Breast implant surface topography triggers a chronic-like inflammatory response

Breast implants are extensively employed for both reconstructive and esthetic purposes. However, the safety of breast implants with textured surfaces has been questioned, owing to a potential correlation with anaplastic large-cell lymphoma and the recurrence of breast cancer. This study investigates the immune response elicited by different prosthetic surfaces, focusing on the comparison between macrotextured and microtextured breast implants. Through the analysis of intraoperatively harvested periprosthetic fluids and cell culture experiments on surface replicas, we demonstrate that macrotextured surfaces elicit a more pronounced chronic-like activation of leucocytes and an increased release of inflammatory cytokines, in contrast to microtextured surfaces. In addition, in vitro fluorescent imaging of leucocytes revealed an accumulation of lymphocytes within the cavities of the macrotextured surfaces, indicating that the physical entrapment of these cells may contribute to their activation. These findings suggest that the topography of implant surfaces plays a significant role in promoting a chronic-like inflammatory environment, which could be a contributing factor in the development of lymphomas associated with a wide range of implantable devices.

Persistent Conjunctival Chemosis after Lower Lid Blepharoplasty: A Comparison of Different Surgical Techniques

Background: Conjunctival chemosis, a complication of lower blepharoplasty, can cause persistent discomfort and functional disturbances with worsening in the postoperative period following surgery. Methods: A review of the records of the lower blepharoplasty procedures carried out at the Humanitas Research Hospital, Rozzano, Milan, Italy was performed. Patients were categorized into two groups depending on the procedure performed: (1) transconjunctival blepharoplasty with the removal of the fatty lodges with canthopexy and (2) transcutaneous blepharoplasty with the removal of the fatty lodges with lateral canthoplasty. Each group was further divided into two more groups based on the surgical method used, that is either (a) cold blade and disposable cautery or (b) radiofrequency cut and coagulation and colorado tip (respectively 1a, 1b, 2a and 2b). All patients underwent a postoperative follow-up up to 24 months, which included an evaluation of cosmetic appearance, eyelid scarring and the severity of chemosis. The aim of the study was to investigate which of the surgical procedures causes a lower incidence of persistent type 3 conjunctival chemosis. Results: A total of 1047 patients who underwent lower lid blepharoplasty were included in the study. A total of 512 patients underwent transcutaneous blepharoplasty and 535 underwent the transconjunctival procedure. Among the first group of patients, 266 belong to group 1a and 246 to group 1b. In the second group, 264 were categorized as group 2a and 271 as group 2b. The incidence of type 3 chemosis in the transcutaneous blepharoplasty procedure with lateral canthoplasty was statistically significantly higher than in the transconjunctival approach, considering both the cold blade and the radiofrequency (p = 0.012, 0.010, 0.006, 0.004, respectively). Conclusions: A higher incidence of persistent type 3 conjunctival chemosis is associated with lateral canthus surgery and with the use of radiofrequency.

CD304 + adipose tissue-derived mesenchymal stem cell abundance in autologous fat grafts highly correlates with improvement of localized pain syndromes

ABSTRACT

Surgery, burns or surgery-free accident are leading causes of scars with altered tissue consistency, a reduced degree of motion and pain. Autologous fat grafting can dramatically improve tissue consistency and elasticity but less frequently results in the reduction of pain. Therefore, we analyzed different cell populations present within the adipose tissue to be engrafted and correlated them with the reduction of pain after surgery. Here, we identify a population of CD3 - CD4 - CD304 + cells present in grafted adipose tissue, whose abundance highly correlates with pain improvement shortly after surgery ( r2 = 0.7243****) as well as persistently over time (3 months later: r2 = 0.6277****, 1 year later: r2 = 0.5346***, and 4 years later: r2 = 0.5223***). These cells are characterized by the absence of the hematopoietic marker CD45, whereas they express CD90 and CD34, which characterize mesenchymal stem cells (MSCs); the concomitant presence of CD10 and CD73 in the plasma membrane supports a function of these cells in pain reduction. We deduce that the enrichment of this adipose tissue-derived MSC subset could enhance the therapeutic properties of adipose grafts and ameliorate localized pain syndromes.

Oncoplastic and reconstructive surgery in SENONETWORK Italian breast centers: lights and shadows

•Despite the significance of oncoplastic procedure, an italian database is lacking. •Senonetwork established a multidisciplinary survey to assess their safety and efficacy. •Reconstructive outcomes were positive across low and high-volume centers. •After mastectomy, implant-based techniques are common. DTI reconstruction is advantageuos. •This contributes to the global understanding of effective strategies against breast cancer.

Rejuvenation in Men Facial Aging: A Combined Approach

Facelift surgery, also known as rhytidectomy, is a popular cosmetic procedure aimed at reversing the signs of facial aging. While facelift surgery is more commonly performed in women, an increasing number of men are seeking this procedure to maintain a youthful appearance. The long recovery period conflicts the overall primary outcome anticipated by men undergoing rhytidectomy, i.e., appear younger, youthful, and ready to reaffirm their value in the working environment. Anterior direct neck lift, blepharoplasty (upper and lower eyelid blepharoplasty), and lipofilling are three techniques that have been shown to be effective in improving facial rejuvenation outcomes in elderly male patients. However, there is little to no evidence of the safety and efficacy of these techniques when used in combination. By combining these techniques, we hypothesized that we could achieve outcomes comparable to traditional facelift surgery, but with a lower risk of complications and a shorter recovery time. We conducted a retrospective case series study of 18 male patients who underwent facial rejuvenation surgery using the combination of anterior direct neck lift, blepharoplasty (upper and lower eyelid blepharoplasty), and lipofilling at our institution between 2018 and 2021. All 18 patients completed the study, with an average follow-up of 12 months. No major complications were observed, and all patients reported a high level of satisfaction with their outcomes.Level of Evidence IV 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 .

