Breast Lipofilling: Is the Bra Really Full? Clinical Bra Pressure Measurement and In Vitro Testing of Processed and Unprocessed Fat Cells.

BACKGROUND: Breast lipofilling, a popular cosmetic and reconstructive procedure, involves the transplantation of autologous fat to enhance breast volume and contour. Despite its widespread use, cell processing and the aftertreatment remain controversial. This study investigates the pressure applied by a compression bra and reports in vitro stress tests of processed and unprocessed fat cells. METHODS: Clinical bra pressure measurements were conducted on a cohort of 45 patients following lipofilling, reduction mammoplasties and DIEP flaps. Laboratory analysis included cell vitality testing using Resazurin assays of processed and unprocessed fat cells after exposure to mechanical or hyperbaric pressure. RESULTS: Our findings show a mean overall pressure value of the compression bra for all patients of 6.7 ± 5.7 mmHg (range 0-35). Cell processing is superior to sedimentation only regarding fat cell vitality. However, neither mechanical pressure within the specified range nor hyperbaric oxygen exposure significantly affected fat graft survival as measured by Resazurin assays. CONCLUSION: The in vitro measurements showed that it was impossible to harm fat cells with external pressure during lipofilling procedures, regardless of their processing. In the clinical context, the compression bra applied pressure values deceeding the perfusion pressure and may therefore not diminish oxygen supply nor harm the transplanted cells. Therefore, we recommend the use of a compression bra for all lipofilling procedures around the breast. 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 Table of Contents or online Instructions to Authors www.springer.com/00266.

The effect of radiotherapy on fat engraftment for complete breast reconstruction using lipofilling only.

PURPOSE: Lipofilling has been established as a standard technique for contour enhancement following breast reconstruction. However, there is a paucity in current literature regarding the use of this technique for complete reconstruction of the female breast as an alternative to conventional techniques, such as expander or flap-based procedures. In particular, the influence of pre-operative irradiation for successful reconstruction has rarely been examined in published studies. Here, the authors describe their experience with successful fat injection in pre-radiated breasts in comparison with non-pre-radiated patients. METHODS: In this retrospective study, we examined a total of 95 lipofilling treatments on 26 patients (28 breasts). All of them experienced mastectomy following breast cancer; local breast defects after partial resection of the gland were not included in this study. In total, 47 lipofilling procedures in 12 non-irradiated patients (14 breasts) and 48 procedures in 14 irradiated women (also 14 breasts) were performed. Per session, approximately 297 ± 112 cc of adipose tissue was grafted in group A (no radiotherapy) and approximately 259 ± 93 cc was grafted in group B (radiotherapy). RESULTS: Among the group of women without pre-operative radiation, 71% of breast reconstructions limited to lipofilling only showed constant engraftment of fat tissue with a successful reconstructive result, whereas only 21% of the patients with pre-radiated breasts showed complete reconstruction of the breast with a permanent fat in-growth. CONCLUSION: Preoperative radiotherapy significantly impedes successful completion of breast reconstructions planned only by autologous fat transfer. Patients should be selected individually and carefully for complete breast reconstruction using lipofilling only.

Autologous fat grafting for breast reconstruction after breast cancer: a 12-year experience.

PURPOSE: The aim of our study was to examine the surgical outcome and complications (efficiency) as well as the incidence of locoregional recurrence and distant metastases (oncological safety) in patients who underwent autologous fat grafting (AFG) of the breast following breast cancer surgery. METHODS: In our monocentric cohort study, retrospective and prospective data were collected from all consecutive patients who underwent AFG after breast cancer between 2008 and 2020; a total of 93 patients met the inclusion criteria. RESULTS: Our long-term results showed no increase in tumor recurrence and distant metastases in the studied collective when compared to the available literature. We observed 1 local recurrence (1.1%), 2 distant metastases (2.2%), and 1 tumor-related death (1.1%). There was a high degree of patient satisfaction; 67.12% of patients reported adequate satisfaction with autologous fat grafting. CONCLUSION: Currently, to our knowledge, this is the study with the longest follow-up time (mean 6.7 years after AFG and 11.5 years after tumor resection). The results of our clinical study will contribute to improve evidence in the broad field of AFG, adipose stem cell and tumor research. Consistent with our study, the literature review shows a clear tendency of clinical trial results with a low incidence rate of tumor recurrence and metastasis following the use of AFG. AFG seems to be a safe procedure also after breast cancer treatment.

