Prosthetic Reconstruction Research Articles

Prosthetic Breast Reconstruction and Red Breast Syndrome: Demystification and a Review of the Literature.

Red breast syndrome (RBS) represents an inflammatory condition that rarely occurs in the setting of acellular dermal matrix use after prosthetic reconstruction. It is characterized by erythema or rubor that occurs directly over the ADM, and its appearance resembles that of a cellulitis. There have been many explanations with regard to etiology, but none have addressed the physiologic alterations leading to the onset and resolution of RBS. RBS is postulated to be the result of lymphatic disruption and is self-limiting. Resolution is postulated to be the result of angiolymphatic regeneration and the re-establishment of lymphatic flow within the mastectomy skin flap and the ADM, resulting in the clearance of inflammatory mediators responsible for the localized erythema.

PSU4 PATIENT EXPERIENCE WITH DIFFERENT IMPLANT BREAST RECONSTRUCTION SURGERIES

Innovations in prosthetic breast reconstruction have led to new techniques for use following mastectomy. Current strategies focus on the variable location of the breast implant and include prepectoral (above the pectoralis major muscle), dual-plane (partial subpectoral) and total subpectoral. Here we present patient-reported outcomes from patient interviews designed to assess experience of prepectoral, dual-plane and revision (dual-plane to prepectoral) prosthetic breast reconstruction. Literature review and surgeon interview results were summarized and used to develop a semistructured patient interview guide. Women who underwent implant-based breast reconstruction and met eligibility criteria attended 1-hour telephone interviews to review their experience after reconstruction. Results were evaluated using thematic analysis. Three surgeons were interviewed and stated that aesthetic, pain, and mobility outcomes were superior following prepectoral versus dual-plane placement. Twenty patients (10 prepectoral; 4 dual-plane; 6 revision) were interviewed. Through Week 1 after surgery, commonly reported outcomes included: • positive: less pain than expected (prepectoral, 7/10 [70%]; dual-plane, 2/4 [50%]; revision, 1/6 [17%]); breast appearance (prepectoral, 1/10 [10%]; dual-plane, 2/4 [50%]; revision, 5/6 [83%]). • negative: restrictions/inability to perform daily tasks (prepectoral, 5/10 [50%]; dual-plane, 4/4 [100%]; revision, 1/6 [17%]) and pain in breast/chest area (prepectoral, 4/10 [40%]; dual-plane, 3/4 [75%]; revision, 2/6 [33%]). Through Month 3, the most commonly reported: • positive outcomes were ability to perform daily tasks/exercise (prepectoral, 7/10 [70%]; dual-plane, 1/4 [25%], revision, 2/6 [33%]); breast appearance (prepectoral, 3/10 [30%]; dual-plane, 3/4 [75%]; revision, 6/6 [100%]). • negative outcome was pain in breast/chest area (prepectoral, 1/10 [10%]; dual-plane, 2/4 [50%]; revision, 2/6 [33%]). These qualitative interviews identified pain, ability to perform tasks, and breast appearance as key outcomes after implant-based breast reconstruction. Patient reported-outcomes were consistent with those reported by surgeons. Large-scale survey studies are needed to quantify the differences between surgical techniques in these key outcomes.

Influence of Radiation Dose to Reconstructed Breast Following Mastectomy on Complication in Breast Cancer Patients Undergoing Two-Stage Prosthetic Breast Reconstruction.

