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BACKGROUND@#Breast cancer patients suffer from lowered quality of life (QoL) after surgery. Breast conservancy surgery (BCS) such as partial mastectomy is being practiced and studied as an alternative to solve this problem. This study confirmed breast tissue reconstruction in a pig model by fabricating a 3-dimensional (3D) printed Polycaprolactone spherical scaffold (PCL ball) to fit the tissue resected after partial mastectomy. @*METHODS@#A 3D printed Polycaprolactone spherical scaffold with a structure that can help adipose tissue regeneration was produced using computer-aided design (CAD). A physical property test was conducted for optimization. In order to enhance biocompatibility, collagen coating was applied and a comparative study was conducted for 3 months in a partial mastectomy pig model. @*RESULTS@#In order to identify adipose tissue and fibroglandular tissue, which mainly constitute breast tissue, the degree of adipose tissue and collagen regeneration was confirmed in a pig model after 3 months. As a result, it was confirmed that a lot of adipose tissue was regenerated in the PCL ball, whereas more collagen was regenerated in the collagen-coated Polycaprolactone spherical scaffold (PCL–COL ball). In addition, as a result of confirming the expression levels of TNF-a and IL-6, it was confirmed that PCL ball showed higher levels than PCL–COL ball. @*CONCLUSION@#Through this study, we were able to confirm the regeneration of adipose tissue through a 3-dimensional structure in a pig model. Studies were conducted on medium and large-sized animal models for the final purpose of clinical use and reconstruction of human breast tissue, and the possibility was confirmed.
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Background@#Ultrasonic devices have potential advantages over electrocautery surgical scalpels for muscle dissection, as they eliminate the risk of muscle contraction caused by electric currents. In this study, we investigated the outcomes of using both device types in subpectoral dissection for breast reconstruction. @*Methods@#In this retrospective single-center study, we examined the electronic medical records of female patients with non-recurrent breast cancer who underwent breast reconstruction. The patients were treated with either Harmonic Focus+ Shears (HFS) or a Bovie electrocautery scalpel (BES) between January 2015 and April 2020. The primary clinical outcomes evaluated were total drainage volume, time to drainage tube removal, and operation time. To control for confounding, outcomes were stratified based on the type of tissue expander used—either Mentor or Natrelle. @*Results@#The study included 303 patients; 155 (51.2%) were treated with HFS (mean age, 45.28±7.38 years) and 148 (48.8%) with BES (mean age, 44.41±9.37 years). Within each expander type, the frequency of drainage exceeding 30 cc per day after 21 postoperative days showed no statistical difference between the HFS and BES devices. The operation time was shorter for HFS in both the Mentor (85.13±19.81 minutes vs. 109.56±21.66 minutes, P<0.001) and Natrelle (88.09±20.64 minutes vs. 99.88±22.66, P<0.001) groups. @*Conclusions@#When controlling for the type of tissue expander as a confounding factor, HFS was associated with reduced operation time. Furthermore, it demonstrated superior clinical effectiveness compared to BES regarding operator convenience.
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Background@#Human immunodeficiency virus (HIV)-associated facial lipoatrophy (FLA) is a stigmatizing side effect associated with the use of highly active antiretroviral therapy. We sought to evaluate the safety and efficacy of the hyaluronic acid filler mixed with micronized cross-linked acellular dermal matrix (HA/MADM) in HIV-associated FLA. @*Methods@#We conducted an open-label safety and efficacy study in patients with HIVassociated FLA. Fourteen patients received single injection of the HA/MADM, and 13 patients completed the 24-week follow-up evaluation. Treatment efficacy, safety, and patient and physician satisfaction were evaluated. Repeated measure analysis of variance with post-hoc analysis with the Wilcoxon signed rank test was performed to compare and incorporate parameters at each time point. @*Results@#All 13 patients maintained a significant improvement of the Carruthers Lipoatrophy Severity Scale grade throughout the study period, along with improvement of the depressed volume due to lipoatrophy measured using a three-dimensional camera system. More than 80% of patients and physicians were satisfied with the treatment, and no treatment-related adverse events were reported, except for one case of transient subcutaneous nodule formation. @*Conclusion@#Our study findings suggest that injectable HA/MADM is a potentially effective and safe treatment option for treating HIV-positive patients with FLA.
