Contrast Enhanced Ultrasound (Ceus) in Detecting Ruptured Breast Implants Ex Vivo -Preliminary Results of a Unique Technique

ABSTRACT Introduction: Detection of ruptured breast implants can be challenging, even with MRI. The aim of this study was to examine different breast implants ex vivo with contrast-enhanced ultrasound (CEUS) to determine whether this technique allows screening of implant failure. Objectives: 20 breast implants were examined. Ultrasound was performed using B-mode and CEUS with a multifrequency linear probe after injecting SonoVue to a box filled with NaCl. For interpretation, a scoring system was created (CEUS 1: intact implant, CEUS 5: obvious leakage, called macro-leakage). Results: CEUS was able to detect leakages of all implants, including micro-leakages, verified via microscopy (sensitivity: 100%). Polyurethane (PU) implants with CEUS 2 had a median time of implantation of 14.1 years, silicone implants with CEUS 5 were implanted 3.1 years on average. Silicone implants displayed no significant linear correlation between foreign body capsule formation (Baker score) and CEUS score (correlation coefficient r=0.08). Most of the PU implants with lower Baker grade 3 showed a lower CEUS grade and vice versa, leading to a high correlation (r=0.77). Conclusions: CEUS can be useful to detect implant rupture as an additional method for patients with equivocal sonographic findings. This is a new technique that can help diagnose surface qualities of breast implants

Incidence of Anaplastic Large Cell Lymphoma and Breast-Implant-Associated Lymphoma—An Analysis of a Certified Tumor Registry over 17 Years

Background: Breast-implant-associated anaplastic large cell lymphoma (BI-ALCL) and primary breast ALCL are rare extranodal manifestations of non-Hodgkin lymphoma. The rarity of both diseases, along with unreleased sales data on breast implants and constant updates of classification systems impede the calculation of an exact incidence. Methods: The database of the Tumor Center Regensburg in Bavaria was searched for patients with CD30-positive and ALK-negative anaplastic large cell lymphoma between 2002 and 2018. These lymphomas were identified by the ICD-O-3 morphology code "97023" and were cross-checked by searching the diagnosis by name the and ICD-10 code C84.7. Furthermore, we tried to calculate the incidence rates and corresponding 95% confidence intervals, standardized to 1,000,000 implant years of breast-implant-associated anaplastic large cell lymphoma and primary breast anaplastic large cell lymphoma. Results: Twelve ALK-negative and CD30-positive anaplastic large cell lymphomas were identified out of 170,405 malignancies. No case was found within the breast tissue and none of the patients had a previous history of breast implant placement. In five cases, lymph node involvement in close proximity to the breast was observed. Conclusion: We found a low incidence of anaplastic large cell lymphoma and no association to breast implants in these patients. A review of the current literature revealed inconsistent use of classification systems for anaplastic large cell lymphomas and potential overestimation of cases

Recommendations for the Use of Antibiotics in Primary and Secondary Esthetic Breast Surgery

The use of systemic prophylactic antibiotics to reduce surgical-site infection in esthetic breast surgery remains controversial, although the majority of surgeons prefer to utilize antibiotics to prevent infection. Nonetheless, postoperative acute and subclinical infection and capsular fibrosis are among the most common complications following implant-based breast reconstruction. After esthetic breast augmentation, up to 2.9% of women develop infection, with an incidence rate of 1.7% for acute infections and 0.8% for late infections. After postmastectomy reconstruction (secondary reconstruction), the rates are even higher. The microorganisms seen in acute infections are Gram-positive, whereas subclinical late infections involving microorganisms are typically Gram-negative and from normal skin flora with low virulence. In primary implantation, a weight-based dosing of cefazolin is adequate, an extra duration of antibiotic cover does not provide further reduction in superficial or periprosthetic infections. Clindamycin and vancomycin are recommended alternative for patients with β-lactam allergies. The spectrum of microorganism found in late infections varies (Gram-positive and Gram-negative), and the antibiotic prophylaxis (fluoroquinolones) should be extended by vancomycin and according to the antibiogram when replacing implants and in secondary breast reconstruction, to target microorganisms associated with capsular contracture. All preoperative antibiotics should be administered <60 minutes before incision to guarantee high serum levels during surgical procedure

Imaging of idle breast implants with ultrasound-strain elastography- A first experimental study to establish criteria for accurate imaging of idle implants via ultrasound-strain elastography

