Plastic and Reconstructive Surgery • February 2015 Reply: The Effects of Postmastectomy Adjuvant Radiotherapy on Immediate Two-Stage Prosthetic Breast Reconstruction: A Systematic Review
Medicine BIOMETRA Plastic Surgery Unit Humanitas Clinical and Research Hospital Rozzano
Sir:
Thank you for inviting us to reply to letter sent by Ribuffo et al. In our previous contribution, we described how our breast unit protocol manages expander insufflations and decreases the complication rate related to postmastectomy radiotherapy. In particular, in patients undergoing postmastectomy radiotherapy after firststage breast reconstruction, we interrupt expansion and restart it 1 to 3 months after the end of radiotherapy. Then, we perform fat grafting 3 months before or at the time of expander substitution depending on late effects of normal tissue–subjective, objective, management, and analytic grade at the end of expansion.1 In patients with grade 1 late effects of normal tissue– subjective, objective, management, and analytic score, we proceed to fat grafting only during second-stage breast reconstruction, whereas in patients with higher grades, we perform fat grafting 3 months before secondstage breast reconstruction and at least 3 months after the end of radiation therapy and a second fat grafting procedure during expander substitution. Ribuffo et al. follow a different protocol based on complete tissue expansion before radiotherapy and two or three fat grafting sessions before second-stage breast reconstruction.2 In our previous contribution, we just presented our preliminary results3 using references to explain biological mechanisms implied in observed fat grafting clinical effects (histologic neovessel formation and tissue regeneration).4 Moreover, we considered the work by Rigotti more relevant, being the first article showing the therapeutic effects of autologous fat grafting on radiotherapy tissue damage.5 Concluding because of the Journal-permitted number of citations, we unfortunately missed the article by Ribuffo et al. DOI: 10.1097/PRS.0000000000000924
Luca Maione University of Milan Reconstructive and Aesthetic Plastic Surgery School Department of Medical Biotechnology and Translational Medicine BIOMETRA Plastic Surgery Unit Humanitas Clinical and Research Hospital Rozzano
Davide Forcellini University of Milan Reconstructive and Aesthetic Plastic Surgery School MultiMedica Holding S.p.A. Plastic Surgery Unit Sesto San Giovanni
Valeriano Vinci Andrea Lisa University of Milan Reconstructive and Aesthetic Plastic Surgery School Department of Medical Biotechnology and Translational
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Fabio Caviggioli Francesco Klinger University of Milan Reconstructive and Aesthetic Plastic Surgery School MultiMedica Holding S.p.A. Plastic Surgery Unit Sesto San Giovanni, Italy Correspondence to Dr. Maione Università degli Studi di Milano Dipartimento di Biotecnologie Mediche e Medcina Traslazionale (BIOMETRA) IRCCS Istituto Clinico Humanitas U.O. Chirurgia Plastica Via Manzoni 56 20090 Rozzano, Milano, Italy [email protected]
disclosure The authors have no financial interest to declare in relation to the content of this communication. references 1. Pavi JJ, Denekamp J, Letschert J, et al. LENT-SOMA scales for all anatomic sites. Int J Radiat Oncol Biol Phys. 1995;31:1049–1091. 2. Ribuffo D, Atzeni M, Serratore F, Guerra M, Bucher S. Cagliari University Hospital (CUH) protocol for immediate alloplastic breast reconstruction and unplanned radiotherapy: A preliminary report. Eur Rev Med Pharmacol Sci. 2011;15:840–844. 3. Maione L, Forcellini D, Vinci V, Lisa A, Caviggioli F, Klinger F. The effects of postmastectomy adjuvant radiotherapy on immediate two-stage prosthetic breast reconstruction: A systematic review. Plast Reconstr Surg. 2014;133: 729e–730e. 4. Klinger M, Caviggioli F, Klinger FM, et al. Autologous fat graft in scar treatment. J Craniofac Surg. 2013;24: 1610–1615. 5. Rigotti G, Marchi A, Galiè M, et al. Clinical treatment of radiotherapy tissue damage by lipoaspirate transplant: A healing process mediated by adipose-derived adult stem cells. Plast Reconstr Surg. 2007;119:1409–1422.
