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Tajziehchi P, Dayaratna N, Holten BE, Dusseldorp JR. Flap neurotisation improves sensation outcomes in abdominally based autologous breast reconstruction: A systematic review and meta-analysis. J Plast Reconstr Aesthet Surg 2024; 90:280-291. [PMID: 38401199 DOI: 10.1016/j.bjps.2024.01.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 01/16/2024] [Accepted: 01/29/2024] [Indexed: 02/26/2024]
Abstract
BACKGROUND Flap neurotisation is a promising solution to restore the diminished or complete loss of sensation following mastectomy. This systematic review compared sensory outcomes in neurotised versus non-neurotised abdominal-based autologous breast reconstructions to establish its benefit in routine clinical practice. METHODS A literature search was performed according to the PRISMA guidelines. Medline, PubMed, EMBASE, and Cochrane databases were queried for relevant studies. Pressure sensitivity, measured using Semmes-Weinstein monofilaments (SWM) or the pressure-specified sensory device (PSSD), was the primary outcome measure. RESULTS A total of 12 studies comprising 367 neurotised and 295 non-neurotised flap reconstructions were included, with 8 studies included in the meta-analysis. Neurotised flaps demonstrated superior sensory outcomes over non-neurotised flaps, with significant differences in SWM scores (mean difference [MD], -1.552 95% CI, -2.351 to -0.7535; p = 0.0001) and PSSD (MD -13.36; 95% CI, -26.41 to -0.3117; p = 0.0448) at follow-up (range 8 to 77 months). The differences in total skin sensation (native and flap skin combined) were statistically significant in the SWM group (p = 0.0010) but not in the PSSD group (p = 0.0649). Investigation on the factors impacting sensation recovery in neurotised flaps yielded inconclusive outcomes. CONCLUSIONS Neurotised flaps consistently demonstrated superior sensation outcomes compared with non-neurotised flaps, irrespective of flap type or neurotisation technique. However, further research is essential to elucidate the factors that impact sensory recovery and standardise neurotisation practices for more optimal post-mastectomy reconstruction outcomes.
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Affiliation(s)
- Parand Tajziehchi
- Faculty of Medicine and Health, Sydney University Medical School, The University of Sydney, Camperdown, New South Wales 2050, Australia; Department of Breast Surgery, Chris O'Brien Lifehouse, 119-143 Missenden Rd, Camperdown, New South Wales 2050, Australia; Westmead Clinical School, Westmead Hospital, Cnr Hawksbury Road and, Darcy Road, Westmead, New South Wales 2145, Australia.
| | - Nirmal Dayaratna
- Faculty of Medicine and Health, Sydney University Medical School, The University of Sydney, Camperdown, New South Wales 2050, Australia; Department of Breast Surgery, Chris O'Brien Lifehouse, 119-143 Missenden Rd, Camperdown, New South Wales 2050, Australia; Concord Clinical School, Concord Repatriation General Hospital, Hospital Road, Concord, New South Wales 2139, Australia
| | - Briona E Holten
- Faculty of Medicine and Health, Sydney University Medical School, The University of Sydney, Camperdown, New South Wales 2050, Australia; Department of Breast Surgery, Chris O'Brien Lifehouse, 119-143 Missenden Rd, Camperdown, New South Wales 2050, Australia; Concord Clinical School, Concord Repatriation General Hospital, Hospital Road, Concord, New South Wales 2139, Australia
| | - Joseph R Dusseldorp
- Faculty of Medicine and Health, Sydney University Medical School, The University of Sydney, Camperdown, New South Wales 2050, Australia; Department of Breast Surgery, Chris O'Brien Lifehouse, 119-143 Missenden Rd, Camperdown, New South Wales 2050, Australia; Department of Plastic Surgery, Concord Repatriation General Hospital, Hospital Road, Concord, New South Wales 2139, Australia
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Wong SM, Apostolova C, Eisenberg E, Foulkes WD. Counselling Framework for Germline BRCA1/2 and PALB2 Carriers Considering Risk-Reducing Mastectomy. Curr Oncol 2024; 31:350-365. [PMID: 38248108 PMCID: PMC10814079 DOI: 10.3390/curroncol31010023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 12/31/2023] [Accepted: 01/05/2024] [Indexed: 01/23/2024] Open
Abstract