AIM: To investigate whether there are fundamental sonographic and elastographic criteria to precisely assess different surfaces and fillings of idle breast implants and to determine their most distinctive parameters. This was a comparative study of different unused breast implant materials, neighter in animals nor in humans. This knowledge should be transferred in vivo to develop an objective measurement tool. METHODS: Nine idle breast implants-silicone and polyurethane (PU)-were examined in an experimental study by using ultrasound B-mode with tissue harmonic imaging (THI), speckle reduction imaging (SRI, level 0-4), cross-beam (CB, low, medium, high), photopic and the colour coded ultrasound-strain elastography with a multifrequency probe (9-15 MHz). Using a standardised protocol the implants' centre as well as the edge were analysed by one experienced examiner. Two independent readers performed analysis and evaluation. For image interpretation a score was created (score 0: inadequate image, score 5: best image quality). RESULTS: The highest score result for the centre was achieved by using ultrasound with B-mode in addition with CB level medium, SRI level 2, THI and photopic (mean: 3.22 +/- SD: 1.56), but without any statistic significant difference (t-value = 0.71). With elastography the implants' edge in general was represented without disruptive artefacts (3.89 +/- 0.60) with statistic significant difference (t-value = 5.29). Implants filled with inner cohesive silicone gel II degrees showed best imaging conditions for their centre via ultrasound (5 +/- 0) as well as for their edge via elastography (4.50 +/- 0.71). CONCLUSION: Ultrasound-strain elastography and high resolution ultrasound represent a valuable measurement tool to evaluate different properties of idle breast implants. These modified ultrasound examinations could be an additional help for clinical investigations and be correlated with Baker's Classification

Impaired Neovascularization in Aging

Recent Advances: Several studies have found significant differences during wound healing between younger and older individuals. The hypoxia-inducible factor 1-alpha (HIF-1 alpha) signaling pathway has recently been identified as a major player in wound healing. Hypoxia-inducible factors (HIFs) are pleiotropic key regulators of oxygen homeostasis. HIF-1 alpha is essential to neovascularization through its regulation of cytokines, such as SDF-1 alpha (stromal cell-derived factor 1-alpha) and has been shown to upregulate the expression of genes important for a hypoxic response. Prolyl hydroxylase domain proteins (PHDs) and factor inhibiting HIF effectively block HIF-1 alpha signaling in normoxia through hydroxylation, preventing the signaling cascade from activating, leading to impaired tissue survival. Critical Issues: Aged wounds are a major clinical burden, resisting modern treatment and costing millions in health care each year. At the molecular level, aging has been shown to interfere with PHD regulation, which in turn prevents HIF-1 alpha from activating gene expression, ultimately leading to impaired healing. Other studies have identified loss of function in cells during aging, impeding processes such as angiogenesis. Future Directions: An improved understanding of the regulation of molecular mediators, such as HIF-1 alpha and PHD, will allow for manipulation of the various factors underlying delayed wound healing in the aged. The findings highlighted in this may facilitate the development of potential therapeutic approaches involved in the alteration of cellular dynamics and aging

Capsular fibrosis in aesthetic and reconstructive-cancer patients: A retrospective analysis of 319 cases

BACKGROUND: Implant-based breast augmentation is one of the most frequently performed operations in plastic surgery worldwide, for aesthetic and reconstructive reasons. Capsular fibrosis is the most common long-term foreign body response after breast implant augmentation. OBJECTIVE: To compare the occurrence of capsular contracture in aesthetic and reconstructive-cancer patients, including those patients who received radiotherapy prior to breast reconstruction with implants. METHODS: We conducted a retrospective evaluation of 319 patients who underwent breast implant revision between Jan 2000 and Oct 2016. The patient group was comprised of 175 reconstructive-cancer patients and 144 patients who underwent operation for aesthetic reasons. The occurrence of capsular fibrosis, other complications and the time-period between implantation of breast implants and revision surgery (TP) was analyzed. RESULTS: For all 319 patients the mean TP was 7.9 years (7.86 +/- 0.45). The most common complication in all revisions was capsular fibrosis (65.1% of all revisions). In aesthetic patients with capsular fibrosis the mean TP was 11.9 years (11.89 +/- 0.95, p < 0.001). This mean TP was significantly higher than the mean TP of 6.1 years (6.13 +/- 0.56, p < 0.001) in breast cancer patients with capsular fibrosis. Preoperatively irradiated cancer patients had a mean TP of 6.2 years (6.17 +/- 0.95), compared to a mean TP of 5.1 years (5.07 +/- 0.19, p = 0.051) in non-irradiated cancer patients, which was not significantly different. CONCLUSIONS: We found that aesthetic patients exhibit a significantly higher mean TP compared to breast cancer patients, suggesting that reconstructive-cancer patients in general develop capsular fibrosis earlier. Despite the literature, we did not find a significant influence of preoperative radiotherapy on the occurrence of capsular fibrosis in reconstructive-cancer patients. Further clinical studies need to be conducted to identify methods to decrease the risk of developing capsular fibrosis

