F. De Lorenzi

Free flaps in burn reconstruction

In this paper, we present our experience of free flap reconstructions in burned patients. It allows the preservation of otherwise unsalvageable deep burn injuries and secondary correction of contracted burn scars. We analyse the indications of different free flaps, according to different anatomic regions and defects: depth and width of the loss of tissue, different colour skin, texture and thickness of the receptor area, weight-bearing or not weight-bearing surface. Free flap reconstructions were successful in 50 of 53 cases (94%). They provide good aesthetic and functional results with low morbidity both in acute deep burn injuries as in delayed reconstructions.

Oncological results of oncoplastic breast-conserving surgery: Long term follow-up of a large series at a single institution: A matched-cohort analysis.

PURPOSE Oncoplastic surgery is a well-established discipline that combines conserving treatment for breast cancer with immediate plastic reconstruction. Although widely practiced, the oncologic outcomes of this combined approach are reported only in small series. The aim of the present paper is to assess the safety of oncoplastic surgery for invasive primary breast cancer. METHODS We compared 454 consecutive patients who underwent an oncoplastic approach between 2000 and 2008 for primary invasive breast tumors (study group) with twice the number of patients who received conservation alone in the same interval time (control group). Disease free survival and overall survival were estimated using the Kaplan-Meier method. The log-rank test was used to assess differences between groups. RESULTS The median follow-up was 7.2 years. The overall survival is similar within the two groups, being 91.4% and 91.3% at 10-yr in the study group and in the control group respectively. The disease free survival is slightly lower in the oncoplastic group (69 vs.73.1% at 10-yr). The difference is not statistically significant. DISCUSSION We have compared a large series of primary breast cancer patients that have undergone oncoplastic surgery (454) with a control group (908) and they were followed for a prolonged period of time. It provides the best available evidence to suggest that oncoplastic surgery is a safe and reliable treatment option for the managing of invasive breast cancer.

The role of free flaps in the treatment of persistent scalp osteomyelitis.

OBJECTIVE: To evaluate the efficacy of the combination of an extensive surgical debridement and simultaneous free flap repair in case of troublesome cranial osteomyelitis. METHODS: Five patients with persistent, frontal bone osteomyelitis were treated with surgical debridement of the infected bone and reconstruction with a free flap. In all patients, osteomyelitis occurred after neurosurgical procedures and lasted from 1 to 7 years. A latissimus dorsi muscle flap with a split skin graft has been performed. RESULTS: No flap failure occurred and donor site morbidity was negligible. No signs of osteomyelitis or soft tissue infection were observed during the mean follow-up period of 3.2 years. Furthermore, the contour of the cranium could be preserved without a need for bone grafts or implants. CONCLUSION: In our experience, the combination of an extensive surgical debridement and a free flap transfer is demonstrated to be an effective treatment for “chronic” osteomyelitis of the cranium.

Recycling spare tissues: splitting a bipedicled TRAM flap for reconstruction of the contralateral breast

A new method of bipedicled transverse rectus abdominis myocutaneous flap splitting to reconstruct the contralateral breast 1 year after the first breast reconstruction is presented. This technique can be useful in cases of large salvage mastectomy for asynchronous breast cancers allowing a bilateral thoracic closure.

Cosmetic and reconstructive surgery and risk of breast cancer

SUMMARY Cosmetic surgery of the breast has been performed since the onset of plastic surgery and nowadays it is a part of cancer treatment. In the last decades, cancer risk related to these procedures has been investigated, especially with regards to implant reconstructions. Experimental studies and clinical trials have been published testing different filling materials of prostheses, first in animals and then in human bodies. In no human study has a cancer transformation been induced by filling materials. Moreover, in the case of implant placement no evidence of delayed diagnosis of local recurrence or primary cancer has been described in literature. With regards to autologous tissue reconstructions, they do not add an increased risk of recurrences or secondary cancer. In addition, small areas of liponecrosis and liposclerosis inside the flaps can be easily investigated with ultrasonography and/or with a mammogram. Another cosmetic procedure is frequently proposed to improve final aesthetic results in patients who underwent a breast reconstruction: a reduction mastoplastly or mastopexy of the contralateral breast. This procedure adds a cancer benefit since a pathological examination of the reduction specimens is always performed. With regards to cosmetic breast augmentation, although the silicone prosthesis behind or above the gland decreased the percentage of breast tissue visualized with a mammogram, the ultrasonography allows a good evaluation both of the glandular tissue and the implant. In this paper we evaluate experimental and clinical data in literature concerning cosmetic and reconstructive surgery and risk of breast cancer. We conclude that breast cosmetic surgery should be considered as a safe procedure if performed after a careful ‘carcinogenic’ check-up preoperatively and planned pathological examinations of any specimen.

S25 Immediate breast reconstruction after mastectomy

Aims: We present a brief overview of the current state of postmastectomy immediate reconstruction, which is actually an integral part of breast cancer treatment with positive aesthetic and psychosocial effects. The preservation of the inframammary fold and the conservation of the skin envelope and nipple areola complex has led to improved cosmetic results following both autologous and implant-based reconstruction. There is a general agreement for immediate breast reconstruction in case of in situ tumors, while the reconstruction is often delayed in cases of invasive cancers or contraindicate in the elderly cohort. Second endpoint of this review is to investigate the safety of immediate postmastectomy reconstruction for invasive cancers and in the elderly population. Methods and results: We reviewed our series and the recent literature on this topic. While there is a general consensus that advanced age is not a contraindication to immediate reconstruction and breast reconstruction can be successfully performed on well-selected elderly patients, most oncologists in Europe do not prefer immediate reconstruction for invasive carcinoma, advocating the risk of delay of the medical adjuvant treatment in case of complications due to the reconstructive procedure. Our experience and a lot of studies suggest that immediate breast reconstruction is a safe and reliable treatment option in case of invasive cancers. However, if postmastectomy irradiation is necessary on the basis of the final pathological finding, this is associated with a high rate of surgical complications and implant loss among patients who underwent immediate reconstruction with prostheses. Moreover, current evidence suggests that postmastectomy radiation therapy also adversely affects autologous tissue reconstruction. Conclusions: Immediate breast reconstruction after mastectomy is an integral part of the complete management of breast cancer. Determining the risk of postmastectomy irradiation prior to definitive resection and reconstructive operations may reduce complications and improve aesthetic outcomes by guiding surgical decision making.

From prophylactic mastectomy to treatment of local relapse

SUMMARY Bilateral prophylactic mastectomy represents a paradox in breast cancer surgery, since important efforts have been recently developed to reduce mutilating surgery. In fact, since the ‘extended radical mastectomy’ has been questioned by the results of the internal mammary node dissection trial, and Fishers paradigm has been adopted, indications for mastectomy have been dramatically reduced. Nowadays, the majority of primary infiltrating breast cancers can be solved by applying conservative techniques, while prophylactic bilateral mastectomy is proposed in certain high-risk situations, especially when genetic modifications have been found. Surgical treatment of local relapses should be discussed considering their clinical behaviour. A slow-growing unifocal local recurrence, next to the mastectomy scar, usually remains isolated for a long time and justifies a surgical treatment. On the contrary, widespread multifocal recurrences on the thoracic wall, which show inflammatory signs, are frequently associated with distant metastases. In these cases, the best treatment is a systemic therapy and local surgery mainly has a psychological purpose. Local relapses occurring after a conservative treatment are signs of primary treatment failure. They require a total mastectomy and sometimes cause a feeling of guilt in patients who regret that they accepted conservative surgery. However, the majority ask for an immediate breast reconstruction, despite difficulties due to previous radiotherapy. In certain extensive local relapses, psychological pressure could be so strong as to induce a wide surgical removal, even if surgery does not modify the prognosis in these patients. Thus, prophylactic mastectomy and surgical treatment of local relapses are both dealing with psychological benefits. The first is related to the fear of developing a cancer which does not yet exist at the time of the mutilation, and the second consists frequently in partially removing the visible cancer, even if it does not provide higher chances of cure.