.771a0.771a,c0.816b,c0.861bBreast-Q Satisfaction with breasts 65.52a60.65b71.29c59.39b Satisfaction with outcome 75.75a66.37b Psychosocial well-being 73.77a66.50b75.78a71.60a Sexual well-being 62.70a50.00b63.33a56.38c Physical well-being: chest 67.39a73.47b,c75.81c72.64bEORTC-QLQ-C30 Physical function 84.53a82.94a85.62a,b87.97b Role function 84.35a80.70b84.02a,b86.02a Pain 15.41a18.93b17.18a,b15.89a,b Financial problems 5.23a8.22b12.30b7.71a,bEORTC-QLQ-BR23 Body image 87.45a80.49b82.28b82.35b Sexual functioning 27.90a27.51a31.95a,b33.35b Sexual enjoyment 57.03a54.82a64.24b63.80b Breast symptoms 13.45a9.94b8.79b10.82a Arm symptoms 12.68a17.12b18.18b16.82dMean values of the respective outcome scale after propensity score weighting and are derived from an estimator of the average treatment effect on the population. Values in the same row not sharing the same subscript do not show overlapping 95% Confidence Intervals in a pairwise comparison. Discussion: Preference-based QoL outcomes are an essential input for cost-effectiveness analyses, used to justify the use of care in a society progressively confronted with increasing health care expenses. The results from this large multicenter cohort study contribute substantially to the current knowledge in the field of breast cancer reconstructive surgery. Citation Format: Kouwenberg CA, Ligt KM, Rakhorst HA, Leeuw D, Siesling S, Buschbach JJ, Kranenburg LW, Mureau MA. Long-term quality of life after four common surgical treatment pathways for breast cancer and the effect of complications [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P5-15-05.

Background The objectives of this study are to determine the incidence and survival rate of patients with head and neck squamous cell carcinoma (HNSCC) with multiple primary tumors (MPT) in the HN‐region, lung, or esophagus. Methods Patient and tumor specific data of 1372 patients with HNSCC were collected from both the national cancer registry and patient records to ensure high‐quality double‐checked data. Results The total incidence of MPTs in the HN‐region, lung, and esophagus in patients with HNSCC was 11% (149/1372). Patients with lung MPTs and esophageal MPTs had a significant worse 5‐year survival than patients with HN‐MPTs (29%, 14%, and 67%, respectively, P

Background Defects following Mohs micrographic surgery (MMS) can range in size from small defects requiring linear closure to large defects needing flap coverage. Reconstruction is dependent on defect size and facial aesthetic unit involvement. The aim of this study was to review the types of facial reconstruction per aesthetic unit involvement and describe their outcomes. Methods All data were retrieved for patients ≥18 years who underwent multidisciplinary treatment including dermatological MMS and plastic surgical reconstruction at a single tertiary hospital center (2001-2017). Patient characteristics, tumor pathology, surgical specifics, reconstructive modalities, and surgical outcomes were analyzed. Results A total of 418 patients were included. Patients were predominantly White, non-Hispanic (97%) and female (58%) with a mean age of 60 ± 13.9 years. Tumor pathology was predominantly basal cell carcinoma in 73% of all cases followed by squamous cell carcinoma in 14%. The nasal aesthetic unit was mostly affected (50%). Local advancement flaps and different types of grafts were used in 51% and 25% of reconstructions, respectively. Complications were observed in 3% and local cancer recurrence in 4% of the patients. Scar revision was needed in 6% of the patients. Conclusion Reconstruction of facial defects after Mohs micrographic surgery can be challenging due to its technical complexity and aesthetic implications. There were differences in complications in reconstructions performed within the same day versus 1 week, with a majority of complications occurring within same-day Mohs reconstructions. A multidisciplinary structured approach, which incorporates patient-reported outcomes, may be needed to optimize surgical results.

