Polyurethane Implants in Revision Breast Augmentation: A Prospective 5-Year Study

BACKGROUND

Revision surgery for aesthetic breast augmentation remains a challenging procedure. Polyurethane (PU) implants have been found to avoid capsular contracture recurrence as well as prevent implant displacement by bio-integrating into the pocket.

OBJECTIVES

Our study aims to assess the use of PU in breast revision surgery and provides an algorithm.

METHODS

Over a 5-year period, a prospective study was conducted involving consecutive patients undergoing implant revision. Patient demographics, previous breast procedures, and specific surgical details were documented. Post-operative outcomes were followed up.

RESULTS

Out of 92 patients (184 breasts), 78 (156 breasts) were included in the analysis. The average age was 47.4, with a BMI of 22.3, and a mean follow-up of 5 years. A majority (63%) represented secondary revision cases, while 37% were tertiary cases. Implant size averaged 296 cc, with 53% placed retropectoral and 47% prepectoral. Significantly more implants in secondary cases were changed from pre- to retropectoral (p = 0.005), and in tertiary changed from retro- to prepectoral (p = 0.002). Complete capsulectomy was performed in 61.5% and partial in 25.6%. Additional lipofilling was performed in 32%, and concurrent mastopexy in 40%. Revision surgery in our series had a 1.9% acute complication rate, 4.5% longer term re-operation rate for corrections, 0.6% implant exchange rate, and no recurrent capsular contracture.

CONCLUSIONS

This is the first study to provide data on outcomes of revision breast augmentation surgery with the use of PU implants. It shows that polyurethane implants offer consistent stability and have low rates of recurrent capsular contracture in revision surgery.

Current status of autologous breast reconstruction in Europe: how to reduce donor site morbidity

Autologous reconstruction techniques for breast reconstruction have significantly evolved in the last few decades in Europe. In the search of reducing the donor site morbidity, surgeons explored the possibilities to preserve the rectus muscle and its function, and a transition to deep inferior epigastric perforator (DIEP) flaps was started in the nineties. Throughout the years, and especially in the last decade, we have increasingly implemented aesthetic refinements for donor site handling in DIEP flap breast reconstruction. In our practice, autologous breast reconstruction provides an opportunity to effectively remodel the donor site, minimising functional morbidity, and maximising aesthetic satisfaction. To achieve this, careful patient selection, pre-operative preparation, meticulous intra-operative dissection, and a clear post-operative protocol are essential. The main goal in autologous breast reconstruction, and its biggest advantage, is to offer the patient a natural look and feel of the reconstructed breast. A second goal is to minimize the number of procedures needed to reach the desired breast shape, size, and volume. In most patients, the number of operations ranges between one and three. The third main goal is to minimize the donor site morbidity, both functionally and aesthetically. Functionally, this implies preserving as much of the rectus abdominis muscle as possible, limiting the fascia incision, preserving the motor branches to the muscle, ensuring an adequate fascial closure, and repairing the rectus diastasis is present. Aesthetically, we aim to have a low position of the scar, an aesthetically pleasing location of the umbilicus, and limited or no lateral skin excess or so called "dogears". In this clinical practice review article, we provide an overview of current autologous reconstruction methods, with a focus on minimising donor site morbidity and enhancing the aesthetic result of the donor site. We discuss key concepts in autologous reconstruction and provide surgical pearls for performing the procedure effectively with optimal reconstructive and aesthetic result.

Using an Elastomeric Skin Protectant to Manage Donor Site Wounds of Split-thickness Skin Grafts: A Case Series

ABSTRACT

Split-thickness skin grafting (STSG) is a common surgical procedure to manage acute and chronic wounds. A plethora of dressings exists to treat STSG donor site wounds (DSWs). Recently, a new elastomeric skin protectant was adopted (Cavilon Advanced Skin Protectant; 3M) in the treatment of incontinence-associated dermatitis. In this report, the authors assess the effects of this elastomeric skin protectant as an alternative wound dressing for STSG donor sites.The authors report a single-center prospective case series that was performed to establish a treatment protocol. Nine consecutive patients with different indications for treatment with an STSG from May to September 2018 were included. Collected data included general patient information, comorbidities, complications, blood loss, pain during dressing change, and the duration of DSW healing.This case series showed promising results in terms of duration of DSW healing when applying the elastomeric skin protectant. The authors also observed less blood loss and less pain during dressing changes. No infections were seen during the trial.

The monsplasty: Surgical and functional outcomes using an effective and reproducible surgical technique

BACKGROUND

The available literature on monsplasty remains sparse and most of the reports are limited to the description of one surgical technique, with limited to no post-operative data. This study aims to describe a reproducible monsplasty surgical technique and to analyze the post-operative functional and esthetic outcomes.

METHODS

Patients with at least grade 2 mons pubis ptosis were included in the study and observed for 3 months. Pre- versus post-operative analysis included body image, psychological function, sexual function, urinary function, hygiene maintenance of the pubic area, and post-operative complications. An additional retrospective analysis of a larger group of patients was also performed.

RESULTS

Between April 2021 and January 2022, a total of 25 patients were included in the prospective study. They reported a significant improvement in body image (p < 0.001), satisfaction with the abdomen (p < 0.001), and sexual functioning (p = 0.009). Functionally, improvements were recorded with regard to visualization of the genitalia (36%), hygiene maintenance of the pubic area (32%), sex life (48%), genital sensitivity (24%), and urinary continence (4%). Patient satisfaction was very high. There were no major complications. The retrospective study included 80 patients between 2010 and 2021, with a mean follow-up time of 18 months. No major complications were noted.

CONCLUSION

Monsplasty is a simple and fast procedure that can truly bring an added value to the patient's satisfaction and functional outcomes. It can be incorporated in both esthetic and reconstructive abdominoplasties and should be a standard component of the procedure for cases with mons ptosis grade 2 or higher.

