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Summary:. Most commercially available breast implants feature some degree of elastomer surface modifications to increase surface roughness, in part because several clinical series have demonstrated positive outcomes from texturizing. However, the literature shows that textured implants support higher rates of bacterial growth, and there is a clear association between increased bacterial contamination and host response in vivo, such as capsular contracture. Furthermore, the infectious theory related to bacterial contamination has recently been described as a potential cause in the etiology of anaplastic large-cell lymphoma. Recent research has focused on the physiology of breast implant surfaces advances and how they interact with the body, creating new surface technologies which have the potential to affect all aspects of breast surgery. Understanding how surface properties affect inflammatory cell response will be essential in designing implants that can provide an esthetic solution while also minimizing long-term clinical complications. This special topic highlights the current knowledge on silicone implant surfaces, as well as innovations that have shaped and will continue to change the silicone breast implant industry in the future. It also provides an overview of the principal surfaces that exist and may find clinical applications in esthetic and reconstructive breast surgery. As additional advances emerge, objective tools will be required to evaluate the different surfaces available on the market, along with the long-term efficacy of new technologies.

Supplemental Digital Content is available in the text., Background: Autologous fat grafting has broad applications in reconstructive and aesthetic breast surgery as a natural filler and for its regenerative purposes. Despite the widespread use of fat grafting, there remains no shared consensus on what constitutes the optimal fat grafting technique and its oncological safety. For this reason, the authors of this study have organized a Survey and an International Consensus Conference that was held at the Aesthetic Breast Meeting in Milan (December 15, 2018). Methods: All studies on fat grafting, both for breast aesthetic and reconstructive purposes, were electronically screened. The literature review led to 17 “key questions” that were used for the Survey. The authors prepared a set of 10 “key statements” that have been discussed in a dedicated face-to-face session during the meeting. Results: The 10 key statements addressed all the most debated topics on fat grafting of the breast. Levels of evidence for the key statements ranged from III to IV with 2 statements (20%) supported by a level of evidence III and 6 statements (60%) by level of evidence IV. Overall consensus was reached for 2 statements (20%) with >75% agreement reached for 7 statements. Conclusions: The survey demonstrated a diversity of opinion and attitude among the panelists with regard to technique. Clear recommendations for evidence-based clinical practice for fat grafting use both in aesthetic and reconstructive breast surgery could not be defined due to the scarcity of level 1 or 2 studies.

The options for prosthetic breast reconstruction have expanded and include prepectoral versus subpectoral location of devices as well as performing these operations in one- or two-stage. Current practice patterns are evolving toward the placement of devices in the prepectoral plane in a single stage. The authors’ patient selection criteria and surgical technique were reviewed and organized in a step-by-step format. On and off label techniques for acellular dermal matrix (ADM) assembly were reviewed. A review of surgical outcomes was completed. Two-stage reconstruction confers several advantages such as reducing pressure on the mastectomy skin flaps, optimal implant selection for the second stage and the opportunity to revise the reconstruction, all of which can increase the likelihood of a successful outcome. This manuscript will review the indications, techniques, and outcomes following prepectoral, two-stage prosthetic breast reconstruction.

Diastasis recti is a relatively common condition in which there is a midline abdominal bulge that can affect a variety of individuals. The etiology and diagnosis is well understood and optimal management depends on the degree of severity. Patients at high risk for diastasis recti include multiparous women, obese patients, and those with multiple previous operations. Diagnosis includes clinical examination and assessment of symptoms. Physical characteristics include a midline abdominal bulge without a fascial defect. Classification systems are based on the degree of separation between the paired midline rectus and myofascial deformity. Optimal management varies and includes simple plication of the midline defect, extensive plication of the anterior abdominal wall, and sometimes the use of resorbable or nonresorbable mesh.

