Nipple Reconstruction Using the "Arrow Flap" Technique: Outcomes and Patients Satisfaction.

INTRODUCTION: Skin-sparing mastectomy (SSM) entails complete removal of the breast tissue and the nipple and areola complex (NAC) with preservation of as much of the overlying skin as possible. The preservation of the natural skin envelope during SSM improves the aesthetic outcome of immediate breast reconstruction, but the lack of NAC determines that the reconstructed breast remains anatomically incomplete with not always satisfactory final results. For this purpose, the aim of the present study was to investigate and evaluate the impact of nipple reconstruction after skin sparing and skin reducing mastectomy on the patients' perception and intimate life. MATERIALS AND METHOD: This was a comparative single-center prospective study that involved 42 patients underwent NAC reconstruction after SSM. A pre- and postoperative quality-of-life and psychological questionnaires Breast-Q questionnaire (Breast Conserving therapy module) were given to all the patients before the surgery and 6 months after. The statistical analysis with chi-square test was performed. RESULTS: After 6 months a prevalence of patients reported to be very satisfied in regard to shape, appearance, naturalness, projection, position and symmetry. The study shows an overall improvement in all the psychological items analyzed with statistically significant difference regarding: "patient's satisfaction," "self-confidence," "appearance of the breast." CONCLUSION: The authors believe that the NAC reconstruction has useful functional and aesthetic results particularly appreciated by patients who feel demoralized after breast demolition surgery.

How Porcine Acellular Dermal Matrix Influences the Development of the Breast Capsule 1 Year after Implantation: A Histopathological Analysis.

Background: In prepectoral breast reconstruction (PPBR) the acellular dermal matrix (ADM)'s integration capacity into the tissue is known. The aim of this study was to analyze the effect of the ADM on development and composition of the peri-implant breast capsule in a dynamic setting of breast tissue expansion during two-stage prepectoral breast reconstruction. Methods: This is a prospective single-center study in which 50 patients who underwent mastectomy and breast reconstruction with prepectoral tissue expander and Braxon ADM (group A) and submuscular tissue expander (group B) were enrolled. One-year post implantation hematoxylin & eosin (H&E) staining and immunohistochemistry analyses were done on capsule tissue samples. Results: The analysis conducted on H&E-stained samples showed a significant reduction of cellular density and a decrease of the cellular infiltration in capsules of ADM-covered expanders compared with naked expander capsules (P < 0.05). The immunohistochemical analyses showed that group A capsules presented significantly less M1 CD68+ macrophages (P < 0.05), lower alfa-SMA expression levels, and a lower number of myofibroblasts (P < 0.05) compared with group B capsules. Presence of lymphatic vessels was minimally detected in both groups. Conclusions: The ADM presence around the prepectoral tissue expander influences the development of the peri-implant capsule, causing a significant reduction of the number of cells and inflammatory infiltrate, especially M1 macrophages and myofibroblasts. The ADM Braxon is therefore effective in creating a noninflamed capsule around the implant and in dynamic tissue conditions, and such an environment is maintained in time.

Early Seroma Treatment Protocol Based on US-Guided Aspiration in DTI Prepectoral Reconstruction: A Prospective Study.

INTRODUCTION: Seroma is a common complication after prepectoral prosthetic breast reconstruction with ADM, leading to wound dehiscencse, infection, and even loss of reconstruction at last. A new ultrasound (US) guided follow-up protocol has been applied to compare primary and secondary complications incidence and their treatment, and evaluate the effect of precocious seroma detection and its evacuation in reducing secondary complications. METHODS: We enrolled 406 patients from January 1st, 2021 to July 1st, 2023 who underwent mastectomy and 1-stage prepectoral reconstruction with ADM. Experimental group counted 96 patients, whom have been treated as protocol fashion, therefore with multiple US-guided evaluations and eventual evacuations along with postoperative period; control group (310 patients) has exclusively been clinically evaluated. RESULTS: Seroma incidence detected rate among experimental group, after 1-year follow-up, was 32.2%, compared to 16.8% in control cohort, additionally no other secondary complications were detected in the first group. Referring to the wound dehiscence incidence, a statistically significant higher frequency was observed in control group compared with treatment 1 (21.2% vs. 0%; P = .0027). CONCLUSIONS: Seroma and correlated secondary complications may lead to additional surgeries, higher sanitary costs and even reconstructive failure. With a seriated US follow-up protocol application, the surgeon could promptly manage and treat seroma, decreasing additional complications rate, particularly wound dehiscence. LEVEL OF EVIDENCE: III.

