Michail Sorotos

Breast Implant-Associated Anaplastic Large Cell Lymphoma: Proposal for a Monitoring Protocol.

Background: The authors report four cases of breast implant–associated anaplastic large cell lymphoma (ALCL) from a single institution and propose a multidisciplinary protocol. Methods: From 2012 to 2014, four breast implant–associated ALCL cases were diagnosed. The authors performed the original operation, and no patients were referred to their practice. Cases 1, 2, and 4 were CD4+/CD30+/ALK− ALCL with previous textured-implant reconstruction, whereas case 3 was CD8+/CD30+/ALK− ALCL with previous polyurethane-implant augmentation. A retrospective study of all patients who underwent breast implant positioning was performed to identify any misdiagnosed cases. Results: Of 483 patients, 226 underwent reconstruction with latissimus dorsi flap and prosthesis, 115 had skin-sparing/nipple-sparing mastectomy and prosthesis, 117 underwent an expander/implant procedure, and 25 underwent breast augmentation. Fifty-eight cases (12 percent) underwent implant replacement for capsular contracture, 15 (3.1 percent) experienced late-onset seroma, and four (0.83 percent) had both capsular contracture and seroma. Seventy-seven symptomatic patients (16 percent) underwent surgical revision (capsulectomy/capsulotomy) and/or seroma evacuation. The second look on histologic specimens did not identify misdiagnosed cases. A multidisciplinary protocol for suspected implant-associated ALCL was established. Ultrasound and cytologic examinations are performed in case of periprosthetic effusion. If implant-associated ALCL is diagnosed, implant removal with capsulectomy is performed. If disseminated disease is detected through positron emission tomography/computed tomography of the total body, the patient is referred to the oncology department. Conclusions: A multidisciplinary protocol is mandatory for both early diagnosis and patient management. Until definitive data emerge regarding the exact etiopathogenesis of breast implant–associated ALCL, the authors suggest offering only autologous reconstruction if patients desire it. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

The axillary versus internal mammary recipient vessel sites for breast reconstruction with diep flaps: A retrospective study of 256 consecutive cases

The aim of this study is to present our experience on the use of various recipient sites for deep inferior epigastric perforator (DIEP) flap breast reconstruction and compare them by means of objective data. Two hundred fifty six DIEP flap breast reconstructions, performed between March 2004 and May 2011, were retrospectively analyzed. Only unilateral reconstructions were included in the study and divided into three groups depending on the recipient site choice: internal mammary vessels (IMV) (n = 52), thoracodorsal vessels (TDV) (n = 109), and circumflex scapular vessels (CSV) (n = 95). Clinical records of each patient were reviewed to acquire relevant data such as operative time, postoperative complications, and use of a second vein anastomosis. CSV group showed a statistically significant lower operative time (4.92 ± 0.54 hours) compared to TDV (5.67 ± 1.01 hours) and IMV groups (6.75 ± 1.09 hours) (P < 0.001). Second vein anastomosis was performed in 84 cases (88.1%) of CSV, in 85 cases (77.9%) of TDV, and in 18 cases (35.1%) of IMV groups (P < 0.001). No significant differences were observed among groups regarding risk factors and complications (P > 0.05). The axillary vessels seem to be the ideal recipient site because of reduced operative time and increased possibility to perform a second vein anastomosis. Among them, CSV can be safely used due to following advantages: easy dissection, larger vessel caliber, and optimal flap insetting. Moreover, their location does not expose them completely to radiotherapy consequences.

Permanent latissimus dorsi muscle denervation in breast reconstruction.

BackgroundA retrospective analysis of our series of denervated latissimus dorsi (LD) breast reconstructions showed a high incidence of postoperative LD contraction. Anatomical studies with a prospective clinical trial are set up to outline a successful denervation procedure. MethodsFifteen fresh cadavers were dissected to study thoracodorsal nerve course. Subsequently, 40 consecutive LD breast reconstructions were divided randomly in equal groups and underwent either distal (group A) or proximal (group B) nerve resection and clipping. The presence of postoperative contraction was evaluated clinically and instrumentally at 2-year follow-up. Statistical analysis of data was performed by Fisher exact test. ResultsCadaver dissections showed distal branching of thoracodorsal nerve in 20% of cases. Incidence of postoperative LD contraction was 35% (7/20) in group A and 0% in group B. A significantly lower rate of contraction in group B was demonstrated (P = 0.004). ConclusionsType B proximal nerve resection allows for effective denervation reducing incidence of postoperative contraction (P = 0.004).

Tips and tricks for DIEP flap breast reconstruction in patients with previous abdominal scar

The aim of this study was to analyze outcomes of patients who had prior abdominal operations and underwent DIEP flap breast reconstruction and to describe technical strategies to insure well‐vascularized flap‐harvest minimizing abdominal donor‐site complications. All patients who underwent DIEP flap breast reconstruction between 2004 and 2014 were reviewed and divided into a control group (CG) and a scar group (SG). Patient demographics, operative details, flap and donor‐site complications were analyzed and compared. For all of the scars, DIEP flap design was not modified, but a standardized approach was developed according to the type and location of the scar, available vascular pedicle, perforator locations, and the required flap tissue for breast reconstruction. Two hundred and eighty patients underwent 292 flaps in CG and 107 underwent 111 flaps in SG. Pfannenstiel, McBurney, laparoscopic, midline and subcostal were the most common previous incisions. There were no significant differences between groups regarding demographics, flap and mastectomy weight, active smoking, or radiation status (P > 0.05). No significant differences were observed in DIEP flap loss (P = 0.909), partial flap loss (P=0.799), or fat necrosis (P=0.871) and in the rate of abdominal donor‐site complications between groups (P > 0.05). SG had a significantly higher mean operative time than CG (P=0.034). Medial raw was a negative risk‐factor for flap complications, while BMI (>25.1 kg/m2) and smoking‐history were significant predictors for donor‐site complications. With careful preoperative planning and appropriate technical strategies, successfully DIEP flap breast reconstruction can be performed without increased flap and donor‐site complications in patients with preexisting abdominal scars.

One-stage DIEP flap breast reconstruction: Algorithm for immediate contralateral symmetrization

The aim of this study was to investigate clinical and aesthetic results of simultaneous contralateral balancing procedures in unilateral DIEP flap reconstructions by means of a symmetrization algorithm. Between 2004 and 2013, 335 patients underwent DIEP flap breast reconstruction with 48 patients (mean age 51.8 years, range 32–69 years) undergoing contralateral procedure. Patients were divided in Group‐A including 31 cases who underwent one‐stage procedure and Group‐B including 17 cases who underwent staged procedure. A symmetrization algorithm was proposed to plan immediate breast reduction/mastopexy. The groups were homogeneous regarding patients age, BMI, mastectomy and flap weight (P > 0.05). All flaps survived. No complications were observed to the mastectomy skin flaps and to the reduction mammaplasty/mastopexy procedures in both groups. The mean operation time was 5 h in Group‐A while 5 h and 37 min in Group‐B (P = 0.0682). Contralateral procedures included 23 breast reductions and 8 mastopexies in Group‐A, while 10 breast reductions and 7 mastopexies were performed in Group‐B. Two and 6 patients required revision of the balancing procedure in Group‐A and Group‐B, respectively. The follow‐up time was 47.3 months (range 14–120 months) in Group‐A and 91.3 months (range 41–110 months) in Group‐B. Volume, upper/lower pole shape, projection, breast mound placement, IMF, symmetry, overall appearance, and general satisfaction sub‐items obtained high‐score evaluation without significant difference between the two groups (P > 0.05). One‐stage DIEP flap reconstruction by means of the symmetrization algorithm resulted in comparable aesthetic outcomes and patient satisfaction to a staged procedure.