EVIDENCE BASED MEDICINE LEVEL

Level II.

Push-Through Filtration of Emulsified Adipose Tissue Over a 500-µm Mesh Significantly Reduces the Amount of Stromal Vascular Fraction and Mesenchymal Stem Cells

BACKGROUND

Mechanical isolation of the stromal vascular fraction (SVF) separates the stromal component from the parenchymal cells. Emulsification is currently the most commonly used disaggregation method and is effective in disrupting adipocytes and fragmenting the extracellular matrix (ECM). Subsequent push-through filtration of emulsified adipose tissue removes parts of the ECM that are not sufficiently micronized, thereby further liquifying the tissue.

OBJECTIVES

The aim of this study was to investigate whether filtration over a 500-µm mesh filter might affect the SVF and adipose-derived mesenchymal stem cell (MSC) quantity in emulsified lipoaspirate samples by removing ECM fragments.

METHODS

Eleven lipoaspirate samples from healthy nonobese women were harvested and emulsified in 30 passes. One-half of the sample was filtered through a 500-µm mesh filter and the other half was left unfiltered. Paired samples were processed and analyzed by flow cytometry to identify cellular viability, and SVF and MSC yield.

RESULTS

Push-through filtration reduced the number of SVF cells by a mean [standard deviation] of 39.65% [5.67%] (P < .01). It also significantly reduced MSC counts by 48.28% [6.72%] (P < .01). Filtration did not significantly affect viability (P = .118).

CONCLUSIONS

Retention of fibrous remnants by push-through filters removed ECM containing the SVF and MSCs from emulsified lipoaspirates. Processing methods should aim either to further micronize the lipoaspirate before filtering or not to filter the samples at all, to preserve both the cellular component carried within the ECM and the inductive properties of the ECM itself.

Redefining the vascular anatomy of the medial gastrocnemius muscle: A computed tomography angiography study

BACKGROUND

The medial gastrocnemius (GN) muscle flap is a historical reconstructive option in lower limb reconstruction. The flap is proximally based on the medial sural artery, and it is assumed not possible to harvest a distally based flap because of the absence of other minor pedicles. The aim of this study is to investigate the presence and the anatomy of a distal secondary pedicle given off by the posterior tibial artery (PTA).

METHODS

A retrospective CTA study was performed of 120 limbs between April 2018 and June 2020. 3D reconstruction was performed to delineate the anatomy of the distal secondary pedicle, if present. The distance of the pedicle, if found, from the intermalleolar line to the patella was noted. The number of pedicles, if multiple, was documented, as well as branches to the soleus muscle and the skin.

RESULTS

A distal pedicle to the gastrocnemius muscle was found in 64% of limbs. The average location from the intermalleolar line is 168 mm. The branching pattern from the PTA showed an isolated vessel going to the distal medial gastrocnemius (32.8%), two branches to the medial gastrocnemius and skin (39.3%), two branches to the medial gastrocnemius and soleus (24.6%), and three branches to the medial gastrocnemius, soleus, and the skin (3.3%).

CONCLUSIONS

This study confirms the presence of the secondary axial distal pedicle of the GN muscle. Furthermore, this study confirms that there is a likely association between the distal medial gastrocnemius pedicle and the PTA skin perforators.

An Algorithm in Managing Deep Inferior Epigastric Vessel Interruption in Free Flap Breast Reconstruction

Previous surgical procedures in the abdomen are no longer contra-indications for free flap breast reconstruction using the deep inferior epigastric artery perforator flap. Nonetheless, a possible consequence of previous surgical procedures may be trauma to the deep inferior epigastric (DIE) pedicle, leading to interruption. In these cases, a modification in operative strategy may be required.

Metabolic aspects of surgical subcutaneous fat removal: An umbrella review and implications for future research

Although obesity is a preventable disease, maintaining a normal body weight can be very challenging and difficult, which has led to a significant increase in the demand for surgical subcutaneous fat removal (SSFR) to improve physical appearance. The need for SSFR is further exacerbated because of the global rise in the number of bariatric surgeries, which is currently the single most durable intervention for mitigating obesity. Fat tissue is now recognized as a vital endocrine organ that produces several bioactive proteins. Thus, SSFR-mediated weight (fat) loss can potentially have significant metabolic effects; however, currently, there is no consensus on this issue. This review focuses on the metabolic sequelae after SSFR interventions for dealing with cosmetic body appearance. Data was extracted from existing systematic reviews and the diversity of possible metabolic changes after SSFR are reported along with gaps in the knowledge and future directions for research and practice. We conclude that there is a potential for metabolic sequelae after SSFR interventions and their clinical implications for the safety of the procedures as well as for our understanding of subcutaneous adipose tissue biology and insulin resistance are discussed.

Schwannoma Arising from the Deep Motor Branch of the Ulnar Nerve - A Case Report and Review of Literature

Schwannomas of the ulnar nerve in the hand are uncommon and those arising from the deep motor branch of the ulnar nerve (DMBUN) are rare. We were able to find only five reports of a schwannoma of the DMBUN. We report a schwannoma arising from DMBUN beyond the Guyon canal and summarise the literature on schwannomas involving the DMBUN. Level of Evidence: Level V (Therapeutic).

The "Hug Flap": Surgical Technique to Enhance the Aesthetic Breast Projection in Autologous Breast Reconstruction

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

Anatomic study of the profunda artery perforators by multidetector CT scanner and clinical use of the banana-shaped flap design for breast reconstruction

BACKGROUND

The profunda artery perforator (PAP) flap is a well-known free flap for breast reconstruction. However, a reproducible perforator mapping system has yet to be developed.

METHODS

The PAP perforators were localized by CTA using a novel X-Y axis system. Flap dimensions were based on the CTA images and localized PAP-perforators. Perioperative findings and postoperative outcomes were analyzed.

