"Immediate pre-pectoral implant-based breast reconstruction after J-pattern skin reducing mastectomy."

SUMMARY: Skin reducing-mastectomy, described several years ago, for single stage reconstruction is considered an oncologically safe procedure and is used in those woman with large and ptotic breasts. This study describes a new technique, the J-pattern skin-reducing breast reconstruction with prepectoral implant and acellular dermal matrix (Braxon fast), which is indicated to patients with large and ptotic breasts who would benefit from a breast reduction and need a mastectomy for curative or prophylactic purpose. We present our case series on 35 breasts in 19 women submitted to the above mentioned procedure from January 2021 to December 2022 at the Plastic and Reconstructive Surgery Department of the University Hospital Santa Maria della Misericordia of Udine, Italy, with a median follow up of 15 months. The advantages of the J scar and consist in a reduced risk of skin necrosis, a reduced bottoming out rate, a simplification of the surgical design and a lower impact of scars not involving the medial quadrants of the breast. Patients were administered the Breast Q 2.0 post-operative questionnaire at 3 months postoperatively, which showed a high average level of satisfaction with the reconstruction. We therefore believe that this surgical technique is a valid option in patients who have a voluminous breast and an adequate pinch test and wish to undergo a curative/prophylactic mastectomy with immediate heterologous reconstruction.

Optimizing Acellular Dermal Matrix Integration in Heterologous Breast Reconstructive Surgery: Surgical Tips and Post-Operative Management.

Background and Objective: Prepectoral implant placement in breast reconstruction is currently a must-have in the portfolios of breast surgeons. The introduction of new tools and conservative mastectomies is a game changer in this field. The prepectoral plane usually goes hand-in-hand with the ADM wrapping of the implant. It is a cell-free dermal matrix comprising a structurally integrated basement membrane complex and an extracellular matrix. The literature reports that ADMs may be useful, but proper patient selection, surgical placement, and post-operative management are essential to unlock the potential of this tool, as these factors contribute to the proper integration of the matrix with surrounding tissues. Materials and Methods: A total of 245 prepectoral breast reconstructions with prostheses or expanders and ADMs were performed in our institution between 2016 and 2022. A retrospective study was carried out to record patient characteristics, risk factors, surgical procedures, reconstructive processes, and complications. Based on our experience, we developed a meticulous reconstruction protocol in order to optimize surgical practice and lower complication rates. The DTI and two-stage reconstruction were compared. Results: Seroma formation was the most frequent early complication (less than 90 days after surgery) that we observed; however, the majority were drained in outpatient settings and healed rapidly. Secondary healing of wounds, which required a few more weeks of dressing, represented the second most frequent early complication (10.61%). Rippling was the most common late complication, particularly in DTI patients. After comparing the DTI and two-stage reconstruction, no statistically significant increase in complications was found. Conclusions: The weakness of prepectoral breast reconstruction is poor matrix integration, which leads to seroma and other complications. ADM acts like a graft; it requires firm and healthy tissues to set in. In order to do so, there are three key steps to follow: (1) adequate patient selection; (2) preservative and gentle handling of intra-operative technique; and (3) meticulous post-operative management.

From Sub-Pectoral to Pre-Pectoral Implant Reconstruction: A Decisional Algorithm to Optimise Outcomes of Breast Replacement Surgery.

