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Khalil AA, ElSharkawy OA, Alsharkawy K, Youssif S, Khalil HH. Supra-arcuate free fascial MS-TRAM, a modified technique to reduce donor site morbidity in obese population-comparative study. Microsurgery 2024; 44:e31124. [PMID: 37846651 DOI: 10.1002/micr.31124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 09/08/2023] [Accepted: 09/28/2023] [Indexed: 10/18/2023]
Abstract
BACKGROUND Abdomen-based free flaps represent the gold standard option in the armamentarium of breast reconstruction. The natural evolution to more preservation with less invasive forms of these flaps has been driven by both patient and surgeon satisfaction. Nevertheless, obese patients are challenging due to the increased risk of compromised flap perfusion and donor site morbidity. This challenge is compounded by the prevalence of obesity worldwide, resulting in more free abdominal flaps being performed for breast reconstruction in obese patients. The authors present the outcomes of a modified supra-arcuate fascial muscle-sparing transverse rectus abdominus myocutaneous (FMS-TRAM) technique compared to standard muscle-sparing transverse rectus abdominus myocutaneous (MS-TRAM) technique to reduce the donor site morbidity while providing a well-vascularized large volume of autologous tissue. METHODS A retrospective comparative data analysis was conducted at two centers: Cairo University Hospitals, Egypt, and University Hospitals Birmingham, United Kingdom. Standard MS-TRAM was performed in 65 patients between 2008 and 2011 (Group 1) versus 275 patients between 2011 and 2020 (Group 2) who underwent FMS-TRAM. The modified technique involved limiting the fascial incision to above or at the level of the arcuate line to preserve the integrity of the anterior rectus sheath caudally. All patients included were of the obese population (BMI≥30 kg/m2 ) and underwent unilateral post-mastectomy reconstruction. Patient demographics, comorbidities, operative details, and outcomes focusing on donor site morbidity and flap complications were recorded and compared between the two groups. RESULTS The median age and BMI for Group 1 were 43 and 32, respectively. While for Group 2, they were 47 and 33, respectively. Flap weight ranged from 560 to 1470 g (Mean 705) for Group 1, while Group 2 ranged from 510 to 1560 (mean 715). The majority (280/340 [82%]) of the patients in both groups received radiotherapy. 7.7% of Group 1 were smokers, while in Group 2 it was 4.7%. The percentage of delayed versus immediate reconstruction in Group 1 was 60%/40%, while in Group 2, it was 43%/56%. The incidence of fat necrosis, partial necrosis, and total necrosis was 7.6%.1.5%, and 3%, respectively, for Group 1 and 8%, 1.4%, and 2.6%, respectively, for Group 2. The two-tailed p-value demonstrated a significant statistical difference (p < 0.00001) in donor site morbidity between both groups, with more bulge 20% (13/65) and hernia 1.5% (2/65) occurrence in Group 1 versus 1.9% (5/275) and 0.7% (2/275) in Group 2 respectively, over a follow-up period ranging from 24 to 60 months (mean 32). CONCLUSION FMS-TRAM flaps are safe, robust, and reliable with less donor site morbidity while maintaining optimal flap perfusion for large volume flaps in obese patients with excellent, durable outcomes. It should be considered a valuable tool in the reconstructive armamentarium of breast reconstruction.
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Affiliation(s)
- Ashraf A Khalil
- Plastic and Reconstructive Surgery Division, General Surgery Department, Faculty of Medicine, Cairo University, Giza, Egypt
| | - Omar A ElSharkawy
- Plastic and Reconstructive Surgery Division, General Surgery Department, Faculty of Medicine, Cairo University, Giza, Egypt
| | - Kareem Alsharkawy
- Plastic and Reconstructive Surgery Department, University Hospitals, Birmingham, UK
| | - Sherif Youssif
- Plastic and Reconstructive Surgery Department, University Hospitals, Birmingham, UK
| | - Haitham H Khalil
- Plastic and Reconstructive Surgery Department, University Hospitals, Birmingham, UK
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
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Rocans RP, Zarins J, Bine E, Deksnis R, Citovica M, Donina S, Mamaja B. The Controlling Nutritional Status (CONUT) Score for Prediction of Microvascular Flap Complications in Reconstructive Surgery. J Clin Med 2023; 12:4794. [PMID: 37510909 PMCID: PMC10381357 DOI: 10.3390/jcm12144794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 07/14/2023] [Accepted: 07/17/2023] [Indexed: 07/30/2023] Open
Abstract
Microvascular flap surgery is a widely acknowledged procedure for significant defect reconstruction. Multiple flap complication risk factors have been identified, yet there are limited data on laboratory biomarkers for the prediction of flap loss. The controlling nutritional status (CONUT) score has demonstrated good postoperative outcome assessment ability in diverse surgical populations. We aim to assess the predictive value of the CONUT score for complications in microvascular flap surgery. This prospective cohort study includes 72 adult patients undergoing elective microvascular flap surgery. Preoperative blood draws for analysis of full blood count, total plasma cholesterol, and albumin concentrations were collected on the day of surgery before crystalloid infusion. Postoperative data on flap complications and duration of hospitalization were obtained. The overall complication rate was 15.2%. True flap loss with vascular compromise occurred in 5.6%. No differences in flap complications were found between different areas of reconstruction, anatomical flap types, or indications for surgery. Obesity was more common in patients with flap complications (p = 0.01). The CONUT score had an AUC of 0.813 (0.659-0.967, p = 0.012) for predicting complications other than true flap loss due to vascular compromise. A CONUT score > 2 was indicated as optimal during cut-off analysis (p = 0.022). Patients with flap complications had a longer duration of hospitalization (13.55, 10.99-16.11 vs. 25.38, 14.82-35.93; p = 0.004). Our findings indicate that the CONUT score has considerable predictive value in microvascular flap surgery.