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The deep inferior epigastric perforator (DIEP) flap has been widely used for autologous breast reconstruction after mastectomy. In the conventional surgical method, a long incision is needed at the anterior fascia of the rectus abdominis muscle to obtain sufficient pedicle length; this may increase the risk of incisional hernia. To shorten the incision, several trials have investigated the use of endoscopic/robotic devices for pedicle harvest; however, making multiple additional incisions for port insertion and operating in the intraperitoneal field were inevitable. Here, we describe the first case, in which a DIEP free flap was successfully made using the da Vinci SP model. Our findings can help surgeons perform operations in smaller fields with a single port in the extraperitoneal space. Moreover, this method is expected to lead to fewer donor-related complications and faster healing.
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Robot-assisted surgery is evolving to incorporate a higher number of minimally invasive techniques. There is a growing interest in robotic breast reconstruction that uses autologous tissue. Since a traditional latissimus dorsi (LD) flap leads to a long donor scar, which can be an unpleasant burden to patients, there have been many attempts to decrease the scar length using minimally invasive approaches. This study presents the case of a patient who underwent a robot-assisted nipple-sparing mastectomy followed by immediate breast reconstruction with an LD flap using a single-port robotic surgery system. With the assistance of a single-port robot, a simple docking process using a short and less visible incision is possible. Compared to multiport surgery systems, single-port robots can reduce the possibility of collision between robotic arms and provide a clear view of the medial border of the LD where the curvature of the back restricts the visual field. We recommend the use of single-port robots as a minimally invasive approach for harvesting LD flaps.
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Background@#In prosthesis-based breast reconstruction patients, the drain tends to be kept in place longer than in patients who undergo only mastectomy. Postoperative arm exercise also increases the drainage volume. However, to preserve shoulder function, early exercise is recommended. In this study, we investigated the effect of early exercise on the total drainage volume and drain duration in these patients. @*Methods@#We designed a prospective randomized trial involving 56 patients who underwent immediate breast reconstruction following mastectomy using tissue expanders. In each group, the patients were randomized either to perform early arm exercises using specific shoulder movement guidelines 2 days after surgery or to restrict arm movement above the shoulder height until drain removal. The drain duration and the total amount of drainage were the primary endpoints. @*Results@#There were no significant differences in age, height, weight, body mass index, or mastectomy specimen weight between the two groups. The total amount of drainage was 1,497 mL in the early exercise group and 1,336 mL in the exercise restriction group. The duration until complete removal of the drains was 19.71 days in the early exercise group and 17.11 days in the exercise restriction group. @*Conclusions@#Exercise restriction after breast reconstruction did not lead to a significant difference in the drainage volume or the average time until drain removal. Thus, early exercise is recommended for improved shoulder mobility postoperatively. More long-term studies are needed to determine the effect of early exercise on shoulder mobility in prosthesis-based breast reconstruction patients.
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Background@#Human adipose-derived mesenchymal stem cells (AMSCs) are an attractive resource for wound healing because their regenerative capacity improves injury repair. Recently, stem cell-derived exosomes have been shown to play a positive role in stem cell-based therapies. However, the effects of exosomes derived from AMSCs (AEXOs) on wound healing are unclear. In this study, we aimed to examine the role of AEXOs in attenuating inflammation and explore their effects in normal wound healing. @*Methods@#We isolated exosomes from AMSCs and established a cellular model of inflammation by treatment with the inflammatory cytokines, interferon gamma and tumor necrosis factor alpha, to determine whether AEXOs can inhibit inflammation. We examined the wound healing effects of AEXOs in in vitro wound healing models and performed a miRNA array to understand the role of AEXOs in inflammation and wound healing. @*Results@#A significant difference was observed in wound closure and the expression of anti-inflammatory and wound-healing-related factors between control and AEXO-treated cells. @*Conclusion@#Our results showed that besides alleviating the inflammation response, AEXOs also promote wound healing. Thus, AEXOs represent a novel, stem-cell-based, therapeutic strategy for wound healing.
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Background@#Human adipose-derived mesenchymal stem cells (AMSCs) are an attractive resource for wound healing because their regenerative capacity improves injury repair. Recently, stem cell-derived exosomes have been shown to play a positive role in stem cell-based therapies. However, the effects of exosomes derived from AMSCs (AEXOs) on wound healing are unclear. In this study, we aimed to examine the role of AEXOs in attenuating inflammation and explore their effects in normal wound healing. @*Methods@#We isolated exosomes from AMSCs and established a cellular model of inflammation by treatment with the inflammatory cytokines, interferon gamma and tumor necrosis factor alpha, to determine whether AEXOs can inhibit inflammation. We examined the wound healing effects of AEXOs in in vitro wound healing models and performed a miRNA array to understand the role of AEXOs in inflammation and wound healing. @*Results@#A significant difference was observed in wound closure and the expression of anti-inflammatory and wound-healing-related factors between control and AEXO-treated cells. @*Conclusion@#Our results showed that besides alleviating the inflammation response, AEXOs also promote wound healing. Thus, AEXOs represent a novel, stem-cell-based, therapeutic strategy for wound healing.
