Prepectoral versus Subpectoral Breast Reconstruction after Nipple-sparing Mastectomy: A Systematic Review and Meta-Analysis.

Background: Implant-based breast reconstruction after nipple-sparing mastectomy (NSM) presents unique benefits and challenges. The literature has compared outcomes among total submuscular (TSM), dual-plane (DP), and prepectoral (PP) planes; however, a dedicated meta-analysis relevant to NSM is lacking. Methods: We conducted a systematic review of studies on immediate breast reconstruction after NSM using TSM, DP, or PP prosthesis placement in PubMed, Embase, and Cochrane databases. In total, 1317 unique articles were identified, of which 49 were included in the systematic review and six met inclusion criteria for meta-analysis. Pooled descriptive outcomes were analyzed for each cohort for all 49 studies. Fixed-effects meta-analytic methods were used to compare PP with subpectoral (TSM and DP) reconstructions. Results: A total of 1432 TSM, 1546 DP, and 1668 PP reconstructions were identified for descriptive analysis. Demographics were similar between cohorts. Pooled descriptive outcomes demonstrated overall similar rates of reconstructive failure (3.3%-5.1%) as well as capsular contracture (0%-3.9%) among cohorts. Fixed-effects meta-analysis of six comparative studies demonstrated a significantly lower rate of mastectomy flap necrosis in the PP cohort compared with the subpectoral cohort (relative risk 0.24, 95% confidence interval [0.08-0.74]). All other consistently reported outcomes, including, hematoma, seroma, infection, mastectomy flap necrosis, nipple -areola complex necrosis, and explantation were comparable. Conclusions: A systematic review of the literature and meta-analysis demonstrated the safety of immediate prepectoral breast reconstruction after NSM, compared with submuscular techniques. Submuscular reconstruction had a higher risk of mastectomy flap necrosis, though potentially influenced by selection bias.

Do we need acellular dermal matrix in prepectoral breast reconstruction? A systematic review and meta-analysis.

Acellular dermal matrices (ADMs) are commonly used in prepectoral breast reconstruction. However, ADM is associated with high cost and potentially infection and seroma. Comparative studies on prepectoral reconstruction with and without ADM are limited to small, single-institution series. The purpose of this study was to perform a meta-analysis of prepectoral reconstruction with and without ADM. A systematic literature review was performed to identify studies comparing prepectoral reconstruction with and without ADM using PubMed, EMBASE, and Cochrane databases. Pooled rates of patient demographics and outcomes were analyzed. Meta-analytic effect size estimates were calculated for reconstructive complications in studies comparing reconstruction with and without ADM. In total, 515 reconstructions from four studies were included. Most cases were nipple-sparing mastectomies and utilized tissue-expander reconstructions. Meta-analysis demonstrated no significant difference in the rate of complications between cohorts with and without ADM. Short-term complications included reconstructive failure (1.2% in ADM cohort and 2.8% in no-ADM), seroma (1.2% and 8.3%, respectively), hematoma (1.2% and 2.1%), infection (4.7% and 4.2%), and mastectomy flap ischemia and/or necrosis (2.4% and 5.2%). Long-term complications included rippling (3.3% in ADM and 5.1% in no-ADM cohorts) and capsular contracture (6.8% and 3.4%, respectively). This meta-analysis demonstrated no difference in the rate of complications between cases with and without ADM. However, the outcomes data from no-ADM reconstruction mostly reflect robust mastectomy flaps. Surgeon discretion as informed by specific clinical scenarios should guide decisions regarding the use of ADM in prepectoral breast reconstruction.

LAMELLAR MACULAR HOLES IN THE PRESENCE OF AGE-RELATED MACULAR DEGENERATION.

PURPOSE: To investigate whether age-related macular degeneration (AMD) has an influence on the prevalence and anatomical characteristics of lamellar macular holes (LMHs). METHODS: Clinical records and spectral-domain optical coherence tomography images of 756 eyes of 423 consecutive patients diagnosed with AMD were reviewed and analyzed. Spectral-domain optical coherence tomography was used to identify degenerative or tractional LMH subtypes and assess their morphology. The clinical and optical coherence tomography findings of AMD eyes with LMH were compared with those of a control group of eyes with LMH without AMD from a previously published report. RESULTS: Lamellar macular holes were identified in 25 eyes of 23 patients (3.3%; 25 of 756). Seventeen of 25 eyes (68%) presented with degenerative LMH and underlying late neovascular AMD. Mean best-corrected visual acuity was worse in eyes with AMD and LMH eyes than in those with AMD and no LMH (20/230 vs. 20/98; P = 0.02). The mean outer diameter was greater in the group with degenerative LMH with concomitant AMD than in the control group of degenerative LMH without AMD (1,323.9 ± 999.1 µm vs. 905.9 ± 356.8 µm, respectively; P = 0.01). CONCLUSION: The incidence of degenerative LMH increased in advanced forms of AMD, whereas the presence of tractional LMH subtype may be unrelated to AMD evolution.

DETECTION OF NEUROSENSORY RETINAL DETACHMENT COMPLICATING DEGENERATIVE RETINOSCHISIS BY ULTRA-WIDEFIELD FUNDUS AUTOFLUORESCENCE IMAGING.

PURPOSE: To determine whether neurosensory retinal detachment complicating degenerative retinoschisis (RS) can be reliably detected with ultra-widefield fundus autofluorescence evaluation. METHODS: Consecutive patients diagnosed with RS who had ultra-widefield fundus autofluorescence imaging were included in this retrospective case series. According to the fundus autofluorescence patterns, we divided the eyes into two groups: 1) eyes with RS and a hyperautofluorescent leading edge and 2) eyes with RS and without hyperautofluorescence. Peripheral spectral domain optical coherence tomography images at the level of RS were obtained. RESULTS: Thirty-eight eyes that met eligibility criteria were identified. Review of ultra-widefield fundus autofluorescence demonstrated 21/39 (55%) eyes with distinctive hyperautofluorescence over the area of RS (Group A) and 17/38 (45%) eyes without any form of hyperautofluorescence (Group B). Spectral domain optical coherence tomography images confirmed the presence of full-thickness neurosensory retina separation from the underlying retinal pigment epithelium in the areas of hyperautofluorescence in 10/10 eyes (100%) from Group A. None (0/11; 0%) of the eyes from Group B showed full-thickness neurosensory retina separation on the spectral domain optical coherence tomography imaging of the retina-RS interface. CONCLUSION: Hyperautofluorescent findings suggest the presence of a neurosensory retinal detachment. Retinal detachment associated with RS can be reliably detected on ultra-widefield fundus autofluorescence and may be a useful diagnostic imaging modality.

Systematic Review of the Impact of Acellular Dermal Matrix on Aesthetics and Patient Satisfaction in Tissue Expander-to-Implant Breast Reconstructions.

BACKGROUND: Acellular dermal matrix is used in most postmastectomy implant-based breast reconstructions in the United States. It is believed to be safe, despite a slightly increased complication rate. Although never established in a unifying study, the primary advantage of acellular dermal matrix is believed to be an enhanced aesthetic result, thus justifying the added expense. The purpose of this study was to assess the aesthetic benefits of acellular dermal matrix in expander-to-implant breast reconstruction. METHODS: A systematic review adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses methodology was performed including all original studies examining aesthetic outcomes of expander-to-implant breast reconstructions with acellular dermal matrix compared to muscular coverage. Direct-to-implant and prepectoral studies were excluded from the evaluation. The results were aggregated and reported as a summary. RESULTS: Among 883 studies identified, 49 full-text articles were reviewed and nine articles ultimately met inclusion criteria. All nine studies were not randomized. Of these, three articles (1448 total patients) evaluated reconstruction aesthetic outcomes by patient satisfaction, whereas six articles evaluated the aesthetic outcomes by external observer (504 total patients). None of the articles evaluating patient satisfaction reported a difference between acellular dermal matrix and muscular reconstruction. Five of the six articles using objective outcomes demonstrated significant improvement in aesthetic outcome in the acellular dermal matrix group. CONCLUSIONS: Although little evidence exists evaluating the aesthetic benefits of acellular dermal matrix for expander-to-implant breast reconstruction, the data suggest that objective observers consider acellular dermal matrix-assisted expander-to-implant breast reconstructions aesthetically superior to reconstruction with only muscular coverage, but patients appear to be equally satisfied with both reconstructive options.

Effects of Collagenase Type II on Vitreous Humor-An In Situ Rheological Study.

The purpose of this study is to quantify the impact of enzyme activity on the vitreous humor structure over time to understand the mechanical characteristics of the vitreous humor gel. Changes in the mechanical behavior of the vitreous occur due to many reasons including aging, which may lead to many vitreoretinal diseases. The degeneration process of the vitreous has been studied; however, in situ experimental procedures to validate the existing hypotheses are limited. We examined thirty-eight porcine eyes using in situ rheological creep tests to measure the mechanical properties of the vitreous humor of the eyes prior to, 1 h and 24 h after the intravitreal injection. Eyes in one group were injected with collagenase type II solution and eyes in the control group were injected with phosphate buffered saline solution (PBS) with calcium and magnesium chloride. Prior to the injection, viscosity and creep compliance intercept values between both groups were not statistically different. At 1 h and 24 h after the injection, vitreous properties in the eyes from the first group showed a statistically significant increase in the J intercept values (representing the inverse of elasticity) compared to the control group. In addition, 1 h and 24 h after the injection, vitreous viscosity was lower in the eyes from the first group than in the eyes from the control group. These findings are a foundation for future studies on the effectiveness of intravitreal drugs that modify the mechanical properties of the vitreous humor.

Microcystoid Macular Changes in Association With Idiopathic Epiretinal Membranes in Eyes With and Without Glaucoma: Clinical Insights.

PURPOSE: To describe the clinical and surgical significance of microcystoid macular changes in the inner nuclear layer in patients with idiopathic epiretinal membranes, with and without glaucomatous optic neuropathy. DESIGN: Retrospective case series. METHODS: Clinical charts and spectral-domain optical coherence tomography images of 264 eyes of 234 consecutive patients diagnosed with idiopathic epiretinal membranes were reviewed and analyzed. Surgical data were analyzed in a subgroup of eyes with microcystoid macular changes treated with pars plana vitrectomy and epiretinal and internal limiting membrane peel. In surgical cases, postoperative functional and anatomic results at 1 and 6 months were compared between glaucomatous and nonglaucomatous eyes. Associations of microcystoid macular changes with visual acuity and other morphometric parameters were assessed by means of linear or multiple logistic regressions. RESULTS: Microcystoid macular changes in the inner nuclear layer were diagnosed in 52 out of 264 eyes with epiretinal membranes (19.7%), of which 28 (55.0%) had concomitant glaucoma. The likelihood to develop microcystoid macular changes increased at advanced glaucoma and epiretinal membrane stages. The morphology of microcystoid macular changes was similar between glaucomatous and nonglaucomatous eyes. Forty-four out of 52 eyes (84.6%) with microcystoid macular changes, of which 20 were with glaucoma and 24 without glaucoma, underwent surgery with pars plana vitrectomy and epiretinal and internal limiting membrane peel. At 1 and 6 months after surgery the mean number of microcysts decreased significantly from baseline in nonglaucomatous eyes (P = .003 and P = .002, respectively) and remained unchanged in glaucomatous eyes (P = .400 and P = .700, respectively). CONCLUSIONS: This study reports a high frequency of microcystoid macular changes in the inner nuclear layer in eyes with concomitant epiretinal membrane and glaucomatous optic neuropathy. In glaucomatous eyes, pars plana vitrectomy with epiretinal and internal limiting membrane peel was ineffective in the treatment of microcystoid macular changes.

Feasibility of a polyethylene glycol-derived polymer as retinal patch to seal retinal breaks during vitrectomy for rhegmatogenous retinal detachment: a prospective, in vivo pilot study in a porcine model.

BACKGROUND: This is a pilot study to test a polyethylene glycol-derived polymer used as a retinal patch to seal retinal breaks during pars plana vitrectomy in the treatment of rhegmatogenous retinal detachment in a porcine model. METHODS: Sixteen eyes from eight pigs were assigned to two study groups (12 eyes) and one control group (four eyes). In all study groups, the polymer was used in vivo, during pars plana vitrectomy, to seal the break of a surgically induced rhegmatogenous retinal detachment. Eyes in study groups were filled with balanced saline solution at the end of the surgery. In the control group, the polymer was not used and the eyes underwent standard rhegmatogenous retinal detachment repair with pars plana vitrectomy. All eyes underwent fundus examination at day 3, week 1 and week 2 after surgery. All eyes from all groups were enucleated and processed for qualitative histological evaluation. RESULTS: Intraoperatively, the polymer showed good adherence and compliance to the retina. At week 1, retina was attached in all cases. The polymer was visible with indirect ophthalmoscopy up to week 1. At week 2, the polymer was no longer visible. Histologically, a mild histiocytic reaction was noticed in the retinas of four out of 12 study eyes (33.3%). In the control eyes, non-specific inflammatory signs of retinal inflammation were reported in two out of four eyes (50%). CONCLUSIONS: This study provides initial data to support the use of this polymer as a promising alternative to standard endo-tamponade agents. Its safety and biocompatibility need to be further assessed.

Lamellar Macular Hole: Two Distinct Clinical Entities?

PURPOSE: To investigate whether lamellar macular holes can be divided into different subgroups. DESIGN: Retrospective observational case series. METHODS: In this institutional study, clinical charts and spectral-domain optical coherence tomography (OCT) images of 102 eyes of 90 consecutive patients diagnosed with lamellar macular hole were reviewed. In OCT imaging, the presence of lamellar macular hole was defined according to the following findings: presence of irregular foveal contour, separation of the layers of the neurosensory retina, and the absence of full-thickness macular defect. Mean outcome was the morphologic and functional characterization of different subtypes of macular hole. RESULTS: Two different subtypes of lamellar macular hole were identified: tractional and degenerative. The first type, tractional, was diagnosed in 43 eyes, and was characterized by the schitic separation of neurosensory retina between outer plexiform and outer nuclear layers. It often presented with an intact ellipsoid layer and was associated with tractional epiretinal membranes and/or vitreomacular traction. The second type, degenerative, was diagnosed in 48 eyes, and its distinctive traits included the presence of intraretinal cavitation that could affect all retinal layers. It was often associated with nontractional epiretinal proliferation and a retinal "bump." Moreover, it often presented with early ellipsoidal zone defect and its pathogenesis, although chronic and progressive, remains poorly understood. Eleven eyes shared common features with both tractional and degenerative lamellar macular holes and were classified as mixed lesions. CONCLUSIONS: Degenerative and tractional lamellar macular holes may be 2 distinct clinical entities. A revision of the current concept of lamellar macular holes is needed.

Actions of Bisphenol A and Bisphenol S on the Reproductive Neuroendocrine System During Early Development in Zebrafish.

Bisphenol A (BPA) is a well-known environmental, endocrine-disrupting chemical, and bisphenol S (BPS) has been considered a safer alternative for BPA-free products. The present study aims to evaluate the impact of BPA and BPS on the reproductive neuroendocrine system during zebrafish embryonic and larval development and to explore potential mechanisms of action associated with estrogen receptor (ER), thyroid hormone receptor (THR), and enzyme aromatase (AROM) pathways. Environmentally relevant, low levels of BPA exposure during development led to advanced hatching time, increased numbers of GnRH3 neurons in both terminal nerve and hypothalamus, increased expression of reproduction-related genes (kiss1, kiss1r, gnrh3, lhß, fshß, and erα), and a marker for synaptic transmission (sv2). Low levels of BPS exposure led to similar effects: increased numbers of hypothalamic GnRH3 neurons and increased expression of kiss1, gnrh3, and erα. Antagonists of ER, THRs, and AROM blocked many of the effects of BPA and BPS on reproduction-related gene expression, providing evidence that those three pathways mediate the actions of BPA and BPS on the reproductive neuroendocrine system. This study demonstrates that alternatives to BPA used in the manufacture of BPA-free products are not necessarily safer. Furthermore, this is the first study to describe the impact of low-level BPA and BPS exposure on the Kiss/Kiss receptor system during development. It is also the first report of multiple cellular pathways (ERα, THRs, and AROM) mediating the effects of BPA and BPS during embryonic development in any species.

Early development of the gonadotropin-releasing hormone neuronal network in transgenic zebrafish.

Understanding development of gonadotropin-releasing hormone (GnRH) neuronal circuits is fundamental to our understanding of reproduction, but not yet well understood. Most studies have been focused on GnRH neurons located in the hypothalamus and preoptic area (POA), which directly regulate the pituitary-gonadal axis. In zebrafish (Danio rerio), two forms of GnRH have been identified: GnRH2 and GnRH3. GnRH3 neurons in this species plays two roles: hypophysiotropic and neuromodulatory, depending on their location. GnRH3 neurons in the ventral telencephalon, POA, and hypothalamus control pituitary-gonadal function; in other areas (e.g., terminal nerve), they are neuromodulatory and without direct action on reproduction. To investigate the biology of GnRH neurons, a stable line of transgenic zebrafish was generated in which the GnRH3 promoter drives expression of a bright variant of green fluorescent protein (Emerald GFP, or EMD). This provides unprecedented sensitivity in detecting and imaging GnRH3 neurons during early embryogenesis in the transparent embryo. Using timelapse confocal imaging to monitor the time course of GnRH3:EMD expression in the live embryo, we describe the emergence and development of GnRH3 neurons in the olfactory region, hypothalamus, POA, and trigeminal ganglion. By 50 h post fertilization, these diverse groups of GnRH3 neurons project broadly in the central and peripheral nervous systems and make anatomical connections with each other. Immunohistochemistry of synaptic vesicle protein 2 (a marker of synaptic transmission) in this transgenic model suggests synaptic formation is occurring during early development of the GnRH3 neural network. Electrophysiology reveals early emergence of responsiveness to the stimulatory effects of kisspeptin in terminal nerve GnRH3 neurons. Overall, our findings reveal that the GnRH3 neuronal system is comprised of multiple populations of neurons as a complicated network.