Summary Background The EuroQol EQ-5D-5L instrument is the most widely used quality of life (QoL) measure in health economic evaluations. It is unclear whether such a generic instrument is valid enough to estimate the benefits of breast reconstruction (BR), given the specific changes observed in QoL after BR. Hence, we aimed to evaluate the validity of the EQ-5D-5L in patients who had undergone postmastectomy BR. Methods In a 10-year cross-sectional cohort study, 463 mastectomy patients completed an online survey: 202 patients with autologous-BR (A-BR), 103 with implant-based-BR (I-BR), and 158 without BR (MAS). The results were used to evaluate the psychometric performance of the EQ-5D-5L with respect to the ceiling effect and to known-group, convergent, and discriminant validity, by comparing it with the Breast-Q, the cancer-specific (EORTC-QLQ-C30), and breast cancer-specific (EORTC-QLQ-BR23) questionnaires. Results The EQ-5D-5L was able to discriminate between patients with and without complications, MAS with or without BR and MAS versus the general population. It was, however, not able to discriminate between A-BR vs. I-BR as well as BR vs. general population. It is not clear whether this was due to the insensitivity of the instrument, insufficient sample sizes, or because there were no actual differences in QoL between these groups. Good convergent and discriminant validity of both the EQ-5D-5L and its individual dimensions were demonstrated. Additional support for the instrument's validity was revealed by moderate correlations between the generic EQ-5D-5L and specific QoL aspects of BR such as sexuality and body image. Conclusions The results of this study support the validity of the EQ-5D-5L as an outcome measure in health economic evaluations of BR.

IntroductionTwo-stage implant-based breast reconstruction is the most commonly performed postmastectomy reconstructive technique. During the first stage, a tissue expander creates a sufficiently large pocket for the definite breast implant placed in the second stage. Capsular contracture is a common long-term complication associated with implant-based breast reconstruction, causing functional complaints and often requiring reoperation. The exact aetiology is still unknown, but a relationship between the outer surface of the implant and the probability of developing capsular contracture has been suggested. The purpose of this study is to determine whether polyurethane-covered implants result in a different capsular contracture rate than textured implants.Methods and analysisThe Textured Implants versus Polyurethane-covered Implants (TIPI) trial is a multicentre randomised controlled trial with a 1:1 allocation rate and a follow-up of 10 years. A total of 321 breasts of female adults undergoing a two-stage breast reconstruction will be enrolled. The primary outcome is capsular contracture at 10-year follow-up which is graded with the modified Baker classification. It is analysed with survival analysis using a frailty model for clustered interval-censored data, with both an intention-to-treat and per-protocol approach. Secondary outcomes are other complication rates, surgical revision rate, patient satisfaction and quality of life and user-friendliness. Outcomes are measured 2 weeks, 6 months, 1, 2, 3, 5 and 10 years postoperatively. Interim analysis is performed when 1-year, 3-year and 5-year follow-up is completed.Ethics and disseminationThe trial has been reviewed and approved by the Medical Research Ethics Committee of the Erasmus MC, University Medical Centre Rotterdam (MEC-2018-126) and locally by each participating centre. Written informed consent will be obtained from each study participant. The results will be disseminated by publication in peer-reviewed journals.Trial registrationNTR7265.

Purpose A breast cancer diagnosis can threaten every aspect of a woman’s wellbeing, including her mental health. With the growing number of breast cancer survivors, longitudinal studies addressing mental health in this population are of increasing importance now more than ever. Therefore, the current study investigated trends in emotional functioning and psychosocial wellbeing of breast cancer survivors, and the demographic and treatment characteristics that may influence these trends. Methods Prospectively collected data of women treated for breast cancer at the Erasmus MC was analyzed in this study. Emotional functioning was measured using the EORTC-QLQ-C30, while psychosocial wellbeing was measured using the BREAST-Q. Type of surgery, age, family status and employment status of study participants were retrieved from patient files. Multilevel analysis was performed to identify trends in emotional functioning and psychosocial wellbeing and to determine the relationship between aforementioned characteristics and these trends. Results 334 cancer survivors were analyzed. Psychosocial wellbeing declined, but emotional functioning showed a steady improvement over time. Type of surgery was associated with changes in emotional functioning and family status with changes in psychosocial wellbeing: women who underwent breast reconstruction showed a steeper increase in their emotional functioning and women with no partner or children showed a greater decline in psychosocial wellbeing between baseline and 12 months after surgery. Conclusion These findings can be utilized by healthcare teams to identify breast cancer patients at risk for emotional problems and to provide adequate psychological support to those women who need help dealing with their emotions and self-concept in order to optimize clinical treatment.

