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Sezer A, Ozalp H, Imge Ucar-Goker B, Gencer A, Ozogul E, Cennet O, Yazici G, Arica Yegin B, Yabanoglu-Ciftci S. Protective role of transforming growth factor-Β3 (TGF-Β3) in the formation of radiation-induced capsular contracture around a breast implant: In vivo experimental study. Int J Pharm 2024; 665:124715. [PMID: 39284424 DOI: 10.1016/j.ijpharm.2024.124715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2024] [Revised: 08/27/2024] [Accepted: 09/11/2024] [Indexed: 09/21/2024]
Abstract
Postmastectomy radiotherapy causes capsular contracture due to fibroproliferation of the capsular tissue around the implant. In fibrosis, unlike normal wound healing, structural and functional disorders are observed in the tissues caused by excessive/irregular accumulation of extracellular matrix proteins. It has been reported that transforming growth factor-β3 (TGF-β3) prevents and reverses fibrosis in various tissues or provides scarless healing with its antifibrotic effect. Additionally, TGF-β3 has been shown to reduce fibrosis in radiotherapy-induced fibrosis syndrome. However, no study in the literature investigates the effects of exogenously applied TGF-β3 on capsular contracture in aesthetic or reconstructive breast implant application. TGF-β3, which has a very short half-life, has low bioavailability with parenteral administration. Within the scope of this study, free TGF-β3 was loaded into the nanoparticles to increase its low bioavailability and extend its duration of action by providing controlled release. The aim of this study is to investigate the preventive/improving effects of radiation induced capsular contracture using chitosan film formulations containing TGF-β3 loaded poly(lactic-co-glycolic acid)-b-poly(ethylene glycol) (PLGA-b-PEG) nanoparticles in implant-based breast reconstruction. In the characterization studies of nanoparticles, the particle size and zeta potential of the TGF-β3-loaded PLGA-b-PEG nanoparticle formulation selected to be used in the treatment group were found to be 123.60 ± 2.09 nm and -34.87 ± 1.42 mV, respectively. The encapsulation efficiency of the formulation was calculated as 99.91 %. A controlled release profile was obtained in in vitro release studies. Chitosan film formulations containing free TGF-β3 or TGF-β3-loaded PLGA-b-PEG nanoparticles were used in in vivo studies. In animal studies, rats were randomly distributed into 6 groups (n = 8) as sham, implant, implant + radiotherapy, implant + radiotherapy + chitosan film containing unloaded nanoparticles, implant + radiotherapy + chitosan film containing free TGF-β3, implant + radiotherapy + chitosan film containing TGF-β3 loaded nanoparticle. In all study groups, a 2 cm incision was made along the posterior axillary line at the thoracic vertebral level in rats to reach the lateral edge of the latissimus dorsi. The fascial attachment to the chest wall was then bluntly dissected to create a pocket for the implants. In the treatment groups, the wound was closed after films were placed on the outer surface of the implants. After administering prophylactic antibiotics, rats were subjected to irradiation with 10 Gy photon beams targeted to each implant site. Each implant and the surrounding excised tissue were subjected to the necessary procedures for histological (capsule thickness, cell density), immunohistochemical, and biochemical (α-SMA, vimentin, collagen type I and type III, TGF-β1 and TGF-β3: expression level/protein level) examinations. It was determined that the levels of TGF-β1 and TGF-β3 collagen type III, which decreased as a result of radiotherapy, were brought to the control level with free TGF-β3 film and TGF-β3 nanoparticle film formulations. Histological analyses, consistent with biochemical analyses, showed that thick collagen and fibrosis, which increased with radiotherapy, were brought to the control level with free TGF-β3 film and TGF-β3 nanoparticle film treatments. In biochemical analyses, the decrease in thick collagen was compatible with the decrease in the collagen type I/type III ratio in the free TGF-β3 film and TGF-β3 nanoparticle film groups. Changes in protein expression show that TGF-β3 loaded nanoparticles are more successful than free TGF-β3 in wound healing. In line with these results and the literature, it is thought that the balance of TGF-β1 and TGF-β3 should be maintained to ensure scarless wound healing with no capsule contracture.
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Affiliation(s)
- Aysima Sezer
- Hacettepe University, Faculty of Pharmacy, Department of Biochemistry, 06100 Ankara, Turkey
| | - Hulya Ozalp
- Hacettepe University, Faculty of Pharmacy, Department of Pharmaceutical Biotechnology, 06100 Ankara, Turkey
| | - Bercis Imge Ucar-Goker
- Kütahya Health Sciences University, Faculty of Medicine, Department of General Surgery, 43000 Kutahya, Turkey
| | - Ayse Gencer
- Hacettepe University, Faculty of Pharmacy, Department of Pharmaceutical Technology, 06100 Ankara, Turkey
| | - Ece Ozogul
- Hacettepe University, Department of Pathology, 06100 Ankara, Turkey
| | - Omer Cennet
- Hacettepe University, Faculty of Medicine, Department of General Surgery, 06100 Ankara, Turkey
| | - Gozde Yazici
- Hacettepe University, Faculty of Medicine, Department of Radiation Oncology, 06100 Ankara, Turkey
| | - Betul Arica Yegin
- Hacettepe University, Faculty of Pharmacy, Department of Pharmaceutical Biotechnology, 06100 Ankara, Turkey; Hacettepe University, Faculty of Pharmacy, Department of Pharmaceutical Technology, 06100 Ankara, Turkey
| | - Samiye Yabanoglu-Ciftci
- Hacettepe University, Faculty of Pharmacy, Department of Biochemistry, 06100 Ankara, Turkey; Hacettepe University, Faculty of Pharmacy, Department of Pharmaceutical Biotechnology, 06100 Ankara, Turkey; Hacettepe University, Institute of Health Sciences, Department of One Health, 06100 Ankara, Turkey.
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Gong JH, Koh DJ, Sobti N, Mehrzad R, Beqiri D, Maselli A, Kwan D. Trends in Hospital Billing for Mastectomy and Breast Reconstruction Procedures from 2013 to 2020. J Reconstr Microsurg 2024; 40:489-495. [PMID: 38052419 DOI: 10.1055/a-2222-8676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2023]
Abstract
BACKGROUND With greater acceptance of postmastectomy breast reconstruction (PMBR) as a safe and reliable treatment option, the role of plastic surgeons in breast cancer management continues to rise. As Medicare reimbursements for surgical procedures decline, hospitals may increase charges. Excessive markups can negatively affect uninsured and underinsured patients. We aimed to analyze mastectomy and breast reconstruction procedures to gain insights into recent trends in utilization and billing. METHODS We queried the 2013 to 2020 Medicare Provider Utilization and Payment Data with 14 Current Procedural Terminology (CPT) codes to collect service count numbers, hospital charges, and reimbursements. We calculated utilization (service counts per million female Medicare enrollees), weighted mean charges and reimbursements, and charge-to-reimbursement ratios (CRRs). We calculated total and annual percentage changes for the included CPT codes. RESULTS Among the 14 CPT codes, 12 CPT codes (85.7%) with nonzero service counts were included. Utilization of mastectomy and breast reconstruction procedures decreased from 1,889 to 1,288 (-31.8%) procedures per million female Medicare beneficiaries from 2013 to 2020. While the utilization of immediate implant placements (CPT 19340) increased by 36.2%, the utilization of delayed implant placements (CPT 19342) decreased by 15.1%. Reimbursements for the included CPT codes changed minimally over time (-2.9%) but charges increased by 28.9%. These changes resulted in CRRs increasing from 3.3 to 4.4 (+33.3%) from 2013 to 2020. Free flap reconstructions (CPT 19364) had the highest CRRs throughout the study period, increasing from 7.0 in 2013 to 10.3 in 2020 (+47.1%). CONCLUSIONS Our analysis of mastectomy and breast reconstruction procedures billed to Medicare Part B from 2013 to 2020 showed increasingly excessive procedural charges. Rises in hospital charges and CRRs may limit uninsured and underinsured patients from accessing necessary care for breast cancer management. Legislations that monitor hospital markups for PMBR procedures may be considered by policymakers.
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Affiliation(s)
- Jung Ho Gong
- Division of Plastic and Reconstructive Surgery, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Daniel J Koh
- Division of Plastic and Reconstructive Surgery, Boston University School of Medicine, Boston, Massachusetts
| | - Nikhil Sobti
- Division of Plastic and Reconstructive Surgery, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Raman Mehrzad
- Division of Plastic and Reconstructive Surgery, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Dardan Beqiri
- Division of Plastic and Reconstructive Surgery, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Amy Maselli
- Division of Plastic and Reconstructive Surgery, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Daniel Kwan
- Division of Plastic and Reconstructive Surgery, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
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Ayyala HS, Afifi T, Castel N, McCarthy C, Cordeiro PG. Replacement of Shaped Textured Implants with Round Smooth Implants in Breast Reconstruction: Long-Term Outcomes. Plast Reconstr Surg 2024; 154:265-271. [PMID: 37606913 DOI: 10.1097/prs.0000000000011001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/23/2023]
Abstract
BACKGROUND The number of patients undergoing exchange of textured implants for smooth devices has greatly increased because of concern over breast implant-associated anaplastic large-cell lymphoma (BIA-ALCL). The authors examined long-term patient- and surgeon-reported outcomes in terms of aesthetics, comfort, and complications. METHODS Patients who underwent reconstruction with shaped, textured implants replaced with round, smooth implants between 1994 and 2022 and who had a minimum follow-up of 1 year were included. Patient-reported outcomes were collected using the BREAST-Q Reconstruction module and a survey evaluating aesthetics and comfort. Surgeon-reported outcomes included evaluation of aesthetics and capsular contracture. RESULTS A total of 530 patients were reviewed, and 307 patients were included. Pairwise comparison of BREAST-Q data demonstrated that psychosocial well-being (72.68 to 76.45; P = 0.0075) and physical well-being (78.79 to 81.88; P = 0.0078) increased significantly. Overall breast satisfaction (61.94 to 67.27; P = 0.0082) and sexual well-being (53.89 to 57.98; P = 0.0002) were also significantly higher in parallel with a clinically meaningful increase in BREAST-Q score of 5.33 and 4.09 points, respectively. Most patients felt they appeared better (56.4%) or similar (27.3%) and were more comfortable (54.4%) or similar (39.4%) after the exchange procedure. The senior surgeon (P.G.C.) rated 40.1% of patients as having a better aesthetic grade after replacement and 50.3% as the same; 36.8% of patients were rated as having a decrease in Baker capsular contracture grade; 2.9% of patients experienced a perioperative complication; and there were no reconstructive failures. CONCLUSION Exchange of textured to smooth implants is safe, does not sacrifice aesthetic outcome, and provides a more comfortable and satisfactory outcome for patients with minimal complications. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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Affiliation(s)
- Haripriya S Ayyala
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Yale School of Medicine
| | - Tarek Afifi
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Memorial Sloan Kettering Cancer Center
| | - Nikki Castel
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Memorial Sloan Kettering Cancer Center
| | - Colleen McCarthy
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Memorial Sloan Kettering Cancer Center
| | - Peter G Cordeiro
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Memorial Sloan Kettering Cancer Center
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Bottosso S, Sidoti GB, Vita L, Scian A, Bonat Guarini L, Renzi N, Ramella V, Papa G. A Multi-Center Retrospective Observational Analysis of Three-Year Experience of Our Protocol for Prevention and Monitoring of Surgical Site Infections in Implant-Based Breast Reconstruction. Cancers (Basel) 2024; 16:2439. [PMID: 39001499 PMCID: PMC11240831 DOI: 10.3390/cancers16132439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2024] [Revised: 06/24/2024] [Accepted: 06/27/2024] [Indexed: 07/16/2024] Open
Abstract
BACKGROUND With the rise in the mastectomy rate, the number of patients who choose to undergo postmastectomy reconstruction has been increasing, and implant-based procedures are the most performed methods for postmastectomy breast reconstruction. Among the possible complications, the most feared is the loss of reconstruction. It can be related to several reasons, but one of the most common is infection of the implant, which can lead to prolonged antibiotic treatment, undesired additional surgical procedures, increased incidence of capsular contracture, and unsatisfactory aesthetics results, with a huge psychological impact on patients. AIMS The primary intent of this study is to analyze the status of infection rates at our institution and evaluate the effectiveness of our prevention protocol since its introduction. Secondly, we compared data of the surgical site infections (SSIs) after implant-based breast reconstruction at Trieste Hospital, where the protocol has been employed since 2020, and in another center, where plastic surgeons of our team are involved, with different prevention procedures. METHODS AND RESULTS We enrolled 396 female patients, who underwent implant-based breast reconstruction, using definitive mammary implants or breast tissue expanders, with or without ADM (acellular dermal matrix), both for breast cancer and risk-reducing surgery in BRCA1/2 patients. Patients treated at the Hospital of Trieste, with the use of the prevention protocol, were considered the experimental group (group 1), while patients treated in Gorizia by the same breast team with standardized best-practice rules, but without the use of the prevention protocol, were considered the control group (group 2). Infected patients were 5 in the first group (1.7%) and 8 in the second one (7.9%), with a global infection rate of 3.2%. CONCLUSION After the introduction of our prevention protocol, we faced a lower incidence of infection after breast surgery with implants or tissue expanders.
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Affiliation(s)
- Stefano Bottosso
- Plastic Surgery Department, Ospedale di Cattinara, ASUGI, Strada di Fiume, 447, 34149 Trieste, Italy
| | - Giulia Benedetta Sidoti
- Department of Medical, Surgical and Health Sciences, Plastic and Reconstructive Surgery Unit, University of Trieste, 34149 Trieste, Italy
| | - Ludovica Vita
- Department of Medical, Surgical and Health Sciences, Plastic and Reconstructive Surgery Unit, University of Trieste, 34149 Trieste, Italy
| | - Alessandro Scian
- Department of Medical, Surgical and Health Sciences, Plastic and Reconstructive Surgery Unit, University of Trieste, 34149 Trieste, Italy
| | - Luigi Bonat Guarini
- Department of Medical, Surgical and Health Sciences, Plastic and Reconstructive Surgery Unit, University of Trieste, 34149 Trieste, Italy
| | - Nadia Renzi
- Plastic Surgery Department, Ospedale di Cattinara, ASUGI, Strada di Fiume, 447, 34149 Trieste, Italy
| | - Vittorio Ramella
- Plastic Surgery Department, Ospedale di Cattinara, ASUGI, Strada di Fiume, 447, 34149 Trieste, Italy
- Department of Medical, Surgical and Health Sciences, Plastic and Reconstructive Surgery Unit, University of Trieste, 34149 Trieste, Italy
| | - Giovanni Papa
- Plastic Surgery Department, Ospedale di Cattinara, ASUGI, Strada di Fiume, 447, 34149 Trieste, Italy
- Department of Medical, Surgical and Health Sciences, Plastic and Reconstructive Surgery Unit, University of Trieste, 34149 Trieste, Italy
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Sachal SS, Golin AP, Gordon T, Williamson JS. The SAEORA Flap for Prosthetic Breast Reconstruction: A Novel Flap Design without the Use of Acellular Dermal Matrices. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e5852. [PMID: 38911580 PMCID: PMC11191962 DOI: 10.1097/gox.0000000000005852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Accepted: 04/04/2024] [Indexed: 06/25/2024]
Abstract
Background The gold standard for implant-based breast reconstruction uses acellular dermal matrices (ADMs). They provide improved inferolateral pole coverage, reduced capsular contracture rates, and increased primary expander fill volumes. However, ADMs are costly and have been associated with increased rates of postoperative infection, seroma, hematoma, implant malposition, and mastectomy flap necrosis (MFN). This study describes a novel autologous flap without the need of ADM, the serratus anterior external oblique rectus abdominis (SAEORA) flap, as an alternative in prosthetic-based breast reconstruction. Methods A retrospective study was conducted on all patients who underwent SAEORA flap breast reconstruction by a single surgeon between January 1, 2013 and May 31, 2020 at a single institution. Patient demographics, diagnosis, treatment, tissue expander (TE) volume, implant size, complications, and results were assessed. Results Forty-seven patients underwent 78 SAEORA flaps. Sixty-two had TEs placed, and 14 were direct-to-implant. Mean body mass index was 23.1 kg per m². Median primary TE fill volume was 150 mL, and final implant volume average was 450 mL. Mean follow-up was 14.5 months. Complications included infection/cellulitis (7.9%), seroma (6.6%), hematoma (5.2%), and MFN (7.9%). Conclusions The SAEORA flap is a novel autologous flap and is a viable option for prosthetic-based breast reconstruction, with an acceptable complication profile relative to ADM-based reconstructions. Additionally, SAEORA is MFN-resistant and has been used effectively in salvage of exposed implants or ADM, and in double-bubble deformity correction.
