Insights on the Choice and Preparation of the Donor Nerve in Corneal Neurotization for Neurotrophic Keratopathy: A Narrative Review.

The article introduces neurotrophic keratopathy (NK), a condition resulting from corneal denervation due to various causes of trigeminal nerve dysfunctions. Surgical techniques for corneal neurotization (CN) have evolved, aiming to restore corneal sensitivity. Initially proposed in 1972, modern approaches offer less invasive options. CN can be performed through a direct approach (DCN) directly suturing a sensitive nerve to the affected cornea or indirectly (ICN) through a nerve auto/allograft. Surgical success relies on meticulous donor nerve selection and preparation, often involving multidisciplinary teams. A PubMed research and review of the relevant literature was conducted regarding the surgical approach, emphasizing surgical techniques and the choice of the donor nerve. The latter considers factors like sensory integrity and proximity to the cornea. The most used are the contralateral or ipsilateral supratrochlear (STN), and the supraorbital (SON) and great auricular (GAN) nerves. Regarding the choice of grafts, the most used in the literature are the sural (SN), the lateral antebrachial cutaneous nerve (LABCN), and the GAN nerves. Another promising option is represented by allografts (acellularized nerves from cadavers). The significance of sensory recovery and factors influencing surgical outcomes, including nerve caliber matching and axonal regeneration, are discussed. Future directions emphasize less invasive techniques and the potential of acellular nerve allografts. In conclusion, CN represents a promising avenue in the treatment of NK, offering tailored approaches based on patient history and surgical expertise, with new emerging techniques warranting further exploration through basic science refinements and clinical trials.

Technical Refinements and Outcomes Assessment in Prepectoral Pocket Conversion After Postmastectomy Radiotherapy.

BACKGROUND: Several studies show how submuscular breast reconstruction is linked to animation deformity, shoulder dysfunction, and increased postoperative chest pain, when compared to prepectoral breast reconstruction. In solving all these life-impairing side effects, prepectoral implant pocket conversion has shown encouraging results. OBJECTIVES: The aim of this study was to propose a refinement of the prepectoral implant pocket conversion applied to previously irradiated patients. METHODS: We conducted a retrospective study on 42 patients who underwent previous nipple- or skin-sparing mastectomy and immediate submuscular reconstruction, followed by radiotherapy. We performed fat grafting sessions as regenerative pretreatment. Six months after the last fat graft, we performed the conversion, with prepectoral placement of micropolyurethane foam-coated implants. We investigated the preconversion and postconversion differences in upper limb range of motion, Upper Extremity Functional Index, and patient satisfaction with the breast and physical well-being of the chest. RESULTS: We reported a resolution of animation deformity in 100% of cases. The range of motion and the Upper Extremity Functional Index scores were statistically improved after prepectoral implant pocket conversion. BREAST-Q scores for satisfaction with the breast and physical well-being of the chest were also improved. CONCLUSIONS: The refined prepectoral implant pocket conversion is a reliable technique for solving animation deformity and improving quality of life in patients previously treated with submuscular reconstruction and radiotherapy.

Prevention of Breast Cancer-Related Lymphedema: An Up-to-Date Systematic Review of Different Surgical Approaches.

Breast cancer-related lymphedema (BCRL) affects approximately 20% of women after breast cancer therapy. Advances in treatment have increased the life expectancy; thus, the prevalence of BCRL will continue to rise with the number of cancer survivors, hence the need to develop strategies to prevent this condition. We provide a systematic review of the literature on the primary prevention of BCRL by prophylactic lymphatic surgery (PLS). Between June and August 2022, we conducted a search of PubMed, Google Scholar and Cochrane. In the end, a total of eighteen papers were selected. The eleven studies without a control group reported only 15 of 342 patients who developed lymphedema at least six months after PLS (4.59%). The seven studies with a control group included 569 patients, 328 cases and 241 controls. Among the cases, 36 (10%) developed lymphedema. In contrast, the incidence of lymphedema in the controls was 40% (98 of 241 patients). The formulation of definite recommendations in favor of PLS is hindered by low-quality studies. There is no consensus on which technique should be preferred, nor on whether adjuvant radiotherapy might affect the efficacy of PLS. Randomized controlled trials are mandatory to conceive evidence-based recommendations.