Purpose: This study investigated the association between radiation dose and complication rate in patients who underwent breast reconstruction to understand the role of radiation hypofractionated regimen, boost radiation therapy (RT), and RT techniques.Methods: We retrospectively evaluated 75 patients treated with post-mastectomy adjuvant RT for breast cancer in the setting of two-stage prosthetic breast reconstruction. Near maximum radiation dose (Dmax) in the 2 or 0.03 cc of reconstructed breast or overlying breast skin was obtained from dose-volume histograms.Results: Post-RT complications occurred in 22.7% of patients. Receiver operating characteristic analysis showed that all near Dmax parameters were able to predict complication risk, which retained statistical significance after adjusting other variables (odds ratio 1.12 per Gy, 95% confidence interval 1.02–1.23) with positive dose-response relationship. In multiple linear regression model (R2 = 0.92), conventional fractionation (β = 11.7) and 16 fractions in 2.66 Gy regimen (β = 3.9) were the major determinants of near Dmax compared with 15 fractions in 2.66 Gy regimen, followed by utilization of boost RT (β = 3.2). The effect of bolus and dose inhomogeneity seemed minor (P > 0.05). The location of hot spot was not close to the high density metal area of the expander, but close to the surrounding areas of partially deflated expander bag.Conclusions: This study is the first to demonstrate a dose-response relationship between risk of complications and near Dmax, where hypofractionated regimen or boost RT can play an important role. Rigorous RT-quality assurance program and modification of dose constraints could be considered as a critically important component for ongoing trials of hypofractionation. Based on our findings, we initiated a multi-center retrospective study (KROG 18-04) and a prospective study (NCT03523078) to validate our findings.

Morphological Measurement of Supracondylar Femur Based on Digital Technology in Chinese Han Population.

ObjectiveRelatively few studies have reported on the morphology of the supracondylar femur, which is a fundamental factor affecting prosthetic reconstruction. The objectives of the present study were to measure the morphological parameters of the supracondylar femur, to classify the supracondylar femur, and to provide theoretical guidance for the development of distal femoral prostheses.MethodsThe study consisted of 82 patients of Han Chinese nationality in North China. There were 57 men and 25 women included in the study, with an average age of 50.9 years (range, 18–87 years). Effective CT data should include a range of more than 10 cm for the distal femur. CT data for the right distal supracondylar femurs was obtained from DICOM files. Results for the cancellous bone and marrow cavity were retained, and information for the cortical bone was erased to obtain information of the lumen. Measurements of the intracortical cavity have not been reported previously. Lumen models were reconstructed with Mimics 17.0 software. The surfaces of the lumen models were smoothed with Geomagic studio 12.0 software. Using the Solidworks 2014 software, we established a 3‐D coordinate system, where variables of the lumen were examined. Correlations between the various measurements were calculated.ResultsThe supracondylar region of the femur was divided into five levels, and the length, breadth, height, and angle values were measured at each level. There were strong correlations between the length indexes (transverse diameter [EF], medial anteroposterior diameter [AC], middle anteroposterior diameter [GH], and lateral anteroposterior diameter [BD]) and the volume index (V). There were also strong correlations among the length indicators (EF, AC, GH, and BD) in each layer. Angle γ was correlated with the lateral anteroposterior diameter (BD) at L2–L6 layers (r = −0.383, −0.385, −0.296, −0.258, −0.24; all P < 0.05) and with the height index (h) at L4–L6 layers (r = −0.244, −0.385, −0.506; all P < 0.05). The most representative parameters were the medial anteroposterior diameter (AC2R2 = 0.865; AC6R2 = 0.932), the coronal width ratio, and the sagittal width ratio with volume. The analysis found that the lumen shape of flower–top hat accounted for 81% at most.ConclusionsThe supracondylar femur has an asymmetrical structural area. The coronal plane is dominated by a flowerpot‐like morphology, and the sagittal plane is narrowest in the lateral 1/3 and resembles a top‐hat‐like morphology. Our results provide theoretical guidance for developing distal femoral prostheses and for their clinical application.

Periimplant Disease and Prosthetic Risk Indicators: A Literature Review.

