Revascularization of the Nipple-Areola Complex following Nipple-Sparing Mastectomy.

BACKGROUND: Preoperative vascular mapping has been demonstrated to be an excellent adjunct to perforator flap surgery by reducing operative times and enhancing surgical precision. This study evaluated the benefit of preoperative vascular mapping using magnetic resonance imaging and Doppler ultrasonography to identify the different perforators to the breast and compared it to postoperative mapping. The authors' intent was to determine whether preoperative knowledge of the various vascular sources to the nipple-areola complex affected the outcome and vitality of the nipple-areola complex. METHODS: A prospective study was performed on 15 patients undergoing 25 nipple-sparing mastectomies for breast cancer or genetic predisposition. Ten patients underwent bilateral mastectomy, and five underwent unilateral mastectomy. Mean age was 52 years (range, 30 to 76 years). The mean patient body mass index was 22.4 kg/m2 (range, 20 to 35 kg/m2). Inclusion criteria consisted of breast cancer or genetic predisposition and grade 1 or 2 breast ptosis. Exclusion criteria included prior breast surgery, grade 3 ptosis, and gigantomastia. All patients underwent immediate direct-to-implant reconstruction. RESULTS: Preoperative vascular mapping by magnetic resonance imaging and external Doppler ultrasonography was performed in all 15 patients. In all 25 breasts, the fifth anterior intercostal artery perforator was identified preoperatively and preserved intraoperatively. Postoperative imaging demonstrated patency of the fifth anterior intercostal artery perforator vessels in all patients. Nipple-areola viability was demonstrated in all breasts. CONCLUSIONS: This study demonstrates that preoperative magnetic resonance imaging and Doppler ultrasonography for mapping breast perforator vessels is a useful strategy and should be considered for select patients undergoing nipple-sparing mastectomy. Identification of dominant perforators to the breast allowed mastectomy planning with preservation of the important perforator to the mastectomy skin flaps and nipple-areola complex. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Symmetry following unilateral two-stage prosthetic breast reconstruction: Is there an optimal time for managing the contralateral breast?

INTRODUCTION: Achieving breast symmetry following unilateral mastectomy remains a challenge. Contralateral procedures are usually necessary to achieve breast symmetry. Controversy exists regarding whether these symmetry procedures should be performed at the time of the initial reconstruction or on a delayed basis. MATERIALS AND METHODS: The study included 105 patients who had unilateral mastectomy, of which 55 had a simultaneous (immediate) contralateral symmetry procedure and 50 had a delayed contralateral symmetry procedure. Outcomes were compared and assessed for each cohort based on demographics, complications, and patient satisfaction. RESULTS: The delayed cohort required more procedures (3.4 vs. 1.8, p < 0.0001) but shorter overall hospitalization length (2.8 vs. 4.1 days, p < 0.0001). The two cohorts experienced a similar rate of revision (38.3% vs. 49.3%, p = 0.17) The delayed cohort required a contralateral balancing procedure after completion of reconstruction more often than the immediate cohort (p = 0.021). Overall reconstruction-specific complication rates were similar in both cohorts. The 36-Item Short-Form Health Survey (SF-36), a validated questionnaire for quality-of-life assessment, was administered 3 months after surgery and demonstrated that both cohorts reported similar outcomes when comparing their satisfaction with treatment. CONCLUSIONS: The results of this study demonstrate that immediate contralateral symmetry operations can be performed safely without increased morbidity. A new algorithm is presented.

The Importance of Fifth Anterior Intercostal Vessels following Nipple-Sparing Mastectomy.

BACKGROUND: The authors describe the vascular anatomy of the fifth anterior intercostal artery perforator and its role for perfusion of the nipple-areola complex following nipple-sparing mastectomy. METHODS: Twenty fresh cadavers were injected with 20 cc of colored latex through the internal mammary artery. The catheter was placed at the level of the second intercostal space after removal of the rib. The fifth intercostal space was dissected under magnification to observe the origin and trajectory of the fifth anterior intercostal artery perforator. Six selective computed tomographic angiograms of the fifth intercostal artery perforator were performed. A clinical case of nipple-sparing mastectomy in a woman with mammary hypertrophy is provided to demonstrate the utility of preserving the fifth anterior intercostal artery perforator. RESULTS: The fifth anterior intercostal artery perforator was consistently observed in all the cases and confirmed by angiography. The perforator gives rise to several branches that traverse in all directions. The ascending branches of the fifth anterior intercostal artery perforator are directed toward the nipple-areola complex and course within the subcutaneous layer between the skin and the parenchyma. The fourth and fifth anterior intercostal artery perforators are independent of one another. CONCLUSION: The main ascending branch of the fifth anterior intercostal artery perforator reaches the nipple-areola complex by the subcutaneous tissue independently of the Würinger fascia.

