The acellular dermal matrix onlay graft for areolar reconstruction.

BACKGROUND: Acellular dermal matrix (ADM) has been well described for use in breast reconstruction. The purpose of this study was to describe a novel use for ADM in areolar reconstruction. METHODS: A total of 19 patients and 24 nipple-areolar complexes of breast cancer or BRCA-positive patients status postmastectomy were treated. After nipple flap reconstruction was completed, the areolar complex was marked at 40-45 mm and de-epithelialized. ADM was reconstituted and cut to size. This was sewn into place as an areolar onlay graft using 5-0 chromic running sutures and a vaseline gauze bolster. RESULTS: All 24 areola re-epithelialized in an average of 8.1 weeks. Graft take was 100% in 23 areolas, while 1 areola had only 75% graft take. Two patients underwent subsequent nipple projection procedures. Sixteen areolas were tattooed for color, with plans to tattoo the others. All patients had satisfactory transition from native skin to nipple-areolar complex. All surveyed patients stated they would undergo the procedure again. Average follow-up was 15.7 months. CONCLUSION: The ADM onlay graft for areolar reconstruction is a feasible addition to the plastic surgeon's armamentarium. The primary benefits of this technique are grafting the donor bed of nipple reconstruction, avoidance of a skin graft donor site wound, and prevention of flattening of the breast dome, as seen with primary closure after nipple flap reconstruction. The cost of ADM must be taken into account ($31 per square centimeter), which could be offset by banking excess ADM at the time of breast reconstruction.

Audiovestibular dysfunction associated with adoptive cell immunotherapy for melanoma.

OBJECTIVE: To understand the audiologic and vestibular toxicities associated with adoptive cell immunotherapy (ACI) targeting pigment-pathway antigens on melanoma and to investigate the use of intratympanic steroid injections in the treatment of these toxicities. STUDY DESIGN: Prospective nonrandomized study. SETTING: Tertiary clinical research center. METHODS: Thirty-two patients with progressive metastatic melanoma who failed conventional therapy underwent ACI with T cells genetically modified to target MART-1 (n = 18) or gp100 (n = 14). All patients received serial audiometric testing. Vestibular testing was performed on patients with vestibular complaints. Patients with significant deficits received intratympanic steroid injections. RESULTS: Of 32 patients, 15 had no hearing change, 9 had mild hearing loss, and 8 had moderate hearing loss following treatment. Ten patients received intratympanic steroid injections for mild (n = 2) or moderate (n = 7) hearing loss or for significant imbalance (n = 1). Of those with mild hearing loss (n = 9), all but 1 recovered to pretreatment hearing levels. Four of 8 patients with moderate hearing loss recovered to baseline hearing levels, and 4 had partial recovery. All 7 patients with posttreatment vestibular complaints had demonstrable vestibular dysfunction. Three of these patients demonstrated recovery to normal vestibular function. The number of modified T cells infused for therapy correlated with the degree of audiovestibular deficit. CONCLUSION: Adoptive cell immunotherapy targeting pigment-pathway cell proteins, a novel therapy for melanoma, can induce hearing loss and vestibular dysfunction. The presumed mechanism of autoimmune attack on normal melanocytes in the cochlear stria vascularis and in the vestibular organs demonstrates the importance of melanocytes in normal inner ear function.