Different types of implants for reconstructive breast surgery.

BACKGROUND: Breast cancer is the most common cancer in women worldwide, and is a leading cause of cancer death among women. Prophylactic or curative mastectomy is often followed by breast reconstruction for which there are several surgical approaches that use breast implants with which surgeons can restore the natural feel, size and shape of the breast. OBJECTIVES: To assess the effects of different types of breast implants on capsular contracture, surgical short- and long-term complications, postoperative satisfaction level and quality of life in women who have undergone reconstructive breast surgery after mastectomy. SEARCH METHODS: We searched the Cochrane Breast Cancer Group's Specialised Register on 20 July 2015, MEDLINE (1985 to 20 July 2015), EMBASE (1985 to 20 July 2015) and the Cochrane Central Register of Controlled Trials (CENTRAL; Issue 8, 2015). We also searched the World Health Organization's International Clinical Trials Registry Platform (WHO ICTRP) and ClinicalTrials.gov on 16 July 2015. SELECTION CRITERIA: We included randomised controlled trials (RCTs) and quasi-RCTs that compared different types of breast implants for reconstructive surgery. We considered the following types of intervention: implant envelope surfaces - texturised versus smooth; implant filler material - silicone versus saline, PVP-Hydrogel versus saline; implant shape - anatomical versus round; implant volume - variable versus fixed; brands - different implant manufacturing companies and implant generation (fifth versus previous generations). DATA COLLECTION AND ANALYSIS: Two review authors independently assessed methodological quality and extracted data. We used standard Cochrane methodological procedures. The quality of the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. MAIN RESULTS: Five RCTs with 202 participants met the inclusion criteria. The women participants were typically in their 50s, and the majority of them (about 82%) received reconstructive surgery following breast cancer, while the others had reconstructive surgery after prophylactic mastectomy. The studies were heterogenous in terms of implant comparisons, which prevented us from pooling the data.The studies were judged as being at an unclear risk of bias for most risk of bias items owing to poor quality of reporting in the trial publications. Three of the five RCTs were judged to be at high risk of attrition bias, and one at high risk of detection bias.Textured silicone versus smooth silicone implants: textured implants were associated with worse outcomes when compared to smooth implants (capsular contracture: risk ratio (RR) 0.82, 95% CI 0.14 to 4.71; 1 study, 20 participants; very low quality evidence; reintervention: RR 0.82, 95% CI 0.14 to 4.71; 1 study, 20 participants; very low quality evidence). No results in this comparison were statistically significant.Silicone versus saline implants: saline-filled implants performed better than silicone-filled implants for some outcomes; specifically, they produced less severe capsular contracture (RR 3.25, 95% CI 1.24 to 8.51; 1 study, 60 participants; very low quality evidence) and increased patient satisfaction (RR 0.60, 95% CI 0.41 to 0.88; 1 study, 58 participants; very low quality evidence). However reintervention was significantly more frequent in the saline-filled implant group than in the silicone-filled group (OR 0.08, 95% CI 0.01 to 0.43; 1 study, 60 participants; very low quality evidence).Poly(N-vinyl-2-pyrrolidone) hydrogel-filled (PVP-hydrogel) versus saline-filled implants: PVP-hydrogel-filled implants were associated with worse outcomes when compared to saline-filled implants (capsular contracture: RR 3.50, 95% CI 0.83 to 14.83; 1 study, 40 participants; very low quality evidence; short-term complications: RR 2.10, 95% CI 0.21 to 21.39; 1 study, 41 participants; very low quality evidence).Anatomical versus round implants: anatomical implants were associated with worse outcomes than round implants (capsular contracture: RR 2.00, 95% CI 0.20 to 20.15; 1 study, 36 participants; very low quality evidence; short-term complications: RR 2.00, 95% CI 0.42 to 9.58; 1 study, 36 participants; very low quality evidence; reintervention: RR 1.50, 95% CI 0.51 to 4.43; 1 study, 36 participants; very low quality evidence). No results in this comparison were statistically significant.Variable-volume versus fixed-volume implants: data about one-stage reconstruction using variable-volume implants were compared with data about fixed-volume implants positioned during the second surgical procedure of two-stage reconstructions. Fixed-volume implant reconstructions were possibly associated with a greater number of women reporting that their reconstruction corresponded with expected results (RR 0.25, 95% CI 0.10 to 0.62; 1 study, 40 participants; very low quality evidence) and fewer reinterventions (RR 7.00, 95% CI 1.82 to 26.89; 1 study, 40 participants; very low quality evidence) when compared to variable-volume implants. A higher patient satisfaction level (rated from 1 to 6, with 1 being very bad and 6 being very good) was found with the fixed-volume implants for overall aesthetic result (mean difference (MD) -1.10, 95% CI -1.59 to -0.61; 1 study, 40 participants; very low quality evidence).There were no studies that examined the effects of recent (fifth) generation silicone implants versus previous generations or different implant manufacturing companies. AUTHORS' CONCLUSIONS: Despite the central role of breast reconstruction in women with breast cancer, the best implants to use in reconstructive surgery have been studied rarely in the context of RCTs. Furthermore the quality of these studies and the overall evidence they provide is largely unsatisfactory. Some of our results can be interpreted as early evidence of potentially large differences between different surgical approaches, which should be confirmed in new high-quality RCTs that include a larger number of women. These days - even after a few million women have had breasts reconstructed - surgeons cannot inform women about the risks and complications of different implant-based breast reconstructive options on the basis of results derived from RCTs.