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Affiliation(s)
- Sukhmeet S. Sachal
- From the Division of Plastic Surgery, Department of Surgery, Western University, London, Ontario, Canada
| | - Andrew P. Golin
- Division of Family Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Travis Gordon
- Division of Plastic Surgery, Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
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Thai JN, Sodagari F, Colwell AS, Winograd JM, Revzin MV, Mahmoud H, Mozayan S, Chou SHS, Destounis SV, Butler RS. Multimodality Imaging of Postmastectomy Breast Reconstruction Techniques, Complications, and Tumor Recurrence. Radiographics 2024; 44:e230070. [PMID: 38573814 DOI: 10.1148/rg.230070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2024]
Abstract
For women undergoing mastectomy, breast reconstruction can be performed by using implants or autologous tissue flaps. Mastectomy options include skin- and nipple-sparing techniques. Implant-based reconstruction can be performed with saline or silicone implants. Various autologous pedicled or free tissue flap reconstruction methods based on different tissue donor sites are available. The aesthetic outcomes of implant- and flap-based reconstructions can be improved with oncoplastic surgery, including autologous fat graft placement and nipple-areolar complex reconstruction. The authors provide an update on recent advances in implant reconstruction techniques and contemporary expanded options for autologous tissue flap reconstruction as it relates to imaging modalities. As breast cancer screening is not routinely performed in this clinical setting, tumor recurrence after mastectomy and reconstruction is often detected by palpation at physical examination. Most local recurrences occur within the skin and subcutaneous tissue. Diagnostic breast imaging continues to have a critical role in confirmation of disease recurrence. Knowledge of the spectrum of benign and abnormal imaging appearances in the reconstructed breast is important for postoperative evaluation of patients, including recognition of early and late postsurgical complications and breast cancer recurrence. The authors provide an overview of multimodality imaging of the postmastectomy reconstructed breast, as well as an update on screening guidelines and recommendations for this unique patient population. ©RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material.
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Affiliation(s)
- Janice N Thai
- From the Department of Radiology, Division of Breast Imaging (J.N.T., F.S., S.H.S.C.); and Department of Surgery, Division of Plastic and Reconstructive Surgery (A.S.C., J.M.W.), Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114; Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT (M.V.R., R.S.B.); Yale New Haven Health, Bridgeport Hospital, Bridgeport, CT (H.M., S.M.); and Elizabeth Wende Breast Care, Rochester, NY (S.V.D.)
| | - Faezeh Sodagari
- From the Department of Radiology, Division of Breast Imaging (J.N.T., F.S., S.H.S.C.); and Department of Surgery, Division of Plastic and Reconstructive Surgery (A.S.C., J.M.W.), Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114; Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT (M.V.R., R.S.B.); Yale New Haven Health, Bridgeport Hospital, Bridgeport, CT (H.M., S.M.); and Elizabeth Wende Breast Care, Rochester, NY (S.V.D.)
| | - Amy S Colwell
- From the Department of Radiology, Division of Breast Imaging (J.N.T., F.S., S.H.S.C.); and Department of Surgery, Division of Plastic and Reconstructive Surgery (A.S.C., J.M.W.), Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114; Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT (M.V.R., R.S.B.); Yale New Haven Health, Bridgeport Hospital, Bridgeport, CT (H.M., S.M.); and Elizabeth Wende Breast Care, Rochester, NY (S.V.D.)
| | - Jonathan M Winograd
- From the Department of Radiology, Division of Breast Imaging (J.N.T., F.S., S.H.S.C.); and Department of Surgery, Division of Plastic and Reconstructive Surgery (A.S.C., J.M.W.), Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114; Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT (M.V.R., R.S.B.); Yale New Haven Health, Bridgeport Hospital, Bridgeport, CT (H.M., S.M.); and Elizabeth Wende Breast Care, Rochester, NY (S.V.D.)
| | - Margarita V Revzin
- From the Department of Radiology, Division of Breast Imaging (J.N.T., F.S., S.H.S.C.); and Department of Surgery, Division of Plastic and Reconstructive Surgery (A.S.C., J.M.W.), Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114; Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT (M.V.R., R.S.B.); Yale New Haven Health, Bridgeport Hospital, Bridgeport, CT (H.M., S.M.); and Elizabeth Wende Breast Care, Rochester, NY (S.V.D.)
| | - Hagar Mahmoud
- From the Department of Radiology, Division of Breast Imaging (J.N.T., F.S., S.H.S.C.); and Department of Surgery, Division of Plastic and Reconstructive Surgery (A.S.C., J.M.W.), Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114; Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT (M.V.R., R.S.B.); Yale New Haven Health, Bridgeport Hospital, Bridgeport, CT (H.M., S.M.); and Elizabeth Wende Breast Care, Rochester, NY (S.V.D.)
| | - Sara Mozayan
- From the Department of Radiology, Division of Breast Imaging (J.N.T., F.S., S.H.S.C.); and Department of Surgery, Division of Plastic and Reconstructive Surgery (A.S.C., J.M.W.), Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114; Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT (M.V.R., R.S.B.); Yale New Haven Health, Bridgeport Hospital, Bridgeport, CT (H.M., S.M.); and Elizabeth Wende Breast Care, Rochester, NY (S.V.D.)
| | - Shinn-Huey S Chou
- From the Department of Radiology, Division of Breast Imaging (J.N.T., F.S., S.H.S.C.); and Department of Surgery, Division of Plastic and Reconstructive Surgery (A.S.C., J.M.W.), Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114; Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT (M.V.R., R.S.B.); Yale New Haven Health, Bridgeport Hospital, Bridgeport, CT (H.M., S.M.); and Elizabeth Wende Breast Care, Rochester, NY (S.V.D.)
| | - Stamatia V Destounis
- From the Department of Radiology, Division of Breast Imaging (J.N.T., F.S., S.H.S.C.); and Department of Surgery, Division of Plastic and Reconstructive Surgery (A.S.C., J.M.W.), Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114; Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT (M.V.R., R.S.B.); Yale New Haven Health, Bridgeport Hospital, Bridgeport, CT (H.M., S.M.); and Elizabeth Wende Breast Care, Rochester, NY (S.V.D.)
| | - Reni S Butler
- From the Department of Radiology, Division of Breast Imaging (J.N.T., F.S., S.H.S.C.); and Department of Surgery, Division of Plastic and Reconstructive Surgery (A.S.C., J.M.W.), Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114; Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT (M.V.R., R.S.B.); Yale New Haven Health, Bridgeport Hospital, Bridgeport, CT (H.M., S.M.); and Elizabeth Wende Breast Care, Rochester, NY (S.V.D.)
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Har-Shai L, Franco E, Shteinberg M, Adir Y, Ad-El D, Lavi I, Stein N, Har-Shai Y, Metanes I. Immediate Unilateral Subpectoral Implant-Based Breast Reconstruction does not Impair Pulmonary Functions: A Preliminary Prospective Study. Aesthetic Plast Surg 2024:10.1007/s00266-024-04021-1. [PMID: 38671243 DOI: 10.1007/s00266-024-04021-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 03/11/2024] [Indexed: 04/28/2024]
Abstract
BACKGROUND Implant-based breast reconstruction is one of the most common procedures among women with breast cancer undergoing mastectomy. Prosthetic devices may be positioned either beneath or above the pectoralis major muscle, which is considered an accessory muscle of ventilation. This preliminary prospective study aimed to investigate whether subpectoral unilateral implant-based breast reconstruction has any effect on patients' pulmonary functions. METHODS A prospective study of fourteen women who underwent immediate unilateral implant-based subpectoral breast reconstruction by a single surgeon over 10 months was conducted. Spirometry and maximal voluntary ventilation tests were conducted 1 day prior to surgery, and 1- and 3 months following breast reconstruction. ANOVA or Friedman test were used to compare pulmonary function tests before and after surgery. RESULTS Fourteen patients completed the study protocol. No statistically significant differences were found when comparing spirometry parameters in the three time points. CONCLUSIONS Pectoralis muscle release does not impair pulmonary function among patients undergoing immediate unilateral implant-based breast reconstruction following mastectomy. LEVEL OF EVIDENCE III This journal requires that 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 .
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Affiliation(s)
- Lior Har-Shai
- The Department of Reconstructive Plastic Surgery & Burns, Rabin Medical Center, Beilinson Hospital, 39 Jabotinski St, 49100, Petah Tikva, Israel.
- School of Medicine, Faculty of Medical and Health Sciences, Tel-Aviv University, Tel-Aviv, Israel.
| | - Eyal Franco
- The Unit of Plastic Surgery, Lady Davis Carmel Medical Center, Haifa, Israel
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Michal Shteinberg
- Pulmonology Institute and CF Center, Lady Davis Carmel Medical Center, Haifa, Israel
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Yochai Adir
- Pulmonology Institute and CF Center, Lady Davis Carmel Medical Center, Haifa, Israel
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Dean Ad-El
- The Department of Reconstructive Plastic Surgery & Burns, Rabin Medical Center, Beilinson Hospital, 39 Jabotinski St, 49100, Petah Tikva, Israel
- School of Medicine, Faculty of Medical and Health Sciences, Tel-Aviv University, Tel-Aviv, Israel
| | - Idit Lavi
- The Department of Community Medicine and Epidemiology, Lady Davis Carmel Medical Center, Haifa, Israel
| | - Nili Stein
- The Department of Community Medicine and Epidemiology, Lady Davis Carmel Medical Center, Haifa, Israel
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Yaron Har-Shai
- The Unit of Plastic Surgery, Lady Davis Carmel Medical Center, Haifa, Israel
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Issa Metanes
- The Unit of Plastic Surgery, Lady Davis Carmel Medical Center, Haifa, Israel
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
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Putnam G, Williams T, Park S, Grundman K, Goel C, Huffman K, Galiano RD. Current Trends in Breast Cancer Treatment in Chinese and Chinese American Women: The Disparity Between Mastectomy and Breast Reconstruction. Ann Plast Surg 2024; 92:463-468. [PMID: 38527354 DOI: 10.1097/sap.0000000000003826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/27/2024]
Abstract
BACKGROUND Breast cancer screening and surgical interventions are often underutilized in the Chinese community. For both Chinese American (CA) and native Chinese (NC) patients, screening rates are well below medical recommendations, which places these patients at risk for late diagnoses and larger tumors. There is also a notable reluctance to breast reconstruction after mastectomy. We investigated the role of sociodemographic and cultural barriers in breast treatment trends among Chinese breast cancer survivors. METHODS A literature search for full-text articles published between 2011 and 2021 was performed using PubMed, The Web of Science, and Embase. The articles that were selected contained information regarding Chinese individuals in the United States or China who had undergone breast cancer screening or diagnosis of breast cancer and received treatment with or without reconstructive surgery. RESULTS Both patient populations exhibited screening rates that were significantly lower than national recommendations. Of the CA patients, 25% reported never receiving a mammogram, whereas 450 million NCs have been left unscreened despite efforts made by the Chinese government. Misinformation, cultural beliefs, and fear significantly contributed to diminished breast health care among CA and NC women. Fear of recurrence, breast value, community influence, and limited health care resources were found to be the primary drivers of low breast reconstruction uptake. CONCLUSIONS In both NC and CA women, there is a critical need for improved breast health information dissemination and overall quality of care. The findings summarized in this review can guide such efforts.
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Affiliation(s)
- Geneviève Putnam
- From the Department of Surgery/Division of Plastic and Reconstructive Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
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9
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Karakawa R, Konishi T, Yoshimatsu H, Hashimoto Y, Matsui H, Fushimi K, Yano T, Yasunaga H. Association between body mass index and outcomes after autologous breast reconstruction: a nationwide inpatient database study in Japan. Breast Cancer Res Treat 2024; 204:69-78. [PMID: 37966699 DOI: 10.1007/s10549-023-07162-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 10/07/2023] [Indexed: 11/16/2023]
Abstract
BACKGROUND Although autologous reconstruction following breast cancer surgery is common, little is known about the association between preoperative body mass index (BMI) and short-term surgical outcomes. This study investigated the association between BMI and short-term surgical outcomes in autologous breast reconstruction using a nationwide Japanese inpatient database. METHODS We retrospectively identified female patients with breast cancer who underwent breast reconstruction using a pedicled flap or free flap from July 2010 to March 2020. Multivariable regression analyses and restricted cubic spline analyses were conducted to investigate the associations between BMI and short-term outcomes with adjustment for demographic and clinical backgrounds. RESULTS Of the 13,734 eligible patients, 7.1% and 22.2% had a BMI of < 18.5 kg/m2 and > 25 kg/m2, respectively. Compared with BMI of 18.5-21.9 kg/m2, overweight (25.0-29.9 kg/m2) and obese (≥ 30.0 kg/m2) were significantly associated with higher occurrences of takebacks (odds ratio, 1.74 [95% confidence interval, 1.28-2.38] and 2.89 [1.88-4.43], respectively) and overall complications (1.37 [1.20-1.57] and 1.77 [1.42-2.20], respectively). In the restricted cubic spline analyses, BMI showed J-shaped associations with takebacks, overall complications, local complications, and wound dehiscence. BMI also demonstrated linear associations with postoperative surgical site infection, duration of anesthesia, duration of drainage, length of stay, and hospitalization costs. CONCLUSION In autologous breast reconstruction following breast cancer surgery, a higher BMI was associated with takebacks, morbidity, a longer hospital stay, and higher total costs, whereas a lower BMI was associated with fewer surgical site infections, a shorter hospital stay, and lower total costs.
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Affiliation(s)
- Ryo Karakawa
- Department of Plastic and Reconstructive Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-Ku, Tokyo, Japan.