BACKGROUND: Innovations and advancements with implant-based breast reconstruction, such as the use of ADMs, fat grafting, NSMs, and better implants, have enabled surgeons to now place breast implants in the pre-pectoral space rather than under the pectoralis major muscle. Breast implant replacement surgery in post-mastectomy patients, with pocket conversion from retro-pectoral to pre-pectoral, is becoming increasingly common, in order to solve the drawbacks of retro-pectoral implant positioning (animation deformity, chronic pain, and poor implant positioning). MATERIALS AND METHODS: A multicentric retrospective study was conducted, considering all patients previously submitted to implant-based post-mastectomy breast reconstruction who underwent a breast implant replacement with pocket conversion procedure at the University Hospital of Udine-Plastic and Reconstructive Surgery Department-and "Centro di Riferimento Oncologico" (C.R.O.) of Aviano, from January 2020 to September 2021. Patients were candidates for a breast implant replacement with pocket conversion procedure if they met the following inclusion criteria: they underwent a previous implant-based post-mastectomy breast reconstruction and developed animation deformity, chronic pain, severe capsular contracture, or implant malposition. Patient data included age, body mass index (BMI), comorbidities, smoking status, pre- or post-mastectomy radiotherapy (RT), tumour classification, type of mastectomy, previous or ancillary procedures (lipofilling), type and volume of implant used, type of ADM, and post-operative complications (breast infection, implant exposure and malposition, haematoma, or seroma). RESULTS: A total of 31 breasts (30 patients) were included in this analysis. Just three months after surgery, we recorded 100% resolution of the problems for which pocket conversion was indicated, which was confirmed at 6, 9, and 12 months post-operative. We also developed an algorithm describing the correct steps for successful breast-implant pocket conversion. CONCLUSION: Our results, although only early experience, are very encouraging. We realized that, besides gentle surgical handling, one of the most important factors in proper pocket conversion selection is an accurate pre-operative and intra-operative clinical evaluation of the tissue thickness in all breast quadrants.

Patients' Question-Asking About Breast Implant-Associated Anaplastic Large Cell Lymphoma (BI-ALCL) and Breast Implant Illness (BII): Implementing Questions in BREAST-Q.

There has been recently heightened media-driven attention to BII and BI-ALCL. Nowadays the importance of receiving correct and complete evidence-based information about these diseases and the potential impact of these emerging issues on disposition to receive breast implants are not investigated on BREAST-Q. The BREAST-Q survey has the potential to create an evidence-based approach to aesthetic surgical practice. We suggest implementing the BREAST-Q subthemes domain in order to investigate the degree of satisfaction about the education received concerning BII and BI-ALCL and to investigate the possible change of patient perception towards breast implants. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Prepectoral Implant-Based Breast Reconstruction Using Meshed ADM.

Prepectoral prosthetic breast reconstruction has been widely reassessed in recent years and is taking on an increasingly important role in the field of immediate breast reconstruction. We report here a case series of 32 patients who underwent nipple-sparing mastectomy for breast carcinoma and prepectoral breast reconstruction involving an acellular dermal matrix (ADM) treated by means of a skin-graft mesher in our hospital from January 2015 to March 2016. The indications for this type of reconstruction were body mass index (BMI) less than 30 kg/m2; no history of radiotherapy; no active smokers; moderate grade breast; and good viability of mastectomy flap: normal skin colour, active bleeding at the fresh cut edges, and thicker than 1 cm mastectomy flaps; the viability of lower thicknesses was ascertained by the fluorescent dye indocyanine green xenon-based imaging technology (4 patients). The mean age of the patients was 56.4 years (range: 39-77 years). Their mean BMI was 27.4 kg/m2. Until the end of follow-up (mean: 17 months), major complications requiring reoperation occurred in 9% of patients and minor complications in 22% of patients. The mean of the 3 pain visual analogue scale scores taken in the first 24 hours after surgery was 1.8. Mean duration of hospital stay has been 2.2 days. Our complication rate was similar to those reported in other studies on prepectoral breast reconstruction featuring total ADM coverage of the implant.

La reconstruction par prothèse mammaire prépectorale a été largement réévaluée ces dernières années et joue un rôle de plus en plus important dans le cadre des reconstructions mammaires immédiates. Les auteurs rendent compte d'une série de 32 patientes qui ont subi une mastectomie d'épargne cutanée à cause d'un carcinome du sein et d'une reconstruction mammaire prépectorale touchant la matrice du derme acellulaire traitée par une ampligreffe à l'hôpital entre janvier 2015 et mars 2016. Les indications pour ce type de reconstruction étaient un indice de masse corporelle inférieur à 30 kg/m2, aucun antécédent de radiothérapie, aucun tabagisme actif, des seins de dimension modérée, une bonne viabilité du lambeau de mastectomie, une couleur normale de la peau, un saignement actif aux bordures fraîchement coupées et des lambeaux de mastectomie de plus de 1 cm. La viabilité de l'épaisseur inférieure était évaluée par la technologie d'imagerie par fluorescence du vert d'indocyanine à base de xénon (chez quatre patientes). Les patientes avaient un âge moyen de 56,4 ans (moyenne de 39 à 77 ans) et avaient un indice de masse corporelle moyen de 27,4 kg/m2. Jusqu'à la fin du suivi (moyenne de 17 mois), 9 % des patientes ont souffert de complications majeures exigeant une réopération, et 22 % ont subi des complications mineures. La moyenne de trois scores de douleur sur l'échelle analogique visuelle calculés dans les 24 heures suivant l'opération s'élevait à 1,8. Le séjour hospitalier était d'une durée moyenne de 2,2 jours. Le taux de complication était semblable à celui déclaré dans d'autres études sur la reconstruction mammaire prépectorale touchant l'intégralité de la matrice dermique acellulaire de l'implant.