Avoiding Complications in Abdominal Wall Surgery: A Mathematical Model to Predict the Course of the Motor Innervation of the Rectus Abdominis.

Ever since its introduction, the transverse rectus abdominis myocutaneous flap has become the mainstay of autologous breast reconstruction. However, concerns regarding donor site morbidity due to the breach of abdominal wall musculature integrity soon followed. Muscle-sparing techniques, eventually eliminating the muscle from the flap all-together with the deep inferior epigastric artery perforator flap, did not eliminate the problem of abdominal wall weakness. This led to the conclusion that motor innervation might be at fault. Studies have shown that even in the presence of an intact rectus abdominis muscle, and an intact anterior rectus sheath, denervation of the rectus abdominis muscle results in significant abdominal wall weakness leading to superior and inferior abdominal bulges, and abdominal herniation. Our aim was to establish a mathematical model to predict the location of the motor innervation to the rectus abdominis muscle, and thus provide surgeons with a tool that will allow them to reduce abdominal morbidity during deep inferior epigastric artery perforator and free muscle-sparing transverse rectus abdominis myocutaneous surgery. We dissected 42 cadaveric hemiabdomens and mapped the course of the thoracolumbar nerves. We then standardized and analyzed our findings and presented them as a relative map which can be adjusted to body type and dimensions. Our dissections show that the motor innervation is closely related to the lateral vascular supply. Thus, when possible, we support the preferred utilization of the medial vascular supply, and the preservation of the lateral supply and motor innervation.

Efficacy and Safety of P2Y12 monotherapy vs standard DAPT in patients undergoing percutaneous coronary intervention: meta-analysis of randomized trials.

BACKGROUND: Debates persist regarding the optimal duration of dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) in coronary artery disease (CAD). Recent trials have introduced a novel approach involving P2Y12 inhibitor monotherapy with ticagrelor or clopidogrel, after a short DAPT. However, the effectiveness and safety of this strategy remains to be established. We aimed to perform a meta-analysis comparing monotherapy with P2Y12 inhibitors versus standard DAPT in patients undergoing PCI at 12 months. METHODS: Multiple databases were searched. Six RCTs with a total of 24877 patients were included. The primary endpoint was all-cause mortality at 12 months of follow-up. The secondary endpoints were cardiovascular mortality, myocardial infarction, probable or definite stent thrombosis, stroke events, and major bleeding. The study is registered with PROSPERO (CRD42024499529). RESULTS: Monotherapy with P2Y12 inhibitor ticagrelor significantly reduced both allcause mortality (HR 0.71, 95 CI [0.55-0.91], P = 0.007) and cardiovascular mortality (HR 0.66, 95% CI [0.49-0.89], P = 0.006) compared to standard DAPT. In contrast, clopidogrel monotherapy did not demonstrate a similar reduction. The decrease in mortality associated with ticagrelor was primarily due to a lower risk of major bleeding (HR 0.56, 95% CI [0.43-0.72], P < 0.001), while the risk of myocardial infarction (MI) remained unchanged (HR 0.90, 95% CI [0.73-1.11], P = 0.32). The risk of stroke was found to be similar across treatments. CONCLUSIONS: In comparison to standard DAPT, P2Y12 inhibitor monotherapy with ticagrelor may lead to a reduced mortality. The clinical benefits are driven by a reduction of bleeding risk without ischemic risk trade-off.

