Abdominoplasty after massive weight loss. Safety preservation fascia technique and clinical outcomes in a large single series-comparative study.

Introduction: Weight loss after bariatric surgery causes very important modifications to the patient's silhouette. Abdominal fat and skin excess reduction are associated with several complications. The most frequent are seroma and hematoma whereas major complications, such as pulmonary embolism, are less frequent. This study aimed to describe our technical procedure for abdominoplasty in patients with massive weight loss after bariatric surgery. Methods: In total, 196 patients were included. All patients who underwent abdominoplasty classic (group A) and abdominoplasty with the preservation and lift of Scarpa fascia (group B) and with umbilical transposition between May 2018 and May 2021 were included. Patients with concomitant correction of ventral hernia were excluded. Demographic and operative data were analyzed according to comorbidities and postoperative complications. Results: There were 160 (81.6%) women. The mean age was 43.6 years; the mean weight was 86.7 kg; and the mean BMI was 28.6 kg/m2. Five patients (2.5%) presented postoperative seroma. Four patients (2%) presented partial dehiscence/skin necrosis one of them requiring a revision. Finally, 26 patients presented a postoperative complication, with an overall incidence of 12.6%. The average postoperative hospital stay was 3.6. The rates of seroma were significantly higher in men, patients with a BMI > 30 kg/m2, and aged >50 years. Conclusion: Preserving Scarpa Fascia during surgical post-bariatric patient procedures reduces the seroma formation and the scar complication and reduces the tension of the inguinal-pubic region with correction of our deformation after weight loss. Improves reducing the drain and reducing seroma incidence suction and hospital stay.

Algorithm of rational approach to reconstruction in Fournier's disease.

BACKGROUND: Fournier's gangrene is a rare form of necrotizing fasciitis that affects the genital area up to the perineal region and sometimes the abdominal wall. OBJECTIVES: Our article aims to show that in the treatment of extensive forms of Fournier's gangrene, correct use of flap and skin grafts and a quick reconstruction of the exposed tissues avoid scarring retraction of the testicles and deformation of the penis. MATERIALS AND METHODS: We retrospectively reviewed the clinical and photographic data of Fournier's gangrene cases treated at our Institute. The data were evaluated to obtain an estimate of the results of the reconstructive technique used, in terms of percentage of occurred healings and eventual complications. RESULTS: A total of 34 patients underwent surgery for Fournier's gangrene. In nine cases (26.5%), we had minor complications: in four patients, suffering from diabetes and obesity, a retard in attachment of graft occurred, while in five patients with perianal problems there was a delay in healing due to the onset of local infection. CONCLUSION: The reconstruction approach described here may reduce surgical times. In Fournier's gangrene, the exposed tissues must be reconstructed as quickly as possible.

First Surgical National Consensus Conference of the Italian Breast Surgeons association (ANISC) on breast cancer management in neoadjuvant setting: Results and summary.

RATIONALE: On October 15th, 2020, the first Surgical National Consensus Conference on neoadjuvant chemotherapy (NACT) was promoted by the Italian Association of Breast Surgeons (ANISC). METHOD: The Consensus Conference was entirely held online due to anti-Covid-19 restrictions and after an introductory four lectures held by national and international experts in the field, a total of nine questions were presented and a digital "real-time" voting system was obtained. A consensus was reached if 75% or more of all panelists agreed on a given question. RESULTS: A total of 202 physicians, from 76 different Italian Breast Centers homogeneously distributed throughout the Italian country, participated to the Conference. Most participants were surgeons (75%). Consensus was reached for seven out of the nine considered topics, including management of margins and lymph nodes at surgery, and there was good correspondence between the 32 "Expert Panelists" and the "Participants" to the Conference. Consensus was not achieved regarding the indications to NACT for high-grade luminal-like breast tumors, and the need to perform an axillary lymph node dissection in case of micrometastases in the sentinel lymph node after NACT. CONCLUSIONS: NACT is a topic of major interest among surgeons, and there is need to develop shared guidelines. While a Consensus was obtained for most issues presented at this Conference, controversies still exist regarding indications to NACT in luminal B-like tumors and management of lymph node micrometastases. There is need for clinical studies and analysis of large databases to improve our knowledge on this subject.

