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Postsurgical Ultrasound Evaluation of Patients with Prosthesis in Acellular Dermal Matrix: Results from Monocentric Experience

Postsurgical Ultrasound Evaluation of Patients with Prosthesis in Acellular Dermal Matrix:... Hindawi International Journal of Surgical Oncology Volume 2019, Article ID 7437324, 9 pages https://doi.org/10.1155/2019/7437324 Research Article Postsurgical Ultrasound Evaluation of Patients with Prosthesis in Acellular Dermal Matrix: Results from Monocentric Experience 1 1 1 1 2 Laura Ballesio, Alice Casinelli , Silvia Gigli, Cristiana Boldrini, Di Taranto Giuseppe, 2 2 Antonio Albano, and Maria Giuseppina Onesti Department of Radiological Sciences, “Sapienza” University of Rome, V.le Regina Elena 324, 00161 Rome, Italy Department of Plastic and Reconstructive Surgery, “Sapienza” University of Rome, V.le Regina Elena 324, 00161 Rome, Italy Correspondence should be addressed to Alice Casinelli; alicecasinelli@gmail.com Received 28 November 2018; Accepted 23 May 2019; Published 16 June 2019 Academic Editor: Steven Curley Copyright © 2019 Laura Ballesio et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Mastectomy and breast prosthetic reconstruction is the most common surgical treatment for women diagnosed with breast cancer. In the last few years, breast prosthetic augmentation in acellular dermal matrix (ADM) has been introduced. eTh aim of this study is to present our single-center experience in evaluating the outcome of patients who underwent breast reconstruction in ADM, using ultrasound (US) examination. US follow-up allows evaluating both normal postoperative findings and changes and potential local complications, demonstrating that ADM is a safe option for women candidates for mastectomy. 1. Introduction also compromise bloody supply to skin leading to a greater risk of tissue damage, infection, capsular reaction, and poor Approximately 35-40% of women with breast cancer undergo aesthetic result, as reported by Quinn et al. [5]. a total mastectomy and most of them are candidates for pros- In the last few years, a novel approach for breast thetic reconstruction. Prosthetic augmentation for recon- reconstruction has been introduced by using ADM that is structivesurgery is a safesurgicaloptionthatcan be done an immunologically inert material prepared by xenoplastic either at the time of the mastectomy, as immediate breast or alloplastic cadaveric dermis devoid of cellular elements reconstruction or as a two-stage reconstruction with a tissue providing a biological structure useful to embrace tissue expander followed by a permanent implant, as delayed breast ingrowth and improve angiogenesis and cellular regeneration reconstruction [1–3]. [6, 7]. The use of ADM reduces tissue expansion improving Although these operations are very common in clinical the implant reconstructive process, avoiding mastectomy practice, there may be some side effect related with a limited flap contraction and providing an additional layer of tissue biocompatibility; the most frequent is capsular contracture. between the skin and the implant and it offers an alternative The development of fibrous tissue around the prosthesis option for one-stage breast reconstruction [8]. represents a physiological mechanism to xfi the implant After surgery, a clinical and diagnostic follow-up should in the breast and to prevent infection and trauma. More- be performed in order to recognize postoperative local over, the capsular tissue may stieff n and extend, becoming complications; in this setting, US represents the most used extremely painful and unaesthetic [4]. Capsular contracture imaging method as it is the most safe, noninvasive, and rates in immediate reconstruction has been reported as being repeatable technique [7, 9]. A confident diagnosis between between 20% and 40.4%, while rates for delayed reconstruc- normal ADM US features and disease recurrence could be tion range from 17% to 26.4% [2]. In addition, radiotherapy, challenging. In this study, we reported our monocentric which is part of adjuvant treatment for breast cancer, can experience in evaluating the US follow-up findings in a group 2 International Journal of Surgical Oncology Figure 1: Biological membrane presenting as a hypoechoic periprosthetic layer at T0. of patients who underwent breast reconstruction to describe Only in one case, during a T2 evaluation on a patient the normal and abnormal imaging findings related with aec ff ted by invasive ductal carcinoma, we observed a hypoe- varying degrees of matrix reabsorption. choic nodule increased in size from the prior examination; we performed a US-guided biopsy and successive histological examination revealed that it was a residual disease. 