Breast Lipofilling: Is the Bra Really Full? Clinical Bra Pressure Measurement and In Vitro Testing of Processed and Unprocessed Fat Cells.

BACKGROUND: Breast lipofilling, a popular cosmetic and reconstructive procedure, involves the transplantation of autologous fat to enhance breast volume and contour. Despite its widespread use, cell processing and the aftertreatment remain controversial. This study investigates the pressure applied by a compression bra and reports in vitro stress tests of processed and unprocessed fat cells. METHODS: Clinical bra pressure measurements were conducted on a cohort of 45 patients following lipofilling, reduction mammoplasties and DIEP flaps. Laboratory analysis included cell vitality testing using Resazurin assays of processed and unprocessed fat cells after exposure to mechanical or hyperbaric pressure. RESULTS: Our findings show a mean overall pressure value of the compression bra for all patients of 6.7 ± 5.7 mmHg (range 0-35). Cell processing is superior to sedimentation only regarding fat cell vitality. However, neither mechanical pressure within the specified range nor hyperbaric oxygen exposure significantly affected fat graft survival as measured by Resazurin assays. CONCLUSION: The in vitro measurements showed that it was impossible to harm fat cells with external pressure during lipofilling procedures, regardless of their processing. In the clinical context, the compression bra applied pressure values deceeding the perfusion pressure and may therefore not diminish oxygen supply nor harm the transplanted cells. Therefore, we recommend the use of a compression bra for all lipofilling procedures around the breast. LEVEL OF EVIDENCE III: This 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 Table of Contents or online Instructions to Authors www.springer.com/00266.

Autologous fat grafting for breast reconstruction after breast cancer: a 12-year experience.

PURPOSE: The aim of our study was to examine the surgical outcome and complications (efficiency) as well as the incidence of locoregional recurrence and distant metastases (oncological safety) in patients who underwent autologous fat grafting (AFG) of the breast following breast cancer surgery. METHODS: In our monocentric cohort study, retrospective and prospective data were collected from all consecutive patients who underwent AFG after breast cancer between 2008 and 2020; a total of 93 patients met the inclusion criteria. RESULTS: Our long-term results showed no increase in tumor recurrence and distant metastases in the studied collective when compared to the available literature. We observed 1 local recurrence (1.1%), 2 distant metastases (2.2%), and 1 tumor-related death (1.1%). There was a high degree of patient satisfaction; 67.12% of patients reported adequate satisfaction with autologous fat grafting. CONCLUSION: Currently, to our knowledge, this is the study with the longest follow-up time (mean 6.7 years after AFG and 11.5 years after tumor resection). The results of our clinical study will contribute to improve evidence in the broad field of AFG, adipose stem cell and tumor research. Consistent with our study, the literature review shows a clear tendency of clinical trial results with a low incidence rate of tumor recurrence and metastasis following the use of AFG. AFG seems to be a safe procedure also after breast cancer treatment.

Pressure distribution and flow characteristics during negative pressure wound therapy.

AIM OF THE STUDY: Negative pressure wound therapy is thought to improve wound healing by altering capillary perfusion. However, despite many theories, the underlying mechanism of action remains controversial. Recent evidence suggests an increased tissue pressure and a temporary decreased microvascular blood flow as the main reasons for the good clinical results [1]. In an attempt to further explain the mechanism of action, we investigated the pressure distribution on the foam interface, and the influence on perfusion in a pre-experimental design. MATERIALS AND METHODS: Pressure distribution was measured using a sensor based on a capacitive dielectric elastomer with flexible electrodes. In vitro flow measurements were done with vessel imitations in a block of 300 bloom ballistic gel to simulate soft tissue. RESULTS: A peak pressure of up to 187 mmHg (255 g/cm2) within the foam interface, as well as decreased perfusion, were found using a standard negative pressure wound therapy setup. In conclusion, negative pressure wound therapy applies positive pressure to adjacent tissue and decreases local flow. The amount of suction applied is proportional to the pressure on the foam interface and reduction in flow. CONCLUSION: In line with previous studies investigating the underlying mechanism of action, these findings may contribute to possible alterations in the use of negative pressure wound therapy, e.g. lowering suction pressure in patients with diminished peripheral blood flow.

