Delaying implant-based mammary reconstruction after radiotherapy does not decrease capsular contracture: An in vitro study

“Hook Shape” Nipple-Sparing Mastectomy and Prepectoral Implant Reconstruction: Technique, Results and Outcomes from a Preliminary Case Series

INTRODUCTION

Nipple-sparing mastectomy (NSM) is a surgical procedure increasingly performed for breast cancer or risk reduction surgeries. The site of skin incision seems to affect not only cosmesis but also technical ease in operating and vascular viability of the nipple. We present a series of patients who underwent a modified vertical surgical approach for NSM, which resulted to be safe, reliable, and with good esthetic results.

MATERIALS AND METHODS

From December 2016 to February 2019, 27 "Hook Shape" incision NSMs were performed. All patients underwent an immediate subcutaneous muscle-sparing reconstruction with tissue expander covered by a titanium-coated polypropylene mesh, followed by a second surgical step with expander substitution and lipofilling on the definitive implant when indicated. Preoperative and postoperative BREAST-Q patient-reported outcomes measure was performed in all cases.

RESULTS

Postoperative morbidity was evaluated: One patient developed seroma and another presented a systemic infection that resolved with intravenous infusion of antibiotics. One patient experienced vertical wound dehiscence, recovered after conservative treatment and without implant exposure. No implant loss was observed. Nipple-areola complex necrosis or ischemia rate was 0%. The BREAST-Q outcomes reported significant increases in the overall satisfaction with breast (p < 0.05), psychosocial well-being (p < 0.05), and sexual well-being (p < 0.05) sections. Scores in the physical impact of surgery section appeared to decline from preoperative to postoperative evaluations, with no statistically significant results.

CONCLUSION

The mastectomy incision pattern can burden the surgical challenge, impact vascular viability of the nipple and significantly affect the aesthetic outcomes in breast reconstruction. We report our experience with an alternative approach for NSM, which appears a safe, practical, and reproducible method for patients with small- to medium-sized breasts and little/medium ptosis (grade I or II).

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Breast Reconstruction after Mastectomy with the Use of an Implant and Serratus Anterior Fascia Flap-Initial Clinical Evaluation

Prosthesis-based techniques are the predominant form of breast reconstruction worldwide. The most performed surgical technique involves the placement of the expander in a partial submuscular plane. The coverage of the implant remains a difficult management problem that can lead to complications and poor outcomes. The use of the serratus fascia flap may be the best choice to create a subpectoral pocket for the placement of a tissue expander, with excellent results in terms of morbidity and cost-effectiveness. A total of 20 breast reconstructions with the inferolateral coverage with the serratus fascia were performed. Patients demonstrated a low overall complication rate (9.5%), such as seroma and infection, with complete resolution during the follow-up and no major complications. The US examination of the soft tissues over the implant reported thickness measurements that demonstrated a good coverage over the inferolateral area. Our study shows that using the serratus fascia flap to create a pocket with the pectoralis major for the placement of the tissue expander is an effective technique during two-stage breast reconstruction. The resulting low rate of morbidity and the US findings collected reveal the safety of this procedure. Its success relies on appropriate patient selection and specific intraoperative technique principles.

Breast Animation Deformity: A Retrospective Study on Long-Term and Patient-Reported Breast-Q Outcomes

BACKGROUND

We evaluated the aesthetic outcomes and quality of life of patients who underwent neurotomy of the lateral and medial branch of the pectoralis nerve for animation deformity after breast reconstruction.

MATERIAL AND METHODS

Health-related quality of life questionnaire and cosmetic outcome evaluation were conducted using the preoperative and the postoperative BREAST-Q modules for reconstructive surgery. An external author also assessed the general aesthetic outcome before and after surgery.

RESULTS

Sixty-two patients with animation deformity after breast reconstruction were enrolled: 43 in group 1 (second-stage breast reconstruction), 10 in group 2 (permanent breast prosthesis), and 9 in group 3 (Baker III-IV capsular contraction). Patients scored high level of satisfaction with outcome concerning all aspects of the survey. Overall satisfaction with breast was significantly increased after surgery in all the 3 groups, whereas physical well-being was improved in group 1 and group 3 and psychosocial well-being was improved in group 1. General outcome evaluation by an external author, compared with the preoperative condition, also showed significant improvement.

CONCLUSIONS

Section of the lateral and medial branches of the pectoralis nerve represents an easy and reproducible technique, associated with low morbidity and very good results in terms of patient satisfaction, comfort, and hospitalization.

