A Novel Method of Implant Coverage for Post-Mastectomy Reconstruction after Previous Augmentation: A Case Report.

BACKGROUND: Breast augmentation is the most common -cosmetic surgical procedure in the USA, with nearly 300,000 women undergoing surgery annually. National incidence rates predict that among women undergoing breast augmentation each year, approximately 35,000 will eventually be diagnosed with breast cancer, in particular individual BRCA1/2 germline mutant carriers. CASE REPORT: Our case introduces a novel method of implant coverage after immediate post-mastectomy reconstruction in augmented patients. A novel "capsular flap" (flap of the pre-existing old capsule) is isolated and refolded to cover the outer lower portion of the implant. CONCLUSION: Tailored surgical approaches can be offered to those patients previously augmented and requiring mastectomy after breast cancer diagnosis.

Evaluation of Aesthetic and Quality-of-Life Results after Immediate Breast Reconstruction with Definitive Form-Stable Anatomical Implants.

BACKGROUND: Although there are many reports on different techniques in breast reconstruction, there are few data regarding immediate breast reconstruction with definitive form-stable anatomical implants in terms of aesthetics and quality-of-life outcomes. METHODS: Ninety-four patients underwent mastectomy with immediate breast reconstruction using anatomical implants and contralateral symmetrization. Aesthetic results were evaluated by three different methods: the patient's self-report, the assessment of four independent specialists (two breast surgeons and two plastic surgeons from different institutions), and the BCCT.core software. Quality of life was evaluated by means of the BREAST-Q instrument. RESULTS: Average age ± SD was 52.1 ± 11.6 years. Most of patients had medium size breasts and T1 tumors. Patients had evaluated their aesthetic results better than did software and specialists. There was no significant difference in the comparison between software and specialist's evaluation. Multifactorial analysis showed that age older than 70 years and radiotherapy were significant risk factors for poor aesthetic outcomes after immediate breast reconstruction with implants. Considering quality of life, most of the patients were satisfied with their outcome and psychosocial and sexual well-being. CONCLUSION: Immediate breast reconstruction with implants and contralateral symmetrization had a positive impact on the quality of life and showed satisfactory outcomes when evaluated by subjective and objective methods.

Outcome of Immediate Breast Reconstruction in Patients With Nonendocrine-Responsive Breast Cancer: A Monoinstitutional Case-Control Study.

BACKGROUND: The long-term prognostic relevance of immediate breast reconstruction (IBR) for patients with estrogen receptor (ER)-negative breast cancer (BC) has not been fully elucidated. PATIENTS AND METHODS: The study population included 444 patients with ER-negative BC who underwent total mastectomy with complete axillary dissection between 1995 and 2006, 339 patients with and 105 patients without IBR. The median follow-up was 8.6 years. RESULTS: Patients treated with IBR were younger (P < .001) and received surgery more recently (2003-2006: 53.1% vs. 39%; P = .0003), and had a lower number of metastatic lymph nodes (>4 lymph nodes involvement: 29.5% vs. 45.7%; P = .0026), smaller tumors (pT1/2: 15% vs. 26.7%; P = .0007), and lower extent of peritumoral vascular invasion (15.9% vs. 21%; P = .032). The 5-year cumulative incidence of locoregional recurrence was 7.1% in the IBR group and 11.7% in the no IBR group (hazard ratio [HR], 0.81; P = .63). The 5-year cumulative incidence of distant metastases were similar in the 2 groups (P = .79). The 5-year overall and disease-free survival proportions were 79.9% versus 69.5% (HR, 1.11; P = .67) and 66.6% versus 54.1% (HR, 1.04; P = .83) in the IBR group and no IBR group, respectively. CONCLUSION: IBR intervention does not significantly affect prognosis of ER-negative BC patients.

Long-Term Comparison of Aesthetical Outcomes After Oncoplastic Surgery and Lumpectomy in Breast Cancer Patients.