The effects of substrate composition and topography on the characteristics and growth of cell cultures of cochlear fibrocytes.

Spiral ligament fibrocytes of the cochlea play homoeostatic roles in hearing and their degeneration contributes to hearing loss. Culturing fibrocytes in vitro provides a way to evaluate their functional characteristics and study possible therapies for hearing loss. We investigated whether in vivo characteristics of fibrocytes could be recapitulated in vitro by modifying the culture substrates and carried out proof of concept studies for potential transplantation of culture cells into the inner ear. Fibrocytes cultured from 4 to 5-week old CD/1 mice were grown on 2D substrates coated with collagen I, II, V or IX and, after harvesting, onto or into 3D substrates (hydrogels) of collagen I alone or mixed collagen I and II at a 1:1 ratio. We also assessed magnetic nanoparticle (MNP) uptake. Cell counts, immunohistochemical and ultrastructural studies showed that fibrocytes grown on 2D substrates proliferated, formed both small spindle-shaped and large flat cells that avidly took up MNPs. Of the different collagen coatings, only collagen II had an effect, causing a reduced size of the larger cells. On hydrogels, the cells were plump/rounded with extended processes, resembling native cells. They formed networks over the surface and became incorporated into the gel. In all culture formats, the majority co-expressed caldesmon, aquaporin 1, S-100 and sodium potassium ATPase, indicating a mixed or uncharacterised phenotype. Time-course experiments showed a decrease to ∼50% of the starting population by 4d after seeding on collagen I hydrogels, but better survival (∼60%) was found on collagen I + II gels, whilst TEM revealed the presence of apoptotic cells. Cells grown within gels additionally showed necrosis. These results demonstrate that fibrocytes grown in 3D recapitulate in vivo morphology of native fibrocytes, but have poorer survival, compared with 2D. Therefore hydrogel cultures could be used to study fibrocyte function and might also offer avenues for cell-replacement therapies, but need more optimization for therapeutic use. Fibrocyte function could be modified using MNPs in combination, for example, with gene transfection.

Conservative mastectomies.

Nowadays, oncological breast surgery has to be performed to maximize cosmetic results, and even mastectomies, when unavoidable, should conform to acceptable aesthetics. We investigated surgical approaches to skin-sparing mastectomies. Scar positioning and volume replacement were evaluated. We also discuss nipple-sparing mastectomy (NSM), probably the most outstanding item in the current debate on breast shape preservation. We give suggestions for safe admission criteria and effective treatment.

New technologies for the assessment of breast surgical outcomes.

BACKGROUND: Although interest in objective and quantitative breast surgical outcome assessment is rapidly increasing, published reports have yet to make a real impact on everyday clinical practice. OBJECTIVE: The authors offer a preliminary report on an innovative methodology customized for breast shape evaluation that, in our opinion, could overcome most of the technical and conceptual limitations of previous studies. METHODS: Three-dimensional/four-dimensional breast scanning was performed using a breast-dedicated prototype laser scanner made up of a handheld device, including a charge-coupled device (CCD) camera coupled to a spot laser source. Two additional motion analyzer cameras were used for handheld device tracking and the acquisition of patient motion. RESULTS: Seven female volunteers, including both subjects who had undergone cosmetic or reconstructive breast surgery and those with no such history, underwent a dynamic breast shape survey. Curvature mapping on three-dimensional mesh warranted precise measurements of local geometric properties of the breast surface. Elaboration and representation of breast dynamic behavior during common motor tasks (eg, walking, running, sitting, and lying) was also possible. CONCLUSIONS: The scanning methodology reported here reliably describes the breast surface not only in a static position, but also at specific postures or during motion of the body. It also opens the door for quantitative static and dynamic assessment of surgical outcomes, the intraoperative assessment of breast shape, and other applications. Limitations include the relatively long amount of time required for each scan and the need for technical and clinical validation, particularly with respect to four-dimensional assessment.

International Expert Panel Consensus on Fat Grafting of the Breast.