The Effect of Adjuvant Radiotherapy on One- and Two-Stage Prosthetic Breast Reconstruction and on Autologous Reconstruction: A Multicenter Italian Study among 18 Senonetwork Breast Centres.

Purpose: In modern breast cancer treatment, a growing role has been observed for breast reconstruction together with an increase in clinical indications for postmastectomy radiotherapy (PMRT). Choosing the optimum type of reconstructive technique is a clinical challenge. We therefore conducted a national multicenter study to analyze the impact of PMRT on breast reconstruction. Methods: We conducted a retrospective case-control multicenter study on women undergoing breast reconstruction. Data were collected from 18 Italian Breast Centres and stored in a cumulative database which included the following: autologous reconstruction, direct-to-implant (DTI), and tissue expander/immediate (TE/I). For all patients, we described complications and surgical endpoints to complications such as reconstruction failure, explant, change in type of reconstruction, and reintervention. Results: From 2001 to April 2020, 3116 patients were evaluated. The risk for any complication was significantly increased in patients receiving PMRT (aOR, 1.73; 95% CI, 1.33-2.24; p < 0.001). PMRT was associated with a significant increase in the risk of capsular contracture in the DTI and TE/I groups (aOR, 2.24; 95% CI, 1.57-3.20; p < 0.001). Comparing type of procedures, the risk of failure (aOR, 1.82; 95% CI, 1.06-3.12, p=0.030), explant (aOR, 3.34; 95% CI, 3.85-7.83, p < 0.001), and severe complications (aOR, 2.54; 95% CI, 1.88-3.43, p < 0.001) were significantly higher in the group undergoing DTI reconstruction as compared to TE/I reconstruction. Conclusion: Our study confirms that autologous reconstruction is the procedure least impacted by PMRT, while DTI appears to be the most impacted by PMRT, when compared with TE/I which shows a lower rate of explant and reconstruction failure. The trial is registered with NCT04783818, and the date of registration is 1 March, 2021, retrospectively registered.

Central Mound Technique in Oncoplastic Surgery: A Valuable Technique to Save Your Bacon.

INTRODUCTION: Breast-conserving surgery (BCS) is a valid method for the reconstruction of partial breast defects, however, there is a great variety of final aesthetic outcomes depending on the location of the tumor in the breast and also on the initial breast volume and the degree of ptosis. Specifically, defects affecting the upper inner/central quadrant represent a reconstructive challenge with not always satisfactory final results. For this purpose, the authors investigated the use of the central mound technique in breast-conserving surgery. The aim of the study was to apply the central mound as an oncoplastic technique and assess the satisfaction rate of the patients. MATERIALS AND METHODS: This was a retrospective study that involved 40 patients (80 breast) underwent breast conserving surgery and contextual bilateral breast remodeling with central mound technique. A pre- and postoperative Breast-Q questionnaire (breast conserving therapy module) was given to all the patients before the surgery, 3 months and 9 months after. The statistical analysis with chi-square test was performed. RESULTS: After 9 months the author found a major increase of all BREAST-Q parameters; the most valuable increments concerned the "Satisfaction with breast" and "Psychosocial well-being." None of the patients experienced a decreased in the quality of life related to the surgical procedure. CONCLUSION: The authors believe that this technique has useful functional and aesthetic results particularly appreciated by patients with upper pole lesion who have a slightly or moderately breast ptosis and a small cup size.

Protocol for Prevention and Monitoring of Surgical Site Infections in Implant-Based Breast Reconstruction: Preliminary Results.

Surgical site infection in implant-based breast reconstruction is a complication with variable incidence reported in the literature. Due to potential loss of implant and reconstruction, it can have a strong psychological impact on patients. Background and objectives: This study aimed primarily at analyzing the current status of the surgical site infection (SSI), (type, time of onset, clinical presentation, pathogens and management) in patients who underwent implant-based breast reconstruction at our Breast Unit. Secondarily, we wanted to establish whether introduction of a new, updated evidence-based protocol for infection prevention can reduce SSI in implant-based breast reconstruction. Materials and Methods: A single-center retrospective study was performed primarily to evaluate the incidence and features of SSI after implant-based breast reconstruction from 2007 to 2020. In June 2020, a protocol for prevention of SSI in implant-based breast reconstruction was introduced in clinical practice. Secondarily, a data analysis of all patients who underwent implant-based breast reconstruction in compliance with this protocol was performed after preliminarily assessing its efficacy. Results: 756 women were evaluated after mastectomy and implant-based breast reconstruction for breast cancer. A total of 26 surgical site infections were detected. The annual incidence of SSI decreased over time (range 0-11.76%). Data relating to infections' features, involved pathogens and implemented treatments were obtained. Since the introduction of the protocol, 22 patients have been evaluated, for a total of 29 implants. No early infections occurred. Conclusions: Surgical site infection rates at our Breast Unit are comparable to those reported in the literature. The SSI rates have shown a decreasing trend over the years. No SSI has occurred since the introduction of the prevention protocol for surgical site infection in June 2020.