RESULTS

A total of 70 lower limbs and 180 PAP perforators were evaluated. An average of 2.78 ± 1.22 and 2.22 ± 0.96 perforators were seen, in the right and left legs, respectively, and were divided in five clusters (PAP1-PAP5) based on their location on the Y-axis. The course of the perforators was noted as well as the average diameter at the origin. The overall average diameter was 1.99 ± 0.86 mm. A banana-shaped PAP-flap was harvested in 10 patients. The mean operative time was 278 min, pedicle length 76 ± 12 mm, and mean flap weight 247 g. No major complications were seen.

CONCLUSION

The PAP flap can be mapped by CTA in a reproducible way. The X and Y axes are based on fixed anatomic landmarks and may form the basis for a banana-shaped flap design of the PAP-flap.

Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL): Review of Epidemiology and Prevalence Assessment in Europe

BACKGROUND

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) epidemiologic studies focus on incidence and risk estimates.

OBJECTIVES

The aim of this study was to perform a thorough literature review, and to provide an accurate estimate of BIA-ALCL prevalence in Europe.

METHODS

We searched PubMed, Web of Science, SCOPUS, and Google Scholar databases to identify publications reporting BIA-ALCL epidemiology. Research was conducted between November 2019 and August 2020. European prevalence was assessed as the ratio between pathology-confirmed cases and breast implant-bearing individuals. The Committee on Device Safety and Development (CDSD) collected data from national plastic surgery societies, health authorities, and disease-specific registries to calculate the numerator. The denominator was estimated by combining European demographic data with scientific reports.

RESULTS

Our research identified 507 articles: 106 were excluded for not being relevant to BIA-ALCL. From the remaining 401 articles, we selected 35 that discussed epidemiology and 12 reviews. The CDSD reported 420 cases in Europe, with an overall prevalence of 1:13,745 cases in the 28 member states of the European Union (EU-28). Countries where specific measures have been implemented to tackle BIA-ALCL account for 61% of the EU-28 population and actively reported 382 cases with an overall prevalence of 1:9121.

CONCLUSION

Countries where specific measures have been implemented show a higher prevalence of BIA-ALCL compared with the European mean, suggesting that these countries have improved the detection of the condition and reduced underreporting, which affects the numerator value. Other nations should adopt projections based on these measures to avoid underestimating how widespread BIA-ALCL is.

LEVEL OF EVIDENCE: 4

Case Report of Two Patients With COVID-19 and Sacral Pressure Injuries Associated with Pyoderma Gangrenosum

ABSTRACT

During the COVID-19 pandemic, an increasing number of patients have been admitted to the ICU with severe respiratory complications requiring prolonged supine positioning. Recently, many case reports have been published regarding dermatologic manifestations associated with COVID-19. However, there is little information about the clinical features of these manifestations. Pyoderma gangrenosum (PG) is an ulcerative noninfectious inflammatory disease of the skin. In at least 50% of the cases, the etiology is unknown. Nevertheless, PG is associated with many systemic diseases. In this article, the authors report two critically ill patients with COVID-19 who developed sacral ulcers during their recovery in the ICU. These ulcers had an atypical course and were exacerbated by surgical debridements. Accordingly, providers suspected PG, which was confirmed by the clinical evolution of the ulcers and biopsies taken from the wounds. To the best of the authors' knowledge, no previous articles have reported sacral pressure injuries associated with PG in patients with COVID-19. Providers should suspect PG in patients with COVID-19 who develop nonhealing pressure injuries.

Sire contribution to fertilization failure and early embryo survival in cattle

Despite passing routine laboratory tests of semen quality, bulls used in artificial insemination (AI) exhibit a significant range in field fertility. The objective of this study was to determine whether subfertility in AI bulls is due to issues of sperm transport to the site of fertilization, fertilization failure, or failure of early embryo or conceptus development. In experiment 1, Holstein-Friesian bulls (3 high fertility, HF, and 3 low fertility, LF) were selected from the national population of AI bulls based on adjusted fertility scores from a minimum of 500 inseminations (HF: +4.37% and LF: -12.7%; mean = 0%). Superovulated beef heifers were blocked based on estimated number of follicles at the time of AI and inseminated with semen from HF or LF bulls (n = 3-4 heifers per bull; total 19 heifers). Following slaughter 7 d later, the number of corpora lutea was counted and the uteri were flushed. Recovered structures (oocytes/embryos) were classified according to developmental stage and stained with 4',6-diamidino-2-phenylindole to assess number of cells and accessory sperm. Overall recovery rate (total structures recovered/total corpora lutea) was 52.6% and was not different between groups. Mean (± standard error of the mean) number of embryos recovered per recipient was 8.7 ± 5.2 and 9.4 ± 5.5 for HF and LF, respectively. Overall fertilization rate of recovered structures was not different between groups. However, more embryos were at advanced stages of development (all blastocyst stages combined), reflected in a greater mean embryo cell number on d 7 for HF versus LF bulls. Number of accessory sperm was greater for embryos derived from HF than for LF bulls. The aim of experiment 2 was to evaluate the effect of sire fertility on survival of bovine embryos to d 15. Day 7 blastocysts were produced in vitro using semen from the same HF (n = 3) and LF (n = 3) bulls and transferred in groups of 5-10 to synchronized heifers (n = 7 heifers per bull; total 42 heifers). Conceptus recovery rate on d 15 was higher in HF (59.4%,) versus LF (45.0%). Mean length of recovered conceptuses for HF bulls was not affected by fertility status. In conclusion, while differences in field fertility among AI sires used in this study were not reflected in fertilization rate, differences in embryo quality were apparent as early as d 7. These differences likely contributed to the higher proportion of conceptuses surviving to d 15 in HF bulls.

