Therapeutic mammaplasty – Impact on the delivery of chemotherapy

A New Level II Oncoplastic Technique for Inferior Pole Defects: The Three-Petal Glandular Reconstruction (3-PR)

INTRODUCTION

Oncoplastic surgery (OPS) allows wide excisions and accurate tumor resection and reduces breast deformities by immediate reconstruction of large defects. Superior pedicled mammaplasties allow excellent results in large breasts. Conversely, loco-regional flaps are the standard of care in small-to-medium breasts. However, both techniques show limitations in case of large resections of the lower pole, resulting in skin retraction and downward deviation of nipple and areola. We present a new technique for inferior pole reconstruction to overcome these limitations. It is called "the three-petal reconstruction" (3-PR).

METHODS

Between September 2016 and May 2019, ten patients with invasive breast cancer of the lower pole underwent breast conservation and 3-PR.

RESULTS

The 3-PR was uneventful in all patients. No major or minor complications were recorded. Patient and surgeon evaluations scored as good to excellent in all cases. Surveillance examinations in the follow-up did not reveal calcifications nor any findings of suspicion within the reconstructed area.

CONCLUSIONS

In case of very large defect of lower pole, the 3-PR reveals to be an easy, fast, reproducible method for inferior pole reconstruction. It can represent a niche between therapeutic mammaplasty and perforator flaps, and it could be added to existing available options for tailored reconstruction.

LEVEL OF EVIDENCE III

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Outcome reporting in therapeutic mammaplasty: a systematic review

BACKGROUND

Therapeutic mammaplasty (TM) is an oncological procedure which combines tumour resection with breast reduction and mastopexy techniques. Previous systematic reviews have demonstrated the oncological safety of TM but reporting of critically important outcomes, such as quality of life, aesthetic and functional outcomes, are limited, piecemeal or inconsistent. This systematic review aimed to identify all outcomes reported in clinical studies of TM to facilitate development of a core outcome set.

METHODS

Medline, EMBASE, CINAHL and Web of Science were searched from inception to 5 August 2020. Included studies reported clinical outcomes following TM for adult women. Two authors screened articles independently for eligibility. Data were extracted regarding the outcome definition and classification type (for example, oncological, quality of life, etc.), time of outcome reporting and measurement tools.

RESULTS

Of 5709 de-duplicated records, 148 were included in the narrative synthesis. The majority of studies (n = 102, 68.9 per cent) reported measures of survival and/or recurrence; approximately three-quarters (n = 75, 73.5 per cent) had less than 5 years follow-up. Aesthetic outcome was reported in half of studies (n = 75, 50.7 per cent) using mainly subjective, non-validated measurement tools. The time point at which aesthetic assessment was conducted was highly variable, and only defined in 48 (64.0 per cent) studies and none included a preoperative baseline for comparison. Few studies reported quality of life (n = 30, 20.3 per cent), functional outcomes (n = 5, 3.4 per cent) or resource use (n = 28, 18.9 per cent).

CONCLUSION

Given the oncological equivalence of TM and mastectomy, treatment decisions are often driven by aesthetic and functional outcomes, which are infrequently and inconsistently reported with non-validated measurement tools.

Factors influencing decisions on contralateral symmetrisation procedure among patients with breast cancer

INTRODUCTION

Oncoplastic breast conserving surgery (OBCS) can cause breast asymmetry. Although contralateral breast surgery to achieve symmetry was offered to these patients, the uptake of symmetrisation was variable. We aimed to determine the factors that deter patients with breast cancer undergoing OBCS from taking up symmetrisation.

METHODS

All patients with breast cancer who underwent OBCS of displacement type but no symmetrisation were prospectively surveyed to explore social, economic, psychological and physical reasons against symmetrisation.

