Current trends in breast reconstruction: survey of American Society of Plastic Surgeons 2010. Ann Plast Surg. 2013;70:103-110. [PMID: 21862916 DOI: 10.1097/sap.0b013e31822ed5ce]

Assessing Outcomes and Safety of Inpatient Versus Outpatient Tissue Expander Immediate Breast Reconstruction

BACKGROUND

With the rising cost of healthcare delivery and bundled payments for episodes of care, there has been impetus to minimize hospitalization and increase utilization of outpatient surgery mechanisms. Given the increase in outpatient mastectomy and immediate tissue expander (TE)-based reconstruction and the paucity of data on its comparative safety to inpatient procedures, we sought to understand the risk for early postoperative complications in an outpatient model compared with more traditional inpatient status using the National Surgical Quality Improvement Program database.

METHODS

NSQIP data files from 2005 to 2012 were queried to identify patients undergoing immediate TE-based breast reconstruction after mastectomy. Patients were stratified by whether they received outpatient or inpatient care and then propensity score matched based on preoperative baseline characteristics to produce matched cohorts. Multivariate regression analysis was used to determine whether outpatient versus inpatient status conferred differing risk for 30-days complications.

RESULTS

Of the 2014 patients who met criteria, 1:1 propensity matching yielded 634 patients in each of the matched cohorts. Overall complications (5.2 vs. 5.4 %), overall surgical complications (4.3 vs. 3.9 %), overall medical complications (1.3 vs. 2.1 %), and return to the operating room (6.6 vs. 7.3 %) were similar between outpatient and inpatients cohorts (p > .2), respectively. There was a small, but significant increased risk of organ/space SSI in outpatients (1.9 vs. 0.5 %, p = .02) and trend for increased risk for pulmonary embolus (PE) and urinary tract infection (UTI) in inpatients (0.3 vs. 0 %, p = .16; 0.3 vs. 0 %, p = .16).

CONCLUSIONS

Our studies suggest that outpatient TE confers similar safety profiles to inpatient TE with regards to 30-day postoperative overall complications, medical and surgical morbidity, and return to the operating room. A slightly increased risk for surgical site infection must be balanced against potential risk for known inpatient-related complications such as UTI and PE.

A comparative analysis of 2 national breast reconstruction surveys: concerns regarding autologous and microsurgical breast reconstruction

Background:

Pertinent findings of two national breast reconstruction (BR) surveys from two different institutions at two separate times (2012 vs 2010) were analyzed for comparison.

Methods:

An appraisal of sampling methodology, sample demographics, years of practice, practice affiliation, BR type, and annual volume between the two studies was conducted using statistical analysis.

Results:

Proper sampling technique and adequate sample size were used in both surveys to represent the typical population of general US plastic surgeons practicing BR. There were no differences in mean age or years of practice between the sample population in both studies. The percentage of plastic surgeons with academic affiliation was higher in the 2012 survey compared to the 2010 survey (28% vs 18%, P<0.05). Implant-based BR was the predominant method among surveyed plastic surgeons in both surveys. There was a substantial decrease in the proportion of plastic surgeons performing >20 cases per year in the 2012 survey compared to the 2010 survey (P<0.05). A high volume of BR, defined as >60 cases per year in the 2010 survey and >20 cases per year in the 2012 survey, correlated significantly with academic practice and multidisciplinary cancer centers, respectively (P<0.05). There was a significant decline in the percentage of plastic surgeons performing microsurgical BR from 2010 to 2012 (35% vs 25%, P<0.05).

Conclusions:

Comparative data suggest that there are fewer high volume BR cases being performed by US plastic surgeons and that there has been a reduction among plastic surgeons in the use of microsurgical BR from 2010 to 2012. We believe that these findings may indicate early signs of the changes in BR trends in the US.