BACKGROUND: Autologous fat grafting has broad applications in reconstructive and aesthetic breast surgery as a natural filler and for its regenerative purposes. Despite the widespread use of fat grafting, there remains no shared consensus on what constitutes the optimal fat grafting technique and its oncological safety. For this reason, the authors of this study have organized a Survey and an International Consensus Conference that was held at the Aesthetic Breast Meeting in Milan (December 15, 2018). METHODS: All studies on fat grafting, both for breast aesthetic and reconstructive purposes, were electronically screened. The literature review led to 17 "key questions" that were used for the Survey. The authors prepared a set of 10 "key statements" that have been discussed in a dedicated face-to-face session during the meeting. RESULTS: The 10 key statements addressed all the most debated topics on fat grafting of the breast. Levels of evidence for the key statements ranged from III to IV with 2 statements (20%) supported by a level of evidence III and 6 statements (60%) by level of evidence IV. Overall consensus was reached for 2 statements (20%) with >75% agreement reached for 7 statements. CONCLUSIONS: The survey demonstrated a diversity of opinion and attitude among the panelists with regard to technique. Clear recommendations for evidence-based clinical practice for fat grafting use both in aesthetic and reconstructive breast surgery could not be defined due to the scarcity of level 1 or 2 studies.

Extra-projected implants as an alternative surgical model for breast reconstruction. Implantation strategy and early results.

The present study reports on patients who underwent breast reconstructions with extra-projection implants. Two-hundred and thirty-four women were treated for 238 breast reconstructions irrespectively of breast shape and size. In this series we aimed to reconstruct for all women a bilateral cosmetic medium-size breast (between 400 and 500 cc), highly projected, with a little to moderate ptosis rather then a ptotic one exactly matching the contra-lateral. This is demonstrated by volume of implants that ranged from 397 cc for ladies with small breast who received an augmentation, to 533 cc for those who side required a reduction surgery. Eighty-six percent of patients received contra-lateral procedures. Complication rate was 8.4% and 66% of reconstructions were rated as good in the patients' opinion. Extra-projection implants, coupled with contra-lateral breast surgery, provide a good aesthetic outcome and avoid myocutaneous flaps only on the basis of breast size and shape.

Autologous fat tissue grafting improves pulmonary healing after laser metastasectomy.

BACKGROUND: Extensive clinical experience has demonstrated the potential usefulness of autologous fat tissue (AFT) graft in tissue reconstruction, repair or regeneration. In the present study, we evaluated the feasibility and safety of AFT in the repair of surgically injured lung surface. METHODS: Eighty consecutive procedures of pulmonary metastasectomy by laser precision resection, were performed in 66 patients between March 2010 and December 2012. In the first 20 procedures, AFT graft was applied on the wounded pulmonary surface without closure of parenchymal surface. The following 40 procedures were carried on without AFT (20 leaving the resection margins open and 20 closing the resection margins with a running suture). In the remaining 20 procedures, AFT was applied and the resection margins closed. The efficacy of this technique was evaluated by comparing the AFT group with the non-AFT group, with respect to prolonged alveolar air leakage (PAAL), time to drain removal, length of hospital stay, and patient survival at four years. RESULTS: The occurrence of PAAL was lower in the AFT group as compared to non-AFT group (17.5% versus 42.5%, p = 0.027), and median time to drain removal shorter (4 versus 6 days respectively, p = 0.016). Overall 4-year survival was 70% for AFT group, and 59% for non-AFT group (p = 0.34). CONCLUSIONS: This prospective cohort observational study demonstrated the feasibility and safety of AFT pulmonary grafting after laser metastasectomy. AFT graft improved pulmonary healing, by reducing the incidence and severity of PAAL. Moreover, there was no evidence of tumor promotion in the metastatic setting, with a similar overall survival at 4 years.

Role of Mitomycin C in Preventing Capsular Contracture in Implant-Based Reconstructive Breast Surgery: A Randomized Controlled Trial.

BACKGROUND: Capsular contracture represents the most frequent complication after implant-based breast reconstruction. An experimental study on mice demonstrated that capsule formation around breast implants is considerably diminished after topical application of mitomycin C. The authors conducted a randomized controlled clinical trial investigating the efficacy of mitomycin C in reducing capsular contracture rates following implant-based breast reconstruction after mastectomy for breast cancer. METHODS: The authors randomized all women older than 18 years scheduled for the second stage of an implant-based breast reconstruction after mastectomy for breast cancer at the National Cancer Institute in Milan from October of 2005 to February of 2010 to receive or not receive the topical application of mitomycin C during surgery. The authors assessed capsular contracture, major postoperative complications, and aesthetic outcome. RESULTS: The authors randomized 322 patients to receive mitomycin C or not at the second stage of implant-based breast reconstruction. One hundred sixty-two patients were allocated to the mitomycin C group and 160 patients were allocated to the control group. The relative risk of capsular contracture in the mitomycin C group was 0.92 (95 percent CI, 0.60 to 1.41). Major complications leading to reintervention, oncologic outcomes, and aesthetic outcomes were comparable between the two groups. CONCLUSIONS: This is the first trial reporting data about the use of mitomycin C in breast reconstructive surgery in a clinical setting. Mitomycin C seems not to significantly affect capsular contracture rate and severity following implant-based reconstructive breast surgery at the tested doses. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, I.

