Nipple-sparing mastectomy using a hemi-periareolar incision with or without minimal medial-lateral extensions; clinical outcome and patient satisfaction: A single centre prospective observational study

Considerable Long-Term Aesthetic Outcomes and Oncologic Safety of Breast-Conserving Surgery Via a Periareolar Incision: A Retrospective Study

BACKGROUND

To investigate the application effect of periareolar incision breast-conserving surgery in patients with early breast cancer.

METHODS

From January 2017 to November 2021, a clinician in our research center performed a total of 533 breast-conserving surgery. After screening, we collected the information of 209 patients through telephone, online questionnaires, and outpatient follow-up. One hundred seventeen patients with early breast cancer underwent breast-conserving surgery under the periareolar incision, while 92 patients underwent surgery through the tumor surface incision. We compared the differences between the 2 groups in the length of stay, postoperative complications, adjuvant therapy, and other clinical indicators, as well as the subjective and objective evaluation of the long-term postoperative breast aesthetic outcome, local recurrence, distant metastasis, and survival.

RESULTS

With a mean follow-up of 3.9 years, patients in the periareolar incision group (PAIG) and tumor surface incision group (TSIG) had no significant differences in clinical indicators, local recurrence, distant metastasis, and survival. However, PAIG patients had better subjective satisfaction with postoperative breast appearance. In the evaluation of objective aesthetic outcomes, PAIG was significantly better than TSIG in texture and elasticity, symmetry, sunken degree of the operative side, skin color, surgical scar, and breast compliance difference.

CONCLUSION

By observing and comparing the clinical indicators, postoperative recurrence, and metastasis of the enrolled patients, this study found that periareolar incision surgery could achieve radical therapeutic effects similar to those achieved through tumor surface incision, and had advantages in improving postoperative aesthetic outcomes, which could provide certain references for clinical practice.

Best Practices for BREAST-Q Research: A Systematic Review of Study Methodology

BACKGROUND

Data heterogeneity and methodologic errors hinder the ability to draw clinically meaningful conclusions from studies using the BREAST-Q Reconstruction Module patient-reported outcome measure. In this systematic review, the authors evaluate the quality of BREAST-Q Reconstruction Module administration in relation to the BREAST-Q version 2.0 user's guide and the reporting of key methodology characteristics. The authors also describe a framework for improving the quality of BREAST-Q data analysis and reporting.

METHODS

The authors conducted a systematic search of PubMed, Embase, Cochrane CENTRAL, and Ovid HAPI databases to identify articles on the BREAST-Q Reconstruction Module to assess postmastectomy breast reconstruction outcomes. The authors registered the protocol before study implementation on Open Science Framework ( https://osf.io/c5236 ) and adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Data on mode of BREAST-Q administration, time horizon justification, and sample size calculation were collected.

RESULTS

The authors included 185 studies in the analysis. Errors in BREAST-Q administration were identified in 36 studies (19.5 percent). Appropriate administration of the BREAST-Q could not be determined in 63 studies (34.1 percent) because of insufficient reporting. Time horizon for the primary outcome was reported in 71 studies (38.4 percent), with only 17 (9.2 percent) reporting a sample size calculation.

CONCLUSIONS

The authors identified important yet actionable shortcomings in the BREAST-Q literature. Researchers are encouraged to review the BREAST-Q user's guide in the study design phase to mitigate errors in patient-reported outcome measure administration and reporting for future trials using the BREAST-Q Reconstruction Module. Adhering to these guidelines will allow for greater clinical utility and generalizability of BREAST-Q research.

Comparing Incision Choices in Immediate Microvascular Breast Reconstruction after Nipple-Sparing Mastectomy: Unique Considerations to Optimize Outcomes

BACKGROUND

Incision planning is a critical factor in nipple-sparing mastectomy outcomes. Evidence on optimal incision patterns in patients undergoing nipple-sparing mastectomy and immediate microvascular breast reconstruction is lacking in the literature.

METHODS

A single-institution retrospective review was performed of consecutive patients undergoing nipple-sparing mastectomy and immediate microvascular autologous reconstruction from 2007 to 2019. Outcomes-including major mastectomy flap necrosis, full nipple-areola complex necrosis, and any major ischemic complication of the skin envelope-were compared among incision types. Multivariable logistic regression identified factors associated with major ischemic complication.