Predicting Mastectomy Skin Flap Necrosis: A Systematic Review of Preoperative and Intraoperative Assessment Techniques.

Mastectomy skin-flap necrosis (MSFN) is one of the most feared complications of immediate implant-based breast reconstruction (IIBR). Traditionally, mastectomy skin-flap viability was based only on surgeons' clinical experience. Even though numerous studies have already addressed the patients' risk factors for MSFN, few works have focused on assessing quality of breast envelope. This review investigates mastectomy's flap viability-assessment methods, both preoperative (PMFA) and intraoperative (IMFA), to predict MSFN and its sequalae. Between June and November 2022, we conducted a systematic review of Pubmed/MEDLINE and Cochrane electronic databases. Only English studies regarding PMFA and IMFA applied to IIBR were selected. The use of digital mammography, ultrasound, magnetic resonance imaging, and a combination of several methods before surgery was shown to be advantageous by several authors. Indocyanine performed better than other IMFA, however both thermal imaging and spectroscopy demonstrated novel and promising results. Anyway, the best prediction comes when preoperative and intraoperative values are combined. Particularly in prepectoral reconstruction, when mastectomy flaps are essential to determine a successful breast reconstruction, surgeons' clinical judgment is insufficient in assessing the risk of MSFN. Preoperative and intraoperative assessment techniques play an emerging key role in MSFN prediction. However, although there are several approaches to back up the surgeon's processing choice, there is still a dearth of pertinent literature on the subject, and more research is required.

Improving Decision-making in Prepectoral Direct-to-implant Reconstruction After Nipple Sparing Mastectomy: The Key Role of Flap Thickness Ratio.

We report our experience in direct-to-implant breast reconstruction with prepectoral polyurethane implants, with a focus on intraoperative mastectomy flap thickness compared to preoperative data (flap thickness ratio) as a reliable predictive variable of ischemic complications and reconstructive outcomes (satisfaction with breast). BACKGROUND: The optimization of nipple sparing mastectomy and implant-based reconstruction techniques led to an increase in the popularity of prepectoral reconstruction. The aim of this study is to explore the ratio between the intraoperative and preoperative breast tissue coverage assessment as reliable tool in order to predict the risk of ischemic complications in prepectoral reconstruction. METHODS: We analyzed 124 preoperative digital mammograms of 100 patients who underwent prepectoral implant-based reconstruction. We applied a Rancati modified score for breast tissue coverage classification, adding 4 measurements on the craniocaudal view. The intraoperative mastectomy flap thickness was measured using an intraoperative ultrasound assessment. We investigated the differences between the groups with and without ischemic complications related to the preoperative, intraoperative, and flap thickness ratio data. RESULTS: The flap thickness ratio was lower in ischemic complication group compared to no ischemic complication group (0.4 vs. 0.8) with statistically significant differences for all ischemic complication subgroups: major mastectomy flap necrosis (P = .000), minor mastectomy flap necrosis (P = .005), partial nipple areola complex necrosis (P = .007), and implant exposure (P = .001).

Preventing Soft Tissue Complications in Secondary Aesthetic Breast Surgery Using Indocyanin Green Angiography.

BACKGROUND: Secondary cosmetic breast surgery after primary augmentation with implant can be associated with an increased risk of adverse events. Partial/complete nipple-areola complex necrosis is particularly feared. In this preliminary study, the authors propose the utilization of indocyanine green (ICG) angiography to assess the blood supply of breast tissue after implant removal. OBJECTIVES: The main objective was to prevent skin and gland necrosis in revision breast surgery. METHODS: The authors performed a retrospective comparative analysis of 33 patients who underwent secondary breast surgery between 2018 and 2021 by a single surgeon (M.S.). Breast tissue perfusion was assessed in 16 patients by intraoperative ICG angiography at the end of implant removal and possible capsulectomy. Non-stained/non-fluorescent areas were judged to be low perfusion areas and were excised with short scar mastopexy. RESULTS: In the ICG angiography group, 7 patients (44%) showed an area of poor perfusion along the inferior pole; all of these patients underwent subglandular breast augmentation. Resection of the poor perfusion areas allowed an uneventful postoperative course. In the non--- ICG angiography group (17 patients), 5 patients experienced vertical-scar dehiscence/necrosis. We found a statistically significant association between the non-ICG angiography group and vertical scar dehiscence/necrosis, and also between vertical scar dehiscence/necrosis and subglandular implant placement (P = 0.04). CONCLUSIONS: Safer secondary surgery can be offered to patients undergoing secondary aesthetic breast procedures, especially when the first augmentation surgery is unknown-for example, implant plane, type of pedicle employed, if the implant is large and subglandular, and if capsulectomy is performed.