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Affiliation(s)
- Rihards P Rocans
- Intensive Care Clinic, Riga East Clinical University Hospital, Hipokrata Street 2, LV-1079 Riga, Latvia
- Department of Anaesthesia and Intensive Care, Riga Stradins University, Dzirciema Street 16, LV-1007 Riga, Latvia
| | - Janis Zarins
- Department of Hand and Plastic Surgery, Microsurgery Centre of Latvia, Brivibas Street 410, LV-1024 Riga, Latvia
- Baltic Biomaterials Centre of Excellence, Headquarters at Riga Technical University, Pulka Street 3, LV-1007 Riga, Latvia
| | - Evita Bine
- Intensive Care Clinic, Riga East Clinical University Hospital, Hipokrata Street 2, LV-1079 Riga, Latvia
| | - Renars Deksnis
- Surgical Oncology Clinic, Riga East Clinical University Hospital, Hipokrata Street 4, LV-1079 Riga, Latvia
| | - Margarita Citovica
- Laboratory Department, Riga East Clinical University Hospital, Hipokrata Street 2, LV-1079 Riga, Latvia
| | - Simona Donina
- Institute of Microbiology and Virology, Riga Stradins University, Ratsupites Street 5, LV-1067 Riga, Latvia
| | - Biruta Mamaja
- Department of Anaesthesia and Intensive Care, Riga Stradins University, Dzirciema Street 16, LV-1007 Riga, Latvia
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Risk Stratification of Surgical Site Outcomes by BMI & Flap Type in Autologous Breast Reconstruction. J Plast Reconstr Aesthet Surg 2023; 80:115-125. [PMID: 37004313 DOI: 10.1016/j.bjps.2023.01.042] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 12/13/2022] [Accepted: 01/29/2023] [Indexed: 02/12/2023]
Abstract
INTRODUCTION Afflicting 2 million lives annually worldwide, breast cancer remains devastating. This study utilized a continuously updated network of electronic medical records (TriNetX Inc, Cambridge, MA) for analysis of 90-day postoperative outcomes of autologous breast reconstruction by increasing body mass index (BMI). METHODS The deidentified electronic medical records (EMRs) of 29,453,000 females, age 18-99 years, were retrospectively screened from 45 healthcare organizations. A combined cohort of 7136 patients undergoing autologous breast reconstruction via transverse rectus abdominus muscle (TRAM), deep inferior epigastric perforator (DIEP), or latissimus flap was categorized by BMI into 5 subgroups: normal (n = 3568), overweight (n = 1239), class I (n = 1166), class II (n = 807), and class III (n = 356) obesity. The normal BMI cohort was then compared with each elevated BMI cohort. BMI strata were analyzed for risk of surgical-site occurrences within 90 days of surgery using CPT codes. Stringent propensity score matching was performed. RESULTS For the combined group (N = 7136), significant linear increases in risk were observed with increasing BMI for infection (risk ratio [RR] 1.39-2.91,p < 0.05) and dehiscence (RR 2.65-5.17, p < 0.05). Similar linear increases were observed for the abdominally based group (N = 5454) for infection (RR 1.45-2.47, p < 0.05) and dehiscence (RR 2.54-4.77, p < 0.05). For DIEP (N = 4874), near-linear increases were observed for infection (RR 1.60-2.79, p < 0.05) and dehiscence (RR 1.57-5.59, p < 0.05). For TRAM (N = 714), significant increases were observed for seroma, infection, dehiscence, deep vein thrombosis (DVT), sepsis, and PE while increased risks of seroma, DVT, PE, and hernia were observed for latissimus (N = 1380). CONCLUSIONS Regardless of flap type, our analysis suggests that a BMI> 39.9 is the inflection point beyond which it may be beneficial not to perform autologous breast reconstruction. Limitations include this study's retrospective nature; thus, future prospective studies would be beneficial.
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Long-term survey of sexual well-being after breast reconstruction using the BREAST-Q in the Japanese population. Asian J Surg 2023; 46:150-155. [PMID: 35221188 DOI: 10.1016/j.asjsur.2022.02.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 01/24/2022] [Accepted: 02/11/2022] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND The objective of this study was to identify response patterns related to sexual well-being following breast operations in the Japanese population. METHODS Patient-reported outcomes were analyzed at 1 year and 5 years after breast operations, including breast reconstruction, for Japanese women at a single center, with a focus on "Sexual well-being" in BREAST-Q. Response analysis and multiple regression analysis were performed. The scores at years 1 and 5 were also compared across three types of operation: mastectomy only, TE/Imp, and DIEP. RESULTS The response rate for Sexual well-being on BREAST-Q in the prospective cohort of patients with breast cancer dropped from 60.0% in postoperative year 1-34.3% in year 5. The mean score for Sexual well-being increased from 32 (year 1) to 38 (year 5). There were significant differences between respondents and non-respondents in age at year 1 (P = 0.007) and for mastectomy only (P = 0.01) and TE/Imp (P = 0.03) at year 5. In regression analysis, only DIEP was positively associated with Sexual well-being at year 1 (p < 0.001) and there were no significant factors at year 5. Among the operative procedures, scores after DIEP were significantly better than those after mastectomy only at year 1 (p < 0.001), but there was no difference at year 5. There were no significant changes from year 1 to year 5 for each operation. CONCLUSIONS A low response rate for Sexual well-being on BREAST-Q was found in Japanese women at 5 years postoperatively. This suggests the need for development of a modified evaluative scale that avoids nonresponse bias and considers ethnic differences.