BACKGROUND: Lumpectomy may result in major deformities and asymmetries in approximately one-third of patients. Although oncoplastic surgery (OP) could be a useful alternative to avoid them, lack of strong data is causing some debate. The purpose of this study was to compare aesthetic outcomes in patients undergoing OP versus lumpectomy using three different assessment methods. METHODS: A total of 122 patients were included in this cross-sectional multicentric study; 57 underwent OP (46.7 %), and 65 underwent lumpectomy (53.3 %). Two breast surgeons and two plastic surgeons from different institutions using the Garbay scale independently evaluated aesthetic outcomes. BCCT.core software was applied in both groups, and the patients evaluated their aesthetic outcomes answering a questionnaire about their satisfaction rate. RESULTS: OP group had a higher proportion of excellent aesthetic results according to the BCCT.core software analysis (p = 0.028) and the specialists (p = 0.002). Multifactorial analyses showed that age ≥70 years (RP = 6.02; 95 % confidence interval [CI] 1.73-21.0; p = 0.005), tumors in the medial, inferior, and central quadrants (RP = 4.21; 95 % CI 1.88-9.44; p < 0.001), and large breasts (RP = 7.55; 95 % CI 2.48-23.0; p < 0.001) were significant risk factors for poor aesthetic outcomes after lumpectomy. The patients classified their results as better than those by the specialists and by the software, with no statistical difference between the groups. CONCLUSIONS: Excellent aesthetic results were more frequent in the OP group according to BCCT.core software analysis and specialists. In addition, some clinical conditions and tumor locations in the breast can be considered risky factors for poor aesthetic outcomes in lumpectomy.

Poly implant prothèse asymmetrical anatomical breast implants: a product recall study.

BACKGROUND: In 2010 high rupture rates were unexpectedly found among prostheses produced by the French manufacturer Poly Implant Prothèse. Since then, several studies have been performed concerning the round implants, but there are still few data available on anatomical implants. METHODS: From 2003 to 2006 Poly Implant Prothèse implants were employed at the authors' institute for immediate or delayed reconstruction after mastectomy. All implants were anatomical and asymmetrical. In November of 2010, the authors began offering free consultation with a plastic surgeon and radiologist. Demographic data, type of reconstruction, implant lifespan, indications for implant removal, and rupture rate were recorded. RESULTS: A total of 578 women underwent postmastectomy immediate or delayed reconstruction with 658 Poly Implant Prothèse implants from 2003 to 2006 at the authors' institute. The authors explanted 409 of 443 prostheses, and 34 were explanted at other centers. Eighty-nine patients died and 120 are alive with the implants in place. The mean implant lifespan was 57.5 months, 76 ruptured implants were explanted (18.5 percent), and in 22 cases (5.4 percent), leakage of silicone gel was detected. CONCLUSIONS: Poly Implant Prothèse implant failure is to be ascribed to shell structure, although the primary safety issue concerned the gel (an industrial-grade and low-cohesive silicone). These issues produce the known rupture rates in the manufacturer's round implants. The authors' use of only anatomical and asymmetrical implants, with their more cohesive silicone gel and more rigid shell allowing a stable form and projection along with a natural feel and touch, probably reduces the rupture rate and silicone spread, although these events remain unacceptably high compared with similar products of other brands. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Does immediate breast reconstruction after mastectomy and neoadjuvant chemotherapy influence the outcome of patients with non-endocrine responsive breast cancer?

BACKGROUND/AIM: In breast cancer (BC) patients, breast surgery followed by immediate breast reconstruction (IBR) might favour recurrences and metastases due to extensive surgical manipulation. We retrospectively investigated whether IBR after mastectomy and neoadjuvant chemotherapy (NT) influenced the outcome in patients with early and locally advanced oestrogen receptor (ER)-negative BC. PATIENTS AND METHODS: Between 1995 and 2006, 133 BC patients received NT followed by total mastectomy, 59 of whom underwent IBR. Patients receiving IBR (IBR group) were compared to patients who did not receive IBR (no-IBR group) over a prolonged median follow-up time (8.2 years). RESULTS: Patients receiving IBR were on average younger than patients not receiving IBR (p<0.001). The percentage of patients with positive clinical nodal status (cN) was 19% in the IBR group and 7% in no-IBR group (p=0.036), whereas patients without IBR were more frequently diagnosed as clinical T4 (59% vs. 15%, p<0.001). The 5-year cumulative incidence of locoregional recurrences were 14% in the no-IBR group and 21% in the IBR group. The hazard of locoregional events, adjusted for age, clinical T and cN, was significantly greater in the IBR group than in the no-IBR group (hazard ratio (HR)=2.77, p=0.045). The 5-year cumulative incidences of distant metastases were similar in the two groups (p=0.414). CONCLUSION: IBR following total mastectomy in patients with ER-negative disease after NT is associated with a worse rate of local relapses. More insight in mechanisms of wound healing and extent of surgery is required to further investigate this observation.

The use of local flaps in the one-step nose reconstruction after cancer resection.

PURPOSE: Purpose of this study is to assess different surgical techniques, comparing them in order to remove nasal skin cancer by restoring the anatomy and the function of the respiratory system without neglecting the aesthetic result. METHODS: A total of 107 patients were enrolled in the study between January 2006 and December 2012. We compared the results obtained using 23 front-glabellar flaps, 30 bilobed flaps, 27 nose-cheek flaps, 15 sliding flaps, 12 frontal island flaps. RESULTS: We obtained the oncological radicality with good aesthetic results. There were no infections and no sensory (numbness and tenderness) and motor abnormalities of the facial nerve. None of the used techniques has lead to scarring ectropion or to alteration of the nasal filter. CONCLUSIONS: The best nasal reconstruction mostly depends on skin cancer location and on the amount of tissue to be removed to definitely eradicate the neoplastic lesion; during the planning of a nasal reconstruction we also must assess adjacent tissue characteristics, the presence of fixed structures and the donor skin area (color, thickness, pils, etc) . Using these parameters we have chosen for the ala the nose-cheek flap, for the dorsum the front-glabellar flap, the bilobed flap and the sliding flap (lateral region) and for the tip both the frontal island flap and the bilobed flap.

Negative pressure dressing in split-thickness skin grafts: experience with an alternative method.

BACKGROUND: The use of negative pressure in the dressing of splitthickness skin grafts has been shown to promote healing by a variety of mechanisms, including a decrease in interstitial edema, an increase in perfusion, and a decrease in bacterial colonization. METHODS: An observational study was performed on 52 patients at the Department of Plastic Surgery, University of Perugia in Perugia, Italy, undergoing split-thickness skin grafting for acute wounds after trauma and for chronic wounds, such as pressure ulcers and diabetic wounds. The dressing used consisted of a single foam sheet, a conventional disposable closed-system suction drain, and an adhesive dressing. RESULTS: In all patients, there was a 95% take of the graft, with 5% of partial loss. There were no significant complications encountered. CONCLUSIONS: Negative pressure wound therapy is an innovative and commercially successful concept for the management of difficultto- treat wounds of nearly every etiology, and the authors' technique is an alternative to commercially available negative pressure dressings..

Risk of locoregional recurrence in patients with false-negative frozen section or close margins of retroareolar specimen in nipple-sparing mastectomy.

BACKGROUND: Our purpose was to evaluate the locoregional recurrence (LRR) of patients with false-negative, frozen-section or close margins of retroareolar specimen in nipple-sparing mastectomy (NSM) procedure. METHODS: From 2002-2008, we recruited patients who had atypia or presence of cancer cells in definitive histology of retroareolar tissue despite of absence of tumor cell in intraoperative retroareolar frozen section. We also included the close margin cases defined as the presence of tumor cells at the first frozen section, but after deeper core out of retroareolar tissue were revealed free of malignancy. The incidence of LRR and NAC recurrence were reported, and the factors associated were analyzed. RESULTS: Of 948 NSM procedures, there were 88 false-negative, frozen-sections and 10 close margin cases. The 5-year cumulative incidence of LRR and NAC recurrence was 11.2 % (10/98 patients) and 2.4 % (2/98 patients), respectively. Analyzing the definitive results of retroareolar tissue, the 5-year cumulative incidence of LRR was 42.9 % (n = 4) for atypia, 10 % (n = 2) for lobular carcinoma in situ (LCIS), 10 % (n = 1) for close margins, 8.7 % (n = 3) for ductal carcinoma in situ (DCIS), and 0 % for invasive carcinoma. In situ carcinoma as a primary tumor was a significant predictor of NAC recurrence (P < 0.01). CONCLUSIONS: Despite a high reliability of frozen section, there is still a minority of false-negative results. Nevertheless, the LRR is considerably low. This fact suggests the possibility of preservation of the NAC after discussion with the patient.