Predictive and Protective Factors for Partial Necrosis in DIEP Flap Breast Reconstruction. Does Nulliparity Bias Flap Viability?

Although success rate of deep inferior epigastric perforator (DIEP) flap breast reconstruction has greatly improved, complications still occasionally occur. Perfusion-related complications (PRCs) (ie, fat necrosis and partial flap necrosis) are the most frequent concern, affecting aesthetic final result of the reconstructed breast.The aim of our study was to retrospectively investigate 287 consecutive DIEP flap breast reconstructions to investigate predictive and protective factors for PRCs.From May 2004 to February 2012, 287 DIEP flap breast reconstructions were performed on 270 patients; 247 unilateral flaps, including Holm vascular zones I to III, were retrospectively selected and analyzed. Tobacco use, mean blood pressure over the first postoperative 48 hours, superficial epigastric vein drainage, medial/lateral row perforator, nulliparity, crystalloid versus combined crystalloid/colloid intravenous fluid infusion therapy, and learning curve were evaluated by univariate and multivariate logistic regression analyses.Perfusion-related complications occurred 32 (12.9%) times, 79 (31.9%) patients were smokers, 48 (19.4%) showed postoperative mean blood pressure less than 75 mm Hg, 29 (11.7%) were nulliparous, and 173 (70%) had superficial epigastric vein drainage. Selected perforators were 110 (44.5%) from lateral row, 137 (55.5%) from medial row; 91 (36.8%) received crystalloid fluid infusion, whereas 156 (63.2%) combined crystalloid/colloid fluid infusion. From univariate analysis emerged significance of nulliparity, perforator row and intravenous fluid infusion for PRC. Nevertheless, multivariate model confirmed only nulliparity as a significant risk factor (P = 0.029), although variable correlations to other predictors were found: both medial row perforator and combined crystalloid/colloid fluid infusion potentially decrease the PRC risk of 11.6% and 27.6%, respectively. Learning curve did not show significant decrease of PRC risk over time.Our study first proved nulliparity as a statistically significant predictor for PRCs in DIEP flap breast reconstruction, possibly due to different superficial abdominal perfusion between pluriparous and nulliparous women, with potential weaker pattern of perforators and smaller angiosomes in the latter. The choice of medial row perforators and combined crystalloid/colloid fluid infusion might reduce PRC risk

DIEP flap perfusion assessment using microdialysis versus Doppler ultrasonography. A comparative study

BackgroundThe increasing number of buried free-tissue transfer procedures and the need for an objective method to evaluate vascular complications of free flaps has led to the development of new technologies. Microdialysis has been used to monitor free flaps using interstitial biological markers. Previous uses mainly focused on muscular flaps. Our aim is to compare external Doppler ultrasonography (EDU) evaluation versus microdialysis in the early follow-up of adipocutaneous flaps, and propose an efficient postoperative monitoring protocol. MethodsWe retrospectively assessed 68 consecutive DIEP flaps (50 patients) performed between January 2019 and March 2021. All flaps received standardized post-operative monitoring using clinical signs, EDU and microdialysis. Glucose and lactate concentrations were assessed using glucose 6 mmol/L as ischemic trend thresholds. We calculated Glucose/Lactate ratio as a new parameter for the assessment of flap viability. ResultsAmong all the 68 flaps, two flaps returned to the operative theater when a combination of unsatisfactory microdialysis values and clinical/EDU signs identified vascular impairment; only one developed total flap necrosis. Reoperation rate was 2.94% with an overall flap success rate of 98.53%. External Doppler ultrasonography had 100% sensitivity and 82% specificity, while microdialysis had 100% sensitivity and 100% specificity. ConclusionsMicrodialysis values proved flap viability sooner than external Doppler ultrasonography, making it an excellent tool for post-operative monitoring. With the appropriate thresholds for glucose and lactate concentrations, and glucose/lactate ratio used as a new parameter, it can help potentially avoiding unnecessary re-explorations, and reducing flap ischemia times

Study of the effect of different breast implant surfaces on capsule formation and host inflammatory response in an animal model

