Endoscopic Delayed Breast Reconstruction With Expanders and Implants via the Axillary Incision Made for Sentinel Lymph Node Biopsy or Lymphadenectomy.

BACKGROUND: Classic techniques of delayed prosthetic breast reconstruction use the mastectomy scar as an access route. As a result, the filling of the expander must be postponed until the wounds have healed. This creates an asymmetry between the breasts with the volume changes caused by the filling of the expander, which may occur over several weeks and cause considerable discomfort. METHODS: Delayed breast reconstruction was performed via the axillary incision made for sentinel lymph node biopsy or lymphadenectomy with endoscopic assistance and detachment of the pectoralis major muscle. The filling of the expander and symmetrization with the contralateral breast was performed in the first stage.The expander was replaced with the definitive prosthesis 3 months later, after endoscopic capsulotomy. Fat grafting was performed to create a lipobed around the implant and to improve tissue quality. RESULTS: Sixty-two patients underwent surgery. Mean follow-up was 19 months. There were no major complications in the reconstructed breast. One case of hematoma in a contralateral breast reduction and an oil cystic mass secondary to fat grafting were recorded. In all cases, the filling of the expander with the definitive volume was possible during the first stage. CONCLUSIONS: Endoscopic delayed breast reconstruction with insertion of implants through the axillary incision for sentinel node biopsy or lymphadenectomy is safe and feasible. It achieves complete intraoperative expansion, symmetry between the volumes of the breasts during the first stage, and avoids problems with the scar and the risk of extrusion, as the scar is placed remotely in the axilla.

Platelet-rich plasma mixed-fat grafting: a reasonable prosurvival strategy for fat grafts?

BACKGROUND: One of the most interesting developments in practical applications of fat grafting in recent years is the use of prosurvival strategies to improve maintenance of volume. Platelet-rich plasma (PRP) plays a decisive role in the repair and regeneration of different tissues via the activation and secretion of a great variety of growth factors and other cytokines stored in the alpha-granules of the platelets. This review aimed to assess the efficacy of PRP mixed-fat grafting as a prosurvival strategy for fat grafts. METHODS: Online searches of the Cochrane Library and MEDLINE until January 2014 were conducted. The review included studies with at least one clinical end point in which the effect of PRP on the absorption and viability of the fat graft could be assessed. RESULTS: The review comprised 6 preclinical studies with a control group and 9 clinical studies of humans. It also included comparative studies performed with other prosurvival strategies for fat grafts, such as combination with the stromal vascular fraction and second-generation PRP, also called "platelet-rich fibrin." The results indicate that PRP may have a dose-dependent positive effect on fat grafts and suggest low complication rates. CONCLUSIONS: The development of new growth factor delivery systems or cell therapies to enrich fat grafts is an area that merits further research.

Treatment of grade 3 tuberous breasts with Puckett's technique (modified) and fat grafting to correct the constricting ring.

BACKGROUND: Augmentation of tuberous breasts classified as grade 3 is a challenge to surgeons. The authors describe their technique for correcting grade 3 tuberous breasts with a book-shaped opening of the breast, insertion of an anatomic prosthesis, and fat grafting. METHODS: The authors' technique for correcting grade 3 tuberous breasts consists of reducing the areolar diameter and performing a book-shaped opening of the breast, applying a modified version of Puckett's technique. The modification consists of opening each breast, remodeling the glandular flap on each side to make them symmetric, inserting the same size subglandular anatomic prosthesis, and covering the prosthesis with the glandular flaps held in place by transcutaneous fixation stitches. After 6 months, fat grafting of the remaining constricting ring and the cleavage is performed. RESULTS: The study enrolled 28 patients with asymmetric bilateral tuberous breasts ages 18 to 39 years. At 12 months, using a questionnaire to rate their results, 68% of the patients were "very satisfied," 25% were "satisfied," and 7% were "not satisfied." The medical team's ratings at 12 months were "excellent" for 82% of the cases and "good" for 18% of the cases. CONCLUSION: For patients with grade 3 tuberous breasts, the authors perform aesthetic breast enlargement by reducing the size of the areola, making a book-shaped opening in the breast, and carrying out fat grafting to correct the cleavage and the remaining constricting ring. The patients and the medical team both expressed high levels of satisfaction with the results.

Effects of autologous adipose-derived regenerative stem cells administered at the time of anterior cruciate ligament reconstruction on knee function and graft healing.

