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Coleman-Belin JC, Barnett J, Khavanin N, Nelson JA, Stern CS, Allen RJ. Imaging in Autologous Breast Reconstruction. Cancers (Basel) 2024; 16:2851. [PMID: 39199622 PMCID: PMC11352801 DOI: 10.3390/cancers16162851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2024] [Revised: 08/08/2024] [Accepted: 08/12/2024] [Indexed: 09/01/2024] Open
Abstract
The evolution of imaging actively shapes clinical management in the field. Ultrasonography (US), computed tomography angiography (CTA), and magnetic resonance angiography (MRA) stand out as the most extensively researched imaging modalities for ABR. Ongoing advancements include "real-time" angiography and three-dimensional (3D) surface imaging, and future prospects incorporate augmented or virtual reality (AR/VR) and artificial intelligence (AI). These technologies may further enhance perioperative efficiency, reduce donor-site morbidity, and improve surgical outcomes in ABR.
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Affiliation(s)
| | | | | | | | | | - Robert J. Allen
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA; (J.C.C.-B.); (N.K.); (J.A.N.); (C.S.S.)
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2
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Wood Matabele KL, Nkana ZH, Seitz AJ, Edalatpour A, Mahajan AY, Poore SO. From Tip of Brush to Tip of Knife: The Relationship Between Post-mastectomy Breast Reconstruction and the Classical Arts. Aesthet Surg J 2024; 44:716-721. [PMID: 38323872 DOI: 10.1093/asj/sjae029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 01/29/2024] [Accepted: 01/30/2024] [Indexed: 02/08/2024] Open
Abstract
Breast reconstruction is highly complex, requiring navigation of not only clinical and operative realities, but of patient expectations as well. The authors sought to identify historical art pieces that exhibit breast asymmetries and deformities for comparison with photographs of breast reconstruction patients seen at the clinic of the senior author (S.O.P.) to demonstrate that achievement of perfect breast cosmesis is challenging in both breast reconstruction and in the classical arts. Open access libraries and Creative Commons images were reviewed to identify appropriate works of art from various time periods and geographic locations. Following artwork selection, photographs of breast reconstruction patients were reviewed and paired with selected artworks exhibiting cosmetically similar breasts. A total of 8 pieces of selected historic art were found to have at least 1 matching patient photograph, with 9 correlative patient photographs ultimately chosen. Common breast asymmetries and deformities identified included ptosis, asymmetric chest wall placement, asymmetric nipple placement, and absence of the nipple. This review identified diverse artworks of varying styles spanning vast expanses of both geography and time that exhibited breast deformities and asymmetries commonly encountered in patients seeking revision of breast reconstruction. This underscores that creating the cosmetically ideal breast is difficult both in the operating room and the art studio. Importantly, the authors emphasized that the arts frequently celebrate that which is considered beautiful, although to the trained eye of a plastic surgeon that which is considered beautiful is often classified as dysmorphic or asymmetric.
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3
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Sapino G, Tay SK, Maruccia M, Nanhekhan L, Watfa W, Mantovani GP, Guillier D, Tedeschi P, Bramhall R, Di Summa PG. Abdominal-Based Microsurgical Breast Reconstruction: How to Inset the Flap to Maximize the Aesthetic Result-A Systematic Review. J Clin Med 2023; 12:6135. [PMID: 37834779 PMCID: PMC10573810 DOI: 10.3390/jcm12196135] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Revised: 08/21/2023] [Accepted: 08/29/2023] [Indexed: 10/15/2023] Open
Abstract
Nowadays, the ultimate goal of microsurgical breast reconstruction is not merely the effective transfer of vascularized tissue but the achievement of a natural, symmetric appearance. The aim of this present study was to systematically summarize the published evidence on abdominal-based free flap inset for breast reconstruction in order to provide principles and classification that could guide the surgeon in choosing the most appropriate inset technique based on patient and flap characteristics. A comprehensive review was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, looking for articles on the insetting technique for free flap breast reconstruction. After screening 306 publications, 24 papers (published from 1994 to 2020) were included in the study. We identified four main breast anatomical features on which the papers reviewed focused when describing their insetting technique: breast width, breast ptosis, breast projection, and upper pole fullness. Patient body type, type of mastectomy, and reported complications are also discussed. Flap shaping and inset during breast reconstruction are fundamental steps in any reconstructive procedure. Despite the low evidence in the current literature, this systematic review provides a framework to guide the surgeon's decision-making and optimize the aesthetic outcomes of abdominal-based free flap breast reconstruction.