An unusual case of late hematoma after implant-based breast reconstruction mimicking an anaplastic large cell lymphoma: a case report and literature review

Late hematoma associated with breast implants used in esthetic and reconstructive breast surgery represents a rare entity. These hematomas do not have a clear etiology, but triggering events like trauma, anticoagulant use, capsule contracture, or chronic inflammation are reported in literature. We describe an 82-year-old patient who developed a unilateral intra-capsular hematoma 19 years after mastectomy and breast reconstruction with McGhan 445 g implant. Differential diagnosis with anaplastic large cell lymphoma (ALCL) was considered and potential causes of hematoma were evaluated. Constant pressure forces on chest wall were defined as pathophysiological cause. A systematic literature review concerning late hematoma cases was carried out, focusing on late hematoma etiology and various surgical treatments.

Level of evidence: Level V, diagnostic study.

The Effect of Postmastectomy Radiation Therapy on Breast Implants: Material Analysis on Silicone and Polyurethane Prosthesis

INTRODUCTION

The pathogenic mechanism underlying capsular contracture is still unknown. It is certainly a multifactorial process, resulting from human body reaction, biofilm activation, bacteremic seeding, or silicone exposure. The scope of the present article is to investigate the effect of hypofractionated radiotherapy protocol (2.66 Gy × 16 sessions) both on silicone and polyurethane breast implants.

METHODS

Silicone implants and polyurethane underwent irradiation according to a hypofractionated radiotherapy protocol for the treatment of breast cancer. After irradiation implant shells underwent mechanical, chemical, and microstructural evaluation by means of tensile testing, infrared spectra in attenuated total reflectance mode, nuclear magnetic resonance, and field emission scanning electron microscopy.

RESULTS

At superficial analysis, irradiated silicone samples show several visible secondary and tertiary blebs. Polyurethane implants showed an open cell structure, which closely resembles a sponge. Morphological observation of struts from treated polyurethane sample shows a more compact structure, with significantly shorter and thicker struts compared with untreated sample. The infrared spectra in attenuated total reflectance mode spectra of irradiated and control samples were compared either for silicon and polyurethane samples. In the case of silicone-based membranes, treated and control specimens showed similar bands, with little differences in the treated one. Nuclear magnetic resonance spectra on the fraction soluble in CDCl3 support these observations. Tensile tests on silicone samples showed a softer behavior of the treated ones. Tensile tests on Polyurethane samples showed no significant differences.

CONCLUSIONS

Polyurethane implants seem to be more resistant to radiotherapy damage, whereas silicone prosthesis showed more structural, mechanical, and chemical modifications.

International multidisciplinary expert panel consensus on breast reconstruction and radiotherapy

BACKGROUND

Conflicting evidence challenges clinical decision-making when breast reconstruction is considered in the context of radiotherapy. Current literature was evaluated and key statements on topical issues were generated and discussed by an expert panel at the International Oncoplastic Breast Surgery Meeting in Milan 2017.

METHODS

Studies on radiotherapy and breast reconstruction (1985 to September 2017) were screened using MEDLINE, Embase and CENTRAL. The literature review yielded 30 controversial key questions. A set of key statements was derived and the highest levels of clinical evidence (LoE) for each of these were summarized. Nineteen panellists convened for dedicated discussions at the International Oncoplastic Breast Surgery Meeting to express agreement, disagreement or abstention for the generated key statements.

RESULTS

The literature review identified 1522 peer-reviewed publications. A list of 22 key statements was produced, with the highest LoE recorded for each statement. These ranged from II to IV, with most statements (11 of 22, 50 per cent) supported by LoE III. There was full consensus for nine (41 per cent) of the 22 key statements, and more than 75 per cent agreement was reached for half (11 of 22).

CONCLUSION

Poor evidence exists on which to base patient-informed consent. Low-quality studies are conflicting with wide-ranging treatment options, precluding expert consensus regarding optimal type and timing of breast reconstruction in the context of radiotherapy. There is a need for high-quality evidence from prospective registries and randomized trials in this field.