Breast Implant Anaplastic Large Cell Lymphoma (BIA- ALCL): A Systematic Review and Case Report Regarding Incidence and Pathology Workup

Background: Breast implant–associated anaplastic large cell lymphoma (BIA ALCL) is a rare indolent yet lethal disease. Recently the WHO accepted it as an individual new entity. Since then national and international registries have attempted to collect epidemiological data, but incidence rates vary strongly. The aim of this article is to provide an update on the status of the national BIA-ALCL registries and identify pitfalls alongside the current collection and diagnostic algorhythm. Methods: A systematic review of the literature was performed and epidemiological data from national registries were compared. Furthermore a case report of a false positive diagnosis was added and the pitfalls alongside the diagnostic algorhythm was worked out. Results: The comparison of national registries revealed significant differences in the collected data. Mean start of the registries was 2014, median 2015. Reporting of BIA-ALCL cases is mandatory except in two countries. Capture rates vary between 0-100%. Incidence rates range from 0.0 up to 8.9 per million implant years. The number of deaths does not correlate with the number of implants or the total population. The very same strains of CD30 can be interpreted differently. Conclusion: Comparing epidemiologic data revealed significant differences among national registries. In particular, non-published sales data of breast implants and non-mandatory recording of the disease lead to an overall underreporting of cases. Therefore, the incidence rates still cannot be compared uniformly. Furthermore the definition of CD30 straining intensity should be standardized and adjusted in the guidelines

Impact of platelet-rich plasma on cell migration processes after external radiation

BACKGROUND: To overcome the compromised wound healing in radiation induced chronic wounds platelet-rich plasma (PRP), as therapeutic agent, is current subject of studies. PRP is associated with pro-angiogenic effects. Nevertheless, effects of platelet-rich plasma in cutaneous wound healing processes are poorly understood so far. Methods: In this study, the migration of endothelial cells, fibroblasts and keratinocytes in conjunction with platelet-rich plasma treatment is investigated in the context of radiation effects. Additionally, cell proliferation and viability after external radiation was analyzed regarding treatment by platelet-rich plasma. RESULTS: All cell cultures showed a trend towards decreasing proliferation and viability after irradiation irrespective of PRP. Upon PRP treatment, irradiated fibroblasts as well as endothelial cells showed an enhanced proliferation whereas proliferation and viability of keratinocytes was reduced after PRP treatment. Scratch assays support the positive effect of PRP on fibroblast and endothelial cell migration, whereas a negative effect on keratinocytes was observed after PRP treatment. CONCLUSIONS: The present study documents both deleterious effects of external radiation as well as the protective effect of PRP. In summary, increased viability, proliferation and migration are indeed a consequence of the pro-proliferative effect exerted by PRP. Therefore, treatment with PRP products might be useful in the management of chronic radiogenic wounds

Mechanotransduction in Wound Healing and Fibrosis

Skin injury is a common occurrence and mechanical forces are known to significantly impact the biological processes of skin regeneration and wound healing. Immediately following the disruption of the skin, the process of wound healing begins, bringing together numerous cell types to collaborate in several sequential phases. These cells produce a multitude of molecules and initiate multiple signaling pathways that are associated with skin disorders and abnormal wound healing, including hypertrophic scars, keloids, and chronic wounds. Studies have shown that mechanical forces can alter the microenvironment of a healing wound, causing changes in cellular function, motility, and signaling. A better understanding of the mechanobiology of cells in the skin is essential in the development of efficacious therapeutics to reduce skin disorders, normalize abnormal wound healing, and minimize scar formation