Breast surgeons updating on the thresholds of COVID-19 era: results of a multicenter collaborative study evaluating the role of online videos and multimedia sources on breast surgeons education and training.

OBJECTIVE: Current trends show a rise of attention given to breast cancer patients' quality of life and the surgical reconstructive result. Along with this trend, surgical training quality and efficacy are gaining importance and innovative training methods such as online videos shared on social media portals, are becoming main updating tools. In hazardous times like COVID-19 pandemic nowadays, online communication becomes of vital importance and adaptation and innovation are fundamental to keep research and education alive. The authors aimed to investigate the role of video and multimedia sources on the daily activity and surgical training of a representative group of surgeons specifically dedicated to oncologic, oncoplastic and reconstructive breast surgeries. MATERIALS AND METHODS: A survey was produced and administered to 20 major Italian Breast Centers. Collected data were analyzed with Fisher's Exact Test. RESULTS: From October 2019 to March 2020, a total of 320 surveys were collected. Among the responders, there were 188 trainees (intern medical doctors and residents) and 110 faculty, 72% of them belonged to a plastic surgery environment, while 28% to general surgery environment. Almost all respondents have ever watched videos concerning breast surgery. CONCLUSIONS: The results of the study show how breast surgeons rely on videos and web platforms, mostly YouTube, when searching for training info about surgical procedures. Social media offer great opportunities for sharing knowledge and diffusion of new ideas but greater attention to their reliability is mandatory.

Prepectoral breast reconstruction with TiLoop® Bra Pocket: a single center prospective study.

OBJECTIVE: In the last decades, immediate breast reconstruction (IBR) raised in frequency, and prepectoral positioning of the implant is becoming the trend nowadays. The aim of this paper is to describe our case series in IBR with prepectoral implant placement and complete coverage of it with the TiLoop® Bra titanium-coated polypropylene mesh (TCPM), pre-shaped as a pocket. PATIENTS AND METHODS: Eighteen women with breast tumors were selected and underwent mono- or bilateral mastectomies and prepectoral IBR with tissue expanders or prostheses. After the prepectoral lodge was ready, the implants were inserted into TiLoop® Bra Pocket meshes and positioned over the pectoralis major muscle fascia. The mean surgical time of their positioning was four minutes. RESULTS: This preliminary study showed meaningful results in prepectoral IBR with TiLoop® Bra Pocket covering the implants, for we observed a reduction of implant's exposure time and risk of bacterial contamination. Of the 18 patients that underwent this procedure, only three presented complications that resolved in a maximum of four weeks. CONCLUSIONS: A considering reduction of surgical time in implant positioning was achieved, lowering exposure time and risk of complications as infection.

Subcutaneous expanders and synthetic mesh for breast reconstruction: Long-term and patient-reported BREAST-Q outcomes of a single-center prospective study.

Recently, prepectoral breast reconstruction is experiencing a revival. Despite the growing body of early reports about subcutaneous breast reconstruction, literature lacks in long-term results and studies focusing on patient-reported outcomes and health-related quality of life. Between January 2012 and December 2016, patients undergoing mastectomy were enrolled at our institution. We selected patients diagnosed with breast cancer or genetic predisposition to breast cancer, undergoing conservative mastectomy, either nipple-sparing or skin-sparing mastectomy, and willing for prepectoral tissue expander reconstruction assisted by a synthetic mesh. Exclusion criteria were body mass index greater than 35 kg/m2 and pregnancy. BREAST-Q questionnaire was administered prior to surgery and after 1 year. Capsular contracture was evaluated using Baker scale. Oncological, surgical, and esthetic outcomes along with the changes in BREAST-Q score were analyzed over time. One hundred eighty-seven patients were enrolled, with an average age of 55.5 years. One hundred thirty-seven unilateral mastectomy and 50 bilateral mastectomy procedures were performed, accounting for a total of 237 operated breasts. The average follow-up period after the second stage was 36.5 months. Postoperative complications that require a second operation occurred in 16 cases (6.7%) (4 wound dehiscence, 2 skin-nipple necrosis, 7 infections, and 3 seroma cases). A locoregional recurrence occurred in 3 cases (1.9%) and a systemic recurrence occurred in 2 cases (1.3%). Patients scored high level of satisfaction with outcome. Overall satisfaction with breasts, psychosocial well-being, and sexual well-being was all significantly increased after the surgery (p < 0.05). Two-stage expander reconstruction technique provides the preservation of the pectoralis major muscle with an acceptable rate of complications. We confirm satisfactory patient-reported and esthetic results, with high patient comfort.

Oncoplastic conservative surgery for breast cancer: long-term outcomes of our first ten years experience.

