Or Friedman

An Oncoplastic Breast Augmentation Technique for Immediate Partial Breast Reconstruction following Breast Conservation

Background: Patients with a small breast volume and a relative large lumpectomy volume are at risk of developing severe breast deformity and asymmetry following breast conservation, presenting a unique surgical challenge. Methods: A series of patients undergoing immediate reconstruction by means of an oncoplastic breast augmentation technique following breast conservation are described. The technique includes local tissue rearrangement and bilateral subpectoral breast augmentation with implants of different sizes and shapes, immediately after lumpectomy for a malignant tumor. Results: Twenty-one consecutive patients underwent the oncoplastic breast augmentation technique (mean follow-up, 23 months; range, 12 to 48 months). Three patients (14.3 percent) had tumor-positive surgical margins. Postoperative complications included grade III/IV capsular contracture in five patients (23.8 percent) and breast infection in two patients (10 percent). All patients received postoperative radiation therapy. The cosmetic outcome was evaluated at least 6 months after radiation therapy, and it was favorable according to the reported high patient satisfaction (81 percent) and independent observers’ evaluation scores (76 percent). Conclusions: The oncoplastic breast augmentation technique described in this article is an acceptable option in small-breasted patients with a relatively large lumpectomy volume who elect to undergo breast conservation. This technique allows conservation of the affected breast and minimizes potential breast deformation and asymmetry following radiation therapy. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Rat Hindlimb Cryopreservation and Transplantation: A Step Toward “Organ Banking”

In 2016, over 5 million reconstructive procedures were performed in the United States. The recent successes of clinical vascularized composite allotransplantations, hand and face transplantations included, established the tremendous potential of these life‐enhancing reconstructions. Nevertheless, due to limited availability and lifelong immunosuppression, application is limited. Long‐term banking of composite transplants may increase the availability of esthetically compatible parts with partial or complete HLA matching, reducing the risk of rejection and the immunosuppressive burden. The study purpose was to develop efficient protocols for the cryopreservation and transplantation of a complete rodent limb. Directional freezing is a method in which a sample is cooled at a constant‐velocity linear temperature gradient, enabling precise control of the process and ice crystal formation. Vitrification is an alternative cryopreservation method in which the sample solidifies without the formation of ice crystals. Testing both methods on a rat hindlimb composite tissue transplantation model, we found reliable, reproducible, and stable ways to preserve composite tissue. We believe that with further research and development, cryopreservation may lead to composite tissue “banks.” This may lead to a paradigm shift from few and far apart emergent surgeries to wide‐scale, well‐planned, and better‐controlled elective surgeries.

Body Builder’s Nightmare: Black Market Steroid Injection Gone Wrong: a Case Report

Summary: In the pursuit of success in sports, some athletes are not deterred by health risks associated with the (mis)use of black market preparations of dubious origin as performance-enhancing agents. Several studies published in the recent years demonstrated that anabolic-androgenic steroids, but also stimulants and growth hormones, are misused by numerous recreational athletes from all over the world. Trenbolone is an anabolic steroid routinely used in the finishing phase of beef production to improve animal performance and feed efficiency. A 35-year-old male patient presented to our plastic surgery clinic after self-intramuscular administration of Trenbolone to the superior gluteal area bilaterally, which led to a full-thickness defect in a cone-like distribution. The wounds underwent surgical debridement and were treated locally with mafenide acetate irrigation and wound dressings. Closure was achieved by secondary intention healing. In this report, we discuss the first documented case of full-thickness skin and subcutaneous tissue necrosis after black market anabolic steroid injection. This illustrates a plastic complication and resolution of a widespread but seldom reported problem.

Targeted Delivery of Adipose Derived Stem Cells into a Transplant by Direct Intra-Arterial Administration

Objective: Mesenchymal Stem Cells (MSCs) are adult multipotent cells that possess regenerative and immunosuppressant properties. Homing of MSCs to target organs remains a major challenge as intravenous delivery results in intravascular entrapment of most MSCs in vascularized organs. Intra-Arterial (IA) administration of MSCs to arteries feeding a specific organ improved the delivery of cells to these organs but often resulted in vessels obstruction. To improve targeting of MSCs into a transplant we designed a novel method for IA delivery of MSCs during the transplantation procedure. This study was aimed at evaluating the safety and efficacy of this method. Methods: A syngeneic groin free flap between Lewis rats was performed in all experiment groups. Treatment groups included 3 groups (n ≥ 7) in which 1 × 106, 0.5 × 106 or 0.05 × 106 adipose derived MSCs (ASCs) were administered via a femoral artery branch prior to the final reperfusion of the flap. In vivo real time fluorescence imaging and intravital microscopy were used to define ASCs IA movement after transplantation. Results: High concentrations of ASCs per injection resulted in poor flap survival rates (14.3%) due to flap necrosis. At 0.05 × 106 ASCs, increased long-term flap viability rates (85%) were observed. Whole-body imaging of fluorescently labeled ASCs demonstrated significant targeting of cells into the flap even at such a low cell quantity. ASCs were detected in proximity to small blood vessels within the viable flap. Conclusions: Local IA administration of ASCs into a vascularized transplant/flap is feasible and allows high local cell concentrations with minimal cell dosing.