36 Analysis of miRNA content of oviduct and uterine extracellular vesicles across the bovine estrous cycle

With the aim of investigating the possible hormonal regulatory effect of the oestrous cycle on miRNA content in the extracellular vesicles (EVs) of bovine oviducal and uterine fluids (OF, UF), we performed a bioinformatic analysis of these miRNAs, their target genes, and their biological pathways. Reproductive tracts were collected from slaughtered heifers and selected according to their corpus luteum morphology, corresponding to the 4 stages of the oestrous cycle (n=5 per stage; S1: days 1 to 4, S2: days 5–10, S3: days 11–17, S4: days 18–20) and transported to the laboratory on ice. EVs were obtained by size exclusion chromatography (PURE-EVs-Hansa Biomed) from the flushing of 1.2mL and 2.5mL of OF and UF, respectively. To concentrate the EVs, they were ultracentrifuged and suspended in 100µL of PBS. Total RNA extraction was obtained from 70µL of the previous pellet, using miRNeasy Mini Kit (Qiagen). Then, 100 to 200ng of the obtained RNA was reverse transcribed using miScript II RT Kit (Qiagen). MicroRNA (miRNA) expression profiling was done by primer-based real-time quantitative PCR of 383 mature miRNA sequences. Possible miRNA target genes and their biological pathways were predicted using the miRWalk database. Among EV miRNAs in OF, bta-miR-130a, bta-miR-382, and bta-miR-1291 were the most abundant at all stages of the oestrous cycle, displaying a significantly progressive increase from stages 1 to 4 (P&lt;0.05). In UF, bta-miR-17-5p, bta-miR-206, bta-miR-22-5p, bta-miR-502a, and bta-miR-503-3p were the most abundant at all stages of the cycle, showing greater differences between S1 and S3 (P&lt;0.05). Other miRNAs were exclusively present in a specific stage of the oestrous cycle in OF: bta-miR-21-5p (S1), bta-miR-146a (S2), bta-miR-128 (S3), and bta-miR-147 (S4). In UF, bta-miR-218 (S1), bta-miR-208b (S2), bta-miR-340 (S3), and bta-miR-335 (S4) were found. Table 1 presents some of these miRNAs, their predicted target genes, and functional pathways. In conclusion, this study highlights the effect of the oestrous cycle on miRNAs contained in the EVs of OF and UF. These miRNAs are related to relevant biological pathways implicated in oviduct and uterus modulation across the cycle, but they may also prepare those organs for embryo/conceptus presence and development. Table 1. Micro (mi)RNAs of oviductal (OF) and uterine fluid (UF) extracellular vesicles (EVs), their target genes, and biological pathways Reproductive fluid miRNAs Target genes Target pathways OF bta-miR-130a BMPR2, SMAD5, SMAD4 BMP signalling bta-miR-1291 SLC2A1 Glucagon signalling bta-miR-21–5p LIF Pluripotency stem cells regulation UF bta-miR-17-5p STAT3 Prolactin signalling bta-miR-206 ESR1 Oestrogen signalling bta-miR-340 HRAS Ras/MAPK/ERK signalling (embryo implantation) This research was funded by MINECO-Spain AGL2015-70140-R, PID2019-111641RB-I00, RTI2018-093548-B-I00; SENESCYT-Ecuador (YNC); FAPESP-Brazil 2017/20339-3 (CLVL), 2014/22887-0 (JCS), 2019/04981-2 (RM); CNPq-Brazil 304276/2018-9, 420152/2018-0 (CLVL).

52 Extracellular vesicles from oviduct and uterus in sequential invitro culture affects mitochondrial activity and lipid metabolism transcripts in bovine embryos

Oviducal fluid (OF) and uterine fluid (UF) improve the quality of embryos during invitro culture, and their extracellular vesicles (EV) may be involved in such an effect. We aimed to evaluate the effect of EV from OF and UF in sequential invitro culture on the development and quality of bovine embryos. Zygotes were cultured in synthetic oviduct fluid supplemented either with 3mg mL−1 BSA (n=1584) or 5% EV-depleted fetal calf serum (dFCS, n=1594) in absence or presence (BSAEV, n=1853 and dFCSEV, n=1473) of 3×105 EV mL−1 from OF (Day 1 to Day 4) and UF (Day 5 to Day 8), mimicking invivo conditions. EV from oviducts (early luteal phase) and uterine horns (mid luteal phase) from slaughtered heifers were isolated by size exclusion chromatography; size and concentration were assessed by nanotracking analysis (NTA) and morphology by transmission electron microscopy (TEM). Blastocyst rate was recorded on Days 7–8 and their quality was assessed for mitochondrial activity by staining with Mitotracker Deep Red (ThermoFisher Scientific), survival rate after vitrification/warming by invitro culture for up to 72h, and relative mRNA abundance of lipid metabolism-related transcripts by quantitative PCR. Housekeeping genes were H2AFZ and ACTB. Data were analysed by one-way ANOVA and Tukey test. TEM confirmed the presence and morphology of EVs, and NTA indicated mode size and concentration of particles (137.2 and 151.2 nm; 2.97×1010 and 7.98×1010 particles mL−1, for OF and UF, respectively). Blastocyst yield was lower (P&lt;0.05) in BSA groups compared with dFCS groups (BSA: 16.2±1.5 and 31.0±1.9; BSAEV: 14.1±1.6 and 26.2±2.0% vs. dFCS: 30.5±2.0 and 40.6±2.4; dFCSEV: 31.1±2.5 and 39.8±2.7%, Day 7 and Day 8, respectively), irrespective of EV supplementation. Blastocyst mitochondrial activity was increased (P&lt;0.05) by EV in dFCSEV compared with the other groups. No differences in survival rate after vitrification/warming were found (range at 72 h: 67.1±8.1 to 87.8±5.7%). PPARGC1B was downregulated and ACC upregulated by EV, irrespective of protein source in medium (P&lt;0.05). In contrast, EV affected some transcripts depending on the protein source in the medium (CD36 upregulated in dFCSEV, downregulated in BSAEV; PLIN2 downregulated in dFCSEV and ATGL downregulated in BSAEV, P&lt;0.05). In conclusion, mimicking physiological conditions using EV from OF and UF in sequential IVC does not affect development but improves embryo quality by increasing blastocysts’ mitochondrial activity and favours the expression of specific lipid metabolism transcripts. Functional effects of EV may be influenced by the protein source in the medium. This research was funded by MINECO-Spain AGL2015-70140-R, PID2019-111641RB-I00, RTI2018-093548-B-I00; YN Cajas, SENESCYT-Ecuador; CLV Leal, FAPESP-Brazil 2017/20339-3, CNPq-Brazil 304276/2018-9.