| | - Takaaki Konishi
- Department of Breast and Endocrine Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Hidehiko Yoshimatsu
- Department of Plastic and Reconstructive Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-Ku, Tokyo, Japan
| | - Yohei Hashimoto
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School, Tokyo, Japan
| | - Tomoyuki Yano
- Department of Plastic and Reconstructive Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-Ku, Tokyo, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
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10
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Lin AM, Lorenzi R, Van Der Hulst JE, Liao EC, Austen WG, Webster A, Smith BL, Colwell AS. A Decade of Nipple-Sparing Mastectomy: Lessons Learned in 3035 Immediate Implant-Based Breast Reconstructions. Plast Reconstr Surg 2024; 153:277-287. [PMID: 37141449 DOI: 10.1097/prs.0000000000010616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
BACKGROUND Nipple-sparing mastectomy is commonly performed for breast cancer treatment or prevention. The authors present one of the largest breast reconstruction series in the literature. METHODS A single-institution retrospective review was conducted from 2007 to 2019. RESULTS The authors' query identified 3035 implant-based breast reconstructions after nipple-sparing mastectomy, including 2043 direct-to-implant and 992 tissue expander-to-implant reconstructions. The overall major complication rate was 9.15%, and the nipple necrosis rate was 1.20%. Therapeutic mastectomy was associated with higher overall complications and explantations compared with prophylactic mastectomy ( P < 0.01). In comparisons of unilateral and bilateral procedures, bilateral mastectomy had an increased risk for complications (OR, 1.46; 95% CI, 0.997 to 2.145; P = 0.05). Tissue-expander reconstructions had higher rates of nipple necrosis (1.9% versus 0.88%; P = 0.015), infection (4.2% versus 2.8%; P = 0.04), and explantation (5.1% versus 3.5%; P = 0.04) compared with direct-to-implant reconstruction. When assessing plane of reconstruction, the authors found similar rates of complications between subpectoral dual-plane and prepectoral reconstruction. There was no difference in complications between reconstruction with acellular dermal matrix or mesh compared with total or partial muscle coverage without acellular dermal matrix/mesh (OR, 0.749; 95% CI, 0.404 to 1.391; P = 0.361). Multivariable regression analysis revealed preoperative radiotherapy (OR, 2.465; 95% CI, 1.579 to 3.848; P < 0.001), smoking (OR, 2.53; 95% CI, 1.581 to 4.054; P < 0.001), and a periareolar incision (OR, 3.657; 95% CI, 2.276 to 5.875; P < 0.001) to be the strongest predictors of complications and nipple necrosis ( P < 0.05). CONCLUSIONS Nipple-sparing mastectomy and immediate breast reconstruction has a low rate of complications. In this series, radiation therapy, smoking, and incision choice predicted overall complications and nipple necrosis, whereas direct-to-implant reconstruction and acellular dermal matrix or mesh did not increase risk. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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Affiliation(s)
- Alex M Lin
- From the Division of Plastic Surgery and Surgical Oncology, Massachusetts General Hospital, Harvard Medical School
| | - Roberto Lorenzi
- From the Division of Plastic Surgery and Surgical Oncology, Massachusetts General Hospital, Harvard Medical School
| | - Juliette E Van Der Hulst
- From the Division of Plastic Surgery and Surgical Oncology, Massachusetts General Hospital, Harvard Medical School
| | - Eric C Liao
- From the Division of Plastic Surgery and Surgical Oncology, Massachusetts General Hospital, Harvard Medical School
| | - William G Austen
- From the Division of Plastic Surgery and Surgical Oncology, Massachusetts General Hospital, Harvard Medical School
| | - Alexandra Webster
- From the Division of Plastic Surgery and Surgical Oncology, Massachusetts General Hospital, Harvard Medical School
| | - Barbara L Smith
- From the Division of Plastic Surgery and Surgical Oncology, Massachusetts General Hospital, Harvard Medical School
| | - Amy S Colwell
- From the Division of Plastic Surgery and Surgical Oncology, Massachusetts General Hospital, Harvard Medical School
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11
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Simion L, Petrescu I, Chitoran E, Rotaru V, Cirimbei C, Ionescu SO, Stefan DC, Luca D, Stanculeanu DL, Gheorghe AS, Doran H, Dogaru IM. Breast Reconstruction following Mastectomy for Breast Cancer or Prophylactic Mastectomy: Therapeutic Options and Results. Life (Basel) 2024; 14:138. [PMID: 38255753 PMCID: PMC10821438 DOI: 10.3390/life14010138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 01/03/2024] [Accepted: 01/12/2024] [Indexed: 01/24/2024] Open
Abstract
(1) Importance of problem: Breast cancer accounted for 685,000 deaths globally in 2020, and half of all cases occur in women with no specific risk factor besides gender and age group. During the last four decades, we have seen a 40% reduction in age-standardized breast cancer mortality and have also witnessed a reduction in the medium age at diagnosis, which in turn means that the number of mastectomies performed for younger women increased, raising the need for adequate breast reconstructive surgery. Advances in oncological treatment have made it possible to limit the extent of what represents radical surgery for breast cancer, yet in the past decade, we have seen a marked trend toward mastectomies in breast-conserving surgery-eligible patients. Prophylactic mastectomies have also registered an upward trend. This trend together with new uses for breast reconstruction like chest feminization in transgender patients has increased the need for breast reconstruction surgery. (2) Purpose: The purpose of this study is to analyze the types of reconstructive procedures, their indications, their limitations, their functional results, and their safety profiles when used during the integrated treatment plan of the oncologic patient. (3) Methods: We conducted an extensive literature review of the main reconstructive techniques, especially the autologous procedures; summarized the findings; and presented a few cases from our own experience for exemplification of the usage of breast reconstruction in oncologic patients. (4) Conclusions: Breast reconstruction has become a necessary step in the treatment of most breast cancers, and many reconstructive techniques are now routinely practiced. Microsurgical techniques are considered the "gold standard", but they are not accessible to all services, from a technical or financial point of view, so pediculated flaps remain the safe and reliable option, along with alloplastic procedures, to improve the quality of life of these patients.
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Affiliation(s)
- Laurentiu Simion
- Department of General Surgery, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; (L.S.); (V.R.); (S.-O.I.); (D.L.); (H.D.)
- General Surgery and Surgical Oncology Department I, Bucharest Institute of Oncology “Prof. Dr. Alexandru Trestioreanu”, 022328 Bucharest, Romania
| | | | - Elena Chitoran
- Department of General Surgery, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; (L.S.); (V.R.); (S.-O.I.); (D.L.); (H.D.)
- General Surgery and Surgical Oncology Department I, Bucharest Institute of Oncology “Prof. Dr. Alexandru Trestioreanu”, 022328 Bucharest, Romania
| | - Vlad Rotaru
- Department of General Surgery, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; (L.S.); (V.R.); (S.-O.I.); (D.L.); (H.D.)
- General Surgery and Surgical Oncology Department I, Bucharest Institute of Oncology “Prof. Dr. Alexandru Trestioreanu”, 022328 Bucharest, Romania
| | - Ciprian Cirimbei
- Department of General Surgery, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; (L.S.); (V.R.); (S.-O.I.); (D.L.); (H.D.)
- General Surgery and Surgical Oncology Department I, Bucharest Institute of Oncology “Prof. Dr. Alexandru Trestioreanu”, 022328 Bucharest, Romania
| | - Sinziana-Octavia Ionescu
- Department of General Surgery, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; (L.S.); (V.R.); (S.-O.I.); (D.L.); (H.D.)
- General Surgery and Surgical Oncology Department I, Bucharest Institute of Oncology “Prof. Dr. Alexandru Trestioreanu”, 022328 Bucharest, Romania
| | - Daniela-Cristina Stefan
- Department of Oncology, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; (D.-C.S.); (D.L.S.); (A.S.G.)
| | - Dan Luca
- Department of General Surgery, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; (L.S.); (V.R.); (S.-O.I.); (D.L.); (H.D.)
- General Surgery and Surgical Oncology Department I, Bucharest Institute of Oncology “Prof. Dr. Alexandru Trestioreanu”, 022328 Bucharest, Romania
| | - Dana Lucia Stanculeanu
- Department of Oncology, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; (D.-C.S.); (D.L.S.); (A.S.G.)
- Oncology Department I, Bucharest Institute of Oncology “Prof. Dr. Alexandru Trestioreanu”, 022328 Bucharest, Romania
| | - Adelina Silvana Gheorghe
- Department of Oncology, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; (D.-C.S.); (D.L.S.); (A.S.G.)
- Oncology Department I, Bucharest Institute of Oncology “Prof. Dr. Alexandru Trestioreanu”, 022328 Bucharest, Romania
| | - Horia Doran
- Department of General Surgery, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; (L.S.); (V.R.); (S.-O.I.); (D.L.); (H.D.)
- Surgical Clinic I, Clinical Hospital Dr. I. Cantacuzino, 030167 Bucharest, Romania
| | - Ioana Mihaela Dogaru
- Department of Plastic Surgery, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania;
- Department of Plastic Surgery, Emergency University Hospital, 050098 Bucharest, Romania
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12
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Frasson AL, Falcone AB, Barbosa F, Anton de Souza AB, Malhone C, Miranda I, Vollbrecht B, Rodriguez Martinez Frasson MA, Kobe L, Lichtenfels M. Low rate of complications in nipple-sparing mastectomy for patients with BRCA1 and BRCA2 mutation. Per Med 2023; 20:493-501. [PMID: 37909344 DOI: 10.2217/pme-2023-0084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2023]
Abstract
Background: To describe the indications and outcomes of BRCA mutation carriers undergoing nipple-sparing mastectomy (NSM). Methods: In this retrospective study, 76 BRCA mutation carriers with no cancer who opted to undergo risk reduction NSM or diagnosed with breast cancer (BC) who opted to undergo therapeutic NSM were included. Results: Indications for NSM: cancer treatment (n = 33), bilateral risk reduction (n = 39) and contralateral prophylactic NSM (n = 4). In a mean follow-up of 45 months (median: 30 months), one patient (2.5%) undergoing risk-reducing NSM developed a new BC. One (3%) local, one (3%) ipsilateral axillary and one (3%) distant recurrence were observed in BC patients. No partial or total nipple necrosis occurred. Conclusion: NSM is safe for reducing the risk of BC development in BRCA mutation carriers and for treating cancer.
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Affiliation(s)
- Antônio Luiz Frasson
- Breast Cancer Group, Albert Einstein Hospital, Albert Einstein Avenue 627, 05652-900, São Paulo, Brazil
- Breast Cancer Center, Hospital São Lucas, Pontifical Catholic University of Rio Grande do Sul (PUCRS), Ipiranga 6690, 90610-000, Porto Alegre, Brazil
| | - Ana Beatriz Falcone
- Breast Cancer Group, Albert Einstein Hospital, Albert Einstein Avenue 627, 05652-900, São Paulo, Brazil
| | - Fernanda Barbosa
- Breast Cancer Group, Albert Einstein Hospital, Albert Einstein Avenue 627, 05652-900, São Paulo, Brazil
| | - Alessandra Borba Anton de Souza
- Breast Cancer Center, Hospital São Lucas, Pontifical Catholic University of Rio Grande do Sul (PUCRS), Ipiranga 6690, 90610-000, Porto Alegre, Brazil
| | - Carolina Malhone
- Breast Cancer Group, Albert Einstein Hospital, Albert Einstein Avenue 627, 05652-900, São Paulo, Brazil
| | - Isabela Miranda
- Breast Cancer Center, Hospital São Lucas, Pontifical Catholic University of Rio Grande do Sul (PUCRS), Ipiranga 6690, 90610-000, Porto Alegre, Brazil
| | - Betina Vollbrecht
- Breast Cancer Center, Hospital São Lucas, Pontifical Catholic University of Rio Grande do Sul (PUCRS), Ipiranga 6690, 90610-000, Porto Alegre, Brazil
| | - Monica Adriana Rodriguez Martinez Frasson
- Breast Cancer Group, Albert Einstein Hospital, Albert Einstein Avenue 627, 05652-900, São Paulo, Brazil
- Breast Cancer Center, Hospital São Lucas, Pontifical Catholic University of Rio Grande do Sul (PUCRS), Ipiranga 6690, 90610-000, Porto Alegre, Brazil
| | - Luiza Kobe
- Breast Cancer Group, Albert Einstein Hospital, Albert Einstein Avenue 627, 05652-900, São Paulo, Brazil
| | - Martina Lichtenfels
- Breast Cancer Group, Albert Einstein Hospital, Albert Einstein Avenue 627, 05652-900, São Paulo, Brazil
- Breast Cancer Center, Hospital São Lucas, Pontifical Catholic University of Rio Grande do Sul (PUCRS), Ipiranga 6690, 90610-000, Porto Alegre, Brazil
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13
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Lizarraga IM, Huang K, Yalamuru B, Mott SL, Sibenaller ZA, Keith JN, Sugg SL, Erdahl LM, Seering M. A Randomized Single-Blinded Study Comparing Preoperative with Post-Mastectomy PECS Block for Post-operative Pain Management in Bilateral Mastectomy with Immediate Reconstruction. Ann Surg Oncol 2023; 30:6010-6021. [PMID: 37526752 DOI: 10.1245/s10434-023-13890-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 06/06/2023] [Indexed: 08/02/2023]
Abstract
BACKGROUND Ultrasound-guided pectoralis muscle blocks (PECS I/II) are well established for postoperative pain control after mastectomy with reconstruction. However, optimal timing is unclear. We conducted a randomized controlled single-blinded single-institution trial comparing outcomes of block performed pre-incision versus post-mastectomy. METHOD Patients with breast cancer undergoing bilateral mastectomy with immediate expander/implant reconstruction were randomized to receive ultrasound-guided PECS I/II either pre-incision (PreM, n = 17) or post-mastectomy and before reconstruction (PostM, n = 17). The primary outcome was the average pain score using the Numerical Rating Score during post-anesthesia care unit (PACU) and inpatient stay, with the study powered to detect a difference in mean pain score of 2. Secondary outcomes included mean pain scores on postoperative day (POD) 2, 3, 7, 14, 90, and 180; pain catastrophizing scores; narcotic requirements; PACU/inpatient length of stay; block procedure time; and complications. RESULT No significant differences between the two groups were noted in average pain score during PACU (p = 0.57) and 24-h inpatient stay (p = 0.33), in the 2 weeks after surgery at rest (p = 0.90) or during movement (p = 0.30), or at POD 90 and 180 at rest (p = 0.42) or during movement (p = 0.31). Median duration of block procedure (PreM 7 min versus PostM 6 min, p = 0.21) did not differ. Median PACU and inpatient length of stay were the same in each group. Inpatient narcotic requirements were similar, as were length of stay and post-surgical complication rates. CONCLUSION Intraoperative ultrasound-guided PECS I/II block administered by surgeons following mastectomy had similar outcomes to preoperative blocks. TRIAL REGISTRATION This trial is registered with Clinical Research Information Service (NCT03653988).
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Affiliation(s)
- Ingrid M Lizarraga
- Department of Surgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA.
- Holden Comprehensive Cancer Center, University of Iowa Hospitals and Clinics, Iowa City, IA, USA.
| | - K Huang
- Department of Surgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
- Holden Comprehensive Cancer Center, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - B Yalamuru
- Pain Division, Department of Anesthesiology, University of Virginia, Charlottesville, VA, USA
| | - S L Mott
- Holden Comprehensive Cancer Center, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Z A Sibenaller
- Holden Comprehensive Cancer Center, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - J N Keith
- Holden Comprehensive Cancer Center, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - S L Sugg
- Department of Surgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
- Holden Comprehensive Cancer Center, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - L M Erdahl
- Department of Surgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
- Holden Comprehensive Cancer Center, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - M Seering
- Department of Anesthesia, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
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14
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Walker JN, Hanson BM, Hunter T, Simar SR, Duran Ramirez JM, Obernuefemann CLP, Parikh RP, Tenenbaum MM, Margenthaler JA, Hultgren SJ, Myckatyn TM. A prospective randomized clinical trial to assess antibiotic pocket irrigation on tissue expander breast reconstruction. Microbiol Spectr 2023; 11:e0143023. [PMID: 37754546 PMCID: PMC10581127 DOI: 10.1128/spectrum.01430-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 07/31/2023] [Indexed: 09/28/2023] Open
Abstract
Bacterial infection is the most common complication following staged post-mastectomy breast reconstruction initiated with a tissue expander (TE). To limit bacterial infection, antibiotic irrigation of the surgical site is commonly performed despite little high-quality data to support this practice. We performed a prospective randomized control trial to compare the impact of saline irrigation alone to a triple antibiotic irrigation regimen (1 g cefazolin, 80 mg gentamicin, and 50,000 units of bacitracin in 500 mL of saline) for breast implant surgery. The microbiome in breasts with cancer (n = 16) was compared to those without (n = 16), as all patients (n = 16) had unilateral cancers but bilateral mastectomies (n = 32). Biologic and prosthetic specimens procured both at the time of mastectomy and during TE removal months later were analyzed for longitudinal comparison. Outcomes included clinical infection, bacterial abundance, and relative microbiome composition. No patient in either group suffered a reconstructive failure or developed an infection. Triple antibiotic irrigation administered at the time of immediate TE reconstruction did not reduce bacterial abundance or impact microbial diversity relative to saline irrigation at the time of planned exchange. Implanted prosthetic material adopted the microbial composition of the surrounding host tissue. In cancer-naïve breasts, relative to saline, antibiotic irrigation increased bacterial abundance on periprosthetic capsules (P = 0.03) and acellular dermal matrices (P = 0.04) and altered the microbiota on both. These data show that, relative to saline only, the use of triple antibiotic irrigation in TE breast reconstruction does impact the bacterial abundance and diversity of certain biomaterials from cancer-naïve breasts. IMPORTANCE The lifetime risk of breast cancer is ~13% in women and is treated with a mastectomy in ~50% of cases. The majority are reconstructed, usually starting with a tissue expander to help restore the volume for a subsequent permanent breast implant or the women's own tissues. The biopsychosocial benefits of breast reconstruction, though, can be tempered by a high complication rate of at least 7% but over 30% in some women. Bacterial infection is the most common complication, and can lead to treatment delays, patient physical and emotional distress and escalating health care cost. To limit this risk, plastic surgeons have tried a variety of strategies to limit bacterial infection including irrigating the pocket created after removing the breast implant with antibiotic solutions, but good-quality data are scarce. Herein, we study the value of antibiotics in pocket irrigation using a robust randomized clinical trial design and molecular microbiology approaches.
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Affiliation(s)
- Jennifer N. Walker
- Department of Microbiology and Molecular Genetics, McGovern Medical School, University of Texas Health Sciences Center, Houston, Texas, USA
- Department of Epidemiology, Human Genetics & Environmental Sciences, Center for Infectious Diseases, School of Public Health, University of Texas Health Sciences Center, Houston, Texas, USA
| | - Blake M. Hanson
- Department of Epidemiology, Human Genetics & Environmental Sciences, Center for Infectious Diseases, School of Public Health, University of Texas Health Sciences Center, Houston, Texas, USA
- Division of Infectious Disease, Department of Pediatrics, McGovern Medical School, University of Texas Health Sciences Center, Houston, Texas, USA
- Center for Antimicrobial Resistance and Microbial Genomics, McGovern Medical School, University of Texas Health Sciences Center, Houston, Texas, USA
| | - Tayler Hunter
- Department of Microbiology and Molecular Genetics, McGovern Medical School, University of Texas Health Sciences Center, Houston, Texas, USA
| | - Shelby R. Simar
- Department of Epidemiology, Human Genetics & Environmental Sciences, Center for Infectious Diseases, School of Public Health, University of Texas Health Sciences Center, Houston, Texas, USA
- Division of Infectious Disease, Department of Pediatrics, McGovern Medical School, University of Texas Health Sciences Center, Houston, Texas, USA
- Center for Antimicrobial Resistance and Microbial Genomics, McGovern Medical School, University of Texas Health Sciences Center, Houston, Texas, USA
| | - Jesus M. Duran Ramirez
- Department of Microbiology and Molecular Genetics, McGovern Medical School, University of Texas Health Sciences Center, Houston, Texas, USA
| | - Chloe L. P. Obernuefemann
- Department of Molecular Microbiology, Washington University School of Medicine, Saint Louis, Missouri, USA
- Center for Women’s Infectious Disease Research, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Rajiv P. Parikh
- Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Marissa M. Tenenbaum
- Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Julie A. Margenthaler
- Division of Surgical Oncology, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Scott J. Hultgren
- Department of Molecular Microbiology, Washington University School of Medicine, Saint Louis, Missouri, USA
- Center for Women’s Infectious Disease Research, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Terence M. Myckatyn
- Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, Saint Louis, Missouri, USA
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15
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Laurent R, Schoucair R, Danino MA. DIEP flap in breast reconstruction: A morbidity study of bilateral versus unilateral reconstruction. ANN CHIR PLAST ESTH 2023; 68:300-307. [PMID: 36642634 DOI: 10.1016/j.anplas.2022.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Accepted: 12/27/2022] [Indexed: 01/15/2023]
Abstract
BACKGROUND The Deep Inferior Epigastric Perforator (DIEP) flap is a modality in breast reconstruction of choice. Despite its well-documented benefits and complications, a lack of evidence remains with regards to the risks of performing a bilateral versus a unilateral reconstruction. As such, we sought to compare the rates of adverse outcomes in the perioperative and postoperative periods associated with a unilateral versus a bilateral DIEP flap breast reconstruction. METHODS A retrospective cohort study of 178 consecutive patients undergoing unilateral versus. bilateral deep inferior epigastric perforator flap breast reconstruction was performed at our tertiary care center over a 3-year period. Data on demographics, operative time, intraoperative and postoperative complications, and surgical re-exploration, were extracted for both groups. Statistical analysis was performed on a per-flap basis. RESULTS A total of 157 unilateral and 42 bilateral deep inferior epigastric perforator flaps were identified. The rate of intra-operative complications was 12.1% for unilateral versus. 4.8% for bilateral flaps (P=0.26). Total post-operative complications rates were 30.6% for unilateral versus 54.7% for bilateral flaps (P=0.003). Surgical re-exploration was performed in 12.7% of unilateral and 11.9% of bilateral cases (P=0.88). The rate of total flap loss was similar between types of reconstruction, occurring in 2.5% of unilateral vs. 2.4% of bilateral flaps (P=1). CONCLUSION This study demonstrates the rate of complications per flap is significantly higher in bilateral versus unilateral deep inferior epigastric perforator flap breast reconstruction. Bilateral DIEP breast reconstruction should be decided on a case-by-case basis. LEVEL OF EVIDENCE Prognostic/Risk Study, Level II.
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Affiliation(s)
- R Laurent
- Department of Plastic and Reconstructive Surgery,University of Montreal Health Care Center (CHUM), Montreal, Québec, Canada
| | - R Schoucair
- Department of Plastic and Reconstructive Surgery,University of Montreal Health Care Center (CHUM), Montreal, Québec, Canada
| | - M A Danino
- Department of Plastic and Reconstructive Surgery,University of Montreal Health Care Center (CHUM), Montreal, Québec, Canada.
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Polanco TO, Shamsunder MG, Parikh RP, Chu JJ, McCarthy C, Tadros A, Matros E, Disa JJ, Mehrara BJ, Allen RJ, Nelson JA. Quality of Life in Breast Reconstruction Patients after Irradiation to Tissue Expander: A Propensity-Matched Preliminary Analysis. Plast Reconstr Surg 2023; 152:259-269. [PMID: 36724013 PMCID: PMC10390648 DOI: 10.1097/prs.0000000000010249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Tissue expanders (TEs) are routinely placed as a first step in breast reconstruction for women who require postmastectomy radiation therapy (PMRT). The final reconstruction can then be performed with implants or conversion to autologous tissues. The purpose of this study was to compare patient-reported outcomes and surgical complications in autologous (ABR) versus implant-based breast reconstruction (IBR) patients following TE-PMRT. METHODS The authors performed a propensity score preliminary analysis (1:1 matching, no replacement) in patients undergoing ABR or IBR following TE-PMRT. Matched covariates included age, race/ethnicity, smoking status, body mass index, history of psychiatric diagnosis, and laterality of reconstruction. Outcomes of interest included complications and BREAST-Q scores for Satisfaction with Breasts, Physical Well-Being of the Chest, Sexual Well-Being, and Psychosocial Well-Being domains. RESULTS Of 341 patients with TE-PMRT, a total of 106 patients were included in the matched analysis: 53 ABR patients and 53 IBR patients. ABR and IBR did not differ significantly in matched baseline, cancer, and surgical characteristics. ABR patients had higher scores for Satisfaction with Breasts (greater than the four-point minimal clinically important difference) at all postreconstruction time points compared with IBR patients ( P < 0.05). There were no significant postoperative differences in other BREAST-Q domains. The incidence of complications after definitive reconstruction did not differ significantly among cohorts. CONCLUSIONS In this matched preliminary analysis, patients who underwent ABR following irradiation to a TE demonstrated superior satisfaction with breast scores compared with IBR patients. Higher powered matched studies are needed to improve shared decision-making for patients who require mastectomy and PMRT as part of their treatment. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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Affiliation(s)
- Thais O. Polanco
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Meghana G. Shamsunder
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Rajiv P. Parikh
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jacqueline J. Chu
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Colleen McCarthy
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Audree Tadros
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Evan Matros
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Joseph J. Disa
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Babak J. Mehrara
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Robert J. Allen
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jonas A. Nelson
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
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Brantley RA, Thuman J, Hudson T, Gregoski MJ, Scomacao I, Herrera FA. Same Day Discharge After Mastectomy and Immediate Implant-Based Breast Reconstruction: A Retrospective Cohort Comparison Using the National Surgical Quality Improvement Program Database. Ann Plast Surg 2023; 90:S395-S402. [PMID: 37332211 PMCID: PMC11177554 DOI: 10.1097/sap.0000000000003459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/20/2023]
Abstract
INTRODUCTION Currently, overnight admission after immediate implant-based breast reconstruction (IBR) is the standard of care. Our study aims to analyze the safety, feasibility, and outcomes of immediate IBR with same-day discharge as compared with the standard overnight stay. METHODS The 2015-2020 National Surgical Quality Improvement Program database was reviewed to identify all patients undergoing mastectomy with immediate IBR for malignant breast disease. Patients were stratified into study (patients discharged day of surgery) and control (patients admitted after surgery) groups. Patient demographics, comorbidities, surgical characteristics, implant type, wound complications, readmission, and reoperation rates were collected and analyzed. Univariate and multivariate logistic regression was used to determine independent predictors of same-day discharge versus admission. In addition, Pearson χ2 test was used for comparison of proportions and t test was used for continuous variables unless distributions required subsequent nonparametric analyses. Statistical significance was defined as a P value less than 0.05. RESULTS A total of 21,923 cases were identified. The study group included 1361 patients discharged same day and the control group included 20,562 patient s admitted for average of 1.4 days (range, 1-86). Average age was 51 years for both groups. Average body mass index for the study group 27 and 28 kg/m2 for the control group, respectively. Total wound complication rates were similar (4.5% study, 4.3% control, P = 0.72). Reoperation rates were lower with same-day discharge (5.7% study, 6.8% control, P = 0.105), though not statistically significant. However, same-day discharge patients had a significantly lower readmission rate compared with the control (2.3% study, 4.2% control, P = 0.001). CONCLUSION National Surgical Quality Improvement Program data analysis over a 6-year period reveals that immediate IBR with same-day discharge is associated with a significantly lower readmission rate when compared with the standard overnight stay. The comparable complication profiles show that immediate IBR with same-day discharge is safe, potentially benefiting both patients and hospitals.
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Affiliation(s)
| | - Jenna Thuman
- Division of Plastic Surgery, Medical University of South Carolina
| | - Todd Hudson
- College of Medicine, Medical University of South Carolina
| | - Mathew J. Gregoski
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC
| | - Isis Scomacao
- College of Medicine, Medical University of South Carolina
- Division of Plastic Surgery, Medical University of South Carolina
| | - Fernando A. Herrera
- College of Medicine, Medical University of South Carolina
- Division of Plastic Surgery, Medical University of South Carolina
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18
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Zhang JX, Kurian AW, Jo B, Nouriani B, Neri E, Gross JJ, Spiegel D. Emotion regulation and choice of bilateral mastectomy for the treatment of unilateral breast cancer. Cancer Med 2023. [PMID: 37083300 DOI: 10.1002/cam4.5963] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 01/01/2023] [Accepted: 04/05/2023] [Indexed: 04/22/2023] Open
Abstract
BACKGROUND There has been steadily increasing use of bilateral mastectomy (BMX) in the treatment of primary breast cancer (BC). In this study, we utilized functional magnetic resonance imaging (fMRI) to examine the influence of emotion regulation on the decision of newly diagnosed BC patients to choose BMX rather than non-BMX treatments. METHODS We recruited 123 women with unilateral BC, 61 of whom received BMX and 62 of whom received non-BMX treatments, and 39 healthy controls. While participants were in the fMRI scanner, we showed them BC-related and non-BC-negative images. In one condition, they were instructed to watch the images naturally. In another, they were instructed to regulate their negative emotion. We compared the fMRI signal during these conditions throughout the brain. RESULTS With non-BC-negative images as the baseline, BC patients showed greater self-reported reactivity and neural reactivity to BC-related images in brain regions associated with self-reflection than did controls. Among the BC patients, the BMX group showed weaker activation in prefrontal emotion regulation brain regions during emotion regulation than did the non-BMX group. CONCLUSIONS BC patients are understandably emotionally hyper-reactive to BC-related stimuli and those who ultimately received BMX experience more difficulty in regulating BC-related negative emotion than non-BMX BC patients. These findings offer neuropsychological evidence that difficulty in managing anxiety related to the possibility of cancer recurrence is a factor in surgical treatment decision-making and may be an intervention target with the goal of strengthening the management of cancer-related anxiety by nonsurgical means. TRIAL REGISTRATION NCT03050463.
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Affiliation(s)
- Jin-Xiao Zhang
- Department of Psychology, Stanford University, Stanford, California, USA
| | - Allison W Kurian
- Departments of Medicine and of Epidemiology and Population Health, Stanford University, Stanford, California, USA
| | - Booil Jo
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, California, USA
| | - Bita Nouriani
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, California, USA
| | - Eric Neri
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, California, USA
| | - James J Gross
- Department of Psychology, Stanford University, Stanford, California, USA
| | - David Spiegel
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, California, USA
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Blok YL, Suijker J, van den Tol MP, van der Pol CC, Mureau MAM, van der Hage JA, Krekel NMA. Preservation of the Pectoral Fascia in Mastectomy With Immediate Reconstruction: A Nationwide Survey. J Surg Res 2023; 284:101-105. [PMID: 36563450 DOI: 10.1016/j.jss.2022.10.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 09/12/2022] [Accepted: 10/16/2022] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Pectoral fascia (PF) removal during mastectomy still seems to be the standard procedure. However, preservation of the PF might improve postoperative and cosmetic outcomes, without compromising oncological safety. Here, we report on a national survey among Dutch plastic surgeons and oncological breast surgeons to evaluate their techniques and opinions regarding the PF. MATERIALS AND METHODS A survey based study was performed in the Netherlands, in which both plastic surgeons and oncological breast surgeons were included, each receiving a different version of the survey. The surveys were distributed to 460 and 150 e-mail addresses, respectively. RESULTS A total of 68 responses were included from more than half of all Dutch medical centers. The results of this study indicate that circa one in five plastic surgeons and breast surgeons routinely preserve the PF during mastectomies and even more surgeons preserve the PF in specific cases. The surgical techniques and opinions regarding PF preservation widely differ between surgeons. CONCLUSIONS Preservation of the PF does occur in a substantial part of the Dutch medical centers and techniques and opinions are contradictory. Future studies on this topic should clarify the effect of PF preservation on oncological safety, complication rates, postoperative pain, cosmetic outcomes, and patient satisfaction.
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Affiliation(s)
- Yara Lynn Blok
- Department of Plastic and Reconstructive surgery, Leiden University Medical Center, Leiden, the Netherlands.
| | - Jaco Suijker
- Department of surgery, Red Cross Hospital, Beverwijk, the Netherlands
| | - Monique P van den Tol
- Department of Surgical Oncology, Medical Center Leeuwarden, Leeuwarden, the Netherlands
| | - Carmen C van der Pol
- Department of Surgical Oncology, Alrijne Ziekenhuis, Leiderdorp, the Netherlands
| | - Marc A M Mureau
- Department of Plastic and Reconstructive surgery, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Jos A van der Hage
- Department of Surgical Oncology, Leiden University Medical Center, Leiden, the Netherlands
| | - Nicole M A Krekel
- Department of Plastic and Reconstructive surgery, Alrijne Ziekenhuis, Leiderdorp, the Netherlands
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20
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Xie J, Wang M, Cao Y, Zhu Z, Ruan S, Ou M, Yu P, Shi J. ADM-assisted prepectoral breast reconstruction is not associated with high complication rate as before: a Meta-analysis. J Plast Surg Hand Surg 2023; 57:7-15. [PMID: 34581645 DOI: 10.1080/2000656x.2021.1981351] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Implant-related breast reconstruction can be divided into subpectoral breast reconstruction (SPBR) and prepectoral breast reconstruction (PPBR) according to the different anatomical planes. The previous stereotype was that PPBR had a high complication rate and was not suitable for clinical use. However, with the emergence of acellular dermal matrix (ADM), the clinical effect of PPBR has been improved. To compare the outcomes difference between SPBR and PPBR, We conducted this meta-analysis. Articles on SPBR versus PPBR were searched in PubMed, Web of Sciences, Embase, and Cochrane databases, strictly following the PRISMA guidelines. According to the set criteria, we included the literature that met the requirements. Extracted data were the incidence of adverse events and the duration of drainage. Results show that SPBR has a higher incidence rate in capsular contracture, animation deformity, infection, hematoma and delayed healing wound than PPBR. There are no significant differences in skin flap necrosis, seroma, implant loss, reoperation and duration of drainage between the two groups. Hence, PPBR is no longer a high complication surgical method and can be used in the clinical practice. However, there are few large sample studies at present, so it is necessary to carry out further studies on PPBR.