RESULTS

Two hundred seventy-nine reconstructions (163 patients) were identified, primarily using internal mammary recipient vessels (98.9 percent). Vertical incisions were used in 139 cases; inframammary, in 53; lateral radial, in 51; and inverted-T, in 35. Thirty-two cases (11.5 percent) had major mastectomy flap necrosis, 11 (3.9 percent) had full nipple-areola complex necrosis, and 38 (13.6 percent) had any major ischemic complication. Inframammary incisions had higher rates of major ischemic complication (25 percent) than vertical (5.8 percent; p < 0.001) and lateral radial (7.8 percent; p = 0.032) incisions. Inverted-T incisions also had higher rates of major ischemic complication (36.1 percent) than both vertical (p < 0.001) and lateral radial (p = 0.002) incisions. Inframammary incisions (OR, 4.382; p = 0.002), inverted-T incisions (OR, 3.952; p = 0.011), and mastectomy weight (OR, 1.003; p < 0.001) were independently associated with an increased risk of major ischemic complication. Inframammary incisions with major ischemic complication demonstrated significantly higher body mass index, mastectomy weight, and flap weight compared to those without.

CONCLUSIONS

Inframammary and inverted-T incisions are associated with a higher risk of major ischemic skin envelope complications after nipple-sparing mastectomy and immediate microvascular breast reconstruction. Radial incisions can be considered to optimize recipient vessel exposure without compromising perfusion.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Immediate-implant-based-breast-reconstruction with two-stage expander-implant reconstruction versus one-stage-reconstruction with acellular dermal matrix: analysis of patients' satisfaction

Background.

The aim of this retrospective study is to evaluate the patient-reported outcome after immediate ADM-assisted implant- based breast reconstruction.

Material and Methods:

Patients underwent breast reconstruction from 2015 to 2019 have been retrospectively divided into group A (partial subpectoral implant and ADM and group B (expander/implant). For each patient we evaluated retrospectively postoperative complications and patients’ satisfaction.

Results:

26 patients from the case group and 40 from the control group completed the BREAST-Q. The incidence of complications in the cases was 18.4%, while in the control group was 20.4%. We found no statistical difference in most of the domains and in the mean score of the questionnaire (mean score cases=69.0±14.4 vs controls=68.4±15.7; p=0.888). A significant difference results only in the domains Q2a and Q2b, sensation of rippling.

Conclusions:

The use of ADM in one-stage reconstruction allows to perform breast reconstruction in only one surgery, with similar complication rates and patient satisfaction. (www.actabiomedica.it)

Pure hemi-periareolar incision versus conventional lateral radial incision mastectomy and direct-to-implant breast reconstructions: comparison of indocyanine green angiographic perfusion and necrosis of the nipple

Background

This study evaluated the feasibility of direct-to-implant breast reconstruction after nipple-sparing mastectomy using pure hemi-periareolar incision without extension and with the aid of indocyanine green angiographic evaluation on the mastectomy skin flap.

Methods

Patients who underwent immediate direct-to-implant breast reconstruction from December 2018 to February 2020 were included. After nipple-sparing mastectomy, indocyanine green angiographic evaluation of perfusion to nipple-areola complex was performed by video recording with a near infrared camera, and nipple perfusion time and perfusion pattern were analyzed. Patients were divided into a pure hemi-periareolar incision group and conventional lateral radial incision groups to compare nipple perfusion and surgical outcomes.

Results

A total of 61 breasts in 56 patients were included. Pure hemi-periareolar incision was used in 41 breasts, and conventional lateral radial incisions were used in 20 breasts. Nipple perfusion time was significantly increased in the pure hemi-periareolar incision group (79.6±65.8 vs. 43.2±49.8 seconds, P=0.031). While minor nipple-areola complex necrosis was significantly increased in the pure hemi-periareolar incision group (19.5% versus 0%; P=0.044), major nipple-areola complex necrosis (2.4% versus 5.0%; P>0.999) was not significantly different between the two groups. The rates of nipple-areola complex necrosis were 0%, 16.7%, and 63.6% in rapid, delayed, and no perfusion groups, respectively (P<0.001). No nipple perfusion pattern was a significant predictor for nipple-areola complex necrosis in univariable and multivariable analyses (P<0.001). There was no case of reconstruction failure.

