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.

Technique for Minimizing Donor-site Morbidity after Pedicled TRAM-Flap Breast Reconstruction: Outcomes by a Single Surgeon's Experience.

BACKGROUND: Breast reconstruction with pedicled transverse rectus abdominis myocutaneous (TRAM) flap can result in significant abdominal wall donor-site morbidity. We present our technique of transversely dividing the anterior fascia and rectus abdominis combined with reinforcement above the arcuate line for closure of the anterior abdominal wall defect to prevent contour deformities performed by a single senior surgeon and compare these results with those of our prior series. METHODS: We described our new technique of closure of the abdominal wall defect and retrospectively performed the comparison between the results of pedicled TRAM flaps using the new closure technique and those of 420 pedicled TRAM flaps from our 2003 publication in terms of abdominal bulging and hernia. RESULTS: Sixty-seven pedicled TRAM flaps in 65 patients were compared with 420 pedicled TRAM flaps of the 2003 series. The new technique was associated with 5 partial TRAM flap necroses (8%). There was no total flap loss with the new technique. The median follow-up period was 13 months (range, 4-36 months). There were no instances of abdominal hernia and bulge during follow-up in the new series. Compared with the previous 2003 series, the new technique was superior in terms of occurrence of abdominal wall hernia or bulging. CONCLUSIONS: We are still performing pedicled TRAM flap for autologous breast reconstruction. Using the technique of transversely dividing the anterior fascia and rectus abdominis combined with reinforcement above the arcuate line can reduce the occurrence of abdominal bulging and hernia.

Evaluation of Lipofilling Safety in Elderly Patients with Breast Cancer.

BACKGROUND: Lipofilling is widely used in breast reconstruction after mastectomy with reconstruction or breast conserving surgery in patients with breast cancer. The aim of this study is focused on complications associated with lipofilling in elderly breast cancer patients with breast defects after breast conserving surgery or reconstruction. METHODS: A total of 137 patients older than 60 years who underwent 153 lipofilling procedures were included. All patients had undergone breast lipofilling using Coleman's technique. Estimated breast defect volume, lipofilling volume, and complications after lipofilling were obtained for analysis. RESULTS: Most patients (67%) had only 1 lipofilling procedure. The median lipofilling volume to breast defect volume ratio was 1.5. No severe complications were found after treatment. Liponecrosis was detected in 10 of 153 breasts (7%) or 9 of 137 patients within 2 weeks after lipofilling and required surgical drainage in 2. No local recurrences were noted. CONCLUSIONS: The incidence of liponecrosis after lipofilling in elderly patients was relatively high, requiring surgical drainage in some cases. As a rough guide, the lipofilling volume should not exceed 1.5 times the defect volume, and close postoperative follow-up within the first 2 weeks is suggested for these patients.

Poly implant prothèse asymmetrical anatomical breast implants: a product recall study.

BACKGROUND: In 2010 high rupture rates were unexpectedly found among prostheses produced by the French manufacturer Poly Implant Prothèse. Since then, several studies have been performed concerning the round implants, but there are still few data available on anatomical implants. METHODS: From 2003 to 2006 Poly Implant Prothèse implants were employed at the authors' institute for immediate or delayed reconstruction after mastectomy. All implants were anatomical and asymmetrical. In November of 2010, the authors began offering free consultation with a plastic surgeon and radiologist. Demographic data, type of reconstruction, implant lifespan, indications for implant removal, and rupture rate were recorded. RESULTS: A total of 578 women underwent postmastectomy immediate or delayed reconstruction with 658 Poly Implant Prothèse implants from 2003 to 2006 at the authors' institute. The authors explanted 409 of 443 prostheses, and 34 were explanted at other centers. Eighty-nine patients died and 120 are alive with the implants in place. The mean implant lifespan was 57.5 months, 76 ruptured implants were explanted (18.5 percent), and in 22 cases (5.4 percent), leakage of silicone gel was detected. CONCLUSIONS: Poly Implant Prothèse implant failure is to be ascribed to shell structure, although the primary safety issue concerned the gel (an industrial-grade and low-cohesive silicone). These issues produce the known rupture rates in the manufacturer's round implants. The authors' use of only anatomical and asymmetrical implants, with their more cohesive silicone gel and more rigid shell allowing a stable form and projection along with a natural feel and touch, probably reduces the rupture rate and silicone spread, although these events remain unacceptably high compared with similar products of other brands. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Nipple sparing mastectomy: does breast morphological factor related to necrotic complications?