Patients' experience of breast reconstruction after mastectomy and its influence on postoperative satisfaction.

PURPOSE: Breast cancer patients have the option to choose a breast reconstruction after mastectomy. A range of studies have postulated that patients' individually appraised significance of their breast is an important factor in the decision for or against breast reconstruction. This study explored the individually perceived significance of the breast among patients with and without breast reconstruction and its correlation with postoperative satisfaction. METHODS: Ten patients without breast reconstruction, and ten patients with immediate breast reconstruction after mastectomy participated in the study. The perceived importance of the breast and the pre-and postoperative esthetic satisfaction of the patients were obtained using an 11-point Likert scale. Qualitative interviews explored patients' views on the meaning of their breast and their experience after surgery. RESULTS: Patients who had decided for breast reconstruction rated the importance of their breast for femininity (p = 0.004) and attractiveness (p = 0.037) significantly higher than patients without reconstruction. The qualitative data provide evidence that the breast of a woman fulfills a variety of intrapsychic and interactional functions. Difficulties in integrating the reconstructed breast into the body image were reported. A high importance of the breast correlated significantly with a decrease in satisfaction with the breast after reconstruction (rs = -0.652, p = 0.041). CONCLUSIONS: Patients who found their breast to be highly important were more likely to decide for a reconstruction. Mastectomy has an impact on various psychosocial variables but impairments may also occur after breast reconstruction. Patients reporting a high significance of their breast showed the greatest decrease in satisfaction with their breast after reconstruction.

Patient characteristics may affect the lymphatic staining ability of Indocyanine green and Patent blue during lymphaticovenous anastomosis.

BACKGROUND: The use of dyes like Indocyanine green (ICG) and Patent blue facilitates the identification of lymphatic vessels during lymphaticovenous anastomosis (LVA) surgery. However, some patients experience "staining failure". In these cases, no stained lymphatic vessels can be detected, making supermicrosurgical LVA even more complex. OBJECTIVE: This study aims to investigate patient-related factors that may interfere with lymphatic vessel staining during LVA. METHODS: A retrospective study was conducted on 30 patient charts, focusing on patient characteristics and the staining quality of ICG and Patent blue dye. Statistical analyses were performed to identify correlations between variables. RESULTS: Significant correlations were found between higher age and secondary lymphedema, longer duration of lymphedema in male patients until surgery and reoccurring cellulitis and Patent blue staining. Notably, recurrent infections to the lymphatic system resulted in inferior staining ability during LVA surgery. CONCLUSIONS: Due to staining failure the detection of functional lymphatic vessels remains challenging in LVA surgery. A more extensive preoperative workup is recommended for patients with recurrent cellulitis to optimize surgical feasibility and procedure quality in LVA treatment for lymphedema.

Extracorporeal shock wave treatment of capsular fibrosis after mammary augmentation - Preliminary results.

Extracorporeal shock wave therapy has undergone continuous development and has become a well-established therapy option both in urology and in orthopaedics/trauma surgery. Experimental and clinical studies have proved the effectiveness of extracorporeal shock wave therapy in the treatment of connective tissue diseases such as fibromatosis. The pathomechanism of capsular fibrosis after augmentation of the female breast with silicone implants presents a series of analogies with mechanisms that are generally recognised to be associated with fibroproliferative diseases. The starting point of the disease is the inflammatory reaction caused by the silicone and/or by the sub-clinical bacterial contamination of the implant surface and can create an inflammatory reaction and fibrosis. A total of 19 cases of capsular fibrosis in 12 patients following insertion of mammary implants were treated with extracorporeal shock wave therapy. The therapy was performed with the Duolith SD1 system manufactured by Storz Medical. Shock waves were applied with the C-Actor handpiece designed for planar shock waves. Extracorporeal shock wave therapy appears to be a non-invasive, well-tolerated and easy-to-use procedure for pain reduction and fibrotic tissue softening, especially after aesthetic breast implant augmentation.

Lightweight implants in breast reconstruction.

OBJECTIVE: Since the first use of silicone implants by Cronin in 1962, there have been several attempts to introduce alternative filling materials for breast implants on the market. A promising new development are lightweight implants, whose filler material is one third lighter than conventional silicone gel. While these implants have been used primarily for aesthetic augmentation, a benefit could be expected particularly in post-mastectomy reconstruction. MATERIALS AND METHODS: Since 2019, 92 operations using lightweight implants have been performed at our clinic, 61 of them for breast reconstruction after mastectomy. These have been compared to 92 breast reconstructions using conventional silicone implants. RESULTS: The average volume of the lightweight implants was 30% higher than of the conventional implants (452 ml resp. 347 ml), whereas the implant weight was comparable in both groups (317 g resp. 347 g). Grade 3-4 capsular fibrosis was seen in 6 cases in both groups; revision was required 9 times (lightweight implants) and 7 times (conventional silicone implants) during the follow-up period. DISCUSSION: To our knowledge, this is the first study to investigate the use of lightweight implants in breast reconstruction. With exception of the filler material, the implants used in the two groups were comparable in shape and surface. The inserted lightweight implants had a greater volume but nearly the same weight as the conventional implants and were used in patients with a higher body mass index. Thus, lightweight implants were preferred in patients whose reconstruction required a larger implant volume. CONCLUSION: Lightweight implants are a new alternative for breast reconstruction especially in case that larger implant volume is demanded. The increased complication rate has to be verified in further studies.

Comparison of skin sensitivity following breast reconstruction with three different techniques: Autologous fat grafting, DIEP flap and expander/implant1.

BACKGROUND: Autologous fat grafting (AFG) has been established over the past two decades as an additive technique during and after breast reconstruction. Complete reconstruction of the breast mound with AFG alone represents an exceptional technique that has been published mostly in case reports or in studies with limited cases.The purpose of this study is to investigate the influence of three different techniques for breast reconstruction on the recovery of skin sensitivity at the reconstructed breast. METHODS: The study included 30 patients after mastectomy following breast cancer. Three groups were examined: A) breast reconstruction by autologous fat grafting (AFG), B) breast reconstruction by deep inferior epigastric artery perforator flap (DIEP) and C) breast reconstruction by expander/implant (TE).Biometric data were compared; sensitivity tests were performed using Semmes-Weinstein monofilaments.The non-operated, healthy contralateral breasts of the patients were used as a reference. RESULTS: While the traditional reconstruction techniques by microsurgical anastomosed perforator flap or expander/implant showed a strongly decreased or completely missing sensitivity of the skin, the tests after reconstruction by AFG represented high values of sensory recovery, which came close to the reference group of non-operated breasts. CONCLUSION: To our knowledge, this is the first study to compare skin sensitivity after AFG-based reconstruction to established techniques for breast reconstruction. We could demonstrate in a limited group of patients, that breast reconstruction by autologous fat grafting can achieve higher values of skin sensitivity compared to traditional techniques.

Intraoperative 3D Comparison of Round and Anatomical Breast Implants: Dispelling a Myth.

BACKGROUND: Thanks to 3D imaging, it is possible to measure the influence of different parameters on breast augmentation. In this study, we compare the effect of different shapes and sizes of breast implants on the topography of the resulting breast. Furthermore, the impact of different breast implants on inter-landmark distances and on changes of the nipple position was assessed. METHODS: This interventional prospective study was carried out on 10 female patients after collecting informed consent. 3D scans of the native and augmented breasts were performed intraoperatively with small, medium, and large sizes of both anatomical and round implants, resulting in a total of n = 130 single breast scans. These scans were analyzed for topographic shift quantification, nipple migration, and inter-landmark distances of the breast. RESULTS: Implant size, but not implant shape leads to significant topographic shifts of the breast (p < 0.001 and p = 0.900, respectively). Both round and anatomical implants lead to a significantly higher volumetric increase in the upper quadrants compared to the lower quadrants (p < 0.001). Nipple migration into the superomedial quadrant was seen in about 90% of augmentations. No evident differences in inter-landmark distances were observed when round and anatomical implants of different sizes were compared. CONCLUSIONS: Implant size rather than shape influences the postoperative aesthetic results. No significant difference in topographic shift was found comparing round and anatomical implants, suggesting that both implant shapes result in comparable aesthetic outcomes.