The purpose of this review was to search in international published peer-review articles, data regarding prosthetic risk indicators affecting the incidence, prevalence, or treatment outcome of periimplant diseases. A literature search was performed in MEDLINE via PubMed database of the US National Library of Medicine of articles published until February 2018; a manual search was also added. Randomized controlled trials, controlled trials, prospective and retrospective cohort studies with a minimum of 20 subjects, having cases with/without exposure to the risk indicator were included. Articles written in another language than English were not included. The 17 articles reviewed indicated the cement residuals at abutments were identified as risk factors for both mucositis and periimplantitis. Among the screw-retained prosthetic reconstructions, prostheses screwed directly to the implants have higher risk to develop periimplant disease. The accessibility and the possibility to perform adequate plaque control around the prosthetic suprastructure decreases the risk for periimplant disease; convex emergence profiles seem to increase it. The crown margins located submucosa may impair the periimplant treatment outcome. Prosthetic reconstruction on implants should be designed in a way to allow accessibility to proper plaque control. Screw-retained suprastructure and crown margins located supra-mucosa should be preferred when possible. When using cement-retained suprastructure, attention should be given to remove cement residuals.

Needs for gerodontological treatment in the elderly living in Lower Silesia.

Many factors influence decisions regarding gerodontological treatment. Apart from the clinical condition of a patient, there is a complex of crucial socioeconomic factors, comorbidities, place of residence, and psychological aspects. Therefore, gerodontological treatment plans are significantly diversified. One of the goals of our cross-sectional epidemiological study of Lower Silesia seniors aged 65-74 was to identify all their needs related to gerodontological treatment. From the randomly selected sample group of 1,600 people, 387 inhabitants of Wrocław and Oława reported to take part in the study. The anamnestic study identified demographic and socioeconomic determinants, coexistence of general diseases and behavioral variables related to oral health behaviors. In the clinical study, the decayed-missing-filled (DMF) index, the community periodontal index (CPI), oral hygiene indices, clinical pathological lesions in oral mucosa, and the index of prosthetic reconstruction of missing teeth according to the World Health Organization (WHO) were determined. Criteria for the need for prosthetic treatment, dental caries treatment, periodontal disease treatment, improvement of oral hygiene, and treatment of mucosal diseases, including potentially pre-cancerous and cancerous disorders, were defined. As many as 95.6% of all respondents required at least 1 form of dental treatment. The most common need (75%) was prosthetic treatment of missing teeth either in the maxilla or in the mandible. Forty-nine per cent of the respondents needed treatment of caries in the clinical crown or root of at least 1 tooth. Further, these needs were related to the following factors: treatment of oral mucosal diseases (35.4%), professional periodontal treatment (35%), improvement of very bad oral hygiene (29.2%), and oncological treatment of pre-cancerous and cancerous lesions in the oral cavity (9.6%). The needs for gerodontological treatment found in the regional study of young Lower Silesian seniors are very high and cannot be met by services provided and funded by the state.

202 Outcomes of Dual Inflatable Penile Prosthesis and Artificial Urinary Sphincter Implantation After Radical Cystectomy and Neobladder

After radical cystectomy (RC) and orthotopic neobladder (ONB), post-operative complications such as erectile dysfunction and stress urinary incontinence can arise. While combined prosthetic reconstruction can treat both these issues, the feasibility and viability of dual implantation has not been studied in this unique subset of patients. To examine the outcomes of male patients who have undergone placement of both an artificial urinary sphincter (AUS) and 3-piece inflatable penile prosthesis (IPP) after RC and ONB diversion. Using a prospectively-maintained IRB-approved institutional database, we identified 39 patients who underwent RC and NB and subsequent implantation of an AUS and IPP from 2003 to 2017. Patients were included if they had devices placed synchronously or metachronously. Two patients with follow-up duration less than 12 months were excluded from analysis. An infrapubic approach was used in most patients for IPP placement, with reservoir placement in the lateral retroperitoneal space through a counter-incision medial to the anterior superior iliac spine. AUS placement was performed using a transperineal incision in all patients. 12 patients underwent synchronous device placement. Patient demographics, perioperative data, and postoperative outcomes including prosthetic infection, mechanical failure, and revision surgery were examined and statistical analysis was performed.

