Single versus Double Drainage for Immediate Two-Stage Implant-Based Breast Reconstruction: A Propensity Score-Matched Analysis.

BACKGROUND: Reports evaluating plastic surgeons' practices indicate there are conflicting trends regarding the use of one or two drains for implant-based breast reconstruction (IBBR). Our study aimed to perform a matched cohort analysis to examine the postoperative outcomes and complications of immediate IBBR with tissue expander (TE) using two drains versus a single drain. METHODS: A propensity score-matched analysis (nearest neighbor, 1:1 matching) of immediate reconstructions using two versus one drain was conducted. Female patients undergoing immediate two-stage IBBR with TEs between January 2011 and May 2021 were included. The covariables were as follows: BMI, mastectomy weight, lymph node surgery, TE surface, plane of reconstruction, use of acellular dermal matrix products, fluorescence imaging use, and intraoperative TE volume. RESULTS: After matching using propensity scores, 192 reconstructions were included in the final analysis: 96 in each group. The rate of 30-day complications and overall complications during the first phase of IBBR were comparable between groups. The time for drain removal, time to initiate and finalize expansions, and time for TE-to-implant exchange were comparable between groups. Diabetes (OR 3.74, p = 0.025) and an increased estimated blood loss (OR 1.004, p = 0.01) were the only independent predictors for seroma formation. CONCLUSION: In this matched cohort analysis evaluating the role of one versus two drains for two-stage IBBR, we found a comparable rate of complications and surgical outcomes between the two cohorts. Using two drains for immediate IBBR needs to be tailored depending on intraoperative findings. LEVEL OF EVIDENCE III: 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 .

Predictors for Prolonged TE-to-Implant Exchange During Implant-Based Breast Reconstruction: A Single Institution Experience.

BACKGROUND: There is limited evidence regarding the factors causing a prolonged time for tissue expander (TE) exchange into a definitive implant using two-stage implant-based breast reconstruction (IBBR). This study aimed to review our experience with IBBR, focusing on the time for TE-to-implant exchange and determining which factors cause a prolonged time for exchange. METHODS: A retrospective review was performed to include women undergoing immediate two-stage IBBR with TEs after total mastectomy between January 2011 and May 2021. Reconstructions with irradiated TEs were excluded. Cases that had a prolonged time for TE-to-implant exchange were defined as those undergoing exchange longer than 232 days, which corresponds to the 75th percentile of the overall study group. RESULTS: We included 442 reconstructions in our analysis. The median age for our series was 51 years and the median body mass index was 26.43-kg/m2. The median time for TE-to-implant exchange was 155 days [IQR, 107-232]. Cases that had a prolonged time for TE-to-implant exchange were defined as those undergoing exchange on postoperative day 232 or afterward. Diabetes (OR 4.05, p = 0.006), neoadjuvant chemotherapy (OR 2.76, p = 0.006), an increased length of stay (OR 1.54, p = 0.013), and a lengthier time to complete outpatient expansions (OR 1.018, p < 0.001) were independently associated with a prolonged time for exchange. CONCLUSION: As evident from our analysis, the time for exchange is highly heterogeneous among patients. Although several factors affect the timing for TE-to-implant exchange, efforts must be directed to finalize outpatient expansions as soon as possible to expedite the transition into a definitive implant. LEVEL OF EVIDENCE III: 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 .

Endoscopy-assisted versus open tissue expander placement in plastic and reconstructive surgery: a meta-analysis.

Tissue expansion can be used to overcome challenges due to tissue deficiency in plastic and reconstructive surgery; however, the long expansion process is often accompanied by numerous complications. This meta-analysis aimed to determine whether endoscopy-assisted expander placement could decrease complications and shorten treatment time. This study followed the principles of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and was registered in PROSPERO (CRD42021226116). A literature search was performed in eight databases from their inception dates up to 25 August 2021, to identify clinical studies on endoscopy-assisted and/or open tissue expander placement in plastic and reconstructive surgery. Seven studies met the inclusion criteria. In seven studies, 194 underwent endoscopy-assisted expander placement, and 565 underwent open expander placement. The overall complication rate in the endoscopy-assisted group was significantly lower than that in the open group (risk difference (RD) -0.28, 95% confidence interval (CI), -0.38, -0.18, p < .001). Subgroup analysis showed significantly lower incidence rates of hematoma, infection and dehiscence in the endoscopy-assisted group. The complication rate in the head/neck was lower with low heterogeneity (RD, -0.18; 95% CI, -0.26 to -0.09, p < .001; I2 = 0%). The endoscopy-assisted group had shorter surgery time, hospital stay and time to full expansion (weighted mean difference (WMD), -13.97 min, -16.88 h, -27.54 days; 95% CI, -15.85, -12.08 min, -24.36, -9.40 h, -38.85, -16.24 days; both p < .001, respectively). Endoscopy-assisted expander placement may help lower the risk of complications, especially in the head/neck, and reduce surgery time, hospital stay, and time to full expansion. Abbreviations: CI: confidence interval; CNKI: China National Knowledge Infrastructure Database; CSTJ, China Science and Technology Journal Database; NOS: the Newcastle-Ottawa Scale; PRISMA: preferred reporting items for systematic reviews and meta-analyses; RCT: randomized controlled trial; RoB: the cochrane risk-of-bias; RD: risk difference; WMD: weighted mean difference; SE: standard error; SND: standard normal deviate.

