Ultrastructural features of the double capsulated connective tissue around silicone prostheses.

The implantation of breast prostheses for both aesthetic and reconstructive purposes has been growing exponentially in the last 20 years. Safety and prosthesis lifespan are majorly debated issues in relation to the correlated long-term complications. Mainly the periprosthetic capsule that develops around the implant is often the cause of complications and particularly for macrotextured silicone breast implants. Some reports have tried to elucidate the mechanism by which macrotextured silicone implants undergo damage and cause double capsule formation. In this study, we investigated the morphological characteristics of double capsule of macrotextured implants surgically removed from patients. With the use of microscopy techniques, this work analyzed the newly formed tissue observed in the interaction between synthetic and biological surfaces.

Drilling Capability of Orthodontic Miniscrews: In Vitro Study.

The aims of this study were to assess the values and mechanical properties of insertion torque (IT) of steel miniscrews inserted in artificial bone blocks (Sawbones, Pacific Research Laboratories, Vashon, WA, USA) with different bone densities and to detect any scratches on the surface of the miniscrews after insertion. Forty self-drilling miniscrews (Leone S.p.A. ø 1.75 mm, L 8 mm) have been inserted into bone blocks that mimic different stability conditions (density: 20 PCF-pounds per cubic foot, 40 PCF, and 30 + 50 PCF with 2 mm and 4 mm of cortical bone). Before insertion and after removal, all miniscrews were inspected with a stereomicroscope 5x and a SEM to detect potential microscopic cracks. Using an electronic surgical motor (W&H Dentalwerk Bürmoos GmbH, Werner Bader Str. 1, 5111 Bürmoos, Austria), the maximum insertion torque value was registered. Stereomicroscope and SEM examination did not indicate any morphological and surface structural changes to the miniscrews, irrespective of the bone density they were inserted into. The findings showed that IT increased significantly with increasing bone density. In each artificial bone block, morphostructural analysis demonstrated the adequate mechanical properties of the self-drilling miniscrews. IT measurements indicated torque values between 6 and 10 Ncm for blocks with a density of 30 + 50 PCF, whereas the suggested values are between 5 and 10 Ncm.

Tissue-engineered breast reconstruction with Brava-assisted fat grafting: a 7-year, 488-patient, multicenter experience.

BACKGROUND: The ability of autologous fat transfer to reconstruct an entire breast is not established. The authors harnessed the regenerative capabilities of external expansion and autologous fat transfer to completely reconstruct breasts. METHODS: The authors performed 1877 Brava plus autologous fat transfer procedures on 616 breasts in 488 women to reconstruct 99 lumpectomies, 87 immediate breast reconstructions, and 430 delayed total breast reconstructions. After 2 to 4 weeks of Brava expansion, which increased volume by 100 to 300 percent, the authors diffusely grafted the breasts with 100 to 400 ml (225 ml average) of 15 g-sedimented, manually harvested lipoaspirate. The procedure was repeated every 8 to 14 weeks until completion. The authors compared costs of this reconstruction with established deep inferior epigastric artery perforator/transverse rectus abdominis musculocutaneous flaps and implant procedures. RESULTS: Follow-up ranged from 6 months to 7 years (mean, 2.5 years), with 0.5 percent locoregional recurrence. Four hundred twenty-seven women completed the reconstruction, whereas 12.5 percent dropped out (2.5 percent medical, 10 percent personal reasons). Completion required 2.7 procedures for nonirradiated and 4.8 procedures for irradiated mastectomies. Patients recovered soft, natural appearing breasts with nearly normal sensation. Complications included five pneumothoraces and 20 ulcerative infections. Radiographically recognized benign palpable masses were observed in 12 percent of nonirradiated and 37 percent of irradiated breasts. The cost of Brava plus autologous fat transfer is 47 percent and 66 percent that of current reconstruction alternatives. CONCLUSION: Brava plus autologous fat transfer is a minimally invasive, incisionless, safe, economic, and effective alternative for breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Aesthetic applications of Brava-assisted megavolume fat grafting to the breasts: a 9-year, 476-patient, multicenter experience.

BACKGROUND: Autologous fat grafting to the breasts was banned in 1987 because of unpredictable graft retention and cyst formation that could not be differentiated from cancer. Surgical and radiologic advances induced a lifting of the ban in 2009. Small- to moderate-volume autologous fat grafting to the breast has become common. The authors present their aesthetic applications of megavolume autologous fat grafting to the breast. METHODS: Autologous fat grafting with Brava preexpansion was performed on 294 patients for aesthetic augmentation, 45 patients for congenital deformity correction, 43 patients for iatrogenic deformity correction, and six patients for implant-to-fat conversion. Autologous fat grafting for implant-to-fat conversion was performed on 88 patients without Brava. A case example is presented for each indication. The baseline, perioperative, grafted, and postoperative volumes were recorded. RESULTS: Follow-up ranges from 6 months to 9 years (mean, 3.5 years). The mean volume grafted was 346 ml per breast, and the mean postoperative augmentation measured at least 6 months postoperatively was 266 ml per breast. No patients required open biopsy or were diagnosed with cancer. There was one pneumothorax, requiring a temporary chest tube, with no further complication. CONCLUSION: Large-volume autologous fat grafting after Brava use or implant removal is a safe and effective alternative for breast augmentation and deformity correction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Computer assisted planning of autologous fat grafting in breast.