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Affiliation(s)
- Jiaheng Xie
- Department of Burn and Plastic Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Ming Wang
- Department of Burn and Plastic Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Yuan Cao
- Fourth School of Clinical Medicine, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Zhechen Zhu
- Department of Burn and Plastic Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Shujie Ruan
- Department of Burn and Plastic Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Mengmeng Ou
- Department of Burn and Plastic Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Pan Yu
- Department of Burn and Plastic Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Jingping Shi
- Department of Burn and Plastic Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
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21
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Kaplan HY, Rysin R, Zer M, Shachar Y. A Single Surgeon's experience with Motiva Ergonomix Round SilkSurface Silicone implants in breast reconstruction over a 5-year period. J Plast Reconstr Aesthet Surg 2023; 80:156-164. [PMID: 37023600 DOI: 10.1016/j.bjps.2023.01.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 12/10/2022] [Accepted: 01/29/2023] [Indexed: 02/18/2023]
Abstract
BACKGROUND Numerous breast implants are used for breast reconstruction. Each has its advantages and disadvantages. Recent data regarding the link between BIA-ALCL and implant texture caused a significant paradigm shift toward the use of smooth round implants. Motiva Ergonomix, a silk-surface breast implant, is classified as a smooth implant. To date, there is little data regarding the use of this specific implant in breast reconstruction. OBJECTIVE Describe a single surgeon's experience with Motiva Ergonomix, silk-textured, round implant for breast reconstruction. PATIENTS AND METHODS A retrospective chart review of all patients undergoing primary or revisionary breast reconstruction procedures, using Motiva Ergonomix, from January 2017 to January 2022. Patient demographics and medical status were extracted. Surgical data, including reconstructive technique, implant size, plane, use of acellular dermal matrix, and complications, were recorded. BREAST-Q questionnaires were completed. RESULTS A total of 156 consecutive patients were retrieved (269 breasts). A total of 257 were direct-to-implant reconstructions and 12 expander-to-implant. Complications were described per breast. Capsular contraction, Baker grade 3-4, was seen in four breasts (1.49%) in the nonirradiated group and six (2.24%) in the irradiated group. Rippling was seen in 11 breast (4.08%), skin ischemia in 17 (6.31%), hematoma in 4 (1.49%), and seroma in 6 (2.23%). BREAST-Q: satisfaction with breast increased by a mean of 9.175 (60.7 points preoperatively to 69.875 postoperatively). Satisfaction with the implant was 6.52 out of 8. DISCUSSION This cohort describes the current most extensive experience with Motiva Ergonomix implant used for reconstructive surgeries. Motiva Ergonomix breast implant endows a unique set of technologies to provide good results with a low complication rate.
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Affiliation(s)
- Haim Yoel Kaplan
- Department of Plastic Surgery, Yitzhak Shamir Medical Center, Tzrifin 70300, Israel; Private Practice, Tel Aviv, Israel.
| | | | - Matan Zer
- Department of Plastic Surgery, Yitzhak Shamir Medical Center, Tzrifin 70300, Israel; Private Practice, Tel Aviv, Israel
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22
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Racial Disparities in Breast Reconstruction at a Comprehensive Cancer Center. J Racial Ethn Health Disparities 2022; 9:2323-2333. [PMID: 34647274 DOI: 10.1007/s40615-021-01169-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 09/29/2021] [Accepted: 10/06/2021] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Breast reconstruction after a mastectomy is an important component of breast cancer care that improves the quality of life in breast cancer survivors. African American women are less likely to receive breast reconstruction than Caucasian women. The purpose of this study was to further investigate the reconstruction disparities we previously reported at a comprehensive cancer center by assessing breast reconstruction rates, patterns, and predictors by race. METHODS Data were obtained from women treated with definitive mastectomy between 2000 and 2012. Sociodemographic, tumor, and treatment characteristics were compared between African American and Caucasian women, and logistic regression was used to identify significant predictors of reconstruction by race. RESULTS African American women had significantly larger proportions of public insurance, aggressive tumors, unilateral mastectomies, and modified radical mastectomies. African American women had a significantly lower reconstruction rate (35% vs. 49%, p < 0.01) and received a larger proportion of autologous reconstruction (13% vs. 7%, p < 0.01) compared to Caucasian women. The receipt of adjuvant radiation therapy was a significant predictor of breast reconstruction in Caucasian but not African American women. CONCLUSIONS We identified breast reconstruction disparities in rate and type of reconstruction. These disparities may be due to racial differences in sociodemographic, tumor, and treatment characteristics. The predictors of breast reconstruction varied by race, suggesting that the mechanisms underlying breast reconstruction may vary in African American women. Future research should take a target approach to examine the relative contributions of sociodemographic, tumor, and treatment determinants of the breast reconstruction disparities in African American women.
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Prepectoral Breast Reconstruction without Acellular Dermal Matrix: Have We Come Full Circle? J Pers Med 2022; 12:jpm12101619. [PMID: 36294758 PMCID: PMC9605327 DOI: 10.3390/jpm12101619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 09/22/2022] [Indexed: 11/16/2022] Open
Abstract
Breast reconstruction is an integral part of breast cancer treatment [...].
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24
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Najmiddinov B, Park JKH, Yoon KH, Myung Y, Koh HW, Lee OH, Hoon JJ, Shin HC, Kim EK, Heo CY. Conventional versus modified nipple sparing mastectomy in immediate breast reconstruction: Complications, aesthetic, and patient-reported outcomes. Front Surg 2022; 9:1001019. [PMID: 36277278 PMCID: PMC9583667 DOI: 10.3389/fsurg.2022.1001019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 08/29/2022] [Indexed: 11/06/2022] Open
Abstract
Background Nipple-sparing mastectomy (NSM) followed by immediate breast reconstruction (IBR) is the optimal surgical treatment for breast cancer. However, investigations are ongoing to improve the surgical technique to achieve better results. This study aimed to evaluate the outcomes of modified NSM (m-NSM), which preserves the anterior lamellar fat layer, in patients who underwent IBR. Methods All patients who underwent modified NSM (m-NSM) or conventional NSM (c-NSM) followed by IBR using autologous tissue or implants were retrospectively reviewed between January 2014 and January 2021. Two mastectomy types were compared in terms of postoperative complications and aesthetic outcomes using panel assessment scores by physicians and reported outcomes using Breast-Q. In addition, postoperative evaluations of the thickness of mastectomy flap was performed using CT scan images. Results A total of 516 patients (580 breasts) with NSM (143 breasts with c-NSM and 437 breasts with m-NSM) followed by IBR were reviewed. The mean ± SD flap thickness was 8.48 ± 1.81 mm in patients who underwent m-NSM, while it was 6.32 ± 1.15 mm in the c-NSM cohort (p = 0.02). The overall major complications rate was lower in the m-NSM group (3.0% vs. 9.0%, p < 0.013). Ischemic complications of the mastectomy flap and nipple-areolar complex (NAC) were more in c-NSM, although the difference was not statistically significant. The mean panel assessment scores were higher in the m-NSM group (3.14 (good) and 2.38 (fair) in the m-NSM and c-NSM groups, respectively; p < 0.001). Moreover, m-NSM was associated with greater improvements in psychosocial (p < 0.001) and sexual (p = 0.007) well-being. Conclusion Preserving the anterior lamellar fat in NSM was associated with thicker mastectomy flap, overall lower rates of complications, including ischemia of the mastectomy flap and nipple-areolar complex, and was associated with better aesthetic outcomes and improved quality of life.
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Affiliation(s)
- Bakhtiyor Najmiddinov
- Department of Plastic and Reconstructive Surgery, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Joseph Kyu-hyung Park
- Department of Plastic and Reconstructive Surgery, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Kyung-Hwak Yoon
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Yujin Myung
- Department of Plastic and Reconstructive Surgery, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Hyoung Won Koh
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Ok Hee Lee
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Jeong Jae Hoon
- Department of Plastic and Reconstructive Surgery, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Hee Chul Shin
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Eun-Kyu Kim
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, South Korea,Correspondence: Eun-Kyu Kim Chan Yeong Heo
| | - Chan Yeong Heo
- Department of Plastic and Reconstructive Surgery, Seoul National University Bundang Hospital, Seongnam, South Korea,Correspondence: Eun-Kyu Kim Chan Yeong Heo
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Lee J, Kang BJ, Park GE, Kim SH. The Usefulness of Magnetic Resonance Imaging (MRI) for the Detection of Local Recurrence after Mastectomy with Reconstructive Surgery in Breast Cancer Patients. Diagnostics (Basel) 2022; 12:diagnostics12092203. [PMID: 36140604 PMCID: PMC9497711 DOI: 10.3390/diagnostics12092203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Revised: 09/04/2022] [Accepted: 09/07/2022] [Indexed: 11/20/2022] Open
Abstract
The purpose of this study is to investigate the usefulness of magnetic resonance imaging (MRI) for the detection of local recurrence after nipple-sparing mastectomy (NSM) or skin-sparing mastectomy (SSM) with immediate reconstructive surgery for breast cancer. Two hundred and eighty-six NSM or SSM procedures and immediate reconstruction cases between August 2015 and February 2020 were reviewed. The detectability rates of for local recurrence using MRI and ultrasound were assessed, and the characteristics of recurrent and primary cancers were evaluated. The patients with multifocal or multicentric primary cancer and a dense parenchymal pattern showed a higher recurrence rate (p < 0.001). A total of 22 cases showed recurrence, and due to multifocal recurrence, a total of 27 recurrent lesions were identified in the reconstructed breast, of which 12 were symptomatic and 15 were asymptomatic (p < 0.001). With the exception of skin recurrence (n = 6), MRI showed a significantly higher detectability rate (95.2%, 20 of 21) than ultrasound (38.1%, 8 of 21) for the recurrence of cancer in the reconstructed breast (p < 0.001), especially for small-sized (<1 cm) asymptomatic lesions. In addition, the mean recurrence interval of MRI-detected asymptomatic lesions was 21.7 months (SD ± 17.7), which was significantly longer than that of symptomatic recurrence. In conclusion, postoperative MRI can be useful for identifying small-sized (<1 cm) asymptomatic recurrence lesions in reconstructed breast tissue after NSM or SSM, which can be implemented within two years of surgery.
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Nelson JA, Shamsunder MG, Myers PL, Polanco TO, Coriddi MR, McCarthy CM, Matros E, Dayan JH, Disa JJ, Mehrara BJ, Pusic AL, Allen RJ. Matched Preliminary Analysis of Patient-Reported Outcomes following Autologous and Implant-Based Breast Reconstruction. Ann Surg Oncol 2022; 29:5266-5275. [PMID: 35366702 PMCID: PMC9253052 DOI: 10.1245/s10434-022-11504-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 02/07/2022] [Indexed: 08/03/2023]
Abstract
BACKGROUND Comparisons of autologous breast reconstruction (ABR) and implant-based breast reconstruction (IBR) involve unavoidable confounders, which are often adjusted for in post hoc regression analyses. This study compared patient-reported outcomes between ABR patients and IBR patients by using propensity score matching to control for confounding variables upfront. METHODS Propensity score matching analysis (2:1 nearest-neighbor matching with replacement) was performed for patients who underwent ABR or IBR without radiotherapy. Matched covariates included age, body mass index, history of psychiatric diagnosis, race-ethnicity, smoking status, and laterality of reconstruction. Outcomes of interest were BREAST-Q questionnaire scores for breast satisfaction and well-being. RESULTS Of the 2334 patients identified, 427 were included in the final analysis: 159 who underwent ABR and 268 who underwent IBR. The ABR group matched the IBR group in the selected characteristics. ABR patients did not differ significantly from IBR patients in breast satisfaction or well-being at either 1 or 2 years after reconstructive surgery. CONCLUSIONS This preliminary analysis of immediate breast reconstruction patients not requiring radiation therapy with similar propensities for ABR or IBR suggests comparable levels of breast satisfaction and well-being within 2 years after reconstructive surgery. Further research is needed with larger sample sizes, statistical power, and follow-up to better understand patient reported outcomes in this population, as the current findings differ from studies where patients were not matched on baseline characteristics.
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Affiliation(s)
- Jonas A Nelson
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| | - Meghana G Shamsunder
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Paige L Myers
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Thais O Polanco
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Michelle R Coriddi
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Colleen M McCarthy
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Evan Matros
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Joseph H Dayan
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Joseph J Disa
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Babak J Mehrara
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Andrea L Pusic
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Robert J Allen
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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Comparison of short-term outcomes between pedicled- and free-flap autologous breast reconstruction: a nationwide inpatient database study in Japan. Breast Cancer 2022; 29:1067-1075. [PMID: 35849270 DOI: 10.1007/s12282-022-01386-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 07/07/2022] [Indexed: 11/02/2022]
Abstract
BACKGROUND Despite the increasing popularity of autologous breast reconstruction, limited evidence is available. The aim of the present study was to compare the short-term outcomes of pedicled- and free-flap breast reconstructions. METHODS Using a nationwide Japanese inpatient database, we identified 13,838 patients who underwent breast reconstruction for breast cancer (July 2010-March 2020) using a pedicled or free-flap (pedicled- and free-flap groups, n = 8279 and 5559, respectively). One-to-one propensity score matching was performed to compare the occurrence of postoperative complications, duration of anesthesia, length of stay, and total costs between the two groups. We also performed subgroup analyses stratified by hospital volume. RESULTS The propensity score-matched analysis involving 3524 pairs showed that the pedicled-flap group had significantly lower proportions of takeback (2.1% vs. 3.2%, p < 0.001), thrombosis (0.6% vs. 1.7%, p < 0.001), and postoperative bleeding (2.1% vs. 5.7%, p < 0.001) than the free-flap group. No significant differences were found in wound dehiscence or tissue necrosis. Compared to the free-flap group, the pedicled-flap group had a short duration of anesthesia (412 vs. 647 min, p < 0.001) and low total hospitalization costs (12 662 vs. 17 247 US dollars, p < 0.001) but a prolonged postoperative length of stay (13 vs. 12 days, p < 0.001). The subgroup analyses showed results compatible with those of the main analysis. CONCLUSIONS In this large nationwide cohort of patients who underwent breast reconstruction, pedicled-flap reconstruction was associated with fewer postoperative complications (excluding necrosis and wound dehiscence) and lower hospitalization costs but a longer postoperative length of stay than free-flap reconstruction.
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Nelson JA, Cordeiro PG, Polanco T, Shamsunder MG, Patel A, Allen RJ, Matros E, Disa JJ, Cuaron JJ, Morrow M, Mehrara BJ, Pusic AL, McCarthy CM. Association of Radiation Timing with Long-Term Satisfaction and Health-Related Quality of Life in Prosthetic Breast Reconstruction. Plast Reconstr Surg 2022; 150:32e-41e. [PMID: 35499580 DOI: 10.1097/prs.0000000000009180] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Radiation therapy is increasingly used after breast cancer surgery, which may impact patients' postoperative quality of life. This study assessed differences in long-term patient satisfaction and health-related quality of life after radiation therapy administered at different stages of implant-based breast reconstruction or with no radiation after surgery. METHODS In this observational study, long-term outcomes were evaluated for four cohorts of women who completed breast reconstruction and received (1) no radiation, (2) radiation before tissue expander placement, (3) radiation after tissue expander placement, or (4) radiation after permanent implant between 2010 and 2017 at Memorial Sloan Kettering. Satisfaction and health-related quality of life were assessed using the prospectively collected Satisfaction with Breasts and Physical Well-Being of Chest BREAST-Q subscales. Score distributions were examined by radiation exposure status for 3 years after surgery using nonparametric analyses and regression models. RESULTS Of 2932 patients who met the inclusion criteria, 25.8 percent received radiation during breast cancer treatment, including before tissue expander placement ( n = 239; 8.2 percent), after tissue expander placement ( n = 290; 9.9 percent), and after implant placement ( n = 228; 7.8 percent). Radiotherapy patients had average scores 7 to 9 points lower at all postoperative time points for Satisfaction with Breasts and Physical Well-Being of Chest subscales ( p < 0.001). Although patient-reported outcomes did not differ by radiation timing, there were higher rates of severe capsular contracture with postimplant radiotherapy ( p < 0.001). CONCLUSIONS Radiation therapy significantly affected patient satisfaction and health-related quality of life following implant breast reconstruction through 3 years postoperatively. Patient perception of outcome was unaffected by radiotherapy timing; however, capsular contracture was higher after postimplant radiotherapy, suggesting there may be an advantage to performing radiotherapy before placement of the final reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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Affiliation(s)
- Jonas A Nelson
- From the Plastic and Reconstructive Surgery Service and Breast Surgery Service, Department of Surgery, and Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center; and Division of Plastic and Reconstructive Surgery, Department of Surgery, Brigham and Women's Hospital
| | - Peter G Cordeiro
- From the Plastic and Reconstructive Surgery Service and Breast Surgery Service, Department of Surgery, and Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center; and Division of Plastic and Reconstructive Surgery, Department of Surgery, Brigham and Women's Hospital
| | - Thais Polanco
- From the Plastic and Reconstructive Surgery Service and Breast Surgery Service, Department of Surgery, and Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center; and Division of Plastic and Reconstructive Surgery, Department of Surgery, Brigham and Women's Hospital
| | - Meghana G Shamsunder
- From the Plastic and Reconstructive Surgery Service and Breast Surgery Service, Department of Surgery, and Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center; and Division of Plastic and Reconstructive Surgery, Department of Surgery, Brigham and Women's Hospital
| | - Aadit Patel
- From the Plastic and Reconstructive Surgery Service and Breast Surgery Service, Department of Surgery, and Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center; and Division of Plastic and Reconstructive Surgery, Department of Surgery, Brigham and Women's Hospital
| | - Robert J Allen
- From the Plastic and Reconstructive Surgery Service and Breast Surgery Service, Department of Surgery, and Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center; and Division of Plastic and Reconstructive Surgery, Department of Surgery, Brigham and Women's Hospital
| | - Evan Matros
- From the Plastic and Reconstructive Surgery Service and Breast Surgery Service, Department of Surgery, and Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center; and Division of Plastic and Reconstructive Surgery, Department of Surgery, Brigham and Women's Hospital
| | - Joseph J Disa
- From the Plastic and Reconstructive Surgery Service and Breast Surgery Service, Department of Surgery, and Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center; and Division of Plastic and Reconstructive Surgery, Department of Surgery, Brigham and Women's Hospital
| | - John J Cuaron
- From the Plastic and Reconstructive Surgery Service and Breast Surgery Service, Department of Surgery, and Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center; and Division of Plastic and Reconstructive Surgery, Department of Surgery, Brigham and Women's Hospital
| | - Monica Morrow
- From the Plastic and Reconstructive Surgery Service and Breast Surgery Service, Department of Surgery, and Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center; and Division of Plastic and Reconstructive Surgery, Department of Surgery, Brigham and Women's Hospital
| | - Babak J Mehrara
- From the Plastic and Reconstructive Surgery Service and Breast Surgery Service, Department of Surgery, and Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center; and Division of Plastic and Reconstructive Surgery, Department of Surgery, Brigham and Women's Hospital
| | - Andrea L Pusic
- From the Plastic and Reconstructive Surgery Service and Breast Surgery Service, Department of Surgery, and Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center; and Division of Plastic and Reconstructive Surgery, Department of Surgery, Brigham and Women's Hospital
| | - Colleen M McCarthy
- From the Plastic and Reconstructive Surgery Service and Breast Surgery Service, Department of Surgery, and Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center; and Division of Plastic and Reconstructive Surgery, Department of Surgery, Brigham and Women's Hospital
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Dosimetric Effect of Injection Ports in Tissue Expanders on Post-Mastectomy Volumetric Modulated Arc Therapy (VMAT) Planning for Left-Sided Breast Cancer. APPLIED SCIENCES-BASEL 2022. [DOI: 10.3390/app12136461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This study aimed to compare the dosimetric effect of traditional metallic ports and radio frequency identification (RFID) ports (Motiva Flora®) on post-mastectomy volumetric modulated arc therapy (VMAT) planning for left-sided breast cancer. Computed tomography (CT) simulation was performed on an anthropomorphic torso phantom by attaching two types of tissue expander on the left chest wall. For the comparison of CT artifacts, five points of interest were selected and compared: point A = central chest wall, B = medial chest wall, point C = lateral chest wall, point D = axilla, and point E = left anterior descending artery. VMAT planning using two partial arcs with a single isocenter was generated, and dosimetric parameters were investigated. Compared to metallic ports, RFID ports tremendously decreased distortion on CT images, with the exception of point D. The V5Gy, V10Gy, V15Gy, V20Gy, V30Gy, and Dmean values of the heart in RFID ports were lower than those in metallic ports. The V5Gy, V15Gy, V20Gy, V30Gy, and Dmean values of the ipsilateral lung in RFID ports were also lower than those in metallic ports. RFID ports showed superior dosimetric results for doses to the heart and lungs as compared to that in metallic ports.