Simultaneous Fat Grafting During Tissue Expander-to-Implant Exchange: A Propensity Score-Matched Analysis.

BACKGROUND: Implant-based breast reconstruction (IBBR) is the most common technique for breast reconstruction. The primary resource for correcting deformities, once patients have achieved an adequate volume with two-stage IBBR, is autologous fat grafting. We compared the surgical outcomes of simultaneous fat grafting during TE-to-implant exchange (SFG + TtIE) versus no fat grafting during TE-to-implant exchange (No-FGX). METHODS: A retrospective review was performed of all consecutive patients undergoing two-stage implant-based breast reconstruction with TE from January 2011 to December 2020. Propensity score matching was implemented to optimize comparability. The control group did not receive fat grafting at the time of TE-to-implant exchange. RESULTS: After propensity score matching, 196 reconstructions were evaluated, 98 in each group. Reconstructions in the SFG + TtIE received larger implants during exchange in comparison with the No-FGX group (539 ± 135.1-cc versus 495.97 ± 148-cc, p=0.035). The mean volume of fat lipoinjected during TE-to-implant exchange in the SFG + TtIE group was 88.79 ± 41-ml. A higher proportion of reconstructions in the SFG + TtIE group underwent additional fat grafting after exchange versus the No-FGX group (19% versus 9%, p = 0.041). After propensity score matching, only the rate of fat necrosis after exchange was significantly higher in the SFG + TtIE group (10% versus 2%, p = 0.017). The rate of breast cancer recurrence (3% versus 5%, p = 1.00) was comparable between the groups. CONCLUSION: SFG + TtIE is a safe procedure to improve the envelope of reconstructed breasts during two-stage IBBR. SFG + TtIE does not increase the rate of periprosthetic infection or wound-related complication versus no fat grafting during TE-to-implant exchange, but increases the rate of fat necrosis. LEVEL OF EVIDENCE III: Therapeutic study. 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.

Subpectoral versus prepectoral two-stage breast reconstruction: A propensity score-matched analysis of 30-day morbidity and long-term outcomes.

BACKGROUND: Approximately 80% of patients undergoing total mastectomy in the US opt for implant-based breast reconstruction (IBBR). A two-stage reconstruction with tissue expander (TE) remains the most common technique. Since the implementation of ADMs, a prepectoral approach has gained popularity and is becoming the standard of care. Herein, we compared the surgical and postoperative outcomes of prepectoral versus subpectoral two-stage IBBR. METHODS: A retrospective chart review was performed between January 2011 and December 2020. We included female patients undergoing immediate two-stage IBBR. The primary outcomes of this study were to compare the 30-day morbidity and the overall rate of complications during the first and second stages of reconstruction, and to compare the time to initiate postmastectomy radiotherapy (PMRT). Propensity score matching was implemented. RESULTS: After matching, 154 reconstructions were analyzed, 77 in each group. The two matched groups exhibited comparable (p > 0.05) characteristics for all analyzed demographic and intraoperative independent variables. Reconstructions in the prepectoral group had a shortened median time for drain removal (13-days vs. 15-days, p = 0.001). The intraoperative expansion volumes were higher in the prepectoral group (300 ml versus 200 ml, p = 0.025). The 30-day morbidity and first- and second-stage complication rates were not significantly different between groups. The time to start postmastectomy radiation therapy (PMRT) was not significantly different between groups (134-days versus 126.5-days, p = 0.58). CONCLUSION: Prepectoral and subpectoral TE placement had comparable complication rates during the first and second stages of IBBR. Timing for TE-to-Implant exchange and initiation of PMRT were comparable between the two approaches.

