Nipple-sparing mastectomy with immediate prosthetic reconstruction is routinely performed because of excellent aesthetic results and safe oncologic outcomes. Typically, subpectoral expanders are ...placed, but in select patients, this can lead to significant postoperative pain and animation deformity, caused by pectoralis major muscle disinsertion and stretch. Prepectoral reconstruction is a technique that eliminates dissection of the pectoralis major by placing the prosthesis completely above the muscle with complete acellular dermal matrix coverage.
A single surgeon's experience with immediate prosthetic reconstruction following nipple-sparing mastectomy from 2012 to 2016 was reviewed. Patient demographics, adjuvant treatment, length and characteristics of the expansion, and incidence of complications during the tissue expander stage were compared between the partial submuscular/partial acellular dermal matrix (dual-plane) cohort and the prepectoral cohort.
Fifty-one patients (84 breasts) underwent immediate prepectoral tissue expander placement, compared with 115 patients (186 breasts) undergoing immediate partial submuscular expander placement. The groups had similar comorbidities and postoperative radiation exposure. There was no significant difference in overall complication rate between the two groups (17.9 percent versus 18.8 percent; p = 0.49).
Prepectoral breast reconstruction provides a safe and effective alternative to partial submuscular reconstruction, that yields comparable aesthetic results with less operative morbidity. In the authors' experience, the incidence of acute and chronic postoperative pain and animation deformity is significantly lower following prepectoral breast reconstruction. This technique is now considered for all patients who are safe oncologic candidates and are undergoing nipple-sparing mastectomy and prosthetic reconstruction.
Therapeutic, III.
Numerous details regarding preoperative planning of scalp expansion are of the utmost importance for maximizing the results of this procedure.
The purpose of this paper is to describe the tips and ...tricks useful for obtaining the best results in scalp expansion.
Basic concepts and operative technique are discussed and detailed.
In scalp reconstruction, the use of tissue expansion allows to obtain successful results, Anyhow, it is mandatory to follow some basic rules, dictated by anatomical, technical, and psychological considerations.
Biological cover over tissue expander prostheses has been introduced to provide soft-tissue support for tissue expanders during breast reconstruction. However, its impact on mechanically induced skin ...growth remains unknown. This study investigates the hypothesis that covering the tissue expander with acellular dermal matrix (ADM) affects mechanotransduction without compromising the efficacy of tissue expansion.
Tissue expansion, with and without use of ADM, was performed on a porcine model. The tissue expanders were inflated twice with 45 mL of saline, and the full-thickness skin biopsy specimens were harvested from expanded and control unexpanded skin 1 week and 8 weeks after the final inflation. Histologic evaluation, immunohistochemistry staining, and gene expression analysis were performed. Skin growth and total deformation were evaluated using isogeometric analysis.
The authors' results demonstrate that use of ADM as a biological cover during tissue expansion does not impede mechanotransduction that leads to skin growth and blood vessel formation. Isogeometric analysis revealed similar total deformation and growth of expanded skin with and without a biological cover, confirming that its use does not inhibit mechanically induced skin growth. In addition, the authors found that use of an ADM cover results in more uniform distribution of mechanical forces applied by the tissue expander.
These results suggest that ADM improves mechanically induced skin growth during tissue expansion by facilitating a more uniform distribution of mechanical forces applied by the tissue expander. Therefore, the use of a biological cover has potential to improve outcomes in tissue expansion-based reconstruction.
In this paper, bright-dark, multi solitons, and other solutions of a (3 + 1)-dimensional cubic-quintic complex Ginzburg-Landau (CQCGL) dynamical equation are constructed via employing three proposed ...mathematical techniques. The propagation of ultrashort optical solitons in optical fiber is modeled by this equation. The complex Ginzburg-Landau equation with broken phase symmetry has strict positive space-time entropy for an open set of parameter values. The exact wave results in the forms of dark-bright solitons, breather-type solitons, multi solitons interaction, kink and anti-kink waves, solitary waves, periodic and trigonometric function solutions are achieved. These exact solutions have key applications in engineering and applied physics. The wave solutions that are constructed from existing techniques and novel structures of solitons can be obtained by giving the special values to parameters involved in these methods. The stability of this model is examined by employing the modulation instability analysis which confirms that the model is stable. The movements of some results are depicted graphically, which are constructive to researchers for understanding the complex phenomena of this model.
