Abstracts til DSPR forårsmøde 2014

Abstracts til DSPR forårsmøde 2014 Title: Utility of Sentinel Lymph Node Biopsy in Patients with High-Risk Squamous Cell Carcinoma Authors: Julie E. Allen, Lars B Stolle Institution: Department of Plastic Surgery, Aarhus University Hospital Aim/background: Currently there is no consensual agreement on the standard use of Sentinel Lymph Node Biopsy (SLNB) in staging of high-risk patients. The aim of the study was to define the predictive value and role of SLNB combined with the different high-risk factors to determine which patients could benefit from SLNB. Material and method: We conducted a review of the literature on cutaneous squamous cell carcinoma (SCC) and SLNB published in the year 2000 until May 2012. 173 patients with SCC tumors and SLNB were found. Risk factors were listed along with lymph node status. Sensitivity, specificity and negative predictive value (NPV) were calculated for the cumulative results for each risk factor. Results: Sensitivity for the total cohort was 79 %, specificity was 100 % and negative predictive value was 96%. The sensitivity, specificity and NPV were 78.26%, 100% and 95.14%, respectively, for tumor size > 2 cm. Sensitivity, specificity and NPV for a tumor localized at a high-risk area were 72.63 %, 100% and 96.74%, respectively. Specificity was 100 % as was NPV for immunosuppression. Discussion/Conclusion: SLNB has a high NPV and low false negative rate and carries a low risk of complications. SLNB may prove to enhance the survival or aid the prognosis of high-risk cscc. Further, detailed investigations and longer follow-up times are needed to define the right group of patients that could benefit from this procedure. The wound inflammatory response exacerbates growth of pre-neoplastic cells and progression to melanoma Nicole Antonio1*, Louise Bønnelykke-Behrndtz2,3*, Ib Jarle Christensen4, Torben Steiniche5, Henrik Schmidt3, Yi Feng3, Paul Martin1,45 *Joint first authors Corresponding authors 1 School of Biochemistry, University of Bristol, UK 2 Department of Plastic and Reconstructive Surgery, Aarhus University hospital, Denmark 3 Department of Oncology, Aarhus, University hospital, Denmark 4 Finsens Laboratory, University of Copenhagen, Denmark 5 Department of Pathology, Aarhus University hospital, Denmark 6 MRC Centre for Inflammation Research, University of Edinburgh, UK 7 School of Physiology and Pharmacology, University of Bristol, UK 8School of Medicine, University of Cardiff, UK There is a longstanding association between wound healing and cancer, with cancer often described as a wound that does not heal. However, little is known about how wounding, such as after cancer surgery or biopsy, or following ulceration, might impact on cancer initiation and progression. Here we use a translucent Zebrafish larval model of Ras-driven neoplasia to live image the interaction between inflammatory cells drawn to a wound and to adjacent pre-neoplastic cells. The correlation of innate immune cells, tumour-cell proliferation and melanoma specific survival is evaluated from a matched cohort of ulcerated and non-ulcerated human melanoma with immunohistochemistry and computer-assisted image analysis. We show that neutrophils and macrophages are rapidly distracted from the wound to competing attractants from the pre-neoplastic cells and that these interactions are trophic and lead to increased proliferation of the pre-neoplastic cells. In an adult model of chronic wounding in fish with a genetic predisposition to melanoma, we 1

show that repeated wounding and consequent inflammation leads to a greater incidence of local cancer growth. Our Zebrafish studies lead us to investigate innate immune cell associations with chronic wounds in patients with melanomas and we find a strong correlation between neutrophil presence and melanoma ulceration. Furthermore, infiltration of neutrophils is associated to increased tumour-cell proliferation and poor prognostic outcome in humans. Titel: 11 primære melanomer på 32 år hos samme patient. Forfattere: Lea Juul Nielsen og Lisbet Rosenkrantz Hölmich Institution arbejdet udgår fra: Plastikkirurgisk afdeling, Herlev hospital, Københavns Universitet. Formål: At præsentere en case med 11 primære maligne melanomer (PMM) hos en enkelt patient, over en periode på 32 år, uden metastasering, med dyplastiske nævi og tilfældigt fundet colon cancer, samt at perspektivere ovenstående med relevant litteratur om emnerne multiple primære melanomer (MPM), dysplastiske nævi og sekundære primære cancere med fokus på epidemiologi, genetik, kliniske og histologiske definitioner, korrelans og prognoser. Materiale og metode: Studiet præsenteres som en kasuistik. Søgning på PubMed blev udført i april 2014, med søgeord Dysplastic nevi syndrome, Multiple malignant melanoma, Malignant melanoma AND second primary cancer and Dysplastic nevi syndrome AND multiple malignant melanoma. Resultater: En case med 11 primære maligne melanomer over 32 år, dysplastiske nævi samt nyopdaget colon-cancer præsenteres og perspektiveres med relevant litteratur. MPM