Ondrej Mestak

Centrifugation versus PureGraft for fatgrafting to the breast after breast-conserving therapy

BackgroundBreast-conserving treatment (BCT) leads to a progressive and deteriorating breast deformity. Fatgrafting is ideal for breast reconstruction after BCT. The most frequently utilized technique for fat processing is centrifugation. The PureGraft device (Cytori Therapeutics, San Diego, CA, USA) is a new method that involves washing and filtering the fat to prepare the graft. We compared the subjective and objective outcomes of two fat-processing methods, centrifugation and PureGraft filtration.MethodsThirty patients underwent breast reconstruction performed by a single surgeon (OM) after BCT in our department between April 2011 and September 2012. The patients were preoperatively divided into two groups randomly: 15 received fatgrafts processed by centrifugation, and 15 received fatgrafts processed by washing in PureGraft bags. The patients were followed up for 12 to 30 months. To measure the subjective outcome, we distributed the BREAST-Q questionnaire to all the patients both preoperatively and 1 year postoperatively. The BCCT.core software evaluated the objective outcome of breast reconstruction by fatgrafting.ResultsThe Breast-Q results indicated a tremendous improvement in the modules “Satisfaction with Breast” and “Psychosocial Well-being”. The “Sexual Well-being” scale also improved. Only the module “Satisfaction with Breasts” significantly differed between groups; patients treated with the PureGraft fat exhibited better outcomes. The BCCT.core results did not significantly differ between the groups.ConclusionOne year postoperatively, the outcomes of the use of PureGraft bags or centrifugation to process fat for breast reconstruction after BCT did not differ. The unpredictability of the results following fatgrafting procedures is likely due to interindividual differences with yet-undisclosed causes.

Evaluation of the Long-Term Stability of Sheath Plication Using Absorbable Sutures in 51 Patients with Diastasis of the Recti Muscles: An Ultrasonographic Study

Background: Rectus sheath plication within abdominoplasty is a standard treatment for diastasis of the recti muscles. There are questions regarding the efficacy and long-term stability of the correction of rectus diastasis and whether absorbable sutures work as well as nonabsorbable sutures. Methods: The authors conducted a case-control study to assess the outcomes of recti muscle diastasis correction with absorbable suture. The authors assessed the outcomes by physical and ultrasonographic examinations and a patient questionnaire, which asked about the number of pregnancies and the types of deliveries, other abdominal operations before or after the abdominoplasty, and the interval of time required to return to full activity. During the examination, the interrecti distances were measured at three levels: halfway between the xiphoid and umbilicus, just above the umbilicus, and halfway between the umbilicus and the pubis. The same examination was performed on a control group of nulliparous women. Results: The authors examined a group of 51 patients aged 25 to 64 years (mean, 41 years). The time interval between the operation and the ultrasonographic examination was 12 to 41 months (mean, 20.8 months). There was no statistically significant difference between the studied group and the control group with respect to their interrecti distances. Conclusion: Rectus sheath plication using absorbable sutures in patients with diastasis of the recti muscles is a reliable method that maintains the long-term stability of the abdominal wall. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Mesenchymal Stem Cells Seeded on Cross‐Linked and Noncross‐Linked Acellular Porcine Dermal Scaffolds for Long‐Term Full‐Thickness Hernia Repair in a Small Animal Model