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Immediate fine-tuning of DIEP flaps using the Wise pattern mastectomy: Description of the technique and a retrospective analysis of complication rates. ANN CHIR PLAST ESTH 2022; 67:189-195. [PMID: 35840458 DOI: 10.1016/j.anplas.2022.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 03/09/2022] [Accepted: 03/16/2022] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Elliptical skin-sparing mastectomy in patients with large or ptotic breasts usually leaves loose mastectomy skin flaps, which need to be either resected or gathered over the DIEP flap. This results in poor control of the breast footprint and under-projected DIEP flaps in a loose mastectomy skin pocket, that tend to slip laterally towards the axilla. We believe that the use of a Wise pattern mastectomy will allow for immediate treatment of these concerns. MATERIALS AND METHODS A retrospective, uncontrolled analysis of a prospectively-maintained database of patients operated by the five surgeons performing breast reconstructions at the University of Montreal Hospital Centre. Study population was patients with a BMI of over 25 and grade II/III breast ptosis who underwent a Wise pattern mastectomy with immediate DIEP flap reconstruction. Analysis was performed of the complication rates of the technique in the first six months after the surgery. RESULTS Out of a total of 53 breasts in 44 patients reconstructed with a DIEP flap immediately post Wise pattern mastectomy, we report nine cases of partial mastectomy-flap necrosis not needing revision, five cases of significant mastectomy flap necrosis needing debridement and skin grafting, and two cases of inability to adequately close the Wise pattern intraoperatively after DIEP placement, necessitating retention of DIEP skin in the inferior pole. None of the mastectomy flap complications occurred in irradiated breasts. CONCLUSION In patients with large or ptotic breasts, the Wise pattern mastectomy before an immediate DIEP reconstruction allows for immediate shaping of the breast by controlling the breast pocket, footprint, and excess skin.
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Bigarella LG, Ballardin AC, Couto LS, de Ávila ACP, Ballotin VR, Ingracio AR, Martini MP. The Impact of Obesity on Plastic Surgery Outcomes: A Systematic Review and Meta-analysis. Aesthet Surg J 2022; 42:795-807. [PMID: 35037936 DOI: 10.1093/asj/sjab397] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Obesity is a potential risk factor for complications in plastic surgeries. However, the data presented by primary studies are contradictory. OBJECTIVES The aim of this study was to summarize and clarify the divergences in the literature to provide a better understanding of the impact of obesity in different plastic surgery procedures. METHODS We conducted a systematic review and meta-analysis of the impact of obesity on plastic surgery outcomes. Searches were conducted in MEDLINE, LILACS, SciELO, Scopus, Embase, Web of Science, Opengrey.eu, and the Cochrane Database of Systematic Reviews. The primary outcomes assessed were surgical complications, medical complications, and reoperation rates. The secondary outcome assessed was patient satisfaction. Subgroup analysis was performed to investigate the impact of each BMI category on the outcomes. RESULTS Ninety-three articles were included in the qualitative synthesis, and 91 were used in the meta-analysis. Obese participants were 1.62 times more likely to present any of the primary outcomes (95% CI, 1.48-1.77; P < 0.00001). The highest increase in risk among plastic surgery types was observed in cosmetic procedures (risk ratio [RR], 1.80; 95% CI, 1.43-2.32; P < 0.00001). Compared with normal-weight participants, overweight participants presented a significantly increased RR for complications (RR, 1.16; 95% CI, 1.07-1.27; P = 0.0004). Most authors found no relation between BMI and overall patient satisfaction. CONCLUSIONS Obesity leads to more complications and greater incidence of reoperation compared with nonobese patients undergoing plastic surgeries. However, this effect is not evident in reconstructive surgeries in areas of the body other than the breast.
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Affiliation(s)
| | | | - Luísa Serafini Couto
- School of Medicine, Universidade de Caxias do Sul (UCS) , Caxias do Sul , Brazil
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Seth I, Seth N, Bulloch G, Rozen WM, Hunter-Smith DJ. Systematic Review of Breast-Q: A Tool to Evaluate Post-Mastectomy Breast Reconstruction. BREAST CANCER (DOVE MEDICAL PRESS) 2021; 13:711-724. [PMID: 34938118 PMCID: PMC8687446 DOI: 10.2147/bctt.s256393] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Accepted: 11/29/2021] [Indexed: 12/12/2022]
Abstract
Purpose The aim of this systematic review is to update and synthesize new evidence on BREAST-Q questionnaire’s ability to reflect patient-reported outcomes in women who have undergone breast reconstruction surgery (BRS) following mastectomy. Methods PubMed, Science Direct, Google Scholar, Cochrane CENTRAL, and Clincaltrial.gov were searched for relevant studies from January 2009 to September 2021. Any interventional or observational studies that used BREAST-Q to assess patient-reported outcomes in the assessment of BRS following mastectomy were included. Results A total of 42 studies were eligible for inclusion in the review. Three were randomized controlled trials and 39 were observational studies. Compared with pre-operative scores, there was an improvement in all BREAST-Q outcome domains following BRS including ‘satisfaction with breasts’, “satisfaction with outcome” “psychosocial”, “physical”, and “sexual wellbeing”. Sexual well-being had the lowest BREAST-Q score both pre-and post-operatively (37.8–80.0 and 39.0–78.0, respectively). Autologous BRS reports higher satisfaction and overall wellbeing compared to implant-based BRS. BREAST-Q has a higher and narrow internal consistency of 0.81 to 0.96 compared with other patient-reported outcome measures (PROMs; EORTC-QLQ, FACT-B, BR-23, BCTOS). The BREAST-Q questionnaire is the only PROM which allows patients to reflect on their care, surgical outcomes, and satisfaction collectively. Conclusion This review highlights the fact that BREAST-Q can effectively and reliably measure satisfaction and wellbeing of breast cancer patients after BRS. Comparatively, sexual wellbeing shows poorer outcomes following BRS and more longitudinal studies are necessary to understand the basis for these findings. Compared to other PROMs, BREAST-Q is reliable and specific to breast cancer surgery. Overall, BREAST-Q can help clinicians improve their quality of service, understand patient experiences, and may be used as an auditing tool for surgical outcomes.