The New Trend of Pre-pectoral Breast Reconstruction: An Objective Evaluation of the Quality of Online Information for Patients Undergoing Breast Reconstruction

The Web has increasingly become the major source of information about health care, and patients who need to undergo breast reconstruction often use the internet to acquire an initial knowledge on the subject. We would like to present our study that investigates the quality of published information on pre-pectoral breast reconstruction. We searched the term "Pre-pectoral breast reconstruction" on Google^® and Yahoo^®. Forty-two web sites were selected and underwent qualitative and quantitative assessment using the expanded EQIP tool. The analysis of document contents showed a critical lack of information about qualitative risks and side-effects descriptions, treatment of potential complications, alert signs for the patient and precautions that the patient may take. Health professionals should inform patients about the potential difficulties of identifying reliable informational web sites about pre-pectoral breast reconstruction. The quality of available information should be improved, especially the important topics included in the content data section of the modified EQIP tool.Level of Evidence IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Evaluation of Prepectoral Implant Placement and Complete Coverage with TiLoop Bra Mesh for Breast Reconstruction: A Prospective Study on Long-Term and Patient-Reported BREAST-Q Outcomes

BACKGROUND

Breast reconstruction is rapidly evolving, because of the changing face of cancer surgery and the growing acceptance of acellular dermal matrices and synthetic meshes. Although some early reports showed encouraging results after prepectoral breast reconstruction, there is a paucity of data on long-term outcomes.

METHODS

Between January of 2012 and March of 2015, 179 patients undergoing mastectomy were enrolled at the authors' institution. Patients underwent mastectomy and immediate prepectoral breast reconstruction with the definitive implant entirely wrapped in a titanium-coated polypropylene mesh (TiLoop). The BREAST-Q questionnaire was administered before surgery and after 2 years. Capsular contracture was evaluated using the Baker scale. Oncologic, surgical, and aesthetic outcomes and changes in BREAST-Q score were analyzed over time.

RESULTS

Average follow-up was 38.5 months. A total of 250 mastectomies were performed. The locoregional recurrence rate was 2.1 percent. Complications requiring reoperation were recorded in six patients (2.4 percent) and implant removal was necessary in three cases (1.2 percent), followed by reconstruction with submuscular expanders. Grade IV capsular contracture was detected in five breasts (2 percent), whereas 212 breasts were evaluated as grade I (84.8 percent), 28 breasts as grade II (11.2 percent), and five breasts as grade III (2 percent). Patients reported significant high rates in the BREAST-Q overall Satisfaction with Outcome (73.8), overall Satisfaction with Breasts (72.5), Psychosocial Well-being (77.7), and Sexual Well-being (57.9), scoring a significant increase in these domains from the preoperative period to the postoperative period (p < 0.05).

CONCLUSION

The authors report encouraging results of a prepectoral direct-to-implant reconstruction technique using a synthetic mesh, supporting the evaluation of the muscle-sparing subcutaneous approach as a valid alternative to traditional submuscular reconstruction.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

From the "Fat Capsule" to the "Fat Belt": Limiting Protective Lipofilling on Irradiated Expanders for Breast Reconstruction to Selective Key Areas

BACKGROUND

The number of patients undergoing mastectomy and immediate breast reconstruction with tissue expanders followed by post-mastectomy radiotherapy (PMRT) is exponentially increasing. To reduce the rate of complications, in 2011, the senior author of this manuscript described the use of protective lipofilling in patients undergoing unplanned PMRT to the expander with a specific protocol aiming to decrease the rate of complications.

OBJECTIVES

A study was performed to evaluate the thickness of the breast irradiated tissue to create a standard pattern of "protective" lipofilling infiltration on limited key areas that could re-establish a thickness similar to non-radiotreated tissues.

METHODS

We studied 15 patients who had modified radical mastectomy (MRM) with immediate breast reconstruction with tissue expanders and PMRT (Group 1) before expansion (Time1), before PMRT (Time2), after PMRT (Time3), 3 months after "protective" lipofilling (Time4), and 6 months after "protective" lipofilling (Time5). As a control group, we studied 15 patients who had MRM and immediate breast reconstruction with tissue expanders that would not undergo PMRT (Group 2) at the same time points of GROUP 1 (Time1,2,3). Tissue thickness was studied in specific areas using ultrasounds (US) and magnetic resonance imaging (MRI).

RESULTS

US and MRI measurements obtained 6 weeks after PMRT and 3 months after lipofilling showed an initial decrease and then an average increase in tissue thickness reaching values even higher than the non-radiotreated control group.

CONCLUSIONS

This preliminary report shows how a one-step "fat belt" surgical pattern of lipofilling delivered to central "selected" areas of the breast can achieve adequate tissue thickness in patients who underwent breast reconstruction with PMRT reaching a thickness similar (and in most cases higher) to non-radiotreated tissues. Further follow-up studies are needed to analyze long-term complications of tissue thinning such as ulceration and implant exposure, in comparison with the "fat capsule" pattern.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .