聚丙烯酰胺水凝胶隆乳取出后同期假体置入

目的 探讨聚丙烯酰胺水凝胶（polyacrylamide hydrogel,PAHG）注射隆乳取出术后,同期行假体置入的临床适应证与疗效.方法 对PAHG注射隆乳后发生并发症者,术前做乳腺超声、磁共振成像（MRI）检查,明确注射物分布层次和组织浸润情况,经乳晕切口行注射物及病变组织彻底清除后,根据组织浸润程度、包膜完整性、胸肌和乳腺变性情况,分别选择乳腺后、胸大肌后、双平面3种方式,同期行硅凝胶假体置入术.结果 56例切口均愈合良好,乳房对称、挺拔.术后随访6个月至3年,乳房外形良好,无瘢痕和假体疝出,无纤维包膜挛缩等并发症发生.结论 依据PAHG取出后乳房畸形特点,同期假体置入重塑乳房形态,既可改善乳房外观,又可缓解心理障碍,效果满意.     

内窥镜下双平面法假体隆乳术的临床研究

目的探讨内窥镜下双平面法假体隆乳术临床应用的实用性。方法自2008年3月至2013年6月,行内窥镜下双平面法假体隆乳术63例,随诊回访3～12个月,全部采取腋窝切口。结果63例（126只）,乳房形态自然,无移位及双乳房现象,其中除有2例（3侧）出现BakerⅡ级,余未见明显肌肉移位而产生乳房畸形的现象,无血肿、感染及包膜挛缩等并发症发生,医患双方均较满意。结论内窥镜下双平面隆乳术与传统的假体隆乳术比较,无论是乳房形态,还是手感方面,都有明显的改善。同时加以内窥镜的应用,有效地减少了并发症的发生,是目前假体隆乳术中值得推荐的术式。     

Reducing implant loss rates in immediate breast reconstructions

UK best practice guidelines for oncoplastic breast reconstruction were published in 2012. Implant-based reconstruction quality indicator (QI) targets for readmission, return to theatre and implant loss rates were set at 5% by 3 months, along with guidance to achieve these targets. The aims of this study were to quantify complication rates following implant-based reconstruction before and after the implementation of the guidelines. A retrospective audit of 86 patients with 106 implants in the 12 months to June 2013 was performed, C1. Following institutional changes including reducing antibiotic usage, a prospective audit was performed on 89 patients with 105 implants to June 2014, C2. Extended follow-up of salvaged implants was also performed. Demographics were not significantly different between the two cohorts apart from smoking. Implant loss rates fell from 7.5%(C1) to 1.9%(C2), p = 0.054 but at the cost of an increase in the return to theatre rate (14.2%–18%, p > 0.05). The implant salvage rate increased from 47% in C1 to 89.5% in C2, however, 3 of the implants that were salvaged were lost in the long term giving an overall salvage rate of 82.4% in C2. While an implant loss rate of <5% at 3 months appears achievable with less antibiotic use, this was made possible by the institution of an aggressive readmission and salvage policy. We would question the QI standards for readmission and return to theatre for immediate implant-based breast reconstruction, given that our implant loss rate of 1.9% was achieved with a return to theatre rate of 18%.     

Local infiltrative anesthesia for transaxillary subpectoral breast implants

Breast augmentations using a transaxillary subpectoral approach are usually performed under general anesthesia. This article describes a technique that uses local infiltrative anesthesia in breast augmentation, adenomastectomies with immediate breast reconstruction, and when placing breast expansors. Large anesthetic solutions with vasoconstrictor and long-acting effects are prepared. The axila, the subpectoral space, and a surrounding area of 3 cm outside the demarcation limits are infiltrated. Minimal bleeding, long-lasting effects, and a considerable postoperative analgesic effect are some of the advantages of this procedure.     

Clinicopathologic correlations in pseudocapsule formation after breast augmentation

In 2,000 patients who underwent augmentation mammoplasties with different types of prostheses, the thickness of the pseudocapsules around gel-filled implants was greater than that of the pseudocapsules forming around inflatable implants. This observation was corroborated by an independent histologic study. Deposition of liquid silicone into the pseudocapsules as well as the adjacent brest tissue and migration into capillaries was demonstrated. Until an impermeable shell or a non-transgressive gel can be manufactured, gel-filled implants should not be used.     