Oxygen levels during negative pressure wound therapy.

AIM OF THE STUDY: Negative pressure wound therapy (NPWT) has become an established treatment modality when dealing with chronic and infected wounds. The underlying mechanism of action is still under discussion and remains controversial. Evidence exists showing rather hypoxic conditions as the main reason for the positive results and bacterial clearance. In an attempt to further explain the mechanism of action, we investigated oxygen levels within the foam interface of a NPWT device. MATERIALS AND METHODS: We used an optical sensor based on the principle of dynamic fluorescence quenching and tested five different commonly available NPWT systems used during our daily clinical routine. All measurements were done in an in vitro experimental design for at least 24 h and multiple vacuum intensities were investigated. RESULTS: Oxygen levels decreased as much as 22.8% and the amount of vacuum applied inversely correlated with the oxygen reduction. A stepwise increase in vacuum of 25 mmHg showed a linear mean drop of 2.75% per setting. All devices were able to maintain a constant level of negative pressure, and no significant difference between the various dressings was found (p > 0.05). CONCLUSION: Therefore, oxygen levels are decreased within the foam of NPWT dressings, likely leading to oxygen deprivation effects in the underlying wound tissue.

Predicting efficacy of epirubicin by a multigene assay in advanced breast cancer within a Danish Breast Cancer Cooperative Group (DBCG) cohort: a retrospective-prospective blinded study.

PURPOSE: Anthracyclines remain a cornerstone in the treatment of primary and advanced breast cancer (BC). This study has evaluated the predictive value of a multigene mRNA-based drug response predictor (DRP) in the treatment of advanced BC with epirubicin. The DRP is a mathematical method combining in vitro sensitivity and gene expression with clinical genetic information from > 3000 clinical tumor samples. METHODS: From a DBCG cohort, 140 consecutive patients were treated with epirubicin between May 1997 and November 2016. After patient informed consent, mRNA was isolated from archival formalin-fixed paraffin-embedded primary breast tumor tissue and analyzed using Affymetrix arrays. Using time to progression (TTP) as primary endpoint, the efficacy of epirubicin was analyzed according to DRP combined with clinicopathological data collected retrospectively from patients' medical records. Statistical analysis was done using Cox proportional hazards model stratified by treatment line. RESULTS: Median TTP was 9.3 months. The DRP was significantly associated to TTP (P = 0.03). The hazard ratio for DRP scores differing by 50 percentage points was 0.55 (95% CI -0.93, one-sided). A 75% DRP was associated with a median TTP of 13 months compared to 7 months following a 25% DRP. Multivariate analysis showed that DRP was independent of age and number of metastases. CONCLUSION: The current study prospectively validates the predictive capability of DRP regarding epirubicin previously shown retrospectively allowing the patients predicted to be poor responders to choose more effective alternatives. Randomized prospective studies are needed to demonstrate if such an approach will lead to increased overall survival.

The mode of delivery in patients with preeclampsia at term subject to elective or emergency Cesarean section.

PURPOSE: Preeclampsia is accompanied by high maternal and fetal morbidity and mortality. Thus, delivery needs to be planned carefully. The aim of this study was to determine the most favorable delivery for patients with preeclampsia between the week 37 and 41 of gestation. METHODS: For this retrospective study, patient data from 2003 to 2011 was collected. Study participants were women having a Cesarean section during week 37 and 41 of gestation. The population was classified into four groups: patients without hypertensive disorders having an elective or emergency Cesarean section and patients suffering from preeclampsia with elective or emergency Cesarean section. Analysis included mode of delivery and neonatal outcome, defined by Apgar score, rate of NICU admission and pH value of the umbilical cord. RESULTS: A total of 130 cases of preeclampsia were recorded. Compared to the control group, we observed a significantly higher Apgar score in the study group with emergency Cesarean section. Furthermore, within the study group the Apgar score at 5 and 10 min was also significantly increased in cases delivered by emergency Cesarean section. Moreover, the pH value of the umbilical cord was significantly higher in the study group. Considering the delivery mode, significant differences were found in favor of the elective Cesarean section. There were no differences in the rate of NICU admission between the groups. CONCLUSION: The most frequent mode of delivery for women suffering from preeclampsia is elective Cesarean section; however, neonates delivered by emergency Cesarean section did not show an adverse neonatal outcome.