Conclusions

Immediate direct-to-implant breast reconstruction after nipple-sparing mastectomy using pure hemi-periareolar incision can be safely performed using indocyanine green angiographic evaluation on the mastectomy skin flap.

A Strategic Approach to Nipple-sparing Mastectomy Reconstruction with a Wide-based Inframammary Fold Flap

The single biggest advancement in the aesthetic outcome of breast reconstruction following mastectomy has been the contribution of nipple-sparing mastectomy. By preserving the nipple–areolar complex, patients do not experience the same sense of loss that is observed in the setting of skin-sparing mastectomy. Despite this significant contribution, the challenge remains as to how surgeons can extend this option to larger-breasted patients or patients with significant breast ptosis. Several strategies have been described, including reduction mammoplasty before mastectomy, bipedicled simultaneous mastopexy with mastectomy, and free nipple grafting. The authors have developed a novel approach to nipple-sparing mastectomy that preserves the nipple–areolar complex on a wide-based inframammary fold (IMF) flap and uses indocyanine green perfusion imaging to successfully and reliably perform nipple-sparing mastectomy with immediate reconstruction in larger-breasted ptotic patients. Six patients underwent bilateral nipple-sparing mastectomies and immediate breast reconstruction with a wide-based IMF flap. All patients underwent immediate reconstruction with prepectoral placement of tissue expanders to treat either breast cancer or ductal carcinoma in situ (DCIS), and all patients successfully completed exchange of expander to implant. There were no complications with infection, seroma, mastectomy flap, or nipple necrosis. Aesthetic results were in line with other nipple-sparing techniques. The wide-based IMF flap with nipple preservation is a viable option for larger-breasted ptotic patients who might not otherwise be candidates for nipple-sparing mastectomy. The approach described is a combination of surgical technique and indocyanine green perfusion technology to deliver reproducible results, with an emphasis on surgical safety and avoidance of complications.

Funnel usefulness in direct-to-implant breast reconstruction using periareolar incision with prepectoral implant placement and complete coverage with acellular dermal matrix

BACKGROUND

The funnel has been used in esthetic breast surgery that requires a small incision. Recent advances in minimally invasive surgical techniques have led to more cases of nipple-sparing mastectomy (NSM) through periareolar incision. However, prepectoral implant placement and complete coverage with acellular dermal matrix (ADM) is almost impossible with the periareolar approach. Funnels can also be useful for direct-to-implant breast reconstruction.

METHODS

NSM with periareolar incision and direct-to-implant breast reconstruction were performed with prepectoral implant placement between January 2017 and July 2019. The ADM full-wrapped anatomic textured implant was inserted using a funnel without additional incisions during surgery.

RESULTS

A total of 21 patients were enrolled, including 2 who received bilateral breast reconstruction. All operations were successfully performed using funnels with minimal periareolar incisions. Anatomic textured implants (mean: 251.7 cc, range: 90-450 cc) wrapped in ADM can be effectively inserted in the prepectoral plane using a funnel. Two patients experienced delayed wound healing of the areola that was treated by conservative wound management. Patients also experienced less pain overall, and the cosmetic result was very good. Patient satisfaction scores were also very high.

CONCLUSIONS

While the periareolar incision is esthetically pleasing, additional resection is often necessary. However, the use of funnels ensured that no additional incision was needed even in large implants. This subsequently led to better results in terms of pain and scarring. Prepectoral breast reconstruction involving complete implant coverage with ADM using a funnel through the periareolar approach represents a good alternative to the traditional dual plane subpectoral method. This method provides good patient satisfaction without adverse outcomes.

Quality of life and patient satisfaction after implant-based breast reconstruction with or without acellular dermal matrix: randomized clinical trial

Background

Acellular dermal matrix (ADM) in implant‐based breast reconstructions (IBBRs) aims to improve cosmetic outcomes. Six‐month data are presented from a randomized trial evaluating whether IBBR with ADM provides higher health‐related quality of life (HRQoL) and patient‐reported cosmetic outcomes compared with conventional IBBR without ADM.