保留皮肤的乳腺癌改良根治术后一期乳房假体再造

目的探讨用硅胶假体植入法修复乳腺癌改良根治术后乳房缺失的疗效。方法2005年6月至11月,10例患者行保留皮肤的乳腺癌改良根治术后,同期于胸大肌后植入硅胶假体再造乳房,并根据冰冻结果决定是否保留乳头乳晕复合体。结果本组病人术后无伤口积液感染,皮肤坏死及异物反应等。10例患者美观效果均满意,其中有4例保留乳头乳晕复合体。所有病人进行术后随访。随访时间为1～6个月。未发现有远处转移和局部复发。无上肢水肿及功能障碍。结论保留皮肤的乳腺癌改良根治术后用硅胶假体行一期乳房再造,具有创伤小、安全、简单、恢复快的特点;再造后乳房美观,效果满意。     

Treatment of acute periprosthetic infections with prosthesis retention: Review of current concepts

Periprosthetic joint infection (PJI) is a devastating complication after total joint arthroplasty, occurring in approximately 1%-2% of all cases. With growing populations and increasing age, PJI will have a growing effect on health care costs. Many risk factors have been identified that increase the risk of developing PJI, including obesity, immune system deficiencies, malignancy, previous surgery of the same joint and longer operating time. Acute PJI occurs either postoperatively (4 wk to 3 mo after initial arthroplasty, depending on the classification system), or via hematogenous spreading after a period in which the prosthesis had functioned properly. Diagnosis and the choice of treatment are the cornerstones to success. Although different definitions for PJI have been used in the past, most are more or less similar and include the presence of a sinus tract, blood infection values, synovial white blood cell count, signs of infection on histopathological analysis and one or more positive culture results. Debridement, antibiotics and implant retention (DAIR) is the primary treatment for acute PJI, and should be performed as soon as possible after the development of symptoms. Success rates differ, but most studies report success rates of around 60%-80%. Whether single or multiple debridement procedures are more successful remains unclear. The use of local antibiotics in addition to the administration of systemic antibiotic agents is also subject to debate, and its pro’s and con’s should be carefully considered. Systemic treatment, based on culture results, is of importance for all PJI treatments. Additionally, rifampin should be given in Staphylococcal PJIs, unless all foreign material is removed. The most important factors contributing to treatment failure are longer duration of symptoms, a longer time after initial arthroplasty, the need for more debridement procedures, the retention of exchangeable components, and PJI caused by Staphylococcus (aureus or coagulase negative). If DAIR treatment is unsuccessful, the following treatment option should be based on the patient health status and his or her expectations. For the best functional outcome, one- or two-stage revision should be performed after DAIR failure. In conclusion, DAIR is the obvious choice for treatment of acute PJI, with good success rates in selected patients.     

Successful salvage of an infected breast prothesis by changing from continuous to intermittent suction under continuous irrigation

IntroductionImplant-based breast reconstruction is a widely performed procedure. However, prostheses are susceptible to infection and there are currently no established guidelines on treatment. In the present case, a prosthesis was salvaged by changing from continuous irrigation and suction to continuous irrigation and intermittent suction. This case report has been reported in line with the SCARE criteria [1].Presentation of caseA 50-year-old female patient underwent implant-based breast reconstruction following surgery for breast cancer. One month later, the left breast prosthesis was infected with abscesses. Surgical treatment and continuous irrigation were performed as postoperative therapy. However, recurrent infection was detected a few days after surgery. Continuous irrigation was changed to continuous irrigation with intermittent aspiration, which successfully controlled the infection.DiscussionFactors that limit the effectiveness of continuous irrigation and aspiration have not yet been identified. Inflow/discharge shunt routes may be established in continuous aspiration, and, thus, sufficient cleaning may not be possible. On the other hand, the storage of water throughout the wound in intermittent aspiration may facilitate cleaning.ConclusionIntermittent suction worked well in this patient and, thus, warrants further study.     

One-stage breast reconstruction using McGhan Style 150 biodimensional expanders: a review of 107 implants with six years experience.

Permanent expanders have revolutionised breast reconstructive surgery, allowing one-stage procedures and the development of increasingly sophisticated implants (textured, anatomically shaped) has played an important role in enhancing the aesthetic outcomes. It is important to evaluate the tolerability of the implant. The aim of this present study was to evaluate the survival curves for McGhan Style 150 permanent expanders, in a consecutive series of breast reconstructions. Complications rates were also examined. Between April 1997 and May 2003, 107 McGhan Style 150 expanders (either full height or short height depending on patients' requirements) were used in 97 consecutive patients for a variety of breast reconstructive procedures. Overall, 46 devices were used for immediate reconstruction, 15 for delayed reconstruction and 46 for implant exchange, respectively. The mean age at implantation was 48 years (min: 26; max: 71). The mean follow-up was 60 months (min: 12; max: 72). Explantation was considered the most objective outcome variable, therefore this parameter was carefully monitored and then analysed using the Kaplan-Meier method of survival analysis. Different curves were compared using the log-rank test. Long term complications were also recorded. Among complications the most frequent finding was Baker 3-4 capsular contracture, occurring in 26% of immediate reconstructions at six years. Explantations increased in an almost linear fashion, with an overall rate of 25%, with a statistically significant difference among immediate reconstruction group and the implant exchange group. The rate of explantations was high, if compared with other series, because the sample included patients undergoing strong adjuvant therapies, particularly in the immediate group (locally advanced disease). The overall rate of explantations and of capsular contracture was found to be significantly lower in the delayed and substitution groups, than the immediate group (p<0.05). In our hands, the McGhan Style 150 anatomically shaped permanent expanders were associated with acceptable results, especially when used as 'permanent prostheses' for second stage procedures.     