Summary Background The radial forearm free flap (RFFF) has been used extensively for complex tissue defect reconstructions; however, the potential for significant donor-site morbidity remains a major drawback. Despite an abundance of literature on donor-site morbidities, no consensus has been reached on exact incidences of sensory morbidities that vary largely between 0% and 46%. Incidences of neuropathic pain in the donor site following RFFF still lack, even though clinical experience shows it often occurs. Therefore, the purpose of this systematic review was to identify the incidence of neuropathic pain and altered sensation in the hand following harvesting of a RFFF. Methods A systematic search was performed in multiple databases (Embase, Medline, Cochrane, Web of Science, and Google Scholar). Studies from 1990 onwards that reported donor-site morbidities following harvest of the RFFF were included. Analyzed parameters included hand pain, hypoesthesia, cold intolerance, hyperesthesia, neuroma formation, paresthesia, sharp sensation loss, light sensation loss, and defect closure. Results Of the 987 selected studies, 51 eligible articles were selected. The mean level of evidence was 3 (SD 0.6). Twenty articles reported pain as a donor-site morbidity, and the mean incidence of pain reported was 23% (SD 7.8). Hypoesthesia was reported by 37 articles and had a mean incidence of 34% (SD 25). Locations of pain and hypoesthesia included, amongst others, the area of the radial sensory nerve and the skin graft area. The mean incidences of cold intolerance and hyperesthesia were 13% (SD 13) and 16% (SD 15), respectively. Conclusion The results of this systematic review suggest that 23% of all patients are dealing with neuropathic pain in the donor-site following harvest of an RFFF. Future studies should therefore focus on the prognostic factors and preventive measures of neuropathic pain to further improve clinical outcomes of this widely used flap.

Background All women undergoing a mastectomy have the right to reconstruction. However, many women do not receive reconstruction and many more are not aware of all the reconstructive options available to them. Travel distance to a center that provides reconstruction and subsequent follow-up may be a contributing factor to this disparity especially among those who seek microsurgical options. Telehealth, which provides patients with remote video consultations and decreases the travel burden, may be a solution to optimize the accessibility of breast reconstruction for these patients. The purpose of this study was to discuss the efficacy and reliability of telehealth to overcome geographic barriers. Methods Patients who received breast reconstruction and participated in video telehealth visits between February and May 2020 were included in this study. Patient demographics, comorbidities, and clinical outcomes were collected. Video telehealth encounters were reviewed to determine specific concerns and questions discussed during these encounters. Results A total of 235 breast reconstruction surgery patient encounters were recorded for 4 plastic surgeons who offer microsurgical breast reconstruction. Eighty-eight patients (37.4%) were seen as telehealth visits, 20 (22.7%) of which were new patient visits. Eight (9.09%) patients were microsurgical breast reconstruction candidates and 25 (28.4%) were following-up after microsurgical breast reconstruction. The majority of telehealth visits included normally healing wounds in the postoperative patient. Conclusion Telehealth provides an avenue for premastectomy consultation, second opinion visits, and postoperative follow-up for patients who have geographical barriers precluding them from reaching plastic surgeons who perform all types of breast reconstruction.

Layperson assessments are becoming increasingly important in the evaluation of surgical procedures of the face, including smile reanimation. In this study, the authors set out to answer 3 questions: (1) are esthetic scores more dependent on the assessor or the person that is being assessed, (2) how does smile reanimation change esthetic scores, (3) do sex and age of the patient and assessor explain some of the esthetic outcomes?Thirty-five assessors scored pre and postoperative photographs of 21 facial palsy patients undergoing smile reanimation. Linear mixed-effect models were used to investigate the effects of assessor and patient factors on esthetic outcome assessments, to examine changes after smile reanimation, and to determine whether sex and age explained part of the esthetic outcomes.Fifty-eight percent of variation in the esthetic scores can be explained by some assessors being more positive in their esthetic scoring compared to other assessors. Twenty-nine percent was attributed to patient baseline esthetic scores. Overall esthetic scores improved after smile reanimation. Sex and age of the patient and assessor could not explain variation in the esthetic scores.Esthetic appearance highly depends on "who is looking.'' These findings are important for preoperative counseling, and for those treating and educating patients with facial palsy.