The role of fat grafting on contracted breast implant capsules: A retrospective comparative histological and immunohistochemical study.

Capsular contracture, a common complication of breast implant reconstruction following postmastectomy radiotherapy (PMRT), represents a challenge for plastic surgeons. Regenerative surgery with multiple autologous fat grafts (lipobed) before replacing the implant has been proven to be a satisfactory approach in the radio-damaged breast. Currently, in literature, there are no data available on the histological features of irradiated capsules after regenerative surgery. We enrolled 80 patients after immediate subpectoral alloplastic breast reconstruction, with indication for revision surgery due to grade IV capsular contracture developed after PMRT. Forty patients were undergoing multiple fat grafting (lipobed group, mean age 48) and 40 patients were not undergoing multiple fat grafting (non-regenerative surgery (NRS) group, mean age 49). The removed capsules were addressed to histological and immunohistochemical assessment. The capsules of the lipobed group patients compared with NRS group patients showed: a lower mean thickness (602.17 versus 670.43 µm; P = 0.013), a lower collagen fiber alignment (median value of angle deviation: 30.34 versus 18.38; P = 0.001), a lower immunohistochemical positivity for myofibroblasts (α-smooth muscle actin [α-SMA] expression: 12.5% versus 52.5%; P = 0.00), a higher immunohistochemical positivity for estrogen receptor-ß (ER-ß; 80% versus 20%; P = 0.00), and a lower immunohistochemical positivity for estrogen receptor-α (ER-α; 53.3% versus 16.7%; P = 0.00). The histological and immunohistochemical differences found are possibly due to alterations in the extracellular microenvironment determined by grafted fat.

Techniques for sentinel node biopsy in breast cancer.

Sentinel node biopsy (SNB) is the standard of care in women with breast cancer (BC) and clinically nonsuspicious axillary lymph nodes (LNs), due to its high negative predictive value (NPV) in the assessment of nodal status. SNB has significantly reduced complications related to the axillary lymph node dissection, such as lymphedema and upper limb dysfunction. The gold standard technique for SNB is the blue dye (BD) and technetium labelled nanocolloid (Tc-99m) double technique. However, nuclear medicine is not available in all Institutions and several new tracers and devices have been proposed, such as indocyanine green (ICG) and superparamagnetic iron oxides (SPIO). All these techniques show an accuracy and detection rate not inferior to that of the standard technique, with different specific pros and cons. The choice of how to perform a SNB primarily depends on the surgeon's confidence with the procedure, the availability of nuclear medicine and the economic resources of the Institutions. In this setting, new tracers, hybrid tracers and imaging techniques are being evaluated in order to improve the detection rate of sentinel lymph nodes (SNs) and minimize the number of unnecessary axillary surgeries through an accurate preoperative assessment of nodal status and to guide new minimally invasive diagnostic procedures of SNs. In particular, the contrast-enhanced ultrasound (CEUS) is an active field of research but cannot be recommended for clinical use at this time. The ICG fluorescence technique was superior in terms of DR, as well as having the lowest FNR. The DR descending order was SPIO, Tc, dual modality (Tc/BD), CEUS and BD. This paper is a narrative review of the most common SNB techniques in BC with a focus on recent innovations.

Ovarian Reserve after Chemotherapy in Breast Cancer: A Systematic Review and Meta-Analysis.