BACKGROUND: Nipple sparing mastectomy (NSM) can be performed for prophylactic mastectomy and the treatment of selected breast cancer with oncologic safety. The risk of skin and nipple necrosis is a frequent complication of NSM procedure, and it is usually related to surgical technique. However, the role of the breast morphology should be also investigated. METHOD: We prospectively performed an analysis of 124 NSM from September 2012 to January 2013 at the European Institute of Oncology, Milan, Italy, focusing on necrotic complications. We analyzed the association between the risks of skin necrosis and the breast morphology of the patients. RESULTS: Among 124 NSM in 113 patients, NSM procedures were associated with necrosis in 22 mastectomies (17.7%) among which included partial necrosis of nipple-areolar complex (NAC) in 15 of 124 NSM (12.1%) and total necrosis in 4 cases (3.5%). The NAC was removed in 5 NSM cases (4%). The volume of breast removed was the only significant factor increasing the risk of skin necrosis. The degree of ptosis was not significantly related to the necrosis risk. CONCLUSIONS: Large glandular specimen increases the risk of NAC necrosis. The degree of ptosis and the distance between the sternal notch and the NAC have no significant impact on necrotic complications in NSM. To reduce the necrotic complications in large breast after NSM, reconstruction should better be performed with autologous flap or slow skin expansion using the expander technique.

Free nipple graft technique to correct nipple and areola malposition after breast procedures.

SUMMARY: Secondary correction of nipple areola complex (NAC) malposition represents a major concern after breast reconstructive procedures. It is frequently requested by patients complaining about asymmetric areolas impairing the whole reconstructive procedure and asking for improved cosmetic outcomes. Several methods have been described to achieve a good symmetry between the 2 areolas, either natural or reconstructed. We describe our correction technique with free NAC graft. A total of 16 patients were treated with free NAC grafts between April 2010 and April 2013 at the European Institute of Oncology, Milan, Italy. This series focused on the surgical technique and its postoperative outcomes. Three cases of partial graft loss (18%) were observed in the postoperative period. No total NAC necrosis occurred. No infection was observed. All the complications were managed with a conservative treatment, not requiring any further surgery. NAC malposition following breast reconstructive procedures can be corrected using the technique of free NAC graft with reliable and satisfactory results.

Immediate breast reconstruction with prostheses after conservative treatment plus intraoperative radiotherapy. long term esthetic and oncological outcomes.

Electron intraoperative radiotherapy (ELIOT) has been introduced for breast conservative treatment (BCT) with promising oncological outcome. Thus, immediate breast reconstruction with prosthesis after BCT became possible due to minimal radiation effect on local tissue from ELIOT. We reported oncological and esthetical results of 29 BCT patients who had immediate implant reconstruction plus 21 Gy-ELIOT as the sole radiation treatment. All patients had prosthesis in ipsilateral breast and had simultaneous contralateral augmentation for symmetrical procedure. The average age was 52.3 years. There were stage Ia thirteen cases, stage Ib seven cases, stage IIa six cases and stage IIIb one case and two cases of intraepithelial neoplasia. From 54.2 (36-88) months follow up, the capsular contracture grading in the reconstructed breast from ELIOT-side is comparable with non-irradiated contralateral side. There was one patient who developed local recurrence (LR) and later on dead with breast related event (LR=0.76% per year). There was no primary ipsilateral carcinomas and distant metastasis.

