Reconstrucción de la mama: ¿qué hacer cuando la reconstrucción primaria falla? / Breast reconstruction: what to do when primary reconstruction failure?

La reconstrucción de la mama, aunque muy perfeccionada y segura, está colmada de complicaciones. Se presentan casos ilustrativos y directrices cuando la reconstrucción inicial falla, de acuerdo con nuestra experiencia de 30 años en el tema. El uso de expansores en el pecho después de la irradiación no se recomienda debido a la alta incidencia de fracasos. La radioterapia después de la reconstrucción del seno con un implante produce contractura capsular; y después de la reconstrucción con colgajo TRAM, produce fi brosis y retracción de la mama reconstruida. La cada vez mayor recurrencia del cáncer de mama después de la tumorectomía y la radiación se maneja con mastectomía con preservación de piel, y a menudo con una mastectomía profi láctica contralateral. Se describe la utilidad y el diseño del colgajo tóraco-abdominal epigástrico y Mid TRAM

Reconstruction of the Breast, although more sophisticated and safer, is fraught with complications. Illustrative cases and guidelines are presented when the initial reconstruction fails based on our 30-year experience in the subject. The use of expanders on post-irradiated chest is not recommended because of the high incidence of failures. Radiation therapy after breast reconstruction with an implant produces capsular contracture; and after TRAM fl ap reconstruction, produces fi brosis and shrinkage of the reconstructed breast. The increasing of breast cancer recurrence after lumpectomy and radiation is managed by non-skin sparing completion mastectomy, and often with a contralateral prophylactic mastectomy. The utility and design of the thoraco-epigastric and Mid Abdominal TRAM fl ap is described

Analysis of clinically significant seroma formation in breast reconstruction using acellular dermal grafts.

With a rise in tissue expander-based breast reconstructions (TEBRs) using acellular dermal matrix (ADM), we have seen an increase in ADM-specific complications. In this study, we aimed to evaluate clinically significant seroma (CSS) formation-defined by the need for a drainage procedure-to determine if there was a difference in incidence between product types: AlloDerm (AL), DermaMatrix (DM), and FlexHD (FHD). This was a retrospective review of consecutive patients who underwent TEBR at a single institution. The total number of reconstructed breasts was separated into the following 4 groups according to the product type: AL, DM, FHD, or no ADM. We identified the total number of CSSs and compared these data between product types. A logistic regression was performed in an attempt to identify independent risk factors associated with seroma formation. In total, we identified 284 consecutive TEBRs. Overall, there were 17 (7.7%) seromas in 220 breast reconstructions in which ADM was used. When comparing the number of CSS between groups-AL (n = 2, 4.0%), DM (n = 6, 5.4%), FHD (n = 9, 14.75%), and no ADM (n = 1, 1.5%)-we found a significant difference in seroma incidence between product types (P = 0.016). Multivariate analysis identified a strong trend toward FHD as an independent predictor of seroma formation (P = 0.061). Our review suggests that there is strong trend in CSS formation with the use of FHD as compared to other product types and reconstructions in which no ADM was used.

Surgical outcomes of gigantomastia breast reduction superomedial pedicle technique: a 12-year retrospective study.

