Annals of Plastic Surgery
& Volume 74, Number 2, February 2015
immediate tissue expander breast reconstruction followed by reconstruction of choice in the setting of postmastectomy radiation therapy,’’ which describe the clinical protocol adopted at Northwestern Memorial Hospital on expander/implant breast reconstruction in the setting of PMRT. The authors suggest a sequence of mastectomy, tissue expansion, radiation therapy, and then definitive reconstruction to avoid delays in the beginning of radiotherapy and to increase reconstructive options. In a total case series of 237 patients, Hirsch and colleagues discovered a 22.3% rate of major complications, which leads to implant removal or conversion to f lap. Considering the data listed, we are persuaded that the clinical approach described by Hirsch and colleagues, which presents common features with the one adopted by our Breast Unit, could be further improved by an additional surgical step. As the authors, we begin radiotherapy within 6 weeks after mastectomy for oncological needs. For these reasons, we do not have sufficient time to finish the expansion, consolidate, and substitute tissue expander for a definitive prosthesis. Thus, in our Breast Unit at Northwestern Memorial Hospital, we perform radiotherapy after stage I breast reconstruction, interrupting tissue expansion during radiation treatment, and we restart expansion after 1 to 3 months after radiotherapy ends. We agree with the authors that, in operating on already irradiated breast, we can obtain a better control on final cosmetic result. Final reconstructive result, indeed, is altered by radiotherapy on permanent implant, due to its deleterious effects on soft tissues which could, for example, increase capsular contracture rate. Differently from the authors, instead, we widely adopt autologous fat grafting to avoid ulceration and implant exposure and to achieve the best reconstructive outcome. Relying on our clinical experience in both scar treatment2,3 and PMPS treatment,4 and relying on the paper of Rigotti et al5 too, our clinical approach consists of autologous fat grafting on breasts irradiated after stage I breast reconstruction, 3 months after radiation treatment conclusion, and during stage II breast reconstruction. At our institution, Humanitas Research Hospital, from 2009 to 2013, we adopted our protocol on a total of 53 mastectomies, subsequently submitted to 2-stage prosthetic breast reconstruction and PMRT. Conflicts of interest and sources of funding: none declared. Copyright * 2015 Wolters Kluwer Health, Inc. All rights reserved ISSN: 0148-7043/15/4702-0270 DOI: 10.1097/SAP.0000000000000324
Letters to the Editor
We have recently started to critically review our case series, discovering an overall complication rate less than the 10% and inferior to the one declared by Hirsch and colleagues. We are convinced that fat grafting can improve vascularity and tissue thickness, reducing breast reconstruction failure incidence when treating soft tissue radiation-induced damage. Our experience supports how its regenerative effect is able to reduce reconstruction failure rate in postmastectomy adjuvant radiotherapy on immediate 2-stage prosthetic breast. We believe this practice adds a fundamental surgical step which could efficiently further reduce complications rate on irradiated breast, maximizing reconstructive outcomes for Breast Units which follow our and Hirsch’s reconstructive procedure.
2.
3.
4.
5.
the setting of postmastectomy radiation therapy. Ann Plast Surg. 2014;72:274Y278. Klinger M, Marazzi M, Vigo D, et al. Fat Injection for cases of severe burn outcomes: a new perspective of scar remodeling and reduction. Aesthetic Plast Surg. 2008;32:465Y469. Klinger M, Caviggioli F, Klinger FM, et al. Autologous fat graft in scar treatment. J Craniofac Surg. 2013;24:1610Y1615. Caviggioli F, Maione L, Forcellini D, et al. Autologous fat graft in postmastectomy pain syndrome. Plast Reconstr Surg. 2011;128:349Y352. Rigotti G, Marchi A, Galie` M, et al. Clinical treatment of radiotherapy tissue damage by lipoaspirate transplant: a healing process mediated by adipose-derived adult stem cell. Plast Reconstr Surg. 2007;119: 1409Y1422.