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Affiliation(s)
- Ishith Seth
- Department of Surgery, Bendigo Health, Bendigo, Victoria, 3550, Australia
| | - Nimish Seth
- Department of Surgery, The Alfred Hospital, Melbourne, Victoria, 3004, Australia
| | - Gabriella Bulloch
- Faculty of Science, Medicine and Health, University of Melbourne, Melbourne, Victoria, 3010, Australia
| | - Warren M Rozen
- Peninsula Clinical School, Central Clinical School at Monash University, The Alfred Centre, Melbourne, Victoria, 3004, Australia
| | - David J Hunter-Smith
- Peninsula Clinical School, Central Clinical School at Monash University, The Alfred Centre, Melbourne, Victoria, 3004, Australia
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Kao KK, Nishikawa SM, Faringer PD. Surgical and Patient Reported Outcomes After DIEP Breast Reconstruction at a Low-Volume Community Hospital Without Microvascular Fellowship Training. EPLASTY 2021; 21:e9. [PMID: 35603019 PMCID: PMC9128728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
BACKGROUND Microsurgical breast reconstruction is typically performed at large, academic centers by fellowship-trained surgeons. This study examines surgical and patient-reported outcomes (PROs) after deep inferior epigastric perforator (DIEP) flap breast reconstruction at a community hospital by surgeons without fellowship training. METHODS A prospective clinical database and BREAST-Q results were obtained from 33 patients after 45 DIEP flaps performed between 2016 and 2020. PROs and complications were compared to normative data and multi-institutional series. Regression analysis of patient and surgical factors with BREAST-Q scores was performed. RESULTS Thirty-one patients completed BREAST-Q (response rate = 94%). Overall flap survival was 97.8%. Complications were not statistically different from larger published series (P > 0.05). Patients reported excellent outcomes after breast reconstruction: satisfaction with breasts (80.6 ± 4.3), satisfaction with outcome (88.3 ±17.7), psychosocial well-being (80.74 ± 17.4), sexual well-being (68.2 ± 24.1), physical well-being - chest (73.8 ± 16.1), and physical well-being - abdomen (73.3 ± 17.4). PROs were not statistically different from published multicenter data with the exception of superior scores in sexual well-being (P < 0.05) and breast satisfaction (P < 0.0001). Satisfaction with outcome varied by patient age and was 20.7 points higher for patients over 55 compared to patients 46 to 55 years of age (P < 0.05). Satisfaction with breasts was 29 points lower after total flap loss (P < 0.005). Psychosocial well-being scores were 26.98 points lower after a takeback (P < 0.05). Sexual well-being and physical well-being - chest scores were negatively related to increasing body mass index (BMI) (P < 0.05). CONCLUSION DIEP flap breast reconstruction can be performed with high quality and excellent PROs at a community hospital by surgeons without microvascular fellowship training.
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Affiliation(s)
- Kenneth K. Kao
- Department of Plastic Surgery, Kaiser Permanente Moanalua Medical Center; Honolulu, HI
| | - Scott M. Nishikawa
- Department of Plastic Surgery, Kaiser Permanente Moanalua Medical Center; Honolulu, HI
| | - Paul D. Faringer
- Department of Plastic Surgery, Kaiser Permanente Moanalua Medical Center; Honolulu, HI
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Patterson CW, Palines PA, Bartow MJ, Womac DJ, Zampell JC, Dupin CL, St Hilaire H, Stalder MW. Stratification of Surgical Risk in DIEP Breast Reconstruction Based on Classification of Obesity. J Reconstr Microsurg 2021; 38:1-9. [PMID: 33853129 DOI: 10.1055/s-0041-1727202] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND From both a medical and surgical perspective, obese breast cancer patients are considered to possess higher risk when undergoing autologous breast reconstruction relative to nonobese patients. However, few studies have evaluated the continuum of risk across the full range of obesity. This study sought to compare surgical risk between the three World Health Organization (WHO) classes of obesity in patients undergoing deep inferior epigastric perforator (DIEP) flap breast reconstruction. METHODS A retrospective review of 219 obese patients receiving 306 individual DIEP flaps was performed. Subjects were stratified into WHO obesity classes I (body mass index [BMI]: 30-34), II (BMI: 35-39), and III (BMI: ≥ 40) and assessed for risk factors and postoperative donor and recipient site complications. RESULTS When examined together, the rate of any complication between the three groups only trended toward significance (p = 0.07), and there were no significant differences among rates of specific individual complications. However, logistic regression analysis showed that class III obesity was an independent risk factor for both flap (odds ratio [OR]: 1.71, 95% confidence interval [CI]: 0.91-3.20, p = 0.03) and donor site (OR: 2.34, 95% CI: 1.09-5.05, p = 0.03) complications. CONCLUSION DIEP breast reconstruction in the obese patient is more complex for both the patient and the surgeon. Although not a contraindication to undergoing surgery, obese patients should be diligently counseled regarding potential complications and undergo preoperative optimization of health parameters. Morbidly obese (class III) patients should be approached with additional caution, and perhaps even delay major reconstruction until specific BMI goals are met.