2. Materials and Methods We performed a prospective study between March 2017 and 3. Results July 2018, including 27 consecutive patients (age range 29-78 years, mean age 50.3 years) who underwent breast prosthetic Considering ADM visibility and thickness, the biological augmentation for surgery reconstruction with ADM. membrane was always visible at T0 as a hypoechoic peripros- Most patients (19) underwent unilateral mastectomy for thetic layer measuring less than a millimeter in thickness (0.3- breast cancer with delayed breast reconstruction; two women 0.6 mm) (Figures 1-2); at T1, it was still partially visible in underwent unilateral mastectomy for cancer with immediate 10 patients, while at T2 and T3, it was not still identifiable prosthetic reconstruction and contralateral breast symmetri- (Figure 3). This is probably due to the high biocompatibility of sation. Three patients, two of them young sisters with BRCA- the biological membrane, causing a mild fibroblastic reaction 1 mutation, underwent a bilateral prophylactic mastectomy with focal tissue integration of the matrix and thus appearing and prosthetic reconstruction. Finally, three women received less visible in course of follow-up. Only in one patient the bilateral aesthetic breast augmentation. biological membrane was more visible at T2 with a thickness All these patients were evaluated after surgery with a of 2 mm; this woman was subjected to a recent radiation follow-up ultrasound (US) examination performed by a therapy on the breast implant (Figure 4). Radiologist with 15 years’ experience in breast imaging, in an In our series we did not observe cases of capsular early-, an intermediate-, and a late-phase of the postsurgical contracture or rupture. convalescence. Therefore, a US evaluation was performed at In most patients, breast prosthesis had regular morpho- T0 (1 month),atT1 (3 months), atT2 (6 months), and at T3 logic aspect with lobulated margins. (12 months) after surgery, by using a Aplio 500 Ultrasound In 18 patients, we observed that the biological membrane system (Toshiba, Toshiba Medical System s.r.l.) and a LOGIQ was well stretched along the convexity while relaxed at the E9 (GE Healthcare) with linear high-frequency transducer medial and lateral side of the implant. In these points, the (10-15 MHz). membrane partially folded and made some curves. This During each US examination, we used a standardized feature is well appreciable in the earlier evaluations probably systematic approach, including the evaluation of the visibility for the presence of periprosthetic u fl id, but over time, and thickness of the biological membrane, the implant membrane folds can merge and stick together, thus appearing morphology, the implant margins, and the presence of medi- sometimes a focal hypoechoic lesion contiguous with the olateral membrane folds. implant profile. The retrospective assessment of this finding In addition, we considered the occurrence of different allowed us to correctly interpret its nature and to distinguish local complications in course of follow-up, such as the pres- this normal evolution of the matrix integration by other ence of periprosthetic u fl id, inhomogeneities of soft tissues, findings suspicious for disease recurrence. liponecrosis, hematoma, seroma, infection, lymphoceles, and During US evaluations, we paid attention to peripros- findings of suspected disease recurrence. thetic structures too, evaluating the presence of peripros- Each one of these normal and abnormal findings was thetic u fl id, inhomogeneities of soft tissues, liponecrosis, and observed and recorded; a standard medical report form was local complications. proposed and adopted fort each patient at T0 and in the Very early postsurgery assessment, as it was proposed in successive evaluations. our protocol, revealed in almost all patients the presence of International Journal of Surgical Oncology 3 Figure 2: Biological membrane presenting as a hypoechoic periprosthetic layer at T0. Figure 3: The biological membrane is partially visible at T2 because of its physiological reimbursement. 4 International Journal of Surgical Oncology Figure 4: The biological membrane is still visible at T2 with a thickness of 2 mm, aer ft radiation therapy. situ (Figure 8). At T1 US evaluation, it was still visible but periprosthetic u fl id, sometimes a corpuscolated one. Fluid collections generally decreased over time and sometimes decreased in size, measuring 2 mm. disappeared in the further assessments; only vfi e patients still Ayoung woman with BRCA-1 mutation who under- presented a thin and corpuscolated u fl id layer at T3. Two went bilateral prophylactic mastectomy reported red, hot, patients had at T0 a marked periprosthetic u fl id collection and painful breast inafl mmation and burning sensation on (40 cc and 30 cc, respectively), which decreased after a week inframammary folds one month aeft r surgery. She underwent of antibiotics to approximately 10 cc (Figure 5). a breast MRI that revealed bilateral breast implant infection, In 20 patients, there was inhomogeneity and thickening treated with antibiotics and resolved in a month. of the subcutaneous adipose tissue in the early postsurgery Finally, during a T0 US examination, we found a little evaluation. This finding was less significant in the successive hypoechoic nodule measuring 6 mm in the lower-internal US evaluations and finally disappeared. Just in one case, the quadrant suggestive for a lump, in a patient who underwent same mentioned above, after radiation therapy, there was an unilateral mastectomy and lymphadenectomy for invasive important inhomogeneity of the breast soft tissue at T2 US ductal carcinoma. At T1, this nodule appeared increasing in examination (Figure 6). size measuring 9 mm, so a US-guided biopsy was performed; Liponecrosis was found in 10 patients in the US exams the histological report revealed that it was a residual disease performed at T2 and T3, appearing as a hypoechoic