Prepectoral versus subpectoral two-stage implant-based breast reconstruction: U.S. medical center experience and narrative review.

Background and Objective: With the incorporation of autologous fat grafting, acellular dermal matrix (ADM) products, and nipple-sparing mastectomy, prepectoral device placement has become more popular in selected patients when compared to partial submuscular (dual plane) or complete submuscular device placement. In this article, we aimed to present a review of the current state-of-the-art for implant-based breast reconstruction (IBBR) using expanders. Additionally, we present a case series of our experience with IBBR evaluating perioperative outcomes, complications, and patient-reported outcomes (PRO). Methods: For our series, we retrospectively evaluated adult female patients undergoing 2-stage immediate IBBR after total mastectomy between 2011 and 2021. We performed a systematic search across PubMed MEDLINE for articles evaluating outcomes of prepectoral versus subpectoral two-stage IBBR with expanders published from database inception through February 28th, 2023. Key Content and Findings: Both prepectoral and subpectoral are safe alternatives for two-stage IBBR. Due to current advancements in the field of breast reconstruction, prepectoral IBBR has gained popularity and has a comparable rate of complications compared to a subpectoral approach in selected patients according to high-quality articles. In patients with several comorbidities, current tobacco use, history of preoperative radiation, and limited perfusion of the mastectomy flaps, subpectoral device placement should be given special consideration as a layer of vascularized tissue can decrease the risk of major complications or unplanned procedures. As prepectoral device placement does not require dissection of the pectoral muscles, faster recovery, better implant position, decreased pain, and a shorter time to complete expansion is expected. The plane of reconstruction does not seem to significantly affect the time for expander-to-implant exchange or PRO for quality-of-life (QOL) according to most studies. Conclusions: Prepectoral and subpectoral IBBR demonstrated a comparable rate of complications in selected patients. Nonetheless, perioperative outcomes seem to be improved using a prepectoral approach in terms of reduced pain, reduced time to conclude outpatient expansions, and less animation deformity.

The investigation of the relation between expansion strategy and outcomes of two-stage expander-implant breast reconstruction.

BACKGROUND: Numerous risk factors for the complications of two-stage, immediate implant-based breast reconstruction have been identified, although few studies have directly examined the impact of breast size and expansion protocols on the surgical outcomes of breast reconstruction. This study aimed to evaluate the impact of breast size, expansion velocity, and volume-related variables on postoperative complications of breast reconstruction. METHODS: The cohort involved patients who underwent immediate breast expander reconstruction at a single center between 2017 and 2019. The breast size was classified into three categories according to the weight of the mastectomy specimen as small (<300 g), medium (≥300 g, ≤500 g), or large (>500 g). Multifactorial logistic regressions were used to assess the impact of variables, and receiver operating characteristic (ROC) curve analysis was used to determine the optimal cut-off value for predicting the complication event. RESULTS: Of the 174 breasts (168 patients), 51 (29.3%), 66 (37.9%), and 57 (32.6%) breasts were classified as small, medium, and large, respectively. The rate of infection (P=0.014) and expander/implant failure (P=0.007) significantly differed according to breast size, with the rate being the highest in large breasts. Multivariate logistic regression analysis showed that body mass index (BMI) [odds ratio (OR): 1.25; P=0.003], nipple-sparing mastectomy (OR: 2.82; P=0.036), sentinel biopsy (OR: 5.10; P=0.016), final expansion volume (OR: 0.99; P=0.022), and expansion velocity (OR: 0.703; P=0.024) were significant independent predictors of any complication. In the ROC analysis, breast weight >696 g could predict the possibility of revision surgery, with a sensitivity of 42.9% and specificity of 81.8%. CONCLUSIONS: The final expansion volume and expansion velocity have a significant negative relationship with overall complications in breast reconstruction. A standard expansion protocol needs to be established to ensure the success of two-stage breast reconstruction.

Reconstrução de couro cabeludo com retalho expandido / Scalp reconstruction with expanded flap

Introdução: A presença de defeitos extensos em couro cabeludo apresenta-se como um grande desafio reconstrutor para o cirurgião plástico. Estes defeitos têm vasta etiologia como: traumática, queimaduras térmicas ou elétricas, ressecções tumorais benignas e malignas ou congênitas, sequelas de tratamentos radioterápicos e infecções. Destacando-se lesões como o escalpelamento e queimaduras (térmicas ou elétricas), geram repercussões significativas como a perda de tecido grave, osteomielite crônica ou sequelas menores como uma alopecia cicatricial. O objetivo deste trabalho é relatar um caso de reconstrução de couro cabeludo em fase tardia com expansor tecidual e posterior retalho de avanço, devido à alopecia cicatricial, em paciente feminina de 11 anos vítima de escaldamento por água quente em região frontotemporal direita. Métodos: Foi realizada análise retrospectiva de prontuário da paciente em questão. O presente trabalho segue os padrões do comitê de ética de Helsinque. Conclusão: A técnica de expansão tecidual de couro cabeludo por estágios e posterior confecção de retalho de avanço de escalpo demonstrou ser eficaz de restaurar a estrutura pilosa e linha da implantação capilar da paciente com mínima distorção local, restituindo a forma e a estética do couro cabeludo da paciente.