Background: Nipple preservation provides superior aesthetic results as well as patient satisfaction in patients treated with both therapeutic and prophylactic mastectomy. Post-operative nipple ischemia and necrosis presents a unique clinical challenge that may be treated with hyperbaric oxygen therapy or conservative measures alone. To date, the efficacy of hyperbaric oxygen on post-operative nipple ischemia has yet to be evaluated. Methods: A retrospective review of patients treated with either hyperbaric oxygen or conservative management was performed. Post-operative photographs were evaluated using a novel imaging data pathway to in both groups to determine rates of healing. Results: Although patients treated with hyperbaric oxygen experienced rates of healing nearly twice those of patients treated with conservative measures alone, no statistical significance was found between groups in this series. Conclusions: No significance difference was found between groups treated with hyperbaric oxygen or conservative management in this series. Further large scale, multi-center studies are warranted to further determine clinical utility and cost-effectiveness of hyperbaric oxygen for nipple ischemia following nipple sparing mastectomy (NSM) and implant based reconstruction.

Summary: Giant juvenile fibroadenomas are relatively rare, accounting for less than 1% fibroadenomas. Large breast tumors create significant asymmetry and provide unique reconstructive challenges after removal. In this case, we describe a 21-year-old female with delayed presentation of a giant fibroadenoma of the right breast. This represents an unusual presentation of benign breast disease requiring reduction of the skin envelope, extensive glandular resection, lower pole reconstruction, and free nipple grafting to achieve symmetry with the opposite breast. A novel modification of the Goldilocks mastectomy technique is described for partial breast reconstruction. Adaptation of the Goldilocks mastectomy technique provides adequate soft tissue for partial breast reconstruction. Using the lower pole deepithelialization breast skin flap provides autologous vascularized tissue to supplement volume loss after tumor and glandular excision. Benign breast disease can create significant breast deformities. Application and combination of the Goldilocks mastectomy technique allow for partial breast reconstruction without the need for an additional donor site or prosthetic devices.

Background: AlloDerm, a human acellular dermal matrix, is available in a ready-to-use (RTU) or freeze-dried (FD) form. A limited number of studies have compared complication rates between RTU and FD in implant-based breast reconstruction. The objective of this report was to conduct a meta-analysis of previously reported complication rates between RTU and FD. Methods: A systematic literature review was conducted from 2010 to 2014 and supplemented by hand searches. Included studies compared both RTU and FD. Odds ratios and relative risks (RRs) with 95% confidence interval (CI), taking into account study heterogeneity, were calculated. Studies reporting patient-level results as opposed to breast-level results were excluded from the primary analysis but included in subsequent sensitivity analyses. Variable follow-up time within and between studies was also considered in a sensitivity analysis. Results: Of the 275 identified studies, 115 studies were eligible for detailed review. Only 5 studies compared RTU with FD, and of these, 2 studies had breast-level data and 1 study had patient-level data appropriate for meta-analysis. The 2 studies included in the primary meta-analysis had a pooled sample size: n = 116 RTU and n = 109 FD patients, or 205 and 186 breasts, respectively. Age and body mass index were similar between groups. Across all meta-analyses, there were no differences in complication rates between RTU and FD: cellulitis (RR = 0.863; 95% CI, 0.272–2.740), seroma (RR = 0.553; 95% CI, 0.026–11.830), and explantation (RR = 0.593; 95% CI, 0.247–1.425). Results remained nonsignificant even after adjustment for variable follow-up time. Conclusion: The results suggest that there are no differences in complication rates between RTU and FD forms.