Trans-axillary approach for breast implant exchange in high risk cases of irradiated or attenuated skin

BACKGROUND

Breast reconstruction with implants after tissue expansion is one of the most common methods of reconstruction. Although this approach is generally reliable, exchange of breast tissue expander for implant through the standard anterior incision presents a challenge in cases with attenuated soft tissue envelope due to radiation, thin anatomy, prior surgery, or combination of the above. We propose that a trans-axillary approach is a safe and alternate approach for implant exchange in the high-risk patients.

TECHNIQUE AND CASE EXAMPLES

A case series of 16 patients with multiple risk factors for compromised soft tissue that underwent a trans-axillary approach for implant exchange is reported. The trans-axillary implant exchange technique involves use of a standard 4 cm axillary incision, removal of the expander, judicious capsulotomy, placement of permanent implant, and closure in three separate tissue layers.

RESULTS

All trans-axillary cases were successful and all incisions were well healed without dehiscence, infection, or seroma. The average patient age was 49.4 years, and 50% of patients had received or were scheduled to receive radiation therapy. Nine patients underwent unilateral trans-axillary expander exchange while 7 patients were bilateral. Median implant size was 360 cc (mean 369 cc, range 150-600 cc), and mean follow-up for all patients was over 24 months. There were no cases of implant extrusion, capsular contracture requiring re-operation, or lymphedema. Six patients underwent concurrent or subsequent nipple reconstruction.

CONCLUSIONS

This approach illustrates application of a technique commonly used in breast aesthetic augmentation to address a common reconstructive dilemma, which we believe to be a useful tool in prosthesis-based breast reconstruction, especially in patients with compromised soft tissue envelopes.

Role of Breast Surgery in BRCA Mutation Carriers

BRCA mutation carriers have a life-long breast cancer risk between 55 and 85% and a high risk of developing breast cancer at a very young age, depending on the type of mutation. The risk of developing contralateral breast cancer after a first breast cancer is elevated up to 65%, especially in case of BRCA1 mutation and young age at the first breast cancer. Since bilateral prophylactic mastectomy is associated with a risk reduction of 90-95% of developing primary or contralateral breast cancer, this option is a key point within the counseling process for patient information and shared decision-making of mutation carriers. Although the local control after breast-conserving therapy in mutation carriers seems to be comparable to that of sporadic breast cancer patients, individual patient information and counseling should include all alternative procedures of oncologically adequate mastectomy techniques and immediate reconstruction. Excellent cosmetic results, high levels of life quality, and good patient acceptance can be achieved with the recent developments in reconstructive surgery of the breast.

Immediate breast reconstruction with acellular dermal matrix: factors affecting outcome

BACKGROUND

The use of acellular dermal matrix (ADM) for coverage of the lower pole in immediate implant-based breast reconstruction has changed surgeons' practice. We present our experience using a porcine ADM (Strattice), focusing on short-term outcomes, patient selection, and technique adaptations that may influence outcome.

METHODS

A two-center, retrospective, cohort study was performed from December 2008 to October 2012 at Guy's and St. Thomas' Hospitals, London, and Clinic Pyramide, Zürich. The study period was divided into two periods: Period 1 which spanned from December 2008 to October 2010 and Period 2 from January 2011 to October 2012 wherein technique adaptations were introduced. Short-term complications after reconstructive surgery were compared between Periods 1 and 2.

RESULTS

A total of 149 patients underwent 200 reconstructions (110 one-stage and 90 two-stage) following oncologic (134 breasts) or prophylactic (66 breasts) mastectomy. The mean follow-up was 22.2 months. The total complication rate was 32.5%, including infection, 11.5%; hematoma, 5%; seroma, 10.5%; skin necrosis, 3.5%; and serious wound breakdowns with implant exposure, 1.5%. Complications resulted in 3% requiring an early exchange of implant/expander and in 12.5% requiring explantation. A significant reduction in total complications, infection, implant exposure, and implant loss were noted in Period 2. Multivariate analysis showed time period of surgery (Period 1), single-stage reconstruction, and patient characteristics (mastectomy weight>600 g, or body mass index (BMI)>30, or smoking) to be statistically significant risk factors for the development of postoperative complications. Neoadjuvant chemotherapy showed a trend towards higher complication rates.