Frontal sinus augmentation: Preliminary results of a new approach in prosthetic orbital reconstruction

PurposeReliable application of endosseous implants for prosthetic facial reconstruction depends on the bone volume available at the defect site. Regarding the orbit, sufficient bone presentation in the medial superior orbital rim is limited due to the frontal sinus. The aim of this article is to report for the first time on the augmentation of the frontal sinus for gaining bone volume for supraorbital implant placement. Materials and methodsBetween 2007 and 2014, five patients with orbital exenteration were treated by frontal sinus augmentation using autogenous cancellous bone graft from the ilium. Extraoral implants for prosthetic orbit reconstruction were placed 4–7 months later. In advance, cadaver surgery was performed to prove the feasibility of the method. Surgical technique is described, and intraoperative images are provided. ResultsThe frontal sinus was successfully augmented in all five patients. No major complications related to the procedure were observed. A total of nine orbital implants were inserted in the augmented bone, thereof one sleeping implant. Six implants were restored prosthetically, two implants were lost at exposure. The observation period ranged from 6 to 97 months (mean: 52.8 months). Mean time for patient rehabilitation was 13 months. High patient satisfaction was achieved with the implant-retained orbital prosthesis. ConclusionThe augmentation of the frontal sinus allows implant placement by providing sufficient bone volume in the medial supraorbital rim. Considering the surgical success of this method and patient satisfaction, this new approach is concluded to be a viable option in a unique subset of patients.

Two-stage Prosthetic Prepectoral Breast Reconstruction: Comparing Tissue Expansion with Carbon Dioxide and Saline.

Background:The AeroForm tissue expander is a carbon dioxide-filled breast tissue expander that allows gradual, needle-free expansion using a hand-held remote controller. This study evaluates 2-stage, prepectoral tissue expander-to-implant breast reconstruction with the carbon-dioxide tissue expanders and compares the outcomes to our recent experience with saline tissue expanders.Methods:This was a retrospective study of consecutive patients from a single institution. The subjects consisted of women who underwent mastectomy and either immediate or delayed breast reconstruction with AeroForm or saline tissue expanders. Outcomes encompassed postoperative complications including mastectomy flap necrosis, infection requiring readmission and/or intravenous antibiotics, capsular contracture, hematoma, seroma, skin dehiscence, extrusion, premature explant, and loss of communication with the device (AeroForm) or rupture of the device (saline).Results:This study evaluated 115 patients with 185 breast reconstructions. Of the 185 breast reconstructions, 74 (40%) utilized AeroForm tissue expanders and 111 (60%) utilized traditional saline tissue expanders. Treatment was successful in 100% and 94% in the AeroForm and saline groups, respectively (P = 0.025). The incidence of adverse events was greater in the saline group (45.9% versus 32.4%). Surgical-site infection occurred more commonly in the saline group (5.4% versus 0%). Full-thickness skin necrosis occurred at a significantly higher rate in the saline cohort as compared with AeroForm (5.4% versus 0%).Conclusions:The use of AeroForm tissue expanders offers notable advantages for breast reconstruction. This device when employed in the prepectoral space may be associated with reduced infection rates and decreased utilization of healthcare and patient resources.

The impact of adjuvant radiotherapy on the outcome of immediate breast reconstruction after mastectomy in breast cancer patients

Background. Data allowing to estimate the impact of postoperative radiotherapy on the possibility of prosthetic breast reconstruction with silicone implants or tissue expanders are mainly presented in single-level retrospective cohort studies.&#x0D; Material and methods. We searched for scientific papers in English published from January 1, 2000 to September 30, 2018 in the PubMed/MEDLINE database. The study parameters included demographic data, the method of breast reconstruction, information about adjuvant radiotherapy parameters, the incidence of postoperative complications.&#x0D; Results and discussion. Having studied the data about immediate prosthetic breast reconstruction with silicone implant or a tissue expander performed after mastectomy in 3,654 breast cancer patients. The complications after surgery were reported in 40% of all clinical observations. In 15% of cases, the specialists stopped the attempts to perform breast reconstruction. In general, the aesthetic results of immediate prosthetic breast reconstruction performed before postop radiotherapy are far from being perfect. Nevetheless, most patients are satisfied with them after the surgery.&#x0D; Conclusion. Adjuvant radiotherapy has a negative impact on the results of immediate prosthetic breast reconstruction after mastectomy. Despite this, the need for radiotherapy should not be regarded as an absolute contraindication for the immediate breast reconstruction with silicone implants and tissue expanders.