Patient satisfaction following augmentation mammaplasty with the gel prosthesis

No evaluation of patient responses to augmentation mammaplasty has been published in the medical literature. This has left the area open for opinion and speculation by both physicians and laity.All patients undergoing pure augmentation mammaplasty during 1976 were sought in four plastic surgery practices using gel prostheses in the Southwest. Responses were obtained from 159 of the 221 patients (72%). Some degree of firmness of one or both breasts was reported by 64% of the patients who responded. External capsulotomy was effective in only 1 patient in 5. Shape distortion because of capsular contracture was reported by 10% of patients. Change in nipple sensation was reported by 42% of patients; 9% found it bothersome. There was no difference statistically between the inframammary and periareolar approach. Improved self-image was reported by 91% of patients. Fifty-five percent reported a positive effect on their sexual lives. Only 3% had a negative effect.Although 91% of patients expressed satisfaction with their operations, an even greater number (97%) would have the operation again. This is a striking affirmation of this cosmetic operation as performed by board-certified plastic surgeons. Obviously, the benefits of augmentation mammaplasty outweigh any unfavorable results.     

Polyurethane-covered silicone gel mammary prosthesis for successful breast reconstruction

A polyurethane-covered silicone gel implant has been used by the author in 150 breast reconstructions and augmentations in the past 9 years. The results have been most gratifying with regard to breast softness, breast compressibility, and esthetics. Only 4 patients have developed a unilateral capsule contracture and firm breast. The reasons are postulated for these satisfying results. Complications have been few and very minor.     

Intra-operative techniques to reduce the risk of capsular contracture in patients undergoing aesthetic breast augmentation – A review

Background

Capsular contracture is a significant complication following aesthetic breast augmentation. Efforts to reduce this incidence have focused on the surgical approach, implant selection and IV antibiotics. Intra-operative methods to reduce the risk have had less investigation. This review focuses on these interventions and will document evidence to support pocket irrigation, nipple shields, drains and the use of an implant insertion funnel.

Correction of breast contour deformities using polyurethane breast implant capsule in revisional breast surgery

Surgeons are commonly confronted with breast contour deformities and defects that result from previous surgical interventions. These soft tissue deformities can be corrected by conventional reconstructive flap surgery using autologous tissue, but there can be donor site morbidity. Smaller volume replacement is possible using temporary fillers such as hyaluronic acid or polylactic acid, or by using 'permanent' fillers such as autologous fat, but large defects are notoriously difficult to fill and often the fillers resorb or migrate. The patient described in this case report had an exchange of polyurethane implant (PU) in the left breast and correction of a contralateral breast contour filling deformity. A left breast partial capsulectomy was performed after implant removal and the capsule graft was inserted into a predissected pocket where soft tissue augmentation was required. A biopsy from the PU capsule was reported to show a foreign body type giant cell reaction to PU material in a fibrous capsule, lined by synovial metaplasia. The post-operative result showed satisfactory soft tissue revolumisation. PU breast implant structured capsule has thus been used as filler to correct breast soft tissue deformity and contour defects. Clearly it may have a use in other anatomical sites.     

六种隆乳材料生物相容性和安全性的比较

目的 比较6种隆乳材料生物相容性和安全性。方法 以12只Beagle犬为研究对象，通过HE染色、Van－Gieson染色，比较交联透明质酸钠假体（CSHP）、非交联透明质酸钠假体（NCSHP）、甲基纤维素假体（CMCP）、硅凝胶假体（SGP）、亲水性聚丙烯酸胺凝胶假体（HPAGP）、注射用聚丙烯酰胺凝胶（IHPAG）所致机体局部组织反应的强弱程度。结果 6种材料引起早期（术后14、30d）组织反应表面为：NCSHP、CMCP、HPAGP周围炎症反应最重；CSHP、SGP次之，IHPAG最轻微。30d后，6种材料周围均形成纤维包膜囊，但构成纤维膜的成分及其排列随材料不同而异，且随时间推移，各材料周围纤维包膜囊的结构及排列均发生不同程度的变化。NCSHP、CMCP、HPAGP的包膜有明显收缩倾向，并在2年后均发生不同程度挛缩。CSHP、SGP未见明显挛缩倾向，2年后，纤维包膜仍较薄并有弹性。IHPAG的包膜2年后仍松软而有弹性。结论 SGP作为一种较为成熟的隆乳材料，生物相容性及美容效果均是目前较为理想的材料；CSHP的生物相容性较好，但美容效果相对较差，且存在渗漏问题，需对材料进一步改进；IHPAG引起的炎症反应轻微，生物相容性好，具有应用前景，但若注射层次掌握不好，材料易被纤维组织分割，影响美容效果，因此在临床应用中，要熟练掌握注射技巧；NCSHP、CMCP、HPAGP生物相容性及美容效果均较差，且存在严重渗漏，故目前暂不适宜用作隆乳材料。     