Is Autologous Fat Grafting an Oncologically Safe Procedure following Breast Conserving Surgery for Breast Cancer? A Comprehensive Review

BACKGROUND

Autologous fat grafting (AFG) is a recognized surgical procedure to correct deformities following breast conservation surgery (BCS) for breast cancer. However, there are concerns about the oncological safety of this technique. In this study we have reviewed the current literature to assess whether AFG adversely influences the oncological outcome after BCS for breast cancer.

METHODS

We have searched the medical literature using the Embase and PubMed search engines from conception until May 2019 to identify all relevant studies of patients who underwent AFG after BCS. Meta-analysis and meta-regression methodologies were used to calculate the overall relative risk (RR) of loco-regional recurrence (LRR) rates for case-control and case series studies (with historical controls) respectively.

RESULTS

We have identified 26 eligible studies with a total of 1640 patients who had undergone fat transfer after lumpectomy for breast cancer. The meta-analysis of 11 studies revealed an overall RR for LRR of 0.82 [95% confidence interval (CI):0.14-1.66]. The meta-regression of case series revealed an overall incidence of LRR of 1.85% compared with 2.53% for historical controls.

CONCLUSIONS

Our study lends further support to the notion that fat transfer after lumpectomy for breast cancer does not seem to increase the risk of LRR. However further prospective research is required in order to confirm this.

Low-Energy Extracorporeal Shockwave Therapy as a Therapeutic Option for Patients with a Secondary Late-Stage Fibro-Lymphedema After Breast Cancer Therapy: A Pilot Study

Background: Secondary lymphedema (LE) can occur after breast cancer (BC) therapy with axillary lymph node surgery and/or radiotherapy. Reported incidence varies around 20%. The aim of this study was to see whether low-energy extracorporeal shockwave therapy (ESWT) is a therapeutic option in end-stage secondary upper limb fibro-LE. Methods and Results: A pilot study was performed on 10 adult patients who presented with an end-stage LE after BC treatment. They were all treated with usual physical therapy and all had lymphatic surgery before. Eight sessions of ESWT were applied, 2600 shocks at 0.1 mJ/mm², 2/week during 4 weeks. Upper limb volume decreased nonsignificantly, from 3086.4 ± 539.47 to 2909.1 ± 471.60 mL. Mean circumference of the upper limb was significantly decreased from 32.3 ± 3.01 to 31.4 ± 2.71 cm at the height of the upper arm, from 29.1 ± 2.89 to 28.1 ± 2.71 cm at the height of the elbow, and from 27.5 ± 4.08 to 26.8 ± 3.75 cm at the height of the forearm. Subjective measurements by visual analog scale showed significant decrease in both hardness from 57.3 ± 15.84 to 24.4 ± 21.89 mm and subjective feeling of edema from 44.2 ± 16.90 to 23.2 ± 21.16 mm. No adverse features were reported. Conclusion: We added some evidence that low-energy ESWT is well supported and has additional benefits also in longstanding fibro-lipo-LE on swelling of the arm leading to more subjective comfort for the patients.

Perforator Mapping Practice for Deep Inferior Epigastric Artery Perforator Flap Reconstructions: A Survey of the Benelux Region

BACKGROUND

 Numerous new and novel imaging techniques for preoperative perforator selection in deep inferior epigastric artery perforator (DIEP) flap planning have been introduced. To what extent, these have been adopted into or replaced routine practice has hitherto remained unknown. The purpose of this study was to identify the currently preferred technique by reconstructive surgeons, the criteria that they regard as most relevant and what impact these have on the preoperative decision-making.

METHODS

 An online survey consisting of 25 questions was sent to members of the Benelux Societies for Plastic Surgery. Information regarding experience and preferred imaging modality was requested. Specific questions addressed the utilization of computed tomography angiography (CTA) and factors that could inform preoperative perforator selection. Results were anonymously collected, managed using REDCap, and analyzed using Chi-square statistic.

RESULTS

 Seventy-nine principal surgeons could be included. A variation in surgeon experience was observed. On CTA, the preferred imaging modality, large-caliber vessels, the location of the perforator in the flap, and its intramuscular course were considered the most significant criteria. Surgeons doing more than 20 DIEP flaps per year are less concerned about the distance of the perforator from the umbilicus (p = 0.003) but more likely to choose a medial perforator (p = 0.011). No statistical difference was found in surgeons' experience between those who would choose and use one specific (medial or lateral) perforator when they are analogous on CTA, and those who would delay the decision until both perforators have been exposed.

CONCLUSION

 Advantages and disadvantages of the current practice of preoperative perforator selection by surgeons who are primarily responsible for harvesting a DIEP flap have been clearly identified. Indications are that these could be widely representative in which case, the quest for a protocol or modality that maximizes the benefit and minimizes harm in preoperative perforator mapping is urgently required.

The "ART" of facial filler injections: Avoid, recognize, and treat hyaluronic acid-induced complications

BACKGROUND

Hyaluronic acid (HA) fillers are frequently used for cosmetic purposes as volumizers or as wrinkle fillers. One of the major advantages of hyaluronic acid use is the possibility to neutralize it by using hyaluronidase should complications occur.

PATIENT

A case of a 21-year-old female patient is presented, in whom a hyaluronic acid injection-induced vascular occlusion was seen four days after the initial injection, with increasing pain and severe signs of ischemia.