Visualized oncoplastic surgery of the breast I: inferior and medial quadrantectomy.

Surgical treatment of breast cancer has changed during the last few decades. Long-term evaluation of several studies performed worldwide have confirmed that conservative surgery (CS) and radical mastectomy have similar survival rates. Due to CS being the gold standard for treatment for most women with breast cancer, advances in materials, mastectomy and reconstructive surgery techniques, now give us the possibility to perform on our patients a great outcome with oncological security. Both advances, in plastic and oncologic surgery, created a new discipline, called oncoplastic breast surgery, that allow surgeons to resect large breast specimens preventing subsequent deformities with the correct previous planning. This is particularly important when more than 30% of the breast volume will be resected because it allows for planning CS depending on the site of the lesion and for establishing the limits between CS and mastectomy.

Cirugía mayor ambulatoria en patología mamaria. Experiencia de Breast Clínica de la Mama ­ Hospital Italiano de La Plata / Major outpatient surgery in breast disease. Experience at Breast Clinic and Italian Hospital in La Plata

Introducción Se presenta un trabajo descriptivo sobre la experiencia de cirugía mayor ambulatoria en patología mamaria de Breast Clínica de la Mama - Hospital Italiano de La Plata. Objetivos El objetivo de este trabajo es describir nuestra experiencia en pacientes operadas por patología mamaria en una unidad de cirugía mayor ambulatoria, dando a conocer: a) los requisitos básicos para el correcto y uniforme funcionamiento de la cirugía ambulatoria; b) el porcentaje de reinternaciones y de complicaciones de dicha modalidad. Material y método Se establecen criterios de selección y de exclusión de las pacientes y se describe el circuito de las mismas desde el diagnóstico hasta la recuperación postquirúrgica. Se evaluó en forma retrospectiva y mediante una encuesta la satisfacción por parte de las pacientes con este tipo de modalidad quirúrgica. Resultados No se hallaron complicaciones inherentes a esta modalidad quirúrgica. El porcentaje de internación fue comparable al de otras publicaciones. Conclusiones Podemos concluir que la cirugía ambulatoria en pacientes con patología mamaria se realiza sin inconvenientes, tanto para procedimientos menores como para cirugías más extensas, como linfadenectomías y mastectomías.

Introduction We present a descriptive work on the experience of major outpatient surgery in breast disease at Breast Clinic and Italian Hospital in La Plata. Objectives To describe our experience on major outpatient surgery in breast disease at an ambulatory surgery unit. To determine: a) the basic requirements for a right and uniform functioning of ambulatory surgery; b) the re-hospitalizazion and complications rates. Materials and method Selective and exclusion criteria of choice are established and the circuit of the patient from the diagnosis to the postsurgical recovery is described. A survey assessed in a retrospective way the acceptance shown by patients to this type of surgery. Results No further problems resulting from this type of surgery were found. The rate of hospitalization could be compared to other publications. Conclusions We can conclude that outpatient surgery in patients with breast pathology is performed satisfactorily both in minor procedures and more serious surgeries like lymphadenectomies and mastectomies.