Andrea Lisa Department of Medical Biotechnology and Translational Medicine BIOMETRA Plastic Surgery Unit Humanitas Clinical and Research Hospital Reconstructive and Aesthetic Plastic Surgery School University of Milan Rozzano, Milan, Italy
Fabio Caviggioli Reconstructive and Aesthetic Plastic Surgery School Plastic Surgery Unit MultiMedica Holding S.p.A. University of Milan Sesto San Giovanni, Milan, Italy
Luca Maione Department of Medical Biotechnology and Translational Medicine BIOMETRA Plastic Surgery Unit Humanitas Clinical and Research Hospital Reconstructive and Aesthetic Plastic Surgery School University of Milan Rozzano, Milan, Italy
Davide Forcellini Reconstructive and Aesthetic Plastic Surgery School Plastic Surgery Unit MultiMedica Holding S.p.A. University of Milan Sesto San Giovanni, Milan, Italy
Valeriano Vinci Department of Medical Biotechnology and Translational Medicine BIOMETRA Plastic Surgery Humanitas Clinical and Research Hospital Reconstructive and Aesthetic Plastic Surgery School University of Milan Rozzano, Milan, Italy
Francesco Klinger Reconstructive and Aesthetic Plastic Surgery School Plastic Surgery Unit MultiMedica Holding S.p.A. University of Milan Sesto San Giovanni, Milan, Italy
Marco Ettore Attilio Klinger, MD Department of Medical Biotechnology and Translational Medicine BIOMETRA Plastic Surgery Unit Humanitas Clinical and Research Hospital Reconstructive and Aesthetic Plastic Surgery School University of Milan Rozzano, Milan, Italy [email protected]
REFERENCES 1. Hirsch EM, Seth AK, Dumanian GA, et al. Outcomes of immediate tissue expander breast reconstruction followed by reconstruction of choice in
Outcomes of Immediate Tissue Expander Breast Reconstruction Followed by Reconstruction of Choice in the Setting of Postmastectomy Radiation Therapy: Reply To the Editor: e would like to thank the authors for their comments on our recent article. Indeed, the rate of complication leading to explantation or conversion to autologous in our previous article1 was 22.3%; however, it should be noted that this ref lects the overall rate of complication leading to explantation or conversion to f lap for both stages of reconstruction combined. In the first stage, 6% of patients experienced complications leading to explant or f lap before radiation therapy, 8% after radiation therapy and before conversion to permanent implants, and 12.5% after conversion to permanent implants. Since the publication of our original article, we have modified our approach to patients with certain risk factors for complications. For example, in obese patients, we perform a judicious excision of skin flaps at the initial stage of reconstruction rather than
W
Received August 26, 2014, and accepted for publication, after revision, October 26, 2014. From the *Brigham Women and Children’s Hospital, Boston, MA; and †Northwestern Memorial Hospital, Chicago, IL. Dr Hirsch is in private practice in Los Angeles, CA. Conflicts of interest and sources of funding: none declared. Reprints: Elliot M. Hirsch, MD, Sherman Oaks, Los Angeles, CA. E-mail: [email protected]. Copyright * 2015 Wolters Kluwer Health, Inc. All rights reserved ISSN: 0148-7043/15/7402Y0271 DOI: 10.1097/SAP.0000000000000404
* 2015 Wolters Kluwer Health, Inc. All rights reserved. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
www.annalsplasticsurgery.com
271
Annals of Plastic Surgery
Letters to the Editor
use larger volumes to fill the larger breast pocket. In the second stage of reconstruction, we are more frequently using a new incision to perform the exchange to an expander rather than the mastectomy scar, especially in patients with multiple risk factors. Anecdotally, these modifications have reduced our complication rate and have improved our results. The authors described protocol of multiple sessions of fat injection for patients undergoing radiation therapy as an intriguing concept. We have also seen fat injection help improve radiated skin and routinely use this technique during the exchange to permanent implant stage of reconstruction. We welcome
272
www.annalsplasticsurgery.com
the publication of the authors’ protocol and results and note that their technique lends itself very well to a prospective randomized study that would help evaluate their algorithm. It is important to note, however, that each trip to the operating room adds risk for infection, risk for anesthetic complication, and cost to the patient’s care. Indeed, in the current health care climate in the United States, some insurance companies will cover only a set number of revisions for breast reconstruction patients. A study that rigorously evaluates the efficacy of multiple sessions of fat injection in this setting will certainly help justify the rationale for this approach.
& Volume 74, Number 2, February 2015
Elliot M. Hirsch, MD Akhil K. Seth, MD Neil A. Fine, MD Brigham Women and Children’s Hospital, Boston, MA Northwestern Memorial Hospital Chicago, IL [email protected]
REFERENCE 1. Hirsch EM, Seth AK, Dumanian GA, et al. Outcomes of immediate tissue expander breast reconstruction followed by reconstruction of choice in the setting of postmastectomy radiation therapy. Ann Plast Surg. 2014;72:274Y278.
* 2015 Wolters Kluwer Health, Inc. All rights reserved. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
& Volume 74, Number 2, February 2015
immediate tissue expander breast reconstruction followed by reconstruction of choice in the setting of postmastectomy radiation therapy,’’ which describe the clinical protocol adopted at Northwestern Memorial Hospital on expander/implant breast reconstruction in the setting of PMRT. The authors suggest a sequence of mastectomy, tissue expansion, radiation therapy, and then definitive reconstruction to avoid delays in the beginning of radiotherapy and to increase reconstructive options. In a total case series of 237 patients, Hirsch and colleagues discovered a 22.3% rate of major complications, which leads to implant removal or conversion to f lap. Considering the data listed, we are persuaded that the clinical approach described by Hirsch and colleagues, which presents common features with the one adopted by our Breast Unit, could be further improved by an additional surgical step. As the authors, we begin radiotherapy within 6 weeks after mastectomy for oncological needs. For these reasons, we do not have sufficient time to finish the expansion, consolidate, and substitute tissue expander for a definitive prosthesis. Thus, in our Breast Unit at Northwestern Memorial Hospital, we perform radiotherapy after stage I breast reconstruction, interrupting tissue expansion during radiation treatment, and we restart expansion after 1 to 3 months after radiotherapy ends. We agree with the authors that, in operating on already irradiated breast, we can obtain a better control on final cosmetic result. Final reconstructive result, indeed, is altered by radiotherapy on permanent implant, due to its deleterious effects on soft tissues which could, for example, increase capsular contracture rate. Differently from the authors, instead, we widely adopt autologous fat grafting to avoid ulceration and implant exposure and to achieve the best reconstructive outcome. Relying on our clinical experience in both scar treatment2,3 and PMPS treatment,4 and relying on the paper of Rigotti et al5 too, our clinical approach consists of autologous fat grafting on breasts irradiated after stage I breast reconstruction, 3 months after radiation treatment conclusion, and during stage II breast reconstruction. At our institution, Humanitas Research Hospital, from 2009 to 2013, we adopted our protocol on a total of 53 mastectomies, subsequently submitted to 2-stage prosthetic breast reconstruction and PMRT. Conflicts of interest and sources of funding: none declared. Copyright * 2015 Wolters Kluwer Health, Inc. All rights reserved ISSN: 0148-7043/15/4702-0270 DOI: 10.1097/SAP.0000000000000324
Letters to the Editor
We have recently started to critically review our case series, discovering an overall complication rate less than the 10% and inferior to the one declared by Hirsch and colleagues. We are convinced that fat grafting can improve vascularity and tissue thickness, reducing breast reconstruction failure incidence when treating soft tissue radiation-induced damage. Our experience supports how its regenerative effect is able to reduce reconstruction failure rate in postmastectomy adjuvant radiotherapy on immediate 2-stage prosthetic breast. We believe this practice adds a fundamental surgical step which could efficiently further reduce complications rate on irradiated breast, maximizing reconstructive outcomes for Breast Units which follow our and Hirsch’s reconstructive procedure.
2.
3.
4.
5.
the setting of postmastectomy radiation therapy. Ann Plast Surg. 2014;72:274Y278. Klinger M, Marazzi M, Vigo D, et al. Fat Injection for cases of severe burn outcomes: a new perspective of scar remodeling and reduction. Aesthetic Plast Surg. 2008;32:465Y469. Klinger M, Caviggioli F, Klinger FM, et al. Autologous fat graft in scar treatment. J Craniofac Surg. 2013;24:1610Y1615. Caviggioli F, Maione L, Forcellini D, et al. Autologous fat graft in postmastectomy pain syndrome. Plast Reconstr Surg. 2011;128:349Y352. Rigotti G, Marchi A, Galie` M, et al. Clinical treatment of radiotherapy tissue damage by lipoaspirate transplant: a healing process mediated by adipose-derived adult stem cell. Plast Reconstr Surg. 2007;119: 1409Y1422.
