Donato Casella

Delaying implant-based mammary reconstruction after radiotherapy does not decrease capsular contracture: An in vitro study☆

We read with great interest the article entitled “Delaying Implant-Based Mammary Reconstruction After Radiotherapy Does Not Decrease Capsular Contracture: An In Vitro Study (J Plast Reconstr Aesthet Surg. 2017 June; pii: S1748-6815(17)30256-5). El-Diwany et al. have published a very interesting in-vitro study about fibrosis and capsular contracture after radiotherapy (RT). In this study they demonstrated with in vitro experiments that RT causes irreversible cellular changes which permanently alter the microenvironment in favour of fibrosis so that delaying breast reconstruction does not decrease the percentage of capsular contracture. This is a very remarkable study since it shows the effects of RT on cellular and biological level and how the modifications can facilitate capsular contracture. We previously published a manuscript to evaluate the interaction between RT and the breast implants’ biomaterials and we demonstrated that no variations occurred in term of mechanical characterization and microstructural

Nipple-sparing bilateral prophylactic mastectomy and immediate reconstruction with TiLoop® Bra mesh in BRCA1/2 mutation carriers: A prospective study of long-term and patient reported outcomes using the BREAST-Q

BACKGROUNDnAlthough demand for prophylactic mastectomy is increasing over time among women at a high risk for breast cancer, there is a paucity of studies on long term patient-reported outcomes after this procedure.nnnMETHODSnBetween January 2011 and January 2015, 46 patients documented BRCA1/2 mutation carriers, eligible for prophylactic nipple-sparing mastectomy (NSM) and immediate breast prosthetic reconstruction were registered at our Institution. Patients underwent NSM and subcutaneous reconstruction with implant covered by a titanium-coated polypropylene mesh (TiLoop®). The BREAST-Q questionnaire was given to patients prior to surgery and at 1 and 2 years follow-up points. Capsular contracture was evaluated by Baker scale. Surgical outcomes along with the changes in BREAST-Q score were analyzed over time.nnnRESULTSnComplications were reported in only one case and after two years the capsular contracture rates were acceptable (grade I: 65,2%; grade II: 32,6%; grade III 2,2%). At one year and two year follow-ups patients reported high rates in the measures of overall satisfaction with breasts (72,5 and 73,7 respectively), psychosocial well-being (78,4 and 78,6), sexual well-being (58,8 and 59,4), physical well-being (77,6 and 80,6) and overall satisfaction with outcome (75,7 and 79,7). A statistically significant increase in all BREAST-domains from the preoperative to the postoperative period was reported at one and two years follow-ups (pu202f<u202f0,05).nnnCONCLUSIONnFollowing bilateral prophylactic NSM and immediate subcutaneous reconstruction with TiLoop®, patients demonstrated high levels of satisfaction and quality of life as measured by BREAST-Q. 2-years outcomes confirmed high patient comfort with increased scores from the preoperative baseline level.

Impact of Evolving Radiation Therapy Techniques on Implant-Based Breast Reconstruction.

BACKGROUND Patients undergoing implant-based reconstruction in the setting of postmastectomy radiation therapy suffer from increased complications and inferior outcomes compared with those not irradiated, but advances in radiation delivery have allowed for more nuanced therapy. The authors investigated whether these advances impact patient outcomes in implant-based breast reconstruction. METHODS Retrospective chart review identified all implant-based reconstructions performed at a single institution from November of 2010 to November of 2013. These data were cross-referenced with a registry of patients undergoing breast irradiation. Patient demographics, treatment characteristics, and outcomes were analyzed. RESULTS Three hundred twenty-six patients (533 reconstructions) were not irradiated, whereas 83 patients (125 reconstructions) received radiation therapy; mean follow-up was 24.7 months versus 26.0 months (p = 0.49). Overall complication rates were higher in the irradiated group (35.2 percent versus 14.4 percent; p < 0.01). Increased maximum radiation doses to the skin were associated with complications (maximum dose to skin, p = 0.05; maximum dose to 1 cc of skin, p = 0.01). Different treatment modalities (e.g., three-dimensional conformal, intensity-modulated, field-in-field, and hybrid techniques) did not impact complication rates. Prone versus supine positioning significantly decreased the maximum skin dose (58.5 Gy versus 61.7 Gy; p = 0.05), although this did not translate to significantly decreased complication rates in analysis of prone versus supine positioning. CONCLUSIONS As radiation techniques evolve, the maximum dose to skin should be given consideration similar to that for heart and lung dosing, to optimize reconstructive outcomes. Prone positioning significantly decreases the maximum skin dose and trends toward significance in reducing reconstructive complications. With continued study, this may become clinically important. Interdepartmental studies such as this one ensure quality of care. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.