Neumodisección con CO2 para lipotransferencia en reconstrucción mamaria / Pneumodissection with CO2 for transfer fat in breast reconstruction

Introducción La incorporación de la transferencia grasa como método accesorio a la reconstrucción con implantes permite hoy mayor seguridad y estabilidad de resultado en el tiempo. Es por ello que la optimización en el tratamiento de la lodge de la mastectomía con CO2 y campana de succión externa cobra un valor agregado en el mejoramiento tegumentario para aumentar la distribución y volumen de cobertura. Objetivos El objetivo es la preparación con succión externa y disección con CO2 del lecho receptor para la realización de reconstrucción mamaria diferida en pacientes mastectomizadas con radioterapia postmastectomía mediante la utilización de lipotransferencia y material protésico. Material y método Abordamos un grupo de 12 pacientes consecutivos con radioterapia postmastectomía que presentaban falta de cobertura, retracción cutánea, irregularidad de superficie, con una media de 43 años de edad ­entre un rango de 28 a 59 años­. Todas habían finalizado su tratamiento radioterapéutico hacía 1 año. La serie tuvo un seguimiento de 7 meses desde el primer procedimiento de lipotransferencia. Resultados En la comparación con nuestra serie general de 80 lipotransferencias en pacientes con radioterapia (sin neumodisector), se evidenció un mejoramiento clínico significativo de la lodge, por el aumento en la distribución a diferentes profundidades de un mismo plano del autoinjerto graso, impactando en una mayor superficie de cobertura y cambios estructurales de la piel. El espesor de los colgajos de la mastectomía fue evaluado con ecografías seriadas y rnm en la misma zona pre y postinjerto. Conclusiones Es evidente el mejoramiento de los tejidos mediante la utilización de la succión externa y aumento del grosor del lecho receptor con insuflación de CO2, con el consiguiente aumento de espesor en la distribución de grasa, que predispone a un mejor grado de prendimiento del autoinjerto y cobertura, pudiendo estos ser expandibles e indicar una reconstrucción con menor grado de morbilidad y mejor aceptación por la paciente.

Introduction The incorporation of transfer fat as accessory method to the reconstruction with implants today enables greater security and stability of result in time, so that the optimization in the treatment of the lodge of mastectomy with CO2 and external suction bell takes on an added value in the integumentary improvement to increase the distribution and volume of coverage. Objectives The aim is the preparation with external suction and dissection with CO2 of the receiving bed to perform breast reconstruction deferred in patients mastectomized and post-mastectomy radiotherapy using lipotransference and prosthetic material. Materials and method We approach a group of 12 consecutive post-mastectomy radiotherapy patients presenting with lack of coverage, cutaneous retraction, irregularity of surface, with an average of 43 years old, ­among a range of 28 to 59 years­. All had finished her radiotherapy treatment for 1 year; series was followed for 7 months from the first procedur eof lipotransference. Results Compared with our overall series 80 lipotransferences in patients with radiotherapy (without neumodissector), there is a significant clinical improvement of the lodge, by the increase in the distribution at different depths of the same level of fatty autograft, impacting on a larger surface coverage and structural changes of the skin. The thickness of the flaps of the mastectomy were assessed with serial ultrasounds and mri in the same area pre and post graft. Conclusions It is obvious the improvement of tissues, using external suction and increase of the thickness of the receptor bed with CO2 insufflation, with the consequent increase in thickness in the distribution of fat, which predisposes to a better degree of catch of autograft and coverage, which can be expandaded and indicate a reconstruction with lower degree of morbidity and better acceptance by the patient.

Improving aesthetic outcomes in mastopexy with the "autoprosthesis" technique.

BACKGROUND: Many techniques have been described for mastopexy, with several types of skin incisions and parenchymal rearrangements. We present a parenchymal rearrangement technique allowing better upper pole fullness and nipple-areola-complex (NAC) projection when performing a mastopexy, with a combination of a superior pedicle for the NAC and an inferiorly-based parenchymal flap, the so-called "autoprosthesis". METHODS: From January 2008 to June 2015, 184 patients underwent "autoprosthesis" mastopexy. Patients' mean ages was 42 years. The mean follow-up period was 39 months. RESULTS: We reported no major complications. All the patients were satisfied with their post-operative unclothed and clothed appearance and overall body image as reported by our questionnaire. CONCLUSIONS: The autoprosthesis technique for mastopexy is a simple and safe, technique, allowing long-lasting results for breast projection and upper pole fullness.

Anatomical basis of pedicles in breast reduction.

