Aesthetic and oncologic outcomes after one-stage immediate breast reconstruction using a permanent biodimensional expandable implant

Indocyanine green angiography guidance for vascular preservation in skin and nipple sparing mastectomy

PURPOSE

The skin and/or nipple-sparing approach has become an oncologically sound and desirable choice for women choosing mastectomy. Indocyanine green (ICG) perfusion imaging has been shown to reduce ischemic complications in mastectomy skin flaps. Immediate reconstruction requires a well-vascularized skin flap capable of tolerating full expansion. Identification of the perforating subcutaneous vessels to the skin envelope may allow for better and more consistent blood vessel preservation and flap perfusion.

METHODS

The authors conducted an institutional review board-approved prospective study with 41 patients to assess the feasibility of using ICG perfusion imaging to visualize, cutaneously map, and preserve the vessels that supply the skin flap and nipple-areolar complex. For each patient, the number of vessels initially mapped, the number of vessels preserved, the extent to which each vessel was preserved, and the proportion of the flap with adequate perfusion (as defined by the SPY-Q > 20% threshold) was recorded and analyzed.

RESULTS

Vessels were able to be identified and marked in a high majority of patients (90%). There was a moderate linear relationship between the number of vessels marked and the number preserved. Successful mapping of vessels was associated with lower rates of wound breakdown (p = 0.036). Mapping and preserving at least one vessel led to excellent flap perfusion (> 90%). No increase in complications was observed from utilizing ICG angiography preoperatively.

CONCLUSION

This prospective study using preoperative ICG perfusion mapping demonstrated safety, feasibility, and good prognostic outcomes.

LEVEL OF EVIDENCE

III.

Long-Term Outcomes of Breast Cancer Patients with Local Recurrence After Mastectomy Undergoing Immediate Breast Reconstruction: A Retrospective Multi-institutional Study of 4153 Cases

BACKGROUND

The number of breast cancer patients in Japan undergoing immediate breast reconstruction (IBR) has increased and the postoperative follow-up period has been extended. This study was conducted to clarify the clinical aspects of, and factors associated with, local recurrence (LR) after IBR.

METHODS

This was a multicenter study which included 4153 early breast cancer patients who underwent IBR. Clinicopathological characteristics were examined and factors potentially contributing to LR were analyzed. Risk factors for LR were examined separately for non-invasive and invasive breast cancers.

RESULTS

The median follow-up period was 75 months. The 7-year LR rates were 2.1% and 4.3% for non-invasive and invasive cancers, respectively (p < 0.001). The proportions of LR detected by palpation, subjective symptoms, and ultrasonography were 40.0%, 27.3%, and 25.9%, respectively. Overall, 75.7% of LR were solitary, and 92.7% of these cases had no further recurrences during the observational period. Multivariate analysis of LR for invasive cancer showed that skin-sparing mastectomy (SSM) or nipple-sparing mastectomy (NSM), the presence of lymphovascular invasion, cancer at the surgical margin, and not receiving radiation therapy were factors related to LR. The 7-year overall survival rates of the patients with LR and non-LR of invasive cancers were 92.5% and 97.3%, respectively, (p = 0.002).

CONCLUSIONS

The rate of LR after IBR was acceptably low and IBR can thus be performed safely for early breast cancer patients. Invasive cancer, SSM/NSM, lymphovascular invasion, and/or cancer at the surgical margin should prompt awareness of the possibility of LR.

Suggestion for the omission of post-mastectomy chest wall radiation therapy in patients who underwent skin-sparing/nipple-sparing mastectomy

AIM

Both skin-sparing mastectomy (SSM) and nipple-sparing mastectomy (NSM) have been widely adopted. Although postmastectomy radiation therapy (PMRT) can improve clinical outcomes, it can worsen cosmesis following reconstruction. Therefore, identifying risk factors of ipsilateral breast tumor recurrence (IBTR) could help de-escalate PMRT after NSM/SSM in patients with pT1-2 disease.

METHODS

We retrospectively reviewed patients treated with SSM (N = 400) and NSM (N = 156) in patients with pT1-2N0-1 disease between 2009 and 2016. Seventy-four patients received PMRT with 50-50.4 Gy in 25-28 fractions. The Cox proportional hazards model was used to analyze the prognostic factors of IBTR.