INTRODUCTION: Reduction mammoplasty in patients with gigantomastia can prove a challenge for the plastic surgeon. Although several techniques have been described to reduce these very large breasts, they can often result in compromise of the nipple-areola complex (NAC), including necrosis, decreased sensation, and inability to breastfeed. The superomedial pedicle (SMP) reduction mammoplasty technique has been demonstrated as a safe and effective method of reduction in cases of mild to moderate hypertrophy. The aim of this study was to determine the risks of SMP in patients with gigantomastia (resection weight >1000 g/breast) at our institution. METHODS/TECHNIQUE: A retrospective study of all patients who underwent reduction mammoplasty with SMP technique by 8 surgeons at a single institution between 1999 and 2011 was performed. Patient demographics, preoperative breast measurements, and perioperative data were analyzed. Exclusion criteria were a reduction mammoplasty specimen weight of less than 1000 g. RESULTS/COMPLICATIONS: Our results show that 200 of 1750 patients who underwent SMP during the study period met the criteria. The average age at the time of the reduction was 39 years. The average body mass index was 36 kg/m. The average sternal notch to nipple distance was 35.5 cm for the right breast and 35.6 cm for the left breast. Average breast resection weight was 1277 g for the right and 1283 g for the left. Average NAC transposition was 11.25 cm for the right breast and 11.40 cm for the left breast. Twenty-one (10.5%) patients experienced partial necrosis of the NAC and 98% of the patients subjectively reported normal NAC sensation postoperatively. All patients exhibited good breast shape and projection postoperatively. CONCLUSIONS: Our study shows that SMP reduction mammoplasty in patients with gigantomastia is a safe and effective reduction mammoplasty technique and is associated with low risk for NAC necrosis with good breast shape.

Complications in tissue expander breast reconstruction: a comparison of AlloDerm, DermaMatrix, and FlexHD acellular inferior pole dermal slings.

Acellular dermal matrix (ADM) is frequently used in tissue expander breast reconstruction (TEBR) for coverage of the inferior pole. Several published studies have suggested increased rates of complications with the use of ADM. It is unknown, however, if the type of ADM used for TEBR impacts complication rates. The aim of this study is to compare 3 different types of ADM for TEBR in regard to clinically significant complications, specifically infection. We performed a retrospective analysis of primary breast cancer-related TEBR with or without ADM. Exclusion criteria consisted of prior major breast surgery, inadequate data, or loss to follow-up. Reconstructions were grouped by dermal sling type, AlloDerm, DermaMatrix (DM), FlexHD (FHD), or no ADM. Complications included cellulitis, abscess, seroma, expander leak or puncture, skin necrosis, wound dehiscence, or hematoma. Those requiring admission to hospital or reoperation were considered significant. Of 284 breasts reconstructed, 49 used AlloDerm, 110 used DM, 62 used FHD, and 64 used no ADM. The total complication rate with AlloDerm was 22% [95% confidence interval (CI), 11-34], with DM was 15% (95% CI, 8-21), and with FHD was 18% (95% CI, 8-28) (P=0.47). Infectious complication rates for AlloDerm, DM, and FHD were equal at 10% (P=0.97). The total complication rate of all ADM reconstructions as a grouped cohort was 17% compared to 11% without ADM (P=0.48). The overall incidence of infectious complications with ADM was 10% compared to 2% without ADM (P=0.09). There is no difference in the clinically significant overall complication rate or incidence of infection between AlloDerm, DM, and FHD. Isolating infectious complications, there is a trend toward increased incidence with ADM compared to reconstructions without.

Current and emerging basic science concepts in bone biology: implications in craniofacial surgery.

Ongoing research in bone biology has brought cutting-edge technologies into everyday use in craniofacial surgery. Nonetheless, when osseous defects of the craniomaxillofacial skeleton are encountered, autogenous bone grafting remains the criterion standard for reconstruction. Accordingly, the core principles of bone graft physiology continue to be of paramount importance. Bone grafts, however, are not a panacea; donor site morbidity and operative risk are among the limitations of autologous bone graft harvest. Bone graft survival is impaired when irradiation, contamination, and impaired vascularity are encountered. Although the dura can induce calvarial ossification in children younger than 2 years, the repair of critical-size defects in the pediatric population may be hindered by inadequate bone graft donor volume. The novel and emerging field of bone tissue engineering holds great promise as a limitless source of autogenous bone. Three core constituents of bone tissue engineering have been established: scaffolds, signals, and cells. Blood supply is the sine qua non of these components, which are used both individually and concertedly in regenerative craniofacial surgery. The discerning craniofacial surgeon must determine the proper use for these bone graft alternatives, while understanding their concomitant risks. This article presents a review of contemporary and emerging concepts in bone biology and their implications in craniofacial surgery. Current practices, areas of controversy, and near-term future applications are emphasized.