New classifications of axillary lymph nodes and their anatomical-clinical correlations in breast surgery.

BACKGROUND: In the last decade, two research groups, the French group by Clough et al. (Br J Surg. 97:1659-65, 2010) and the Chinese one by Li et al. (ISRN Oncol 2013:279013, 2013), proposed two types of classification of axillary lymph nodes in breast cancer, identifying novel anatomic landmarks for dividing the axillary space in lymph node dissection. MAIN BODY: Knowledge of the exact location of the sentinel node helps to focus the surgical dissection and to reduce the morbidity of sentinel lymph node biopsy procedures, in particular the risk of arm lymphedema, without compromising sensitivity. CONCLUSION: In this article, we aimed at focusing on the clinical impact that the most recent classifications of axillary lymph nodes have obtained in literature, highlighting the importance of defining new demarcations to preserve the axillary lymph nodes as much as possible in breast surgery.

Locoregional Surgery in Metastatic Breast Cancer: Do Concomitant Metabolic Aspects Have a Role on the Management and Prognosis in this Setting?

Although they cannot be considered curative, the new therapeutic integrated advances in metastatic breast cancer (MBC) have substantially improved patient outcomes. Traditionally, surgery was confined to palliation of symptomatic or ulcerating lumps. Data suggest, in some cases, a possible additive role for more aggressive locoregional surgical therapy in combination with systemic treatments in the metastatic setting, although a low level of evidence has been shown in terms of improvement in overall survival in MBC patients treated with surgery and medical treatment compared to medical treatment alone. In this light, tumor heterogeneity remains a challenge. To effectively reshape the therapeutic approach to MBC, careful consideration of who is a good candidate for locoregional resection is paramount. The patient's global health condition, impacting on cancer progression and morbidity and their associated molecular targets, have to be considered in treatment decision-making. In particular, more recently, research has been focused on the role of metabolic derangements, including the presence of metabolic syndrome, which represent well-known conditions related to breast cancer recurrence and distant metastasis and are, therefore, involved in the prognosis. In the present article, we focus on locoregional surgical strategies in MBC and whether concomitant metabolic derangements may have a role in prognosis.

Retrospective Evaluation of the Effectiveness of a Synthetic Glue and a Fibrin-Based Sealant for the Prevention of Seroma Following Axillary Dissection in Breast Cancer Patients.

Introduction: Seroma formation represents one of the most frequent postoperative complications of axillary dissection in breast cancer (BC) patients. We aimed to retrospectively explore the effectiveness of the intraoperative use of a synthetic cyanoacrylate glue (specifically Glubran®2) vs. the intraoperative use of a fibrin sealant (specifically Tisseel) in reducing seroma formation compared to the use of nonsealant in BC patients who underwent breast surgery and axillary dissection. Materials and Methods: We conducted a retrospective, monocentric observational study on BC patients who underwent axillary dissection associated with breast surgery. The axillary dissection was completed with the application of a closed suction drain and was preceded by the application of either Glubran®2 glue or Tisseel sealant or nonsealant. We analyzed the quantity of serum drained in the first 3 postoperative days, length of hospitalization, days of permanence of axillary drain, seroma development, and presence of postoperative infection signs. Results: Forty-one BC patients were considered. Based on the device used during the surgical treatment, the patients were divided into three groups: group A (17 patients), to whom suction axillary drain was applied; group B (7 patients), to whom Tisseel and axillary suction drain were applied; and group C (17 patients), to whom Glubran®2 and axillary suction drain were applied. Among the three groups, we did not find significant differences in terms of amount of serum drained in the first 3 postoperative days, length of hospitalization, and incidence of seroma. Group C maintained the axillary drain in a significantly lower number of days compared to the other two groups (p = 0.02); it also had a lower incidence of postoperative infections (6%) compared to group A (23%) and group B (57%) (p = 0.02). Conclusions: We did not find any evidence that the use of surgical glues may reduce the formation of seroma following axillary dissection in BC patients. Nevertheless, the use of cyanoacrylate glue in association with closed suction axillary drain seems to contribute to the reduction in days of axillary drain permanence and of postoperative infections, which are known factors delaying the schedule of any adjuvant oncological therapies.

Evolution and time trends of nipple-sparing mastectomy: a single-center experience.

Nipple Sparing Mastectomy (NSM) requires the entire breast tissue to be removed, maintaining the nipple-areola complex, and represents nowadays the gold standard of the demolitive breast surgery. Although it represents the evolution of conservative breast surgery, NSM presents some limitations in the selection of women candidates for treatment, and still there are no real guidelines regarding its indications, but simply objective data to address the choice. How the breast surgery approach to demolitive and conservative surgery has changed over time? We evaluated throughout the years (from 2009 up to 2018) the time trend of NSM at our institution and analysed the main differences between patients undergone NSM and other mastectomies and/or breast conserving surgery in terms of cancer size, multicentricity and biological profile. We found 781 NSMs, 1261 other mastectomies and 5621 breast conservative surgeries. Among NSMs, 39.6% were reconstructed with tissue expander and 58.1% with definitive prosthesis. From 2009 to 2018 we found a general increase of NSM rate (from 21.3% of all mastectomies in 2009 to 67.3% in 2018) and a decrease of total mastectomies (from 78.7% of all mastectomies in 2009 to 32.7% in 2018). In line with the literature data, our data confirm that in the recent years NSM represents the gold standard for radical breast surgery. Undisputed in prophylaxis, NSM is continuously acquiring more support in being used as first line treatment for locally advanced disease.

Mucinous breast cancer: A narrative review of the literature and a retrospective tertiary single-centre analysis.

Mucinous carcinoma (MC) is a rare breast cancer characterized by the presence of large extracellular mucin amount. Two main subtypes can be distinguished: pure (PMC) and mixed (MMC). We conducted a retrospective MC analysis in our prospective maintained database, calculating disease-free survival (DFS) and 5-year overall survival (OS). We found a global 92.1% OS (higher in MMC group and statistically significative) and a DFS of 95.3% (higher in MMC group but not statistically significative).

Breast Cancer and Multiple Primary Malignant Tumors: Case Report and Review of the Literature.

Multiple primary malignant neoplasms are multiple tumors with different pathogenetic origin. They may be synchronous or metachronous. The management of these conditions represents an interesting clinical scenario. A crucial aspect is the decision regarding which tumor to treat initially, and how to schedule further treatments according to individual tumor risk. This process involves a multidisciplinary physician team to ensure favorable outcomes. We describe a case report of a female patient affected by primary synchronous tumors of the breast and pectoral skin, which raised a series of diagnostic, etiological and therapeutic issues persuading us to carry out a critical review of the literature.

Breast cancer subtypes affect the nodal response after neoadjuvant chemotherapy in locally advanced breast cancer: Are we ready to endorse axillary conservation?

We evaluated the impact of breast cancer subtypes on pathologic complete response (pCR) in 181 patients with positive nodes undergoing neoadjuvant chemotherapy (NAC). After NAC, patients underwent surgery, with sentinel lymph node biopsy (SLNB) or axillary dissection (ALND). In 28.2% of cases a pCR was achieved, with the highest rate in Her2+ and triple negative tumors. Overall, nodal pCR was more frequent than breast pCR (P = 0.003) with higher percentages in Her2+ and LLB-Her2+ (P < 0.05). In the Her2+ group, nodal pCR was observed only with breast pCR. Thus, in Her2+ tumors, breast pCR predicts node pCR, supporting the use of SLNB in this subgroup to stage the axilla avoiding ALND.

Counseling interventions delivered in women with breast cancer to improve health-related quality of life: a systematic review.

BACKGROUND: Higher survival rates for breast cancer patients have led to concerns in dealing with short- and long-term side effects. The most common complications are impairment of shoulder functions, pain, lymphedema, and dysesthesia of the injured arm; psychological consequences concern: emotional distress, anxiety, and depression, thereby, deeply impacting/affecting daily living activity, and health-related quality of life. OBJECTIVE: To perform a systematic review for assessing the efficacy or effectiveness of interventions aiming at improving health-related quality of life, return to daily activity, and correct lifestyles among breast cancer patients. METHODS: A literature search was conducted in December 2016 using the databases PubMed and Scopus. Search terms included: (counseling) AND (breast cancer) AND (quality of life). Articles on counseling interventions to improve quality of life, physical and psychological outcomes were included. RESULTS: Thirty-five articles met the inclusion criteria. The interventions were grouped in five main areas: concerning lifestyle counseling interventions, related to combined interventions (physical activity and nutritional counseling), physical therapy, peer counseling, multidisciplinary approach, included psychological, psycho-educational interventions, and cognitive-behavior therapy (CBT). Exercise counseling as well as physical therapy are effective to improve shoulder mobility, healing wounds, and limb strength. Psychological therapies such as psychoeducation and CBT may help to realize a social and psychological rehabilitation. CONCLUSION: A multidisciplinary approach can help in sustaining and restoring impaired physical, psychosocial, and occupational outcomes of breast cancer patients.

Plasma Cell Mastitis in Men: A Single-center Experience and Review of the Literature.

Plasma cell mastitis is an inflammatory disease of the breast parenchyma, rare in males. In the last 40 years, few cases have been described in literature. Our recent treatment of male patients affected by plasma cell mastitis raised a series of issues which led us to carry out a critical review of the literature. Plasma cell mastitis is often not well defined and is difficult to assess by clinical examination and radiological investigation alone. An understanding of the pathogenesis and the mechanisms behind plasma cell mastitis may help improve the diagnostic and therapeutic course of the disease, leading to a more targeted and less invasive treatment.

Oncoplastic central quadrantectomies.

Tumors localized in the central quadrant (centrally located breast tumors) have always represented a challenge for the surgeon because of the critical aesthetical matters related to the nipple-areola complex (NAC). Many years of experience with breast cancer patients treated by using various oncoplastic techniques, has allowed us to develop the modified hemibatwing for the treatment of central breast tumors, where the NAC is involved. Modified hemibatwing-along with the removal of the NAC-is a useful oncoplastic technique and it represents an ideal option for the treatment of central tumors because it assures oncological safety, a reduced surgical timetable and greater aesthetical results.

Nipple-sparing Mastectomy in Patients with Preoperative Diagnosis of Non-invasive Breast Carcinoma. A Single-center Experience.

BACKGROUND: Nipple-sparing mastectomy (NSM) is a recognized treatment for selected patients with breast cancer (BC). Our study aimed to analyze 7 years' experience in NSM and breast reconstruction for patients with preoperative diagnosis of non-invasive BC. PATIENTS AND METHODS: All NSMs with breast reconstruction, performed between January 2007 and December 2013 in patients with preoperative diagnosis of non-invasive BC, were considered. RESULTS: Thirty-five NSMs were performed, 23 cases confirming the diagnosis of non-invasive BC, and in 12 patients it also resulted in findings of an invasive component. Patients were stratified into two groups: breast reconstruction was performed i) with silicone definitive implant, ii) with a temporary breast tissue expander. An invasive component at the postoperative histological examination was significantly associated with tissue expander reconstruction (p=0.03). CONCLUSION: In selected cases, NSM is a valid and safe procedure. Further critical evaluations are required for more evidence on this argument.

Nodal status assessment in breast cancer: strategies of clinical grounds and quality of life implications.

Even in the era of gene-expression profiling, the nodal status still remains the primary prognostic discriminant in breast cancer patients. The exclusion of node involvement using noninvasive methods could reduce the rate of axillary surgery, thereby preventing from suffering complications. However, lymphatic mapping with sentinel node biopsy (SNB) is one of the most interesting recent developments in surgical oncology. Optimization of procedure could be implemented by dual mapping injection site skills, resection of all hot or blue nodes through tracer combination, and improvement in atypical drainage patterns mapping. This anatomical analysis suggests safety measures in patients with high probability of node metastasis through a renewed interest in surgical management. The perspective of a guided axillary sampling (GAS) could represent a potential development of recent anatomical and functional acquisitions, offering a dynamic technique shared according to clinical and anatomical disease parameters. Furthermore, the surgical staging procedures may adopt a conservative approach through the evaluation of upper arm lymphatics, thus defining a functional model aimed at the reduction of short- and long-term adverse events. Quality results in breast cancer surgery need to generate oncological safety devoid of complications through renewed clinical experience.