ses med en incidens, for melanompatienter, på 0,2% - 13%. Heraf rapporteres hyppigst om op til 3 PMM og kun sjældent over 5, dog er der fundet enkelte cases med hhv. 24, 48 og 100 PMM. Efterfølgende PMM er typisk tyndere og mindre mitotisk aktive end det første primære melanom og patienter med MPM har en god prognose. Patienter med dysplastiske nævi er i større risiko for at udvikle melanomer og bør følges livslangt. Flere typer af sekundære primære cancere ses signifikant korrelerende til malignt melanom, dog ikke colon cancer. Konklusion: 11 primære maligne melanomer ses yderst sjældent. Patientens kliniske billede med multiple dysplastiske nævi og langtidsoverlevelse uden tegn på metastasering stemmer overenes med litteraturen på området. Patienter med dysplastiske nævi og multiple primære maligne melanomer bør følges livslangt, inkl. kliniske foto og PET-CT. Title: Hyperbaric Oxygen for Prevention and Treatment of Osteoradionecrosis of the Jaws. Authors: Anne Kristine Larsen¹, Jens Ahm Sørensen² and Torben Henrik Thygesen³ Institution: Department of Plastic Surgery¹ University Hospital of Copenhagen, Herlev.Department of Plastic Surgery² and Department of Orthodontic Surgery³, University Hospital of Odense. Background: Surgery in combination with radiotherapy has been and is still a very common oncologic treatment of head and neck cancers. One of the most severe and serious complications to the radiotherapy is osteoradionecrosis (ORN) which is seen in up to 15% of the cases. Hyperbaric oxygen treatment (HBO) has been used since the 1960s and is still being used to treat or reduce osteoradionecrosis, but the results remain controversial. Aim: To evaluate current literature on the potential effects of HBO on ORN of the jaws. Material and Methods: Based upon PubMed, Cochrane and Embase literature search English written reviews, randomized trials and case series/cohort studies are included. Non-English articles are excluded. Results: 2

Currently a total of 38 articles are included consisting of 2 randomized trials, 6 reviews and 30 case series. The first randomized trial with 12 patients compare 1.2 ATA HBO with 3.0 ATA HBO showing that patients receiving higher atmospheric pressure (3,0) had better healing of ORN. The other randomized trial shows no effect of HBO among 68 patients. Overall the case series show that there might be a beneficial in using HBO for ORN of the jaws. Discussion: Published results are consistently positive, but the level of evidence for individual publications is usually not high level, consisting mostly of case series and case reports. The RCT of Annane et al (2004) reported negative results in their study applying HBO to stage I osteoradionecrosis patients which led to major criticism from other authors. The latest review by Feldmeier (2012) reports positive outcome in applying HBO to the treatment of mandibular osteoradionecrosis. At the DSPR meeting the above mentioned articles will be presented and the overall results using HBO for ORN of the jaws will be presented and discussed. Mikrokirurgisk behandling af lymfødem. Tos T & Siim E. Plastikkirurgisk afdeling, Herlev Hospital Kræftens Bekæmpelses skønner ca. 20.000 at lider af sekundært lymfødem i Danmark. Afhængig af definitionen af lymfødem kan tallet dog være langt større. En del af disse patienter har store gener i form af tyngefornemmelse, smerte og nogle patienter har svært ved at varetage deres erhverv eller vanskeligheder med kompressionsbandagen. Mikrokirurgisk behandling af lymfødem har været udført internationalt såvel som i Danmark gennem en årerække, men med varierende resultater og ofte beskeden succes. Internationalt har denne form for behandling fået ny bevågenhed p.ga ny viden om lymfesystemets anatomi og funktion. Der er kommet nye metoder til visualisering af lymfebanerne og dermed bedre mulighed for identificering af patienter, der er egnede kandidater til kirurgi. Ved hjælp af supramicrosurgery og hertil specielt fine instrumenter, er det lykkedes forskellige centre både i Japan, USA og Europa at opnå bedre og reproducerbare resultater. Hovedsageligt findes der to typer af mikrokirurgiske operationer: Transplantation af vaskulariserede lymfeknuder til den afficerede extremitet eller lymfo-venøse anastomoser. Som følge af de positive internationale erfaringer, har vi startet et projekt på Plastikkirurgisk afdeling Herlev, hvor patienter med kronisk lymfødem bliver undersøgt med henblik på om de er egnet til behandling med lymfo-venøse anastomoser efter injektion af Indocyaningrønt i finger / tå interstitser hvorved man med flourescens lymfografi kan fremstille de subkutane lymfebaner. Alle patienter gennemgår desuden præ og post operativ evaluering med Dexascanning til nøje volumenbestemmelse af lymfødemet of fordelingen mellem fedt og væske, lymfescintigrafi, MRscanning og nøje klinisk undersøgelse. Vi har valgt at fokusere vores behandling på lymfo-venøse anastomoser og vil berette om vores principper for patientudvælgelse og den kirurgiske teknik der anvendes, samt vores første erfaringer med mikrokirurgisk behandling med multiple lymfo-venøse anastomoser. Title: Complications in skin grafts when continuing antithrombotic therapy prior to cutaneous surgery requiring skin grafting: a systematic review Authors: Reem Dina Jarjis, Lene Birk-Sørensen, Lone Jørgensen, Kenneth Finnerup Institution: Department of Plastic Surgery, Aalborg University Hospital Aim/background 3