Background: Breast implants are biomaterials eliciting a physiological and mandatory foreign body response. Objectives: The authors designed an animal study to investigate the impact of different implant surfaces on the formation of the periprosthetic capsule, the inflammatory response, and the cellular composition. Methods: The authors implanted 1 scaled-down version of breast implants by different manufactures on 70 female Sprague Dawley rats. Animals were divided into 5 groups of 14 animals. Group A received a smooth implant (Ra ≈ 0.5 µm) according to the ISO 14607-2018 classification, Group B a smooth implant (Ra ≈ 3.2 µm), Group C a smooth implant (Ra ≈ 5 µm), Group D a macrotextured implant (Ra ≈ 62 µm), and Group E a macrotextured implant (Ra ≈ 75 µm). At 60 days, all animals received a magnetic resonance imaging (MRI), and 35 animals were killed and their capsules sent for histology (capsule thickness, inflammatory infiltrate) and immunohistochemistry analysis (cellular characterization). The remaining animals repeated the MRI at 120 days and were killed following the same protocol. Results: MRI showed a thinner capsule in the smooth implants (Groups A-C) at 60 days (P < .001) but not at 120 days (P = .039), confirmed with histology both at 60 days (P = .005) and 120 days (P < .001). Smooth implants (Groups A-C) presented a mild inflammatory response at 60 days that was maintained at 120 days and a high M2-Macrophage concentration (anti-inflammatory). Conclusions: Our study confirms that smooth implants form a thinner capsule, inferior inflammatory infiltrate, and a cellular composition that indicates a mild host inflammatory response. A new host inflammatory response classification is elaborated classifying breast implants into mild, moderate, and high

Free-style technique versus computed tomographic angiography-guided perforator selection in deep inferior epigastric perforator flap harvest: a prospective clinical study

Background: Computed tomographic angiography (CTA) is the preferred diagnostic tool in preoperative deep inferior epigastric perforator (DIEP) flap assessment, though some surgeons prefer approaching perforator selection with intraoperative findings alone. Methods: This prospective observational study conducted between 2015 and 2020 assessed our intraoperative decision-making "free-style" technique for DIEP flap harvest. Any patient with indication for immediate or delayed breast reconstruction using abdominally based flaps and who received preoperative CTA was enrolled. Only unilateral cases performed by the same surgeon were considered. Allergy to iodine-based contrast media, renal impairment and claustrophobia were other exclusion criteria. Primary endpoint consisted in comparing operative times and complication rates between free-style technique and CTA-guided approach. Secondary endpoints included evaluation of agreement rate between intraoperative findings and CTA, and identification of variables affecting operative time and complication rate. Demographics, surgical information, agreement versus non-agreement and complications were collected. Results: Starting from 206 patients, 100 were enrolled. Fifty were assigned to Group A, receiving DIEP flap with free-style technique. The other 50 were assigned to Group B, receiving DIEP flap with CTA-guided perforators selection. Study groups' demographics were homogenous. Operative time was statistically lower (p = .036) in free-style group (252.4 ± 44.77 min vs. 265.6 ± 31.67 min). Complication rates were higher in CTA-guided group (10% vs. 2%) though this was not significant (p = .092). Overall agreement rate in dominant perforator selection between intraoperatively and CTA-based assessment was 81%. Multiple regression analysis showed no variable increased complication rate, though CTA-guided approach, BMI > 30 and harvesting more than one perforator were respectively associated with B-coefficient of 17.391 (2.430-32.351, 95% CI) [p = .023], 3.50 (0.640-6.379, 95% CI) [p = .017] and 18.887 (6.232-31.542, 95% CI) [p = .004], predicting increased operative time. Conclusions: The free-style technique proved to be a useful tool for guiding DIEP flap harvest with good sensibility in detecting the dominant perforator suggested by CTA without statistically increasing surgery duration and complications

Breast implant associated anaplastic large cell lymphoma. proposal for a monitoring protocol

BACKGROUND: The authors report four cases of breast implant-associated anaplastic large cell lymphoma (ALCL) from a single institution and propose a multidisciplinary protocol. METHODS: From 2012 to 2014, four breast implant-associated ALCL cases were diagnosed. The authors performed the original operation, and no patients were referred to their practice. Cases 1, 2, and 4 were CD4/CD30/ALK ALCL with previous textured-implant reconstruction, whereas case 3 was CD8/CD30/ALK ALCL with previous polyurethane-implant augmentation. A retrospective study of all patients who underwent breast implant positioning was performed to identify any misdiagnosed cases. RESULTS: Of 483 patients, 226 underwent reconstruction with latissimus dorsi flap and prosthesis, 115 had skin-sparing/nipple-sparing mastectomy and prosthesis, 117 underwent an expander/implant procedure, and 25 underwent breast augmentation. Fifty-eight cases (12 percent) underwent implant replacement for capsular contracture, 15 (3.1 percent) experienced late-onset seroma, and four (0.83 percent) had both capsular contracture and seroma. Seventy-seven symptomatic patients (16 percent) underwent surgical revision (capsulectomy/capsulotomy) and/or seroma evacuation. The second look on histologic specimens did not identify misdiagnosed cases. A multidisciplinary protocol for suspected implant-associated ALCL was established. Ultrasound and cytologic examinations are performed in case of periprosthetic effusion. If implant-associated ALCL is diagnosed, implant removal with capsulectomy is performed. If disseminated disease is detected through positron emission tomography/computed tomography of the total body, the patient is referred to the oncology department. CONCLUSIONS: A multidisciplinary protocol is mandatory for both early diagnosis and patient management. Until definitive data emerge regarding the exact etiopathogenesis of breast implant-associated ALCL, the authors suggest offering only autologous reconstruction if patients desire it

