Polyurethane Implants in 2-Stage Breast Reconstruction: 9-Year Clinical Experience

BACKGROUND

Capsular contracture (CC) is a major complication of breast surgery with smooth and textured implants. Polyurethane (PU) foam-coated breast implants were developed to decrease the incidence of CC.

OBJECTIVES

The authors determined the incidence of CC following 2-stage breast reconstruction using PU foam-covered implants, with and without radiation therapy.

METHODS

The records of 92 patients who received 115 PU implants were retrospectively reviewed. The rates of CC over time were compared for irradiated and nonirradiated groups with a Kaplan-Meier analysis and log-rank test. CC rates also were analyzed with respect to age.

RESULTS

The median follow-up time for patients was 103.3 months. Nine patients experienced unilateral Baker grade III or IV fibrous CC, including 6 patients from the irradiated group and 3 patients from the nonirradiated group. The overall cumulative incidence of CC at 9 years was 8.1%. In the irradiated and nonirradiated groups, the 9-year cumulative incidence was 10.7% and 5.5%, respectively. CC occurred within 3 years in the irradiated group and within 7 years in the nonirradiated group. The incidence of CC appeared to be higher among younger patients.

CONCLUSIONS

Radiation therapy increases the risk of high-grade CC with textured or smooth implants. PU implants are associated with a much lower cumulative incidence of CC following 2-stage breast reconstruction, even when radiotherapy is performed. LEVEL OF EVIDENCE 3.

The Modern Polyurethane-Coated Implant in Breast Augmentation: Long-Term Clinical Experience

BACKGROUND

First-generation polyurethane foam-coated breast implants were associated with a low risk of capsular contracture (CC), but the risk of CC with modern polyurethane-coated silicone implants has not been established.

OBJECTIVES

The authors sought to determine the long-term rates of CC after primary breast augmentation with Microthane, a polyurethane-coated silicone gel implant.

METHODS

A total of 131 patients (255 breasts) were evaluated in a retrospective study. Data were compiled from postoperative follow-up sessions at 2 weeks; 1, 3, 6, and 12 months; and annually thereafter. Rates of various complications, including CC, were determined.

RESULTS

CC developed in 3 of the 255 implanted breasts (1.2%; Baker grade III or IV), and postoperative hematoma occurred in 2 implanted breasts (0.8%). Spontaneous CC that was not associated with other complications was observed in 1 implanted breast (0.4%). All instances of CC occurred before the 31st postoperative month.

CONCLUSIONS

For patients who undergo primary breast augmentation with modern polyurethane-coated implants, the long-term risk of CC is low.

LEVEL OF EVIDENCE

3 Therapeutic.

Salvage of infected vascular graft via 'perivascular venous banding' technique coupled with rectus abdominis myocutaneous muscle flap transposition

This is the case of a severe Pseudomonas aeruginosa biological vascular graft infection, completely involving the perianastomotic tract of a femoro - femoral crossover bypass and resulting in repeated bleeding from the offended vessel wall. After the failure of a sartorious rotational muscle flap transposition into the infected groin wound, this 'high-grade' vascular graft infection was finally treated successfully by wrapping a great saphenous vein patch reinforcement circumferentially around the damaged biological vascular conduit and filling the infected wound with a rectus abdominis myocutaneous muscle flap transposition. The aim of this report is to illustrate this novel, to our knowledge, 'perivascular venous banding' technique and to evaluate the prospective of future testing of this surgical procedure. Starting from this singular case, we will also review the role of the rotational muscle flaps in the conservative management of major vascular graft infections.

[Mechanical microanastomosis in reconstructive surgery of the neck and face]

Aim of the study is to report our preliminar experience with MCA Coupler System in mechanical microanastomoses performed in head and neck reconstructive surgery. During almost 7 months we performed 7 end-to-end venous anastomoses: 3 of them regarding the cephalic district. We had no vascular thrombosis, vascular congestion or flap loss. Mean time of execution of anastomosis with MCA Coupler System was 10 minutes. In our experence it is essential the choice of the appropriate size of the device and a good dissection of recipient vessels. In our opinion the Coupler System is an easy applicable device, and an efficient alternative to manual micro-anastomoses.

