Implant-based Breast Reconstruction Infections: The Importance of Recognizing Local Pathogens.

BACKGROUND: Implant-based breast reconstruction (IBR) is the most common method of reconstruction for breast cancer. Bacterial infection is a well-known risk with reported rates ranging from 1% to 43%. The most common pathogens of breast implant infection described in the literature are Staphylococcus aureus, Staphylococcus epidermidis, and coagulase-negative staphylococci. However, the prevalence of other pathogens and their antibiotic sensitivity profile differs profoundly in different parts of the world. OBJECTIVES: To review the current literature and protocols with respect to our region and to determine a more accurate antibiotic protocol aimed at our specific local pathogens. METHODS: A retrospective review was conducted of all cases of clinically infected implant-based breast reconstruction in our institution from June 2013 to June 2019, as well as review of microbiologic data from around the world based on current literature. RESULTS: A total of 28 patients representing 28 clinically infected implant-based breast reconstruction were identified during the studied period. Thirteen patients (46.4%) had a positive bacterial culture growth, with P. aeruginosa being the most common microorganism identified (46.1%). Review of international microbiological data demonstrated significant variation at different places and time periods. CONCLUSIONS: Microbiological data in cases of infected breast reconstructions should be collected and analyzed in every medical center and updated every few years due to the variations observed. These data will help to adjust the optimal empirical antibiotic regimens given to patients presenting with infections after breast reconstruction.

Implications of Internal Mammary Lymph Node Sampling During Microsurgical Breast Reconstruction.

INTRODUCTION: Internal mammary lymph node (IMN) chain assessment for breast cancer is controversial; however, current oncologic data have shed new light on its importance. Metastatic involvement of the IMN chain has implications for staging, prognosis, treatment, and survival. Here, we analyzed our data gathered during sampling of the IMN and the oncologic treatment changes that resulted from our findings. METHODS: A retrospective chart review was performed on 581 patients who underwent free-flap breast reconstruction performed by the senior author. All dissected IMNs were submitted for pathological examination. Patient demographics, oncologic data, and the results of IMN sampling were reviewed. RESULTS: 581 patients undergoing 981 free flaps were identified. A total of 400 lymph node basins were harvested from 273 patients. Of these, nine had positive IMNs. Two of these nine patients had positive IMNs of the contralateral nonaffected breast. Five patients had positive axillary lymph nodes. Four patients had multifocal tumors, one of which was bilateral. Seven patients had an increase in cancer stage as a result of having positive IMNs. Six patients had a change in treatment: two patients required additional chemotherapy, one received adjuvant radiation therapy, and three necessitated both supplemental chemotherapy and radiation. CONCLUSIONS: Opportunistic biopsy of the IMN while dissecting the recipient vessels is simple and results in no added morbidity. We recommend that biopsy of the IMN chain be performed whenever internal mammary vessels are dissected for microsurgical anastomosis in breast cancer patients. Positive IMN involvement should encourage thorough oncological workup and treatment reevaluation. LEVEL OF EVIDENCE IV: Case series.

Functional abnormalities in iPSC-derived cardiomyocytes generated from CPVT1 and CPVT2 patients carrying ryanodine or calsequestrin mutations.

Catecholaminergic polymorphic ventricular tachycardia (CPVT) is an inherited arrhythmia characterized by syncope and sudden death occurring during exercise or acute emotion. CPVT is caused by abnormal intracellular Ca(2+) handling resulting from mutations in the RyR2 or CASQ2 genes. Because CASQ2 and RyR2 are involved in different aspects of the excitation-contraction coupling process, we hypothesized that these mutations are associated with different functional and intracellular Ca(²+) abnormalities. To test the hypothesis we generated induced Pluripotent Stem Cell-derived cardiomyocytes (iPSC-CM) from CPVT1 and CPVT2 patients carrying the RyR2(R420Q) and CASQ2(D307H) mutations, respectively, and investigated in CPVT1 and CPVT2 iPSC-CM (compared to control): (i) The ultrastructural features; (ii) the effects of isoproterenol, caffeine and ryanodine on the [Ca(2+) ]i transient characteristics. Our major findings were: (i) Ultrastructurally, CASQ2 and RyR2 mutated cardiomyocytes were less developed than control cardiomyocytes. (ii) While in control iPSC-CM isoproterenol caused positive inotropic and lusitropic effects, in the mutated cardiomyocytes isoproterenol was either ineffective, caused arrhythmias, or markedly increased diastolic [Ca(2+) ]i . Importantly, positive inotropic and lusitropic effects were not induced in mutated cardiomyocytes. (iii) The effects of caffeine and ryanodine in mutated cardiomyocytes differed from control cardiomyocytes. Our results show that iPSC-CM are useful for investigating the similarities/differences in the pathophysiological consequences of RyR2 versus CASQ2 mutations underlying CPVT1 and CPVT2 syndromes.