Mechanically Activated Adipose Tissue as a Source for Novel Therapies in Neurological Disease/Injury

In this review, we describe a new avenue that involves the therapeutic use of human adipose tissue. In the past two decades, thousands of papers have described the potential clinical use of human fat and adipose tissue. Moreover, mesenchymal stem cells have been a source of great enthusiasm in clinical studies, and these have generated curiosity at academic levels. On the other hand, they have created considerable commercial business opportunities. High expectations have emerged for curing some recalcitrant diseases or reconstructing anatomically defective human body parts, but several concerns have been raised by generating criticism on the clinical practice that have not been substantiated by rigorous scientific evidence. However, in general, the consensus is that human adipose-derived mesenchymal stem cells inhibit the production of inflammatory cytokines and stimulate the production of anti-inflammatory cytokines. Here, we show that the application of a mechanical elliptical force for several minutes to human abdominal fat activates anti-inflammatory properties and gene-related expression. This may pave the way for new unexpected clinical developments.

Case report: a step-by-step body contouring approach in a case of young patient with CLOVES syndrome

CLOVES syndrome is a rare overgrowth disorder caused by gene mutations. This case study describes a 28-year-old woman with CLOVES syndrome who underwent multiple surgeries to achieve a positive outcome while preserving lymphovascular structures. The report underscores the importance of a multidisciplinary approach and tailored surgical interventions for managing CLOVES.

Topical Tranexamic Acid: Risks, Benefits and Novel Complications in Aesthetic Plastic Surgery

Antifibrinolytics, particularly tranexamic acid (TXA), are agents used to reduce bleeding. TXA is a synthetic reversible competitive inhibitor to the lysine receptor found on plasminogen. By reversibly binding to this site, it leads to plasminogen being unable to bind to fibrin and so prevents fibrinolysis, this stabilizes the clot and thus prevents hemorrhage. (Pekrul in Der Anaesth 70:515-521, 2021) It can be used either intravenously or topically but has never entered mainstream use in plastic surgery. (Pekrul in Der Anaesth 70:515-521, 2021) This is most likely due to understandable fears of thromboembolic events. On the other hand, the tempting benefits are reduced bleeding (perioperatively) decreased bruising and swelling, and thus increased aesthetic, important for obvious reasons. A review of the literature was done to go deeper on this issue, examining topical use in aesthetic surgery. Clear benefit was shown in the literature, it could be postulated that it would not be unwise to consider more research on topical use of TXA in certain cases, the benefits could greatly outweigh the risks. Old fears and conceptions, unsupported by the literature at the time of writing, should not hold back further research, and the benefits shown could even potentially justify the topical use of these agents in the near future. Further studies evaluating the utility of TXA in Panniculectomy and Abdominoplasty surgery should be performed especially, since only one was found which reported no significant benefit. Minor complications were present, such as minor delayed post-auricular skin healing, temporary unilateral marginal mandibular neuropraxia and increased cumulative seroma volume. These were novel findings and could warrant further investigation as well. After performing a review of the literature, it was seen that topical TXA generally adds benefit in aesthetic plastic surgery, with no particularly significant complications. We would like to bring more attention to the issue and support more studies on TXA use. 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 .

Literature Review: Venous Thromboembolism Prophylaxis in Plastic Surgery

Venous thromboembolism (VTE) is a postoperative complication experienced in all branches of surgery, including plastic surgery. Its occurrence can be lowered with adequate prophylaxis in the light of the patient's risk category and the type of surgery that will be performed. Nevertheless, thromboembolic prophylaxis is not routinely administered in plastic surgery. The prevention of VTE has gained significant attention in the past 5 years due to increased knowledge about the disease process and the alarming incidence rates. This literature review is specifically aimed at carrying out a synopsis of VTE prophylaxis trials conducted on plastic surgery patients. Antithrombotic agents have generally been avoided by plastic surgeons due to the increased risk of bleeding or hematomas; however, the prevalence of clinically important bleeding has not been found to increase with their use, as it emerges from numerous studies. VTE events can lead to increased morbidity and mortality rates, as well as a rise in healthcare costs. As it emerges from multiple studies, as a preventive measure against VTE, it is strongly advised to use mechanical prophylaxis along with low-molecular-weight heparin as the primary treatment option for plastic surgery patients who are at a greater risk. Up to date though, this practice is not commonly embraced by physicians. Preventing VTE is crucial, and measures to do so are necessary. However, there is no clear evidence to support the use of anticoagulation for plastic surgery patients, and some surgeons are hesitant to use it due to potential bleeding in extensive dissection areas.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 .