Five years of experience using a dermal substitute: indications, histologic studies, and first results using a new single-layer tool.

BACKGROUND: Dermal substitutes have been used in Europe since 1996 as a mean of reconstructing the dermal layer. OBJECTIVES: To introduce the dermal substitute as a dual-stage reconstructing procedure using the dual-layer version and as a single-stage procedure, combining the single layer with a skin graft to achieve immediate closure. Our further objective was to evaluate the persistence of a commercial dermal substitute in the host's dermal layer using serial histologic studies. MATERIALS AND METHODS: The dermal substitute used was a membrane made using a porous coprecipitate of type I bovine collagen and glycosaminoglycan organized in a three-dimensional structure that allows the host's cell to migrate into it. It is available in a double-layer structure, covered by a silicone sheet, and in a single-layer structure without silicon. RESULTS AND CONCLUSION: We describe the dermal substitute indications in dermatologic surgery and our first results with the single layer as a single-stage procedure with an 80% to 100% take rate. Our histological studies of both products show their perfect integration and the persistence of the peculiar three-dimensional structure (neodermis) 5 years from implantation of the dual-layer dermal substitute.

Human skin penetration of silver nanoparticles through intact and damaged skin.

There is a growing interest on nanoparticle safety for topical use. The benefits of nanoparticles have been shown in several scientific fields, but little is known about their potential to penetrate the skin. This study aims at evaluating in vitro skin penetration of silver nanoparticles. Experiments were performed using the Franz diffusion cell method with intact and damaged human skin. Physiological solution was used as receiving phase and 70 microg/cm2 of silver nanoparticles coated with polyvinylpirrolidone dispersed in synthetic sweat were applied as donor phase to the outer surface of the skin for 24h. The receptor fluid measurements were performed by electro thermal atomic absorption spectroscopy (ETAAS). Human skin penetration was also determined by using transmission electron microscope (TEM) to verify the location of silver nanoparticles in exposed membranes. Median silver concentrations of 0.46 ng cm(-2) (range

In vitro percutaneous absorption of metal compounds.

It is well known that contact with metals can be responsible for allergic contact dermatitis; also, there is experimental evidence that nickel ions are readily available on the surface of used coins containing nickel and copper. The aim of this study was to prove that metal powders of nickel (Ni), cobalt (Co) and chromium (Cr) dispersed in synthetic sweat are oxidised into respective ions that can permeate the skin. Suspensions of 5 g of metal powder (Ni, Co and Cr) in 100 mL of synthetic sweat at pH 6.5 were prepared and shaken with a stirring plate at room temperature for 30 min. Human skin membranes were set up in Franz-diffusion cells and 2 mL of the freshly made suspension were applied to the outer surface of the skin for 24h. The appearance of metal ions in the aqueous receptor phase (NaCl 0.9%) was quantified by Electro Thermal Atomic Absorption Spectroscopy (ETAAS). Also, metals ions were analysed using Differential Pulse Polarography (DDP), Differential Pulse Voltammetry (DPV) and Inductively Coupled Plasma Atomic Emission Spectroscopy (ICP-AES) techniques both in the receiving phase and in the donor solution to evaluate the presence of different ionic metallic species. DPP and DPV measurements of cobalt and nickel suspensions confirmed the presence of Co2+ and Ni2+ ions in concentration, respectively of 33.3+/-3.2 and 27.1+/-3.2 mg L(-1). Chromium ions concentration below 0.1 mg L(-1) were found in chromium suspensions bearing evidence of synthetic sweat inefficacy of oxidising chromium metal powder. Cobalt and nickel skin permeation was demonstrated in in vitro experiments using the Franz cell system giving a permeation flux of 0.0123+/-0.0054 microg cm(-2) h(-1) for cobalt and of 0.0165+/-0.00036 microg cm(-2) h(-1) for nickel and a lag time of 1.55+/-0.71 h for cobalt and of 14.56+/-0.56 for nickel. Chromium below 0.1 microg L(-1) was found in the receiving solutions. Our experiments demonstrated that metallic nickel and cobalt can be oxidised when suspended in synthetic sweat, while chromium would probably need stronger oxidising conditions. Metallic ions can permeate the skin and the Franz cell system showed that it is possible to measure a flux of ions through the skin for cobalt and nickel but not for chromium.