Reconstruction of unicoronal plagiocephaly with a hypercorrection surgical technique.

OBJECT Successful surgical repair of unicoronal plagiocephaly remains a challenge for craniofacial surgeons. Many of the surgical techniques directed at correcting the stigmata associated with this craniofacial deformity (for example, ipsilateral supraorbital rim elevation [vertical dystopia], ipsilateral temporal constriction, C-shaped deformity of the face, and so on) are not long lasting and often result in deficient correction and the need for secondary revision surgery. The authors posit that the cause of this relapse was intrinsic deficiencies of the current surgical techniques. The aim of this study was to determine if correction of unilateral coronal plagiocephaly with a novel hypercorrection surgical technique could prevent the relapse of the characteristics associated with unicoronal plagiocephaly. METHODS The authors performed a retrospective analysis of 40 consecutive patients who underwent surgical repair of unicoronal plagiocephaly at their institution between 1999 and 2009. In all cases, the senior author (S.R.B.) used a hypercorrection technique for surgical reconstruction. Hypercorrection consisted of significant overcorrection of the affected ipsilateral frontal and anterior temporal areas in the sagittal and coronal planes. Demographic, perioperative, and follow-up data were collected for comparison. The postsurgical appearance of the forehead was documented clinically and photographically and then evaluated and scored by 2 independent graders using the expanded Whitaker scoring system. A relapse was defined as a recurrence of preoperative features that required secondary surgical correction. RESULTS The mean age of the patients at the time of the operation was 13 months (range 8-28 months). The mean follow-up duration was 57 months (range 3 months to 9.8 years). The postsurgical hypercorrection appearance persisted on average 6-8 months but gradually dissipated and normalized. No patients exhibited a relapse of unicoronal plagiocephalic characteristics that required surgical correction. In all cases the aesthetic results were excellent. Only 3 patients required reoperation for the management of persistent calvarial bone defects (2 cases) and removal of a symptomatic granuloma (1 case). CONCLUSIONS Our study demonstrates that patients who undergo unicoronal plagiocephaly repair with a hypercorrection surgical technique avoid long-term relapse. Our results suggest that the surgical technique used in the correction of unilateral coronal synostosis is strongly associated with the prevention of postsurgical relapse and that the use of this novel method decreases the need for surgical revision.

Effects of auricular chondrocyte expansion on neocartilage formation in photocrosslinked hyaluronic acid networks.

The overall objective of this study was to examine the effects of in vitro expansion on neocartilage formation by auricular chondrocytes photoencapsulated in a hyaluronic acid (HA) hydrogel as a next step toward the clinical application of tissue engineering therapies for treatment of damaged cartilage. Swine auricular chondrocytes were encapsulated either directly after isolation (p = 0), or after further in vitro expansion ( p = 1 and p = 2) in a 2 wt%, 50-kDa HA hydrogel and implanted subcutaneously in the dorsum of nude mice. After 12 weeks, constructs were explanted for mechanical testing and biochemical and immunohistochemical analysis and compared to controls of HA gels alone and native cartilage. The compressive equilibrium moduli of the p = 0 and p = 1 constructs (51.2 +/- 8.0 and 72.5 +/- 35.2 kPa, respectively) were greater than the p = 2 constructs (26.8 +/- 14.9 kPa) and the control HA gel alone (12.3 +/- 1.3 kPa) and comparable to auricular cartilage (35.1 +/- 12.2 kPa). Biochemical analysis showed a general decrease in glycosaminoglycan (GAG), collagen, and elastin content with chondrocyte passage, though no significant differences were found between the p = 0 and p = 1 constructs for any of the analyses. Histological staining showed intense and uniform staining for aggrecan, as well as greater type II collagen versus type I collagen staining in all constructs. Overall, this study illustrates that constructs with the p = 0 and p = 1 auricular chondrocytes produced neocartilage tissue that resembled native auricular cartilage after 12 weeks in vivo. However, these results indicate that further expansion of the chondrocytes (p = 2) can lead to compromised tissue properties.