Inner-ear decompression sickness in nine trimix recreational divers.

INTRODUCTION: Recreational technical diving, including the use of helium-based mixes (trimix) and the experimentation of new decompression algorithms, has become increasingly popular. Inner-ear decompression sickness (DCS) can occur as an isolated clinical entity or as part of a multi-organ presentation in this population. Physiological characteristics of the inner ear make it selectively vulnerable to DCS. The inner ear has a slower gas washout than the brain thus potentially making it more vulnerable to deleterious effects of any bubbles that cross a persistent foramen ovale (PFO) and enter the basilar artery, whilst the inner ear remains supersaturated but the brain does not. METHODS: A questionnaire was made widely available to divers to analyse the incidence of inner-ear DCS after technical dives. One-hundred-and-twenty-six divers submitted completed questionnaires, and we studied each incident in detail. RESULTS: Nine (7.1%) of the 126 responders reported to have had at least one episode of inner-ear DCS, of which seven occurred without having omitted planned decompression stops. Of these seven, four suffered from DCS affecting just the inner ear, while three also had skin, joint and bladder involvement. Five of the nine divers affected were found to have a PFO. All affected divers suffered from vestibular symptoms, while two also reported cochlear symptoms. Three divers reported to have balance problems long after the accident. CONCLUSIONS: This small study is consistent with a high prevalence of PFO among divers suffering inner-ear DCS after trimix dives, and the pathophysiological characteristics of the inner ear could contribute to this pathology, as described previously. After an episode of DCS, vestibular and cochlear injury should always be examined for.

Lack of activation of telomere maintenance mechanisms in human adipose stromal cells derived from fatty portion of lipoaspirates.

BACKGROUND: Significant improvement in the understanding of mesenchymal stem cell biology paved the way to their clinical use. Human lipoaspirates derived from mesenchymal stem cells (adipose-derived stem cells) continue to draw the attention of researchers in the field of basic and applied research due to their regenerative, reparative, angiogenic, antiapoptotic, and immunosuppressive properties, all of which collectively point out their therapeutic potential. There is still, however, a need for further investigation to improve the knowledge of stem cell biology, to broaden their field of use, and to enhance their therapeutic effectiveness. METHODS: The authors characterized human adipose-derived stem cells at different in vitro culture time points in terms of immunophenotype, multilineage differentiation, long-term survival with self-renewal capacity, and presence of telomere maintenance mechanisms (telomerase activity and alternative lengthening of telomere) for excluding their eventual susceptibility to malignant transformation. RESULTS: Adipose-derived stem cells were isolated from the abdomen and peritrochanteric region of 31 female donors, propagated, and monitored in vitro for several passages. The outgrown cells shared the biological properties of mesenchymal stem cells, with adherence to plastic, expression of the typical surface markers, and induction of adipogenic, osteogenic, and chondrogenic differentiation. Telomerase activity and alternative lengthening of telomere mechanisms at different passages of cultures were not evidenced. CONCLUSION: The results support the concept that in vitro expanded adipose-derived stem cells obtained from fat tissue are not susceptible to developing one of the hallmarks of malignant transformation and can be considered amenable for cell therapy approaches.

Impact of contra-lateral breast reshaping on mammographic surveillance in women undergoing breast reconstruction following mastectomy for breast cancer.