METHOD

Treatment consisted of an immediate hyaluronidase injection, supplemented with administration of acetylsalicylic acid, piracetam, low molecular weight heparin (LMWH), corticosteroids, analgesics, prophylactic antibiotics, application of topical nitroglycerin and warmth, smoking cessation, and hyperbaric oxygen therapy.

RESULTS

The initial progress and evolution of the deformity with possible therapeutic options are being discussed.

CONCLUSION

The "ART" (avoid, recognize, and treat) in handling filler complications is presented, as a new universal guideline for clinical aesthetic practitioners and injectors.

The Impact of Coronavirus Disease 2019 on Plastic Surgery Training: The Resident Perspective

The coronavirus disease 2019 (COVID-19) pandemic has led to marked changes in surgical training, including that of plastic surgery residents. We performed a survey to gain an insight into the self-reported current and future impact of COVID-19 on plastic surgery residents.

METHODS

A 20-point questionnaire was designed by a panel of surgical trainees and trainers, which was filled in by Belgian plastic surgery residents and their international network of peers between 19 and 26 April 2020-week 6 of stringent Belgian lockdown measures. Questions covered the impact of COVID-19 on surgical activity, surgical training, and the future of training.

RESULTS

Thirty-five of 38 plastic surgery residents in Belgium filled in the questionnaire, as did 51 of their international peers from 9 other countries. Decreased surgical activity of >75% was reported by 86% of Belgian trainees and by 73% of international colleagues. All consultations were stopped for 26% of Belgian trainees and 37% of international peers. Forty-six percents of Belgian trainees and 27% of international peers were reassigned to different departments. Eighty-five percent of all trainees felt surgical training had suffered, yet 54% of Belgian residents and 39% of international peers felt training should not be prolonged. Anxiety regarding the pandemic was present in 54% of Belgian residents and 69% of international colleagues.

CONCLUSIONS

This is the first report, expressing the voice of a representative group of plastic surgery residents, showing a significant impact of COVID-19 on training and activity. A joint effort is needed to provide continued forms of education by virtual education and skills-based learning.

Abstract P4-13-05: The oncological safety of autologous fat grafting after breast conserving surgery for breast cancer: A systematic review, meta- analysis and meta regression analysis of observational studies

Background: Autologous fat grafting (AFG) has been widely adopted to correct deformities resulting from breast conserving surgery (BCS) for breast cancer. However, clinical and animal studies and in vitro experiments have revealed conflicting results regarding the oncological safety of AFG.

Aim: The aim of this study was to systematically evaluate the current literature regarding the oncological safety of AFG in patients who underwent BCS for breast cancer by performing a meta-analysis of observational studies.

Methods: A literature research was performed using the PubMed and Embase search engines from conception until May 2019 to identify all studies of patients who underwent AFG following BCS for breast cancer. Reference lists of retrieved articles and relevant previous reviews were also searched. The primary outcome was the locoregional recurrence rate. For case-control studies a standard meta-analysis was performed to calculate a pooled relative risk (RR). For case series studies, subgroup analysis and meta-regression techniques were used with historical control data to increase reliability.

Results: 26 studies reporting on 1640 BCS patients who had undergone AFG met the inclusion criteria for analysis. There were 11 case-control studies and 15 case series. For the case-controlled studies, meta-analysis using the random effects model revealed no significant difference in the locoregional recurrence rates between the AFG and control groups [RR=0.82(95% CI= 0.41-1.66)]. The mean follow up duration from surgery for the AFG group and the control group was 39 and 49 months, respectively. For the case series and historical controls, the locoregional recurrence rates were 1.85% and 2.53% respectively (p=0.33) according to subgroup and meta regression analysis. There was no strong evidence of publication bias however selection bias could not be excluded.

Conclusions: Our study suggests that AFG does not increase the risk of locoregional recurrence after BCS for breast cancer. However further prospective research is needed to confirm the oncological safety of this technique particularly in patients with high risk disease.

Citation Format: Salim Tayeh, Amtul R Carmichael, Humaa Darr, Zuhair Al-Fardan, Abdul Kasem, Moustapha Hamdi, Kefah Mokbel. The oncological safety of autologous fat grafting after breast conserving surgery for breast cancer: A systematic review, meta- analysis and meta regression analysis of observational studies [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P4-13-05.

76 Extracellular vesicles from oviduct and uterus in sequential culture improve the quality of bovine embryos produced invitro