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Affiliation(s)
- Charles W Patterson
- Division of Plastic and Reconstructive Surgery, Louisiana State University Health Sciences Center, New Orleans, Louisiana
| | - Patrick A Palines
- Division of Plastic and Reconstructive Surgery, Louisiana State University Health Sciences Center, New Orleans, Louisiana
| | - Matthew J Bartow
- Division of Plastic and Reconstructive Surgery, Louisiana State University Health Sciences Center, New Orleans, Louisiana
| | - Daniel J Womac
- Division of Plastic and Reconstructive Surgery, Louisiana State University Health Sciences Center, New Orleans, Louisiana.,Department of Plastic and Reconstructive Surgery, University Medical Center-LCMC Health, New Orleans, Louisiana
| | | | - Charles L Dupin
- Division of Plastic and Reconstructive Surgery, Louisiana State University Health Sciences Center, New Orleans, Louisiana.,Department of Plastic and Reconstructive Surgery, University Medical Center-LCMC Health, New Orleans, Louisiana
| | - Hugo St Hilaire
- Division of Plastic and Reconstructive Surgery, Louisiana State University Health Sciences Center, New Orleans, Louisiana.,Department of Plastic and Reconstructive Surgery, University Medical Center-LCMC Health, New Orleans, Louisiana
| | - Mark W Stalder
- Division of Plastic and Reconstructive Surgery, Louisiana State University Health Sciences Center, New Orleans, Louisiana.,Department of Plastic and Reconstructive Surgery, University Medical Center-LCMC Health, New Orleans, Louisiana
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Dinis J, Junn A, Shah R, Allam O, Mehta S, Mozaffari MA, Avraham T, Alperovich M. Abdominal subcutaneous fat thickness as a substitute for BMI in predicting complications in abdominally-based autologous breast reconstruction. Microsurgery 2021; 41:341-347. [PMID: 33720454 DOI: 10.1002/micr.30732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 02/07/2021] [Accepted: 03/03/2021] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Patient selection for autologous tissue transfer for postmastectomy breast reconstruction often utilizes body mass index (BMI) to risk stratify patients, though it only estimates fat content and does not address fat distribution. This study aims to identify a measurement of abdominal subcutaneous fat thickness (ASFT) from preoperative computed tomography (CT) angiography imaging to better predict complications. METHODS A retrospective review of patients who underwent an abdominal microvascular free flap breast reconstruction was performed. The average of the bilateral distances from the lateral border of the rectus abdominus to the most proximal point of the dermis at the L4-L5 space was measured on preoperative imaging to estimate ASFT. This measurement was compared to BMI in regards to correlation with any complication, major or minor complications, and donor or recipient site complications. Statistical analysis utilized point-biserial correlations and multivariable logistic regression analyses. RESULTS Three hundred and nine cases comprising a total of 496 breast reconstructions were identified. BMI did not correlate with any of the grouped complications, while ASFT correlated with occurrence of any complication (p = .003), minor complications (p = .001), and recipient site complications (p = .001). Further analysis revealed ASFT is specifically correlated with fat necrosis (p = .005). In independent multivariable regression models, both BMI (p = .011) and ASFT (p = .001) were significant predictors of fat necrosis. The ASFT model had a BIC of 335.42 compared to the BMI model with a value of 340.89, with smaller numbers representing more predictive models. CONCLUSION Estimation of ASFT is easily performed and is a significantly better predictor of flap fat necrosis than BMI.
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Affiliation(s)
- Jacob Dinis
- Section of Plastic and Reconstructive Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Alexandra Junn
- Section of Plastic and Reconstructive Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Rema Shah
- Section of Plastic and Reconstructive Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Omar Allam
- Section of Plastic and Reconstructive Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Sumarth Mehta
- Section of Plastic and Reconstructive Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Mohammad Ali Mozaffari
- Section of Plastic and Reconstructive Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Tomer Avraham
- Section of Plastic and Reconstructive Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Michael Alperovich
- Section of Plastic and Reconstructive Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
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Capitelli-McMahon H, Kiely J, Williams AM. Re: Body mass index and abdominal wall thickness correlate with perforator caliber in free abdominal tissue transfer for breast reconstruction. J Plast Reconstr Aesthet Surg 2020; 73:1357-1404. [PMID: 32007427 DOI: 10.1016/j.bjps.2020.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Accepted: 01/05/2020] [Indexed: 10/25/2022]
Affiliation(s)
- Helen Capitelli-McMahon
- Department of Plastic and Reconstructive Surgery, Bradford Teaching Hospitals Foundation Trust, Bradford BD9 6RJ, UK.
