Post-operative KEloids iRradiation (POKER): does the surgery/high-dose interventional radiotherapy association make a winning hand?

PURPOSE: To report the results involving post-operative interventional radiotherapy (POIRT) in a homogenous cohort of patients affected by keloid and treated at a single institution with the same fractionation schedule. PATIENTS AND METHODS: Inclusion criteria were: surgery with a histopathological diagnosis of keloid, subsequent high-dose rate interventional radiotherapy (HDR-IRT)-12 Gy in 4 fractions (3 Gy/fr) twice a day-and follow-up period ≥ 24 months. RESULTS: One-hundred and two patients and a total of 135 keloids were eligible for the analyses. Median follow-up was 64 [IQR: 25-103] months. Thirty-six (26.7%) recurrences were observed, 12-months and 36-months cumulative incidence of recurrence were 20.7% (95% CI 12.2-28.5) and 23.8% (95% CI 14.9-31.7) respectively. History of spontaneous keloids (HR = 7.00, 95% CI 2.79-17.6, p < 0.001), spontaneous cheloid as keloid cause (HR = 6.97, 95% CI 2.05-23.7, p = 0.002) and sternal (HR = 10.6, 95% CI 3.08-36.8, p < 0.001), ear (HR = 6.03, 95% CI 1.71-21.3, p = 0.005) or limb (HR = 18.8, 95% CI 5.14-68.7, p < 0.001) keloid sites were significantly associated to a higher risk of recurrence. CONCLUSIONS: The findings support the use of surgery and POIRT as an effective strategy for controlling keloid relapses. Further studies should focus on determining the optimal Biologically Effective Dose and on establishing a scoring system for patient selection.

Tuberous Breasts Associated with Chest Wall Deformity: A Challenging Planning for Breast Augmentation.

Tuberous breast deformity is characterized by a deficiency in the vertical and horizontal dimensions of the breast, as well as breast underdevelopment and asymmetry. Concomitant chest wall deformities are not uncommon and increase the difficulty when planning breast augmentation in such patients. We present a unique case of tuberous breasts and chest wall deformity successfully treated employing a novel technique that incorporated breast implants and fat grafting. A 24-year-old patient with no significant past medical history presented to the plastic surgery clinic seeking correction of a severe breast asymmetry and desiring increase in breast volume. The right breast was Grolleau type 1 cup A, while the left breast was Grolleau type 3 cup C. The left hemithorax presented an accentuated prominence of the costochondral junction of 4th left rib, along with minor prominence of the 3rd and 5th left ribs. In addition, the 5th and 6th ribs were fused together. The surgical plan involved bilateral augmentation with implant and fat grafting. A 285 cc Motiva implant was placed subfascial on the right. Multiple refinements were necessary to the left breast, including areolar reduction, inframammary fold adjustment, and medial glandular modifications. A 140 cc Motiva implant was placed subfascial. Fat grafting was used in both breasts to enhance contour, projection and conceal the chest wall deformity. Postoperative recovery was uneventful, and results at 3-month follow-up showed improved breast symmetry and aesthetics.Level of Evidence V 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 the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Reply to: A Two-Step Approach for Breast Augmentation with Chest Wall Deformity?

Patients asking for cosmetic breast surgery often appreciate that their breasts have an unpleasing appearance, but they often do not have a full appreciation of the degree of potential anatomic abnormalities of the chest wall and of the specific anatomical characteristics, which require a meticulous surgical planning and techniques in comparison with a standard breast cosmetic surgery. Failure to recognize this will predispose the patient to an unsatisfactory outcome and secondary deformities. To maximize surgical predictability and patients' satisfaction, the authors proposed a two-stage approach in the scenario of patients presenting with chest wall deformities and asking for breast augmentation. However, as we contemplate adopting the authors' approach to our case, we anticipate encountering two primary challenges. Firstly, utilizing custom-made 3D silicone implants might exacerbate the projection of the chondrocostal prominence present in our patient. Indeed, we believe that these implants are more beneficial for addressing concave defects (such as pectus excavatum) rather than convex prominences, as observed in our case.Level of Evidence V 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 the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Reply to Comment to: Tuberous Breast Associated with Chest Wall Deformity: A Challenging Planning for Breast Augmentation.

Even in cases of noticeable breasts asymmetry, such as in our case, it is advisable to use implants with the same volume and projection, in order to maintain a similar breast footprint and allow a similar aging behavior over time. This can be achieved by reducing the size of the larger breast, thereby addressing the volume discrepancy before the placement of the implants. However, in our case, the skeletal deformities resulted in a significant disparity in the projection of the right and left sides of the chest wall, hindering the use of breast implants with identical projection. Therefore, due to this asymmetrical chest wall deformity, the left prosthesis was placed behind the central and lateral glandular parenchyma, avoiding hyper-projection in the medial part of the breast.Level of Evidence V 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 the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Rib Reduction Technique in Patients with Isolated Chondrocostal Chest Wall Prominence Undergoing Breast Augmentation.