Female BRCA1/2 and PALB2 germline pathogenic variant carriers have an increased lifetime risk of breast cancer and may wish to consider risk-reducing mastectomy (RRM) for surgical prevention. Quantifying the residual lifetime risk and absolute benefit from RRM requires careful consideration of a patient's age, pathogenic variant, and their personal history of breast or ovarian cancer. Historically, patients have been counselled that RRM does not necessarily prolong survival relative to high-risk surveillance, although recent studies suggest a possible survival benefit of RRM in BRCA1 carriers. The uptake of RRM has increased dramatically over the last several decades yet varies according to sociodemographic factors and geographic region. The increased adoption of nipple-sparing mastectomy techniques, ability to avoid axillary staging, and availability of reconstructive options for most germline pathogenic variant carriers has helped to minimize the morbidity of RRM. Preoperative discussions should include evidence regarding postmastectomy sensation, the potential for supplemental surgery, pregnancy-related chest wall changes, and the need for continued clinical surveillance. Approaches that include sensation preservation and robotic nipple-sparing mastectomy are an area of evolving research that may be more widely adopted in the future.
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Affiliation(s)
- Stephanie M. Wong
- Department of Surgery, McGill University, Montreal, QC H3G 1A4, Canada
- Stroll Cancer Prevention Centre, Sir Mortimer B. Davis Jewish General Hospital, Montreal, QC H3T 1E2, Canada
- Gerald Bronfman Department of Oncology, McGill University, Montreal, QC H4A 3T2, Canada
| | - Carla Apostolova
- Department of Surgery, McGill University, Montreal, QC H3G 1A4, Canada
- Stroll Cancer Prevention Centre, Sir Mortimer B. Davis Jewish General Hospital, Montreal, QC H3T 1E2, Canada
| | - Elisheva Eisenberg
- Department of Surgery, McGill University, Montreal, QC H3G 1A4, Canada
- Stroll Cancer Prevention Centre, Sir Mortimer B. Davis Jewish General Hospital, Montreal, QC H3T 1E2, Canada
| | - William D. Foulkes
- Stroll Cancer Prevention Centre, Sir Mortimer B. Davis Jewish General Hospital, Montreal, QC H3T 1E2, Canada
- Gerald Bronfman Department of Oncology, McGill University, Montreal, QC H4A 3T2, Canada
- Department of Human Genetics, McGill University, Montreal, QC H3A 0C7, Canada
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Smeele HP, Martin L, van Kuijk SMJ, Zwanenburg PR, van der Hulst RRWJ, Tuinder SMH, Fromy B. Local heating-induced cutaneous vasodilation in reinnervated and noninnervated deep inferior epigastric perforator flaps. Microsurgery 2024; 44:e31122. [PMID: 37788020 DOI: 10.1002/micr.31122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 09/06/2023] [Accepted: 09/22/2023] [Indexed: 10/04/2023]
Abstract
INTRODUCTION Cutaneous vascular reactivity to local heating in free flaps has not been characterized. We aimed to assess local heating-induced cutaneous vasodilation in reinnervated and noninnervated deep inferior epigastric perforator (DIEP) flaps. METHODS We conducted a cross-sectional study of 21 female patients with an uncomplicated unilateral delayed DIEP breast reconstruction at least 2 years after surgery. DIEP flaps and contralateral breasts were subjected to direct local heating, and skin blood flow was assessed using laser-Doppler flowmetry. To evaluate sensory-nerve-fiber function, touch perception thresholds were assessed using a 20-piece Touch-test™ Sensory Evaluator, and cutaneous warm detection and heat pain thresholds were measured using a TSA-II device. RESULTS Of the participants, 10 had a reinnervated DIEP flap with a single coapted nerve (mean flap weight, 610 ± 296 g) and 11 had a noninnervated DIEP flap (mean flap weight, 613 ± 169 g). Mean age was 58 ± 11 years, mean follow-up time was 5 ± 1 years, and mean BMI was 24 ± 3 kg/m2 . DIEP flaps exhibited significantly weaker cutaneous vasodilation in response to local heating than contralateral breasts (median peak skin blood flow, 59 [25th-75th percentile, 36-71] a.u. for DIEP flaps versus 94 [74-141] a.u. for contralateral breasts; p < .001). The magnitude of the response was similar between reinnervated and noninnervated flaps (median peak skin blood flow, 55 [25th-75th percentile, 39-68] a.u. for reinnervated DIEP flaps versus 66 [36-77] a.u. for noninnervated DIEP flaps; p = .75). Of participants with reinnervated DIEP flaps, 90% perceived heat pain below the 50°C safety threshold, as compared to 36% of participants with noninnervated DIEP flaps (two-tailed p = .02). CONCLUSION Our results suggest that free flap transfer causes longstanding impairment, yet not complete abolition, of both the sensory nerve-mediated and nitric oxide-dependent local heating-induced cutaneous vasodilatory systems. We found no statistical evidence that flap reinnervation improves the ability to raise skin blood flow in response to local heating.