Implant-Based Breast Reconstruction: Impact of Body Mass Index on Postoperative Complications and Aesthetic Results: A 5-Year, Single-Center Study

BACKGROUND

Increasing adoption of implant-based breast reconstruction (IBR) has raised expectations regarding postoperative outcomes and aesthetic results. BMI has been extensively explored as a predictor of complications. This study is the first to examine complication rates in underweight subjects, and compares these rates among underweight, normal weight, overweight, and obese patients.

OBJECTIVES

The aim of this study was to investigate the influence of BMI on postoperative complications and aesthetic results in IBR following mastectomy.

METHODS

Retrospective analysis encompassed patients undergoing mastectomy with subsequent IBR, performed by a collaborative team of breast and plastic surgeons. Demographics, treatment specifics, and outcomes were evaluated by univariate and multivariate regression models. Significance was determined at P < .05.

RESULTS

In total, 1046 IBRs were performed in 921 patients, of whom 63 had a BMI <18.5 kg/m2, 572 were normal weight, 215 were overweight, and 71 were obese. Significantly higher complication rates were observed in both obese and overweight patients compared with normal-weight patients (P < .001). Each unit increase in BMI correlated to 7% increased odds of overall complications and 13% increased odds of reconstructive failure. Underweight individuals had higher capsular contracture rates than normal-weight patients, 14.3% vs 3.65%, respectively (P = .001). In addition, aesthetic complications rates in underweight patients were higher than in normal-weight patients, 36.4% vs 25.7%, respectively (P < .05).

CONCLUSIONS

This study confirmed BMI to be a strong predictor of postoperative complications and aesthetic outcomes, and demonstrates that low BMI has a significant impact on the incidence of capsular contracture and aesthetic complications.

LEVEL OF EVIDENCE: 3

Immune-related gigantomastia: a case study

PD-1/PDL-1 inhibitors have revolutionized cancer treatment, especially in lung cancer. Despite their efficacy, a new spectrum of side effects, called immune-related adverse events, may occur and their management could be difficult. Gigantomastia, a rare condition characterized by excessive growth of the breasts, has been associated with some drugs, but no correlation with immunotherapy has ever been reported. Here, we report the case of a possible immune-related gigantomastia.

On the Safety of Implanted Breast Prostheses in Accidental Impacts

The employment of breast silicone implants, both in aesthetic and reconstructive medicine, is widespread thanks to their recognized biocompatibility and durability. Some critical situations, for example, in the case of accidental impacts, may induce concerns by potential patients about their use. Dynamic tests reproducing frontal impacts at speeds up to 90 km/h, with anthropomorphic dummies carrying 330 cc prostheses and wearing safety belts, were conducted. Tests showed a significant probability of internal gel loss following implant damage at the highest speed. Moreover, considering that prostheses may remain implanted for many years, the effects of accelerated aging at 37 °C, 60 °C, 75 °C and 90 °C in physiological solution were also investigated. Tensile tests of the shell material and compressive tests of the full prosthesis showed evidence of variation in the prostheses' mechanical characteristics after aging, which affects their stiffness, deformability and strength. These results stress the importance of medical investigations for possible damages of the implanted prostheses in the case of an accident.

Surgical Tips for Aesthetic Lower Lid Blepharoplasty: Prevention of Round Eye

In the present study, we highlight surgical tips based on our experience in lower eyelid blepharoplasty. These have been shown to be crucial in the prevention of several complications, specifically lateral lower-lid displacement.

Methods

A series of bilateral lower-lid blepharoplasties were performed on 280 patients at Humanitas-Research-Hospital (Milan, Italy) between January 2016 and January 2020. Patients with a history of lower-lid blepharoplasty and patients requiring canthopexy/canthoplasty were excluded. Needing to singularly evaluate and correct several lower-eyelid structures to obtain a harmonic result, we preoperatively assessed the amount of skin excess, the eyelid margin malposition relative to the globe, and the presence/absence of herniated fat-pads. Pre- and postoperative standard photographs were collected. Patients were evaluated by measuring scleral show, snap-back test, and distraction test. Blinded-fashioned photograph analysis was performed by independent plastic and oculoplastic surgeons who did not execute the procedures. A visual analogue scale was administered to all patients to assess satisfaction.

Results

In total, 280 patients underwent successful lower blepharoplasty, with satisfactory results of scleral show, snap-back test, and distraction test. Of the 280 patients, four presented postoperative complications. At 10-month follow-up visit, we achieved a mean patient visual analogue scale satisfaction score of 8.4. Postoperative surgeon's photographs mean score was 4.5.

Conclusions

Without the use of muscle flaps, our technique averts tarsal ligament misposition, preserves orbicularis-muscle innervation, and limits thermal spread, assuring excellent stability of results and high patient and surgeon satisfaction. Cosmetic outcome in terms of symmetry, appearance, and lower lid line definition revealed high satisfaction with the result over time, with a remarkably low complication rate.

Comment on "Reverse Expansion Following Nipple Sparing Mastectomy: A Natural, Safe and Effective Autologous Technique for Breast Reconstruction"

Level of Evidence IV 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 .