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Affiliation(s)
- Gianluca Sapino
- Department of Plastic and Hand Surgery, Centre Hospitalier Universitaire Vaudois (CHUV), 1011 Lausanne, Switzerland (L.N.)
| | - Sherilyn K. Tay
- Canniesburn Plastic Surgery Department, Glasgow Royal Infirmary, Glasgow G4 0SF, UK; (S.K.T.); (R.B.)
| | - Michele Maruccia
- Department of Plastic and Reconstructive Surgery, University Hospital of Bari, 70124 Bari, Italy; (M.M.)
| | - Lloyd Nanhekhan
- Department of Plastic and Hand Surgery, Centre Hospitalier Universitaire Vaudois (CHUV), 1011 Lausanne, Switzerland (L.N.)
| | - William Watfa
- Department of Plastic and Reconstructive Surgery, Saint George University Hospital, Beirut 1100, Lebanon;
| | - Gian Piero Mantovani
- Department of Plastic and Reconstructive Surgery, University Hospital of Modena, 41121 Modena, Italy;
| | - David Guillier
- Department of Plastic Reconstructive and Hand Surgery, Department of Oral and Maxillofacial Surgery—University Hospital, 21000 Dijon, France;
| | - Pasquale Tedeschi
- Department of Plastic and Reconstructive Surgery, University Hospital of Bari, 70124 Bari, Italy; (M.M.)
| | - Russell Bramhall
- Canniesburn Plastic Surgery Department, Glasgow Royal Infirmary, Glasgow G4 0SF, UK; (S.K.T.); (R.B.)
| | - Pietro Giovanni Di Summa
- Department of Plastic and Hand Surgery, Centre Hospitalier Universitaire Vaudois (CHUV), 1011 Lausanne, Switzerland (L.N.)
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4
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Atamian EK, Smith ML. Optimizing aesthetic results in autologous breast reconstruction. Gland Surg 2023; 12:1110-1121. [PMID: 37701300 PMCID: PMC10493624 DOI: 10.21037/gs-22-647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 06/29/2023] [Indexed: 09/14/2023]
Abstract
Advances in breast cancer management have provided most patients with the hope for cure or avoidance of cancer altogether. Such advances have made quality of life much more important after treatment and have led to equally incredible advances in breast reconstruction, to the point where reconstructive goals have altered the way mastectomies are now performed. As experience and expertise in microsurgery has grown, the surgical feat of successfully transferring tissue to restore breast volume is no longer considered an adequate endpoint for aesthetic breast reconstruction. A shift towards patient-centered care has motivated plastic surgeons to adapt their approaches to reconstruction integrating aesthetic principles to the process of recreating a breast mound in order to provide patients with a long-term, natural, and optimal result. Vital to restoring a shapely breast is a thorough preoperative assessment and the understanding of the breast footprint, breast conus, skin envelope and nipple-areolar complex (NAC) position. These aesthetic goals should also extend to the donor site, where adequate contour improvement is sought to offset the price of the donor site scar and the morbidity is minimized. By utilizing strategies for optimizing the NAC position, incorporating novel techniques to ensure core projection, and paying attention to the donor site, the skilled microsurgeon can elevate breast reconstruction to the level of true aesthetic surgery where the reconstructed appearance is superior to the presurgical one.
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Affiliation(s)
- Elisa K Atamian
- Division of Plastic & Reconstructive Surgery, The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Mark L Smith
- Division of Plastic & Reconstructive Surgery, The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
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5
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Dung PTV, Sơn TT, Dung VT, Hậu NX, Nghĩa PT. Techniques of inserting deep inferior epigastric perforator flap obliquely in immediate breast reconstruction after total mastectomy. JPRAS Open 2023; 36:1-7. [PMID: 36844476 PMCID: PMC9950802 DOI: 10.1016/j.jpra.2023.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 01/15/2023] [Indexed: 01/26/2023] Open
Abstract
Objective This study aimed to share the experience of inserting a deep inferior epigastric perforator (D.I.E.P) flap obliquely in immediate breast reconstruction after total mastectomy. Method Forty patients underwent immediate breast reconstruction with flap D.I.E.P after total mastectomy. The flaps were placed obliquely, with the upper edge facing downward and inward. After being placed in the recipient region, parts of the flap at both ends were removed, the upper end was fixed into the II-III intercostal space next to the sternum, and the lower end was folded to create a projection of the lateral lower pole of the breast. The flap pedicle was anastomosed to the thoracodorsal vessels (TDVs) if the contralateral flap pedicle was used; conversely, the mammary vessels (IMVs) were used. Satisfaction with breast shape was assessed after 6 months using the BREAST-Q questionnaire. Results A total of 37/40 flaps were well vascularized; 36/37 patients with a survival flap were interviewed, showing that the average BREAST-Q evaluation score of satisfaction with breast shape was 62.22 (51-78). The number of answers for satisfied and very satisfied with breast shape accounted for 94.44%. Conclusion Inserting the D.I.E.P flap obliquely has the advantage of being easy to shape the breast contour, creating a moderate projection and symmetry to the opposite breast. The author suggested using the IMVs as the receiving vessels when using the pedicle of the flap on the ipsilateral side and the TDVs when the contralateral pedicle flap was used.
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Affiliation(s)
- Phạm Thị Việt Dung
- Department of Plastic and Reconstructive Surgery, Hanoi Medical University, Hanoi, Vietnam,Department of Plastic Reconstructive and Aesthetic Surgery, Bach Mai Hospital, Hanoi, Vietnam,Hightech unit of Plastic Reconstructive and Aesthetics Surgery, Hanoi Medical University Hospital, Hanoi, Vietnam,Corresponding author.
| | - Trần Thiết Sơn
- Department of Plastic and Reconstructive Surgery, Hanoi Medical University, Hanoi, Vietnam,Department of Plastic Reconstructive and Aesthetic Surgery, Bach Mai Hospital, Hanoi, Vietnam,Department of Plastic Surgery, Saint Paul Hospital, Hanoi, Vietnam
| | - Vũ Thị Dung
- Hightech unit of Plastic Reconstructive and Aesthetics Surgery, Hanoi Medical University Hospital, Hanoi, Vietnam
| | - Nguyễn Xuân Hậu
- Oncology and Palliative Care department, Hanoi Medical University Hospital, Hanoi, Vietnam,Department of Oncology, Hanoi Medical University, Hanoi, Vietnam
| | - Phan Tuấn Nghĩa
- Department of Plastic and Reconstructive Surgery, Hanoi Medical University, Hanoi, Vietnam
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6
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Hamdi M, Al Harami S, Chahine F, Giunta G, De Baerdemaeker R, Zeltzer A. The "Hug Flap": Surgical Technique to Enhance the Aesthetic Breast Projection in Autologous Breast Reconstruction. Aesthet Surg J 2021; 41:NP1462-NP1470. [PMID: 33480982 DOI: 10.1093/asj/sjab030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Obtaining a natural breast mound shape contributes profoundly to a symmetrical and successful outcome in breast reconstruction. OBJECTIVES The authors sought to describe a new and efficient technique that enhances breast projection in delayed breast reconstruction employing abdominal free flaps and compare it with the current standard methods utilized. METHODS The charts of 490 consecutive patients who underwent delayed breast reconstruction employing free abdominal perforator flaps were reviewed between 2007 and 2017. Three methods of breast reconstruction were compared: undermining, de-epithelialization, and the "hug flap" (HF). In the newly described technique, the caudal mastectomy skin was de-epithelialized, and then the medial and lateral thirds were undermined and folded over to cover the central part. The rates of complications and secondary corrections were analyzed between the 3 groups. RESULTS There were 570 free abdominal flaps performed. The de-epithelization technique was the most commonly utilized (328 cases) followed by the undermining technique (153 cases). The HF technique was employed in 89 cases. The majority of HFs were performed in unilateral breast reconstruction. Bilateral cases were conducted in only 12 patients. The need for additional fat grafting was significantly (P = 0.003) less required in the HF group compared with the undermining and de-epithelializing groups (12% vs 28% and 21%, respectively). CONCLUSIONS Although all breast-enhancing options can be mixed and matched based on the surgeon's preference and experience as well as each patient's needs, the HF can be considered as an adjunct tool to provide adequate flap projection and enhance breast symmetry. LEVEL OF EVIDENCE: 4
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Affiliation(s)
- Moustapha Hamdi
- Department of Plastic and Reconstructive Surgery, Brussels University Hospital – Vrij Universiteit Brussel (VUB), Brussels, Belgium
| | - Sara Al Harami
- Department of Plastic and Reconstructive Surgery, Brussels University Hospital – Vrij Universiteit Brussel (VUB), Brussels, Belgium
| | - Fadel Chahine
- Department of Plastic and Reconstructive Surgery, Brussels University Hospital – Vrij Universiteit Brussel (VUB), Brussels, Belgium
| | - Gabriel Giunta
- Department of Plastic and Reconstructive Surgery, Brussels University Hospital – Vrij Universiteit Brussel (VUB), Brussels, Belgium
| | - Randy De Baerdemaeker
- Department of Plastic and Reconstructive Surgery, Brussels University Hospital – Vrij Universiteit Brussel (VUB), Brussels, Belgium
| | - Assaf Zeltzer