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Affiliation(s)
- Hansje P Smeele
- Department of Plastic, Reconstructive and Hand Surgery, GROW-School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Lisa Martin
- Functional Integrity of the Skin Group, Tissue Biology and Therapeutic Engineering Laboratory (LBTI), CNRS UMR5305, Université Lyon 1, Lyon, France
| | - Sander M J van Kuijk
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Pieter R Zwanenburg
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam Infection & Immunity, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - René R W J van der Hulst
- Department of Plastic, Reconstructive and Hand Surgery, GROW-School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Stefania M H Tuinder
- Department of Plastic, Reconstructive and Hand Surgery, GROW-School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Bérengère Fromy
- Functional Integrity of the Skin Group, Tissue Biology and Therapeutic Engineering Laboratory (LBTI), CNRS UMR5305, Université Lyon 1, Lyon, France
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Murphy RNA, Reid AJ, Columb MO, O'Ceallaigh S, Duncan J, Holt R. Breast-Q sensory outcomes of non-neurotized, autologous, unilateral breast reconstruction with a minimum of 3-year follow-up. J Plast Reconstr Aesthet Surg 2023; 85:86-91. [PMID: 37473644 DOI: 10.1016/j.bjps.2023.06.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 06/18/2023] [Accepted: 06/22/2023] [Indexed: 07/22/2023]
Abstract
INTRODUCTION Sensory reinnervation of autologous breast tissue after free flap reconstruction is highly variable. There is no long-term follow-up data exploring spontaneous reinnervation and how this affects patients' quality of life nor the nerve-related symptoms they experience. To address this issue, we invited patients with a minimum of 3 years after non-neurotized, free flap breast reconstruction to complete patient-reported outcome measures exploring sensation, quality of life and breast-related symptoms. METHODS We performed a retrospective cohort study of patients undergoing unilateral Muscle-Sparing Transverse Rectus Abdominus Muscle (MS-TRAM) or deep inferior epigastric artery perforator (DIEP) flap breast reconstruction between 01-01-2015 and 31-12-2019 in the Department of Plastic and Reconstructive Surgery at Manchester University NHS Foundation Trust. We invited participants to complete the recently developed Breast-Q© Breast Sensation Module. RESULTS All patients had undergone unilateral immediate (n = 85) or delayed (n = 82) breast reconstruction after mastectomy using either a free DIEP (n = 150) or TRAM (n = 17) flap reconstruction a minimum of 3 years prior. The median age at operation was 48. Sensation after reconstruction was significantly reduced in the reconstructed breast compared with the contralateral breast (P < 0.0001) with a reduction in reported quality of life (immediate (68.0 [54.0, 89.0]) and delayed (68.0 [62.0, 83.8])). The sensation was significantly better in immediate vs delayed procedures (P = 0.024). Sensory scores after reconstruction increased with age (P = 0.036). DISCUSSION Breast sensation after non-neurotized reconstruction with autologous tissue is significantly reduced at long-term follow-up with a reduction in quality of life. A minimum outcome set for quantification of breast sensation is required and future research into the cost-benefit of neurotized, autologous breast reconstruction is needed.