Background: Worldwide, breast cancer (BC) is the most common malignancy in the female population. In recent years, its diagnosis in young women has increased, together with a growing desire to become pregnant later in life. Although there is evidence about the detrimental effect of chemotherapy (CT) on the menses cycle, a practical tool to measure ovarian reserve is still missing. Recently, anti-Mullerian hormone (AMH) has been considered a good surrogate for ovarian reserve. The main objective of this paper is to evaluate the effect of CT on AMH value. METHODS: A systematic review and meta-analysis were conducted on the PubMed and Scopus electronic databases on articles retrieved from inception until February 2021. Trials evaluating ovarian reserves before and after CT in BC were included. We excluded case reports, case-series with fewer than ten patients, reviews (narrative or systematic), communications and perspectives. Studies in languages other than English or with polycystic ovarian syndrome (PCOS) patients were also excluded. AMH reduction was the main endpoint. Egger's and Begg's tests were used to assess the risk of publication bias. RESULTS: Eighteen trials were included from the 833 examined. A statistically significant decline in serum AMH concentration was found after CT, persisting even after years, with an overall reduction of -1.97 (95% CI: -3.12, -0.82). No significant differences in ovarian reserve loss were found in the BRCA1/2 mutation carriers compared to wild-type patients. CONCLUSIONS: Although this study has some limitations, including publication bias, failure to stratify the results by some important factors and low to medium quality of the studies included, this metanalysis demonstrates that the level of AMH markedly falls after CT in BC patients, corresponding to a reduction in ovarian reserve. These findings should be routinely discussed during oncofertility counseling and used to guide fertility preservation choices in young women before starting treatment.

Direct to Implant Breast Reconstruction With Prepectoral Micropolyurethane Foam-Coated Implant: Analysis of Patient Satisfaction.

BACKGROUND: Immediate implant reconstruction after mastectomy with submuscular implant placement is widely used in order to avoid implant exposure, capsular contracture and poor aesthetic result. Postoperative complications can be reduced by maintain mastectomy flap thickness and asses flap vascularity with near infrared imaging. The prepectoral reconstruction with polyurethane implants has been utilized with encouraging results. Postoperative patient satisfaction was assessed with the BREAST-Q scores in patients who underwent prepectoral reconstruction with polyurethane implants. Additionally the impact of mastectomy flap thickness on breast reconstruction was investigated. MATERIALS AND METHODS: The Breast Q-scores of satisfaction with the breast, the postoperative outcome and physical well-being of the chest in 70 patients underwent immediate implant breast reconstructions with prepectoral polyurethane implant were retrospectively reviewed. The correlation between mastectomy flap thickness and satisfaction with breast was analyzed. RESULTS: At 12-month follow-up the mean Q-score for satisfaction with breast was 71.73 (standard deviation: 13.31), and for physical well-being chest was 70.73 (standard deviation: 7.94). A positive linear correlation between mastectomy flap thickness and satisfaction with the breast was identified. CONCLUSIONS: The postoperative Q-scores are encouraging in the use of polyurethane prepectoral implants in immediate breast reconstruction, especially in patients with "thick" mastectomy flaps.

Improving Outcomes in Anterolateral Thigh Flap Donor-Site Reconstruction Using Propeller Flaps: A Retrospective Comparative Study with Skin Grafting.

BACKGROUND: After anterolateral thigh (ALT) flap harvesting, skin graft of the donor site is commonly performed. When the defect width exceeds 8 cm or 16% of thigh circumference, it can determine lower limb function impairment and poor aesthetic outcomes. In our comparative study, we assessed the functional and aesthetic outcomes related to ALT donor-site closure with split-thickness skin graft compared with thigh propeller flap. METHODS: We enrolled 60 patients with ALT flap donor sites. We considered two groups of ALT donor-site reconstructions: graft group (30 patients) with split-thickness skin graft and flap group (30 patients) with local perforator-based propeller flap. We assessed for each patient the range of motion (ROM) at the hip and knee, tension, numbness, paresthesia, tactile sensitivity, and gait. Regarding the impact on daily life activities, patients completed the lower extremity functional scale (LEFS) questionnaire. Patient satisfaction for aesthetic outcome was obtained with a 5-point Likert scale (from very poor to excellent). RESULTS: In the propeller flap group, the ROMs of hip and knee and the LEFS score were significantly higher. At 12-month follow-up, in the graft group, 23 patients reported tension, 19 numbness, 16 paresthesia, 22 reduction of tactile sensitivity, and 5 alteration of gait versus only 5 patients experienced paresthesia and 7 reduction of tactile sensitivity in the propeller flap group. The satisfaction for aesthetic outcome was significantly higher in the propeller flap group. CONCLUSION: In high-tension ALT donor-site closure, the propeller perforator flap should always be considered to avoid split-thickness skin graft with related functional and aesthetic poor results.