The mammary gland is composed of multiple tubules acinar pockets in which the secretory layer, connective tissue stroma, and fatty tissue all respond to hormonal and systemic influences. These structures are irrigated by three vascular pedicle branches, from the axillary artery, internal mammary artery, and intercostal artery. This vascular anastomotic arrangement forms the anatomical basis of the flaps used in breast reduction techniques. The veins form a strong subdermal network, latticed with the arterial network. The lymph vessels have three well-defined pedicles, skin, glandular and milk ducts that drain into internal, external, and posterior ducts. The understanding of these anatomical structures determines the selection of different pedicles in breast volume reduction and preservation of the nipple-areola complex circulation.

Management of the Ischemic Nipple-Areola Complex After Breast Reduction.

Early and accurate diagnosis and treatment of nipple-areolar complex (NAC) ischemia and necrosis are fundamental to the practice of breast surgery. Knowledge of breast anatomy, risk factors, and proper technique is not sufficient for avoiding this complication in all cases. Management of this situation is dynamic; it depends on the time of detection, and knowledge of different surgical maneuvers for NAC reperfusion. Management of this complication will continue to improve with technologic advances and research.

Effect of TGF-ß1 Stimulation on the Secretome of Human Adipose-Derived Mesenchymal Stromal Cells.

Adipose tissue is an attractive source of mesenchymal stromal cells (MSCs) owing to the relative ease of obtaining large volumes with more MSC abundance compared with other sources. Increasing evidence supports the fact that trophic factors secreted by MSCs play a pivotal therapeutic role. Several strategies in regenerative medicine use MSCs, mainly exploiting their immunosuppressive effect and homing capacity to sites of damage. Transforming growth factor-ß1 (TGF-ß1) is a pleiotropic cytokine that, depending on the cell niche, can display either anti-inflammatory or proinflammatory effects. TGF-ß1 expression increases in various tissues with damage, especially when accompanied by inflammation. Thus, we analyzed the effect of TGF-ß1 on the secretion by adipose-derived mesenchymal stromal cells (ASCs) of a panel of 80 cytokines/chemokines using an antibody array. To avoid a possible effect of fetal bovine serum (FBS) on ASCs secretion, we performed our analysis by culturing cells in FBS-free conditions, only supplemented with 0.1% of bovine serum albumin. We report the cytokine profile secreted by ASCs. We also found that TGF-ß1 exposure modulates 8 chemokines and 18 cytokines, including TGF-ß1 and -ß2, and other important cytokines involved in immunosuppression, allergic responses, and bone resorption.

Subobstrucción intestinal por hernia de Ritchet: diagnóstico por videolaparoscopía / Intestinal sub-obstruction by Ritchet hernia: diagnostic by videolaparoscopy

Presentamos en este trabajo una paciente portadora de un cuadro suboclusivo intestinal por una hernia de Ritchet. El diagnóstico de la misma fue realizado lpor videolaparoscopía así como la reducción del asa intestinal. La hernia crural se resolvió por vía convencional. Proponemos la utilización de la videolaparoscopía para el diagnóstico y eventual tratamiento.

Subobstrucción intestinal por hernia de Ritchet: diagnóstico por videolaparoscopía / Intestinal sub-obstruction by Ritchet hernia: diagnostic by videolaparoscopy

Presentamos en este trabajo una paciente portadora de un cuadro suboclusivo intestinal por una hernia de Ritchet. El diagnóstico de la misma fue realizado lpor videolaparoscopía así como la reducción del asa intestinal. La hernia crural se resolvió por vía convencional. Proponemos la utilización de la videolaparoscopía para el diagnóstico y eventual tratamiento. (AU)

Diagnóstico y tratamiento de la hernia de Spieghel / Diagnostic and treatment of the Spigelian hernia

El objetivo de este trabajo es presentar la experincia adquirida como residentes de cirugía general en el diagnóstico y tratamiento de la Hernia de Spieghel. Entre mayo de 1994 y mayo de 1997 fueron atendidos en nuestro hospital 4 pacientes portadores de Hernia de Spieghel. Tres pacientes eran masculino y uno femenino, con una edad media de 58,7 años. El tumor pararrectal y el dolor abdominal fueron los síntomas más comunes. Un paciente presentó abdomen agudo obstructivo. Los métodos complementarios de diagnóstico utilizados fueron la ecografía y el colon con enema. Todos los pacientes fueron operados con diagnóstico de Hernia de Spieghel. La técnica utilizada consistió en reparación anatómica del defecto herniano con sutura contínua monoplano. Tres pacientes fueron abordados por una incisión transversa pararrectal y uno por vía abdominal. No hubo morvilidad ni mortalidad. Pese al corto período de seguimiento no hay recidivas. La Hernia de Spieghel no es una patología frecuente, debemos pensar en ella ante la presencia de un paciente que presente tumor y dolor abdominal acompañado a una dibilidad en la pared anterior del abdomen. Debido a la posibilidad de estrangulación, el tratamiento debe ser quirúrgico.