Dental Implant Rehabilitation After Jaw Reconstruction Assisted by Virtual Surgical Planning.

To evaluate effects of preoperative virtual planning and jaw reconstruction guided by dental implant rehabilitation on dental prosthesis rehabilitation after jaw reconstruction. Patients indicated for segmental jaw resection and who agreed to receive jaw reconstruction procedures were enrolled in the study. Appropriate surgical procedures were determined by a maxillofacial surgeon and a prosthodontist before surgery. The virtual design was created according to preoperative computed tomography. Patients were divided into navigation and non-navigation groups. Implant surgery was performed 6 months after reconstruction surgery. After treatment completion, factors such as survival rate of implants, site of reconstruction, type of graft, and type of prosthesis were compared. In total, 29 patients were included in the study, with 16 patients in the non-navigation group and 13 in the navigation group. A total of 101 implants were inserted, and the implant success rate was 98.02% (2 implants extracted due to peri-implantitis). All patients received prosthetic treatment. Of the 13 navigation group patients, 9 received fixed implant-supported prostheses, whereas the other 4 received removable dentures. Of the 16 non-navigation group patients, 9 eventually received fixed implant-supported prostheses and 7 received removable dentures. There were no significant intergroup differences in terms of prosthesis type (P = .702). However, the proportion of fixed implant-supported prostheses in the navigation group was higher compared with the non-navigation group. Preoperative virtual planning and dental implant rehabilitation-guided jaw reconstruction through preoperative designing can provide a good opportunity to achieve high rates of implant success and dental rehabilitation. This method can also benefit fixed implant-supported prosthetic restorations. Moreover, the use of navigation after virtual planning has no effect on the type of prosthetic reconstruction.

Evaluation of Acellular Dermal Matrix Efficacy in Prosthesis-Based Breast Reconstruction

Background Although many studies have examined the safety of acellular dermal matrix in immediate prosthetic breast reconstruction, few studies have evaluated efficacy. This study examined initial tissue expander fill volume as a marker of efficacy, comparing patients after staged prosthetic breast reconstruction assisted with acellular dermal matrix versus breast reconstruction not assisted with acellular dermal matrix. Number of fill visits and time interval to implant exchange were examined as secondary endpoints. Methods An institutional review board-approved retrospective chart review was conducted to identify consecutive staged prosthetic reconstruction cases over 12 years. Results Mean initial tissue expander fill volume was significantly higher in the acellular dermal matrix group compared with the non-acellular dermal matrix group (180.8 ± 150.0 versus 45.8 ± 74.4; p = 0.00). Normalizing for final implant size, the acellular dermal matrix group exhibited significantly higher perioperative fill (0.33 ± 0.24 versus 0.11 ± 0.16; p = 0.00). A collinear trend was observed between acellular dermal matrix use and direct-to-implant reconstruction procedures during the study period. Conclusions These results suggest that acellular dermal matrix use is more efficacious in achieving greater initial fill volume, fewer visits for expansion, and a shorter time interval to implant exchange compared with non-acellular dermal matrix procedures. The authors also describe a collinear relationship between acellular dermal matrix use and transition to direct-to-implant procedures at their institution. This work serves as a framework for future studies evaluating acellular dermal matrix efficacy, and guides innovation of biomaterials to support breast reconstruction. Clinical question/level of evidence Therapeutic, III.

