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Validazione clinica dell’App BREAST-V
No full textIntroduzione
La valutazione del volume mammario è uno degli step più importanti nella programmazione preoperatoria della chirurgia ricostruttiva ed estetica della mammella.
La conoscenza del volume mammario può facilitare le procedure chirurgiche della mastoplastica riduttiva, la correzione di asimmetrie e il planning preoperatorio di una ricostruzione mammaria per ottenere la simmetria in un unico tempo operatorio con la mammella controlaterale. Sebbene la pianificazione di un intervento dipenda soprattutto dalle capacità chirurgiche ed esperienza del chirurgo, numerose metodiche per la determinazione del volume mammario sono state già riportate in letteratura per migliorare la sola valutazione clinica. Tra queste si ricorda l’utilizzo di misure antropometriche che è considerato un metodo rapido, economico e riproducibile. Nonostante questo, la validità degli studi che hanno cercato di trovare una relazione tra le misure antropometriche e il volume mammario, è stata oggetto di critiche. Scopo dello studio è di valutare l’attendibilità dell’applicazione BREAST-V*, disponibile per sistemi iOS ed Android, per predire il volume mammario. Tale applicazione è basata sull’utilizzo di tre misurazioni antropometriche che sono la distanza giugulo-capezzolo, la distanza solco inframammario-capezzolo e la distanza solco inframammario-proiezione del solco inframammario.
Ipotesi
L'ipotesi è che nei pazienti sottoposti a mastectomia, il BREAST-V prevede efficacemente il volume mammario.
Materiali e metodi
Da ottobre 2014 a ottobre 2015, 30 pazienti affette da tumore della mammella e candidate a mastectomia sono state prospetticamente arruolate nello studio. Tutti i pazienti hanno accettato di partecipare allo studio previo consenso informato.
I criteri d’inclusione dello studio erano: età superiore ai 18 anni, pazienti candidate a mastectomia (mastectomia radicale modificata secondo Madden, skin-sparing mastectomy, nipple-sparing mastectomy). I criteri di esclusione erano: pazienti sottoposte a precedenti interventi sulla mammella sui cui eseguire la mastectomia e pazienti candidate a intervento di mastectomia radicale secondo Patey o Hasteld.
Di ciascuna paziente sono stati raccolti i seguenti dati: età, peso, altezza, body mass index, 11 misurazioni antropometriche per la misurazione della mammella, chirurgo che ha raccolto i dati antropometrici della mammella, tipo di mastectomia, chirurgo operatore e peso della mammella intraoperatorio.
I dati antropometrici raccolti sono stati: distanza giugulo-capezzolo ≥1cm, distanza medioclavicolare-capezzolo, distanza capezzolo-solco inframammario ≥1cm, distanza capezzolo-solco inframammario, distanza solco inframammario-proiezione solco inframammario ≥0cm, equatore, circonferenza della mammella al solco, circonferenza della mammella in ortostatismo, circonferenza della mammella in clinostatismo, diametro areola, proiezione capezzolo.
Ogni paziente ha eseguito una risonanza magnetica volumetrica senza mezzo di contrasto preoperatoria e misurazione del volume mammario mediante l’App BREAST-V.
Primay endpoint ed analisi:
Verificare l’accuratezza dell’App BREAST-V nel predire il volume della mammella;
per questo scopo sono stati confrontati i valori del volume della mammella ottenuti dal BREAST-V, dal peso intraoperatorio e dal volume derivante dai dati della risonanza magnetica volumetrica.
Secondary endpoints ed analisi:
-verificare l’accuratezza del BREAST-V nella valutazione del volume della mammella in differenti tipi di mastectomia (mastectomia radicale modificata secondo Madden, skin-sparing mastectomy, nipple-sparing mastectomy);
-verificare l’accuratezza del BREAST-V nella valutazione del volume della mammella quando sono coinvolti diversi chirurghi operatori;
-verificare l’accuratezza del BREAST-V nella valutazione del volume della mammella in mammelle non ptotiche con valore pari a zero della distanza dal solco inframammario alla proiezione del solco inframammario.
La raccolta dati è stata eseguita utilizzando un foglio excel per la versione Windows 2010. L’analisi statistica è stata condotta utilizzando R software version 2.14.2.
