Maurizio Bruno Nava

Skin-reducing mastectomy.

Background: The authors propose a combined flap technique to reconstruct large and medium-sized ptotic breasts in a single-stage operation by use of anatomical permanent implants. Methods: The authors enrolled 28 patients fulfilling criteria for skin-sparing mastectomy and presenting with ptotic breasts whose areola-to-inframammary fold distance was more than 8 cm. All reconstructions were performed as a single-stage procedure. After preoperative planning, a large area in the lower half of the breast was deepithelialized according to the conventional Wise pattern. Mastectomy was then carried out. To perform reconstructions, the inferomedial fibers of the pectoralis major muscle were dissected and sutured to the superior border of the inferior dermal flap. An anatomical implant was then inserted into the pouch, which was closed laterally with the previously harvested serratus anterior fascia. Skin flaps were finally closed down to the inframammary fold. Results: The authors performed 30 procedures on 28 patients. The medium size anatomical implants was 433 cc. Twelve women achieved symmetrization in a single stage ending in a symmetric inverted-T scar. The overall complication rate was 20 percent, with four cases (13 percent) complicated by severe, extensive necrosis of the skin flaps requiring implant removal. Conclusions: Breast cancer treatment must nowadays optimize cosmetic results. This can be accomplished in selected cases by means of a single-stage operation that the authors call “skin-reducing mastectomy.” The final scars imitate those of cosmetic surgery. Careful patient selection and improvement in the learning curve may reduce the complication rate.

Skin/nipple sparing mastectomies and implant-based breast reconstruction in patients with large and ptotic breast: oncological and reconstructive results.

In this study we performed 77 procedures on 65 patients fulfilling the oncological criteria for skin-sparing mastectomy and presenting with large or medium size breasts. All the operations were performed as a single-stage procedure with an anatomical prosthesis allocated into a compound pouch, made up of the pectoralis major, serratus anterior fascia, and a lower dermal adipose flap. The medium size of the anatomical implants employed was 444.3 cc. The implant removal rate was 14.2%. At a median follow-up of 36 months we reported a 0.5% local recurrence rate per year. The overall specific survival rate was 98.2%. This study confirms the safety and effectiveness of this technical variation of skin and nipple-sparing mastectomies. All breast, irrespective of mammary shape and size, can be reconstructed with medium size implants and, if required, contralateral adjustments. The overall complication rate is in keeping with previous studies.

Improved sub-areolar breast tissue removal in nipple-sparing mastectomy using hydrodissection

We report on a new technique of dissection of the nipple-areola-complex (NAC) in nipple-sparing mastectomy (NSM). NACs removed due to the presence of tumor cells beneath them were histologically examined for the presence of normal breast glandular tissue. Cases were divided into cohort 1, where NACs were dissected by sharp isolation, coring the nipple, and cohort 2, where the same procedure was preceded by hydrodissection of the areola. In 20 (17.4%) cases the planned NSM was converted to skin-sparing mastectomy (SSM) because of intraoperative findings of cancer in retro-areolar tissue. Histological examination of 20 NSMs converted to SSM showed the presence of glandular tissue in 12 out of 13 cohort 1 cases (92%) and in 1 out of 7 cohort 2 cases (14%). We conclude that hydrodissection creates a subdermal plane facilitating NAC dissection and permitting a more complete removal of breast tissue in NSM. Such radicality could prove important in the treatment of breast cancer and in BRCA 1-2 mutation carriers because of its potential for reducing the risk of relapse.

Understanding rare adverse sequelae of breast implants: Anaplastic large-cell lymphoma, late seromas, and double capsules

Breast implant-associated anaplastic large cell lymphoma (BI-ALCL) is a distinct type of T-cell lymphoma arising around breast implants. The United States FDA recently updated the 2011 safety communication, warning that women with breast implants may have a very low risk of developing ALCL adjacent to a breast implant. According to the World Health Organization, BI-LCL is not a breast cancer or cancer of the breast tissue; it is a lymphoma, a cancer of immune cells. BI-ALCL is highly curable in the majority of patients. Informed consent should include the risk of BI-ALCL with breast implant patients. Women with breast implants are encouraged to contact their plastic surgeon if they notice swelling, fluid collections, or unexpected changes in breast shape. Physicians are encouraged to send suspicious peri-prosthetic fluid for CD30 immunohistochemistry, cell block cytology, and culture in symptomatic patients. An observation from reported cases indicates a predominance of textured device involvement. More information is needed to fully understand risk factors and etiology. The association of bacteria and biofilm with ALCL is currently being investigated and one theory is that biofilm may play a role in this disease process stressing the importance of best practice techniques intraoperatively. Recent studies have reported clinical presentation, prognosis, and treatment outcomes with long term followup demonstrating the critical role for surgical management.

The forehead zygomatic-orbital artery-based island flap

This article describes an original forehead flap arterialized on the zygomatic-orbital artery. The idea became reality during the harvesting of a routine flap, when the discovery of an increased-caliber zygomatic-orbital artery and a small frontal branch of the superficial temporal artery prompted surgeons to try switching the arterial supply. This case demonstrates both the viability and the mobility of this flap used in the reconstruction of the lower third of the face. The second part of the article examines the anatomy of the zygomatic-orbital artery and its variants and relationships with the superficial temporal artery. To confirm the potential of this alternative flap and to improve current knowledge of the artery, the vascular anatomy of 50 frontotemporal zygomatic territories was investigated by ultrasonography. The three aspects verified were incidence, course constancy, and relationship with the frontal branch of the superficial temporal artery. The study suggests that the zygomatic-orbital artery could be a suitable replacement for the frontal artery when the latter is small, absent, or positioned too high to ensure maintenance of an adequate lateral flow to the forehead.