Extracellular vesicles (EVs) are released by cells and transport cargo that affect functions of other cells. Oviductal fluid (OF) and uterine fluid (UF) have been shown to improve quality of embryos during invitro culture (Hamdi et al. 2017 Reprod. Fertil. Dev. 30, 935-945) which may be due to their content of EV (Lopera-Vásquez et al. 2017 Reproduction 153, 461-470). Thus, the aim of this study was to evaluate the effect of EVs from OF and UF on a sequential invitro culture system on the development and quality of bovine embryos. Zygotes were cultured in synthetic oviduct fluid (SOF) supplemented with 3mgmL−1 bovine serum albumin (BSA; n=1228) or 5% EV-depleted fetal calf serum (dFCS, n=1261) in the presence (BSAEV, n=1265 and dFCSEV, n=1253) or absence of 3×105 EVmL−1 from OF (Day 1 to Day 4) and UF (Day 4 to Day 9), mimicking invivo conditions. The EVs pooled from 5 oviducts (early luteal phase) and 5 uterine horns (middle luteal phase) from slaughtered heifers were isolated by a Size Exclusion Chromatography kit (Hansa BioMed). The EV size and concentration were assessed by the nanotracking analysis system and morphology by transmission electron microscopy. Embryo development was recorded on Days 7/9. Day 7/8 blastocysts were assessed for quality by staining with (a) Hoechst 33342 (10 µgmL−1, 30min) for total cell number, (b) Bodipy 493/503 (20 µgmL−1, 1h) for lipid content (lipid droplet area in µm2), and (c) for survival rate after vitrification/warming. Data were analysed by one-way ANOVA and Tukey test. The EV concentration was 2.97 and 7.98×1010 particlesmL−1, and mode size 137.2 and 151.2nm for OF and UF, respectively. Transmission electron microscopy confirmed EV presence and size, showing typical cup-shaped morphology. Blastocyst yield was lower (P&lt;0.05) on Day 7 in the BSA groups (BSA: 15.7±1.9 and BSAEV: 15.2.4%) compared with serum groups (dFCS: 28.1±2.6 and dFCSEV: 30.1±2.9%) irrespective of EV supplementation; however, these differences were compensated at Days 8 and 9 (range: 30.0±3.2-40.8±3.9%). The EVs increased (P&lt;0.05) blastocyst total cell number in dFCSEV (152.6±2.9) and BSAEV (140.5±1.5) compared with dFCS (117.9±2.0) and BSA groups (122.4±1.1). However, lipid content was decreased (P&lt;0.05) in the presence of EVs only in dFCSEV (0.231±0.05µm2) compared with BSA (0.393±0.03µm2) and BSAEV (0.379±0.03µm2) groups. The dFCS did not differ from any group (0.371±0.05µm2; P&gt;0.05). Blastocyst survival after vitrification/warming was high in all groups up to 72h (range: 80.0±3.8-100%; P&gt;0.05). In conclusion, mimicking physiological conditions using EV from OF and UF during invitro culture does not affect development but improves embryo quality by increasing blastocyst total cell numbers and decreasing lipid contents. These results provide evidence of the association of the reproductive tract environment and developing embryo, confirming embryo-maternal communication. Funding was provided by MINECO-Spain AGL2015-70140-R; Y. N. Cajas, SENESCYT-Ecuador; C. L. V. Leal, FAPESP-Brazil 2017/20339-3.

In vitro evaluation of novel low-pressure spark plasma sintered HA–BG composite scaffolds for bone tissue engineering

The low-pressure spark plasma sintering (SPS) technique is adopted to fabricate hydroxyapatite–bioglass (HA–BG) scaffolds while maintaining the physical properties of both components, including their bulk and relative density and hardness. However, prior to their orthopaedic and dental applications, these scaffolds must be validated via pre-clinical assessments. In the present study, scaffolds with different ratios of HA : BG, namely, 100 : 0 (HB 0 S), 90 : 10 (HB 10 S), 80 : 20 (HB 20 S) and 70 : 30 (HB 30 S) were fabricated. These scaffolds were characterized by investigating their physicochemical properties (X-ray diffraction (XRD) and surface wettability), bioactivity in a simulated body fluid (SBF) (field emission scanning electron microscopy (FESEM), Fourier-transform infrared spectroscopy (FTIR) and calcium dissolution), antimicrobial properties, biocompatibility and osteoinduction of human bone marrow-derived mesenchymal stromal cells (hBMSCs) and human monocyte immune cell response. The XRD and surface wettability results confirmed no formation of undesirable phases and the enhanced surface hydrophilicity of the scaffolds, respectively. The bioactivity in SBF indicated the formation of bone-like apatite on the surface of the scaffolds, corresponding to an increase in BG%, which was confirmed through FTIR spectra and the increasing trend of calcium release in SBF. The scaffolds showed inhibition properties against Staphylococcus aureus and Staphylococcus epidermidis. The scanning electron microscopy (SEM) micrographs and Alamar Blue proliferation assay indicated the good attachment and significant proliferation, respectively, of hBMSCs on the scaffolds. Alizarin Red S staining confirmed that the scaffolds supported the mineralisation of hBMSCs. The osteogenic protein secretion (bone morphogenetic protein-2 (BMP2), type-I collagen (COL1) and osterix (OSX)) was significant on the HB 30 S-seeded hBMSCs when compared with that of HB 0 S. The monocyte migration was significantly halted in response to HA–BG-conditioned media when compared with the positive control (monocyte chemoattractant protein-1: MCP-1). In conclusion, the HB 30 S composite scaffold has a greater potential to substitute bone grafts in orthopaedic and dental applications.

HB 30 S composite scaffold inhibits Staphylococcus spp., supports the biocompatibility and osteogenic differentiation of hBMSCs and resists monocyte migration.

Deep inferior epigastric artery perforator flap harvest after full abdominoplasty

Abdominal scars are no longer a contra-indication for abdominal perforator flap harvesting. Few research data exists about the regeneration potential of the abdominal wall's perforator system. Therefore, previous abdominoplasty with umbilical transposition is an absolute contra-indication for a DIEaP-flap (deep inferior epigastric artery perforator flap). A 50-year-old patient required a breast reconstruction of the right breast, 10 years after an abdominoplasty with undermining of the superior abdomen and umbilical transposition. The patient was scheduled for a free lumbar artery perforator (LaP) flap. The preoperative computed tomography-angiography mapping showed nice lumbar perforators and to our surprise a good-sized DIEa perforator in the peri-umbilical region. The DIEa perforator on the right hemi-abdomen, consisting of two veins and one artery, was pulsatile and found suitable in size. A classical flap harvest and transfer was further performed. This case report is the first in which a dominant perforator is found in the area of undermining after a full abdominoplasty with umbilical repositioning. Further investigations regarding the nature and timing of re-permeation or regeneration of perforators after abdominoplasty are to be done. Nevertheless, we are convinced that with appropriate perforator mapping and a suitable plan B, previous abdominoplasty is no longer an absolute but a relative contra-indication for performing DIEaP-flap.