右美托咪定对硅胶囊隆乳术患者术后早期情绪反应的影响

目的探讨右美托咪定对硅胶囊隆乳术患者术后早期情绪反应的影响。方法60例择期全身麻醉下行硅胶囊隆乳术患者,ASA分级I、Ⅱ级,年龄18～48岁。麻醉诱导和维持分别采用右美托咪定组（A组）和丙泊酚组（B组）。同时均吸入七氟烷,术后两组患者静脉镇痛用药方案相同。术前1d及术后48h内,使用医院焦虑抑郁量表（HAD）评估患者情绪反应（虑、抑郁状态）,使用QoR-40调查问卷评估术后恢复情况,术后30min,采用视觉模拟评分法（VAS）测定疼痛程度,采用Ramsay法评估镇静程度,并记录所有患者麻醉结束至拔管的时间,拔管时呛咳,苏醒期躁动谵妄,术后30rain内镇静、头晕、恶心、呕吐、复视、幻觉等不良反应情况。结果A组患者术后48h医院焦虑抑郁量表焦虑（HAD—A）评分、抑郁（HAD—D）评分均低于B组,差异有统计学意义（P〈0．05）;术后48h两组患者QoR40总分无统计学意义（P〉0．05）,但A组患者术后48hQoR-40情绪状态评分高于B组（P〈0．05）;A组患者拔管后30nlin时疼痛VAS评分低于B组（P〈0．05）,术后30rain镇静评分两组患者无统计学意义（P〉0．05）;两组患者麻醉后拔管时间、拔管后呛咳、苏醒期躁动及谵妄发生率均无统计学意义（P〉0．05）。术后30min内未见头晕、恶心、呕吐、复视等不良反应发生。结论右美托咪定可降低硅胶囊隆乳术患者手术后早期（48h内）医院焦虑抑郁量表焦虑评分（HAD—A）、抑郁评分（HAD—D）及QoR40情绪状态评分,减轻患者拔管后30min时疼痛VAS评分。提示右美托咪定可改善硅胶囊隆乳术患者全身麻醉手术后早期焦虑／抑郁情绪反应,提高术后恢复质量,有利于促进患者术后早期康复。     

Anatomic and Physiologic Advantages of Totally Subfacial Breast Implants

For the past 4 years, whenever it was possible to choose between the subglandular or the submuscular location for the implant pocket (in cases with no precise indication for the submuscular location), the authors have opted for the totally subfascial plane (subaponeurotic) to avoid the disadvantages of the other locations and to obtain additional benefits. The subfascial plane lies below the deep thoracic fascia, or deep aponeurosis, which is not only that of the pectoralis (the muscle connecting with the breast in its upper two-thirds only). The implant is placed completely beneath this fascia, which covers, in addition to the pectoralis major muscle, the serratus, the lateral oblique, and the rectus anterior muscles. This study included 100 women who had breast implanted in the subfascial (subaponeurotic) plane. Of these women, 63 were thin patients with little fatty tissue. Textured surface implants were used McGhan style 120 and 110. All procedures were approached through an inferior periareolar incision. Excellent coverage of the implant as well as natural shape and mobility was achieved for all patients. No rippling in the upper half was observed. Two patients had Baker grade 2 capsular contracture (2%). No seromas or infections were seen, and only once was a surgical exploration necessary for excess drainage volume (1%). In the immediate postoperative period, less edema was recorded and recovery was faster than with the other two procedures: submuscular and subglandular. When circumstances indicate a subglandular pocket, the subfascial plane would seem to be the logical place for mammary implants.     

Potential immune response to breast implants after immunization with COVID-19 vaccines

Besides reports of alarming potential side effects after COVID-19 vaccinations there have been rare observations of rather benign reactions to foreign materials such as cosmetic hyaluronic acid filler injections after a COVID-19 immunization. Likewise to dermal fillers any foreign material may cause a reaction when the immune system is triggered. In the recent weeks we observed four noteworthy potential reactions in association with breast implants between one and three days after COVID-19 vaccinations. We release these information at the earliest to educate colleagues and draw attention to possible reactions between the COVID-19 vaccines and foreign bodies such as breast implants.