nodule (Figure 9) (Table 1 and Figure 10). or mass with well-den fi ed margins, ranging from 4 mm to 10 mm in size (Figure 7). Thanks to the strict follow-up, it was possible to observe and describe the natural history of this 4. Discussion inflammatory process from the initial changes into fat tissue. Surgical options for breast reconstruction include alloplastic Another complication that we observed in immediate and autogenous reconstructions. In autologous approach, postoperative period was the occurrence of lymphocele, that abdominal tissue is the gold-standard donor site. If the is a collection of lymphatic u fl id within the surgical site. Three abdomen is not a suitable donor site, secondary donor sites patients had an axillary lymphocele in the US exams at T0 and such as the thigh or buttock are considered. Autologous T1. tissues in breast reconstruction, however, involve the execu- At T0 US evaluation, we found a hypoechoic nodule with tion of generally more invasive interventions, a prolonged irregular margins measuring 4 mm in the periareolar area on therightbreast,suggestiveforasuturegranuloma,inapatient recovery (on average 5-7 days), and a longer postoperative who underwent bilateral mastectomy for ductal carcinoma in rehabilitation [10]. International Journal of Surgical Oncology 5 Figure 5: Marked periprosthetic u fl id collection. Figure 6: Inhomogeneity and thickening of the subcutaneous adipose tissue at T2, aer ft radiation therapy. 6 International Journal of Surgical Oncology Figure 7: Hypoechoic nodule with well-defined margins in the inferior-external quadrant of the right breast that is a liponecrosis. Figure 8: Hypoechoic nodule with irregular margins measuring 4 mm in the periareolar area on the right breast, suggestive for a suture granuloma. International Journal of Surgical Oncology 7 Table 1: Results of the study, patients. T0 T1 T2 T3 Parameters Visibility of the membrane 27 22 8 1 Mediolateral membrane folds 18 18 18 18 Periprosthetic u fl id 19 10 7 5 Inhomogeneity of soft tissues 20 13 8 3 Liponecrosis 9 10 10 7 Complications Seroma 3 3 - - Suture granuloma 1 1 - - Nipple introflexion - - 1 - Prosthetic infection 1 - - - Residual disease - 1 - - Figure 9: Hypoechoic nodule measuring 6 mm in the lower-internal quadrant, suggestive for a lump at T0 examination. At T1, this nodule occurred increasing in size measuring 9 mm, so a US-guided biopsy was performed. Since then, this strategy gradually spread among recon- structive surgeons because of the better cosmesis in breast reconstruction, the reduction of late or irradiation-induced capsular contracture, and the improved aesthetic outcomes [13]. These advantages are particularly evident in prepec- toral breast reconstruction in one-stage surgery technique. Among the “elderly” population, defined as those with a chronological age ≤ 65 years, breast cancer is largely rep- T3 resented. Although breast reconstruction in elderly patients T2 0 is considered controversial, it is real part of the healing T1 A process, improving their quality of life; people are living longer and healthier and the survival rate for breast cancer T0 is also improving. In these women, one-stage surgical option T0 T2 should be preferred because it is less invasive, allowing rapid T1 T3 recovery and prompt return to routinely activities. Among surgical techniques, the muscle-sparing Braxon wrap is the Figure 10: Graphic representation of the results of US evaluation over time, patients. A: membrane visibility; B: mediolateral mem- one that better satisfies these points [14]. Braxon non-cross- brane folds; C: periprosthetic u fl id; D: inhomogeneity of soft tissues; linked ADM allowed this new muscle-sparing technique and E: liponecrosis. that preserves the pectoralis major muscle. Maruccia et al. described that this surgical approach to Braxon ADM breast reconstruction involved skin- or nipple-sparing mastectomy Regarding alloplastic breast reconstructions techniques, that maintained a well-vascularized subcutaneous layer. The ADM edges were sutured together around the breast, placed ADM prosthesis was first described for use in breast surgery in 2001 by Dieterich et al. [11] and Salzberg [12]. into the subcutaneous breast pocket and then secured with 8 International Journal of Surgical Oncology apical, medial, and lateral absorbable stitches directly onto Despitesomelimitssuch asthe small sample sizeand the pectoralis major muscle. One vacuum drain was inserted the short-term follow-up during only 12 months, in our in the inframammary fold and removed between the seventh experience the US evaluation and clinical follow-up allowed observing the natural postoperative changes in ADM pros- and tenth postoperative days, and the skin was closed in two layers. This surgical approach allowed reducing complica- thesis and becoming familiar with normal findings. This tions as u fl id collection, promoting the early host integration aspect is necessary in order to distinguish benign findings of the matrix [15]. from malignant ones. In last few years, ADM has been introduced into more than 60% alloplastic reconstructions in the United States, 5. Conclusion as reported by the American Society of Plastic Surgeons [16]. The increasingly use of ADM determines a consequent In conclusion, ADM has been shown as a safe option for increasingly interest in describing