Factors influencing the shape, size, symmetry and scar of the nipple-areola complex after bilateral reduction mammoplasty.

BACKGROUND: Asymmetry and scar formation of the nipple-areola complex (NAC) after reduction mammoplasty with periareolar suture are common complications and can significantly affect patient satisfaction. OBJECTIVE: The aim of this study was to investigate possible procedure-specific influencing factors on asymmetry and shape disturbances of the nipple-areola complex to optimize postoperative outcome and thus improve patient satisfaction. METHODS: 78 patients were followed-up after a 5-year period as part of a retrospective cohort study. Objective parameters as areolar diameter, symmetry, scar patterns, dimensions of the breast, and anthropometric measurements were recorded. All patients underwent surgery according to an established treatment algorithm depending on the preoperative measurements. Follow up was 1 week, 6 week, 6 months and 3 years postoperatively. RESULTS: The periareolar suture-technique significantly influenced the symmetry and shape of the NAC. Compared to the intraoperative determined diameter and the postoperative diameter, the net-suture technique showed the highest NAC symmetry and minimal divergence. Patients who underwent Hall-Findlay mammoplasty showed significantly higher rates of asymmetry and deformity of the NAC with teardrop formation in comparison to Lejour mammoplasty. Scar formation was affected by periareolar ruffle formation especially after purse string suture. CONCLUSIONS: Regardless of what reduction mammoplasty techniques and periareolar suturing-technique are used, a tension-free suture of the NAC is crucial for shape, symmetry and scar formation. The net suture technique resulted in significantly higher symmetry of the NAC.

Patient characteristics may affect the lymphatic staining ability of Indocyanine green and Patent blue during lymphaticovenous anastomosis.

BACKGROUND: The use of dyes like Indocyanine green (ICG) and Patent blue facilitates the identification of lymphatic vessels during lymphaticovenous anastomosis (LVA) surgery. However, some patients experience "staining failure". In these cases, no stained lymphatic vessels can be detected, making supermicrosurgical LVA even more complex. OBJECTIVE: This study aims to investigate patient-related factors that may interfere with lymphatic vessel staining during LVA. METHODS: A retrospective study was conducted on 30 patient charts, focusing on patient characteristics and the staining quality of ICG and Patent blue dye. Statistical analyses were performed to identify correlations between variables. RESULTS: Significant correlations were found between higher age and secondary lymphedema, longer duration of lymphedema in male patients until surgery and reoccurring cellulitis and Patent blue staining. Notably, recurrent infections to the lymphatic system resulted in inferior staining ability during LVA surgery. CONCLUSIONS: Due to staining failure the detection of functional lymphatic vessels remains challenging in LVA surgery. A more extensive preoperative workup is recommended for patients with recurrent cellulitis to optimize surgical feasibility and procedure quality in LVA treatment for lymphedema.

Comparison of skin sensitivity following breast reconstruction with three different techniques: Autologous fat grafting, DIEP flap and expander/implant1.

BACKGROUND: Autologous fat grafting (AFG) has been established over the past two decades as an additive technique during and after breast reconstruction. Complete reconstruction of the breast mound with AFG alone represents an exceptional technique that has been published mostly in case reports or in studies with limited cases.The purpose of this study is to investigate the influence of three different techniques for breast reconstruction on the recovery of skin sensitivity at the reconstructed breast. METHODS: The study included 30 patients after mastectomy following breast cancer. Three groups were examined: A) breast reconstruction by autologous fat grafting (AFG), B) breast reconstruction by deep inferior epigastric artery perforator flap (DIEP) and C) breast reconstruction by expander/implant (TE).Biometric data were compared; sensitivity tests were performed using Semmes-Weinstein monofilaments.The non-operated, healthy contralateral breasts of the patients were used as a reference. RESULTS: While the traditional reconstruction techniques by microsurgical anastomosed perforator flap or expander/implant showed a strongly decreased or completely missing sensitivity of the skin, the tests after reconstruction by AFG represented high values of sensory recovery, which came close to the reference group of non-operated breasts. CONCLUSION: To our knowledge, this is the first study to compare skin sensitivity after AFG-based reconstruction to established techniques for breast reconstruction. We could demonstrate in a limited group of patients, that breast reconstruction by autologous fat grafting can achieve higher values of skin sensitivity compared to traditional techniques.