CONCLUSION

The high rate of early complications in this study was mostly related to patient characteristics and learning curves and highlights the importance of patient selection and technique principles in optimizing the outcome.

Impact of breast reconstruction on the decision to undergo contralateral prophylactic mastectomy

BACKGROUND

In the last decade, there has been increasing use of contralateral prophylactic mastectomy (CPM) in patients with unilateral breast cancer and ductal carcinoma-in-situ (DCIS) undergoing mastectomy. Although many factors have been proposed to explain this trend, the impact of breast reconstruction on CPM has not been studied.

METHODS

A retrospective review of patients with unilateral invasive breast cancer or DCIS from Surveillance, Epidemiology, and End Results registry data (2004-2008) was conducted. Characteristics of patients undergoing CPM and reconstruction were evaluated.

RESULTS

A total of 102,674 patients diagnosed with DCIS or stage I to III infiltrating breast cancer underwent mastectomy for their primary lesion. Of these, 16,197 patients (16 %) underwent a CPM. A significantly higher proportion of women undergoing CPM had reconstruction performed (46 %) than those patients not undergoing CPM (15 %) (p < 0.001). Of the 20,760 patients (20 %) who underwent reconstruction, 7410 (36 %) had implant reconstruction, 7705 (37 %) tissue reconstruction, and 1941 (9 %) combined tissue/implant reconstruction; there were no data for 3,702 (18 %). There was an increasing trend of patients undergoing reconstruction from 2004 (n = 3390, 16.3 %) to 2008 (n = 5406, 26 %) (p < 0.001). On multivariable analysis, significant variables predicting CPM included age <45 years, stage I disease (odds ratio [OR] 1.44, 95 % confidence interval [CI] 1.35-1.54), lobular histology (OR 1.15, 95 % CI 1.11-1.20), and undergoing breast reconstruction (OR 3.58, 95 % CI 3.41-3.75).

CONCLUSIONS

Besides age, undergoing reconstructive surgery is the factor most strongly associated with CPM. This suggests that apart from risk reduction, the availability of and/or patient willingness to undergo breast reconstruction may influence the decision to undergo CPM.

Long-term follow-up of changing practice patterns in breast reconstruction due to increased use of tissue expanders and perforator flaps

BACKGROUND

As the science of breast reconstruction evolves, significant changes in reconstruction strategies and outcomes are expected. The purpose of this study is to determine the changes in breast reconstruction trends and outcomes that occurred at a multidisciplinary academic institution during the last decade.

METHODS

We compared 265 patients over two distinct 6-month intervals separated by 5 years (2002 vs. 2007) and performed long-term follow-up (4.75 ± 3.38 years 2002, 2.99 ± 2.25 years 2007). We studied patients seeking prophylactic mastectomy, patients with early breast cancer, and patients with locally advanced disease. We analyzed demographic data, breast cancer history and treatment, type and timing of reconstruction, and complications.

RESULTS

Implant to flap reconstruction ratio was 48:49 in 2002 and 76:102 in 2007. Use of transverse rectus abdominis myocutaneous flap declined from 57 to 4%; conversely, deep inferior epigastric perforator flap increased from 27 to 91% (P < 0.001). Correspondingly, donor site chronic pain (4 vs. 0, P = 0.012) and postoperative abdominal wall bulge (9 vs. 3, P = 0.004) rates decreased. Timing of reconstruction showed increased staged cases in 2007 compared to 2002 (P = 0.045). Post-final reconstruction radiation therapy was reduced in 2007 (P = 0.016), with subsequent lower rates of implant rupture (P < 0.001).

CONCLUSIONS

At our institution and over the last decade, increasing staged reconstructions have successfully reduced the rates of post-final reconstruction radiotherapy with optimized outcomes. Contrary to national trends, the rates of autologous flap reconstructions have increased with reduced donor site morbidity. This suggests that academic breast reconstruction trends are independent from national trends.