Autologous fat grafting is an emerging and promising surgical technique in regenerative medicine, and its application is quickly spreading in plastic and reconstructive surgery of the breast. However, despite the advantages of the technique, surgical complications may occur, such as implanted tissue necrosis and resorption and onset of microcalcifications. In view of the hypothesis that the uniformity of the lipoaspirate transplantation is related to graft survival and a lower probability of complications, we developed an interactive lipomodeling planning software application based on a genetic algorithm that allows automatic optimization of the uniformity of fat tissue distribution. The input dataset consists of a 3D model of the patient's thorax, created from MRI scans, on which relevant structures are segmented. The developed software was tested starting from either an automatically generated plan or an initial guess of the optimal surgical plan, and in both cases the application yielded a consistent improvement in the planned fat tissue distribution by optimizing the position of the insertion points and the direction of the insertion pathways. On the basis of the simulations performed, the use of genetic algorithms for optimization of the geometry of autologous fat transfer in the breast proved to be effective. These results will foster further activities focused on the comparison of predicted optimized geometries and those obtained in real surgical cases as a means of obtaining a deeper knowledge of the potential influence of a uniform fat tissue distribution on the quality of the surgical outcome. The presented application is also put forward as representing a noteworthy step towards the clinical application of computer assisted planning tools in breast surgery.

Determining the oncological risk of autologous lipoaspirate grafting for post-mastectomy breast reconstruction.

This study compares the incidence of local and regional recurrence of breast cancer between two contiguous time windows in a homogeneous population of 137 patients who underwent fat tissue transplant after modified radical mastectomy. Median follow-up time was 7.6 years and the follow-up period was divided into two contiguous time windows, the first starting at the date of the radical mastectomy and ending at the first lipoaspirate grafting session and the second beginning at the time of the first lipoaspirate grafting session and ending at the end of the total follow-up time. Although this study did not employ an independent control group, the incidence of local recurrence of breast cancer was found to be comparable between the two periods and in line with data from similar patient populations enrolled in large multicenter clinical trials and who did not undergo postsurgical fat tissue grafting. Statistical comparison of disease-free survival curves revealed no significant differences in relapse rate between the two patient subgroups before fat grafting and after fat grafting. Although further confirmation is needed from multicenter randomized clinical trials, our results support the hypothesis that autologous lipoaspirate transplant combines striking regenerative properties with no or marginal effects on the probability of post-mastectomy locoregional recurrence of breast cancer.

Clinical treatment of radiotherapy tissue damage by lipoaspirate transplant: a healing process mediated by adipose-derived adult stem cells.

BACKGROUND: There is evidence that stem cells contribute to the restoration of tissue vascularization and organ function. The objective of this study was to assess the presence of adipose-derived adult stem cells left in their natural scaffold in the purified lipoaspirate and to assess the clinical effectiveness of lipoaspirate transplantation in the treatment of radiation side effects. METHODS: This study was designed beginning with surgical procedures in 2002 and envisaging a continuous patient follow-up to 31 months. Twenty consecutive patients undergoing therapy for side effects of radiation treatment with severe symptoms or irreversible function damage (LENT-SOMA scale grade 3 and 4) were enrolled. Purified autologous lipoaspirates (60 to 120 cc) taken from a healthy donor site were administered by repeated low-invasive computer-assisted injection. Therapy outcomes were assessed by symptoms classification according to the LENT-SOMA scale, cytofluorimetric characterization, and ultrastructural evaluation of targeted tissue. RESULTS: In the isolated stromal vascular fraction of 2 cc of human lipoaspirate, cells with mesenchymal stem cell physical properties and immunophenotype were in average 1.07 +/- 0.5 percent (n = 4), with a clonogenic fraction of 0.139 percent. At least 1.02 x 10(3) colony-forming units-fibroblast were present in each lipoaspirate. Ultrastructure of target tissue systematically exhibited progressive regeneration, including neovessel formation and improved hydration. Clinical outcomes led to a systematic improvement or remission of symptoms in all evaluated patients, including otherwise untreatable patients exhibiting initial irreversible functional damage. CONCLUSIONS: This surgical procedure is a low-invasive therapeutic approach for resolving the late side effects of radiotherapy. According to the proposed hypothesis of the ischemic nature of radiolesions, treatment with lipoaspirate transplantation is potentially extended to other forms of microangiopathies.

Sensory empathy and enactment.

The authors propose the concept of sensory empathy which emerges through contact between analyst and patient as they get in touch with an area concerning the primary bond. This area is not so much based on thoughts and fantasies as it is on physical sensations. Sensory empathy has to do with that instrument described by Freud as pertaining to the unconscious of any human, which enables one person to interpret unconscious communications of another person. The authors link this concept to that of enactment precisely because the latter concerns unconscious, early elements that fi nd in the act a fi rst meaningful expression. It involves both analyst and patient. In other words, the authors wish to emphasize the importance of the analytical process maintaining contact with that immense field of human interaction that can be defined as primary sensory area and which becomes intertwined with the evolution of affects. Clinical examples are provided to clarify these hypotheses.