Introduction: The presence of extensive scalp defects is a major reconstructive challenge for the plastic surgeon. These defects have a vast etiology, such as traumatic, thermal or electrical burns, benign and malignant or congenital tumor resections, radiotherapy treatments sequelae, and infections. Noting that injuries such as scalping and burns (thermal or electrical), generate significant repercussions such as severe tissue loss, chronic osteomyelitis or minor sequelae such as scar alopecia. This study aims to report a case of late scalp reconstruction with a tissue expander and posterior advancement flap, due to cicatricial alopecia, in an 11-year-old female, victim of scalding by hot water in the right frontotemporal region. Methods: It was performed a retrospective analysis of the patient's medical record. The present work follows the standards of the Helsinki ethics committee. Conclusion: The scalp tissue expansion technique by stages and subsequent scalp advancement flap performing proved to be effective in restoring the patient's hair structure and hairline with minimal local distortion, restoring the scalp's shape and aesthetics of the patient.

Does chemotherapy or radiotherapy affect the postoperative complication in breast cancer patients who underwent immediate breast reconstruction with tissue expander?

BACKGROUND: Immediate breast reconstruction with tissue expander in breast cancer patients who were expected to receive adjuvant therapy, such as chemotherapy or radiotherapy, has been a topic of debate. Postoperative complications from tissue expander procedures can delay the timing of adjuvant treatment and subsequently increase the probability of recurrence. The purpose of this study was to identify the impact of chemotherapy and radiotherapy on postoperative complications in patients who underwent immediate reconstruction (IR) using tissue expander. METHODS: We conducted a retrospective study of 1081 breast cancer patients who underwent mastectomy and IR using tissue expander insertion between 2012 and 2017 in Samsung Medical Center. The patients were divided into two groups based on complications (complication group vs. no complication group). Complication group was regarded to have surgical removal or conservative treatment based on clinical findings such as infection, capsular contracture, seroma, hematoma, rupture, malposition, tissue viability, or cosmetic problem. The complication group had 59 patients (5.5%) and the no complication group had 1022 patients (94.5%). RESULTS: In univariate analysis, adjuvant radiotherapy and adjuvant chemotherapy were significantly associated with postoperative complications. In multivariate analysis, however, only higher pathologic N stage was significantly associated with postoperative complications (p < 0.001). Chemotherapy (p = 0.775) or radiotherapy (p = 0.825) were not risk factors for postoperative complications. CONCLUSIONS: IR with tissue expander after mastectomy may be a treatment option even when the patients are expected to receive adjuvant chemotherapy or radiotherapy. These results will aid patients who are concerned about the complications of IR caused by chemotherapy or radiotherapy determine whether or not to have IR. TRIAL REGISTRATION: Patients were selected and registered retrospectively, and medical records were evaluated.

The efficacy of ultrasound-guided erector spinae plane block after mastectomy and immediate breast reconstruction with a tissue expander: a randomized clinical trial.

BACKGROUND: We aimed to investigate the analgesic efficacy of an erector spinae plane block (ESPB) in immediate breast reconstruction (IBR) with a tissue expander. METHODS: Adult women undergoing IBR with a tissue expander after mastectomy were randomly assigned to either intravenous patient-controlled analgesia (IV-PCA) alone (group P) or IV-PCA plus ESPB (group E). The primary outcome was the total amount of opioid consumption during 24 hours postoperatively between the two groups. Secondary outcomes were patient satisfaction, pain score at rest and on shoulder movement using numerical rating scale, incidences of postoperative nausea and vomiting (PONV), and a short form of the brief pain inventory (BPI-SF) at 3 and 6 months after surgery between the groups. RESULTS: Fifty eight patients completed the study. At 24 hours postoperatively, total opioid consumption was significantly less in group E than in group P (285.0 ± 92.0, 95% confidence interval [CI]: 250.1 to 320.0 vs. 223.2 ± 83.4, 95% CI: 191.5 to 254.9, P = 0.005). Intraoperative and cumulative PCA fentanyl consumption at 3, 6, 9, and 24 hours were also less in group E than in group P (P = 0.004, P = 0.048, P = 0.020, P = 0.036, and P < 0.001, respectively). Patient satisfaction was higher in group E (6.9 ± 1.8 vs. 7.8 ± 1.4, P = 0.042). The incidences of PONV was similar. CONCLUSIONS: The ESPB decreased postoperative opioid consumption and increased patient satisfaction without significant complications after IBR with a tissue expander after mastectomy.