The management of abdominal contour defects following TRAM flap breast reconstruction

BACKGROUND

Incisional hernia can develop following breast reconstruction with abdominal tissue regardless of technique, and the management is often challenging.

OBJECTIVES

The authors characterize hernias following transverse rectus abdominis musculocutaneous (TRAM) flap procedures and evaluate outcomes of different strategies for repair.

METHODS

All patients who underwent repair of a TRAM-related hernia or bulge between 2003 and 2011 at a single institution were retrospectively reviewed. A minimum of 2 years' follow-up was required for inclusion in this series. Outcomes of different techniques for repair were compared and risk factors for hernia recurrence identified.

RESULTS

Forty-three patients underwent repair of a TRAM-related hernia or bulge, most often with mesh (74.4%, n=32). At a mean overall follow-up of 5.2 years, 9 patients (20.9%) developed recurrent hernia or bulge. Compared to primary suture closure, the use of mesh was protective against recurrence (odds ratio, 0.05; 95% confidence interval, 0.00-0.65; P=.02), with the best results observed with fascial closure and underlay mesh reinforcement.

CONCLUSIONS

Incisional hernia following TRAM flap breast reconstruction can be a challenging problem. Attention to surgical technique and the use of mesh minimize the risk of recurrence.

Adjuvant chemotherapy increases the prevalence of fat necrosis in immediate free abdominal flap breast reconstruction

BACKGROUND

Fat necrosis is one of the most common complications following free flap breast reconstruction. Although a minor complication, fat necrosis can compromise esthetic results and confuse with cancer recurrence. Perfusion-related factors and post-operative radiotherapy are the known risks. However, the influence of adjuvant chemotherapy on fat necrosis prevalence remains unknown.

METHODS

Our initial experience of 88 consecutive breast reconstructions with free abdominal flaps was reviewed. The prevalence of fat necrosis was recorded and the risk factors were analyzed using univariate and multivariate logistic regression models.

RESULTS

The overall prevalence of fat necrosis was 36.4% in this series. In a multivariate logistic regression model, adjuvant chemotherapy significantly increased the risk of fat necrosis. The relative risk was 4.762 (95% confidence interval (CI), 1.767-12.831; p = 0.002). There was no evidence of a specific chemotherapeutic agent causing fat necrosis. The first cycle of adjuvant chemotherapy was frequently delivered earlier in patients with fat necrosis than those without fat necrosis, although this tendency was not statistically significant.

CONCLUSIONS

Our initial experience with free flap breast reconstruction seems to suggest that chemotherapy may increase the risk of fat necrosis following immediate breast reconstruction. Patients should be fully informed, and the initiation of post-operative chemotherapy may be adjusted accordingly.

Comparing five alternative methods of breast reconstruction surgery: a cost-effectiveness analysis

BACKGROUND

The purpose of this study was to assess the cost-effectiveness of five standardized procedures for breast reconstruction to delineate the best reconstructive approach in postmastectomy patients in the settings of nonirradiated and irradiated chest walls.

METHODS

A decision tree was used to model five breast reconstruction procedures from the provider perspective to evaluate cost-effectiveness. Procedures included autologous flaps with pedicled tissue, autologous flaps with free tissue, latissimus dorsi flaps with breast implants, expanders with implant exchange, and immediate implant placement. All methods were compared with a "do-nothing" alternative. Data for model parameters were collected through a systematic review, and patient health utilities were calculated from an ad hoc survey of reconstructive surgeons. Results were measured in cost (2011 U.S. dollars) per quality-adjusted life-year. Univariate sensitivity analyses and Bayesian multivariate probabilistic sensitivity analysis were conducted.

RESULTS

Pedicled autologous tissue and free autologous tissue reconstruction were cost-effective compared with the do-nothing alternative. Pedicled autologous tissue was the slightly more cost-effective of the two. The other procedures were not found to be cost-effective. The results were robust to a number of sensitivity analyses, although the margin between pedicled and free autologous tissue reconstruction is small and affected by some parameter values.