Shape-from-focus for real-time terahertz 3D imaging

Thanks to significant advances in real-time terahertz imaging in terms of resolution and image quality, adapting and extending optical methods for 3D imaging at the millimeter scale is now promising. The shape-from-focus algorithm is a post-processing tool used in optical microscopy to reconstruct the external shape surface of a convex surface object. Images acquired at different distances from the object-side focal plane are implemented in this algorithm. We localize the best focus position in the stack of images for each pixel and then reconstruct the object in 3D due to the short depth of field. In this Letter, we propose an application of this algorithm in active and real-time terahertz imaging. We achieve the experimental reconstruction in 3D with a terahertz waves imaging system composed of a powerful source and a real-time terahertz camera.

Association Between Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL) Risk and Polyurethane Breast Implants: Clinical Evidence and European Perspective

This article aims to present an overview on the use of polyurethane (PU) breast implants and the possible association with the risk of developing breast implant-associated anaplastic large cell lymphoma (BIA-ALCL), with a special look at the current situation in Europe. It is well known that the real cause of BIA-ALCL remains unknown. Although this is a rare disease, many interesting theories surrounding its development have been advanced; however, none of these theories has been able to demonstrate with statistical significance, as required by the criteria of evidence-based medicine, definitive clinical proof as to why BIA-ALCL develops. It is widely assumed that the implant surface plays a crucial role. Most BIA-ALCL cases are associated with macro-textured implants, but from a strictly scientific point of view, this link is not supported by any clear clinical evidence. A deeper discussion of the various implant surfaces indicates that adding further categories to the existing surface classification (smooth, micro-, and macro-textured) should be avoided. Moreover, one of the most common misunderstandings should be clarified: PU breast implants cannot be classified as macro-textured implants. The PU foam that covers breast implants provides a completely different surface, and the mechanisms of action related to tissue adhesion, as well as to fibrous capsule formation, differ substantially from those of smooth or textured implants.

Percutaneous Purse-String Suture: An Innovative Percutaneous Technique for Inframammary Fold Creation and Improved Breast Projection in Reconstructive Surgery

BACKGROUND

Lipofilling for breast reconstruction has become increasingly common. Creation of a well-defined inframammary fold (IMF) is integral to achieving symmetrical aesthetic results. This has traditionally been done under direct vision through an open incision.

OBJECTIVES

The authors present their experience in reconstructive breast surgery with a novel percutaneous technique for IMF creation and improvement of projection without the need for large incisions.

METHODS

From June 2011 to January 2015, 180 patients underwent a percutaneous purse-string suture (PPSS) to enhance their IMF and improve breast projection. After completion of lipofilling, a curved cannula is tunneled subcutaneously. The suture is placed into the cannula and passed around the circumference of the breast footprint. After the completion of two passes in different anatomic levels around the footprint, the suture is tightened at the breast's tail zone to achieve the desired IMF definition and breast projection. Surgical technique, results, and follow up are presented.

RESULTS

The PPSS technique was combined either with lipofilling only or as part of flap breast reconstruction in 30 and 150 patients, respectively. The average follow-up time was 34 months (range, 11-48 months). PPSS was redone in 25 patients to further improve breast projection. One patient complained of postoperative pain. No other PPSS-related complication was reported.

CONCLUSIONS

PPSS is an innovative technique designed to complement the emerging field of lipofilling for breast reconstruction. The technique is safe, easily reproduced, and provides excellent results. Breast IMF and projection are immediately improved without the need for open incisions.

LEVEL OF EVIDENCE 4

A Review of Lymphedema for the Hand and Upper-Extremity Surgeon

Secondary lymphedema of the upper limb is frequently seen in Western countries after cancer treatment (most often breast in women). It is a chronic disease that affects quality of life and functioning. In its extreme form, it may be debilitating. A review is given of the pathology, nonsurgical treatment, and surgical treatment with a protocol.

MR lymphography in patients with upper limb lymphedema: The GPS for feasibility and surgical planning for lympho-venous bypass

BACKGROUND AND OBJECTIVES

Lymphedema is caused by insufficient lymphatic drainage leading to abnormal accumulation of interstitial fluid within soft tissues. Lympho-venous anastomosis (LVA), as a surgical option for selected patients, is widely applied. Through preoperative localization of functional lymphatics with indocyanine green, real time visualization of functioning lymphatic vessels is possible. This examination is time consuming and operator dependant and is not suitable to differentiate the ratio of fat hypertrophy to liquid edema. We investigated whether MR lymphangiography is accurate for imaging functional lymphatics and adjacent veins in arms. Furthermore, we investigated the accuracy and predictability of preoperative mapping for the feasibility of performing LVA and the preoperative decision making in lymphedema surgery.

METHODS

A prospective study was performed in which 25 patients suffering from lymphedema of the upper extremity were examined. MR lymphography with contrast agent injection in a deep dermal plane was performed.

RESULTS

Precise localization of lymphatic vessels crossing a vein was achieved in 18 of 25 arms. In 16 of the 18 patients in whom functional lymphatics were localized with an adjacent vein on MRI an LVA was performed successfully.

CONCLUSIONS

MR lymphangiography is an accurate and reproducible method for imaging and mapping of lymphatic channels in the lymphedemateous limb.

Clinicians Should Actively Promote Exercise in Survivors of Breast Cancer

Breast cancer is the most common cancer affecting women, causing 29% of all female cancers and afflicting 14% of all female cancer-related deaths worldwide. It remains a significant clinical, psychological, and financial burden. Exercise has been suggested to reduce cancer recurrence and cancer-related mortality from research in the past decade. Recent American and European guidelines advise on exercise for breast cancer survivors, not only to improve quality of life and decrease fatigue, but also to aid in decreasing recurrence and improve breast cancer related mortality. Nonetheless, adherence to guidelines remains low, with lack of awareness and fatigue related to chemotherapy as the most common barriers. It remains to be elucidated whether a particular type of exercise, or whether group or individualized activity is most effective. The importance of exercise in avoiding recurrence and improving quality of life needs to be recognized and taken into account in the management of breast cancer survivors. Further patient awareness and education is essential towards this goal, and the role of group exercise should be further explored.