Human mesenchymal stem cells shift CD8+ T cells towards a suppressive phenotype by inducing tolerogenic monocytes.

The mechanisms underlying the immunomodulatory effects of mesenchymal stem cells (MSCs) have been investigated under extreme conditions of strong T cell activation, which induces the rapid death of activated lymphocytes. The objective of this study was to investigate these mechanisms in the absence of additional polyclonal activation. In co-cultures of peripheral mononuclear blood cells with human MSCs (hereafter referred to as hMSCs), we observed a striking decrease in the level of CD8 expression on CD8+ cells, together with decreased expression of CD28 and CD44, and impaired production of IFN-gamma and Granzyme B. This effect was specific to hMSCs, because it was not observed with several other cell lines. Downregulation of CD8 expression required CD14+ monocytes to be in direct contact with the CD8+ cells, whereas the effects of hMSCs on the CD14+ cells were essentially mediated by soluble factors. The CD14+ monocytes exhibited a tolerogenic pattern when co-cultured with hMSCs, with a clear decrease in CD80 and CD86 co-stimulatory molecules, and an increase in the inhibitory receptors ILT-3 and ILT-4. CD8+ cells that were preconditioned by MSCs had similar effects on monocytes and were able to inhibit lymphocyte proliferation. Injection of hMSCs in humanized NSG mice showed similar trends, in particular decreased levels of CD44 and CD28 in human immune cells. Our study demonstrates a new immunomodulation mechanism of action of hMSCs through the modulation of CD8+ cells towards a non-cytotoxic and/or suppressive phenotype. This mechanism of action has to be taken into account in clinical trials, where it should be beneficial in grafts and autoimmune diseases, but potentially detrimental in malignant diseases.

Partial breast reconstruction with mini superficial inferior epigastric artery and mini deep inferior epigastric perforator flaps.

In this study, partial breast reconstruction was undertaken after breast conservation therapy using mini abdominal free flaps on both an immediate and delayed basis.Patient demographics, oncologic status, reconstructive data, and complications were collected from medical records.Twelve patients (age range 39-60) were included in this study with a mean follow-up time of 5 years. Ten mini superficial inferior epigastric artery flaps and 2 mini deep inferior epigastric perforator flaps were used (7 immediate and 5 delayed reconstructions). No flap lost, 1 minor abdominal wound dehiscence, and no local or distant recurrences were noted. Good to excellent results were reported by 91% of the women.In properly selected patients with high motivation toward breast conservation, tailored abdominal mini-free flaps can safely and satisfactorily be implemented for the reconstruction of partial mastectomy defects. Patients should be comprehensively educated on the potential future implications of using the abdominal donor site for partial breast reconstruction.

Breast reconstruction after bilateral prophylactic mastectomy in women at high risk for breast cancer.

Several studies have shown the effectiveness of bilateral prophylactic mastectomies (BPM) at reducing the risk of developing breast cancer in women by more than 90%. A growing number of women at high risk for breast cancer are electing to undergo prophylactic mastectomy as part of a risk reduction strategy. This unique group of women frequently chooses to undergo reconstructive surgery as a part of their immediate treatment plan. Breast reconstruction after BPM has profound physiological and emotional impact on body image, sexuality, and quality of life. These factors should be taken into consideration and addressed when consulting the patient prior to BPM and reconstructive surgery. The timing of reconstructive surgery, the type of mastectomy performed, the reconstructive modalities available, and the possibility to preserve the nipple-areola complex, should all be discussed with the patient prior to surgery. In this article, we review our experience and the current existing literature on breast reconstruction for high-risk women after BPM.

The role of the plastic surgeon in dealing with soft tissue injuries: experience from the second Israel-Lebanon war, 2006.

