Facial Transplantation: Nonimmune-Related Hyperacute Graft Failure-The Role of Perfusion Injury: A Case Report.

BACKGROUND: The aim of this study was to report the first case of acute facial allograft transplantation (facial allograft transplantation) failure with allograft removal and autologous free-flap reconstruction. METHODS: A 49-year-old female patient affected by neurofibromatosis type 1 with a massive neurofibroma infiltrating the whole left hemiface was planned for FAT for the left hemiface including the auricle, all skin and soft tissues from the temporal region, periorbital and nasal region, and up to the perioral area. The maxillary process of the zygomatic bone, left hemimaxilla, and hemimandible from contralateral parasyphysis to the incisura mandibulae were also included. RESULTS: Total surgical time was 26 hours. There were 2 intraoperative arterial thromboses that were solved with new anastomoses and sufficient flap perfusion. On postoperative day 2, the allograft became pale with suspected arterial occlusion and the patient returned to the operative room for exploration no flow into the FAT was found. The allograft was removed and the recipient site reconstructed with a skin-grafted composite left latissimus dorsi-serratus anterior flap. CONCLUSIONS: Hyperacute loss of FAT is a very dramatic event, and the activation of a backup surgical plan is crucial to save patient's life, give a reasonable temporary reconstruction, and return on the waiting-list for a second face transplantation.

[The integrated care pathway for non melanoma skin cancer: the Istituto Dermopatico dell'Immacolata - IRCCS experience in Rome.] / Il percorso diagnostico-terapeutico e assistenziale nella gestione del paziente affetto da tumore cutaneo non melanocitario: l'esperienza dell'IDI - IRCCS di Roma.

The incidence of non-melanoma skin cancers (NMSC) is increasing worldwide and these skin cancers have become an important health issue. An integrated care pathway (ICP) is a multidisciplinary outline of anticipated care, placed in an appropriate timeframe, to help a patient with a specific condition. The aim of this paper is to define the ICP for patients affected by NMSC referring to the Istituto Dermopatico dell'Immacolata - IRCCS of Rome and Villa Paola, Italy. This ICP is multidisciplinary and included various specialists like dermatologist, oncologist, general surgeon, plastic surgeon, anatomopathologist, molecular biologist and epidemiologist. This ICP is based on the most recent acquisitions in the literature, referring in particular to the national (EADO and SIDEMAST) and international guidelines (EDF and NCCN). We firstly valued the current practice for patients affected by NMSC referring to our Institute to define the multidisciplinary process map. This process delineated the activities and the responsibilities performed during delivery of care to the patients and the potential problem areas or opportunities for improvements. Subsequently, we defined the final ICP process. This ICP of NMSC represents an innovative strategy to provide high quality healthcare. This allows to ensure all the necessary procedures for the patient, optimizing the "continuum" of care and the use of health services, and improving the organization of the Institute regarding an important health issue.

Septum-Based Mammaplasties: Surgical Techniques and Evaluation of Nipple-Areola Sensibility.

BACKGROUND: The aim of the study was to describe details of surgical techniques and objectively evaluate nipple-areola (NAC) sensibility and viability of septum-based mammaplasties compared to not septum-based reduction techniques. METHODS: Data regarding NAC sensibility for static and moving one- and two-point discrimination were prospectively collected from 63 active group hypertrophic-breasted patients undergoing septum-based reduction mammaplasty preoperatively, at 6 and 12 months postoperatively, and from a control group of 60 patients who underwent not septum-based techniques. Fixed and mixed effect models were used for statistical analysis. RESULTS: Comparison of complications showed no significant differences between groups (p = 0.07). After adjusting the results of the active group according to type of sensory testing, it emerged that the threshold decreases by 10% (p = 0.0003) at 6 months and even reaches 43% (p < 0.0001) at 12 months. The results have been modulated according to age, since the variation is less marked when age increased, by 0.6% at 6 months and 0.8% at 12 months (p = 0.019). The effects of the BMI can only be seen at 12 months, with an increase by 1.3% per year (p = 0.033). Among septum-based techniques, the inferior-central pedicle showed better sensibility outcomes even if not significantly (p = 0.06). Comparison of NAC sensibility outcomes showed that active group had thresholds that were 48% lower when compared to those of the control group at 12 months postoperatively (p < 0.001). CONCLUSION: Septum-based mammaplasty gives optimal results in terms of NAC viability with a significant improvement of sensibility postoperatively. Comparative outcomes on sensibility were also significantly better than not septum-based techniques. LEVEL OF EVIDENCE II: 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.