Complications using tissue expanders in burn sequelae treatment at a reference university hospital: a retrospective study / Complicações com o uso de expansores teciduais para tratamento de sequela de queimaduras em um hospital universitário de referência: estudo retrospectivo

ABSTRACT Background: tissue expanders have high relevance in plastic surgery and among indications it is worth mentioning their use in the treatment of burn reconstruction. Although it shows good results, its use requires special care because some complications can interrupt the reconstruction process. The objective of this study was to report the experience of the Clinics Hospital (University of Sao Paulo) with the use of tissue expanders to treat burn sequelae, establishing the incidence of complications, and identifying risk factors for their occurrence. Methods: a retrospective, observational, and analytical study, evaluating the use of expanders in burns sequelae treatment from 2009 to 2018. Results: 245 expanders were placed in 84 patients, 215 were female, with a mean age of 19.96 years, being 40% in the trunk and 20% in the scalp, with a predominance of rectangular shape in 76.7% of cases. Complications were classified as major and minor.Complications occurred in 17.95% of cases, and extrusion and infection were the most common. There was a higher incidence of complications in expanders used in the upper and lower limbs as well as in those who did not undergo concomitant expansion (p <0.05), with an even higher chance of major complications in patients submitted to additional expansion. From 2009 to 2018, we observed a decrease in the incidence of complications. Conclusion: the complication rate (17.95%) is similar to other studies of the literature, there was a higher rate of complication with expanders placed in the limbs and a higher rate of major complications when additional expansion was done.

RESUMO Introdução: os expansores teciduais são de importante relevância na cirurgia plástica, e dentre suas indicações destaca-se seu uso no tratamento de sequelas de queimaduras. Ainda que apresente bons resultados, seu uso requer cuidados especiais pois a incidência de complicações não é desprezível. Objetivo: relatar a experiência do Hospital das Clínicas da FMUSP com a utilização de expansores teciduais para tratamento de sequelas de queimaduras, estabelecendo a incidência de complicações e identificando possíveis fatores de risco para ocorrência das mesmas. Método: estudo retrospectivo, observacional e analítico, avaliando o uso de expansores no tratamento de sequelas de queimaduras no período de 2009 a 2018 no Hospital das Clínicas da FMUSP. Resultados: no período de análise estabelecido, foram colocados 245 expansores, sendo 215 em pacientes do sexo feminino, com idade média de 19,96 anos, sendo 40% em tronco e 20% em couro cabeludo, predominando uso do retangular em 76,7% dos casos. As complicações foram divididas em maiores e menores. As complicações ocorreram em 17,95% dos casos, sendo extrusão e infecção as de maior incidência. Houve maior incidência de complicação em expansores utilizados nos membros superiores e inferiores bem como naqueles que não realizaram expansão concomitante (p<0,05), havendo ainda maior chance de complicações absolutas nos pacientes submetidos à expansão adicional. Observou-se também diminuição no número de complicações entre 2009 e 2018. Conclusão: a taxa de complicação (17,95%) é semelhante a da literatura, observando-se maior taxa de complicação nos expansores colocados em membros e maior taxa de complicações absolutas quando realizada expansão adicional.

Multifactorial analysis of the surgical outcomes of giant congenital melanocytic nevi: Single versus serial tissue expansion.