One-stage DIEP flap reconstruction: algorithm for immediate contralateral breast symmetrization

The aim of this study was to investigate clinical and aesthetic results of simultaneous contralateral balancing procedures in unilateral DIEP flap reconstructions by means of a symmetrization algorithm. Between 2004 and 2013, 335 patients underwent DIEP flap breast reconstruction with 48 patients (mean age 51.8 years, range 32–69 years) undergoing contralateral procedure. Patients were divided in Group‐A including 31 cases who underwent one‐stage procedure and Group‐B including 17 cases who underwent staged procedure. A symmetrization algorithm was proposed to plan immediate breast reduction/mastopexy. The groups were homogeneous regarding patients age, BMI, mastectomy and flap weight (P > 0.05). All flaps survived. No complications were observed to the mastectomy skin flaps and to the reduction mammaplasty/mastopexy procedures in both groups. The mean operation time was 5 h in Group‐A while 5 h and 37 min in Group‐B (P = 0.0682). Contralateral procedures included 23 breast reductions and 8 mastopexies in Group‐A, while 10 breast reductions and 7 mastopexies were performed in Group‐B. Two and 6 patients required revision of the balancing procedure in Group‐A and Group‐B, respectively. The follow‐up time was 47.3 months (range 14–120 months) in Group‐A and 91.3 months (range 41–110 months) in Group‐B. Volume, upper/lower pole shape, projection, breast mound placement, IMF, symmetry, overall appearance, and general satisfaction sub‐items obtained high‐score evaluation without significant difference between the two groups (P > 0.05). One‐stage DIEP flap reconstruction by means of the symmetrization algorithm resulted in comparable aesthetic outcomes and patient satisfaction to a staged procedure.

Diep flap sentinel skin paddle positioning algorithm

Although clinical examination alone or in combination with other techniques is the only ubiquitous method for flap monitoring, it becomes problematic with buried free‐tissue transfer. We present a DIEP flap sentinel skin paddle (SSP) positioning algorithm and its reliability is also investigated using a standardized monitoring protocol. All DIEP flaps were monitored with hand‐held Doppler examination and clinical observation beginning immediately after surgery in recovery room and continued postoperatively at the ward. Skin paddle (SP) position was preoperatively drawn following mastectomy type incisions; in skin‐sparing mastectomies types I–III a small SP (sSP) replaces nipple–areola complex; in skin‐sparing mastectomy type IV, SSP is positioned between wise‐pattern branches while in type V between medial/lateral branches. In case of nipple‐sparing mastectomy SSP is positioned at inframammary fold or in lateral/medial branches of omega/inverted omega incision if used. Three hundred forty‐seven DIEP flap breast reconstructions were reviewed and stratified according to SP type into group A including 216 flaps with large SP and group B including 131 flaps with SSP and sSP. Sixteen flaps (4.6%) were taken back for pedicle compromise, 13 of which were salvaged (81.25%), 11 among 13 from group A and 2 among 3 from group B. There was no statistical difference between the groups concerning microvascular complication rate (P = 0.108), and time until take‐back (P = 0.521) and flap salvage rate (P = 0.473) resulted independent of SP type. Our results suggest that early detection of perfusion impairment and successful flaps salvage could be achieved using SSP for buried DIEP flap monitoring, without adjunctive expensive monitoring tests.

Breast Reconstruction in Elderly Patients: Risk Factors, Clinical Outcomes, and Aesthetic Results