Reanimação estática do lábio inferior na paralisia facial como complicação de preenchimento / Static lower lip reanimation as a filler complication of facial paralysis

Procedimentos de rejuvenescimento facial substitutos da cirurgia tradicional tornaram-se cada vez mais populares para promover uma aparência jovial com procedimentos minimamente invasivos, como toxina botulínica injetável, preenchimento de tecidos moles e peelings químicos. No entanto, complicações podem ocorrer mesmo na presença de um injetor habilidoso e experiente. Apresentamos o caso de uma paciente submetida a reanimação labial estática usando retalho dermoadiposo para lesão do nervo facial direito após remoção de nódulos como complicação de preenchimento. A "abordagem modificada de bull horn" foi realizada para elevação do lábio superior em torno das asas nasais e columela e ao longo do sulco nasolabial direito. O retalho foi desepitelizado e obtido. Usando a ponta aberta de uma pequena cânula de lipoaspiração, a porção distal do retalho foi encapsulada e fixada diretamente em C-loop e foram utilizados pontos U, transfixando o retalho para o periósteo do arco zigomático. Nos três anos de seguimento não foram observadas complicações significativas e a paciente não relatou nenhuma limitação funcional ou insatisfação com o aspecto das cicatrizes no sulco nasolabial e ao redor das asas nasais e da columela.

Facial rejuvenation procedures to circumvent traditional surgery have become increasingly popular to promote a youthful appearance with minimally invasive procedures such as injectable botulinum toxin, soft-tissue fillers, and chemical peels. Nevertheless, complications can occur even with an astute and experienced injector. Here we present the case of a patient who underwent static lip reanimation using a dermoadiposal flap for right facial nerve damage following nodule removal as a filler complication. A "modified bulls horn approach" to the upper lip lift was performed around the nasal wings and columella and along the right nasolabial fold. The flap was de-epithelized and harvested. Using the open tip of a small liposuction cannula, the distal portion of the flap was tunneled and fixed directly in a C-loop fashion using U stitches, transfixing the flap to the periosteum of the zygomatic arch. At 3 years follow-up, no significant complications were observed, and the patient reported no functional limitations or dissatisfaction with the scars in the nasolabial fold or around the nasal wings and columella.

Aesthetic improvements of radial forearm flap donor site by autologous fat transplantation.

Despite its reliability, radial forearm (RF) flap is still affected by high donor site morbidity with poor cosmetic and functional outcomes after coverage with skin grafts. Having fat grafting demonstrated promising and effective filling and rejuvenating properties, we considered and tested it as a valuable alternative to dermal substitutes for the aesthetic improvement of RF flap donor site. Thirty-three patients with previous RF free flap reconstruction and poor donor site outcomes after full-thickness skin grafting to RF region were evaluated for secondary fat injection to improve outcomes. Objective and subjective assessments of results with standardized ultrasonographic soft tissue thickness measurements, cutaneous sensibility tests with the pressure-specified sensory device and scar assessment scale (POSAS) have been performed. Bivariate statistical analyses were performed comparing outcomes with contralateral healthy forearm. All cases showed significant improvement in soft tissue thickness (p< 0.031), cutaneous sensibility and scar appearance, with improved patient's and observers' scar assessment scores (<0.001). In conclusion, fat transplantation is an effective procedure that provided us with an adjunctive autologous layer in-between skin graft and underlying fascia, as well as a rejuvenating effect on skin and scars.

Double-barrel vascularized dual fibula transfer with epiphyseal growth plate for hip reconstruction: A case report.

We present a case report of a 10-year-old girl diagnosed with Ewing sarcoma treated with intra-articular wide resection of the right femur and reconstruction with a series-connected double-barrel bilateral vascularized fibula graft (db-BVFG), including fibular head for articulation with the acetabulum of the pelvic bone and preservation of the epiphyseal growth plates for eventual limb growth. No postoperative complications were observed and bone union was achieved with fibular graft hypertrophy, allowing for full weight bearing. Neither local recurrence nor metastasis was observed at 17-year follow-up. Range of motion degrees at last follow up: hip flexion 90 degree, extension 12 degree, abduction 31 degree, rotation 25 degree. Right versus left limb discrepancy was 60 mm. Db-BVFG may be an option for reconstruction of long femoral defects and hip joint restoration following tumor resection and inclusion of epiphysis within the graft is a viable option in pediatric patients to restore longitudinal growth of the reconstructed long bone.