BACKGROUND: Giant congenital melanocytic nevus (GCMN) is a rare disease, for which complete surgical resection is recommended. However, the size of the lesions presents problems for the management of the condition. The most popular approach is to use a tissue expander; however, single-stage expansion in reconstructive surgery for GCMN cannot always address the entire defect. Few reports have compared tissue expansion techniques. The present study compared single and serial expansion to analyze the risk factors for complications and the surgical outcomes of the two techniques. METHODS: We retrospectively reviewed the medical charts of patients who underwent tissue expander reconstruction between March 2011 and July 2019. Serial expansion was indicated in cases of anatomically obvious defects after the first expansion, limited skin expansion with two more expander insertions, or capsular contracture after removal of the first expander. RESULTS: Fifty-five patients (88 cases) were analyzed, of whom 31 underwent serial expansion. The number of expanders inserted was higher in the serial-expansion group (P<0.001). The back and lower extremities were the most common locations for single and serial expansion, respectively (P=0.043). Multivariate analysis showed that sex (odds ratio [OR], 0.257; P=0.015), expander size (OR, 1.016; P=0.015), and inflation volume (OR, 0.987; P=0.015) were risk factors for complications. CONCLUSIONS: Serial expansion is a good option for GCMN management. We demonstrated that large-sized expanders and large inflation volumes can lead to complications, and therefore require risk-reducing strategies. Nonetheless, serial expansion with proper management is appropriate for certain patients and can provide aesthetically satisfactory outcomes.

Blossom smart expander technology for tissue expander-based breast reconstruction facilitates shorter duration to full expansion: A pilot study.

BACKGROUND: This study evaluated the Blossom system, an innovative self-filling, rate-controlled, pressure-responsive saline tissue expander (TE) system. We investigated the feasibility of utilizing this technology to facilitate implant-based and combined flap with implant-based breast reconstruction in comparison to conventional tissue expansion. METHODS: In this prospective, single-center, single-surgeon pilot study, participants underwent either implant-based breast reconstruction or a combination of autologous flap and implantbased breast reconstruction. Outcome measures included time to full expansion, complications, total expansion volume, and pain scores. RESULTS: Fourteen patients (TEs; n=22), were included in this study. The mean time to full expansion was 13.4 days (standard error of the mean [SEM], 1.3 days) in the combination group and 11.7 days (SEM, 1.4 days) in the implant group (P=0.78). The overall major complication rate was 4.5% (n=1). No statistically significant differences were found in the complication rate between the combination group and the implant group. The maximum patient-reported pain scores during the expansion process were low, but were significantly higher in the combination group (mean, 2.00±0.09) than in the implant group (mean, 0.29±0.25; P=0.005). CONCLUSIONS: The reported average duration for conventional subcutaneous TE expansion is 79.4 days, but this pilot study using the Blossom system achieved an average expansion duration of less than 14 days in both groups. The Blossom system may accommodate single-stage breast reconstruction. The overall complication rate of this study was 4.5%, which is promising compared to the reported complication rates of two-stage breast reconstruction with TEs (20%-45%).

Lipoenxertia em reconstruções mamárias com expansor e implantes / Fat grafting in breast reconstructions with expanders and implants

A lipoenxertia autóloga foi inicialmente descrita há mais de 100 anos por Neuber objetivando correção de defeitos faciais. Ao mesmo tempo, Czerney descreveu a utilização de lipoma nas costas para recriar uma mama pós-mastectomias. A técnica foi popularizada por Coleman, que descreveu o uso de lipoaspiração e purificação de adipócitos para injeção na face como preenchimento de tecido mole. Bircoll e Novack (1987 apud Costantini et al.4) expandiram então esta aplicação para as mamas. Em 1990 houve um crescimento no uso da lipoenxertia, após o trabalho de Coleman, que confirmou que o tecido adiposo poderia ser transferido satisfatoriamente com a formalização de um protocolo restrito para preparação e injeção de gordura. A técnica de Coleman é de longe a mais comumente usada. O tecido adiposo é infiltrado com uma solução tumescente e, em seguida, manualmente aspirada. O lipoaspirado é subsequentemente centrifugado para isolar o tecido adiposo da fração oleosa e aquosa e finalmente injetado. A transferência de gordura de uma área em excesso, como o abdômen ou as coxas para reconstrução ou melhorar a forma e o volume da mama, não é uma ideia nova. Seguindo o trabalho de Illouz sobre a lipoaspiração, que levou ao seu uso generalizado em todo o mundo. As imagens mamográficas após lipoenxertia são variadas, a absorção de gordura e sua evolução à necrose gordurosa variam de cistos lipídicos a achados suspeitos de malignidade, como microcalcificações agrupadas, áreas espiculadas de opacidade aumentada e massas focais.

