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O'Connell RL, Di Micco R, Khabra K, Kirby AM, Harris PA, James SE, Power K, Ramsey KWD, Rusby JE. Comparison of Immediate versus Delayed DIEP Flap Reconstruction in Women Who Require Postmastectomy Radiotherapy. Plast Reconstr Surg 2018; 142:594-605. [PMID: 29927832 PMCID: PMC6112844 DOI: 10.1097/prs.0000000000004676] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Accepted: 03/16/2018] [Indexed: 11/27/2022]
Abstract
BACKGROUND The authors investigated aesthetic outcome and patient satisfaction in women who have undergone deep inferior epigastric artery perforator (DIEP) flap reconstruction in the setting of postmastectomy radiotherapy. Patients who underwent DIEP flap reconstruction without postmastectomy radiotherapy were the control group. METHODS Participants who had undergone DIEP flap reconstruction between September 1, 2009, and September 1, 2014, were recruited, answered the BREAST-Q, and underwent three-dimensional surface-imaging. A panel assessed the aesthetic outcome by reviewing these images. RESULTS One hundred sixty-seven women participated. Eighty women (48 percent) underwent immediate DIEP flap reconstruction and no postmastectomy radiotherapy; 28 (17 percent) underwent immediate DIEP flap reconstruction with postmastectomy radiotherapy; 38 (23 percent) underwent simple mastectomy, postmastectomy radiotherapy, and DIEP flap reconstruction; and 21 (13 percent) underwent mastectomy with temporizing implant, postmastectomy radiotherapy, and DIEP flap reconstruction. Median satisfaction scores were significantly different among the groups (p < 0.05). Post hoc comparison demonstrated that women who had an immediate DIEP flap reconstruction were significantly less satisfied if they had postmastectomy radiotherapy. In women requiring radiotherapy, those undergoing delayed reconstruction after a simple mastectomy were most satisfied, but there was no significant difference between the immediate DIEP flap and temporizing implant groups. Median panel scores differed among groups, being significantly higher if the immediate reconstruction was not subjected to radiotherapy. There was no significant difference in panel assessment among the three groups of women who had received radiotherapy. CONCLUSIONS Patients who avoid having their immediate DIEP flap reconstruction irradiated are more satisfied and have better aesthetic outcome than those who undergo postmastectomy radiotherapy. In women requiring radiotherapy and who wish to have an immediate or "delayed-immediate" reconstruction, there were no significant differences in panel or patient satisfaction. Therefore, immediate DIEP flap reconstruction or mastectomy with temporizing implant then DIEP flap surgery are acceptable treatment pathways in the context of post-mastectomy radiotherapy.
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Affiliation(s)
- Rachel L O'Connell
- From the Departments of Breast Surgery, Statistics, Clinical Oncology, and Plastic Surgery, The Royal Marsden NHS Foundation Trust
| | - Rosa Di Micco
- From the Departments of Breast Surgery, Statistics, Clinical Oncology, and Plastic Surgery, The Royal Marsden NHS Foundation Trust
| | - Komel Khabra
- From the Departments of Breast Surgery, Statistics, Clinical Oncology, and Plastic Surgery, The Royal Marsden NHS Foundation Trust
| | - Anna M Kirby
- From the Departments of Breast Surgery, Statistics, Clinical Oncology, and Plastic Surgery, The Royal Marsden NHS Foundation Trust
| | - Paul A Harris
- From the Departments of Breast Surgery, Statistics, Clinical Oncology, and Plastic Surgery, The Royal Marsden NHS Foundation Trust
| | - Stuart E James
- From the Departments of Breast Surgery, Statistics, Clinical Oncology, and Plastic Surgery, The Royal Marsden NHS Foundation Trust
| | - Kieran Power
- From the Departments of Breast Surgery, Statistics, Clinical Oncology, and Plastic Surgery, The Royal Marsden NHS Foundation Trust
| | - Kelvin W D Ramsey
- From the Departments of Breast Surgery, Statistics, Clinical Oncology, and Plastic Surgery, The Royal Marsden NHS Foundation Trust
| | - Jennifer E Rusby
- From the Departments of Breast Surgery, Statistics, Clinical Oncology, and Plastic Surgery, The Royal Marsden NHS Foundation Trust
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Maass SWMC, Bagher S, Hofer SOP, Baxter NN, Zhong T. Systematic Review: Aesthetic Assessment of Breast Reconstruction Outcomes by Healthcare Professionals. Ann Surg Oncol 2015; 22:4305-16. [PMID: 25691279 DOI: 10.1245/s10434-015-4434-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2014] [Indexed: 11/18/2022]
Abstract
BACKGROUND Achieving an aesthetic outcome following postmastectomy breast reconstruction is both an important goal for the patient and plastic surgeon. However, there is currently an absence of a widely accepted, standardized, and validated professional aesthetic assessment scale following postmastectomy breast reconstruction. METHODS A systematic review was performed to identify all articles that provided professional assessment of the aesthetic outcome following postmastectomy, implant- or autologous tissue-based breast reconstruction. A modified version of the Scientific Advisory Committee's Medical Outcomes Trust (MOT) criteria was used to evaluate all professional aesthetic assessment scales identified by our systematic review. The criteria included conceptual framework formation, reliability, validity, responsiveness, interpretability, burden, and correlation with patient-reported outcomes. RESULTS A total of 120 articles were identified: 52 described autologous breast reconstruction, 37 implant-based reconstruction, and 29 both. Of the 12 different professional aesthetic assessment scales that exist in the literature, the most commonly used scale was the four-point professional aesthetic assessment scale. The highest score on the modified MOT criteria was assigned to the ten-point professional aesthetic assessment scale. However, this scale has limited clinical usefulness due to its poor responsiveness to change, lack of interpretability, and wide range of intra- and inter-rater agreements (Veiga et al. in Ann Plast Surg 48(5):515-520, 2002). CONCLUSIONS A "gold standard" professional aesthetic assessment scale needs to be developed to enhance the comparability of breast reconstruction results across techniques, surgeons, and studies to aid with the selection of procedures that produce the best aesthetic results from both the perspectives of the surgeon and patients.