the radiologic findings of women candidates for mastectomy. If Radiologists make ADM in postmastectomy reconstruction patients and poses experience in US examination during postsurgery follow-up, a diagnostic challenge for Radiologists. Familiarity with the US technique can be a valid tool for the evaluation and the imaging features of ADM is essential for a correct diagnosis of identification of both physiological and pathological n fi dings, normal matrix integration and of the possible complications, such as local surgery complications and recurrent disease. but to date, there is still a poor medical literature available on this topic [17]. Data Availability Parvizi et al. first reported contrast-enhanced ultrasound evaluation (CEUS) to describe the vascularisation of ADM The authors confirm that all data underlying the findings are after implant-based breast reconstruction. They proved the fully available without restriction. “in vivo” evaluation of vascular ingrowth and tissue forma- tion aer ft breast reconstruction with ADM after follow-up of Conflicts of Interest 1–18 months postoperatively in 16 patients [18]. In 2016, Seon Kim reported his experience of ultrasonog- The authors declare that they have no conflicts of interest. raphy findings of AlloDerm in a patient who developed a palpable mass along the lower lateral profile of her recon- References structed breast. The lesion did not show vascularity on color Doppler imaging. A left mediolateral oblique view (MLO) [1] N.Bertozzi, M. Pesce, P.Santi,and E. Raposio, “One-stage mammography and a simple chest radiography demonstrated immediate breast reconstruction: a concise review,” BioMed Research International, vol.2017, Article ID 6486859,12pages, a band-like lesion at the lower aspect of the reconstructed left breast. Nonenhanced computed tomography (CT) of the [2] M. Gardani, N.Bertozzi, M.P.Grieco etal.,“Breast recon- chest demonstrated an oval-shaped lesion with soft tissue struction with anatomical implants: A review of indications and density along the superficial aspect of the implant. After techniques based on current literature,” Annals of Medicine and discussion with the plastic surgeon, this location and config- Surgery, vol. 21, pp. 96–104, 2017. uration was identified as consistent with the AlloDerm  sling [3] M. Scheflan and A. S. Colwell, “Tissue reinforcement in used in reconstruction surgery (BI-RADS 2) [19]. implant-based breast reconstruction,” Plastic and Reconstruc- In 2009, Buck et al. reported the case of a patient tive Surgery,2014. with a new palpable mass in her breast after mastectomy. [4] A.S. Colwell, O. Tessler,A.M. Lin et al., “Breastreconstruction After surgical excision, it was confirmed to be a foreign following nipple-sparing mastectomy: Predictors of complica- body giant cell infiltration, secondary to the ADM used in tions, reconstruction outcomes, and 5-year trends,” Plastic and reconstruction [20]. Reconstructive Surgery, vol.133,no. 3,pp. 496–506,2014. All these experiences show how enhanced characteriza- [5] T. T. Quinn, G. S. Miller, M. Rostek et al., “Prosthetic breast tion of benign finding may help in distinguishing them from reconstruction: indications and update,” Gland Surgery,vol. 5, tumorrecurrence orother foreignbody. no. 2, pp. 174–186, 2016. As recently proved by Onesti et al. performing the biopsy [6] S. A Macadam and P. A Lennox, “Acellular dermal matrices: usein reconstructiveand aestheticbreastsurgery,” Canadian of the periprosthetic tissue 12 months after surgery, histo- Journal of Plastic Surgery, vol.20,pp. 75–89,2012. logical examination showed the almost complete integration [7] M. Y. Nahabedian, “Acellular dermal matrices in primary breast of ADM with the patient tissue. In the biopsy specimen, reconstruction: principles, concepts, and indications,” Plastic the matrix was crowded with lymphocyte, histiocytes, and and Reconstructive Surgery, vol.130,supplement 2,no. 5,pp. vascular vessels containing erythrocytes. The immunohisto- 44S–53S, 2012. chemical analysis conducted on the biopsy confirmed the [8] A.M.S.Ibrahim, M.Shuster, P.G.L. Koolen et al., “Analysis presence of active proliferation within the matrix (Ki-67 of the national surgical quality improvement program database positive cells), myob fi roblast invasion ( 𝛼 -smooth muscle in 19,100 patients undergoing implant-based breast reconstruc- actin positive cells), and neovascular ingrowth (CD31 positive tion: complication rates with acellular dermal matrix,” Plastic cells) [21]. and Reconstructive Surgery, vol.132,no. 5,pp.1057–1066, 2013. These specific findings were confirmed in imaging by US [9] C.U.Lee,A.Bobr,and J.Torres-Mora, “Radiologic-pathologic examinations conducted in our study. correlation: acellular dermal matrix (alloderm)used in breast International Journal of Surgical Oncology 9 reconstructive surgery,” Journal of Clinical Imaging Science,vol. 7,no.1,2017. [10] P. Ciudad, M. Maruccia, G. Orfaniotis et al., “eTh combined transverse upper gracilis and profunda artery perforator (TUG- PAP) flap for breast reconstruction,” Microsurgery,vol. 36, no. 5, pp. 359–366, 2016. [11] M. Dieterich, J. Angres, J. Stubert, A. Stachs, T. Reimer, and B. Gerber, “Patient-reported outcomes in implant-based breast reconstruction alone or in combination with a titanium-coated polypropylene mesh - a detailed analysis of the