Risultati
Il peso medio della mammella era di 585±290g (range, 150-1500g). I test statistici effettuati confermavano come più importanti predittori del volume mammario la distanza giugolo-capezzolo, la distanza solco inframammario-capezzolo e la distanza solco inframammario-proiezione al solco inframammario nelle mammelle picccole, medie e grandi. Per mammelle piccole di volume 1200g è stato necessario apportare delle modifiche da inserire nella versione aggiornata dell’applicazione.
Conclusioni
Il BREAST-V è un valida metodica per predire il volume di mammelle piccole, medie e grandi che può essere usato come strumento complementare alla valutazione clinica eseguita da parte del chirurgo. L’App BREAST-V per iOS and Android è disponibile tramite download gratuito nell’Apple App Store and Google Play Store.
*Longo B., Farcomeni A., Ferri G., Campanale A., Sorotos M., Santanelli F. The BREAST-V: a unifying predictive formula for volume assessment in small, medium and large breasts. Plast Reconstr Surg. 2013;132(1):1e-7
Breast Reconstruction in Elderly Patients: Risk Factors, Clinical Outcomes, and Aesthetic Results
No full textBackground Correlation among age, clinical, and aesthetic outcomes in implant-based and autologous breast reconstructions was investigated. Methods Between 2004 and 2014, a retrospective study was performed on patients who underwent reconstruction following mastectomy. Patients were divided in group A (< 50 years), group B (≥ 50-59 years), group C (≥ 60-69 years), and group D (≥ 70 years). Demographics, comorbidities, American Society of Anesthesiologists (ASA) class, and length of stay were assessed using chi-square and Kruskal-Wallis H analysis considering p ≤ 0.05 as significant. Pre- and postoperative photographs were taken to grade aesthetic results by patients and blinded plastic surgery team. Results A total of 993 patients underwent 1,251 breast reconstructions, of which 356 (28.5%) were implant-based, 402 (32.1%) pedicled-flap, 445 (35.6%) free-flap, and 48 (3.8%) fat-graft reconstructions. There were 316 (25.2%) complications, of which 124 (34.8%) in implant-based, 74 (18.4%) in pedicled-flap, 111 (24.9%) in free-flap, and 2 (4.2%) in fat-graft reconstructions. Mean length of stay was 5.4 days without significant difference between age groups (p = 0.357). The incidence of overall complications was not significantly related to age, ASA class, smoking history, and previous radiotherapy. Body mass index was a significant predictor (p = 0.001), but odds ratio (OR: 1.2) demonstrated only a minimal increase in risk. Implant-based reconstruction was associated with a higher risk for complications compared with the other ones (OR: 2.5, p = 0.001). Patient and surgeon aesthetic surveys demonstrated an overall positive opinion in all age groups for each reconstructive option. Conclusion Advanced age should not be considered a risk factor for breast reconstruction, while implant-based technique was associated with a higher risk for complications compared with autologous that may provide older women with greater benefits
Aesthetic improvements of radial forearm flap donor site by autologous fat transplantation
No full textDespite its reliability, radial forearm (RF) flap is still affected by high donor site morbidity with poor cosmetic and functional outcomes after coverage with skin grafts. Having fat grafting demonstrated promising and effective filling and rejuvenating properties, we considered and tested it as a valuable alternative to dermal substitutes for the aesthetic improvement of RF flap donor site. Thirty-three patients with previous RF free flap reconstruction and poor donor site outcomes after full-thickness skin grafting to RF region were evaluated for secondary fat injection to improve outcomes. Objective and subjective assessments of results with standardized ultrasonographic soft tissue thickness measurements, cutaneous sensibility tests with the pressure-specified sensory device and scar assessment scale (POSAS) have been performed. Bivariate statistical analyses were performed comparing outcomes with contralateral healthy forearm. All cases showed significant improvement in soft tissue thickness (p< 0.031), cutaneous sensibility and scar appearance, with improved patient's and observers' scar assessment scores (<0.001). In conclusion, fat transplantation is an effective procedure that provided us with an adjunctive autologous layer in-between skin graft and underlying fascia, as well as a rejuvenating effect on skin and scars
Double free fillet foot flap. sole of foot and dorsalis pedis in severe bilateral lower extremity trauma, a 10-year follow-up case report