Studies in Fat Grafting: Part I. Effects of Injection Technique on In Vitro Fat Viability and In Vivo Volume Retention; and Studies in Fat Grafting: Part II. Effects of Injection Mechanics on Material Properties of Fat Sir:
W
e read with great interest the articles by Chung et al. and Atashroo et al. entitled “Studies in Fat Grafting: Part I. Effects of Injection Technique on In Vitro Fat Viability and In Vivo Volume Retention”
Volume 135 Number 2 • Letters and “Studies in Fat Grafting: Part II. Effects of Injection Mechanics on Material Properties of Fat,” respectively.1,2 Autologous fat is promising as an ideal filler.3 However, the procedure can be tedious, and results vary. The study characterized a novel device, the adipose tissue injector, which improves precision, reduces trauma and, more importantly, produces superior results. We look forward to obtaining one for handson experience. Close examination of the study raised some questions that might compromise accurate interpretation of results, which we would like to communicate with the authors. The “modified Coleman technique” is not referenced. The Coleman technique encompasses gentle manual harvest, centrifugation refinement, and slow low-volume retrograde placement of fat.3 The control technique described therein looked quite different. Preinjection fat manipulation was not identical between groups. Specifically, two more transfers (60-cc syringe, to a 10-cc and then to a 1-cc syringe) occurred in the control group. The adipose tissue injector is designed to reduce shear trauma; additional passes through tubing might render the comparison unbalanced.2 The rate of injection is not specified. Coleman emphasizes retrograde delivery at a very low rate (1/10 to 1/30 ml per withdrawal),3 possibly lower than the adipose tissue injector settings (0.5 to 1 cc/second).2 This matters, as slower flow possibly reduces shear force and trauma.2 Two questions arose concerning statistical analysis. First, as the experimental design produced matched readings (the fat of each donor underwent processing three times), repeated measures one-way analysis of variance might better be used. Second, comparison between two groups, carried out when analysis of variance revealed significant differences among the three groups, should be performed with multiple comparison methods for post hoc testing of analysis of variance, rather than with multiple t tests. The latter approach predisposes to type I error (false-positives). Volume retention measured in both groups was lower than that reported by Thanik et al. in a similar model.4 The disparity remains unaddressed, as multiple variables (e.g., donor site, animal species, techniques, and recipient site) were different between them.1,4 Part II of the study measured mechanical properties of fat injected differentially. The adipose tissue injector group more closely resembled minimally processed fat. However, one notes that the test conditions were far different from what the graft will experience in a grafting session. One also wonders whether and to what extent those differences translate into clinical superiority. Despite these issues, the studies were welldesigned explorations into the impact of the adipose
tissue injector on fat grafting. In addition to the low-shear trauma exerted, it will probably save time and labor, enhance precision and reproducibility of results delivered, and shorten the learning curve of fat grafting. Future improvements might be made to improve compatibility with other fat collection and refinement systems, to provide more control over flow to prevent pool formation, to incorporate real-time monitoring of interstitial fluid pressure,5 and to develop customized cannulas with modified inner surfaces to further reduce shear trauma. The pursuit of more precise, less traumatic, more reproducible, and less strenuous ways of delivering satisfactory results should always be admired, and we hope that the adipose tissue injector will prove to be both a technical success and a business success. DOI: 10.1097/PRS.0000000000000931
Yihong Jia, M.D. Nanze Yu, M.D. Yang Wang, M.D. Ang Zeng, M.D. Lin Zhu, M.D. Xiaojun Wang, M.D. Division of Plastic and Reconstructive Surgery Department of Surgery Peking Union Medical College Hospital Beijing, People’s Republic of China Correspondence to Dr. Wang Peking Union Medical College Hospital No. 1, Shuaifuyuan Dongdan Dongcheng District 10005 Beijing, People’s Republic of China [email protected]
DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. REFERENCES 1. Chung MT, Paik KJ, Atashroo DA, et al. Studies in fat grafting: Part I. Effects of injection technique on in vitro fat viability and in vivo volume retention. Plast Reconstr Surg. 2014;134:29–38. 2. Atashroo D, Raphel J, Chung MT, et al. Studies in fat grafting: Part II. Effects of injection mechanics on material properties of fat. Plast Reconstr Surg. 2014;134:39–46. 3. Coleman SR. Structural fat grafting: More than a permanent filler. Plast Reconstr Surg. 2006;118(Suppl):108S–120S. 4. Thanik VD, Chang CC, Lerman OZ, et al. A murine model for studying diffusely injected human fat. Plast Reconstr Surg. 2009;124:74–81. 5. Khouri RK, Rigotti G, Cardoso E, Khouri RK Jr, Biggs TM. Megavolume autologous fat transfer: Part II. Practice and techniques. Plast Reconstr Surg. 2014;133:1369–1377.
