Rossella Elia

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.

Methylene Blue: A Color Test for a Quality De-epithelialization

Dear Sir, The first stage of most techniques of breast reduction and mastopexy involves the de-epithelialization of a greater or lesser breast surface. This stage is known as time-consuming and demanding for surgeons, and it needs assistance to ensure adequate tension on the skin. Different methods and instruments have been described in the literature to reduce the time of the de-epithelialization procedure. In addition to standard techniques involving the use of a scalpel or scissors [1], Barr et al. [2] advocated the use of an electrocautery device instead of a scalpel for the same procedure. Also the VersaJet hydrosurgery system has been proposed for quicker de-epithelialization [3]. Nevertheless, a review of the literature yields only a few articles discussing the depth required to properly de-epithelialize and does not highlight the risk of the procedure, namely the formation of epidermal inclusion cysts. An epidermal inclusion cyst is a benign cutaneous or subcutaneous lesion that is lined with mature stratified squamous epithelium. It may be associated with breast surgery if epithelial elements are retained within the infolded dermoglandular structures or at any other skin closure. The development of this complication requires reoperation for resolution and may lead to a false-positive finding on a mammogram [4]. We recommend an extremely simple method to verify the quality of the de-epithelialization procedure through a ‘‘color test’’ with methylene blue dye. We begin with the standard ‘‘hand and knife’’ technique with scissors or scalpel. Right after this quick step, we instill a few cubic centimeters of methylene blue, just enough to color all the de-epithelialized breast surface. The immediate flush with physiological solution highlights all the areas with intact epidermis as not colored. A precise and complete deepithelialization can now be performed (Figs. 1, 2). Methylene blue or 3,7-bis(dimethylamino) phenozathionium chloride tetramethyl thionin chloride is a phenothiazine derivative. It has been used in biologic stains, hair dyes, photodynamic treatment of herpes, treatment of methemoglobinemia, and lymphatic mapping, and it has been shown to be relatively safe with few adverse reactions being reported from its use. Unstaining of the epidermis during the ‘‘color test’’ is not surprising because methylene blue is an alcohol-soluble compound and it is not absorbed through the skin. On the contrary, dermal tissue immediately turns a blue color [5]. We believe that the ‘‘color test’’ with methylene blue dye could be an easy method to ensure accuracy during the de-epithelialization step of breast surgery and whenever a de-epithelialization procedure is required—harvest of dermal flap or graft. The simple and inexpensive application of the dye adds a little time to the overall procedure, but it enables a quality surgery. & R. Elia rossellaelia4@gmail.com; rossella.elia@hotmail.it

Reply to “melanoma pattern of care in ontario: A call for strategic alignment of multidisciplinary care)”

We read with great interest the recent article entitled “Melanoma patterns of care in Ontario: a call for strategic alignment of multidisciplinary care” by Look Hong NJ et al. In this article, the authors did an extremely valuable work in collecting data related to patterns of melanoma diagnosis and treatment in Ontario. Although melanoma is the sixth most commonly diagnosed malignancy across North America, the authors stated that one patient out of nine is inadequately treated and it seems that referral to sub-specialized providers is critical for ensuring appropriate care. Inspired by the authors, wewould like to express some comments. In particular, we would like to report how someMelanoma Centers are been trying to achieve the “strategic alignment of care” in Italy and to present the experience of amultidisciplinary network that has been set in Puglia with our Melanoma Center as a plastic surgery component. First, the authors collectedmelanoma cases from theOntario Cancer Registry (OCR) and linked data to other administrative databases to perform a retrospective analysis. Since the incidence of melanoma has been increasing also in Italy, in 2013 the Italian Melanoma Intergroup (IMI) promoted the creation of aNational Registry (CNMR) to collect data related to melanoma current treatments, results and costs. The primary objective for IMI was to document the variation in melanoma management, especially in advanced stages. Secondary endpoints were the assessment of a quality index in melanoma surgery and evaluate treatment outcomes. Referring to the wide variations in melanoma treatment mentioned by the authors of the article, in 2015 Sommariva et al published a consensus of the Italian Melanoma Intergroup to standardize some aspects of care related to surgery and define a quality assurance programs in melanoma surgery. In this regard, in consideration of the extensive series reported by the authors, it would be interesting to know their percentage of post-operative complications. Our interest is mainly on lymphedema that could be caused both by sentinel node biopsy and lymphadenectomy procedures. It is the most disabling complication but we are able now to offer to patients preventive and curative surgical solutions. Second, our understanding of melanoma continues to improve, and we can now differentiate low-risk from high-risk patients on the basis of multifactorial analyses from several series of large patients. It is not reasonable that some patients still receive inappropriate treatment andwe strongly agreewith the authors stating that there is a need to create multidisciplinary networks to promote the access to melanoma specialists. In this regard, we would like to underline that this objective can be easily achieved through multimedia communication. Most patients search for medical information through a “Google research” before consulting the family doctor. OurMelanomaCenter is part of a multidisciplinary network together with other specialists (Oncologists, Dermatologists, Pathologists, etc.) with an online domain. Patients can easily collect information about melanoma diagnosis and treatment by the website consultation. Thus, we think that the strength of the online portal is the possibility for family doctors or melanoma patients to book directly a consultation with a specialist and the analysis made by the authors of the article supports the idea that this makes the difference.

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.

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.