RESULTS

28 patients participated in a survey administered at a mean 21.6 (range 2-47) months after OBCS. A combination of factors, such as worry and desire to treat breast cancer first (67.9%), not being overly concerned about breast cosmesis (57.1%) and fear of pain from additional operation (28.6%) deterred patients from immediate symmetrisation. Worry and desire to treat breast cancer first was the most important single factor for 50% of patients. Reasons for no delayed symmetrisation included not being overly concerned about breast cosmesis (70.4%), fear of breast cancer recurrence (48.1%) and being happy with current breast cosmesis (33.3%), with the former two reasons equally cited as the single most important deterrent by 30% of patients each.

CONCLUSION

A combination of factors may deter patients from symmetrisation. The most significant factors deterring OBCS among patients were worry and desire to treat breast cancer first for immediate symmetrisation, and not being overly concerned about breast cosmesis and fear of breast cancer recurrence for delayed symmetrisation. Reassurance of these patients may increase their uptake of symmetrisation, thereby improving patient cosmesis and satisfaction.

Batwing mammoplasty: a safe oncoplastic technique for breast conservation in breast cancer patients with gigantomastia

BACKGROUND

Surgical management of breast cancer with gigantomastia can be challenging when planning breast conservation, as major breast reduction is required. Complex oncoplastic procedures can carry an additional surgical risk in this situation. We suggest batwing mammoplasty as a simple and safe oncoplastic procedure for those patients.

MATERIALS AND METHODS

Fourteen patients with gigantomastia diagnosed with breast cancer were included in this prospective cohort study. All underwent batwing mammoplasty and contralateral symmetrisation procedure between May 2016 and June 2018. Patient satisfaction assessed by the Breast-Q questionnaire.

RESULTS

All patients had a body mass index above 30kg/m2 with a mean of 36.7kg/m2 (range 31.6-44.9kg/m2). The mean distance from midclavicular point to nipple was 42cm (range 38-50cm). The mean operative time was 83 minutes for procedures done by a single surgeon. Mean specimen weight was 1.2kg (ranging from 1.035-1.63kg). Postoperative complications occurred in 14.2% of patients. Nipple-areola complex viability was not compromised nor sensation impaired. The mean Breast-Q score for patient satisfaction with breasts was 68.6 (range 61-74). The mean score for physiological wellbeing was 77.3 (range 64-84) and the mean score for physical wellbeing was 35 (range 31-40).

CONCLUSION

Batwing mammoplasty is a safe and simple oncoplastic procedure in patients who have breast cancer with gigantomastia. It has short operative time and low complications rate. In our cohort of patients, there was no delay in the delivery of adjuvant treatment. The cosmetic outcome was favourable with a high patient satisfaction.

Current practice and short-term outcomes of therapeutic mammaplasty in the international TeaM multicentre prospective cohort study

BACKGROUND

Therapeutic mammaplasty, which combines breast reduction and mastopexy techniques with tumour excision, may extend the boundaries of breast-conserving surgery and improve outcomes for patients, but current practice is unknown and high-quality outcome data are lacking. This prospective multicentre cohort study aimed to explore the practice and short-term outcomes of the technique.

METHODS

Consecutive patients undergoing therapeutic mammaplasty at participating centres between 1 September 2016 and 30 June 2017 were recruited to the study. Demographic, preoperative, operative, oncological and complication data were collected. The primary outcome was unplanned reoperation for complications within 30 days of surgery. Secondary outcomes included re-excision rates and time to adjuvant therapy.

RESULTS

Overall, 880 patients underwent 899 therapeutic mammaplasty procedures at 50 centres. The most common indications were avoidance of poor cosmetic outcomes associated with standard breast-conserving surgery (702 procedures, 78·1 per cent) or avoidance of mastectomy (379, 42·2 per cent). Wise-pattern skin incisions were the most common (429 of 899, 47·7 per cent), but a range of incisions and nipple-areola pedicles were used. Immediate contralateral symmetrization was performed in one-third of cases (284 of 880, 32·3 per cent). In total, 205 patients (23·3 per cent) developed a complication, but only 25 (2·8 per cent) required reoperation. Median postoperative lesion size was 24·5 (i.q.r. 16-38) mm. Incomplete excision was seen in 132 procedures (14·7 per cent), but completion mastectomy was required for only 51 lesions (5·7 per cent). Median time to adjuvant therapy was 54 (i.q.r. 42-66) days.