INTRODUCTION: When planning for breast augmentation, it is important to consider not only implant choice, surgical technique and patient desires, but also the chest wall shape and deformities or irregularities, which remain often underestimated. They can be responsible for implant malposition and breast asymmetry after augmentation. Chondrocostal junction prominence is a minor but frequent chest wall deformity. The aim of this study is to report a new technique for sculpturing isolated chondrocostal prominence deformities in patients undergoing breast augmentation. METHODS: A retrospective study was conducted to review surgical outcomes of a novel technique for costal prominence sculpturing and reshaping in patients undergoing breast augmentation. After reaching the subpectoral space, an inferiorly-based perichondral-periosteal flap is harvested just above the prominence. Once the deformity is corrected, the perichondral flap is repositioned over the sculpted rib. RESULTS: A total of six patients presenting with isolated chondrocostal prominence underwent bilateral breast implant placement and costal reduction using the described technique. Three patients were primary augmentations while the remaining patients were two secondary breast augmentation and one augmentation mastopexy. No complications were reported. No additional pain was referred at the side of rib remodelling in comparison with the contralateral breast. All the patients were satisfied with cosmetic results. CONCLUSIONS: The described technique for contouring of isolated chondrocostal deformities is fast, easy reproducible and offers advantages over the standard partial rib reduction technique. It can prevent implant malposition and projection asymmetry, eventually enhancing breast augmentation outcomes. LEVEL OF EVIDENCE V: 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 the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Non-contrast MRI and post-mastectomy silicone breast implant rupture: preventing false positive diagnoses.

BACKGROUND: Breast implants are not lifelong, with implant rupture being the third leading cause of revisional surgery in augmented women. Noncontrast MRI is a reliable tool to assess implant integrity; however, false positive and false negative diagnoses have been reported due to an incorrect interpretation of MRI signs. This study aims to investigate the incidence of these misleading results, comparing MRI findings with intraoperative surgical observations and exploring signs of nonunivocal interpretation. MATERIALS AND METHODS: Between March 2019 and October 2022, our hospital, a referral center for breast cancer care, conducted 139 breast MRI examinations to evaluate implant integrity. Surgical intervention was deemed necessary for patients diagnosed with suspected or confirmed implant rupture at MRI. Those patients who did not undergo any surgical procedure (63 cases) or had surgery at different institutes (11 cases) were excluded. RESULTS: Among the 65 patients who underwent preoperative MRI and subsequent surgery at our institute, surgical findings confirmed the preoperative MRI diagnosis in 48 women. Notably, 17 women exhibited a discordance between MRI and surgical findings: three false negatives, 11 false positives and three possible ruptures not confirmed. Signs of nonunivocal or misleading interpretation were assessed on a patient-by-patient basis. The importance of obtaining detailed information about a patient's breast implant, including fill materials, number of lumens, manufacturer and shape, proved immensely beneficial for interpreting MRI signs accurately. CONCLUSION: Pre-MRI knowledge of implant details and a meticulous evaluation of non-univocal signs can aid radiologists in accurately assessing implant integrity, reducing the risk of unnecessary revisional surgeries, and potentially averting allegations of medical malpractice.

Resection to restoration: Assessing the synergy of polypropylene mesh (Marlex®) combined with methyl-methacrylate and latissimus dorsi flap for primary chest wall sarcomas.

BACKGROUND: Chest-wall sarcomas are treated with extensive resections and complex defect reconstruction to restore chest-wall integrity. It is a difficult surgical procedure that incorporates a multidisciplinary approach for the best outcome, preventing paradoxical chest movement issues and reducing complications. OBJECTIVE: We aimed to describe our experience of chest-wall reconstruction using polypropylene mesh (Marlex® Mesh) combined with methyl-methacrylate and soft-tissue coverage with a latissimus dorsi flap following sarcoma resection. PATIENTS AND METHODS: Among the 53 patients treated for primary chest-wall sarcomas at the European Institute of Oncology (IEO) in Milan, Italy, from 1998 to 2020, 14 cases underwent chest-wall resection and reconstruction using polypropylene mesh, methyl-methacrylate and the latissimus dorsi flap. Patients with locally advanced breast cancers, locally advanced lung cancers, squamous cell carcinomas, and other secondary chest-wall malignancies were excluded from the study, as were the patients with different types of chest-wall reconstruction. RESULTS: In this study, 14 patients (6 men and 8 women) with various primary chest-wall sarcomas were enrolled. On an average, 2 ribs (range: 1-5) were removed during the surgeries, and the chest-wall defects ranged from 20 to 150 cm2 with an average size of 73 cm2. The mean follow-up period for these patients was approximately 63.80 months CONCLUSION: The combination of Marlex® mesh filled with methyl-methacrylate and covered using latissimus dorsi myocutaneous flap provides safe, low-cost and effective single-stage chest-wall reconstruction after surgery for primary sarcomas.