Autologous fat grafting was first described more than 100 years ago by Neuber to correct facial defects. At the same time, Czerney described the use of a lipoma on the back to recreate a post-mastectomy breast. The technique was popularized by Coleman, who described the use of liposuction and adipocyte purification for injecting into the face as a soft tissue filling. Then, Bircoll and Novack (1987 apud Costantini et al.4) extended this use to breasts. In 1990, there was a growth in the use of fat grafting after Coleman's technique. This confirmed that adipose tissue could be satisfactorily transferred with the formalization of a restricted protocol for fat injection preparation. Coleman's technique is by far the most commonly used. The adipose tissue is infiltrated with a tumescent solution and then manually aspirated. The liposuction material is subsequently centrifuged to isolate the adipose tissue from the oily and aqueous fraction and was then injected. Transferring fat from an excess area such as the abdomen or thighs to reconstruct or improve the shape and volume of the breast is not a new idea. Later, a study by Illouz on liposuction promoted the widespread use of the technique worldwide. Postoperative mammographic images to control fat absorption and necrosis vary. These can present as lipid cysts, suspected malignant findings such as grouped microcalcifications, spiculated areas of increased opacity, and focal masses.

Minimally invasive salvage of infected breast tissue expanders: A continuous closed irrigation technique based on surface biofilm disruption.

BACKGROUND: Removal of the infected device has been the general treatment for device-associated infection in antibiotic failure. There have been anecdotal attempts to salvage infected medical devices by introducing a continuous closed irrigation system. OBJECTIVE: This study examines whether continuous closed irrigation of an infected device is a successful alternative to removal in patients with recalcitrant device-associated infection. METHODS: Patients who were diagnosed with recalcitrant periexpander infections during the course of expander-implant breast reconstruction from 2010 to 2018 were enrolled in a retrospective case-control study. Patients who failed antibiotics before 2017 underwent expander removal, but patients since 2017 underwent continuous closed irrigation of the infected expanders. Treatment details and clinical outcomes were compared. Rationale for expander irrigation was based on review of the current literature on biofilm research. RESULTS: During the study period, 21 out of the 1176 patients were diagnosed with periexpander infection recalcitrant to antibiotic therapy. Among the 21 patients, 16 underwent expander removal and five underwent expander irrigation. Clinical outcomes were comparable in terms of resolution of infection signs. The irrigation group showed fewer patients who abandoned reconstruction after infection treatment (removal = 11/16, irrigation = 1/5). Literature review revealed that expander irrigation might have induced hydrodynamic disruption of the biofilm structure. CONCLUSION: Expander irrigation was less invasive than removal and effective in suppressing severe recalcitrant periexpander infection. Continuous closed irrigation of infected expander devices may be a successful antibiofilm strategy in treating device-associated infections in select patients.

Early Rehabilitation after Total Mastectomy and Immediate Reconstruction with Tissue Expander Insertion in Breast Cancer Patients: A Retrospective Case-control Study.

PURPOSE: To prevent surgical site complications, many plastic surgeons use the so-called "conventional protocol," which immobilizes the shoulder and upper arm for 1 month after reconstruction. In an effort to improve the shoulder mobility of patients who received immediate breast reconstruction with tissue expander insertion (TEI), we introduced an early rehabilitation protocol with a short-term immobilization period of 2 weeks. This study aims to compare this early rehabilitation exercise program with the conventional protocol and to determine factors affecting shoulder mobility and quality of life of patients after immediate breast reconstruction. METHODS: A total of 115 patients with breast cancer who underwent reconstructive surgery were retrospectively reviewed. For patients who underwent reconstruction before January 2017, the conventional protocol was followed with immobilization of their shoulder for over 4 weeks. Patients who underwent reconstruction after January 2017 were educated to undergo a self-exercise program after a short-term immobilization period of 2 weeks. We compared shoulder mobility, pain, quality of life, and complications at postoperative 1 and 2 months between the groups. RESULTS: Patients who received early rehabilitation showed greater shoulder flexion and abduction range at postoperative 1 month than those who received the conventional protocol. This increased shoulder abduction range continued until postoperative 2 months. There were no significant surgical site problems in both groups during the 2 months of follow-up. CONCLUSION: To enhance the recovery of shoulder mobility, early rehabilitation with a shorter immobilization period should be recommended to patients with breast cancer undergoing reconstruction surgery with TEI. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03541161.

[Pott's puffy tumour: innovative technique in calvarial reconstruction].

BACKGROUND: Pott's puffy tumour is a rare complication of sinusitis. This osteomyelitis can affect the outer and inner tables of the frontal sinus. The treatment of Pott's puffy tumour combines medical and surgical approaches. Surgical approaches have traditionally been open, but endoscopic techniques have been adopted recently in select cases. The bony defect from debridement can be left alone, or closed with autografts or allografts. OBJECTIVE: To describe a technique for the reconstruction of a large skull vault after the debridement of extensive osteomyelitis of the anterior cranial vault. METHODS: Modified distraction osteogenesis is used in the cranial vault, to induce new bone formation. This is customarily used to lengthen long bones. The advantages of this technique include avoiding autologous grafts or alloplastic cranioplasty in the infected surgical bed, and allowing primary closure. RESULTS: Early post-operative imaging results have been encouraging, with no reported complications. CONCLUSION: Modified distraction osteogenesis is a novel technique in the primary reconstruction of calvarial bone.

