title: Can titanium mesh influence local recurrence management after implant-based breast reconstruction?
abstract: BACKGROUND
  TiLOOP(®) Bra is a permanent titanium-coated polypropylene mesh currently used in post-mastectomy breast reconstruction with implants. This mesh is generally presented as inducing low-grade inflammatory reactions, but only few reports focused on its possible side effects. In the case described here, the use of the mesh led to minor clinical problems that needed to be clinically and surgically managed at the same time as a local relapse.
  
  
  METHODS
  A patient with high-grade ductal carcinoma in situ underwent primary surgery (nipple-sparing mastectomy and one-stage reconstruction using the TiLOOP(®) Bra mesh) and was subsequently referred for radiological and clinical investigation when various nodules became apparent during a follow-up physical examination. Prior to the histopathological proof, the diagnosis of local recurrence was complicated by the occurrence of an extensive granulomatous reaction in the fixation areas along with mild inflammatory changes scattered on the surface of the mesh.
  
  
  RESULTS
  This case illustrates a side effect of titanium-coated permanent mesh in immediate implant-based reconstruction, i.e. the formation of granulomas in the inframammary fold, probably in the area where the mesh had been folded or fixed. We propose a safer technical approach to avoid the problem and a clinical management strategy for patients at high risk of local recurrence who develop granuloma-like nodules.
  
  
  CONCLUSIONS
  A surgical technique is suggested to prevent granuloma formation. If, however, subcutaneous nodules that may be local recurrences do appear, they should not be interpreted by default as a granulomatous reaction, but should be fully investigated and possibly excised.
authors.affiliation: Unit of Plastic and Reconstructive Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, 20133 Milan, Italy.
authors.forename: Egidio
authors.initials: E
authors.lastname: Riggio
authors.affiliation: Unit of Breast Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, 20133 Milan, Italy.
authors.forename: Camelia
authors.initials: C
authors.lastname: Chifu
authors.affiliation: Unit of Breast Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, 20133 Milan, Italy.
authors.forename: Gabriele
authors.initials: G
authors.lastname: Martelli
authors.affiliation: Unit of Breast Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, 20133 Milan, Italy.
authors.forename: Cristina
authors.initials: C
authors.lastname: Ferraris
keywords: Granuloma; Implant reconstruction; Local recurrence risk; Nipple-sparing mastectomy; Titanium-coated polypropylene mesh