CONCLUSIONS

Autologous pedicled tissue was slightly more cost-effective than free tissue reconstruction in irradiated and nonirradiated patients. Implant-based techniques were not cost-effective. This is in agreement with the growing trend at academic institutions to encourage autologous tissue reconstruction because of its natural recreation of the breast contour, suppleness, and resiliency in the setting of irradiated recipient beds.

Breast reconstruction de novo by water-jet assisted autologous fat grafting--a retrospective study

BACKGROUND

Autologous fat grafting has become a frequent, simple, reproducible and low-risk technique for revisional or partial breast reconstruction. The presented European multicenter study describes an optimized treatment and follow-up protocol for the de novo breast reconstruction after total mastectomy by lipotransfer alone.

METHODS

A retrospective European multicenter trial included 135 procedures on 28 (35 breasts) postmastectomy patients (mean 52.4 years). All women were treated with the water-jet assisted fat grafting method (BEAULI™) combined with additional procedures (NAC reconstruction, contralateral mastoplasty) and evaluated with at least 6 months follow-up (mean 2.6 years). Sonography or mammography, clinical examination, patient questionnaire (10-point Likert scale) and digital photographs were carried out.

RESULTS

On average the patients received 4 to 6 procedures each with a single volume of 159 ml (±61 ml) over 21 months (range 9 months to 2.5 years). In total 1,020 ml (±515 ml) fat were grafted till a complete breast reconstruction was achieved. Irradiated patients needed a significantly higher volume than non-irradiated (p<0.041). Main treatment complications were liponecrosis (2.59%), infection (0.74%) and granuloma (0.74%). Patient satisfaction was overall high to very high (96%) and confirmed the good aesthetic results (68%) and the natural softness, contour and shape of the reconstructed breast.

CONCLUSIONS

A complete breast reconstruction with large volume fat grafting is alternatively possible to standard techniques in selected cases. It takes at least 4 to 6 lipotransfers in the course of 2 years. Patients with prior radiotherapy may require even up to 8 sessions over nearly 3 years of treatment.

Porcine acellular dermis-assisted breast reconstruction: influence of adjuvant radiotherapy on complications and outcomes

Background:

Implant-based reconstruction is the most frequently performed breast reconstruction procedure. A persistent issue with this approach is optimizing outcomes in the setting of radiotherapy. Experimental evidence suggests that acellular dermal matrix use may provide a protective benefit, but clinical evidence is lacking. The purpose of this study was to assess postoperative complications and the effect of radiotherapy on complications and outcomes in women who underwent immediate, porcine acellular dermal matrix (PADM, Strattice)-assisted, implant-based breast reconstruction postmastectomy.

Methods:

Patients with at least 1 year of follow-up were included in this retrospective study. Patient charts were reviewed for demographic data, adjunctive therapy use, duration of follow-up, and type and incidence of complications during follow-up.

Results:

A total of 158 reconstructions were performed in 103 patients. Adjuvant therapy included chemotherapy in 51% of patients and radiotherapy in 25% of breasts. Mean follow-up was 36.2 months. Complications occurred in 17 breasts (10.8%): implant/expander loss (8.2%); infection (5.7%); dehiscence (3.8%); eschar (1.9%); and ischemia, hematoma, and seroma (0.6% each). Nine breasts with complications had been irradiated; all were irradiated prereconstruction. Rate of total complications, implant/expander loss, and dehiscence was significantly higher in irradiated breasts. Breasts irradiated postreconstruction had no complications.

Conclusions:

Addition of PADM to implant-based reconstruction is associated with acceptable complication rates comparable to those observed with standard submuscular reconstructions. Complications are increased in the setting of radiotherapy; but PADM use may protect against the adverse effects of postreconstruction radiotherapy.