Methods

In this multicentre open‐label RCT, women with breast cancer planned for mastectomy with immediate IBBR in four centres in Sweden and one in the UK were allocated randomly (1 : 1) to IBBR with or without ADM. HRQoL, a secondary endpoint, was measured as patient‐reported outcome measures (PROMs) using three validated instruments (EORTC‐QLQC30, QLQ‐BR23, QLQ‐BRR26) at baseline and 6 months.

Results

Between 24 April 2014 and 10 May 2017, 135 women were enrolled, of whom 64 with and 65 without ADM were included in the final analysis. At 6 months after surgery, patient‐reported HRQoL, measured with generic QLQ‐C30 or breast cancer‐specific QLQ‐BR23, was similar between the groups. For patient‐reported cosmetic outcomes, two subscale items, cosmetic outcome (8·66, 95 per cent c.i. 0·46 to 16·86; P = 0·041) and problems finding a well‐fitting bra (−13·21, −25·54 to −0·89; P = 0·038), yielded higher scores in favour of ADM, corresponding to a small to moderate clinical difference. None of the other 27 domains measured showed any significant differences between the groups.

Conclusion

IBBR with ADM was not superior in terms of higher levels of HRQoL compared with IBBR without ADM. Although two subscale items of patient‐reported cosmetic outcomes favoured ADM, the majority of cosmetic items showed no significant difference between treatments at 6 months. Registration number: NCT02061527 ( www.clinicaltrials.gov).

Nipple-sparing mastectomy through periareolar incision with immediate reconstruction

Purpose

Nipple-sparing mastectomy (NSM) has become increasingly popular due to improved cosmesis without compromising oncologic safety. Radial and inframammary incisions are usually used to achieve NSM, with periareolar incisions usually being avoided because of the risk to nipple-areola complex viability. In an attempt to maximize esthetic effects, we performed NSM through periareolar incision with immediate reconstruction. We report our initial experience.

Methods

This case series consisted of all consecutive patients (n = 34) who underwent NSM through a periareolar incision in our institution between August 2017 and December 2018. All patients underwent NSM through periareolar incision followed by immediate reconstruction with an implant or deep inferior epigastric perforator flap. Patient demographics, tumor and treatment characteristics, and short-term postoperative outcomes were reviewed.

Results

The mean patient age was 46.74 ± 6.69 years (range, 38–62 years), and the mean operation time was 96.68 ± 28.00 minutes. Indications included in situ cancer in 12 cases and invasive cancer in 22 cases. There was 1 major complication (postoperative hematoma) requiring operative reintervention. No other complications including fistula, implant exposure, or reconstruction failure was observed. At the time of writing, no case of local recurrence has been observed.

Conclusion

Our initial report shows that NSM with immediate reconstruction may successfully be performed through periareolar incision. This method maximizes esthetic effects and may be an appropriate surgical option for NSM.

Utility of the periareolar incision technique for breast reconstructive surgery in patients with breast cancer

PURPOSE

Periareolar incisions for nipple-sparing mastectomy offer the advantages of smaller inconspicuous wounds and easier resection below the nipple-areolar complex. However, they provide a narrow surgical field, which complicates the procedure and carries a risk of nipple necrosis. This study evaluated the clinical outcomes and safety of periareolar incisions for breast reconstructive surgery in patients with breast cancer.

METHODS

The study included 181 patients with primary operable breast cancer who underwent nipple-sparing mastectomy for reconstructive breast procedures without intraoperative nipple-areolar complex resection. The clinical outcomes and complications were retrospectively evaluated. The recurrence-free survival was compared using Kaplan-Meier curves.

RESULTS

Nipple-sparing mastectomy was performed via inframammary fold and periareolar incisions in 31 and 150 patients, respectively. There were no significant differences in clinical outcomes related to surgery, frequency of complications, nipple necrosis (inframammary fold incision vs. periareolar incision: 0% vs. 3.3%, P = 0.590), or the recurrence-free survival (P = 0.860) between the 2 groups.

CONCLUSION

Our results showed that the clinical outcomes and complication rates of periareolar incisions for breast reconstruction were equivalent to those of inframammary fold incisions, suggesting that the periareolar incision technique for breast reconstructive surgery may safely improve cosmetic outcomes if done with adequate care.