Surgical Treatment with Locoregional Flap for the Nose

Nonmelanotic skin cancers (NMSCs) are the most frequent of all neoplasms and nasal pyramid represents the most common site for the presentation of such cutaneous malignancies, particularly in sun-exposed areas: ala, dorsum, and tip. Multiple options exist to restore functional and aesthetic integrity after skin loss for oncological reasons; nevertheless, the management of nasal defects can be often challenging and the best “reconstruction” is still to be found. In this study, we retrospectively reviewed a total of 310 patients who presented to our Department of Plastic and Reconstructive Surgery for postoncological nasal reconstruction between January 2011 and January 2016. Nasal region was classified into 3 groups according to the anatomical zones affected by the lesion: proximal, middle, and distal third. We included an additional fourth group for complex defects involving more than one subunit. Reconstruction with loco regional flaps was performed in all cases. Radical tumor control and a satisfactory aesthetic and functional result are the primary goals for the reconstructive surgeon. Despite tremendous technical enhancements in nasal reconstruction techniques, optimal results are usually obtained when “like is used to repair like.” Accurate evaluation of the patients clinical condition and local defect should be always considered in order to select the best surgical option.

Liposuction aspirate fluid-ASCs injection and secondary healing in fingertip injury, a pilot study

Background: Although fingertip injuries account for a high proportion of trauma patients, the correct surgical approach is still debated. The authors compared the traditional conservative approach and a new treatment based on the injection of liposuction aspirate fluid. Methods: Forty consecutive patients with a fingertip injury were dichotomized into group A (control group; conservative approach) and group B (treatment group). Group B underwent liposuction, followed by filtration of the lipoaspirate in a closed device (MyStem EVO kit), allowing the nonenzymatic separation of liposuction aspirate fluid, which was then injected at the site of injury. Objective outcomes were time for healing, strength, mobility of joint, and touch and sensory function. Subjective outcomes were cold intolerance, pain, hand disability, and aesthetic result. An aliquot of liposuction aspirate fluid was sent to the laboratory for cellular isolation and analysis by flow cytometry and in vitro differentiation assays. Results: The average healing time was 22.3 days in group B and 24.9 days in group A (p < 0.05). Eighty-five percent of group B patients and 67 percent of group A patients scored normal to diminished superficial sensibility (p < 0.05). Group A had higher pain and cold intolerance scores (p < 0.05). Group B scored greater aesthetic and disabilities outcome results (p < 0.05). The cell isolation yield was 8.3 × 105/ml, with a percentage of viable cells of 74.3 percent. Flow cytometry identified a mesenchymal immunophenotype, and in vitro osteogenic and adipogenic induction confirmed the bilinear potential of the isolated cells. Conclusion: This clinical study demonstrates for the first time the regenerative potential of liposuction aspirate fluid adipose-derived stem cells in a clinical application. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Diagnostic Value and Safety of Dynamic MRI of Contralateral Breast and Axilla in Subjects with Tissue Expander