Diagnóstico y tratamiento de la hernia de Spieghel / Diagnostic and treatment of the Spigelian hernia

El objetivo de este trabajo es presentar la experincia adquirida como residentes de cirugía general en el diagnóstico y tratamiento de la Hernia de Spieghel. Entre mayo de 1994 y mayo de 1997 fueron atendidos en nuestro hospital 4 pacientes portadores de Hernia de Spieghel. Tres pacientes eran masculino y uno femenino, con una edad media de 58,7 años. El tumor pararrectal y el dolor abdominal fueron los síntomas más comunes. Un paciente presentó abdomen agudo obstructivo. Los métodos complementarios de diagnóstico utilizados fueron la ecografía y el colon con enema. Todos los pacientes fueron operados con diagnóstico de Hernia de Spieghel. La técnica utilizada consistió en reparación anatómica del defecto herniano con sutura contínua monoplano. Tres pacientes fueron abordados por una incisión transversa pararrectal y uno por vía abdominal. No hubo morvilidad ni mortalidad. Pese al corto período de seguimiento no hay recidivas. La Hernia de Spieghel no es una patología frecuente, debemos pensar en ella ante la presencia de un paciente que presente tumor y dolor abdominal acompañado a una dibilidad en la pared anterior del abdomen. Debido a la posibilidad de estrangulación, el tratamiento debe ser quirúrgico. (AU)

Colecistitis aguda: su tratamiento por videolaparoscopía. Experiencia sobre 320 casos / Acute cholecystitis: treatment by videolaparoscopy. Experience on 320 cases

Presentamos en este trabajo nuestra experiencia en el tratamiento de la colecistitis aguda (CA) por videolaparoscopía en el Hospital Italiano de La Plata y en distintos Hospitales y Sanatorios de nuestro medio, desde el mes de abril de 1991 hasta septiembre de 1997. Hemos realizado un total de 1425 colecistectomía laparoscópicas, de las cuales 320 fueron CA. Realizamos consideraciones acerca de la evaluación preoparatoria de los pacientes tratados por este método. Haciendo hincapié en la introducción de la videolaparoscopía para el tratamiento de las mismas. Concluímos coincidiendo con otros autores que no es más la CA una contraindicación para la videolaparoscopía. Proponemos el uso de la colangiografía intraoperatoria como método de seguridad para el tratamiento de esta afección y para el diagnóstico para las litiasis coledocianas no sospechadas presentes en la CA. Comparamos nuestros resultados con otras estadísticas y con las de la cirugía convencional.

Colecistitis aguda: su tratamiento por videolaparoscopía. Experiencia sobre 320 casos / Acute cholecystitis: treatment by videolaparoscopy. Experience on 320 cases

Presentamos en este trabajo nuestra experiencia en el tratamiento de la colecistitis aguda (CA) por videolaparoscopía en el Hospital Italiano de La Plata y en distintos Hospitales y Sanatorios de nuestro medio, desde el mes de abril de 1991 hasta septiembre de 1997. Hemos realizado un total de 1425 colecistectomía laparoscópicas, de las cuales 320 fueron CA. Realizamos consideraciones acerca de la evaluación preoparatoria de los pacientes tratados por este método. Haciendo hincapié en la introducción de la videolaparoscopía para el tratamiento de las mismas. Concluímos coincidiendo con otros autores que no es más la CA una contraindicación para la videolaparoscopía. Proponemos el uso de la colangiografía intraoperatoria como método de seguridad para el tratamiento de esta afección y para el diagnóstico para las litiasis coledocianas no sospechadas presentes en la CA. Comparamos nuestros resultados con otras estadísticas y con las de la cirugía convencional. (AU)