Implant Reconstruction in Nipple Sparing Mastectomy

Nipple sparing mastectomy has been popularized in the modern era of breast cancer treatment due to its touted advantages with regard to resultant body image and reconstructive outcome. Implant-based techniques remain the most prevalent means of breast reconstruction. Special considerations regarding patient selection and technique are reviewed for implant reconstruction in the setting of mastectomy with nipple preservation. Applications for prepectoral and direct-to-implant reconstruction are discussed and published outcomes are summarized.

Nipple-Sparing Mastectomy and Immediate Breast Reconstruction With a Deep Inferior Epigastric Perforator Flap: A Study of Patient Satisfaction

INTRODUCTION

The morphological result of nipple-areola complex (NAC) reconstruction may be disappointing for patients who undergo skin-sparing mastectomies and immediate breast reconstruction, followed by secondary reconstruction of the nipple-areola complex.The aim of this study was to analyze patient satisfaction after nipple-sparing mastectomy and immediate breast reconstruction with a deep inferior epigastric perforator flap.

MATERIALS AND METHODS

Our retrospective study involved all patients who underwent an immediate breast reconstruction after unilateral mastectomy with conservation of the NAC. The following three kinds of surgical approach were used: mastectomy with periareolar incision, mastectomy with hemiperiareolar incision and lateral extension, and mastectomy with inverted-T mammoplasty incision. Our study was based on a survey using a standardized questionnaire and a Likert scale to report patient satisfaction on the basis of criteria defined by the investigators.

RESULTS

We evaluated 17 patients. All reconstruction patients were satisfied or very satisfied with the overall aesthetic appearance, projection, and volume as well as the appearance of scarring on the reconstructed breast. None of our patients reported dissatisfaction in response to the criteria under evaluation. A periareolar incision was used most often to perform the mastectomy (10 patients). Partial NAC necrosis was observed in five patients, without negatively influencing their perception of the morphological outcome of their reconstruction.

CONCLUSIONS

Immediate breast reconstruction using a deep inferior epigastric perforator free flap after nipple-sparing mastectomies met with a high rate of general satisfaction among patients and resulted in a low rate of nipple-areola complex necrosis.

A Study of the Relation Between Mastectomy Specimen Weight and Volume With Implant Size in Oncoplastic Reconstruction

BACKGROUND

There is no general consensus regarding the best and most accurate method for assessing the size of implant required for achieving the best symmetry in oncoplastic reconstruction.

MATERIALS AND METHODS

Breast weight, volume and size of implant were recorded prospectively on patients undergoing immediate reconstruction over a 3-year period. Cases with specimen size greater than 2,000 g were excluded. The primary endpoint was size of implant used in relation to specimen weight and volume. Secondary endpoints were the influence of age and histology on specimen weight, volume and breast density.

RESULTS

A total of 278 mastectomies were performed. Correlation of implant size with volume was marginally stronger than that with weight (r=81%, p<0.001 vs. r=78.9%, p<0.001 respectively). Women aged 50 years and above had lower breast weight for the same breast volume than women under 50 years. The difference was merely 4%, but was statistically significant (p=0.001). Histology had no statistically significant influence on breast density.

CONCLUSION

Specimen weight and volume were found to be closely correlated. Weight can be measured more accurately and easily with reproducible readings compared to volume.

The Evolving Role of Pre-pectoral ADM-assisted Approach in Implant-based Immediate Breast Reconstruction Following Conservative Mastectomy: An Overview of the Literature and Description of Technique

BACKGROUND/AIM

The recent development of acellular dermal matrix (ADM) devices has enhanced implant-based breast reconstruction surgery following conservative mastectomy for therapeutic and risk-reducing purposes leading to improved aesthetics. In the traditional sub-pectoral approach, coverage of the implant is provided by the pectoral muscles superiorly and the ADM inferiorly. The need to eliminate breast animation, reduce post-operative dysfunctional pain and the risk of capsular contracture, have stimulated surgeons to investigate the feasibility of placing the implant over the pectoralis major muscle with complete coverage with ADM thus inventing a novel pre-pectoral approach.

MATERIALS AND METHODS

We reviewed the literature regarding this evolving technique of muscle sparing ADM-assisted implant-based immediate breast reconstruction. Also, we describe our technique, and present pictures of the post-operative result.

