Impact of polyurethane versus acellular dermal matrix coating on prepectoral reconstruction outcomes: Interface does matter

BACKGROUND

Interfaces continue to be used in prepectoral breast reconstruction to refine breast appearance, but more clinical data are required to assess their effectiveness. This study compares the rates of capsular contracture, breast esthetics, and patient satisfaction between two commonly used interface materials, acellular dermal matrix (ADM) and polyurethane (PU) foam.

METHODS

A cross-sectional assessment was conducted on all patients who underwent prepectoral direct-to-implant reconstruction with an interface material between June 2018 and June 2022. We compared capsular contracture rates (assessed in-person), esthetic outcomes (evaluated by a three-member panel using a specially designed scale), and patient satisfaction (measured using the Breast-Q questionnaire) among the members of the interface groups.

RESULTS

Among the 79 reconstructed breasts (20 bilateral cases), 35 were reconstructed using ADM and 44 using PU implants. The ADM group had a significantly higher frequency of Baker III/IV capsular contracture compared with the PU group (14.3% vs. 0%, p = 0.014) and lower ratings from the panel in terms of capsular contracture (median 3.7 vs. 4.0, p < 0.001). PU reconstructions scored worse in implant visibility (median 2.3 vs. 3.3, p < 0.001) and rippling (median 3.0 vs. 3.7, p < 0.001). However, after appropriate adjustment for confounders, no significant differences in overall appearance and patient satisfaction were found.

CONCLUSIONS

ADM reconstructions are prone to capsular contracture with all their related esthetic issues, but PU implants have certain cosmetic flaws, such as implant visibility and malposition. Since each technique has its own limitations, neither the experienced surgeons nor patients exhibited a clear preference for either approach.

A Two-Year Retrospective Analysis of the Clinical Outcomes of Immediate Submuscular Breast Reconstructions With Native® Acellular Dermal Matrix

BACKGROUND

Implant-based submuscular breast reconstruction (SBR) can be performed with the aid of acellular dermal matrices (ADM) for implant coverage on their inferolateral pole, aiming at providing a biological interface for hiding the implant and therefore reducing the risk of complications. The purpose of this study is to assess the long-term post-operative outcomes obtained using the SBR-specific Native® ADM (DECO med s.r.l., Marcon, Venice, Italy).

METHODS

All cases of Native®-assisted immediate SBR performed at our institution between October 2016 and March 2020 were retrospectively analysed. Demographic and surgical data were collected, and post-operative outcomes, including minor and major complications, were evaluated. Particular attention was paid to complications emerging before and after patient discharge. Dependence analyses were performed to uncover statistically significant relationships between risk factors and reconstructive outcomes.

RESULTS

Data on 100 patients were collected, for a total of 128 breasts. The mean age of the cohort was 49.5 years, the mean BMI was 23.4 kg/m2, and the mean follow-up was 24 months. Out of this, 14.1% of patients received pre-operative radiotherapy, while 16.4% underwent post-mastectomy radiotherapy. Breasts appeared to develop short-term minor complications more likely during hospitalisation (11.7% vs. 7.8%), while short-term major complications occurred more often after discharge (7.8% vs. 15.6%). The most frequent long-term complications were capsular contracture and contour defects (both 9.4%). Risk factors that showed a statistically significant relationship with complications were pre- and post-mastectomy radiotherapy and post-operative chemotherapy.

CONCLUSIONS

The retrospective analysis showed results in line with clinical outcomes reported in the literature for the same reconstructive technique. The use of Native® ADM in SBR is safe and effective in the long term.

Therapeutic Reduction Mammoplasty: Experience of a Single Institute

INTRODUCTION

Breast cancer is the most common malignancy in women worldwide as reported by the World Health Organization. The concept of oncoplastic breast surgery appeared as an extension of breast-conserving surgery, applying breast reduction techniques with more acceptable aesthetic and functional outcomes. The purpose of the present study was to describe the breast cancer population of a single institute submitted to lumpectomy and bilateral immediate breast reduction or mastopexy and its complications.

MATERIAL AND METHODS

This is a retrospective observational study including patients submitted to lumpectomy and immediate bilateral breast reduction or mastopexy. Patients and tumour characteristics, surgical technique, complications, follow-up period, and recurrence data were obtained and analyzed.

RESULTS

A total of 49 patients were submitted to lumpectomy and bilateral breast therapeutic reduction/mastopexy, with a mean age of 56.47 ±8.58 years and a mean body mass index of 28.68kg/m² ±3.94 kg/m² between January 2019 and December 2021. Invasive tumours of no specific type, associated or not, with carcinoma intraductal in situ were the most common histological type corresponding to almost 80% of the cases with T1 stage corresponding to more than half of the cases. Sixteen percent of the patients had early minor complications with wound dehiscence associated with wound delayed healing, corresponding to 75% of the cases. Body mass index had a statistical difference between groups (p=0,006, t-test).

CONCLUSIONS

The low rates of minor and major complications show that immediate therapeutic breast reduction can be a suitable approach in selected cases.