Tissue engineering cartilage with aged articular chondrocytes in vivo.

BACKGROUND: Tissue engineering has the potential to repair cartilage structures in middle-aged and elderly patients using their own "aged" cartilage tissue as a source of reparative chondrocytes. However, most studies on tissue-engineered cartilage have used chondrocytes from postfetal or very young donors. The authors hypothesized that articular chondrocytes isolated from old animals could produce neocartilage in vivo as well as articular chondrocytes from young donors. METHODS: Articular chondrocytes from 8-year-old sheep (old donors) and 3- to 6-month-old sheep (young donors) were isolated. Cells were mixed in fibrin gel polymer at 40 x 10 cells/ml until polymerization. Cell-polymer constructs were implanted into the subcutaneous tissue of nude mice and harvested at 7 and 12 weeks. RESULTS: Samples and native articular cartilage controls were examined histologically and assessed biochemically for total DNA, glycosaminoglycan, and hydroxyproline content. Histological analysis showed that samples made with chondrocytes from old donors accumulated basophilic extracellular matrix and sulfated glycosaminoglycans around the cells in a manner similar to that seen in samples made with chondrocytes from young donors at 7 and 12 weeks. Biochemical analysis revealed that DNA, glycosaminoglycan, and hydroxyproline content increased in chondrocytes from old donors over time in a pattern similar to that seen with chondrocytes from young donors. CONCLUSIONS: This study demonstrates that chondrocytes from old donors can be rejuvenated and can produce neocartilage just as chondrocytes from young donors do when encapsulated in fibrin gel polymer in vivo. This study suggests that middle-aged and elderly patients could benefit from cartilage tissue-engineering repair using their own "aged" articular cartilage as a source of reparative chondrocytes.

Influence of gel properties on neocartilage formation by auricular chondrocytes photoencapsulated in hyaluronic acid networks.

The objective of this study was to determine how changes in the network structure and properties of hyaluronic acid (HA) hydrogels, due to variations in the macromer molecular weight (50-1,100 kDa) and macromer concentration (2-20 wt %), affect neocartilage formation by encapsulated auricular chondrocytes. To investigate tissue formation, swine auricular chondrocytes were photoencapsulated in the various networks, implanted subcutaneously in the dorsum of nude mice, and explanted after 6 and 12 weeks for biochemical and histological analysis. After 12 weeks, the various constructs were 81-93% water, contained between 0.1 x 10(6) and 0.6 x 10(6) chondrocytes per sample, and consisted of 0-0.049 microg chondroitin sulfate/mug wet weight (glycosaminoglycan (GAG) content) and 0.002-0.060 microg collagen/microg wet weight. Histological staining showed an even distribution of chondrocytes and GAGs in addition to minimal type I collagen staining and intense and uniform type II collagen staining in the constructs with greatest neocartilage production. Hydrogels fabricated from 2 wt % of the 50 kDa HA macromer most resembled the properties of native cartilage and show the greatest promise for continued development for cartilage regeneration.

Cranioplasty with subcutaneously preserved autologous bone grafts.

BACKGROUND: The efficacy of reconstructing a cranial defect with the craniectomy bone graft (bone flap) banked in a subcutaneous pocket of the abdominal wall after emergency decompressive craniotomy was evaluated. METHODS: A retrospective study was performed on 53 of 65 consecutive patients who underwent emergency decompressive craniectomy and bone graft placement in the abdominal wall and survived to graft replacement. Clinical outcome after graft replacement was determined by the adequacy of the recovered craniectomy graft to achieve satisfactory reconstruction, the incidence of infection and the need for revisional surgery. RESULTS: Forty-nine of the 53 patients (92 percent) in whom delayed autogenous graft replacement was attempted achieved a satisfactory one-stage reconstruction. In 42 of these 49 patients, autogenous graft replacement alone was performed. In eight patients it was necessary to supplement the graft with alloplastic material to achieve desired contour. One patient who underwent reconstruction with the autogenous bone graft alone, underwent late revision cranioplasty to improve contour. There were three infections. One graft was found infected in the abdominal pocket at retrieval. Two were lost to operative infection after graft replacement. Histology of two stored grafts performed after abdominal pocket retrieval demonstrated a mixture of necrotic and newly formed woven bone. A bone scan performed 1 year after graft replacement showed radionuclide activity of the graft almost identical to that of intact neighboring bone. CONCLUSIONS: Subcutaneous storage preserves viability of portions of autogenous bone grafts. Cranioplasty performed with a subcutaneously preserved craniectomy graft has a low revision rate.