Objectives: To define metastatic categories based on their prognostic significance. We hypothesized that oligometastasis in patients with head and neck squamous cell carcinoma (HNSCC) is associated with better post-distant metastasis disease specific survival (post-DM DSS) compared to patients with polymetastasis. Furthermore, the impact on survival of synchronous versus metachronous distant metastasis (DM) occurrence was assessed. Materials and methods: Retrospective cohort study in which patients with DM were stratified into three groups: oligometastasis (maximum of 3 metastatic foci in ≤2 anatomic sites), explosive metastasis (≥4 metastatic foci at one anatomic site) and explosive-disseminating metastasis (spread to ≥3 anatomic sites or >3 metastatic foci in 2 anatomic sites). In addition, patients were divided into synchronous versus metachronous DM. Results: Between January 1, 2006 and December 31, 2013, a total of 2687 patients with HNSCC were identified, of which 324 patients developed DM. In this group, 115 (35.5%) patients had oligometastasis, 64 (19.8%) patients had explosive metastasis and 145 (44.8%) patients had explosive-disseminating metastasis. Their median post-DM DSS were 4.7 months, 4.1 months and 1.7 months respectively (p

Background There is no consensus regarding the impact of oncoplastic surgery (OPS) on rates of re‐excision and conversion to mastectomy following breast‐conserving surgery (BCS). Here these two outcomes after BCS and OPS were compared in a nationwide population‐based setting. Methods In Denmark, all OPS is registered and categorized into volume displacement, volume reduction or volume replacement. Patients who underwent BCS or OPS between 2012 and 2018 were selected from the Danish Breast Cancer Group database. Multivariable analyses were performed to adjust for confounders, and propensity score matching to limit potential confounding by indication bias. Results A total of 13 185 patients (72·5 per cent) underwent BCS and 5003 (27·5 per cent) OPS. Volume displacement was used in 4171 patients (83·4 per cent), volume reduction in 679 (13·6 per cent) and volume replacement in 153 (3·1 per cent). Re‐excision rates were 15·6 and 14·1 per cent after BCS and OPS respectively. After adjusting for confounders, patients were less likely to have a re‐excision following OPS than BCS (odds ratio (OR) 0·80, 95 per cent c.i. 0·72 to 0·88), specifically after volume displacement and reduction. The rate of conversion to mastectomy was similar after OPS and BCS (3·2 versus 3·7 per cent; P = 0·105), but with a lower risk in adjusted analysis (OR 0·69, 0·58 to 0·84), specifically after volume displacement and reduction procedures. Findings were similar after propensity score matching. Conclusion A modest decrease in re‐excision rate and less frequent conversion to mastectomy were observed after OPS compared with BCS., Compared with breast‐conserving surgery, oncoplastic surgery results in a modest decrease in re‐excision rates and less frequent conversion to mastectomy. Rates similar to breast‐conserving surgery only

Background Previous studies have shown that breast cancer patients with a low socioeconomic status (SES) are less likely to undergo postmastectomy immediate breast reconstruction (IBR). However, these studies were performed in countries with unequal access to healthcare. Therefore, the aim of this study was to investigate whether SES also contributes to the likelihood of receiving IBR in a country with equal access to healthcare. Materials and methods Patients with stage I or II breast cancer diagnosed between 2011 and 2018 who underwent mastectomy were selected from the Netherlands Cancer Registry. SES was calculated from the average incomes of each postal code which were divided into 10-deciles. Primary outcome was the effect of SES on the likelihood of receiving IBR, controlled for patient, tumour and hospital characteristics expressed as Odds Ratio (OR) with 95% confidence interval (CI). Results Higher SES significantly increased the probability of undergoing postmastectomy IBR (OR 1.05 per 10% SES stratum), just as larger hospital volume (average volume OR 1.89 and large volume 2.58), oestrogen positive tumours (OR 1.19) and neo-adjuvant therapy (OR 1.42). In contrast, factors significantly reducing the likelihood of receiving IBR were older age (OR 0.92 per year), stage II (OR 0.61 compared to stage I) and adjuvant therapy (OR 0.56). Conclusion Women with lower SES undergoing mastectomy were less likely to receive postmastectomy IBR. More research is warranted to study whether lifestyle factors associated with lower SES such as smoking and higher BMI, language barrier, illiteracy and less access to internet explain these differences.

