Aesthetic outcomes in women undergoing breast-conserving therapy followed by mastectomy and microsurgical reconstruction

Head-to-Head Analysis of Vertical vs Horizontal Incision Patterns in Breast Reconstruction: Surgical Outcomes and Aesthetic Implications

BACKGROUND

Modern aesthetically optimized breast reconstruction requires collaboration between the patient, breast surgeon, and plastic surgeon. To optimize both surgical outcome and aesthetic results, incision patterns must be carefully planned.

OBJECTIVES

We aimed to determine whether vertical or horizontal orientation of mastectomy incision was preferred in the general population and to analyze corresponding complication profiles.

METHODS

A retrospective review was performed of all patients undergoing bilateral mastectomy followed by autologous breast reconstruction utilizing either vertical or horizontal incision from January 2011 to November 2022. Postoperative complications of the 2 incision patterns were analyzed. Additionally, crowdsourcing was utilized to assess aesthetic implications of horizontal and vertical incision patterns on postoperative pictures of completed breast reconstruction. Survey rater demographics were also analyzed to assess differences in scoring based on voter characteristics.

RESULTS

There were no significant differences in postoperative breast complications between patients with horizontal or vertical incisions when considering wound, infection, seroma, hematoma, fat necrosis, or overall complications (P > .05). Crowdsourcing showed that, regardless of voter demographics, vertical incisions were preferred over horizontal incisions (P < .001). Additionally, voters who knew someone who had undergone breast reconstruction were more likely to rate all incision patterns higher than other voters (P < .001).

CONCLUSIONS

Although there are no significant differences in complication profiles between vertical and horizontal incisions in autologous breast reconstruction patients, vertical incision patterns are preferred aesthetically by the general population.

LEVEL OF EVIDENCE: 4

Prepectoral Versus Subpectoral Breast Reconstruction in High-Body Mass Index Patients

BACKGROUND

The effect of body mass index (BMI) on complication rates in prepectoral implant-based breast reconstruction is not well established. The purpose of this study was to compare complication rates between different BMI groups in subpectoral and prepectoral reconstruction.

METHODS

A single-surgeon, 4-year, retrospective review was performed of consecutive prosthetic breast reconstructions. During this time, the senior author's practice shifted from a subpectoral to prepectoral technique. Patients were stratified into BMI subgroups (<25, 25-35, and >35 kg/m2) and complication rates were analyzed. A survey was administered to blinded medical personnel and patients comparing esthetic results.

RESULTS

Implant-based reconstructions were performed in 195 patients (103 subpectoral and 92 prepectoral). No significant difference in major complication rate was observed between techniques. Among patients with BMI greater than 35 kg/m2, implant exposure occurred at a significantly higher rate in the prepectoral group (P = 0.04). In patients with BMI greater than 25 kg/m2, minor asymmetry was more prevalent with prepectoral reconstruction (12.3% vs 0%; P = 0.02). Regardless of technique, the odds of reoperation increased by 7% per point increase in BMI, although this did not reach statistical significance (P = 0.07; odds ratio, 1.07; 95% confidence interval, 0.99-1.15).A total of 66 survey responses were received. Physicians rated esthetic results more positively than patients did. Patients with a BMI of less than 25 kg/m2 were rated better than other BMI groups in nearly all categories. The position of submuscular reconstruction was rated significantly better than prepectoral.

CONCLUSIONS

There is a trend toward higher complication rates in prepectoral versus subpectoral breast reconstruction with increasing BMI. Nonetheless, the technique appears to be safe, with comparable clinical and cosmetic results.

How do breast cancer surgery scars impact survivorship? Findings from a nationwide survey in the United States

Background

The surgical treatment of breast cancer has been associated with negative consequences for patients’ body image, sexual functioning, mental health, and social adjustment. Recent advances in the surgical approach to breast cancer allow the oncologic surgeon to safely optimize cosmetic outcomes. Little is known about the possible relevance of surgical scars. The aim of this research was to gather the perspective of breast cancer survivors themselves on the issue of surgical scars and their negative impact on survivorship.

Methods

An internet survey was conducted nationwide in the United States among women who reported being surgically treated by lumpectomy, mastectomy, or both procedures for breast cancer. To improve generalizability, census-based enrollment quotas were applied for geographic region, health insurance, and income.

Results

The five hundred respondents reported lumpectomy only (n = 215), mastectomy only (n = 140), or both surgeries (n = 132). In response to the statement, “I do not like the location of my surgical scar”, 64% of lumpectomy-only respondents and 67% of mastectomy-only respondents agreed somewhat or strongly. Only 26% of lumpectomy respondents and 14% of mastectomy respondents reported minimal or no negative impact as a consequence of the surgical scars.

Conclusion

Consistent with previous literature, this nationwide US survey shows that the majority of women feel negatively affected by their breast cancer surgery scars. Surgeons should consider this outcome when planning surgery, which may improve patients’ survivorship journey.

Electronic supplementary material

The online version of this article (10.1186/s12885-019-5553-0) contains supplementary material, which is available to authorized users.

Vertical Mastectomy Incision in Implant Breast Reconstruction After Skin Sparing Mastectomy: Advantages and Outcomes

BACKGROUND

The type of since skin-sparing mastectomy (SSM) incision directly impacts the final aesthetic and functional results of reconstruction. Different incisions are used for SSM depending on tumor location, previous biopsy scars, breast weight, and ptosis degree. A vertical scar is less visible to the patient, reminiscent of a mastopexy, and patients may not have the stigma of mastectomy.

OBJECTIVE

This study investigates complication rates, patient demographics, patient reported outcomes, and plastic surgeon evaluations to compare vertical incision mastectomy to other incisions.

METHODS

After institutional review board approval, a retrospective chart review was performed. A total population of 167 patients that underwent mastectomy with tissue expander reconstruction was separated into vertical incision and nonvertical incision mastectomy groups consisting of 38 and 129 patients, respectively. Patient demographics, complications, tumor margins, staging, breast weight, and breast implant volume were compared. BREASTQ Survey analysis was conducted using patient reported outcomes from the patient's perspective. Aesthetic evaluations of postoperative photos were systematically scored by plastic surgeons to obtain data from the plastic surgeon's perspective.

RESULTS

Vertical incision orientation did not increase surgical complication rates or mastectomy skin necrosis (P = 0.142). Vertical incisions did not interfere with obtaining adequate tumor margins (P = 0.907). Vertical incisions did not have a significantly different breast weight or implant volume. There was no statistical difference for patient satisfaction or plastic surgeon aesthetic evaluation.

CONCLUSIONS

The use of vertical incision does not increase complication rates; does not interfere with tumor margins; and can be applied to all age, BMI, breast weight, and breast implant volume groups.