Prepectoral breast reconstruction and radiotherapy-a closer look.

Prosthetic breast reconstruction in the setting of post-mastectomy radiation therapy (PMRT) has historically been plagued by complications and poor outcomes. We study the effects of PMRT in the setting of prepectoral prosthetic breast reconstruction in an attempt to ascertain the value of this muscle sparing technique as it relates to complications and outcomes. A retrospective analysis was performed on patients who underwent immediate, prepectoral, direct-to-implant or two-staged expander/implant breast reconstruction following skin-sparing mastectomy (SSM) or nipple-sparing mastectomy (NSM) and had postmastectomy radiotherapy. Results and complications were recorded. In patients who underwent two-staged reconstruction, at the second stage, on visual inspection, the acellular dermal matrix was noted to be completely integrated in all breasts, including those that had been irradiated after expander placement. Postoperative complications in irradiated breasts were limited to two breasts. In one breast, there was one incidence of wound dehiscence after expander irradiation, which led to expander removal and salvage with transverse rectus abdominis musculocutaneous (TRAM) flap reconstruction. In the second breast, there was one incidence of seroma after implant irradiation, which was managed conservatively as an outpatient. The seroma was drained and the patient treated with oral antibiotics. There were no complications in nonirradiated breasts. There was no incidence of clinically significant capsular contracture (grade III/IV) in irradiated or nonirradiated breasts. Prepectoral breast reconstruction has been an important addition to our reconstructive armamentarium and is proving to be a safe and effective means of performing prosthetic breast reconstruction in a wide array of patient populations. We have seen excellent physiologic and aesthetic outcomes in our patients following PMRT with minimal complications. Indeed, long-term follow-up will be required to elucidate the true effectiveness of this technique but preliminary results are quite promising.

Two-stage prepectoral breast reconstruction.

The options for prosthetic breast reconstruction have expanded and include prepectoral versus subpectoral location of devices as well as performing these operations in one- or two-stage. Current practice patterns are evolving toward the placement of devices in the prepectoral plane in a single stage. The authors' patient selection criteria and surgical technique were reviewed and organized in a step-by-step format. On and off label techniques for acellular dermal matrix (ADM) assembly were reviewed. A review of surgical outcomes was completed. Two-stage reconstruction confers several advantages such as reducing pressure on the mastectomy skin flaps, optimal implant selection for the second stage and the opportunity to revise the reconstruction, all of which can increase the likelihood of a successful outcome. This manuscript will review the indications, techniques, and outcomes following prepectoral, two-stage prosthetic breast reconstruction.

Correction of animation deformity with subpectoral to prepectoral implant exchange

Breast animation deformity is a known complication associated with submuscular prosthetic breast reconstruction. Patients often will present months to years after their initial reconstruction complaining of chronic pain and visible contraction deformity of their chest, with minimal voluntary activation of their pectoralis musculature. This is aesthetically displeasing and physically uncomfortable. Our preferred method for addressing existing animation deformity and alleviating patients' symptoms involves reoperation, with implant pocket conversion to the prepectoral plane, with acellular dermal matrix (ADM) coverage. We performed a retrospective review of all patients who underwent prepectoral conversion of their breast reconstruction for correction of animation deformity with the senior author (HS) between March 2016-April 2018. Demographics, operative details, and post-operative outcomes were assessed. Thirty-one patients underwent 55 revision breast reconstructions for a history of significant animation deformity following their initial submuscular breast reconstruction. All initial breast reconstructions were done with partial muscular coverage of their implant at the time of reconstruction. All patients experienced complete resolution of animation deformity without recurrence. Unplanned return to the operating room occurred in 14.5% of reconstructions. This was four cases of capsular contracture, three infections and one hematoma evacuation. Overall rate of infection requiring intravenous antibiotics was 14.5%. One patient lost both of her reconstructed breasts for an overall implant loss rate of 1.8% implant coverage with ADM was performed in 83.6% of cases, whereas 16.4% of reconstructions were performed with implant pocket change alone. The cohort that did not use ADM had a 44.4% instance of capsular contracture requiring reoperation, compared to a 0% rate of capsular contracture when ADM was used (P<0.01). Implant pocket change from the submuscular plane to the prepectoral plane is a safe and effective means of addressing submuscular associated breast animation deformity. The application of preoperative fat grafting and intraoperative ADM coverage contributes towards lower rates of complications and decreases the need for revisionary procedures.