| | - John Kiely
- Department of Plastic and Reconstructive Surgery, Bradford Teaching Hospitals Foundation Trust, Bradford BD9 6RJ, UK
| | - Andrew M Williams
- Department of Plastic and Reconstructive Surgery, Bradford Teaching Hospitals Foundation Trust, Bradford BD9 6RJ, UK
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Nelson JA, Sobti N, Patel A, Matros E, McCarthy CM, Dayan JH, Disa JJ, Cordeiro PG, Mehrara BJ, Pusic AL, Allen RJ. The Impact of Obesity on Patient-Reported Outcomes Following Autologous Breast Reconstruction. Ann Surg Oncol 2019; 27:1877-1888. [PMID: 31811437 DOI: 10.1245/s10434-019-08073-5] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND Obesity is a significant public health concern and clear risk factor for complications following breast reconstruction. To date, few have assessed patient-reported outcomes (PROs) focused on this key determinant. OBJECTIVE Our study aimed to investigate the impact of obesity (body mass index ≥ 30) on postoperative satisfaction and physical function utilizing the BREAST-Q in a cohort of autologous breast reconstruction patients. METHODS An Institutional Review Board-approved prospective investigation was conducted to evaluate PROs in patients undergoing autologous breast reconstruction from 2009 to 2017 at a tertiary academic medical center. The BREAST-Q reconstruction module was used to assess outcomes between cohorts preoperatively and at 6 months, 1 year, 2 years, and 3 years after reconstruction. RESULTS Overall, 404 patients underwent autologous breast reconstruction with abdominal free-tissue transfer (244 non-obese, 160 obese) and completed the BREAST-Q. Although obese patients demonstrated lower satisfaction with breasts preoperatively (p = 0.04), no significant differences were noted postoperatively (p = 0.58). However, physical well-being of the abdomen was lower in the obese cohort compared with their non-obese counterparts at long-term follow-up (3 years; p = 0.04). CONCLUSION Obesity significantly impacts autologous breast reconstruction patients. Although obese patients are more likely to present with dissatisfaction with breasts preoperatively, they exhibit comparable PROs overall compared with their non-obese counterparts, despite increased complications.
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Affiliation(s)
- Jonas A Nelson
- Section of Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| | - Nikhil Sobti
- Section of Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Aadit Patel
- Section of Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Evan Matros
- Section of Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Colleen M McCarthy
- Section of Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Joseph H Dayan
- Section of Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Joseph J Disa
- Section of Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Peter G Cordeiro
- Section of Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Babak J Mehrara
- Section of Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Andrea L Pusic
- Division of Plastic and Reconstructive Surgery, Brigham and Womens Hospital, Boston, MA, USA
| | - Robert J Allen
- Section of Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Abstract
BACKGROUND There is an increasing prevalence of obesity in society, often associated with increased medical comorbidities and surgical complications. Some health providers are now placing a body mass index (BMI) limit on whom can be offered breast reconstruction. The objective of this study was to determine the impact of obesity on quality of life as measured by the BREAST-Q, in women undergoing breast reconstruction. METHODS A review of the breast reconstruction database (n = 336) at the Flinders Breast Reconstruction Service was performed, with demographic data, complication rates, and BREAST-Q data being extracted and analyzed. Participants were divided into 2 groups: nonobese (BMI <30 kg/m) and obese (BMI ≥30 kg/m) for comparison. RESULTS Preoperatively, obese women scored lower than nonobese women in terms of BREAST-Q scores. Mean prereconstruction scores were 51.62 versus 57.10 (psychosocial), 40.18 versus 48.14 (satisfaction with breasts), and 34.30 versus 40.72 (sexual well-being) (all P < 0.05), and 68.48 versus 72.15 (physical well-being) (P = 0.08). At 12 months post-mound reconstruction, there was a significant improvement in scores in both groups. Additionally, there were no significant differences for BREAST-Q scores between the 2 groups 12 months after surgery. While there was a significantly higher minor complication rate in the obese group compared with the nonobese group, there was no significant difference in the rate of major complications (eg, requiring revision surgery) between the 2 groups. CONCLUSIONS Obese participants gain a similar, if not better, improvement in quality of life after breast reconstruction, despite a higher rate of minor complications. This study did not support withholding breast reconstruction from obese women.
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Ochoa O, Garza R, Pisano S, Chrysopoulo M, Ledoux P, Arishita G, Ketchum N, Michalek JE, Nastala C. Prospective Longitudinal Patient-Reported Satisfaction and Health-Related Quality of Life following DIEP Flap Breast Reconstruction: Relationship with Body Mass Index. Plast Reconstr Surg 2019; 143:1589-1600. [PMID: 30907803 DOI: 10.1097/prs.0000000000005616] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Breast reconstruction plays a significant role in breast cancer treatment recovery. Introduction of the BREAST-Q questionnaire has facilitated quantifying patient-reported quality-of-life measures, promoting improved evidence-based clinical practice. Information regarding the effects of body mass index on patient-reported outcomes and health-related quality of life is significantly lacking. METHODS Consecutive deep inferior epigastric perforator (DIEP) flap breast reconstruction patients prospectively completed BREAST-Q questionnaires preoperatively and at two points postoperatively. The first (postoperative time point A) and second (postoperative time point B) postoperative questionnaires were completed 1 month postoperatively and following breast revision, respectively. Postoperative flap and donor-site complications were recorded prospectively. BREAST-Q scores were compared at all time points and stratified by body mass index group (≤25, >25 to 29.9, 30 to 34.9, and ≥35 kg/m). RESULTS Between July of 2012 and August of 2016, 73 patients underwent 130 DIEP flap breast reconstructions. Breast satisfaction and psychosocial and sexual well-being scores increased significantly postoperatively. Chest and abdominal physical well-being scores returned to baseline levels by postoperative point B. Preoperatively, stratified by body mass index, breast satisfaction and psychosocial well-being scores were significantly lower among patients with body mass index of 35 or higher and of more than 30, respectively. After reconstruction, not only were breast satisfaction, psychosocial, and sexual well-being scores significantly improved in all body mass index groups versus baseline, but also between-body mass index group differences were no longer present. Outcome satisfaction, flap, and donor-site morbidity were similar irrespective of body mass index. CONCLUSIONS Patient-reported outcomes demonstrate significant improvements in breast satisfaction and psychosocial and sexual well-being among patients following DIEP flap reconstruction. Preoperative differences in quality-of-life scores were improved in patients with obesity (body mass index ≥30 kg/m). CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, II.
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Affiliation(s)
- Oscar Ochoa
- From Plastic Reconstructive & Microsurgical Associates; and the University of Texas Health Science Center at San Antonio
| | - Ramon Garza
- From Plastic Reconstructive & Microsurgical Associates; and the University of Texas Health Science Center at San Antonio
| | - Steven Pisano
- From Plastic Reconstructive & Microsurgical Associates; and the University of Texas Health Science Center at San Antonio
| | - Minas Chrysopoulo
- From Plastic Reconstructive & Microsurgical Associates; and the University of Texas Health Science Center at San Antonio
| | - Peter Ledoux
- From Plastic Reconstructive & Microsurgical Associates; and the University of Texas Health Science Center at San Antonio
| | - Gary Arishita
- From Plastic Reconstructive & Microsurgical Associates; and the University of Texas Health Science Center at San Antonio
| | - Norma Ketchum
- From Plastic Reconstructive & Microsurgical Associates; and the University of Texas Health Science Center at San Antonio
| | - Joel E Michalek
- From Plastic Reconstructive & Microsurgical Associates; and the University of Texas Health Science Center at San Antonio
| | - Chet Nastala
- From Plastic Reconstructive & Microsurgical Associates; and the University of Texas Health Science Center at San Antonio
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Prospective Evaluation of Obese Patients Undergoing Autologous Abdominal Free Flap Breast Reconstruction. Plast Reconstr Surg 2019; 142:120e-125e. [PMID: 29794640 DOI: 10.1097/prs.0000000000004550] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Obesity has been viewed as a relative contraindication against autologous free flap breast reconstruction because of increased risks of complications, including flap loss. METHODS The authors conducted a prospective analysis of obese patients undergoing autologous breast reconstruction. RESULTS Overall, 72 patients (average age, 48.5 years; average body mass index, 35.7 kg/m) underwent abdominal free flap breast reconstruction. There were 43 bilateral reconstructions and the remainder were unilateral (n = 115 flaps). There were 67 muscle-sparing transverse rectus abdominis musculocutaneous (TRAM) flaps (58.3 percent), 44 deep inferior epigastric perforator (DIEP) flaps (38.2 percent), two free bipedicle DIEP flaps, one superficial inferior epigastric perforator flap, and one free TRAM flap. Forty-two patients (58.3 percent) had prior radiation, and 51 (70.8 percent) had prior chemotherapy. Forty-three patients (59.7 percent) underwent delayed reconstruction and 21 (29.2 percent) underwent immediate reconstruction. Eight patients (11.1 percent) had bilateral reconstruction, with one breast reconstructed in an immediate and the other in a delayed fashion. Half of the patients (n = 36) had mesh placed in an underlay fashion to reinforce the donor site. Regarding breast complications, there were 11 wound dehiscences, one hematoma, one infection, and two patients with mastectomy skin flap necrosis. Twelve patients had donor-site wound healing complications, there were four infections, and three patients developed a bulge/hernia. There were no flap losses. Comparison to historic controls demonstrated no significant differences in overall flap loss rates (p = 0.061) or donor-site bulge/hernia (p = 0.86). CONCLUSION Autologous abdominal free flaps can be performed safely in obese patients without increased risks for donor-site bulge/hernia or flap loss compared to nonobese patients; however, patients should be counseled carefully regarding the potential risks of complications. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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16
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Dec W. Optimizing aesthetic outcomes for breast reconstruction in patients with significant macromastia or ptosis. JPRAS Open 2018; 16:24-30. [PMID: 32158807 PMCID: PMC7061626 DOI: 10.1016/j.jpra.2018.01.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Accepted: 01/31/2018] [Indexed: 12/01/2022] Open
Abstract
Background Achieving excellent aesthetic outcomes in reconstruction of large or ptotic breasts is especially challenging. Incorporating a Wise pattern into the mastectomy design is effective in reducing the excess breast skin, however it increases the risk of mastectomy skin necrosis. The aim of this study is to describe surgical maneuvers which optimize aesthetic outcomes, anticipate flap volume requirements, and limit mastectomy skin necrosis in autologous reconstruction in patients with macromastia and grade III ptosis. Methods This is a retrospective review of operative and clinical records of patients who underwent unilateral or bilateral breast reconstruction with autologous tissue between August 2015 and May 2017. Patients were divided into macromastia and ptosis groups. Key surgical maneuvers for safely achieving aesthetically optimal results were identified. Results A total of 29 breasts were successfully reconstructed in 19 patients with a Wise pattern mastectomy skin reduction. Free flap weights were similar in both groups, mastectomy weights were greater in the macromastia group, p < 0.05. Complications were limited to three cases of wound breakdown and one case of mastectomy skin necrosis. Total number of revision stages was reduced in unilateral reconstructions when a contralateral breast reduction or mastopexy was performed during the first stage. Conclusions A Wise pattern can safely and effectively be incorporated into a mastectomy incision design in patients who are not candidates for a nipple sparing mastectomy. Optimal aesthetics are achieved with similar volume flaps for both macromastia and ptosis patients. In cases of unilateral breast reconstruction a contralateral breast reduction or mastopexy should be performed at the time of the immediate breast reconstruction.