BREAST-Q and overview of the literature,” Geburtshilfe und Frauenheilkunde, vol.75,no.7,pp.692–701,2015. [12] C. A. Salzberg, “Nonexpansive immediate breast reconstruction using human acellular tissue matrix graft (AlloDerm),” Annals of Plastic Surgery, vol.57,no.1,pp.1–5, 2006. [13] G. Ho, T. J. Nguyen, A. Shahabi, B. H. Hwang, L. S. Chan, and A. K. Wong, “A systematic review and meta-analysis of complications associated with acellular dermal matrix-assisted breast reconstruction,” Annals of Plastic Surgery,vol. 68, no. 4, pp. 346–356, 2012. [14] M. Maruccia, M. Mazzocchi, L. A. Dessy, and M. G. Onesti, “One-stage breast reconstruction techniques in elderly patients to preserve quality of life,” European Review for Medical and Pharmacological Sciences, vol.20,no. 24,pp.5058–5066,2016. [15] M. Maruccia, G. Di Taranto, and M. G. Onesti, “One-stage muscle-sparing breast reconstruction in elderly patients: A new tool for retaining excellent quality of life,” The Breast Journal , vol. 24, no. 2, pp.180–183,2018. [16] American Society of Plastic Surgeons, Plastic surgery statistics report 2012. [17] J. P. Agarwal, S. D. Mendenhall, L. A. Anderson et al., “eTh breast reconstruction evaluation of acellular dermal matrix as a sling trial (BREASTrial): Design and methods of a prospective randomized trial,” Plastic and Reconstructive Surgery,vol. 135, no.1,pp.20–28, 2015. [18] D. Parvizi, F. Haas, F. Peintinger et al., “First experience using contrast-enhanced ultrasound to evaluate vascularisation of acellular dermal matrices aer ft implant-based breast recon- struction,” The Breast Journal ,vol.20,no. 5,pp.461–467, 2014. [19] Y. Seon Kim, “Ultrasonography findings of alloderm  used in postmastectomy alloplastic breast reconstruction: a case report and literature review,” Iranian Journal of Radiology,vol. 13, no. 3, Article ID e38252, 2016. [20] D. W. Buck II, K. Heyer, J. D. Wayne, A. Yeldandi, and J. Y. S. Kim, “Diagnostic dilemma: acellular dermis mimicking a breast mass after immediate tissue expander breast reconstruction,” Plastic and Reconstructive Surgery, vol.124, no. 1, pp.174–176, [21] M. G. Onesti, M. Maruccia, G. Di Taranto et al., “Clinical, histological, and ultrasound follow-up of breast reconstruction with one-stage muscle-sparing “wrap” technique: A single- center experience,” Journal of Plastic, Reconstructive & Aesthetic Surgery, vol. 70, no. 11, pp. 1527–1536, 2017. 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Postsurgical Ultrasound Evaluation of Patients with Prosthesis in Acellular Dermal Matrix: Results from Monocentric Experience

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Hindawi Publishing Corporation
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Copyright © 2019 Ballesio Laura et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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2090-1402
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2090-1410
DOI
10.1155/2019/7437324
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Abstract

Hindawi International Journal of Surgical Oncology Volume 2019, Article ID 7437324, 9 pages https://doi.org/10.1155/2019/7437324 Research Article Postsurgical Ultrasound Evaluation of Patients with Prosthesis in Acellular Dermal Matrix: Results from Monocentric Experience 1 1 1 1 2 Laura Ballesio, Alice Casinelli , Silvia Gigli, Cristiana Boldrini, Di Taranto Giuseppe, 2 2 Antonio Albano, and Maria Giuseppina Onesti Department of Radiological Sciences, “Sapienza” University of Rome, V.le Regina Elena 324, 00161 Rome, Italy Department of Plastic and Reconstructive Surgery, “Sapienza” University of Rome, V.le Regina Elena 324, 00161 Rome, Italy Correspondence should be addressed to Alice Casinelli; alicecasinelli@gmail.com Received 28 November 2018; Accepted 23 May 2019; Published 16 June 2019 Academic Editor: Steven Curley Copyright © 2019 Laura Ballesio et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Mastectomy and breast prosthetic reconstruction is the most common surgical treatment for women diagnosed with breast cancer. In the last few years, breast prosthetic augmentation in acellular dermal matrix (ADM) has been introduced. eTh aim of this study is to present our single-center experience in evaluating the outcome of patients who underwent breast reconstruction in ADM, using ultrasound (US) examination. US follow-up allows evaluating both normal postoperative findings and changes and potential local complications, demonstrating that ADM is a safe option for women candidates for mastectomy. 1. Introduction also compromise bloody supply to skin leading to a greater risk of tissue damage, infection, capsular reaction, and poor Approximately 35-40% of women with breast cancer undergo aesthetic result, as reported by Quinn et al. [5]. a total mastectomy and most of them are candidates for pros- In the last few years, a novel approach for breast thetic reconstruction. Prosthetic augmentation for recon- reconstruction has been introduced by using ADM that is structivesurgery is a safesurgicaloptionthatcan be done an immunologically inert material prepared by xenoplastic either at the time of the mastectomy, as immediate breast or alloplastic cadaveric dermis devoid of cellular elements reconstruction or as a two-stage reconstruction with a tissue providing a biological structure useful to embrace tissue expander followed