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Medicine BIOMETRA Plastic Surgery Unit Humanitas Clinical and Research Hospital Rozzano
Sir:
Thank you for inviting us to reply to letter sent by Ribuffo et al. In our previous contribution, we described how our breast unit protocol manages expander insufflations and decreases the complication rate related to postmastectomy radiotherapy. In particular, in patients undergoing postmastectomy radiotherapy after firststage breast reconstruction, we interrupt expansion and restart it 1 to 3 months after the end of radiotherapy. Then, we perform fat grafting 3 months before or at the time of expander substitution depending on late effects of normal tissue–subjective, objective, management, and analytic grade at the end of expansion.1 In patients with grade 1 late effects of normal tissue– subjective, objective, management, and analytic score, we proceed to fat grafting only during second-stage breast reconstruction, whereas in patients with higher grades, we perform fat grafting 3 months before secondstage breast reconstruction and at least 3 months after the end of radiation therapy and a second fat grafting procedure during expander substitution. Ribuffo et al. follow a different protocol based on complete tissue expansion before radiotherapy and two or three fat grafting sessions before second-stage breast reconstruction.2 In our previous contribution, we just presented our preliminary results3 using references to explain biological mechanisms implied in observed fat grafting clinical effects (histologic neovessel formation and tissue regeneration).4 Moreover, we considered the work by Rigotti more relevant, being the first article showing the therapeutic effects of autologous fat grafting on radiotherapy tissue damage.5 Concluding because of the Journal-permitted number of citations, we unfortunately missed the article by Ribuffo et al. DOI: 10.1097/PRS.0000000000000924
Luca Maione University of Milan Reconstructive and Aesthetic Plastic Surgery School Department of Medical Biotechnology and Translational Medicine BIOMETRA Plastic Surgery Unit Humanitas Clinical and Research Hospital Rozzano
Davide Forcellini University of Milan Reconstructive and Aesthetic Plastic Surgery School MultiMedica Holding S.p.A. Plastic Surgery Unit Sesto San Giovanni
Valeriano Vinci Andrea Lisa University of Milan Reconstructive and Aesthetic Plastic Surgery School Department of Medical Biotechnology and Translational
446e
Fabio Caviggioli Francesco Klinger University of Milan Reconstructive and Aesthetic Plastic Surgery School MultiMedica Holding S.p.A. Plastic Surgery Unit Sesto San Giovanni, Italy Correspondence to Dr. Maione Università degli Studi di Milano Dipartimento di Biotecnologie Mediche e Medcina Traslazionale (BIOMETRA) IRCCS Istituto Clinico Humanitas U.O. Chirurgia Plastica Via Manzoni 56 20090 Rozzano, Milano, Italy [email protected]
disclosure The authors have no financial interest to declare in relation to the content of this communication. references 1. Pavi JJ, Denekamp J, Letschert J, et al. LENT-SOMA scales for all anatomic sites. Int J Radiat Oncol Biol Phys. 1995;31:1049–1091. 2. Ribuffo D, Atzeni M, Serratore F, Guerra M, Bucher S. Cagliari University Hospital (CUH) protocol for immediate alloplastic breast reconstruction and unplanned radiotherapy: A preliminary report. Eur Rev Med Pharmacol Sci. 2011;15:840–844. 3. Maione L, Forcellini D, Vinci V, Lisa A, Caviggioli F, Klinger F. The effects of postmastectomy adjuvant radiotherapy on immediate two-stage prosthetic breast reconstruction: A systematic review. Plast Reconstr Surg. 2014;133: 729e–730e. 4. Klinger M, Caviggioli F, Klinger FM, et al. Autologous fat graft in scar treatment. J Craniofac Surg. 2013;24: 1610–1615. 5. Rigotti G, Marchi A, Galiè M, et al. Clinical treatment of radiotherapy tissue damage by lipoaspirate transplant: A healing process mediated by adipose-derived adult stem cells. Plast Reconstr Surg. 2007;119:1409–1422.
Studies in Fat Grafting: Part I. Effects of Injection Technique on In Vitro Fat Viability and In Vivo Volume Retention; and Studies in Fat Grafting: Part II. Effects of Injection Mechanics on Material Properties of Fat Sir:
W
e read with great interest the articles by Chung et al. and Atashroo et al. entitled “Studies in Fat Grafting: Part I. Effects of Injection Technique on In Vitro Fat Viability and In Vivo Volume Retention”
Volume 135 Number 2 • Letters and “Studies in Fat Grafting: Part II. Effects of Injection Mechanics on Material Properties of Fat,” respectively.1,2 Autologous fat is promising as an ideal filler.3 However, the procedure can be tedious, and results vary. The study characterized a novel device, the adipose tissue injector, which improves precision, reduces trauma and, more importantly, produces superior results. We look forward to obtaining one for handson experience. Close examination of the study raised some questions that might compromise accurate interpretation of results, which we would like to communicate with the authors. The “modified Coleman technique” is not referenced. The Coleman technique encompasses gentle manual harvest, centrifugation refinement, and slow low-volume retrograde placement of fat.3 The control technique described therein looked quite different. Preinjection fat manipulation was not identical between groups. Specifically, two more transfers (60-cc syringe, to a 10-cc and then to a 1-cc syringe) occurred in the control group. The adipose tissue injector is designed to reduce shear trauma; additional passes through tubing might render the comparison unbalanced.2 The rate of injection is not specified. Coleman emphasizes retrograde delivery at a very low rate (1/10 to 1/30 ml per withdrawal),3 possibly lower than the adipose tissue injector settings (0.5 to 1 cc/second).2 This matters, as slower flow possibly reduces shear force and trauma.2 Two questions arose concerning statistical analysis. First, as the experimental design produced matched readings (the fat of each donor underwent processing three times), repeated measures one-way analysis of variance might better be used. Second, comparison between two groups, carried out when analysis of variance revealed significant differences among the three groups, should be performed with multiple comparison methods for post hoc testing of analysis of variance, rather than with multiple t tests. The latter approach predisposes to type I error (false-positives). Volume retention measured in both groups was lower than that reported by Thanik et al. in a similar model.4 The disparity remains unaddressed, as multiple variables (e.g., donor site, animal species, techniques, and recipient site) were different between them.1,4 Part II of the study measured mechanical properties of fat injected differentially. The adipose tissue injector group more closely resembled minimally processed fat. However, one notes that the test conditions were far different from what the graft will experience in a grafting session. One also wonders whether and to what extent those differences translate into clinical superiority. Despite these issues, the studies were welldesigned explorations into the impact of the adipose
tissue injector on fat grafting. In addition to the low-shear trauma exerted, it will probably save time and labor, enhance precision and reproducibility of results delivered, and shorten the learning curve of fat grafting. Future improvements might be made to improve compatibility with other fat collection and refinement systems, to provide more control over flow to prevent pool formation, to incorporate real-time monitoring of interstitial fluid pressure,5 and to develop customized cannulas with modified inner surfaces to further reduce shear trauma. The pursuit of more precise, less traumatic, more reproducible, and less strenuous ways of delivering satisfactory results should always be admired, and we hope that the adipose tissue injector will prove to be both a technical success and a business success. DOI: 10.1097/PRS.0000000000000931
Yihong Jia, M.D. Nanze Yu, M.D. Yang Wang, M.D. Ang Zeng, M.D. Lin Zhu, M.D. Xiaojun Wang, M.D. Division of Plastic and Reconstructive Surgery Department of Surgery Peking Union Medical College Hospital Beijing, People’s Republic of China Correspondence to Dr. Wang Peking Union Medical College Hospital No. 1, Shuaifuyuan Dongdan Dongcheng District 10005 Beijing, People’s Republic of China [email protected]
DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. REFERENCES 1. Chung MT, Paik KJ, Atashroo DA, et al. Studies in fat grafting: Part I. Effects of injection technique on in vitro fat viability and in vivo volume retention. Plast Reconstr Surg. 2014;134:29–38. 2. Atashroo D, Raphel J, Chung MT, et al. Studies in fat grafting: Part II. Effects of injection mechanics on material properties of fat. Plast Reconstr Surg. 2014;134:39–46. 3. Coleman SR. Structural fat grafting: More than a permanent filler. Plast Reconstr Surg. 2006;118(Suppl):108S–120S. 4. Thanik VD, Chang CC, Lerman OZ, et al. A murine model for studying diffusely injected human fat. Plast Reconstr Surg. 2009;124:74–81. 5. Khouri RK, Rigotti G, Cardoso E, Khouri RK Jr, Biggs TM. Megavolume autologous fat transfer: Part II. Practice and techniques. Plast Reconstr Surg. 2014;133:1369–1377.
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