Acral Lentiginous Melanoma of the Thumb: Dermoscopy and Treatment

Melanoma affecting glabrous skin is a challenging entity that needs to be managed by an interdisciplinary team of dermatologists, oncologists, and surgeons. The thin subcutaneous layer of glabrous skin, which speeds up its metastatic spread, is one of the key elements that contributes to the aggressiveness of this form of cutaneous cancer when identified in this anatomical region. Acral lentiginous melanoma is a rare melanocytic malignancy that is usually associated with ominous outcomes, especially in those with dark skin. Moreover, more extensive research is needed to elucidate the puzzle of molecular drivers and their relationship with thermal injury. We reported our experience in order to highlight the value of timely diagnosis and treatment

Determining Breast Implant Prevalence. A Population Study of Italian Chest Radiographs

Background Current breast implant prevalence within the general population remains elusive. An accurate prevalence is critical to serve as the denominator for any assessment of breast implant-related complication. The purpose of this manuscript is to assess this prevalence in women aged 20-70 years in Italy.Materials and Methods Eight reviewers, demonstrating a mean sensitivity of 87.0% and specificity of 97.0%, were recruited for retrospective identification of implants on chest radiographs from a tertiary academic hospital in a major urban setting. Three final reviewers were selected, and they assessed all eligible chest radiographs collected between January and December 2019. The hospital-based population was compared to epidemiological data at a local, regional and national level to demonstrate homogeneity of age structures using the phi correlation coefficient.Results We identified 3,448 chest X-rays which yielded 140 implants, with an overall prevalence of 4.1% for women aged 20-70. Implants were bilateral in 76% of cases and unilateral in 24%. They were placed cosmetically in 47.1% cases and used for reconstruction in 52.9% cases. Phi correlation coefficient found no differences across hospital-based, local, regional and national populations.Conclusion A validated method was performed to estimate implant prevalence from an academic hospital in a major urban setting at 4.1% and was used to estimate national prevalence in Italy. The implications of this epidemiologic study may reach across national borders for improved understanding of breast implant epidemiology and in predicting the total number of patients within a given population that may be affected by device complications

EURAPS Editorial: BIA-ALCL, a brief overview

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Comment on the Invited Discussion on "Assessment of Risk Factors for Rupture in Breast Reconstruction Patients with Macrotextured Breast Implants"

We here present a few comments on the invited discussion of Dr. van Heijningen on the paper "Assessment of Risk Factors for Rupture in Breast Reconstruction Patients with Macrotextured Breast Implants ". Dr. van Heijningen made some reservations regarding paper conclusions due to the high dropout rate, the adopted exclusion criteria and the location and mechanism of implant rupture. First of all, a high dropout rate is not unbeknown to researchers in surveys-based studies and may be expected when recalling in 6 months a population observed during last 20 years. In our study data are missing at random not affecting the risk of bias, while the population accurately depicts the people we care, mainly but not only reconstructive. Patients who did not respond to the questionnaire could not participate to the survey, while those who did not hold recent imaging were excluded because of the risk of false negative due to possible silent rupture, accounting to 10% in some reports. MRI imaging often shows that implants fold back on their selves when capsular contracture reduces implant pocket. As the use of the underwire bra prevents implant inferior displacement, repeated muscular contraction may worsen implant folds and the chronic wear-and-tear mechanism may be responsible for the rupture. Finally, folding is presumably easier to occur at the upper quadrants where anatomical implant shell is thinnest and gel concentration reduced than the opposite, therefore is not surprising that the higher percentage of ruptures is located in the upper implant quadrants

Thromboembolism Risk Factor Assessment

This application is based on the official Thromboembolism Risk assessment protocol adopted by the Sant'Andrea Hospital of Rome, after a multidisciplinary consensus for the prevention of DVT/PE in surgical patients. The protocoll represent a modification of the original Caprini Risk assessment model