Antonio Bulla

Toxic epidermal necrolysis (Lyell's disease)

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are severe adverse drug reactions, characterized by a low incidence but high mortality, initially described as separate entities, but today considered variants of the same pathologic process and differing only for severity. The majority of cases appear to be related to idiosyncratic drug reactions. The drugs most commonly involved are: antibiotics such as sulfonamides, beta-lactam, tetracyclines and quinolones; anticonvulsants such as phenytoin, phenobarbital and carbamazapine; antiretroviral drugs; nonsteroidal anti-inflammatory drugs, allopurinol. There is common agreement to consider TEN as the manifestation of a disregulated immune reaction against epithelial cells. During the first stages of TEN, apoptosis mediates keratinocyte death and the pivotal role of Fas-FasL pathway activation during TEN is undoubted. T cell cytotoxicity, demonstrated during TEN, has been shown to be mediated by the perforin-granzyme pathway. It seems, also, clear that a peculiar cytokine pattern plays an important role in TEN pathogenesis. The cutaneous findings result in an acute macular erythematous rash with bullae. These lesions rapidly exhibit Nikolskys sign and a separation of large sheets of epidermis from the dermis and a subsequent localised shedding develops rapidly, which can become very extensive. When feasible, admission in burn or intensive care unit, positioning the patients in air-fluidised beds, is universally considered crucial in TEN treatment. The prompt withdrawal of the suspected drug, fluid and electrolyte replacement and topical wound care are the first line of therapy. The use of corticosteroids has been abandoned and the role of immunosuppressants, despite some success, is not well defined and is not considered as a standard. A trial comparing thalidomide versus placebo in TEN patients was suspended because mortality rate increased in the treated group. Infliximab, a chimeric monoclonal antibody to TNF-alpha, has been administered to a patient, in single infusion, with a favourable outcome. Plasmapheresis is reported to lead to some success in TEN treatment, with improvement of clinical conditions and high percentage of survival. Different authors reported good results in terms of decreasing mortality and morbidity or improving clinical conditions of the use of human intravenous immunoglobulins (IVIGs). Regardless, the true utility of this treatment remains controversial. In 2005, the authors (ML and RC), dealing with a number of severe TEN cases, proposed a new protocol based on the combination of these last two techniques reporting their preliminary results in the treatment of severe TEN patients.

Flap size/flow rate relationship in perforator flaps and its importance in DIEAP flap drainage ☆

The vascular architecture within a perforator flap is different from a conventional muscle or myocutaneous flap. The purpose of this paper is to understand the correlation between flow rate and flap size in perforator flaps. With extrapolation of these data, we have provided an indirect analysis of the venous drainage and its correlation with flap size. A prospective study was planned. Twenty-five patients were enrolled in this study: six patients were operated on using an anterolateral thigh (ALT) flap and 19 using a deep inferior epigastric artery perforator (DIEAP) flap. One month postoperatively, echo-colour-Doppler measurements were performed on pedicle and perforator arteries to calculate blood flow rate in the flaps. A correlation between weight and flow rate was analysed. Spearman rho statistic was calculated. A linear regression model was made from patient data of flow rate/flap weight and predicted values of flow per flap weight were calculated. Then, flow rate values of veins of various diameters were estimated using Hagen-Poiseuilles formula. Our data show that flow rate measured postoperatively on flap arteries is significantly correlated with flap weight [rho(23 d.f.)=0.725, P<0.01 (two-tailed)]. Moreover, we have calculated the minimum size of veins able to drain flaps of increasing weights with different patterns, i.e. our data show that veins of 1.30, 1.50 and 1.75 mm diameter could safely drain flaps of, respectively, 300, 500 and 900 g in weight. This can be useful preoperatively to estimate the risk of flap congestion and in planning additional drainage.