- Department of Plastic and Reconstructive Surgery, Brussels University Hospital – Vrij Universiteit Brussel (VUB), Brussels, Belgium
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7
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Brown CA, Losken A. Commentary on: The "Hug Flap": Surgical Technique Refinement For Enhanced Aesthetic Breast Projection in Autologous Breast Reconstruction. Aesthet Surg J 2021; 41:NP1471-NP1472. [PMID: 33674878 DOI: 10.1093/asj/sjab009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Ciara A Brown
- Emory Division of Plastic and Reconstructive Surgery, Atlanta, GA, USA
| | - Albert Losken
- Emory Division of Plastic and Reconstructive Surgery, Atlanta, GA, USA
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8
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Preshaping DIEP Flaps: Simplifying and Optimizing Breast Reconstruction Aesthetics. Plast Reconstr Surg 2021; 147:1059-1061. [PMID: 33890887 DOI: 10.1097/prs.0000000000007889] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
SUMMARY One key component of a successful autologous breast reconstruction is insetting the flap to accurately resemble an aesthetic breast. The authors describe a novel technique used to shape a deep inferior epigastric artery perforator flap into a coned breast mound before introducing it into the breast pocket. With the flap perfusing on the chest wall, an area of skin estimating the size and location of the skin paddle is marked. The skin to be buried is then deepithelialized. Once hemostasis is ensured, the shaping is performed. Two 2-0 polydioxanone sutures are anchored in the Scarpa fascia at the 10- and 2-o'clock positions and then run at the level of the Scarpa fascia to the 6-o'clock position. The two sutures are then cinched together to achieve the desired shape and then tied. The flap is then placed in the breast pocket and secured into place at the inferomedial and inferolateral corners, and at its cranial aspect. The size of the skin paddle can then be finalized. In the authors' series of 21 breast reconstructions in 11 patients using flap preshaping, they have not seen any compromise in flap perfusion, with one patient showing a small area of secondary fat necrosis. In addition, the flaps maintained their aesthetic breast shape throughout follow-up. The authors believe this technique for shaping inferior epigastric artery perforator flaps before inset into the breast pocket to be both safe and predictable, simplifying one of the more tedious aspects of autologous breast reconstruction.
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9
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Rutherford CL, Tan BK, Lim SZ, Chew KY. Shaping of the abdominal flap in breast reconstruction: The coning technique in muscle sparing TRAM. JPRAS Open 2020; 25:93-98. [PMID: 32904163 PMCID: PMC7451599 DOI: 10.1016/j.jpra.2020.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 07/23/2020] [Indexed: 11/21/2022] Open
Abstract
In the setting of autologous breast reconstruction, achieving an aesthetic outcome through shaping of the flap is of the upmost importance. We describe the abdominal flap folding technique of ‘coning’ and the indications. We define ‘coning’ as the technique of folding the abdominal flap in a circular fashion to create a conical breast mound, with the line of fusion forming a pillar of tissue for structural integrity. A retrospective study of 34 patients undergoing unilateral muscle-sparing TRAM flap was performed. Of these patients, the majority (79.4%) underwent immediate reconstruction, with the thoracodorsal vessels largely acting as the recipients (94.1%). Three (8.8%) patients were noted to have a contour defect secondary to incomplete folding of the flap. Two (5.9%) patients had partial skin envelope necrosis. One patient had 50% flap loss, requiring return to theatre for excision. In conclusion, coning was used exclusively in the muscle-sparing TRAM flap. This cuff of muscle protected the pedicle during folding through cushioning the perforators at their most vulnerable points. This technique allowed for muscle cuff harvest whilst minimising anterior sheath sacrifice. Coning achieved long-term maintenance of shape, volume and projection.