Andrea Lisa Department of Medical Biotechnology and Translational Medicine BIOMETRA Plastic Surgery Unit Humanitas Clinical and Research Hospital Reconstructive and Aesthetic Plastic Surgery School University of Milan Rozzano, Milan, Italy
Fabio Caviggioli Reconstructive and Aesthetic Plastic Surgery School Plastic Surgery Unit MultiMedica Holding S.p.A. University of Milan Sesto San Giovanni, Milan, Italy
Luca Maione Department of Medical Biotechnology and Translational Medicine BIOMETRA Plastic Surgery Unit Humanitas Clinical and Research Hospital Reconstructive and Aesthetic Plastic Surgery School University of Milan Rozzano, Milan, Italy
Davide Forcellini Reconstructive and Aesthetic Plastic Surgery School Plastic Surgery Unit MultiMedica Holding S.p.A. University of Milan Sesto San Giovanni, Milan, Italy
Valeriano Vinci Department of Medical Biotechnology and Translational Medicine BIOMETRA Plastic Surgery Humanitas Clinical and Research Hospital Reconstructive and Aesthetic Plastic Surgery School University of Milan Rozzano, Milan, Italy
Francesco Klinger Reconstructive and Aesthetic Plastic Surgery School Plastic Surgery Unit MultiMedica Holding S.p.A. University of Milan Sesto San Giovanni, Milan, Italy
Marco Ettore Attilio Klinger, MD Department of Medical Biotechnology and Translational Medicine BIOMETRA Plastic Surgery Unit Humanitas Clinical and Research Hospital Reconstructive and Aesthetic Plastic Surgery School University of Milan Rozzano, Milan, Italy [email protected]
REFERENCES 1. Hirsch EM, Seth AK, Dumanian GA, et al. Outcomes of immediate tissue expander breast reconstruction followed by reconstruction of choice in
Outcomes of Immediate Tissue Expander Breast Reconstruction Followed by Reconstruction of Choice in the Setting of Postmastectomy Radiation Therapy: Reply To the Editor: e would like to thank the authors for their comments on our recent article. Indeed, the rate of complication leading to explantation or conversion to autologous in our previous article1 was 22.3%; however, it should be noted that this ref lects the overall rate of complication leading to explantation or conversion to f lap for both stages of reconstruction combined. In the first stage, 6% of patients experienced complications leading to explant or f lap before radiation therapy, 8% after radiation therapy and before conversion to permanent implants, and 12.5% after conversion to permanent implants. Since the publication of our original article, we have modified our approach to patients with certain risk factors for complications. For example, in obese patients, we perform a judicious excision of skin flaps at the initial stage of reconstruction rather than
W
Received August 26, 2014, and accepted for publication, after revision, October 26, 2014. From the *Brigham Women and Children’s Hospital, Boston, MA; and †Northwestern Memorial Hospital, Chicago, IL. Dr Hirsch is in private practice in Los Angeles, CA. Conflicts of interest and sources of funding: none declared. Reprints: Elliot M. Hirsch, MD, Sherman Oaks, Los Angeles, CA. E-mail: [email protected]. Copyright * 2015 Wolters Kluwer Health, Inc. All rights reserved ISSN: 0148-7043/15/7402Y0271 DOI: 10.1097/SAP.0000000000000404
* 2015 Wolters Kluwer Health, Inc. All rights reserved. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
www.annalsplasticsurgery.com
271
Annals of Plastic Surgery
Letters to the Editor
use larger volumes to fill the larger breast pocket. In the second stage of reconstruction, we are more frequently using a new incision to perform the exchange to an expander rather than the mastectomy scar, especially in patients with multiple risk factors. Anecdotally, these modifications have reduced our complication rate and have improved our results. The authors described protocol of multiple sessions of fat injection for patients undergoing radiation therapy as an intriguing concept. We have also seen fat injection help improve radiated skin and routinely use this technique during the exchange to permanent implant stage of reconstruction. We welcome
272
www.annalsplasticsurgery.com
the publication of the authors’ protocol and results and note that their technique lends itself very well to a prospective randomized study that would help evaluate their algorithm. It is important to note, however, that each trip to the operating room adds risk for infection, risk for anesthetic complication, and cost to the patient’s care. Indeed, in the current health care climate in the United States, some insurance companies will cover only a set number of revisions for breast reconstruction patients. A study that rigorously evaluates the efficacy of multiple sessions of fat injection in this setting will certainly help justify the rationale for this approach.
& Volume 74, Number 2, February 2015
Elliot M. Hirsch, MD Akhil K. Seth, MD Neil A. Fine, MD Brigham Women and Children’s Hospital, Boston, MA Northwestern Memorial Hospital Chicago, IL [email protected]
REFERENCE 1. Hirsch EM, Seth AK, Dumanian GA, et al. Outcomes of immediate tissue expander breast reconstruction followed by reconstruction of choice in the setting of postmastectomy radiation therapy. Ann Plast Surg. 2014;72:274Y278.
* 2015 Wolters Kluwer Health, Inc. All rights reserved. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