[Expanders and the prosthetic short line in breast reconstruction after mastectomy: experience with the first 130 surgically treated cases]

Breast reconstruction as now to be consider as a complementary treatment of breast cancer surgery. Between 1998-1999 we developed a project of collaboration with Polytech-Silimed Europe Gmbh for a new textured tissue expander. This new system allows expansion of the middle and lower quadrant of the breast acting a physiologic ptosis of the breast. Authors report their experience on the first 130 patients.

[Five hundred sixty-nine flaps used in reconstruction of the head and neck: morbidity analysis and results]

Aim of the study is to provide high-level results in terms of functionality and softness of the tissues achieved with different reconstructive techniques performed in oncological surgery of the head and neck. Test group was composed of 528 patients recovered with a diagnosis of head and neck cancer. We performed 569 flaps: myocutaneous, cutaneous and fasciocutaneous, and free flaps. The clinical outcome and the morpho-functional evaluation show that free flaps can ensure excellent results, especially in defined anatomical areas such as the cervical-esophageal region, jaw and tongue. As to myocutaneous and cutaneous/fasciocutaneous flaps, they are still the first reconstructive choice, according to their minimal or no functional implications.

[500 reconstructive flaps in oncological surgery of the head and neck: critical review of 10 years experience]

AIM

Oncologic surgery of the head and neck, according to the principle of oncological radicality, involves large demolition often including skin, soft tissues and bone structures. The aim of this study is to provide a high-level perspective of results achieved in terms of functionality and softness with the different reconstructive techniques during the last ten years.

METHODS

The test group was composed of 467 patients, hospitalised in the "Regina Elena" National Cancer Institute in Rome and treated for head and neck cancer; 86% of the treated patients suffered from stage III or IV of the disease. For the reconstructive phase, 506 flaps were used, 45.5% were myocutaneous flaps, 37.1% cutaneous and fasciocutaneous flaps and 17.4% free flaps. Ischemic complications occurred in 5.2% of the myocutaneous flaps group and in 10.3% of the free flaps group.

RESULTS

"Minor complications" affected 3.9% of the cases in the free flaps group and 20.8% of cases in the myocutaneous flaps group.

CONCLUSION

The analysis of the results shows that generally free flaps are more reliable than myocutaneous flaps in terms of minor complications, however they tend to prolong the patient's hospitalisation and increase the overall treatment cost. Furthermore in morpho-functional terms, free flaps ensure results, in defined anatomical areas (such as the cervical-esophageal region, jaw, tongue) that today cannot be compared to the "conventional" procedures. As for myocutaneous and cutaneous/ fasciocutaneous flaps, according to personal opinion they are still the first choice for reconstruction having minimal or no functional implications.

A new surgical technique for the correction of the inverted nipple

Many techniques have been proposed over the years to correct the inverted nipple, a condition which causes both aesthetic and functional problems. In more severe cases, other than causing infections and inflammations, breastfeeding is impossible because of the lack of nipple erection. Reconstructive surgical techniques today are oriented toward methods that allow adequate filling to maintain the nipple permanently everted. In the technique we propose, the nipple is pulled out and extruded by way of a periareolar incision after sectioning the galactophorous ducts and fibrous tissue. To guarantee a permanent eversion, a single trilobed dermoglandular flap is created, overturned, and fixed to fill the "dead space" below the nipple after the lobes have been sutured together. Finally, two transfixed U-shaped sutures are employed to keep the flap in place. From an analysis of the various techniques and results obtained, this method appears to be effective above all in resolving the aesthetic problem in a stable manner and is simpler than the techniques that employ multiple flaps.