Adipose Tissue-Derived Stem Cell Yield Depends on Isolation Protocol and Cell Counting Method.

In plastic surgery, lipofilling is a frequent procedure. Unsatisfactory vascularization and impaired cell vitality can lead to unpredictable take rates in the fat graft. The proliferation and neovascularization inducing properties of adipose tissue-derived stem cells may contribute to solve this problem. Therefore, the enrichment of fat grafts with stem cells is studied intensively. However, it is difficult to compare these studies because many factors-often not precisely described-are influencing the results. Our study summarizes some factors which influence the cell yield like harvesting, isolation procedure and quantification. Stem cells were isolated after liposuction. Quantification was done using a cell chamber, colony counting, or flow cytometry with changes to one parameter, only, for each comparison. Quantification of cells isolated after liposuction at the same harvesting site from the same patient can vary greatly depending on the details of the isolation protocol and the method of quantification. Cell yield can be influenced strongly by many factors. Therefore, a comparison of different studies should be handled with care.

Facial Rejuvenation with Concentrated Lipograft-A 12 Month Follow-Up Study.

Lipofilling is a popular technique to treat volume loss in aging patients. The isolated adipose tissue is composed of adipocytes and stromal vascular fraction cells, which include adipose-derived stem cells (ASC). We hypothesize that the patient's wrinkle severity scale (WSS) and patient's satisfaction on the global aesthetic improvement scale (GAIS) can be improved after using concentrated lipoaspirate. Fourteen patients (54 years ± 11.09 years) with volume loss in the midface area underwent waterjet-assisted liposuction (Human Med AG, Schwerin, Germany). Fat was centrifuged in an ACP Double Syringe (Arthrex GmbH, Munich, Germany) using Rotofix 32A centrifuge (Andreas Hettich, GmbH & Co.KG, Tuttlingen, Germany). Homogenization was performed using the double syringe and a 1.4 mm female-female luerlock connector. After a second centrifugation, patients received periorbital (PO) and nasolabial (NL) lipografting. ASC count was performed after enzymatical digestion. Vitality of cells was assessed using a resazurin assay. During long-term follow up (12 months, n = 10), we found a high patient's satisfaction (GAIS 1+/-0.52) and a good improvement of the WSS during short- and long-term follow-up. The ASC count of processed lipoaspirate was 2.1-fold higher than of unprocessed lipoaspirate (p < 0.001). The difference of ASC in sedimented and simply centrifuged lipoaspirate was also significant (p < 0.05). Facial rejuvenation with concentrated fat graft offers good results concerning objective aesthetic outcome and patient's satisfaction.

Preservation of quality of life in patients with human epidermal growth factor receptor 2-positive metastatic breast cancer treated with tucatinib or placebo when added to trastuzumab and capecitabine (HER2CLIMB trial).