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Robot-assisted nipple-sparing mastectomy with immediate reconstruction is currently performed in an attempt to seek smaller and indistinct incisions. Robotic surgery system has been evolving under the concept of minimal invasive technique which is a recent trend in surgery. One of the latest version is the da Vinci SP Surgical System (Intuitive Surgical). In this report, we will share our experiences. Two patients underwent robot-assisted nipple-sparing mastectomy, each followed by immediate robot-assisted expander insertion and prepectoral direct-to-implant breast reconstruction, respectively. There was no open conversion or major postoperative complication. One patient experienced mild infection, which was resolved by intravenous antibiotic treatment. Simple docking process, multi-joint instruments, and third-arm functionality are among the new surgical system’s advantages. The present cases suggest that robot-assisted nipple-sparing mastectomy with immediate reconstruction using the da Vinci SP Surgical System is feasible and safe. The promising features and potential application of da Vinci SP in breast reconstruction need further study.
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Background@#Although loss of sensation in patients with breast cancer after mastectomy followed by breast reconstruction is an important factor affecting patients’ quality of life, the mechanism of sensory recovery is still unclear. Our study aimed to identify variables that affect sensory recovery, especially pain, in reconstructed breasts. @*Methods@#All patients with breast cancer who underwent mastectomy followed by immediate breast reconstruction, including nipple reconstruction or areolar tattooing, were included in this study. Sensation was evaluated in the nipple as an endpoint of sensation recovery of the whole breast. Patients rated pain severity using a 3-point verbal rating scale (VRS): grade 0, no pain; grade 1, mild to moderate pain; and grade 2, severe pain. The VRS was assessed by a single experienced plastic surgeon. @*Results@#In the univariate analysis, the odds ratio (OR) for sensation recovery was 0.951 for age (P=0.014), 0.803 for body mass index (P=0.001), 0.996 for breast volume before surgery (P=0.001), 0.998 for specimen weight after mastectomy (P=0.040), and 1.066 for the period between mastectomy and sensory assessment (P=0.003). In the multivariate analysis, the variables that showed a significant effect were age (OR, 0.953; P=0.034), the period between mastectomy and sensory assessment (OR, 1.071; P=0.006), and reconstruction using abdominal tissue instead of prosthetic reconstruction (OR, 0.270; P=0.004). @*Conclusions@#Based on our results, it can be inferred that aging has a negative impact on the recovery of sensation, breast sensation improves with time after surgery, and the recovery of sensation is better in prosthetic reconstruction.
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Rectovaginal fistula, which can arise after an injury to the vaginal canal or rectum, is a troublesome obstacle for patients’ everyday life. In most cases, it can be covered with a local flap, but previous radiation therapy increases the recurrence rate, making it especially difficult to cure. As the application of stromal vascular fraction (SVF) obtained from enzymatically digested autologous adipose tissue has become increasingly common, several reports have advocated its effectiveness for the treatment of refractory wounds. In light of the angiogenic, regenerative characteristics of SVF, it was incorporated as a treatment option in two cases of rectovaginal fistula discussed here. As described in this report, irradiated rectovaginal fistulas in rectal cancer patients were successfully treated with SVF injection, and we suggest SVF as a feasible treatment option for cases of rectovaginal fistula that would otherwise be very difficult to cure.
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Purpose@#The purpose of this study was to understand the experience of exercise participation among patients following transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction surgery. @*Methods@#A phenomenological method was used in this study. Exercise experiences for twelve patients, who had undergone TRAM flap breast reconstruction, were collected through focus group interviews. @*Results@#The factors that contributed to exercise barriers in the experience of TRAM flap breast reconstruction patient exercise participation were categorized into 3 groups: ‘fear of exercise after surgery’, ‘weakened emotional condition’, and ‘lack of exercise information’. Exercise facilitators after TRAM flap breast reconstruction were also categorized into 3 groups: ‘desire to improve appearance’, ‘feasiable exercise program’, and ‘exercise experience’. @*Conclusion@#The results of this study reveal the exercise barriers and facilitators for patients following TRAM flap breast reconstruction, which should be considered to develop effective exercise programs.