During the 2006 war between Israel and Lebanon, 282 Israeli soldiers were evacuated to Rambam Health Care Campus. Of these, 210 were admitted for observation or treatment, and 15 of these were admitted to the Department of Plastic and Reconstructive Surgery. Thirty-five other soldiers, hospitalized in other departments, required the care of Plastic Surgeons, either for conservative or surgical treatment. The injury profile observed was consistent with data from previous low-intensity warfare, which demonstrated that over 80% of injuries were produced by fragmentation weapons, such as artillery, mortarshells, rockets, and missiles. It differs, however, from our experience in previous wars and our expectations regarding burn wounds, both in incidence and severity, which were significantly lower as compared with the past. This article presents our management of extensive soft tissue injuries, and details 3 representative cases. It highlights the role of the Plastic Surgeon as part of the whole treatment in this type of injury and helps to predict the needs of the medical system in preparation for the future.

Three-step management of a newborn with a giant, highly vascularized, cervical teratoma: a case report.

BACKGROUND: A giant congenital cervical teratoma is often highly vascularized; thus, in addition to a life-threatening airway occlusion at birth it comprises a high risk for significant and lethal blood loss during resection. In the case presented, an endovascular embolization of the carotid artery that supplied a giant congenital cervical teratoma was done as part of a three-stage treatment soon after birth and contributed to an overall good outcome. Embolization in cases of cervical teratomas was not described previously. CASE PRESENTATION: We present a case of a preterm newborn from a Sephardic jewish origin with a giant, highly vascularized, congenital cervical teratoma that was managed successfully in three stages: (1) delivery by an ex utero intrapartum treatment procedure after extensive preoperative planning and followed by tracheostomy, (2) endovascular embolization of the carotid artery that supplied the tumor in order to decrease blood loss during resection, and (3) complete surgical resection. The parents were involved in all the ethical and medical decisions, starting just after the cervical mass was diagnosed prenatally. CONCLUSION: The management of giant congenital cervical teratoma is often challenging from both a medical and ethical prospective. Meticulous perinatal planning and parents' involvement is crucial. Endovascular embolization of the tumor feeding vessels can significantly improve the resection outcome and overall prognosis.

Breast augmentation under general anesthesia versus monitored anesthesia care: a retrospective comparative study.

Breast augmentation is one of the leading esthetic surgeries, enjoying high satisfaction rates. Pain, nausea, and vomiting are frequent shortcomings of the immediate postoperative period. The aim of this study was to compare breast augmentation from the anesthetic point of view: general anesthesia (GA) versus monitored anesthesia care (MAC). The charts of 115 patients were reviewed in this retrospective study performed over a period of 2 years. Sixty-nine women chose to have the surgery done under MAC, and 46 under GA. Statistically significant differences were noted in both postoperative hospital stay (16.1 +/- 6.78 hours vs. 11.7 +/- 6.10 hours) and frequency of vomiting (mean, 0.5 vs. 0.22 times per patient) after GA and MAC, respectively (Mann-Whitney, P < 0.01). Postoperative pain, assessed using the visual analog scale, was significantly higher (mean visual analog scale, 5 vs. 3.27) when the prosthesis was placed in the submuscular plane compared with the subglandular plane (Mann-Whitney, P = 0.043). When offered a choice, more women preferred MAC over GA for their breast augmentation procedure. Less vomiting and shorter postoperative hospitalization were prominent in the MAC group.

Using intense pulsed light for cosmetic purposes: our experience.

The authors' experience using intense pulsed light for skin rejuvenation is summarized and analyzed with regard to its efficacy, safety, and complications. Rejuvenation using intense pulsed light was performed on 59 patients over a 6-month period (January of 2002 to July of 2002); these patients served as the study group. The areas treated were the face, neck, chest, hands, and legs. The parameters used during the procedure, patient satisfaction, and complications are described. Ninety-five percent of the patients included in the study had one or two sessions. Good to very good results were reported by 93.1 percent. Most patients had minor side effects and only three patients (5 percent) experienced complications (hyperpigmentation or scars). Intense pulsed light is an effective and safe method for skin rejuvenation. Its efficacy is mainly manifested by eliminating senile pigmentation and telangiectasias and a achieving a younger and fresher appearance of the skin. Although in the literature intense pulsed light skin rejuvenation is mainly reported for the face, the authors have obtained good results by using it for other areas of the body. The majority of the patients were satisfied. The authors conclude that intense pulsed light skin rejuvenation is a safe and effective method for facial and nonfacial rejuvenation.