OBJECTIVE: The main goal of oncoplastic breast surgery (OBS) is to optimize cosmetic outcomes and reduce patient morbidity, while still providing an oncologically-safe surgical outcome and extending the target population of conservative surgery. Although the growing number of reported experiences with oncoplastic surgery, few studies account for the long-term outcomes. PATIENTS AND METHODS: Between January 2000 and December 2010, 1024 consecutive oncoplastic surgeries were performed and prospectively included in a database. Demographic data, histological and oncological evaluation and surgical complications were recorded. The role of tumor and patients' characteristics on the development of local recurrence and metastases were assessed by multivariate analysis. RESULTS: Median follow up was 74.2 months. The average age of patients was 56.24. In 869 patients (84.9%) an invasive tumor and in 155 (15.1%) an in situ tumor (11% DCIS and 4% LIN) was found. The average size of the tumor was 24.5 mm. A positive margin presented in 67 (6.5%) patients. Forty patients (50%) underwent re-excision and 39 (49.4%) underwent mastectomy. The overall breast conservation rate was 96.2%. Reported complications were: 17 wound infections (1.7%); 106 hematomas (10.4%); 94 lymphorrheas (9.2%), 48 partial wound dehiscence (4.7%). Local recurrences (LR) were observed in 49 patients (4.7%). The risk of local recurrence was significantly higher in the group of patients with lymphovascular invasion and with high grade (G) (p < 0.05). 52 (5.07%) distant metastases were reported and the related risk was significantly higher in the group of patients with lymphovascular invasion and with negative receptors (p < 0.05). CONCLUSIONS: Oncoplastic surgery provides an acceptable oncological long-term outcome and can be used to treat with conservative surgery also a selected population of patients who would had otherwise undergone mastectomy in the past.

Oncological safety of stromal vascular fraction enriched fat grafting in two-stage breast reconstruction after nipple sparing mastectomy: long-term results of a prospective study.

OBJECTIVE: Autologous fat transfer (AFT) is commonly used to treat implant palpability and prevent fibrosis and thinning in mastectomy skin flaps. A major limit to this procedure is volume retention over time, leading to the introduction of fat enrichment with stromal vascular fraction (SVF+AFT). Oncological concerns have been raised over the injection of an increased concentration of progenitors cells (ASCs) in the SVF. The aim of the study is to evaluate the long-term cancer recurrence risk of SVF+AFT cases compared to AFT, in patients undergoing Nipple Sparing Mastectomy (NSM). PATIENTS AND METHODS: A prospective study was designed to compare three groups of patients undergoing NSM followed by SVF+AFT, AFT or none (control group), after a two-stage breast reconstruction. Patients were strictly followed-up for at least 5-years from the second stage reconstructive procedure. Loco-regional and systemic recurrence rate were evaluated over time as the primary outcome. Logistic regression was used to investigate which factors were associated with recurrence events and independent variables of interest were: surgical technique, age above 50 years old, lympho-vascular invasion, oncological stage, adjuvant or neoadjuvant chemotherapy, adjuvant radiotherapy and adjuvant hormone therapy. RESULTS: 41 women were included in G1 (SVF+AFT), 64 in G2 (AFT), and 64 in G3 (control group). Loco-regional recurrence rate was 2.4% for G1, 4.7% for G2, and 1.6% for G3. Systemic recurrence was 7.3%, 3.1%, and 3.1%, respectively. Among the variables included, there were no significant risk factors influencing a recurrence event, either loco-regional or systemic. In particular, SVF+AFT (G1) did not increase the oncological recurrence. CONCLUSIONS: Our data suggest that both centrifuged and SVF-enhanced fat transfer have a similar safety level in comparison to patients who did not undergo fat grafting in breast reconstruction after NSM.

Randomized clinical trial comparing regional and general anaesthesia in minimally invasive video-assisted parathyroidectomy.

BACKGROUND: This randomized clinical trial was performed in a single institution to compare the results of minimally invasive video-assisted parathyroidectomy (MIVAP) conducted under regional anaesthesia (RA) or general anaesthesia (GA). METHODS: Fifty-one patients undergoing MIVAP for primary hyperparathyroidism were assigned randomly to either RA (26 patients) or GA (25). RA involved a bilateral deep cervical block, and local infiltration of the incision site with a mixture of 0.25 per cent lignocaine and 0.15 per cent bupivacaine. GA was induced by intravenous administration of propofol, remifentanil and rocuronium bromide. RESULTS: The two groups were matched for age, sex, adenoma size, and preoperative serum calcium and parathyroid hormone levels. The interval from skin incision to closure was similar in the two groups (27.6 and 25.8 min for RA and GA respectively), whereas the total operating time (from induction of anaesthesia to return to the ward) was significantly lower with RA (72.1 versus 90.2 min; P = 0.001). The postoperative requirement for pain medication, measured in terms of amount of ketorolac administered at the request of the patient, was significantly lower in the RA group (28.5 versus 80 mg/day; P < 0.001). CONCLUSION: MIVAP performed under RA was associated with a shorter overall operating time and a reduced need for postoperative pain relief.