Biological meshes are biomaterials consisting of extracellular matrix that are used in surgery particularly for hernia treatment, thoracic wall reconstruction, or silicone implant-based breast reconstruction. We hypothesized that combination of extracellular matrices with autologous mesenchymal stem cells used for hernia repair would result in increased vascularization and increased strength of incorporation. We cultured autologous adipose-derived stem cells harvested from the inguinal region of Wistar rats on cross-linked and noncross-linked porcine extracellular matrices. In 24 Wistar rats, a standardized 2×4 cm fascial defect was created and repaired with either cross-linked or noncross-linked grafts enriched with stem cells. Non-MSC-enriched grafts were used as controls. The rats were sacrificed at 3 months of age. The specimens were examined for the strength of incorporation, vascularization, cell invasion, foreign body reaction, and capsule formation. Both materials showed cellular ingrowth and neovascularization. Comparison of both tested groups with the controls showed no significant differences in the capsule thickness, foreign body reaction, cellularization, or vascularization. The strength of incorporation of the stem cell-enriched cross-linked extracellular matrix specimens was higher than in acellular specimens, but this result was statistically nonsignificant. In the noncross-linked extracellular matrix, the strength of incorporation was significantly higher in the stem cell group than in the acellular group. Seeding of biological meshes with stem cells does not significantly contribute to their increased vascularization. In cross-linked materials, it does not ensure increased strength of incorporation, in contrast to noncross-linked materials. Owing to the fact that isolation and seeding of stem cells is a very complex procedure, we do not see sufficient benefits for its use in the clinical setting.

Breast Reconstruction after a Bilateral Mastectomy Using the BRAVA Expansion System and Fat Grafting.

Summary: Fat graft breast reconstruction following a mastectomy is always limited by the size of the skin envelope, which affects the amount of graft that can be injected in 1 session. Because the fat graft naturally resorbs in all patients, several sessions of fat grafting are necessary. BRAVA’s negative pressure causes a “reverse” expansion of the skin envelope, thus permitting more space for the fat graft. This allows decreasing number of required procedures for an adequate breast reconstruction. We operated on a 38-year-old patient 4 years after bilateral mastectomy without irradiation for breast cancer. Before the procedure, the patient was instructed to wear the BRAVA system for 12 hours daily for 2 months before the first session, at all times between the sessions and for 1 month following the last fat grafting session. We performed 3 fat grafting sessions, as planned. Altogether, we injected 840 cm3 of fat on the right side and 790 cm3 of fat on the left side. Four months after the last operation, the patient was very satisfied with her new breasts. The breasts were soft, with good sensation and a natural feel. Using the BRAVA external expansion system for the enhancement of fat grafting is a suitable technique for breast reconstruction after a mastectomy. This technique produces soft and natural feeling breasts in fewer operative sessions, with a minimal risk of complications. Patient compliance, however, is greatly needed to achieve the desired results.

Comparison of Patient-reported Outcomes after Implant Versus Autologous Tissue Breast Reconstruction Using the BREAST-Q

Background: The demand for reconstructive breast procedures of various types has accelerated in recent years. Coupled with increased patient expectations, it has fostered the development of oncoplastic and reconstructive techniques in breast surgery. In the setting of postmastectomy reconstruction, patient satisfaction and quality of life are the most significant outcome variables when evaluating surgical success. The aim of this study was to evaluate the quality of life after implant breast reconstruction compared with autologous breast reconstruction. Materials and Methods: A cross-sectional study design was used. A total of 65 women who had completed postmastectomy implant-based or autologous reconstruction in the participating center were asked to complete the BREAST-Q (Reconstruction Module). Results: Data analysis demonstrated that women with autologous breast reconstruction were significantly more satisfied with their breasts (P = 0.0003) and with the overall outcome (P = 0.0001) compared with women with implant breast reconstruction. All other BREAST-Q parameters that were considered and observed were not significantly different between the 2 patient groups. Conclusions: Through statistical analysis, our results showed that patients who underwent autologous tissue reconstruction had better satisfaction with the reconstructed breast and the outcome, while both techniques appear to equally improve psychosocial well-being, sexual well-being, and chest satisfaction.