AIMS: In HER2CLIMB, tucatinib significantly improved progression-free and overall survival in patients with human epidermal growth factor receptor 2-positive (HER2+) metastatic breast cancer. We evaluated the impact of tucatinib on health-related quality of life (HR-QoL) in HER2CLIMB. METHODS: Patients were randomised 2:1 to tucatinib or placebo combined with trastuzumab and capecitabine. Starting with protocol version 7, the EuroQol 5 Dimensions 5 Levels (EQ-5D-5L) questionnaire and EQ visual analogue scale (VAS) were administered at day 1 of cycle 1, every two cycles during cycles 3-9, every three cycles during cycle 12 and thereafter and at each patient's 30-day follow-up visit. RESULTS: Among 364 patients eligible for HR-QoL assessment, 331 (91%) completed ≥1 assessment. EQ-VAS scores were similar for both arms at baseline and maintained throughout treatment. EQ-5D-5L scores were similar between the treatment arms, stable throughout therapy and worsened after discontinuing treatment. Risk of meaningful deterioration (≥7 points) on EQ-VAS was reduced 19% in the tucatinib vs. placebo arm (hazard ratio [HR]: 0.81; 95% confidence interval [CI]: 0.55, 1.18); the median (95% CI) time to deterioration was not reached in the tucatinib arm and was 5.8 months (4.3, -) in the placebo arm. Among patients with brain metastases (n = 164), risk of meaningful deterioration on EQ-VAS was reduced 49% in the tucatinib arm (HR: 0.51; 95% CI: 0.28, 0.93); the median (95% CI) time to deterioration was not reached in the tucatinib arm and was 5.5 months (4.2, -) in the placebo arm. CONCLUSIONS: HR-QoL was preserved for patients with HER2+ metastatic breast cancer who were treated with tucatinib added to trastuzumab and capecitabine and maintained longer with tucatinib therapy than without it among those with brain metastases. CLINICAL TRIAL REGISTRATION: NCT02614794.

Recommendations for the Use of Antibiotics in Primary and Secondary Esthetic Breast Surgery.

The use of systemic prophylactic antibiotics to reduce surgical-site infection in esthetic breast surgery remains controversial, although the majority of surgeons prefer to utilize antibiotics to prevent infection. Nonetheless, postoperative acute and subclinical infection and capsular fibrosis are among the most common complications following implant-based breast reconstruction. After esthetic breast augmentation, up to 2.9% of women develop infection, with an incidence rate of 1.7% for acute infections and 0.8% for late infections. After postmastectomy reconstruction (secondary reconstruction), the rates are even higher. The microorganisms seen in acute infections are Gram-positive, whereas subclinical late infections involving microorganisms are typically Gram-negative and from normal skin flora with low virulence. In primary implantation, a weight-based dosing of cefazolin is adequate, an extra duration of antibiotic cover does not provide further reduction in superficial or periprosthetic infections. Clindamycin and vancomycin are recommended alternative for patients with ß-lactam allergies. The spectrum of microorganism found in late infections varies (Gram-positive and Gram-negative), and the antibiotic prophylaxis (fluoroquinolones) should be extended by vancomycin and according to the antibiogram when replacing implants and in secondary breast reconstruction, to target microorganisms associated with capsular contracture. All preoperative antibiotics should be administered <60 minutes before incision to guarantee high serum levels during surgical procedure.

Perfusion control of a partial revascularized hand via application of Indocyanine green (ICG) and Near-infrared Fluorescence Imaging.

BACKGROUND: Intra- and postoperative assessment of perfusion with near-infrared fluorescence imaging is commonly used among plastic surgeons to evaluate the quality of a microsurgical anastomosis in free flaps. OBJECTIVE: As microsurgical anastomosis can be monitored with near-infrared fluorescence imaging there is potential concerning revascularized fingers and hands with soft tissue depths not exceeding 7 mm above anastomosis. In a case of a severe crush injury of the hand more information about the perfusion was necessary as clinical assessment suspected loss of perfusion. METHODS: A 49-year old male suffered from a severe crush injury of his left hand with dissection of the ulnar superficial palmar arterial arch and a lesion of median nerve. After revascularization and reconstruction of the nerve, the patient developed postoperatively a loss of perfusion of thumb and index finger. An evaluation of the perfusion status was obtained by fluorescence imaging after intravenous application of ICG. RESULTS: After intravenous application of ICG the near-infrared imaging showed a delayed but sufficient perfusion of the hand so that a salvage surgery was not indicated. CONCLUSIONS: In scenarios of critical perfusion in revascularized fingers and hands, the perfusion control via application of ICG and near-infrared fluorescence imaging can be a helpful tool.