title: Management of Implant Exposure in One-Stage Breast Reconstruction Using Titanium-Coated Polypropylene Mesh: Sub-Mammary Intercostal Perforator Flap.
abstract: BACKGROUND
  One-stage implant-based breast reconstruction using titanium-coated polypropylene mesh is a novel approach widely used in Europe. Complication rates in breast reconstruction with the use of titanium-coated meshes seem to be comparable to those in patients with implant-based breast reconstruction alone. However, the use of synthetic meshes in implant-based breast reconstructive surgery leads to new clinical scenarios with the need for the breast surgeon to face new complications. We present an innovative treatment of implant exposure in the absence of infection in patients who underwent nipple-sparing mastectomy and immediate breast reconstruction with silicone implants and titanium-coated polypropylene mesh by using a pedicled sub-mammary intercostal perforator flap.
  
  
  METHODS
  Four patients who experienced implant exposure without infection have been treated with the use of a sub-mammary intercostal perforator flap. Whole coverage of the exposed implant/mesh with a sub-mammary intercostal perforator flap was obtained in all cases. No post-operative complications have been observed, whereas a pleasant aesthetic result has been achieved. Patients' post-operative quality of life and satisfaction levels were measured by the European Organisation for Research and Treatment of Cancer breast cancer-specific quality of life QLQ-BR23 questionnaire and showed an average good satisfaction with the post-operative outcomes (mean QLQ-BR23 score 1.9).
  
  
  CONCLUSIONS
  For the first time, a sub-mammary intercostal perforator flap has been used with the aim of treating implant exposures without removing the prosthesis even in the presence of synthetic meshes, when wound infection was excluded. Although tested on a small series, the sub-mammary intercostal perforator flap might represent a simple, versatile and cost-effective procedure for the management of implant exposure following nipple-sparing mastectomy and immediate reconstruction with silicone implants and synthetic meshes. It should be considered to avoid implant removal followed by delayed free flap reconstruction as "salvage surgery."
  
  
  METHODS
  This journal requires that the authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
authors.affiliation: Breast Department, National Cancer Institute of Naples IRCCS "G. Pascale", Naples, Italy.
authors.forename: Michele Antonio
authors.initials: MA
authors.lastname: De Riggi
authors.affiliation: Department of Clinical Medicine and Surgery, University of Naples "Federico II", Via S. Pansini 5, 80131, Naples, Italy. nicolarocco2003@gmail.com.
authors.forename: Nicola
authors.identifier: http://orcid.org/0000-0001-6941-7873
authors.initials: N
authors.lastname: Rocco
authors.affiliation: Breast Department, National Cancer Institute of Naples IRCCS "G. Pascale", Naples, Italy.
authors.forename: Giulio
authors.initials: G
authors.lastname: Gherardini
authors.affiliation: Breast Department, National Cancer Institute of Naples IRCCS "G. Pascale", Naples, Italy.
authors.forename: Emanuela
authors.initials: E
authors.lastname: Esposito
authors.affiliation: Breast Department, National Cancer Institute of Naples IRCCS "G. Pascale", Naples, Italy.
authors.forename: Massimiliano
authors.initials: M
authors.lastname: D'Aiuto
mesh_terms: D000328:Adult; D019928:Breast Implantation / Q000009:adverse effects*; D018427:Breast Implants / Q000009:adverse effects*; D001943:Breast Neoplasms / Q000473:pathology / Q000601:surgery; D020099:Coated Materials, Biocompatible; D004954:Esthetics; D005260:Female; D006801:Humans; D008323:Mammary Arteries / Q000637:transplantation; D015414:Mastectomy, Subcutaneous / Q000379:methods; D008875:Middle Aged; D061525:Perforator Flap / Q000098:blood supply / Q000637:transplantation*; D011126:Polypropylenes; D011475:Prosthesis Failure; D012086:Reoperation / Q000379:methods; D018570:Risk Assessment; D012494:Sampling Studies; D013526:Surgical Mesh; D016896:Treatment Outcome; D014945:Wound Healing / Q000502:physiology
chemical_list: D020099:Coated Materials, Biocompatible; D011126:Polypropylenes
keywords: Breast reconstruction; Implant exposure; Sub-mammary intercostal perforator flap; TiLOOP Bra