INTRODUCTIONnTo verify the diagnostic value of contrast-enhanced breast and axillary MRI in patients with tissue expander labeled as MR-unsafe and to confirm its safety.nnnPATIENTS AND METHODSnBreast MRI examinations performed in patients with tissue expander in the period from August 2010 to December 2017 were reviewed after IRB approval. In the case of breast lesion or lymph node, breast MRI exams after definitive prosthetic replacement were used for comparison. Breast MRI was performed using 1.5xa0T equipment with a dedicated coil. The protocol included axial STIR sequence and axial dynamic sequence with fat suppression (1 pre-contrast and 4 post-contrast phases). Two radiologists experienced in breast imaging reviewed images using six parameters for image quality evaluation. t-Test for dependent samples, Wilcoxon and Sign test were used.nnnRESULTSnTwenty-three patients (49u202f±u202f9 years, range 34-68 years) with tissue expander who underwent contrast-enhanced MRI were reviewed. Thirteen breast lesions (12.92u202f±u202f4.84u202fmm) and eleven lymph nodes (11.00u202f±u202f4.29u202fmm) were found. In breast MRI examinations used for comparison no significant difference was observed in breast lesions (12.69u202f±u202f4.71u202fmm, Pu202f=u202f0.707) or lymph node dimensions (10.58u202f±u202f3.00u202fmm, Pu202f=u202f0.538). No significant difference was observed in lesion classification. A significantly lower visibility was observed for vascular maps (Pu202f<u202f0.001). None of the patients reported sensations of heating or skin burns. None of the patients revealed any clinical effects or signs of pathology after MRI examination.nnnCONCLUSIONnWhen necessary, after adequate information and preparation, contrast-enhanced breast MRI can be performed in patients with tissue expanders maintaining its diagnostic value and safety.

Skin cancers and dermal substitutes: Is it safe? Review of the literature and presentation of a 2‐stage surgical protocol for the treatment of non‐melanoma skin cancers of the head in fragile patients

Non‐melanoma skin cancers (NMSC) represent the most common skin tumours of the head region. We describe the use of dermal substitute in a 2‐stage surgery protocol for selected fragile patients to remove NMSC of the head region. A review of the literature focusing on dermal substitutes’ safety after skin tumours excision is provided. A total of 45 fragile patients with NMSC in the head region were selected and scheduled for the 2‐stage surgical protocol. The first stage consisted of traditional surgical excision and immediate coverage with Hyalomatrix (Fidia Advanced Biopolymers, Abano Terme, Italy). After histology confirmed diagnosis and clearance of the margins, full‐thickness skin autografts were performed. All of the patients reached complete tumour excision and wound healing. No local recurrences were registered during 24u2009months follow up. The 2‐stage surgical therapeutic‐diagnostic‐reconstructive approach represents a less stressful and oncologically safe surgical protocol in selected fragile patients. When patients cannot tolerate invasive and long surgical procedures, general anaesthesia, and long hospitalisation, skin grafting following temporary skin substitute coverage can achieve oncological clearance and provide good functional and aesthetic results. The use of dermal substitutes represents a valid alternative surgical option in cases of ASA III, fragile patients non‐eligible for complex reconstructive surgery. To our knowledge, this is the first paper reviewing literature focusing on dermal substitutes’ applications and safety after skin tumour excision.

Preliminary result with incisional negative pressure wound therapy and pectoralis major muscle flap for median sternotomy wound infection in a high-risk patient population

Deep sternal wound infection (DSWI) represents a dangerous complication that can follow open‐heart surgery with median sternotomy access. Muscle flaps, such as monolateral pectoralis major muscle flap (MPMF), represent the main choices for sternal wound coverage and infection control. Negative pressure incision management system has proven to be able to reduce the incidence of these wounds complications. Prevena™ represents one of these incision management systems and we aimed to evaluate its benefits. A total of 78 patients with major risk factors that presented post‐sternotomy DSWI following cardiac surgery was selected. Thrity patients were treated with MPMF and Prevena™ (study group). Control group consisted of 48 patients treated with MPMF and conventional wound dressings. During the follow‐up period, 4 (13%) adverse events occurred in the study group, whereas 18 complications occurred (37·5%) in the control group. Surgical revision necessity and mean postoperative time spent in the intensive care unit were both higher in the control group. Our results evidenced Prevena™ systems ability in improving the outcome of DSWI surgical treatment with MPMF in a high‐risk patient population.