BACKGROUND: The ultimate goal of breast reconstruction is to achieve symmetry with the contra-lateral breast. Contra-lateral procedures with wide parenchymal rearrangements are suspected to impair mammographic surveillance. This study aims to evaluate the impact on mammographic detection of mastopexies and breast reductions for contralateral adjustment in breast reconstruction. PATIENTS AND METHODS: We retrospectively evaluated 105 women affected by uni-lateral breast cancer who underwent mastectomy and immediate two-stage reconstruction between 2002 and 2007. We considered three groups according to the contra-lateral reshaping technique: mastopexy or breast reduction with inferior dermoglandular flap (group 1); mastopexy or breast reduction without inferior dermoglandular flap (group 2); no contra-lateral reshaping (group 3). We assessed qualitative mammographic variations and breast density in the three groups. RESULTS: Statistically significant differences have been found when comparing reshaped groups with non reshaped groups regarding parenchymal distortions, skin thickening and stromal edema, but these differences did not affect cancer surveillance. The surveillance mammography diagnostic accuracy in contra-lateral cancer detection was not significantly different between the three groups (p = 0.56), such as the need for MRI for equivocal findings at mammographic contra-lateral breast (p = 0.77) and the need for core-biopsies to confirm mammographic suspect of contra-lateral breast cancer (p = 0.90). CONCLUSIONS: This study confirms previous reports regarding the safety of mastopexies and breast reductions when performed in the setting of contra-lateral breast reshaping after breast reconstruction. Mammographic accuracy, sensitivity and specificity are not affected by the glandular re-arrangement. These results provide a further validation of the safety of current reconstructive paradigms.

Skin/nipple sparing mastectomies and implant-based breast reconstruction in patients with large and ptotic breast: oncological and reconstructive results.

In this study we performed 77 procedures on 65 patients fulfilling the oncological criteria for skin-sparing mastectomy and presenting with large or medium size breasts. All the operations were performed as a single-stage procedure with an anatomical prosthesis allocated into a compound pouch, made up of the pectoralis major, serratus anterior fascia, and a lower dermal adipose flap. The medium size of the anatomical implants employed was 444.3 cc. The implant removal rate was 14.2%. At a median follow-up of 36 months we reported a 0.5% local recurrence rate per year. The overall specific survival rate was 98.2%. This study confirms the safety and effectiveness of this technical variation of skin and nipple-sparing mastectomies. All breast, irrespective of mammary shape and size, can be reconstructed with medium size implants and, if required, contralateral adjustments. The overall complication rate is in keeping with previous studies.

Outcome of different timings of radiotherapy in implant-based breast reconstructions.

BACKGROUND: The therapeutic role of postmastectomy radiation therapy has been demonstrated both in locally advanced breast cancer and in other high-risk conditions. Implant-based breast reconstruction for irradiated patients can generate higher complication rates. In this study, the authors observed the effects of radiation on temporary expanders and permanent implants. The estimate of the totally failed reconstruction rate was the principal endpoint of this study. Capsular contracture rates and patients' and surgeons' subjective evaluations were the secondary endpoints. METHODS: Two hundred fifty-seven patients were consecutively involved in this study. The population was stratified into two groups: group 1, postmastectomy radiation therapy on permanent implants (n = 109 patients); and group 2, postmastectomy radiation therapy on tissue expanders (n = 50 patients). A nonirradiated control group made up of 98 patients was selected randomly. All patients underwent a two-stage immediate breast reconstruction with subpectoral temporary expanders and permanent implants. RESULTS: The totally failed reconstruction rate was significantly higher in group 2, with 40 percent of unsuccessful reconstructions compared with 6.4 percent in group 1 and 2.3 percent in the control group (p < 0.0001). The capsular contracture rate was significantly higher for groups 1 and 2 compared with the control group. The shape and symmetry assessment and the patients' opinions demonstrated a higher incidence of good results in group 1 in comparison with group 2. The best scores were always obtained by the control group. CONCLUSION: This study demonstrated that radiotherapy during tissue expansion may compromise the outcome of implant-based breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

The "rib-like" technique for surgical treatment of sternal tumors: lessons learned from 101 consecutive cases.

BACKGROUND: Sternal tumors represent a rare subgroup of chest wall neoplasms in which indication, surgical issues, and long-term results are rarely reported. Thus, in this study we reevaluated our experience in sternal replacement from a series of 101 consecutive cases during the last 30 years. METHODS: Clinical records of patients who underwent sternal resection between January 1980 and December 2008 were reviewed. The technique of reconstruction after sternectomy varied over time, including mesh replacement in 52 patients (group A), rigid prosthesis in 27 patients (group B), and the "rib-like" technique, a semi-rigid tridimensional prosthesis reproducing the shape of native ribs, in 22 patients (group C). Postoperative outcomes and long-term survival were analyzed. RESULTS: Of 101 patients, 42 underwent resection for primary chest wall tumors, 30 for breast cancer, 15 for locally advanced tumors, 11 for metastatic disease, and 3 for benign disease. One patient died postoperatively. The overall major complications rate was similar between groups. Local infection required prosthetic removal in 7 patients of groups A and B (9%). No infection occurred in group C (p = 0.02). Median survival exceeded 60 months for primary sternal tumors and 22 months for other cancer (p = 0.01). The worst survival was recorded in radioinduced sarcoma (17 months) and in patients who underwent previous resection before salvage sternectomy (18 months). CONCLUSIONS: Results from this study showed that an adequate sternal resection should be done at the first operation and that improving prosthetic integration with surrounding tissues may reduce the local complication rate.