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Affiliation(s)
- Wojciech Dec
- Department of Plastic Surgery, Lenox Hill Hospital, 100 East 77th Street, New York, NY, USA
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17
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Papadakis M, Schuster F, Djedovic G, Rahmanian-Schwarz A. Super obesity is not necessarily a contraindication to deep inferior epigastric perforator flap breast reconstruction. BMJ Case Rep 2018; 2018:bcr-2017-223065. [PMID: 29367225 DOI: 10.1136/bcr-2017-223065] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
The deep inferior epigastric perforator (DIEP) flap is widely recognised as a safe and reliable flap for use as a first-choice option in autologous tissue breast reconstruction. Patients with obesity represent a challenging group for autologous breast reconstruction, as they are at increased risk of developing major and minor complications in comparison with patients with normal weight. We report a 59-year-old woman with super obesity, who presented to our department with right breast skin necrosis after implant reconstruction following mastectomy for right breast cancer. After implant removal and local treatment with both surgical debridement and negative pressure wound therapy, the patient successfully underwent a DIEP flap breast reconstruction. We conclude that super obesity should not be a contraindication to DIEP flap breast reconstruction.
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Affiliation(s)
- Marios Papadakis
- Department of Plastic, Reconstructive and Hand Surgery, HELIOS Universitätsklinikum Wuppertal, Wuppertal, Germany
| | - Frauke Schuster
- Department of Plastic, Reconstructive and Hand Surgery, HELIOS Universitätsklinikum Wuppertal, Wuppertal, Germany
| | - Gabriel Djedovic
- Department of Plastic, Reconstructive and Hand Surgery, HELIOS Universitätsklinikum Wuppertal, Wuppertal, Germany
| | - Afshin Rahmanian-Schwarz
- Department of Plastic, Reconstructive and Hand Surgery, HELIOS Universitätsklinikum Wuppertal, Wuppertal, Germany
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Indications and Controversies for Abdominally-Based Complete Autologous Tissue Breast Reconstruction. Clin Plast Surg 2018; 45:83-91. [DOI: 10.1016/j.cps.2017.08.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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19
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O'Connell RL, DiMicco R, Khabra K, O'Flynn EA, deSouza N, Roche N, Barry PA, Kirby AM, Rusby JE. Initial experience of the BREAST-Q breast-conserving therapy module. Breast Cancer Res Treat 2016; 160:79-89. [PMID: 27637781 DOI: 10.1007/s10549-016-3966-x] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Accepted: 08/26/2016] [Indexed: 10/21/2022]
Abstract
PURPOSE The most recently developed module of the BREAST-Q, a validated patient outcome measure, is for patients who have undergone breast-conserving therapy (BCT) for cancer. This aim of this study was to assess patient satisfaction and quality of life after BCT using BREAST-Q, investigate clinical risk factors for lower satisfaction and explore the relationship between patient satisfaction with the appearance of their breasts and the other domains of the BREAST-Q. METHODS Women who had undergone unilateral BCT in the preceding 1-6 years were invited to participate at the time of their annual surveillance mammogram. Clinicopathological data were collected from an electronic database. Linear regression was used to evaluate risk factors for lower satisfaction. Spearman's rho correlation coefficients were calculated to evaluate the relationship between domains. RESULTS 200 women completed the questionnaire. Mean age was 60 years (SD 11.1). Time from surgery was 35.5 months (SD 17.8). Median score for 'Satisfaction with breasts' was 68 (interquartile range 55-80). Lowest scores were for 'sexual wellbeing' (57, IQR 45-66). On multivariate analysis, BMI at the time of surgery (p = 0.002), delayed wound healing (p = 0.001) and axillary surgery (p = 0.003) were independent risk factors for lower satisfaction. There was significant correlation between 'Satisfaction with breasts' and all other BREAST-Q domains. CONCLUSION High BMI, delayed wound healing and axillary surgery are risk factors for lower patient satisfaction. This first publication reporting the whole dataset for the BREAST-Q BCT will serve as a benchmark for future studies of patient satisfaction following BCT.
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Affiliation(s)
- Rachel L O'Connell
- Department of Breast Surgery, The Royal Marsden NHS Foundation Trust, Royal Marsden Hospital, Orchard House, Downs Road, Sutton, Surrey, SM2 5PT, UK
| | - Rosa DiMicco
- Department of Breast Surgery, The Royal Marsden NHS Foundation Trust, Royal Marsden Hospital, Orchard House, Downs Road, Sutton, Surrey, SM2 5PT, UK
| | - Komel Khabra
- Department of Statistics, The Royal Marsden NHS Foundation Trust, Sutton, UK
| | - Elizabeth A O'Flynn
- Cancer Research UK Cancer Imaging Centre, Institute of Cancer Research and Royal Marsden NHS Foundation Trust, Sutton, UK
| | - Nandita deSouza
- Cancer Research UK Cancer Imaging Centre, Institute of Cancer Research and Royal Marsden NHS Foundation Trust, Sutton, UK
| | - Nicola Roche
- Department of Breast Surgery, The Royal Marsden NHS Foundation Trust, Royal Marsden Hospital, Orchard House, Downs Road, Sutton, Surrey, SM2 5PT, UK
| | - Peter A Barry
- Department of Breast Surgery, The Royal Marsden NHS Foundation Trust, Royal Marsden Hospital, Orchard House, Downs Road, Sutton, Surrey, SM2 5PT, UK
| | - Anna M Kirby
- Department of Clinical Oncology, The Royal Marsden NHS Foundation Trust, Sutton, UK
| | - Jennifer E Rusby
- Department of Breast Surgery, The Royal Marsden NHS Foundation Trust, Royal Marsden Hospital, Orchard House, Downs Road, Sutton, Surrey, SM2 5PT, UK.
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