Integrative repair of cartilage with articular and nonarticular chondrocytes.

Articular chondrocytes can synthesize new cartilaginous matrix in vivo that forms functional bonds with native cartilage. Other sources of chondrocytes may have a similar ability to form new cartilage with healing capacity. This study evaluates the ability of various chondrocyte sources to produce new cartilaginous matrix in vivo and to form functional bonds with native cartilage. Disks of articular cartilage and articular, auricular, and costal chondrocytes were harvested from swine. Articular, auricular, or costal chondrocytes suspended in fibrin glue (experimental), or fibrin glue alone (control), were placed between disks of articular cartilage, forming trilayer constructs, and implanted subcutaneously into nude mice for 6 and 12 weeks. Specimens were evaluated for neocartilage production and integration into native cartilage with histological and biomechanical analysis. New matrix was formed in all experimental samples, consisting mostly of neocartilage integrating with the cartilage disks. Control samples developed fibrous tissue without evidence of neocartilage. Ultimate tensile strength values for experimental samples were significantly increased (p < 0.05) from 6 to 12 weeks, and at 12 weeks they were significantly greater (p < 0.05) than those of controls. We conclude that articular, auricular, and costal chondrocytes have a similar ability to produce new cartilaginous matrix in vivo that forms mechanically functional bonds with native cartilage.

Injectable tissue-engineered cartilage with different chondrocyte sources.

Injectable engineered cartilage that maintains a predictable shape and volume would allow recontouring of craniomaxillofacial irregularities with minimally invasive techniques. This study investigated how chondrocytes from different cartilage sources, encapsulated in fibrin polymer, affected construct mass and volume with time. Swine auricular, costal, and articular chondrocytes were isolated and mixed with fibrin polymer (cell concentration of 40 x 10 cells/ml for all groups). Eight samples (1 cm x 1 cm x 0.3 cm) per group were implanted into nude mice for each time period (4, 8, and 12 weeks). The dimensions and mass of each specimen were recorded before implantation and after explantation. Ratios comparing final measurements and original measurements were calculated. Histological, biochemical, and biomechanical analyses were performed. Histological evaluations (n = 3) indicated that new cartilaginous matrix was synthesized by the transplanted chondrocytes in all experimental groups. At 12 weeks, the ratios of dimension and mass (n = 8) for auricular chondrocyte constructs increased by 20 to 30 percent, the ratios for costal chondrocyte constructs were equal to the initial values, and the ratios for articular chondrocyte constructs decreased by 40 to 50 percent. Constructs made with auricular chondrocytes had the highest modulus (n = 3 to 5) and glycosaminoglycan content (n = 4 or 5) and the lowest permeability value (n = 3 to 5) and water content (n = 4 or 5). Constructs made with articular chondrocytes had the lowest modulus and glycosaminoglycan content and the highest permeability value and water content (p < 0.05). The amounts of hydroxyproline (n = 5) and DNA (n = 5) were not significantly different among the experimental groups (p > 0.05). It was possible to engineer injectable cartilage with chondrocytes from different sources, resulting in neocartilage with different properties. Although cartilage made with articular chondrocytes shrank and cartilage made with auricular chondrocytes overgrew, the injectable tissue-engineered cartilage made with costal chondrocytes was stable during the time periods studied. Furthermore, the biomechanical properties of the engineered cartilage made with auricular or costal chondrocytes were superior to those of cartilage made with articular chondrocytes, in this model.