The risk of postoperative bleeding and wound healing complications in skin grafts among anticoagulated patients undergoing cutaneous surgery has not been firmly established. The objective was to review the literature and to ascertain the frequency of postoperative bleeding or wound healing complications in skin grafts in anticoagulated patients, compared to patients who discontinue or patients who are not receiving antithrombotic therapy prior to cutaneous surgery requiring skin grafting. Methods A systematic review examining the effect of antithrombotic therapy on cutaneous surgery was performed. PubMed and Embase databases were primarily searched for relevant literature in the period from the start date of each database to 2014. A total of eight studies representing 443patients met criteria for inclusion. No randomized controlled trials were found; the included studies were of prospective and retrospective design. Results Most studies found that there is no statistically significant effect of aspirin, warfarin or NSAID on the rate of bleeding complications observed. Multiagent regimen, e.g. aspirin plus clopidogrel, was associated with higher risk of significant postoperative bleeding and graft necrosis. Conclusion The use of antithrombotic therapy increases the risk of bleeding complications in skin grafts slightly and care should be taken when operating on these patients. However, graft failure is rare and given the risk of thrombotic events, the reviewed studies recommend continuing all medically necessary anticoagulant medications. Limitations of this study are the small sample size and the level of evidence; hence more research is needed to substantiate these preliminary findings. TITLE: Static suspension of facial palsy, using a double layered palmaris longus tendon; a case series AUTHORS: Navid M. Toyserkani, Vivi Bakholdt, Jens Ahm Sørensen INSTITUTION: Department of Plastic and Reconstructive Surgery, Odense University Hospital, Denmark AIM/BACKGROUND: Facial palsy is a debilitating condition leading to both cosmetic and functional limitations. Static suspension procedures can be performed when more advanced dynamic techniques are not indicated. Since 2006 we have used a double layered palmaris longus tendon graft through an ovular skin excision in the melolabial fold for access. The aim is to describe our surgical technique and present our case series. MATERIAL AND METHODS: The study was a retrospective case series in a university hospital setting. All patients who had this procedure performed were included until August 2013. Data from electronic patient records was retrieved and patients were invited for a follow-up visit and results were measured using the Lip Reanimation Outcomes Questionnaire and standardized photographs were taken and evaluated by multiple surgeons. RESULTS: In total 14 patients were included with a mean follow up of 46 months (range 3-89 months). 93% noted an improvement of their facial appearance at follow up. 7 out of 11 patients with preoperative problems with speech noted an improvement at follow up. 8 out of 13 patients with preoperative problems with oral competence noted an improvement at follow up. Photographic evaluation revealed an acceptable symmetry at rest with an increasing asymmetry with increasing smile intensity. No postoperative complications were noted in any of our patients. CONCLUSION : Our technique is easy to perform with no noteworthy complications and improves the quality of life of patients with facial palsy. It is an acceptable alternative when more advanced procedures are not indicated. 4

Titel: Lokalanalgesi med vasokonstriktor kan anvendes i områder med endearterier. Forfattere: Lea Juul Nielsen, Pavia Lumholt og Lisbet Rosenkrantz Hölmich Institution arbejdet udgår fra: Plastikkirurgisk afdeling, Herlev hospital, Københavns Universitet. Formål: Lærebøger, instrukser og undervisere på medicinstudiet docerer fortsat, at anvendelse af lokalanalgesi (LA) tilsat vasokonstriktor i det terminale vaskulære system i fingre, tæer, ører og næse er kontraindiceret og kan medføre iskæmi og nekrose. Mange klinikere har dog erfaret, at LA tilsat vasokonstriktor kan anvendes sikkert og med store fordele. Formålet med dette review er at fremlægge evidens for at anvendelse af LA tilsat vasokonstriktor ikke medfører komplikationer. Materiale og metode: Studiet er et litteraturstudie. Søgning på PubMed blev udført med søgeord Local anesthesia AND epinephrine, Local anesthesia AND norepinephrine, Finger AND epinephrine, Ischemia AND epinephrine, Ischemia AND accidental injection og Phentolamine. De nyeste udgaver af større tekstbøger er gennemgået ligesom skadestueinstrukser på Region Hovedstadens netværk. Resultater: Der fandtes 5 prospektive observationsstudier, 1 prospektivt, randomiseret og kontrolleret studie, 4 prospektive, randomiserede, kontrollerede og dobbelt-blindede studier, 6 retrospektive opgørelser og 7 reviews. I alt indgår 15.189 patienter, hvoraf 14.631 har fået injiceret LA med adrenalin. Ingen af de gennemgåede artikler beskriver tilfælde af iskæmi eller gangræn efter anvendelse af LA med adrenalin. Konklusion: Lidokain med adrenalin er sikkert at anvende som lokalanalgesi i hhv. fingre, tæer, næse og ører. Title: Retrospective analysis of patients with and without muscle flap transposition to reconstruct defect after deep sternal wound infection due to open-heart surgery. Authors: Tina S. Videbæk, MD PhD, Alexander A. Juhl, MD, Per H. Nielsen, MD, Sofie Hody, Stud. Med. & Tine E. Damsgaard MD PhD Institution: Plastic Surgery Research Unit and Dept. of Thoracic Surgery, Aarhus University Hospital, Aarhus, Denmark Aim/background The management of sternal defects arisen after deep sternal wound infection (DSWI) continues to pose a challenge and interdisciplinary teamwork between plastic and thoracic surgeons is often needed. At present, no standard treatment algorithm is available for the timing of plastic surgery intervention. In this study, DSWI patients with and without flap reconstruction were analysed to clarify the right time for plastic surgery intervention. Material and Methods The study was performed as a retrospective study of all patients who developed DSWI after openheart surgery (OHS) at Aarhus University Hospital from 1999-2011. Patients were identified by means of The Danish Hearth Database. Results: In total, 131 patients developed DSWI after OHS in the studied period. Of these, 112 patient records were available for review. Flap reconstruction was needed in 42% of cases. The baseline characteristics were comparable for patients with (n=47) and without (n=65) flap surgery in regards to age, gender, smoking, diabetes, EuroSCORE, and thoracic surgery type. Sternal reconstructions were performed with pectoralis muscle flaps, either bilateral (n=30), unilateral (n=8), in combination with a rectus abdominis muscle flap (n=8), or a rectus abdominis muscle flap alone (n=1). Time from primary thoracic surgery to DSWI diagnosis was similar between groups, but 5

patients who received flap surgery had significantly longer hospital stays (56 vs. 36 days) and the time from DSWI to discharge was prolonged (52 vs. 27 days). Of patients with flap reconstruction 15 (32.6%) had more than four reoperations before flap reconstruction as compared to 14 (21.2%) of the patients without flap reconstruction. The median patient with flap surgery was discharged 15 days after reconstruction. Discussion/Conclusion Patients receiving flap reconstruction has significantly longer hospital stays. However, after flap reconstruction patients are relatively quickly discharged. The number of reoperations and the hospital stay could potentially be reduced by earlier plastic surgery intervention. Outcomes after curative or palliative surgery for locoregional recurrent breast cancer Authors: Alexander Andersen Juhl1, Marco Mele2, Tine Engberg Damsgaard1 Institution: 1Plastic Surgery Research Unit, Department of Plastic Surgery, Aarhus University Hospital, Aarhus, Denmark. 2 Breast and Endocrine Unit, Aarhus University Hospital, Aarhus, Denmark Aim/background Locoregional recurrence (LRR) after breast cancer is an independent predictor for later systemic disease and poor long-term outcome. As the surgical treatment is complex and often leaves the patient with extensive defects, reconstructive procedures involving flaps, and thus plastic surgical assistance, are often required. The aim of the present study was to evaluate our institution s approach to surgical treatment for locoregional recurrence of a breast cancer. Material and Methods In the present retrospective, single-centre study, we evaluate our experience with 12 patients who underwent surgery for locally recurrent breast cancer at Aarhus University Hospital between 2006 and 2010. Nine patients underwent wide local excision. The remaining three patients underwent full thickness chest wall resection. Results There was no perioperative mortality and no major complications. Minor complications occurred in four (33 %) of the patients. Median overall survival was 22 months, regardless of the surgery being curative or palliative. A median disease-free survival of 18 months was achieved for patients having achieved radicality. Discussion/Conclusion Both wide local excision and full thickness chest wall resection offer the opportunity of local control and palliation in patients with LRR. The plastic surgical reconstructive procedures are associated with a low complication rate, and thus not postponing further adjuvant therapy. However, a multidisciplinary approach with a highly careful patient selection is critical in order to ensure the best outcome for the patient. Title: Practice of preoperative breast cancer screening in mammaplasty in Denmark. Authors: Thomas Foged, Jens Ahm Sørensen, Camilla Bille. Institution: Department of Plastic Surgery, Odense University Hospital. Aim/background: In Denmark, mammaplasty, including breast reduction, breast augmentation and mastopexy, is done by plastic surgeons at the 8 public plastic surgery departments and in more than 50 private clinics. These procedures are often performed at women aged 20-50 years. Screening for breast cancer is offered all Danish women from 50-69 years old. There exist no national guideline regarding when to perform preoperative breast imaging before mammaplasty. The objective of this study was to investigate selection criteria for preoperative breast imaging prior to mammoplasty among plastic surgeons in Denmark. 6