Pathologic response and residual tumor cellularity after neo-adjuvant chemotherapy predict prognosis in breast cancer patients

INTRODUCTION

Residual tumor cellularity (RTC) and pathologic complete response (pCR) after neo-adjuvant chemotherapy (NAC) are prognostic factors associated with improved outcomes in breast cancer (BC). However, the majority of patients achieve partial pathologic response (pPR) and no clear correlation between RTC patterns and outcomes was described. Our aims were to define predictive factors for pCR and compare different outcomes of patients with pCR or pPR and with different RTC patterns.

MATERIALS AND METHODS

Baseline and post-NAC demographics, clinicopathological characteristics, post-operative data, survival and recurrence status were recorded from our institutional database. A multivariable analysis was performed using a logistic regression model to identify independent predictors of pCR. Disease-free survival (DFS), distant disease-free survival (DDFS), and overall survival (OS) analyses were performed using the Kaplan-Meier method.

RESULTS

Overall, of the 495 patients analyzed, 148 (29.9%) achieved pCR, 347 (70.1%) had pPR, and the median RTC was 40%. Multivariable analysis identified 3 independent factors predictive of pCR: tumor stage before NAC (cT1-2 84.5% versus cT3-4 15.5%), BC sub-type (HER2-positive 54.7% versus triple-negative 29.8% versus luminal-like 15.5%), and vascular invasion (absence 98.0% versus presence 2.0%). We found statistically significant longer DFS, DDFS, and OS in patients with pCR and with RTC <40%; no difference was observed in terms of OS between RTC <40% and RTC ≥40% groups.

CONCLUSIONS

Tumor stage before NAC, BC sub-type, and vascular invasion are significant and independent factors associated with pCR. Patients with pCR and with RTC <40% have longer DFS, DDFS, and OS compared with patients with pPR.

Smartphone Dynamic Infrared Thermography for Harvesting AICAP Flap in a Large Breast-conservative Surgery

Flaps based on perforators of the intercostal arteries have been described for the reconstruction of defects resulting from partial mastectomies. Dynamic infrared thermography (DIRT) identifies hot spots that accurately correspond to and evaluate perforator vessels toward the skin. The new generation of portable thermal cameras has become smaller, less expensive, more sensitive, and compatible with common smartphones. One option is the FLIR ONE system (FLIR Systems, Inc., Wilsonville, OR), a smartphone-compatible thermal camera. Despite its lower resolution, compared with the larger infrared camera models, it represents a viable option for thermal skin mapping, and its compact nature allows for easy portable use. The purpose of this article is to report a case of a preoperative study with smartphone DIRT used in the preparation of an anterior intercostal artery perforator-based flap for breast reconstruction after a wide resection at the level of the right infer-internal breast region, including a skin excision. Our study documents how smartphone DIRT is a rapid, sensitive, easily accessible and cost-effective diagnostic method for the topographical identification of intercostal artery perforators. It can be used as a rescue method at any stage of the intervention if it differs from the preoperative planning. It also confirms the proven usefulness of this flap for the reconstruction of partial defects in the breast and thoracic region.

Quantitative Analysis of the Histological Features of Tuberous Breast

INTRODUCTION

Tuberous breast deformity (TB) is a condition mostly characterized by breast stenosis, areolar widening and glandular asymmetry. The most accredited hypothesis describes an abnormal thickening of the fascia corporis that might influence an alteration in the glandular development, limiting the horizontal growth of breast parenchyma. Alterations in the extracellular matrix components (ECM) might be involved in the abnormal breast development.

PATIENTS

The aim of our case control study is to use histological specimens to analyze qualitative and quantitative differences in collagen fibers, elastic fibers and vessel densities in TB and normal breasts of 20 patients using a software for digital pathology.

RESULTS

The quantitative findings showed increasing concentrations of collagen fibers and decreasing elastic fibers in TB, compared to normal breasts. No difference was seen in vessel density among the two groups. The qualitative findings highlighted differences in the distribution of the ECM among the TB specimens. Collagen fibers showed a packed appearance rather a scattered distribution, while elastic fibers visibly presented a reduction and a focal distribution of their concentration.

CONCLUSIONS

The study proposes a correlation between abnormalities in ECM concentrations and TB, resulting in a higher degree of fibrosis and in the characteristic stenotic and less elastic morphology of the deformity.

LEVEL OF EVIDENCE IV

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 .

Abstract P1-09-09: Salvage mastectomy is not always necessary for aggressive subtypes of ipsilateral breast cancer recurrence: A single-institution retrospective study