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30
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Nelson JA, Rubenstein RN, Haglich K, Chu JJ, Yin S, Stern CS, Morrow M, Mehrara BJ, Gemignani ML, Matros E. Analysis of a Trend Reversal in US Lumpectomy Rates From 2005 Through 2017 Using 3 Nationwide Data Sets. JAMA Surg 2022; 157:702-711. [PMID: 35675047 DOI: 10.1001/jamasurg.2022.2065] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Importance Rates of lumpectomy for breast cancer management in the United States previously declined in favor of more aggressive surgical options, such as mastectomy and contralateral prophylactic mastectomy (CPM). Objective To evaluate longitudinal trends in the rates of lumpectomy and mastectomy, including unilateral mastectomy vs CPM rates, and to determine characteristics associated with current surgical practice using 3 national data sets. Design and Setting Data from the National Surgical Quality Improvement Program (NSQIP), Surveillance, Epidemiology, and End Results (SEER) program, and National Cancer Database (NCDB) were examined to evaluate trends in lumpectomy and mastectomy rates from 2005 through 2017. Mastectomy rates were also evaluated with a focus on CPM. Longitudinal trends were analyzed using the Cochran-Armitage test for trend. Multivariate logistic regression models were performed on the NCDB data set to identify predictors of lumpectomy and CPM. Results A study sample of 3 467 645 female surgical breast cancer patients was analyzed. Lumpectomy rates reached a nadir between 2010 and 2013, with a significant increase thereafter. Conversely, in comparison with lumpectomy rates, overall mastectomy rates declined significantly starting in 2013. Cochran-Armitage trend tests demonstrated an annual decrease in lumpectomy rates of 1.31% (95% CI, 1.30%-1.32%), 0.07% (95% CI, 0.01%-0.12%), and 0.15% (95% CI, 0.15%-0.16%) for NSQIP, SEER, and NCDB, respectively, from 2005 to 2013 (P < .001, P = .01, and P < .001, respectively). From 2013 to 2017, the annual increase in lumpectomy rates was 0.96% (95% CI, 0.95%-0.98%), 1.60% (95% CI, 1.59%-1.62%), and 1.66% (95% CI, 1.65%-1.67%) for NSQIP, SEER, and NCDB, respectively (all P < .001). Comparisons of specific mastectomy types showed that unilateral mastectomy and CPM rates stabilized after 2013, with unilateral mastectomy rates remaining higher than CPM rates throughout the entire time period. Conclusions This observational longitudinal analysis indicated a trend reversal with an increase in lumpectomy rates since 2013 and an associated decline in mastectomies. The steady increase in CPM rates from 2005 to 2013 has since stabilized. The reasons for the recent reversal in trends are likely multifactorial. Further qualitative and quantitative research is required to understand the factors driving these recent practice changes and their associations with patient-reported outcomes.
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Affiliation(s)
- Jonas A Nelson
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Robyn N Rubenstein
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Kathryn Haglich
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jacqueline J Chu
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Shen Yin
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Carrie S Stern
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Monica Morrow
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Babak J Mehrara
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Mary L Gemignani
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Evan Matros
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
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Surgical and Patient-Reported Outcomes of Autologous versus Implant-Based Reconstruction following Infected Breast Device Explantation. Plast Reconstr Surg 2022; 149:1080e-1089e. [PMID: 35349553 DOI: 10.1097/prs.0000000000009091] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Implant-based breast reconstruction infections often require implant explantation. Whereas some plastic surgeons pursue autologous reconstruction following the first implant-based breast reconstruction failure caused by infection, others argue that a second attempt is acceptable. METHODS The authors conducted a retrospective study of patients who underwent a second reconstruction attempt with implant-based or free flap breast reconstruction following explantation because of infection between 2006 and 2019. Surgical and patient-reported outcomes were compared between the two groups. RESULTS A total of 6093 implant-based breast reconstructions were performed during the study period, of which 130 breasts met our inclusion criteria [implant-based, n = 86 (66 percent); free flap, n = 44 (34 percent)]. No significant differences in rates of overall (25 percent versus 36 percent; p = 0.2) or major (20 percent versus 21 percent; p = 0.95) complications were identified between the free flap and implant-based cohorts, respectively. Implant-based breast reconstruction patients were more likely to experience a second infection (27 percent versus 2 percent; p = 0.0007) and reconstruction failure (21 percent versus 5 percent; p = 0.019). Among irradiated patients, reconstruction failure was reported in 44 percent of the implant-based and 7 percent of the free flap cohorts (p = 0.02). Free flap patients reported significantly higher scores for Satisfaction with Breasts (73.7 ± 20.1 versus 48.5 ± 27.9; p = 0.0046). CONCLUSIONS Following implant-based breast reconstruction explantation because of infection, implant-based and free flap breast reconstruction had similar rates of overall and major complications; however, implant-based breast reconstruction had considerably higher rates of infection and reconstructive failures and lower patient-reported scores for Satisfaction with Breasts. Given the high rates of implant-based breast reconstruction failure in patients with prior radiotherapy and infection-based failure, plastic surgeons should strongly consider autologous reconstruction in this patient population. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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Weinzierl A, Schmauss D, Brucato D, Harder Y. Implant-Based Breast Reconstruction after Mastectomy, from the Subpectoral to the Prepectoral Approach: An Evidence-Based Change of Mind? J Clin Med 2022; 11:jcm11113079. [PMID: 35683465 PMCID: PMC9181810 DOI: 10.3390/jcm11113079] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 05/16/2022] [Accepted: 05/27/2022] [Indexed: 01/15/2023] Open
Abstract
Over the last years, prepectoral implant-based breast reconstruction has undergone a renaissance due to several technical advancements regarding mastectomy techniques and surgical approaches for the placement and soft tissue coverage of silicone implants. Initially abandoned due to the high incidence of complications, such as capsular contraction, implant extrusion, and poor aesthetic outcome, the effective prevention of these types of complications led to the prepectoral technique coming back in style for the ease of implant placement and the conservation of the pectoralis muscle function. Additional advantages such as a decrease of postoperative pain, animation deformity, and operative time contribute to the steady gain in popularity. This review aims to summarize the factors influencing the trend towards prepectoral implant-based breast reconstruction and to discuss the challenges and prospects related to this operative approach.
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Affiliation(s)
- Andrea Weinzierl
- Institute for Clinical & Experimental Surgery, Saarland University, 66421 Homburg, Germany;
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, 8091 Zurich, Switzerland
| | - Daniel Schmauss
- Department of Plastic, Reconstructive and Aesthetic Surgery, Ospedale Regionale di Lugano, Ente Ospedaliero Cantonale (EOC), 6900 Lugano, Switzerland; (D.S.); (D.B.)
- Faculty of Biomedical Sciences, Università della Svizzera Italiana, 6900 Lugano, Switzerland
| | - Davide Brucato
- Department of Plastic, Reconstructive and Aesthetic Surgery, Ospedale Regionale di Lugano, Ente Ospedaliero Cantonale (EOC), 6900 Lugano, Switzerland; (D.S.); (D.B.)
| | - Yves Harder
- Department of Plastic, Reconstructive and Aesthetic Surgery, Ospedale Regionale di Lugano, Ente Ospedaliero Cantonale (EOC), 6900 Lugano, Switzerland; (D.S.); (D.B.)
- Faculty of Biomedical Sciences, Università della Svizzera Italiana, 6900 Lugano, Switzerland
- Correspondence:
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Yan M, Kuruoglu D, Boughey JC, Manrique OJ, Tran NV, Harless CA, Martinez-Jorge J, Nguyen MDT. Postmastectomy Breast Reconstruction is Safe in Patients on Chronic Anticoagulation. Arch Plast Surg 2022; 49:346-351. [PMID: 35832147 PMCID: PMC9142228 DOI: 10.1055/s-0042-1744405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background
Postmastectomy breast reconstruction (PMR) increases patient satisfaction, quality of life, and psychosocial well-being. There is scarce data regarding the safety of PMR in chronic anticoagulated patients. Perioperative complications can reduce patient satisfaction; therefore, it is important to elucidate the safety of PMR in these patients.
Methods
A retrospective case–control study of patients who underwent PMR with implants and were on chronic anticoagulation was performed at our institution. Inclusion criteria were women ≥ 18 years old. Exclusion criteria included autologous reconstructions, lumpectomy, and oncoplastic procedures. Two controls for every one patient on anticoagulation were matched by age, body mass index, radiotherapy, smoking history, type of reconstruction, time of reconstruction, and laterality.
Results
From 2009 to 2020, 37 breasts (20 patients) underwent PMR with implant-based reconstruction and were on chronic anticoagulation. A total of 74 breasts (40 patients) who had similar demographic characteristics to the cases were defined as the control group. Mean age for the case group was 53.6 years (standard deviation [SD] = 16.1), mean body mass index was 28.6 kg/m
2
(SD = 5.1), and 2.7% of breasts had radiotherapy before reconstruction and 5.4% after reconstruction. Nine patients were on long-term warfarin, six on apixaban, three on rivaroxaban, one on low-molecular-weight heparin, and one on dabigatran. The indications for anticoagulation were prior thromboembolic events in 50%. Anticoagulated patients had a higher risk of capsular contracture (10.8% vs. 0%,
p
= 0.005). There were no differences regarding incidence of hematoma (2.7% vs. 1.4%,
p
= 0.63), thromboembolism (5% vs. 0%,
p
= 0.16), reconstructive-related complications, or length of hospitalization (1.6 days [SD = 24.2] vs. 1.4 days [SD = 24.2],
p
= 0.85).
Conclusion
Postmastectomy implant-based breast reconstruction can be safely performed in patients on chronic anticoagulation with appropriate perioperative management of anticoagulation. This information can be useful for preoperative counseling on these patients.
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Affiliation(s)
- Maria Yan
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, Minnesota
| | - Doga Kuruoglu
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, Minnesota
| | - Judy C. Boughey
- Division of Breast Melanoma Surgical Oncology, Mayo Clinic, Rochester, Minnesota
| | - Oscar J. Manrique
- Division of Plastic Surgery, University of Rochester, Rochester, New York
| | - Nho V. Tran
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, Minnesota
| | - Christin A. Harless
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, Minnesota
| | - Jorys Martinez-Jorge
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, Minnesota
| | - Minh-Doan T. Nguyen
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, Minnesota
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Rubenstein RN, Stern CS, Plotsker EL, Haglich K, Tadros AB, Mehrara BJ, Matros E, Nelson JA. Effects of COVID-19 on mastectomy and breast reconstruction rates: A national surgical sample. J Surg Oncol 2022; 126:205-213. [PMID: 35411946 PMCID: PMC9088456 DOI: 10.1002/jso.26889] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 03/30/2022] [Indexed: 11/29/2022]
Abstract
Background The COVID‐19 pandemic profoundly impacted breast cancer treatment in 2020. Guidelines initially halted elective procedures, subsequently encouraging less invasive surgeries and restricting breast reconstruction options. We examined the effects of COVID‐19 on oncologic breast surgery and reconstruction rates during the first year of the pandemic. Methods Using the National Surgical Quality Improvement Program, we performed an observational examination of female surgical breast cancer patients from 2017 to 2020. We analyzed annual rates of lumpectomy, mastectomy (unilateral/contralateral prophylactic/bilateral prophylactic), and breast reconstruction (alloplastic/autologous) and compared 2019 and 2020 reconstruction cohorts to evaluate the effect of COVID‐19. Results From 2017 to 2020, 175 949 patients underwent lumpectomy or mastectomy with or without reconstruction. From 2019 to 2020, patient volume declined by 10.7%, unilateral mastectomy rates increased (70.5% to 71.9%, p = 0.003), and contralateral prophylactic mastectomy rates decreased. While overall reconstruction rates were unchanged, tissue expander reconstruction increased (64.0% to 68.4%, p < 0.001) and direct‐to‐implant and autologous reconstruction decreased. Outpatient alloplastic reconstruction increased (65.7% to 73.8%, p < 0.0001), and length of hospital stay decreased for all reconstruction patients (p < 0.0001). Conclusions In 2020, there was a nearly 11% decline in breast cancer surgeries, comparable mastectomy and reconstruction rates, increased use of outpatient alloplastic reconstruction, and significantly reduced in‐hospital time across all reconstruction types.
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Affiliation(s)
- Robyn N Rubenstein
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Carrie S Stern
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Ethan L Plotsker
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Kathryn Haglich
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Audree B Tadros
- Breast Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Babak J Mehrara
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Evan Matros
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Jonas A Nelson
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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Mastopexy: with or without Acellular Dermal Matrix? PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2022; 10:e3952. [PMID: 35506020 PMCID: PMC9049028 DOI: 10.1097/gox.0000000000003952] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 09/28/2021] [Indexed: 11/26/2022]
Abstract
In the years after unilateral breast reconstruction, the reconstructed breast resists ptosis more than natural breast tissue in the native contralateral breast. As acellular dermal matrix (ADM) becomes fully incorporated into the recipient's anatomy, thus reinforcing the inferior pole of the uplifted breast, we combined our mastopexy cases with ADM in an attempt to reduce the rate of recurrent ptosis. Method This was a prospective randomized analysis of a cohort of 24 patients, divided into two groups (A and B); all underwent primary unilateral mastopexy to correct grade III breast ptosis. Our patients had previously undergone contralateral skin sparing mastectomy with immediate breast reconstruction, for invasive breast cancer or ductal carcinoma in situ that originally was symmetrical to their native breast. The symmetrization mastopexy in half of our patients was carried out with the addition of an ADM sling to the inferior pole of the breast, to act as an internal, subcutaneous supportive "bra" (A). The other half of patients received a standard symmetrization mastopexy, without the addition of an ADM support (B). Patients were followed up for 36 months. Results The difference between control arm and study groups revealed a statistical difference (P < 0.05), when comparing the follow-up period. From the sixth postoperative month onward, the measurements for group A revealed a statistically significant difference (P < 0.05) when compared with group B. Conclusion The additional ADM sling acts as an added layer of support, thus delaying reoccurrence of ptosis following mastopexy.