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Since April 2015, post-mastectomy breast reconstruction has been covered by the Korean National Health Insurance Service (NHIS). The frequency of these procedures has increased very rapidly. We analyzed data obtained from the Big Data Hub of the Health Insurance Review and Assessment Service (HIRA) and determined annual changes in the number of breast reconstruction procedures and related trends in Korea. We evaluated the numbers of mastectomy and breast reconstruction procedures performed between April 2015 and December 2018 using data from the HIRA Big Data Hub. We determined annual changes in the numbers of total, autologous, and implant breast reconstructions after NHIS coverage commenced. Data were analyzed using Microsoft Excel. The post-mastectomy breast reconstruction rate increased from 19.4% in 2015 to 53.4% in 2018. In 2015, implant reconstruction was performed in 1,366 cases and autologous reconstruction in 905 (60.1% and 39.8%, respectively); these figures increased to 3,703 and 1,570 (70.2% and 29.7%, respectively) in 2018. Free tissue transfer and deep inferior epigastric perforator flap creation were the most common autologous reconstruction procedures. For implant-based reconstructions, the rates of directto-implant and tissue-expander breast reconstructions (first stage) were similar in 2018. This study summarizes breast reconstruction trends in Korea after NHIS coverage was expanded in 2015. A significant increase over time in the post-mastectomy breast reconstruction rate was evident, with a trend toward implant-based reconstruction. Analysis of data from the HIRA Big Data Hub can be used to predict breast reconstruction trends and convey precise information to patients and physicians.
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Background@#Closed-suction drains are widely used in expander-based breast reconstruction. These drains are typically removed using a volume-based criterion. The drainage volume affects the hospital stay length and the recovery time. However, few studies have analyzed the factors that influence drainage volume after expander-based breast reconstruction. @*Methods@#We retrospectively analyzed data regarding daily drainage from patients who underwent expander-based breast reconstruction between April 2014 and January 2018 (159 patients, 176 expanders). Patient and operative factors were analyzed regarding their influence on total drainage volume and drain placement duration using univariate and multivariate analyses and analysis of variance. @*Results@#The mean total drainage volume was 1,210.77±611.44 mL. Univariate analysis showed correlations between total drainage volume and age (B=19.825, P<0.001), body weight (B=17.758, P<0.001), body mass index (B=51.817, P<0.001), and specimen weight (B=1.590, P<0.001). Diabetes history (P<0.001), expander type (P<0.001), and the surgical instrument used (P<0.001) also strongly influenced total drainage. The acellular dermal matrix type used did not affect total drainage (P=0.626). In the multivariate analysis, age (B=11.907, P=0.004), specimen weight (B=0.927, P<0.001), and expander type (B=593.728, P<0.001) were significant predictors of total drainage. @*Conclusions@#Our findings suggest that the total drainage and the duration of drain placement needed after expander-based breast reconstruction can be predicted using preoperative and intraoperative data. Patient age, specimen weight, and expander type are important predictors of drainage volume. Older patients, heavier specimens, and use of the Mentor rather than the Allergan expander corresponded to a greater total drainage volume and a longer duration of drain placement.
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Subpectoral implant insertion is considered to be the standard procedure for breast augmentation and reconstruction. However, in some patients who have undergone breast augmentation or reconstruction surgery with a prosthesis, implant removal may be required for various reasons, including infection or implant rupture. According to a literature review, the standard technique for implant removal has not been thoroughly investigated. This study aimed to report the case of a patient who developed animation deformity after implant removal and to suggest a technique for preventing such complications. A 51-year-old woman underwent breast augmentation surgery with silicone implants. However, the patient complained of an unpleasant foreign body sensation; hence, the implant was removed 6 months after the first operation. After removal of the implant, undesirable movement of the chest wall on both breasts occurred. Revision surgery under general anesthesia was planned 18 months after implant removal. Capsulectomy was performed on both sides, and the pectoralis major muscle was completely isolated and repositioned. The undesirable movement in the skin of the chest wall disappeared postoperatively. This case suggests the need for capsulectomy and repositioning of the pectoralis muscle to its original position during implant removal.
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Minimal invasive surgical technique has been increasingly applied to breast surgery. Since the first robot-assisted nipple-sparing mastectomy was introduced, we have been performing nipple-sparing mastectomy using multi-port robotic surgical system. Last year, the new robotic surgical system with single port was introduced. We report the development of a robotic nipple-sparing mastectomy with immediate reconstruction through a single incision using the updated single-port surgical robot system for a patient with ductal carcinoma in situ (DCIS). Breast reconstruction was performed using implants. Postoperative pathological examination revealed DCIS in both breasts. There were no major immediate complications, except for a minor skin burn on the right breast. Overall, the initial operation using the updated platform was safely performed.