Introduction: Patients with triple-negative (TN) or HER2-enriched ipsilateral breast cancer recurrence (IBCR) seem to be excluded from a second breast-conserving surgery (BCS) under the assumption that salvage mastectomy would provide better oncological outcomes. Objectives: The objective of this study was to describe the clinical features of these patients, to compare the two surgical alternatives (salvage mastectomy versus second BCS) in terms of oncological results, and to identify independent factors influencing prognosis and surgical treatment. Methods: We retrospectively reviewed all the consecutive patients with histologically confirmed TN or HER2-enriched IBCR. Disease-free survival (DFS), distant disease-free survival (DDFS), overall survival (OS), and breast cancer-specific survival (BCSS) were analyzed and compared between the two groups. Results: Eighty-five patients were affected by TN or HER2-enriched IBCR, with a median age of 60 years (range, 32-87 years). The majority of patients (72.9%) were treated with salvage mastectomy. There was no significant difference in terms of DFS between patients receiving a second BCS or mastectomy (p=0.596). However, patients undergoing a second BCS had significantly better DDFS, OS, and BCSS compared to mastectomy (p=0.009; p=0.002; p=0.001, respectively). Tumor dimension &lt; 16 mm (78.3% versus 38.7%, hazard ratio (HR)=3.602, 95% confidence interval (95% CI)=1.534-8.459, p=0.003) was found to significantly increase the probability of receiving a second BCS and positively affects recurrence and survival outcomes (DFS: HR=8.065, 95% CI=2.320-28.034, p=0.001; DDFS: HR=17.011, 95% CI=3.853-75.099, p=0.001; OS: HR: 13.881, 95% CI=2.730-70.579, p=0.002; BCSS: HR=36.773, 95% CI=4.579-295.322, p=0.001). Second BCS represents an independent protective factor for OS and BCSS (OS: HR=0.246, 95% CI=0.027-0.697, p=0.002; BCSS: HR=0.313, 95% CI=0.092-0.511, p=0.002). Conclusion: Salvage mastectomy is not always necessary and it does not seem to increase survival compared to a second BCS. This reinforces the concept that the prognosis of TN and HER2-enriched BC recurrence is mainly driven by the biology of the disease, rather than by the extent of surgery. In patients with small (&lt; 16 mm) aggressive subtypes of IBCR, a second conservative approach can still be evaluated and offered, presenting acceptable loco-regional control and survival.

Citation Format: Damiano Gentile, Andrea Sagona, Erika Barbieri, Simone Di Maria Grimaldi, Ruggero Spoto, Davide Franceschini, Stefano Vaccari, Valeriano Vinci, Ersilia Biondi, Lorenzo Scardina, Corrado Tinterri. Salvage mastectomy is not always necessary for aggressive subtypes of ipsilateral breast cancer recurrence: A single-institution retrospective study [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P1-09-09.

The Effect of Adjuvant Radiotherapy on One- and Two-Stage Prosthetic Breast Reconstruction and on Autologous Reconstruction: A Multicenter Italian Study among 18 Senonetwork Breast Centres

Purpose

In modern breast cancer treatment, a growing role has been observed for breast reconstruction together with an increase in clinical indications for postmastectomy radiotherapy (PMRT). Choosing the optimum type of reconstructive technique is a clinical challenge. We therefore conducted a national multicenter study to analyze the impact of PMRT on breast reconstruction.

Methods

We conducted a retrospective case-control multicenter study on women undergoing breast reconstruction. Data were collected from 18 Italian Breast Centres and stored in a cumulative database which included the following: autologous reconstruction, direct-to-implant (DTI), and tissue expander/immediate (TE/I). For all patients, we described complications and surgical endpoints to complications such as reconstruction failure, explant, change in type of reconstruction, and reintervention.

Results

From 2001 to April 2020, 3116 patients were evaluated. The risk for any complication was significantly increased in patients receiving PMRT (aOR, 1.73; 95% CI, 1.33-2.24; p < 0.001). PMRT was associated with a significant increase in the risk of capsular contracture in the DTI and TE/I groups (aOR, 2.24; 95% CI, 1.57-3.20; p < 0.001). Comparing type of procedures, the risk of failure (aOR, 1.82; 95% CI, 1.06-3.12, p=0.030), explant (aOR, 3.34; 95% CI, 3.85-7.83, p < 0.001), and severe complications (aOR, 2.54; 95% CI, 1.88-3.43, p < 0.001) were significantly higher in the group undergoing DTI reconstruction as compared to TE/I reconstruction.

Conclusion

Our study confirms that autologous reconstruction is the procedure least impacted by PMRT, while DTI appears to be the most impacted by PMRT, when compared with TE/I which shows a lower rate of explant and reconstruction failure. The trial is registered with NCT04783818, and the date of registration is 1 March, 2021, retrospectively registered.

Immediate direct-to-implant breast reconstruction: A single center comparison between different procedures

Background

The increased incidence of conservative mastectomy operations (nipple- and skin- sparing) has increased the frequency of immediate breast reconstructions (IBR). In order to guarantee patients the best possible aesthetic outcome, the least chance of complications and moreover, the least postoperative pain, the technique with prepectoral prosthetic pocket was recently reconsidered with the use of ADM. This is the first study using Fortiva® in prepectoral breast reconstruction, and it compares the outcomes of three different patient populations (undergoing retromuscular, prepectoral and prepectoral reconstruction with ADM). The authors suggest that prepectoral breast reconstruction with ADM may bring benefits compared to the current standard technique (retromuscular) as well as compared to the prepectoral reconstruction without ADM.

Methods

Retrospective data analysis of patients who underwent mastectomy followed by immediate breast reconstruction with silicone implants (DTI), performed by a team of breast surgeons and plastic surgeons. Logistic factor regressions were performed in order to investigate the effects of the three different intervention techniques on the incidence of complications. Fisher's exact test was used to analyze the differences in the occurrence of each complication. Mann Whitney test was used to compare the averages of referred pain. A p value &lt;0.05 was considered significant.