RESULTS AND CONCLUSION

The early reported results of the pre-pectoral breast reconstruction approach are encouraging and confirmed the potential benefits of eliminating breast animation and reducing postoperative pain. However, most of these studies had a small sample size (<100 patients) and were retrospective in nature with a limited follow-up duration and lack of data regarding the objective aesthetic assessment and oncological outcome. Nevertheless, suitable patients undergoing conservative mastectomy and implant-based reconstruction should be offered this option while further evaluation is being performed.

Quality of life and patient satisfaction after one-stage implant-based breast reconstruction with an acellular dermal matrix versus two-stage breast reconstruction (BRIOS): primary outcome of a randomised, controlled trial

BACKGROUND

There is increasing interest in the use of acellular dermal matrices (ADMs) in implant-based breast reconstruction (IBBR). Suggested advantages are that ADMs facilitate one-stage IBBR and improve aesthetic outcomes. We compared immediate one-stage ADM-assisted IBBR with two-stage IBBR (current standard of care). Our previously reported secondary endpoint showed that one-stage ADM-assisted IBBR was associated with significantly more adverse outcomes. Here, we present the primary endpoint results aiming to assess whether one-stage IBBR with ADM provides higher patient-reported quality of life (QOL) compared with two-stage IBBR.

METHODS

This multicentre, open-label, randomised controlled trial (BRIOS study) was done in eight hospitals in the Netherlands. We recruited women aged older than 18 years with breast carcinoma or a genetic predisposition who intended to undergo skin-sparing mastectomy and immediate IBBR. Participants were randomly assigned to undergo one-stage IBBR with ADM (Strattice, LifeCell, Branchburg, NJ, USA) or two-stage IBBR. Randomisation was stratified by centre and indication for surgery (oncological or prophylactic) in blocks of ten participants. The primary endpoint was patient-reported QOL, as measured with the BREAST-Q (ie, health-related QOL scales and satisfaction scales), in the modified intention-to-treat population. The study follow-up is complete. This study is registered with the Netherlands Trial Register, number NTR5446.

FINDINGS

Between April 14, 2013, and May 29, 2015, we enrolled 142 women, of whom 69 were randomly assigned to receive one-stage ADM-assisted IBBR and 73 to receive two-stage IBBR. After exclusions, the modified intention-to-treat population comprised 60 patients in the one-stage group and 61 patients in the two-stage group. Of these, 48 women (mean follow-up 17·0 months [SD 7·8]) in the one-stage group and 44 women (17·2 months [SD 6·7]) in the two-stage group completed the BREAST-Q at least 1 year after implant placement. We found no significant differences in postoperative patient-reported QOL domains, including physical wellbeing (one-stage mean 78·0 [SD 14·1] vs two-stage 79·3 [12·2], p=0·60), psychosocial wellbeing (72·6 [17·3] vs 72·8 [19·6], p=0·95), and sexual wellbeing (58·0 [17·0] vs 57·1 [19·5], p=0·82), or in the patient-reported satisfaction domains: satisfaction with breasts (63·4 [15·8] vs 60·3 [15·4], p=0·35) and satisfaction with outcome (72·8 [19·1] vs 67·8 [16·3], p=0·19).

INTERPRETATION

Taken together with our previously published findings, one-stage IBBR with ADM does not yield superior results in terms of patient-reported QOL compared with two-stage IBBR. Risks for adverse outcomes were significantly higher in the one-stage ADM group. Use of ADM for one-stage IBBM should be considered on a case-by-case basis.

FUNDING

Pink Ribbon, Nuts-Ohra, and LifeCell.

Nipple sparing mastectomy and the evolving direct to implant breast reconstruction

In this paper, we describe the evolving use of the nipple-sparing mastectomy (NSM) and direct to implant breast reconstruction according to existing literature and our own experience. The surgical method enables superior aesthetic results resembling that of a natural breast while maintaining oncologic safety. Acellular dermal matrix enables direct to implant breast reconstruction by serving as a hammock and can be used with acceptable rates of complications. A successful nipple-sparing mastectomy and direct to implant breast reconstruction approach with acceptable postoperative complication rates relies upon quality of the mastectomy skin flaps and correct patient selection. The surgical method has developed with a rapid pace and expected to evolve further in terms of technical modalities, safety measure and lasting results.