Update on breast reconstruction techniques and indications.

Breast reconstruction is considered as part of the breast cancer treatment when a mastectomy is required. Implants or expanders are the most frequent techniques used for the reconstructions. Expander provides usually a better symmetry. A contralateral mastoplasty often is required to improve the symmetry. The nipple areola complex, which can be preserved in certain conditions, is usually removed and can be reconstructed in a second stage under local anesthesia. In case of radical mastectomy and/or radiotherapy, a musculocutaneous flap, such as rectus abdominis or latissimus dorsi autologous flaps, is required. When microsurgical facilities are available, free or perforator flaps respecting the muscle are preferred to decrease the donor site complications. In situ carcinomas or prophylactic mastectomy can be reconstructed immediately as well as invasive carcinoma according to the recent literature. Locally advanced breast cancer can be reconstructed after complete oncologic treatment. Radiotherapy of the thoracic wall is proposed in case of lymph node metastases, raising the discussion about the technique choice and the timing of the reconstruction. Plastic surgery procedures can improve the cosmetic results of the conservative surgery, also extending its indications and reducing both mastectomy and reexcision rates. Oncoplasty techniques are becoming more and more sophisticated, requiring the skill of trained plastic surgeons. Numerous publications confirm the psychosocial benefit resulting from the breast reconstruction.

Paget's disease as a local recurrence after nipple-sparing mastectomy: clinical presentation, treatment, outcome, and risk factor analysis.

BACKGROUND: Paget's disease is a rare clinical and histological type of local recurrence (LR) after breast cancer treatment both in case of conservative surgery or nipple-sparing mastectomy (NSM) with or without intraoperative radiation. METHODS: We performed an analysis of 861 NSM with electron beam intraoperative radiotherapy (ELIOT) patients treated at the European Institute of Oncology from 2002 to 2008, focused on Paget's disease local recurrence. RESULTS: In 861 patients (713 invasive carcinoma and 148 intraepithelial neoplasia), there were 36 local recurrences (4.18%), and among these were 7 Paget's disease local recurrences (0.8%). Median follow-up was 50 months. Four cases presented with nipple areola complex (NAC) erosions, two crusted lesions, and one ulcerated NAC. The average latency period from the NSM to Paget's disease local recurrence is 32 months (range, 12-49). Complete NAC removal was performed in all seven recurrences. The average follow-up after NAC removal was 47.4 months (range, 20-78). We found neither locoregional relapse nor metastatic event in this group. All patients were alive without disease. CONCLUSIONS: Paget's disease local recurrence can be found in a significant proportion after NSM. Any suspicious lesion on NAC requires prompt pathological confirmation. Primary carcinoma with ductal intraepithelial neoplasia or invasive ductal carcinoma with extensive in situ component, negative hormonal receptor, high pathological grade, overexpression of HER2/neu, and "HER2 positive (nonluminal)" subtype tend to be significantly associated with more Paget's disease local recurrence and should be followed carefully.

Merkel cell carcinoma of the lower extremity: report of four cases and new considerations.

Merkel cell carcinoma (MCC) is a rare neuroendocrine cutaneous malignancy that predominantly arises in the head and neck region. We describe clinical features, diagnosis, and treatment in 4 cases of MCC, presenting an uncommon female predominant occurrence and an unusual primary site: the lower limb. In all cases diagnosis was established by histopathologic examination. Primary MCC and locally recurrence disease were treated in all patients with a wide surgical excision (3-cm margin) including fascia. Lymphadenectomy was reserved for a patient with clinical evidence of nodal involvement. Both chemotherapy administered in 2 cases and radiotherapy in 1 case produced limited responses. Early diagnosis is critical because this tumor is aggressive and has a high rate of local recurrence and metastatic spread. However, its nondistinctive appearance frequently delays diagnosis and its rarity avoids an optimal treatment guideline setting.