PURPOSE: To compare the healing and clinical outcomes of anterior cruciate ligament (ACL) reconstruction between patients with or without intraoperative administration of adipose-derived regenerative stem cells (ADRC). METHODS: Between 2013 and 2014, the outcomes of 20 soccer players undergoing ACL reconstruction using bone-patellar tendon-bone autograft infiltrated with ADRC at the end of the procedure were compared to a historical, matched cohort of 19 soccer players undergoing the same procedure without ADRC. Outcomes were obtained at baseline, and 6 and 12 months postop for IKDC (International Knee Documentation Committee), Lysholm, and Lequesne, and at 2, 4, 6, and 12 months postop for VAS (visual analogue scale) for pain and graft maturation to evaluate the ligamentization process (magnetic resonance imaging (MRI)-based). RESULTS: Both groups significantly improved the IKDC (p < 0.001 in both groups), Lysholm (p < 0.001 in both groups), Lequesne index (p < 0.001 in both groups), VAS for pain (p = 0.002 for the ADRC and p < 0.001 for the control group), and MRI scores (p < 0.001 in both groups) in the 12 months postop compared to baseline scores. However, there were no significant differences in the improvement of the outcomes between groups across time (p > 0.05). All patients returned to sports after surgery, but 8 (40%) patients in the ADRC and 13 (68.4%) patients in the control group had lower Tegner activity score at 12 months postop. CONCLUSIONS: Patients receiving ADRC at the time of ACL reconstruction significantly improved knee function and healing/maturation of the graft at 12 months. However, this improvement was not statistically significant compared to a control group undergoing ACL reconstruction alone.

Assessing the long-term viability of facial fat grafts: an objective measure using computed tomography.

BACKGROUND: Autologous fat transplantation for soft tissue augmentation is a commonly used technique without a universally accepted approach. The literature includes a variety of reports describing varying degrees of success or failure. OBJECTIVE: To evaluate the behavior of facial fat grafts in humans with the use of an objective measuring tool. METHODS: A prospective randomized study, comparing patients pre- and postoperatively, was designed to evaluate the long-term viability of fat grafting. Participants were 18 men and 8 women between 34 and 59 years of age (mean, 45.07 yrs; standard deviation, 6.54 yrs). A total of 52 hemifaces in 26 patients diagnosed with HIV and demonstrating facial lipoatrophy were treated with fat transplantation using Coleman's technique. HIV-positive patients were chosen as study participants because their nearly total lack of subcutaneous fat diminishes the bias in the evaluation of fat volume. Fat graft viability was evaluated by measuring the volume of adipose tissue evolution via computed tomography scan before fat grafting, at the second month after fat grafting, and 1 year after fat grafting. Descriptive statistical analysis was performed. RESULTS: The mean volume on the right and left cheeks before fat grafting was 1.57 cc. The mean volume 2 months after the procedure was 2.93 cc with a statistically significant mean increase of 1.36 cc (P < .001) between baseline and the second month after the procedure. The mean volume after 12 months was 3.29 cc (P < .001), with a mean increase compared with the baseline of 1.72 cc, and of 0.36 cc between months 2 and 12. The statistically significant posttreatment improvement (P < .001) was maintained until month 12 of the follow-up period. CONCLUSIONS: Using objective measurement, this study demonstrates that with one fat grafting procedure a durable result can be achieved, persisting for a minimum of 12 months without any trend towards reabsorption.

Breast Cleavage Remodeling with Fat Grafting: A Safe Way to Optimize Symmetry and to Reduce Intermammary Distance.

BACKGROUND: In their descriptions of the ideal breast, most studies have focused primarily on the dimensions, shape, and proportions. The distance between the breasts has only very rarely been considered. The intermammary distance and the medial symmetry between the breasts are important parts of the outcome of surgery and have a strong bearing on patient satisfaction. However, the control surgeons have over these factors is only relative, and depends heavily on the underlying anatomical characteristics of the patients. METHODS: Eighty-six patients undergoing breast augmentation, breast reduction, or mastopexy and breast reconstruction with separated or asymmetric breasts underwent fat grafting in the medial quadrants. Intermammary distances were measured before fat grafting and 12 months later. Complications were also recorded. RESULTS: This technique obtained a statistically significant reduction in the mean intermammary distance (p < 0.0001) from 3 ± 0.6 cm (range, 1.6 to 5 cm) to 1.7 ± 0.4 cm (range, 1 to 2.8 cm) at 12-month follow-up. There were no major complications: one capsular contracture in a breast reconstruction requiring capsulotomy and an oil cyst requiring aspiration were reported. CONCLUSION: The authors' technique allows safe remodeling of the medial cleavage of the breast, reducing the intermammary distance and optimizing the symmetry between the breasts. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Abdominoplasty with Customized Transverse Musculoaponeurotic Plications.