ESPRAS Survey on Breast Reconstruction in Europe

BACKGROUND

 The European Leadership Forum (ELF) of the European Society of Plastic, Reconstructive and Aesthetic Surgery (ESPRAS) previously identified the need for harmonisation of breast reconstruction standards in Europe, in order to strengthen the role of plastic surgeons. This study aims to survey the status, current trends and potential regional differences in the practice of breast reconstruction in Europe, with emphasis on equity and access.

MATERIALS AND METHODS

 A largescale web-based questionnaire was sent to consultant plastic and reconstructive surgeons, who are experienced in breast reconstruction and with understanding of the national situation in their country. Suitable participants were identified via the Executive Committee (ExCo) of ESPRAS and national delegates of ESPRAS. The results were evaluated and related to evidence-based literature.

RESULTS

 A total of 33 participants from 29 European countries participated in this study. Overall, the incidence of breast reconstruction was reported to be relatively low across Europe, comparable to other large geographic regions, such as North America. Equity of provision and access to breast reconstruction was distributed evenly within Europe, with geographic regions potentially affecting the type of reconstruction offered. Standard practices with regard to radiotherapy differed between countries and a clear demand for European guidelines on breast reconstruction was reported.

CONCLUSION

 This study identified distinct lack of consistency in international practice patterns across European countries and a strong demand for consistent European guidance. Large-scale and multi-centre European clinical trials are required to further elucidate the presented areas of interest and to define European standard operating procedures.

Negative pressure wound therapy for skin graft closure in complex pilonidal disease

Pilonidal disease occurs in 26 in 100 000 people, affecting mainly men aged 20-30 years. It is treated by a variety of surgical techniques; however, there is a lack of consensus on the optimal choice of treatment for complex pilonidal disease. In addition, there is no consensus regarding care of the wound after surgery. Negative pressure wound therapy applied to open wounds following pilonidal disease surgery has been suggested as a way to decrease healing times and costs and is an emerging option for complex and or recurrent pilonidal disease. This study describes a case of complex pilonidal disease managed with local excision and negative pressure wound therapy followed by a split-thickness skin graft.

Microsurgical reconstruction of the maxilla: Algorithm and concepts

INTRODUCTION

The main purpose of this article is to highlight free tissue transfers as the first-choice method for three-dimensional (3D) maxillary reconstruction, particularly in providing enough bone for palate and maxillary arch reconstruction and consequently an implant-retained prosthesis. To achieve this, the myosseous free iliac crest was selected whenever possible as the first choice inside the reconstructive algorithm and free flap armamentarium. A new maxillectomy classification and algorithm reconstruction are proposed. Technical modifications and improvements accomplished over time are discussed, considering palate, dental implants and prosthesis, nasal sidewall, cranial base and dura, as well as recipient vessels. We present functional and aesthetic outcomes of the senior author's past 24-year experience (H. C.) with complex midface reconstructions.

MATERIAL AND METHODS

The authors report and analyse a 24-year experience with 57 midface defects in 54 patients (30 males and 24 females). A total of 57 maxillary defects - classified as Class I (limited maxillectomy) = 12, Class II (subtotal maxillectomy) = 15, Class III (total maxillectomy) = 19 and Class IV (orbitomaxillectomy) = 11 - were analysed regarding sex, age, tumour recurrence, free flap, reconstruction and necrosis. In addition, functional outcomes were evaluated regarding diet, speech, globe position and vision, while aesthetic outcomes were evaluated by patient and surgeon scores.

RESULTS

A total of 52 free flaps were performed in 47 patients; three patients were operated upon twice; and two other patients needed two sequentially linked flow-through flaps. The free flap survival was 96% with two total flap losses (4%). The other seven patients were fitted with a soft tissue-retained obturator prosthesis.

CONCLUSIONS

Microsurgical vascularised osteomyocutaneous free flaps are actually the gold standard for reconstruction of complex defects following maxillectomy. This algorithm is based on the anatomofunctional defect of the maxilla and it facilitates flap selection, which is a must.

Fetal face: the whole picture

The fetal face is an essential source of information. Its evaluation makes it possible to diagnose several fetal diseases and syndromes. Three-dimensional ultrasound and four-dimensional ultrasound facilitate the evaluation of superficial anatomical facial structures and have become essential complementary tools to two-dimensional ultrasound, providing additional and more precise information about the presence and severity of facial defects. This article reviews the normal facial development essential to understand the pathogenesis of facial malformations as well as the assessment of a normal and dysmorphic face with two-dimensional, three-dimensional and four-dimensional ultrasound and discusses the clinical implications of detecting facial anomalies in the prenatal period.