Age as a risk factor in cervicofacial reconstruction

The Authors report their experience from January 1980 to January 1998 with 392 reconstructive flaps for the oncological reconstruction of the cervicofacial district. One hundred and forty-two were conventional flaps, 187 were myocutaneous or pedicled muscular ones and 63 were microvascular. Ninety percent of the patients had Stage IV disease, 80% were tumors involving the oral cavity structures, 40% of the patients had received preoperative radiotherapy; 35% of the cases were recurrences. The complications related to the surgery were evaluated for each type of flap, comparing them to the same flaps employed in patients > 70. Complications were divided into major and minor that were observed at an overall rate of 22%. With the use of conventional flaps, there was an 11.3% rate of minor complications and a 5.6% rate of major ones. Examining the 187 myocutaneous or pedicled muscular flaps, 21% of the overall 27% were minor and 6% were major complications. Of the remaining 63 free flaps, minor complications were observed in 4.7% and major complications in 14.2% of cases. Thirty-four of the 392 flaps, 24 of which were myocutaneous or pedicled muscular and 10 free flaps, were utilized in elderly patients and compared with the 216 of the same type, in patients < 70. A comparative analysis shows that there was a major complication rate of 11.7% in the flaps employed on the elderly patients as opposed to 7.9% for those employed in the younger patients. In terms of minor complications, a 20.5% complication rate was observed for those > 70 as opposed to 16.7% for patients < 70. A more detailed analysis of these data, enabled to postulate that the smaller group of flaps used in elderly patients is statistically influenced by the "dilution" of the complication rate in favour of the larger group of younger patients. Furthermore, by appropriately correcting the risk factors due to concomitant diseases that were not related to surgery in the older patients, a realignment of the results may be seen. Therefore, a careful preoperative study must be carried out in the elderly patients with cervicofacial tumors who are eligible for surgery to establish and possibly treat the concomitant disease responsible for the increased peri- and postoperative morbidity. In conclusion, complications in elderly patients are correlated to the state of co-morbidity and neither to age nor to the duration of the operation. Responsiveness may therefore be obtained also in elderly patients employing sophisticated techniques such as microvascular flaps.

[Free radial forearm flap and myocutaneous flaps in oncological reconstructive surgery of the oral cavity, Comparison of functional results]

In modern multi-disciplinary cancer treatment, rehabilitation and functional results represent utmost intent in reconstructive surgery of the oral cavity. Even in cases where the stage of disease is advanced) and the perspective of survival is limited, it is possible to achieve an acceptable quality of life. The authors report, in this study, the morpho-functional results and the morbidity observed in glossectomies in which the reconstruction was performed using three different methods. In a total of 264 reconstructive flaps of the head and neck regions, the authors considered three groups of 15 patients that had had reconstruction after the demolitive procedure. Respectively these groups were divided by the followed methods: free forearm flap, pectoralis major myocutaneous flap and nasolabial flap. The morbidity showed an extremely low rate of flap loss in all the groups, but "minor" complications, such as fistulas and leakages, were significantly more frequent in the myocutaneous flaps group. Functional evaluation for speech and deglutition showed good results in most patients. Extremely severe postoperative conditions as a permanent NG tube or incomprehensible speech had been observed in less than 15% of the cases. Particularly, the pectoralis major flap, showed its best functional performances in the total or subtotal glossectomies with a sacrifice of the muscles of the oral floor. The free forearm flap is reliable and safe with its low thickness and pliability, especially for partial glossectomies. The nasolabial flap was confirmed to be the first reconstructive choice for selected limited resections of the tongue and of the antero-lateral floor. With this experience it is possible, even in more complex free flaps, to reduce the time consumption and the complication rate. Free flaps do not substitute routinely myocutaneous and conventional flaps, but they represent the "ideal" reconstructive alternatives for specific and selected indications.

