Update on breast reconstruction techniques and indications

The significance of timing in breast reconstruction after mastectomy: An ACS-NSQIP analysis

BACKGROUND

A variety of breast reconstruction (BR) options are available. The significance of timing on outcomes remains debated. This study aims to compare complications in breast cancer patients undergoing implant-based and autologous BR immediately after mastectomy or at a delayed time point.

METHODS

We reviewed the ACS-NSQIP database (2008-2021) to identify all female patients who underwent BR for oncological purposes. Outcomes were stratified by technique (implant-based versus autologous) and timing (immediate versus delayed), and included 30-day mortality, reoperation, (unplanned) readmission, and surgical and medical complications.

RESULTS

A total of 21,560 patients were included: 11,237 (52%) implant-based (9791/87% immediate, 1446/13% delayed) and 10,323 (48%) autologous (8378/81% immediate, 1945/19% delayed). Complications occurred in 3666 (17%) patients (implant-based: n = 1112/11% immediate, n = 64/4.4% delayed cohorts; Autologous: n = 2073/25% immediate, n = 417/21% delayed cohorts). In propensity score weighting (PSW) analyses, immediate BR was associated with significantly more complications than delayed BR (p < 0.0001). This was the case for both implant-based and autologous BR, with a greater difference between the two time points noted in implant-based. Confounder-adjusted multivariable analyses confirmed these results.

CONCLUSION

At the 30-day time point, delayed BR is associated with significantly lower complication rates than immediate BR, in both the implant-based and autologous cohorts. These findings are not a blanket recommendation in favor of immediate and/or delayed BR. Instead, our insights may guide surgeons and patients in decision-making and help refine patients' eligibility in a case-by-case workup.

Benefits of Using Magnetic Resonance Imaging During Breast Tissue Expansion: Literature Review and Case Series

Breast cancer results in up to 1.6 million new candidates for yearly breast reconstruction (BR) surgery. Two-stage breast reconstruction surgery with the use of a tissue expander (TE) is a common approach to reconstructing the breast after mastectomy. However, a common disadvantage encountered with the traditional breast TE is the magnetic injection port, which has been reported to cause injuries in patients undergoing magnetic resonance (MR) imaging. Therefore this type of breast TE is labeled "MR unsafe." Recent technological advances have incorporated radio-frequency identification (RFID) technology in the TE to allow for the location of the injection port without magnetic components, resulting in an MR-conditional TE. This paper aims to review the information regarding the safety profile of TEs with magnetic ports and to gather distinct clinical scenarios in which an MR-conditional TE benefits the patient during the BR process. A literature review ranging from 2018 to 2022 was performed with the search terms: "tissue expander" OR "breast tissue expander" AND "magnetic resonance imaging" OR "MRI." Additionally, a case series was collected from each of the authors' practices. The literature search yielded 13 recent peer-reviewed papers, and 6 distinct clinical scenarios were compiled and discussed. Most clinicians find MRI examinations to be the state-of-art diagnostic imaging modality. However, due to the preexisting risks associated with TEs with magnetic ports, the MRI labeling classification should be considered when deciding which TE is the most appropriate for the patient requiring MRI examinations.

LEVEL OF EVIDENCE: 4

Latissimus dorsi flap - the main force in breast reconstruction for breast tumor in Chinese population

Background

The latissimus dorsi flap (LDF) is the most commonly used autologous flap for breast reconstruction (BR) in China. We conducted this study to explore the current status of BR using LDF with/without implants.

Methods

This study was a single-center retrospective study that included breast tumor patients who underwent LDF breast reconstruction at Fudan University Shanghai Cancer Center (FUSCC) between 2000 and 2021.

Results

We analyzed 4918 patients who underwent postmastectomy BR, including 1730 patients (35.2%) with autologous flaps. LDF was used for BR in 1093 (22.2%) patients, and an abdominal flap was used in 637 (13.0%) patients. The proportion of LDFs used in autologous BR patients decreased each year and dropped to approximately 65.0% after 2013 due to the increased use of abdominal flaps. Among these patients, 609 underwent extended LDF (ELDF) BR, 455 underwent LDF BR with implants, and 30 received a LDF as a salvage flap due to previous flap or implant failure. Patients who underwent ELDF reconstruction were older and had a higher BMI than those who received a LDF with implants. There was no significant difference in the mean postoperative hospital stay, neoadjuvant chemotherapy rates, or adjuvant radiotherapy rates between the two groups. Major complications requiring surgical intervention occurred in 25 patients (2.29%). There was no significant difference in the incidence of major complications between the two groups (P=0.542).