Full text linkThis study reports a unique 10 years follow-up case of a patient who underwent a free fillet of sole flap for left leg stump coverage and free dorsalis pedis flap for soft tissue reconstruction of contralateral popliteal fossa following severe bilateral lower leg injury
Interdental papillae reconstruction in glossopelvectomy defects
No full textInterdental Papillae Reconstruction in Glossopelvectomy Defect
Contralateral sensitive cross flap for reconstruction of a burned breast
No full textSeveral different approaches for reconstruction have been already described taking into account size and shape of the native breast, location and type of cancer, whether adjuvant radiation and/or chemotherapy is needed, patient’s demographic information, and surgeon’s preferences and experience. We report a case of reconstruction in burn patient using a breast sensitive perforator flap from the contralateral side. Thanks to the volume excess, the left side was large enough to reconstruct the affected side. A supero-medial pedicled reduction mammaplasty was performed on the left breast, and the excess inferior-part was elevated laterally and caudally off the pectoralis major. The flap was supplied by two perforators from the internal mammary vessels, and it was transposed to the right side after resection of the burned breast tissue. The right nipple-areola complex was left buried under the flap. After 2 months, the flap pedicle was deepithelialized, debulked, and passed through inframammary fold. The nipple-areola complex was released as a pedicled flap and sutured to the flap tissue approximately at the same level of the contralateral from the sternal notch. Preoperative sensitivity assessment demonstrated worst sensation of the right breast compared to the uninjured side. At 6 months, postoperatively, the patient could localize pressure and sensibility tested by the use of cotton wool and a pinprick test was quite normal. A clear improvement was observed in cutaneous pressure sensation thresholds over the time. At 12 months, she could recognize cotton wool and a pinprick. No changes were observed in the nipple-areola complex sensibility. Level of Evidence: Level V, therapeutic study
Lymphatic drainage study after latissimus dorsi flap breast reconstruction
No full textBackground Recurrence of breast cancer to latissimus dorsi (LD) flap donor site is a very rare condition, and as a result, few data are currently available on its possible causes. The aim of the study was to investigate the role of LD flap transfer in lymphangiogenesis and connection to the preexisting lymphatic network after mastectomy and axillary lymph node dissection and the lymphatic drainage involvement in local relapse to flap donor site. Methods Lymphoscintigraphy was performed on subgroup of ten patients who had previously undergone modified radical mastectomy, axillary lymph node dissection, and pedicled LD flap reconstruction. Lymphatic drainage was imaged by static gamma camera acquisitions after two intradermal injections of 37 MBq 99mTc-Nanocoll® on residual breast skin and LD skin paddle, respectively. Results In eight cases (80 %), the residual breast skin showed fast lymphatic drainage directed only toward the ipsilateral axilla, while in two cases (20 %), it was also seen to the internal mammary nodes. LD skin paddle showed slower drainage in all cases but 1, where no visible drainage was observed within 2 h after injection. Conclusions Although a small case series is the study limitation, our findings suggested that the LD flap harvest can promote a preferential route of lymphatic drainage in the axillary region and could be involved in a metastatic spread to the dorsum because of the new tissue plane opening. The direct communication created between recipient and donor sites could have lead to cell cancer transfer to the donor site either by lymphatic or a contiguity pathway.Level of Evidence: Level V, diagnostic study. © 2014 Springer-Verlag Berlin Heidelberg.Background
Recurrence of breast cancer to latissimus dorsi (LD) flap donor site is a very rare condition and as a result few data are currently available on its possible causes. The aim of the study was to investigate the role of LD flap transfer in lymphangiogenesis and connection to the pre-existing lymphatic network after mastectomy and axillary lymph-nodes dissection, and the lymphatic drainage involvement in local relapse to flap donor site.
Methods
Lymphoscintigraphy was performed on subgroup of 10 patients who had previously undergone modified radical mastectomy, axillary lymph-nodes dissection and pedicled LD flap reconstruction. Lymphatic drainage was imaged by static gamma camera acquisitions after two intradermal injections of 37MBq 99mTc-Nanocoll® on residual breast skin and latissimus dorsi skin paddle, respectively.