[Reconstruction using pedicle and free flaps in partial or total resections of the hypopharyngeal-esophageal tract]

Modern surgical treatment of cancer of the hypopharyngo-esophageal cannot be conditioned by the reconstructive procedures. Reconstructive options are based on the size and position of the defect in this important anatomical region. Currently the reconstruction of the hypopharyngo-esophageal tract allows a rapid and suitable restoration of the vital functions, a low morbidity and shortened hospital stay. The purpose of this study was to compare the various reconstructive approaches in terms of morbidity and functional results. Between January 1990 and June 1994, 17 patients with hypopharyngo-esophageal tract malignancies and one with a stenosis received treatment. The reconstructive procedures included 19 flaps: five myocutaneous pectoralis major flaps, one myocutaneous trapezius flap, five deltopectoral flaps, one radial forearm free flap and seven free jejunal grafts. There were six complications: one total necrosis and two stenosis in the free jejunal grafts group, one partial necrosis and one dehiscence in two myocutaneous pectoralis major flaps and one stenosis in a deltopectoral flap. Based on our studies, we believe that the free jejunal graft is the first choice for total reconstruction of the hypopharyngo and cervical esophageal tract. However the radial forearm free flap is certainly a valid solution for subtotal hypopharyngo-esophageal reconstruction. Pedicled flaps and particularly the myocutaneous pectoralis major flaps are a good alternatives for limited reconstructions (< 50%) of the hypopharyngo-esophageal tract.

[Reconstructive oncologic surgery of the head and neck. Morbidity and comparative results of conventional and myocutaneous flaps]

The authors analyzed the data obtained from their experiences in extensive head and neck resections, and, reconstructive treatments using myocutaneous and conventional flaps. They tried to evaluate comparatively the reconstructive approach, in terms of morbidity and functional results. The 145 cases of advanced had and neck cancer, treated from January 1990 to January 1994, were considered in this study. The reconstructive procedures consisted of 193 flaps. In this study, 106 were myocutaneous flaps (pectoralis major or trapezius flap); 72 were conventional flaps (fasciocutaneous, cutaneous or muscular only) and the remainder were 15 free flaps. The morbidity related to both flap procedures had been low: 33% in myocutaneous flaps versus 11% in conventional flaps. This report demonstrated the versatility, usefulness, and reliability of both kinds of these reconstructive procedures, especially in intra-oral reconstruction. The expected morphological and functional results were quite encouraging in terms of swallowing and speech.

[The rectus abdominis free flap in reconstructive surgery of the head and neck]

The Authors describe their preliminary experience with rectus abdominis free flap in reconstructive surgery of the head and neck. Out of the 29 cases of microsurgery in treating head and neck tumours, four inferior rectus abdominis free tissue transfers were used: two for complex intraoral reconstruction and two for composite facial defects. There was one flap loss due to late infection in the region of anastomosis, while there were two complications in the remaining three cases. The morphological and functional results have proved to be highly satisfactory. The flap, based on the deep inferior epigastric vessels, appears to be versatile in terms of skin island design, thickness and length of the pedicle. As with the forearm free flap, the inferior rectus abdominis has the advantage of offering the possibility of simultaneous demolition and reconstruction in one surgical session. The Authors conclude that the low morbidity concerned with this microvascular flap, also reported in international literature, confirm its validity as a soft tissue transfer in the in the treatment of advanced head and neck cancer.