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Affiliation(s)
- Saskia W M C Maass
- Division of Plastic & Reconstructive Surgery, Department of Surgery and Surgical Oncology, University Health Network, Toronto, ON, Canada.,Division of Plastic & Reconstructive Surgery, University of Toronto, Toronto, ON, Canada
| | - Shaghayegh Bagher
- Division of Plastic & Reconstructive Surgery, Department of Surgery and Surgical Oncology, University Health Network, Toronto, ON, Canada.,Division of Plastic & Reconstructive Surgery, University of Toronto, Toronto, ON, Canada
| | - Stefan O P Hofer
- Division of Plastic & Reconstructive Surgery, Department of Surgery and Surgical Oncology, University Health Network, Toronto, ON, Canada.,Division of Plastic & Reconstructive Surgery, University of Toronto, Toronto, ON, Canada.,Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Nancy N Baxter
- Departments of Surgery and Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada.,The Keenan Research Centre, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada.,Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Toni Zhong
- Division of Plastic & Reconstructive Surgery, Department of Surgery and Surgical Oncology, University Health Network, Toronto, ON, Canada. .,Division of Plastic & Reconstructive Surgery, University of Toronto, Toronto, ON, Canada. .,Department of Surgery, University of Toronto, Toronto, ON, Canada.
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Dutra AK, Neto MS, Garcia EB, Veiga DF, Netto MM, Curado JH, Ferreira LM. Patients' satisfaction with immediate breast reconstruction with a latissimus dorsi musculocutaneous flap. J Plast Surg Hand Surg 2012; 46:349-53. [DOI: 10.3109/2000656x.2012.704726] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Dutra AK, Neto MS, Garcia ÉB, Veiga DF, Domingues MC, Yoshimatsu EK, Curado JH, Ferreira LM. The role of transverse latissimus dorsi musculocutaneous flap immediate breast reconstruction. EUROPEAN JOURNAL OF PLASTIC SURGERY 2009. [DOI: 10.1007/s00238-009-0366-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Stolier AJ, Sullivan SK, Dellacroce FJ. Technical considerations in nipple-sparing mastectomy: 82 consecutive cases without necrosis. Ann Surg Oncol 2008; 15:1341-7. [PMID: 18256883 DOI: 10.1245/s10434-007-9753-5] [Citation(s) in RCA: 86] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2007] [Revised: 11/22/2007] [Accepted: 11/26/2007] [Indexed: 01/26/2023]
Abstract
BACKGROUND Even without comparative trials, nipple-sparing mastectomy (NSM) is gaining traction in the treatment of established breast cancer and in the prophylactic setting. As yet, there are no established techniques that are universally applied to NSM. Herein we describe our surgical approach. METHODS All mastectomies performed by a single surgeon (AJS). Reconstructions performed included synthetic implants, deep inferior epigastric (DIEP) and gluteal artery perforator flaps (GAP). A lateral incision (12.1%) and a 6:00 radial incision (87.9%) were used in all patients. The areola was elevated just beneath the deep dermis and ductal tissue within the nipple papilla was "cored". RESULTS Fifty-eight patients underwent 82 NSMs for both cancer and prophylaxis. No patient developed necrosis of the nipple-areola complex (NAC). Minor skin-edge necrosis not involving the NAC occurred in 2 patients. Four patients developed a hematoma, 2 requiring re-operation. One patient required re-operation to correct a vein problem. There were no flap losses. CONCLUSIONS NSM can be performed with a minimal incidence of skin-flap related complications. In our hands, radial incisions perform well in this regard. Indications for NSM and the optimal technique are yet to be determined.