An overview of animation deformity in prosthetic breast reconstruction.

Animation deformity is an unsightly complication after sub-pectoral breast reconstruction characterized by implant displacement with pectoralis muscle contraction. Recent increased awareness of this phenomenon has driven interest in pre-pectoral breast reconstruction but research is limited regarding the causes and implications of animation deformity. Specifically, no patient-specific risk factors have been identified as contributing to animation deformity. Placement in a sub-pectoral plane and division of the pectoralis are the only peri-operative factors associated with severity of animation deformity. Our own quantitative analysis of animation deformity has further refined our understanding of this phenomenon, which we present here along with a review of current grading scales. We also more broadly review the current literature surrounding animation deformity, including its causes, risk factors, impact on patient outcomes and current treatment options. Overall, patients find this to be an emotionally distressing complication and most patients would like to be educated on alternative surgical options to avoid animation deformity. Treatment options range from conversion to a pre-pectoral plane to muscle-splitting techniques to selective nerve ablation to Botox injections. Further research into causes, implications and ways to enhance pre-pectoral reconstruction are needed to improve patient outcomes with this phenomenon.

In Vivo Measurement of Root Canal Wall Temperature at Different Stages Prior to Fiber Post Cementation.

Objective This study measured the in vivo temperature of prepared root canal walls during various stages of treatment prior to endodontic postcementation. Materials and Methods One tooth each from five patients requiring endodontic treatment received conventional gutta-percha obturation. The coronal 4 mm of gutta-percha was removed by drilling and the canal wall temperature was measured. A sterile, saline rinse was applied, and another temperature value was recorded. Paper points were placed, and the wall temperature was recorded. A standardized period of 1.5 minute passed, simulating time needed to mix and place the resin cement and post (no resin was placed), after which the final wall temperature was obtained. The tooth was temporized and scheduled for prosthetic reconstruction. A one-way repeated measure analysis of variance (with Tukey's post hoc test) was performed among mean temperature values for each treatment stage (preset α 0.05). Results Significant temperature differences were found among the treatment stages. Canal space drilling yielded the highest temperature (35.5 ± 0.8°C), while the lowest was obtained after saline rinsing (34.0 ± 0.9°C). The temperature of prepared root canal wall prior to postplacement (34.9 ± 1.2°C) and following paper point drying (34.8 ± 1.1°C) presented intermediate results, with no statistical difference between them. Conclusions This study suggested that root canal wall temperature varied during various stages of preparation prior to endodontic post.

Subcutaneous Prosthetic Breast Reconstructions following Skin Reduction Mastectomy.