RESULTS

With a median follow-up of 66.2 months, 17 IBTR events were observed, with 5-year IBTR-free rate of 97.2%. Although only one IBTR was observed after PMRT, there was no statistical difference in the 5-year IBTR-free rate (PMRT vs. no PMRT, 98.6% vs. 97.0%, p = 0.360). Multivariable analyses demonstrated that age ≤45 years and lymphovascular invasion (LVI) were adverse features of IBTR. The low-risk group (0 risk factor) showed a better 5-year IBTR-free rate than the high-risk group (≥1 risk factor) (100.0% vs. 95.8%, p = 0.003). In the high-risk group, PMRT slightly improved 5-year IBTR-free rate compared with no PMRT (98.6% vs. 95.2%, p = 0.166). In addition, PMRT increased 5-year cumulative incidence of reconstruction failure (10.0% vs. 2.8%, p = 0.001).

CONCLUSION

We identified risk factors (age and LVI) related to IBTR following upfront SSM/NSM with pT1-2 disease. As a hypothesis-generating study, de-escalation of PMRT by omitting chest wall irradiation in selective patients could improve reconstruction-related complications without compromising oncologic outcomes.

Pattern of local recurrence after mastectomy and reconstruction in breast cancer patients: a systematic review

Background

This study aimed to describe the locations of local recurrences based on the mastectomy and reconstruction type in breast cancer patients.

Methods

In November 2020, a systematic literature review was performed through MEDLINE/PubMed and the Cochrane Centre Register of Controlled Trials. Publications that included skin-sparing or nipple-sparing mastectomy followed by breast reconstruction and described the location of local recurrences were analyzed. Exclusion criteria included salvage or prophylactic mastectomy, unclear distinction between local and regional recurrences, rare tumor types.

Results

From 19 publications, 272 local recurrences lesions were reported in a total of 4,787 patients. After autologous reconstruction (n=2,465), local recurrences were located in the skin in 45 (1.8%) patients, in the chest wall in 18 (0.7%), and in the nipple-areolar complex in 9 (0.4%). After implant reconstruction (n=1,917), local recurrences sites included the skin in 91 (4.7%) patients, chest wall in 8 (0.4%), and nipple-areolar complex in 8 (0.4%). Of the 70 lesions with reported in-breast location, 57 (81.4%) relapsed in the original tumor location.

Discussion

Although meta-analysis was not conducted, present analysis demonstrated that most local recurrences after skin-sparing or nipple-sparing mastectomy occurred within the skin or subcutaneous tissues. It was found that the original tumor location was the most frequent site of relapse. Therefore, special attention should be paid to the original tumor overlying the skin while planning postmastectomy radiation therapy.

Factors Associated With Complications in Immediate Breast Reconstruction in 1 Stage With Completely Submuscular Implants

BACKGROUND

Immediate breast reconstruction in 1 stage using permanent implants is gaining popularity and can be performed with or without the use of acellular dermal matrices. This study aimed to investigate the results of breast implants placed submuscularly without acellular dermal matrix and assess the factors affecting surgical complications.

METHODS

From November 2009 to March 2018, 138 patients underwent immediate breast reconstruction with permanent submuscular implants after concomitant skin-sparing or nipple-sparing mastectomies in a single institution. All implants were covered with sufficient soft tissue under a submuscular pocket.

RESULTS

One hundred thirty-eight patients were enrolled, and a total of 196 breasts were operated. The average age and body mass index (BMI) of the patients were 44.9 ± 8.8 years and 23.7 ± 3.6 kg/m, respectively. The majority of the mastectomies were therapeutic (81%). The average volume of implants was 389 ± 89 mL, and the mean follow-up was 33 months. The overall complication rate was 17% (n = 23), with skin necrosis being the most common complication followed by infections. Having a BMI equal to or greater than 25 kg/m was found to be a statistically significant predictor for overall complications (P = 0.002), whereas smoking history, age, and implant volume were not statistically significant.

CONCLUSIONS

Immediate breast reconstruction in 1 stage using permanent implants can be performed with acceptable complication rates and cosmetic outcomes. Our study demonstrated that high BMI is a risk factor for overall complications. With proper patient selection and surgical technique, implants could be completely covered under a submuscular pocket.

Influence of Incision Site on Postoperative Outcome in Skin-/Nipple-Sparing Mastectomy: Is There a Difference between Radial and Inframammary Incision?

Background

The aim of this study was to determine whether there is a difference in results between the radial and the inframammary approach in nipple-/skin-sparing mastectomy and immediate reconstruction.

Methods

The patients were divided into two groups (group 1: radial incision; group 2: inframammary fold incision [IMF]), each consisting of two subgroups for direct-to-implant reconstruction (1a, 2a) and expander reconstruction (1b, 2b). The patients were operated on between March 2012 and May 2017. Preoperative tumor parameters, reconstruction parameters, postoperative tumor parameters, and immediate and late complications were assessed. Postoperative photographs were evaluated by the patients and 8 plastic surgeons by means of grading (1-5) and the visual analog scale (VAS; 1-10).

Results

Enrolled in this study were 28 patients, namely, 7 patients in each subgroup. The median age was 46 years, and the median follow-up period was 40 months. No immediate complications occurred. Three patients had late complications, but there was no case of evident capsular fibrosis. Twenty-seven patients (96.42%) evaluated the postoperative result as excellent/good. The postoperative evaluation by the plastic surgeons was excellent/good for a median of 18 patients (64.28%). Group 1 showed a median VAS score of 7.63 (expander group: 7.50; direct-to-implant group: 7.75); the median VAS score for group 2 was 8.25 (expander group: 8.75; direct-to-implant group: 7.50).

Conclusions

Our study shows good results for implant breast reconstruction in both groups, with minimally better results for the IMF group. In the direct-to-implant subgroups, the radial group showed slightly better results.

Submuscular and Pre-Pectoral ADM Assisted Immediate Breast Reconstruction: A Literature Review

Background and objectives: Breast cancer treatment has deeply changed in the last fifty years. Acellular dermal matrices (ADMs) were introduced for breast reconstruction, with encouraging results, but with conflicting reports too. The present paper aims to summarize the current data on breast reconstruction using acellular dermal matrices. Materials and Methods: We reviewed the literature regarding the use of ADM-assisted implant-based breast reconstruction. Results: The main techniques were analyzed and described. Conclusions: Several authors have recently reported positive results. Nevertheless, an increased complications' rate has been reported by other authors. Higher cost compared to not-ADM-assisted breast reconstruction is another concern.

Acellular dermal matrix for esophageal stricture prevention after endoscopic submucosal dissection in a porcine model

BACKGROUND AND AIMS

Endoscopic submucosal dissection (ESD) is considered an effective treatment for early esophageal cancer and precancerous lesions. Esophageal stenosis is closely associated with quasi-circumferential ESD. We examined whether post-ESD esophageal stricture can be prevented by grafting an acellular dermal matrix (ADM) membrane.

METHODS

Fourteen Bama miniature pigs were randomly divided into an ADM group (n = 7) and a control group (n = 7). Semicircumferential ESD was performed at the distal esophagus in all animals, and in the ADM group an ADM patch graft was placed at the resection site and secured innovatively with metal clips. Animals in the control group underwent ESD only. Endoscopy was performed at 3 days, 1 week, 2 weeks, and 4 weeks post-ESD, and fluoroscopy was performed at 4 weeks for assessment of the degree of stenosis, after which the remodeled esophageal tissues were excised for histologic analysis.

RESULTS

No animals in the ADM group developed clinically significant esophageal stenosis, whereas 42.8% (3/7) in the control group did. The degree of stenosis was severe in the control group (39.8% vs 17.2%, respectively; P = .01). Animals in the ADM group had less feeding difficulty and lost less weight (-.9 kg vs -4.1 kg, respectively; P = .007). Histologically, complete mucosal epithelium, slight local inflammation, and organized collagenous fibers were observed in the ADM group.

CONCLUSIONS

ADM patch graft appears, after short-term observation, to be a potentially useful new treatment strategy for prevention of esophageal stricture after ESD. A metal clip fixation technique is effective for endoscopic graft attachment.

One-Stage Immediate Breast Reconstruction: A Concise Review

BACKGROUND

One-stage direct-to-implant immediate breast reconstruction (IBR) is performed simultaneously with breast cancer resection. We explored indications, techniques, and outcomes of IBR to determine its feasibility, safety, and effectiveness.

MATERIAL AND METHODS

We reviewed the available literature on one-stage direct-to-implant IBR, with or without acellular dermal matrix (ADM), synthetic mesh, or autologous fat grafting. We analyzed the indications, preoperative work-up, surgical technique, postoperative care, outcomes, and complications.

RESULTS

IBR is indicated for small-to-medium nonptotic breasts and contraindicated in patients who require or have undergone radiotherapy, due to unacceptably high complications rates. Only patients with thick, well-vascularized mastectomy flaps are IBR candidates. Expandable implants should be used for ptotic breasts, while anatomical shaped implants should be used to reconstruct small-to-medium nonptotic breasts. ADMs can be used to cover the implant during IBR and avoid muscle elevation, thereby minimizing postoperative pain. Flap necrosis, reoperation, and implant loss are more common with IBR than conventional two-staged reconstruction, but IBR has advantages such as lack of secondary surgery, faster recovery, and better quality of life.

CONCLUSIONS

IBR has good outcomes and patient-satisfaction rates. With ADM use, a shift from conventional reconstruction to IBR has occurred. Drawbacks of IBR can be overcome by careful patient selection.