Results

A total of 67 patients underwent DTI reconstruction, of which 43 with retromuscular prosthesis, 13 prepectoral and 11 prepectoral with ADM. We found a significantly lower incidence of surgical complications with ADM, exclusively in comparison with retromuscular reconstruction (p = 0.028). It emerges prepectoral reconstruction with ADM involves significantly less visibility of the implant than both the prepectoral surgery without ADM (p = 0.013) and the retromuscular technique (p = 0.029). Finally, postoperative pain referred at twelfth month is significantly less relevant in the group with prepectoral prosthesis and ADM, both in the group with retromuscular (p &lt; 0.001) and prepectoral without ADM (p = 0.001).

Conclusions

This study demonstrates that immediate prepectoral breast reconstruction with ADM is a safe and reliable technique, able to exceed some type of limits imposed by prepectoral reconstruction. Moreover, it provides benefits if compared to the current standard technique. In the future, this technique could also be added to it, after a proper selection of patients in pre- and intraoperative time.

Review of Tuberous Breast Deformity: Developments over the Last 20 Years

Tuberous breast (TB) deformity is a condition characterized by alterations in breast morphology and tissue structure with high prevalence in the general population. The literature provides sparse descriptions of TB, as not many investigations on the condition have been conducted. The aim of this review was to analyze and provide a holistic overview on the morphological characteristics of the TB.

Methods

A review of current literature was performed using the PubMed database from 2001 to 2021. The key words used for the review included "tuberous breast," "constricted breast," and "stenotic breast." We included articles that analyzed the anatomic and histologic characteristics of TB.

Results

From 213 articles, only 42 met the inclusion criteria. A total of 171 articles were excluded, as they were letters, not related to the condition, or were written in a foreign language. The studies in this review drew on hypothesis on the embryological origin of TB and analyzed the composition of TB tissues, consisting in a constricting fibrous ring, made of longitudinally arranged collagen and elastic fibers. Furthermore, the review reports the different anatomical and surgical classifications, as well as the various surgical corrective procedures developed throughout history up to 2021.

Conclusion

The review describes all etiological, epidemiologic, anatomical, histological, and surgical characteristics of tuberous breast.

Blended practical learning in compliance with COVID-19 social distancing

COVID-19 pandemic has imposed great changes in everyday life. Starting from January 2020, Humanitas University proposed to students digital instruction for continuing medical education, in particular, concerning practical activities. The latter, defined as Professionalizing activities, were transformed into complete online learning. From September 2020, in accordance to the imposed rules of social distancing, we modified the approach to Professionalizing activities. Despite following the new constrains, we came up with a blend online and face-to-face education program. The Kirkpatrick's evaluation model has been followed for validation of the project. Two ad hoc satisfaction questionnaires have been proposed to evaluate the project. Different approaches to blended learning have been described in literature; however, we propose a new method application, which fits to the post-pandemic era, with the purpose of sharing our experience in the field. Advantages and limitations are described. According to students, the overall satisfaction was rated 6.8, while tutors evaluated it with 7.4. The qualitative analysis of data confirms the advantage of the blended learning activities in order to guarantee a continuation of the clinical curriculum. Although it highlighted the necessity for, an increased technical support and an improvement in organization of the meetings. Blended learning is becoming more accepted among academic communities because it combines “the best of both worlds.” However, its effectiveness depends on several factors. With our approach, we propose a method, specifically designed to make effective this kind of teaching, which can be considered essential in the pandemic era we are facing.

Sting Technique: A New Procedure for Hypoplasic Lower Breast Poles

BACKGROUND

In breast augmentation patients affected by hypoplasic lower poles are a difficult challenge for plastic surgeons. Indeed in these cases it is difficult to create a nice and round contour, especially if a tight thoracic skin is present. Various techniques have been described in the past in order to solve this problem including parenchymal manipulation, fat grafting alone or after subcutaneous release of the stenotic tissue (Rigottomy). Following a large experience with the use of needles to deliver fat grafting in fibrotic tissue of different type of scars the Authors report in this paper their preliminary experience with a new surgical technique consisting of a multiple percutaneous stings of the skin and gland of the inferior breast quadrants associated to an implant to correct a flat, rigid and hypoplasic lower breast pole.

METHODS

A total of 24 patients affected by this malformation have been treated during the breast augmentation procedure using the above-mentioned technique. Hypoplasic lower poles (skin and subcutaneous tissues) have been punctured several times using an 18 G needle before inserting the implant. Results have been evaluated by the Authors and patients grading them from 0, extremely poor, to 10, extremely satisfactory outcome.

RESULTS

Aesthetic results evaluated by the surgeons group reported a mean outcome of 7.9, whereas the ones of the patients reported a mean value of 8.3. In one case a capsulotomy for monolateral capsular contracture was performed. In another patient the aesthetic result was revised performing a fat grafting in order to further correct the lower pole. In six cases a subcutaneous blood effusion, due to the prick of the skin, was experienced while in two patients with darker skin (Fitzpatrick III) the use of the needle left pigmented spots that completely disappeared after the use of hydroquinone cream 4% for two months.

CONCLUSIONS

Even with the limitations of this preliminary study, such as the small number of patients and the short follow-up, the sting technique seems to be an efficacious and safe new tool in the armamentarium of plastic surgeons to treat hypoplasic breasts with stenotic lower poles.