Recommendations for the Use of Antibiotics in Primary and Secondary Esthetic Breast Surgery.

The use of systemic prophylactic antibiotics to reduce surgical-site infection in esthetic breast surgery remains controversial, although the majority of surgeons prefer to utilize antibiotics to prevent infection. Nonetheless, postoperative acute and subclinical infection and capsular fibrosis are among the most common complications following implant-based breast reconstruction. After esthetic breast augmentation, up to 2.9% of women develop infection, with an incidence rate of 1.7% for acute infections and 0.8% for late infections. After postmastectomy reconstruction (secondary reconstruction), the rates are even higher. The microorganisms seen in acute infections are Gram-positive, whereas subclinical late infections involving microorganisms are typically Gram-negative and from normal skin flora with low virulence. In primary implantation, a weight-based dosing of cefazolin is adequate, an extra duration of antibiotic cover does not provide further reduction in superficial or periprosthetic infections. Clindamycin and vancomycin are recommended alternative for patients with ß-lactam allergies. The spectrum of microorganism found in late infections varies (Gram-positive and Gram-negative), and the antibiotic prophylaxis (fluoroquinolones) should be extended by vancomycin and according to the antibiogram when replacing implants and in secondary breast reconstruction, to target microorganisms associated with capsular contracture. All preoperative antibiotics should be administered <60 minutes before incision to guarantee high serum levels during surgical procedure.

Interleukin-6 trans-signaling is a candidate mechanism to drive progression of human DCCs during clinical latency.

Although thousands of breast cancer cells disseminate and home to bone marrow until primary surgery, usually less than a handful will succeed in establishing manifest metastases months to years later. To identify signals that support survival or outgrowth in patients, we profile rare bone marrow-derived disseminated cancer cells (DCCs) long before manifestation of metastasis and identify IL6/PI3K-signaling as candidate pathway for DCC activation. Surprisingly, and similar to mammary epithelial cells, DCCs lack membranous IL6 receptor expression and mechanistic dissection reveals IL6 trans-signaling to regulate a stem-like state of mammary epithelial cells via gp130. Responsiveness to IL6 trans-signals is found to be niche-dependent as bone marrow stromal and endosteal cells down-regulate gp130 in premalignant mammary epithelial cells as opposed to vascular niche cells. PIK3CA activation renders cells independent from IL6 trans-signaling. Consistent with a bottleneck function of microenvironmental DCC control, we find PIK3CA mutations highly associated with late-stage metastatic cells while being extremely rare in early DCCs. Our data suggest that the initial steps of metastasis formation are often not cancer cell-autonomous, but also depend on microenvironmental signals.

Breast sensitivity after mastectomy and autologous reconstruction.