Patient-reported Outcomes after ADM-assisted Implant-based Breast Reconstruction: A Cross-sectional Study

Background

Although the use of acellular dermal matrices (ADMs) in implant-based reconstruction increases, there is a lack of studies evaluating patient-reported outcome measures after this reconstruction method. We aim to evaluate the patient satisfaction after ADM-assisted implant-based breast reconstruction (IBBR) in 1 of the largest series of patients undergoing ADM-assisted IBBR.

Methods

Patients with ADM-assisted IBBR were invited to fill out the BREAST-Q, a validated and standardized questionnaire to measure patient satisfaction after a breast reconstruction. A retrospective chart review was performed to identify patient and surgical characteristics.

Results

In total, 208 patients (38.4%) responded and reported a mean satisfaction of 70.6 ± 20.2 with their breasts and 78.0 ± 20.5 with the outcome. An overall complication rate of 7.7% was noted, with 1.5% severe complications leading to hospital readmission (0.5%) and implant removal (0.5%). Patients with complications and unilateral reconstruction for oncological reasons reported overall less satisfaction rates compared with patients with bilateral, preventive surgery, and an uncomplicated postoperative course. Strongly related domains indicate the importance of patient satisfaction with their breasts and outcome on psychosocial and sexual functioning and satisfaction with information on satisfaction with breasts, outcome, and surgeon.

Conclusion

There is an increased demand for patient-reported outcome measures in a changing practice to which the opinion of the patient assumes a larger role. With high satisfaction rates, ADM-assisted IBBR is a valuable reconstruction method, provided that complication rates remain low. Hence, it should only be performed in a selected group of women.

The evolving role of pre-pectoral ADM-assisted implant-based immediate breast reconstruction following skin-sparing mastectomy

INTRODUCTION

The increasing use of acellular dermal matrix (ADM) and fat transfer in the context of breast reconstruction, following skin sparing mastectomy (SSM) for therapeutic and risk reducing purposes, combined with the need to eliminate animation deformities, reduce post-operative dysfunctional pain and the risk of capsular contracture, has prompted surgeons to investigate the possibility of placing the mammary implant over the pectoralis major muscle with complete coverage with ADM thus reviving the pre-pectoral approach which was previously abandoned due to high complications rates and poor aesthetics in the pre-ADM era.

METHODS

We reviewed the literature regarding this evolving technique of muscle sparing ADM-assisted implant-based immediate breast reconstruction.

RESULTS AND CONCLUSIONS

Several authors have recently reported positive early results confirming the potential benefits of eliminating breast animation and reducing postoperative pain, however, most of these reports contain insufficient numbers of patients (<100) and were retrospective in nature with a very short-term follow-up and lack of data regarding objective aesthetic assessment. Prospective data are required for more definitive recommendations.

Complications following Nipple-Sparing Mastectomy and Immediate Acellular Dermal Matrix Implant-based Breast Reconstruction-A Systematic Review and Meta-analysis

BACKGROUND

Acellular dermal matrix was introduced in breast reconstruction in 2001 and is gradually becoming a standard component for immediate breast reconstruction and nipple-sparing mastectomy. The reconstructive technique allows for improved aesthetic outcomes. However, there seems to be uncertainty regarding complication rates. The aim of this review was to systematically evaluate complication rates related to this method.

METHODS

This systematic review was conducted according to the recommendations outlined in the Cochrane Handbook for reviews and reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Relevant databases were searched for in the literature concerning the use of acellular dermal matrix in implant-based nipple-sparing mastectomy and immediate breast reconstruction. All studies underwent detailed quality assessment. Summarized outcome rates were computed using meta-analysis.

RESULTS

Nine of 1,039 studies were eligible for inclusion yielding 778 procedures. The quality was acceptable for all included studies. The meta-analysis found the rate of skin necrosis to be 11%, nipple necrosis 5%, infection in 12%, hematoma in 1%, treated seroma in 5%, explantation 4%, and unplanned return to the operating room in 9%.

CONCLUSION

The use of acellular dermal matrix in nipple-sparing mastectomy and implant-based breast reconstruction can be done with acceptable complication rates in selected patients. We recommend future studies to include specific definitions when reporting complication rates. Furthermore, future studies should elaborate on demographic characteristics of the included study samples and include predictor analysis to enhance knowledge of high risk patients.