[Total/near-total glossectomy for advanced carcinoma of the tongue]

Poor survival rates and the limited palliation afforded by radiotherapy alone, together with progress made in reconstructive surgery in restoring mucosal continuity after large resections, make total glossectomy reasonably indicated for treatment of advanced carcinoma of the tongue. The Authors reviewed 19 cases (17 males, 2 females, mean age 58.4 years) of total and near total glossectomy without laryngectomy treated at National Cancer Institute "Regina Elena" of Rome from 1990 to 1993 in order to evaluate oncological and functional results. All patients were reconstructed immediately, 16 with a pectoralis major flap, 2 with a nasolabial flap and 1 with a radial forearm free flap and were available for follow-up from 6 to 45 months (mean 29 months). There was no operative mortality and no patient needed total laryngectomy for aspiration. The rate of local recurrencies was 52.6%, most of them (75%) in patients who had undergone total/near total glossectomy for recurrence. Survival rate was 61.5% after 1 year and 20% after 2 years. 94% of patients resumed swallowing and independent oral alimentation (48% of them without any dysphagia); 84%; of the patients were decannulated and 48% produced easily intellegible speech. Data from our experience let us conclude that, in the light of the acceptable functional results obtained with reconstructive flaps, total glossectomy should be considered as the primary treatment modality in advanced carcinoma of the tongue (including T2 > 3 cm exceeding midline), and should not be reserved only for salvaging hopeless situations.

[Morbidity and the morphofunctional aspects of myocutaneous flaps used in the head and neck area]

The authors analysed the data obtained from their experiences in extensive head and neck resections as well as reconstructive treatments using myocutaneous flaps. They tried to evaluate the reconstructive approach in terms of morbidity and functional results. Sixty-nine patients, treated from January 90 to November 92 for advances intra-oral cancer, were considered in this study. The reconstructive procedure in 68 cases was the pectoralis major myocutaneous flap while in 5 cases the trapezius flap was utilized. Even though the oncological results were poor, the functional ones were quite encouraging. In fact, the assessment of speech and swallowing was extremely satisfactory in 83% of the cases. The morbidity related to both flap procedures was low and the patients' life quality was good. Indeed, the use of a free flap offers additional advantages, without necessarily compromising safety of the reconstruction. Free flaps in general allow greater leeway in flap design and donor-site choice than pedicled flaps. Several reports have already demonstrated the versatility, usefulness and reliability of these flaps, especially in intra-oral reconstruction. The intricate nature of microsurgery and the expense of microsurgical equipment inhibit this kind surgery in many institutions around the world where the standard myocutaneous flaps would be a more practical procedure. In conclusion, even those patients with a poor prognosis may be considered potential candidates for demolitive and reconstructive treatment with which satisfactory results may be obtained.

[Excisional and reconstructive treatment of stage IV tumors in the oral cavity. Results and limits]

The patients with advanced stages of intraoral cancer, having a limited life expectancy, are often considered non-surgical cases. Radiochemotherapy does not warrant an acceptable quality of life. The authors analysed the data obtained from their experiences in resections that had been extensive, as well as, reconstructive treatment of these kinds of neoplasms. They tried to evaluate the demolitive and reconstructive approach, in terms of morbidity, functional results and survival rate. Thirty-six patients, treated from January 1990 to August 1991 for advanced intraoral cancer, were considered in this study; 58% of the cases had primary tumors and 42% had recurrences. The reconstructive procedure used in all cases, was the pectoralis major myocutaneous flap. Even though the expected oncological results had been poor, the functional ones, had been quite encouraging. In fact, the assessment of speech and swallowing was extremely satisfactory, respectively in 82% and 89% of cases. The morbidity related to the flap procedure had been low. The quality of the residual life of the patients was good, especially if compared with the life of those patients who had not been treated. In conclusion, the authors maintain that even patients with limited prognosis may be considered as potential candidates for demolitive and reconstructive treatment.

[Immediate breast reconstruction. A retrospective analysis of 7 years' experience]

The collaboration between oncological and plastic surgeons proved to be essential in the multifaceted treatment of the neoplasms and high-risk lesions of the breast. It guarantees psychological advantages, and improves the quality of life of the patient, who is a candidate for demolition surgery. The authors analyse the results obtained over a 7-year period, through their experiences of 98 immediate breast reconstructions performed after subcutaneous simplex, Patey or Halsted mastectomies. They assessed the validity of this approach due to the brilliant esthetic results obtained, the minimal surgical time, and the low morbidity.