CONCLUSION

Therapeutic mammaplasty is a safe and effective alternative to mastectomy or standard breast-conserving surgery. Further work is required to explore the impact of the technique on quality of life, and to establish cost-effectiveness.

Closed Incision Negative Pressure Therapy in Oncological Breast Surgery: Comparison with Standard Care Dressings

Background:

Negative pressure wound therapy was developed for treating wounds associated with unfavorable healing factors. The principles of the negative pressure wound therapy applied on clean and closed surgical incision originate the closed incision negative pressure therapy (ciNPT). We evaluated the use of ciNPT in the setting of oncological breast surgery.

Methods:

From January 1, 2015, to June 31, 2015, we prospectively selected 37 patients undergoing oncological breast surgery with a minimum of 4 risk factors. Seventeen patients (25 surgeries) voluntary tested ciNPT (ciNPT sample), whereas the remaining 20 (22 surgeries) chose conventional postsurgery dressing (Standard Care sample). Follow-up controls to evaluate postsurgical complications were performed on days 7, 14, 30, and 90. At 12 months, the quality of life, scar, and overall aesthetic outcomes were evaluated with specific questionnaires filled in by surgeon and patient. The Standard Care sample was investigated on risk factors associated with poor healing.

Results:

The ciNPT sample showed a significant prevalence of high risk factors, especially extensive undermining and bilateral surgeries, and a predominance of women under 65 years; only 1/25 (4%) surgical procedures was followed by complications. In the Standard Care sample, 10 of 22 surgeries (45%) were followed by complications. The difference in complication rate between the 2 samples was significant. The BIS (Body Image Scale) scores suggested that most patients were satisfied with their body image regardless of the type of dressing. All other questionnaire scores clearly vouched for a significant superiority of the ciNPT. Previous surgery ≤ 30 days emerged as the surgery-related high risk factor most frequently associated with postsurgery complications.

Conclusion:

The results of our study support the use of ciNPT in oncological breast surgery: it showed to be a well-tolerated, adaptable, and reliable dressing capable of reducing postsurgical complications and improving scar outcomes in patients presenting with high risk factors.

Current Practice of Therapeutic Mammaplasty: A Survey of Oncoplastic Breast Surgeons in England

Introduction. Therapeutic mammaplasty (TM) is a useful technique in the armamentarium of the oncoplastic breast surgeon (OBS). There is limited guidance on patient selection, technique, coding, and management of involved margins. The practices of OBS in England remain unknown. Methods. Questionnaires were sent to all OBS involved with the Training Interface Group. We assessed the number of TM cases performed per surgeon, criteria for patient selection, pedicle preference, contralateral symmetrisation, use of routine preoperative MRI, management of involved margins, and clinical coding. Results. We had an overall response rate of 43%. The most common skin resection technique utilised was wise pattern followed by vertical scar. Superior-medial pedicle was preferred by the majority of surgeons (62%) followed by inferior pedicle (34%). Twenty percent of surgeons would always proceed to a mastectomy following an involved margin, whereas the majority would offer reexcision based on several parameters. The main absolute contraindication to TM was tumour to breast ratio >50%. One in five surgeons would not perform TM in smokers and patients with multifocal disease. Discussion. There is a wide variation in the practice of TM amongst OBS. Further research and guidance would be useful to standardise practice, particularly management of involved margins and coding for optimal reimbursement.

PICO™ incision closure in oncoplastic breast surgery: a case series

Single-use negative pressure wound therapy (PICO™) has been used on high-risk surgically incised wounds with encouraging results, but there is no evidence for its use in oncoplastic breast surgery. This article reports a case series with closed incisions in oncoplastic breast procedures following the introduction of PICO™.