by a permanent implant, as delayed breast ingrowth and improve angiogenesis and cellular regeneration reconstruction [1–3]. [6, 7]. The use of ADM reduces tissue expansion improving Although these operations are very common in clinical the implant reconstructive process, avoiding mastectomy practice, there may be some side effect related with a limited flap contraction and providing an additional layer of tissue biocompatibility; the most frequent is capsular contracture. between the skin and the implant and it offers an alternative The development of fibrous tissue around the prosthesis option for one-stage breast reconstruction [8]. represents a physiological mechanism to xfi the implant After surgery, a clinical and diagnostic follow-up should in the breast and to prevent infection and trauma. More- be performed in order to recognize postoperative local over, the capsular tissue may stieff n and extend, becoming complications; in this setting, US represents the most used extremely painful and unaesthetic [4]. Capsular contracture imaging method as it is the most safe, noninvasive, and rates in immediate reconstruction has been reported as being repeatable technique [7, 9]. A confident diagnosis between between 20% and 40.4%, while rates for delayed reconstruc- normal ADM US features and disease recurrence could be tion range from 17% to 26.4% [2]. In addition, radiotherapy, challenging. In this study, we reported our monocentric which is part of adjuvant treatment for breast cancer, can experience in evaluating the US follow-up findings in a group 2 International Journal of Surgical Oncology Figure 1: Biological membrane presenting as a hypoechoic periprosthetic layer at T0. of patients who underwent breast reconstruction to describe Only in one case, during a T2 evaluation on a patient the normal and abnormal imaging findings related with aec ff ted by invasive ductal carcinoma, we observed a hypoe- varying degrees of matrix reabsorption. choic nodule increased in size from the prior examination; we performed a US-guided biopsy and successive histological examination revealed that it was a residual disease. 2. Materials and Methods We performed a prospective study between March 2017 and 3. Results July 2018, including 27 consecutive patients (age range 29-78 years, mean age 50.3 years) who underwent breast prosthetic Considering ADM visibility and thickness, the biological augmentation for surgery reconstruction with ADM. membrane was always visible at T0 as a hypoechoic peripros- Most patients (19) underwent unilateral mastectomy for thetic layer measuring less than a millimeter in thickness (0.3- breast cancer with delayed breast reconstruction; two women 0.6 mm) (Figures 1-2); at T1, it was still partially visible in underwent unilateral mastectomy for cancer with immediate 10 patients, while at T2 and T3, it was not still identifiable prosthetic reconstruction and contralateral breast symmetri- (Figure 3). This is probably due to the high biocompatibility of sation. Three patients, two of them young sisters with BRCA- the biological membrane, causing a mild fibroblastic reaction 1 mutation, underwent a bilateral prophylactic mastectomy with focal tissue integration of the matrix and thus appearing and prosthetic reconstruction. Finally, three women received less visible in course of follow-up. Only in one patient the bilateral aesthetic breast augmentation. biological membrane was more visible at T2 with a thickness All these patients were evaluated after surgery with a of 2 mm; this woman was subjected to a recent radiation follow-up ultrasound (US) examination performed by a therapy on the breast implant (Figure 4). Radiologist with 15 years’ experience in breast imaging, in an In our series we did not observe cases of capsular early-, an intermediate-, and a late-phase of the postsurgical contracture or rupture. convalescence. Therefore, a US evaluation was performed at In most patients, breast prosthesis had regular morpho- T0 (1 month),atT1 (3 months), atT2 (6 months), and at T3 logic aspect with lobulated margins. (12 months) after surgery, by using a Aplio 500 Ultrasound In 18 patients, we observed that the biological membrane system (Toshiba, Toshiba Medical System s.r.l.) and a LOGIQ was well stretched along the convexity while relaxed at the E9 (GE Healthcare) with linear high-frequency transducer medial and lateral side of the implant. In these points, the (10-15 MHz). membrane partially folded and made some curves. This During each US examination, we used a standardized feature is well appreciable in the earlier evaluations probably systematic approach, including the evaluation of the visibility for the presence of periprosthetic u fl id, but over time, and thickness of the biological membrane, the implant membrane folds can merge and stick together, thus appearing morphology, the implant margins, and the presence of medi- sometimes a focal hypoechoic lesion contiguous with the olateral membrane folds. implant profile. The retrospective assessment of this finding In addition, we considered the occurrence of different allowed us to correctly interpret its nature and to distinguish local complications in course of follow-up, such as the pres- this normal evolution of the matrix integration by other ence of periprosthetic u fl id, inhomogeneities of soft tissues, findings suspicious for disease recurrence. liponecrosis, hematoma, seroma, infection, lymphoceles, and During US evaluations, we paid attention to peripros- findings of suspected disease recurrence. thetic structures too, evaluating the presence of peripros- Each one of these normal and abnormal findings was thetic u fl id, inhomogeneities of soft tissues, liponecrosis, and observed and recorded; a standard medical report form was local complications. proposed and adopted fort each patient at T0 and in the Very early postsurgery assessment, as it was proposed in successive evaluations. our protocol, revealed in almost all patients the presence of International Journal of Surgical Oncology 3 Figure 2: Biological membrane presenting as a hypoechoic periprosthetic layer at T0. Figure 3: The biological membrane is partially visible at T2 because of its physiological reimbursement. 4 International Journal of Surgical Oncology Figure 4: The biological membrane is still visible at T2 with a thickness of 2 mm, aer ft radiation therapy. situ (Figure 8). At T1 US evaluation, it was still visible but periprosthetic u fl id, sometimes a corpuscolated one. Fluid collections generally decreased over time and sometimes decreased in size, measuring 2 mm. disappeared in the further assessments; only vfi e patients still Ayoung woman with BRCA-1 mutation who under- presented a thin and corpuscolated u fl id layer at T3. Two went bilateral prophylactic mastectomy reported red, hot, patients had at T0 a marked periprosthetic u fl id collection and painful breast inafl mmation and burning sensation on (40 cc and 30 cc, respectively), which decreased after a week inframammary folds one month aeft r surgery. She underwent of antibiotics to approximately 10 cc (Figure 5). a breast MRI that revealed bilateral breast implant infection, In 20 patients, there was inhomogeneity and thickening treated with antibiotics and resolved in a month. of the subcutaneous adipose tissue in the early postsurgery Finally, during a T0 US examination, we found a little evaluation. This finding was less significant in the successive hypoechoic nodule measuring 6 mm in the lower-internal US evaluations and finally disappeared. Just in one case, the quadrant suggestive for a lump, in a patient who underwent same mentioned above, after radiation therapy, there was an unilateral mastectomy and lymphadenectomy for invasive important inhomogeneity of the breast soft tissue at T2 US ductal carcinoma. At T1, this nodule appeared increasing in examination (Figure 6). size measuring 9 mm, so a US-guided biopsy was performed; Liponecrosis was found in 10 patients in the US exams the histological report revealed that it was a residual disease performed at T2 and T3, appearing as a hypoechoic nodule (Figure 9) (Table 1 and Figure 10). or mass with well-den fi ed margins, ranging from 4 mm to 10 mm in size (Figure 7). Thanks to the strict follow-up, it was possible to observe and describe the natural history of this 4. Discussion inflammatory process from the initial changes into fat tissue. Surgical options for breast reconstruction include alloplastic Another complication that we observed in immediate and autogenous reconstructions. In autologous approach, postoperative period was the occurrence of lymphocele, that abdominal tissue is the gold-standard donor site. If the is a collection of lymphatic u fl id within the surgical site. Three abdomen is not a suitable donor site, secondary donor sites patients had an axillary lymphocele in the US exams at T0 and such as the thigh or buttock are considered. Autologous T1. tissues in breast reconstruction, however, involve the execu- At T0 US evaluation, we found a hypoechoic nodule with tion of generally more invasive interventions, a prolonged irregular margins measuring 4 mm in the periareolar area on therightbreast,suggestiveforasuturegranuloma,inapatient recovery (on average 5-7 days), and a longer postoperative who underwent bilateral mastectomy for ductal carcinoma in rehabilitation [10]. International Journal of Surgical Oncology 5 Figure 5: Marked periprosthetic u fl id collection. Figure 6: Inhomogeneity and thickening of the subcutaneous adipose tissue at T2, aer ft radiation therapy. 6 International Journal of Surgical Oncology Figure 7: Hypoechoic nodule with well-defined margins in the inferior-external quadrant of the right breast that is a liponecrosis. Figure 8: Hypoechoic nodule with irregular margins measuring 4 mm in the periareolar area on the right breast, suggestive for a suture granuloma. International Journal of Surgical Oncology 7 Table 1: Results of the study, patients. T0 T1 T2 T3 Parameters Visibility of the membrane 27 22 8 1 Mediolateral membrane folds 18 18 18 18 Periprosthetic u fl id 19 10 7 5 Inhomogeneity of soft tissues 20 13 8 3 Liponecrosis 9 10 10 7 Complications Seroma 3 3 - - Suture granuloma 1 1 - - Nipple introflexion - - 1 - Prosthetic infection 1 - - - Residual disease - 1 - - Figure 9: Hypoechoic nodule measuring 6 mm in the lower-internal quadrant, suggestive for a lump at T0 examination. At T1, this nodule occurred increasing in size measuring 9 mm, so a US-guided biopsy was performed. Since then, this strategy gradually spread among recon- structive surgeons because of the better cosmesis in breast reconstruction, the reduction of late or irradiation-induced capsular contracture, and the improved aesthetic outcomes [13]. These advantages are particularly evident in prepec- toral breast reconstruction in one-stage surgery technique. Among the “elderly” population, defined as those with a chronological age ≤ 65 years, breast cancer is largely rep- T3 resented. Although breast reconstruction in elderly patients T2 0 is considered controversial, it is real part of the healing T1 A process, improving their quality of life; people are living longer and healthier and the survival rate for breast cancer T0 is also improving. In these women, one-stage surgical option T0 T2 should be preferred because it is less invasive, allowing rapid T1 T3 recovery and prompt return to routinely activities. Among surgical techniques, the muscle-sparing Braxon wrap is the Figure 10: Graphic representation of the results of US evaluation over time, patients. A: membrane visibility; B: mediolateral mem- one that better satisfies these points [14]. Braxon non-cross- brane folds; C: periprosthetic u fl id; D: inhomogeneity of soft tissues; linked ADM allowed this new muscle-sparing technique and E: liponecrosis. that preserves the pectoralis major muscle. Maruccia et al. described that this surgical approach to Braxon ADM breast reconstruction involved skin- or nipple-sparing mastectomy Regarding alloplastic breast reconstructions techniques, that maintained a well-vascularized subcutaneous layer. The ADM edges were sutured together around the breast, placed ADM prosthesis was first described for use in breast surgery in 2001 by Dieterich et al. [11] and Salzberg [12]. into the subcutaneous breast pocket and then secured with 8 International Journal of Surgical Oncology apical, medial, and lateral absorbable stitches directly onto Despitesomelimitssuch asthe small sample sizeand the pectoralis major muscle. One vacuum drain was inserted the short-term follow-up during only 12 months, in our in the inframammary fold and removed between the seventh experience the US evaluation and clinical follow-up allowed observing the natural postoperative changes in ADM pros- and tenth postoperative days, and the skin was closed in two layers. This surgical approach allowed reducing complica- thesis and becoming familiar with normal findings. This tions as u fl id collection, promoting the early host integration aspect is necessary in order to distinguish benign findings of the matrix [15]. from malignant ones. In last few years, ADM has been introduced into more than 60% alloplastic reconstructions in the United States, 5. Conclusion as reported by the American Society of Plastic Surgeons [16]. The increasingly use of ADM determines a consequent In conclusion, ADM has been shown as a safe option for increasingly interest in describing the radiologic findings of women candidates for mastectomy. If Radiologists make ADM in postmastectomy reconstruction patients and poses experience in US examination during postsurgery follow-up, a diagnostic challenge for Radiologists. Familiarity with the US technique can be a valid tool for the evaluation and the imaging features of ADM is essential for a correct diagnosis of identification of both physiological and pathological n fi dings, normal matrix integration and of the possible complications, such as local surgery complications and recurrent disease. but to date, there is still a poor medical literature available on this topic [17]. Data Availability Parvizi et al. first reported contrast-enhanced ultrasound evaluation (CEUS) to describe the vascularisation of ADM The authors confirm that all data underlying the findings are after implant-based breast reconstruction. They proved the fully available without restriction. “in vivo” evaluation of vascular ingrowth and tissue forma- tion aer ft breast reconstruction with ADM after follow-up of Conflicts of Interest 1–18 months postoperatively in 16 patients [18]. In 2016, Seon Kim reported his experience of ultrasonog- The authors declare that they have no conflicts of interest. raphy findings of AlloDerm in a patient who developed a palpable mass along the lower lateral profile of her recon- References structed breast. The lesion did not show vascularity on color Doppler imaging. A left mediolateral oblique view (MLO) [1] N.Bertozzi, M. Pesce, P.Santi,and E. 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Orfaniotis et al., “eTh combined transverse upper gracilis and profunda artery perforator (TUG- PAP) flap for breast reconstruction,” Microsurgery,vol. 36, no. 5, pp. 359–366, 2016. [11] M. Dieterich, J. Angres, J. Stubert, A. Stachs, T. Reimer, and B. Gerber, “Patient-reported outcomes in implant-based breast reconstruction alone or in combination with a titanium-coated polypropylene mesh - a detailed analysis of the BREAST-Q and overview of the literature,” Geburtshilfe und Frauenheilkunde, vol.75,no.7,pp.692–701,2015. [12] C. A. Salzberg, “Nonexpansive immediate breast reconstruction using human acellular tissue matrix graft (AlloDerm),” Annals of Plastic Surgery, vol.57,no.1,pp.1–5, 2006. [13] G. Ho, T. J. Nguyen, A. Shahabi, B. H. Hwang, L. S. Chan, and A. K. Wong, “A systematic review and meta-analysis of complications associated with acellular dermal matrix-assisted breast reconstruction,” Annals of Plastic Surgery,vol. 68, no. 4, pp. 346–356, 2012. [14] M. Maruccia, M. 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