Purpose Breast-contour preservation (BCP) is possible for most women treated for early-stage breast cancer. BCP can be defined as primary breast-conserving treatment (BCT), neoadjuvant chemotherapy (NAC) followed by BCT and immediate postmastectomy breast reconstruction (IBR). This study provides insight in current BCP strategies in Denmark and the Netherlands and aims to identify opportunities for improvement within both countries. Methods A total of 92,881 patients with early-stage breast cancer who were operated in Denmark and the Netherlands between 2012 and 2017 were selected from the Danish Breast Cancer Group and the Dutch National Breast Cancer Audit databases. BCP procedures and predictive factors were analyzed within and between both countries. Results BCP was achieved in 76.7% (n = 16,355) of the Danish and in 74.5% (n = 53,328) of the Dutch patients. While BCP rate did not change significantly over time in Denmark (p = 0.250), a significant increase in BCP rate from 69.5% in 2012 to 78.5% in 2017 (p Conclusions In more than 75% of all Danish and Dutch patients, surgically treated for early-stage breast cancer, the breast-contour was preserved. The different use of BCP strategies within Denmark and the Netherlands and the differences observed between hospitals in both countries emphasize the need for more (inter)national consensus on treatment modalities.

Virtual and augmented reality (VR and AR) are fast-developing technologies that allow the three-dimensional visualization of digital information.This systematic review aimed to compare the application of VR and AR to conventional methods in preoperative planning of plastic surgical procedures.A systematic literature search was conducted in Embase, Medline (Ovid), Web-of-Science, Cochrane, and Google Scholar databases on October 11, 2019. All literature comparing AR and/or VR with conventional methods for preoperative planning was collected. Only articles that studied at least one of the following outcomes were included: technical accuracy of the procedure, operative time, complications, and costs of total intervention.No articles on VR were found. Six articles were found on interventions performed with AR assistance. AR showed to be significantly better for the accuracy of osteotomies in mandibular angle osteotomies and intraoral mandible distraction compared to conventional methods. For synostotic plagiocephaly and orbital hypertelorism correction, the use of AR demonstrated a precise osteotomy. Intraoperative perforator identification in DIEP flap procedures was more accurate with AR compared to Doppler ultrasound. Harvesting time (p0.012) and operative time (p0.01) in DIEP-flap procedures and mandibular angle osteotomies, respectively, were significantly reduced if AR was used. No articles were found regarding the costs of using AR for preoperative planning.AR technology has the potential to assist the plastic surgeon in operating more accurately, safely, and fast. Studies on VR technology for preoperative planning in plastic surgery are lacking. More comparative studies are necessary, including data on clinical outcomes and cost-effectiveness.

Introduction: Currently, there is limited literature on reconstructive trends for inpatient head and neck skin cancer. Rather, studies have focused primarily on patients treated on an outpatient basis. To gain a better understanding of the effect that reconstructive correction of complex skin cancer defects has on the healthcare system, we examined the existing incidence and reconstructive trends of head and neck melanoma and nonmelanoma skin cancer (NMSC) in the inpatient setting. Method: We performed the analysis of the Healthcare Cost and Utilization Project Nationwide Inpatient Sample Database (NIS) for the years 2012–2014 of the United States (US). Adults diagnosed with melanoma skin cancer or NMSC of the head and neck region were included. Patient characteristics, reconstructive modality, surgical specifics, and outcomes were retrieved. Trends with time for reconstruction techniques were analyzed. Results: In total, 41,185 patients with a diagnosis of skin malignancy were identified, of whom 5,480 (13.3%) underwent reconstruction. Most patients were white (90.0%), male (71.6%), and had a diagnosis of NMSC (79.2%). An increase in flap reconstruction (p < 0.001) was observed. After population adjustment, the highest incidence of skin malignancy was found in the Northeast. Conclusion: There has been a trending increase in inpatient NMSC and melanoma skin cancer of the head and neck region, correlating to an increase in the reconstructive procedures performed, and greater cost burden. Resources may be allocated toward early identification and treatment for skin cancer to help control the current rise in complex skin cancer cases necessitating inpatient admission.