Pulmonary eosinophilia in a murine model of allergic inflammation is attenuated by small molecule alpha4beta1 antagonists

Inhibition of alpha4beta1/vascular cell adhesion molecule-1 (VCAM-1) interactions have therapeutic potential in treating allergic airway disease because of the importance of these adhesion molecules in the trafficking of eosinophils, lymphocytes, and monocytes. We examined several small molecule inhibitors of alpha4beta1/VCAM-1 interactions with in vitro potencies (IC(50) values) ranging from 0.52 nM (CP-664511; 3-[3-(1-[2-[3-methoxy-4-(3-O-tolyl-ureido)phenyl]-acetylamino]-3-methyl-butyl)isoxazol-5-yl]-propionic acid) to 38.5 nM (CP-609643; 3-[3-methyl-1-[2-[4-(3-O-tolyl-ureido)-phenyl]-acetylamino]-butyl)-isoxazol-5-yl]-propionic acid). The same compounds were evaluated in vivo using a murine model of ovalbumin-induced pulmonary eosinophilia. In this model, systemic administration of antibodies against alpha4 reduced bronchoalveolar lavage (BAL) eosinophilia approximately 60%. Small molecule alpha4beta1 antagonists were administered by intratracheal instillation and demonstrated dose-dependent inhibition of BAL eosinophil numbers and achieved a maximum inhibition of approximately 60%. In general, the rank order of potency for these compounds in vitro was consistent with that observed in vivo, which confirms that their efficacy is likely via blockade of alpha4beta1/VCAM-1 interactions. The most potent compound, CP-664511, also inhibited BAL eosinophilia following s.c. administration (1-10 mg/kg, s.c.). These data support the utility of small molecule alpha4beta1 antagonists in the treatment of relevant diseases, such as asthma.

The influence of age on propofol pharmacodynamics

BACKGROUND

The authors studied the influence of age on the pharmacodynamics of propofol, including characterization of the relation between plasma concentration and the time course of drug effect.

METHODS

The authors evaluated healthy volunteers aged 25-81 yr. A bolus dose (2 mg/kg or 1 mg/kg in persons older than 65 yr) and an infusion (25, 50, 100, or 200 microg x kg(-1) x min(-1)) of the older or the new (containing EDTA) formulation of propofol were given on each of two different study days. The propofol concentration was determined in frequent arterial samples. The electroencephalogram (EEG) was used to measure drug effect. A statistical technique called semilinear canonical correlation was used to select components of the EEG power spectrum that correlated optimally with the effect-site concentration. The effect-site concentration was related to drug effect with a biphasic pharmacodynamic model. The plasma effect-site equilibration rate constant was estimated parametrically. Estimates of this rate constant were validated by comparing the predicted time of peak effect with the time of peak EEG effect. The probability of being asleep, as a function of age, was determined from steady state concentrations after 60 min of propofol infusion.

RESULTS

Twenty-four volunteers completed the study. Three parameters of the biphasic pharmacodynamic model were correlated linearly with age. The plasma effect-site equilibration rate constant was 0.456 min(-1). The predicted time to peak effect after bolus injection ranging was 1.7 min. The time to peak effect assessed visually was 1.6 min (range, 1-2.4 min). The steady state observations showed increasing sensitivity to propofol in elderly patients, with C50 values for loss of consciousness of 2.35, 1.8, and 1.25 microg/ml in volunteers who were 25, 50, and 75 yr old, respectively.

CONCLUSIONS

Semilinear canonical correlation defined a new measure of propofol effect on the EEG, the canonical univariate parameter for propofol. Using this parameter, propofol plasma effect-site equilibration is faster than previously reported. This fast onset was confirmed by inspection of the EEG data. Elderly patients are more sensitive to the hypnotic and EEG effects of propofol than are younger persons.

The influence of method of administration and covariates on the pharmacokinetics of propofol in adult volunteers

BACKGROUND

Unresolved issues with propofol include whether the pharmacokinetics are linear with dose, are influenced by method of administration (bolus vs. infusion), or are influenced by age. Recently, a new formulation of propofol emulsion, containing disodium edetate (EDTA), was introduced in the United States. Addition of EDTA was found by the manufacturer to significantly reduce bacterial growth. This study investigated the influences of method of administration, infusion rate, patient covariates, and EDTA on the pharmacokinetics of propofol.

METHODS

Twenty-four healthy volunteers aged 26-81 yr were given a bolus dose of propofol, followed 1 h later by a 60-min infusion. Each volunteer was randomly assigned to an infusion rate of 25, 50, 100, or 200 microg x kg(-1) x min(-1). Each volunteer was studied twice under otherwise identical circumstances: once receiving propofol without EDTA and once receiving propofol with EDTA. The influence of the method of administration and of the volunteer covariates was explored by fitting a three-compartment mamillary model to the data. The influence of EDTA was investigated by direct comparison of the measured concentrations in both sessions.

RESULTS

The concentrations of propofol with and without EDTA were not significantly different. The concentration measurements after the bolus dose were significantly underpredicted by the parameters obtained just from the infusion data. The kinetics of propofol were linear within the infusion range of 25-200 microg x kg(-1) x min(-1). Age was a significant covariate for Volume2 and Clearance2, as were weight, height, and lean body mass for the metabolic clearance.

CONCLUSIONS

These results demonstrate that method of administration (bolus vs. infusion), but not EDTA, influences the pharmacokinetics of propofol. Within the clinically relevant range, the kinetics of propofol during infusions are linear regarding infusion rate.