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Affiliation(s)
- Claire Louise Rutherford
- Department of Plastic, Reconstructive and Aesthetic Department, Singapore General Hospital, Outram Road, Singapore
| | - Bien-Keem Tan
- Department of Plastic, Reconstructive and Aesthetic Department, Singapore General Hospital, Outram Road, Singapore
| | - Sue Zann Lim
- Singhealth Duke-NUS Breast Disease Centre, Singapore.,Department of General Surgery, Singapore General Hospital, Singapore
| | - Khong-Yik Chew
- Department of Plastic, Reconstructive and Aesthetic Department, Singapore General Hospital, Outram Road, Singapore
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10
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Rodkin B, Hunter-Smith DJ, Rozen WM. A review of visualized preoperative imaging with a focus on surgical procedures of the breast. Gland Surg 2019; 8:S301-S309. [PMID: 31709172 DOI: 10.21037/gs.2019.09.07] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Preoperative imaging has become a valuable tool in the planning of perforator flaps, and to date, computed tomographic angiography (CTA) has been shown to be the gold standard in this role. The evidence for this is a source of constant investigation, with advances in newer modalities coming to the fore. A literature review was undertaken to evaluate the current role of relevant imaging modalities in 'visualized surgery'-the ability to map anatomy prior to surgical incision. A focus is made on their accuracy in perforator mapping and correlation with improved clinical outcomes in the context of deep inferior epigastric artery perforator (DIEP) flap surgery. Other applications for preoperative imaging in breast surgery such as imaging of alternate donor sites or of the recipient site and imaging for volumetric assessment are also discussed. Preoperative imaging is integral to the planning of reconstructive breast surgery. This review has discussed the range of imaging techniques used to map and visualize perforator vasculature, and whilst there are varied clinical applications for the imaging modalities, CTA has been demonstrated to be the most precise and to confer the best clinical outcomes. Applications of the other imaging techniques are varied and these should remain as valid alternatives, particularly for patients where radiation or contrast exposure should be limited. Further studies could focus on the development of a more definitive protocol regarding the approach to preoperative imaging in breast surgery.
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Affiliation(s)
- Bridget Rodkin
- Department of Plastic, Reconstructive and Hand Surgery, Peninsula Health, Frankston, Victoria, Australia.,Peninsula Clinical School, Central Clinical School at Monash University, The Alfred Centre, Melbourne, Victoria, Australia
| | - David J Hunter-Smith
- Department of Plastic, Reconstructive and Hand Surgery, Peninsula Health, Frankston, Victoria, Australia.,Peninsula Clinical School, Central Clinical School at Monash University, The Alfred Centre, Melbourne, Victoria, Australia
| | - Warren M Rozen
- Department of Plastic, Reconstructive and Hand Surgery, Peninsula Health, Frankston, Victoria, Australia.,Peninsula Clinical School, Central Clinical School at Monash University, The Alfred Centre, Melbourne, Victoria, Australia
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Abstract
The tumor heterogeneity and interindividual variability is a major problem when treating cancer as every patient responds in a different way to the current drug therapies. 3D printing is a tool that can hamper the issues faced in cancer patients allowing for individualization of treatment by the production of in vitro models with microenvironments mimicking more closely real cancer conditions facilitating complex therapies. Further improvements are required, for example the development of biocompatible bioinks or need for vascularization. The journey from bench to bedside is challenging from the regulatory point of view where the establishment of manufacturing guidelines, quality systems and safety of use and administration of personalized medicines remains unclear. This review will provide an insight into the major applications of 3D printing in cancer both in the development of in vitro cancer models as well as personalized medicines for cancer patients focused on hydrogels and therapeutic implants. [Formula: see text]
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Affiliation(s)
- Dolores R Serrano
- Department of Pharmaceutics & Food Technology, School of Pharmacy, Universidad Complutense de Madrid, Plaza Ramon y Cajal s/n, 28040 Madrid, Spain
- Instituto Universitario de Farmacia Industrial (IUFI), School of Pharmacy, Universidad Complutense de Madrid, Avenida Complutense, 28040 Madrid, Spain
| | - Maria C Terres
- Department of Pharmaceutics & Food Technology, School of Pharmacy, Universidad Complutense de Madrid, Plaza Ramon y Cajal s/n, 28040 Madrid, Spain
| | - Aikaterini Lalatsa
- Institute of Biomedical & Biomolecular Sciences, School of Pharmacy & Biomedical Sciences, University of Portsmouth, White Swan Road, Portsmouth, PO1 2DT, UK
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