Results
In 8 cases (80%) the residual breast skin showed fast lymphatic drainage directed only towards the ipsilateral axilla, while in 2 cases
Skiing as a possible cause of late seroma after breast augmentation
No full textThe interest surrounding this issue
is now even greater given recent reports of a possible
rare connection between implants and anaplastic large
cell lymphoma (ALCL), as these tumors often present
as late seromas [6–9]. We present two cases of late
seroma after breast augmentation with textured implants
(Natrelle; Allergan, Inc, Irvine, California)
Total Breast Reconstruction Using the Thoracodorsal Artery Perforator Flap without Implant
No full textBackground: The thoracodorsal artery perforator flap was described mainly for partial breast reconstruction by Hamdi. The purpose of this article is to describe the use of the pedicled thoracodorsal artery perforator flap for total autologous breast reconstruction without using an implant. Methods: Between January of 2009 and December of 2011, seven patients underwent total breast reconstruction with a pedicled thoracodorsal artery perforator flap. The mean age of the patients was 53 years (range, 43 to 62 years), and the mean body mass index was 27 kg/m(2) (range, 24 to 32 kg/m(2)). Results: The mean size of the harvested skin paddle was 23.7 x 8.8 cm(2) (range, 15 x 7 cm(2) to 39 x 14 cm(2)). The flaps were based on one to three perforators and successfully transferred with an average operative time of 3 hours. No seroma occurred at the donor site. Average hospital stay was 4 days (range, 3 to 6 days). At an average follow-up of 21.5 months, two patients underwent additional revisions using autologous fat grafting, with overall fat injection volumes of 240 and 280 cc, respectively. Conclusion: The pedicled thoracodorsal artery perforator flap offers an alternative for total autologous breast reconstruction in small to medium breasted patients when abdominal tissues are not available.Purpose: The thoracodorsal artery perforator (TDAP) was mainly described for partial breast reconstruction by Hamdi. The purpose of is paper is to describe the use of the pedicled TDAP flap for total autologous breast reconstruction without implant.
Material and Methods: Between January 2009 and December 2011, seven patients underwent total breast reconstruction with TDAP pedicled flap. The mean patients’ age was 52.7 years (range, 43 to 62 years), while the body mass index was 26.5 kg/m2 (range, 23.7 to 32 kg/m2).
Results: The mean size of harvested skin paddle was 23.7 x 8.8 cm (range, 15 x 7 cm to 39 x 14 cm). The flaps were based on 1 to 3 perforators and successfully transferred with an average operative time of 3 hours. No seroma occurred in the donor site. Average hospital stay was 4 days (3-6 days). With average follow-up of 18 months, 2 patients underwent additional revisions using autologous fat grafting with an overall fat injection of 240 cc and 280 cc respectively.
Conclu
Functional sequelae following bilateral latissimus dorsi flap harvest for breast reconstruction
No full textABSTRACT
Background: Functional arm sequelae following harvest of a unilateral Latissimus Dorsi (LD) flap are a controversial issue. Bilateral LD harvesting after mastectomy is considered a potentially disabling procedure. To clarify this point we evaluated arm and shoulder disability in an homogeneous group of patients undergoing bilateral mastectomy and LD flap reconstruction.
Methods: A retrospective review of thirty bilateral mastectomies and immediate reconstruction with denervated LD flaps, performed between 2005 and 2009, was undertaken at the Plastic Surgery Unit of the Faculty of Medicine and Psychology of “Sapienza” University of Rome, Italy. No patient suffered co morbidity or previous shoulder illness. Arm disability was investigated by conducting the Disability of Arm, Shoulder and Hand (DASH) test, at a mean 23 months (range 12 - 51) from operation. Disability scores ranged from 1-100 percent, and 1-25% was regarded as mild dysfunction, 26-50% as moderate dysfunction, 51-75% as severe dysfunction and 76-100% as total dysfunction. Statistical analysis was performed with Fisher exact test and the linear regression model for variables.
Results: Mean Global Dash score was 14.8 percent %. Twenty-four patients presented a mild functional deficit (< 25 percent%) while six moderate a one (< 50 percent %). Five of them presented a score < 40 percent %, only 1 patient a score of 49.1 percent %. Higher scores were significantly associated (p < 0.001) with major postoperative complications, while lower ones with re-innervated LD flaps (p <0.01).
Conclusion: Results showed a mild functional impairment in the majority of patients, while a moderate to severe deficit in the group with complications. Greater impairment is observed in the heavy activities. The DASH test is a useful tool to inform patients how mastectomy and LD harvesting can affect every day life
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