The Multi Centre Canadian Acellular Dermal Matrix Trial (MCCAT): study protocol for a randomized controlled trial in implant-based breast reconstruction

BACKGROUND

The two-stage tissue expander/implant (TE/I) reconstruction is currently the gold standard method of implant-based immediate breast reconstruction in North America. Recently, however, there have been numerous case series describing the use of one-stage direct to implant reconstruction with the aid of acellular dermal matrix (ADM). In order to rigorously investigate the novel application of ADM in one-stage implant reconstruction, we are currently conducting a multicentre randomized controlled trial (RCT) designed to evaluate the impact on patient satisfaction and quality of life (QOL) compared to the two-stage TE/I technique.

METHODS/DESIGNS

The MCCAT study is a multicenter Canadian ADM trial designed as a two-arm parallel superiority trial that will compare ADM-facilitated one-stage implant reconstruction compared to two-stage TE/I reconstruction following skin-sparing mastectomy (SSM) or nipple-sparing mastectomy (NSM) at 2 weeks, 6 months, and 12 months. The source population will be members of the mastectomy cohort with stage T0 to TII disease, proficient in English, over the age of 18 years, and planning to undergo SSM or NSM with immediate implant breast reconstruction. Stratified randomization will maintain a balanced distribution of important prognostic factors (study site and unilateral versus bilateral procedures). The primary outcome is patient satisfaction and QOL as measured by the validated and procedure-specific BREAST-Q. Secondary outcomes include short- and long-term complications, long-term aesthetic outcomes using five standardized photographs graded by three independent blinded observers, and a cost effectiveness analysis.

DISCUSSION

There is tremendous interest in using ADM in implant breast reconstruction, particularly in the setting of one-stage direct to implant reconstruction where it was previously not possible without the intermediary use of a temporary tissue expander (TE). This unique advantage has led many patients and surgeons alike to believe that one-stage ADM-assisted implant reconstruction should be the procedure of choice and should be offered to patients as the first-line treatment. We argue that it is crucial that this technique be scientifically evaluated in terms of patient selection, surgical technique, complications, aesthetic outcomes, cost-effectiveness, and most importantly patient-reported outcomes before it is promoted as the new gold standard in implant-based breast reconstruction.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT00956384.

Clinical outcomes of percutaneous drainage of breast fluid collections after mastectomy with expander-based breast reconstruction

PURPOSE

To determine clinical outcomes of patients who underwent imaging-guided percutaneous drainage of breast fluid collections after mastectomy and breast reconstruction.

MATERIALS AND METHODS

A retrospective review was performed including all consecutive patients who underwent percutaneous drainage of fluid collections after mastectomy with tissue expander-based reconstruction between January 2007 and September 2012. During this period, 879 mastectomies (563 patients) with expander-based breast reconstruction were performed. Fluid collections developed in 28 patients (5%), which led to 30 imaging-guided percutaneous drainage procedures. The median follow-up time was 533 days. Patient characteristics, surgical technique, microbiology analysis, and clinical outcomes were reviewed.

RESULTS

The mean age of patients was 51.5 years (range, 30.9-69.4 y), and the median time between breast reconstruction and drainage was 35 days (range, 4-235 d). Erythema and swelling were the most common presenting symptoms. The median volume of fluid evacuated at the time of drain placement was 70 mL. Drains were left in place for a median 14 days (range, 6-34 d). Microorganisms were detected in the fluid in 12 of 30 drainage procedures, with Staphylococcus aureus being the most common microorganism. No further intervention was needed in 21 of 30 drainage procedures (70%). However, surgical intervention (removal of expanders) was needed after 6 (20%) drainage procedures, and additional percutaneous drainage procedures were performed after 3 (10%) drainage procedures.

CONCLUSIONS

Percutaneous drainage is an effective means of treating postoperative fluid collections after expander-based breast reconstruction and can obviate the need for repeat surgery in most cases.

Trends in post-mastectomy reconstruction: a SEER database analysis

BACKGROUND AND OBJECTIVES

This study was performed to investigate recent trends and factors associated with immediate breast reconstruction (IBR) using a large population-based registry. We hypothesized that rates of IBR have increased since passage of the Women's Health and Cancer Rights Act of 1998.