The perturbed chiral nonlinear Schrö dinger equation (PCNLSE) reflects the quantum actions such as quantum pictures of Bohm potential and internal self-potential properties. Indeed, this equation ...introduces the basics of the hidden variable theory in quantum mechanics. Two unified solver methods and expFormula: see text-expansion technique applied to PCNLSE to present many solitonic solutions in an explicit and effective way. The behaviour of these solutions is of qualitatively different structural natures, relying on physical coefficient parameters. The application of three mathematical techniques to our model system provides us with several possible physical property solutions that account for the majority of many phenomena the model under study attempts to depict. The reported bright explosive envelopes, explosive solitons, periodic blow up, bright periodic envelope and huge solitary waves are highly applicable in plasma and nuclear physics, optical communications, electro-magnetic propagations, superfluid and in a lot other applied sciences. The results of this system's solitary structures are consistent with the characteristics of the nonlinear Schrödinger equation systems used to study dispersive modes and higher-order perturbed systems. For more details about the physical dynamical representation of the presented solutions, we have illustrated them with profile pictures using Mathematica and Matlab 18, to obtain complete configurations. The proposed approach can be applied to several equations arising in all applied sciences.
Acellular dermal matrix has gained widespread acceptance in immediate expander/implant reconstruction because of perceived benefits, including improved expansion dynamics and superior aesthetic ...results. Although previous investigators have evaluated its risks, few studies have assessed the impact of acellular dermal matrix on other outcomes, including patient-reported measures.
The Mastectomy Reconstruction Outcomes Consortium Study used a prospective cohort design to evaluate patients undergoing postmastectomy reconstruction from 10 centers and 58 participating surgeons between 2012 and 2015. The analysis focused on women undergoing immediate tissue expander reconstruction following mastectomies for cancer treatment or prophylaxis. Medical records and patient-reported outcome data, using the BREAST-Q and Numeric Pain Rating Scale instruments, were reviewed. Bivariate analyses and mixed-effects regression models were applied.
A total of 1297 patients were evaluated, including 655 (50.5 percent) with acellular dermal matrix and 642 (49.5 percent) without acellular dermal matrix. Controlling for demographic and clinical covariates, no significant differences were seen between acellular dermal matrix and non-acellular dermal matrix cohorts in overall complications (OR, 1.21; p = 0.263), major complications (OR, 1.43; p = 0.052), wound infections (OR, 1.49; p = 0.118), or reconstructive failures (OR, 1.55; p = 0.089) at 2 years after reconstruction. There were also no significant differences between the cohorts in the time to expander/implant exchange (p = 0.78). No significant differences were observed in patient-reported outcome scores, including satisfaction with breasts, psychosocial well-being, sexual well-being, physical well-being, and postoperative pain.
In this multicenter, prospective analysis, the authors found no significant acellular dermal matrix effects on complications, time to exchange, or patient-reported outcome in immediate expander/implant breast reconstruction. Further studies are needed to develop criteria for more selective use of acellular dermal matrix in these patients.
Therapeutic, II.
•A sampling method is proposed for high-dimensional time-variant reliability analysis.•Time-variant system is reinterpreted as multi-response time-invariant system.•The proposed method is tested on ...two high-dimensional dynamic reliability problems.•Results are compared to MCS and the original subset simulation.
A new sampling-based method is proposed for high-dimensional time-variant reliability analysis with both random variables and random process as inputs. The new method employs the series expansion methods, e.g., the Karhunen-Loève expansion, to represent the input random process into a set of random variables. Based on the concepts of composite limit state, the time-variant reliability analysis is converted into a series system reliability problem with multiple responses. Then the generalized subset simulation is applied to compute cumulative failure probabilities which are further used to interpolate a completely cumulative failure probability curve for a given time interval. The advantage of the proposed method is that only a single run can provide a cumulative failure probability curve instead of repeated runs. Two high-dimensional time-variant reliability problems with input random process are used to demonstrate the performance of the proposed method.