The arrow flap for nipple reconstruction: Long term results

Figure 1 The modified arrow flap technique. Nipple Areola Complex reconstruction is the final step in breast reconstruction. Although it could be considered a minor surgical procedure, it has an important impact on the whole procedure. Today, above others, local flap-based techniques are the most popular one. Commonly, the reconstructed nipple flattens over time: as a consequence, nipple projection is the critical parameter to evaluate nipple reconstruction during the followup. Despite a lot of publications on this subject, there is a lack of evidence-based data. Momeni, in 2008, from a total of 10,476 published original articles in four plastic surgery journals over a 16-year period, identified only one RCT and one CCT addressing nipple reconstruction. The only RCT found by Momeni was our modification of Thomas technique, the arrow flap, that proved to have a higher residual projection than the modified star flap. In this paper, we report a prospective observational longitudinal study in order to assess if residual projection of arrow flaps is stable over time. Forty women, operated on for mammary reconstruction after breast cancer mastectomy, were enrolled for this study. All patients were informed about the study and their consent obtained. All patients underwent nipple reconstruction using the modified arrow flap. The operative technique was the same as described in the original article. The nipple is considered as a cylinder (Figure 1) with a base diameter of D and a height H. It can be unfolded in the plane to a circle of diameter D, representing its top, with a rectangle, that measures pi D H, attached. The rectangle height is 150% of the final required nipple projection and a triangular area above the circle is added. This area will be de-epithelised before flap raising. The flap pedicle is centrally located, on the opposite side. One extremity of the rectangle will be marked as an arrow point, the other side as an arrow tail; the arrow tail will be de-epithelised; the flap is harvested with a little superficial subcutaneous fat to preserve sub-dermal blood supply. The

Is mammary reconstruction with the anatomical Becker expander a simple procedure? Complications and hidden problems leading to secondary surgical procedures: a follow-up study.

Debate over the role of Becker expander implants (BEIs) in breast reconstruction is still ongoing. There are no clear indications for BEI use. The main indications for BEI use are one-stage breast reconstruction procedure and congenital breast deformities correction, due to the postoperative ability to vary BEI volume. Recent studies showed that BEIs were removed 5 years after mammary reconstruction in 68% of operated patients. This entails a further surgical procedure. BEIs should not, therefore, be regarded as one-stage prostheses. We performed a case-series study of breast reconstructions with anatomically shaped Becker-35™ implants, in order to highlight complications and to flag unseen problems, which might entail a second surgical procedure. A total of 229 patients, reconstructed from 2005 to 2010, were enrolled in this study. Data relating to implant type, volume, mean operative time and complications were recorded. All the patients underwent the same surgical procedure. The minimum follow-up period was 18 months. During a 5-year follow-up, 99 patients required secondary surgery to correct their complications or sequelae; 46 of them underwent BEI removal within 2 years of implantation, 56 within 3 years, 65 within 4 years and 74 within 5 years. Our findings show that two different sorts of complications can arise with these devices, leading to premature implant removal, one common to any breast implant and one peculiar to BEIs. The Becker implant is a permanent expander. Surgeons must, therefore, be aware that, once positioned, the Becker expander cannot be adjusted at a later date, as in two-stage expander/prosthesis reconstructions for instance. Surgeons must have a clear understanding of possible BEI complications in order to be able to discuss these with their patients. Therefore, only surgeons experienced in breast reconstruction should use BEIs.

A new contrast agent for radiological and dissection studies of the arterial network of anatomic specimens

PurposeThe aim of the present study is to propose a new contrast agent that can be easily applied both to CT and dissection studies to replace lead oxide based formulas for comparative anatomical analyses of the vascularisation of cadaveric specimens.MethodsThe infusion material was an epoxy resin, especially modified by the addition of barium sulphate to enhance its radiopacity. The final copolymer was toxicologically safe. To test the properties of the new material, several cadaveric limb injections were performed. The injected specimens were both CT scanned to perform 3D vascular reconstructions and dissected by anatomical planes.ResultsThere was a perfect correspondence between the image studies and the dissections: even the smallest arteries on CT scan can be identified on the specimen and vice versa. The properties of the epoxy allowed an easy dissection of the vessels.ConclusionsThe new imaging techniques available today, such as CT scan, can evaluate the vascular anatomy in high detail and 3D. This new contrast agent may help realising detailed vascular studies comparing CT scan results with anatomical dissections. Moreover, it may be useful for teaching surgical skills in the field of plastic surgery.