Underdiagnosed and disfiguring - Radiation-induced morphea following breast cancer treatment

OBJECTIVES Radiation-induced morphea (RIM) is a rare, painful and disfiguring complication in women who receive adjuvant radiotherapy treatment for breast cancer. It is a distinct entity unrelated to radiation-induced fibrosis of the breast. MATERIALS AND METHODS Between the years 2005-2016, approximately 12,000 breast cancer cases were treated with surgery and radiation in the central district of Israel. From that population, we have identified and managed the cases of breast RIM by a multidisciplinary team of dermatologists, breast surgeons, and plastic surgeons. Demographic, oncologic, diagnostic and treatment data were collected and reviewed. RESULTS Three cases of breast radiation-induced morphea, with an estimated prevalence of 1:3000 cases of post-breast cancer radiation where identified. The first signs of morphea appeared years after the completion of standard RT. Early management leads to superior cosmetic results. CONCLUSIONS Unfortunately, there are no known predictors for RIM. Early recognition by the oncologist, the breast surgeon or the reconstructive surgeon during follow-up enables expeditious provision of patient reassurance and helps guide potential treatment options.

DIEP Flap Breast Reconstruction Complication Rate in Previously Irradiated Internal Mammary Nodes

Background Postmastectomy radiation therapy (PMRT) is a widely accepted treatment for locally advanced breast cancer. Some patients require additional boost radiation to the internal mammary nodes as the part of regional nodal irradiation (RNI). Delayed breast reconstruction with an autologous free flap using the internal mammary vessels for microvascular flap anastomosis is a common practice for these patients. The aim of our study was to evaluate the effect of RNI on autologous microvascular breast reconstruction. Patients and Methods A retrospective study was performed on 57 patients (69 flaps) undergoing deep inferior epigastric perforator (DIEP) flap for delayed breast reconstruction after radiation therapy. The study group included 37 patients (65%) who received PMRT and RNI to the internal mammary nodes. The control group included 20 patients (35%) who received PMRT alone. Early and delayed surgical complications, including wound complications, fat necrosis, and flap loss, were compared between the groups. Results The patient demographics in both groups were similar. Complication rate showed a higher trend in the study group for flap loss (8.3% versus 0%) and vascular anastomosis failure (5.6% versus 0%), but with no statistical difference (p = 0.54, 0.53, respectively). The control group showed a higher trend in fat necrosis (25% versus 8.3%, p = 0.11). Conclusions DIEP flap breast reconstructions with internal mammary vessels anastomosis should be performed with cautious in patients who had received RNI to internal mammary nodes because of potential added risk for surgical complications.

Immunological and inflammatory mapping of vascularized composite allograft rejection processes in a rat model

Background Hand and face vascularized composite allotransplantation (VCA) is an evolving and challenging field with great opportunities. During VCA, massive surgical damage is inflicted on both donor and recipient tissues, which may contribute to the high VCA rejection rates. To segregate between the damage-induced and rejection phase of post-VCA responses, we compared responses occurring up to 5 days following syngeneic versus allogeneic vascularized groin flap transplantations, culminating in transplant acceptance or rejection, respectively. Methods The immune response elicited upon transplantation of a syngeneic versus allogeneic vascularized groin flap was compared at Post-operative days 2 or 5 by histology, immunohistochemistry and by broad-scope gene and protein analyses using quantitative real-time PCR and Multiplex respectively. Results Immune cell infiltration began at the donor-recipient interface and paralleled expression of a large group of wound healing-associated genes in both allografts and syngrafts. By day 5 post-transplantation, cell infiltration spread over the entire allograft but remained confined to the wound site in the syngraft. This shift correlated with upregulation of IL-18, INFg, CXCL9, 10 and 11, CCL2, CCL5, CX3CL1 and IL-10 in the allograft only, suggesting their role in the induction of the anti-alloantigen adaptive immune response. Conclusions High resemblance between the cues governing VCA and solid organ rejection was observed. Despite this high resemblance we describe also, for the first time, a damage induced inflammatory component in VCA rejection as immune cell infiltration into the graft initiated at the surgical damage site spreading to the entire allograft only at late stage rejection. We speculate that the highly inflammatory setting created by the unique surgical damage during VCA may enhance acute allograft rejection.