BACKGROUND: Breast Carcinoma is the most common malign tumor disease in women. 20-30% of these tumors have to be treated by removing all of the breast tissue. After that kind of therapeutic procedure, most of the women are severely traumatized and ask for reconstruction. The goldstandard of breast reconstruction is the free perforator flap from the lower abdomen (DIEAP-flap), which can provide body-own tissue and natural shape for the reconstructed breast.Many studies evaluate the shape of the reconstructed breast but neglect the skin sensitivity. Claim of this study was to compare this important part of reconstruction on two different techniques of mastectomy. OBJECTIVE: In this retrospective study we evaluated which technique of mastectomy and breast reconstruction with DIEAP-Flap offers the highest outcome for sensibility of the reconstructed breast. Skin sparing mastectomy was compared with conventional mastectomy and the results of skin sensitivity were measured. METHODS: Ten patients underwent breast reconstruction with free abdominal perforator flap between 2011 and 2015 after conventional mastectomy (CM) and were compared with ten patients, who had a skin sparing mastectomy (SSM) with immediate reconstruction by DIEAP-flap during the same time interval. These two groups were matched by age, height, weight and the time between reconstruction and examination. The sensitivity of the skin was measured by Semmes-Weinstein-Filaments in the strength beginning from 0,07 g till 300 g for deep sensation. The logarithmic profile of these measurements had been transferred into a continuous data system beginning from 1 point, which stands for no sensation, till 7 points for pressure threshold of 0,07 g. RESULTS: Patients who underwent DIEAP-reconstruction after skin sparing mastectomy showed a higher sensation at all regions of the new breast in comparison to reconstruction after conventional mastectomy, beginning from the nipple to the areola and the breast skin. The results in the CM-group were 1.0 points at the mamilla, 1.33 pts. at the areola and 1.78 pts. at the breast skin. In the SSM-group, the findings were 3 pts. at the mamilla, 3.25 pts. at the areola and 5.25 pts. at the breast skin. CONCLUSION: The skin sparing mastectomy combined with immediate reconstruction by DIEAP-flap provides an excellent therapeutic option for patients, who are suitable for this technique, which takes into account not only the form but also the sensitivity of the breast.

Bacterial colonization is of major relevance for high-grade capsular contracture after augmentation mammaplasty.

Many studies indicate that subclinical bacterial colonization plays a pivotal role in capsular contracture. Nevertheless, it has not been clarified whether bacterial stimuli are only associated with high-grade (Baker III/IV) or low-grade (Baker I/II) capsular contractures. The study included 45 female patients suffering from unilateral capsular fibrosis following augmentation mammaplasty with silicone implants (smooth: n = 28; textured: n = 17). In total, there were 16 (35.6%) bacterially contaminated swabs. No significant difference could be detected between colonization rates of smooth (52.9%) and textured (25.0%) implants (z = 1.575, P = 0.115). Interestingly, no colonization was detected for Baker I/II contractures, but the colonization rate for Baker III/IV contractures amounted to 66.7%, showing a highly significant difference between the 2 groups (z = 4.351, P < 0.001). Our study shows significant differences in bacterial contamination rates between high-grade and low-grade capsular contractures. One might speculate that bacterial stimuli accelerate the process of inflammation and fibrosis in patients who tend to develop capsular fibrosis.

Surgical treatment of chronic phantom limb sensation and limb pain after lower limb amputation.

BACKGROUND: Therapy for phantom sensation and phantom limb pain following amputation is still difficult, because pathophysiologic mechanisms have not been clarified. This report illustrates a simple and useful surgical intervention. The authors propose that changes at the peripheral nerve site can influence the central feeling of phantom sensation and pain. METHODS: Fifteen patients (mean age, 56 years) with lower limb amputation were included in the study. In all patients, the sciatic nerve was split at a point approximately 3 cm proximal to the popliteal fossa, and the two parts were reconnected in a sling fashion using an epiperineurial technique under microscopic vision. The nerves were covered with a fibrin patch and anesthetics were applied by means of a local pain catheter. Frequency, duration, intensity, and quality of phantom pain were compared preoperatively and 1 week, 3 months, 6 months, and 1 year postoperatively. RESULTS: Fourteen of 15 patients defined the procedure as very helpful. Average, maximum, and minimum pain intensity were significantly reduced 1 week, 3 months, 6 months, and 1 year postoperatively (p < 0.001). Pain intensity scores decreased significantly over the long term after surgical intervention (median visual analogue scale score: preoperatively, 7; 1 year postoperatively, 4) (p < 0.001). The duration of pain attack shortened from approximately 120 minutes to 5 to 10 minutes. CONCLUSIONS: This study shows that accurate treatment of the peripheral nerve can help to successfully reduce phantom limb pain. The authors feel encouraged to perform future investigations to test their operative method in a prospective, randomized, matched control study including electrophysiologic tests for more objective pain assessment.