Subject(s)
Female , Humans , Breast , Breast Neoplasms , Burns , Carcinoma, Intraductal, Noninfiltrating , Mammaplasty , Mastectomy , Mastectomy, Subcutaneous , Minimally Invasive Surgical Procedures , Robotic Surgical Procedures , SkinABSTRACT
BACKGROUND@#As the indications for postmastectomy radiotherapy expand, innovative solutions are required to reduce operative complications and reconstructive failure after prosthetic breast reconstruction. In this study, we investigated the effectiveness of acellular dermal matrix (ADM) inlay grafts in preventing postoperative wound dehiscence of irradiated breasts in the context of prosthetic breast reconstruction.@*METHODS@#A retrospective analysis was conducted of 45 patients who received two-stage prosthetic reconstruction and radiotherapy following mastectomy. An ADM graft was placed beneath the incisional site during the second-stage operation in 19 patients using marionette sutures, whereas the control group did not receive the ADM reinforcement. Patient demographics and complications such as wound dehiscence, capsular contracture, peri-prosthetic infection, cellulitis, and seroma were compared between the two groups.@*RESULTS@#During an average follow-up period of 37.1 months, wound dehiscence occurred significantly less often in the ADM-reinforced closure group (0%) than in the non-ADM group (23.1%) (P=0.032). There was no significant difference between the two groups in relation to other complications, such as capsular contracture, postoperative infection, or seroma.@*CONCLUSIONS@#The ADM inlay graft is a simple and easily reproducible technique for preventing incisional dehiscence in the setting of radiotherapy after prosthetic breast reconstruction. The ADM graft serves as a buttress to offload tension during healing and provides a mechanical barrier against pathogens. Application of this technique may serve to reduce complications in prosthetic breast reconstruction after radiotherapy.
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BACKGROUND: The use of anatomic implants has improved the aesthetic results of breast surgery; however, implant malrotation is an uncommon, but serious complication of these procedures. Nevertheless, little research has explored implant adhesion. In this study, we investigated adhesion between the expander and the capsule. METHODS: Seventy-nine cases of immediate breast reconstruction via two-stage implant-based reconstruction performed between September 2016 and November 2017 were evaluated. Mentor CPX4 expanders were used in 14 breasts, and Natrelle expanders in 65. We analyzed areas of adhesion on the surfaces of the tissue expanders when they were exchanged with permanent implants. We investigated whether adhesions occurred on the cephalic, caudal, anterior, and/or posterior surfaces of the expanders. RESULTS: Total adhesion occurred in 18 cases, non-adhesion in 15 cases, and partial adhesion in 46 cases. Of the non-adhesion cases, 80% (n=12) were with Mentor CPX4 expanders, while 94.4% (n=17) of the total adhesion cases were with Natrelle expanders. Of the partial adhesion cases, 90.7% involved the anterior-cephalic surface. The type of tissue expander showed a statistically significant relationship with the number of attachments in both univariate and multivariate logistic regression analyses (P<0.001) and with total drainage only in the univariate analysis (P=0.015). CONCLUSIONS: We sought to identify the location(s) of adhesion after tissue expander insertion. The texture of the implant was a significant predictor of the success of adhesion, and partial adhesion was common. The anterior-cephalic surface showed the highest adhesion rate. Nevertheless, partial adhesion suffices to prevent unwanted rotation of the expander.
Subject(s)
Female , Humans , Breast Implantation , Breast Implants , Breast , Drainage , Logistic Models , Mammaplasty , Mentors , Tissue Expansion DevicesABSTRACT
Robotic surgery facilitates surgical procedures by employing flexible arms with multiple degrees of freedom and providing high-quality 3-dimensional imaging. Robot-assisted nipplesparing mastectomy with immediate reconstruction is currently performed to avoid breast scars. Four patients with invasive ductal carcinoma underwent robot-assisted nipple-sparing mastectomy and immediate robot-assisted expander insertion. Through a 6-cm incision along the anterior axillary line, sentinel lymph node biopsy and nipple-sparing mastectomy were performed by oncologic surgeons. The pectoralis major muscle was elevated, an acellular dermal matrix (ADM) sling was created with robotic assistance, and an expander was inserted into the subpectoral, sub-ADM pocket. No patients had major complications such as hematoma, seroma, infection, capsular contracture, or nipple-areolar necrosis. The mean operation time for expander insertion was 1 hour and 20 minutes, and it became shorter with more experience. The first patient completed 2-stage prosthetic reconstruction and was highly satisfied with the unnoticeable scar and symmetric reconstruction. We describe several cases of immediate robot-assisted prosthetic breast reconstruction. This procedure is a feasible surgical option for patients who want to conceal surgical scars.