Staphylococcus aureus and Staphylococcus epidermidis Virulence Strains as Causative Agents of Persistent Infections in Breast Implants

Staphylococcus epidermidis and Staphylococcus aureus are currently considered two of the most important pathogens in nosocomial infections associated with catheters and other medical implants and are also the main contaminants of medical instruments. However because these species of Staphylococcus are part of the normal bacterial flora of human skin and mucosal surfaces, it is difficult to discern when a microbial isolate is the cause of infection or is detected on samples as a consequence of contamination. Rapid identification of invasive strains of Staphylococcus infections is crucial for correctly diagnosing and treating infections. The aim of the present study was to identify specific genes to distinguish between invasive and contaminating S. epidermidis and S. aureus strains isolated on medical devices; the majority of our samples were collected from breast prostheses. As a first step, we compared the adhesion ability of these samples with their efficacy in forming biofilms; second, we explored whether it is possible to determine if isolated pathogens were more virulent compared with international controls. In addition, this work may provide additional information on these pathogens, which are traditionally considered harmful bacteria in humans, and may increase our knowledge of virulence factors for these types of infections.

A Case Series Study on Complications After Breast Augmentation with Macrolane

BackgroundThe use of Macrolane™ seems to have several advantages compared to the other standard methods for breast augmentation: it is faster, less invasive, and requires only local anesthesia. Nevertheless, various complications associated with the use of Macrolane™ have been described, e.g., encapsulated lumps in breast tissue, infection, and parenchymal fibrosis. We report the results of our case series study on the clinical and imaging evaluations of patients who came to our attention after breast augmentation with Macrolane™ injection and evaluate the effect of this treatment on breast cancer screening procedures.MethodsBetween September 2009 and July 2010, seven patients, treated elsewhere with intramammary Macrolane™ injection for cosmetic purposes, presented to our institution complaining of breast pain. In all patients, Macrolane™ had been injected under local anesthesia in the retromammary space through a surgical cannula.ResultsOn mammography, nodules appeared as gross lobulated radiopacities with polycyclic contours. On breast ultrasound, the nodules showed hypo-anaechogenic cystlike features. In all cases, image analysis by the radiologist was hindered by the presence of the implanted substance, which did not allow the complete inspection of the whole breast tissue.ConclusionsFrom our experience, although safe in other areas, injection of Macrolane™ into breast tissue cannot be recommended at this time. Our study, along with other reports, supports the need to start a clinical trial on the use of injectable fillers in the breast to validate their safety and effectiveness.Level of Evidence IVThis journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Reply: An original technique for securing the inflation port in Becker implant-based breast reconstruction.

