Giuseppe Visconti

Approach and management of primary ectopic breast carcinoma in the axilla: Where are we? A comprehensive historical literature review

Primary ectopic breast carcinoma is a rare disease and, at present, no specific guidelines on its diagnosis and treatment are available. The purpose of this article is to review the world literature in English on primary ectopic breast carcinoma located in the armpit and to offer guidelines for diagnosis and treatment. Data for this review were identified by searches of MEDLINE, PubMed, The Cochrane Library, ACNP (Italian catalogue of journals) and references from relevant articles using relevant search terms and data published in the previous reviews. Primary ectopic breast carcinoma of the axilla mostly affects women of over 40 (range 28-90 yrs) years of age. The most frequent histological diagnosis is invasive ductal carcinoma not otherwise specified (NOS) (72%). Because of its rareness, in most cases, the diagnosis is delayed for on average 40.5 months. This disease is rare, but a high level of suspicion for carcinoma is mandatory when confronted with a tumour in this area. Once diagnosed, patients should undergo staging, and prognostic and adjuvant treatment procedures identical to orthotopic breast carcinoma guidelines. There are some limitations for the staging. Loco-regional treatment, on indication, combined with endocrine therapy and/or chemotherapy seems the treatment of choice.

Magnetic Resonance Imaging and Ultrasound Evaluation after Breast Autologous Fat Grafting Combined with Platelet-Rich Plasma

Background:Breast lipofilling is a fairly simple and safe procedure if it is performed by experienced surgeons.Methods:The authors evaluated the radiologic findings from 24 breasts (15 women) subjected to a lipofilling procedure (two sessions) for corrective surgery or cosmetic reasons. Mammography,

The Retrograde Limb of Internal Mammary Vessels as Reliable Recipient Vessels in DIEP Flap Breast Reconstruction: A Clinical and Radiological Study

AbstractFor many microsurgeons, antegrade internal mammary vessels (AIMVs) represent the recipients of choice in autogenous breast reconstruction. For the past few years, the retrograde internal mammary vessels (RIMVs) have been demonstrated to be a further reliable option when needed, according to many papers focusing more on the vein than on the artery. Besides the clinical evidence, the hemodynamic features of the retrograde system have been very seldom analyzed.In this article, we report our clinical experience with deep inferior epigastric perforator (DIEP) flaps anastomosed to RIMVs, along with a perioperative radiological follow-up to study RIMVs’ hemodynamics and to further support the reliability of the retrograde system with particular focus on the retrograde internal mammary artery.Prospective, preoperative, and postoperative (3 days, 21 days, and 3 months, respectively) color Doppler sonographies of the internal mammary artery (IMA) and DIEPs have been performed to collect the velocity of flow (v) and resistive index (RI) data. Twenty-two patients agreed to undergo this protocol, of which 10 unipedicle flaps were anastomosed to AIMVs (“control” group), 10 bipedicle DIEPs to both AIMVs and RIMVs (“study” group), and 2 DIEPs anastomosed to retrograde internal mammary artery and antegrade internal mammary vein (not statistically analyzed for their paucity). Student t test was performed to compare the “control” and “study” groups.All the flaps survived, and no re-exploration was needed. Internal mammary artery and perforators v showed similar but speculate trend, whereas IMA and perforators RI looked stable during that time. Significant differences have been found in the “study” group for IMA v at 3-day period, for perforator v at 21- and 90-day periods, and for perforator RI at 90-day period, without any clinical implication for flap viability.Retrograde internal mammary vessels can be considered reliable vessels for both arterial flap input and venous flap outflows, either as additional or the sole recipients. However, further and larger studies would be useful to better understand the hemodynamics of the retrograde system.

Anteromedial thigh perforator-assisted closure of the anterolateral thigh free flap donor site

Primary closure of the anterolateral thigh free flap donor site is advisable as skin grafting can be associated with higher morbidity. However, this is not possible when anterolateral thigh free flap width is over 8-9 cm with a corresponding flap width-to-thigh circumference ratio over 16%. The authors report their experience and technique with the anteromedial thigh perforator dissection during anterolateral thigh free flap donor-site closure that, on demand, can be used to design a local perforator flap to achieve primary closure of the donor site. Between July and December 2012, 20 consecutive patients underwent elective anterolateral thigh free flap reconstruction for head and neck oncologic surgery. Attempts to close directly the anterolateral thigh free flap donor site failed in two patients with large flaps and V-Y anteromedial thigh perforator flaps were advanced to close the defect. Flaps healed uneventfully. Except two patients, at least one>1-mm perforator was found in all the remaining thighs. Further investigation is needed to establish the maximum anterolateral thigh free flap donor-site width that can be served by this reconstruction. This represents an ideal model for residents to start training on perforator dissection.

Deep inferior epigastric artery perforator flap donor-site closure with cannula-assisted, limited undermining, and progressive high-tension sutures versus standard abdominoplasty: complications, sensitivity, and cosmetic outcomes.

Background: In deep inferior epigastric artery perforator (DIEP) flap breast reconstruction, abdominal donor-site cosmetic and sensibility outcomes and the closure technique have drawn little attention in the literature, with many surgeons still following the principles of standard abdominoplasty. In this article, the authors report their experience with the cannula-assisted, limited undermining, and progressive high-tension suture (“CALP”) technique of DIEP donor-site closure compared with standard abdominoplasty. Methods: Between December of 2008 and January of 2013, 137 consecutive women underwent DIEP flap breast reconstruction. Of these, 82 patients (between December of 2008 and November of 2011) underwent DIEP flap donor-site closure by means of standard abdominoplasty (control group) and 55 patients (from December of 2011 to January of 2013) by means of cannula-assisted, limited undermining, and progressive high-tension suture (study group). The abdominal drainage daily output, donor-site complications, abdominal skin sensitivity at 1-year follow-up, cosmetic outcomes, and patient satisfaction were recorded and analyzed statistically. Results: Daily drainage output was significantly lower in the study group. Donor-site complications were significantly higher in the control group (37.8 percent versus 9 percent). Seroma and wound healing problems were experienced in the control group. Abdominal skin sensibility was better preserved in the study group. Overall, abdominal wall aesthetic outcomes were similar in both groups, except for scar quality (better in the study group). Conclusion: According to the authors’ experience, cannula-assisted, limited undermining, and progressive high-tension suture should be always preferred to standard abdominoplasty for DIEP donor-site closure to reduce the complication rate to improve abdominal skin sensitivity and scar quality. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Contralateral Breast Symmetrisation in Immediate Prosthetic Breast Reconstruction after Unilateral Nipple-Sparing Mastectomy: The Tailored Reduction/Augmentation Mammaplasty

Background In the literature on nipple-sparing mastectomy (NSM) with one-stage immediate implant reconstruction, contralateral symmetrisation has drawn little attention, with many surgeons still performing standard cosmetic mammaplasty procedures. However, standard implant-based mammaplasty usually does not result in proper symmetry with the mastectomy side, especially regarding breast projection, overall shape, and volume distribution. Methods We retrospectively reviewed 19 consecutive patients undergoing unilateral NSM with immediate prosthetic reconstruction and contralateral simultaneous symmetrisation by using the tailored reduction/augmentation mammaplasty technique between June 2012 and August 2013. Results The average follow-up time was 13 months (range, 10-24 months). No major complications, such as infection, haematoma, and nipple-areola complex necrosis, were experienced. Conclusions Our experience suggests that simultaneous contralateral symmetrisation with tailored reduction/augmentation mammaplasty after unilateral immediate implant reconstruction after NSM facilitates durable and pleasant symmetric outcomes.

Oncoplastic Breast Surgery with Oxidized Regenerated Cellulose: Appraisals Based on Five-year Experience

To the Editor: We have read with great interest the article by Tanaka et al. reporting improved cosmetic outcomes after breast conserving surgery with the use of oxidized regenerated cellulose (ORC) (1) in 94 breast cancer patients treated at the Osaka Medical College Hospital (Osaka, Japan). Evaluation of cosmetic outcomes, performed by three staff surgeons at least 2 months after surgery using the scoring system (0–12 points) of the Japanese Breast Cancer Society, documented very positive results, with a mean score of 9.5 (3–12 points) and 71 patients (75.5%) categorized as “Excellent” (≥11 points) or “Good” (8–10 points), and only one patient (1.1%) as “Poor” (≤4 points). We have previously reported our 5-year experience with the use of ORC at the Catholic Breast Unit of Rome and agree with the Authors that the use of this biomaterial can improve the cosmetic results (Fig. 1) in patients undergoing an oncoplastic procedures for breast cancer (2). However, as ORC is being increasingly utilized in breast conserving surgery (1–3), we think that it is important to properly inform the patients not only about the potential cosmetic advantages but also about possible postoperative complications of this technique. Tanaka et al. report a 18% rate of allergic reaction with the use of ORC, mainly presenting as acute dermatitis and eczema, and one case of exudation followed by wound dehiscence. In our series, we noted a 10% rate of allergic skin reactions with irritation, redness, itching, swelling, rash, and hives in the mammary region, successfully managed with steroids and antihistamine medications. In addition, we experienced a significant seroma in the site of ORC placement in 45% of our patients. This

Reconstruction of an extended defect in the axilla using a thoracodorsal fasciocutaneous perforator flap

BackgroundEctopic primary carcinoma of breast tissue is a rare entity, and its diagnosis often is delayed. The axilla is the most common site involved. The Limberg flap as a random flap is easy and practicable for coverage of many defects including those involving the axilla. In the reported case, the vascularity of the flap was improved by including a thoracodorsal artery perforator.MethodsThis report presents the clinical features of a case of ectopic breast carcinoma in the axilla and an alternative tension-free Limberg thoracodorsal artery perforator flap for reconstruction of the extended defect after excision of the tumor.ResultsThe flap survived and healed without further problems. A good functional and aesthetic result was obtained.ConclusionEctopic primary carcinoma of breast tissue is a rare entity. Correct early diagnosis should be made. A tension-free fasciocutaneous flap according to Limberg, supercharged using a thoracodorsal artery perforator, can provide skin and soft tissue coverage for extended defects in the axilla with a satisfactory outcome. The operative procedure is easy and reliable. This is a further surgical option for soft tissue extended reconstruction in the armpit.

Ultrasound-Assisted Lymphaticovenular Anastomosis for the Treatment of Peripheral Lymphedema

1. Rome, Italy Department of Plastic and Reconstructive Surgery, Università Cattolica del “Sacro Cuore” – University Hospital “A. Gemelli” 2. Tokyo, Japan Plastic Surgeon, Department of Plastic and Reconstructive Surgery, Tokyo Metropolitan Bokutoh Hospital 3. Chiba, Japan Department of Plastic Surgery, Asahi General Hospital Corresponding Author: Akitatsu Hayashi, M.D. Address: 1326, I, Asahi, Chiba, 289-2511, Japan. Tel: +81-479-63-8111, Fax: +81-479-62-3757 E-mail: promise_me_now65@yahoo.co.jp AC CE PT ED

Necrosis of nose skin after varicella zoster infection: A case report

Varicella zoster virus (VZV) is the causal agent of varicella (chickenpox) and herpes zoster (shingles). Primary VZV infection is a common childhood disease, but elderly patients and those having a compromised immune system are also at risk. We present the case of progressive necrosis of the nose skin in a patient with a compromised immune system and a generalised VZV infection. During the course of his hospital stay and follow-up, the lesion gradually improved with conservative treatment.