Background Correlation among age, clinical, and aesthetic outcomes in implant‐based and autologous breast reconstructions was investigated. Methods Between 2004 and 2014, a retrospective study was performed on patients who underwent reconstruction following mastectomy. Patients were divided in group A (< 50 years), group B (≥ 50‐59 years), group C (≥ 60‐69 years), and group D (≥ 70 years). Demographics, comorbidities, American Society of Anesthesiologists (ASA) class, and length of stay were assessed using chi‐square and Kruskal‐Wallis H analysis considering p ≤ 0.05 as significant. Pre‐ and postoperative photographs were taken to grade aesthetic results by patients and blinded plastic surgery team. Results A total of 993 patients underwent 1,251 breast reconstructions, of which 356 (28.5%) were implant‐based, 402 (32.1%) pedicled‐flap, 445 (35.6%) free‐flap, and 48 (3.8%) fat‐graft reconstructions. There were 316 (25.2%) complications, of which 124 (34.8%) in implant‐based, 74 (18.4%) in pedicled‐flap, 111 (24.9%) in free‐flap, and 2 (4.2%) in fat‐graft reconstructions. Mean length of stay was 5.4 days without significant difference between age groups (p = 0.357). The incidence of overall complications was not significantly related to age, ASA class, smoking history, and previous radiotherapy. Body mass index was a significant predictor (p = 0.001), but odds ratio (OR: 1.2) demonstrated only a minimal increase in risk. Implant‐based reconstruction was associated with a higher risk for complications compared with the other ones (OR: 2.5, p = 0.001). Patient and surgeon aesthetic surveys demonstrated an overall positive opinion in all age groups for each reconstructive option. Conclusion Advanced age should not be considered a risk factor for breast reconstruction, while implant‐based technique was associated with a higher risk for complications compared with autologous that may provide older women with greater benefits.

Breast reconstruction following nipple-sparing mastectomy: clinical outcomes and risk factors related complications

Abstract Background: The aim of this study was to investigate clinical outcomes and risk factors related complications in patients who had undergone nipple-sparing mastectomy (NSM) followed by implant-based or autologous reconstruction. Methods: Between 2004–2014 a single-institution retrospective review was collected on NSMs reconstruction. Patient demographics, comorbidities, breast morphological factors, type and timing of radiotherapy, type of incision, reconstruction type and timing, implant volume and complications were collected. Results: A total of 288 patients had undergone 369 NSMs, 81 (28.1%) of which were bilateral while 207 (71.9%) unilateral. One-hundred mastectomies were performed for prophylactic purposes whereas 269 were therapeutics. Thirteen (4.5%) patients were active smokers, while 2 (0.7%) were diabetics. Fifty-five breasts (14.9%) were previously irradiated and average time elapsed between radiotherapy and NSM was 9-year, (range, 5–15 yrs). Total complication rate was 13.5% at mean follow-up of 47.98 months (range, 6–114 months). Partial-thickness and full-thickness mastectomy skin flap and NAC necrosis occurred in 39 (78%) and in 10 (20%) breasts, respectively. Previous radiotherapy and implant volume were significant predictors of complications (OR: 10.14, 95% CI: 3.99–27.01; OR × 100 g: 3.13, 95% CI: 1.64–6.33). Overall mastectomy type incision was not predictive of complications (p = .426). No association was observed between radiotherapy and mastectomy type access (p = .349). Conclusions: From our experience NSM followed by implant-based and autologous reconstruction had a relative high rate of complications comparable to previous reports. Despite this, it should be carefully offered to patients in whom potential risk factors are identified.

Microvascular reconstruction of complex foot defects, a new anatomo-functional classification

Up until recently severe foot defects have been underestimated and amputation considered the treatment of choice. Inadequate treatment of foot defects is generally responsible for impaired deambulation resulting in physical and psychological handicap to the patient and producing a negative impact on social life. Foot reconstruction represents a recent advancement but is still a great challenge to the plastic surgeon; indeed the absence of a comprehensive anatomical classification of foot defects makes sharing clinical experiences difficult, slowing down the progress in this field. We report a single surgeon experience on a consecutive series of 47 complex foot reconstructions performed on 45 patients with microvascular free flaps over a 27-year period. A retrospective review of the cases was performed, a detailed analysis of the defects is presented and possible solutions debated so as to outline the key points in the diagnosis and treatment of foot defects. In the decision making process, soft tissue defect location, dimension, and functional relevance have proven to be as important as the exact definition of the bone defect. A new anatomical classification scheme for composite defects of the foot, involving both bone and soft tissue, is proposed in order to allow for a correct evaluation of the wound and an easier identification of the ideal treatment.