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Lastly, techniques to expand indications for NSM and maximize nipple viability as well as preshape the breast are discussed. Through thoughtful preoperative planning and intraoperative technique, ideal aesthetic results in NSM may be achieved.The aesthetics of breast reconstruction inherently rely on both the ablative and reconstructive procedures. Mastectomy flap quality remains one of the most critical factors in determining the success of a reconstruction and its aesthetic outcome. Maintaining the segmental perfusion to the nipple and skin envelope during mastectomy requires preserving the subcutaneous tissue superficial to the breast capsule. Because this layer of tissue varies in thickness among different patients and within each breast, anatomic dissection along the appropriate planes is required rather than a "one-size-fits-all" mentality. A team-based approach between the breast surgeon and plastic surgeon will optimize both the ablative and reconstructive procedures while engaging in a process of shared decision-making with the patient. Preoperative clinical analysis and utilization of imaging to assess individual breast anatomy will help guide mastectomies as well as decisions on reconstructive modalities. Critical assessment of mastectomy flaps is paramount and requires flexibility to adapt reconstructive paradigms intraoperatively to minimize the risk of complications and provide the best aesthetic result.With continuous technical and functional advances in the field of breast reconstruction, there is now a greater focus on the artistry and aesthetic aspects of autologous reconstruction. Whereas once surgeons were most concerned with flap survival and vessel patency, they are now dedicated to reconstructing a similarly or even more aesthetically pleasing breast than before tumor resection. We discuss the approach to shaping the breast through the footprint, conus, and skin envelope. We then discuss how donor site aesthetics can be optimized through flap design, scar management, and umbilical positioning. Each patient has a different perception of their ideal breast appearance, and through conversation and counseling, realistic goals can be set to reach optimal aesthetic outcomes in breast reconstruction.
Prepectoral placement of prosthetic devices is rapidly becoming the preferred method of breast reconstruction.
The objective of this study was to review long-term surgical and aesthetic outcomes following prepectoral prosthetic breast reconstruction.
The study included 90 patients (139 breasts). Follow-up for all patients ranged from at least 1 year up to a maximum of 4.3 years. Parameters analyzed included preoperative and postoperative breast symmetry, rippling, edge visibility, and capsular contracture, as well as secondary procedures such as fat grafting, implant exchange, contralateral procedures, and autologous flap conversion.
The incidence of breast symmetry, which was noted preoperatively in 84.4% of patients, gradually declined to 68.9% after 1 to 2 years and to 56.7% after 2 to 5 years. Rippling and edge visibility were noted in 19.4% and 12.9% of patients, respectively. Explantation without replacement of the device was performed in 12 breasts (8.6%). Secondary procedures included autologous fat grafting (23.7%), implant replacement (7.2%), conversion to an autologous flap (12.2%), and a contralateral breast procedure in 15 of 41 patients (36.6%). Capsular contracture (grade 3-4) was demonstrated in 14 of 139 breasts (10.1%).
Prepectoral breast reconstruction can provide good to excellent short-term (1-2 years) and longer-term (2-4.3 years) benefits; however, over time, the quality of prepectoral breast reconstruction as well as breast symmetry can change due to various factors.
Implant-based breast reconstruction is the most common means to rebuild the breast following mastectomy. Although largely successful in restoring breast shape, suboptimal results may occur secondary to inadequate size or projection, malposition, rippling and contour irregularities, nipple malposition, capsular contracture, or implant rotation/flipping. This article reviews common strategies to improve implant reconstruction outcomes with revisional surgery.
The standard Western diet is high in processed hyperpalatable foods that displace nutrient-dense whole foods, leading to inflammation and oxidative stress. There is limited research on how these adverse metabolic drivers may be associated with maladaptive neuroplasticity seen in chronic pain and whether this could be attenuated by a targeted nutritional approach. The aim of this study was to review the evidence for whole-food dietary interventions in chronic pain management.
A structured search of eight databases was performed up to December 2019. Two independent reviewers screened studies and evaluated risk of bias by using the National Institutes of Health assessment tool for controlled or pre-post studies and the Joanna Briggs checklist for case reports. A meta-analysis was performed in Review Manager.
Forty-three studies reporting on 48 chronic pain groups receiving a whole-food dietary intervention were identified. These included elimination protocols (n = 11), vegetarian/vegan diets (n = 11), sing an overall positive effect of whole-food diets on pain, with no single diet standing out in effectiveness. This suggests that commonalities among approaches (e.g., diet quality, nutrient density, weight loss) may all be involved in modulating pain physiology. Further research linking how diet can modulate physiology related to pain (such as inflammation, oxidative stress, and nervous system excitability) is required.
Current prophylaxis options for people at risk for HIV infection include two US FDA-approved daily pre-exposure prophylaxis (PrEP) regimens and guidelines for a 2-1-1 event-driven course specifically for men who have sex with men. Despite this, PrEP use rates remain suboptimal, and additional PrEP options may help to improve uptake among diverse populations. Plerixafor order Here, we evaluated protective efficacy of two-dose PrEP and two-dose postexposure prophylaxis (PEP) schedules with emtricitabine (FTC)/tenofovir alafenamide (TAF) with or without bictegravir (BIC) in an SHIV macaque model.
Macaques received one oral dose of 200 mg emtricitabine, 25 mg tenofovir alafenamide and 25-100 mg of bictegravir to establish pharmacokinetic profiles of each drug either in the plasma or the peripheral blood mononuclear cells. Protective efficacy of multiple two-dose PrEP and PEP schedules with FTC/TAF with or without bictegravir was then assessed in two repeat low-dose rectal SHIV challenge studies.
The data revealed over 95% per-exposure risk reduction with FTC/TAF PrEP initiated 2 h before the exposure, but a loss of significant protection with treatment initiation postexposure.