Conclusions

LDF breast reconstruction is a well-developed and safe procedure. The duration of postoperative hospitalization nor the incidence of major complications was affected by implant use.

Does concurrent gynaecological surgery affect infectious complications rate after mastectomy with implant-based reconstruction?

BACKGROUND

Women who undergo breast cancer surgery often have an indication for gynaecological procedure. The aim of our study was to compare infectious complications rate after mastectomy with implant-based reconstruction in patients with and without concurrent gynaecological procedure.

PATIENTS AND METHODS

We retrospectively reviewed clinical records of 159 consecutively operated patients after mastectomy with implant-based reconstruction. The patients were divided in 2 groups: 102 patients without (Group1) and 57 with (Group 2) concurrent gynaecological procedure. Infectious complications rates between the groups were compared using χ²-test. Logistic regression was performed to test for association of different variables with infectious complications.

RESULTS

There were 240 breast reconstructions performed. Median follow-up time was 297 days (10-1061 days). Mean patient age was 47.2 years (95% CI 32.8-65.9); 48.2 years (95% CI 46.1-50.3) in Group 1 and 45.8 years (95% CI 43.2-48.3) in Group 2; p = 0.002). Infectious complications rate was 17.6% (17.6% vs. 17.5%, p = 0.987), implant loss occurred in 5.7% (4.9% vs. 7.0%, p = 0.58). Obesity (body mass index [BMI] > 30 kg/m²), age, previous breast conserving treatment (BCT) with radiotherapy (RT) were identified as risk factors for infectious complications in univariate analysis. Obesity (adjusted odds ratio [aOR] 3.319, 95% CI 1.085-10.157, p = 0.036) and BCT with RT (aOR 7.481, 95% CI 2.230-25.101, p = 0.001) were independently associated with infectious complications in multivariate model.

CONCLUSIONS

Concurrent gynaecological procedure for patients undergoing mastectomy with implant-based reconstruction did not carry an increased risk for infectious complications.

Analysis of robot-assisted nipple-sparing mastectomy using the da Vinci SP system

BACKGROUND

As patients tend to be diagnosed with breast cancer at an early stage, the demand for better cosmetic outcomes has increased. Several studies revealed that robot-assisted nipple-sparing mastectomy (RNSM) shows favorable outcomes. The aim of the study was to reveal the feasibility of RNSM using the da Vinci single-port (SP) system with a minimal incision, hidden in the arm.

METHODS

From 2018 to 2021, 81 cases (70 patients) were retrospectively reviewed. Clinicopathologic characteristics, operative outcomes, and postoperative complications were evaluated. The operative outcomes were analyzed using the Mann-Whitney U test.

RESULTS

The median age was 42 years (range, 26-60 years). Bilateral RNSM was performed in 11 (27.2%) patients. The median size of the initial skin incision was 40 mm (range, 20-55 mm). Immediate reconstruction with direct-to-implant was performed in 54 (66.7%) patients and deep inferior epigastric perforator (DIEP) flaps in 15 (18.5%) patients. Postoperative complications of Clavien-Dindo Classification III occurred in six (7.5%) patients. Patients reconstructed with a DIEP flap had large breasts with more severe ptosis, yet grade III complications did not occur.

CONCLUSIONS

RNSM using the SP system can be applied for curative and risk-reducing mastectomy, regardless of breast size or ptosis grade.

The Failed Breast Implant in Postmastectomy Reconstruction: A Systematic Literature Review of Complications of Implant-Based Breast Reconstruction

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.

Complicated Wound Closure Following Mastectomy and Breast Reconstruction

Breast reconstruction incidence increased, including preventive surgery. In this context, providing women best surgical care and results is crucial, with minimum complications, such as wound dehiscence and skin flap necrosis. Tension-free closure of skin flaps is mandatory for successful healing. However, since this is not always possible, various techniques have been developed to reduce tension from wound-margins, facilitate primary wound-closure, and minimize and improve scarring. These techniques have not been investigated in breast surgeries. The aim of this study was to describe our experience with the Tension-Relief System in mastectomy and breast reconstructive patients, and the advantages of using this technique. The retrospective cohort consisted of 13 breasts of 11 women aged 29-74 years who underwent surgery with primary wound-closure using the System, in 2019-2020 in our department. It was applied averagely 19.7 days, demonstrated effectiveness in preventing complications and as secondary treatment following complications. This enabled avoiding further and more extensive surgeries, including donor-site morbidity when needed. In mastectomy and breast-reconstruction, the System minimizes complications and yields satisfactory aesthetic and functional outcomes, with minimal inconvenience to the patient, and good pain-control. The technique is low-cost, simple to use, and does not require special settings, surgical equipment, or particular skills.