Characteristics of adhesion areas between the tissue expander and capsule in implant-based breast reconstruction.

BACKGROUND: The use of anatomic implants has improved the aesthetic results of breast surgery; however, implant malrotation is an uncommon, but serious complication of these procedures. Nevertheless, little research has explored implant adhesion. In this study, we investigated adhesion between the expander and the capsule. METHODS: Seventy-nine cases of immediate breast reconstruction via two-stage implantbased reconstruction performed between September 2016 and November 2017 were evaluated. Mentor CPX4 expanders were used in 14 breasts, and Natrelle expanders in 65. We analyzed areas of adhesion on the surfaces of the tissue expanders when they were exchanged with permanent implants. We investigated whether adhesions occurred on the cephalic, caudal, anterior, and/or posterior surfaces of the expanders. RESULTS: Total adhesion occurred in 18 cases, non-adhesion in 15 cases, and partial adhesion in 46 cases. Of the non-adhesion cases, 80% (n=12) were with Mentor CPX4 expanders, while 94.4% (n=17) of the total adhesion cases were with Natrelle expanders. Of the partial adhesion cases, 90.7% involved the anterior-cephalic surface. The type of tissue expander showed a statistically significant relationship with the number of attachments in both univariate and multivariate logistic regression analyses (P<0.001) and with total drainage only in the univariate analysis (P=0.015). CONCLUSIONS: We sought to identify the location(s) of adhesion after tissue expander insertion. The texture of the implant was a significant predictor of the success of adhesion, and partial adhesion was common. The anterior-cephalic surface showed the highest adhesion rate. Nevertheless, partial adhesion suffices to prevent unwanted rotation of the expander.

Atypical proliferative nodule in congenital melanocytic nevus with dural invasion: a case report.

Here we report a case of a focal atypical proliferative nodule (PN) arising from a congenital melanocytic nevus (CMN). Diagnosis was challenging because it had both benign and malignant clinical features. Unusual histopathology, immunohistochemistry, and intraoperative findings of this atypical PN are discussed. A 5-year-old girl was admitted for a congenital 5× 5 cm sized scalp mass. This hemangioma-like soft mass showed biphasic characteristics such as a slow, gradual, and benign increase in size but worrisome dural invasion with cranial bone defect. We removed the scalp mass with clear resection margins. Interoperatively, we found that the cranial bone defect had already filled. Histopathologic examination showed CMN with focal atypical PN. The nodule showed sharp demarcation and cellular pleomorphism. However, in immunohistochemical study, Ki-67 proliferation index and expression levels of protein S-100 and Melan-A were very low. These were unusual findings of atypical PNs. Despite her worrisome preoperative radiologic features, she showed an indolent clinical course compatible with previously reported biologic behavior. The patient underwent follow-up inspection with magnetic resonance imaging every 6 months for up to 3 years. The nodule appeared to be stationary at the last visit.

Early experiences with robot-assisted prosthetic breast reconstruction.

Robotic surgery facilitates surgical procedures by employing flexible arms with multiple degrees of freedom and providing high-quality 3-dimensional imaging. Robot-assisted nipplesparing mastectomy with immediate reconstruction is currently performed to avoid breast scars. Four patients with invasive ductal carcinoma underwent robot-assisted nipple-sparing mastectomy and immediate robot-assisted expander insertion. Through a 6-cm incision along the anterior axillary line, sentinel lymph node biopsy and nipple-sparing mastectomy were performed by oncologic surgeons. The pectoralis major muscle was elevated, an acellular dermal matrix (ADM) sling was created with robotic assistance, and an expander was inserted into the subpectoral, sub-ADM pocket. No patients had major complications such as hematoma, seroma, infection, capsular contracture, or nipple-areolar necrosis. The mean operation time for expander insertion was 1 hour and 20 minutes, and it became shorter with more experience. The first patient completed 2-stage prosthetic reconstruction and was highly satisfied with the unnoticeable scar and symmetric reconstruction. We describe several cases of immediate robot-assisted prosthetic breast reconstruction. This procedure is a feasible surgical option for patients who want to conceal surgical scars.