Indocyanine Green Lymphography, Lymphoscintigraphy, and Genetic Analysis in Nonsyndromic Primary Lymphedema: The Distal Dermal Backflow Grading System and the Print Sign.

BACKGROUND: Investigating correlations between clinical, instrumental, and genetic features of primary lymphedema (PL) with the aim to facilitate the diagnosis, the staging, and the management of this subgroup of patients. METHODS: A prospective observational study was conducted from September 2016 to May 2018, including patients with diagnosis of nonsyndromic PL. All patients underwent a lymphoscintigraphic rest-stress test, an indocyanine green (ICG) lymphographic test, and a genetic test from sputum sample. RESULTS: A total of 20 patients were enrolled in the study and 44 limbs were examined. The totality of clinically affected limbs (32/44) showed lymphographic and lymphoscintigraphic abnormalities. Concerning clinically healthy limbs (12/44), an abnormal pattern was demonstrated in 33.3% of ICG lymphographic test and 75% of lymphoscintigraphy. Regarding lymphography findings, the most frequent pattern was the distal dermal backflow (DDB). We distinguished four grades of DDB, which correlates with clinical and lymphoscintigraphic features. Furthermore, we found a new lymphographic alteration consisting of fluorescence appearing distally to the injection site of ICG, including fingers/toes and palmar/plantar surface of the hand and of the foot. This alteration, called "print sign," seems to be typical of DDB pattern PL. Genetic test did not help us make any etiological diagnosis. CONCLUSION: To our knowledge, this is the first study about PL comparing clinical, ICG lymphographic, lymphoscintigraphic, and genetic findings. As expected, all clinically affected limbs showed abnormalities in ICG lymphographic and lymphoscintigraphic tests. In opposition to what has previously been reported, also clinically healthy limbs showed lymphographic and lymphoscintigraphic alterations and this could suggest the existence of a subclinical form of PL. We proposed a grading of the DDB pattern, which correlates with clinical and lymphoscintigraphic features. Furthermore, we have described a new lymphographic alteration that seems to be typical of DDB pattern PL, the "print sign."

Successful Treatment of Pneumocephalus Using a Free-Style Chimeric Free Flap From a Scarred Thigh.

Pneumocephalus is an air collection in cranial cavity caused by accidental exposition of intracranial compartment after trauma or surgery. Skull base reconstruction with free flap is a useful surgical tool to avoid cerebral herniation or intracranial infection. The authors describe a patient of pneumocephalus following anterior skull base meningioma resection, unsuccessfully treated with 2 attempts of fascia lata grafts harvested from both thighs. A free-style chimeric anterolateral thigh free flap was performed using middle third of rectus femoris muscle to fill the planum spheno-ethmoidalis defect and adipocutaneous paddle for postoperative monitoring and for favoring a tension free skin closure. Free-style dissection with limited undermining in the previously scarred thigh was performed to avoid donor-site complication. Postoperative course was uneventful with complete resolution of the pneumocephalus.

Postoperative Monitoring of Free DIEP Flap in Breast Reconstruction with Near-Infrared Spectroscopy: Variables Affecting the Regional Oxygen Saturation.

BACKGROUND: The timing of surgical reexploration in microanastomotic thrombosis is directly related to the salvage rate of free flap. Near-infrared spectroscopy (NIRS) is a noninvasive technique, which allows a continuous bedside monitoring of flap oxygenation. The current literature is lacking in the assessment of variables able to modify the NIRS monitoring. The aim of this study is to identify patient and flap-related variables that can affect regional oxygen saturation (rSO2). METHODS: We retrospectively analyzed the data obtained from 45 consecutive patients undergoing breast reconstruction with deep inferior epigastric perforator (DIEP) flap. The monitoring device used is the Somanetics INVOS 5100C Cerebral/Somatic Oximeter (Covidien). Baseline measures of demographic-anthropometric variables (age, weight, height, body mass index [BMI]) and flap factors (flap size in grams, skin flap area in square centimeters, perforator number, and perforator size in millimeters) were collected from preoperative and intraoperative assessment. We investigated the linear correlation between mean rSO2 and BMI, flap size, skin flap area, perforator number, and perforator size. RESULTS: A positive linear correlation between rSO2 values and skin flap area, perforator number, and perforator size was found. A negative linear correlation between rSO2 values and BMI and flap size was found. All correlations are statistically significant. Despite the overall negative linear correlation between rSO2 values and flap size, we observed a bimodal trend: a positive relation up to 800 g, which is inverted above 800 g. CONCLUSION: The NIRS is a reliable additional tool in free flap monitoring. A careful evaluation should be given to patients and surgery factors that can change the oximetry data.