Efficacy of double mirrored omega pattern for skin sparing mastectomy to reduce ischemic complications.

BACKGROUND: Excellent cosmetic results from skin-sparing mastectomy (SSM) are often impaired by skin flaps' necrosis (SFN), from 8%-25% or worse in smokers. This study prospectively investigated the efficacy of Double-Mirrored Omega Pattern (DMOP-SSM) compared to Wise Pattern SSM (WP-SSM) for immediate reconstruction in moderate/large-breasted smokers. METHODS: From 2008-2010, DMOP-SSM was performed in 51 consecutive immediate breast reconstructions on 41 smokers (mean age = 49.8 years) with moderate/large and ptotic breasts. This active group (AG) was compared to a similar historical control group (CG) of 37 smokers (mean age = 51.1 years) who underwent WP-SSM and immediate breast reconstruction, with a mean follow-up of 37.6 months. Skin ischaemic complications, number of surgical revisions, time to wound healing, and patient satisfaction were analysed. Descriptive statistics were reported and comparison of performance endpoints was performed using Fisher's exact test and Mann-Whitney U-test. A p-value <.05 was considered significant. RESULTS: Patients' mean age (p = .316) and BMI (p = .215) were not statistically different between groups. Ischaemic complications occurred in 11.7% of DMOP-SSMs and in 32.4% of WP-SSMs (p = .017), and revision rates were, respectively, 5.8% and 24.3% (p = .012), both statistically significant. Mean time to wound healing was, respectively, 16.8 days and 18.4 days (p = .205). Mean patients' satisfaction scores were, respectively, 18.9 and 21.1, statistically significant (p = .022). CONCLUSION: Although tobacco use in moderate/large breasted patients can severely impair outcomes of breast reconstruction, the DMOP-SSM approach, compared to WP-SSM, allows smokers to benefit from SSM, but with statistically significant reduced skin flaps ischaemic complications, revision surgery, and better cosmetic outcomes.

Time-dependent factors in DIEP flap breast reconstruction.

BACKGROUND: The process of harvesting and performing microsurgical anastomosis may lengthen deep inferior epigastric artery perforator (DIEP) flap breast reconstruction affecting results and patient safety. The aim of the study was to investigate the associations between predictors and operative time (OT). METHODS: Between 2004 and 2016, 336 immediate and 68 delayed unilateral reconstructions were performed in 404 patients. Age, weight, height, body mass index (BMI), nulliparity, or pluriparity condition were collected to determine the impact of patient characteristics on OT. Flap weight, mastectomy type, flap zone, perforator number, venous anastomoses, recipient vessels selection, reconstruction timing, contralateral symmetrization, and a dedicated anesthesiologist were analyzed as possible predictors. RESULTS: Mean OT was 289 min (range, 150-550 min). Using univariate analysis, for each increment of BMI value and patient weight OT increased, respectively, 3.5- and 1.4 min (97.5% CI: 1.768-5.145, 97.5% CI: 0.739-1.949; P < 0.001). Skin-sparing mastectomy (SSM) (97.5% CI: 2.487-36.637; P = 0.025), perforator number, and venous anastomoses (97.5% CI: 24.468-43.690, 97.5% CI: 24.843-50.492; P < 0.001) negatively influenced OT while nipple-sparing mastectomy (NSM) reduced OT of 22.7-min (97.5% CI: -40.333 to -5.098; P = 0.012). The use of circumflex scapular vessels as recipients reduced OT of 75.4-min while internal mammary vessels (IMV) increased OT of 55.8-min (97.5% CI: -88.631 to -62.209, 97.5% CI: 22.918-88.642; P < 0.001). A dedicated anesthesiologist and the learning curve (LC) reduced OT, respectively, of 39.63-min and of 13-min for every year (97.5% CI: -57.119 to -22.137, 97.5% CI: -14.666 to -11.898; P < 0.001). Using multivariate regression, LC was a negative predictor while SSM, perforators number, superficial epigastric vein, IMV, and flap weight were positive predictors (P < 0.001). CONCLUSIONS: The increase of flap weight, related perforators number, and venous drainage negatively influence OT. LC meaning systematic approach for surgery can optimize DIEP flap surgery efficiency.