Background:Prepectoral prosthetic breast reconstruction is gaining popularity, offering muscle preservation and outcomes similar to subpectoral implant placement in small or moderate size breasts. This study compares the complications of prepectoral and subpectoral immediate prosthetic breast reconstructions following skin reduction mastectomy in large and ptotic breasts.Methods:All consecutive patients who underwent immediate tissue expander-based reconstruction following Wise pattern skin reduction mastectomy from November 2011 through August 2017 by a single surgeon were reviewed. The collected data included patient demographics and complications (eg, skin necrosis, hematoma, infection, seroma, implant loss, capsular contracture).Results:A total of 54 patients underwent 87 immediate breast reconstructions including 45 subpectoral and 42 prepectoral tissue expander placements. The subpectoral patients had greater body mass indexes (32.5 ± 6.6 versus 29.9 ± 5.4, P = 0.026), higher initial (518 ± 168 ml versus 288 ± 140 ml, P < 0.001) and final (694 ± 123 ml versus 585 ± 122 ml, P = 0.014) implant volumes, more skin flap necrosis (40.0% versus 16.7%, P = 0.044) and infections (37.8% versus 11.9%, P = 0.01) than their prepectoral counterparts, whereas seromas were more common in the prepectoral group (4.4% versus 26.2%, P = 0.015). The overall complication rate, although higher in the subpectoral group compared with the prepectoral group, was not significantly different (62.2% versus 40.5%, P = 0.072).Conclusions:Prepectoral tissue expander placement after skin reduction mastectomy is an appealing reconstructive option in patients with large and ptotic breasts. Prosthetic reconstruction following Wise-pattern skin reduction mastectomy is invariably associated with high complication rates irrespective of the plane of implant placement. Greater emphasis should be placed on patient counseling and complication prevention in this challenging patient population.

Early experiences with robot-assisted prosthetic breast reconstruction.

Robotic surgery facilitates surgical procedures by employing flexible arms with multiple degrees of freedom and providing high-quality 3-dimensional imaging. Robot-assisted nipplesparing mastectomy with immediate reconstruction is currently performed to avoid breast scars. Four patients with invasive ductal carcinoma underwent robot-assisted nipple-sparing mastectomy and immediate robot-assisted expander insertion. Through a 6-cm incision along the anterior axillary line, sentinel lymph node biopsy and nipple-sparing mastectomy were performed by oncologic surgeons. The pectoralis major muscle was elevated, an acellular dermal matrix (ADM) sling was created with robotic assistance, and an expander was inserted into the subpectoral, sub-ADM pocket. No patients had major complications such as hematoma, seroma, infection, capsular contracture, or nipple-areolar necrosis. The mean operation time for expander insertion was 1 hour and 20 minutes, and it became shorter with more experience. The first patient completed 2-stage prosthetic reconstruction and was highly satisfied with the unnoticeable scar and symmetric reconstruction. We describe several cases of immediate robot-assisted prosthetic breast reconstruction. This procedure is a feasible surgical option for patients who want to conceal surgical scars.

In Vivo Accuracy of Implant Placement Using a Full Digital Planning Modality and Stereolithographic Guides.

The aim of this study was to investigate a guided implant surgery procedure performed without any manual processes, by assessing the in vivo results following a digital planning and placement of dental implants using surgical templates. Eligible patients were screened and enrolled in this prospective clinical study. A cone beam computed tomography (CBCT) scan was acquired, and the remaining dentition and soft tissues were recorded by an intraoral scanner after enrollment. The CBCT data and intraoral scan were fused in the planning software. The prosthetic reconstructions were digitally designed by a prosthodontist, and the ideal position of the dental implants was determined. The surgical template was digitally designed based on this plan, and a guide design was exported and manufactured in a stereolithographic process. The entire surgical procedure was performed with the aid of the template. An intraoral scan was performed 10 days after stage-two surgery using scan bodies placed on the implants. Digital preoperative and postoperative models were compared, and the metric difference between the planned and achieved implant positions was calculated. Twenty-seven implants were placed in 20 patients using tooth-supported surgical templates after a digital planning procedure. No implants were lost during the study period. The mean lateral deviation measured at the coronal point was 1.05 mm (SD: 0.59; range: 2.74 to 0.36). The mean lateral deviation measured at the apical point was 1.63 mm (SD: 1.05; range: 5.16 to 0.56). The mean depth displacement was + 0.48 mm (SD: 0.50; range: 1.33 to -0.52). The mean angle deviation was 3.85 degrees (SD: 1.83; range: 8.6 to 1.25). A simplified full digital planning procedure yields results comparable to conventional guided implant surgery. The main deviation between the planned and achieved implant positions in this prospective clinical study was angular. More clinical studies are needed to verify the procedure further.