Multicentric breast cancer with heterogeneous histopathology: a multidisciplinary review

Multiple synchronous (multifocal or multicentric) ipsilateral breast cancers with heterogeneous histopathology are a rare clinical occurrence, however, their incidence is increasing due to the use of MRI for breast cancer screening and staging. Some studies have demonstrated poorer clinical outcomes for this pattern of breast cancer, but there is no evidence to guide clinical practice. In this multidisciplinary review, we reflect on pathology and molecular characteristics, imaging findings, surgical management including conservation and reconstructive options and approach to the axilla, and the role of chemotherapy and radiotherapy. Multidisciplinary discussions appear decisive in planning an appropriate surgical choice and defining the correct systemic treatment tailored to each clinical condition.

[Clinical and morphological indications for delayed breast reconstruction]

A full range of breast reconstructions procedures exists and had to be proposed within a surgical team, from the simplest to the most complex. The choice of the technique is simply based on the discussion between the surgeon and the patient during a consultation. A computed tomographic angiography might be required in the case of DIEP flap reconstruction. The surgeon bases his decision on a clinical exam of the breast area, the quality of the tissues and looks for potential flaps or fat donor sites. The patient expresses her expectations in terms of breast volume, form and is clearly informed about potential risks and follow-up. Thus the surgeon could propose the most adequate procedure in the case of the patient, who will take the final decision. The surgeon should ensure to find the most adapted procedure to each individual. A well-determined indication will lead to a truly satisfied patient, which is the main goal of breast reconstruction. We decided to present this dialogue and the path towards the final choice in a fun and original format.

Objective assessment of flap volume changes and aesthetic results after adjuvant radiation therapy in patients undergoing immediate autologous breast reconstruction

BACKGROUND

The use of immediate breast reconstruction and adjuvant radiation therapy is increasing in breast cancer patients. This study aimed to analyze the aesthetic outcome and changes in flap volume in patients with breast cancer undergoing radiation therapy of the surgical site after immediate autologous tissue reconstruction.

METHODS

Immediate abdominal free flap breast reconstruction following unilateral mastectomy was performed in 42 patients; 21 patients received adjuvant radiation (study group) and 21 patients did not (control group). To compare flap volume, three-dimensional computed tomography (CT) was performed before and after radiation. Also, aesthetic analysis was performed in both groups to evaluate shape changes.

RESULTS

There was a 12.3% flap volume reduction after the completion of radiation in the experimental group that was significantly greater than the 2.6% volume reduction observed in the non-radiation group (P<0.01). There was no significant difference in the short- and long-term aesthetic results between the groups.

CONCLUSIONS

When performing immediate autologous breast reconstruction, 14% volume overcorrection is recommended for patients in whom adjuvant radiation therapy is anticipated to improve aesthetic outcomes.

Immediate breast reconstruction with expander in pregnant breast cancer patients

BACKGROUND

Breast reconstruction after mastectomy is currently considered an essential component in managing breast cancer patients, particularly those diagnosed at a young age. However, no studies have been published on the feasibility of immediate breast reconstruction in patients diagnosed and operated during the course of gestation.

METHOD

We retrospectively identified all breast cancer patients who were subjected to mastectomy and immediate breast reconstruction during pregnancy at the European Institute of Oncology between 2002 and 2012. Patient demographics, gestational age at surgery, tumor stage, adjuvant treatment, details of the surgical procedures, surgical outcomes and fetal outcomes were analyzed.

RESULTS

A total of 78 patients with breast cancer diagnosed during pregnancy were subjected to a surgical procedure during the course of gestation. Twenty-two patients had mastectomy; of whom 13 were subjected to immediate breast reconstruction. Twelve out of 13 patients had a two-stage procedure with tissue expander insertion. Median gestational age at surgery was 16 weeks. No major surgical complications were encountered. Only one patient elected to have an abortion, otherwise, no spontaneous abortions or pregnancy complications were reported. Median gestational age at delivery was 35 weeks (range: 32-40 weeks). No major congenital malformations were reported. At a median follow-up of 32 months, all patients are alive with no long-term surgical complications.

CONCLUSIONS

This is the first study of immediate breast reconstruction in pregnant breast cancer patients. Tissue expander insertion appears to ensure a short operative time, and does not seem to be associated with considerable morbidity to the patient or the fetus. Hence, it could be considered in the multidisciplinary management of women diagnosed with breast cancer during pregnancy.