Tips and Tricks to Improve Clinical and Aesthetic Outcomes in Latissimus Dorsi Flap Breast Reconstruction.

Background The aim of this study is to present technical strategies to decrease donor-site complications, to optimize breast shaping, and to achieve symmetry in one-stage procedure in latissimus dorsi (LD) flap reconstruction. Methods Between 2004 and 2014, a retrospective review was performed on LD flap reconstructions. Demographics, reconstructive details, clinical and aesthetic outcomes were collected and analyzed. Patients were divided in historical control group (HCG) and new strategy group (NSG). In HCG, a horizontal/oblique LD skin paddle (SP) was drawn; only LD muscle was harvested for the implant pocket; and a contralateral symmetrization was planned without any algorithm. In NSG, a transverse LD-SP was centered on the middle to lower bra strap area; a double-layer muscle coverage was used to create the implant pocket; and a planning algorithm was developed to achieve symmetry. Results A total of 418 breast reconstructions were performed on 296 patients. The two groups were homogeneous regarding demographics, mastectomy weight, and implant volume (p > 0.05). No differences were observed in the incidence of a contralateral surgery, mean hospitalization time, and mastectomy skin flap and nipple-areola complex complications (p > 0.05), while surgical revision of the balancing procedure was more common in HCG than NSG (p = 0.001). Overall, donor-site morbidities occurred in 50 cases including 3 (1%) seroma in NSG and 17 (14.1%) in HCG, and 8 (2.7%) wound dehiscence in NSG and 18 (14.5%) in HCG (p = 0.001). Mean number of take backs to the operating room for secondary procedure was statistically significant between the groups in favor of NSG (p = 0.001). Conclusion Careful preoperative planning and adoption of appropriate reconstructive strategies can improve clinical and aesthetic outcomes in LD flap breast reconstruction at long-term follow-up. Level of Evidence This is a level III, therapeutic study.

Breast reconstruction following nipple-sparing mastectomy: clinical outcomes and risk factors related complications.

BACKGROUND: The aim of this study was to investigate clinical outcomes and risk factors related complications in patients who had undergone nipple-sparing mastectomy (NSM) followed by implant-based or autologous reconstruction. METHODS: Between 2004-2014 a single-institution retrospective review was collected on NSMs reconstruction. Patient demographics, comorbidities, breast morphological factors, type and timing of radiotherapy, type of incision, reconstruction type and timing, implant volume and complications were collected. RESULTS: A total of 288 patients had undergone 369 NSMs, 81 (28.1%) of which were bilateral while 207 (71.9%) unilateral. One-hundred mastectomies were performed for prophylactic purposes whereas 269 were therapeutics. Thirteen (4.5%) patients were active smokers, while 2 (0.7%) were diabetics. Fifty-five breasts (14.9%) were previously irradiated and average time elapsed between radiotherapy and NSM was 9-year, (range, 5-15 yrs). Total complication rate was 13.5% at mean follow-up of 47.98 months (range, 6-114 months). Partial-thickness and full-thickness mastectomy skin flap and NAC necrosis occurred in 39 (78%) and in 10 (20%) breasts, respectively. Previous radiotherapy and implant volume were significant predictors of complications (OR: 10.14, 95% CI: 3.99-27.01; OR × 100 g: 3.13, 95% CI: 1.64-6.33). Overall mastectomy type incision was not predictive of complications (p = .426). No association was observed between radiotherapy and mastectomy type access (p = .349). CONCLUSIONS: From our experience NSM followed by implant-based and autologous reconstruction had a relative high rate of complications comparable to previous reports. Despite this, it should be carefully offered to patients in whom potential risk factors are identified.

Breast Reconstruction in Elderly Patients: Risk Factors, Clinical Outcomes, and Aesthetic Results.