Low Versus High Vacuum Suction Drainage of the Submuscular Pocket in Primary Breast Reconstruction: A Retrospective Study.

BACKGROUND: Placement of suction drainage in submuscular pockets is routinely performed in breast reconstruction. Days of drain permanence (DDP) are associated with hospital stay and related health care costs. The aims of this study are to retrospectively compare data related to DDP and total drainage volume between high and low vacuum suction drainage groups and to identify correlations with patient or surgery-related factors. METHODS: We retrospectively analyzed data of 100 patients undergoing immediate or delayed breast reconstruction with expanders and implants. We considered 2 groups depending on suction pressure applied by 2 different surgical teams: group A (number, 50 patients) with high vacuum suction and group B (number, 50 patients) with low vacuum suction. RESULTS: Days of drain permanence was not significantly different between group A and group B (P = 0.451). The same was found for total drainage volume (P = 0.183). The distribution of DDP was statistically different only between patients with or without intraoperative bleeding in group A (P = 0.005) and smoking or nonsmoking patients in group A (P = 0.045). Statistical significance was kept in multivariate regression. CONCLUSIONS: There is no significant difference in DDP and total drainage volume using low or high vacuum suction drainage in breast reconstruction. The only factors affecting drainage permanence were intraoperative filling of expander, smoking, and intraoperative bleeding. Therefore, we can reduce the DDP, avoiding overfilling of expander and using of high vacuum suction in nonsmoking patients and in patients with significant intraoperative bleeding.

Deep tissue biopsy vs. superficial swab culture, including microbial loading determination, in the microbiological assessment of Skin and Soft Tissue Infections (SSTIs).

Thirty-two patients affected by SSTIs including DFIs were enrolled between 2013 and 2014. Superficial swab was obtained before and after cleansing with sterile saline, and after ultrasonic debridement; deep tissue biopsy was obtained from ulcer base. Samples were diluted with 1 mL of saline, serial 10-fold dilutions to 10-6 were made and 50 µL of each dilution was plated onto appropriate media. Bacteria were identified by Vitek II system. Microbial load was expressed as CFU/mL. Statistical analysis was performed by χ2. Incidence of Gram positives was higher than Gram negatives (S. aureus and P. aeruginosa being the most frequent); concordance (same bacteria isolated before and after debridement) never exceeded 60%. Ultrasonic debridement significantly reduced bacterial load or even suppressed bacterial growth. While reliability of superficial swab is poor for microbiological diagnosis of SSTIs, swabbing after ultrasonic debridement and biopsy of the ulcer base may be equally reliable.

Infections in breast implants: a review with a focus on developing countries.

The risk of surgical site infection is always present in surgery; the use of prosthetic materials is linked to an increased possibility of infection. Breast augmentation and breast reconstruction with implants are gaining popularity in developing countries. Implant infection is the main complication related to breast aesthetic and reconstructive surgery. In the present paper, we reviewed the current microbiological knowledge about implant infections, with particular attention to risk factors, diagnosis, clinical management, and antibiotic prophylaxis, focusing on reports from developing countries. After breast aesthetic surgery, up to 2.9% of patients develop a surgical site infection, with an incidence of 1.7% for acute infections and 0.8% for late infections. The rate of surgical site infection after post-mastectomy breast reconstruction is usually higher, ranging from 1% to 53%. The clinical features are not constant, and bacterial culture with antibiogram is the gold standard for diagnosis and for identification of antibiotic resistance. While waiting for culture results, empiric therapy with vancomycin and extended-spectrum penicillins or cephalosporins is recommended. Some patients require removal of the infected prosthesis. The main methods to bring down the risk of infection are strict asepsis protocol, preoperative antibiotic prophylaxis, and irrigation of the surgical pocket and implant with an antibiotic solution.