Motion compensation in hand-held laser scanning for surface modeling in plastic and reconstructive surgery.

The purpose of this work is to develop a new integrated methodology for breast morphology assessment in plastic and reconstructive surgery. Such a methodology comprises hand-held laser scanning with active compensation of breathing motion and involuntary movements, in order to obtain a thorough and artifacts-free representation of patient breast shape. This was obtained by tracking surface motion with a configuration of passive markers fitted on the patient's thoraco-abdominal region. The proposed method, based on a mapping procedure, has been compared with respiratory gating, that is commonly used in radiotherapy and biomedical imaging applications. The results show that the implemented procedure is adequately able to compensate for motion, resulting in quantitative surface description to be used for clinical evaluation.

Maximizing the use of abdominoplasty incision in oncoplastic and aesthetic breast surgery: four transabdominal (transumbilical-like) augmentations.

BACKGROUND: The transabdominal (transumbilical [TUBA]) procedure for breast implant insertion is known for aesthetic aims, but cosmetic and psychosocial improvements reported in aesthetic surgery should be transferred to breast reconstruction patients. METHODS: Surgical and psychological aspects were analyzed in four cases through clinical evaluation and psychosocial assessment. Three patients were candidates for postmastectomy reconstruction by transverse rectus abdominis myocutaneous (TRAM) flap, and one patient was a candidate for cosmetic abdominoplasty. The expectations of the patients were met, and body image improvement was provided through contralateral breast augmentation in all cases. Details of the surgical approach focused on the inframammary fascial system. The psychosocial implications of the TUBA-like breast augmentation combined with the abdominoplasty procedure were emphasized through the analysis of the technical details and the psychological behaviors affecting the surgery. RESULTS: The result, after long-term clinical follow-up (37 months) and administration of a satisfaction questionnaire (CSQ-8), established the importance of scarless surgery to healthy breast tissue and the positive reception by women with different life histories. CONCLUSION: This report concerns only a few potential patients, but supports a trend that surgeons should consider. An elective indication for transabdominal breast augmentation can be represented even by those few patients who are candidates for TRAM flap reconstruction, who are agreeable to a small augmentation in the absence of a scar on their healthy breast, and whose reconstructed breast is larger and more prominent at the central part of the mound than on the contralateral side.

The lateral intercostal artery perforators: anatomical study and clinical application in breast surgery.

BACKGROUND: The lateral intercostal artery perforator flaps are based on intercostal perforators that arise from the costal groove. Cadaver dissections have been performed to improve the understanding of lateral intercostal perforator anatomy. The clinical applications of this study are demonstrated. METHODS: The intercostal perforators were dissected in 24 fresh cadavers and evaluated in a field that extended between the third and the eighth intercostal spaces and between the latissimus dorsi and pectoralis major muscles. Their relationship with the anterior border of the latissimus dorsi muscle and the serratus anterior vessels was investigated. RESULTS: A mean value of 3.91 perforators per side was found. The majority of the intercostal perforators were found between the fifth and the eighth intercostal space level (88.4 percent). Mean distances of intercostal perforators to the anterior border of the latissimus dorsi muscle varied between 2.67 and 3.49 cm. The largest or "dominant" perforator was most frequently found in the sixth intercostal space (38.6 percent of cases) at an average of 2.5 to 3.5 cm from the anterior border of the latissimus dorsi muscle. In 10 of 47 sides (21 percent), vascular connections were found between the serratus anterior branch and the intercostal perforators. The connection was observed more frequently in the seventh and the sixth intercostal spaces, in 38 percent and 30 percent of cases, respectively. This vascular connection enables harvest of a serratus anterior artery perforator flap. CONCLUSION: Lateral intercostal artery perforator flaps can be used to address challenging defects over the breast without sacrificing the pedicle of the latissimus dorsi muscle.