[Postmastectomy breast reconstruction using myocutaneous rectus abdominalis flap. Our experience]

The paper compares the results of 34 patients undergoing reconstructive surgery following radical mastectomy using a TRAM flap with those reported in the literature. The parameters taken into consideration in this study were indications for reconstructive surgery, morbidity and the results of reconstruction. The monopedicle flap offered good cosmetic results and a low rate of complications if correctly and selectively used. This selection should exclude high-risk patients. The bipedicle flap is an effective alternative and the morbidity rate was no higher among the abdominal donor.

[External trans-columella access to nasal surgery. Results and impressions in 51 operated cases]

The Authors report their personal experience relating to 51 cases of nose plastic surgery using an external trans-columella access route. From an evaluation of results, it emerges that by allowing full exposure of the nasal cartilaginous structure, this technique is ideally suited to the treatment of congenital deformities, and post-traumatic and iatrogenic consequences. Given the good esthetic results of the cutaneous scar, with which all subjects were satisfied, this method might also be proposed in selected cases of nose plastic surgery for esthetic reasons. Extremely pointed, bifurcate or bulbous nose can easily be treated given the direct and "dynamic" view of the anatomic peculiarities present. In conclusion, the advantages offered by external access outweight its "invasiveness", which appears to be more theoretical than that observed during follow up.

[Immediate reconstructive approach in neoplastic pathology and "high risk" of the breast]

One of the most important aims in oncology should be the quality of life, even in the cases of limited life expectancy. With this objective, the Authors report their experience of immediate breast reconstruction after surgical treatment for neoplasms and "high risk" lesions. In 76 cases they analyzed aesthetic results and morbidity. In immediate reconstruction after Patey mastectomies, the tissue expanders offered good cosmetic results with an acceptable complication rate in comparison with more complex methods as myocutaneous flaps. These flaps represent the alternative in selected cases of Halsted mastectomies, where the mutilation is not acceptable to the patient. In "high risk" lesions surgical approach, namely subcutaneous mastectomy, may be proposed in selected cases only. The Authors emphasize that subcutaneous mastectomy with an immediate submuscular reconstruction offer good aesthetic results especially in small size breasts with mild ptosis. The capsular contracture is however significant in 25% of the patients treated with these techniques.

[Immediate breast reconstruction and oncologic criteria: our current definition]

After a review of the literature, the authors attempt at a definition of the oncologically safe candidate to an immediate reconstruction after modified radical mastectomy for breast cancer. The analysis of the natural history of locally recurrent breast cancer indicates that the potential for its masking is negligible. Survival curves of patients submitted to immediate breast reconstruction are similar to those reported for historical controls. The ideal candidate for an immediate reconstruction is a stage I (negative axillary nodes) patient. As immediate breast reconstruction does not alter the prognosis of breast cancer patients nor does it harm the use of adjuvant therapies, the authors believe that even a well motivated stage II (positive axillary nodes) patient should be considered as a candidate for an immediate reconstructive procedure.

Peritoneovenous shunt and neoplastic ascites: a 5-year experience report

The cases of 42 patients with malignant ascites treated with a peritoneal venous shunt over a 5-year period are reviewed to establish the incidence of surgical and postsurgical complications. Although the yield of malignant cells found in the peripheral blood was increased after shunting, no new hematogenous metastases were observed after the operation. No evidence of disseminated intravascular coagulation was observed after shunt placement. While the shunt effectively relieved the discomfort due to abdominal distention and respiratory impairment, no restoration of cutaneous hypersensitivity was observed in the nine patients who were anergic prior to surgery. The median survival of patients with breast and gynecological cancer, after surgery, was significantly longer than the survival of patients with primary gastrointestinal neoplasma. In conclusion, peritoneal venous shunt appears to be an effective and safe method to improve the quality of life of patients with malignant ascites.