Material and Methods: The authors conducted two questions: 1) which age groups preoperative imaging is recommended, and 2) how old such an imaging was allowed to be before repeated. We studied all accessible websites on plastic surgery departments and private clinics offering plastic surgery in Denmark. We contacted those who did not have accessible information, together with all breast surgery departments, via e-mail. Results: Information was obtainable from 88% of the selected surgical facilities. Overall 53% recommended a preoperative screening among women aged 40+. Among the plastic surgery departments, 62% and 38% recommended preoperative screening among 40+ and 35+ year old women respectively. Among the breast surgery departments 42%, 33% and 17% recommended screening among women aged 40+, 35+ and 30+. Recommendations at the private clinics differed more, but still with 55% recommending preoperative screening among 40+ year old women. Often the second question, allowed age of the imaging, was unanswered. However, 25 out of 33 respondents accepted an imaging younger than 12 months. Conclusion: Even though some variations in recommendations for preoperative breast cancer screening in Denmark exist, most places recognize the importance of screening for breast cancer before mammaplasty. Måling af livskvalitet hos brystrekonstruktionspatienter: Breast-- Q nu tilgængeligt på dansk Forfattere: Cecilie Balslev Willert, Caroline Asirvatham Gjørup, Lisbet Rosenkrantz Hölmich Institution arbejdet udgår fra: Plastikkirurgisk Afdeling V, Herlev Hospital Formål: At foretage en lingvistisk validering af Breast-- Q mhp. måling af livskvalitet hos danske brystrekonstruktionspatienter. Baggrund: I Danmark foretages skønsmæssigt 300 brystrekonstruktioner årligt. Operationens primære formål er at fremme patientens livskvalitet, og det er derfor relevant også at se på patientens ændring i livskvalitet som supplement til komplikationsrater og objektive resultater, når behandlingseffekten vurderes. Der er i Danmark endnu ikke videnskabelig evidens for, at en brystrekonstruktion fremmer patientens livskvalitet. Til at måle livskvalitet benyttes ofte spørgeskemaer. Et generisk spørgeskema kan bruges på tværs af patientgrupper, mens et specifikt Spørgeskema kun kan bruges til en særlig patientgruppe. Sidstnævnte har større sensitivitet. Brystrekonstruktionspatienter har problemstillinger der adskiller sig væsentligt fra andre patientgrupper, og et specifikt spørgeskema er derfor at foretrække. Et sådant findes endnu ikke på dansk. Breast-- Q er et nyt nordamerikansk spørgeskema der måler sundhedsrelateret livskvalitet og Patienttilfredshed hos patienter der får foretaget rekonstruktiv og kosmetisk brystkirurgi. Breast-- Q består af 4 moduler (mastektomi, rekonstruktion, augmentation, reduktion). For at kunne anvende Breast-- Q (rekonstruktionsmodul) i Danmark er det nødvendigt at foretage en lingvistisk validering, et projekt som netop er afsluttet. Formålet med præsentationen er at gøre rede for, hvordan en lingvistisk validering foregår, samt præsentere spørgeskemaet. Metode: Til den lingvistiske validering blev retningslinjerne fra MAPI Research Trust (www.mapi- - trust.org) brugt. Det indebærer forward og backward translation samt patienttestning. Resultater: Breast-- Q (rekonstruktionsmodul) har gennemgået en lingvistisk validering og er godkendt til brug i Danmark. Det forventes taget i brug foråret/sommeren 2014. Der planlægges fsamtidigt en dansk fvalidering. Diskussion/konklusion: Måling af livskvalitet hos brystrekonstruktionspatienter i Danmark kan optimere behandlingen og patientvejledningen i fremtiden, samt få sundhedspolitisk betydning. Breast-- Q (rekonstruktionsmodul) er et spørgeskema udviklet specifikt til denne patientgruppe og er netop godkendt til brug i Danmark. Lingvistiske valideringer af de øvrige moduler er under udarbejdelse. Måling af livskvalitet hos brystrekonstruktionspatienter: Breast-- Q nu tilgængeligt på dansk 7

Cecilie Balslev Willert, Caroline Asirvatham Gjørup, Lisbet Rosenkrantz Hölmich Mid-term evaluation of delayed unilateral breast reconstruction after mastectomy Authors: Alexander Andersen Juhl1, Bekka O. Christensen1, Tine Engberg Damsgaard1 Institution: 1Plastic Surgery Research Unit, Department of Plastic Surgery, Aarhus University Hospital, Aarhus, Denmark Aim/background The number of breast reconstructive procedures is increasing, and according to Danish guidelines, all women having undergone mastectomy are offered a breast reconstruction. The aim of the study was to assess the mid-term subjective and objective outcome of different reconstructive methods. Material and Methods A total of 135 women who underwent a delayed unilateral breast reconstruction after mastectomy in the Central Region of Denmark, between January 2005 and July 2011, were included. Data were collected from the patient charts, a study specific questionnaire evaluating the satisfaction with the breast reconstruction, and a clinical follow-up. Results 117 (87%) women answered the questionnaire and 64 (47%) participated in the follow-up visit. The median follow-up time was 3.8 years. Women reconstructed with abdominal based flaps were more pleased with their aesthetic outcome, compared to women who received reconstructions based on implants, latissimus dorsi or thoracodorsal flaps. The objective evaluation did not reveal any significant difference between the reconstructive methods. There were no significant differences in major complications between the groups. Complications did not have an impact on the subjective or objective aesthetic outcome. Discussion/Conclusion Women reconstructed with an abdominal flap were significantly more pleased with the aesthetic result of their breast reconstruction. This was not supported by the clinical evaluation. No difference in the overall satisfaction with having received a breast reconstruction or the perceived gain in quality of life was found between the different reconstructive procedures. Regardless of reconstructive type, the women reported a high general satisfaction. Titel: Lipofilling til korrektion af indtrukken lumpektomi-cikatrice Forfattere: Anne Kristine Larsen, Elsebeth Siim og Lisbet Rosenkrantz Hölmich Institution: Plastikkirurgisk afdeling, Herlev Hospital Baggrund: Kirurgisk behandling af brystkræft består i cirka 2/3 af tilfældene af en brystbevarende operation (lumpektomi). I nogle tilfælde kan der forekomme uskøn indtrukken lumpektomi-cikatrice og synlig vævsmangel. Lipofilling er en ret ny metode, hvor konturdefekter i brystet eller indtrukken cikatrice kan korrigeres med eget væv i form af fedtceller, som efter udsugning andetsteds på kroppen og raffineringsprocedure kan injiceres i det område af brystet, hvor der er vævsmangel eller indtrukken cikatrice. Samtidig løsnes arret. Komplikationer til lipofilling er få, men metodens berettigelse er diskuteret pga. frygt for efterfølgende at overse tegn på brystkræft recidiv ved mammografi. Formål: Projektet har til formål at beskrive resultater ved lipofillingprocedure, evt. komplikationer, patologiske fund ved efterfølgende mammografiscreening og via en patient spørgeskemaundersøgelse klarlægge, hvorvidt patienterne synes, at der var gavnlig effekt af lipofillingproceduren eller ej. 8

Materiale og Metode: Inklusion af 23 lumpektomerede kvinder som fra 2009-2013 på Herlev Hospital har fået foretaget lipofilling til lumpektomi-cikatrice i korrigerende øjemed. Data er hentet via journal-gennemgang samt en spørgeskemaundersøgelse. Resultater: Ved 27 lipofillingprocedurer blev der gennemsnitlig injiceret 88 ml fedt (10-200 ml). 2 patienter (8,6 %) udviklede postoperativt behandlingskrævende (tablet) infektion i brystet. 4 kvinder (17,3 %) beskriver donorsted sequelae i form af ujævnheder eller smerter. Ved kontrol mammografi (n=18) fandtes fedtnekroser og cyster hos henholdsvis 3 (13 %) og 3 (13 %) patienter. 1 patient har siden udviklet lokalrecidiv af cancer cirka 3 år efter lipofilling. Spørgeskemaundersøgelsen viser, at 69 % af patienterne synes der er effekt af lipofilling. Diskussion og Konklusion: Lipofilling er i udlandet en anerkendt metode til rekonstruktion af vævsmangel i brystet som følge af brystkræftoperation. Overfladiske uregelmæssigheder og strammende strøg som er relateret til arvæv både efter kirurgi og strålebehandling kan løsnes ved lipofilling proceduren. Resultatet af denne mindre patientopgørelse viser effekt af lipofilling hos 69 %, og med få komplikationer. Undersøgelsen understøtter metodens anvendelighed hos denne patient-kategori. Titel: Implementering af onkoplastisk mammakirurgi i Danmark et nationalt survey Forfattere: Lena Carstensen, Afdelingslæge, Ringsted sygehus Michael Rose, Overlæge, Sydvestjysk sygehus Niels Kroman, Professor, overlæge dr. med., Rigshospitalet Formål/Baggrund: Over 4000 danske kvinder bliver diagnosticeret med operabel brystkræft hvert år. Over 70% får tilbudt brystbevarende behandling, og uden brug af plastikkirurgiske teknikker (onkoplastik), vil 20-- 30% få et utilfredsstillende kosmetisk resultat. Sundhedsstyrelsen kræver, at der tilbydes onkoplastisk kirurgi i mindst et center i hver region. Formålet med studiet er, at undersøge status for implementeringen af onkoplastik på nationalt plan. Materiale og metode: Et elektronisk spørgeskema blev sendt til alle aktive mammakirurger og plastikkirurger involveret i onkoplastisk kirurgi. Spørgeskemaet omfattede