METHODS

The SEER (surveillance, epidemiology and end results) database was used to evaluate Stage I-III breast cancer (BC) patients who underwent total mastectomy from 1998 to 2008. Univariate and multivariate analyses were performed to study predictors of IBR.

RESULTS

Of 112,348 patients with BC treated by mastectomy 18,001 (16%) had IBR. Rates of IBR increased significantly from 1998 to 2008 (P < 0.0001). Use of IBR significantly decreased as patient age increased (P < 0.0001), as stage increased (P < 0.0001), and as the number of positive lymph nodes increased (P < 0.0001). Estrogen receptor+/progesterone receptor+ (ER+/PR+) patients had significantly higher IBR rates than ER-/PR-patients (P < 0.0001). IBR was used in 3,615 of 25,823 (14.0%) of patients having post-mastectomy radiation (XRT) and in 14,188 of 86,513 (16.4%) of those not having XRT (P < 0.0001).

CONCLUSIONS

The utilization of IBR has increased significantly over the last decade. IBR was found to be significantly associated with age, race, geographical region, stage, ER, grade, LN status, and XRT (P < 0.0001).

440 Consecutive immediate, implant-based, single-surgeon breast reconstructions in 281 patients: a comparison of early outcomes and costs between SurgiMend fetal bovine and AlloDerm human cadaveric acellular dermal matrices

BACKGROUND

A 2010 nationwide survey of plastic and reconstructive surgeons indicated that approximately 83 percent performed predominantly implant-based breast reconstruction, with acellular dermal matrix used by approximately half of those practitioners. Although the medical literature documents well over 2000 cases of breast reconstruction with matrices, relatively few cases using other than human cadaveric acellular dermal matrices have been reported. The author compared complications and costs using SurgiMend fetal bovine and AlloDerm human cadaveric acellular dermal matrices.

METHODS

A retrospective review of a single surgeon's 5-year experience was performed for consecutive, nonrandomized immediate breast reconstructions with acellular dermal matrix from 2005 to 2010.

RESULTS

Two hundred eighty-one patients had 440 implant-based reconstructions using SurgiMend [222 patients (79.0 percent)] or AlloDerm [59 patients (21.0 percent)]. No significant differences in complication rates were observed between SurgiMend and AlloDerm for hematoma, infection, major skin necrosis, or breast implant removal. Seroma was the most prevalent complication; the seroma rate for AlloDerm (15.7 percent) was significantly greater than that for SurgiMend (8.3 percent). Using recent product costs for equivalently sized AlloDerm and SurgiMend units, the cost of SurgiMend was $1024 less per breast than AlloDerm.

CONCLUSIONS

SurgiMend fetal bovine and AlloDerm human cadaveric acellular dermal matrices demonstrate similar rates of major early complications in breast reconstruction in this study. This similarity in complication rates between SurgiMend and AlloDerm and the cost savings seen with the use of SurgiMend are factors for the surgeon to consider in choosing a matrix for breast reconstruction.

CLINICAL QUESTION/LEVEL OF EVIDENCE

: Therapeutic, III.

Plastic surgical management of the contralateral breast in post-mastectomy breast reconstruction

Breast reconstruction following mastectomy can be reliably undertaken using many different techniques. Although excellent cosmetic results can be achieved without contralateral balancing surgery, many unilateral breast reconstructions require a balancing procedure on the contralateral breast in order to achieve symmetry; the ultimate goal in breast reconstruction. This article attempts to summarise the existing literature on the plastic surgical management of the contralateral breast. It also outlines the multifactorial and complex issues involved in the planning and undertaking of such surgery with illustrative examples. The implications for future oncological management and radiological surveillance following the procedure are also discussed in brief.

The deep inferior epigastric perforator and pedicled transverse rectus abdominis myocutaneous flap in breast reconstruction: a comparative study

Background

Our objective was to compare the complication rates of two common breast reconstruction techniques performed at our hospital and the cost-effectiveness for each test group.