Background Correlation among age, clinical, and aesthetic outcomes in implant-based and autologous breast reconstructions was investigated. Methods Between 2004 and 2014, a retrospective study was performed on patients who underwent reconstruction following mastectomy. Patients were divided in group A (< 50 years), group B (≥ 50-59 years), group C (≥ 60-69 years), and group D (≥ 70 years). Demographics, comorbidities, American Society of Anesthesiologists (ASA) class, and length of stay were assessed using chi-square and Kruskal-Wallis H analysis considering p ≤ 0.05 as significant. Pre- and postoperative photographs were taken to grade aesthetic results by patients and blinded plastic surgery team. Results A total of 993 patients underwent 1,251 breast reconstructions, of which 356 (28.5%) were implant-based, 402 (32.1%) pedicled-flap, 445 (35.6%) free-flap, and 48 (3.8%) fat-graft reconstructions. There were 316 (25.2%) complications, of which 124 (34.8%) in implant-based, 74 (18.4%) in pedicled-flap, 111 (24.9%) in free-flap, and 2 (4.2%) in fat-graft reconstructions. Mean length of stay was 5.4 days without significant difference between age groups (p = 0.357). The incidence of overall complications was not significantly related to age, ASA class, smoking history, and previous radiotherapy. Body mass index was a significant predictor (p = 0.001), but odds ratio (OR: 1.2) demonstrated only a minimal increase in risk. Implant-based reconstruction was associated with a higher risk for complications compared with the other ones (OR: 2.5, p = 0.001). Patient and surgeon aesthetic surveys demonstrated an overall positive opinion in all age groups for each reconstructive option. Conclusion Advanced age should not be considered a risk factor for breast reconstruction, while implant-based technique was associated with a higher risk for complications compared with autologous that may provide older women with greater benefits.

Tips and tricks for DIEP flap breast reconstruction in patients with previous abdominal scar.

The aim of this study was to analyze outcomes of patients who had prior abdominal operations and underwent DIEP flap breast reconstruction and to describe technical strategies to insure well-vascularized flap-harvest minimizing abdominal donor-site complications. All patients who underwent DIEP flap breast reconstruction between 2004 and 2014 were reviewed and divided into a control group (CG) and a scar group (SG). Patient demographics, operative details, flap and donor-site complications were analyzed and compared. For all of the scars, DIEP flap design was not modified, but a standardized approach was developed according to the type and location of the scar, available vascular pedicle, perforator locations, and the required flap tissue for breast reconstruction. Two hundred and eighty patients underwent 292 flaps in CG and 107 underwent 111 flaps in SG. Pfannenstiel, McBurney, laparoscopic, midline and subcostal were the most common previous incisions. There were no significant differences between groups regarding demographics, flap and mastectomy weight, active smoking, or radiation status (P > 0.05). No significant differences were observed in DIEP flap loss (P = 0.909), partial flap loss (P=0.799), or fat necrosis (P=0.871) and in the rate of abdominal donor-site complications between groups (P > 0.05). SG had a significantly higher mean operative time than CG (P=0.034). Medial raw was a negative risk-factor for flap complications, while BMI (>25.1 kg/m2 ) and smoking-history were significant predictors for donor-site complications. With careful preoperative planning and appropriate technical strategies, successfully DIEP flap breast reconstruction can be performed without increased flap and donor-site complications in patients with preexisting abdominal scars. © 2015 Wiley Periodicals, Inc. Microsurgery 37:282-292, 2017.

Double free fillet foot flap: sole of foot and dorsalis pedis in severe bilateral lower extremity trauma, a 10-year follow-up case report.

This study reports a unique 10 years follow-up case of a patient who underwent a free fillet of sole flap for left leg stump coverage and free dorsalis pedis flap for soft tissue reconstruction of contralateral popliteal fossa following severe bilateral lower leg injury.

Complete DIEP flap survival following pedicle resection, 4 years after its transfer. Clinical evidence of autonomization.

We report a case of complete DIEP flap survival, following venous congestion due to the excision of a local recurrence with main pedicle, 4 years after its transfer for breast reconstruction.

Prospective control study using fibrin sealants and Harmonic® scalpel in Latissimus Dorsi flap transfer.