BACKGROUND: The standard abdominoplasty technique uses a wide, vertically oriented plication of the rectus sheath to narrow the waistline. However, this plication is not always enough to achieve good cosmetic and functional results. This is also the case with other plication techniques. To strengthen the abdominal wall at the points of greatest weakness in each particular patient, the authors have developed a personal technique consisting of customized transverse plications at the points of maximum protrusion in the musculoaponeurotic layer, in addition to the classic vertical plication. METHODS: Ninety-eight women were divided randomly into two groups: the control group (group A) comprised 44 patients (44.9 percent) who underwent classic vertical plication; the experimental group (group B) comprised 54 patients (55.1 percent) in whom vertical plication was associated with one or more customized horizontal plications. Results were rated on a scale of 0 to 10 by external observers and the patients. Complications and recurrences were recorded. RESULTS: In group A, the mean global rating scores were 8.5 of 10 for external raters and 8.3 of 10 for patients. In group B, they were 9.5 of 10 and 9.8 of 10, respectively. In group B, there were no recurrences of prominences, whereas three were recorded in group A. Five cases of seroma were registered in each group and resolved by closed suction. CONCLUSION: In some cases, vertical plication with customized transverse plications produces results that are aesthetically superior to those of the classic approach, achieves long-lasting effects, and does not increase the rate of recurrences or the risk of complications.

Treatment of facial fat atrophy related to treatment with protease inhibitors by autologous fat injection in patients with human immunodeficiency virus infection.

A parallel effect of the use of protease inhibitors in human immunodeficiency virus-positive patients is the appearance of facial fat atrophy. To correct this, the authors propose lipoinjection of autologous fat into the areas of facial atrophy by a technique based on the atraumatic procurement of fat and posterior treatment with decantation, centrifugation, and cleaning of other material obtained by aspiration. The method of fat injection is also important and is performed by means of interlaced tunnels and the introduction of a small volume of fat into each tunnel as a graft. In 30 percent of the cases, reinjection of fat was required during the first postoperative months. The results obtained after the experience of 2 years were very satisfactory.

New marking designs for vertical scar breast reduction.

According to the authors, a new marking design for vertical scar breast reduction avoids the tension at nipple level that may occur with the use of a mosque-shaped marking (Lejour technique). Furthermore, better symmetry may be achieved in placement of the areola and nipple.

Fat grafting in postmastectomy breast reconstruction with expanders and prostheses in patients who have received radiotherapy: formation of new subcutaneous tissue.

BACKGROUND: In secondary mammary reconstruction in irradiated patients, the use of expanders and prostheses is controversial, given that radiotherapy increases tissue fibrosis and capsular contracture. The authors assessed the usefulness of tissue expansion, prostheses, and fat grafting in patients who had received radiotherapy. METHODS: The authors conducted a study of 65 mastectomized patients (age range, 34 to 62 years) who had received radiotherapy with a 6-MeV electron accelerator. In the first operation, they inserted the Natrelle 133-MV expander (Allergan, Inc., Irvine, Calif.) endoscopically under the pectoralis major at the end of the mastectomy scar and performed total immediate expansion. The authors injected a mean quantity of 150 +/- 25 cc of fat in the upper quadrants between the skin and the muscle and also inside the muscle. After 3 months, they removed the expander through the same incision, inserted the McGhan Style 410 cohesive silicone prosthesis, and injected a mean 150 +/- 30 cc of fat in the lower quadrants. In the third stage, the nipple-areola complex was reconstructed. RESULTS: Mean follow-up was 1 year, with controls after 1 week, 1 month, 3 months, and 12 months. No complications were recorded with the fat injections. Patients' mean satisfaction rating was 4 on a scale of 1 (low) to 5 (high), and the capsular contracture was never above 1 on the Baker classification. CONCLUSION: In mastectomized patients who received radiotherapy, fat grafting in addition to traditional tissue expander and implant breast reconstruction achieves better reconstructive outcomes with the creation of new subcutaneous tissue, accompanied by improved skin quality of the reconstructed breast without capsular contracture.

Endoscopic breast reconstruction with intraoperative complete tissue expansion and partial detachment of the pectoralis muscle.

We present the surgical technique for mammary reconstruction using tissue expander with endoscopic approach, associated to partial detachment of the pectoralis muscle at the fourth rib and complete or nearly complete intraoperative expansion. Tissue expansion for breast reconstruction is a well-honored technique that provides satisfying esthetic outcomes, with minimal morbidity for the patient. Nevertheless, this technique has some potential problems: (1) wound dehiscence with extrusion of the expander; (2) the patient discomfort during the expansion process (weekly visits for the refill of the expander); (3) the poor definition of the lower pole of the breast and cranial migration of the expander with excessive roundness of the upper pole. By using intraoperative tissue expansion, these drawbacks can be avoided. We report herein our experience with this technique in 53 consecutive patients (56 breasts) undergoing a secondary breast reconstruction since December 2001.

Mammary reconstruction using tissue expander and partial detachment of the pectoralis major muscle to expand the lower breast quadrants.

The techniques commonly used in breast reconstruction with tissue expanders do not provide a good definition of the lower breast quadrant. With the authors technique a better profile of the breast is achieved. Partial detachment of the pectoral muscle is performed, suturing it to the lower skin flap and thereby avoiding cranial migration of the expander. In addition a rounded shape of the lower quadrants is achieved and the expander remains in a subcutaneous position.