LEVEL OF EVIDENCE IV

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 .

Algorithm-Assisted Decision Making in Otoplasty

INTRODUCTION

Ear congenital deformities represent an aesthetical concern in adult patients and a social matter in children. An accurate assessment of ear defects should be made preoperatively in order to plan surgery adequately.

MATERIALS AND METHODS

In order to correctly assess the ear preoperatively the authors have considered four different subunits: helical and scaphal region (A), antihelical region (B), conchal region (C) and lobule region (D). Surgical planning should start from sub-unit A evaluation, ending with sub-unit D, in a concentric fashion. When sub-unit A defects have to be corrected, an anterior approach is preferred.

DISCUSSION

A correct evaluation of ear defects prior to surgery is of dramatic importance. Sub-unit A ear defects are often disregarded, and surgical techniques for their correction are rarely considered. Correcting helical and scaphal defects requires an anterior approach, influencing the technique employed for the correction of subunits B and C defects. Sub-unit B defects should be evaluated and corrected before sub-unit C defects in order to avoid overcorrection of ear protrusion.

CONCLUSION

Several surgical techniques have been described in the literature for correcting ear defects. After many years of experience, we outlined a schematic flowchart that prevents from leaving areas of the ear untreated, providing the best possible result for the patient.

LEVEL OF EVIDENCE IV

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 .

Safety of autologous fat grafting in breast cancer: a multicenter Italian study among 17 senonetwork breast units autologous fat grafting safety: a multicenter Italian retrospective study

BACKGROUND

Autologous fat grafting (AFG), defined as the re-implant to the breast of fat tissue from different body areas, has been firstly applied to esthetic plastic surgery and then has moved to reconstructive surgery, mainly used for scar correction and opposite breast altering. Nevertheless, due to the potentially unsafe stem-like properties of adipocytes at the tumoral bed level, no clear evidence of the procedure's oncological safety has been clearly documented at present.

PATIENTS AND METHODS

We retrospectively collected data of early breast cancer (BC) patients from 17 Italian Breast Units and assessed differences in terms of locoregional recurrence rate (LRR) and locoregional recurrence-free survival (LRFS) between patients who underwent AFG and patients who did not. Differences were analyzed in the entire cohort of invasive tumors and in different subgroups, according to prognostic biological subtypes.

RESULTS

With a median follow-up time of 60 months, LRR was 5.3% (n = 71) in the matched population, 3.9% (n = 18) in the AFG group, and 6.1% (n = 53) in the non-AFG group, suggesting non-inferiority of AFG (p = 0.084). Building Kaplan-Meier curves confirmed non-inferiority of the AFG procedure for LRFS (aHR 0.73, 95% CI 0.41-1.30, p = 0.291). The same effect, in terms of LRFS, was also documented among different biological subtypes (luminal-like group, aHR 0.76, 95% CI 0.34-1.68, p = 0.493; HER2 enriched-like, aHR 0.89, 95% CI 0.19-4.22, p = 0.882; and TNBC, aHR 0.61, 95% CI 0.12-2.98, p = 0.543).

CONCLUSIONS

Our study confirms in a very large, multicenter cohort of early BC patients that, aside the well-known benefits on the esthetic result, AFG do not interfere negatively with cancer prognosis.

Normal CMR bi-atrial and biventricular reference values in sickle cell disease patients without heart damage

Funding Acknowledgements

Type of funding sources: Private company. Main funding source(s): The MIOT project receives “no-profit support” from industrial sponsorships (Chiesi Farmaceutici S.p.A., ApoPharma Inc.).

Background. Cardiac function indices in patients with hemoglobinopathies are different from those in healthy population, mainly due to chronic anemia. Normal reference values specific for SCD patients are not available by CMR.

Aim. We aimed to define the normal cut-off value in SCD patients for bi-atrial and biventricular cardiac magnetic resonance (CMR) parameters.

Methods. We considered forty-eight adult SCD patients with no known risk factors or cardiac disease, normal electrocardiogram, no macroscopic myocardial fibrosis, and all cardiac segments with T2*≥20 ms, consecutively enrolled in the MIOT network (Myocardial iron overload in thalassemia). SCD patients were compared with ninety-six healthy controls and 96 thalassemia major (TM) patients without cardiac damage, both matched for age and gender. Nine pediatric SCD patients were also analysed in comparison with 9 TM patients and 9 healthy subjects matched for age and gender. Cine images were acquired to quantify biventricular function parameters: LV and RV end-diastolic volume (EDV), end-systolic volume (ESV) and stroke volume (SV) were normalized for body surface area (EDVI, ESVI, SVI), as well as biventricular mass and atrial areas. Myocardial iron overload was assessed by segmental T2* technique. Late gadolinium enhancement (LGE) images were acquired for evaluation of macroscopic myocardial fibrosis.

Results. In all three groups males showed higher biventricular volumes and mass indexes than females. SCD male patients had significantly higher LVEDVI (p &lt; 0.0001), LVESVI (p = 0.010), LVSVI (p = 0.003), cardiac index (p = 0.002), LV and RV mass index  (p = 0.008 and p = 0.001, respectively) and left and right atrial areas (p &lt; 0.001 and p = 0.011) than healthy subjects. No significant differences were found in RVEDVI, EVESVI and biventricular EF. Compared to healthy volunteers, females with SCD showed a larger LVEDVI (p = 0.020), LVSVI (p = 0.039), RV mass index (p = 0.002) and left atrial area (p = 0.008).