BACKGROUND: Latissimus dorsi flap (LD) is used in breast reconstruction procedures, although prolonged donor site drainage is a frequent complication. To decrease this problem, quilting sutures and/or fibrin sealants were proposed, with alternate results. The primary objective of this study was to assess the effectiveness of Tisseel® in association with the Harmonic Synergy® blade system to reduce this complication. MATERIALS AND METHODS: Between 2010-2012, 20 consecutive patients undergoing immediate unilateral breast reconstruction with LD were enrolled in the study (Group A) and matched with 20 patients in which LD was raised with electrocautery (Group B), and 20 patients in which LD was harvested with Harmonic® (Group C). After informed consent acquisition, Harmonic® was used in Group A for LD harvesting, but differed from other groups as fibrin glue was applied to the donor site prior to closure. In all groups donor site drainage measurements at 24 and 48 hours, total drain volume, days to drain removal, operation time, and complication rate were recorded. Pearson's Chi-squared, ANOVA, and Bonferroni post-hoc tests were used to analyze the data. RESULTS: Data analysis did not show any statistical difference. Prolonged drains output ≥ 15 days occurred in one patient of Group A and C, and in three Group B patients. CONCLUSION: Although the combined use of Harmonic® and Tisseel® presents a low donor site fluid collection rate, the fibrin glue seems not to have further beneficial effects in reducing the post-operative serous drainage or to lead to an early drain removal when compared to Harmonic® only.

One-stage DIEP flap breast reconstruction: Algorithm for immediate contralateral symmetrization.

The aim of this study was to investigate clinical and aesthetic results of simultaneous contralateral balancing procedures in unilateral DIEP flap reconstructions by means of a symmetrization algorithm. Between 2004 and 2013, 335 patients underwent DIEP flap breast reconstruction with 48 patients (mean age 51.8 years, range 32-69 years) undergoing contralateral procedure. Patients were divided in Group-A including 31 cases who underwent one-stage procedure and Group-B including 17 cases who underwent staged procedure. A symmetrization algorithm was proposed to plan immediate breast reduction/mastopexy. The groups were homogeneous regarding patient's age, BMI, mastectomy and flap weight (P > 0.05). All flaps survived. No complications were observed to the mastectomy skin flaps and to the reduction mammaplasty/mastopexy procedures in both groups. The mean operation time was 5 h in Group-A while 5 h and 37 min in Group-B (P = 0.0682). Contralateral procedures included 23 breast reductions and 8 mastopexies in Group-A, while 10 breast reductions and 7 mastopexies were performed in Group-B. Two and 6 patients required revision of the balancing procedure in Group-A and Group-B, respectively. The follow-up time was 47.3 months (range 14-120 months) in Group-A and 91.3 months (range 41-110 months) in Group-B. Volume, upper/lower pole shape, projection, breast mound placement, IMF, symmetry, overall appearance, and general satisfaction sub-items obtained high-score evaluation without significant difference between the two groups (P > 0.05). One-stage DIEP flap reconstruction by means of the symmetrization algorithm resulted in comparable aesthetic outcomes and patient satisfaction to a staged procedure.

Breast Implant-Associated Anaplastic Large Cell Lymphoma: Proposal for a Monitoring Protocol.

BACKGROUND: The authors report four cases of breast implant-associated anaplastic large cell lymphoma (ALCL) from a single institution and propose a multidisciplinary protocol. METHODS: From 2012 to 2014, four breast implant-associated ALCL cases were diagnosed. The authors performed the original operation, and no patients were referred to their practice. Cases 1, 2, and 4 were CD4/CD30/ALK ALCL with previous textured-implant reconstruction, whereas case 3 was CD8/CD30/ALK ALCL with previous polyurethane-implant augmentation. A retrospective study of all patients who underwent breast implant positioning was performed to identify any misdiagnosed cases. RESULTS: Of 483 patients, 226 underwent reconstruction with latissimus dorsi flap and prosthesis, 115 had skin-sparing/nipple-sparing mastectomy and prosthesis, 117 underwent an expander/implant procedure, and 25 underwent breast augmentation. Fifty-eight cases (12 percent) underwent implant replacement for capsular contracture, 15 (3.1 percent) experienced late-onset seroma, and four (0.83 percent) had both capsular contracture and seroma. Seventy-seven symptomatic patients (16 percent) underwent surgical revision (capsulectomy/capsulotomy) and/or seroma evacuation. The second look on histologic specimens did not identify misdiagnosed cases. A multidisciplinary protocol for suspected implant-associated ALCL was established. Ultrasound and cytologic examinations are performed in case of periprosthetic effusion. If implant-associated ALCL is diagnosed, implant removal with capsulectomy is performed. If disseminated disease is detected through positron emission tomography/computed tomography of the total body, the patient is referred to the oncology department. CONCLUSIONS: A multidisciplinary protocol is mandatory for both early diagnosis and patient management. Until definitive data emerge regarding the exact etiopathogenesis of breast implant-associated ALCL, the authors suggest offering only autologous reconstruction if patients desire it. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.