Paolo Annoscia

Dual plane breast implant reconstruction in large sized breasts: How to maximise the result following first stage total submuscular expansion

Introduction Women who were good candidates for a skin reducing mastectomy, but were instead treated with a skin-sparing mastectomy and reconstruction with expanders, show discrepancy of volume and form between the healthy breast (voluminous and ptotic) and the expanded mastectomy envelope and muscle, which has a smaller size as well as excessive amount of skin at the lower pole. Methods From January 2014 to March 2015, we recruited 18 women with breasts of medium to large volume and with moderate to severe ptosis, already treated at a different centre with a one-side mastectomy and reconstruction by means of an expander. These women were treated at our unit for the second reconstructive step with a dual plane technique and a contralateral reduction/mastopexy. Results The minimum duration of follow-up was 2 years (range 24–30 months). The average volume of the implants was 613u2009g. The reconstructive outcome at the final follow-up (at least 24 months) was judged by the specialist as excellent in 5 cases, very good in 10 cases and good in 3 cases. Breast Q average score was 87.08. Discussion The disinsertion of the expanded muscle dome and the use of a dual plane technique for the placement of the definitive implant provide a solution to the skin-volume mismatch problem. The subcutaneous placement of the implant at the level of the lower pole extends the excessive amount of skin and gives the reconstructed breast fullness and natural ptosis. Further validation of our results is needed.

Lymphatic-venous anastomosis in a rat model: A novel exercise for microsurgical training: LEUZZI et al.

Lymphedema is a condition of localized fluid retention and tissue swelling caused by a compromised lymphatic system. Lymphaticovenular anastomoses (LVA) and multiple lymphatic‐venous anastomoses (MLVAs) have been recognized as efficient methods to treat chronic lymphedema. Because few models for lymphatics microsurgical training have been described, the aim of this study is to present a new training model for MLVA in a rat.

Breast cancer cutaneous metastases mimicking Papilloma Cutis Lymphostatica. Biopsy to avoid pitfalls

Highlights • We present a singular case of secondary lymphedema is the most frequent long-term complication of axillary lymphadenectomy. It can result in complication as erysipelas, warts, Papilloma Cutis Lymphostatica (PCL), or angiosarcomas. Moreover, in women affected by breast cancer an accurate differential diagnosis among these conditions or complication related to radiation dermatitis or cutaneous metastasis is essential. We report the case of a 60-year-old postmenopausal Caucasian woman affected by secondary lymphedema following complete mastectomy for breast cancer. These lesions had clinical typical features of PCL, but histopathological analysis revealed dermo-hypodermic metastasis of breast carcinoma.• The presence of skin lesions in secondary lymphedema after oncological lymphadenectomy requires an accurate differential diagnosis. In fact, these lesions can emulate degenerative or infective skin diseases; anyway, in patients affected by secondary lymphedema other less common conditions - as PLC, nodular-type lichen myxedematosus or Gottron’s carcinoid papillomatosis - should be taken into account.• Our case reports the possibility that metastases of breast cancer might also mimic these conditions.

Abdominoplasty with “Scarpa Fascia” preservation: Case Report

Highlights • The aim of this study is to propose our experience with abdominoplasty with Scarpa Fascia preservationand compare it with recent scientific literature.• This technique seems to have a positive impact on reducing seroma formation, reducing the amount of drained fluids and the drainage time.• The abdominoplasty with the Scarpa Fascia preservation is a safe, repeatable technique with good aesthetic results.• Few cases in literature have dealt with this issue.

Discussion: Optimizing Patient Selection for Direct-to-Implant Immediate Breast Reconstruction Using Wise-Pattern Skin-Reducing Mastectomy in Large and Ptotic Breasts

We read with great interest the paper entitled ‘‘Optimizing Patient Selection for Direct-to-Implant Immediate Breast Reconstruction Using Wise-Pattern Skin-Reducing Mastectomy (WPSRM) in Large and Ptotic Breasts’’ by Inbal et al. [1]. We agree with the authors about the minor psychological impact in the one-stage breast reconstruction, and we also agree that the wise pattern remains in use for mastectomies of large and ptotic breasts with acceptable outcomes because it has wide applicability to the greater grades of breast hypertrophy and breast ptosis [1]. The authors perform a retrospective study of consecutive patients who underwent WPSRM and immediate implantbased breast reconstruction at their institution and propose an algorithm for improving patient and implant selection. By reading the sample data we noticed that no patients were smokers. We believe this was a decisive factor in reducing the risk. In fact, in clinical practice, we try to avoid immediate reconstructions in smokers even though it is a relative contraindication [2]. We would like to ask if smoking is an absolute or relative contraindication in their practice. We also believe that it can be a factor to be considered in a therapeutic algorithm for immediate breast reconstruction. Skin necrosis is a frequent complication in this type of surgery and may result in the loss of the breast implant. To prevent the exposure of the implant we use negative pressure therapy in the immediate postoperative period [3]. In fact, it is known that negative pressure increases tissue perfusion with improved microcirculation [4]. This has allowed us to avoid further surgical times and also to save the areola–nipple complex in nipple-sparing-mastectomy. We believe it can be useful in managing necrotic complications of the skin in immediate breast reconstruction with implants. We believe it is very interesting and we are grateful for the precise risk assessment for every 100 g of weight of mastectomy. Although it is not always possible to estimate the preoperative amount of tissue to be removed, in our opinion it is a very useful intuition.

Why Choose the Septum-Supero-Medial (SSM)-Based Mammaplasty in Patients with Severe Breast Ptosis: An Anatomical Point of View

AbstractNipple–areola complex (NAC) loss is one of the most devastating complications of mastopexy or breast reduction, and it requires revisional procedures with poor aesthetic outcome. In high-risk patients, a free nipple graft could be a choice, but it is associated with the same aesthetic concerns for both patients and surgeons. We report our experience with the septum-supero-medial-based mammaplasty to treat 22 patients with severe breast ptosis (nipple-to-sternal-notch distanceu2009>u200940xa0cm). No NAC loss was observed. The study highlights surgical technical details and discusses anatomical considerations to justify the successful result.Level of Evidence IVThis journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.n

Single-stage excision and sentinel lymph node biopsy in cutaneous melanoma in selected patients: a retrospective case–control study

Sometimes, diagnostic excision of a primary melanoma would already necessitate skin grafting or transposition skin flaps, especially in areas with an esthetic or functional importance. The utility of sentinel lymph node biopsy (SLNB) after skin reconstruction is controversial. We carried out a single-institution retrospective case–control study. In patients with a wide primary lesion at high clinical–dermatoscopic suspicion for invasive melanoma in anatomical region in which a reconstruction with a skin graft or a flap is required, we proposed the performance of a confocal microscopy examination and an incisional biopsy of the primary lesion. If these diagnostic methodologies confirmed the suspicion of melanoma, lymphatic mapping was performed before the wide excision (WE) of the primary lesion, and WE and SLNB were performed during the same operative procedure. The database evaluation showed 496 patients who had undergone a previous complete local excision and a subsequent SLNB (two-stage group), whereas 61 patients underwent WE and SLNB during the same surgical time (one-stage group). Histological results of the excisional biopsy confirmed the diagnosis of melanoma in all patients of the one-stage group. The false-negative rate was lower in the one-stage group (5.5%) than in the two-stage group (16.7%). Patients of the two groups showed a similar recurrence-free and overall survival period even when corrected for clinic-demographical variables. The concomitant execution of SLNB and WE after confocal microscopy examination and incisional biopsy appears to be a safe and accurate procedure in patients with a wide primary melanoma that requires a skin flaps or a skin graft to cover the residual defect.