Seroma Formation in Pre-pectoral Implant-Based ADM Assisted Breast Reconstruction: A Comprehensive Review of Current Literature.

In the field of implant-based breast reconstruction (IBBR), the most recent and successful progress has been the evolution of the prepectoral approach through the use of acellular dermal matrix (ADM). ADM-assisted breast reconstruction is now gaining a foothold as standard practice, but its advantages are often clouded due to discouraging studies reporting increased seroma formation. The origin of the serum accumulation still remains unclear, but it has always been the most frequent early complication in breast reconstruction, thus proving to be crucial to address since it can lead to further complications. Using a standardized approach to obtain high-quality scientific evidence, the aim of this review is therefore to investigate the occurrence of seroma in breast implant-based reconstructive surgery and its possible relation with matrices. We conducted the review investigating only pre-pectoral implant positioning and one specific ADM (BraxonÃÂî) which is the one who has the highest number of cases in literature. nterestingly, ADM does not appear to be causative of seroma formation, but a surgery-related origin is discussed. In this setting, a series of rigorous guidelines have therefore been identified and analyzed to allow not only the treatment, but also the prevention of seroma, thus leading to a reduction in the incidence of this frequent problem.

Common Peroneal Nerve Injury Related to Small Saphenous Vein Surgery: Report of 2 Cases and Review of the Literature.

Although iatrogenic damage is less often involved, deep nerve injuries are reported especially as a result of small saphenous vein (SSV) dissection. Complete or partial division of the common peroneal nerve (CPN) during varicose vein operations causes substantial and serious disability. Most CPN injuries recover spontaneously; nonetheless, some require nerve surgery. Treatment depends on the nature of CPN injury. This report chronicles 2 instances of CPN injury after SSV surgery, addressing treatment strategies and therapeutic gains. The pertinent literature is also reviewed.

Posterior lamellar reconstruction: a comprehensive review of the literature.

The aim of the review is to describe the different techniques and materials available to reconstruct the tarsoconjunctival layer of the eyelid; to analyze their indications, advantages, and disadvantages. We searched the Cochrane, PubMed, and Ovid MEDLINE databases for English articles published between January 1990 and January 2017 using variations of the following key words: "posterior lamella," "eyelid reconstruction," "tarsoconjunctival," "flap," and "graft." Two reviewers checked the abstracts of the articles found to eliminate redundant or not relevant articles. The references of the identified articles were screened manually to include relevant works not found through the initial search. The search identified 174 articles. Only a few articles with a therapeutic level of evidence were found. Techniques for the posterior lamellar reconstruction can be categorized as local, regional, and distant flaps; tarsoconjunctival, heterotopic, homologous, and heterologous grafts. Several techniques and variations on the techniques exist to reconstruct the posterior lamella, and, for similar indications, there's no evidence of the primacy of one over the other. Defect size and location as well as patient features must guide the oculoplastic surgeon's choice. The use of biomaterials can avoid possible complications of the donor site.

A modified technique for securing drains to the skin.

There is a wide range of surgical procedures that require placement of drains. It is important to ensure that the drains remain in the correct position until their removal. The classic method for fixing drains to the skin involves the use of surgical knots. Typically, one or more of them are tied directly to the skin surface, close to the drain exit site, so potentially giving rise to problems involving tissue damage or the development of obvious scars, if the knots are excessively tight around the skin. With the drain fixation technique that we developed none of the knots constricts the skin, so avoiding any kind of damage to it.