Breast Reinnervation: DIEP Neurotization Using the Third Anterior Intercostal Nerve.

BACKGROUND: The purpose of this article is to evaluate a new method of DIEP flap neurotization using a reliably located recipient nerve. We hypothesize that neurotization by this method (with either nerve conduit or direct nerve coaptation) will have a positive effect on sensory recovery. METHODS: Fifty-seven deep inferior epigastric perforator (DIEP) flaps were performed on 35 patients. Neurotizations were performed to the third anterior intercostal nerve by directly coapting the flap donor nerve or coapting with a nerve conduit. Nine nonneurotized DIEP flaps served as controls and received no attempted neurotization. All patients were tested for breast sensibility in 9 areas of the flap skin-island and adjacent postmastectomy skin. Testing occurred at an average of 111 weeks (23-309) postoperatively. RESULTS: At a mean of 111 weeks after breast reconstruction, neurotization of the DIEP flap resulted in recovery of sensibility that was statistically significantly better (lower threshold) in the flap skin (P < 0.01) and statistically significantly better than in the native mastectomy skin into which the DIEP flap was inserted (P < 0.01). Sensibility recovered in DIEP flaps neurotized using the nerve conduit was significantly better (lower threshold) than that in the corresponding areas of the DIEP flaps neurotized by direct coaptation (P < 0.01). CONCLUSION: DIEP flap neurotization using the third anterior intercostal nerve is an effective technique to provide a significant increase in sensory recovery for breast reconstruction patients, while adding minimal surgical time. Additionally, the use of a nerve conduit produces increased sensory recovery when compared direct coaptation.

Reconstruction of congenital defects of the vagina.

Congenital absence of the vagina is a relatively rare condition most commonly associated with Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome. Historically, several reconstructive techniques have been described to provide for functional vaginal reconstruction on these patients, both operative and nonoperative. Although there are many advantages and disadvantages of the various procedures, one experience with the use of split thickness skin grafts to reconstruct the vagina has produced acceptable functional results with limited donor site morbidity. Careful planning and timing of this form of reconstruction can produce predictable results in patients who are nearing sexual maturity.

The utility of the posterior thigh flap for complex pelvic and perineal reconstruction.

BACKGROUND: Complex wounds of the pelvis and perineum commonly occur as a result of primary and secondary ablative procedures for colorectal and gynecologic malignancies, particularly following previous radiation therapy to these regions. In certain instances, the more traditional flaps such as the vertical rectus abdominis and gracilis flaps are either unavailable or unsuitable for the reconstruction of particular defects. The posterior thigh flap has been described previously for pelvic defects but has not become as widely accepted as other regional flaps. METHODS: This study sought to retrospectively review the authors' experience with the posterior thigh flap as an alternative to these more commonly performed transfers for difficult wounds of the perineum and pelvic structures. A total of 27 posterior thigh flaps were used in 19 patients for complex perineal wound closure. RESULTS: Successful transfer of the posterior thigh flap was noted in 26 of 27 flaps (11 unilateral and eight bilateral), with only one flap failure (3.7 percent). Primary wound healing was ultimately achieved in all patients; however, early wound-healing complications were common (53 percent). Secondary procedures were necessary in seven patients (37 percent), with only one patient requiring a secondary flap procedure. CONCLUSIONS: The authors found the posterior thigh flap to be a useful and reliable flap for coverage of complex perineal wounds. This was particularly true for those patients in whom a laparotomy was best avoided and those who have had both urinary and fecal diversion.

Multimodality gynecomastia repair by cross-chest power-assisted superficial liposuction combined with endoscopic-assisted pull-through excision.

Numerous methods of gynecomastia repair have been described to accomplish removal of breast tissue. Our multimodality surgical approach for the treatment of gynecomastia combines the use of power-assisted superficial cross-chest liposuction with direct pull-through excision of the breast parenchyma under endoscopic supervision. Seventeen patients, aging 17-39, underwent this multimodality approach. According to Simon's grading, 3 patients had grade 1, 5 had grade 2a, 6 had grade 2b, and 3 had grade 3 gynecomastia. Power-assisted liposuction was performed with a 3- or 4-mm triple-hole cannula inserted through the contralateral periareolar medial incision to suction the contralateral prepectoral fatty breast. At the end of the liposuction, the fibrous tissue was easily pulled through the ipsilateral stab wound and excised under endoscopic control. Follow-up time ranged from 6 to 34 months. The amount of fat removed by liposuction varied from 100-800 mL per breast, and the amount of breast parenchyma removed by excision varied from 20-110 g. All patients recovered remarkably well. No complications were recorded. All patients were satisfied with their results. This technique enables an effective treatment of both the fatty and fibrous tissue of the male breast and avoids skin redundancy due to skin contraction. A smooth masculine breast contour is consistently achieved without the stigma of this type of surgery.