Sir: Although the internal mammary vessels remain the recipient vessels of choice in free flap breast reconstruction, the thoracodorsal vessels are still chosen for a variety of reasons. The use of the internal mammary artery as a recipient vessel is justified despite concern for future coronary revascularization.1 The thoracodorsal vessels continue to be used because of surgeon preference and cases of suboptimal internal mammary vessels upon dissection. The potential disadvantages of the thoracodorsal artery and vein as recipient vessels include difficultly in achieving medial fullness in the final breast mound and the inability to use the latissimus flap for future breast reconstruction. We present a case in which the serratus branch is used as recipient vessels for microvascular tissue transfer, with the advantage of preserving the thoracodorsal vessels for future flap reconstruction. The patient is a 44-year-old woman with history of left breast cancer status post mastectomy, who presented for delayed autologous free flap reconstruction. After excision of the previous mastectomy scar, the prepectoral pocket was created. It was noted that the previous mastectomy scar went quite lateral, and therefore, the decision was made to dissect the thoracodorsal vessels. During the dissection, the serratus branch of the thoracodorsal vessels was noted to be quite large and suitable for microvascular anastomosis (Fig. 1). We chose to use the serratus branch as recipient vessels to spare the thoracodorsal vessels. This would allow for future use of her latissimus muscle for breast or general reconstruction. Fig. 1. Dissection of the thoracodorsal vessels. The serratus branch of the thoracodorsal vessels was found large and suitable for microvascular anastomosis. Few studies have described the use of the serratus branch as recipient vessels for microvascular transfer. Arnez et al2 describe a case of a patient who underwent a free transverse rectus abdominis myocutaneous flap reconstruction with the serratus anterior branch as a recipient vessel, thus conserving the remainder of the thoracodorsal vessels in case they were needed in a secondary salvage surgery. In a study describing their experience with 50 free TRAM flap reconstructions, Arnez et al3 describe 1 of 2 reconstructions using the serratus branch, citing the superior back flow of the serratus branch in comparison with the flow of the proximal pedicle. Another group describes their use of the serratus branch as recipient vessels in 4 patients undergoing partial breast reconstruction with mini-superficial inferior epigastric artery and mini-deep inferior epigastric artery perforator flaps to achieve the proper anatomic placement of miniflaps.4 Most cases describe the use of the serratus branch and other distal branches of the thoracodorsal artery as a means to successfully salvage a deep inferior epigastric artery perforator flap through retrograde flow anastomosis.5 In conclusion, the serratus branch of the thoracodorsal vessels provides a viable recipient site for microvascular tissue transfer with the advantages of sparing the thoracodorsal vessels for future latissimus flap reconstruction.

The purpose of this study was to analyze the performance of a porcine-derived acellular dermal matrix (Strattice Reconstructive Tissue Matrix) in patients at increased risk for perioperative complications. We reviewed medical records for patients with complex abdominal wall reconstruction (AWR) and Strattice underlay from 2007 to 2010. Intermediate-risk patients were defined as having multiple comorbidities without abdominal infection. Forty-one patients met the inclusion criteria (mean age, 60 years; mean body mass index, 35.5 kg/m2). Comorbidities included coronary artery disease (63.4%), diabetes mellitus (36.6%), and chronic obstructive pulmonary disease (17.1%). Fascial closure was achieved in 40 patients (97.6%). Average hospitalization was 6.4 days (range, 1–24 days). Complications included seroma (7.3%), wound dehiscence with Strattice exposure (4.9%), cellulitis (2.4%), and hematoma (2.4%). All patients achieved abdominal wall closure with no recurrent hernias or need for Strattice removal. Patients with multiple comorbidities at intermediate risk of postoperative complications can achieve successful, safe AWR with Strattice.

Soluble suppressor factors in the sera of cancer patients inhibit lectin-stimulated lymphocyte proliferation. These factors, derived from human material, preclude easy corroboration by other investigators. To gain a general understanding of soluble suppressor factors and to avoid the necessary restrictions of human experimentation, an animal model was devised. Sprague-Dawley rats were injected ip with the Walker 256 carcinoma. The resultant ascites proved to be a stable, reproducible source of soluble suppressor factors. Ascites inhibited phytohemagglutinin (PHA)-induced blastogenesis of normal splenocytes by 98%. The possibility of a toxic effect was eliminated by vital staining of splenocytes and by examination in a specific lymphotoxin assay. Suppressor activity persisted after heating at 100 degrees C for 40 min. Extraction by lipid solvents revealed that the bulk of suppressor activity resides in the lipid phase. The active fraction of heat-treated ascites passed through an Amicon PM-10 filter. Thin-layer chromatography revealed the presence of prostaglandins E2 and F2 alpha. Tissue culture supernatants from short-term cultures derived from tumor-bearing animals revealed suppressor activity from thymus, spleen, and liver cultures (97, 91, and 71%, respectively). No suppressor activity was detected in cultures of cancer cells. This study has demonstrated in this animal model that prostaglandins play a major role in suppression of lectin-induced blastogenesis. All suppressor factors appear to be host derived. An understanding of the mechanism of release of these suppressor substances may open new avenues in the immunotherapy of cancer.