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Affiliation(s)
- Ralph N A Murphy
- Department of Plastic Surgery & Burns, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester M23 9LT, UK; Blond McIndoe Laboratories, Division of Cell Matrix Biology and Regenerative Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester M13 9PT, UK.
| | - Adam J Reid
- Department of Plastic Surgery & Burns, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester M23 9LT, UK; Blond McIndoe Laboratories, Division of Cell Matrix Biology and Regenerative Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester M13 9PT, UK
| | - Malachy O Columb
- Department of Anaesthesia and Intensive Care Medicine, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester M23 9LT, UK
| | - Siobhan O'Ceallaigh
- Department of Plastic Surgery & Burns, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester M23 9LT, UK
| | - Jonathan Duncan
- Department of Plastic Surgery & Burns, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester M23 9LT, UK
| | - Rachel Holt
- Department of Plastic Surgery & Burns, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester M23 9LT, UK
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Chen X, Chen A, Liu C, Zhang B. Immediate Prosthesis Breast Reconstruction: A Comparison Between Ambulatory Surgery Versus Traditional Hospitalization Based on the Propensity Score Matching Method. Aesthetic Plast Surg 2022; 47:584-592. [PMID: 36203096 PMCID: PMC9540132 DOI: 10.1007/s00266-022-03121-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 09/03/2022] [Indexed: 12/05/2022]
Abstract
Background The positive benefits of immediate prosthesis breast reconstruction (IPBR) are incontrovertible. During the COVID-19 pandemic, health care resources became scarce. The implementation of outpatient immediate prosthesis breast reconstruction (OIPBR) can improve the efficiency of medical care and reduce viral exposure. Very few studies have focused on OIPBR and this study aimed to fill this gap by evaluating outcomes of OIPBR compared with traditional hospitalization IPBR (THIPBR) in terms of complications and quality of life. Material and Methods The study enrolled patients undergoing IPBR at Tianjin Medical University Cancer Institute and Hospital between January 1, 2020, and September 30, 2021. Outcomes were defined as postoperative complications and quality of life before reconstruction and at 3-month follow-up. Quality of life was assessed by BREAST-Q questionnaire. Inverse probability of treatment weighting and propensity score matching (PSM) were applied to adjust for confounders. Results A total of 135 patients were enrolled, including 110 with THIPBR and 25 with OIPBR. After matching, baseline characteristics were well balanced. Patients with OIPBR had lower rates of lymphedema on the surgery side (p = 0.041) and readmission (p = 0.040) than patients with THIPBR. No statistically significant differences in the quality of life metrics of psychosocial well-being, sexual well-being, satisfaction with breast and physical well-being of the chest were found between the two groups. Conclusion OIPBR is a safe and efficient alternative to THIBPR during the COVID-19 pandemic. It is recommended when medical conditions allow to conserve medical resources. Accelerated technical training for the performance of OIPBR at the hospital level should be expedited. Level of Evidence III 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.
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Affiliation(s)
- Xiao Chen
- The First Department of Breast Cancer, National Clinical Research Center for Cancer, Tianjin Medical University Cancer Institute and Hospital, North Huanhu West Road, Sports Institute, Hexi District, Tianjin, China
| | - Aoxiang Chen
- The First Department of Breast Cancer, National Clinical Research Center for Cancer, Tianjin Medical University Cancer Institute and Hospital, North Huanhu West Road, Sports Institute, Hexi District, Tianjin, China
| | - Chaoqi Liu
- The First Department of Breast Cancer, National Clinical Research Center for Cancer, Tianjin Medical University Cancer Institute and Hospital, North Huanhu West Road, Sports Institute, Hexi District, Tianjin, China
| | - Bin Zhang
- The First Department of Breast Cancer, National Clinical Research Center for Cancer, Tianjin Medical University Cancer Institute and Hospital, North Huanhu West Road, Sports Institute, Hexi District, Tianjin, China.
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