Searching for the favorable donor site for fat injection: in vivo study using the nude mice model.

BACKGROUND: The use of suctioned fat grafts for correction of soft tissue defects is a widespread procedure in esthetic and reconstructive surgery. The main disadvantage of this simple and sensible procedure is the unpredictable absorption rate of the fat graft. A lot of research has been performed aiming for enhancement of the take of the fat grafts. OBJECTIVE: Our study was performed to find if there is any favorable donor site for fat harvesting. METHODS: This in vivo experiment using the nude mice model enables the study of the long-term survival of human fat in an animal model. The fat was harvested from three donor areas: the thigh, abdomen, and breast of a 48-year-old woman who came for an elective esthetic procedure. After centrifugation, 1 cc of fat was injected subcutaneously into the scalp of the nude mouse. There were 15 mice in each of the three groups, according to the selected donor sites. The animals were sacrificed 16 weeks after the procedure. The extracted fat was evaluated in terms of weight, volume, and six histologic parameters: integrity, vascularization, cyst formation, fibrosis, necrosis, and inflammation. RESULTS: This study could not find any statistically significant differences between the three investigated donor sites in the evaluated parameters. CONCLUSION: On the basis of this study, there is no favorable area for harvesting fat grafts. The donor site can be chosen according to the preference of the surgeon and the patient.

Hair removal using intense pulsed light (EpiLight): patient satisfaction, our experience, and literature review.

Applications for intense pulsed light (IPL) for hair removal are gaining favor among other methods, including lasers, because of its noninvasive nature, versatility regarding different skin and hair types, safety, and ease of use. Hair removal using IPL was performed from January 2002 to December 2003 on 108 consecutive patients. Eighty of these patients answered a questionnaire and were enrolled in the study group. The investigated parameters were hair and skin type, number of pulses, fluence, pulse duration, pulse delay, the filters used, and the treated area. The patient assessment of improvement (satisfaction) rate was graded from 1 to 5 points: 1, worse; 2, no improvement; 3, mild improvement; 4, good result; and 5, excellent result. The patients had between 1 and 13 treatments most of them during 2 to 6 sessions. Sixty-seven percent of the patients reported no complications. Prolonged erythema for more than 7 days was reported by 16.25%, blisters by 6.25%, temporary hyperpigmentation by 8.75%, leukotrichia was present in 1 case, and 1 case of persistent hypopigmentation was noted in a young girl. An increased number of complications and a decreased satisfaction rate were noted with higher skin types, but it was not statistically significant. Patients who underwent fewer treatments (1-3 treatments) were more satisfied compared with those who had more than 7 treatments (P < 0.02). Sixty percent of the patients rated their satisfaction to be good to excellent and 65% would ill recommend this treatment to their friends. To minimize the complication rate the authors found that the preset parameters should be adjusted at every treatment session according to the skin response at the previous one. Permanent hair removal cannot be guaranteed and it is not possible to predict the improvement rate. Nevertheless, based on patient satisfaction rate in this study, the authors recommend using IPL for hair removal.

Fate of exposed breast implants in augmentation mammoplasty.

Exposure of silicone breast implants usually leads to infection and extrusion. According to the literature, implant extrusion rates are not higher than 2% 1 and removal of the implant is recommended. 2 During the past 3 years, the authors dealt with eight implant exposures (six women: two cases of bilateral exposure and four cases of unilateral exposure). All the pockets were infected. Patients were offered two alternatives: immediate removal of the implant and reimplantation after a few months or conservative treatment with an effort to close the exposed area after the discharge stopped. All the patients in this study chose the latter alternative. Four out of eight implants were saved. The authors had to remove the other four. The average follow-up of these women was 2 years and there were no signs of capsular contracture or any other problems. According to this series, 50% of eight exposed breast implants could be saved with conservative treatment.