[Minimally invasive video-assisted thyroidectomy--techniques and results over 4 years of experience (1999-2002)]. / Tiroidectomia video-assistita minimamente invasiva (Mivat)--cenni di tecnica an e risultati di 4 anni di esperienza (Analisi della casistica 1999-2002).

INTRODUCTION: This study reviews four years of Minimally Invasive Video Assisted Thyroidectomy (MIVAT) technique and compares the results to those of traditional thyroid surgery. MATERIALS AND METHODS: Between 1999 and 2002, a series of 427 patients were submitted to MIVAT at our Department. Selection criteria were: thyroid nodule maximum diameter of 3.5 cm, total thyroid volume under 25 cc, no signs associated thyroiditis, diagnosis of benign thyroid disease or "low risk" thyroid tumor, no evidence of nodal disease of the neck. RESULTS: We operated on 362 females and 65 males and the mean age of the population was 39.6 years (range 10-77). A total thyroidectomy was performed in 208 cases, and 219 patients underwent a single-side procedure. Mean operative time was 30.4 minutes for lobectomy (range 20-140 minutes) and 50.2 for total thyroidectomy (range 35-140). Complications were represented by definitive recurrent nerve palsy in 3 patients (0.7%) and one case of definitive hypoparathyroidism (0.4%). A wound infection is reported in 3 cases and we had no major bleeding that required surgical revision. A conversion to open procedure was performed in 5 cases (1.2%); mean hospitalisation was 1.28 days (range: 1-4). CONCLUSIONS: This series demonstrates that MIVAT is not different to conventional open surgery in terms of complications, radicality of the procedure and operative time. Moreover, even if not statistically proved, MIVAT appears to offer some advantages in terms of cosmetic results and postoperative pain. In conclusion, we believe that MIVAT is a perfectly reproducible and safe technique for both benign and low-risk malignant thyroid disease, when correct indications are strictly followed.

Leiomyosarcoma of the popliteal artery: case report and review of the literature.

Vascular leiomyosarcomas are rare tumors, and only 21 have been described as developing in the systemic arteries. We present a case, the sixth in the literature, of a leiomyosarcoma originating in the popliteal artery of a 67-year-old woman treated with en bloc excision of the neoplasia and the artery followed by a popliteal tibioperoneal trunk bypass. The patient then was underwent adjuvant radiotherapy and chemotherapy. After 31 months of follow-up, the patient has mild claudication but does not have either recurrence or metastasis.

[Video-assisted minimally invasive parathyroidectomy with median access. Technical changes: case load 1999-2002]. / Paratiroidectomia miniinvasiva videoassistita con accesso mediano. Evoluzione tecnica: casistica 1999-2002.

INTRODUCTION: In 1997 a Minimally Invasive Video Assisted Technique for Parathyroidectomy (MIVAP) was developed in the University of Pisa. In this review we examine the last three years of MIVAP (240 cases) in order to identify the advantages and the limits of the procedure after the first-period development of the technique. RESULTS: In our experience, 65% of patients affected by primary hyperparathyroidism (PHPT) turned out to be eligible for MIVAP. During the first years several selection criteria were strictly followed; more recently, some initially absolute contraindications to the operation have been interpreted more flexibly. Mean operative time is 35 minutes. 18 conversions (7.5%) to traditional open cervicotomy were needed and in 4 cases (1.6%) no affected parathyroid tissue was removed. CONCLUSIONS: At present, we consider absolutely necessary for MIVAP: preoperative localization of an adenoma with at least one imaging study (US or MIBI scintiscan) and the availability of QPTH intraoperative assay. No absolute contraindications other than the size of the lesions and the suspect of parthyroid carcinoma are identified for patients with PHPT. Moreover, MIVAP has proved to have further advantages when compared to other mini invasive procedures such as the demonstrated possibility to perform a traditional bilateral exploration, when indicated. Nevertheless, a great degree of experience is requested for this procedure. In conclusion, MIVAP permits to significantly reduce postoperative pain, size of the incision, days of hospitalisation and, finally, the cost of the entire procedure without affecting in any way the success rate of the traditional operation and without an increase of the complications.