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van Egdom LSE, de Ligt KM, de Munck L, Koppert LB, Mureau MAM, Rakhorst HA, Siesling S. Predictors of delayed breast reconstruction in the Netherlands: a 5-year follow-up study in stage I-III breast cancer patients. Breast Cancer 2022; 29:324-335. [PMID: 34780034 PMCID: PMC8885490 DOI: 10.1007/s12282-021-01313-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2021] [Accepted: 10/31/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE Delayed breast reconstruction (DBR) is a valid option for postmastectomy breast cancer patients who have a desire for breast reconstruction but are not considered suitable for immediate breast reconstruction (IBR). The objective of this study was to investigate the clinical practice and predictors of the use of DBR in the Netherlands. METHODS Stage I-III breast cancer patients diagnosed from January to March 2012 and treated with mastectomy were selected from the Netherlands Cancer Registry. Routinely collected patient, tumor, treatment and hospital characteristics were complemented with data about DBR up to 2018. Multivariable logistic regression analyses were performed to identify factors independently associated with postmastectomy DBR. Factors associated with time to DBR were identified through Cox regression analyses. RESULTS Of all patients who underwent mastectomy (n = 1,415), 10.2% underwent DBR. DBR patients more often received autologous reconstruction compared to IBR patients (37.5% vs 6.2%, p < 0.001). Age below 50 years (age < 35 OR 15.55, age 35-49 OR 4.18) and neoadjuvant and adjuvant chemotherapy (OR 2.59 and OR 2.83, respectively) were significantly associated with DBR. Mean time to DBR was 2.4 years [range 1-6 years]. Time to DBR was significantly associated with age < 35 years (HR 2.22), and a high hospital volume (HR 1.87). DISCUSSION The use of DBR after mastectomy could not be fully explained by age below 50 years, chemotherapy, and hospital volume. Treatment with radiotherapy and adjuvant chemotherapy increased time to DBR. More information about patient preferences is needed to understand the use and timing of reconstruction.
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Affiliation(s)
- L S E van Egdom
- Department of Surgical Oncology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands.
- Department of Plastic and Reconstructive Surgery, Erasmus MC Cancer Institute, University Medical Center, P.O. 2040, 3000 CA, Rotterdam, the Netherlands.
| | - K M de Ligt
- Department of Psychosocial Research, Division of Psychosocial Research and Epidemiology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - L de Munck
- Department of Research and Development, Comprehensive Cancer Organisation (IKNL), Utrecht, The Netherlands
| | - L B Koppert
- Department of Surgical Oncology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands
| | - M A M Mureau
- Department of Plastic and Reconstructive Surgery, Erasmus MC Cancer Institute, University Medical Center, P.O. 2040, 3000 CA, Rotterdam, the Netherlands
| | - H A Rakhorst
- Department of Plastic and Reconstructive Surgery, Medisch Spectrum Twente, Enschede, The Netherlands
| | - S Siesling
- Department of Research and Development, Comprehensive Cancer Organisation (IKNL), Utrecht, The Netherlands
- Department of Health Technology and Services Research, Technical Medical Centre, University of Twente, Enschede, The Netherlands
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Pittelkow E, DeBrock W, Christopher L, Mercho R, Suh LJY, Fisher CS, Hartman B, Lester M, Hassanein AH. Advantages of the Delayed-Immediate Microsurgical Breast Reconstruction: Extending the Choice. J Reconstr Microsurg 2022; 38:579-584. [PMID: 35135030 DOI: 10.1055/s-0041-1742240] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Deep inferior epigastric perforator (DIEP) reconstruction can be performed in an immediate (at time of mastectomy), delayed-immediate (immediate tissue expander followed by staged DIEP), or delayed timing following mastectomy. Avoiding flap radiation is a known benefit of the delayed-immediate approach. The purpose of this study is to evaluate patients who chose DIEP flap as the reconstructive method during initial consultation and compared characteristics of surgery in relation to their final reconstructive choice. METHODS Consecutive patients having breast reconstruction from 2017 to 2019 were divided into three groups: immediate DIEP after mastectomy (Group I); delayed-immediate DIEP with tissue expander first followed by DIEP (Group II); and patients who initially chose delayed-immediate DIEP but later decided on implants for the second stage of reconstruction (Group III). Exclusion criteria were patients that had delayed DIEP (no immediate reconstruction) or had initially chose implant-based reconstruction. RESULTS The study included 59 patients. Unilateral free flaps in Group II had shorter operative times (318 minutes) compared with Group I unilateral free flaps (488 minutes) (p = 0.024). Eleven patients (30.6%) had prophylactic mastectomies in Group I compared with none in Group II (p = 0.004). Patients who had immediate tissue expansion frequently changed their mind from DIEP to implant for second stage reconstruction frequently (52.2%). CONCLUSION Delayed-immediate DIEP reconstruction has several advantages over immediate DIEP flap including shorter free flap operative times. Patients commonly alter their preference for second stage reconstruction. A patient-centered advantage of delayed-immediate reconstruction is prolonging the time for patients to make their choice for the final reconstruction.
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Affiliation(s)
- Eric Pittelkow
- Division of Plastic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Will DeBrock
- Divison of Surgical Oncology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Laura Christopher
- Division of Plastic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Raphael Mercho
- Division of Plastic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Lily Ji-Yun Suh
- Division of Plastic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Carla S Fisher
- Divison of Surgical Oncology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Brett Hartman
- Division of Plastic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Mary Lester
- Division of Plastic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Aladdin H Hassanein
- Division of Plastic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
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The Failed Breast Implant in Postmastectomy Reconstruction: A Systematic Literature Review of Complications of Implant-Based Breast Reconstruction. Ann Plast Surg 2022; 88:695-703. [PMID: 35102018 DOI: 10.1097/sap.0000000000002980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Breast cancer is the most diagnosed malignant neoplasia of female patients worldwide in 2019. Survival has increased making it necessary to offer breast reconstructive procedures to improve quality of life and self-esteem. Implant-based breast reconstruction is the most common approach, making it necessary to quantify the associated complications. METHODS A systematic literature review of the PubMed, Cochrane, and Web of Science databases was performed. A total of 9608 citations were identified, and 44 studies met the inclusion criteria. RESULTS Studies included reported the incidence of complications either per patient or per breast leading consequently to 2 complication rates depending on the type of reporting. A total of 14.3% of patient-related and 28.8% of breast-related complications while undergoing implant-based reconstruction were reported.Among total complications reported, 72.6% of patient-related and 48.5% of breast-related complications were classified as major complications.A total of 37.6% of patients respectively 15.1% of breasts required prosthesis explantation due to severe complications. Depending on reporting, 9.7% of patients and 4% of breasts required autologous flap reconstruction due to reconstructive failure. CONCLUSIONS High complication and failure rates are associated with implant-based breast reconstruction. Lacking randomized controlled trials, the choice between implant-based and autologous breast reconstruction has to be made individually for each patient.
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Invited Response on: Commentary on "Skin Reducing Mastectomy and Prepectoral Breast Reconstruction in Large Ptotic Breasts". Aesthetic Plast Surg 2021; 45:3054-3055. [PMID: 33625527 DOI: 10.1007/s00266-021-02188-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 02/08/2021] [Indexed: 10/22/2022]
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Shamsunder MG, Polanco TO, McCarthy CM, Allen RJ, Matros E, Coriddi M, Mehrara BJ, Pusic A, Nelson JA. Understanding Preoperative Breast Satisfaction among Patients Undergoing Mastectomy and Immediate Reconstruction: BREAST-Q Insights. Plast Reconstr Surg 2021; 148:891e-902e. [PMID: 34847108 PMCID: PMC8638966 DOI: 10.1097/prs.0000000000008521] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND This study aims to present normative values for satisfaction with breasts among preoperative breast reconstruction patients as assessed using the BREAST-Q instrument and to delineate factors associated with preoperative breast satisfaction. METHODS A retrospective analysis of prospectively collected data was performed examining women undergoing postmastectomy breast reconstruction at a tertiary care center who preoperatively completed the BREAST-Q from 2010 to 2017. Because breast satisfaction scores were nonnormally distributed, scores were categorized into quartiles for analysis. Patient- and treatment-level variables were tested in a multivariable ordinal logistic regression model as predictors of breast satisfaction. Preoperative satisfaction was also tested for association with choice of reconstructive modality. RESULTS Among 1306 postmastectomy reconstruction patients included in the study, mean preoperative Satisfaction with Breasts score was 61.8 ± 21.5 and the median score was 58.0 (interquartile range, 48 to 70). Factors associated with significantly lower preoperative satisfaction included history of psychiatric diagnosis, preoperative radiotherapy, marital status (married), and higher body mass index. Factors associated with significantly higher scores were malignancy (localized tumor), medium bra size (B to C cup), and self-identification as black. Preoperative breast satisfaction was lower among patients who elected autologous reconstruction than among those with implant reconstruction (p < 0.001). CONCLUSIONS Preoperative breast satisfaction is influenced by multiple factors. Understanding these factors may improve preoperative counseling and expectation management for patients who undergo postmastectomy breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, III.
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Affiliation(s)
- Meghana G Shamsunder
- From the Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center; and the Division of Plastic and Reconstructive Surgery, Department of Surgery, Brigham and Women's Hospital
| | - Thais O Polanco
- From the Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center; and the Division of Plastic and Reconstructive Surgery, Department of Surgery, Brigham and Women's Hospital
| | - Colleen M McCarthy
- From the Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center; and the Division of Plastic and Reconstructive Surgery, Department of Surgery, Brigham and Women's Hospital
| | - Robert J Allen
- From the Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center; and the Division of Plastic and Reconstructive Surgery, Department of Surgery, Brigham and Women's Hospital
| | - Evan Matros
- From the Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center; and the Division of Plastic and Reconstructive Surgery, Department of Surgery, Brigham and Women's Hospital
| | - Michelle Coriddi
- From the Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center; and the Division of Plastic and Reconstructive Surgery, Department of Surgery, Brigham and Women's Hospital
| | - Babak J Mehrara
- From the Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center; and the Division of Plastic and Reconstructive Surgery, Department of Surgery, Brigham and Women's Hospital
| | - Andrea Pusic
- From the Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center; and the Division of Plastic and Reconstructive Surgery, Department of Surgery, Brigham and Women's Hospital
| | - Jonas A Nelson
- From the Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center; and the Division of Plastic and Reconstructive Surgery, Department of Surgery, Brigham and Women's Hospital
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Beier L, Faridi A, Neumann C, Paepke S, Mau C, Keller M, Strittmatter HJ, Gerber-Schäfer C, Bauer L, Karsten MM, Kümmel S, Blohmer JU. Human Acellular Dermal Matrix (Epiflex®) in Immediate Implant-Based Breast Reconstruction after Skin- and Nipple-Sparing Mastectomy and Treatment of Capsular Fibrosis: Results of a Multicenter, Prospective, Observational NOGGO-AWOGyn Study. Breast Care (Basel) 2021; 16:461-467. [PMID: 34720805 DOI: 10.1159/000512201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 09/24/2020] [Indexed: 11/19/2022] Open
Abstract
Background Over the last decades, the number of acellular dermal matrix (ADM)-assisted implant-based breast reconstructions (IBBR) has substantially increased. However, there is still a lack of prospective data on complication rates. Methods We performed a non-interventional, multicenter, prospective cohort study to evaluate complication rates of a human ADM in patients undergoing an IBBR after skin- and nipple-sparing mastectomies. Patients with primary reconstruction (cohort A) and patients undergoing a secondary reconstruction after capsular fibrosis (cohort B) using the human ADM Epiflex® (DIZG gGmbH, Berlin, Germany) were enrolled in this study. Patients were followed-up for 12 months after surgery. Results Eighty-four eligible patients were included in this study of whom 28 women underwent a bilateral breast reconstruction, leading to 112 human ADM-assisted reconstructions in total (cohort A: 73, cohort B: 39). In 33.0% of the reconstructed breasts at least one of the complications of primary interest occurred, including implant loss 7.1%, seroma 15.2%; infection 5.4%, rash 8.0%, and Baker grade III/IV capsular fibrosis 2.7%, with no statistically significant differences between the cohorts. Previous radiation therapy was significantly associated with occurrence of any postoperative complication (OR 20.41; p value 0.027). Conclusion The rates of most complications were comparable to the rates reported for other ADMs with relatively low rates of capsular fibrosis and infections. The rate of seroma was increased in our study. Prior radiation therapy increased the risk of any postoperative complications. Therefore, the use of ADM in these patients should be considered carefully.
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Affiliation(s)
- Lea Beier
- Gynecology and Breast Center, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Nord-Ostdeutsche Gesellschaft für Gynäkologische Onkologie e.V., Berlin, Germany
| | - Andree Faridi
- Senology and Breast Center, University Hospital Bonn, Bonn, Germany
| | - Corina Neumann
- Breast Center, St. Franziskus Hospital, Münster, Germany
| | - Stefan Paepke
- Comprehensive Cancer Center, Brustzentrum der Technischen Universität München Klinikum Rechts der Isar, Munich, Germany
| | - Christine Mau
- Gynecology, Breast Center, HELIOS Hospital Berlin-Buch, Berlin, Germany
| | - Maren Keller
- Nord-Ostdeutsche Gesellschaft für Gynäkologische Onkologie e.V., Berlin, Germany
| | | | | | - Lelia Bauer
- Gynecology, GRN Hospital Weinheim, Weinheim, Germany
| | | | - Sherko Kümmel
- Breast Unit, Kliniken Essen-Mitte, Evangelische Huyssens-Stiftung, Essen, Germany
| | - Jens-Uwe Blohmer
- Gynecology and Breast Center, Charité-Universitätsmedizin Berlin, Berlin, Germany
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Coudé Adam H, Frisell A, Liu Y, Sackey H, Oikonomou I, Docherty Skogh AC, Frisell J, de Boniface J. Effect of radiotherapy on expanders and permanent implants in immediate breast reconstruction: long-term surgical and patient-reported outcomes in a large multicentre cohort. Br J Surg 2021; 108:1474-1482. [PMID: 34694356 DOI: 10.1093/bjs/znab333] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 08/17/2021] [Indexed: 11/13/2022]
Abstract
BACKGROUND Current evidence for the effects of radiotherapy (RT) on implant-based immediate breast reconstruction (IBR) is limited by short follow-up and lack of patient-reported outcomes (PROs). It is central to integrate long-term comprehensive outcome data into the preoperative decision-making process. The aim of the present study was to determine long-term surgical outcomes and PROs in relation to RT after implant-based IBR. METHODS This was a longitudinal cohort study of PRO data obtained in surveys conducted in 2012 and 2020 using the BREAST-Q questionnaire. All women undergoing therapeutic mastectomy and implant-based IBR between 1 January 2007 and 31 December 2011 at four breast centres in Stockholm, Sweden, were identified. The endpoint was implant removal owing to surgical complications or patient preference. RESULTS Median follow-up was 120 (range 1-171) months. After 754 IBRs in 729 women, implant removal occurred in 128 (17 per cent): 34 of 386 (8.8 per cent) in the no-RT group, 20 of 64 (31.3 per cent) in the group with previous RT, and 74 of 304 (24.3 per cent) in the postoperative RT group (P < 0.001). Implant removal was because of surgical complications in 60 instances (7.9 per cent), and patient preference in 68 (9.0 per cent). The BREAST-Q response rate was 72.2 per cent. Women with previous RT scored lower than those without RT on all scales, apart from psychosocial well-being. Women with postoperative RT scored lower only on physical well-being. No scores in the two RT groups had deteriorated between the survey time points, whereas satisfaction with breasts and overall outcome had decreased in the no-RT group. CONCLUSION Although RT was significantly associated with higher implant removal rates, PROs remained stable over 8 years despite irradiation.