SCD and TM patients showed comparable values of bi-atrial and biventricular volumes and function. When compared to TM, SCD patients showed a larger LV (p &lt; 0.001) and RV mass index (p = 0.001) in male group and a larger RV mass index (p = 0.001) in female group. Table 1 shows the cut-offs for bi-atrial and biventricular MR parameters for adult SCD patients by gender.

No significant differences in MR parameters were found among the pediatric groups.

Conclusions. Normal reference ranges of bi-atrial and biventricular MR parameters for adult males and females SCD patients were established. The use of these reference values will prevent possible misdiagnosis of cardiomyopathy in patients with SCD.

Upper eyelid blepharoplasty following hyaluronic acid injection with improved facial aesthetics and eye symptoms: a case report

BACKGROUND

Dermatochalasis of the upper eyelids (blepharochalasis) is a typical age-related change in the upper third of the face and a major concern for facial aesthetics. Nowadays both surgical and nonsurgical interventions are available for patients complaining of upper eyelid dermatochalasis. Although nonsurgical treatments are often easier to perform, if they are not performed correctly, complications may ensue and worsen the condition.

CASE PRESENTATION

We describe the case of a Caucasian patient presenting with bilateral upper eyelid dermatochalasis, previously treated with multiple injections of hyaluronic acid filler. Following these procedures, the patient reported nonspecific eye symptoms (such as a sense of heaviness and asthenopia) and cosmetic concerns. We decided to perform an upper eyelid blepharoplasty. During the procedure we found a ribbon of hard, fibrous material, which was carefully removed. The patient reported resolution of functional eye symptoms owing to the reduction of upper lid heaviness, which also resulted in subjective improvement of the visual field. Patient satisfaction was assessed preoperatively and 3 months postoperatively using the Blepharoplasty Outcomes Evaluation (BOE), which showed an overall satisfaction rate of 95.8 %.

CONCLUSIONS

Blepharoplasty not only treated the patient's blepharochalasis but also allowed us to correct the previous nonsurgical intervention by removing the excessive amount of injected hyaluronic acid. Both aesthetic and functional results were successfully achieved.

Evaluation of the ex vivo Effects of Tamoxifen on Adipose-Derived Stem Cells: A Pilot Study

Autologous fat grafting (AFG) is a safe and minimally invasive procedure to correct soft tissue defects. The benefit of AFG is attributed to adipose-derived stem cells (ASCs) in fat tissue graft. This technique is useful also in patients undergoing reconstructive surgery following quadrantectomy for breast cancer. However, these patients are frequently treated with tamoxifen. We evaluated the ex vivo effects of tamoxifen on ASCs to understand if cellular functions of ASCs are affected. We selected 24 female patients; 10 of which were breast cancer patients treated with quadrantectomy and tamoxifen. As control group, we selected 14 healthy female subjects (9 premenopausal and 5 menopausal). We found that tamoxifen has no effect on cellular proliferation, VEGF secretion or apoptosis of ASCs. The gene expression assessment demonstrated no impairment in differentiation capacity of ASCs. Our results showed that tamoxifen has no effect on cellular functions of ASCs for the first time in an ex vivo single-center study.

Study of Inflammatory and Infection Markers in Periprosthetic Fluid: Correlation with Blood Analysis in Retrospective and Prospective Studies

BACKGROUND

Surgical site infection represents the most severe complication in prosthetic breast reconstruction. Risk profiling represents a useful tool for both clinicians and patients.

MATERIALS AND METHODS

In our hospital, 534 breast reconstructions with tissue expander implants, in 500 patients, were performed. Several clinical variables were collected. In our study, we evaluated the different inflammatory markers present in the periprosthetic fluid and we compared them with the ones present in plasma.

RESULTS

The surgical site infection rate resulted to be 10.5%, and reconstruction failed in 4.5% of the cases. The hazard ratio for complications was 2.3 in women over 60 (CI: 1.3-4.07; p = 0.004), 2.57 in patients with expander volume ≥ 500 cc (CI: 1.51-4.38; p < 0.001), 2.14 in patients submitted to previous radiotherapy (CI: 1.05-4.36; p < 0.037), and 1.05 in prolonged drain use (CI: 1.03-1.07; p < 0.001). 25-OH, PCT, and total protein were less concentrated, and ferritin and LDH were more concentrated in the periprosthetic fluid than in plasma (p < 0.001). CRP (p = 0.190) and β-2 microglobulin (p = 0.344) did not change in the two fluids analyzed. PCT initial value is higher in patients who underwent radiotherapy, and it could be related to the higher rate of their postoperative complications. Patients with a tissue expander with a volume ≥ 500 cc show an increasing trend for CRP in time (p = 0.009).

CONCLUSIONS

Several risk factors (prolonged time of drains, age older than 60 years, and radiotherapy) have been confirmed by our study. The study of markers in the periprosthetic fluid with respect to their study in plasma could point toward earlier infection detection and support early management.