Staged subpectoral expander-implant breast reconstruction is widely performed. Disruption of the pectoralis major origin and the frequent occurrence of animation deformity and functional discomfort ...associated with subpectoral reconstruction remain ongoing concerns. Prepectoral single-stage direct-to-implant reconstruction resolves many of these issues. In this study, the authors explored the rationale for prepectoral single-stage implant-based breast reconstruction with anterior AlloDerm coverage as an alternative to the staged approach.
Seventy-three breasts in 50 patients were reconstructed using a single-stage direct-to-implant prepectoral approach with total anterior AlloDerm coverage during a 24-month period. The decision to proceed with single-stage reconstruction was predicated upon the adequacy of mastectomy skin flap blood flow based on indocyanine green fluorescence perfusion assessment. The patients were followed up for a maximum of 32 months.
Ninety-seven percent of patients achieved complete healing within 8 weeks. There were 2 implant losses (2.7%) due to infection. Major seroma rate requiring repeated aspiration and drain insertion was 1.2%. There were no full-thickness skin losses. Capsular contracture was 0% in nonradiated patients. There were no cases of animation deformity. The authors were unable to establish significant correlation between complications and any of the usually stated risk factors, such as smoking, obesity, and large mastectomy weights, presumably due to the rigorous application of intraoperative skin perfusion assessment.
Single-stage direct-to-implant reconstruction using a prepectoral approach appears to be a safe and effective means of breast reconstruction in many patients, assuming adequate skin perfusion is present.
The benefits of tissue expansion go unrealized if flap design and coverage concepts do not exist in preoperative thinking. Without proper analysis, the surgeon will likely burden the patient with ...more expanders than necessary. Tissue coverage needs can be simplified in forms of triangles and rectangles to determine expanded tissue advancement. Single or double back-cuts allow use of all the expanded tissue. Furthermore, early subtotal excisions, especially in children younger than 4 months, can reduce the number of expanders required. With methods presented herein, the face can be resurfaced with better color and less distortion. Eyebrows should be maintained and positioned by keeping the lower frontalis muscles intact. Cheeks can be covered with a large Schrudde design, and color can be improved by using upper neck skin preferentially over lower neck harvest. Laser hair removal allows larger swaths of forehead to be covered by hair-bearing scalp tissue. Prior incisional delay can expedite success with no tissue loss. The results speak for themselves when surfaces are covered with large, expanded flaps that are expeditiously harvested.
Breast augmentation by autologous fat transfer is an appealing alternative in need of scientific validation.
In a prospective multicenter study, 81 women (age range, 17 to 63 years) wore the Brava ...device, a bra-like vacuum-based external tissue expander, for 4 weeks and then underwent autologous fat injection using 10 to 14 needle puncture sites into each breast in a three-dimensional fanning pattern (average, 277 ml volume injected per breast). Patients resumed Brava wear within 24 hours for 7 or more days. Pretreatment and posttreatment breast volumes were derived from three-dimensional volumetric reconstruction of magnetic resonance imaging scans, and outcomes were compared with a meta-analysis of six recent published reports on autologous fat transfer breast augmentation without expansion. Follow-up ranged from 12 months to 6 years (average, 3.7 years).
Breast volume was unchanged between 3 and 6 months. Seventy-one of the treated women were compliant with Brava wear and had a mean augmentation volume at 12 months of 233 ml per breast compared with 134 ml per breast in published series without Brava (p < 0.00001). Graft survival was 82 ± 18 percent compared with 55 ± 18 percent without Brava (p < 0.00001). There was a strong linear correlation (R = 0.87) between pregrafting Brava expansion and the resultant breast augmentation. There were no suspicious breast masses or nodules. Magnetic resonance imaging recognized a 16 percent incidence of fat necrosis easily identified at 1-year mammographic evaluation.
: The addition of Brava expansion before autologous fat grafting leads to significantly larger breast augmentations, with more fat graft placement, higher graft survival rates, and minimal graft necrosis or complications, demonstrating high safety and efficacy for the procedure.
Therapeutic, IV.
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