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Affiliation(s)
- Alan J Stolier
- Department of Surgery, Tulane University, 2525 Severn Ave., Metairie, New Orleans, LA 70002, USA.
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Mosahebi A, Ramakrishnan V, Gittos M, Collier J. Aesthetic outcome of different techniques of reconstruction following nipple-areola-preserving envelope mastectomy with immediate reconstruction. Plast Reconstr Surg 2007; 119:796-803. [PMID: 17312480 DOI: 10.1097/01.prs.0000251999.52374.09] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Nipple-preserving mastectomy and immediate reconstruction has further improved the aesthetic outcome of skin-sparing mastectomy. To investigate the effect of the type of reconstruction technique on aesthetic outcome, three different methods of reconstruction were compared using four evaluation modalities. METHODS Sixty-one cases of nipple-sparing envelope mastectomy with immediate reconstruction were studied, with a mean follow-up of 48 months. The methods of reconstruction used were implant-only reconstruction, pedicled latissimus dorsi muscle with implant, and deep inferior epigastric perforator flap. Evaluation methods were objective applanation tonometry, clinical evaluation, photography-based assessment, and patient satisfaction survey. RESULTS All three reconstruction methods achieved good evaluation scores in the four modalities. However, in patients who had postoperative radiotherapy, objective tonometry showed that the breast remained softer in deep inferior epigastric perforator flap reconstruction. CONCLUSION In patients who are undergoing nipple-preserving envelope mastectomy with immediate reconstruction and who are likely to have postoperative radiotherapy, deep inferior epigastric perforator flap reconstruction achieved a better aesthetic outcome.
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Affiliation(s)
- Afshin Mosahebi
- St. Andrew's Centre for Plastic Surgery, Broomfield Hospital, Essex, UK
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Cheng MH, Lin JY, Ulusal BG, Wei FC. Comparisons of Resource Costs and Success Rates between Immediate and Delayed Breast Reconstruction Using DIEP or SIEA Flaps under a Well-Controlled Clinical Trial. Plast Reconstr Surg 2006; 117:2139-42; discussion 2143-4. [PMID: 16772907 DOI: 10.1097/01.prs.0000218286.64522.15] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Every year many patients diagnosed with breast cancer are subjected to mastectomy. Some of them choose to undergo breast reconstruction to restore their body image. Immediate or delayed reconstruction is possible, depending on medical, financial, and emotional considerations. High success rate and cost-effectiveness are two important factors that may guide decision making in the management plan. The objective of this study was to compare the resource costs and success rates of immediate and delayed breast reconstructions using either deep inferior epigastric perforator (DIEP) or superficial inferior epigastric artery (SIEA) flaps. The resource cost is referred to as the cost of operation and hospitalization. METHODS From September of 2000 through August of 2001, 42 patients underwent immediate (n = 21) or delayed (n = 21) unilateral breast reconstruction using either a DIEP (n = 30) or SIEA (n = 12) flap by one surgeon. RESULTS There were no statistical differences in resource costs, success, and complication rates between DIEP and SIEA flaps in both the immediate and delayed breast reconstruction groups. CONCLUSIONS Using either a DIEP or SIEA flap as the autologous tissue, delayed breast reconstruction is as cost-effective as immediate reconstruction.
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Affiliation(s)
- Ming-Huei Cheng
- Department of Plastic Surgery, Chang Gung Memorial Hospital, Kwei-Shan, Tao-Yuan, Taiwan.
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Mosahebi A, Ramakrishnan V, Gittos M, Collier DSJ. Envelope mastectomy and immediate reconstruction (EMIR), improving outcome without oncological compromise. J Plast Reconstr Aesthet Surg 2006; 59:1025-30. [PMID: 16996423 DOI: 10.1016/j.bjps.2005.11.029] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2005] [Revised: 10/04/2005] [Accepted: 11/17/2005] [Indexed: 11/26/2022]
Abstract
AIM To determine the long term oncological safety and aesthetic acceptability of envelope mastectomy and immediate reconstruction (EMIR). PATIENTS AND METHODS A retrospective review of 71 cases was carried out. Oncological assessment was by clinical examination, mammography, ultrasound, and, where indicated, MRI scan. Aesthetic assessment was based on detailed clinical examination as well as subjective self-assessment of the outcome. RESULTS During follow-up (mean 48 months), there were three local recurrences, only one involving the nipple-areolar complex. The mean aesthetic score was 0.75 (out of 1), representing a good aesthetic outcome and patient satisfaction. CONCLUSION Nipple-areolar complex preservation is a safe option and EMIR produced a good aesthetic outcome, which is oncologically safe. Furthermore, it does not preclude post-operative radiotherapy.
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Affiliation(s)
- A Mosahebi
- St Andrew's Centre for Plastic Surgery, Broomfield Hospital, Chelmsford, Essex CM1 7ET, UK
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