Surgical decision making in conservative mastectomies

We present some clinical advice to drive the decision process in performing conservative mastectomies. Several factors are taken into consideration to indicate these techniques. First of all, we need to identify patients who need a mastectomy due to the extension of the disease. In this case we suggest assessing patients anthropometric characteristics (breast volume-ptosis), and personal preferences regarding the extension of surgical treatment. Small, medium size, without ptosis or with moderate ptosis can be better served by standard nipple-sparing mastectomy. Large and ptotic breast can be removed and reconstructed performing a skin-reducing mastectomy. Mastectomies cannot replace breast conservation and should be discouraged whenever breast-conserving surgery can be performed with good results. However, in some selected cases, and especially in patients with small breast, conservative mastectomies with contralateral reshape can yield favourable results.

Lack of activation of telomere maintenance mechanisms in human adipose stromal cells derived from fatty portion of lipoaspirates.

Background: Significant improvement in the understanding of mesenchymal stem cell biology paved the way to their clinical use. Human lipoaspirates derived from mesenchymal stem cells (adipose-derived stem cells) continue to draw the attention of researchers in the field of basic and applied research due to their regenerative, reparative, angiogenic, antiapoptotic, and immunosuppressive properties, all of which collectively point out their therapeutic potential. There is still, however, a need for further investigation to improve the knowledge of stem cell biology, to broaden their field of use, and to enhance their therapeutic effectiveness. Methods: The authors characterized human adipose-derived stem cells at different in vitro culture time points in terms of immunophenotype, multilineage differentiation, long-term survival with self-renewal capacity, and presence of telomere maintenance mechanisms (telomerase activity and alternative lengthening of telomere) for excluding their eventual susceptibility to malignant transformation. Results: Adipose-derived stem cells were isolated from the abdomen and peritrochanteric region of 31 female donors, propagated, and monitored in vitro for several passages. The outgrown cells shared the biological properties of mesenchymal stem cells, with adherence to plastic, expression of the typical surface markers, and induction of adipogenic, osteogenic, and chondrogenic differentiation. Telomerase activity and alternative lengthening of telomere mechanisms at different passages of cultures were not evidenced. Conclusion: The results support the concept that in vitro expanded adipose-derived stem cells obtained from fat tissue are not susceptible to developing one of the hallmarks of malignant transformation and can be considered amenable for cell therapy approaches.

Role of Mitomycin C in Preventing Capsular Contracture in Implant-Based Reconstructive Breast Surgery: A Randomized Controlled Trial.

Background: Capsular contracture represents the most frequent complication after implant-based breast reconstruction. An experimental study on mice demonstrated that capsule formation around breast implants is considerably diminished after topical application of mitomycin C. The authors conducted a randomized controlled clinical trial investigating the efficacy of mitomycin C in reducing capsular contracture rates following implant-based breast reconstruction after mastectomy for breast cancer. Methods: The authors randomized all women older than 18 years scheduled for the second stage of an implant-based breast reconstruction after mastectomy for breast cancer at the National Cancer Institute in Milan from October of 2005 to February of 2010 to receive or not receive the topical application of mitomycin C during surgery. The authors assessed capsular contracture, major postoperative complications, and aesthetic outcome. Results: The authors randomized 322 patients to receive mitomycin C or not at the second stage of implant-based breast reconstruction. One hundred sixty-two patients were allocated to the mitomycin C group and 160 patients were allocated to the control group. The relative risk of capsular contracture in the mitomycin C group was 0.92 (95 percent CI, 0.60 to 1.41). Major complications leading to reintervention, oncologic outcomes, and aesthetic outcomes were comparable between the two groups. Conclusions: This is the first trial reporting data about the use of mitomycin C in breast reconstructive surgery in a clinical setting. Mitomycin C seems not to significantly affect capsular contracture rate and severity following implant-based reconstructive breast surgery at the tested doses. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, I.

How to prevent complications in breast augmentation

No high-level evidences about the best technique or the best implant to use for obtaining the best outcomes in aesthetic breast augmentation, with low complications and re-interventions rates exist from available literature. In this paper we present the actual best evidence about the etiopathogenesis of main complications in aesthetic breast augmentation, identifying some basic rules to follow in order to reduce complication rates in our daily activity, minimizing re-interventions, obtaining long lasting results and high womens satisfaction levels.

Preoperative digital mammography imaging in conservative mastectomy and immediate reconstruction

BACKGROUND Digital mammography clearly distinguishes gland tissue density from the overlying non-glandular breast tissue coverage, which corresponds to the existing tissue between the skin and the Coopers ligaments surrounding the gland (i.e., dermis and subcutaneous fat). Preoperative digital imaging can determine the thickness of this breast tissue coverage, thus facilitating planning of the most adequate surgical techniques and reconstructive procedures for each case. METHODS This study aimed to describe the results of a retrospective study of 352 digital mammograms in 176 patients with different breast volumes who underwent preoperative conservative mastectomies. The breast tissue coverage thickness and its relationship with the breast volume were evaluated. RESULTS The breast tissue coverage thickness ranged from 0.233 to 4.423 cm, with a mean value of 1.952 cm. A comparison of tissue coverage and breast volume revealed a non-direct relationship between these factors. CONCLUSIONS Preoperative planning should not depend only on breast volume. Flap evaluations based on preoperative imaging measurements might be helpful when planning a conservative mastectomy. Accordingly, we propose a breast tissue coverage classification (BTCC).