Methods

All patients who underwent deep inferior epigastric perforator (DIEP) flap and transverse rectus abdominis myocutaneous (TRAM) flap by the same surgeon were selected and matched according to age and mastectomy with or without axillary clearance. Patients from each resultant group were selected, with the patients matched chronologically. The remainder were matched for by co-morbidities. Sixteen patients who underwent immediate breast reconstruction with pedicled TRAM flaps and 16 patients with DIEP flaps from 1999 to 2006 were accrued. The average total hospitalisation cost, length of hospitalisation, and complications in the 2 year duration after surgery for each group were compared.

Results

Complications arising from both the pedicled TRAM flaps and DIEP flaps included fat necrosis (TRAM, 3/16; DIEP, 4/16) and other minor complications (TRAM, 3/16; DIEP, 1/16). The mean hospital stay was 7.13 days (range, 4 to 12 days) for the pedicled TRAM group and 7.56 (range, 5 to 10 days) for the DIEP group. Neither the difference in complication rates nor in hospital stay duration were statistically significant. The total hospitalisation cost for the DIEP group was significantly higher than that of the pedicled TRAM group (P<0.001).

Conclusions

Based on our study, the pedicled TRAM flap remains a cost-effective technique in breast reconstruction when compared to the newer, more expensive and tedious DIEP flap.

Intensity modulated proton therapy for postmastectomy radiation of bilateral implant reconstructed breasts: a treatment planning study

BACKGROUND AND PURPOSE

Delivery of post-mastectomy radiation (PMRT) in women with bilateral implants represents a technical challenge, particularly when attempting to cover regional lymph nodes. Intensity modulated proton therapy (IMPT) holds the potential to improve dose delivery and spare non-target tissues. The purpose of this study was to compare IMPT to three-dimensional (3D) conformal radiation following bilateral mastectomy and reconstruction.

MATERIALS AND METHODS

Ten IMPT, 3D conformal photon/electron (P/E), and 3D photon (wide tangent) plans were created for 5 patients with breast cancer, all of whom had bilateral breast implants. Using RTOG guidelines, a physician delineated contours for both target volumes and organs-at-risk. Plans were designed to achieve 95% coverage of all targets (chest wall, IMN, SCV, axilla) to a dose of 50.4 Gy or Gy (RBE) while maximally sparing organs-at-risk.

RESULTS

IMPT plans conferred similar target volume coverage with enhanced homogeneity. Both mean heart and lung doses using IMPT were significantly decreased compared to both P/E and wide tangent planning.

CONCLUSIONS

IMPT provides improved homogeneity to the chest wall and regional lymphatics in the post-mastectomy setting with improved sparing of surrounding normal structures for woman with reconstructed breasts. IMPT may enable women with mastectomy to undergo radiation therapy without the need for delay in breast reconstruction.

Technique for seroma drainage in implant-based breast reconstruction

Seromas are a common complication associated with breast reconstructive surgery. In expander based breast reconstructions, a seroma can pose a particularly difficult problem related to final tissue envelope shape as well as an increase in the risk of infection and possible tissue necrosis. Unfortunately, the literature describes few non-image related techniques to drain a seroma with a breast implant in place. We present a technique to drain a seroma associated with expander based breast reconstruction in conjunction with expander inflation, minimizing the risk of expander puncture, utilizing the same equipment necessary for expander inflation in the office. The benefit to this technique is that diagnostic and therapeutic imaging is not necessary and the risk of expander damage is minimized.

[Double DIEP flaps for unilateral breast reconstruction]

DIEP flap is a reliable option for autologous breast reconstruction after mastectomy. Previously performed lower median laparotomy can cause some difficulties in cases when more volume is needed than the DIEP flap harvested from one side can provide. We performed breast reconstruction using double hemi-DIEP flaps in three of the cases discussed. All patients recovered without complications and had a good aesthetic outcome. This method offers a safe opportunity and broadens the spectrum of breast reconstruction.