Reply: An Original Technique for Securing the Inflation Port in Becker Implant–Based Breast Reconstruction Sir: We read carefully and with great interest the original technique described by Dr. Demiri and colleagues for securing the inflation port in Becker implant breast reconstruction. Port displacement, or flip-over, is, in our findings, the most common complication following Becker implant mammary reconstruction.1 In a more recent study regarding our largest Becker reconstruction series (275 implants), we found the port flip-over rate to be much higher than that reported before, at about 15 percent of reconstructed patients.2 We believe port flip-over is scarcely reported in the literature, probably because there are few studies analyzing complications in large series of Becker reconstructions. Therefore, we appreciate every single study trying to reduce or prevent port flip-over. Again, we welcome this new technique developed to secure the Becker port in place. Over the years, we have tried to stabilize the Becker port by securing the connection tube between the expander and the port with a single 4-0 Vicryl stitch directly on the subdermal tissues along the midline at the inframammary sulcus level, just before the beginning of the subdermal pocket. We cannot secure the port directly because of the difficulty working in such a small area as the subdermal tunnel, undermined to allocate the port. Again, we tried to prevent port flip-over using sterile strips directly on the skin around the port, trying to spread far from the port the postoperative edema. Both of these techniques were ineffective in preventing port flip-over. Fixing the port directly on the skin, as described in this interesting work, seems to us a great idea, really effective in preventing port displacement. However, a few concerns arise in reading about this technique. First of all, how do the authors make the needle pass through the subdermal tunnel without damaging the expander or the connection tube? Do they go blindly, or do they enlarge the tunnel so as to see directly where to stitch? Second, sutures lying directly on the skin for more than 2 weeks, even if a bolster technique is used, may sometimes leave unpleasant marks in situ. Did the authors find this complication? Third, might this technique promote bacterial port contamination? Skin stitches could carry bacteria directly to the port. Further study will be necessary to confirm the safety of this technique. In conclusion, we congratulate the authors on their great idea for avoiding Becker port flip-over. Moreover, we thank them again for having focused their attention on this complication that in our experience is much more frequent than has been reported in the literature. DOI: 10.1097/PRS.0b013e31829accdf

Syringe liposuction in lipofilling: an easy and cheap way to speed the procedure up

Nowadays, lipofilling is becoming an office-based procedure. Fat graft harvesting is obtained with a syringe liposuction, usually 10or 35-ml Luer-lock syringe, connected to a stainless steel dedicated cannula, in order to obtain a mild subcutaneous negative pressure suction and prevent adipocyte damage. The mild pressure and the small size of the Coleman’s cannula ease off in fat removal, but this prolongs the operative time. The use of a bigger syringe, 60 ml or more as in smallvolume liposuction, allow larger and faster fat graft removal. We routinely employ a 60 ml syringe connected with a very short transparent tube (the same used with the power aspirator for traditional liposution) to a standard 3 mm Mercedes cannula, in order to make the procedure faster. This manoeuvre, using two alternate syringes, allows, in a few minutes, the desired amount of fat harvest in sterile conditions. The absence of a long suction tube makes the procedure more comfortable for the surgeon. The tube should be cut only long enough to be connected to

Mastectomy patterns, but not rates, are changing in the treatment of early breast cancer. Experience of a single European institution on 2315 consecutive patients

BACKGROUND Recent literature reports that rates of mastectomy are increasing in early breast cancer. However, data from European institutions are limited and revealed conflicting results. We report on 15-year trends of mastectomy, mastectomy plus immediate reconstruction and contralateral prophylactic mastectomy (CPM) at an academic institution. METHODS We identified women diagnosed with unilateral early breast cancer at stage 0-IIa, with tumour size ≤ 4 cm, between 2002 and 2016. Trends were assessed using the Cochrane-Armitage test. Multivariable logistic regression was used to identify factors associated with receipt of mastectomy plus immediate reconstruction. RESULTS A total of 2315 patients were identified. Of them, 65.7% underwent breast conserving surgery (BCS), while 34.3% underwent mastectomy as upfront surgery. Two point four per cent also received CPM. Immediate reconstruction was performed in 36.0% of patients receiving mastectomy. There was no change in trends of mastectomy over the 15 years studied (p = 0.69), as well as in trends of patients undergoing CPM (p = 0.44). In contrast, rates of immediate reconstruction rose significantly over the study period (from 12.2% in 2002 to 62.7% in 2016, p < 0.0001). Women were more likely to receive mastectomy plus immediate reconstruction if they were aged 50 years or younger, or had tumours larger than 2 cm, or had non-invasive carcinoma. CONCLUSIONS Our study suggests that rates of both mastectomy and CPM in early breast cancer are not increasing, while use of immediate reconstruction is on the rise.