demografiske data, uddannelse, erfaring med operative procedurer og holdninger til onkoplastik. Resultater: Skemaet blev sendt til 50 mammakirurger og 22 plastikkirurger med samlet svarprocent på 67%. Alle klinikker havde et etableret samarbejde med plastikkirurger. Der rapporteredes, at mammakirurger langt overvejende udførte unilaterale displaceringsteknikker og enkelte kirurger udførte brystreduktionsteknikker, mens plastikkirurger også inkluderede brystreduktions-- og replaceringsteknikker med lokale lapper. Næsten alle symmetriskabende indgreb udførtes af plastikkirurger. Mammakirurger havde opsøgt mere onkoplastik-- specifik efteruddannelse end plastikkirurger, både internationale kliniske ophold og specialespecifikke kurser. Store dele af begge lægegrupper mente, at både det ablative og det rekonstruktive delindgreb bør ligge indenfor deres eget speciale. Den samme opfattelse sås i lægernes holdning til hvor den fremtidige uddannelse til mammakirurg bør ligge. Diskussion/Konklusion: Sundhedsstyrelsens krav om indførelsen onkoplastik i alle regioner er opfyldt, om end brugen af onkoplastiske indgreb ikke er fuldt implementeret. For at opnå det bedste resultat for patienterne, og større vidensdeling mellem specialerne, peger resultaterne af denne undersøgelse på, at den initiale vurdering af patienterne bør foretages i et multidisciplinært team hvor plastikkirurger også deltager på lige fod med mammakirurger, patologer og radiologer. 9

Titel: The over-wise mammoplasty et modificeret wise-mønster til store, superficielle tumores; en ny onkoplastisk teknik Forfattere: Lena Carstensen, Afdelingslæge, Ringsted sygehus Formål/Baggrund: Onkoplastisk mammakirurgi giver mulighed for at større tumores kan behandles med brystbevarende kirurgi ved hjælp af omplacering eller replacering af mammavæv. En ny teknik for excision af store overfladiske tumores i øvre kvadranter beskrives, og resultaterne efter et pilotstudie rapporteres. Patienter og metode: Retrospektiv opsamling af præ- og postoperative data blev indsamlet fra patienter, som havde fået foretaget over-wise mammoplastik pga. invasiv brystcancer eller DCIS. Resultater: 10 patienter blev opereret mellem november 2011 februar 2014 på Ringsted Sygehus. Gennemsnitsalderen var 53 år. Gennemsnitlig resektionsvægt var 177 g (55-570g) for tumorområder mellem 27 og 84 mm. Alle patienter fik fjernet yderligere væv mhp. formning af brystet samt modsidig reduktionsplastik. Der var frie resektionsrande hos 90%. Der var ingen recidiv eller dissiminering i followup-perioden. Kosmetisk resultat var tilfredsstillende hos alle patienter. Diskussion/Konklusion: Den deformitet, som er associeret med store resektioner i brystets øvre kvadranter bliver modvirket af denne nye operationsteknik. Komplikations- og reoperationsrate er sammenlignelig med med traditionel brystbevarende behandling. Mange onkoplastiske teknikker er baseret på Wise-mønstret, og rotation at dette i forhold til tumorplacering. Over-wise-mønstret en en simpel modifikation, som muliggør store resektioner i øvre kvadranter med et godt kosmetisk resultat. Preliminary Opinion on the safety of Poly Implant Prothèse (PIP) Silicone Breast Implants (2014 update) Lisbet Rosenkrantz Hölmich, Associate Professor, Consultant, DMSc Department of Plastic Surgery, Herlev University Hospital, Denmark Background PIP implants have since 2001been produced with non-medical grade silicone and with sub-standard production methods. The European Commision asked the Scientific Committee on Emerging and Newly Identified Health Risks (SCENIHR) to provide an updated scientific opinion on The safety of PIP silicone breast implants from 2012. Materials and Methods We performed a thorough literature review and collected data from member states as well as outside EU. Results PIP silicone gel filled breast implants (PIP implants) are reported to have a higher occurrence of rupture than other silicone breast implants, and ruptures also occur earlier than is the case with other implants. Since the previous SCENIHR opinion on PIP SBI several cyclic siloxanes (known as D4, D5 and D6) have been identified in PIP devices at much higher concentrations than in other silicone breast implants. These chemicals are commonly present in the bodies of women even without breast implants. Cyclic siloxanes D4, D5 and D6 are non-toxic and not irritant in standard tests. In some cases, implant gel-bleed or rupture has been associated with an inflammatory reaction either locally or in regional lymph nodes. In many cases, ruptures were free of symptoms. Neither 10

implant rupture, nor local inflammation, has been found to be associated with breast cancer or anaplastic large cell lymphoma. In the case of implant rupture, explantation is strongly advised. Because of the widespread concern of undetected ruptures, there is a need for women with PIP breast implants to seek regular clinical examinations, and where deemed appropriate, individual counseling and imaging with ultrasonography or MRI. Discussion and conclusion There is currently no convincing medical, toxicological or other data to justify precautionary removal of intact PIP implants. However, based on individual assessment, explantation could be considered for women who experience psychological impairment due to carrying PIP breast implants, even in the absence of implant malfunction. Title: Further optimization of autologous breast reconstruction using the fast track methodology Background Authors: Christian Bonde1, Hoda Khorasani1, Jens Elberg1, Henrik Kehlet2 Institution: 1Department of Plastic Surgery, Breast Surgery and Burns, section2102, 2Section of Surgical Pathophysiology. Rigshospitalet,Copenhagen University Hospital. We recently presented our experience with fast track surgery in autologous breast reconstruction1. We demonstrated that a simple, perioperative care concept could reduce the length of stay (LOS) after a DIEP flap procedure from 7.4 days to 6.2 days without increasing complication rates or flap loss. The aim of the present study was further improvement of the protocol and to identify specific clinical and logistical factors that keep patients in hospital. We present our experience from the first 16 cases treated with the new regime. Material and Methods We performed a total revision of our patient information. Multimodal analgesia was used with paracetamol, a COX-- 2 inhibitor, and gabapentin. Nurses removed suction drains without consulting the doctors. Fulfillment of functional discharge criteria (flap monitoring, ambulation etc.) were assessed twice daily and specified reasons for not allowing discharge registered. Results At present, 16 patients have been treated using the new paradigm. All patients were discharged on the third postoperative day (POD) except two who were ready for discharge by day 4. Follow-- up (4 weeks) revealed that none of the patients had been re-- operated and all flaps survived with no major complications except one case of partial flap necrosis < 5%) and one case of seroma. All drains were removed on 2 nd or 3d POD. Median VAS score at discharge was 1 (range 0-- 4). All patients were pain free, ambulating, eating and managing personal hygiene by morning POD 2. All were mobilized by afternoon POD 2. Data will be presented along with our revised protocol and analysis of the factors that keep the patients in hospital. Conclusions LOS after autologous breast reconstruction using DIEP flaps can be reduced to about 3 days using the fast track methodology. Thorough patient information and close cooperation with the nursing staff are essential to the success. presented at the 24 th Annual EURAPS meeting, Antalya, Turkey, May 23-- 25, 2013 Article submitted for publication, JPRAS. Title: 1000 Smiles for Kashmir Plastic Surgery Camp 2013 Author: Javed Akram Tage-Hansens Gade 21, 1. tv, 8000 Århus C, javedakram@hotmail.com Institution: Department of Plastic Surgery, Århus University Hospital, Nørrebrogade 44, Århus, Danmark. Background: In May 2013 the presenter joined a team from England in Kashmir (Pakistan). 11

Material and Method: The team operated 127 patients in a period of two weeks. The operations were primarily burn contractures and cleft lip and palates. Results and Discussion: Examples of operated patients, the set and setting and requirements for such a project are reviewed. Furthermore learning features for western residents and specialists, ethical considerations and the global aspect of plastic surgery are discussed. Titel: 1000 smil til Kashmir Plastic Surgery Camp 2014 Forfatter: Reem Dina Jarjis, reservelæge Institution: Plastikkirurgisk Afdeling, Aalborg Universitetshospital Baggrund: I mange udviklingslande er relevant lægehjælp ikke tilgængelig eller økonomisk uoverkommelig. Derfor modtager mange patienter ikke den nødvendige rekonstruktive behandling, hvilket på længere sigt fører til stigmatisering og yderligere forringelse af livskvalitet. Metode: Rejsebeskrivelse fra en reservelæges velgørenhedsarbejde i Kashmir af to ugers varighed, hvor der blev udført plastikkirurgiske operationer af et lægehold fra bl.a. England, Tyskland og Danmark. Resultater: Omkring 100 veludførte operationer, tilfredse og glade patienter samt et stærkt inspireret, fagligt og kulturelt styrket lægehold. Konklusion: Lægeligt velgørenhedsarbejde er anbefalelsesværdigt, da det er til stor gavn for patienterne hvor behandlingen er hårdt tiltrængt. Derudover byder det på en række personlige og professionelle udfordringer og bidrager samtidig til et stort fagligt og personligt udbytte. Titel: EBOPRAS-eksamen. Forfatter: Janne Horn Institution: Plastikkirurgisk Afd. V, Herlev Hospital. Baggrund: EBOPRAS-eksamen (European Board of Plastic, Reconstructive and Aesthetic Surgery) er en europæisk specialisteksamen i plastik- rekonstruktiv og æstetisk kirurgi samt håndkirurgi. Eksamen består af 2 dele en skriftlig MCQ og en mundtlig del. Efter bestået eksamen tildeles titlen Fellow af EBOPRAS. Resultat: Efter veloverstået eksamen ønsker jeg at dele mine erfaringer fra eksamensforberedelsen og eksamen, for dermed forhåbentlig at inspirere og motivere andre til at tage EBOPRAS-eksamen. 12