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Affiliation(s)
- Hannah Coudé Adam
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Axel Frisell
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Yihang Liu
- Department of Surgery, Capio St Göran's Hospital, Stockholm, Sweden
| | - Helena Sackey
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Department of Breast and Endocrine Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Ira Oikonomou
- Department of Surgery, South General Hospital, Stockholm, Sweden.,Department of Clinical Science and Education, Karolinska Institutet, Stockholm, Sweden
| | - Ann-Charlot Docherty Skogh
- Department of Surgery, South General Hospital, Stockholm, Sweden.,Department of Clinical Science and Education, Karolinska Institutet, Stockholm, Sweden
| | - Jan Frisell
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Department of Breast and Endocrine Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Jana de Boniface
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Department of Surgery, Capio St Göran's Hospital, Stockholm, Sweden
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Masoomi H, Hanson SE, Clemens MW, Mericli AF. Autologous Breast Reconstruction Trends in the United States: Using the Nationwide Inpatient Sample Database. Ann Plast Surg 2021; 87:242-247. [PMID: 33443887 DOI: 10.1097/sap.0000000000002664] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Autologous tissue is the criterion standard in breast reconstruction, but traditionally has been used as a secondary option after implant-based options because of reduced reimbursement relative to effort and required additional technical skill. We intended to evaluate the overall frequency and trends of autologous breast reconstruction (ABR), the trends of ABR in teaching versus nonteaching hospitals and the trends of ABR in different hospital regions in the United States. METHODS Using the Nationwide Inpatient Sample database, we examined the clinical data of patients who underwent immediate or delayed ABR from 2009 to 2016 in the United States. RESULTS A total of 146,185 patients underwent ABR during this period. The overall rate of ABR increased 112%, from 26.6% to 56.5%. The majority of ABR were delayed reconstructions (62.3%), which increased gradually from 54.9% to 80% during the study period. The overall frequency of flaps included the deep inferior epigastric perforator (32.1%), latissimus dorsi myocutaneous (28.4%), free transvers rectus abdominus myocutaneous (15.9%), pedicled transvers rectus abdominus myocutaneous flap (14.5%), gluteal artery perforator (0.6%), superficial inferior epigastric artery (0.6%), and unspecified-ABR (7.2%). Most ABRs were performed in teaching hospitals (78.6%) versus nonteaching hospitals (21.4%). The teaching hospitals' ABR rate increased from 70.5% to 88.7%. The greatest proportion of ABRs were performed in the south (39.6%) followed by northeast (23.0%), midwest (18.9%), and west (18.5%). CONCLUSIONS The deep inferior epigastric perforator flap has become the predominant ABR method in the United States. In addition to more delayed reconstructions being performed in recent years, ABR rates are increasing overall and shifting from pedicled flaps to free flaps.
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Affiliation(s)
- Hossein Masoomi
- From the Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston, TX
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Destination Design msTRAM: For Greater Reconstructive Certainty. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3704. [PMID: 34422522 PMCID: PMC8376307 DOI: 10.1097/gox.0000000000003704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 05/27/2021] [Indexed: 12/01/2022]
Abstract
Performing delayed reconstruction to a unilateral breast while simultaneously performing a balancing procedure on the contralateral side can be the most difficult situation to achieve symmetry. We present here a novel approach to free TRAM-based breast reconstruction using reverse planning and subunit principles with simultaneous balancing reduction mastopexy and immediate nipple reconstruction.
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The Association of Overall Annual Hospital Volume and Perioperative Outcomes following Free Flap Breast Reconstruction. Plast Reconstr Surg 2021; 147:196e-206e. [PMID: 33565821 DOI: 10.1097/prs.0000000000007549] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Hospital volume has been correlated with improved outcomes in oncologic care and complex surgical procedures. The authors sought to determine the relationship between overall annual hospital volume and perioperative outcomes following free flap breast reconstruction. METHODS Free flap breast reconstruction patients (n = 7991) were identified at 1907 centers using the Healthcare Cost and Utilization Project National Inpatient Sample database. Logistic regression characterized the association of hospital volume (total discharges per year) with systemic, surgical, and microsurgical complications. Patients were categorized as being treated at low- versus high-volume hospitals based on identified threshold volumes, and the association with the incidence of complications was estimated. RESULTS Initially, restricted cubic spline analysis suggested potential threshold volumes of 13,018 (95 percent CI, 7468 to 14,512) and 7091 (95 percent CI, 5396 to 9918) discharges per year, at which the risk for developing systemic and microsurgical complications may change, respectively. However, further patient-level evaluation of treatment at low- versus high-volume hospitals demonstrated that hospital volume did not predict the risk of developing perioperative systemic (OR, 1.28; 95 percent CI, 0.75 to 2.18; p = 0.36) or microsurgical complications (OR, 1.06; 95 percent CI, 0.78 to 1.44; p = 0.73). CONCLUSIONS Perioperative complications after free flap breast reconstruction did not differ between patients treated at low- versus high-volume hospitals after in-depth multiprong analysis. Patient outcomes are more likely associated with surgeon and programmatic experience. Overall annual hospital volume should not serve as a proxy for high-quality breast free flap care. . CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, III.
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Implant Loss and Associated Risk Factors following Implant-based Breast Reconstructions. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3708. [PMID: 34316425 PMCID: PMC8301285 DOI: 10.1097/gox.0000000000003708] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 05/27/2021] [Indexed: 01/10/2023]
Abstract
Implant loss is the most severe complication of implant-based breast reconstructions. This study aimed to evaluate the incidence of implant loss and other complications, identify associated risk factors, and create a risk model for implant loss. Methods This was a retrospective cohort study of all patients who underwent a mastectomy, followed by either a two-stage or a direct-to-implant breast reconstruction. Patient variables, operative characteristics, and postoperative complications were obtained from the patient records. A multivariate mixed-effects logistic regression model was used to create a risk model for implant loss. Results A total of 297 implant-based breast reconstructions were evaluated. Overall, the incidence of implant loss was 11.8%. Six risk factors were significantly associated with implant loss: obesity, a bra cup size larger than C, active smoking status, a nipple-preserving procedure, a direct-to-implant reconstruction, and a lower surgeon's volume. A risk model for implant loss was created, showing a predicted risk of 8.4%-13% in the presence of one risk factor, 21.9%-32.5% in the presence of two, 47.5%-59.3% in the presence of three, and over 78.2% in the presence of four risk factors. Conclusions The incidence of implant loss in this study was 11.8%. Six associated significant risk factors were identified. Our risk model for implant loss revealed that the predicted risk increased over 78.2% when four risk factors were present. This risk model can be used to better inform patients and decrease the risk of implant loss by optimizing surgery using personalized therapy.
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Manne SL, Smith BL, Frederick S, Mitarotondo A, Kashy DA, Kirstein LJ. B-Sure: a randomized pilot trial of an interactive web-based decision support aid versus usual care in average-risk breast cancer patients considering contralateral prophylactic mastectomy. Transl Behav Med 2021; 10:355-363. [PMID: 30608607 DOI: 10.1093/tbm/iby133] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
The use of contralateral prophylactic mastectomy (CPM) is increasing among breast cancer patients who are at average or "sporadic" risk for contralateral breast cancer. Because CPM provides no survival benefit for these patients, it is not medically recommended for them. Decision support aids may facilitate more informed, higher quality CPM decision. The purpose of this study was to evaluate the feasibility and acceptability of B-Sure, an online decision support aid to facilitate informed decisions regarding CPM, and to compare the impact of B-Sure in increasing CPM knowledge, reducing decisional conflict, and increasing preparedness to make the CPM decision among breast cancer patients at sporadic risk who are considering CPM. Ninety-three patients with unilateral, nonhereditary breast cancer considering CPM completed a baseline survey, were randomized to receive B-Sure or Usual care, and completed a 4-week follow-up survey assessing decisional conflict, preparedness to make the CPM decision, and CPM knowledge as well as self-efficacy, perceived risk, worry, CPM motivations, and the surgical decision. Study participation was high. B-Sure was viewed by almost 80% of the participants and was evaluated positively. At follow-up, patients assigned to B-Sure reported significantly higher clarity regarding the personal values relevant to the CPM decision and higher knowledge about CPM. B-Sure had smaller effects on other aspects of decisional conflict. B-Sure improved CPM knowledge and reduced decisional conflict. Patients considering CPM may benefit from an online decision support aid, but may be sensitive to approaches that they perceive as biased against CPM.
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Affiliation(s)
- Sharon L Manne
- Department of Medicine, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
| | - Barbara L Smith
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Sara Frederick
- Department of Medicine, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
| | - Anna Mitarotondo
- Department of Medicine, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
| | - Deborah A Kashy
- Department of Psychology, Michigan State University, East Lansing, MI, USA
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O'Donnell JPM, Murphy D, Ryan ÉJ, Gasior SA, Sugrue R, O'Neill BL, Boland MR, Lowery AJ, Kerin MJ, McInerney NM. Optimal reconstructive strategies in the setting of post-mastectomy radiotherapy - A systematic review and network meta-analysis. Eur J Surg Oncol 2021; 47:2797-2806. [PMID: 34301444 DOI: 10.1016/j.ejso.2021.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 05/17/2021] [Accepted: 07/05/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND A third of breast cancer patients require mastectomy. In some high-risk cases postmastectomy radiotherapy (PMRT) is indicated, threatening reconstructive complications. Several PMRT and reconstruction combinations are used. Autologous flap (AF) reconstruction may be immediate (AF→PMRT), delayed-immediate with tissue expander (TE [TE→PMRT→AF]) or delayed (PMRT→AF). Implant-based breast reconstruction (IBBR) includes immediate TE followed by PMRT and conversion to permanent implant (PI [TE→PMRT→PI]), delayed TE insertion (PMRT→TE→PI), and prosthetic implant conversion prior to PMRT (TE→PI→PMRT). AIM Perform a network metanalysis (NMA) assessing optimal sequencing of PMRT and reconstructive type. METHODS A systematic review and NMA was performed according to PRISMA-NMA guidelines. NMA was conducted using R packages netmeta and Shiny. RESULTS 16 studies from 4182 identified, involving 2322 reconstructions over three decades, met predefined inclusion criteria. Studies demonstrated moderate heterogeneity. Multiple comparisons combining direct and indirect evidence established AF-PMRT as the optimal approach to avoid reconstructive failure, compared with IBBR strategies (versus PMRT→TE→PI; OR [odds ratio] 0.10, CrI [95% credible interval] 0.02 to 0.55; versus TE→PMRT→PI; OR 0.13, CrI 0.02 to 0.75; versus TE→PI→PMRT OR 0.24, CrI 0.05 to 1.05). PMRT→AF best avoided infection, demonstrating significant improvement versus PMRT→TE→PI alone (OR 0.12, CrI 0.02 to 0.88). Subgroup analysis of IBBR found TE→PI→PMRT reduced failure rates (OR 0.35, CrI 0.15-0.81) compared to other IBBR strategies but increased capsular contracture. CONCLUSION Immediate AF reconstruction is associated with reduced failure in the setting of PMRT. However, optimal reconstructive strategy depends on patient, surgeon and institutional factors. If IBBR is chosen, complication rates decrease if performed prior to PMRT. PROSPERO REGISTRATION CRD 42020157077.
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Affiliation(s)
- J P M O'Donnell
- Department of Plastics and Reconstructive Surgery, Galway University Hospitals, Galway, Ireland; Department of Surgery, Galway University Hospitals, Galway, Ireland.
| | - D Murphy
- Department of Plastics and Reconstructive Surgery, Galway University Hospitals, Galway, Ireland; Department of Surgery, Galway University Hospitals, Galway, Ireland
| | - É J Ryan
- Department of Surgery, Galway University Hospitals, Galway, Ireland
| | - S A Gasior
- University of Limerick School of Medicine, University of Limerick, Ireland
| | - R Sugrue
- Department of Plastics and Reconstructive Surgery, Galway University Hospitals, Galway, Ireland; Department of Surgery, Galway University Hospitals, Galway, Ireland
| | - B Lane O'Neill
- Department of Plastics and Reconstructive Surgery, Galway University Hospitals, Galway, Ireland; Department of Surgery, Galway University Hospitals, Galway, Ireland
| | - M R Boland
- Department of Surgery, The Royal College of Surgeons in Ireland, 123 St Stephen's Green, Dublin, Ireland
| | - A J Lowery
- Department of Surgery, Galway University Hospitals, Galway, Ireland; The Lambe Institute for Translational Research, National University of Ireland, Galway, Ireland
| | - M J Kerin
- Department of Surgery, Galway University Hospitals, Galway, Ireland; The Lambe Institute for Translational Research, National University of Ireland, Galway, Ireland
| | - N M McInerney
- Department of Plastics and Reconstructive Surgery, Galway University Hospitals, Galway, Ireland; Department of Surgery, Galway University Hospitals, Galway, Ireland
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Shammas RL, Sergesketter AR, Taskindoust M, Glener AD, Cason RW, Hollins A, Atia AN, Mundy LR, Hollenbeck ST. An Assessment of Patient Satisfaction and Decisional Regret in Patients Undergoing Staged Free-Flap Breast Reconstruction. Ann Plast Surg 2021; 86:S538-S544. [PMID: 34100812 DOI: 10.1097/sap.0000000000002699] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND In the setting of radiation therapy or significant medical comorbidities, free-flap breast reconstruction may be intentionally delayed or staged with tissue expander placement ("delayed-immediate" approach). The effect of a staged approach on patient satisfaction and decisional regret remains unclear. METHODS All patients undergoing free-flap breast reconstruction (n = 334) between 2014 and 2019 were identified. Complication rates, patient satisfaction using the BREAST-Q, and decisional regret using the Decision Regret Scale were compared between patients undergoing immediate, delayed, and staged approaches. RESULTS Overall, 100 patients completed the BREAST-Q and Decision Regret Scale. BREAST-Q scores for psychosocial well-being (P = 0.19), sexual well-being (P = 0.26), satisfaction with breast (P = 0.28), physical well-being (chest, P = 0.49), and physical well-being (abdomen, P = 0.42) did not significantly vary between patients undergoing delayed, staged, or immediate reconstruction. Overall, patients experienced low regret after reconstruction (mean score, 11.5 ± 17.1), and there was no significant difference in regret scores by reconstruction timing (P = 0.09). Compared with normative BREAST-Q data, unlike immediate and delayed approaches, staged reconstruction was associated with lower sexual well-being (P = 0.006). Furthermore, a significantly higher infection rate was seen among staged patients (immediate 0%, delayed 5%, staged 20%, P = 0.01). CONCLUSIONS Staged free-flap breast reconstruction confers similar long-term satisfaction and decisional regret as immediate and delayed reconstruction but may be associated with worsened sexual well-being, when compared with normative data, and an increased risk of surgical site infection. When counseling patients regarding the timing of reconstruction, it is important to weigh these risks in the context of equivalent long-term satisfaction and decisional regret between immediate, delayed, and staged approaches.
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Affiliation(s)
- Ronnie L Shammas
- From the Division of Plastic, Maxillofacial, and Oral Surgery, Department of Surgery, Duke University Health System, Durham, NC
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Abstract
BACKGROUND Nipple-areola preservation positively impacts quality of life of the patients and helps them to achieve a better psychological and sexual well-being, as well as higher satisfaction with their reconstruction. Patients with large or ptotic breasts, however, represent a technical challenge to surgeons, and nipple-areola preservation may be deferred in this clinical scenario. The aim of this study is to report our experience in patients with large or ptotic breasts who underwent nipple-sparing mastectomy (NSM) and prepectoral implant-based breast reconstruction with immediate mastopexy. METHODS A single-institution retrospective chart review was performed in all consecutive patients who underwent NSM and prepectoral implant-based breast reconstruction, simultaneously with mastopexy. This procedure was offered preoperatively to patients who had ptotic or large breasts, which could benefit from mastopexy to obtain a better result. Aesthetic outcomes were evaluated using a modified 5-point Likert scale, and satisfaction and quality of life were evaluated using the reconstruction module of the BREAST-Q questionnaire. RESULTS Seventeen NSMs with simultaneous mastopexy were performed on 9 patients. All completed reconstruction successfully, and there were no cases of nipple ischemia or necrosis. Global aesthetic evaluation score was 3.77 (±0.95). The Q-scores were as follows: satisfaction with breast was 90, psychosocial well-being was 95, sexual well-being was 80, and physical well-being with chest was 86. CONCLUSIONS In patients with large and/or ptotic breasts, NSM with prepectoral breast reconstruction and immediate mastopexy showed promising results. However, adequate preoperative planning and intraoperative flap assessment are necessary in order to minimize complications.
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