Background Microsurgical reconstruction of upper extremity injuries is often challenging, and the resulting impact on the quality of life (QoL) may be significant. However, there is a lack of knowledge on long-term patient-reported QoL. Methods In a retrospective long-term follow-up study, all consecutive patients with an upper extremity injury who had undergone a free flap reconstruction were identified and categorized into three groups based on the type of injury. Patient-reported upper extremity function and QoL were assessed using three validated questionnaires: the 36-item Short Form Health Survey (SF-36), the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, and the Michigan Hand Outcomes Questionnaire (MHQ). Results A total of 61 patients were identified, of whom 10% had undergone a free flap reconstruction for soft tissue loss only, 62% for an injury accompanied by a fracture, and 28% for a (sub) total amputation. Twenty-one (44%) patients responded to the questionnaires, with a mean follow-up time of 9.7 ± 6.2 years. Patients, on average, reported poorer SF-36 “physical component score” and “role limitations due to physical health” scores compared with Dutch norms. Also, they reported poorer mean DASH scores compared with the general population, indicating worse upper extremity function. Mean MQH scores were lower for the injured side compared with the noninjured side. Pain correlated negatively with the total scores of DASH, MHQ, and SF-36. Conclusion Free flap upper extremity reconstruction is challenging. At 10 years of follow-up, the injury and its treatment continued to have a significant impact on the upper extremity function and daily QoL, with chronic pain being an important factor negatively affecting these outcomes.

Background: Differences in quality-of-life outcomes after different surgical breast cancer treatment options, including breast reconstruction, are relevant for counseling individual patients in clinical decision-making, and for (societal) evaluations such as cost-effectiveness analyses. However, current literature shows contradictory results, because of use of different patient-reported outcome measures and study designs with limited patient numbers. The authors set out to improve this evidence using patient-reported outcome measures in a large, cross-sectional study for different surgical breast cancer treatment options. Methods: Quality of life was assessed through the EQ-5D-5L, European Organization for Research and Treatment of Cancer Quality of Life Questionnaires C30 and BR23, and the BREAST-Q. Patients with different treatments were compared after propensity-weighted adjustment of pretreatment differences. The EQ-5D was used to value the effect of surgical complications. Results: A total of 1871 breast cancer patients participated (breast-conserving surgery, n = 615; mastectomy, n = 507; autologous reconstruction, n = 330; and implant-based reconstruction, n = 419). Mastectomy patients reported the lowest EQ-5D score (mastectomy, 0.805, breast-conserving surgery, 0.844; autologous reconstruction, 0.849; and implant-based reconstruction, 0.850) and functioning scores of the C30 questionnaire. On the BREAST-Q, autologous reconstruction patients had higher mean Satisfaction with Outcome, Satisfaction with Breasts, and Sexual Well-being scores than implant-based reconstruction patients. Complications in autologous reconstruction patients resulted in a substantially lower quality of life than in implant-based reconstruction patients. Conclusions: This study shows the added value of breast conservation and reconstruction compared with mastectomy; however, differences among breastconserving surgery, implant-based reconstruction, and autologous breast reconstruction were subtle. Complications resulted in poorer health-related quality of life. (Plast. Reconstr. Surg. 146: 1, 2020.)

Background The use of simultaneous, multiple free flaps has become a reliable reconstructive option in patients with extensive composite defects after resection of locally advanced head and neck cancer. However, some reluctance remains among reconstructive surgeons with concerns regarding flap outcomes and limited patient survival. Therefore, we evaluated complications, long-term patient survival, and patient-reported outcomes following these extensive head and neck reconstructions. Methods All consecutive patients treated with multiple free flaps for reconstruction of extensive composite defects after resection of locally advanced head and neck cancer between 1999 and 2014 were retrospectively reviewed. Patient charts were evaluated for demographics, treatment details, complications, and patient survival. In addition, all patients alive at the start of the study were asked to complete the 10-item Eat Assessment Tool (EAT-10) and the Intelligibility Rating Scale (IRS). Results Eighty-four simultaneous, multiple free flaps were performed in 42 patients. The predominant free flap combination consisted of a fibula with either an anterolateral thigh (n = 22) or a radial forearm flap (n = 14). Complete flap survival was 95%. Nineteen patients were still alive with a mean follow-up of 55 months. Five-year patient survival was 46.3%. Mean EAT-10 score was 8.4 (range: 0–29), with only one patient reporting problematic swallowing. Ninety percent of the patients had moderate to good speech intelligibility with the IRS. Conclusion Multiple, simultaneous free flaps can be performed safely, leading to acceptable long-term patient survival and patient-reported functional outcomes. Our study demonstrates that it is worthwhile to perform these challenging microvascular reconstructions in patients with locally advanced head and neck cancer.