The effect of different biologic and biosynthetic wound covers on keratinocyte growth, stratification and differentiation in vitro:

The purpose of this study was to compare, by means of in vitro cultivation technique, five marketed brands of wound covers used in the treatment of burns and other skin defects (Biobrane®, Suprathel®, Veloderm®, Xe-Derma®, and Xenoderm®) for their ability to stimulate the keratinocyte growth, stratification, and differentiation. In three independent experiments, human keratinocytes were grown on the tested covers in organotypic cultures by the 3T3 feeder layer technique. Vertical paraffin sections of the wound covers with keratinocytes were processed using hematoxylin–eosin staining and immunostaining for involucrin. Keratinocyte populations on the dressings were assessed for (1) number of keratinocyte strata (primary variable), (2) quantitative growth, (3) thickness of the keratinocyte layer, and (4) cell differentiation. The Xe-Derma wound cover provided the best support to keratinocyte proliferation and stratification, with the number of keratinocyte strata significantly (p < 0.05) higher in comparison to all products studied, except Xenoderm. However, in contrast to Xe-Derma, Xenoderm did not significantly differ from the other dressings. The results of this in vitro study show that the brands based on porcine dermal matrix possess the strongest effect on keratinocyte proliferation and stratification. The distinctive position of Xe-Derma may be related to its composition, where natural dermal fibers form a smooth surface, similar to the basement membrane. Furthermore, the results indicate that in vitro evaluation of effects on epithelial growth may accelerate the development of new bio-engineering-based wound covers.

Hyperprolactinaemia: a cause of severe postoperative complication after reduction mammaplasty.

Abstract Galactorrhoea is a rare complication of wound healing after breast reduction and its association with necrosis of the areolar skin in women with no recent history of breast feeding has to our knowledge never been described. Galactorrhoea is common and there are many differential diagnoses. We report a case of a 46-year-old woman who had bilateral reductions of the breast and developed hyperprolactinaemia and galactorrhoea six weeks postoperatively. Subsequently she developed dry necrosis of both areolas. All radiographic and laboratory findings were within the reference ranges except for of prolactin.

Unusual regression of severe recurrent lymphatic malformation of a face after contraception and pregnancy

We report the case of a female who had suffered from progressive lymphatic malformation in the orbito-temporal region since childhood. Many surgical interventions were performed, including radical excision and shunt drainage. Despite aggressive surgical treatment, recurrence was observed after every intervention. Eventually, the condition regressed after the patient began taking a contraceptive. Moreover, it virtually disappeared after pregnancy.

Reply: evaluation of the long-term stability of sheath plication.

Reply: Evaluation of the Long-Term Stability of Sheath Plication Sir: We are grateful for the comments of Nathan and Nathan, which will allow us to better clarify our article. Diastasis of recti muscles differs from a regular incisional hernia. A hernia is defined as the protrusion of an organ or part of an organ through a defect in the wall of the cavity.1 Incisional hernia arises from different causes, such as surgical-site infection, excessive tension on the suture, or use of inappropriate suturing material. Diastasis of recti muscles, on the other hand, is a result of spread in the area of the linea alba without any organ protrusion. The complex but flexible structural composition of the linea alba makes it prone to fatigue in cases of long-lasting increased intraabdominal pressure, such as that resulting from pregnancy. Consequently, the recti abdominis muscles will separate, leading to diastasis with a widened linea alba.2 The articles cited by Nathan and Nathan evaluating outcomes of hernia correction are excellent level 1 articles evaluating methods of abdominal fascia closure and incisional hernia therapy. However, in our opinion, these findings cannot be interpolated to the treatment of diastasis recti abdominis muscles for the reasons stated above. Level 1 or 2 studies evaluating approaches to the therapy of diastasis recti muscles are lacking. We think that use of absorbable suture for this repair has advantages that are described in our article, and we believe our study provides the best scientific data in this field to date. Abdominal musculature plays a crucial role in postural muscle balance. There are studies suggesting that back pain, pelvic floor dysfunction, and other comorbidities are related to diastasis recti abdominis muscles.3,4 As far as we know, there are no scientific data evaluating the impact of surgical correction of diastasis recti muscles on these comorbidities. Our cohort consisted of patients who were consecutively operated on in our department from 2007 to 2010. DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication.